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1. Explain what is meant by patient perspectives.
- Views: treatment preferences
- Ideas: health and illness causation
- Concerns: worries
- Expectations: outcomes
- Values: independence, getting to worship etc
Why should Doctors take
into account patients preferences and perspectives?
a) Patients have rights to be involved in their care - ethics/policies
b) Research - many patients experts in own illness.
c) Can - aid diagnosis
- lead to increased patient satisfaction
- lead to better patient outcomes - asthma research
What are the Key messages of GMC 2001?
As a doctor you must:
to patients and respect their views.
the rights of patients to be fully involved in decisions about their care.
- 3. Give patients information in a way they can
- 4. Make sure that your personal beliefs do not
- prejudice your patients’ care.
What 3 sets of factors need to be considered in clinical decision making?
- 1. Patients clinical state and circumstances
- 2. Research evidence
- 3. Patient’s perspectives and likely actions
These vary from person - person, circumstance - circumstance
Explain the components of the biopsychosocial model of health
A. Biological - underlying health probs, inherited disease, family history, ethnicity, gender, life expectancy, bad habits.
B. Psychological - health beliefs/perspectives, education, behaviour
C. Social - socioeconomics, health inequalities, ethnicity, behaviours
What types of Dr - patient relationships exist?
What are the features of the paternalistic model of Dr-patient
- 1. Patient Passive
- 2. No sharing of info so no partnership
- 3. Assumes - Doctor knows best
- 4. Appropriate in some situations e.g. Medical Emergency
- 5. If patient prefers this approach, agree this first thereby establishing a partnership
What are the features of the shared model of Dr-patient
- 1. Doctor & patient share all info and stages of decision making process.
- 2. Agreement and joint decision on how to proceed – i.e. treatment plan.
- 3. If disagree - negotiation
- NB The current trend is towards that of a doctor-patient partnership but have to identify which is most appropriate in
- each case as not a case of “one shoe fits all”. The method may even change during a consultation – it is the doctor’s responsibility to ensure discussion about the preference.
What are the features of the informed model of Dr-patient
- 1. Doctor communicates all relevant info and treatment options to the patient and their risk and benefits
- 2. Doctor’s key contribution is info provision
- 3. Decision making is solely the prerogative of the patient
What are the challenges of using the shared model (3 types of challenge)?
- 1. Creating an environment where patient feels able to express ICE
- 2. Presenting info and choices to patients & eliciting patient preferences - communictaion barriers - literacy/children/elderly - May need decision aids.
- 3. Positive discrimination
- 4. Patient prefs may also disagree with clinical guidelines
What are the 2 negative and 2 positive definitions of health?
- A. Negative - Absence of illness
- - Functional ability (not able to do normal daily activities)
- B. Positive - equilibrium (mind, body, spirit in synch)
- - Freedom (do and live how you want to)
What is the WHO definition of health?
- “a state of complete physical, social and
- mental well being and not merely the absence of disease or infirmity”
What are the features of the medical/biological model of health (give 4)?
- 1. state of health is a biological fact
- 2. ill health is due to biological misfortunes
- 3. causes identified by signs and symptoms and the process of diagnosis
- 4. medical knowledge is exclusionary – the job of experts
- 5. biomedicine = disease orientated, concerned with pathology
What are the features of the social model of health?
- 1. state of health is socially constructed – it is varied, uncertain and diverse
- 2. Ill health is caused by social factors
- 3. causes are identified through beliefs and interpretations
- 4. knowledge is NOT exclusionary – it has a historical, cultural and social aspect
- 5. the social model is holistic and concerned with peoples lives & experiences
What are lay - beliefs?
- - people’s common sense knowledge about health and illness
- - medical knowledge derived from scientific knowledge and/or evidence based practice
- - generally rooted in peoples own experiences
- - not necessarily different from medical
Where to lay beliefs come from?
- 1. Personal knowledge & experience
- 2. Previous medical encounters
- 3. Media and internet
- 4. Folk knowledge
- 5. Religious beliefs
- 6. Alternative and complementary medicine
Give 4 “triggers” to seeking medical help
- 1. Interpersonal crisis - depression, marriage breakdown
- 2. interference social/personal relationships - relationships with partner
- 3. sanctioning - friends/family applying pressure
- 4. temporalising of symptomology - perceived illness has gone on too long/ is something serious “if im not better in a week I’m going to the doctors!”
- 5. Interference with job/social life
Give 3 main reasons why lay beliefs are important to Drs?
- 1. Help you better understand peoples illness related behaviour - whether they consult
- - their compliance
- - continuation of treatment
2. Gain insight into needs of patients and their expectations of you as doctors
3. Results in more satisfied patients and doctors
What are the pro’s and cons of the expert patient programme?
- 1. Better management of condition - improvements or stable
- 2. More confidence
- in seeking the right health services
- 3. Decreased GP/OPD visits
- 4. Work together to find best solutions and treatments
- 1. Participation inequalities – poor, rural
- 2. No corresponding strategy to challenge professional attitudes
Define health inequalities
- Differences in health status or in the distribution of health determinants between different population groups.
- Some - attributable to biological variation, others to environment/conditions outside an individuals control.
How is socio-economic status measured?
- access to/ownership of assets
What 2 problems can occur when measuring health using socio-economic status?
1. Household social class determined by head of household.
2. Growing no people unclassified (classifications = professional, managerial, manual, unskilled, other).
What 4 factors may shape the relationship between socio-economic status and health?
- 1. Age & Socio-economic- Inequalities in all age groups across socio-economic groups
- - Most pronounced differences are in childhood
- 2. Gender & Socio-economic
- - Gradients in mortality are less steep for women than men
- 3. Ethnicity
- - Ethnic health inequalities more pronounced with age
- 4. Geography
- - North/South divide – mortality rates
- - Favourable averages may hide ‘pockets’ of social inequality in rural areas
What are the 3 main explanatory models for health inequalities?
- 1. Behavioural explanation
- 2. Materialist explanation (expanded to neomaterialistic and life course approach)
- 3. Psycho-social explanation
Describe the behavioural model of health inequalities
- 1. Health inequalities due to health related behaviours
- 2. Result of individual choices – e.g. smoking, diet, lack of exercise
- 3. Smoking more prevalent in lower social groups
- - Increased cigarettes, decreased quitting attempts, begin earlier.
- 4. Lower social class = increased likelihood of
- risky behaviours (Ill informed or don’t have discipline to stop)
- 5. Important BUT DONT account for all patterns
- of health inequality (approx 50%)
- 6. If circumstances are good, stopping bad
- behaviours makes a huge difference. In bad circumstances it makes very little.
Describe the materialist model of health inequalities
- 1. Result of material circumstances due to income (Black Report 1980)
- 2. Largely outside of the person’s control – housing, nutrition, work environment
- 3. Housing – Damp develops asthma and COPD in
- future, asbestos, overcrowding, noise, poor water
- 4. Food – Healthier diet is more expensive, less
- choice, access, availability. Increases CHD NIDM, cancer
Describe the psychosocial model of health inequalities
- 1. Result of stressful conditions or low self esteem.
- 2. Stress affects health a) indirectly - Stressed so smoking, drinking etc – harmful coping behaviours
- b) directly - Increased susceptibility to mental & physical illness “feeling run down”
- 3. Psychological stress affecting health likely to be chronic rather than acute
- 4. Lower social groups tend to face stress more
- frequently e.g. low income – bills to pay.
- 5. Perception of our social position very
- important to health
- 6. Relative poverty – below “acceptable”
- standards of living compared to rest of population - big impacts on self esteem and therefore health.
What 2 models are expansions of the materialist model?
Give explanations for them both.
- 1. Neomaterialistic:
- - Think of community not just individual – related to public underinvestment, health & social infrastructure
- 2. Life-course approach:
- - The traditional materialist model doesn’t
- account for observed health inequalities between people of £100k and £70k incomes.
- - Neither are poor. May be due to disadvantages when they were younger.
- - Poor childhood circumstances set people on pathways that make it more likely they will be exposed to future disadvantages.
- - Cyclical problem.
- - Disadvantages “cluster” across life course
Compare and contrast the health of men and women
- 1. WOMEN
- - INCREASED - rates of illness,disability, anxiety,depression& use of health services
- - Peripheral obestity, neuroendocrine reactionto stressors
- - Duties within the home, bear brunt of lowincome - more vunerable to poverty.
- - Increased social isolation and denial of self(some cases)
- 2. MEN
- - INCREASED likely to die at all stages of lifecourse, participate in bad health behaviours, take more risks - more accidental deaths etc
- - Central obesity, lifelong sensitivity to damaging metabolites
- - Mortality increases may be due to occupational accidents/diseases, masculinity - take more risks
- - Masculine sanctioning coping behaviours -
- stress relief - extreme sports/drugs/alcohol.
- - Strong alcohol/depression/suicide link in men
- - Often MORE ALONE
What are the explanations for these differences between men and women?
- 1. Women - more likely to consult GP
- 2. Men - use ED/locums instead of GP
- - wait longer to seek help
- - less likely to attend screening/well person checks, - normalise symptoms
What are the main reasons that males engage with healthcare services less?
- 1. Taught to be self sufficient, not to complain, be strong in mind/body - decreases consultations
- 2. Perceive themselves as less vulnerable to illnesses than women
- 3. Less likely to accept emotional pain as valid
- 4. Perceive health as woman’s responsibility
- 5. Fear wasting doctors time
- 6. Don’t like embarrassing tests
Give 2 examples of the influence of gender on healthcare provision.
– “Man’s Disease”…women less likely to be diagnosed even if presenting with chest pain.
- 2. Mental Health – “Woman’s Disease”…Valium – Mother’s little helper. Doctor is more likely to
- perceive a physical illness as psychological if the patient is a woman (advertising reinforces). Women prescribed 2x more antipsychotics.
Why is understanding health behaviours important for doctors (8 reasons, give 6)
1. Changing health behaviour associated with health at individual and population level
2. Must recognise behaviours are difficult to change and WHY
3. Doctors belief about why patient got ill and the link between behaviours and health may affect views about patient & treatment.
4. SOCIAL INEQUALITY - strong determinant of health behaviour
5. Many factors affecting an individuals health are NOT related to their behaviour - access to food, culture, environmental (pollution).
6. Behaviour = complex & multifactorial (ie social & psychological) therefore needs broader approach.
7. MUST understand social patterning of health behaviours CANT be explained by attitudes/knowledge.
8. More likely to be able to help/support patient if you recognise their challenges in changing health behaviours.
Describe the links between socio-economic class and smoking.
- - Step-wise gradient – lower classes smoke more - significant association
- - more likely to smoke and less likely to quit
because of - less motivation, lack of knowledge of effects, find it harder to give up (no statistical significance)
2. MORE addicted
- nicotine dependence increases with deprivation.
3. MORE drawn
to smoking - for managing stress & for cheap form of recreation/socialising.
Describe the links between gender and smoking
- 1. Women
- - Smoking is closely linked with deprivation - only leisure activity/ personal expenditure
- - Associated with marital/personal/social stress
- - Heavy caring burdens tend to lead to heavy smokers
- - Coping strategies – quick and easy way of coping & decreasing stress.
- 2. Men
- - engage in coping strategies outside of the home (less of a carer role in the family).
- - Affirms status in social network
Define inequity and explain why it differs to inequality
- 1. EQUALITY - everyone gets the same
- - equal access will increase health inequalities
- 2. EQUITY - high quality care services targeted/provided
- according to need
- - must consider access (facilities, treatment, care), utilisation and availability
- Bad level of service for an entire population e.g. rural village
- Those that need a service most cannot access it e.g. ill ethnic minorties can’t access a particular service due to language barrier
Define pro poor bias and pro rich bias
1. Pro-Poor Bias – Those with the greatest care need have the greatest access to care. E.g. Access to GP
2. Pro-Rich Bias – USA (private healthcare). Also seen UK - higher income groups are more likely to see a specialist etc.
List some inequities in access in secondary care
- 1. Lower use of GP’s by older men
- 2. Asylum seekers, homeless people have difficulty in accessing primary care
- 3. Chronic conditions & mental health –
- higher service use but not responsive to their needs
- 4. Under utilisation of preventative services
- like screening & immunisations in disadvantaged groups
- 5. Higher income groups more likely to receive better secondary care – OPA, surgery, some ethnic minorities
- less likely to receive.
- 6. Males more likely to receive surgery
What are the names of the 2 barriers that create healthcare inequities?
- 1. Supply side (provider)
- 2. Demand side (user)
Explain provider (supply side) barriers
- 1. Quality of care - Postcode lottery
- 2. Information – Presenting info in different languages
- 3. Cost – Wales & Scotland have free prescriptions
- 4. Availability of services – geographical barriers - Postcode lottery
Explain user (demand side) barriers
- 1. Education – Appropriate info for informed decisions
- 2. Preferences – GP opening hours
- 3. Info - culturally appropriate availability
- 4. Cultural attitudes – Some women may prefer a female clinician
- 5. Affordability & Indirect Costs – Time off work, prescription costs
A concept concentrating on assumed biological/genetic differences between different groups of people
- Shared history distinguishing one group from
- another with NO reference to biology/ genetics (cultural tradition, defined by geography). E.g. polish in UK.
What are the 5 explanations that link ethnicity to healthcare inequalities?
– Eg Sickle cell BUT rarely true!! Genetics has little role in explaining inequalities, ignores wider causes of ill health that affect larger numbers in minority groups (black men and prostate cancer)
– Health beliefs and behaviours of an ethnic group – Stereotyping and “culture blaming”
detaches health experiences from social context. (e.g. Asian Ricketts caused by Asian diet!!)
- 3. Migratory – Migrants selected by health characteristics e.g. Sickest wouldn’t travel – only those capable of making the journey would.
- - Salmon bias – ill people tend to return to their country of origin to die (therefore not recorded as a UK death and not in the UK stats!).
- - Migrants’ health tends to revert to the mean standard of their country of origin rather than where they have moved to.
- - May DIRECTLY affect health of 1st generation migrants - social economic upheaval
4. Social Deprivation
– Socio-economic factors make a HUGE contribution to health
– Direct (health differences) and the Indirect fear of racism (stress/worry)
Define upstream and downstream approaches of tackling health inequalities, give examples of both.
- 1. Upstream
- – Deal with wider influences
- - Income, benefits, employment, housing etc
- 2. Downstream – Health behaviours, lifestyle,
- - smoking, diet, access to care
- - Just adopting these wont significantly decrease inequalities!!
Name the 3 different approaches for tackling/reducing health inequalities and give a brief description of each.
- 1. Reducing health disadvantage
- - Aims to help the worst off
- - Only targets the very worst off groups so no effect on health gradient (not population wide)
- 2. Narrowing health gap - Aims to reduce the gap between the worst off and the population average
- - Still targets “worst off” so no effect on health gradient
- 3. Reducing health gradient - Aims to bring everyone up to the very highest level of care (levelling up - WHO)
- - Population wide approach
- - Therefore health improvements have to be highest in the poorest groups