Course notes: Part I MFPHM revision



Part A MFPH

revision COURSE handout

“I couldn’t wait to get in there and tell them what I’d learned”

Stanley Hauerwas

The Hauerwas reader p25

For maximum benefit -

USE this handout:

Annotate, scribble, write examples

‘Read and forget; write and remember’

EPIDEMIOLOGY 5

Epidemiological studies: design 6

Expressing the main result 6

Concepts and measures of risk 6

Interpreting the result 7

Chance 7

Bias 7

Confounding 7

Other problems 7

Effect modifiers [interaction] 8

Causation 9

Putting it together – guidelines and recommendations 10

Hierarchy of evidence 10

Surveys 11

HEALTH INFORMATION 13

Routine data sources 13

Population 13

Ad hoc censuses 14

Census based measures 14

Routine statistics 14

Epidemiology: how much do I need to know? 16

HEALTH ECONOMICS 18

Economic appraisal 19

Decision analysis 21

Option appraisal 21

SOCIAL SCIENCES 22

Sociology 22

Qualitative methods 22

Capturing qualitative data 22

Qualitative analysis: 22

Rigour in qualitative studies: 22

Concepts of health and illness 23

Deviance 25

Variations in health 26

Social factors in the aetiology of illness 27

Social health 27

HEALTH PROMOTION 28

Strategy in health promotion 29

Running programmes 30

Environment 32

Health at work 33

Nutrition 34

SCREENING 36

Quality assurance in screening 37

ETHICS 38

GENETICS 39

STATISTICAL METHODS 40

Elementary probability theory 40

What’s this? 41

Meta analysis 42

Interpreting multiple regression models 43

Non statistical stuff 44

How would you analyse….. 45

Parametric and non parametric 45

Three famous models 47

COMMUNICABLE DISEASE 48

Communicable disease – how much do I need to know? 51

ORGANISATION AND MANAGEMENT - theory 53

Organisations 53

Change 54

Innovation 54

Leadership 55

Motivation 55

Negotiation 55

Groups 56

Within the group 56

Between groups 56

Managing people 57

Self management 57

Miscellaneous 57

Creativity 57

Delegation 57

Effective communication 57

MANAGEMENT GURUS 58

Models 58

Running health services 59

Funding of health services 59

Resource allocation 59

Policy formulation 60

HOW COMMISSIONING WORKS 61

Planning 62

Funding 63

Priority setting 63

Types of contract 63

NHS finance systems 63

Monitoring 64

Performance - overview 64

Performance – evaluation of a service 64

Performance - exceptional events 64

Governance and risk management 64

International health care 65

Social policy 65

TIPS ON EXAM TECHNIQUE 66

PREPARATION 66

GENERAL 66

PAPER I 67

PAPER IIA: strengths and weaknesses 74

PAPER IIB: data skills 75

Some facts and figures 76

Reports / briefing papers 77

DATA PRACTICE: CALCULATIONS 78

Past papers – question grid 83

EPIDEMIOLOGY

: Epidemiology for the uninitiated

NOTE – Throughout the handout anything in this typeface (Arial 10) is a direct cut-and-paste from the syllabus

a) Epidemiology: use of routine vital and health statistics to describe the distribution of disease in time and place and by person; numerators, denominators and populations at risk; time at risk; methods for summarising data; incidence and prevalence including direct and indirect standardisation, years of life lost; measures of disease burden (event-based and time-based) and population attributable risks including identification of comparison groups appropriate to Public Health; sources of variation, its measurement and control; common errors in epidemiological measurement, their effect on numerator and denominator data and their avoidance; concepts and measures of risk; the odds ratio; rate ratio and risk ratio (relative risk); association and causation; biases; confounding, interactions, methods for assessment of effect modification; strategies to allow / adjust for confounding in design and analysis; the design, applications, strengths and weaknesses of descriptive studies and ecological studies; analysis of health and disease in small areas; design, applications, strengths and weaknesses of cross-sectional, analytical studies, and intervention studies (including randomised controlled trials); clustered data - effects on sample size and approaches to analysis; Numbers Needed to Treat (NNTs) - calculation, interpretation, advantages and disadvantages; time-trend analysis, time series designs; nested case-control studies; methods of allocation in intervention studies; studies of disease prognosis.

Appropriate use of statistical methods in the analysis and interpretation of epidemiological studies, including life-table analysis; electronic bibliographical databases and their limitations; grey literature; evidence based medicine and policy; the hierarchy of research evidence - from well conducted meta-analysis down to small case series, publication bias; the Cochrane Collaboration

1 Epidemiological studies: design

• Descriptive studies: “How much of this stuff have we got?”

• Case control studies: “What caused these cases?”

• Cohort studies: “What effect does this have?”

• Interventions incl. RCTs

PICO

(Modelling studies)

(Systematic reviews)

Retrospective vs prospective studies: ‘Five a day’

Interventional vs observational studies: beta carotene and lung cancer, HRT and CHD

2 Expressing the main result

Intention to treat analysis

2 Concepts and measures of risk

Relative risk

Absolute risk

Deaths per 100,000 male doctors per year from lung cancer:

smokers (>25 per day): 327

non-smokers: 14

Ratio of incidence (incidence rate ratio) =

Absolute risk difference =

(Excess rate/ risk attributable to smoking = )

Population attributable “risk” (aetiologic fraction)

Odds ratio

Number needed to treat (NNT)

3

3 Interpreting the result

Could the result be due to

• Chance?

• Bias?

• Confounding?

• REAL effect?

1 Chance

P values, CIs etc – but remember Type I and Type II errors

2 Bias

Systematic differences in

• Sample / subjects

• Measuring instrument

• Observer

3 Confounding

The ‘other explanation’

Control of confounding:

Design

Analysis

Standardisation

Residual confounding

Over-adjustment

4 Other problems

Ecological fallacy

5 Effect modifiers [interaction]

This is a type of REALITY

Age related macular degeneration (de Jong PTVM NEJM 2006; 355: 1474 – 85)

Smokers (vs non): Odds ratio = 2.4

Homozygous for CFH Y 402H polymorphism Odds ratio = 7.6

Smoker AND homozygous Odds ratio = ?

Graphically:

fluoridation of water supply more beneficial to poor than to rich.

Riley JL et al Int J Epidemiol 1999; 28: 300 –5. Jones CM et al BMJ 1997; 315: 514 – 7

[pic]

6

7 Causation

Bradford Hill criteria for causality (in order of importance):

[AB Hill. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295 - 300]

1. strength of association

2. consistent in different studies

3. specific

4. temporality

5. biological gradient e.g. more drinks / day -> higher RR

6. biologically plausible

7. coherence

8. experimental evidence

9. analogy (if thalidomide and rubella cause foetal malformation so may other drugs / viruses)

Mnemonic courtesy of Martin Bull:

A Statistical Cohort of Surgeons with TB Postulated the Cause to be an Environmental Agent!

NB if picture muddy may need to think about different types of cause:

Necessary / Sufficient

Underlying / Trigger

Etc

8

9

10

11

Uses of epidemiology (Jerry Morris):

Morris JN Uses of epidemiology Br Med J. 1955 August 13; 2(4936): 395–401

1. Historical trend

2. Community diagnosis

3. “Individual chances”

4. Operational research - how well services are working

5. Completing the clinical picture – study ALL cases

6. Identification of syndromes – ‘peptic ulcer’, ‘frailty’

7. Clues to causes

12 Putting it together – guidelines and recommendations

GRADE – strong and weak recommendations

Importance – prevents death

Size of effect – 30% reduction in risk

Precision – narrow CI

Certainty – many high quality RCTs

Risks and Burdens of therapy – no adverse effect but fortnightly iv infusion

Risk of event

Costs

Values (e.g. life or comfort?)

AGREE – quality of guidelines

13 Hierarchy of evidence

NB ‘Cultures of evidence’

4 Surveys

Constructing the survey instrument

Construction of valid questionnaires

Validity

• content

• face

• criterion

concurrent

predictive

• construct validity

Convergent/ discriminant

Reliability

‘degree to which measurement is free from measurement error’

• Test - retest

• Multiple form

• Split half

Scales:

• should be uni-dimensional

• some instruments have domains

o [e.g. “total SF36 score” is wrong]

Doing the fieldwork

methods of sampling from a population

The sample

Methods of sampling and allocation

random, quasi-random,

stratified

cluster

quota

convenience

nomination / snowball

the design of documentation for recording survey data

The instrument

Typography: font size, layout, tick boxes etc

Items: ambiguous questions / double questions / leading qq

Whole thing: running order (e.g. sensitive last)

Mode: paper - computer – telephone - internet

The interview

Interviewers

Select

Train

Monitor

Respondents

Introduction – gaining consent etc

Attempts to contact (how many? Time of day?)

Use of proxy allowed?

Methods for validating observational techniques

Validation of observational techniques:

inter-observer

interviewer training

videotaping

Observer variation

HEALTH INFORMATION

- Capture: how accurate? How complete?

– Coding – how fine grained?

- Output: how detailed? how often? How aggregate?

Routine data sources

Populations: conduct of censuses; collection of routine and ad hoc data; demography; important regional and international differences in populations, in respect of age, sex, occupation, social class, ethnicity and other characteristics; methods of population estimation and projection; life-tables and their demographic applications; population projections; the effect on population structure of fertility, mortality and migration; historical changes in population size and structure and factors underlying them; the significance of demographic changes for the health of the population and its need for health and related services; policies to address population growth nationally and globally

Sickness and health: sources of routine mortality and morbidity data, including primary care data, and how they are collected and published at international, national, regional and district levels; biases and artifacts in population data; the International Classification of Diseases and other methods of classification of disease and medical care; rates and ratios used to measure health status including geographical, occupational, social class and other socio-demographic variations; routine notification and registration systems for births, deaths and specific diseases, including cancer and other morbidity registers; pharmacoepidemiology, including use of prescribing and Pharmacy sales data; pharmacovigilance; data linkage within and across datasets

2 Population

UK Census

Census 2011

Health question

2011: How is your health in general? Very good / good / fair/ bad/ very bad

2001: Over the last 12 months would you say your health has on the whole been good / fairly good / not good ?

Disability question

2011: Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months?

2001: Do you have any long-term illness, health problem or disability which limits your daily activities or the work you can do?

• Include problems which are due to old age

Income question – there isn’t one in the UK census!

1

2 Ad hoc censuses

3

4 Census based measures

Deprivation scores

• Jarman / Townsend score

• Index of multiple deprivation IMD2000 - NOT census based: 7 domains / 33 indicators: Income, Employment, Health and disability, Education skills and training, Barriers to housing and services, Living environment and Crime. See

Population

Estimates and projections

Historical change in population structure

1946 baby boom plus second wave

effect of economic downturn

3 Routine statistics

• Mortality

• Hospital

Inpatient

Ambulatory – A&E, outpatient

Diagnostics – lab, radiology

• Primary care

Medical

Dental

Pharmacy

• Registers

• Surveys

Measurement surveys

Self report surveys

• Non-health service: fire, police, social services department

[NB – poor definitions in non-health sources]

• Research: synthetic estimates

Classifications:

ICD10

[OPCS4 coding for operations]

Read codes - a nomenclature not a classification

Epidemiology: how much do I need to know?

• Clinical features (don’t overdo this)

• Time (secular trend - last 50 years, more recent)

• Place

• Person

age, sex, socio-economic

ethnic, occupation, familial

lifestyle

• Causes & determinants

THINK ABOUT SOURCES of knowledge (e.g. ‘CHD is declining’)

==========================================================

[Infections: covered later]

Neoplasms:

*Breast

*cervix,

*colon,

*lung,

*skin (melanoma and SCC)

Metabolic, endocrine:

*Diabetes mellitus

Psychiatric:

*Schizophrenia,

*dementia

*suicide,

deliberate self harm

Nervous system:

CVD

*CHD

*stroke

Abdominal aortic aneurysm

Respiratory

*asthma,

*chronic bronchitis

Trend summary E&W deaths 1990 – 1999 :

CHD, stroke, asthma, bronchitis: down [smoking]

Digestive:

Caries

peptic ulcer -> Helicobacter

Perinatal

SIDS

Congenital and hereditary

Down syndrome

Injury & poisoning

Falls

Epidemiology of lifestyle

*smoking,

*alcohol,

*sexual behaviour

*diet (obesity)

*exercise

Syllabus: ‘the effects on health of different diets (e.g. the ‘Western diet’), obesity, physical activity, alcohol, drugs, smoking, sexual behaviour and sun exposure

1 HEALTH ECONOMICS

Health economics: principles of health economics (including the notions of scarcity, supply and demand, marginal analysis, distinctions between need and demand, opportunity cost, discounting, time horizons, margins, efficiency and equity); assessing performance; financial resource allocation; systems of health and social care and the role of incentives to achieve desired end-points; techniques of economic appraisal (including cost-effectiveness analysis and modelling, cost-utility analysis, option appraisal and cost-benefit analysis, the measurement of health benefits in terms of QALYs and related measures); marginal analysis; decision analysis; the role of economic evaluation and priority setting in health care decision making including the cost effectiveness of Public Health, and Public Health interventions and involvement.

Perfect market

| |Elective surgery |Specialist psychiatry |

|Many sellers (and buyers) | | |

|Free entry (and exit) | | |

|Perfect information | | |

|Homogeneous product | | |

No externality: I pay, someone else benefits (e.g. host purchaser / infrastructure costs)

Risk pools (Insurance systems)

1. Rare event

2. High cost

3. Population demand predictable

4. Individual's probability of demand independent

adverse selection

moral hazard

1 Economic appraisal

Measurement of COST

Marginal vs unit costs (and benefits):

e.g screening interval, change in admissions

Incremental cost

Opportunity cost

Direct vs indirect

Tangible (can invoice / bill for this) vs intangible (pain, suffering etc)

Discounting

• future costs

• ?discount future health benefits

• NICE recommends 3.5% annual discount for costs and health benefits

• Cost effectiveness:

Cost minimisation – (e.g. to achieve no Hep B in drug users)

Sensitivity analysis

• Cost utility:

Step 1: Assess health state after treatment using Quality of Life scale e.g. EQ5D

Step 2: Place a value (utility) on that health state

(e.g. on a rating scale score of 0 – 100)

Could use time trade off or standard gamble instead of rating scale

Disability weighting: see

Stouthard MEA et al. Disability weights for disease. Eur JPH 2000; 10: 24 – 30

• Cost benefit:

Used by government to decide whether or not to go with a programme: overall cost to society

Air pollution clean up:

cost £785m - £1100m estimate for UK

12,000 - 24,000 deaths in 1996 (COMEAP)

Do costs outweigh benefits?

May need to value life:

“Gross output”

Willingness to pay

Pay to reduce road deaths

Pay for risky occupations

Willingness to spend (e.g. for a smoke alarm)

2 Decision analysis

Economic appraisal plus sensitivity analysis

May also involve decision tree

diabetic-retinopathy.screening.nhs.uk

Also Richardson WS et al JAMA 1995; 273: 1292 - 5

3

4

5

6 Option appraisal

Where should paediatric cardiac surgery take place?

Efficiency: generally about getting the most out of your resources

Cost efficiency – no money wasted

Technical efficiency – no inputs wasted i.e. no kit, staff, standing idle

[Doesn’t work when you’re comparing different mixes of inputs and outputs

cf option appraisals]

Allocative efficiency – can’t give A more without taking from B i.e. no surplus

OR Technical – do CABG as cheaply as possible

Allocative – allocate funds for anti-smoking (achieves more / more efficient CHD reduction)

Equity

vertical: greater resource for greater need

horizontal: equal resource for equal need

Equality - of what?

• Equal spend per person

• Equal spend for equal need

• Equal spend for equal benefit

SOCIAL SCIENCES

1 Sociology

‘study of individuals in groups and social formations’ (Lawson and Garrod) includes institutions

Organisations and management

Social identity – age class gender race

Family and friendship

Power and class (Marxism?)

Work including professions and status

Norms and deviance, discrimination

Social welfare, education etc

2 Qualitative methods

The principles of qualitative methods including semi-structured and in-depth interviewing, focus groups, action research, participant observation, and their contribution to public health research and policy; their appropriate use, analysis and presentation; the ethical issues which may arise; validity, reliability and generalisability; common errors and their avoidance; strengths and weaknesses.

1 Capturing qualitative data

ethnography

long interview

diary

analysis of documents and images

2 Qualitative analysis:

grounded approaches

semiotics (symbolism)

discourse analysis / repertoires

3 Rigour in qualitative studies:

Researchers' perspective (e.g. feminist)

Full description of fieldwork method

Subject selection

Recording (e.g. tape plus transcription)

Main results

Verbatim quotes

Exceptions noted (e.g. help seeking and masculinity)

Concepts of health, wellbeing and illness and aetiology of illness: the theoretical perspectives and methods of enquiry of the sciences concerned with human behaviour; illness as a social role; concepts of health and wellbeing; concepts of primary and secondary deviance; stigma and how to tackle it; impairment, disability and handicap; social and structural iatrogenesis; role of medicine in society; explanations for various social patterns and experiences of illness (including differences of gender, ethnicity, employment status, age and social stratification); the role of social, cultural, psychological and family relationship factors in the aetiology of illness and disease; social capital and social epidemiology.

Health care: different approaches to health care (including self-care, family care, community care, self-help groups); hospitals as social institutions; professions, professionalisation and professional conflicts; the role of clinical autonomy in the provision of health care; behaviour in response to illness and treatments; psychology of decision-making in health behaviour.

Epilepsy ‘from a sociological perspective’ ?

3 Concepts of health and illness

Culture and health beliefs: (your culture = your rules on how to eat / drink / etc)

Cultural beliefs about the body

Shape: beautiful baby competitions

Size: bodybuilding

Clothing: white coat

Surface: no hat = catch cold

Anatomy: circumcision

Physiology: no concept of brain death = no transplants (Japan 1997)

Culture and diet

Junk food

Moslem / Hindu / Jewish

"Plain" food

Spraying mercury (Cuba, Dominica, Puerto Rico)

Ayurvedic and Chinese medicine (lead, mercury, arsenic)

Mildred Blaxter on lay concepts of health (mostly age related):

Health and lifestyles London: Routledge 1990 Table 3.1

May include community values (‘Healthy Hawaiian’)

Kleinman on how people do health care (think cold, headache, backpain)

Zola – triggers to seeking professional help



Illness as a social role (Parsons)

Iatrogenesis (Illich) Assets/3621.php

Clinical – adverse effects of drugs

Social – childbirth as a clinical event

Structural or cultural - “stripping away from human culture of ways of coping with pain, birth and death and their replacement by a sanitised technological medical intervention”

Colpo d’aria

“Oh, the dreaded Colpo d’Aria!  If you’ve suffered a Colpo d’Aria you’ve been struck by some moving air, most probably chilly air, and most probably on your chest or perhaps the back of your neck.  If you live in Italy, it can be deadly; ask any Italian!  I’ve heard Colpo d’Aria blamed for everything from stiff muscles, to inner ear infections, chest colds and even heart attacks.  I have not yet heard anyone say that a Colpo d’Aria caused his cancer, but that, and gum disease, are about the only illnesses for which a stiff breeze has not been held responsible.

Fortunately there is some good treatment available should you fall victim to an evil air current.  The first thing you want to do is go to the pharmacy and get a bastone di zolfo, a stick of sulphur.”

Sociology of health care

Professions

According to Freidson (1970), a profession

1. controls entrance into the ranks;

2. professional expertise is not a commercial property;

3. control of practice is exercised by professional colleagues; and

4. the primary mechanism for quality control is personal responsibility and integrity.

Related to autonomy in clinical practice

Hospitals as social institutions: LS and acute (Goffman on asylums)

Asylum

Prison

Factory

Business

University

City

4 Deviance

Implications of labelling behaviour for organic and psychiatric disease

Illness as deviance and doctor as agent of social control: ?smoking, homosexuality, alcohol, obesity?

Primary and secondary deviance

Stigma

Disability and handicap

e.g. Intellectual impairment > learning disability > mental handicap

Handicap pejorative in US

WHO now suggests ‘abilities’ and ‘participation’

5 Variations in health

Explanations for socio-economic patterning of ill health

Current, early life or life-course:

• Lifestyle

• Material

• Drift

• Psycho-social stress

Explanations for area differences:

• Composition

the type of people who live there

social capital?

• Physical

climate

facilities (food supply, health services etc)

6 Social factors in the aetiology of illness

1 Social health

Social breakdown as a cause of illness

Durkheim – anomie (lack of rules / order) and suicide rates

Effect of divorce on health

Kawachi on census measures of fragmentation

Income inequality (Wilkinson)

e.g. Brazil / Cuba:

Brazil higher MEAN income but more inequality / worse infant mortality

Social capital: a social construct:

• Existence of community networks

• Participation in networks (civic engagement)

• Having a local identity and sense of solidarity

• Having norms of trust and reciprocal help and support

Equality, equity and policy: concepts of need and social justice; priorities and rationing; balancing equity and efficiency; consumerism and community participation; prioritisation frameworks and equity of service provision; public access to information; user and carer involvement in service planning; problems of policy implementation; principal approaches to policy formation; appreciation of concepts of power, interests and ideology; inequalities in the distribution of health and health care and its access, including inequalities relating to social class, gender, culture and ethnicity, and their causes; health and social effects of migration, and the health effects of international trade; global influences on health and social policy; critical analysis of investment in health improvement, and the part played by economic development and global organisations

HEALTH §

Principles and practice of health promotion: collective and individual responsibilities for health, both physical and mental; interaction between, genetics and the environment (including social, political, economic, physical and personal factors) as determinants of health, including mental health; ideological dilemmas and policy assumptions underlying different approaches to health promotion; the prevention paradox; health education and other methods of influencing personal life-styles which affect health; appropriate settings for health promotion (e.g. schools, the workplace); the value of models in explaining and predicting health-related behaviour; risk behaviour in health and the effect of interventions in influencing health related behaviour in professionals, patients and the public; theory and practice of communication with regard to heath education; the role of legislative, fiscal and other social policy measures in the promotion of health; methods of development and implementation of health promotion programmes; community development methods; partnerships; evaluation of health promotion, public health or public policy interventions; international initiatives in health promotion; opportunities for learning from international experience.

Disease prevention, models of behaviour change: evaluation of preventative actions, including the evidence base for early interventions on children and families, support for social and emotional development; pre-determinants of health including the effect of social cohesion on health outcomes; approaches to individual behaviour change including economic and other incentives; the role social marketing; involvement of the general public in health programs and their effects on health care; concepts of deprivation and its effect on health of children and adults; the benefits and means of community development, including the roles and cultures of partner organisations; health impact assessment of social and other policies; the role of strategic partnerships and the added value of organisations working together; the role of setting targets and goals .

1 Strategy in health promotion

Health promotion framework

• Legislative

Fiscal: tax (e.g. tobacco) or subsidy (e.g. free school fruit)

Legal

• Health service:

Health authority

Hospital

Primary care (Med, Den, Pharm)

• Other players

Voluntary

District councils (Environmental health, housing, leisure)

County (schools, transport)

Others: police?

Use this for: smoking – diet – exercise – alcohol - IVdrugs – falls - teen pregnancy

Social marketing – four ‘P’s aimed at ‘social good’

‘Product’ (or ‘proposition’) - brand / message / desired behaviour

Place (setting) - school, workplace , home

Promotion - e.g. paid adverts, free publicity, giveaways

Price - free / subsidised

Includes concepts of

consumer focus

market segmentation



2 Running programmes

Models of health behaviour

• Becker and Maiman Health beliefs model

• Social learning

• Locus of Control: Internal / external

• Prochaska & DiClemente 1984 stages of change

Susan Michie Behaviour Change Wheel

Development, implementation and evaluation of health promotion

• Karelia [Heartbeat Wales]

• The ASSIST study

• SureStart evaluations

Early intervention

Preschool day care in deprived populations – 1960s onwards

(Cochrane review – 8 studies, all USA)

Perry Pre School project / Head Start (USA);

Sure Start

Parenting programmes (Sarah Stewart-Brown)

Parenting skills for teenage mums (Cochrane review – 4 studies)

3

4 Environment

Environmental determinants of disease; risk and hazard; the effects of global warming and climate change; principles of sustainability; methods for monitoring and control of environmental hazards including: food and water safety; atmospheric pollution and other toxic hazards, noise, and ionising and electromagnetic radiation; the use of legislation in environmental control; health impact assessment for environmental pollution; transport policies;

Monitoring of :

• Food

• Water

• Air

Smoke, SO2, NO2, ozone; radiation; cigarettes



Smoke: London smog: 500 microgm / m3; = ten times current

Radiation:

Bq

Gy

Sv

general population limit: 5 mSv / yr

UK exposure 2.6 mSv / yr

of which 50% Radon, further 35% natural.

97% of artificial exposure is medical

10 weeks in Cornwall = 50 Chest X ray = 250 hours long haul = 1 mSv

CT of chest = 8mSv

Non-ionising radiation

Power lines and cancer

Acute episodes:

Mercury contamination:

Bhopal

Goiania

Emergency planning: PLAN – PREPARE – RESPOND – RECOVER - RECORD

The health problems associated with poor housing and home conditions, inadequate water supplies, flooding, poor sanitation and water pollution

Physical health

Damp housing

Overcrowding and TB – slum clearance and the MoH

Shanty towns and typhus

Mental health

Social health

Evidence based housing interventions:

Pest control

Keeping the house dry and removing mould

Radon

Smoke-free

Lead control

Smoke alarms

Swimming pool fencing

Preset water temperature

Housing RCTs – heating and insulation (NZ); poor vs rich neighbourhoods (Chicago)

Water supply and sanitation

Sustainability

1

2

3 Health at work

appreciation of factors affecting health and safety at work (including the control of substances hazardous to health); occupation and health;

Occupational hazards in the NHS – biol and chem.

Famous occupational diseases

Radiation workers

Coal miners

Furniture makers in High Wycombe

Wool sorters disease

5 Nutrition

principles of nutrition, nutritional surveillance and assessment in specific populations including its short and long term effects; the influence of malnutrition in disease aetiology, pregnancy, and in growth and development; markers of nutritional status, nutrition and food; the basis for nutritional interventions and assessment of their impact; social, behavioural and other determinants of the choice of diet; Dietary Reference Values (DRVs), current dietary goals, recommendations, guidelines and the evidence for them; the effects on health of different diets (e.g. “Western” diet)

Methods

Diary – record or weighed

FFQ

Blood measurements

Studies

Clinical observation

Ecological – 7 countries, InterSalt

Whole diet - Mediterranean

Intervention

component – Beta-carotene, DASH

whole diet – Atkins etc

Classic deficiency diseases

Pellagra

Goitre and cretinism

Vitamin A, iron, zinc – third world

Food fortification

Iodised salt

Folate (USA)

‘Western diet’

Total energy (calorie intake)

Fat

Fibre (non starch polysaccharide)

Salt

Current dietary goals and recommendations:

Whole population

2500 kcal = 10,000 kJ; chisquared test

[More than two columns – perhaps chisquared for trend]

People } bigger}

2. “Is one group of towns } wiser } the other one?”

Numbers} different from}

Analysis of variance (ANOVA):

• one way: e.g. blood pressure mean in different racial groups

• two way: e.g. blood pressure mean by sex in different racial groups

Special case of this is :

t test - model for difference in means,

Validity assumptions: what you’re measuring is (1) Normally distributed and (2) has same variance in populations from which groups / sample drawn (may not know this for sure and have to use the samples to guess) and (3) measurements are independent of each other

Non parametric version: Mann Whitney U test etc [e.g. SF36]

3. Matched pairs – McNemar’s chisquared test for discordant pairs

[McNemar’s statistic: (A-B)2 / A+B : same ‘how often that big’ i.e. distribution as chi-squared]

1 Parametric and non parametric

• Parametric:

“IF we can assume that in these people [blood pressure] is Normally distributed,

THEN this is a very odd [low P] result…...”

• Non parametric:

“………But it isn’t so odd if [blood pressure] isn’t Normally distributed”

So: parametric tests more powerful [likely to produce low P / declare significant] provided assumptions justified.

B: ASSOCIATION i.e. “PLEASE PUT ME ON A SCATTERGRAM”

Pearson product moment [= least squares] - parametric

Spearmann rank correlation – non parametric

Multiple regression

[Cronbach’s alpha for internal consistency of e.g. a questionnaire

kappa statistic for agreement between raters e.g. reading a mammogram]

C: SURVIVAL

Cox proportionate hazards model - parametric

Log rank – non parametric

D. TIME SERIES

Simple stuff:

Inspect the graph: trend, seasonality

Annual totals: up or down?

Moving average to smooth out

Predictive models e.g. does daily up and down of particulates in air predict daily up and down of hospital admissions?

Serial correlation: auto regressive (AR) to cope with serial correlation

Moving average (MA) to smooth bumps

Hence ARMA or ARIMA models – too advanced for Part A!

Scales

Nominal

Ordinal

Interval

Ratio

Kappa – measure of agreement for nominal scales e.g. do two judges put observations into same categories?

2 Three famous models

These all function by converting numbers into probabilities

(i.e they are probability density functions)

You have to specify some things about the model (cf "what scale is this model aircrcaft?")

To model:

• Toss up (yes / no event): binomial function (specify expected proportion of yes/no)

• Count (whole number): Poisson function (specify mean / expected number for thing you are modelling)

NB admissions are a count, bed days are not

• Rate (e.g. age standardised death rate): Normal Gaussian function (specify mean and sd of the thing you are modelling)

doi: 10.1093/ije/dyr101

SBP DBP

Europeans (n=149) 140 (sd 17) 82 (sd 10)

Punjabi Sikh (n=151) 144 (sd 17) 82 (sd 8)

COMMUNICABLE DISEASE

definitions (incubation, communicability and latent period; susceptibility, immunity, and herd immunity); surveillance - national and international -, its evaluation and use; methods of control; the design, evaluation, and management of immunisation programmes; choices in developing an immunisation strategy; the steps in outbreak investigation including the use of relevant epidemiological methods; emergency preparedness and response to natural and man-made disasters; knowledge of natural history, clinical presentation, methods of diagnosis and control of infections of local and international Public Health importance (including emerging diseases and those with consequencies for effective control); organisation of infection control; a basic understanding of the biological basis, strengths and weaknesses of routine and reference microbiological techniques (see also 2d); international aspects of communicable disease control including Port Health.

epidemic theory (effective and basic reproduction numbers, epidemic thresholds) and techniques for infectious disease data (construction and use of epidemic curves, generation numbers, exceptional reporting and identification of significant clusters);

================================================================

Surveillance

(NB this is an information activity)

High quality surveillance is:

Accurate

Complete

Timely

Cost-effective

(Anything else?)

Purpose of surveillance – POWER! (Thanks to Anj Saha)

Priorities for resource allocation

Outbreaks detected early

Warning system

Evaluate effectiveness of interventions

Risk groups characterised

Special arrangements: AIDS, leprosy

Enhanced surveillance, salivary diagnosis

Disease control

Surveillance

How is it spreading?

Any risk groups?

Basic science for new diseases e.g Ebola, MERSCoV

Diagnosis

Diagnostic techniques

Access to diagnosis

Screening

Treatment

Access to health services

Compliance with treatment

Prevention

Specific - imm & vacc programmes

General – sewage / enough food / good housing etc

Contacts

Identification and management of contacts

Hepatitis B control:

1. Surveillance

2. Screening blood products & organ donations

3. Sterilisation of sharps inc non-medical (eg tattoos)

4. Safe disposal of Sharps

5. Stab! ie vaccinate risk groups

6. Safe sex &needle exchange education

Epidemiology in outbreak investigation and control: Galbraith

PROCESS AND TASKS

• Confirm facts

• Immediate measures : to contain / treat illness

• Case definition - > case finding: Full extent in time and place

• active

• enhanced surveillance

• Descriptive epidemiology: e.g. all babies / ethnics / swimmers

• Hypothesis: usually mode of spread, sometimes cause

• Test hypothesis

• Action: e.g. Broad St pump

[Media handling - usually not for Part A]

Molecular epidemiology:

e.g. whole genome sequencing for TB control

Emergency planning (SARS, pandemic influenza):

• Plan

• Prepare (stockpiles etc) and Prevent (vaccinate)

• Respond

• Recover (from the event including psychological care)

• Record

Communicable disease – how much do I need to know?

AgORMICS and PIDQUICS

1. Clinical – one line only

2. Agent: Is it virus / bacteria / protozoa etc;

How do you diagnose it?

3. Occurrence in named country

(e.g. winter epidemics / sporadic / imported cases only)

4. Reservoir

5. Mode of transmission:

(parenteral / faecal-oral / something else),

6. Incubation (omit unless you’re sure)

7. Communicability (e.g. communicable while still excreting in stool)

8. Susceptibility and resistance (e.g. infection confers resistance)

or: (exam comments Jan 99): Identification, Causative Organism, incidence, reservoirs, how transmitted

2. Control: prevention, control of case: isolation, disinfection, quarantine, immunisation, contacts, specific measures, [PIDQUICS], ? epidemic measures

Food poisoning:

Salmonella (enteritidisPT4)

Shigella

Campylobacter

Cryptosporidiosis

Listeria

E coli 0157

Typhoid

Cholera

Meningitis:

Meningococcus

Haemophilus

Pneumonias

Pneumococcus

Legionnaires

TB** Mantoux, γ interferon tests etc

Viral fevers Ebola, Lassa

Dengue

Zika

Hepatitis

A

B

C

Immunisable

D: inc cutaneous

P

[T]

polio: OPV vs IPV

[M]

M inc SSPE

R

HIB

Sexual:

Chlamydia

Gonorrhoea

Syphilis

HIV

SARS and other corona viruses

Herpes

Influenza: vaccine, treatments, surveillance

Rabies

Lyme disease

Q fever

Plague – Madagascar

Giardiasis

Head lice

Scabies

Toxocara

Toxoplasma

Malaria

ORGANISATION AND MANAGEMENT - theory

Internal and external organisational structures environments; evaluating internal resources and organisational capabilities; identifying and managing internal and external stakeholder interests; structuring and managing inter-organisational (network) relationships, including intersectoral work, collaborative working practices and partnerships; social networks and communities of interest; assessing the impact of Political, economic, socio-cultural, environmental and other external influences

Motivation, creativity and innovation in individuals, and its relationship to group and team dynamics; barriers to, and stimulation of, creativity and innovation (e.g. by brainstorming); learning with individuals from differing professional backgrounds; personal management skills (e.g. managing: time, stress, difficult people, meetings); the effective manager; principles of leadership and delegation; principles of negotiation and influencing; principles, theories and methods of effective communication (written and oral) in general, and in a management context. Interactions between managers, doctors and others; the theoretical and practical aspects of power and authority, role and conflict; professional accountability - clinical governance, performance and appraisal; behaviour change in individuals and organisations.

1 Organisations

Describing an organisation:

7 S

Some common Structures:

• Divisional

• Functional teams

• Matrix

Handy on Styles

Culture

Management and Change: management models and theories associated with motivation and leadership and change management, and their application to practical situations and problems; critical evaluation of a range of principles and frameworks for managing change; an understanding of the issues underpinning the design and implementation of performance management against goals and objectives

2 Change

Gleicher’s formula:

Dissatisfaction x vision x first steps > resistance

Susan Michie Behaviour Change Wheel

PEST

SWOT (Ansoff)

1

2

3 Innovation

Innovators: High SES and “cosmopolitan” (Coleman)

2.5% innovators > 13.5% early adopters > 68% majority > 16% laggards

Network theory

Cliques and hierarchies (Newton)

Innovations will spread quickly (Ryan & Gross, Iowa) if:

• Relative advantage

• Compatibility

• Simplicity

• Can Trial

• Observable benefit

Red Cabbage Sounds Too Organic!

3 Leadership

Theories about leadership:

1. Trait - [intelligence, self confidence, persistence, etc - also charisma] – the hero

2. Skills – US military [knowledge, problem solving, social judgement]

3. Contingency: “best fit” between leader, led, task

Public health leaders (Day et al):

Mentor

Shape

Network

Know

Advocate

Microscopic sheep need kingsize armbands

1 Motivation

Maslow

McGregor

Social power (French and Raven 1959)

Expert: technical

Legitimate: obligations

Reward: pay etc

Referent: makes me feel valued

Coercive: make life difficult for

2 Negotiation

(Fisher and Ury: Harvard Negotiation Project “Getting to Yes”)

• Separate the problem from the people (not “He doesn’t understand”)

• Focus on interests not positions (‘family friendly’ not ‘home at 3.30pm’)

• Invent options (e.g. crèche, school taxi service, etc etc)

• Objective criteria (e.g. meets requirements of Care for the Family Charter)

• Work on BATNA

4 Groups

1 Within the group

Adair: group needs, task needs, individual needs: - NB ALL THREE must be met

Belbin roles

Plant (ideas)

• Resource investigator

• Team worker (hugs everyone)

• Completer / finisher

• Specialist (technical expertise)

• Etc

Tuckman: Forming – storming – norming – performing

Polite hello – big rows about basics – consensus – on with the task

2 Between groups

Lingard’s concepts of ownership and trade

Managing people

Job design

Selection

Appraisal

6 Self management

Assertiveness

Time management

Delegation

7 Miscellaneous

1 Creativity

Group

Brainstorm

Time out

Knowledge management

Personal

Play

Mind map

Art

2 Delegation

• Explain

• Train

• Monitor

• Praise

“Delegate responsibilities not tasks”

3 Effective communication

Written

Customer focussed

Short words – short sentences

Technical language appropriate to readership

Spoken

Remember non verbal aspects

Two way!

8 MANAGEMENT GURUS

1 Models

Taylor: “Scientific management” c. 1910 - the one best way to do things

e.g. doctor to patient in A&E

Fayol: 1910 / 1950 – 5 tasks of management:

• Plan, Organise, Co-ordinate, Command, Control

Mayo: c.1930 – Hawthorne experiments – social processes at work

i.e. morale matters!

Mintzberg: c.1975 – what managers do (mostly muddle through)

• Interpersonal - figurehead, leader, liaison

• Informational- monitor, disseminate, spokesman

• Decisional – entrepreneur, disturbance handler, resource allocator, negotiator

Motivation:

McGregor: X (lazy) and Y (great people)

Maslow: Hierarchy of Needs [NB once a want is satisfied it is no longer important]

Mayo: see above

Herzberg: 1959 Motivation to work –

• Satisfaction = Motivators – achivement, recognition, career progress etc

• Dissatisfaction = ‘hygiene’ factors – status, salary, work conditions, company policy

Running health services

c) Approaches to the assessment of health care needs, utilisation and outcomes, and the evaluation of health and health care: the uses of epidemiology and other methods in defining health service needs and in policy development; participatory needs assessment; formulation and interpretation of measures of utilisation and performance; measures of supply and demand; study design for assessing effectiveness, efficiency and acceptability of services including measures of structure, process, service quality, and outcome of health care; measures of health status, quality of life and health care; population health outcome indicators; deprivation measures; principles of evaluation, including quality assessment and quality assurance; equity in health care; clinical audit; confidential enquiry processes; the use of Delphi methods; economic evaluation (see also 4.d); appropriateness and adequacy of services and their acceptability to consumers and providers; epidemiological basis for preventive strategies; health and environmental impact assessment.

1 Funding of health services

Taxation – general or hypothecated

Insurance – personal or ‘social’

Personal savings (‘provident’)

Patients belong as:

Citizens (e.g. NHS)

Employees (e.g. armed forces)

Customers (e.g. HMO)

NB Most countries have all of these – key issue is which one dominates

International comparisons: USA, Germany

2 Resource allocation

• Population size

• Age

• Morbidity – proxy by mortality (SMR) and LLSI (Census)

Policy and strategy development and implementation: differences between policy and strategy, and the impact of policies on health; principles underpinning the development of policy options and the strategy for their delivery; stakeholder engagement in policy developing, including its facilitation and consideration of possible obstacles; implementation and evaluation of policies including the relevant concepts of power, interests and ideology; strategy communication and strategy implementation in relation to health care; theories of strategic planning; analysis, in a theoretical context of the effects of policies on health; major national and global policies relevant to public health; health service development and planning; methods of organising and funding health services and their relative merits, focusing particularly on international comparisons and their history;

Health and social service quality risk management; principles underlying the development of clinical guidelines, clinical effectiveness and quality standards, and their application in health and social care; integrated care pathways; public and patient involvement in health service planning; professional accountability, clinical governance, performance and apprasial; historical development of personal health services and of public health.

2 Policy formulation

Central policy: Power, ideology in health policy formation

• Ideology e.g. centralise or localise, competition or planning, consumerism vs technical (maternity services)

• Special interests e.g. professional, commercial (tobacco, drugs)

• Data e.g. Euro data on cancer survival

• Expert advice e.g. vCJD, SARS, flu policy

Local policy: Consumer and community participation

• Focus groups, opinion polls etc

• Citizen’s jury

• GP as proxy for local public

• Non executives on local Boards

John Kingdon framework for policy development

3 streams:

Problem stream

Proposals stream

Political stream

Need to align to provide a policy window

Lindblom Muddling through – rational incrementalism

HOW COMMISSIONING WORKS

PLAN

Assess need

Does proposal meet the need? (Evidence review)

Write specification

Procure capacity

Number work

FUND

Prioritisation

Fair decisions (Theories of justice)

Contract type

MONITOR

Overview

Service

Event

Use of information for health service planning and evaluation; specification and uses of information systems; common measures of health service provision and usage; the uses of mathematical modeling techniques in health service planning; indices of needs for and outcome of services; the strengths, uses, interpretation and limitations of routine health information; use of information technology in the processing and analysis of health services information and in support of the provision of health care; principles of information governance

3 Planning

Need = ability to benefit (Stevens)

Need / demand / supply : Bradshaw

Symptoms not the same as need (stoical patients)

Assessing needs for a population (e.g. immigrants)

• Physical health:

Public health programmes:

Imm and vac

Screening

Lifestyle

Primary care

Medical

Dental

Pharmacy

Specialist (same as anyone else)

• Mental health: e.g. depression / anxiety / post traumatic etc

• Social health: e.g. keep groups together, language culture etc

Joint strategic needs assessment

Asset based needs assessment

Planning capacity – numbers

Assessing needs for a specific condition or service (e.g. arthritis, ECMO)

• Epidemiological

Definition

Numbers

absolute e.g. incidence

marginal e.g. waiting times

norms

Model of care

• Comparative

Neighbouring services

• “Corporate need”

Government policy

Stakeholder views

4 Funding

1 Priority setting

Government policies

Local opinion

Economic evaluation

Strength of evidence

Justice

• Bentham

• Rawls

• Procedural

Procedural justice and IFRs

2 Types of contract

Block / capitation

Tariff / item of service

Finance, management accounting and relevant theoretical approaches: the linkages between demographic information and health service information - its public health interpretation and relationship to financial costs; budgetary preparation, financial allocation, contracts and service commissioning; methods for audit of health care spending.

2 NHS finance systems

Budget reports usually show:

Pay (staff salaries)

Non Pay (e.g. drugs and equipment)

Spend:

year-to-date

forecast to year end

Separate recurrent from non-recurrent (e.g. buying a piece of equipment)

Non-recurrent = ‘capital’ spending

5 Monitoring

1

1 Performance - overview

Outcome framework for NHS in England – 5 ‘domains’

• Effective

o Prevent premature death

o Good QoL for long term conditions

o Recovery from acute episodes

• Good experience

• Safe

Quality outcomes framework (QOF) for GPs



2 Performance – evaluation of a service

Donabedian: process, structure, outcome

• structure e.g. beds, opening hours, staff qualifications and numbers etc.,

• process e.g. number of admissions. Operations

• outcome

3

4 Performance - exceptional events

• Confidential enquiries

• Sentinel audit

• Untoward incident – ‘never’ events

Root cause analysis – active errors and latent errors

=========================================================

5 Governance and risk management

• How serious?

• How likely?

Risks to:

• Patients

• Staff

• Buildings & equipment

• Reputation

migration, and the health effects of international trade; international influences on health and social policy; critical analysis of investment in health improvement, and the part played by economic development and global organisations

6 International health care

Infections e.g. SARS

People going abroad for treatment

Tourists

People retiring e.g. to Spain

Immigrants

Border issues

7 Social policy

“role of state in relation to welfare of citizens”

SHEESH

• Social security

• Housing

• Education

• Employment

• Social services

• Health

Michael Hill Understanding social policy 6th ed Oxford: Blackwell 2000.

A good read.

TIPS ON EXAM TECHNIQUE

1

2 PREPARATION

You MUST get enough sleep for the five days before the exam.

Dement WC. The promise of sleep. London: Macmillan 2001

Book diary time for revision, but Benedict Carey (‘How we learn’) says that following a routine of same time, same place may not be optimal. It’s ok to potter, mull things over etc.

Always quickly revise what you did yesterday – that’s an important aid to memory. (Ideally do it again a week later too.)

Don’t just read passively - test yourself.

Buy a watch or clock with a big face; analog not digital.

3 GENERAL

1. WATCH YOUR TIMING!

Paper IA and IB: 25 minutes per qq: 5 minutes to plan; 20 minutes to write.

When allowed to open the paper, write down the start time opposite each question:;

10.00; 10.25; 10.50; 11.15; 11.40; 12.05

2.00; 2.25; 2.50; 3.15

If you’ve gone over the allotted time on a question - or part of a question –

STOP WRITING AND MOVE ON!

Paper IIA: The exam assumes you will take 50 minutes to read the article. You can then allow one minute per 1% of marks i.e. 40 minutes for 40% of the marks. Again:

If you’ve gone over the allotted time on a question - or part of a question –

STOP WRITING AND MOVE ON!

Paper IIB: 5 questions in 90 minutes = 18 minutes per question.

2. HEADINGS

You must structure your answer. The easy way to do this is to use headings: two per page.

No headings needed if, as if often the case nowadays, the question is broken down into many parts.

3. EXAMPLES

Give examples: name authors ; cite studies

Rule #1: If the example is implicit in the question (e.g. ‘discuss screening for colorectal cancer’) stick to that, don’t wander off

Rule #2: If the example is not implicit in the question (e.g. ‘discuss quality assurance in screening programmes), use a wide variety of examples

4. CRITIQUE

Explain everything: Say ‘because…’ ‘hence’ ‘and so’ as often as possible!

Give both sides of any argument: ‘on the one hand...’ ‘on the other hand’

Point out any limitations e.g. of data sources, problems with somebody’s theory etc etc

5. AMOUNT

You need to write about 250 words every ten minutes i.e. about 2-3 sides of A4 for a 20 minute answer when practising (The exam answer paper has very wide margins so you will cover more paper.)

4 PAPER I

If you can't think of a better structure:

For short questions e.g. "write short notes on":

• What is it? (definition if possible but if not talk around it)

• What do people use it for? – give an example

• Something in favour

• Something against

and, if time allows:

• Current issues in.....

OR for more social / management questions:

• Definitions and subcategories of the problem

• How to tackle the problem

• How to prevent the problem

General frameworks

Mind map:

Method:

• Underline the key word in the question

• Construct mind map of anything that comes to mind

• Fill out mind map with names / data / case studies

• Add in some topical examples

• Number main areas of map to give the order for your main paragraphs

• Always start with points on definitions

Basic roles of public health:

• Health improvement e.g. lifestyle programmes

• Health protection e.g. vaccination programme, outbreak response

• Health services e.g. screening programmes, commissioning

• Health intelligence e.g. surveillance of trends etc

• [Academic – R&D] e.g. basic research

Epidemiology

1. If ‘describe the ep of’:

• Time [secular trends - 50year, more recent]

• Place [UK, Euro, world]

• Person

• age / sex / soc cl

• ethnic / occupations / lifestyles

• familial / genetic

• any other famous facts?

FILL OUT the answer by thinking about the quality of study / data (e.g. ascertainment)

2. If ‘cause’ or ‘association’: Bradford Hill framework

3. 'What is the evidence?' or 'How would you study…?'

Consider evidence from:

Descriptive: time trend, spatial, people affected: do they fit the hypothesis?

Surveys

Case - control

Cohorts

Interventions

Remember studies in special groups e.g. high risk, occupational

Evaluation

If "how would you evaluate…" mention Donabedian then

• structure e.g. beds, opening hours, staff qualifications and numbers etc.,

• process e.g. number of admissions. operations

• outcome e.g. survival, quality of life

If "assess the performance of..."

Could use Donabedian, may need to consider performance framework:

Health improvement public health

Fair Access equity

Appropriate Delivery of effective health care EBM

Patient / carer experience complaints/survey

Outcome of NHS care audit

Needs assessment

If “assess the health needs of …" a group e.g. immigrants

• Physical health:

Public health programmes:

Hygiene – food water shelter

Imm & Vacc

Screening

Lifestyle programmes

Primary care: medical (e.g. skin / foot problems) dental, pharmacy

Specialist (same as anyone else)

• Mental health: e.g. depression / anxiety / post traumatic etc

• Social health: e.g. keep groups together, language culture etc

If “assess the needs for" a condition e.g. arthritis

• Epidemiological

Definition

Numbers (absolute e.g. incidence or marginal e.g. waiting times)

How do we meet the need now? (e.g. admit to orthopaedic bed)

Does this work? (e.g. how many get back to work?)

Other ways to meet the need (e.g. out patient phsyio, home exercise)

• Comparative

Royal College norms or standards

Neighbouring services

• Corporate

Government policy

Stakeholder views

Communicable disease / environmental health

Mention TASKS and MANAGEMENT PROCESS to achieve them

TASKS

Outbreak framework if possible

• Confirm facts

• Immediate measures : to contain / treat illness

• Case definitionS : definite, possible, probable

• Case finding: FULL EXTENT in time and place

• active

• enhanced surveillance

• Descriptive epidemiology: e.g. all babies / ethnics / swimmers

• Hypothesis: usually mode of spread, sometimes cause

• Test hypothesis

• Action: e.g. Broad St pump

MANAGEMENT PROCESS

OB plan, multiagency team, press releases etc

Similar can work for acute chemical exposure

Health information

Always consider all of (even if only to say “not much use”):

• Mortality

• Hospital: Inpatient, OPD / A&E, lab

• Primary care: Medical, [dental], prescribing, NHS Direct

• Register: e.g. cancer

• Surveys

• Non-health: fire, police, social services etc

Health promotion and disease prevention

Again TASKS and MANAGEMENT PROCESS

Health promotion framework:

• Legislative

Fiscal tax or subsidy

Bans

• Health service:

Local policy

Hospitals (treatment but also as a major local employer)

Primary care

• Local:

Schools

Leisure

Others e.g. transport, policy, voluntary groups etc

Short notes e.g. statistics, economics

What is it?

When would you use it? –give an example (preferably real, if not make a hypothetical)

Something good / useful

Something tricky / difficult

[Hot topics]

Sociology / social policy / management

Basic requirement is to match theories with facts.

Use one of the theories (see above: e.g. Maslow, Handy) as a way of describing how the world works.

Remember the big picture e.g. other agencies to involve in any practical problem:

• UP: Department of Health involvement; Colleges; GMC?

• SIDEWAYS: Colleagues in your organisation, neighbours (e.g.hospitals)

• DOWN: GPs, public

Social policy

Use the SHEESH headings, one paragraph about each:

Social security (disability benefit, pensions etc)

Housing

Employment

Education

Social service

Health

Ethics

Use the headings, one paragraph about each:

Good - how can this do good to the patient

Harm - how might this do harm to the patient

Autonomy (let people decide for themselves)

Justice (fairness to other people)

5 PAPER IIA: strengths and weaknesses

50 minutes to read the paper; 10 minutes for each 10% of the marks

Top tips:

1. ‘Strengths and weakness’ is only 40% of marks: remember the other 60%

2. It takes 30 minutes to write 600 words so take 10 minutes to PLAN the S&W answer fully

3. Say ‘… because’ a lot!

Technique is in two stages:

1. assemble material – see below

2. group into findings, strengths and weaknesses

Strengths and weakness – the task is to deliver 600 words on strengths and weakness, or 300 words on each. That’s two sentences ( = 25 words) of strengths and same again on weaknesses on each of the following 12 headings:

1. AIM

POPULATION

2. Main study population

3. Exclusions

METHOD

4. Design

5. Execution

6. Instrument

INTERVENTION

7. Design

8. Fidelity

RESULT

9. Big?

10. Chance (Type I and II errors)

11. Bias

12. Confounding

6 PAPER IIB: data skills

Reading graphs etc: – Data content – obvious features – possible interpretation

A general approach to reading tables

• Size (using common sense: high or low e.g. smoking rates all above 60%?)

• Spread (highest and lowest; spread out or clumped together?)

• Trend (is the Table in some order?)

• Variation by Gender / Age / Practitioners / Spatial (GAPS)

Interpretation: ABC E

Artefacts:

• Error e.g. typing mistake

• coding

Blip:

• P values / confidence intervals etc

• Consistency – time (blip?), sex (male AND female affected?) etc

Category:

• Primary into secondary

• Health / social care

Epidemiology of underlying disease or its risk factors

|LA Name |SMR CIRCULATORY DISEASE I00 - |CHD Admissions (SAR) I20|Angiography (SAR) K63 |IMD 2004 |

| |I99 |- I25 | | |

|Wigan |126 |113 |103 |29.3 |

|Salford |121 |108 |85 |38.2 |

|Allerdale |120 |88 |97 |22.9 |

|Lancaster |117 |87 |89 |22.3 |

|Liverpool |116 |124 |140 |49.8 |

|Carlisle |113 |104 |66 |22.2 |

|Barrow-in-Furness |108 |97 |112 |33.0 |

|Ribble Valley |107 |72 |62 |10.3 |

|Crewe and Nantwich |105 |98 |58 |17.1 |

|Chester |99 |76 |69 |17.0 |

|South Lakeland |97 |77 |81 |12.0 |

|Macclesfield |96 |73 |68 |11.2 |

| | | | | |

|Health Inequalities (2005). North West Public Health Observatory. .uk/information” |

| | | | | |

7 Some facts and figures

Basic facts and figures (England) for 250,000 people : all VERY approximate – designed for ease of remembering!

250,000 people

15% over 65

15% under 16

Smokers 20% of ADULT population; obese also 20% of adult popn

25 people HIV positive (more in London)

40 teenage (under 18) conceptions

--------------------------------------------------------------------------

Deaths per year: 2500 (1 in 100) = births per year!

CHD under 75yr : 200

Lung cancer 150

Bowel cancer 75

Breast cancer 50 deaths (100 cases / registrations)

Suicide 50

RTA 20

Cancer of cervix 5

Pregnancy with congenital anomaly:

Congenital heart disease: 10 (5 per 1000 births each)

Down syndrome, NTD, cerebral palsy: 5 each (1 per 1000)

------------------------------------------------------------------------

Screening: 1 or 2 cases per 1000 screened (breast: 12 cases / 1 per month)

------------------------------------------------------------------------

GP consults 1,250,000 per year

OP attendances 200,000 per year (of which 60 new, 140 old)

A&E attendance 75,000 per year

Hospital admissions: 50,000 per year

Emergency 40 / day; Elective 60 / day

AMI, stroke, O/D, pneumonia: each 1 or 2 per day / 400 per year

Hip replacement 4 per week = 200 per year

People with schizophrenia (point prevalence 1 in 1000): 250

--------------------------------------------------------------------------

Hospital docs 350; 100 consultant, 250 junior

GPs n = 250+ (list size c. 1800)

Attendances = 20% of popn every 2 weeks

NHS Dentists n = 125

Money: about £1000 per head = £250m for 250,000 people

£125m hospital; £25m GP drugs

8 Reports / briefing papers

"Write a report / briefing paper":

• Purpose: one sentence ‘The aim of this briefing is to …’

• Background

Scientific – ‘What is already known about this topic’

Policy: any government policies / NICE guidelines / NSFs?

• This data / report ‘What this study / data adds’

NB NO TECHNICAL TERMS – e.g. death not mortality, illness not morbidity etc etc, don’t quote P values or CIs

• Implementation

Likely views of:

Consultants

GPs

Public / patients

Any ethical issues?

Requirements for

more staff

equipment

buildings

Cost and cost per QALY (or similar)

• Conclusion and recommendation

_____________________________________________________________________

9 DATA PRACTICE: CALCULATIONS

1. Here is an extract from Doll’s data on death rates in British doctors followed for 35 years (BMJ 1992; 305 p1523)

Death rate per 100,000 men per year, age standardised by cigarettes smoked per day

| |0 |1-14 |15-24 |25 or more |

|Lung cancer |14 |100 |182 |327 |

|IHD |526 |752 |825 |956 |

|Chronic bronchitis |9 |77 |93 |180 |

|Suicide |25 |29 |32 |60 |

For each of the four conditions, calculate the excess risk associated with being a heavy (25 or more) smoker rather than a non smoker.

2. Patients with breast cancer were randomised to receive trastuzumab or placebo. After a median of 23.5 months follow up, 59 of the 1703 patients receiving trastuzumab had died, compared to 90 of 1698 patients receiving placebo. [Lancet 2007; 369: 29 – 36]

a. What is the relative risk reduction?

b. What is the absolute risk reduction?

c. What is the Number Needed to Treat?

3. I have invented a new scale for quality of life, and obtained scores from seven Part A MFPH students, which are as follows: 5, 6, 8, 9, 12, 15, 22.

a. What is the mean score in these seven students?

b. If we take that mean as an estimate of the mean score among all Part A students, what is the standard error of the estimate?

4. In a trial of medication review intended to reduce admissions to hospital of old people, the number of emergency hospital admissions in the intervention and control groups were as follows ()

[weighted average]

Number of admissions

| |0 |1 |2 |3 |4 |5 |6 |

|Intervention |253 |113 |34 |10 |3 |1 |1 |

|Control |281 |99 |26 |5 |3 |0 |0 |

a. Calculate the mean number of admissions per person in (a) the intervention and (b) the control group.

b. Would a t test be an appropriate way to judge whether the difference in mean admissions per person is due to chance?

5. In patients over 65 with newly diagnosed glioblastoma, the median overall survival was longer with radiotherapy plus temozolomide than with radiotherapy alone (9.3 months vs. 7.6 months; hazard ratio for death, 0.67; 95% confidence interval [CI], 0.56 to 0.80; P ................
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