Membership of the Faculty of Public Health (MFPH) Health Improvement and the Wider Determinants of Health Syllabus

Health Improvement and the Wider Determinants of Health syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Health Improvement and the Wider Determinants of Health in Membership of the Faculty of Public Health (MFPH), not a summary of it.

1. 1

   Determinants of Health and Health Inequalities

   4 topics

   • Social determinants of health
     • Dahlgren and Whitehead rainbow model
     • Marmot review and proportionate universalism
   • Measuring health inequalities
     • Slope and relative index of inequality
     • Index of Multiple Deprivation
     • Concentration index
   • Causes of inequalities
     • Materialist, behavioural and psychosocial explanations
     • Life-course epidemiology
   • Inverse care law and access to services
2. 2

   Major Public Health Challenges

   6 topics

   • Tobacco control and smoking cessation
   • Alcohol and substance misuse
   • Obesity, nutrition and physical activity
   • Mental health and wellbeing promotion
   • Sexual and reproductive health
   • Non-communicable disease prevention
3. 3

   Life-Course and Population Group Approaches

   4 topics

   • Maternal, child and adolescent health
   • Healthy ageing and frailty
   • Workplace and occupational health
   • Vulnerable and marginalised groups
     • Homelessness and inclusion health
     • Migrant and asylum seeker health
4. 4

   Community and Asset-Based Approaches

   4 topics

   • Community development and engagement
   • Asset-based community development
   • Social capital and cohesion
   • Health in All Policies

Health Improvement and the Wider Determinants of Health flashcards for Membership of the Faculty of Public Health (MFPH)

20 of 51 cards from the Health Improvement and the Wider Determinants of Health deck — real questions with worked answers.

1. What are the social determinants of health, as defined by the WHO?

   The conditions in which people are born, grow, live, work and age, and the wider set of forces and systems shaping the conditions of daily life (economic policies, social norms, political systems). They are mostly responsible for health inequities and lie largely outside the health-care sector.

2. In Dahlgren and Whitehead's 'rainbow' model of health determinants, what are the layers from the centre outwards?

   (1) Fixed/constitutional factors (age, sex, genetics) at the core; (2) individual lifestyle factors; (3) social and community networks; (4) living and working conditions (housing, education, work, food, services); (5) general socioeconomic, cultural and environmental conditions.

3. Distinguish between health inequality and health inequity.

   Health inequality is any measurable difference in health between groups or individuals. Health inequity is the subset of inequalities that are unfair, avoidable and unjust (driven by unequal distribution of social determinants).

4. What is the difference between 'proportionate universalism' and a purely targeted approach to reducing inequalities?

   Proportionate universalism (Marmot) means actions are universal but delivered with a scale and intensity proportionate to the level of disadvantage, so the whole social gradient is addressed rather than only the worst-off.

5. State the social gradient in health.

   Health follows a gradient across the whole of society: the lower a person's socioeconomic position, the worse their health, in a stepwise fashion. It is not simply a poor-versus-rest divide; each step down the ladder has worse outcomes than the one above.

6. How is the slope index of inequality (SII) defined?

   The SII is the absolute difference in a health outcome between the hypothetical highest and lowest ends of the socioeconomic distribution, derived from a regression of the outcome on the population-weighted cumulative rank of socioeconomic groups. It is an absolute, regression-based measure using the whole population.

7. What does the relative index of inequality (RII) measure, and how does it relate to the SII?

   The RII is the relative version of the SII: typically the ratio of the predicted outcome at the bottom to that at the top of the socioeconomic distribution (or SII divided by the mean). It expresses inequality in relative rather than absolute terms.

8. Define the population attributable fraction (PAF) and give its formula.

   The PAF is the proportion of disease in the whole population attributable to an exposure (the reduction if exposure were eliminated). $$PAF = \frac{P_e(RR-1)}{1 + P_e(RR-1)}$$ where $P_e$ is the proportion of the population exposed and $RR$ the relative risk.

9. What is the difference between absolute and relative measures of health inequality, and why does it matter?

   Absolute measures (e.g. rate difference, SII) give the actual gap in events; relative measures (e.g. rate ratio, RII) give proportional differences. The same data can show a narrowing relative gap while the absolute gap widens (or vice versa), so both should be reported.

10. State the Inverse Care Law (Tudor Hart, 1971).

    The availability of good medical care tends to vary inversely with the need of the population served; this operates most strongly where medical care is most exposed to market forces.

11. Outline the four main explanations for health inequalities proposed in the Black Report (1980).

    (1) Artefact (inequalities are an artefact of measurement); (2) natural/social selection (ill health causes low social position); (3) cultural/behavioural (lifestyle differences); (4) materialist/structural (material conditions and the distribution of resources) — the structural explanation was favoured.

12. What are the four levels of the policy intervention 'hierarchy' (the Nuffield intervention ladder) from least to most intrusive on individual choice?

    From least to most intrusive: do nothing/monitor; provide information; enable choice; guide choice through changing the default; guide choice through incentives; guide choice through disincentives; restrict choice; eliminate choice. Less intrusive options are preferred unless justified.

13. What is a 'lifecourse' approach to health inequalities, and name two of its key concepts.

    It examines how exposures across life accumulate to affect health. Key concepts: critical/sensitive periods (exposure at a specific developmental window has lasting effects), and accumulation of risk (hazards build up over time); also chains of risk.

14. What are the three overarching recommendations of the WHO Commission on Social Determinants of Health (2008)?

    (1) Improve daily living conditions; (2) tackle the inequitable distribution of power, money and resources; (3) measure and understand the problem and assess the impact of action (monitoring, evidence, training).

15. What does the abbreviation NCD stand for, and name the four main NCDs and their four shared behavioural risk factors targeted by WHO.

    NCD = non-communicable disease. The four main NCDs: cardiovascular disease, cancer, chronic respiratory disease, and diabetes. The four shared modifiable behavioural risk factors: tobacco use, harmful alcohol use, unhealthy diet, and physical inactivity.

16. What is the MPOWER package for tobacco control introduced by the WHO?

    Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; Raise taxes on tobacco.

17. What pharmacotherapies are first-line for smoking cessation, and roughly how much do they increase quit rates?

    First-line: nicotine replacement therapy (NRT), varenicline, and bupropion. Combined behavioural support plus pharmacotherapy roughly doubles to triples quit rates compared with willpower alone; varenicline and combination NRT are among the most effective.

18. In a 'very brief advice' (VBA) model for smoking, what are the three components (Ask, Advise, Act)?

    ASK and record smoking status; ADVISE on the best way of quitting (that stopping with support is most effective); ACT by offering referral to a stop-smoking service and/or pharmacotherapy.

19. How is a 'unit' of alcohol defined in the UK and what is the formula to calculate units from a drink?

    One UK unit = 10 ml (8 g) of pure ethanol. $$\text{Units} = \frac{\text{volume (ml)} \times \text{ABV (\%)}}{1000}$$ where ABV is alcohol by volume.

20. What is the current UK Chief Medical Officers' low-risk drinking guideline?

    Both men and women should drink no more than 14 units per week on a regular basis; spread drinking over three or more days if drinking that amount; and have several drink-free days. There is no completely safe level of drinking.

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