1
Q
What kind of patient-doctor relationships exist? (3)
A
- Paternalistic - Doctor-led
- Shared - Partnerships
- Informed - Patient-led
2
Q
Describe the Paternalistic Model of Patient-Doctor Relationships
A
- Dr makes systematic enquiry into pt illness
- Patient passive and simply answers dr q
- Information flow largely dr to pt
- Dr makes the decision about what is best for pt, underlying assumption that doctor is best placed to make decision
- Expectation pt will agree with doctor
3
Q
Describe the Shared Model of Patient-Doctor Relationships
A
- 2-way exchange of information
- Both participants bringing expertise, dr medical, pt personal
- Pt and Dr reach decision together
- Agreement reached / Consensus on appropriate treatment.
- Disagreements lead to negotiation towards shared decision
4
Q
Describe the Informed Model of Patient-Doctor Relationships
A
- Dr communicates all relevant info and treatment options, risks and benefits to pt
- Information giving is doctor’s key contribution
- Patient very active in this model
- Decision making is sole prerogative of pt.
5
Q
What is current thinking on doctor-patient relationships?
A
Shared model is most advocated. In policy and professional discourses. Shared decision-making seen key element of person-centred care. But need a ‘repertoire of doctor-patient relationships’ as nature of relationship may change within and across consults
6
Q
How have doctor-patient relationships been affected by social forces and change over time?
A
- Much current political currency in ‘patient choice’ and direct links with consumerism. Linked with drive for patient to have direct access to all their medical data easily and drive for healthcare system to be able to gather electronic data and evidence on effective treatments
7
Q
Identify the major Pattern of Health Indicators in health and disease in the UK (P25b)
A
- Infant Mortality - Proxy marker, correlates well with other proxy measures e.g. disability adjusted life expectancy. Easier to measure
- Mortality and Morbidity in F&Ms
- Life expectancy
8
Q
Identify the major trends in health indicators in the UK (P25b)
A
- Infant mortality generally decreasing
- Life expectancy at birth generally increasing, slight plateau since 2011. Slightly higher for females than males
- Death register trends - Males main cause of death = Ischaemic heart disease IHD. Females = Dementia and Alzheimer Disease
9
Q
Identify Factors Affecting Social Patterns (Social Epidemiology) of Health within a Population
A
- Socio-economic status
- Gender
- Ethnicity
- Age
- Geographical location
10
Q
What is Social Epidemiology in relation to Distribution of Health?
A
Studies of social distribution and social determinants of health - Socio-economic status, gender, age, ethnicity. Not all individuals within group will experience same environment/outcome
11
Q
How is Socio-economic Status measured?
A
- Occupation/income/education etc.
- Most commonly used = Registrar General’s Socio-economic classification.
- Used to look at health inequality based on occupation
- Is proxy for status, income, access to material resources, education
12
Q
Examine how health is socially patterned within a population by socio-economic status (P24c).
A
- Males and Females living in most deprived areas had statistically significant higher avoidable mortality rates than those living in least deprived areas.
- Children in lowest SES households highest infant mortality rates.
- Linear gradient in health deteriorating as lower socio-economic status. Evident across general health and morbidity measures too
13
Q
Examine how health is socially patterned within a population by Gender (P24c)
A
Male life expectancy from birth also decreases in regular linear pattern from most advantaged socio-economic class to most disadvantaged class
14
Q
Examine how health is socially patterned within a population by Geographical Location (P24c)
A
- Variations in health between regions and neighbourhoods
- Morbidity and mortality rates consistently higher in north and west and in urban areas
- Can be substantial inequalities in morbidity and mortality rates within local areas
15
Q
Identify the major trends in health and disease in the UK (P25b) (3)
A
- Undergone epidemiological transition
- Increase life expectancy at birth but growth has slowed/halted
- Public health advances e.g. better sanitisation and clean water, with changes in social and built environment are associated with changes in pattern of disease
- Disease pattern changing - Cancer most common cause of mortality then respiratory then circulatory
16
Q
Define the term Health Inequality (P24d).
A
- Unfair and avoidable differences in health across population / different groups within a community
- Systematic difference in health and illness across social groups:
- Socio-economic, Gender, Ethnicity, Culture, Religion
17
Q
Identify and the Main Explanatory Models for Health Inequalities (P24d). (4)
A
- Behavioural and cultural model
- Material and Neo-materialistic model
- Psychosocial model
- Life course model
- Latter 3 - Responsible for social gradient in health inequalities
18
Q
Describe the Behavioural/Cultural model of Health Inequality
A
- Proposes that: Health inequalities are result of variations in health behaviours and lifestyles e.g. smoking, diet, exercise etc
- Result of: Individual choices, Knowledge, Culture
19
Q
Appraise (Assess) the Behavioural/Cultural model of Health Inequality
A
- Most important health behaviours follow the social gradient: Smoking, lack of physical activity, poor nutrition = Higher in lower socio-economic groups
- Health related behaviour cannot account for all current patterns of health inequalities
- Health behaviour important but others must be taken into account too.
20
Q
Describe the Materialistic Model of Health Inequality
A
- Health inequalities result from differences between socio-economic groups in access to material resources (social inequality)
- Health inequality results from direct effects of poverty and material deprivation
- Access to material health resources is shaped by broader structural factors: Place in society, policies, etc
21
Q
Appraise the Materialistic Model of Health Inequality
A
- Lower socio-economic status associated with poorer access to material health resources
- Black report found material explanation most important in explaining social class difference in health
- Accounts for Income, food, fuel, heating , housing, transport, healthy environments, exercise facilities
22
Q
Appraise the Materialistic Model of Health Inequality
A
- Lower socio-economic status associated with poorer access to material health resources
- Black report found material explanation most important in explaining social class difference in health
- Accounts for Income, food, fuel, heating , housing, transport, healthy environments, exercise facilities
23
Q
How does Food (Material Model) contribute to Health Inequality
A
- Poor diets and nutritional status associated with elevated risk of CHD, Type 2 diabetes, childhood obesity
- High income generally associated with better diet, more fruit and veg, higher fibre intake, lower sugar intake.
24
Q
Describe the Neo-Materialistic Approach to Health Inequality
A
- Emphasises the combination of negative exposures and lack of resources held by individuals + Systemic underinvestment in physical, social, and health infrastructure
- Combines individual and community level resources.
25
Describe the Psychosocial Explanation of Health Inequality
- Health inequality linked to the way people's environment makes them feel
- Psychosocial stress affects health: Directly ('Allosteric load' links neuroendocrine pathway) + Indirectly (Adoption of 'unhealthy behaviours)
- Psychosocial stress associated with social inequality leads to social gradient of health outcomes: Money and other worries, and position in social hierarchy
26
Describe the Lifecourse Model of Health Inequality
- Material, Behavioural, psychosocial and biological processes operate independently, cumulatively, and interactively across an individual's life course/ generations, influence development of disease risk
- E.g. Individuals who experience poor home conditions in childhood are more likely to experience occupational disadvantages
27
Define Epidemiological Transition
Changing patterns of population distributions in relation to changing patterns of mortality, fertility, life expectancy and leading causes of death
28
Define Gender
- Socially constructed roles, behaviours, expressions and identities. Not confined to binary or static, exists along a continuum and can change over time
29
Define Health Behaviour + Outline the 3 Types
- Behaviours that are related to the health status of the individual
- Good health behaviours: Sleeping 7-8hrs, regular exercise, healthy eating
- Health protective behaviours: Wearing seatbelt, attending regular check ups and screening
- Health impairing habits: Smoking, eating high fat diet, alcohol abuse - Detrimental to health
30
What are the Three Core Models of Health Behaviours
- Behaviourism
- Social Psychology
- Social Cognition Theories
31
Describe the Behaviourism Theory for Behaviour
- Behaviour is a conditioned response occurring in the presence of a stimuli
- How reward and punishment stimuli affect emotion and behaviour (response)
- If a behaviour is learned, it can also be unlearned/modified through conditioned learning (association)
32
Describe the Social Psychology Theory for Behaviour
- Scientific study of way in which people's thoughts, feelings, and action are influenced by the social environment
- E.g. Milgram's Obedience study - Perceived legitimate authority facilitates obedience.
33
Outline the Social Cognition Theories for Behaviour
- Attempt to explain the relationship between social cognitions (e.g. beliefs, attitudes) and behaviour
- Include:
- Health Belief Model (Rosenstock, 1966) - Weighed up sum of Perceived Threats and Efficacy, defines whether ind engages
- Theory of Planned Behaviour (Ajzen, 1988)
- Transtheoretical Model (Prochaska and DiClemente, 1983)
- COM-B Model
34
Explain the Health Belief Model in Health Behaviour
- Patients weigh up Perceived Susceptibility + Perceived Severity = Perceived Threat // And Perceived Benefits + Perceived Barriers = Perceived Efficacy
- Health Behaviour is the weighed up sum which defines whether the ind. engages or not.
- E.g. Smoking/Covid-19 - Central response
35
Give a criticism of the Health Belief Model
Fails to take into account the influence of others - Social environment + interactions
36
Explain the Theory of Planned Behaviour for Health Behaviour
- Behavioural beliefs + Outcome evaluation = Behavioural attitude --> Behavioural Intention
- Normative beliefs (family and friends/society) + Motivation to comply = Subjective Norm --> Behavioural Intention
- Control beliefs + Self-efficacy = Perceived Behavioural Control --> Behavioural intention/Directly Behaviour
- Theory suggests Perceived Behavioural Control is most influential in deciding whether to engage or not. Outweighs other components.
- Pt internal perceived abilities and external barriers.
- E.g. smoking
37
Explain the Transtheoretical Model (A.K.A Stages of Change)
- Individuals will go through certain stages of behaviour change before they actually reach maintenance of that specific behaviour change.
- As go through stages, perceived self-efficacy (confidence in ability to engage) increases
- Temptations to relapse decrease
- Benefits of behaviour change + Barriers/Perceived disadvantages of engaging in behaviour change decreases
- Pre-Contemplation (PC), Contemplation (C), Preparation (P), Action (A), Maintenance (M).
38
Describe the Stages of the Transtheoretical Model of Behaviour Change
- Pre-contemplation - Individual not considering changing/unwilling/unable to change behaviour, due to health beliefs, attitude, intentions.
- Contemplation - Possibility of Behaviour, possible advantages
- Preparation - Considering change + preparing
- Action - Step towards change but not stable
- Maintenance - Achieved goal and has maintained
- Relapse - Possible to relapse throughout stages and several times.
- Clinicians can help by assessing where individual is in process and adjusting help implement strategies
39
Explain the COM-B Model of Understanding Behaviour
- Reflects Capability, Motivation, and Opportunity. Interact with each other in order to predict whether pt/ind. will engage in a behaviour change.
- Capability - Reflects whether ind has right physical skills, strength, stamina to actually engage. Psychological capability - knowledge, interpersonal skills
- Motivation - Reflective (planning beliefs and intention to engage) + Automatic (emotional response to desires and reflects habits)
- Opportunity - Physical and Social - Space, time, location and availability to attend and social - representations of social norms, also motivation to comply to social norms
40
Identify the domains to be considered when promoting behaviour change
41
Define Prevention
- Actions aimed at eradicating, eliminating, or minimising the impact of disease and disability
- If not feasible, retarding the progress of disease and disability
42
Define Health Promotion
- Process of enabling people to increase control over their health and its determinants, thereby improve their health
- Offers positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual wellbeing
43
How is Health Promotion done?
- Communication - Raising awareness about healthy behaviours for the general public
- Education - Empowering behaviour change and actions through increased knowledge
44
Outline the 3 Levels of Prevention of Disease
- Primary - Prevent occurrence / increase resistance to a disease/injury
- Secondary - Reduce impact of disease already occurred (medication etc)
- Tertiary - Limits damage from disease to reduce progress of ongoing disease/injury
45
How is Primary Prevention of Disease/Injury Achieved?
- Reduces incidence + prevalence by preventing disease before occurs
- Achieved by
- Health Promotion - Health education, Environmental modifications, Nutritional Interventions, Lifestyle and behavioural changes
- Specific Protection - Immunisation + Seroprophylaxis, Chemoprophylaxis, Specific nutrients/supplements, Safety of drugs+foods, Control of environmental hazards e.g air pollution
46
Give examples of Prevention for High BP Management
- Primary - Dietary limitations, Education, Exercise
- Secondary - BP control medications, naturopathic treatment
- Tertiary - Treatment for disease risk factor of HBP i.e. stroke
47
Who are the targets for Primary/Secondary Prevention?
- Individuals at high-risk of disease
| - Whole population
48
Describe and Compare the Individual and Population approach to Primary/Secondary Prevention
- High risk individuals - Extension of clinical approach, High patient motivation, high doctor motivation, can be more cost-effective
- Population - Benefits for population as a whole, attempts to control root cause/determinants of disease, shifts cultural norms, more permanents.
Limitations
- Individual - High resource use on identifying high risk, medicalise prevention, does not produce lasting change at pop level.
- Population - Benefit is small for each individual, low subject motivation
49
Describe Rose's Prevention Paradox
- A preventative measure that brings large benefits to the community offers little to each participating individual
50
Summarise the best-evidence for how health promotion can be achieved
- Ottawa Charter WHO 1986
- Action areas:
- Build healthy public policy
- Create supportive environments
- Reinforce community actions
- Develop personal skills
- Reorient health services from treatment to provision
51
What is meant by the victim-blaming approach?
- Implies if people are given info/advice and do not adhere to it, then their health problems are their own fault
- Does not take into account what limitations pt may have or ability to change behaviour
52
Outline Ewles & Simnett's 5 Approaches in Health Promotion
- Medical - Screening/Imms
- Behaviour change
- Educational - Provide info, informed choice
- Client centred - Health issues identified by pt
- Societal change - E.g. Changing physical, social, economic envi - policy/legislation
53
Why are health inequalities a concern of doctors?
- Fairness & Social justice
- Health as a human right
- Reduce the cost associated with premature deaths and illness
- Good medical practice can make a difference
- Key theme in government health policy - life course framework, helping people live longer, healthier and more fulfilling lives.
54
What is the Marmot Review (2010)?
Proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work, and age, and which can lead to health inequalities
55
What has been concluded as the major determinants of health inequalities?
- Social inequalities - Marmot Report 2010
| - Structural determinants and conditions of daily life - Commission on Social Determinants of Health, 2008)
56
Summarise the best-evidence for how health inequalities can be tackled
- Marmot Review 2010 - Reduce the social gradient, Action across all social determinants and all sectors, participatory decision making at local level. Action across the life course
57
What is meant by the Social Gradient in Health?
- Phenomena where people who are less advantaged in terms of socioeconomic position and worse health than those who are more advantaged
58
What is the aim of reducing the social gradient in health?
- A more equal distribution of health chances across socio-economic groups
- Population-wide
- Need absolute improvements in all groups, but rate of improvement which increases at each step downwards on socio-economic ladder
- Provide resources and services at a progressively greater level as needs increase
- = Progressive / Proportionate Universalism
59
Proportional / Progressive Universalism is an approach to addressing health inequalities that
1. Prioritises social or health disadvantage
2. Tackles the social gradient in health
3. Prioritises the downstream factors which may impact health inequalities
60
Describe Interventions Reducing Health Inequality
- Evidence that upstream interventions reduce inequality
- Workplace interventions - Increase employee control over work envt
- Housing interventions - Improve standard of housing, more choices for low income families
- Water fluoridation - Strong relationship between tooth decay and social deprivation in fluoridated + non-protected communities
- Evidence base limited:
- Resource provision and fiscal interventions: Free folic acid supplements, Tobacco price increases
- Improving educational level
- High quality parenting programmes
- Incentivised prescribing e.g. preventative
61
What is meant by inverse prevention law
- Even where interventions are successful in improving health across nation, they may increase health inequalities
- Where an intervention benefits advantaged (low-risk) more than disadvantaged (high-risk) groups - Intervention generated inequalities
62
What are examples of intervention generated inequalities?
- Mass media campaigns on 'stopping smoking' and folic acid intake
- Workplace smoking bans
63
Explain the role that doctors and health care professionals can play in combating health inequality
- Clinicians - Ensure access to quality care for vulnerable groups, support service referrals, data on inequality attributable admissions
- Advocates - Development of services/programmes for better outcomes
- Managers+ Clinical leads - Model
- Educators - Provide placements in disadvantaged areas, investigate social determinants, local projects
64
What does tackling Health Inequalities entail?
- Tackling social determinants
- Tackling social gradient
- Difference between social gradient approach and health disadvantage
- Need to tackle determinants and across sectors
- Target young children + families =- But life course approach essential
65
What do Upstream and Downstream Approaches to tackling health inequalities mean?
- Upstream - Causes
| - Downstream - Avoiding or preventing
66
Define Race
- Seen to be characterised by physical appearance and determined by genetic ancestry and is usually permanent
67
Define Ethnicity
- Common perception: Ethnicity is defined as a sense of belonging and is a group identity, it is determined by social pressures and psychological need and is partially changeable.
- Results from many aspects of difference such as genetics,
culture, religion and nationality and is how you see yourself and your identity
68
Define Culture
A set of behaviours and attitudes of a group and is
| often determined by upbringing and choice and is changeable.
69
What is the 'healthy migrant effect'?
- The mortality advantage in migrants relative to the majority population in host countries that is reported in many countries
- Could be due to the selective migration of healthy individuals and/or healthier lifestyles such as lower smoking and alcohol consumption.
70
Outline and explain the links between ethnicity, culture and health.
- Evidence suggests a complex interplay of deprivation, environmental, physiological, health-related behaviours, ‘healthy migrant effect’
- Ethnic minority groups are disproportionately affected by socio-economic deprivation, a key determinant of health in all communities but not clear if applies equally across all ethnic groups
71
Define Sex
This is the assignment/classification of people as male, female, intersex, or another sex, often based on physical anatomy at birth or karyotyping
72
Define Gender
Socially constructed role, behaviours, activities, and attributes that a given society considers appropriate for males and females
73
Define Gender Identity
Internal sense of one’s own gender
74
Define Transgender
Umbrella term for people whose gender identity differs from the sex they were assigned at birth. The term is not indicative of gender expression, sexual orientation, hormonal makeup, or physical anatomy
75
Outline and explain the links between gender and health
- women spend a greater proportion of their lives in poor health and with disability
- social and economic factors can put women at greater risks of poor mental health
- male Covid 19 mortality was higher than female
- Explained? - Biological differences, Differences in health behaviour, gender roles and exposure (caring roles - Physical and mental-ill health), use of and access to health services (women more likely), socio-economic factors (women more likely to be in poverty), gender inequality
Block 2
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