Public Health and Health Behavior

Three domains of public health?

1. Health improvement - Efforts to aimed at preventing disease, promoting health and reducing inequalities

2. Health protection - Measures to control ID (immunisations), safeguard against emergencies, and environmental hazards

3. Health care - Focus on clinical effectiveness, efficiency, audit, and clinical governance // organisation and delivery of safe, high quality services

What is Health Psychology? Domains?

Study of health behavior, illness behavior, and sick role behavior -

1. Health behaviour - Actions aimed at preventing disease, such as maintaining a healthy diet

2. Illness behaviour - Actions aimed at seeking remedy, such as visiting a doctor

3. Sick role behaviour - Actions aimed at getting well, such as taking medication and resting

What is health behavior

Actions aimed at preventing disease, such as maintaining a healthy diet

What is illness behavior

Actions aimed at seeking remedy, such as visiting a doctor

What is sick role behavior

Actions aimed at getting well, such as taking medication and resting

WHO estimation of medication adherence?

In developed countries, the average is 50%

Health psychology - Interventions at the population level vs individual level?

Health promotion - process of enabling people to exert control over their health

Patient-centred approach - care responsive to individual needs

What is health promotion?

Process of enabling people to control their health, includes:

- Awareness campaigns e.g. 5 a day and every mind matters

- Screening and immunisations

What is patient-centered approach?

Care responsive to individual needs

What is unrealistic optimism?

Continuing health-damaging behaviors due to inaccurate risk and susceptibility perceptions

4 factors influencing perception of risk?

- lack of personal experience

- belief in preventability (by personal action),

- believing that the problem is infrequent

- that if it hasn't happened by now, its not likely to

Transition points named by NICE - aka points in life at which interventions are thought to be more effective? (6)

- leaving school

- entering the workforce

- becoming a parent

- unemployment

- retirement

- bereavement

Name a few models and theories of behaviour change?

- Health belief model

- Theory of planned behaviour

- Trans-theoretical model

- Social norms theory

- Motivational interviewing

- Social marketing

- Nudging (choice of architecture) e.g. fruits and veg near till

- Financial incentives

What is the health belief model?

(Becker, 1974) Perceived barriers have been demonstrated to be the most important factor in addressing behaviour change in patients. Individuals will change if they believe:

1. they are susceptible to the condition

2. that the behaviour has serious consequences

3. that taking action reduces susceptibility

4. that the benefits of acting outweigh costs

Critique the health belief model?

- Does not consider outcome expectancy or self-efficacy

- Does not consider influence of emotions on behaviour

- Does not differentiate between first time and repeat behaviour

What is the theory of planned behavior?

Proposes the best predictor of behaviour change is INTENTION, which is determined by:

1. Personal attitude to the behaviour

2. Social pressure to change behaviour (social norm)

3. Person's perceived behaviour control

Critique the theory of planned behaviour? (4)

- Lacks temporal element or lack of direction and causality

- Doesn't take into account emotions

- Doesn't explain the 3 factors interact to determine intention

- Doesn't take into account habits and routines

Stages of change in the trans-theoretical model

PC-PAM

pre-contemplation, contemplation, preparation, action, maintenance

Critique the trans-theoretical model / advantages of it?

Advantages - accounts for relapse and temporal element

Critique -

- not everyone move through every stage linearly

- change might operate on a continuum rather than discrete stages

- doesn't take into account habits, culture, social and economics

Social norms theory?

Behavior influenced by perceived norms within a social group

Motivational interviewing?

Communication technique to elicit behavior change

Social marketing?

Applying marketing principles to promote behavior change

Nudging?

Choice architecture to encourage desired behaviors, e.g., placing fruits and vegetables near the till

Financial incentives?

Offering rewards to motivate behavior change

Central elements to developing food behaviour (4)?

- maternal diet

- breastfeeding

- parenting practices

- age of food introduction and types of food given

What is Non-organic feeding disorders (NOFED)?

High prevalence in under 6s, includes feeding aversion, food refusal, and negative mealtime interactions

What are the determinants of health?

P - place of residence

R - race

O - occupation

G - gender

R - religion

E - education

S - socio-economic

S - social capital

What is equity? Subtypes of equity?

Differentiate against equality?

Equity = giving people what they need to achieve equal

outcomes

- Subtypes = horizontal and vertical equity

Equality = everyone having an equal share

What is horizontal equity?

Equal treatment for people with equal healthcare needs, regardless of individual characteristics -

e.g. all individuals with pneumonia should be treated equally

What is vertical equity?

Unequal treatment for unequal need, based on individual characteristics - e.g. patients with cold and pneumonia should be treated differently

Define Equality?

Everyone having an equal share

What is the inverse care law?

The availability of good medical care tends to vary inversely with the need for it in the population served

Levels of interventions in public health? Examples?

- Individual - e.g. immunisation

- Community - on a local level e.g. community and playgrounds

- Ecological (population) e.g. clean air act, legislation to ban smoking in public places

What is a health needs assessment?

= resource allocation

Systematic method for reviewing health issues facing a population, setting priorities and allocating resources to improve health and reduce inequalities

NICE definition of need?

- 2017 SAQ (1 mark)

ability to benefit from an intervention

NICE definition of demand? & supply?

what individuals ask for / what is provided (i.e. the services that are available)

Four types of social needs as deemed by Bradshaw (1972)?

Normative need

Felt need

Expressed need (demanded need)

Comparative Need

Define normative need & give an example?

Need that is defined by experts. Normative needs are not absolute and there may be different standards laid down by different experts.

Vaccinations // a decision by a surgeon that a patient needs an operation

Define felt need & give an example?

Need perceived by an individual. Felt needs are limited by individual perceptions and knowledge of services.

Having a headache, feeling knee pain

Define expressed / demanded need & give an example?

Felt needs turned into action. Help seeking.

Going to the dentist for a toothache

Define comparative need & give an example?

Needs identified by comparing the services received by one group of individuals with those received by another comparable group.

A rural village may identify a need for a well or a school if the neighbouring village has one

What is an example of a health related intervention that is supplied, but not needed or demanded? Why?

- 2017 3a SAQ (1 mark) (1 mark)

Routine Caesarean sections on women with a history of a previous Caesarean section

What is an example of a health related intervention that is supplied, needed but not demanded? Why?

- 2017 SAQ (1 mark) (1 mark)

Health promotion; screening procedures; psychiatric treatment; vaccinations

What is an example of a health related intervention that is supplied and demanded, but not needed?

- prescription of antibiotics for uncomplicated viral URTI / mild infection

- vitamins

- over the counter antibiotics

What is an example of a health related intervention that is demanded and needed but not supplied?

Elective procedures being delayed by large waiting lists

Approaches to health needs assessment

Epidemiological, corporate, and comparative approaches

How might an epidemiological approach to health needs look like?

- 2017 SAQ (2 marks)

Considers the

- epidemiology of the condition (inci + prev + morb + mort)

- current service provision

- effectiveness and cost-effectiveness of interventions and services

- Data is from: disease registry, hospital admissions, GP databases, mortality data, primary data collection

Critique the epidemiological approach to health needs?

ADV

- uses existing data

- provides data on disease incidence / mortality / morbidity

DISADV

- quality of data variable

- data collected may not be data required

- does not consider felt needs / opinions of patients

How might a corporate approach to health needs look like?

- 2017 SAQ (1 mark)

Asking the local population what their health needs are

- Use of focus groups, interviews and public meetings

- Wide variety of stakeholder e.g. teachers, healthcare professionals, social workers, charity works, local businesses, council workers and politicians

Critique the corporate approach to health needs?

ADV

- based on felt and expressed needs to population

- Recognise detailed knowledge and experiences of those working with population

- takes into account wider range of views

DISADV

- can be difficult to distinguish need from demand

- groups may have vested interests

- may have political agendas

How might a comparative approach to health needs look like?

- 2017 SAQ (1 mark)

- Compare the needs/provision of healthcare in one population with another

- Can be spatial (e.g. different towns) or social (e.g. two age groups in the same town)

Critique the comparative approach to health needs?

- 2017 SAQ (1 mark)

ADV

- quick and cheap if data available

- shows quality of service in the compared groups

DISADV

- can be difficult to find comparable population

- data may not be available / high quality

Maslow's hierarchy of needs - describe and what is self-actualization?

Self-actualization - a person's motivation to reach their full potential. Their basic needs must be met before actual self-actualization can be achieved.

- this includes morality, creativity, spontaneity, problem solving, lack of prejudice

Pyramid =

Self-actualization

Esteem

Love / belonging

Safety

Physiological

3 Resource allocation methods and what are they based on?

Egalitarian - Provide all care that is necessary and required to everyone

(equal but expensive)

Maximising - based solely on consequences

(resources allocated to those most likely to benefit, but those who don't make the cut receives nothing)

Libertarian - Each individual responsible for own health

(promotes positive engagement, but most diseases are not self inflicted)

What is utilitarianism?

Consequences of an action should be measured by effects - greatest good for the greatest number of people

What is deontology?

DUTY BASED ETHICS, right or wrong are decided based on the action,

It specifically does not look to consequences of actions to determine right or wrong. Instead it examines a situation for the existence of essential right or wrong.

What is the opposite of deontology?

Duty based ethics - right or wrong is dependent on the situation / circumstance

What is virtue ethics?

Actions are judged based on the character of the individual carrying out the action

= Based on the virtues they hold

Define evaluation? Provide examples of evaluation frameworks?

Assessment of whether a service achieves its objectives

e.g. Donabedian's framework of health service evaluation, Maxwell's dimensions of Quality of health

What is Donabedian's framework of health service evaluation? What does it include?

A framework used to evaluate health services - Donabedian's looks at the structure, process and outcome of the health service.

- Structure: actually is the service e.g. how many heart surgeons there are

- Process - how does the process work

- Outcome - 5 Ds = death, disease, disability, discomfort, dissatisfaction

Issues with the way Donabedian's framework evaluates the health service?

▪ Link between health service and health outcome can be difficult to confirm

▪ Time lag between service and outcome may be long

▪ Large sample sizes may be needed

▪ Data may not be available or have a problem with it (CART = completeness, accuracy, relevance, timeliness)

What is Maxwell's Dimensions of Quality of health care

A framework used to evaluate health services - Maxwells looks at the 3E's & 3A's:

- Effectiveness, efficiency, equity

- Acceptability, accessibility, & appropriateness

What processes are in a health needs assessment?

Needs assessment - Planning - Implementation - Evaluation

What is epidemiology?

The study of the frequency, distribution and determinants of diseases and health-related states in populations in order to prevent and control disease.

Define Incidence

- 2018 3b SAQ (1 mark)

Number of new cases in a population over a period of time

Define (point) Prevalence

- 2018 3b SAQ (1 mark)

Number of existing cases in a population at a particular point in time

Define Absolute risk

the incidence of disease in a population - with specific numbers and units

Define Relative risk

Risk in one category compared to another

= risk in exposed group A / risk in unexposed group B

Define Attributable risk

Rate of disease in the exposed population that maybe attributed to exposure

= risk of control grp - risk of exposed group = excess risk caused by exposure

Define number needed to treat?

average number of patients who need to be treated to prevent one additional bad outcome

= inverse of absolute risk (1 / AR)

Define Bias?

A systemic deviation from the true estimation of the association between exposure and outcome

= example of a systematic error

Types of bias:

- selection bias

- information bias

- allocation bias

- publication bias

- lead time bias

- length time bias

Name four information bias? Explain?

Measurement bias

- diff equip measuring differently

Observer bias

- observer expectations influence reporting

Recall bias

- past events not recalled correctly

Reporting bias

- ppl don't report the truth due to shame / judgement

Define selection bias?

unintended differences between the participants in different groups - may present during the selection or allocation process

Define Information bias?

errors in procedures for gathering relevant information

-ex: in recall, collecting data, interviews & reporting

Define publication bias?

bias that occurs when research that is published isn't representative of all completed studies - trials with negative results are less likely to be published

Define lead time bias?

Screening identifies diseases earlier and therefore gives the impression that survival is prolonged but survival time is actually unchanged.

Define length time bias?

diseases that progress rapidly from onset to symptoms are less likely to be detected by screening than disease that progresses slowly - screening identifies more tx-responsive subgroup

Define Confounding factors?

- 2018 3b SAQ

Factor associated with exposure and outcome but not on the causal pathway

e.g. smoking causes lung cancer but alcohol consumption is associated with both (dependence, lifestyle etc)

What is the Bradford Hill criteria for causality?

•In 1965 Austin Bradford-Hill detailed criteria for assessing evidence of causation:

- Strength

- Dose-response

- Consistency

- Specificity

- Temporality

- Biological plausibility

- Coherence

- Analogy

Meeting the Bradford-Hill criteria confirms:

True association

What is reverse causality?

A situation in which one variable is said to cause another variable, when in reality the reverse is true.

e.g. stress could have caused HTN rather than HTN causing stress

Types of prevention? Explain?

PRIMARY - preventing a disease before it happens

- vaccines

SECONDARY - catching a disease in the early/pre-clincical phase & prevent it from worsening

- screening

TERTIARY - preventing complications of disease

- prevent worsening renal function in CKD

(2) Approaches to prevention? Explain?

POPULATION BASED - Preventative measure delivered on a population wide basis (or to a relevant subgroup)

Seeks to shift the risk factor distribution curve

E.g. dietary salt reduction through legislation, working with the food industry reformulation, PH advice to the general public should shift the blood, pressure distribution curve to the left

HIGH RISK APPROACH - Identifies and treats individuals above a chosen cut-off

E.g. screening for people with high blood pressure and treating them

What is the prevention paradox?

A preventative measure that benefits the population but offers little to each individual

E.g. If all male British doctors wore their car seat belts on every journey throughout their working lives, then for one life saved there would be 400 who never benefit from it.

Types of disease screening (5)?

- Population-based

- opportunistic

- communicable diseases

- pre-employment

- commercially provided

What is the criteria for screening disease used by the NHS? Broadly describe the criteria?

Wilson and Junger criteria.

Condition - should be important. Hx, staging, RF & disease markers should be understood.

Screening should be ongoing and not one off. Cost effective.

Test - simple, safe, precise and validated screening. Acceptable to population. Target population, distribution of results and cut off defined and agreed. Agreed policy on further diagnosis of those with + results and choices available.

Treatment - effective intervention / tx available for those identified, and evidence exists of early tx giving better outcomes than late. Agreed policy on who to tx and facilities available.

Wilson and Jungner criteria - explain for 6 points?

In Exam Season NAP

Important disease

Effective tx available

Simple and safe

Natural hx of disease known

Acceptable (not too invasive)

Policy on who to treat agreed

Disadvantages of screening?

- exposure of well individuals to distressing or harmful diagnostic tests

- detection and treatment of sub-clinical diseases that would never cause any problems

- preventative measures may cause harm to individual or population

Young people and adult screening programmes?

AAA

Bowel cancer

Breast cancer

Cervical screening

Diabetic eye

Define sensitivity? Formula?

the ability of a test to correctly identify those who actually have the disease (true positives)

TP/(TP + FN)

Define specificity? Formula?

the ability of a test to correctly identify those who do not actually have the disease

proportion of people without disease correctly excluded by screening test

TN/(TN + FP)

What is a positive predictive value?

Probability that a pt w/ a positive test truly has the disease.

The more specific a test, the higher its PPV

Prevalence dependent: the higher the disease prevalence, the higher the PPV of the test for that disease

What is a negative predictive value?

Probability that a pt w/ a neg test truly does not have the disease.

The more sensitive a test, the higher its NPV.

Prevalence dependent: the lower the disease prevalence, the higher the NPV of the test for that disease

What is a cohort study?

preplanned following at least two subset (exposed vs unexposed) of population over a period of time

incidence of disease compared.

observational and prospective. uses relative risk.

Advantages and disadvantages of cohort studies?

ADV

- Follow up rare exposures

- Identifies risk factors

- Sequence of happenings can prove cause-effect

- Multiple exposure and outcomes can be measured

DISADV

- Expensive and time consuming.

- Large sample size required

- Impractical for rare diseases / long latent periods

- Subjects may be lost to follow-up during the course of the study.

- Exposures can be misclassified.

What are case-control studies?

Retrospective look on subjects that have the outcome of interest

Groups with and without a disease are selected and past exposures identified

Advantages and disadvantages of case control studies?

ADV

- quick

- good for rare & long latency diseases

- multiple exposures can be studied

DISADV

- selection & information bias

- impractical for rare exposures

- hard to establish sequence of events

- difficult to tell apart confounding factors

What is a cross-sectional study?

exposure and outcome are measured simultaneously at a particular point (snapshot study)

Advantages and disadvantages of cross-sectional studies?

ADV

- Can assess a large sample size

- Quick

- Provides prevalence data

- Provides trend data

- Hypothesis generating

- Can rptx = show change overtime

DISADV

- Risk of reverse causality

- Unclear timeline

- Not useful in rare diseases

- Difficult to establish an in-depth developmental assessment of the interrelationships of the phenomena

What is a randomised control trial?

a study where a group of STRICTLY SELECTED participants are then RANDOMLY ALLOCATED to either an experimental group or a control group

Allows for comparison in order to assess the effectiveness of an intervention