Public Health PTS Flashcards
(318 cards)
1
Q
Why is health economics relevant?
A
Finite resources
Hard choices – some patients will not get something that will benefit them
As a doctor we have to explain this to patients
As a commissioner – will have to decide
2
Q
What is opportunity cost?
A
To spend resources on one activity (e.g. heart transplant) means a sacrifice in terms of a lost opportunity cost elsewhere (e.g. fewer hip replacements)
The opportunity cost of an activity is the sacrifice in terms of the benefits forgone from not allocating resources to the next best activity
i.e. if one patient gets a very expensive treatment, others miss out on another treatment
3
Q
What is economic efficiency?
A
Achieved when resources are allocated between activities in such a way as to maximise benefit
i.e. if you have £3000 to spend and one treatment costs 1500 compared to another which costs 300, it would be more efficient to go with the cheaper treatment to save more lives/help more people
4
Q
What is economic equity?
A
About what is fair and just
Fair and just distribution of costs and benefits
Economists are clear in principle about the definition of efficiency, but there are opposing views about what is ‘fair’
Such considerations are difficult to quantify and the decision making process is much more complex and subjective
5
Q
What is meant by an equity-efficiency trade-off?
A
Improving equity often leads to a loss in efficiency
For example – funding the treatment of rare disease with very expensive drugs that may only have a limited benefit
This funding is then not available to treat other people with common diseases where the benefits will be much greater for the same cost
On balance there is a loss of health
This is inefficient, but it’s more equitable
6
Q
Define economic evaluation
A
The assessment of efficiency - a comparative study of the costs and benefits of healthcare interventions (i.e. cost benefit analysis)
Costs and effects are analysed in terms of their ‘increments’ or differences
Are the incremental benefits of a new treatment worth the incremental costs?
7
Q
How can health benefits be measured?
A
Natural units – e.g. blood pressure/pain score/number of cases detected
Quality adjusted life years
Monetary value
8
Q
What is a quality adjusted life year (QALY)?
A
Combines length of life with quality of life
Length (years) x quality (“utility”) weighting (0 to 1 scale)
One QALY = 1 year perfect health
One QALY = 2 years in half perfect health
Allows comparison across diseases
9
Q
What are the 4 types of economic evaluation?
A
Cost-effectiveness analysis
Cost-utility analysis
Cost-benefit analysis
Cost-minimisation analysis
10
Q
What is cost-effectiveness analysis?
A
Outcomes measured in natural units
E.g. incremental cost per life year gained
11
Q
What is cost-utility analysis?
A
Outcomes measured in QALYs
E.g. incremental cost per QALY gained
Remember because the name for quality of life in the QALY eqution is utility
12
Q
What is cost-benefit analysis?
A
Outcomes measured in monetary units
e.g. net monetary benefit
13
Q
What is cost-minimisation analysis?
A
Outcomes (measured in any units) are the same in both treatments
Therefore, just minimise cost
14
Q
What is incremental analysis?
A
Everything is relative
There must always be a comparison – for example:
New drug vs old drug
New treatment vs watch and wait
New surgical option vs medical treatment
15
Q
What is cost effectiveness analysis?
A
Simplest form of economic evaluation is cost-effectiveness analysis (CEA)
Uses ‘natural’ units to measure health e.g. life years gained
Comparison across disease areas difficult
Which do you fund:
ICER (heart transplants) = £10,000 per life year gained
ICER (hip replacement) = £3,000 per pain-free year gained
16
Q
Cost utility analysis?
A
More complex – using QALYs
Combined length of life and quality of life
In principle, all treatments can be evaluated using CUA – making funding decisions easier
ICER (heart transplants) = £18,000 per QALY
ICER (hip replacements) = £8,000 per QALY
17
Q
Cost benefit analysis?
A
Rarely used in healthcare
As it requires putting a monetary value on all outcomes which is difficult
18
Q
What is a funding threshold?
A
When a new more experience treatment is funded, another treatment somewhere else in the NHS needs to have its funding stopped to pay for it
NICE thinks that any services that are closed down to fund new services probably generate benefits at around £20,000 per QALY
Taking £20,000 from somewhere else therefore loses 1 QALY
So it only makes sense to fund new things if we get at least 1 QALY per £20,000 (cost must be less than £20,000 per QALY)
19
Q
What are some other considerations that need to be taken into account in health economics?
A
Age (equity)
Severity of illness (equity)
End-of-life (equity)
Rarity of condition (equity)
Causation (equity)
Innovation (wider economic benefit)
Patient convinience (and choice)
20
Q
What are the 3 main models of financing healthcare?
A
Publicly-funded health systems
Social insurance funded health systems
Privately funded health systems
21
Q
Define epigenetics
A
The expression of a genome depends on the environment
22
Q
Define allostasis
A
The same as homeostasis
The stability through change of our physiological systems to adapt rapidly to change in environment
23
Q
Define allostatic load
A
Long-term overtaxation of our physiological systems leading to impaired health (stress)
24
Q
Define salutogenesis
A
Favourable physiological changes secondary to experiences which promote healing and health
25
Define emotional intelligence
The ability to identify and manage one’s own emotions, as well as those of others
26
What is the role of primary care?
Managing illness and clinical relationships over time
Finding the best available clinical solutions to clinical problems
Preventing illness
Promoting health
Managing clinical uncertainty
Getting the best outcomes with available resources
Working in the primary health care team
Shared decision making with patients
27
What are the main dangers of over-prescribing antibiotics?
Unnecessary side effects
Medicalisation of self-limiting conditions
Antibiotic resistance
28
What criteria should be used for prescribing antibiotics to someone with a sore throat?
CENTOR criteria
29
What are the centor criteria?
Tonsillar exudate
Absence of cough
Tender or large cervical lymphadenopathy
Fever
30
What are some other criteria for when to prescribe antibiotics?
Bilateral otitis media < 2 years old
Otitis media with otorrhoea
Acute sore throat with ≥ 3 centor criteria
Systemically very unwell
High risk – e.g. comorbidities, immune suppression, ex-prem baby
Aged > 65 and 2 of the following, or >80 and one of the following – hospital admission within the last 12 months, DM, CCF, glucocorticoid use
Pneumonia, mastoiditis, peritonsillar abscess, cellulitis
31
Which antibiotics should be used for otitis media?
Amoxicillin
500mg TDS for 5 days
32
Which antibiotics are used for sinusitis?
Amoxicillin
Or doxycycline
33
Which antibiotics should be used for tonsillitis?
Penicillin V for 10 days
34
Which antibiotics should be used for LRTI?
Amoxicillin
35
Which Abx should be used for a UTI?
Trimethoprim – 200mg BD for 3 days
OR nitrofurantoin – 50mg QDS for 3 days
36
Define public health
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
37
What are the 3 domains of public health?
Health improvement
Health protection
Improving services
38
What are the key concerns of public health?
Inequalities in health
Wider determinants of health
Prevention
39
What is the domain of health improvement concerned with?
Societal interventions:
Inequalities
Education
Housing
Employment
Lifestyles
Family/community
Surveillance and monitoring of specific diseases and risk factors
40
What is the public health domain of health protection concerned with?
Measures to control infectious disease risks and environmental hazards:
Infectious diseases
Chemicals and poisons
Radiation
Emergency repsonse
Environmental health hazards
41
What is the public health domain of improving services concerned with?
Organisation and delivery of safe, high quality services for prevention, treatment and care:
Clinical effectiveness
Efficiency
Service planning
Audit and evaluation
Clinical governance
Equity
42
How can health interventions be applied?
Delivered at an individual level (i.e. vaccinations to prevent an individual from getting ill)
Delivered at a community level (i.e. opening a new outdoor play area in a particular town)
Delivered at a population level (i.e. putting iodine in salt to prevent iodine deficiency)
43
What needs to be done/performed before a health intervention is made?
A health needs assessment
44
What is a health needs assessment?
A systematic method for reviewing the health issues facing a population
Leading to agreed priorities and resource allocation that will improve health and reduce inequalities
45
What are the 3 different approaches of health needs assessments?
Epidemiological
Comparative
Corporate
46
Define need
Ability to benefit from an intervention
47
Define demand
What people ask for
48
Define supply
What is provided
49
What is a health need and how is it measured?
A need for health
Measured using - mortality, morbidity, socio-demographic measures
50
What is a health care need?
A need for healthcare – the ability to benefit from health care
Depends on the potential of prevention, treatment and care services to remedy health problems
51
What are the 4 sociological perspectives of need?
Felt need – individual perceptions of variation from normal health
Expressed need – individual seeks help to overcome variation in normal health (demand)
Normative need – professional defines intervention appropriate for the expressed need
Comparative need - comparison between severity, range of interventions and cost
52
What does an epidemiological approach to a health needs assessment involve?
Define problem
Look at the size of the problem – incidence/prevelance
Services available – prevention/treatment/care
Evidence base – effectiveness and cost-effectiveness
Models of care – including quality and outcome measures
Existing services – unmet need; services not needed
Recommendations
53
What are some potential sources of data for an epidemiological HNA?
Disease registry
Hospital admissions
GP databases
Mortality data
Primary data collection (e.g. postal/patient survey)
54
What are the advantages of an epidemiological HNA?
Uses existing data
Provides data on disease incidence/mortality/morbidity etc.
Can evaluate services by trends over time
55
What are the disadvantages of an epidemiological HNA?
Quality of data variable
Data collected may not be the data required
Does not consider the felt needs or opinions/experiences of the people affected
56
What does a comparative approach to a health needs assessment involve?
Compares the services received by a population (or subgroup) with others:
Spacial
Social (age, gender, class, ethnicity)
i.e. COMPARES THE SERVICES FOR A PARTICULAR HEALTH ISSUE IN TWO DIFFERENT AREAS
57
What factors might a comparative HNA examine?
Health status
Service provision
Service utilisation
Health outcomes (mortality, morbidity, quality of life, patient satisfaction)
58
What are the advantages of a comparative HNA?
Quick and cheap if data available
Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)
59
What are the disadvantages of a comparative HNA?
May be difficult to find comparable population
Data may not be available/high quality
May not yeild what the most appropriate level (e.g. of provision or utilisation) should be
60
What does the corporate approach to a health needs assessment involve?
Ask the local population what their health needs are
Uses focus groups, interviews, public meetings etc.
Wide variety of stakeholders e.g. teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians
61
What are the advantages of a corporate HNA?
Based on the felt and expressed needs of the population in question
Recognises the detailed knowledge and experience of those working with the population
Takes into account wide range of views
62
What are the disadvantages of a corporate HNA?
Difficult to distinguish “need” from “demand”
Groups may have invested interests
May be influenced by political agendas
63
Define primary prevention and give an example
Preventing disease before it has happened
Examples – change4life, 5 a day
64
Define secondary prevention and give an example
Catching a disease in its early or pre-clinical phase
Example – breast screening programme (and all screening)
65
Define tertiary prevention and give an example
Preventing complications of a disease
Example – diabetic foot care, reviews for eyes in diabetic patients, attending physio/rehab after a stroke to prevent immobility and aspiration pneumonia
66
What are the 2 general approaches to prevention?
Population approach – preventative measures e.g. dietary salt reduction through legislation to reduce BP, adding iodine to salt to prevent iodine deficiency
High risk approach – identifying individuals above a chosen cut-off and treat e.g. screening for hypertension,
67
What is meant by the prevention paradox?
A preventative measure which brings much benefit to the population often offers little to each participating individual
i.e. it’s about screening a large number of people to help a small number of people
68
What is screening?
A process which picks out apparently well people who are at risk of a disease, in the hope of catching the disease at its early stage
NOT a diagnostic process – simply a means of assessing risk and catching diseases in their early stage
69
What are the Wilson and Junger criteria needed for a screening programme?
The disease must be an important problem
The disease must have a known and detectable latent phase
The disease must have a known natural course/progression
There must be a test which is acceptable to the population
There must be a treatment for the disease
There must be an agreed at-risk population of which to screen
There must be an agreed policy on who to treat
The costs of the screening should be economically balanced
70
What are the different types of screening?
Population-based screening programmes (e.g. cervical cancer, breast cancer)
Opportunistic screening (e.g. performing BP measurements in GP)
Screening for communicable disease
Pre-employment and occupational medicals
Commercially provided screening (where you can pay to get your blood sent off and tested for all sorts of genetic problems)
Genetic counselling (i.e. genetic testing for people with FHx of genetic disease)
71
What are some disadvantages of screening?
Exposure of well individuals to distressing or harmful diagnostic tests
Detection and treatment of sub-clinical disease that would never have caused any problems
Preventative interventions that may cause harm to the individual or population
72
What is the sensitivity of a screening test and how do you calculate it?
The proportion of people with the disease who are correctly identified by the screening test
True positive / (true positive + false negative)
73
What is the specificity of screening and how is it calculated?
The proportion of people without the disease that are correctly excluded by the screening test
True negative / (true negative + false positive)
74
What is the positive predicted value and how is it calculated?
The proportion of people with a positive test result who actually have the disease
True positive / (true positive + false positive)
75
What is the negative predictive value and how is it calculated?
The proportion of people with a negative test result who do not have the disease
True negative / (true negative + false negative)
This is lower if the prevalence is higher
76
Define incidence?
The number of new cases of a disease in a population (e.g. per 100,000) in a given time frame (e.g. per year)
77
Define prevalence
The total number of people with a condition per 100,000 per year
Number of existing cases/population/point in time
78
What is meant by lead time bias?
When screening identifies an outcome earlier than it would otherwise have been identified
This results in an apparent increase in survival time, even if screening has no effect on outcome
79
What is meant by length time bias?
A type of bias resulting from differences in the length of time taken for a condition to progress to severe effects that may affect the apparent efficacy of a screening method
80
What does a descriptive study design involve?
Case reports or case series – study individuals
Ecological studies – use routinely collected data to show trends in data and thus is useful for generating hypotheses. Shows prevalence and association, cannot show causation
81
What does a descriptive and analytical study design involve?
Cross section study/survey
Divides populations into those without the disease and those with the disease and collects data on them once at a defined time to find associations at that point in time
They are used to generate hypotheses but are prone to bias and have no time reference
82
What are the advantages of cross sectional study?
Relatively cheap and quick
Provide data on prevalence at a single point in time
Large sample size
Good for surveillance and public health planning
83
What are the disadvantages of a cross sectional study?
Risk of reverse causality (don’t know whether outcome or exposure came first)
Cannot measure incidence (number of new cases)
Risk recall bias and non-response
84
What is a case control study?
A type of analytical study
Retrospective
Takes people with a disease and matches them to people without the disease for age/sex/habitat/class etc
Study previous exposure to the agent in question
Quick and inexpensive
But retrospective nature shows only an association and data may not be reliable due to problems with patients’ memories
85
What are the advantages of a case-control study?
Good for rare outcomes (e.g. cancer)
Quicker than cohort of intervention studies (as the outcome has already happened – it’s retrospective)
Can investigate multiple exposures
86
What are the disadvantages of case-control studies?
Difficulties finding controls to match with cases
Prone to selection and information bias
87
What is a cohort study?
Prospective
Start with a population without the disease in question and study them over time to see if they are exposed to the agent in question and if they develop the disease in question or not
88
What are the advantages of a cohort study?
Possible to distinguish preceding causes from concurrent associated factors
Lower chance of selection and recall bias
Absolute, relative and attributable risks can be determined
Prospective - so can show causation where retrospective can’t
Good for common and multiple outcomes
89
What are the disadvantages of a cohort study?
Requires a control group to establish causation
Takes a long time
Loss to follow-up (people drop out)
Need a large sample size
90
What is a randomised control trial?
Patients are randomised into groups, one group is given an intervention and the other is given a placebo/control and the outcome is measured
Randomisation allows confounding factors to be equally distributed
Confounding and biases are minimalised
Lage, expensive, volunteer bias
Ethical issues – is it ethical to withhold a treatment that is strongly believed to be effective
Shows causation
91
What are the advantages of a RCT?
Low risk of bias and confounding
Can infer causality (gold standard)
92
What are the disadvantages of an RCT?
Time consuming
Expensive
Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people)
93
What are is the main issue with a controlled trial that is not randomised?
Very subject to bias
Confounding factors are not equally spread across the groups
94
What is an independent variable?
A variable that can be altered in a study
95
What is a dependant variable?
A variable that is dependant on the independant variables, or one that cannot be altered
96
What is meant by “odds” of an event and how is it calculated?
The odds of an event is the ratio of the probability of an occurrence compared to the probability of a non-occurrence
Odds = probability/ (1 – probability)
97
What is meant by odds ratio and how is it calculated?
The odds ratio is the ratio of offs for the exposed group to the odds for the non exposed groups
(P exposed/ (1- P exoposed)) / (P unexposed/ (1 – P unexposed))
Or can be interpreted as a relative risk when the event is rare
For case control studies it’s not possible to calcuate the relative risk, so the odds ratio is used
For X-sectional and cohort studies – both can be derived but odds ratio is used if it’s not clear which is the IV and which is the DV
98
What is meant by epidemiology?
The study of frequency, distribution and determinants of disease and health related states in populations in order to prevent and control disease
Usual factors when measuring epidemiology of a disease – time, place, person (age, gender, class, ethnicity)
99
What is meant by person time?
Measure of time at risk i.e. time from entry to a study to
i) disease onset
Ii) loss to follow-up
Iii) end of study
Used to calculate incidence rate which uses person time as the denominator
100
Define incidence rate
Incidence rate = Number of persons who have become cases in a given time period / total person-time at risk during that period
101
What is meant by absolute risk?
Gives a feel for the actual numbers involved i.e. has units (e.g. 50 deaths/ 1000 population)
102
What is meant by attributable risk and how is it calculated?
The rate of disease in the exposed that may be attributed to the exposure
Attributable risk = incidence in exposed – incidence in unexposed
It’s about the size of the effect in absolute terms – gives a feel for the public health impact if causality is assumed
103
What is meant by relative risk and how is it calculated?
Ratio of risk of disease in the exposed to the risk in the unexposed
Relative risk = incidence in exposed / incidence in unexposed
Tells us about the strength of association between a risk factor and a disease
104
What is relative risk reduction and how is it calculated?
The reduction in rate of the outcome in the intervention group relative to the control group
(incidence in non exposed – incidence in exposed) / incidence in non-exposed
105
What is absolute risk reduction and how is it calculated?
The absolute difference in the rates of events between the 2 groups
Gives an indication of the baseline risk and the intervention effect
Incidence in non-exposed – incidence in exposed
i.e. assuming exposed means they have had a particular intervention (such as giving statins to people with hypercholesterolaemia and then a control group who do not have statins and seeing how many in each group have a heart atttack to see if the intervention of statins is effective
106
What is meant by number needed to treat and how is it calculated?
NNT = the number of patients we need to treat to prevent one bad outcome
NNT = 1/(risk in non-exposed – risk in exposed)
Aka 1/absolute risk reduction
107
What are the 5 factors that could be responsible if a study finds an association between an exposure and an outcome?
Bias
Chance
Confounding factors
Reverse causality (i.e. the one thing is actually causing the other)
A true causal association
108
Define bias
A systematic deviation from the true estimation of the association between exposure and outcome
109
What are the 3 main types of bias?
Selection bias
Information (measurement) bias
Publication bias
110
What is a selection bias?
A systematic error either in the selection of study participants or the allocation of participants to different study groups
E.g. non-response, loss to follow up, those in the intervention group different in some way from the controls other than the exposure in question
111
What is an information/measurement bias?
A systematic error in the measurement or classification of the exposure or outcome
112
What are some potential sources of information/measurement bias?
Observer bias
Participant – recall bias, reporting bias
Instrument – a wrongly calibrated instrument
113
What is meant by confounding?
A situation in which the estimate of association between an exposure and outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome
114
What is meant by reverse causality?
This refers to a situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
115
What are the Bradford-Hill criteria for causality?
Strength of association – the magnitude of the relative risk
Dose-response – the higher the exposure, the higher the risk of disease
Consistency – similar results from different researchers using various study designs
Temporality – does exposure precede the outcome
Reversibility (experiment) – removal of the exposure reduces the risk of disease
Biological plausibility – biological mechanisms explain the link
Coherence – logical consistency with other information
Analogy – similarity with other established cause-effect relationships
Specificity – relationship specific to outcome of interest
116
Define addiction
Craving, tolerance, compulsive drug/substance seeking behaviour, physiological withdrawal state
117
What are the 3 main effects of dependant drug use?
Physical
Social
Psychological
118
Describe some physical effects of dependant drug use
ACUTE:
Complications of injecting (DVT, abscesses, SBE – subacute bacterial endocarditis)
Overdose (respiratory depression)
Poor pregnancy outcome
Side effects of opiates – constipation, dry mouth
CHRONIC:
Blood-borne virus transmission
Effects of poverty (e.g. spending money on drugs so not being able to afford food)
Side effects of cocaine (vasoconstriction, local anaesthesia)
119
Describe some social effects of drug use
Effects on families
Drive to criminality
Imprisonment
Social exclusion
120
Describe some psychological effects of drug use
Fear of withdrawal
Craving
Guilt
Depression
Pre-occupation with finding the next load of the drug can lead to anxiety and low mood
121
How often must heroin be used in people with heroin dependency to avoid withdrawal?
8 hourly
122
What are the effects of heroin?
Eurphoria
Intense relaxation
Miosis
Drowsiness
123
What are the adverse effects of heroin?
Dependence
Withdrawal symptoms
Nausea
Itching
Sweating
Constipation
Overdose 🡪 respiratory depression and death
124
What can be offered in primary care to a newly presenting drug user?
Health check
Screening for blood borne viruses and referral if positive result
Contraception, smear
Sexual health advice
Check general immunisation status and hep A/B
Signpost to additional help – counselling, benefits, housing
Information on local drug services – including needle exchange
125
What is some harm reduction advice you can give to a drug user?
Not injecting or safe injecting (don’t share needles, use a new one each time)
Not mixing respiratory depressants
Not using drugs alone
Reducing amount taken after intervals where tolerance is lost
Call an ambulance if necessary
Safe sex
Information about blood borne viruses
126
Where can you refer someone with a drug problem?
Specialist drug services
Voluntary sector services
Infectious disease services
127
In which groups of patients is detoxification more likely to work?
Younger users
Less time addicted
Lower level of drug use
128
What medication can be used for heroin detoxification?
Buphrenorphine (subutex) first line treatment
129
Which medication is used for heroin overdose?
Naloxone
130
Which medications can be used for maintenance of staying off heroin?
Methadone (full opioid agonist)
Buprenorphine (partial agonist/antagonist)
131
What non-medical treatments should be used to help treat heroin users?
Psychological interventions and counselling
Alternative therapies – exercise, art therapy etc.
Referral for associated problems (Hep C, STIs)
132
What are the aims of treatment for heroin users?
To reduce harm to the user, family and society
To improve health
To stabilise lifestyle and reduce amount of elicit drug use
To reduce crime
133
What is the evidence for using methadone and buprenorphine in recovering heroin users?
Significantly reduces mortality
Reduces drug-related morbidity
Reduces crime
Reduces risk-taking behaviour and spread of blood borne viruses
Evidence that this can be done safely without increased iatrogenic mortality
134
How can cocaine/crack be taken?
Oral
Snorting
Smoking
IV
135
What is the mode of action of crack/cocaine?
Blocks reuptake or serotonin and dopamine at synapse 🡪 intense pleasurable sensation
Depletion of serotonin and dopamine at secretory neurone 🡪 anxiety, panic, adrenaline secretion, ’wired’
136
What are the effects of cocaine?
Confidence
Euphoria
Impulsivity
Increased energy
Alertness
Impaired judgement
Decreased need for sleep
Bad - Anxiety, HTN, arrhythmias, “crash”
137
What are the chronic effects of cocaine use?
Depression
Panic
Paranoia
Psychosis
Damaged nasal septum
CVA
Respiratory problems
138
How is cocaine/crack use treated?
Harm reduction – advice on risky behaviour, safe sex advice, blood borne virus advice
Brief intervention – explanation of effects and risks, advice on controlled use, setting limits, cognitive based approaches
Team working – referral for sexual health/infectious diseases, voluntary agencies, specialist advice
139
What is health psychology?
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness
140
What are the 3 main types of health behaviours?
Health behaviour – behaviour aimed to prevent disease (e.g. eating healthy)
Illness behaviour – behaviour aimed at seeking remedy (e.g. going to the doctor)
Sick role behaviour – any activity aimed at getting well (e.g. taking prescribed medications, resting)
Health behaviours can also be health impairing or health promoting
141
What is the theory of planned behaviour?
Proposes that the best predictor of behaviour is INTENTION i.e. “I intend to give up smoking”
142
What are the 3 factors that determine intention in the theory of planned behaviour?
A persons attitude - e.g. I do not think smoking is a good thing
Subjective norms (the perceived social pressure to undertake the behaviour) – e.g. people who are important to me want me to give up smoking
Perceived behavioural control (a persons appraisal of their ability to perform the behaviour) – e.g. I CAN give up smoking
143
What are some criticisms of the theory of planned behaviour?
Doesn’t take into account emotions
Relies on self-reported behaviour (i.e. people may lie)
Lack of temporal element (there is no timescale on it)
Assumes that attitudes, subjective norms and perceived behavioural control can be measured
144
What are the 6 stages of the stages of change model? Give an example for each
Pre-contemplation – haven’t thought about stopping smoking
Contemplation – thinking about stopping smoking
Preparation – goes to the doctor/pharmacy, gets a prescription for NRT/Champix to prepare them for stopping. Sets a stop date. Throws away cigarettes
Action – stops smoking on quit date, uses medications to help them
Maintenance – continues with abstaining from smoking by going for regular reviews, picking up more medication etc.
(relapse) – potential for relapse after a “trigger” type event
145
What is the other name for the stages of change model?
Transtheoretical model
NB they are interchangeable in the exam
146
What are some advantages of the stages of change model?
Acknowledges individual stages of readiness
Accounts for relapse/allows patient to move backwards in the stages
Gives an idea of time-frame/progression (albeit arbitrary)
147
What are some criticisms of the stages of change model?
Not all people move through every stage
Change might operate on a continuum rather than through discreet changes
Doesn’t take into account values, habits, culture, social and economic factors
148
What is the role of motivational interviewing?
A counselling approach for initiating behaviour change by resolving ambivalence
Ambivalence = the state of having mixed feelings or contradictory ideas about something
i.e. the role of motivational interviewing is to allow someone to change their behaviour by helping them make a decision about the behaviour – such as helping someone to see whether smoking was bad for them or not
149
What is meant by “nudge” theory?
Changing the environment to make the best/healthiest option the easiest
For example placing fruit next to the checkouts at supermarkets instead of sweets, opt-out schemes such as pensions
150
What are the typical transition points in life which may influence how someone changes their behaviour?
Leaving school
Starting work/new job
Becoming a parent
Becoming unemployed
Retirement
Bereavement
NB these factors could either make someone more likely or less likely to change their behaviour, depending on the person and their attitude
151
What are the 4 factors of the health beliefs model?
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
152
Give an example for each stage of the health belief model
Individuals will change their behaviour if they:
Believe they are susceptible to the condition
Believe that the condition has serious consequences
Believe that taking action reduces susceptibility (benefits of changing)
Believe that the benefits of taking action out weight the costs
153
Which factor of the health beliefs model has been shown to be the most important?
Perceived barriers
This is all about the patient having poor self-efficacy (i.e. not being able to stick to a behaviour change they have made)
154
What are some criticism for the health beliefs model?
Doesn’t consider the influence of emotions and behaviour
Does not differentiate between first time and repeat behaviour
Cues to action are often missing
155
What are some examples of cues to action which may influence behaviour change?
Cues can be internal or external
Internal = increase in pain, decrease in ADLs
External = reminders in the post, reminders for GP apts, pressure from families etc.
156
What are some other factors to consider when it comes to behaviour change?
Impact of personality traits on health behaviour – not everyone responds in the same way due to their own personality
Assessment of risk perception
Impact of past behaviour/habit
Automatic influences on health behaviour
Predictors of maintenance of health behaviours – does it stay changed 6 months down the line?
Social environment – environment massively influences behaviours
157
What impact does social norms have on health behaviours?
Social norms = behaviours and attitudes that are most common in a group
One of the most important factors influencing behaviour
Sometimes belief or norms is different to actual norms – allows people who want to do high risk behaviours to think they’re just doing what everyone else is doing (but is often not the case)
Providing the truth about social norms could decrease high risk behaviours – e.g. only 20% of people smoke
However – DOESN’T work when the risky behaviour is the social norm (drinking alcohol, obesity)
158
What is a meta analysis?
Take lots of studies and combine the results (statistical procedure)
Not the same as a systematic review – this doesn’t involve a stats procedure
159
What are some factors for poor compliance to medication?
Side effects (warn them)
Comorbidities (esp. mental health/dementia)
Polypharmacy
Complex drug regimes
Poor understanding of disease state
Social factors – i.e. they have dependants/act as carers for someone else so they don’t prioritise their own health
160
What is a cohort study?
Prospective
Population free from disease initially
Follow up on exposed and non-exposed group and see what the outcome is
Limitation = very expensive
161
What approaches can be used to help people act on their intentions?
Perceived control – ask them to reflect on how they felt when something went well (i.e. when they said no to a cigarette)
Anticipated regret – ask them to reflect on how they felt when they didn’t do something (i.e. when they weren’t able to say no to a cigarette)
Preparatory actions – remind people to prepare for their change of behaviour (i.e. throwing away cigarettes)
Implementation intentions – help them help themselves incorporate the behaviour change into their routine (i.e. putting tablets next to the kettle so they know to take it when they make a cup of tea)
162
Give examples of how health promoting interventions can be applied at a population, community and individual level
Population level – cigarette and alcohol tax
Community level – introducing more cycle paths to make cycling safer, having to pay a fee for bringing a car into an area (London), building an outdoor gym in a particular town
Individual level – patient centred approach to care. The care responds to their individual needs
163
Why do patients continue high risk behaviours despite knowing the risks?
Fun
Justifies behaviour with other things
Doesn’t have the willpower to stop
Unrealistic optimism
164
What is meant by unrealistic optimism?
The only theory for why patients engage in risky behaviours
Individuals continue to practice health damaging behaviours due to inaccurate perceptions of risk and susceptibility
i.e. they are aware of the risks but “don’t think it would happen to them”
165
What are the factors of unrealistic optimism that influence people’s perception of risk?
Lack of personal experience with the problem
Belief that it’s preventable by personal action
Belief that if not happened by now, it’s not likely to
Belief that the problem is infrequent
You need to figure out what your patients think about their risk level and see how you can address it. If someone doesn’t think they are at risk, then they are less likely to comply to their medications/come to their follow up appts
166
What do NICE advise we do about behaviour change?
Planning interventions
Assessing the social context
Education and training
Individual level interventions
Community level interventions
Population level interventions
Evaluating cost-effectiveness
Assessing cost-effectiveness
167
What can doctors actually do to help individuals change their health behaviours?
Work with patients priorities
Aim for easy changes over time
Set and record goals
Plan explicit coping strategies – e.g. avoid relapses by planning for stressful times
Review progress regularly (this is very important) – e.g. the annual diabetes check
Remember the public health impact of lots making making small differences to lots of individuals
168
What is the role of NCSCT?
NCSCT = national centre for smoking cessation and training
Role:
Delivers training and assessment programmes
Provides support services for local and national providers
Conducts research into behaviour support for smoking cessation
Evidence-based tobacco control programmes and smoking cessation interventions
169
What is the impact of smoking on health?
Leading cause of preventable death in the UK
100,000 people in the UK die each year due to smoking
Smoking-related deaths are mainly due to cancer, COPD and heart disease
About half of all smokers die from smoking related disease
170
What is the economical impact of smoking?
£5 billion to the NHS a year
Avg. smoker spends £2,900 on smoking a year
Loss in productivity from smoking breaks
Increased absenteeism
Cleaning up cigarette butts - £342 million
Loss of economic output from death of smokers and passive smokers
171
What is the difference between an infectious disease and a communicable disease?
Infectious disease = any disease caused by an infection
Communicable disease = disease that can spread from one person to another
172
What are the mechanisms by which communicable disease can be spread?
Cough/sneeze – airborne/droplet infection – 2 different respiratory route transmissions
Skin contact
Exchange of body fluids – sex, bite, needle stick injury
Animal to person (rabies, flu)
Mother to unborn child
Indirect contact (inanimate objects - e.g. remote control, desk surface)
Insect bites
Contaminated food/water
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What makes a communicable disease of public health importance?
High mortality – e.g. rabies (100% mortality)
High morbidity – causes significant illness e.g. flu, meningococcal disease, E. Coli O157
Highly contagious – affects large no. of people (measles, flu)
Expensive to treat – prevention is cheaper than treatment (HIV)
Effective interventions available – e.g. Hep B (vaccine available)
174
What is a notifiable disease?
A disease who’s name is on a lost of Public Health diseases that must be notified of
175
What is notification of disease?
If a registered medical practitioner becomes aware or suspects that a patient is suffering from a notifiable disease or food poisoning
Send a notification as soon as possible, even if there is just suspicion of a notifiable disease
176
What type of illnesses need notifying?
Individual cases of notifiable diseases
Outbreaks of a particular communicable disease
Other infections or contaminations (chemical or radiological) which are believed to present a significant risk to human health
Laboratories are also required to notify if they find an notifiable disease when they are looking at results
If you are ever worried about something – if in doubt notify
Use common sense – chickenpox itself is not notifiable but if a nurse on a cancer ward has chickenpox then that is a large risk to a lot of people
177
Who needs to be notified?
The proper officer of the local authority
Usually the Consultant in Communicable Diseases of Public Health England
But not always – sometimes it’s the chief infective disease officer
178
Which infections do ordinary doctors need not notify about?
Health Care Associated Infections (HCAIs)
Sexually transmitted infections
These are notified by GUM and I.D. departments
The only exception to this is Hepatitis B
179
How is notification carried out?
A registered medical practitioner should send a written notification so that it’s received within 3 days of the RMP forming the clinical suspicion
If the RMP thinks the case is urgent, they should notify orally by telephone within 24 hours (and still follow–up with written notification)
NB – written notifications need to be DOUBLE ENVELOPED to ensure confidentiality if sent to the wrong place
If telephoning – make sure you are speaking to the Communicable Disease Consultant for PHE
180
Give some examples of some diseases that must be notified urgently
Acute meningitis – if bacterial, meningococcal septicaemia
Acute poliomyelitis
Anthrax
Botulism
Cholera
Diphtheria
Typhoid
Food poisoning – if in outbreaks or clusters
Measles
181
Give some examples of communicable diseases that need to be notified, but not urgently
Acute encephalitis
Leprosy
Mumps
Rubella
Typhus
Whooping cough (if not diagnosed during acute phase – if diagnosed during acute phase it’s urgently notifiable)
182
How is communicable disease notification performed?
Fill in the form on the hospital computer system
183
What are some causes of infectious bloody diarrhoea?
Campylobacter
Shigella
E.Coli
184
Legionnaires disease is not communicable, but why is it still important to notify?
Infectious disease from a common infective source – so there is a chance it’ll make a lot of other people ill
Air conditioning, hot tubs, saunas, jet washers (anywhere you can aerosolise water)
185
Why would you notify about notifiable diseases?
Legal requirement
Good medical practice
It’s a clinical governance issue if you don’t
Because it leads to action – which might be urgent
Allows surveillance – need to know how commonly the disease is happening
Monitoring of immunisation programmes - to see if they are successful by noting a drop in prevalence after introduction of vaccinations
186
What is the role of consultant in communicable disease control (CCDC)?
Surveillance – using notification, lab and other data to monitor communicable diseases
Prevention – trying to stop people getting infectious disease in the first place e.g. immunisation programmes, infection control advice
Control – what to do when outbreaks occur
187
Which is the strain of E.Coli that we need to know about?
E.coli O157
Tiny dose can cause large impact on many people
Bloody diarrhoea, cramps, usually self-limiting
Small proportion of children develop life threatening haemolytic uraemic syndrome
Wash hands, wash salads, boil water, cook thoroughly, avoid cross contamination
Exclude from school/work for 48 hours after symptoms stop
Exclude food handlers and healthcare workers until 2 negative stool samples
188
What is the aim of outbreak control?
To identify and control the source of infection and the route of transmission to prevent spread of infection (further cases)
Where, what caused it, prevent others getting it
189
Define cluster
An aggregation of cases – may or may not be linked
190
Define suspected outbreak
Occurrence of more cases of a disease than normally expected within a specific place or group of people over a given period of time
2 or more cases who are linked through common exposure, personal characteristics, time or location
A single case of a rare of disease disease such as diphtheria, rabies, viral haemorrhagic fever or polio
191
Define confirmed outbreak
Link confirmed through investigation (epidemiological/microbiological)
192
How should outbreaks be managed?
Make a diagnosis
Decide if it’s an outbreak
Get whatever help you need – microbiologist, ID consultant, infection control nurse
Outbreak meeting
Identify the cause
Initiate control measures
193
Define food poisoning
Any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food or water
Includes all food or water borne illness, regardless of the presenting symptoms and signs
Includes illness caused by toxic chemicals
Excludes allergies and food intolerances
194
What action needs to be taken for food poisoning?
Identify affected cohort
Identify source
? Close restaurant
People sampling
Food sampling
Questionnaire
195
What is the role of schools in infectious disease breakouts?
Requirement to keep children away from school
Requirement for school to provide a list of attendees
196
What may the court require if there’s an communicable disease outbreak?
Seizure or destruction of objects that could be infectious
Isolation or quarantine of people
Disinfection/decontamination
Closure of premises
197
What are the levels of Maslow’s hierarchy of needs?
(at the bottom) – Physiological – breathing, food, water, sleep
Safety – security of employment, resource's, family, health, property
Love/belonging - friendship, family, sexual intimacy
Esteem – self-esteem, confidence, achievement, respect of others
Self-actualisation - morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
198
What are the causes of homelessness?
Relationship breakdown
Mental illness
Domestic abuse
Disputes with parents
Bereavement - more than half say they have “no family ties”
Drugs
Alcohol
No money
No job
199
What are some major health problems faced by homeless adults?
Infectious disease – TB, hepatitis
Poor condition of feet and teeth
Respiratory problems
Injuries – following violence, rape
Sexual health problems
Serious mental illness – schizophrenia, depression, personality disorders
Poor nutrition
Addiction/substance misuse
200
What are some barriers to healthcare for travellers?
Reluctance of GPs to register travellers and to visit traveller sites
Poor reading and writing skills – many are illiterate
Communication difficulties
Too few permanent sites
Mistrust of professionals
Lack of choice
201
What are some barriers to healthcare for homeless people?
Difficulties with access to healthcare – opening times, appointment & procedures location, perceived +/- actual discrimination
Lack of integration between primary care services and other agencies - housing, social services, criminal justice system
Other things on their mind – people do not prioritise their health when there are more immediate survival issues
May not know where to go
May not be able to get there
202
Define asylum seeker
A person who has made an application for refugee status
203
Define refugee
A person granted asylum and refugee status, usually means leave to remain for 5 years and then re-apply
204
What is humanitarian protection?
Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years then re-apply
205
How do asylum seekers live?
No choice dispersal
Vouchers/70% of income support sum
NASS support package
Full access to NHS
Not allowed to work
206
What are some physical health problems affecting asylum seekers?
Common illness
Illness specific to country of origin
Injuries from war and travelling
No previous health surveillance/neonatal screening/immunisatoins
Malnutrition
Torture and sexual abuse
Infestations
Communicable disease/blood borne disease
Untreated chronic disease/congenital problems
207
What are some mental health problems that affect asylum seekers?
PTSD
Depression
Sleep disturbance
Psychosis
Self-harm
208
What is meant by ’error’?
An unintended outcome
209
What are some common issues with accidents/safety in healthcare?
Wrong diagnosis 🡪 wrong plan
Medication reconciliation – if they have forgotten to reconcile the medication list then patients could end up with duplicates, medications that interact etc.
High concentration medication solutions
Patient identification
Patient care handovers
210
Why is safety compromised so often in healthcare?
Healthcare is a complex, high risk environment
Resource intensive
System, patient and practitioner interaction
Responsibilities are often shared
Practitioners often take risks unknowingly
211
What are the 4 different ways in which errors can be classified?
Intention
Action
Outcome
Context
212
Describe how error can be classified based on intention
Failure of planned actions to achieve desired outcome
Skill based errors - action made is not what was intended
Rule-based mistakes – incorrect application of a rule/inadequacy of the plan
Knowledge based mistakes – a lack of knowledge in a certain situation
Automatically makes us prone to actions not as planned
Limited attentional resources
Memory containing mini theories rather than facts – liable to confirmation bias
213
Describe how an error can be classified based on action
Generic factors – e.g. omission, intrusion, wrong order
Task specific factors – wrong blood vessels/organ/side, bad knots in surgery
214
Describe how an error can be classified based on outcome
Near miss
Successful detection and recovery
Death/injury/loss of function
Prolonged intubation/stay in ICU
Cost of litigation
Unplanned transfer
215
Describe how an error can be classified based on context
Anticipations and perseverations
Interruptions and distractions
Nature of procedure
Team factors
Organisation factors
Equipment and staffing issues
Accumulation of stressors
216
What are the 2 different perspectives on error?
The person approach – focus on the individual
The system approach – focus on the working conditions
217
Describe the person approach perspective on error
Essentially looks at and blames an individual or group of individuals
Errors are the product of unpredictable mental processes
Focuses on the unsafe acts of people on the front line
Shortcomings – anticipation of blame promotes ‘cover up’ and need for a detailed analysis to prevent recurrence
218
Describe the system approach perspective on error
Essentially blames some kind of flaw in the system
Errors are commonplace – adverse events are the products of many casual factors
Sharpenders are more likely to be the inheritors than the investigators
Remedial efforts directed at removing error traps and strengthening defences
Interaction between active failures and latent conditions – proactive risk management – remedy latent factors
219
What are some strategies that can be used to reduce errors and harm?
Simplification and standardisation of clinical processes
Checklists and aide memoires – SBAR
Information technology
Team training
Risk management programmes
Mechanisms to improve uptake of evidence based treatment patterns
220
What are some tools used for risk identification?
Incident reporting
Complaints and claims
Audit, service evaluation and benchmarking
External accreditation
Active measurement/compliance
221
What is the definition of a never event? Give some examples
Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
Examples:
Surgery – wrong site/implant, retained item (swab etc.)
Medication – wrong preparation/route (the intrathecal vincristine situation)
Mental health – suicide
222
What are the 4 main leadership styles?
Inspirational
Transactional
Laissez-faire (letting things take their own course without interfering)
Transformational – inclusive leadership is distributed throughout all levels of an organisation
223
What are the mechanisms underlying inhumane behaviour?
Bystander effect – number of bystanders (lack of leadership?), ambiguity, similarity of bystandar to victim
Pressing situational factors can override explicitly announced value systems
Unwillingness to speak out against prevailing view (i.e. afraid to whilstle blow)
224
What are the 10 basic types of error? Give an example of each
Sloth – not bothering to check results accurately, inadequate documentation
Fixation and loss of perspective – early unshakeable focus on a diagnosis, inability to see bigger picture
Communication breakdown – unclear instructions of plans, not listening to or considering other’s opinions
Poor team working – some out of their depth, some underutilised
Playing the odds – choosing the common and dismissing the rare
Bravado – working beyond your competence/without adequate supervision (opposite holds true for timidity)
Ignorance – lack of knowledge, not knowing what you don’t know
Mis-triage – over/underestimating the seriousness of a situation
Lack of skill – lack of appropriate skills, teaching or practice
System error – environmental, technology, equipment or organisation features. Inadequate safeguards built in to the system
225
Which skill, attribute or behaviour is missing in each type of basic error?
Sloth – conscientiousness
Fixation and loss of perspective – open mindedness, situational awareness
Communication breakdown – effective communication
Poor team working – good team work
Playing the odds – probability assessment
Bravado/timidity – humility (accurate self-evaluation)
Ignorance – self-awareness
Mis-triage – prioritisation
Lack of skill – effective technical skills
System error - good system design
226
Define negligence
Failure to take proper care over something
A breach of duty of care which results in damage
227
What are the factors that contribute to negligence?
System failure
Human factors
Judgement failure (defective decision making)
Neglect
Poor performance
Misconduct
228
Give an example of how system failure can lead to negligence?
Computer system may shut down, losing patient’s notes
If the patient is unconscious and unable to communicate, important information may be lost at a critical moment
Hackers could get into computer systems and remove confidential information
Letting confidentiality be broken in this way could be considered negligence
229
Describe how human factors could lead to negligence
Personal factors – i.e. they are having a bad day and it causes them to make mistakes at work
Teamwork problems - miscommunication, not liking people in the team
Working environment
Decision density – i.e. leaving one person to make all the decisions puts a lot of pressure on that person and would make them more likely to make a mistake
230
Describe how judgement failure can lead to negligence?
Defective decision making
Analytical or intuitive
Wrong amount of type of information
Wrong decision making strategy
Bias
231
Describe how neglect can lead to negligence
Not showing sufficient care
Falling below expected standard
Often a chain of minor failures
May be multidisciplinary – communication and assumptions
May or may not lead to harm
232
Describe how poor performance can lead to negligence
Repeated minor mistakes
Not learning from mistakes
Usually extends beyond attitude to patient care – timekeeping, reliability, sickness, scruffy appearance
233
Describe how misconduct can lead to negligence
Deliberate harm
Covering up errors
Fraud/theft/abuse – falsely claiming sickness or expenses, drug or alcohol misuse
Improper relationships – i.e. with other staff members, patients etc.
234
What 4 questions need to be asked when negligence is suspected?
Is there a duty of care?
Was there a breach in that duty?
Did the patient come to any harm?
Did the breach cause the harm?
235
What are 2 tests that can be used to decide whether there was a breach in a duty of care?
Bolam test = would a group of responsible doctors do the same?
Bolitho test = would it be reasonable of them to do so?
236
What factors influence how much money a patient will get from a successful negligence claim?
Loss of income
Cost of extra care
Pain and suffering
237
What are the factors that make up the tripartite model of types of learning?
Surface – fear of failure, desire to complete a course. Learning by rote and focus on particular tasks
Strategic – desire to be successful, leads to a patchy and variable understanding (well organised form of surface learning)
Deep approach – intrinsic, vocational interest, personal understanding. Making links across materials, search for deeper understanding of the material, look for general principles
238
What are the 4 types of learner?
Theorist – complex situation, can question ideas, offered challenges
Activist – new experiences, extrovert, likes deep end, leads
Pragmatist – wants feedback, purpose, may like to copy
Reflector – watches others, reviews work, analyses, collects data
239
What is it important to do about these learning styles?
Choose activities which best match your learning style
Identify least dominant style so that you can strengthen these
240
What are the features of Kolb’s learning cycle?
Experience (activist)
Review, reflect on experience (reflection)
Conclusions from experience (theorist)
What can I do differently next time? (pragmatist)
241
How should a skill be taught?
Breaking the task down into smaller components
Utilising an internal commentary
See one, do one, teach one
242
What are the key responsibilities of small group teachers?
Managing the group, activities and the learning
Facilitate the learning – leading discussions, asking open-ended questions, guiding process and task, enabling active participation of learners and engagement with ideas
243
What are the 4 fundamental questions that a small group teacher must ask themselves?
Who am I teaching? Numbers, level, names
What am I teaching? The topic or subject, the type of expected learning (knowledge, skills, behaviours)
How will I teach it?
How will I know if the students understand/understood?
244
What are the 7 types of question strategies?
Evidence – how do you know that? Where is the supportive evidence?
Clarification – can you give me an example? Can you explain that term?
Explanation – why is that the case? How would we know that?
Linking and extending – how does this idea support/challenge what we explored earlier in the session?
Hypothetical – what might happen if? What would be the potential benefits of x?
Cause and effect – how is this response related to management? Why is/isn’t that drug suitable for that condition?
Summary and synthesis – what remains unsolved/uncertain?
245
Why is it important to teach diversity?
Better outcomes for patients – more likely to adhere to treatment, fewer tests and referrals
More satisfying doctor-patient encounters – patients more satisfied with their care, better able to understand their problems, fewer complaints
246
What is the “iceberg” model of culture?
Things which are visible from the surface – you can have an idea of their age, nationality, ethnicity and gender
Things which you cannot possibly see from the surface – socioeconomic status, occupation, health, religion, education, sexual orientation, political orientation, cultural beliefs
247
Define culture
A socially transmitted pattern of share meanings by which people communicate, perpetuate and develop their knowledge and attitudes about life
Cultural identity may be based on heritage as well as indivial circumstances and personal choice
It is a dynamic entity
248
Define ethnocentrism
The tendency to evaluate other groups according to the values and standards of one’s own culture group, especially with the conviction that one’s own culture group is superior to that of others
249
Define stereotype
Involves generalisations about the ’typical’ characteristics of members of a group
250
Define prejudice
Attitude towards another person based solely on their membership of a group
251
Define discrimination
Actual positive or negative actions towards the objects of prejudice
252
What is Kleinman’s explanatory model of illness?
What do you call your illness? What name does it have?
What do you think has caused the illness?
Why and when did it start?
What do you think the illness does? How does it work?
How severe is it? Will it have a short or long course?
What kind of treatment do you think you should receive? What are the most important results you hope to achieve from treatment?
What are the chief problems the illness has caused?
What do you fear most about the illness?
253
Why have rationing needs increased in terms of resource allocation?
(question is essentially asking why we need to ration resources more strictly)
Shift from acute illness to chronic long term
Normal physiological events medicalised
Increase in choice and increase in expensive drugs
254
What is meant by rationing?
Resource is refused because of lack of affordability rather than clinical ineffectiveness
255
What are the 3 allocation theories?
Egalitarian principles – provide all care that is necessary and appropriate to everyone. (challenge – tension between egalitarian aspirations and finite resources)
Maximising principles (utilitarian) – criteria that maximise public utility
Libertarian principles – each is responsible for their own health, well-being and fulfilment of life plan
256
What are some problems that arise from increasing health promotion and check up programmes?
Despite reaching out to everyone, there is much better uptake in higher income groups
257
What are the human rights articles that are frequently engaged in healthcare?
Article 2 – the right to life (limited)
Article 3 – the right to be free from inhumane and degrading treatment (absolute)
Article 8 – the right to respect for privacy and family life (qualified)
Article 12 – right to marry and found a family
258
What are the benefits of using social media as a doctor?
Establishing wider and more diverse social and professional networks
Engaging with the public and colleagues in debates
Facilitating public access to accurate health information
Improving patient access to services
259
What are the risks of using social media as a doctor?
Loss of personal privacy
Potential breaches of confidentiality
Online behaviour that may be perceived as unprofessional, offensive or inappropriate by others
Risks of posts being reported by the media or sent to employers
260
What are the GMC duties of a doctor?
Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care - keep professional skills up to date, recognise limits of competence, work with colleagues to serve patients best interests
Treat patients as individuals and respect their dignity and confidentiality
Work in partnership with patients
Be honest, open and act with integrity – act without delay if you believe a colleague is putting patients at risk
261
What are the main principles to consider when dressing a wound?
Remove excess exudate and toxic components
Maintain a high humidity at the wound-dressing interface (needs to be a warm, moist environment)
Allow gaseous exchange
Provide thermal insulation
Impermeable to bacteria
Allow for changes without trauma
Be acceptable to the patient
Highly absorbent (for heavily exudative wounds)
Cost-effective
Mechanical protection
Comfortable and mouldable
Be able to be sterilised
262
How does a moist wound environment affect the wound?
Increases the rate of epithelial migration
Reduces lag phase between epithelial cell proliferation and differentiation
Encourages collagen synthesis
Promotes formation of capillary loops
Decreases length of inflammatory phase
Reduces pain and trauma due to dressing adherence
Promotes breakdown of necrotic tissue
Speeds wound contraction
263
What are the 4 phases of wound healing?
Vascular response
Inflammatory response
Proliferation
Maturation
264
What are the 5 features of inflammation?
Rubor (redness)
Calor (heat)
Dolor (pain)
Tumour (swelling)
Loss of function
265
What is meant by primary, secondary and tertiary intention with respect to wound healing?
Primary intention – little or no tissue loss, wound edges directly opposed (linear scarring)
Secondary intention – wound edges not oppose, would allowed to granulate, epithelialisation occurs from edge of hair follicle remnants in the base of the wound
Tertiary intention – wound is purposefully left open e.g. infection, foreign body, initially cleaned, debrided and observed. Surgically closed later
266
What are some general patient factors which act as a barrier to healing?
Elderly
Diabetes – microvascular disease, neuropathy, raised glucose
Malnutrition
Malignancy
Renal or hepatic failure
Drugs
Immunosuppression
Vitamin deficiencies
267
What are some local wound factors which act as a barrier to healing?
Site
Infection
Oedema
Vascular insufficiency
Previous radiotherapy
268
What are the 5 main types of wound dressing?
Hydrogel
Alginate
Hydrocolloid
Foams
Non-adherent dressings
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What is the definition of domestic abuse?
Controlling, coercive, threatening behaviour, violence of abuse between those aged 16 or over who are or have been intimate partners or family members
Includes – psychological, physical, sexual, financial and emotional abuse
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What are the 3 main ways in which domestic abuse presents to healthcare?
Traumatic injuries following an assault – fractures, bruises, bleeds
Somatic problems or chronic illness consequent from living with abuse – headaches, GI disorders, chronic pain, premature delivery
Psychological or psychosocial problems secondary to the abuse – PTSD, attempted suicide, substance misuse, depression, anxiety, eating disorders
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What is the role of a doctor if they suspect a case of domestic abuse?
Try and speak to them alone (i.e. away from their partner and away from their children)
Document EVERYTHING THEY SAY
Document what their injuries look like
Only report to the police if it’s safe to do so - focus on safety
Tell them you can help them and point them in the right direction for proper support
Display posters about helplines etc. in your GP surgery
Ask direct questions – be non-judgement and reassuring
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Which tool can be used to assess domestic abuse?
DASH tool (Domestic abuse and Sexual Harassment tool)
This tool encourages you to gather information about everything that is going on in the situation
There is no “score” that means they are at high risk, but they may say something that suddenly makes you think they are at high risk and you need to intervene
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What do you do if you think someone is at medium/standard risk of domestic abuse?
in these cases it’s their CHOICE what they do
Give them contact details for domestic abuse services and let them decide what to do
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What do you do if you believe someone is high risk for domestic abuse?
Refer to MARAC/IDVAS wherever possible with consent
In HIGH RISK – you can break confidentiality if you don’t get their consent, but always try and get consent first
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What is the role of the domestic homicide review?
A review of the circumstances in which the death of a person aged 16 or over has or appears to have resulted from violence, abuse or neglect
Includes suicides if you think domestic abuse contributed to the suicide
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What is the definition of an evaluation (of health services)?
Evaluation is the assessment of whether a service achieves its objectives
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What are the 3 things that make up the framework for a health service evaluation?
Structure
Process
Outcome
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What sort of things would be evaluated for structure in a health service evaluation?
Buildings – locations where a particular clinic is provided
Staff – number of vascular surgeons per 1000 population
Equipment – number of ICU beds in a hospital
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What sort of things would be evaluated for process in a health service evaluation?
What is done… e.g.:
Number of patients seen in A&E
Number of operations performed (may be expressed as a rate)
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What sort of things would be evaluated to assess outcomes in a health service evaluation?
Mortality
Morbidity
Quality of life/PROMS
Patient satisfaction
The 5 D’s can also be used – death, disease, disability, discomfort, dissatisfaction
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What are some examples of PROMS questionnaires used in primary care?
Oxford Hip Score and Oxford knee score
EQ-5D
Aberdeen varicose vein questionnaire
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What are some issues with health outcomes in an evaluation?
Link (cause and effect) between health service provided and health outcome may be difficult to establish as many other factors may be involved
Time lag between service provided and outcome may be long
Large sample sizes may be needed to detect statistically significant effects
Data may not be available
There may be issues with data quality
283
When assessing the quality of health services, Maxwell’s classification lists 6 dimensions. List the 6 dimensions
3 A’s and 3 E’s:
Acceptability – how acceptable is the service for people needing it
Accessibility – geographical access, costs for patients, waiting times
Appropriateness – right treatment given to the right people?
Effectiveness – does the intervention produce the desired effect?
Efficiency – is the output maximised for a given input?
Equity – are patients being treated fairly?
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What are the 2 different methods which can be used for evaluation?
1. Qualitative – interviews, focus groups
2. Quantitative – routinely collected data, review of records, surveys,
epidemiological methods
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Although using measures of health outcomes is desirable in evaluation of health services, there are potential limitations. Explain why it may be difficult to attribute a health outcome to the service provided?
Other factors can affect it – wealth, socioeconomic status
Link may be difficult to establish between service provided and outcomes
Time lag
Sample sizes inadequate
286
What is thought to be one of the main reasons of an increase in alcohol related liver disease in the UK?
Thought to be largely due to an increase in binge drinking
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How much alcohol is the recommended number of units per week?
14 units for both men and women
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How much alcohol is in a unit?
8 grams
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What is the calculation for number of units of alcohol?
Litres x %
So in 1 litre of 12% vodka - 12 units
In a 250ml glass of 14% wine – 1 litre would be 14 units so it’s 14/4 = 3.5
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Name some aetiological/risk factors for drinking problems?
Family
Religion
Personality
physical health/gender
Occupation
Availability of alcohol
Peer group
Advertising
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Why are more women drinking now than ever?
More socially acceptable
More disposable income
More drinks marketed at women 🡪 cocktails
More drinking places aimed at women customers 🡪 themed bars, well decorated
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What are some social and psychological risk factors for problem drinking?
Drinking within the family
Childhood problem behaviour relating to impulse control – introducing children to it early does NOT decrease their risk, it increases it
Early use of alcohol, nicotine and drugs
Poor coping responses to life events
Depression as a cause, not as a result of problem drinking – drink to help themselves feel better
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What is the link between socioeconomic deprivation and problem drinking?
Adverse effects of alcohol exacerbated amongst lower socioeconomic groups – i.e. if a CEO is too hungover to drive to work, they can pay for a taxi. But someone of a lower class may not be able to afford a taxi to work so may get fired
Low socioeconomic status – less likely to have good support from friends and family
Vicious cycle – low mood from lack of social support causes them to drink which isolates them even more
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What are the most common causes of death due to alcohol?
Accidents and violence – drink driving!
Malignancies – all types of cancer, not just liver
Cerebrovascular disease – strokes
Coronary heart disease
Alcohol 🡪 raises BP and triglycerides
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What are some other health problems caused by alcohol?
GI issues
Liver disease
CVD
Neurological – Wernicke’s, Korsakoff’s
MSK – gout
Birth defects – foetal alcohol syndrome
Gynae cancers
Kidney and bladder cancers
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How is alcoholic fatty liver disease managed?
Completely reversible if alcohol is withdrawn
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Why is it important to check clotting profile in alcoholics?
Liver makes the clotting factors
Severe hepatitis is a medical emergency – causing ascites, bleeding and encephalopathy
Also at risk of oesophageal varices
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Which types of cancer have been associated with alcohol?
Head and neck – mouth, larynx, pharynx, oeseophageal
GI – liver, stomach, colon, rectum, pancreas
Breast and gynae
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What are some features of fetal alcohol syndrome?
Microcephaly
Upturned nose
Hypoplastic (underformed) jaw
Short palpebral fissure
Smooth philtrum
Thin upper lip
Epicanthic folds
300
What are some important questions to ask in an alcohol history?
CAGE and AUDIT screening tools
How much do you drink?
What do you drink?
Who do you drink with? Where?
Occupation?
Steady regular drinking or binging at weekends?
Debts?
What does your partner think about your drinking?
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What are some general/supportive measures of treatment for alcoholics?
Most importantly = address other health problems they may have
Consider vitamin supplementation – Thiamine (B1) as alcoholics do not eat well
Assess IHD risk
Consider osteoporosis risk
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Why is it NOT necessary to take a blood sample for alcohol level in alcoholics?
It’s a transient measure so is not helpful in chronic alcohol abuse
303
What things should be included in motivational interviewing about alcohol use?
Potential harm caused
Reasons for changing behaviour – health and wellbeing, relationships
Cover obstacles to change – life stresses, lonelieness
Strategies to combat obstacles
Goals
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Which medications can be used in relapse prevention for alcoholics?
Disulfram (ANTABUSE) – gives them horrible flushing and hangovers
Acamprosate – GABA blocker
Naltrexone
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What are the symptoms of alcohol dependence syndrome?
Cluster of 3 of the following in a 12 month period:
Tolerance
Physiological withdrawal
Difficulty controlling drinking (onset, amount, stopping)
Neglect of social and other areas of life
Spending more time obtaining and using alcohol
Continued use despite negative physical and psychological effects
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What are the symptoms of delirium tremens?
Toxic confusional state as a result of alcohol withdrawal
Clouding of consciousness/confusion/seizures
Hallucinations – any sensory modality
Marked tremor
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How is delirium tremens treated?
Chlordiazepoxide to prevent fitting
Supportive fluids
Pabrinex
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What is a cohort study?
Prospective
Looks at an exposed and non-exposed population
To see whether either of them experience a particular outcome
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What is a case control study?
RETROSPECTIVE
Looks at a control group and a case group (i.e. one of them has a disease and one group doesn’t)
Comparing which ones of them were exposed to a particular exposure or not
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What are some determinants of health?
Genes
Environment – social and economic, physical (mould etc.)
Lifestyle
Healthcare
Wider determinants – inequalities in health, primary, secondary and tertiary prevention
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What is the difference between equity and equality?
Equity = what is fair and just (i.e. on a moral level)
Equality = concerned with equal shares (i.e. on a financial level)
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What are the 2 types of equity?
Horizontal equity – equal treatment for equal need (people with the same disease should be treated equally)
Vertical equity – unequal treatment for unequal need (e.g. areas with poorer health may need higher expenditure on health serviceS)
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What are the dimensions of health equity?
Spatial – geographical
Social – age, gender, socioeconomic status, ethnicity
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How can health equity be examined?
Supply of healthcare
Access to healthcare
Utilisation of healthcare
Healthcare outcomes
Health status
Resource allocation
Wider determinants of health
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What are the 3 domains of Public Health practice?
Health improvement – education, housing, lifestyles, community
Health protection – infectious disease, chemicals/poisons, emergencies, environmental health hazards
Improving services (health care) – service planning, audit and evaluation, clinical governance
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What’s the difference between the 3 different types of prevention?
Primary - stop something before it happens (lifestyle, education, immunisations)
Secondary – catch disease in early/pre-symptomatic stage (breast cancer screening)
Tertiary - aims to prevent complications of the disease (diabetic eye clinic, stroke clinic)
317
Explain the swiss cheese model of negligence
An organisations defences against failure are modeled as a series of barriers, represented as slices of cheese
The holes in the slices represent weakness in individual parts of the system
The holes are continually varying in size and position across the slices
The system produces failures when a hole in each slice momentarily aligns
Permitting a “trajectory accident opportunity” so that a hazard passes through holes in all of the slices – leading to failure
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