Membership of the Faculty of Public Health (MFPH) Disease Prevention, Health Promotion and Screening Syllabus

Name the three adult cancer screening programmes in England and their eligible age ranges.

Breast (mammography) for women aged 50–70 (extension to 47–73 being phased in), every 3 years; cervical (HPV primary screening) for those aged 25–64; and bowel cancer (faecal immunochemical test, FIT) for adults aged 50/54–74.

What conditions are screened for in the UK newborn bloodspot test?

Nine conditions: sickle cell disease, cystic fibrosis, congenital hypothyroidism, and six inherited metabolic diseases (PKU, MCADD, MSUD, IVA, GA1 and homocystinuria).

What two non-cancer adult screening programmes exist in England besides cancer screens?

Diabetic eye screening (for people with diabetes aged 12+) and the NHS Abdominal Aortic Aneurysm (AAA) screening programme (ultrasound for men in the year they turn 65).

Define lead-time bias in screening evaluation.

The apparent increase in survival time that arises simply because screening advances the time of diagnosis, without delaying death. Survival measured from diagnosis appears longer even though the date of death is unchanged.

Define length-time bias in screening.

The tendency of screening to preferentially detect slowly progressing, less aggressive disease (which spends longer in the detectable pre-clinical phase), making screen-detected cases appear to have better prognosis than they truly do.

What is overdiagnosis in the context of screening?

The detection through screening of disease (often indolent) that would never have caused symptoms or death within the person's lifetime, leading to unnecessary diagnosis, anxiety and treatment (overtreatment). It is an extreme form of length-time bias.

What is selection (healthy volunteer) bias in screening studies?

People who attend screening tend to be healthier, more health-conscious and of higher socio-economic status than non-attenders, so they have better outcomes regardless of screening, inflating the apparent benefit of the programme.

How can the biases inherent in screening evaluation best be avoided?

By using a randomised controlled trial with disease-specific (and all-cause) mortality as the outcome rather than survival from diagnosis, since mortality endpoints are not affected by lead-time, length-time or selection bias.

Define sensitivity and specificity of a screening test using their formulas.

Sensitivity = proportion of those with disease correctly testing positive, $\text{Sensitivity}=\frac{TP}{TP+FN}$. Specificity = proportion of those without disease correctly testing negative, $\text{Specificity}=\frac{TN}{TN+FP}$.

Write the formulas for positive and negative predictive value of a screening test.

$$PPV=\frac{TP}{TP+FP}, \qquad NPV=\frac{TN}{TN+FN}$$ PPV is the probability that a person with a positive test truly has the disease; it falls as disease prevalence falls.

Why does the positive predictive value of a screening test fall when prevalence is low?

At low prevalence there are few true cases relative to the large disease-free population, so even a highly specific test generates many false positives; the ratio $\frac{TP}{TP+FP}$ therefore decreases, meaning most positive results are false alarms.

What is quality assurance (QA) in a screening programme and why is it essential?

A systematic, ongoing process of setting standards, monitoring performance against defined quality measures, and acting to maintain/improve quality across the whole screening pathway. It is essential because screening invites apparently healthy people, so the programme must minimise harm and ensure benefits outweigh harms.

What is meant by 'informed choice' in screening, and how does it differ from informed consent?

Informed choice means providing balanced information on benefits, harms (including false positives, false negatives and overdiagnosis) and limitations so that individuals can make a personal value-based decision whether to participate. It goes beyond informed consent by explicitly supporting the option to decline.

Name the main models/approaches of health promotion described by Beattie or similar typologies.

Common approaches include the medical/preventive model, the behaviour change model, the educational model, the empowerment/client-centred model, and the social change (radical/political) model. Beattie's model classifies interventions along authoritative–negotiated and individual–collective axes (health persuasion, legislative action, personal counselling, community development).

What is Tannahill's model of health promotion?

Health promotion as three overlapping spheres: health education, prevention, and health protection. Their overlaps generate seven domains (e.g. preventive health education, preventive health protection), emphasising that the activities work together.

Describe the stages of the Transtheoretical (Stages of Change) model of behaviour change.

Precontemplation (no intention to change) → Contemplation (considering change) → Preparation (planning/ready to act) → Action (actively changing behaviour) → Maintenance (sustaining change >6 months); with relapse possible. Developed by Prochaska and DiClemente.

State the core constructs of the Health Belief Model.

Perceived susceptibility, perceived severity, perceived benefits, and perceived barriers; modified by cues to action and self-efficacy. A person is more likely to take preventive action when perceived threat (susceptibility × severity) and net benefits are high.

What are the components of the Theory of Planned Behaviour?

Behavioural intention is determined by attitudes towards the behaviour, subjective norms (perceived social pressure), and perceived behavioural control; intention plus perceived behavioural control predicts the behaviour. It extends the Theory of Reasoned Action.

What is the COM-B model of behaviour change?

Behaviour (B) results from the interaction of Capability (psychological and physical), Opportunity (physical and social), and Motivation (reflective and automatic). It sits at the hub of the Behaviour Change Wheel, which links to intervention functions and policy categories.

What is a 'settings-based' approach to health promotion? Give examples.

An approach that promotes health by intervening in the everyday environments where people live, work, learn and play, addressing the whole setting rather than only individuals. Examples: Healthy Schools, Healthy Workplaces, Health Promoting Hospitals, Healthy Cities.

Name the five action areas of the WHO Ottawa Charter for Health Promotion (1986).

1) Build healthy public policy; 2) Create supportive environments; 3) Strengthen community action; 4) Develop personal skills; 5) Reorient health services.

What three basic strategies for health promotion does the Ottawa Charter identify?

Advocate (for health, to create favourable conditions), Enable (so all can achieve their fullest health potential), and Mediate (between different interests in society in pursuit of health).

What is social marketing in health promotion?

The systematic application of commercial marketing concepts and techniques to achieve specific behavioural goals for social good. It uses customer/audience insight, the marketing mix (product, price, place, promotion), audience segmentation, exchange theory and competition analysis.

What does the evidence suggest about the effectiveness of mass media campaigns for health behaviour change?

Mass media campaigns can raise awareness and shift knowledge and attitudes across large populations and can produce modest behaviour change, but are most effective when sustained, well-funded, theory-based and combined with other interventions (e.g. legislation, services); used alone they may widen inequalities.

Define nudge theory ('libertarian paternalism').

Influencing behaviour predictably through changes to the 'choice architecture' without forbidding options or significantly changing economic incentives, so people can still freely choose. Popularised by Thaler and Sunstein in 'Nudge'.

Give examples of choice-architecture interventions ('nudges') used in public health.

Setting healthy defaults (e.g. opt-out organ donation, default water instead of fizzy drinks); changing placement (healthy foods at eye level); portion-size reduction; salience/framing of information; and social-norm feedback. Summarised in the MINDSPACE and EAST frameworks.

Distinguish active from passive immunisation.

Active immunisation stimulates the recipient's own immune system to produce a protective (often long-lasting) response, via live attenuated or inactivated vaccines/toxoids/subunits. Passive immunisation provides pre-formed antibodies (e.g. immunoglobulin, maternal transplacental IgG) giving immediate but temporary protection.

Distinguish live attenuated from inactivated vaccines, giving an example of each.

Live attenuated vaccines contain weakened organisms that replicate to produce strong, often lifelong immunity but are generally contraindicated in pregnancy and immunosuppression (e.g. MMR, BCG, rotavirus, nasal flu). Inactivated/subunit vaccines contain killed organisms or components, are safer in those groups but usually need boosters (e.g. inactivated polio, hepatitis B, diphtheria/tetanus toxoid).

Define herd (population) immunity and the herd immunity threshold formula.

Herd immunity is the indirect protection of susceptible individuals that occurs when a sufficiently high proportion of the population is immune, interrupting transmission. The threshold proportion is $$H_{t}=1-\frac{1}{R_{0}}$$ where $R_{0}$ is the basic reproduction number.

For a disease with basic reproduction number $R_{0}=12$ (e.g. measles), what proportion must be immune for herd immunity?

$$H_{t}=1-\frac{1}{R_{0}}=1-\frac{1}{12}\approx 0.92$$ so about 92–95% must be immune, which is why very high measles vaccine coverage is required.

List the routine UK childhood immunisations given at 8, 12 and 16 weeks of age.

8 weeks: 6-in-1 (DTaP/IPV/Hib/HepB), rotavirus, MenB. 12 weeks: 6-in-1 (2nd dose), pneumococcal (PCV), rotavirus (2nd dose). 16 weeks: 6-in-1 (3rd dose), MenB (2nd dose).

What vaccines are given at one year of age in the UK schedule?

Around 12–13 months: Hib/MenC booster, MMR (1st dose), pneumococcal (PCV) booster, and MenB (3rd/booster dose).

What immunisations are offered to UK adolescents and the elderly?

Adolescents: HPV vaccine (around year 8, age 12–13), and the teenage booster of Td/IPV plus MenACWY (around 14). Older adults: annual influenza, pneumococcal polysaccharide (PPV23) at 65, shingles vaccine, and RSV vaccine for older adults; pertussis and RSV are also offered in pregnancy.

What is the 6-in-1 vaccine and when is it given in the UK?

A combined vaccine protecting against diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B (DTaP/IPV/Hib/HepB), given as a primary course at 8, 12 and 16 weeks of age.

What is the difference between a vaccine adverse event and an adverse reaction?

An adverse event following immunisation (AEFI) is any untoward medical occurrence after vaccination that is temporally associated but not necessarily causally related. An adverse reaction is an AEFI that is judged to be causally related to the vaccine.

What is the Yellow Card Scheme?

The UK's spontaneous pharmacovigilance reporting system, run by the MHRA, through which healthcare professionals and the public report suspected adverse drug reactions and adverse events following immunisation, contributing to ongoing safety monitoring.

What are the strengths and limitations of spontaneous (passive) pharmacovigilance reporting?

Strengths: cheap, covers the whole population and all products, can detect rare or unexpected (signal) reactions and works from the moment of licensing. Limitations: under-reporting, reporting bias, no denominator so incidence cannot be calculated, and it cannot prove causation.

Define vaccine hesitancy (WHO SAGE).

A delay in acceptance or refusal of vaccines despite availability of vaccination services. It is context-specific, varies across time, place and vaccine, and is influenced by factors captured in the '3 Cs' model: Confidence, Complacency and Convenience.

Explain the '3 Cs' (and extended '5 Cs') model of vaccine hesitancy.

3 Cs: Confidence (trust in vaccine safety/effectiveness and providers), Complacency (low perceived risk of disease so vaccination seen as unnecessary), and Convenience/Constraints (accessibility, affordability, availability). The 5 Cs add Calculation (information searching/risk weighing) and Collective responsibility.

What interventions improve vaccine uptake?

Reminder/recall systems, default/opt-out scheduling, improving access (extended hours, outreach, school/pharmacy delivery), reducing cost barriers, provider recommendation and training, addressing misinformation, community engagement and tailored communication, and financial/non-financial incentives. Multicomponent approaches work best.

What is the 'cold chain' in immunisation programmes?

The system of transporting and storing vaccines within the recommended temperature range (typically +2°C to +8°C for most vaccines) from manufacture to administration, to preserve potency. It requires reliable refrigeration, monitoring, trained staff and a fail-safe process for handling breaches.

What is a cold-chain breach and how is it managed?

An excursion of vaccine storage temperature outside the recommended +2°C to +8°C range. Management: quarantine affected vaccines (do not use or discard immediately), record the temperatures and duration, and seek advice from the manufacturer or local immunisation/medicines team on whether the stock remains usable.

Define vaccine efficacy and its formula.

Vaccine efficacy is the proportional reduction in disease incidence (attack rate) in the vaccinated group compared with the unvaccinated group under trial conditions: $$VE=\frac{ARU-ARV}{ARU}=1-RR$$ where ARU and ARV are the attack rates in unvaccinated and vaccinated, and RR is the relative risk.

Distinguish vaccine efficacy from vaccine effectiveness.

Efficacy is the protection measured under ideal, controlled conditions (e.g. a randomised trial). Effectiveness is the protection observed in real-world field use, which is usually lower because of factors such as cold-chain lapses, varied population health, timing and coverage.

What is a 'catch-up' immunisation campaign and when is it used?

A supplementary activity to vaccinate individuals who missed routine doses or to rapidly raise population immunity (e.g. during an outbreak or after introducing a new vaccine), aiming to close immunity gaps and reach the herd-immunity threshold; it complements routine ('selective') programme delivery.

Why does the population strategy risk widening or narrowing health inequalities, and what is a key counter-measure?

Population-wide interventions can widen inequalities if more advantaged groups adopt them faster ('intervention-generated inequalities'). Proportionate universalism — delivering universal action with intensity proportionate to need (Marmot) — is the key counter-measure to reduce the social gradient in health.