Public Health

What is meant by the public health approach to disease?

A public health approach begins by using surveillance procedures to identify and categorise the problem. It then determines the risk and protective factors that can be used to reduce the overall prevalance of the problem. After that, it uses this knowledge to develop and test interventions and finally, there is a continuation of efforts to implement interventions with high fidelity.

What do health economists do?

Well, health economics is the study of how scare resources are allocated among alternative uses for the care of sickness and the promotion, maintenance and improvement of health. Health economists are concerned with the economic organisation of health services and the interactions between health and the economy. This occurs on two levels. Firstly, there is what social scientists call the macro level (i.e. societal level). In this regard, health economists look at health and the economy, such as international comparsions and at efficiency and equity of health services. Health care priorities, like public spending and taxation and impact of private sector also come under their gaze. Additionally, they would look at the economic influences on health, such as income, employment, lifestyle and consumption (not dissimilar to medical sociologists and anthropologists who look at societal and cultural influences on health). Secondly, on a micro level, health economists look at finance and organisations (e.g. how organisations are financed). This would include looking at markets for inputs and how budgets, regulation and incentives are set. Health economists examine the DDS of health services - Demand (i.e. wants and needs, barriers to access and health information), Delivery (i.e. rationing, economic evaluation and monitoring) and Supply (i.e. costs and quality of services).

What are health-care associated infections?

Health care-associated infections are characterised by pathology related to the presence of infectious agents or their products as a result of exposure to health-care procedures. They are often caused by bacteria which have acquired resistance to one or more antimicrobial agent. These bacteria have the ability to colonise human beings for prolonged periods. Colonised patients may disseminate these nosocomial pathogens both during and after their hospital stay.

Health care-associated infections can sometimes be called hospital acquired infections. Examples include surgical wound infections, bloodstream infections, urinary tract infections (usually associated with urine catheters and the aseptic insertion and management) and lower respiratory tract infections. They can occur due to one or more of the following:

1. Breaches in normal body defences (surgery, invasive devices) 2. Underlying illness increases vulnerability (immune response, diabetic ulcers) 3. Opportunistic pathogens (take advantage of the critically ill, resistant/epidemic strains) 4. Exposure to micro-organisms (cross-infection) 5. Weaker standards of cleanliness and hygiene 6. Lack of awareness of and senior management attention given to health care associated infections.

Means to control health care associated infections will need to adapt to the changing nature of medicine and health-care delivery and demand a thorough understanding of the underlying dynamics of health care associated infections with respect to their ecology, epidemiology and economic ramifications. Best practice is to adopt evidence based and cost effective methods.

What is meant by 'Travel Health'?

Good question. Please see here for my interpretation.

I'm a public health professional but not a public health doctor. Is there anywhere I can update my learning as I work?

Absolutely! If you're into e-learning, www.healthknowledge.org.uk is a really good resource to have at the tip of your fingers.

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Research Problems

I'm a 5th year medical student and I have to do a dissertation as part of my degree. I recently submitted my proposal but my tutor said that it lacks focus and that he can't see what it is that I want to do. How do I address this?

This is a really common problem. Very often I have read proposals where people have got excited about a topic and either go off in dozens of directions or they expect to find what it is they are looking for once they head into the field. (You'd be amazed the number of times I have reviewed a questionnaire without a purpose to go with it!) To focus your proposal, try this simple exercise. Imagine your grandmother or another close relative comes to visit you. She asks you what your research project is all about. If you can answer in a sentence or two, you have focused your research question. Remember, don't have a research question that can be answered yes or no. Test yourself by asking why? "Why is this interesting?" Hope this helps and good luck with your dissertation.

I'm a first year social science student and my friends have been using an essay writing agency to help with their assignments. I know that it is plagarism of sorts but they seem to be getting away with it and they say that it is expected. Is this the future? Will my work be judged on how well I can put an essay together with professional writing help?

Don't worry, these essay writing agencies are not necessarily the best route nor are they a necessary evil. If you are in a small tutorial group, your tutor will become very aware of your work and will undoubtedly be able to see if you have a voice or not. Believe me, you can tell if an essay has the student's personality or not. It is not difficult. For big lecture groups, you could get away with it but would you want to? At the end of the day, you'll have left university without mastering the skill of putting together an argument. You could end up in a job where you'll be expected to put together reports and policies and if you can't string an argument together from the evidence, then you'll be in some trouble. Forget the pressure. Keep your money and use your spellcheck. In the end, you'll end up the winner.

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MFPH Part A Questions

I'm taking the Part A MFPH in June and I am getting quite stressed! I am particularly struggling to find information on the management modules. I have got Charles Handy's book and have printed out the health knowledge pages, but am not finding either hugely helpful for this section. Can you help?

I can see why you're finding these modules the hardest - I did too! For management, the key things are change management [i.e. organising it - think the 4 step approach of where are we now? where do we need to get to? how will we get there? and how will we know when we are there? (measurements, monitoring, key performance indicators); managing it - the 5 stages of grief that staff have to be managed through], managing teams (Belbin's team roles and the forming, storming, norming, disbanding/reforming stages), how to write a strategy, reach targets and management performance. For strategy development, don't forget to add in the PEST analysis (political, economic, social and technological) plus ELI (ecological, legislative and industry). Also look up Simon's 4 steps for problem solving, i.e. perception, formulation, evaluation and choice. If you haven't done any management courses, try managment for dummies or one of the other general, easy to read management books you can get in Borders (go in, get a cup of coffee and scan!). If you're feeling pressured for time, look to past exam papers and develop a few general frameworks that you could apply to a large number of frameworks. As to the health service delivery, think of partnership working at a local level and how to lead/negotiate on public health when there are different agendas and viewpoints. I remember using the public health handbook to help develop some answers.

I've been looking through the syllabus and I'm at a loss at what epidemiological paradigms mean. What do I need to know?

Epidemiological paradigms refer to three different approaches to explaining the development of chronic conditions, e.g. cancer and cardiovascular diseases (like CHD). These approaches are biological programming, adult risk factors and life-course. Please click here for some notes on these approaches. These are not exhaustive but should help your exam preparation.

What is meant by the McKinsey's 7s framework?

The seven S's stand for strategy, structure, systems, staff, style, shared values and skills. The McKinsey 7 S framework is used to help identify the strengths and weaknesses of an organisation and how change in one can affect the other.

I've been looking at the difference between leadership and management and I am a little confused about what leadership skills are and what people mean by the five management functions.

An easy way to understand the difference between leadership and management is to think Leader: vision and strategy; Manager: action and planning. A leader 'leads' on strategy development whilst a manager 'organizes' by maximising the use of resources to meet the needs and tasks of the organisation (think of policy development and implementation). The leadership skills needed are group formation, negotiation, delegation, communication, innovation and creativity. The five management functions that people refer to are: (1) Forecast and plan [vision and SMART objectives]; (2) Organize [build up equity and structure]; (3) Command [maintain activity amongst personnel]; (4) Co-ordinate [unify and harmonise activity] and (5) control. However, note that this is old fashioned and that it does not work in public health. Perhaps, it may be better to think of Mintzberg's POMC (i.e. plan, organize, motivate and control). Under 'Plan', we include a current analysis of where are we now, goals & objectives, how we can get there and how to know if it is successful; 'Organize' consists of manpower, materials, machines and money plus organisational structure, delegation and communication; 'Motivate' means the ability to get people to commit to organisational goals and 'Control' could come in the form of a performance appraisal.

Can you explain to me what the three elements of cost are? What is meant by discounting costs?

The three elements of cost are materials, labour and expenses. In relation to health economics, you'll come across resource cost (e.g. a day in hospital, GP consultation), unit cost (e.g. cost per in-patient day, cost per GP consultation, cost of setting up a programme) and opportunity costs (alternative or value of other resources, e.g. this hospital costs 5 million as this is the price we'll get if demolished and land is sold with planning permission). Other terms to know are stochastic cost (if resource use cannot be predicted exactly due to influence of other variables, measurement error or chance, it is said to be stochastic and must be estiminated) and deterministic costs (if resource use is the same for all patients, no estimation is required). Costs can be fixed or variable (i.e. vary with X), direct (cost of treatment and services) or indirect (e.g. patient expenses, loss of productivity, informal care) and there may be productivity costs and marginal costs (i.e. additional cost of additional output). People also talk about tangible costs (can we invoice for this?) and intangible (pain, suffering etc). Phew!

Discounting costs look to the future and at the estimated costs and consequences of interventions/services used now. Future benefits are valued less than current benefits, regardless of inflationary effects. Discounting is based on the assumption that most people's real income increases over time. Discounting costs should extend far enough into the future to capture all costs and consequences of interventions being evaluated. Costs occuring in the future must be discounted and according to the rational of time preference (i.e. people like to postpone paying for things) and opportunity costs.To discount, you take the amount of the future and see what it would be now, e.g. it tells us the present value of cost incurred next year. So for example, if a cost of an intervention today was 10 pounds, the cost incurred next year could be 20 pounds and 30 pounds the year after. Taking the current interest (discount) rate as 6% (this is the British Treasury's discount rate for public sector projects), you would estimate the present value of the future intervention costs as 10 plus 20/(1+0.06) plus 30/(1+0.06). This gives you 10 + 18.87 + 26.70, which = 55.57. Present value is 55 pounds and 57 pence.

What are Local Area Agreements (LAA)?

Local Area Agreements bring health inequalities and health outcomes to forefront of community planning. They comprise of joint working and agreed priorities with local authorities or a government office for region. They usually relate to children and young people; safer & stronger communities; healthier communities and older people Local Area Agreements support public health work across boundaries.

What are the priorities in local delivery plans?

These typically include the following:

(1) Improve the health of population (think increasing life expectancy, reduce CVD mortality and inequalities, reduce cancer mortality and inequalities, improve mental health - including reducing suicide rates, reduce health inequalities by 10% by 2010, reduce smoking and obesity levels and in relation to sexual health, improve life expectancy at birth, access to GUM clinics and reduce teenage conception rates). (2) Support people with long-term conditions. (3) Improve access to Services. (4) Improve patient/user experience.

What is meant by being a business strategist?

Business strategist changes performance by identifying and understanding root causes rather than operating on symptoms.

What are the 5 elements of health care?

The five elements of care are prevention, diagnosis, treatment, care (self-care, family care, community care, self-help groups, health service care) and rehabilitation.

How do you go about planning health improvement programmes?

This is based on PDSA - plan - do - study - act. There are 5 stages, which can be remember by DSCAE:

1. Problem Definition 2. Solution generated 3. Capacity building 4. Health Promotion Actions 5. Evaluation

Do you have any notes on the health and social behaviour module of the syllabus?

Yes, I do. Please click here for the pdf.

What does the infection control committee in a hospital do?

Membership of this committee includes consultant microbiologist; infection control nurses (hospital and community); other nursing staff, microbiologists, physicians, surgeons, occupational health representative, pharmacy; catering services and HPA and PCT representatives. They meet roughly twice a year.

The infection control committee deals with:

1. Pandemic flu (formulating an operational plan for the trust)

2. Clean your hands campaign and audit of hand hygiene products

3. Dress code & changing facilities

4. Implementing 'Saving Lives' document - (1) looks at reviewing operating environment and facilities including cleaning and patient environment, (2) review of patient journey to reduce risk of transmission of infections; (3) engaging senior management in infection control; (4) adopting national evidence based guidelines; (5) auditing infection control practice throughout the trust; (6) implementing robust Trust-wide policies for decontamination)

5. Catering and Hygiene

6. Sharps injuries

7. Outbreaks

8. MRSA, Clostridium difficile (causes diarrhoea), viral gastroenteritis, wound infections

9. Immunisations

The microbiology bit seems really detailed. It is doing my head in! Any tips?

No short cuts I'm afraid. You just have to know the definitions. I've attached some of my notes here. Hope they are of use to you.

What is an environmental health survey?

An environmental health survey aims to determine the doses of relevant pollutants to a population and relate these to what is known about the health effects. This is usually at higher doses or to statutory standards for ambeint pollution. Measures can then be instituted to reduce pollutant levels if necessary and for continued surveillance of pollutant levels. Surveillance would look at reducing the risk and on identifying specific health problems rather than looking at general mortality and morbidity. Pollutants, by the way, can be physical (i.e. naturally occuring, e.g. heavy metals or may result from human activity, e.g. noise), chemical (i.e. may be related to unusal but naturally occurring toxins or synthetic toxins) or biological (i.e. micro-organisms may be affected by environmental factors, such as overcrowding and become pathogenic). Pollution (caused by pollutants) can divided into three types: air, water and food.

Still on environmental health, what is meant by environmental epidemiology?

This is about identifying and measuring the influence of environmental factors on human disease in different communities. It aims to provide scientific evidence based on epidemiological research for sound environmental and health policies and practices. The main areas of concern are: (1)enviromnental factors causing or promoting the spread of infectious diseases and (2) environmental toxins leading directly to disease. Problems arise from there being small samples for local areas and of course, the effects of confounding factors.

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