Overview of PopMed KFQ

Stage 2 BA
Disclaimer
• THIS IS BY NO MEANS COMPLETE, IT’S MEANT TO BE JUST A GUIDE FOR REVISION
• The following information is only intended for sharing and peer learning purposes.
It is only based on students’ learning experience and sharing of own reading and
hence is bound to errors.
• It is not intended to replace any formal teachings.
• Should any conflict or confusion arise, please refer to lecture notes / respective
lecturers for clarification.

• Please do not hesitate to ask questions or correct anything in the slides, we are all
learning together.
The exam – based on what we know
• YOU WON’T FAIL THIS (HOPEFULLY)
• 10 questions with subquestions
• Each question 10 marks (10 marks x 10 = 100)
• 90 minutes (9 mins per question)
• Usually
• 2 statistics questions
• 1 occupational health question
• Remaining 7 from other domains/ topics
Public Health Domains
• Epidemiology
• Biostatistics (including EBM)
• Occupational Health
• Family Health
• Environmental Health
• Health Policy & Management
 UMMP Lectures
Public Health Domain Blocks Lectures
Epidemiology Block 2 • Principles of prevention and control
• Surveillance and outbreak management
• EOR: Principles of screening NCD
Block 3 • EOR: Principles of prevention - falls

Block 4 • Cardiovascular diseases: PopMed perspectives

Block 5 • Epidemiology of TB
• EOR: Epidemiology of respiratory infections
Block 6
Block 7 • Epidemiology of stroke
Block 8 • Epidemiology and prevention of HIV
• Population issues & sexually transmissible diseases (STDs)
Block 9 • EOR: Prevention of chronic renal failure

Block 10 • Outbreak management of foodborne disease in Malaysia

• EOR: Hepatitis B virology, clinical features and epidemiology
Block 11 • EOR: Epidemiology of lung cancer
UMMP Lectures
Public Health Domain Blocks Lectures

Biostatistics/ EBM Block 2 • What is EBM – Asking question

Block 3 • Study design

Block 4 • Frequency
• Prognosis
Block 5

Block 6 • Diagnostic studies

Block 7 • Intervention studies

Block 8

Block 9 • Systematic review & meta analysis

Block 10

Block 11 • EBM: Translating EBM into clinical practice

UMMP Lectures
Public Health Domain Blocks Lectures
Occupational / Block 2 • Environment and Health
Environment Health
Block 3 • EOR: Ergonomic hazards at workplace
• EOR: Musculoskeletal pain in the workplace
• EOR: The law and work-related injury

Block 4 • EOR: Adverse impacts of air pollution on the cardiovascular system

Block 5 • Road trauma: active and passive safety

• Prevention and awareness in asthma
• Sleepiness in workplace
• Lung disease resulting from occupational and environmental exposure
• EOR: Occupational disability and impairment
Block 6

Block 7

Block 8

Block 9

Block 10

Block 11 • EOR: Occupational factors in lung cancer

UMMP Lectures
Public Health Domain Blocks Lectures
Family Health Block 2 • Demography
• Cervical cancer
• Maternal and child health
• Principles of family health
• Health promotion & health education
Block 3

Block 4 • Environment and foetal programming

Block 5

Block 6 • Services for the elderly

Block 7 • Mental health
• EOR: Effects of chronic illness on the family
• EOR: Service provision in mental health

Block 8 • Diet and diabetes

• Community issues in obesity
• Principles of family health
• EOR: Diet exercise and diabetes
• EOR: Health behaviour & beliefs in youth

Block 9

Block 10 • Calculations of nutrient

• Consequences of nutrient malabsorption
• Poverty and child health
• EOR: Nutritional approaches to GI disease
• EOR: Short bowel syndrome

Block 11 • EOR: Diet and cancer

UMMP Lectures
Public Health Domain Blocks Lectures

Health Policy & Management Block 2 • The Malaysian Population Health

Block 3 • Impact – Musculoskeletal disease in the community

Block 4

Block 5 • Advocacy and lobbying for tobacco control

• Evidence for tobacco as a cause of disease
• EOR: Public health policy in tobacco control
• EOR: Ethical dilemmas in tobacco control policy
Block 6

Block 7

Block 8 • EOR: Health advocacy in AIDS

Block 9

Block 10

Block 11 • Resource Allocation (Efficiency & Equity)

• EOR: Quality assurance and cancer screening programs
What does that mean to me (you)?
• Biostatistics/ EBM
• Occupational health & environmental health
• Road trauma
• Occupational diseases Lung, MSK

• Epidemiology & family health

• Principles of prevention
• NCD: CVD, stroke, diabetes, obesity, mental health, cancer screening
• CDC: TB, HIV, foodborne illness, outbreak management
• Maternal and child health
• Nutrition
• Health policy & management
• Malaysia healthcare system
• Tobacco control
EBM & BIOSTATISTICS
The most confusing thing… but it is fun if you understand it
Analyze study from others study.

Self-conducted study

No intervention Intervention
 Study designs
Observational (No intervention is done)

Cohort study :
E —> O (Requires follow up)

Identify smokers —> Follow up +ve / -ve lung Ca

RF has to be present prior to disease development.

+ve Lung Ca —> Identify if he / she is smoker

Looks to see if odds of prior exposure or risk
factor differ by disease state.
Case control —> Odds ratio
Study design at a glance Diagnostic research

Population at risk Onset of disease

Diagnostics
Risk factors
Diseased

Etiologic research

Outcome
Prognostic Intervention
(Cure / Death)
research
Experimental
research
Level of evidence

Cohort study
PADE
PA-C
Putting it in another way…
Question
How common is the problem?
What causes the problem?
What should I do about this
condition or problem?
Does this person have the
condition or problem
Who will get the condition or
problem
What are the types of
problems?
Question Type Types of study design
Frequency and rate Cross sectional / cohort
Aetiology and risk factors Cohort/Case control/ analytical
Cross sectional
Intervention RCT
Diagnosis Cross Sectional
Prognosis and prediction Cohort/ survival
Phenomenon or thoughts Qualitative
Research questions
 Cross-sectional studies “survey” at particular time frame
does not follow up / intervene

• Descriptive
• Analytical

Prevalance : Proportion of a population that has a clinical outcome at a given point.

Incidence : Proportion of a population, who are initially free of outcome of interest,

develop the outcome over a given period of time.
 Can show association between exposure & outcome,
Cross-sectional studies but does not show causality / cannot determine the
direction of causality.

• Descriptive
• Analytical
High BMI is a/w high cholesterol, but unsure if high BMI cause high cholesterol or vice versa.
Association is not causation.
Can investigate link but not direction of causation.

Cross sectional study is NOT suitable for rare outcomes.

Cohort study
• Exposure → outcome

Pros :
1. Exposure comes before outcome —> Can determine causality.
2. Suitable to study / evaluate multiple outcomes (follow up over time)
E.g. Exposure : smoker / never smoker ; Outcomes : lung Ca, HTN, IHD

Cons :
1. Not suitable for rare outcomes (large sample is needed)
2. Not suitable for quick results (more time needed for follow up)
3. Requires large sample size
4. Confounding bias (Other variables which are measured / not
measured can affect outcome, e.g. an uncontrolled study shows an
association between drinking coffee and lung Ca, however people who
drink coffee “may smoke more”, which could account for association)
 Outcome is always on top.

Diseased / Total exposed Diseased / Total unexposed

i.e. relative risk

RR = 1 —> No association between exposure and disease.

RR > 1 —> Exposure associated with ↑ disease occurrence.
RR < 1 —> Exposure associated with ↓ disease occurrence.

Cohort study identifies “outcomes” from exposure.

Always aim at +ve outcomes (a & c) !!
+ve outcomes (diseased) w total exposed / total unexposed.
RR determines magnitude of association.
Case control study
• Outcome → exposure
Pts die of CVD —> Determine if he / she is smoker.

Pros :
1. Suitable for rare outcomes —> Selection of
cohort based on outcome of interest.
2. No problem w loss to follow-up
3. Require less time & less expensive (do not
require follow up)
4. Require smaller sample size

Cons:
1. Selection bias (Non-random / Selective
sampling such that study population is not
representative of target population)
2. Susceptible to recall bias (Patients with disease
recall exposure after learning of similar cases —>
Overestimation of association)
3. Not suitable for rare exposures
 aka Sick

Tend to be
unknown

Case control study identifies “exposure” based

on outcomes.
Represents “odds of exposure” among cases (a/c)
vs controls (b/d).
OR = 1 —> odds of exposure are equal in cases Control —> Odds ratio
and controls. Memorize formula
OR > 1 —> odds of exposure are greater in cases.
Not suitable for rare exposures Not suitable for rare outcomes
 Caveat
All “+ve” values

https://sphweb.bumc.bu.edu/otlt/mph-
modules/ep/ep713_analyticoverview/ep
713_analyticoverview5.html

https://theebmproject.wordpress.com/f
undamentals/study_design/observationa
l-studies/
Diagnostic studies
• Cross sectional
• SpIN
• SnOUT
 262 SEC TION II PUBLIC HEALTH SCIENCES ` PUBLIC HEALTH SCIENCES—EPIDEMIOLOGY AND BIOSTATISTICS

Evaluation of Sensitivity and specificity are fixed properties Disease

–
diagnostic tests of a test. PPV and NPV vary depending on
disease prevalence in population being tested. PPV
TP FP = TP/(TP + FP)

Test
NPV
– FN TN
Sensitivity = 0.8 = TN/(TN + FN)
Pts w CVS, 80% chance for tests to be +ve. Sensitivity Specificity Prevalence
PPV = 0.02 TP + FN
= TP/(TP + FN) = TN/(TN + FP) (TP + FN + FP + TN)
+ve test, 2% chance of pts actually have CVS

Sensitivity (true- Proportion of all people with disease who test = TP / (TP + FN)
positive rate) positive, or the ability of a test to correctly = 1 – FN rate
identify those with the disease. SN-N-OUT = highly SeNsitive test, when
Value approaching 100% is desirable for ruling Negative, rules OUT disease
out disease and indicates a low false-negative High sensitivity test used for screening
rate.
Specificity (true- Proportion of all people without disease who = TN / (TN + FP)
negative rate) test negative, or the ability of a test to correctly = 1 – FP rate
identify those without the disease. SP-P-IN = highly SPecific test, when Positive,
Value approaching 100% is desirable for ruling rules IN disease
in disease and indicates a low false-positive High specificity test used for confirmation after a
rate. positive screening test
Positive predictive Probability that a person who has a positive test PPV = TP / (TP + FP)
value result actually has the disease. PPV varies directly with pretest probability
(baseline risk, such as prevalence of disease):
high pretest probability Ž high PPV
Negative predictive Probability that a person with a negative test NPV = TN / (TN + FN)
value result actually does not have the disease. NPV varies inversely with prevalence or pretest
probability
Possible cutoff values for vs – test result
Disease Disease A = 100% sensitivity cutoff value
Number of people

absent present B = practical compromise between specificity and sensitivity

C = 100% specificity cutoff value

TN TP Lowering the cutoff value: ↑ Sensitivity ↑ NPV

↑ ↑ ↑
B A (↑ FP FN) Specificity PPV
↑

FN FP
Raising the cutoff value: ↑ Specificity ↑ PPV
A B C B C (↑ FN FP)
↑ ↑
Sensitivity NPV
↑
↑

Test results

Receiver operating ROC curve demonstrates how well a diagnostic Ideal test (AUC = 1)
1
characteristic curve test can distinguish between 2 groups (eg, 1)
<
disease vs healthy). Plots the true-positive rate UC
<A
(sensitivity) against the false-positive rate .5
t (0
TP rate (sensitivity)

0.5)
(1 – specificity).
s
l te

C=
ua

The better performing test will have a higher AU

e(
Act

lu
area under the curve (AUC), with the curve va
it ve
ic
closer to the upper left corner. pr
ed
o
In diseases diagnosed based on low lab values N
(eg, anemia), the curve is flipped: lowering the
cutoff further Ž  FP,  FN; raising the cutoff
FP rate (1 – specificity) 1
Ž  FN,  FP.

FAS1_2022_06-PubHealth.indd 262 11/4/21 12:18 PM

Experimental studies RCT
 Some terms

Placebo

Always aim at +ve outcomes (a & c) !!

EER = +ve outcome / total +ve exposure (intervention)
CER = +ve outcome / total -ve exposure (placebo) Relative risk / Risk ratio (< 1) —>
Intervention reduces risk vs control
(e.g. placebo)
ARR = CER - EER
*** Same as RR in cohort study.

Similar to RR in cohort study !!

Intervention
• RR = EER/CER
RR = EER / CER
RRR = 1-RR (Proportion of risk reduction due to the
intervention as compared to a control)
• RRR = 1-RR
Relative risk reduction

Control (Placebo) - Intervention

Does not compare (vs RR)

Number of patients who need to

be treated for 1 patient to benefit.
 Basis of inferential statistics – the p’s and CI’s
There is SOME association btwn A & B.
There is NO association between A & B.
P < 0.05 : Null hypothesis is rejected / Results are statistically significant.
P value : Commonly accepted as 0.05 (< 5% of results occur
due to chance), assuming that H0 is correct.
*** Measure of strength of evidence against null hypothesis.
As sample size increases, CI width decreases.
P <0.05 is statistically significant (> 95% results are not occurring by chance).
95% Confidence interval (CI) : When the study repeats 100x, 95x stay in that range of values.
95% CI crosses line of no difference (= 1) —> Null hypothesis is NOT rejected & Results are NOT statistically significant
(Indicates results occur by chance, is not representative for whole population).
If the 95% CI for RR is, 0.7 to 0.9, then the null value of 1 is not within the interval (does not cross line of no difference)
—> 95% CI for RR is less than 1, does not cross line of no difference, hence results are statistically significant (meaningful),
null hypothesis is rejected.
If the 95% CI for RR is 0.5 to 1.2, then it has crossed line of no difference. This suggests that null hypothesis is not rejected,
and the result is not statistically significant.
Example 1
Does not follow up over time.
Does not trace back exposure.

• A survey is done on 200 individuals to relate T2DM & alcohol

drinking, 90 of 200 individuals drink alcohol. Given that 80 out of 200
has T2DM. Also given 60 out of 80 who has T2DM drink alcohol.
• What is the study design Cross sectional study OR = AD / BC

• Calculate the odds ratio comparing those with and without T2DM = 9 (>1)
Odds in exposure (alcohol) is

• Interpret the result, if the 95% CI is 0.8-12 greater in cases (T2DM).

95% CI = 0.8 —> Crosses line of no difference (0-1)

The odds of developing T2DM in individuals who drink alcohol is 9 times compared to
individuals who do not drink alcohol.
However, since 95% confidence interval crosses line of no difference, the result is not statistically
significant (Results are occurring by chance, is not representative of whole population)

Ways to improve data design to make the result statistically significant :

Aetiology study —> Cohort study is GOLD standard.
Increase sample size (Make study more generalized to / reprensentative of whole population)
Example 2
• A study with median follow-up of 15 years showed that 70% of
people who smoke develop lung cancer while 5% of people who do
not smoke develop lung cancer. The relative risk of developing lung
cancer in smokers is 14 (95% CI: 12-16) compared to non-smokers.
• What is the study design Cohort study (Only cohort study requires follow up : Exposure —> Outcome)
• Define null hypothesis There is NO association between smoking and developing lung cancer.
• Interpret the results
The risk of developing lung cancer in smokers is 14 times compared to non-smokers.
The results are statistically significant (95% confidence interval does not cross line of no difference).
Null hypothesis is rejected.

Assuming that RR = 1.5,

The risk of developing lung cancer in smokers is 50% higher than non smokers.
 Interventional study : Randomized controlled trials

Example 3 Hypothesis : Taking Vitamin X decreases risk of failing exam.

Exposure - Taking Vitamin X
Outcome - Failing exam

Fail exam Do not fail exam

Vitamin X (n=228) 29 199

Placebo (n=222) 67 155

EER

• Define the null hypothesis Vitamin X does not reduce risk of failing exam.
= Outcome w total exposed
= 29 / (29+199)

EER / CER (Similar to cohort study) CER - EER CER

• Calculate relative risk and absolute risk reduction = Outcome w total unexposed (placebo)
= 67 / (67+155)

• Interpret the results, if p<0.001 for both RR and ARR

< 0.1% results occur by chance.

• Calculate NNT Statistically significant, null hypothesis is rejected.

 RR = 1
RR There is no difference between taking
= outcome w total exposure / total unexposed vitamin X & placebo in decreasing risk
= 29 / (29+199) 67 / (67+155) of failing exam.
= 0.42
RR = 0.42 (<1)
RRR = 1-RR = 0.58 Taking vitamin X reduces the risk of
failing exam by 58% compared to
ARR placebo.
= CER - EER
= 67 / (67+155) - 29 / (29+199) ARR = 0.175
= 0.175 Taking vitamin X reduces the risk of
failing exam by 17.5%
NNT
= 1/ARR NNT = 5.71
= 1/0.175 At least 6 ppl must be treated to prevent
= 5.71 1 person from failing exam.
EPIDEMIOLOGY
Epidemiology triad
• Communicable
diseases

+ vector
Notification < 24 hrs :
Acute poliomyelitis
Cholera
Dengue
Diphtheria
Food poisoning
Rabies
Yellow fever
Plague
 Health :
State of complete physical, mental and social well-being + absence of disease.

CDC & NCD

Communicable dx control + Non communicable dx

• NCD • Definition
• Cancers • Risk factors
• Breast cancer
• Cervical cancer • Prevention strategies
• Colorectal cancer • Screening
• Mental health
• National plans/
• DM, HPT, Dyslipidaemia, Obesity programmes
• CDC implemented
• HIV & STD
• Challenges
• TB
• Foodborne illness
NCDs National health screening initiative (NHSI)
Komuniti Sihat Perkasa Negara (KOSPEN)
Health promotion
FAMILY HEALTH
Social Determinants of Health
“Conditions in the environments in which people are born, live, learn, work, play, worship, and age
that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
health indicator of country

HOW TO PREVENT?
Maternal mortality

Obstetric embolism
Postpartum haemorrhage
 Absolute poverty : Income is insufficient to maintain basic subsistence /

Poverty and child health survival.

Relative poverty : Income is insufficient to maintain social role, participate

in relationship, follow customary behaviours of society.

• Types of poverty
• Absolute poverty
• Relative poverty
• Factors affecting poverty
• Impact of poverty
• Initiatives
Mental health most common : anxiety
modul minda sihat
Geriatric care
Falls in the elderly
Diet & Nutrition
• “Healthy diet”
• DM – low GI
• CKD – Refer CPG CKD : low protein, phosphate, potassium
Dialysis - normal protein, low potassium & phosphate
• HPT – DASH
• IBS – FODMAPS Low FODMAP diet
improves IBS symptoms

• Enteral vs parenteral feeding

• Assessment: ABCD
 primordial (prevent RF) =
Subsidize fruits and vege sold in school canteens.
Provide community education about prevention of
communicable disease.
Free membership to fitness centers.

primary (prevent onset of dx) = counsel / vaccination / school-based interventions

secondary (early detection of dx) = screen / help
tertiary (prevent complication / recurrence) = rehab / pharmacological / surgical tx

OCCUPATIONAL & ENVIRONMENT HEALTH

Haddon matrix
 PR SRDV

WHO five pillars of road safety management

 2 out 5
Occupational hazards starts when begins to work
resolved when stop working
 Work-related vs work-aggravated
Occupational diseases scheme?
dosh /oshe?

• Occ Lung disease • MSD

• Occ Asthma • Trigger finger
• Pneumoconiosis • Carpal Tunnel Syndrome
• Mesothelioma • PID Prolapsed intervertebral disc
• CNS disorder • Pressure related diseases
• Lead poisoning • Barotrauma
• Mercury poisoning • Decompression illness
• NIHL • Occ Infections
• Occ skin disorders • Occ Tuberculosis
• Allergic Contact Dermatitis • Occ HIV Infection
• Irrtitant Contact Dermatitis • Mental disorder
• PTSD
HEALTH POLICY AND MANAGEMENT
funds
Tobacco
 • Biostatistics
• STD & HIV
• Mental Health
• Maternal Health
• Smoking
• Geriatric
• Road Traffic Accidents - Haddon’s matrix
FAQs •
•
Nutrition & Diet
Diabetes
• Screening (eg Cervical cancer, breast cancer)
• Child Health & Poverty