List four key features of a high-quality systematic review on treatments for an illness (4 marks)
Protocol written in advance with inclusion criteria
Multidisciplinary team led by methodologists/ inclusion criteria by at least two people
Studies included and excluded clearly described
Risk of bias assessed
Findings are interpreted in the light of the risk of bias
effects of corticosteroids on death at 2 to 24 months follow up? How can you express this in a single sentence using GRADE. Indicate the likely impact of future research (2 marks)
Corticosteroids reduce mortality compared to control and further trials are unlikely to
change this conclusion
Which trial contributed most to the meta-analysis and give your reasons why that is
– because the variance is low/confidence interval narrow
Also acceptable – The study is largest and has many events
Using the eyeball test on the forest plot for all studies combined at 2-24 months of follow-up,
and the I2test result, assess the degree of overall heterogeneity in the studies. Is it
appropriate to pool the result of these studies? (4 marks)
eyeball - overlap - good, low heterogeneity
I2 = 0% - no heterogeneity
p value of Chi2 = high - good for homogeneity
overall appropriate to pool the results
Health inequity
Health inequity is defined as unfair, avoidable differences arising from poor governance, corruption or cultural
exclusion.
Inequity – as opposed to inequality – has a moral and ethical dimension, resulting from avoidable and unjust
differentials in health status.
example of equity
gender roles – adverse health consequences of girls not being allowed to attend
school.
framework, model for social determinants of health?
Dahlgreen-Whitehead model
compounded effects of separate social determinants of health on the lived experience
and risk of disease/poor health outcomes
Outline and explain the two different sorts of bias that may occur in randomised controlled trials
Bias from poor randomisation: numbers not random, or clinicians know the allocated group
Bias from the people assessing the outcomes knowing which group people are allocated to
Bias from people dropping out from follow up, and this being related to the intervention
Bias from only reporting some outcomes and not others
Describe THREE characteristics of an effective indicator for monitoring the performance of a healthcare system.
Important – indicator should target an important area of performance
- Valid – indicator should measure what it is claiming to measure, and with good precision, face, construct
validity
- Precise – effect size should have low levels of associated uncertainty
- Available – necessary data should be collected and be easily accessible
- Consistent – Data should be collected regularly and in a consistent manner over time
- Suitable – Data should be appropriate for making comparisons between subgroups and not create perverse
incentives or gaming behaviours, should be culturally sensitive
List with suitable examples THREE types of indicator which could be used to describe the performance of a
childhood vaccination clinic in a low/middle-income setting.
Structural indicators – e.g. staff numbers, staff training/qualifications, fridge capacity
- Process indicators – e.g. vaccine supply chain – temperature control, accessibility of clinic to population
(opening hours, location etc.)
- Output indicators – e.g. number of vaccinations delivered / vaccine coverage, proportion of vaccinations
delivered at correct time interval/age, patient satisfaction
- Outcome indicators – vaccine-preventable disease incidence in local community
Using the example of the Sustainable Development Goals, discuss the advantages and disadvantages of
using targets to improve standards in healthcare and other settings
Advantages
- Importance of setting a collective agenda – global priorities for action which can lead to greater political interest
- SDGs are universal – cover both high and low income
- Expressed commitment to reducing inequality within SDGs
- Improve comparability of outcomes across different settings
- Define ‘success’ and monitor improvements
Disadvantages
-Ignore underlying inequalities – focus on what can be easily measured
- Goals are not binding / enforceable
- Lack ambition – targets have to be agreed by all partners
- Top-down – may not be applicable to all contexts
- Data quality for many indicators may be inadequate in some settings
- Can encourage ‘gaming’ of system – e.g. selective reporting of data to meet targets
- Can distort priorities – focus on what can be easily measured, at expense of competing issues
Humanitarian emergency response:
rapid emergency response
vaccine coverage
water and sanitation
food and nutrition
shelter and site planning
curative meds
CD prevention
Inconsistency in GRADE marking refers to?
heterogeneity
outbreak
unusual increase no cases / time / geography
time place person
vs expected
Objectives of outbreak mx:
confirm epidemic/outbreak
ID source/transmission mode
ID causal agent
ID at risk groups
Strategies to prevent future
Outbreak mx (10)
prepare case work
establish outbreak - cluster, seasonal, notification
Verify Dx - micro
Define and ID cases - confirmed, probable, suspected
Describe epi - time, person, place
Make hypothesis
test hypotheses - attack rates? studies, epi, lab
control and prevention
surveillence
communicate findings
sensitivity
% true +s correctly IDd
sspecificity
% true negatives correctly IDd
Epi curves:
point source - food source
Continual - eg cholera from water source
propogated -human - human transmission
Use which study to do during outbreak?
case control - ID exposures
(not well defined populations usually)
Odds ratios
EPI preventing vaccines:
local epi, resources, acceptable, legal requirements
birth - BCG, OPVO, Hep B
6 wks - OPV1, DPT1, Hep B, HiB
10 - OPV2, DPT2, Hib
14 - OPV3, DTP3, Hep B, Hib
9/12 - measles, YF
5->22 - RTSS1-4
9 - HPV
Malawi added Rotavirus and typhoid
Missed vaccine opportunity:
every time a child enters a HC facility, has no CIs but does not receive vaccine…
HCW attitudes/community attitudes
Resources
failure to screen
perceived CIs
vaccine wastage:
eg closed vial - physical damage/OOD,
storage failure - cold chain
open vials - spilled, wasted (expect a level of waste).
vaccine costs small relative to HC costs of VPDs
Social determinants of health:
conditions in which people born, age, live, work, grow
lead to health inequalities
IN general - do you live in poor or rich society?
