Social Medicine Notes

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SOCIAL MEDICINE - NOTES
Social Medicine (Medical University-Pleven)
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SOCIAL MEDICINE
(2017 – 2018)
Cristina Ribera Soler

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I. FUNDAMENTAL PART
OF PUBLIC HEALTH –
SCOPE AND METHODS OF
PUBLIC HEALTH

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TOPIC1. SOCIAL MEDICINE AS A SCIENCE. SUBJECT

MATTER. THE DISCIPLINES OF SOCIOLOGY, DEMOGRAPHY,
EPIDEMIOLOGY, STATISTICS AND THEIR RELATION TO
SOCIAL MEDICINE. DESCRIPTIVE AND PRESCRIPTIVE PARTS
OF SOCIAL MEDICINE. METHODS OF SOCIAL MEDICINE.
SOCIAL MEDICINE AS A SCIENCE.

Social medicine is a science that is concerned with public health.
It is the study of the factors which have an impact on the group and individual health, and
the practical measures in the society that may be taken to promote health, prevent disease
and assist recovery of the sick. These factors are:
- Socio-economic factors
- Environmental factors
- Cultural factors
- Psychological factors
- Genetic factors
THE DISCIPLINES OF SOCIOLOGY, DEMOGRAPHY,

EPIDEMIOLOGY, STATISTICS AND THEIR RELATION TO
SOCIAL MEDICINE.
The laboratory to practice social medicine is the whole community.
The tools for diagnosing community health are epidemiology and biostatistics.
Social therapy does not consist in administration of drugs but social and political action for
the improvement of conditions of life.
The main objective of social medicine is to protect the health of the population, and its tasks
may be defined as follows:
- To assess the health of the population and its development
- To work out methods and means for health promotion and prevention of disease,
disability, and infirmity.
- To organize medical care and rehabilitation for the whole population.
- To assess and control the sanitary conditions of the environment.
- To control the birth rate in order to secure the harmonious development of the
population (in developing countries).

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In order to achieve its objectives, social medicine has to deal with the information on:
- Social anatomy
o Age and sex composition of the population
o Housing
o Social groups
o Economic patterns
o Per capita income and expenditure
o Environmental sanitation
o Social environment
o Density of population, industries, geographical features, availability of food,
the towns, cities, districts, etc.
- Social physiology – the way the society functions as an organized unit
- Social pathology – systematic study of the relationship between diseases and social
conditions.
o It deals with the dysfunction prevailing in the community as a result of such
factors as malnutrition, age and sex composition, poverty, accidents, illiteracy,
standard of living, etc.
o The extent of social pathology is determined by epidemiological surveys.
o They bring to light the trends in morbidity and mortality and their correlation
with social factors and social changes.
- Social therapy – consists of social and political action for the improvement of
conditions of life. It also implies political action, which the society undertakes in the
form of legislation to prevent disease, protect and promote health of its citizens.
SUBJECT MATTER.
The subject matter of social medicine is public health.
For a quantitative estimation of public health, the following indices are used:
1. Demographic indices (death rate, birth rate, average life expectancy)
2. Morbidity rate
3. Disability rate
4. Indicators of physical development of the population
The greater part of these indicators is of negative character → it concentrates doctors’
attention to pathological conditions and health definition through morbidity intensity.

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DESCRIPTIVE AND PRESCRIPTIVE PARTS OF SOCIAL

MEDICINE.
According to its specific objectives, social medicine could be divided into two parts:
- Descriptive part – epidemiology of population health
- Prescriptive part – organization and management of health services activities.
METHODS OF SOCIAL MEDICINE.

Social medicine is a multidisciplinary science which uses methods from many other
branches of science to study community health, to develop appropriate preventive measures,
to effectively use the scare recourses, knowledge…
- Methods of Statistics
- Methods of Epidemiology – observational and experimental epidemiology
- Methods of Demography – population size and composition, birth and mortality
rates
- Methods of Sociology (self-administrated questionnaires, interviews, observation
- Economic Methods
DEVELOPMENT OF CONCEPTS.
The history of occurrence of our science is closely connected with the need of doctors to
explain the reasons of health and illnesses of their patients and also to learn to control their
health.
From the time, immemorial man has been interested in trying to control disease.
It is possible to give many examples from history of medicine confirming that many doctors
connected occurrence of diseases with adverse conditions of a life of their patients.
- Hippocrates (460 – 370 BC)
o “The majority of illnesses depend on acts, thoughts of the person and his life
conditions”.
o He studied such things as climate, water, clothing, diet, habits of eating and
drinking, and the effect they had in producing disease.
o His book “Airs, Water and Places” is considered a treatise on social
medicine and hygiene. The Hippocratic concept of health and disease
stressed the relation between man and his environment.

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- Abu Ali Ibn-Sina (980 – 1037)

o The great doctor of medieval East Abu Ali Ibn-Sina, known to the western
world as Avicenna, named three important conditions for health preservation:
§ Moderate physical exercise
§ Rational diet
§ Sleep
- Bernardino Ramazzini (1633 – 1714)

o Italian doctor Bernardino Ramazzini proved for the first time that not only
conditions of life and behavior of a person, but also working conditions can
cause illness.
o Its scientific work “Reasoning’s on illnesses of handicraftsmen” contains the
description of 60 occupational diseases with specifying of their reasons,
preventive and treatment measures.
- Rudolf Virchow (“Die Medicinische Reform, 1848)

o He advocated that medicine had to be reformed on the basis of the following
principles:
§ The health of people is a matter of direct social concern.
§ Social and economic conditions have and important effect on health and
disease.
§ The measures to promote health and combat disease must be social as
well as medical.
- Many Russian doctors also considered that, “it is necessary to treat not illness, but a
patient”, that is a person taking into account individual character, temperament, life
and work conditions.
o At the end of the 18th century many of the professors of the Moscow University
stressed the necessity of public health study and introduction of a new subject
at medical faculties.
o But the lecture course on public health was introduced only in the second half
of the 19th century, and only at several medical faculties and occasionally.
- Formation of a new science studying public health has occurred at the very beginning
of the 20th century in Germany.
o Interest to public health in Germany has been caused by adoption of the law of
social insurance providing three sources of payment for medical aid: means of
the state budget, businessmen’s profit, and worker’s inpayments.
o Under new conditions, businessmen became interested in studying health stat
of workers, morbidity decrease, carrying out of preventive measures…
o A German doctor Alfred Grotjan became a founder of social hygiene (the
original name of a science studying public health state).

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§ In 1903, Alfred Grotjan began publishing a magazine on social hygiene.

§ In 1905, he founded a scientific organization on social hygiene and
medical statistics in Berlin.
§ In 1920, Alfred Grotjan became successful in establishment of the Chair
of Social Hygiene at Medical Faculty of the Berlin University.
- 1912 – Rene Zand founded the Belgian Social and Medical Association
- 1922 – Semaško → first chair of Social hygiene in Moscow University.
- 1942 – first chair in England (at Oxford).
In the thirtieth years of the last century in other countries of the world the chairs studying
public health have opened.
Social hygiene is a young science; it still continues to be formed and consequently has no
common unitized name as a teaching subject.
In many countries, this subject is called social medicine, medical sociology, preventive and
social medicine, sociology of public health services (USA), public health…
THE EDUCATION IN SOCIAL MEDICINE.

MISSION
To contribute to the development of a well-rounded (holistic) medical professional, who will
demonstrate knowledge and competence with compassion in dealing with primary health
care, desire for lifelong learning, evidence-based practice, interdisciplinary team work, and
professional and ethical behavior in practice in order to improve and sustain the health of the
population.
GOAL
To ensure that the medical graduate has acquired broad public health competencies needed to
solve health problems of the community with emphasis on health promotion, disease
prevention, cost-effective interventions and follow up.
OBJECTIVES
At the end of the course the graduate doctors should be able to:
- Conceptualize people as the focus of the lifetime service of a doctor and be ready to
help always and specially in time of need, minimize the suffering of people and have
the ability to “think globally and act locally”.
- Apply the basic epidemiological principles to investigation of diseases, outbreaks,
health promotion and disease prevention.

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- Contribute to health systems’ performance as a member of the health team in the

generation and efficient utilization of human and logistic resources.
- Foster healthy lifestyles in the individual and the community level to prevent
environmental degradation and to promote social harmony.
- Identify the health needs of populations and population subgroups through planning,
intervention, monitoring and evaluation.
- Provide patient-centered comprehensive primary health care including referral,
continuing care and follow-up.
- Ensure research competencies in:
o Accessing and appraising scientific information.
o Preparation of reports and maintaining records.
o Presentation of research findings and publishing.

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TOPIC 2. THE CONCEPT OF HEALTH AND DISEASE.

DIMENSIONS OF HEALTH. POSITIVE HEALTH.
DETERMINANTS OF HEALTH.
THE CONCEPT OF HEALTH AND DISEASE.

CONCEPT OF HEALTH
“Health is a state of complete physical, mental and social well-being, and not merely an
absence of disease or infirmity”
- Physical well-being → state where all the organs of the body are of unexceptional size
and function normally.
- Mental well-being → a mentally healthy person:
o Feels satisfied with himself
o Is well adjusted (able to get along well with others)
o Has good self-control (faces problems and tries to solve them intelligently)
- Social well-being → includes the levels of social skills one possesses, social
functioning and the ability to see oneself as a member of a larger society.
DIMENSIONS OF HEALTH.

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POSITIVE HEALTH.
A person who enjoys health at all three planes (physical, mental and social) is said to be in a
state of “positive health”.
The attainment of positive health is one of the important ingredients of good life that a nation
should assure for every citizen.
HEALTH AS A RELATIVE CONCEPT.

There are no fixed standards governing health. What is considered normal in one person may
be abnormal to another. Thus, health is a relative concept and standards of health vary from
person to person, and from country to country.
NEW PHYLOSOFPHY OF HEALTH.

Involves not only the well-being in the conception of health but also some new dimensions
about what health is:
- Health is a fundamental human right
- Health is the essence of productive life
- Health is intersectorial
- Health is integral part of development
- Health is quality of life
- Health involves individual governmental and international responsibility
- Maintenance of health is a major social investment
- Health is worldwide social goal
In medico-social researches, at health estimation, it is accepted to point out four levels:

1. Health of a separate person – individual health
2. Health of social and ethnic groups – group health
3. Health of the population of administrative territory – regional health
4. Health of population, a society as a whole – public health
Unlike the majority of medical and clinical disciplines dealing with a separate person, an
individual and his health, public health and public health systems study a state of health of all
population of the country.

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CONCEPT OF PUBLIC HEALTH

Winslow: “Public health is the Science and Art of preventing disease, prolonging life and
promoting health through organized community efforts for:
- Sanitation of the environment
- Control of communicable diseases
- Education of the individual in personal hygiene
- Organization of medical and nursing services for early diagnosis and preventive
treatment
- Development of social machinery to ensure everyone and adequate standard of
living for the maintenance of health”.
Public health is the planning, carrying out and evaluation of health measures and system
services that both maintain and improve the health of a population group and prevent and
control diseases within that population group.
SPECTRUM OF HEALTH.
The health of an individual is a dynamic phenomenon. Health and disease form a
continuum.
- Positive health
- Better health
- Freedom from sickness
- Unrecognized sickness
- Mild sickness
- Severe sickness
- Death
CONCEPT OF DISEASE.
- Webster: “A condition in which body health is impaired, a departure from a state of
health, an alteration of the human body interrupting the performance of vital
functions”
- Oxford English Dictionary: “A condition of the body or some part or organ of the body
in which its functions are disturbed or deranged”.
- Alan Gregg: “Maladjustment of the human organism to the environment”.
- Susser: “A physiological dysfunction”.

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FACTORS INFLUENCING HEALTH.
FACTORS OF COMMUNITY HEALTH FACTORS OF INDIVIDUAL HEALTH

Related to material production Personal characteristics
Related to human reproduction: Factors related to family background
- family
- lifestyle
- public health care
- education
- …
Related to intellectual production: Factors related to occupational environment
- science
- law
- religion
- art
- politics
- …
Related to communications: Factors related to social environment
- massmedia
- transport
- language
Social management Factors related to Health Services

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TOPIC 3. SOCIOLOGICAL APPROACHES IN SOCIAL MEDICINE

– SOURCES AND METHODS OF COLLECTING SOCIOLOGICAL
DATA. QUESTIONNAIRE DESIGN – QUESTIONS AND
QUESTIONNAIRE FORMATS. SELF-ADMINISTERED
QUESTIONNAIRE.
SOCIOLOGICAL APPROACHES IN SOCIAL MEDICINE –

SOURCES AND METHODS OF COLLECTING SOCIOLOGICAL
DATA.
SOCIOLOGY AS APPLIED TO MEDICINE AND HEALTH CARE SYSTEM

WHAT DO MEDICAL SOCIOLOGISTS STUDY?
- Social causes and patterns of health and disease
- Social behavior of health care personnel and their patients
- Social functions of health organizations and institutions
- Relationship of health care delivery systems to other social systems
Important field of study because:

- Recognizes the critical role social factors play in determining or influencing the health
of individuals, groups, and the larger society
Sociologists use the following methods:

- Surveys
- Observations
- Experiments → research method for investigating cause and effect under highly
controlled conditions
- Secondary analysis → research method in which a researcher utilizes data collected by
others

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QUESTIONNAIRE DESIGN – QUESTIONS AND

QUESTIONNAIRE FORMATS.
SURVEY RESEARCH → Method in which subjects respond to a series of statements or

questions in a self-administered questionnaire or an interview.
- Surveys are directed at populations, the people who are the focus of research.
- Usually we study a sample, a part of a population that represents the whole. Random
sampling is commonly used to be sure that the sample is actually representative of the
entire population.
Surveys involve questionnaires → a series of written questions a researcher presents to
subjects
- A questionnaire is an instrument (form) to:
o Collect answers to questions
o Collect factual data
o Gathers information or measures
This technique uses statistical methods to analyze data
DESIGN THE QUESTIONNAIRE

- Determine survey objectives → plan what to measure
- Decide on format (e.g. personal interview, telephone, self-administered…)
- Formulate questions to obtain the needed information
- Decide on the wording of questions
- Decide on the question sequence and layout of the questionnaire
- Using a sample, test the questionnaire for omissions and ambiguity – pilot study
- Correct the problems (pretest again, if necessary)
The major decisions in questionnaire design:

1. Content → What should be asked?
2. Wording → How should each question be phrased?
3. Sequence → In what order should the questions be presented?
4. Layout → What layout will best serve the research objectives?
The most difficult step is specifying exactly what information is to be collected from each
respondent!
1. CONTENT – Questions must meet 5 requirements

- Are the questions relevant? Do they pertain to the research problem?
- Are the questions accurate? Do they accurately depict the attitudes, behaviors, etc.
intended to investigate?
- Do respondents have the necessary information?
- Do respondents understand and interpret the question correctly?
- Will respondents give the information?

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2. WORDING – How should the questions be asked?

Format: How much freedom do we give respondents in answering questions?
Open ended questions

- Key advantages:
o Wide range of responses and information can be obtained
o Answers based on respondent’s not researcher’s terms
o Lack of influence
o Particularly useful as introduction to survey or topic
o When too many possible responses to be listed or unknown
- Key disadvantages:
o Interviewer’s ability to record answers quickly or summarize accurately
o Interviewer’s attitude influences response
o Time consuming
o Difficulty in coding
o Require respondents to be articulate
o Respondents may miss important points
o Non-response
Closed questions
- Scales for measuring attitude
o Lickert scale → Stray dogs carry a higher risk of rabies?
- Advantages
o Ease of understanding
o Requires less effort on part of interviewer and respondent
o Ease of analysis
o Less error prone
o Less interviewer bias
o Less time consuming
o Answers directly comparable from respondent to respondent
- Disadvantages
o Middle/Neutral categories often selected inappropriately
o Less opportunity for self-expression or subtle qualifications
o Less involving for respondents
o Order of response categories can have major impact on results
o Difficult for preparation and pre-determination of answers

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- Things to avoid:
o Complexity: use simple, direct, conversational language
o Leading questions – that suggest or imply certain answers
o Loaded questions – suggest social desirability, or are emotionally charged
o Ambiguity and vagueness:

§ Words such as “often”, “occasionally”, “usually”, “regularly”,
“frequently”, “many”, should be used with caution. If these words have
to be used, their meaning should be explained properly.
o Long-worded questions
o Double-barreled questions → Questions that refer to two or more issues

within the same question. Where respondent may agree with only 1 part of
multipart statement.
§ Do you like cheese or salami? Yes/No
o Making implicit assumptions
o Jargon
o Burdensome questions → that may tax the respondent’s memory

§ How many tubes of toothpaste have you purchased in the last 3 months?
o Using double negatives
o Embarrassing, sensitive, or threatening questions:

§ Have you eaten more sweets than you should?
3. SEQUENCE → Question sequence & Layout decisions

Initial stages:
- Introduction to the topic
- Screening or qualifying questions
- Need to gain and maintain respondent’s cooperation
- Opening questions should be interesting, simple, and easy to answer
Transition questions → Questions directly related to research objectives which require more
effort and get respondent thinking about the topic
Basic – Difficult and complicated questions

- On the topic
- Respondent now committed

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Identification – Classifying and demographic questions

- Characterize respondents
Other considerations:
- Questions should flow logically from one to the next.
- General questions should be asked before more specific ones.
- Earlier questions should not influence response to later ones.
- Questions should flow from factual and behavioural questions to attitudinal and
opinion questions.
- Questions should flow from the least sensitive to the most sensitive.
- Demographic questions should come at the end.
1. Initial questions – screening and rapport questions

2. Middle – product specific questions
3. End – demographic questions
- Use multiple questions instead of one

- Similar questions together → consistent mindset for respondents
- Develop a logical flow
- Use transitions between sections (e.g. In this section we ask questions about X)
- Distinguish between instructions, questions and responses
4. LAYOUT
The layout and physical attractiveness of a questionnaire are important aspects.
- Questionnaires should be designed to appear as short as possible
- Questionnaires should not appear overcrowded
- Leave lots of space for open ended questions
- Questionnaires in booklet form are often recommended
Opening
- Provide name of company doing research
- Provide reason for survey and topic
- Give information how the results will be used
- Give guarantee of anonymity
- Tell respondent approximate time to complete
- Reinforce that respondent’s time is appreciated
- Invite to participate
Closing
- Thank for time
- Ask if they had a positive experience and remind them that their opinions count

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PRETESTING AND CORRECTING PROBLEMS

Purpose of pretest → To ensure that the questionnaire meets the expectations in terms of the
information that will be obtained
- Is question necessary? → does it serve a purpose, will info be used
- Missing important variables → does it provide the info needed
- Match questions to objectives
- Pretest specific questions for:
o Meaning
o Task difficulty
o Respondent interest and attention
o Ambiguous, ill-defined, loaded, double-barreled questions
- Pretest the questionnaire
o Flow of the questionnaire
o Length
- Respondent interest and attention
QUESTIONNAIRE DESIGN FLOW CHART

1. Specify what information will be sought
2. Determine type method of administration
3. Determine the content of individual questions
4. Determine form of response for each question
5. Determine wording for each question
6. Determine sequence of questions
7. Determine physical characteristics of questionnaire
8. Revise steps 1-7, revise if necessary
9. Pretest questionnaire, revise if necessary
10. Implement
SELF-ADMINISTERED QUESTIONNAIRE.
TYPES OF QUESTIONNAIRES
INTERVIEWER-ADMINISTRATED SELF-ADMINISTRATED
Face to face Direct group
Telephone Direct individual
Structured/Unstructured/Semi-structured By post
Personal/Collective Email/Internet
Single time/Repetitive (panel) Indirect

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ADVANTAGES/DISADVANTAGES
INTERVIEWER-ADMINISTRATED
ADVANTAGES DISADVANTAGES
Participation by illiterate people Interviewer bias
Clarification of ambiguity Needs more resources
Quick answers Only short questionnaires possible
(especially on telephone)
More detailed responses Difficult for sensitive issues
Greater control over filling out of response Quality of data depends upon the quality of
form the interviewer
SELF-ADMINISTRATED
Cheap and easy to administer Low response rate
Preserves confidentiality Questions can be misunderstood
Completed at respondent’s convenience No control by interviewer
No influence by interviewer Time and resources loss
Difficult to elicit detailed responses
Less control over how the form is filled
Cannot elicit additional information

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TOPIC 4. INTERVIEW: TYPES, METHODS OF CONDUCTING,

INTERVIEW PROCESS. SOCIOLOGICAL OBSERVATION:
TYPES, ADVANTAGES AND DISADVANTAGES, OBSERVER
ROLES.
INTERVIEW: TYPES, METHODS OF CONDUCTING,

INTERVIEW PROCESS.
INTERVIEW → Conversation between interviewers and interviewees with the purpose to
collect certain information.
TYPES OF INTERVIEW
- According to the type of questionnaire:
o STRUCTURED INTERVIEW
§ Closed response answers
§ Precise order of questions
§ The interviewer writes the answers! → no freedom for him
o UNSTRUCTURED INTERVIEW
§ More freedom for the interviewer
§ Opened questions
§ The order is not so strict → depending on the answers of the interviewed
subject
§ Informal structure
o SEMISTRUCTURED INTERVIEW
§ Some strict order
§ Closed and opened questions (or semi-closed questions)
§ Mix of structured/unstructured interviews
- According to the number of interviewees:
o PERSONAL INTERVIEW → interviewer and subject
o COLLECTIVE INTERVIEW
§ Main disadvantage → loose the individual opinion → we get only the
group one
- According to the number of meetings:
o SINGLE-TIME INTERVIEW → 1 interview

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o PANEL (REPETITIVE) INTERVIEW

§ We ask the same questions to the same people during a specific period
of time → to see the changes in people’s opinion
- According to the methods of conducting the interview:

o FACE-TO-FACE
o INTERVIEW WITH DISTANCE MEANS OF COMMUNICATION

§ Telephone interview
• Cheaper, less time consuming
• But! → not suitable for every researches → specially, if the
interviewer-interviewee are not well-known.
- According to the way of recording

o VIDEO RECORDING
§ Very intrusive → ethical problems: the subject must know it!
• The information that we obtain may not be objective because the
behavior changes when knowing that they are recorded.
o AUDIO RECORDING
§ Not as much intrusive, but also with ethical problems
§ Both video and audio recording are very useful
o RESPONSE SHEET
§ It may be boring
o UNSTRUCTURED NOTES
§ Cheap and simple
§ Main disadvantage: interviewer has to remember all answers and some
data may be omitted
Requirements for interviewers are very important in the interviews: age, sex… according to
the subject which is interviewed.
INTERVIEW PROCESS.
1. Selection of interviewees
2. Recruitment of interviewers
3. Starting the interview
4. Securing rapport with the interviewee
5. Recall → when the interviewee drifts away from the main subject, the interviewer
should give them enough time to recollect and may also refresh their memory by
pointing out what they had been saying last
6. Probe questions → used when the subject side-tracks some important aspects of the
problem

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7. Encouragement of the interviewee

8. Guiding the interview → necessary when the subject digresses in his narration to less
important topics
9. Recording → should be reduced to a minimum
10. Closing the interview → should not be abruptly → should be brought by the
interviewer in a natural way + greetings
11. Report → should be complied soon after the interview when the mind is still fresh
about the narration
12. Analysis of data → interview transcript is analyzed (quantitative and qualitative
analysis are applied)
SOCIOLOGICAL OBSERVATION: TYPES, ADVANTAGES AND

DISADVANTAGES, OBSERVER ROLES.
Sociologists use the following methods:

- Surveys
- Observations
- Experiments
- Secondary analysis
MAJOR TYPES OF OBSERVATION

- Naturalistic
- Structured/ non-structured
- Non-participant observation
- Participant observation

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NATURALISTIC OBSERVATION
- General characteristics:
o Observation in the respondent’s natural social settings
o Respondent’s behavior is examined and recorded without consent of him
o Researcher has no influence on respondent’s behavior
- Advantages:
o Spontaneous behavior
o Less disruptive
- Disadvantages:
o Threat to confidentiality
STRUCTURED OBSERVATION
- Method relatively underused in social research
- Systematically and planned observing behavior in a controlled environment
- Direct observation of behavior and recording of the behavior and the recording of that
behavior in term of categories that have been devised prior to start data collection
- Advantages:
o Observing direct behavior
o Allows control of extraneous variable
o Reliability of results by repetitive study
o Provides a safe environment to study continuous concepts
- Disadvantages:
o Control can affect behavior
o Observer bias
o Imposing of irrelevant framework
o Not possible to know intentions behind behavior
o Unable to produce data a whole
UNSTRUCTURED OBSERVATION
- No use of observation schedule for recording of behavior
- Gives narrative account of the behavior
- Unplanned and informal
- It studies behavior of respondent in the natural social settings
- Advantages:
o Broad overview of the situation and conditions prevailing in the society
o Useful when subject matter is clear

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- Disadvantages:
o Appropriate as first step
o Not specific approach as it is the narrative description of observation
o Problem of generalization
NON-PARTICIPATING OBSERVATION
- Observer observes but does not participate in what is going on in the social settings
- Planned and structured
- Observer abstains himself from his physical presence in the social settings
- Other sources are used to come to conclusion
- Advantages:
o Avoidance of Observer effect
o Biased free
o Low cost and less time consuming
- Disadvantages:
o Reliance on secondary sources which may be inaccurate
o No identification of real problem and prevailing social settings
o No in-depth study
PARTICIPANT OBSERVATION
- Method by which researchers systematically observe people while joining in their
routine activities
- It is descriptive and often exploratory
- It is normally qualitative research, inquiry based on subjective impressions
- Best known method in social science research
- Associated with qualitative research
- Prolonged physical immersion of observer in a social setting in which he seeks to
observe the behavior of members of that setting
- In-depth study of the society and subject
- Close interaction and relation between observer and subject
- Advantages:
o Insiders view
o Researcher becomes an accepted part of the environment
o Detailed study of social settings
o Identification of real problems and elements that are leading to such problems
- Disadvantages:
o Problem of objectivity
§ Documentation relies on memory, personal discipline, and diligence of
researcher

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o Close relation affects study

o Time taking process
o Unstructured
- Characteristics:
o Gathering data while experiencing subject’s social contexts with them
o Gain holistic perspective on social living
o To understand how things work
o Real view of how people behave in their settings
o See guiding principles of an organization, setting, sub-group, or culture
o To understand how it feels to be a member of a given group
HOW TO CONDUCT FIELD WORK?
Phase Description
Planning You decide what you want to do, why you want to do it, what resources
you need, and what research may have already been done on the same
subject
Collecting You gather the information, make notes and observations about the
information, its character and the collecting events
Analyzing You need to index the filed-collected materials for an archive,
summarize them, and write them up
- How many observers?

o More than one:
§ May remove bias
§ Has higher costs
§ May change behaviors more
- Ways of recording
o Notes
o Audio
o Video
- Types of notes – Field (descriptive) include:

o Description of setting
o Identification of people
o Description of content of the activities
o Documentation of interactions
o Description and assessment
o Unanticipated things

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- Researcher skills
o For studies of different culture – know the language
o Be aware of what people are doing and saying. Otherwise you take in what you
expected to see rather than what you saw.
o Good note taking skills.
o Patience.
o Practice objectivity → Personal ideas can kill accuracy.
§ Personal beliefs may not fit your research context. Don’t try to empty
your mind of pre-conceived notions and don't try to disbelieve what you
believe. Just be aware that alternative views are possible.
- Social role
o Certain topics cannot be studied by other means. Some groups won't let you see
anything unless you are part of their lives.
o Many settings are too intricate to be understood with piecemeal techniques.
o Helps formulate survey questions that are sensible and appropriately phrased.
o Participant observation is respectful of subjects. Rather than just hitting them
up for data, you invest your time in them and treat them like experts in their
setting.
o Pedagogically, research based in participant observation is often the most
convincing, easily understood sociological research
OBSERVER ROLES.

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TOPIC 5. EPIDEMIOLOGY – DEFINITION AND SCOPE OF

EPIDEMIOLOGY. ACHIEVEMENTS IN EPIDEMIOLOGY. USES
OF EPIDEMIOLOGY. BASIC CONCEPTS – RISK, RISK FACTOR,
POPULATION AT RISK, RATE, RATIO, PROPORTION.
DEFINITION AND SCOPE OF EPIDEMIOLOGY.
EPIDEMIOLOGY (CDC definition) → the study of the distribution and determinants of

health-related states in specified populations, and the application of this study to control
health problems”.
- Distribution → occurrence of cases by time, place, and person
- Determinants → all the causes and risk factors for the occurrence of a disease,
including physical, biological, social, cultural and behavioral factors
- Health-related States
o Diagnosis of specific disease or cause of death
o Health-related behavior (e.g. smoking, taking prenatal vitamins)
- Specified population → a measurable group, defined by location, time, demographics,
and other characteristics
- Application → analysis, conclusion, distribution, and timely use of epidemiologic
information to protect the health of the population
DESCRIPTIVE EPIDEMIOLOGY
- Studies the pattern of health events and their frequency in populations in terms of:
o Person
o Place
o Time
- Purpose:
o To identify problems for further study
o To plan, provide, and evaluate health services
ANALYTIC EPIDEMIOLOGY
- Studies the association between risk factors and disease
- Purpose:
o To determine why disease rates are high (or low) in a particular group

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ACHIEVEMENTS IN EPIDEMIOLOGY.
PURPOSE OF EPIDEMIOLOGY
- To measure frequency of disease → quantify disease
- To assess distribution of disease
o Who is getting disease?
o Where is disease occurring?
o When is disease occurring?
- To form hypotheses about causes and preventive factors
- To identify determinants of disease
o Hypotheses are tested using epidemiologic studies
EPIDEMIOLOGIC ASSUMPTIONS
- Diseases and other health-related events do not occur at random
- Diseases and other health-related events usually have casual and preventive factors
that can be found
USES OF EPIDEMIOLOGY.

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BASIC CONCEPTS – RISK, RISK FACTOR, POPULATION AT

RISK, RATE, RATIO, PROPORTION.
RISK → The probability that an event will occur – an individual will become ill.
RISK FACTOR → An aspect of personal behavior or lifestyle, an environmental exposure,

or a hereditary characteristic that is associated with an increase in the occurrence of a
particular disease, injury, or other health condition.
- Risk factors are observable or identifiable prior to the event they predict
- Classification:
o Modifiable/Non-modifiable
§ MODIFIABLE → a risk factor that can be reduced or controlled by
intervention, thereby reducing the probability of disease.
• The WHO has prioritized the following four:
o Physical inactivity
o Tobacco use
o Alcohol use
o Unhealthy diets
§ NON-MODIFIABLE → a risk factor that cannot be reduced or
controlled by an intervention, for example:
• Age
• Gender
• Race
• Family history (genetics)
o Individual/Community
Risk factors contributing

for non-communicable
diseases
Life style
Environmental
Genetic
Health services

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EXPOSED GROUP → A group whose members have been exposed to a supposed cause of
a disease or health state of interest, or possess a characteristic that is a determinant of the
health outcome of interest.
POPULATION AT RISK
- That part of the population which is susceptible to a disease.
- All those to whom an event could have happened whether it did or not.
- Those who are capable of having or acquiring the disease or condition in question
(sometimes it may be necessary to exclude people which are not at risk)
RATE → A measure of the occurrence of health event in a population group at a specified

time period.
- Consistency between the numerator and the denominator
- The numerator should be part of the denominator
&'($)"#*)
!"#$ = . ('/#,0/,$)
+$&*(,&"#*)
1'(2$) *3 4"5$5 *3 5#'+,$+ $6$&#

!"#$ = . 10<
7*0'/"#,*& "# ),58 3*) #ℎ,5 $6$&#

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Types of rates:
- CRUDE RATES → consider the entire population
- SPECIFIC RATES → consider differences among subgroups of the population
- ADJUSTED RATES → adjust for differences in population composition
RATIO → Relation in size between two random quantities.

- The numerator is not a component of the denominator
&'($)"#*) (&*# " 4*(0*&$&# *3 #ℎ$ +$&*(,&"#*))

!"#,* =
+$&*(,&"#*)
3$("/$5
?."(0/$: A$. !"#,* =
("/$5
PROPORTION → Relation in magnitude of a part of the whole.

- The numerator is always included in the denominator
- Usually expressed in percentage
7B!C *3 #ℎ$ Dℎ*/$ $6$&#

7)*0*)#,*& = . 100 (%)
#ℎ$ Dℎ*/$ $6$&#

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TOPIC 6. MEASURING HEALTH AND DISEASE. MEASURING

DISEASE FREQUENCY – PREVALENCE, INCIDENCE RATE,
CUMULATIVE INCIDENCE. RELATIONSHIPS BETWEEN
DIFFERENT MEASURES.
PREVALENCE → The number of all current cases (old and new) existing in a defined
population at a specified point of time, or over period of time in a given population.
*+,-#" /0 #12342'5 (%3#3 /0 623#%3#

P"#$%&#'(# = 1 10<
7/8+&%42/' %4 "239
- POINT PREVALENCE
- PERIOD PREVALENCE
INCIDENCE → The number of new cases occurring in a given population during a specified
period of time.
*+,-#" /0 '#> (%3#3 /0 623#%3#

='(26#'(# = 1 10<
7#"3/' − @#%"3

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Person – years:
- Person → sum of length of time during which each person in the population is at risk
- Years → average size of the study population multiplied by the length of the study
period
CUMULATIVE INCIDENCE → Number of new cases of disease occurring over a

specified period of time in a population at risk (at the beginning of the interval).
- Simpler measure of the occurrence of a disease or health status
- The probability or risk of individuals in the population getting the disease during the
specified period
*+,-#" /0 '#> (%3#3 /0 623#%3#

A+,+&%42$# ='(26#'(# = 1 10<
7/8+&%42/' %4 "239 %4 4ℎ# -#52'2'5 /0 4ℎ# 8#"2/6
RELATIONSHIPS BETWEEN DIFFERENT MEASURES.
I = 3/33 x 100 = 9.1 cases per 100 person-years

CI = 3/7 x 100 = 43 cases per 100 persons
P (at year 4) = 2/6 x 100 = 33 cases per 100 persons

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TOPIC 7. COMPARING DISEASE OCURRANCE. ABSOLUTE

COMPARISON – RISK DIFFERENCE, ATTRIBUTABLE
FRACTION, POPULATION ATTRIBUTABLE RISK. RELATIVE
COMPARISON – RELATIVE RISK, ODDS RATIO.
COMPARING DISEASE OCURRANCE.

ABSOLUTE COMPARISON RELATIVE COMPARISON
Indicates on an absolute scale how much

Indicates how much more likely one group
greater the frequency of the disease is in
is to develop a disease than another
one group compared with the other
- Risk difference (Excess risk,

Attributive risk of exposed)
- Relative risk
- Etiologic (attributable) fraction of
- Odds ratio
exposed
- Population attributive risk
ABSOLUTE COMPARISON – RISK DIFFERENCE,

ATTRIBUTABLE FRACTION, POPULATION ATTRIBUTABLE
RISK.
RISK DIFFERENCE
- Provides information about the absolute effect of the exposure or the excess risk of
disease in those exposed compared with those non-exposed.
- Quantifies the risk of disease in the exposed group that can be considered attributable
to the exposure by removing the risk of disease that would have occurred anyway due
to the other causes (the risk in the non-exposed)
- The number of cases of the disease among the exposed that could be eliminated if the
exposure was eliminated.
!"#$ &"''()(*+( !, = ./ − .1

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ETIOLOGIC (ATTRIBUTABLE) FRACTION OF EXPOSED

- The proportion of the disease in the specific population that would be eliminated in the
absence of exposure.
- A useful tool for assessing priorities for public health action.
./ − .1
23"4546"+ ')7+3"4* (29) = ; 100
./
POPULATION ATTRIBUTABLE RISK

- Measure of the excess rate of disease in a total study population which is attributable
to an exposure.
- Determines the proportion by which the incidence rate of the outcome in the entire
population would be reduced if exposure was eliminated.
- Helps to determine which exposures have the most relevance to the health of a
community.
.C − .D
>4?@573"4* 733)"A@37A5( )"#$ (>B!) = ; 100
.C
RELATIVE COMPARISON – RELATIVE RISK, ODDS RATIO.
RELATIVE RISK
- Estimates the magnitude of an association between exposure and disease.
- Indicates how many times the risk of developing disease by the exposed is greater than
the risk of developing the same disease by the non-exposed.
- The larger the relative risk, the stronger the association between cause and effect.
./
!(573"E( )"#$ (!!) =
.1

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RD = 49,6 - 17,7 = 31,9 per 100 000 person-years

EF = 31,9 / 49,6 x 100 = 64%
PAR = 30,2 - 17,7 / 30,2 x 100 = 41,4%
RR = 49,6 / 17,7 = 2,8
ODDS RATIO
- Estimates the magnitude of an association between risk factor and outcome.
- Substitute RR when we are not able to calculate the incidence rate among the exposed
and non-exposed because we have no data about the population at risk (in case-control
studies).
DISEASE EXPOSURE YES NO TOTAL

YES a b a+b
NO c d c+d
TOTAL a+c b+d a+b+c+d
7 ; &
F&&# )73"4 (F!) =
A ; +

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TOPIC 8. TYPES OF EPIDEMIOLOGICAL STUDIES –

CLASSIFICATION. DESCRIPTIVE STUDIES. ANALYTICAL
STUDIES (ECOLOGICAL AND CROSS-SECTIONAL STUDIES).
TYPES OF EPIDEMIOLOGICAL STUDIES – CLASSIFICATION.
ALTERNATIVE UNIT OF
TYPE OF STUDY
NAME STUDY
Descriptive studies
Ecological Correlational Populations

OBSERVATIONAL
STUDIES Analytical Cross-sectional Prevalence Individuals
studies Case-control Case-reference Individuals
Cohort Follow-up Individuals
Randomized controlled trials Clinical trials Individuals
Cluster randomized controlled

Groups
EXPERIMENTAL trials
(INTERVENTION) Healthy
STUDIES Field trials
people
Community
Community trials intervention Communities
studies
DESCRIPTIVE STUDIES.
- Descriptive studies are usually the first phase of an epidemiological investigation.
- Descriptive studies are concerned with observing the distribution of disease or health-
related characteristics in human populations and identifying the characteristics with
which the disease in question seems to be associated.
- Descriptive studies basically ask the questions:
o When is the disease occurring? – time distribution
o Where is it occurring? – place distribution
o Who is getting the disease? – person distribution

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Time distribution
- Short-term fluctuations
- Periodic fluctuations
- Long-term trends
By monitoring of time trends, the epidemiologist seeks which diseases are increasing, which
are decreasing and which are emergency health problems and what is the effectiveness of
measures to control old ones.
Place distribution
- International variations
- National variations
- Rural-urban variations
- Local distributions (Snow’s study)
Person distribution
- Age
- Sex
- Ethnicity
- Marital status
- Occupation
- Social class
- Behavior
USES OF DESCRIPTIVE EPIDEMIOLOGY

- Provides data regarding the magnitude of the disease load (amount of disease) and
types of disease problems of the community in terms of morbidity and mortality rates
and ratios.
- Provides clues to disease etiology, and help in the formulation of an etiological
hypothesis.
- Provides background data for planning, organizing and evaluating preventive and
curative services.
- Contributes to research by describing variations in disease occurrence by time, place
and person.

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ANALYTICAL STUDIES (ECOLOGICAL AND CROSS-

SECTIONAL STUDIES).
ECOLOGICAL STUDIES
- The units of study are populations or groups of people rather than individuals.
- Compare disease frequencies between different groups during the same period of time
- Compare disease frequencies in the same population at different points in time – may
avoid some of the socioeconomic confounding that is the potential problem in
ecological studies.
Simple to conduct Lack of ability to control potential
confounding factors
Useful for the formulation of hypotheses Cannot be used to test the hypotheses
Difficult to interpret – since correlation
studies refer to whole populations, it is not
possible to link exposure to occurrence of
disease in the same person =
ECOLOGICAL FALLACY.
On the contrary, BIOLOGICAL FALLACY = is an error that may occur when the attempt
to explain variations in population groups is based on individual study results.

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CROSS-SECTIONAL STUDIES
- Purpose → to learn about the characteristics of a population at one point in time (like
a photo “snap shot”)
- Design → no comparison group
- Population → all members of a small, defined group or a sample from a large group
- Results → produces estimates of the prevalence of the population characteristic of
interest
When to conduct a Cross-Sectional study?

- To estimate prevalence of a health condition or prevalence of a behavior, risk factor,
or potential for disease.
- To learn about characteristics such as knowledge, attitude and practices of individuals
in a population.
- To monitor trends over time with serial cross-sectional studies.
Does not require follow-up and is therefore Since exposure and disease status are
less costly and quicker than other designs measured at the same time, it is not possible
to determine the direction of the association.
Helpful for program planning and policy
In other words, it is not known if the
development
exposure preceded the disease and is
Hypotheses generating therefore a potential cause of disease.
Examples of Cross-Sectional studies:

A cross-sectional study can be used to look at the association between obesity and television
watching. A sample of people from the population that you are interested in can be polled
and asked about their height/weight ratio and the number of hours of television the person
watches each week. This study will give insight as to whether obesity and television watching
are associated, but it will not help to determine which might cause the other. In other words,
it is not known if obesity causes more television watching or if more television watching
causes obesity.

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TOPIC 9. COHORT STUDIES – TYPES, DESIGN, CONDUCTING,

ADVANTAGES AND DISADVANTAGES OF COHORT STUDIES.
POTENTIAL ERRORS IN COHORT STUDIES.
COHORT STUDIES.
What is a cohort? → A well-defined group of individuals who share a common characteristic
or experience.
Example: Individuals born in the same year
What are other examples of cohorts?

- Cohort study (longitudinal study/follow-up study)
o Participants classified according to exposure status and followed-up over time
to ascertain outcome.
o Can be used to find multiple outcomes from a single exposure.
o Appropriate for rare exposures or defined cohorts.
o Ensures temporality (exposure occurs before observed outcome).
TYPES OF COHORT STUDIES.

- PROSPECTIVE COHORT STUDIES
o Group participants according to past or current exposure and follow-up into the
future to determine if outcome occurs.
Example: relation between smoking and lung cancer (doll and hill)

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- RETROSPECTIVE COHORT STUDIES

o At the time that the study is conducted, potential exposure and outcomes have
already occurred in the past.
- AMBISPECTIVE COHORT STUDY → combined prospective and retrospective

cohort study
o Investigator uses existing data collected in the past to:
§ Identify the population and the exposure status (exposed/non-exposed
groups)
§ Follow them into the future for the development of the disease
o Investigator:
§ Spends a relatively short time to assemble study population (and the
exposed/non-exposed groups) from past data
§ Will spend additional time following them into the future for the
development of disease

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- NESTED CASE-CONTROL DESIGN

o A cohort is identified and followed until sufficient number of cases develop.
o More detailed information is then collected and analyzed but only for “cases”
and for a sample from disease-free individuals (“controls”), not for all members
of the cohort.
o Particularly useful if complex and expensive procedures are being applied.
DESIGN OF A COHORT STUDY.
1. SELECTION OF STUDY SUBJECTS

- General population – when the exposure or cause of death is fairly frequent in the
population.
- Special groups:
o Selected groups – professional groups (Doll and Hill – British doctors),
government employees, insured persons, etc. – homogenous population,
accessible and easy follow-up.
o Exposure groups – when the exposure is rare.

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2. OBTAINING DATA ON EXPOSURE

- Directly from the cohort members – personal interviews or mailed questionnaires (Doll
and Hill)
- Review of records – dose of radiation, kinds of surgery, details of medical treatment,
etc.
- Medical examination or special tests – blood pressure, serum cholesterol, etc.
- Environmental surveys – information on exposure levels of the suspected factor.
3. CLASSIFICATION OF COHORT MEMBERS ON THE BASIS OF RECEIVED

INFORMATION
- According to whether or not they have been exposed to the suspected factor
- According to the level or degree of exposure
4. SELECTION OF COMPARISON GROUPS

- Internal comparisons – the members of the cohort may be classified into several
comparison groups according to the degrees or levels of exposure to risk before the
development of the disease in question. The groups, so defined, are compared in terms
of their subsequent morbidity and mortality rates.
- External comparisons – when information on degree of exposure is not available, it is

necessary to put up an external control, to evaluate the experience of the exposed group
(for example, smokers and non-smokers). The study and control cohorts should be
similar in demographic and possibly important variables.
- Comparison with general population rates – if none is available, the mortality

experience of the exposed is compared with the mortality experience of the general
population in the same geographic area as the exposed people.
5. FOLLOW-UP
- Periodic medical examination of each member of the cohort
- Reviewing physician and hospital records
- Routine surveillance of death records
- Mailed questionnaires, telephone calls, periodic home visits
6. ANALYSIS
- Incidence rates of outcome among exposed and non-exposed groups
- Estimation of risk:
o Relative risk
o Risk difference
o Ethiologic fraction

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ADVANTAGES AND DISADVANTAGES OF COHORT STUDIES.
POTENTIAL ERRORS IN COHORT STUDIES.

BIAS → A systematic error in a study that leads to a distortion of the results.
- Selection bias
o Select participants into exposed and non-exposed groups based on some
characteristics that may affect the outcome.
- Information bias
o Collect different quality and extent of information from exposed and non-
exposed groups.
o Loss to follow-up differs between exposed and non-exposed (or between
disease and no disease).
- Misclassification bias
o Misclassify exposure status or disease status.
The effects of non-participation

In practically every cohort study, only a proportion of those who are eligible to participate
actually agree to do so and are entered into the study.
Those who agree to participate are likely to differ from nonparticipants in a number of
important ways, including basic levels of motivation and attitudes towards health as well as
risk factor status.
- For example, nonparticipants are more likely than participants to be current smokers.
The effect of this difference between these groups concerns the generalizability of the study
results.

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Multiple comparison groups

- When we cannot be sure that any single group will be sufficiently similar to the
exposed group in terms of the distribution of potential confounding variables.
- In such circumstances → the study results may be more convincing if a similar
association was observed for a number of different comparison groups.

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WHEN IS A COHORT STUDY WARRANTED?

- When the (alleged) exposure is known.
- When exposure is rare and incidence of disease among exposed is high (even if the
exposure is rare, determined investigators will identify exposed individuals).
- When the time between exposure and disease is relatively short.
- When adequate funding is available.

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TOPIC 10. CASE-CONTROL STUDIES – TYPES, DESIGN,

CONDUCTING, ADVANTAGES AND DISADVANTAGES.
POTENTIAL ERRORS IN CASE-CONTROL STUDIES.
CASE-CONTROL STUDIES.
CASE-CONTROL STUDY → Type of observational analytic epidemiologic investigation in

which subjects are selected on the basis of whether they do (case) or do not (controls) have a
particular disease under study. The groups are then compared with respect to the proportion
having a history of an exposure or characteristic of interest.
- Purpose:
o To study rare diseases
o To study multiple exposures that may be related to a single outcome
- Study subjects → participants selected based on outcome status:

o Case-subjects have outcome of interest
o Control-subjects do not have outcome of interest
DESIGN OF A CASE-CONTROL STUDY.

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1. SELECTION OF A CASES AND CONTROLS
CASES CONTROLS
1. Definition of case: 1. Requirements:
• diagnostic criteria of the • must be free from the disease
disease and the stage of the under study
disease to be included in the • must be as similar to the case as
study possible
• eligibility criteria 2. Sources of controls:
2. Sources of data: • hospital - patients with different
• hospitals illness
• general population • relatives
• neighborhood - living in the
same locality, working in the
same factory, attending the same
school
• general population - random
sample of individuals free from
the study disease
3. How many controls are needed?
• if the study is large and many
cases are available - one control
for each case
• if the study group is small - 2, 3
or even 4 controls can be selected
for each study subject
2. MATCHING
MATCHING → Process by which we select controls in such a way that they are similar to
cases with regard to certain appropriate selected variables which are known to influence the
outcome of disease and which if not adequately matched for comparability, could distort or
confound the results.
- If the confounding factor is age matching will involve taking equal proportion of each
age group in case and control groups.
- The suspected etiological factor we wish to measure should not be matched
(overmatching).
3. MEASUREMENT OF EXPOSURE

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4. ANALYSIS
ANALYSIS FORMAT
ADVANTAGES AND DISADVANTAGES.
EXAMPLE:

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POTENTIAL ERRORS IN CASE-CONTROL STUDIES.
CONFOUNDING
- An alternative explanation for observed association between an exposure and disease.
- A mixing of effects → The association between exposure and disease is distorted
because it is mixed with the effect of another factor that is associated with the disease.
RESPONDER BIAS
- Occurs when the validity of the information provided by the subjects differs for cases
and controls.
- Subjects with serious disease are likely to have been thinking hard about possible
causes of their condition and so cases may be inclined to give answers that fit with
what they believe (or think is acceptable to say) is the cause of their illness = RECALL
BIAS
- Can be minimized by keeping study subjects unaware of the hypotheses under study
and, where possible, ensuring that both cases and controls have similar incentives to
remember past events.
WHEN TO CONDUCT A CASE-CONTROL STUDY?

- The outcome of interest is rare.
- Multiple exposures may be associated with a single outcome.
- Funding or time is limited.

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TOPIC 11. CAUSATION IN EPIDEMIOLOGY. THE CONCEPT OF

CAUSE. ESTABLISHING THE CAUSE OF THE DISEASE.
CAUSATION IN EPIDEMIOLOGY.
CAUSALITY
- Causality can be defined as cause-effect relationship.
- In epidemiology cause is the exposure and effect is disease or death.
- Causal relation is a complex phenomenon.
ESTABLISHING THE CAUSE OF THE DISEASE.

How to establish causal inference?
For
Koch’s
infectious
disease postulate
For chronic Hill’s

disease criteria
- HENLE-KOCH POSTULATE (1884)

o The parasite must be present in all who have the disease.
o The parasite can never occur in healthy persons.
o The parasite can be isolated, cultured and capable of passing the disease to
healthy experimental animal.
o The organism must be isolated from the experimentally infected animal.
Limitations
o Disease production may require co-factors.
o Viruses cannot be cultured like bacteria because viruses need living cells in
which to grow.
o Pathogenic viruses can be present without clinical disease (sub-clinical
infections, carrier states).

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- BRADFORD-HILL CRITERIA
1. Strength of the association
§ According to Hill, the stronger the association between a risk factor and
an outcome, the more likely the relationship to be causal.
2. Consistency of findings
§ Have the same findings must be observed among different populations,
in different study designs and different times?
3. Specificity of the association
§ There must be a one to one relationship between cause and outcome
4. Temporal sequence of association
§ Exposure must precede outcome
5. Biological gradient
§ Change in disease rates should follow from corresponding changes in
exposure (dose-response)
6. Biological plausibility
§ Presence of a potential biological mechanism
§ Does the association make sense biologically?
7. Coherence
§ Does the relationship agree with the current knowledge of the natural
history/biology of the disease?
8. Experiment
§ Does the removal of the exposure alter the frequency of the outcome?
9. Analogy
§ Have there been similar situations in the past?
STRENGTH OF ASSOCIATION
How strong is strong (rule of thumb)?
RELATIVE RISK “MEANING”
1.1 – 1.3 Weak
1.4 – 1.7 Modest
1.8 – 3.0 Moderate
3–8 Strong
8 – 16 Very strong
16 – 40 Dramatic
40+ Overwhelming

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SPECIFICITY
- This means a cause lead to a single effect, not multiple effect.
- However, a single cause often leads to multiple effect. Smoking is a perfect example.

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TOPIC 12. DEMOGRAPHIC APPROACH TO HEALTH

ASSESSMENT. POPULATION SIZE AND POPULATION
COMPOSITION BY SEX AND RESIDENCE. POPULATION AGE
STRUCTURE – TYPES, DEPENDENCY RATIOS, MEDICAL AND
SOCIAL CONSEQUENCES OF POPULATION AGEING.
DEMOGRAPHIC APPROACH TO HEALTH ASSESSMENT.

DEMOGRAPHY → Statistical study of human population.
Why? → It is impossible to evaluate any aspect of public health and development of health
systems without appropriate information on population.
- POPULATION STATICS → Study of population size and structure at a particular

time.
- POPULATION DYNAMICS → Studies changes in population as a result to main
events:
o Migration
o Natural events (birth, death…)

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How do we collect demographic data?

- Population censuses
- Vital registration
- Causes of death (death certificates)
- Surveys
United Nations classification of countries
• Developed market economies

Developed world • Economies in transition (CCEU)
• Developing countries
Developing world • Least developed (48)
TYPES OF INDICATORS
RATES
- Crude (unstandardized)
- Specific
- Standardized
'()$*"#+* ",- #.)$ /0$1.2.1"#.+,

!"#$ = 4 )(5#.05.$*
3$,+).,"#+* ",- #.)$ /0$1.2.1"#.+,
'()6$* +2 1"/$/ +2 #ℎ$ $8$,#

!"#$ = 4 )(5#.05.$*
9+0(5"#.+, "# *./: 2+* #ℎ./ $8$,#
PROPORTION
'()$*"#+* (<=><?@ ABC=DEFE AB GHF EFBIJAB<GIK)

9*+0+*#.+, = 4 100
3$,+).,"#+*
RATIO
'()$*"#+* (BIG < CIJOIBFBG IP GHF EFBIJAB<GIK)
!"#.+ =
3$,+).,"#+*

lOMoARcPSD|3490782
POPULATION SIZE AND POPULATION COMPOSITION BY SEX

AND RESIDENCE.
Collect information about population size
- CENSUS = Complete statistical observation conducted by specially trained personnel
and covering the total population of a country at a specified time → in the world there
is about 7 billion people
- The world population has experienced continuous growth.
Collect information about population structure
- BY SEX → sex ratio = males/females

o Sex ratio at birth → it is about 105 boys to 100 girls (48 – 49% females vs. 51
– 52% males)
o Sex ratio for whole population (more female than man, specially in older age
groups)
§ Exceptions: some countries such as China
- BY RESIDENCE
'()6$* +2 0$+05$ ., " 05"1$

4 100 (%)
Qℎ+5$ 0+0(5"#.+,
GROWING URBANIZATION → process related to the movement of the rural

people to urban areas
POPULATION AGE STRUCTURE – TYPES, DEPENDENCY

RATIOS, MEDICAL AND SOCIAL CONSEQUENCES OF
POPULATION AGEING.
Population age structure can be characterized by 4 different approaches:
1. Comparison of the age groups:

o Comparing 3 groups of people by age:
§ 0 – 14
§ 15 – 49
§ > 50
0 – 14 15 – 49 > 50
PROGRESSIVE 30% 50% 20%
STATIONARY 25% 50% 25%
REGRESSIVE 20% 50% 30%

lOMoARcPSD|3490782
- PROGRESSIVE AGE STRUCTURE → Countries with high birth and death rates
and short life expectancy.
- STATIONARY AGE STRUCTURE → Result of low or average birth and death

rates and longer life expectancy.
- REGRESSIVE AGE STRUCTURE → Regions and countries with stable trends of

low birth and death rates and high life expectancy.
2. Assessment of population over 60 or over 65 over the whole population
0 – 14 15 – 49
YOUNG < 10% < 5%
AT THE
BEGINNING 10 – 15% 5 – 10%
OF AGEING
AGEING > 15% > 10%
3. Calculation of dependency ratios

o Groups:
§ 0 – 14 → dependent young people
§ 15 – 64 → working people
§ > 65 → dependent old people
0 − 14
S+(#ℎ -$0$,-$,1T *"#.+ = 4 100
15 − 64
> 65
Y5- -$0$,-$,1T *"#.+ = 4 100
15 − 64
0 − 14 + (> 65)
[+#"5 -$0$,-$,1T *"#.+ = 4 100
15 − 64
> 65
]^$.,^ .,-$4 = 4 100
0 − 14
AGEING INDEX → most informative dependency ratio. Values above 100% are critical
indicating that future active population is less than the elderly at the moment of calculation.

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4. Construction of age pyramid
POPULATION STRUCTURE BY AGE – WHO CLASSIFICATION

- YOUNG PEOPLE → 0 – 44
- MIDDLE AGE → 45 – 59
- ADULTS → 60 – 74
- OLD PEOPLE → 75 – 89
- LONG-LIVES → over 90
AGEING OF THE POPULATION → Demographic trend toward higher proportions of

middle-aged and older people with lower proportions of children and young adults that occurs
when birth rates decline without a corresponding decline of death rates over a period of
generation or more.

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TOPIC 13. FERTILITY-RELATED INDICATORS: DEFINITIONS

OF DIFFERENT INDICATORS, ASSESSMENT SCALES,
WORLDWIDE TRENDS.
FERTILITY → Production of live offspring excluding still births, fetal deaths, and
miscarriages.
LIVE BIRTH → Complete expulsion or extraction from its mother of a product of
conception, irrespective of the duration of pregnancy, which, after such separation, breathes
or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical
cord, or any definite movement of voluntary muscles, whether or not the umbilical cord has
been cut or the placenta is attached.
CRUDE BIRTH RATE (CBR)
/#0'%" 12 3456 7489:; $#"(<= )ℎ% >%+"

!"#$% '(")ℎ "+)% !,- = D 1000
?($ − >%+" A1A#B+)(1< (< )ℎ% C+0% >%+"
- It is very affected by the age structure of the population

- It is not precise → includes population not able to give birth → does not give a good
idea of the fertility of the population.
- Scale of assessment:
o LOW → < 15‰
o AVERAGE → 15 – 25‰
o HIGH → > 25‰
GENERAL FERTILITY RATE (GFR)
/#0'%" 12 3456 7489:; $#"(<= )ℎ% >%+"

G%<%"+B 2%")(B()> "+)% (GI-) = D 1000
?($ − >%+" 2%0+B% A1A#B+)(1< 15 − 49
- The reproductive age period stated by the WHO is 15 – 49 years.
!,- 1
=
GI- 4

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AGE SPECIFIC FERTILITY RATE (ASFR)
/#0'%" 12 3456 7489:; (< + >%+" )1 P10%< (< CA%Q(2(Q +=% ="1#A
NOI- = D 1000
?($ − >%+" 2%0+B% A1A#B+)(1< (< )ℎ% C+0% ="1#A +<$ >%+"
- ASFRs are used to measure the reproductive performance of women of a given age
and they through light on the fertility pattern by age.
- Specific age groups → provide important information of trends in delivering first child
and spacing of births.
o 15 – 19
o 20 – 24
o 25 – 29
o 30 – 34
o 35 – 39
o 40 – 44
o 45 – 49
WORLDWIDE TRENDS.

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TOPIC 14. POPULATION REPRODUCTION RATES – TOTAL

FERTILITY RATE, GROSS REPRODUCTION RATE, NET
REPRODUCITON RATE – DEFINITONS, WORLDWIDE TRENDS,
PROBLEMS.
SPECIFIC REPRODUCTION INDICATORS
- TOTAL FERTILITY RATE (TFR) → Average number of children that a woman

would have if she were to pass through her reproductive years bearing children at the
same rates as the women now in each age group, i.e. if ASFR remain the same
(unchanged).
o If it is between 2.3 – 2.5 → stationary level of reproduction
S &'"# ( 5
!"# =
1000
- GROSS REPRODUCTION RATE → Average number of girls a woman would

have if she experiences the current fertility patterns throughout her reproductive span
(15 – 49 years), assuming no mortality, i.e. if ASFR remain the same.
,## = !"# ( % ./0123. 4/567/8
The percentage of newborn females is normally 0.48 or 0.49.
- NET REPRODUCTIVE RATE → Average number of girls a woman would have

during her reproductive period if ASFR and ASMR (age-specific mortality rates)
remain unchanged.
o It is used to evaluate the replacement level of a population:

§ NRR < 1 → below the replacement level
§ NRR = 1 → stationary level
§ NRR > 1 → extended reproduction

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WORLDWIDE TRENDS.
COUNTRY CBR TFR

Bulgaria 9,1 1,46
Niger 49 6,62
Somalia 43 5,89
Spain 8,7 1,49
Italy 7,8 1,43
Germany 9,3 1,44
USA 12 1,87
Singapore 10 0,82

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TFR WORLD TRENDS
The world’s TFR for 1998 was less than 3. In more developed countries TFRs are already
well below the replacement rate → TFRs will continue to decline.

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TOPIC 15. MORTALITY-RELATED INDICATORS: DEFINITIONS

OF DIFFERENT INDICATORS, ASSESSMENT SCALES,
WORLDWIDE TRENDS, PROBLEMS. LEADING CAUSES OF
DEATHS IN DEVELOPED AND DEVELOPING COUNTRIES.
STANDARDIZATION – STANDARD POPULATIONS,
STANDARDIZED DEATH RATES.
MORTALITY-RELATED INDICATORS: DEFINITIONS OF

DIFFERENT INDICATORS, ASSESSMENT SCALES,
WORLDWIDE TRENDS, PROBLEMS.
CRUDE DEATH RATE
-#./%" 01 $%'(ℎ2 $#"345 (ℎ% 6%'"

!"#$% $%'(ℎ "'(% !*+ = ; 1000
73$ − 6%'" 909#:'(304 34 (ℎ% 2'.% 6%'"
- Cannot be used for intercountry comparisons because of the influence of age structure
over the indicator → in different age groups the age-specific death rates differ
significantly.
o For comparing different populations with different age structure, we have to use
STANDARDIZED DEATH RATES (SDR)
§ STANDARDIZATION by age removes the confounding effect of
different age structures and allows to come to a single standardized or
adjusted rate, by which the total mortality experience can be compared
directly.
o LOW → < 10‰
o HIGH → > 15‰
SPECIFIC DEATH RATES

- By residence
-#./%" 01 "#"': $%'(ℎ2

; 1000
+#"': 909#:'(304
o We expect to have higher number of rural deaths than urban. Specially, due to
the fact that, normally old people live in that areas.

lOMoARcPSD|3490782
- By sex
-#./%" 01 .':% $%'(ℎ2

; 1000
7':% 909#:'(304
- By cause or disease
-#./%" 01 $%'(ℎ2 $#% (0 !'"$30>'2?#:'" $32%'2%

; 100 000
73$ − 6%'" 909#:'(304
- By age – AGE SPECIFIC MORTALITY RATE (ASMR)
-#./%" 01 $%'(ℎ2 34 ' 29%?313? '5% 5"0#9

@A7+ = ; 1000
73$ − 6%'" 909#:'(304 01 (ℎ'( 29%?313? '5% 5"0#9
o Groups are normally divided in:

§ < 1 → INFANT MORTALITY RATE
§ 1–9
§ 10 – 19
§ 20 – 29
§ …
§ 60 +
§ 70 +

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MATERNAL MORTALITY RATIO (MMR)
-#./%" 01 ?'2%2 01 $%'(ℎ 01 B0.%4 34 "%:'(304 (0 9"%54'4?6,

$%:3>%"6 '4$ B3(ℎ34 42 $'62 '1(%" $%:3>%"6
77+ = ; 100 000
-#./%" 01 FGHI JGKLMN 34 (ℎ% 2'.% 6%'"
- It is a sensitive indicator → affects the socio-economic situation of the country.

- It is one of the most important public health indicators
CASE FATALITY RATE (CFR)

- It is calculated to get information about the killing power of a disease.
-#./%" 01 $%'(ℎ2 $#% (0 ' 29%?313? $32%'2%

!O+ = ; 100 000
-#./%" 01 9%09:% B3(ℎ (ℎ% 2'.% $32%'2%

lOMoARcPSD|3490782
PROPORTIONAL MORTALITY (proportion of deaths from specific cause)
-#./%" 01 $%'(ℎ2 $#% (0 29%?313? $32%'2%

; 100
P0(': $%'(ℎ2 1"0. ':: ?'#2%2
LEADING CAUSES OF DEATHS IN DEVELOPED AND

DEVELOPING COUNTRIES.
HIGH-INCOME COUNTRIES LOW-INCOME COUNTRIES

Cardiovascular diseases Infectious diseases
Cancer Cardiovascular diseases
Alzheimer disease and other dementias Preterm birth complications, birth asphyxia
and birth trauma (perinatal causes)
Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease and
Cancers
Injuries Injuries

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STANDARDIZATION – STANDARD POPULATIONS,

STANDARDIZED DEATH RATES.
CRUDE DEATH RATE
-#./%" 01 $%'(ℎ2 $#"345 (ℎ% 6%'"

!"#$% $%'(ℎ "'(% !*+ = ; 1000
73$ − 6%'" 909#:'(304 34 (ℎ% 2'.% 6%'"
o LOW → < 10‰
o HIGH → > 15‰
ADVANTAGES
- Mortality is expressed within a single figure.
- It can be used for comparing mortality within an area over a period of time.
DISADVANTAGES
- Cannot be used for intercountry comparisons because of the influence of age structure
over the indicator → in different age groups the age-specific death rates differ
significantly.
Assessment of age structure:

- % of people over 65+
o YOUNG → < 5‰
o AT THE BEGINNING OF AGEING → 5 – 10‰
o AGEING → > 10‰
STANDARDIZED DEATH RATES

For comparing different populations with different age structure, we have to use
STANDARDIZED DEATH RATES (SDR)
- They are hypothetical death rates that show the mortality that would be in a country if
the age of the population stayed the same.
STANDARDIZATION by age removes the confounding effect of different age structures and
allows to come to a single standardized or adjusted rate, by which the total mortality
experience can be compared directly.

lOMoARcPSD|3490782
STANDARDIZATION → To minimize the “error” when comparing two countries →

allows comparison of mortality!
- It is carried out by one of two methods: direct or indirect standardization
- Both methods begin by choosing a “STANDARD POPULATION” = artificial

population with fictitious age structures used in age standardization as uniform basis
for the calculation of comparable measures for the respective reference population(s).
o EUROPEAN STANDARD POPULATION (ESP) = older‼

o WORLD STANDARD POPULATION (WSP)
They reflect the features of population age composition in Europe and in the World
and have versions for males and females.
WORLD STANDARD POPULATION EUROPEAN STANDARD POPULATION
CDR in the World < CDR in Europe

lOMoARcPSD|3490782
TOPIC 16. INFANT MORTALITY-RELATED INDICATORS –

DEFINITIONS OF DIFFERENT INDICATORS, WORLDWIDE
TRENDS, LEADING CAUSES OF INFANT MORTALITY IN
DEVELOPED AND DEVELOPING COUNTRIES. UNDER 5
MORTALITY RATE.
INFANT MORTALITY-RELATED INDICATORS.
INFANT MORTALITY RATE (IMR)

INFANT MORTALITY → Mortality during the first year of life.
%&'()* ,- .)/0ℎ2 34 5ℎ36.*)4 &4.)* 1 8)/* ,- /9) .&*349 0ℎ) 8)/*

!"# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC 34 0ℎ) 2/') 8)/*
- It is very sensitive to socio-economic changes and general health status of the

population.
o VERY LOW → < 5 ‰
o LOW → 5 – 10‰
o HIGH → 25 – 50‰
o VERY HIGH → > 50‰

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AGE-SPECIFIC MORTALITY RATES
NEONATAL MORTALITY RATE
%&'()* ,- .)/0ℎ2 34 5ℎ36*)4 ,- 0 − 28 ./82

%),4/0/6 "# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC 34 0ℎ) 2/') 8)/*
- EARLY NEONATAL MORTALITY RATE
%&'()* ,- .)/0ℎ2 34 5ℎ36*)4 ,- 0 − 7 ./82

I/*68 4),4/0/6 "# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC 34 0ℎ) 2/') 8)/*
- LATE NEONATAL MORTALITY RATE
%&'()* ,- .)/0ℎ2 34 5ℎ36*)4 ,- 7 − 28 ./82

K/0) 4),4/0/6 "# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC CL@=<=<MN AB> OAB PQR
POSTNEONATAL MORTALITY RATE
%&'()* ,- .)/0ℎ2 34 5ℎ36*)4 ,- 28 ./82 − 1 8)/*

S,204),4/0/6 "# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC CL@=<=<MN AB> TUAB PQR
PERINATAL MORTALITY RATE
%º ,- CA<;; ?<@ABC + %º ,- .)/0ℎ2 34 5ℎ36*)4 ,- 0 − 7 ./82

S)*34/0/6 "# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC 34 0ℎ) 2/') 8)/*
Still births → Death of fetus weighing 500g or more, or of 22 weeks of gestation or more if
weight is unavailable.

lOMoARcPSD|3490782
WORLDWIDE TRENDS.
- During the past decades → steady decline in infant mortality.
o The drop in IMR was greatest for developed countries and lowest for least
developed countries.
o Attributed to:
§ Improved obstetric and perinatal care
§ Improvement in quality of life
§ Better control of communicable diseases
§ Better nutrition
§ Family planning
LEADING CAUSES OF INFANT MORTALITY IN DEVELOPED

AND DEVELOPING COUNTRIES.

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UNDER 5 MORTALITY RATE (U5MR)
%&'()* ,- .)/0ℎ2 34 5ℎ36.*)4 &4.)* 5 8)/*2 ,- /9)

X5"# = D 1000
:,0/6 4&'()* ,- ;<=> ?<@ABC 34 0ℎ) 2/') 8)/*
o VERY LOW → < 10‰
o LOW → 10 – 20‰
o HIGH → 50 – 100‰
o VERY HIGH → > 100‰

lOMoARcPSD|3490782
TOPIC 17. LIFE EXPECTANCY – DEFINITION, LIFE TABLES,

WORLDWIDE TRENDS.
DEFINITION.
LIFE EXPECTANCY → Average number of years which a person (or a generation) of a
given age may expect to live, according to mortality pattern in the country (if ASMRs remain
unchanged).
Characteristics of life expectancy:
- The best indicator of public health in a country
- Reflects very well the level of overall socio-economic development
- Hypothetical indicator
- Calculated using mortality tables
- Higher for women, than for men (few exceptions)
- The higher the life expectancy, the bigger the difference between women and men
LIFE TABLES.
TOTAL MEN WOMEN
Global life expectancy 70 68 73
Low-income countries 62 60 63
High-income countries 79 76 82
Africa 60 58,3 61,8
Americas 76,9 74 79,9
South-East Asia 69 67,3 70,7
by WHO regions
Europe 76,8 73,2 80,2
Eastern Mediterranean 68,8 67,3 70,3
Western Pacific 76,6 74,5 78,7
COUNTRY LIFE EXPECTANCY IN WOMEN LIFE EXPECTANCY IN MEN

Bulgaria 78,01 71,02
Lesotho 49 49
Botswana 46 48
Switzerland 85 81
Japan 86 80
Germany 83 79
USA 81 76

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WORLDWIDE TRENDS.
- Great improvement in life expectancy at birth.
- Higher for women, than for men → few exceptions:
o In developing countries → where high maternal mortality may result in shorter
female life expectancy
- The greater improvement in survival for women is a result of a complex relationship
between behavioral social, environmental, economic and genetically liked factors
- The excess male mortality can be largely accounted for by higher mortality from
coronary heart diseases, carcinoma of the bronchi, cirrhosis of the liver and fatal
accidents.
- At birth → developed countries have higher life expectancy than developing countries.
INDICATORS FOR LIFE EXPECTANCY.

HALE (HEALTH-ADJUSTED LIFE EXPECTANCY) → Average number of years that
a person can expect to live in “full health”.
DFLE (DISABILITY-FREE LIFE EXPECTANCY) = HLY (HEALTHY LIFE

YEARS) → Average number of years that a person would expect to live without disability.
QALYs (QUALITY-ADJUSTED LIFE YEARS → Unit of health gain attributable to an

intervention typically used in cost-utility analysis. Product of absolute change in survival and
quality of life experienced during the period.
DALYs (DISABILITY-ADJUSTED LIFE YEARS) → Number of lost years due to

premature death or disability.
- Premature death = one that occurs before the age to which the dying person could
have expected to survive.

lOMoARcPSD|3490782
TOPIC 18. MORBIDITY-RELATED INDICATORS: MEASURES

OF MORBIDITY – INCIDENCE, POINT PERIOD PREVALENCE,
ICEBERG OF MORBIDITY. FACTORS, INFLUENCING
INCIDENCE AND PREVALENCE.
PUBLIC HEALTH → It is the planning, carrying out and evaluation of health measures and
health system services that both maintain and improve the health of a population and prevent
and control diseases within that population.
Winslow defined public health as “the science and art of preventing disease, prolonging life
and promoting health through the organized efforts for:
- The sanitation of the environment
- Control of communicable diseases
- Education of the individual in personal hygiene
- Organization of medical and nursing services for early diagnosis and preventive
treatment
- Development of social machinery to insure everyone and adequate standard of living
for the maintenance of health”.
Public health measurement

- Through indicators
- Most common for operative purposes
o Demographic indicators
o Morbidity and disability indicators
o Indicators for physical development
MORBIDITY.
MORBIDITY → any departure, subjective or objective, from a state of physiological
well-being.
The WHO Expert Committee on Health Statistics noted in its 6th Report that morbidity could
be measured in terms of three units:
- Persons who are ill
- The illnesses (periods or spells of illness) that these persons experienced
- The duration (days, weeks) of these illnesses

lOMoARcPSD|3490782
These three aspects of morbidity are commonly measured by morbidity rates or morbidity
ratios:
- Frequency
o Measured by incidence and prevalence rates.
- Duration
o Measured by the average duration per case or the disability rate (the average
number of days of disability per person).
- Severity
o Measured by case-fatality rate (the total number of deaths due to a particular
disease divided by the total number of cases due to the same disease and
multiplied by 100).
MEASURES OF MORBIDITY – INCIDENCE, POINT PERIOD

PREVALENCE, ICEBERG OF MORBIDITY.
INCIDENCE RATE → number of new cases of a particular disease occurring in a defined

population during a specified period of time.
)*+,&- ./ "&0 #12&2 ./ 23&#$/$# %$2&12&

!"#$%&"#& ! = 8 100
+$% − 5&1- 3.3*617$."
There are also some specific incidence rates:

- Attack rate (case rate)
o Incidence rate (usually expressed as per cent), used only when the population
is exposed to risk for a limited period of time such as during an epidemic.
- Secondary attack rate

o It is the number of exposed persons developing the disease within the range of
the incubation period following exposure to a primary case.
- Hospital admission rate

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PREVALENCE → measures all cases of the disease existing (in contrast to incidence)
- Point prevalence (at a point in time) → the “point” may be a day, several days or even
a few weeks
- Period prevalence (over a period of time)

o Less commonly used measure of prevalence
)*+,&- ./ &8$27$"= #12&2 ./ 1 23&#$/$# %$2&12&

;-&<16&"#& ; = 8 100
+$% − 5&1- 3.3*617$."
ICEBERG MORBIDITY (HIDDEN MORBIDITY)
!#&,&-= +.-,$%$75 !> = ;.$"7 3-&<16&"#& − ;&-$.% 3-&<16&"#&

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FACTORS, INFLUENCING INCIDENCE AND PREVALENCE.

The value of prevalence and incidence rate.
1. The incidence is an estimate of the risk of developing the disease and hence is of value
mainly to search for the causes or determinants of the disease.
2. Prevalence helps to estimate the magnitude of health or disease problems in the
community, and identify potential high risk populations.
3. Prevalence is of a particular value in planning health services or workload, since it
indicates the amount of illness requiring care.
To an increasing extent, measurements concern not only the occurrence of diseases, but also
the persistence of the consequences of disease: impairments, disabilities, handicaps and
disease burden.

lOMoARcPSD|3490782
TOPIC 19. MORBIDITY – SOURCES AND METHODS OF

STUDYING MORBIDITY. INTERNATIONAL CLASSIFICATION
OF DISEASES – 10TH REVISION.
MORBIDITY.
MORBIDITY → any departure, subjective or objective, from a state of physiological
well-being.
The WHO Expert Committee on Health Statistics noted in its 6th Report that morbidity could
be measured in terms of three units:
- Persons who are ill
- The illnesses (periods or spells of illness) that these persons experienced
- The duration (days, weeks) of these illnesses
These three aspects of morbidity are commonly measured by morbidity rates or morbidity
ratios:
- Frequency
o Measured by incidence and prevalence rates.
- Duration
o Measured by the average duration per case or the disability rate (the average
number of days of disability per person).
- Severity
o Measured by case-fatality rate (the total number of deaths due to a particular
disease divided by the total number of cases due to the same disease and
multiplied by 100).
WHAT IS THE RELATION AND THE DIFFERENCE BETWEEN MORBIDITY

AND MORTALITY?
1. Death rates are particularly useful for investigating diseases with a high case-fatality.
o However, many diseases have low case-fatality. In this situation, data on
morbidity (the frequency of illness) are more useful than mortality rates.
2. Morbidity data are helpful in clarifying the reasons for particular trends in mortality.

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MORBIDITY DATA
In considering the value of morbidity data, it is important to be aware of their limitations:
- Different criteria may be used among doctors in determining different disease
conditions.
- Self-reporting illnesses is enormously variable → patients do not have common
threshold in presenting illness to a general practitioner.
- A wide diversity of data about morbidity are collected:
o Nationally or locally
o Routinely or an ad hoc for a specific purpose
o As a statutory requirement, or on a voluntary basis
When using morbidity data, it is important to understand how complete a coverage of the
disease problem these data provide.
- It is important to decide how valid was the method of ascertaining whether disease
was present or absent.
Many routinely available sources are deficient in both these aspects.
- If they are based upon the information about patients who have made contact with
services, they will not include all cases that exist in the population.
In deciding how completely a particular source of morbidity data describes the disease
problem in the population, it is helpful to bear in mind the “iceberg” concept of health care
→ only a proportion of patients make contact with health services.
SOURCES FOR STUDYING MORBIDITY.

- Notifications → for diseases of major public health importance, notifications are
collated by WHO and published in the Weekly epidemiological record.
- Data on hospital admissions and discharges
- Outpatient and primary health care consultations, and specialist services (such as
accident treatment)
- Registers of disease events (cancer and congenital malformations)
Because of the numerous limitations of routinely recorded morbidity data, many countries
rely on the collection of new data using specially designed questionnaires and screening
methods on representative samples of the population.

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The value of morbidity data:

1. Describe the extent and the nature of disease burden in the community, and thus assist
in the assessment of health status of the population and in the establishment of
priorities for public heath action.
2. Provide more comprehensive and more accurate and clinically relevant information on
patient characteristics as compared to the information from mortality data and
therefore morbidity data are essential for basic research.
3. Serve as a starting point for etiologic studies, and thus they play a crucial role in disease
prevention.
4. Needed for monitoring and evaluation of disease.
METHODS OF STUDYING MORBIDITY.

- Active methods → where medical professionals actively collect data through:
o Regular check-ups
o Application of sociological approaches to gather information from the patient
and his family
- Passive methods → where the initiative to seek medical care is left to the patients.
Thus, morbidity is studied through:
o Data from medical examinations
o Data from causes of death
INTERNATIONAL CLASSIFICATION OF DISEASES – 10TH

REVISION.
The World Health Organization, by international agreement, produces “The International
Statistical Classification of Disease and Health Related Problems” or “ICD” and it is used
in many countries as the principal means of classifying and coding both mortality and
morbidity experience.
The latest revision of the ICD, known as ICD-10, was published by WHO in 1992, and
replaced its predecessor, ICD-9, as the standard coding system.
The existence and widespread use of such an internationally agreed disease classification is
of vital importance.
- Without it, comparisons of statistics over time and between different places would not
be possible.

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The 10-th revision groups: diagnosis, signs and symptoms, causes and other factors into 21
chapters.
The codes are alphanumeric, and run from A00.0 to Z99.9, excluding the letter U, which is
reserved for additional codes and changes arising between revisions of the classification.
- The first three characters of a code define a category, with the fourth character
supplying extra detail.
EXAMPLE: K26 is the category “Duodenal ulcer” and K26.1 is “Duodenal ulcer - acute
with perforation”.

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II. THE PRACTICE OF

PUBLIC HEALTH

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TOPIC 20. COMMUNICABLE DISEASES - WORLDWIDE

TRENDS, LEADING CAUSES OF INFECTIOUS MORBIDITY.
GLOBAL BURDEN OF INFECTIOUS DISEASES. PRINCIPLES OF
INFECTIOUS DISEASE CONTROL.
COMMUNICABLE DISEASES - WORLDWIDE TRENDS,

LEADING CAUSES OF INFECTIOUS MORBIDITY.
KEY POINTS
- Infectious diseases → leading causes of morbidity, mortality and disability
- Infectious diseases control is a constant challenge
- Only one infectious disease was eradicated – smallpox
- Re-emerging diseases – tuberculosis, malaria
- Tetanus – will always be a threat
- New infectious diseases – AIDS, SARS, swine flu, Ebola
DEFINITIONS
- INFECTION → occurs when an infectious agent enters the body and develops or
multiplies.
- INFECTIOUS AGENTS → organisms capable of producing unapparent infection or

clinically manifested disease.
- CONTROL OF INFECTIOUS DISEASES → actions and programs directed towards

reducing disease incidence (primary prevention), prevalence, or completely
eradicating the disease.
GLOBAL BURDEN OF INFECTIOUS DISEASES.

-
DISEASE RELATED DEATHS ANNUALLY

Acute respiratory infections 4 million
HIV 2,7 million
Diarrheal diseases 1,8 million
Tuberculosis 1,6 million
Malaria 1,3 million
Influenza 500 000 to 1 million
-
-
-

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PRINCIPLES OF INFECTIOUS DISEASE CONTROL.
- PRIMARY PREVENTION MEASURES → Individual or community-wide

measures:
o Maintaining good nutritional status
o Keeping physically fit
o Immunization against infectious diseases
o Providing safe water
o Ensuring proper disposal of feces
- SECONDARY PREVENTION MEASURES

o Shortening the duration of the infectious disease
o Early detection of disease
o Prompt antibiotic treatment
o Ensuring adequate nutrition
- TERTIARY PREVENTION MEASURES

o Reducing or eliminating the long-term impairments
o Reducing or eliminating disabilities
o Minimization of suffering
o Promotion of adjustment to permanent disability
o Rehabilitation
CONTROL MEASURES ACCORDING TO THE TRANSMISSION.

1. DIRECT TRANSMISSION
2. INDIRECT TRANSMISSION
o Vehicle-born → contaminated inanimate materials
o Vector-born
§ Mechanical → simple carriage (flying insect through soiling on feet)
§ Biological
o Air-born
TOOLS FOR CONTROL OF INFECTIOUS DISEASES.

SURVEILLANCE OF DISEASE
Process of systematic:
- Collection
- Orderly consolidation
- Analysis
- Evaluation
of pertinent data with prompt dissemination of results to those who need to know, particularly
those who are in position to take action.

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Systematic collection and evaluation of:

- Morbidity and mortality reports
- Special reports of field investigations of epidemics and individual cases
- Isolation and identification of infectious agents by laboratories
- Data concerning the availability, use, and untoward effects of vaccines, insecticides
and other substances used in control
- Information regarding immunity levels in segments of population
- Other relevant epidemiologic data
CONTROL MEASURES APPLIED TO THE HOST

- Active immunization
- Passive immunization (received antibodies)
- Chemoprophylaxis
- Behavioral change
- Reverse isolation
- Barriers
- Improving host resistance
CONTROL MEASURES APPLIED TO THE VECTORS

- Chemical
- Environmental
- Biological
CONTORL MEASURES APPLIED TO THE INFECTED HUMANS

- Chemotherapy
- Isolation
- Quarantine
- Restriction of activities
- Behavioral change
CONTROL MEASURES APPLIED TO ANIMALS

- Active immunization
- Isolation
- Quarantine
- Restriction or reduction
- Chemoprophylaxis
- Chemotherapy

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CONTROL MEASURES APPLIED TO THE ENVIRONMENT

- Provision of safe water
- Proper disposal of feces
- Food and milk sanitation
- Design of facilities and equipment
CONTROL MEASURES APLPLIED TO THE INFECTIOUS AGENTS

- Cleaning
- Cooling
- Pasteurization
- Disinfection
- Sterilization
CONTROL MEASURES CAN BE DIRECTED TO:

- INDIVIDUAL LEVEL → directed towards the specific infectious diseases threats to
the particular individual
- INSTITUTIONAL LEVEL → directed to group of people who are in close contact

with each other
- COMMUNITY LEVEL → directed to the community at large

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THE EBOLA EPIDEMIC.

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THE DEVELOPMENT
Year(s) Country Ebola Reported Reported Situation
subtype number number (%)
of human of deaths
cases among cases
Outbreak occurred in multiple
August – Democratic villages in the Democratic Republic
November Republic of Zaire virus 66 49 (74%) of the Congo. The outbreak was
2014 the Congo unrelated to the outbreak of Ebola in
West Africa.
Ongoing outbreak across multiple
March
Multiple countries in West Africa. Number of
2014 – Zaire virus 16933 6002 (35%)
countries patients is constantly evolving due to
Present
the ongoing investigation.
Laboratory infection by accidental
1976 England Sudan virus 1 0
stick of contaminated needle.
Occurred in Nzara, Maridi and the
Sudan
surrounding area. Disease was spread
1976 (South Sudan virus 284 151 (53%)
mainly through close personal
Sudan)
contact within hospitals.
Occurred in Yambuku and
Zaire surrounding area. Disease was spread
(Democratic by close personal contact and by use
1976 Republic of Ebola virus 318 280 (88%) of contaminated needles and syringes
the Congo – in hospitals/clinics. This outbreak
DRC) was the first recognition of the
disease.
WHO → GLOBAL ALERT AND RESPONSE (GAR)

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EBOLA MESSAGES FOR GENERAL PUBLIC

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TOPIC 21. MAJOR NON-COMMUNICABLE DISEASES –

SIGNIFICANCE FOR THE POPULATION HEALTH,
WORLDWIDE TRENDS OF CVD, CANCER, COPD, ACCIDENTS
AND DIABETES. THE BURDEN OF NON-COMMUNICABLE
DISEASES – DALYs.
MAJOR NON-COMMUNICABLE DISEASES – SIGNIFICANCE

FOR THE POPULATION HEALTH, WORLDWIDE TRENDS OF
CVD, CANCER, COPD, ACCIDENTS AND DIABETES.
The 20th century revolution in health and the consequent demographic transition lead to major
changes in the pattern of morbidity.
→ The world entered the epidemiological transition that results in a major shift in
causes of death and disability from infectious diseases to non-communicable diseases.
Despite the success in health achieved globally, the avoidable burden of disease and
malnutrition remain a priority in international health.
The resulting new epidemics of non-communicable diseases and injuries challenge the
finances and capacities of health systems.
Thus, in the early decades of the 21st century, health systems and healthy policy-makers need
to address a double burden of disease:
1. The emerging epidemics of non-communicable diseases and injuries → which are
becoming more prevalent in industrialized and developing countries alike.
2. Some major infectious diseases which survived the 20th century as part of the
unfinished health agenda and some new infectious diseases that the world face at the
beginning of the 21st century.
THE BURDEN OF NON-COMMUNICABLE DISEASES – DALYs.

MEASURING THE BURDEN OF DISEASE
To provide valid basis for health policy decisions, there is a great need for the development
of reliable and consistent data on the health status of population worldwide.
For a number of years, researchers worldwide have attempted to construct such an indicator
→ it would take into account morbidity, mortality, and disability (would measure the burden
of disease → which is the gap between a population’s actual health status and some reference
population health status).
The composite indicator that is most commonly used during the last two decades to measure
global burden of disease is called DALYs.

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DALYs (DISABILITY-ADJUSTED LIFE YEARS) → It expresses years of life lost due

to premature death and years lived with disability, adjusted for the severity of disability →
Number of lost years due to premature death or disability. One DALY is one lost year of
healthy life.
- Premature death = one that occurs before the age to which the dying person could
have expected to survive.
The indicator was firstly introduced in 1993 by the World Bank in its World Development
Report I which the results of the first study of global burden of disease (GBD 1990) were
reported.
Later on, the other large-scale GBD studies – GBD 2000 and GBD 2010 – were undertaken
and their results enlarged greatly the knowledge about morbidity, mortality and disability
trends worldwide.
- GBD 1990 → 107 diseases and 10 risk factors
- GBD 2000 → 159 diseases in 14 regions
- GBD 2010 → 291 diseases, 67 risk factors, 235 causes of death, and 187 countries.
Five leading risk factors contributing DALYs

GBD 1990 GBD 2010
Underweight in childhood High blood pressure
Home air pollution due to solid fuels Smoking (including passive)
High blood pressure Home air pollution due to solid fuels
Short-term breastfeeding Insufficient use of fruits and vegetables
Ranking of the ten leading causes for DALYs

GBD 1990 GBD 2010
Lower respiratory infections Ischemic heart disease
Diarrheal diseases Lower respiratory diseases
Perinatal conditions Cerebrovascular disease
Ischemic heart disease Diarrheal diseases
Cerebrovascular disease HIV/AIDS
Chronic obstructive pulmonary disease Low back pain
Malaria Malaria
Tuberculosis Perinatal conditions
Undernutrition Chronic obstructive pulmonary disease
Neonatal encephalopathy Road traffic injuries

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SOCIALLY SIGNIFICATN DISEASES

The ranking of diseases according to their contribution to morbidity, disability and mortality
differ substantially by regions and countries according to their socioeconomic development.
Diseases that take a great roll in the burden of disease are referred as socially significant
diseases for a particular region or country.
To label some disease or class of diseases as socially significant some common characteristics
should be met:
1. High incidence and prevalence with continuous negative trends → especially among
the active population
2. High mortality and case-fatality rate, high proportion among the leading causes of
death in the population → especially among the active population
3. High proportion in morbidity with temporary and permanent disability
4. High proportion in hospital admissions and hospital expenditures for treatment and
rehabilitation and considerable burden to the social insurance system
5. Considerable social, medical, economical and psychological damages to the patients
and their families

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TOPIC 22. MAJOR DETERMINANTS OF NON-COMMUNICABLE

DISEASES – LIFE STYLE RISK FACTORS, ENVIRONMENTAL
RISKS, BIOLOGICAL AND GENETIC FACTORS, HEALTH CARE
SERVICES FACTORS.
DETERMINANTS OF HEALTH
DETERMINANTS OF HEALTH → include the range of personal, social, economic and
environmental factors which determine the health status of individuals or populations.
The health and well-being individuals and populations are influenced by a wide range of
factors which are within and outside the individual’s control.
Dahlgren and Whitehead’s social model of health → captures the interrelationship between
all these factors.
According to this model, the determinants of health are divided in 2 basic groups:
1. UNMODIFIABLE FIXED INDIVIDUAL CHARACTERISTICS
- Internal, unmodifiable such as: sex, age, genetic factors (heredity, constitutional
factors) → situated in the center of the rainbow.
2. POTENTIALLY MODIFIABLE FACTORS

- Expressed as series of four consecutive layers of impact:

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o First layer → personal behavior and ways of living that can promote or
damage health.
o Second layer → impact of social and community networks.
o Third layer → structural factors related to living and working conditions
(housing, work environment…).
o Fourth layer → socioeconomic, cultural and environmental conditions.
This method is useful in providing a framework for raising questions about:

- The size of the contribution of each of the layers to health.
- The feasibility of changing specific factors.
- The complementary action that would be required to influence linked factors in
other layers.
It has helped researchers:

- To construct a range of hypotheses about the determinants of health.
- To explore the relative influence of these determinants on different outcomes and
the interactions between the various determinants.
In developed countries, for example, the relative impacts that the various domains of health
determinants have on the leading causes of death and health damages have been estimated as
follows:
- 49 – 53% → behavioral patterns
- 18 – 20% → contributions of genetic predispositions and biological factors
- 18 – 20% → social circumstances and environmental risk factors exposures
- 8 – 10% → shortfalls in medical care (inadequate medical care, low quality of
health services…)
Places with different population structure, under different conditions, will show a very
different picture.
In developing countries, the main determinants of the most common health conditions are:
- Malnutrition
- Bad hygiene and living conditions
- Lack of safe drinking water
- Poor living standards
In 2003, WHO published an influential document “The Solid Facts” on the social
determinants of health, which reviewed the evidence for causal relationship between social
and environmental factors and health, and outlined policy implications.

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TOPIC 23. HEALTH CARE SYSTEM AS A SOCIAL SYSTEM –

DEFINITIONS OF MAIN TERMS (HEALTH SYSTEM, HEALTH
CARE, MEDICAL CARE), OBJECTIVES, EVOLUTION,
REFORMS. WHO APPROACH TO HEALTH SYSTEMS
ASSESSMENT.
HEALTH CARE SYSTEM AS A SOCIAL SYSTEM – DEFINITIONS

OF MAIN TERMS (HEALTH SYSTEM, HEALTH CARE,
MEDICAL CARE).
HEALTH SYSTEM
- All activities whose primary purpose is to improve or maintain health (Murray and
Frenk, 2000).
- The economic, fiscal, and political management method that nations use to run the
national health services (Last 2007)
- All organizations, institutions and resources, that are devoted to performing health
activities (WHR – 2000).
Formal health services, including the professional delivery of personal medical attention, are
clearly within these boundaries.
- So are actions by traditional healers, and all use of medication, whether prescribed by
a provider or not.
- So is home care of the sick, which is how somewhere between 70% and 90% of all
sickness is managed.
Such traditional public health activities as health promotion and disease prevention, and other
health enhancing interventions like road and environmental safety improvement, are also part
of the health system.
Beyond the boundaries of this definition are:

- Those activities whose primary purpose is something other than health – education,
for example – even if these activities have a secondary, health-enhancing benefit.
Hence, the general education system is outside the boundaries, but specifically health-
related education is included.
- So are actions intended chiefly to improve health indirectly by influencing how non-
health systems function – for example, actions to increase girls’ school enrolment or
change the curriculum to make students better future caregivers and consumers of
health care.

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HEALTH CARE
- A multitude of services provided to individuals, families or communities by agents of
the health services or professions, for the purpose of promoting, maintaining,
monitoring or restoring health.
MEDICAL CARE
- Therapeutic action by or under the supervision of a physician.
- Those personal services that are provided directly by physicians or as a result of
physician’s instruction.
Relation between terms:
HEALTH SYSTEM OBJECTIVES.

Fundamental goals:
- Improve population’s health
- Answer people’s expectations
- Provide financial risk protection
FUNCTIONS
Progress towards these goals depends on 4 vital functions:
1. Service provision
2. Resource generation
3. Financing
4. Stewardship – leadership, oversight of all other functions

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HEALTH SYSTEM EVOLUTION.

1. Traditional practices based on herbal cures integrated with spiritual counselling →
nowadays coexist with modern medicines.
o Example: Chinese medicine can be traced back more than 3000 years, and still
plays a huge role in the Chinese health system.
2. Organized health systems in the modern sense – a century ago.

o Hospitals have longer history but few people visited them. Until the 19th
century they were mostly run by charitable organizations, and often were
refuges for the orphaned or the insane.
o There was nothing like the modern practice of referrals from one level of the
system to another, and little protection from financial risk.
3. Industrial revolution → recognition of the huge toll of death, illness and disability
among workforces → great losses in productivity → company owners began providing
medical services to their workers.
o Bismark, Chancellor of Germany, in 1833, Germany enacted a law requiring
employer contributions to health coverage for low-wage workers in certain
occupations - first example of a STATEMANDATED SOCIAL INSURANCE
MODEL.
o Adoption of similar legislation in Belgium in 1894 and Norway in 1909.
o In 1922, Japan added health benefits to the other benefits for which workers
were eligible.
o In 1924, Chile brought all workers under the umbrella of a Ministry of Labour
scheme.

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o By 1935, 90% of Denmark’s population was covered by work-related health

insurance.
o In the Netherlands, social insurance was introduced during the Second World
War.
HEALTH SYSTEM REFORMS.

1. The first-generation reforms – the founding of national health care systems, and
the extension of social insurance systems, mostly in the 1940s and 1950s in richer
countries and later in poorer countries.
o Health services still were used mostly by the better-off, and efforts to reach the
poor were often incomplete.
o Need for radical change that would make systems more cost-efficient,
equitable, and accessible.
2. The second-generation reforms – the promotion of primary health care as a route

to achieving affordable universal coverage.
o Experience with disease control in the 1940s in countries such as South Africa,
China, Cuba, Guatemala, Indonesia, Niger, the United Republic of Tanzania,
and Maharashtra State in India, Costa Rica and Sri Lanka - very good health
outcomes at relatively little cost, adding 15 to 20 years to life expectancy at
birth in two decades.
o Primary health care as the strategy for achieving the goal of “Health for All” at
the International Conference on Primary Health Care (Alma-Ata, 1978).
§ Minimum level for all of health services, food and education, adequate
supply of safe water and basic sanitation.
§ Public health measures, prevention, essential drugs, and education of the
public by community health workers.
3. The third-generation reforms – characterized by an increasing interest to respond

more to people’s demand, with greater emphasis on individual choice and
responsibility, and greatly increased interest in explicit insurance mechanisms,
including privately financed insurance.
o “New universalism” – delivery to all of high-quality essential care, defined
mostly by criteria of effectiveness, cost and social acceptability.
§ It implies explicit choice of priorities among interventions, respecting
the ethical principle that it may be necessary and efficient to ration
services, but that it is inadmissible to exclude whole groups of the
population.
o Transformation from centrally planned to market-oriented economies, reduced
state intervention in national economies, fewer government controls, and more
decentralization.
o Greater emphasis on individual choice and responsibility.
o Limited promises and expectations about what governments should do.

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WHO APPROACH TO HEALTH SYSTEMS ASSESSMENT.

WHO developed a new approach of assessment incorporating the following criteria:
1. Level of health (HALE, DALY…) → 25%
2. Distribution of health (U5MR…) → 25%
3. Level of responsiveness → how the system performs towards the patients → 12.5%
o RESPECT FOR PERSONS
§ Respect for the dignity of the person
§ Confidentiality
§ Autonomy
o CLIENT ORIENTATION
§ Prompt attention
§ Amenities (cleanness, space, hospital food…)
§ Access to social support networks
§ Choice of provider
4. Fair financing/Distribution of responsiveness → 12.5%
5. Fairness of financial contributions → 25%

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TOPIC 24. THE CONCEPT OF HEALTH CARE. MAIN

CHARACTERISTICS OF HEALTH CARE. LEVELS OF HEALTH
CARE.
THE CONCEPT OF HEALTH CARE.

HEALTH CARE → Multitude of services provided to individuals, families or communities
by agents of the health services or professions for the purpose of promoting, maintaining,
monitoring or restoring health.
MAIN CHARACTERISTICS OF HEALTH CARE.

According to WHO health care has many characteristics, the most important among them are
5 A’s:
1. Appropriateness (relevance) → whether the service is needed at all in relation to
essential human needs, priorities and policies
2. Adequacy → if the service is proportionate to requirement
3. Availability → the ratio between the population of an administrative unit and the
health facility (e.g. population per center, doctor-population ratio…)
4. Accessibility → geographic, economic or cultural accessibility
5. Affordability → the cost of health care should be within the means of the individual
and the state
Among the other characteristics, it is worth to mention:

- Comprehensiveness → whether there is an optimum mix of preventive, curative and
promotional services
- Feasibility → operational efficiency of certain procedures, logistic support, manpower
and material resources
LEVELS OF HEALTH CARE.

Health services are usually organized at three levels, each level supported by a higher level
to which the patient is referred:
- PRIMARY HEALTH CARE

o First level of contact between the individual and the health system where
“essential” health care is provided.
o A majority of prevailing health complaints and problems can be satisfactory
dealt with at this level.
o This level of care is closest to the people.

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- SECONDARY HEALTH CARE

o At this level, more complex problems are dealt with.
o This care comprises essentially curative services and is provided by district
hospitals and community health centers.
o This level serves as the first referral level in the health system.
- TERTIARY HEALTH CARE

o This level offers super-specialized care provided by regional/central level
institutions.
o These institutions provide also planning and managerial skills and teaching for
specialized staff.
The infrastructure of the health system:

- Health care providers
- Health care administrative and financing authorities
These two groups closely relate to each other and to the population of health care consumers
(users).
The professionals and health institutions orient the consumers through the institutions and
prescribe different diagnostic tests and therapeutic means → they are at the same time in
relationship with the authorities charged with the administration and financing.

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TOPIC 25. TYPOLOGY OF HEALTH SYSTEMS IN DEVELOPED

COUNTRIES. STATE MONOPOLY SYSTEM. HEALTH
INSURANCE SYSTEM. HEALTH SYSTEM OF LIBERAL
PLURALISM. REFORMS IN HEALTH SYSTEMS IN UK AND USA
(OBAMACARE – MOTIVATION, GOAL, MAIN
CHARACTERISTICS).
TYPOLOGY OF HEALTH SYSTEMS IN DEVELOPED

COUNTRIES.
Why a typology?
A typology is a useful tool in understanding the key framework of a country’s health care
system.
A typology or a system of categorization groups countries according to some of their key
features.
The earliest attempt to develop a typology was made by Mark Field in 1973, who classified
four categories of health care systems into:
- Pluralistic
- Insurance
- Health service
- Socialized types
Criteria:
1. Extend of public control over health resources
o Funding
o Personnel
o Knowledge
o Legitimacy
2. Professional autonomy
In 1977 Terris introduced the National Health System (NHS) and the Social Health
Insurance (SHI) types of health care system based on the provision of health care.
- The crucial feature of an NHS is that all health care workers are government
employees and that health care is provided in government hospitals and health centers,
as well as covering the whole population.
- The crucial feature of a SHI is that the health providers are independent
entrepreneurs who enter into a contractual arrangement with the government to deliver
health services revenue and health care provision by the government.

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In the 1980s Vincent Navarro studied the health system typologies and found independent
variables in determining the shaping of a country’s health care system. According to what
variable determines the path of the health care system in each country, he presupposed three
types of health care system: NHS, SHI (called the Corporate Model) and the liberal
models.
Frank and Donabedian (1987) enlarged the previous typologies by correlating the form of
state control and the basis for eligibility. They came to classify twelve modalities of health
care systems.
The Organization for Economic and Cooperation and Development (OECD) in 1994, based
on the sources of financing and dominant service providers, suggested several types of health
care systems.
Health care provision

Public Mixed (public + Private
provider private) provider
Belgium, France,
contribution Germany, Austria,
Luxemburg, Japan
Ireland, Spain,
Financing Public Denmark,
Finland, Greece,
Australia, New
taxation Portugal, Canada
Zealand
Norway,
Sweeden, Italy,
UK
Mixed (public + Netherlands,
Turkey, Korea
private) Mexico
Private USA, Swiss
Ten years later, on 2004, the OECD suggested a simplified typology by deleting the mixed
mode in health care provision and financing, thus finally narrowing health system down to
three types: the public integrated; the public contact; and the private insurance-provider
model.
Health care provision

Public provider Private provider
Public Public integrated model Public contract model
Financing
Private Private insurance-provider model

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According to OECD (2004) a good typology should be based on the three main principles:
1. FIRST, it should be based on characteristics of the health care system that are
objectively identifiable
2. SECOND, it should be consistently applied to all countries
3. THIRD, the typology should be relevant for policy analysis and data collection
The contemporary typology of health systems has been driven by the understanding of
industrialized country health systems.
The common typology reflecting an ideal set of macro-institutional characteristics should be
based on variations in:
- The funding of health care
- Corresponding differences in the organization of health care provision, e.g. the
role of the Government and local authorities in the health care organization, the type
of meeting the basic health needs, etc.
In general, three well-known types of health care system exist:

- NATIONAL HEALTH SERVICE (NHS) – STATE MONOPOLY
- SOCIAL HEALTH INSURANCE (SHI)
- PRIVATE HELATH INSURANCE (PHI) – LIBERAL PLURALISM
STATE MONOPOLY SYSTEM.

STATE MONOPOLY – NATIONAL HEALTH SERVICE (NHS) MODEL
It is characterized by:
- Universal coverage
- Funding out of general taxation
- Public provision of health services
- The predominant role of the Government in health care organization
- The Government is the owner of all health care resources (except health professionals)
- The administration of the system is highly centralized
The system is appropriate when there is a need for strict coordination of health care activities
as in cases of emergency and limited resources.
The system is exposed to a risk of bureaucratization and going away from the health needs of
the population.
Such health systems were typical for all former socialist countries. Good examples of such
systems are in: UK, Sweden…

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HEALTH INSURANCE SYSTEM.

HEALTH INSURANCE SYSTEM – SOCIAL HEALTH INSURANCE (SHI) MODEL
It is typical for most western countries (Germany, France…) and is characterized by:
- The availability of insurance system presented by powerful insurance funds,
independent from the state, and covering more often compulsory the whole population.
- The insurance funds come from three partners: the Government, the employers and
the employees.
- The public and private provision of health care.
There are many different schemes of insurance funds:

- The Government may have a predominant role (as in some Nordic countries).
- The employers and the employees may have a greater proportion than the Government
(as in the most of western countries).
- The employers and the employees may have the same proportion in insurance.
The system is based on the principles of:

- SOCIAL RIGHTNESS → the monthly payment is proportionate to the income (the
better-off pay more than the poorer).
- SOCIAL SOLIDARITY → all the participants will get the care they need without
referring to the amount of money they had paid.
Health care resources are both public and private.

The system is highly decentralized. The role of the Government is to provide with a strong
legislative package and the local authorities have a predominant role in the self-administration
of health care.
HEALTH SYSTEM OF LIBERAL PLURALISM.

LIBERAL PLURALISM – PRIVATE HEALTH INSURANCE (PHI) MODEL
Health care is funded by the individual and employer premiums and health delivery relies
predominantly on private ownership.
- The prototype of health care system model is the United States.
- The system is based on the economic liberalism and pluralistic ownership of the
resources.
- The role of the Government is strong to assure a healthy environment and lifestyle
factors but it is very restricted in health care organization and provision of health
services.

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The entire Social Health Protection system in USA is made up of four types of institutions:
- Medicare
- Medicaid
- Private insurance companies – more than 1500 population
- Health maintenance organizations (HMOs)
Some part of the population is not covered by any of these organizations and their health
needs must be met by charity hospitals, which are decreasing in number. Some hospitals
managed by municipalities (city hospitals) provide for the uninsured.
- MEDICARE → nation’s largest health insurance program, which covers more than
37 million Americans. It was enacted in 1965 under Title XVIII of the Social Security
Act (“provided by the federal government”).
o Provides insurance to:
§ People who are 65 years old
§ People who are disabled
§ People with permanent kidney failure
MEDICARE has two parts:

o Medicare Part A → provides:
§ Coverage of inpatient hospital services
§ Skilled nursing facilities
§ Home health services
§ Hospital care
o Medicare Part B → helps pay for the cost of:
§ Physician services
§ Outpatient hospital services
§ Medical equipment and supplies
§ Other health services and supplies
- MEDICAID → jointly-funded, Federal – State health insurance program for certain

low-income and needy people.
o It covers approximately 36 million individuals including children, the aged,
blind and/or disabled, and people who are eligible to receive federally assisted
income maintenance payments.
o Became law in 1965 under Title XIX on the Social Security Act as a jointly
funded cooperative venture between the Federal and State governments to assist
States in the provision of adequate medical care to eligible needy persons.
o Largest program providing medical and health-related services to America’s
poorest people. Within broad national guidelines which the Federal government
provides, each of the states:
§ Establishes its own eligibility standards
§ Determine the type, amount, duration, and scope of services
§ Sets the rate of payment for services
§ Administers its own program

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REFORMS IN HEALTH SYSTEMS IN UK AND USA

(OBAMACARE – MOTIVATION, GOAL, MAIN
CHARACTERISTICS).
NATIONAL HEALTH SERVICE UK

- When state monopoly system is functioning in the context of market economy it may
be successful. For example, in UK within the health care reform starting in 1990 there
is a strong division between health care providers (health trusts, hospitals, general
practitioners, etc.) and purchasers of health care (health authorities, health
commissions, etc.) that contracted health care for their population.
- There is also a strong managed competition between different health providers to
assure high quality health care for the population.
Changes since April 2013:

- These changes have an effect on who makes decisions about NHS services, how these
services are commissioned and the way money is spent.
- Abolition of primary care trusts (PCTs) and strategic health authorities (SHAs), and
the introduction of clinical commissioning groups (CCGs) and Healthwatch England.
- Competition between providers that meet NHS standards on price, quality and safety,
with a new regulator (Monitor).
- Local authorities have taken on a bigger role, assuming responsibility for budgets for
public health. Local authorities are expected to work more closely with other health
and care providers, community groups and agencies, using their knowledge of local
communities to tackle challenges such as smoking, alcohol and drug misuse and
obesity.
- Changes DO NOT AFFECT access to NHS – GP appointments, prescriptions,
referrals to specialists.

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HEALTH CARE REFORM IN USA – OBAMA CARE

- Patient Protection and Affordable Care Act – signed 23 March 2010
- Amended through Health care and Education Reconciliation Act
- Motivation:
o USA spends more than similarly-developed nations but has lower public health
indication.
o Significant underinsurance (the individual have health insurance but it does not
offer complete financial protection).
o Significant impending unfunded liabilities from its aging demographic.

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- Additional motivation:
o Decline in number of employers who offer health insurance
o Even for employed health insurance vary a lot in its coverage
o 20 – 30% of health spending under MEDICARE and MEDICAID services is
waste:
§ Overtreatment of patients
§ Failure to coordinate care
§ Administrative complexity
§ Burdensome rules
§ Fraud (3 – 10% of all health expenditures)
o Public opinion: majority of the public support various levels of governmental
involvement in health care.
1. Goal: to give more Americans access to affordable, quality health insurance, and to
reduce the growth in health care spending.
2. Regulates health insurance not health care!
3. Companies can no longer charge members based on gender, burdening men with the
health care costs of women.
4. Allowance for dependents to remain on their plan until 26.
5. Stop insurance companies from dropping people when they are sick.
6. Stop insurance companies from making unjustified rate hikes.
7. Mandate that insures fully cover certain preventive services – early check-ups,
immunizations, counseling and screening.
8. High-risk pools for uninsured.
9. Tax credits for business to provide insurance to employees.
10. Allowed the FDA to approve generic biologic drugs and specifically allows for 12
years of exclusive use for newly developed biologic drugs.
11. The law also requires for reduced MEDICARE reimbursements for hospitals with
excess readmissions and eventually ties physician MEDICARE reimbursements to
quality of care metrics.
NOT ASKED IN THE EXAM ABOUT IT!

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TOPIC 26. HEALTH POLICY. PRIORITIES OF HEALTH POLICY

IN DEVELOPED COUNTRIES.
HEALTH POLICY.
Health policy is a statement based on human aspirations, set of values, commitments,
assessment of health situation and an image of a desired future situation.
A national health policy is an expression of goals for improving the health situation, the
priorities among those goals, and the main directions for attaining them.
Health policy is often defined at a national level.
Each country will have to develop a health policy for its own aimed and defined goals, for
improving the people’s health, in the light of its own problems, particular circumstances,
social and economic structures, and political and administrative mechanisms.
Among the crucial factors affecting realization of these goals are:
- A political commitment
- Financial implications
- Administrative reforms
- Community participation and basic legislation
PRIORITIES OF HEALTH POLICY IN THE DEVELOPED

COUNTRIES.
Developed countries have many common features in their health policy goals.
Among these priorities, the most important are:
1. Shift from hospital care to primary health care
2. New approaches to prevention: greater emphasis on primary prevention and within it
– to population strategy of primary prevention instead of high-risk strategy
3. Health promotion as a central part in combined efforts to improve people’s health
4. Quality control and evaluation of health care activities
5. Marked orientation of health care
6. New preventive, diagnostic and curative technologies
7. Improvement of health legislation, development of health management and promotion
of managerial culture in the health systems
8. Highly developed information technologies
9. Decentralization and involvement of local authorities in the health system regulation
10. Integral approach to the management and functioning of health systems

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TOPIC 27. INTERNATIONAL HEALTH COLLABORATION.

WORLD HEALTH ORGANIZATION. OTHER UN AGENCIES.
MILLENNIUM GOALS.
INTERNATIONAL HEALTH COLLABORATION.

The history of the world health collaboration
The first known efforts to create an international public health mechanism to fight epidemics
of infectious diseases date back to 1851.
After the 1830 outbreak of cholera in Europe, which claimed the lives of thousands of people
in different countries, the first International Sanitary Conference was held in Paris to produce
an international sanitary convention → First attempt failed, but worked on the convention
continued.
In 1892, the International Sanitary Convention, restricted to cholera, was adopted by
European countries.
In 1897, the International Convention dealing with preventive measures against plague.
In 1902, the International Sanitary Bureau in Washington was created, later renamed Pan
American Sanitary Bureau, and subsequently Pan American Health Organization – PAHO.
In 1907, l’Office International d’hydiene publique (OIHP) was established in Paris, with a
permanent secretariat and a permanent committee of senior public health officials from 12
member States, nine of which were European.
In 1919, the League of Nations was created and charged with matters of prevention and
disease control.
In 1926, the International Sanitary Convention was revised to include provisions against
smallpox and typhus.
In 1935, the International Sanitary Convention for aerial navigation was adopted.
In 1945, the United Nations Conference on International Organizations in San Francisco

approved a proposal by Brazil and China to establish a new and autonomous international
health organization.

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WORLD HEALTH ORGANIZATION.

World health organization – objectives, membership, activities of the WHO, structure
In 1946, the International Health Conference in New York approved the Constitution of the
World Health Organization (WHO).
Finally, on 7 April 1948, the WHO constitution came into force (now marked as World Health
Day each year).
Independent agency within the UN – now includes 193 countries.

- Own constitution
- Own governing bodies
- Own membership
- Own budget
WHO Constitution defined health as “a state of complete physical, mental and social well-
being and not merely the absence of disease and infirmity”.
Constitution’s basic principles

1. The enjoyment of the highest attainable standard of health is one of the fundamental
rights of every human being without distinction of race, religion, political belief, and
economic and social condition.
2. The health of all people is fundamental to the attainment of peace and security and
is dependent upon the fullest cooperation of individuals and States.
3. The achievement of any state in the promotion of health is of value to all.
4. Unequal development in different countries in the promotion of health and
control of disease, especially communicable diseases, is a common danger.
5. Healthy development of the child is of basic importance; the ability to live
harmoniously in a changing total environment is essential to such development.
6. The extension to all people of the benefits of medical, psychological and related
knowledge is essential to the fullest attainment of health.
7. Informed opinion and active cooperation on the part of the public are of utmost
importance in the improvement of the health of people.
8. Governments have a responsibility for the health of their people, which can be
fulfilled by the provision of adequate health and social measures.

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Functions
WHO specific functions, listed in article 2, include the following:
1. To act as the directing and coordinating authority on international health work
2. To assist governments in strengthening health services and emergency aid
3. To promote maternal and child health and welfare
4. To foster activities in the mental health field
5. To promote the improvement of nutrition, housing, sanitation, recreation; and of
economic, working, and environmental conditions
6. To study and report on public health and medical care
7. To promote research and health training
8. To advance work to eradicate epidemic, endemic, and other diseases, and to prevent
injuries
9. To propose conventions, agreements, and regulations, and make recommendations
regarding international health matters
10. To standardize diagnostic procedures and revise as necessary international
nomenclatures of diseases, causes of death, and public health practices
11. To develop, establish, and promote international standards with respect to food,
biologicals, pharmaceuticals, and similar products
The work of the WHO is divided into two major categories:

- Central technical services
o Gathering epidemiologic information
o Development of international health agreements
o Standardization of vaccines and pharmaceuticals
o Dissemination of knowledge through meetings of experts
o Technical reports
- Services to governments
o Provision of support to interregional and intraregional projects
o Coordination of the work of WHO collaborating centers, laboratories, and
institutes
WHO Governing bodies

- World health assembly
- The Executive Board
- The Secretariat
- Director-General
- Membership

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The World Health Assembly is the supreme decision-making body for WHO. It meets each
year in May in Geneva, and is attended by delegations from all 193 Member States. The
functions of the WHA include:
- Determining the policies of the Organization
- The naming of Members entitled to designate a person to serve on the Executive Board
- Appointing the Director-General
WHO Executive Board (EB) consists of 34 members representing the national governments
– balanced among the WHO regions and elected for 3-term years.
The WHO Director-General is elected by the WHA every 5 years and is subject to the
authority of the Executive Board.
It is important to note that the WHO can only intervene in countries when requested and that
all resolutions urge but never oblige member states to act.
WHO members are required to provide routine reports on domestic health to meet the specific
needs of a geographical area → distributed in 6 regional organizations.
REGION HEADQUARTERS
Europe (EURO) Copenhagen
Eastern Mediterranean (EMRO) Cairo
Africa (AFRO) Brazzaville
Southeast Asia (SEARO) New Delhi
Western Pacific (WPRO) Manila
The Americas (PAHO) Washington
OTHER UN AGENCIES.
- UNICEF (United Nations International Children Emergency Fund)
- UNESCO (United Nation’s Education, Science and Culture Organization)
- UNDP (United Nations Development Program)
- UNFPA (United Nation’s Population Fund)
- FAO (Food and Agriculture Organization)
- WFP (World Food Program)
- ILO (International Labor Organization)
- UNAIDS (United Nation’s AIDS Program)

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- UNHCR (UN Higher Commissioner for Refugees)

- UNOHCHR (Un Office of the High Commissioner for Human Rights)
- UNEP (United Nation’s Environment Program)
- UN-HABITAT (UN Human Settlements Program)
MILLENNIUM GOALS.
Signed in September 2000, the eight goals that all UN Member States have agreed to try to
achieve by the year 2015 include the following:
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development

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TOPIC 28. DEVELOPMENT, MAIN GOAL AND BASIC TARGETS

OF WHO GLOBAL STRATEGY “HEALTH FOR ALL IN THE 21
CENTURY”.
DEVELOPMENT
In May 1997, the 30th WHA adopted resolution in which it decided that the main social target
of governments and of WHO in the coming decades should be the attainment by all the people
of the world by the year 2000 of a level of health that will permit them to lead a socially and
economically productive life = “Health for all by the year 2000”
- What does “Health for all” mean?
o WHO Constitution defines the objective of the Organization as “the attainment
by all peoples of the highest possible level of health”.
o It is therefore not a single, finite target; it is a process leading to progressive
improvement in the health of people.
In 1979, the Executive Board of WHO issued guiding principles for the first strategy for
“Health for all by the year 2000”. Twelve basic global indicators were accepted to evaluate
the progress in achieving the Strategy goals.
Health for all in the 21st century aims to help realize the vision of Health for all, launched
at the Alma-Ata Conference in 1978.
- Sets out, for the first two decades of the 21st century, global priorities and targets which
will create the conditions for people worldwide to reach and maintain the highest
available level of health throughout their lives.
- It is a continuation of the HFA process.
According to the WHO declaration adopted by the world health community at the 51th World
Health Assembly, May 1998, the Member States of the WHO acknowledge that changes in
the world health situation require giving effect to the “Health for all Policy for the 21st
century” through relevant regional and national policies and strategies.
Despite gains based on three major evaluation of the Global Strategy HFA by the year 2000,
WHO has concluded that progress has been hampered for several reasons, including:
- Insufficient political commitment to the implementation of HFA
- Failure to achieve equity in access to all PHC elements
- The continuing low status of women
- Slow socioeconomic development
- Difficulty in achieving intersectorial action for health
- Unbalanced distribution of, and weak support for, human resources
- Widespread inadequacy of health promotion activities
- Weak health information systems and no baseline data

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- Pollution, poor food safety, and lack of safe water supply and sanitation
- Insufficient funding for health
- Rapid demographic and epidemiological changes
- Inappropriate use of, and allocation of resources for, high-cost technology
- Natural and man-made disasters
New trends influencing health in the 21st century → should be taken into account in the
future strategy:
- Widespread absolute and relative poverty
- Demographic changes: ageing and the growth of cities
- Epidemiological changes:
o Continuing high incidence of infectious diseases
o Increasing incidence of non-communicable diseases, injuries and violence
- Global environment threats to human survival
- New technologies: information and telemedicine services
- Advances in biotechnologies
- Partnerships for health between private and public sectors and civil society
- Globalization of trade, travel and the spread of values and ideas
MAIN GOAL
The broad goals of HFA in the 21st century are based on the following key values:
1. The right to the highest attainable standard of health.
2. Ethics in all aspects of HFA planning and implementation: the conduct health
professionals, the policies and priorities of for health systems and services, the science,
research and technology.
3. Equity.
4. A gender perspective in health policy.
BASIC TARGETS
HEALTH OUTCOMES
1. Health equity → childhood stunting
2. Survival → maternal mortality rate, child mortality rate, life expectancy
3. Reverse global trends in five major pandemics → tuberculosis, HIV, malaria, tobacco-
related diseases and violence/trauma.
4. Eradicate and eliminate certain diseases
INTERSECTORAL ACTION ON THE DETERMINANTS OF HEALTH

5. Improve access to water, sanitation, food and shelter
6. Measures to promote health

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HEALTH POLICIES AND SYSTEMS

7. Develop, implement and monitor national HFA policies
8. Improve access to comprehensive essential, quality health care
9. Implement global and national health information and surveillance systems
10. Support research to health

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TOPIC 29. PRIMARY HEALTH CARE – DEFINITION,

ELEMENTS. WHO STRATEGY FOR PRIMARY HEALTH CARE.
DECLARATION OF ALMA-ATA.
PRIMARY HEALTH CARE – DEFINITION. DECLARATION OF

ALMA-ATA.
Primary health care – definition and main characteristics according to Alma-Ata Declaration
(1978):
- PRIMARY HEALTH CARE = essential health care based on practical, scientifically
sound and socially acceptable methods and technology made universally accessible to
individuals and families in the community at a cost they can afford → based on:
o Evidence-based approach
o Social acceptability
o Accessibility of technology
o Participatory approach involving communities
o Affordability of services
It forms an integral part both of the country’s health system and of the overall social and
economic development of the community.
It is the first level of contact of individuals, the family and community with the national
health system bringing health care as close as possible to where people live and work.
PRIMARY HEALTH CARE – ELEMENTS. DECLARATION OF

ALMA-ATA.
Primary health care:
1. Reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country.
2. Addresses the main health problems in the community, providing promotive,
preventive, curative and rehabilitative services accordingly.
ELEMENTS
- Education concerning prevailing health problems and the methods of preventing and
controlling them – Health education
- Promotion of food supply of safe water and basic sanitation
- Maternal and child health care, including family planning
- Immunization against the major infectious diseases
- Prevention and control of locally endemic diseases (non-communicable diseases)
- Appropriate treatment of common diseases and injuries.
- Provision of essential drugs.

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GENERAL MEDICINE AND THE GENERAL PRACTITIONER/FAMILY

PHYSICIAN AS A KEY FIGURE IN PHC
Primary health care is characterized by:
- Usual entry in the health care system.
- Should be easily available to any patient who looks for medical advice and treatment
since practices should be largely distributed within the community.
- Covers the whole population, of both sexes and of all age groups.
- Comprehensive medicine including prevention, health education and curative care.
- Continuous care to the patient.
à IMPORTANT ROLE IN COORDINATION OF CARE provided to his patients and in

the way the patient uses health resources.
Within the primary health care, 4 types of activities could be pointed out:
1. Medical and paramedical care → general practice, obstetrics, dentistry,
physiotherapy, pharmacy, diet…
2. Social care → information and counselling, psychosocial care and support, general
social activities…
3. Nursing care → maternity nursing care, community nursing…
4. Other types of care → care at home and at specific health centers
The basic features of GP care are:

1. General care
2. Comprehensive care
3. Continuous care
4. Personal care → It is a patient-centered care not an illness-centered.
5. Integral care → GP takes into account non-medical factors such as social and family
characteristics of the patient.
6. Context-related care
7. Community oriented care
8. Coordinated care → GP advises his patients on their health, treats them when they
are sick and in case of severe or complex diseases, refers them to more specialized or
appropriate health care units → plays a role of a “gate-keeper” of the health care
system.
o GP usually takes in charge and is able to solve at his own level about 90% of
the health problems submitted.
The profile and tasks of the GP are very well determined in the definition of GP, drawn up
by the Leewenhorst Group (1974) which is now recognized all over the world:
- “The general practitioner is a licensed medical graduate who gives personal, primary
and continuing care to individuals, families and a practice population irrespective of
age, sex and illness. It is the synthesis of these functions which is unique”.

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- “He will attend his patients in the consulting room and in their homes and sometimes
in a clinic or hospital. His aim is to make early diagnoses. He will include and
integrate physical, psychological and social factors in his considerations about health
and illness. He will make an initial decision about every problem which is presented
to him as a doctor.”
- “He will undertake the continuing management of his patient with chronic, recurrent
or terminal illnesses. Prolonged contact means that he can use repeated opportunities
to gather information at a pace appropriate to each patient and build up a relationship
of trust which he can use professionally.”
- “He will practice in a cooperation with other colleagues, medical and non-medical.
He will know how and when to intervene through treatment, prevention and education
to promote the health of his patients and their families. He will recognize that he also
has a professional responsibility to the community”.
WHO STRATEGY FOR PRIMARY HEALTH CARE.

World Health Report 2008 – PRIMARY HEALTH CARE (Now More Than Ever)
The report underlined 4 sets of reforms that reflect a convergence between:
- The values of primary health care
- The expectations of citizens
- The common health performance challenges that cut across all contexts

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Five common shortcomings of health care delivery
1. Inverse care → People with the most means (whose needs for health care are often
less) consume the most care, whereas those with the least means and greatest health
problems consume the least.
o Public spending on health services most often benefits the rich more than the
poor in high and low income countries alike.
2. Impoverishing care → Wherever people lack social protection and payment for care
is largely out-of-pocket at the point of service, they can be confronted with catastrophic
expenses.
o Over 100 million people annually fall into poverty because they have to pay for
health care.
3. Fragmented and fragmenting care → The excessive specialization of health-care

providers and the narrow focus of many disease control programs discourage a holistic
approach to the individuals and the families they deal with and do not appreciate the
need for continuity in care.
o Health services for poor and marginalized groups are often highly fragmented
and severely under-resourced, while development aid often adds to the
fragmentation.
4. Unsafe care → Poor system design that is unable to ensure safety and hygiene
standards leads to high rates of hospital-acquired infections, along with medication
errors and other avoidable adverse effects that are an underestimated cause of death
and ill-health.
5. Misdirected care → Resource allocation clusters around curative services at great

cost, neglecting the potential of primary prevention and health promotion to prevent
up to 70% of the disease burden.

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HOW EXPERIENCE HAS SHIFTED THE FOCUS OF THE PHC MOVEMENT

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TOPIC 30. HOSPITAL CARE – MISSION, STRUCTURE AND

GOALS. ASSESSMENT OF UTILIZATION OF HOSPITAL BEDS.
QUALITY OF HOSPITAL CARE.
HOSPITAL CARE – MISSION, STRUCTURE AND GOALS.
HOSPITAL → health care institution providing patient treatment with specialized staff and
equipment.
Health care facility in which physicians and other health professionals and personnel provide
all or some of the following activities:
- Diagnosis and treatment of diseases in cases when treatment goals cannot be reached
at the level of primary health care
- Care at delivery
- Rehabilitation
- Diagnosis and consultation on demand of professionals from another health care
facility
- Medico-cosmetic services
- Clinical trials of drugs and medical equipment
- Educational and scientific activities
CLASSIFICATION OF HOSPITALS (TYPES)

1. According to the average length of stay
o SHORT-TERM HOSPITALS → < 30 days
o LONG-TERM HOSPITALS → include psychiatric, rehabilitation, chronic
illnesses (tuberculosis), drug dependency…
2. According to the type of ownership

o PRIVATE (PROPIETARY) HOSPITALS
o GOVERNMENT HOSPITALS
o VOLUNTARY HOSPITALS → established by community members
3. According to the focus of care (type of disease)

o GENERAL HOSPITALS → provide diagnostic and treatment services in both
surgical and non-surgical conditions
o SPECIALIZED HOSPITALS → provide particular type of service (maternity,
pediatrics…)

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HOSPITAL’S FUNCTIONS
- Clinical function → diagnosis, treatment and rehabilitation, care at delivery, medico-
cosmetic services.
- Consultation function → among different specialties or different hospitals

(coordination)
- Preventive function
o Primary → health education of patients and families towards life style changes,
prevention of intra-hospital infections.
o Secondary → prevention of the occurrence of disease complications.
o Tertiary → prevention of invalidization.
- Social function → social history of disease, provision of information, respect for

patients’ rights, relations to patients’ relatives etc.
- Qualification function → permanent activities for increasing qualification of the own

personnel and specialization of other health professionals.
- Economical function → depending on the country
- Teaching function
STRUCTURE
- Clinics/wards
- Diagnostic facilities
- Hospital chemistry
- Consultation offices
- Administrative units
- Additional units
HOSPITAL MANAGEMENT
Usually, big hospitals have hospital board with decision-makers on how resources will be
used. They can delegate day-to-day responsibilities (surgical planning…) to hospital
director.
ACCESSIBILITY TO HOSPITAL CARE

It is assessed by the number of beds per population:
- LOW → if < 4 beds per 1000 inhabitants (or < 400 per 100 000)
- AVERAGE → if 4 – 7 beds per 1000 inhabitants (or 400 – 700 per 100 000)
- HIGH → if 7 – 10 beds per 1000 inhabitants (or 700 – 1000 per 100 000)
- VERY HIGH → if > 10 beds per 1000 inhabitants (or > 1000 per 100 000)

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ASSESSMENT OF HOSPITAL CARE

- QUANTITY INDICATORS → describe how beds are utilized
- QUALITATIVE INDICATORS → such as hospital case-fatality rate, postoperative
complications, etc.
Required data:
- Beds available
- Hospital/patient days
- Patients passed
"*,$##%* )"#$%&#' + *$'.ℎ"01%* + *$%*

!"#$%&#' )"''%* =
2
ASSESSMENT OF UTILIZATION OF HOSPITAL BEDS.
QUANTITATIVE INDICATORS (UTILIZATION OF HOSPITAL BEDS)
- BED OCCUPANCY RATE
74')$#"8 *"6'
3%* 4..5)"&.6 = (*"6')
3%*' "9"$8":8%
Example: If BOR = 260 → 260/365 days x 100 = 60%
- AVERAGE LENGTH OF STAY
74')$#"8 *"6'
=9%0"1% 8%&1#ℎ 4> '#"6 = (*"6')
!"#$%&#' )"''%*
- BED TURNOVER
!"#$%&#' )"''%*
3%* #50&49%0 = (&5,:%0 4> )"#$%&#')
3%*' "9"$8":8%

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QUALITY OF HOSPITAL CARE.
QUALITATIVE INDICATORS
- HOSPITAL CASE-FATALITY RATE
A5,:%0 4> ℎ4')$#"8 *%"#ℎ' *$%* )"#$%&#'

?"'% − >"#"8$#6 0"#% = B 100
!"#$%&#' )"''%* "*,$##%*
It is important to compare it with out-patient case fatality rate for the same region, for
the same diseases, etc.

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TOPIC 31. PUBLIC HEALTH NEEDS OF SPECIFIC POPULATION

GROUPS: MOTHERS. MATERNAL MORTALITY, FAMILY
PLANNING. HEALTH SERVICES FOR MOTHERS - ANTENATAL,
INTRANATAL, POST-NATAL CARE. RISK APPROACH.
DELIVERING HEALTH CARE TO MOTHERS.
PUBLIC HEALTH NEEDS OF POPULATION GROUPS:

MOTHERS.
MATERNAL AND CHILD HEALTH CARE.
- Significance of MCHC
- Content and specific objectives of MCHC
- Maternal health care
- Child health care
- Maternal and child care and MDGs
SIGNIFICANCE OF MCHC.
- In any community, mothers and children constitute a priority group.
- They comprise approximately 70% of the population of the developing countries, and
about 45-50% in developed countries.
- Mothers and children as “vulnerable” or high-risk group:
o For women – the risk is connected with child-bearing
o For infants children – with growth development and survival
MOTHER AND CHILD – ONE UNIT

1. During the antenatal period the foetus is part of the mother.
2. Child health is closely related to maternal health. A healthy mother = a healthy baby.
3. Certain diseases and conditions during pregnancy (syphilis, German measles, AIDS,
drug intake) are likely to have effects upon the foetus.
4. After birth, the child is dependent upon the mother.
5. Almost all care services to the mother and child are closely related.
6. The mother is the first teacher of the child.
Nowadays, the current trend all over the world is to provide integrated maternal and child
care and family planning services.
New concepts:
- Social obstetrics
- Preventive pediatrics
- Social pediatrics

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THE WORLD HEALTH REPORT 2005 – MAKE EVERY MOTHER AND CHILD
COUNT
The key message in WHR 2005 = MOTHERS AND CHILDREN MATTER – SO DOES
THEIR HEALTH!
CONTENT AND SPECIFIC OBJECTIVES OF MCHC.

MCH PROBLEMS COVER A BROAD SPECTRUM
- IN DEVELOPED REGIONS
o Perinatal problems
o Congenital malformations
o Genetic and behavioral problems
- IN DEVELOPING REGIONS
o Reduction of maternal and child mortality and morbidity
o Spacing of pregnancies
o Limitation of family size
o Prevention of communicable diseases
o Improvement of nutrition
o Promoting acceptance of health services
MATERNAL AND CHILD HEALTH

MATERNAL AND CHILD HEALTH → refers to the promotive, preventive, curative and
rehabilitative health care for mothers and children
MCH includes the sub-areas:
- Maternal health
- Child health
- Family planning
- School health
- Handicapped children
- Adolescence and health aspects of children care in special settings
SPECIFIC OBJECTIVES OF MCH GLOBALLY

- Reduction of maternal, perinatal, infant and childhood mortality and morbidity
- Promotion of reproductive health
- Promotion of the physical and psychological development of the child and adolescent
within the family.
The ultimate objective of MCH services is lifelong health.

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HEALTH SERVICES FOR MOTHERS - ANTENATAL,

INTRANATAL, POST-NATAL CARE.
The primary aim – to achieve at the end of a pregnancy a healthy mother and a healthy
baby.
OBJECTIVES OF ANTENATAL CARE

- To promote, protect and maintain the health of the mother during pregnancy.
- To detect “high risk” pregnancies and give them special attention – high risk
approach.
- To foresee complications and prevent them
- To remove anxiety associated with delivery
- To reduce maternal and infant mortality and morbidity
- To teach the mother elements of child care, nutrition, personal hygiene
- To sensitize the mother to the need of family planning including advice to cases
seeking medical termination of pregnancy.
OBJECTIVES OF INTRANATAL CARE

The aims of a good intranatal care are to provide:
- Through asepsis
- Delivery with minimum injury to the infant and mother
- Readiness to deal with complications such as prolonged labor, antepartum
hemorrhage, convulsions, mal-presentations, prolapse of the cord, …
- Care of the baby at delivery – resuscitation, care of the cord, care of the eyes, …
DOMICILIARY CARE
INSTITUTIONAL CARE → for all high-risk cases
OBJECTIVES OF POST-NATAL CARE

- CARE OF THE MOTHER (POSTPARTAL CARE) → responsibility of the
obstetrician
- CARE OF THE NEWBORN → a combined responsibility of the obstetrician and
pediatrician
The objectives of post-partal care:
- To prevent complications of the post-partal period
- To provide care for the rapid restoration of the mother to optimum health
- To check adequacy of breast feeding
- To provide family planning services
- To provide basic health education to mother/family

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The World Health Report 2005 – Make Every Mother and Child Count
FACT SHEET
Each year almost 11 million children under 5 years of age die from causes that are largely
preventable.
- Among them – 4 million babies do not survive the first month of life.
- More than half a million women die in pregnancy, childbirth or soon after.
- Every day, 1500 women die from pregnancy or childbirth-related complications. In
other words, annually there are about 500 000 maternal deaths worldwide.
- Every year, more than 1 million children are left motherless and vulnerable because
of maternal death. Children who have lost their mothers are up to 10 times more likely
to die prematurely than those who have not.
Where do maternal deaths occur?

- The incidence of maternal death is inequitably spread throughout the world reflecting
the gap between rich and poor.
- Developing countries account for 99% of all maternal deaths worldwide. More than
half of these deaths occur in sub-Saharan Africa, 1/3 in South Asia
- In some developing regions, the MMR is 1100 maternal deaths per 100000 live births,
compared to 2 in developed regions.
- A woman’s lifetime risk of maternal death is one in 75 in the developing regions,
compared to one in 7300 in developed regions.

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What are the leading causes of maternal deaths?

Direct or indirect causes in pregnancy, childbirth or the postpartum period.
MAJOR KILLERS INDIRECT CAUSES
Severe bleeding Complications after unsafe abortions (13%)
Infections Diseases (20%) that complicate pregnancy
or aggravated by pregnancy:
Hypertensive disorders - Malaria
- Anemia
- HIV/AIDS
Obstructed labor
- CVD
How can the mothers’ lives be saved?

- Most maternal deaths are avoidable as the medical solutions to prevent or manage the
fatal causes are well known.
- Skilled care at birth (good quality of intranatal care) can make the difference between
life and death.
- For instance, if unattended, severe bleeding in the third stage of labor can kill even a
healthy woman within two hours. An injection of the drug oxytocin given immediately
after childbirth reduces the risk of bleeding very effectively.
- Sepsis, the second most frequent cause of maternal death, can be widely reduced if
aseptic techniques are respected.
- The third-cause, pre-eclampsia, is a common hypertensive disorder in pregnancy,
which can be monitored. Although pre-eclampsia cannot be completely cured before

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the delivery, the administration of drugs like magnesium sulfate can lower a woman’s
risk of developing convulsions (eclampsia).
- Another frequent cause of maternal death, obstructed labor, can be prevented or
managed by skilled birth attendants. Obstructed labor occurs when the fetus’ head is
too big compared to the mother’s pelvis or if the baby is abnormally positioned.
- A simple tool to identify problems in labor early is the partograph to monitor the
progress of labor and the maternal and fetal condition. Skilled practitioners can use
the partograph to recognize and deal with slow progress before labor becomes
obstructed, and, if necessary, refer the woman to cesarean section.
Why mothers not get the care they need?

In 2006, only about 60% of deliveries in developing countries were assisted by a skilled birth
attendant. In other words, there were about 50 million home deliveries not assisted by skilled
health personnel.
The main reasons why women do not receive the care they need before, during and after
childbirth:
- No availability of professional care
- Poor quality of care provided
- Lack of access to health facilities (no transportation inability to afford costs of
transport or the health services’ user-fees)
- Cultural beliefs
- A woman’s low status in society…
To improve maternal health gaps in the capacity and quality of health systems and barriers to
accessing health services must be identified and tackled at community level.
The WHO strategy “Making pregnancy safer” is directed to:

- Improve maternal health
- Assists countries to ensure skilled care before, during and after pregnancy and
childbirth
- Strengthen national health systems in order to achieve Millennium Development
Goals.
A cornerstone of Making Pregnancy Safer is the integrated management of pregnancy and
childbirth:
- Guidance and tools to increase the availability of high-quality health services to
pregnant women.
- Clinical guidelines for the management of complications before, during and after
childbirth
- Recommendations and standards for interventions for a continuum of care for mothers
and newborns were developed.
- Involvement of individuals, families and communities to increase the access to quality
care.

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Goal 5: Improve maternal health

- Target 1: reduce by 3/4 the Maternal Mortality Ratio
- Target 2: achieve universal access to reproductive health
What needs to be done?

1. Provide sufficient financing to strengthen health systems for maternal, childcare and
other reproductive health services, and ensure appropriate procurement and
distribution of contraception, drugs and equipment.
2. Establish national programs to reduce maternal mortality and ensure universal access
to reproductive health care, including family planning services.
3. Provide trained health workers during and after pregnancy and childbirth for delivery
of quality antenatal care, timely emergency obstetric services and contraception.
4. Ensure access to timely emergency obstetric services and provide adequate
communication, skilled personnel, facilities and transportation systems, especially in
areas where poverty, conflict, great distances and overloaded health systems obstruct
such efforts.
5. Adopt and implement policies that protect poor families from the catastrophic
consequences of unaffordable maternity care, including through access to health
insurance or free services.
6. Protect pregnant women from domestic violence; and involve men in maternal health
and wider reproductive health.
7. Increase access to contraception and sexual and reproductive health counseling for
men, women and adolescents.
8. Increase efforts to prevent child marriage and ensure that young women postpone their
first pregnancy.
RISK APPROACH.
RISK APPROACH → introduced by WHO in 1970s as a strategy to determine high-risk
groups in the population and to direct specific preventive measures to these groups and
individuals in order to minimize the effects of risk factors.
- HIGH-RISK PREGNANCIES
o Elderly primi
o Short statured primi (140 cm and below)
o Malpresentations, viz breech, transverse lie
o Antepartum hemorrhage, threatened abortion
o Preeclampsia and eclampsia
o Anemia
o Twins, hudramnios
o Previous stillbirth, intrauterine death
o Elderly granmultiparas
o Prolonged pregnancy (14 days after expected day of delivery)
o History of previous caesarean or instrumental delivery
o General diseases (CVD, kidney disease, diabetes, TBC, liver disease, …)

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GROUPS: CHILDREN AND ADOLESCENTS. HEALTH
PROBLEMS OF CHILDREN AND ADOLESCENTS. HEALTH
SERVICES, COMMUNITY HEALTH AND POLICIES.
PUBLIC HEALTH NEEDS OF SPECIFIC POPULATION GROUPS:

CHILDREN AND ADOLESCENTS.
CARE OF CHILDREN
The age group 0 – 14 years is the most important in all societies because:
- They constitute about 40% of the total population worldwide.
- The determinants of chronic diseases and health behavior are laid down at this stage.
- It is a vital period of socialization and transmission of attitudes, customs and behavior
that may impact the health in later life, etc.
HEALTH PROBLEMS OF CHILDREN AND ADOLESCENTS.

AGE-PERIOD COMMON PROBLEMS
INFANCY Infant mortality
Developed countries Developing countries

1. Perinatal causes – asphyxia, 1. Immunopreventable diseases – diphtheria,
hypoxia, injuries, low birth tetanus, whooping cough, measles,
weight tuberculosis, poliomyelitis
2. Congenital abnormalities 2. Diarrhea
3. Respiratory diseases 3. Acute respiratory infections
- Malnutrition. Anemia, xerophthalmia
- Infections. Respiratory infections,
pneumonia, influenza. Intestinal
infections and parasites.
PRE-SCHOOL AGE - Accidents and poisoning. Burns and
trauma from home accidents. Traffic
accidents.
- Risk factors from the family
background.
- Malnutrition
- Infectious diseases
- Intestinal parasites
- Diseases of skin, eye and ear
SCHOOL AGE - Dental caries
- Spinal problems. Allergies. Asthma.
Hypodynamics.
- Neurosis. Psycho-emotional stress.
- Social adaptation. Sexual maturation.

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FACT 1
- A child’s risk of dying is highest in the first month of life.
- Preterm birth, birth asphyxia and infections cause most newborn deaths.
- Until the age of 5 years the main causes of deaths are pneumonia, diarrhea, malaria,
measles and HIV.
- Malnutrition contributes to more than half of all child deaths.
FACT 2
- Annually almost four million children die in the first month of life.
- Health risks to newborns can be minimized by:
o Quality care during pregnancy
o Safe delivery by a skilled birth attendant
o Strong neonatal care (immediate attention to breathing and warmth, hygienic
cord and skin care, and exclusive breastfeeding)
FACT 3
- Pneumonia is the largest single cause of death in children under 5 years of age.
- Addressing the major risk factors for the illness is essential to prevention, along with
vaccination.
- Antibiotics and oxygen are vital treatment tools for pneumonia.
FACT 4
- Diarrheal diseases are among the leading causes of sickness and death among
children in developing countries.
- Breastfeeding helps prevent diarrhea among young children.
- Treatment with Oral Rehydration Salts (ORS) and Zing supplements is cost-effective
and saves lives.
FACT 5
- Every 30 seconds a child dies from malaria in Africa.
- It is the leading cause of death in that region among under-fives.
- Insecticide-treated nets prevent transmission and increase child survival.
- Early treatment with anti-malarial medication saves lives.
FACT 6
- Over 90% of children with HIV are infected through mother-to-child transmission,
which is preventable with the use of anti-retrovirals and safer delivery and feeding
practices.
- An estimated 2.3 million children under 15 years of age are living with HIV, and every
day more than 1400 are newly infected.
- Without intervention, more than half of all HIV infected children die before their
second birthday.

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FACT 7
- About 20 million children under 5 years of age worldwide are severely malnourished.
- Around three-quarters of them can be treated with “ready-to-use therapeutic foods”.
- These highly fortified and energy-rich foods can be used at home without
refrigeration, and even where hygiene conditions are not ideal.
FACT 8
- Child survival rates differ significantly around the world → ¾ of child deaths occur
in Africa and South-East Asia.
- Within countries, child mortality is higher in rural areas, and among poorer and less
educated families.
FACT 9
- Child health is improving.
- About 2/3 of child deaths are preventable through access to practical, low-cost
interventions, and effective primary care up to 5 years of age.
- Stronger health systems are crucial for improving access to care and prevention.
FACT 10
- Greater investment is the key to achieving reduction of under-5 mortality rate.
- Public and private partners must come together to fill the gap in order to meet this
goal.
- The launch of the International Health Partnership, the related Global Campaign for
the Health MDGs, and several large bilateral donor pledges are important steps in this
direction.
HEALTH SERVICES, COMMUNITY HEALTH AND POLICIES.

Millennium Development Goal 4: REDUCE CHILD MORTALITY
- Target 1: reduce by 2/3, between 1990 and 2015, the under-five mortality rate.

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Current situation
Worldwide, deaths of children under-five years of age declined from 93 to 72 deaths per 1000
live births between 1990-2006.
Despite the progress, in 62 countries, under-five mortality is not declining fast enough to meet
the Goal 4 – Target 1. In many countries, malnutrition and lack of access to quality primary
health care and basic infrastructure, including water and sanitation, continue to cause ill health
and death among children and mothers.
What needs to be done?

Measures to achieve the necessary reductions in child mortality should include:
1. Ensure full coverage of immunization programs
2. Scale up vitamin A supplementation
3. Pursue exclusive breastfeeding for children under 6 months of age and breastfeeding
plus appropriate complementary feeding for children aged 6 months to 2 years.
4. Provide adequate nourishment for children of poor families, despite food price rises.
5. Promote hand-washing and treatment of home drinking water.
6. Target the underlying socioeconomic causes of child mortality such as mothers’ access
to reproductive health education and employment.
7. Prevent and provide effective treatment of pneumonia, diarrhea, malaria and other
infectious diseases.
8. Promote comprehensive and universal coverage of primary health-care systems →
with the engagement of community health workers – accompanied by sustained
delivery of health services and women’s education programs.
9. Ensure sufficient financing for the strengthening of health systems to meet the demand
for maternal and childcare and other reproductive health services.

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GROUPS: PEOPLE WITH DISABILITIES. ASSESSMENT.
MEASURES OF HEALTH AND DISABILITY. PUBLIC HEALTH
SERVICES AND INTERVENTIONS.
PEOPLE WITH DISABILITIES.

Definitions
- By diagnosis – traditional approaches to defining disability for public health have
focused on equating a particular diagnosis with disability (e.g. blindness).
- Focus on the impairment.
- Limitations in particular activities (e.g. self-care).
- Identification of those with problems in working or going to school.
- Identification of those who need special programs (e.g. special education).
- To ask the individuals themselves if they or others would identify them as someone
with disability (self-identification).
Disability has traditionally been placed alongside morbidity and mortality as the negative
public health outcomes → preventing disabilities, therefore, has been a goal of public health
activities.
What happens to those who become disabled despite of our best primary prevention efforts?
- Traditional approach – medical and rehabilitation services (outside the purview of
public health).
Public health approach to people with disabilities
Assessment
Policy development
Assurance

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ASSESSMENT.
ICF – International Classification on Functioning, Disability and Health components.
- The ICF is a classification of health and health-related conditions for children and
adults that was developed by WHO and published in 2001.
- ICF classification system to be considered a partner to the ICD. Whereas the ICD
classifies disease, the ICF looks at functioning. Therefore, the use of the two together
would provide a more comprehensive picture of the health of persons and populations.
- ICF is not based on etiology or “consequence of disease”, but as a component of health.
Thus, while functional status may be related to a health condition, knowing the health
condition does not predict functional status.
- ICF describes health and health related domains using standard language → wide
application.
Benefits of ICF
- Integration of the medical and social aspects of patient’s condition instead of solely
focusing on his or her diagnosis.
- Identifying the limitations of function is often the information used to plan and
implement interventions.
- Knowing how a disease affects one’s functioning enables better planning of services,
treatment, and rehabilitation for persons with long-term disabilities or chronic
conditions.

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Chapters of ICF
1. Body function
o Mental functions
o Sensory functions and pain
o Voice and speech functions
o Functions of the cardiovascular, haematological, immunological and
respiratory systems
o Functions of the digestive, metabolic, endocrine systems
o Genitourinary and reproductive functions
o Neuromusculoskeletal and movement-related functions
o Functions of the skin and related structures
2. Body structure
o Structure of the nervous system
o The eye, ear and related structures
o Structures involved in voice and speech
o Structure of the cardiovascular, immunological and respiratory systems
o Structures related to the digestive, metabolic and endocrine systems
o Structure related to genitourinary and reproductive systems
o Structures related to movement
o Skin and related structures
3. Activities and Participation

o Learning and applying knowledge
o General tasks and demands
o Communication
o Mobility
o Self-care
o Domestic life
o Interpersonal interactions and relationships
o Major life areas
o Community, social and civic life
4. Environmental factors
o Products and technology
o Natural environment and human-made changes to environment
o Support and relationships
o Attitudes
o Services, systems and policies

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ICF Qualifier scales:

- Generic qualifier:
0. No problem 4. Complete problem
1. Mild problem 8. Not specified
2. Moderate problem 9. Not applicable
3. Severe problem
- Qualifier for Environmental factors

-0 No barrier +0 No facilitator
-1 Mild barrier +1 Mild facilitator
-2 Moderate barrier +2 Moderate facilitator
-3 Severe barrier +3 Substantial facilitator
-4 Complete barrier +4 Complete facilitator
-8 Barrier, not specified +8 Facilitator, not specified
-9 Not applicable +9 Not applicable

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POLICY DEVELOPMENT.
Why?
- Data obtained about persons with disabilities alone do not make a difference in public
health or in their own lives.
- Policy development addresses the need for public health policies to use scientific
knowledge in decision-making, as public health policy is best formulated on the
foundation of strong data.
UN Standard rules on the equalization of opportunities for persons with disabilities

(1993)
PRECONDITIONS TARGET AREAS IMPLEMENTATION
MEASURES
Rule 1. Awareness raising Rule 5. Accessibility Rule 13. Information and research
Rule 2. Medical care Rule 6. Education Rule 14. Policy making and planning
Rule 3. Rehabilitation Rule 7. Employment Rule 15. Legislation
Rule 4. Support services Rule 8. Income maintenance/ social Rule 16. Economic policies
security
Rule 17. Coordination of work
Rule 9. Family life and personal
Rule 18. Organizations of people with
integrity
disabilities
Rule 10. Culture
Rule 19. Personnel training
Rule 11. Recreation and sport
Rule 20. National
Rule 12. Religion monitoring/evaluation of disability
programs
Rule 21. Technical and economic
cooperation
Rule 22. International cooperation
ASSURANCE.
What does it mean?
- Certitude that needed services will be provided to individuals and communities so that
health goals can be reached.
- Services must not only be present but also maintained so that goals can be met.
- Not only presence of services, but also access to those services:
o Physical proximity o Financial access
o Reasonable transport to the o Attitudes that encourage
services participation in the services
o Physical accessibility

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GROUPS: OLDER PEOPLE. HEALTH PROBLEMS AND HEALTH
NEEDS OF OLDER PEOPLE. HEALTH PROMOTION AND
PREVENTION. PUBLIC HEALTH IMPLICATIONS OF AGEING.

OLDER PEOPLE.
GENERAL CHARACTERISTICS
Ageing is a continuous process of limitation over vitality and increase of disease
susceptibility.
- Higher incidence of physical and mental disorders.
- Age specific diseases.
- Increased risk for certain diseases.
- Chronic multiple diseases.
- Changed reactivity – severe diseases.
- Blurred symptoms of disease.
- More disease complications.

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HEALTH PROBLEMS AND HEALTH NEEDS OF OLDER

PEOPLE.
LEADING HEALTH PROBLEMS
- Senile caract
- Glaucoma
- Nerve deafness
PROBLEMS DUE TO THE AGEING
- Bony changes
PROCESS
- Emphysema
- Failure of special senses
- Changes in mental outlook
- Degenerative diseases of heart and
blood vessels
- Cancer
- Accidents. Fracture neck of femur
PROBLEMS ASSOCIATED WITH
- Diabetes
LONG-TERM ILLNESS
- Disease of locomotor system
- Respiratory illnesses. Chronic
bronchitis. Asthma. Emphysema.
- Genitourinary system
- Mental changes
PSYCHOLOGICAL PROBLEMS - Sexual adjustment
- Emotional disorders

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HEALTH PROMOTION AND PREVENTION.
AREA POTENTIALLY AMENABLE TO PREVENTIVE HEALTH CARE IN THE

ELDERLY
PRIMARY SECONDARY TERTIARY
1. Health habits 1. Screening for: 1. Rehabilitation

- Smoking - Hypertension, diabetes - Physical deficits
- Alcohol abuse - Periodontal disease - Cognitive deficits
- Obesity - Sensory impairment - Functional deficits
- Nutrition - Colo-rectal cancer
- Sleep - Breast cancer, cervical 2. Caretaker support
cancer - Introduction of
2. Coronary heart - Prostatic cancer support necessary to
disease risk factors - Nutritionally-induced prevent loss of
- Depression, stress autonomy
3. Immunization - Urinary incontinence
- Influenza - Tuberculosis
- Pneumovax
- Tetanus 2. Stroke prevention
4. Injury prevention 3. Myocardial infarction
5. Osteoporosis
MADRID ACTION PLAN ON AGING (12 April 2002)
We recognize that concerted action is required to transform the opportunities ant the quality
of life of men and women as they age and to ensure the sustainability of their support systems,
thus building the foundation for a society for all ages.
It focuses on three priority areas:

- Older persons and development
- Advancing health and well-being into old age
- Ensuring enabling and supportive environments
It is a resource for policymaking, suggesting ways for Governments, non-governmental
organizations, and other actors to reorient the ways in which their societies perceive, interact
with and care for their older citizens.

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Priority 1 – Older persons and development

- Active participation in society and development
- Recognition of the social, cultural, economic and political contribution of older people
- Participation of older persons in decision-making process at all levels
- Work and the ageing labor force, employment opportunities for all older persons who
want to work
- Improvement of living conditions and infrastructure in rural areas
- Access to knowledge, education and training
- Full utilization of the potential and expertise of persons of all ages, recognizing the
benefits of increased experience with age
- Intergenerational solidarity
- Sufficient minimum income for all age persons, paying particular attention to socially
and economically disadvantaged groups
Priority 2 – Advancing health and well-being into old age

- Health promotion and well-being throughout life
- Reduction of cumulative effects of factors that increase the risk of disease and
consequently potential dependence in older age
- Development of policies to prevent ill-health among older persons
- Access to food and adequate nutrition for all older persons
- Universal and equal access to health-care services
- Development and strengthening of primary health care services to meet the needs of
older persons and promote their inclusion in the process
- Development of continuum of health care to meet the needs of older persons
- Training of care providers and health professionals
- Mental health needs of older persons
- Older persons and disabilities
Priority 3 – Ensuring enabling and supportive environments

- Housing and the living environment
- Improved availability of accessible and affordable transportation for older people
- Care and support for caregivers
- Images of ageing, enhancement of public recognition of the authority, wisdom,
productivity and other important contributions of older people
ACTIVE AGING.
Active aging is the process of optimizing opportunities for health, participation and security
in order to enhance quality of life as people age.
Active ageing allows people to realize their potential for physical, social, and mental well-
being throughout the life course and to participate in society, while providing them with
adequate protection, security and care when they need.

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GROUPS: FAMILY HEALTH. PROCESSES WITHIN FAMILIES
AND HEALTH EFFECTS. MACRO-LEVEL PROCESSES:
DEMOGRAPHIC, TECHNOLOGICAL, ECONOMIC AND
POLITICAL FACTORS. FUTURE CHALLENGES.

FAMILY HEALTH.
BASIC CONCEPTS
- Families are dynamic, heterogenous entities that vary by size and have different age,
gender and generational compositions.
- Families can affect health in a myriad of complex, indirect and potentially overlapping
pathways.
PROCESSES WITHIN FAMILIES AND HEALTH EFFECTS.

WITHIN-FAMILY (MICRO) PROCESSES.
- Resource distribution within the family and effect on health
o Direct resources for health
o Parents: investment in children and indirect effect on children’s health
o Authority relationships
o Gender roles
- Socialization
o Parents modeling behaviors (taste and habits)
o Culture impact
o Women’s time for paid work/childbearing/housework
o Women work more > divorce rate > poverty
o Reproductive behavior → fertility decisions, family planning
o Married have better health
- Social support
o Financial, social and emotional to the individual inside the family <> negative
effects of life circumstances (safety net)
o Human capital investment → improved health in long term
o Reciprocal obligations of individuals to families → kin obligations
- Reciprocal effects
o Health of the individual can affect the family
§ Draw resources
§ Unstable employment for the relatives-caregivers

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MACRO-LEVEL PROCESSES: DEMOGRAPHIC,

TECHNOLOGICAL, ECONOMIC AND POLITICAL FACTORS.
DEMOGRAPHIC FACTORS
- Fertility and mortality
o More children > less resources
o Benefit for the parents in later life – more caregivers
o Lower mortality > less children – fist demographic transition
- Divorce and non-marital childbearing

o Emotional, behavioral and academic problems
o Positive effects, if there was abuse in the marriage
o General impoverishment
o Multi-partner fertility – complex family structure
- Maternal age
o U-shaped association with infant health
o Low-income > younger maternal age > impact on education
- Decoupling of sex and marriage – multiple relations and risk of STD (sexually-
transmitted diseases)
- Middle generation squeeze – support for young (longer education) and old
generations (ageing)
TECHNOLOGICAL FACTORS
- Contraception – development and availability
- Neonatal care – increased survival of (underdeveloped) infants BUT increased costs

for healthcare systems and families
- Assisted reproduction
o Ageing parent population
o Multiple births and health risks
- Prenatal care
o Selective abortions for genetic diseases of preferred sex > clear health
advantages BUT ethical problems

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ECONOMIC AND POLITICAL FACTORS

- Female labor force participation
o More caregivers for children
o Institutions for children care
o Higher income vs. unclear health effects (children cognitive development?)
- Abortion laws
- Gay marriage and civil unions

o No much empirical studies on health effects
FUTURE CHALLENGES.
Smaller
21-
Diverse century Older
families
Complex
- Legal – redefining family and parental rights

- Social policy – economic and social support for single mothers
- Retirement system – adaptation to ageing
o Increased contribution into pension system
o Reduction of pension payments
o Delay in retirement
- End-of-life decisions – whose right and responsibility?

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TOPIC 36. NEEDS ASSESSMENT. HEALTH INEQUALITIES.

IMPACT OF SEX AND GENDER ON SPECIFIC HEALTH
PROBLEMS. GENDER AND THE DELIVERY OF HEALTH CARE.
SOCIO-ECONOMIC INEQUALITIES. REDUCING HEALTH
INEQUALITIES.
HEALTH INEQUALITIES.
HEALTH INEQUALITIES → avoidable inequalities in health between groups of people
within countries and between countries.
Arise from inequalities within and between societies.
What causes health inequalities?

“The social determinants of health are mostly responsible for health inequities – the unfair
and avoidable differences in health status seen within and between countries. The structural
roots of health inequities lie within education, taxation, labor and housing markets, urban
planning, government regulation, health care systems, all of which are powerful determinants
of health, and ones over which individuals have little or no direct personal control but can
only be altered through social and economic policies and political processes.”
Determinants of health

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Health and lifestyle issues (poor eating habits and obesity)

It is generally recognized that Western lifestyle is bad for health.
- The number of overweight children is a growing phenomenon in the Western World.
- Often, opposition from the food industry where a large % of profits can be made from
junk food profits.
- Fat seems also to be a class issue.
- Proposals to stop children eating junk food.
What is the role of health care?

Public Health Agency of Canada: “there is mounting evidence that the contribution of
medicine and health care is quite limited, and that spending more on health care will not result
in significant further improvements in population health. On the other hand, there are strong
and growing indications that other factors such as living and working conditions are crucially
important for a healthy population.”
Theories for health inequality

- Poverty
- Culture and behavior
- Biological response to stress
- Life-course effects starting from early years
- Social stratification and discrimination
Types
- By gender - By social class
- By place of living - By race or ethnic group
The common denominator of all these factors is that they all link to POVERTY!
How could a neighborhood affect health?

- Safe places to exercise
- Access to healthy food
- Exposure to targeted advertising of harmful substances
- Social networks & support
- Norms, role models, peer pressure
- Fear, anxiety, stress, despair
- Violence and fear
- Quality of schools

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ETHNIC HEALTH INEQUALITIES.

There is a variation in health amongst various racial groups (for example, Asians are more
prone to heart disease and Caribbeans have a higher incidence of mental problems)
However, one of the main reasons of ill-health inequalities amongst ethnic communities
seems to arise from racism and discrimination.
- Poor “life chances” often leads to poor educational, employment and housing
opportunities.
- This leads to POVERTY and increased chances of illness and disease.
GENDER INEQUALITIES.
The gender you belong to can also be a contributory factor to the amount of health you enjoy.
Due to 3 main factors:
- Biological – women’s role in reproduction can cause ill-health
- Material – women are still seen as “carers” – commitments often force them to take
low paid/part time jobs → can lead to POVERTY and ill-health
- Ageing – women live longer more prone to ill-health connected to old age.
o Women tend to live longer than men, but they suffer from more illness during
their lives
INEQUALITIES IN SOCIAL CLASS.

Black report (1980) concluded that while the health of the nation as a whole had improved,
inequalities in health had not been eliminated.
In fact, Black stated that the “Health Gap” between higher and lower social classes was
widening.
He claimed that this was as a result of differences in social and economic conditions.
He said that people from lower social classes tend to drink and smoke more, exercise less
and have poorer diets than those in higher social classes.
These poor habits can be traced back to POVERTY.
How could income effect health?

- Income directly shapes
o Nutrition & physical activity options
o Housing quality
o Neighborhood conditions
o Social networks & support

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o Stress due to inadequate resources to face daily challenges

o Medical care
- Parent’s income shapes the next generations

o Education, which shapes:
§ Working conditions
§ Physical conditions
§ Psychosocial conditions
§ Income
Children raised in poverty

- Have lower levels of education attainment
o More likely to score lower on standardized tests, be held back a grade, drop out
of high school
o Less likely to get a college degree
o Attend schools with fewer resources
o Suffer from poor nutrition, chronic stress, and other health problems that
interfere with their school work
o Change residences and schools frequently as their families struggle to find
affordable housing
- Have lower earnings and are more likely to live in poverty as adults
WHY HEALTH INEQUALITIES ARE IMPORTANT?

- For health policy on national and regional level.
- Measurement of country’s development – solidarity inside the country and in the EU.
- Forming attitude towards the vulnerable groups.
HOW WE MEASURE HEALTH INEQUALITY?

Comparison of health indicators:
- Life expectancy
- HALE
- Standardized death rates
- Specific death rates by cause of death
- Infant mortality
- Proportion of low birth weight – highly sensible indicator to social factors and
environmental changes

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WHERE DO WE MEASURE HEALTH INEQUALITIES?

- Between countries (high, middle, low-income)
- Between regions
- Inside the country – between groups differing in income, education, ethnicity and other
factors
- Most vulnerable groups (e.g. people with disabilities)
SOCIAL GRADIENT
SOCIAL GRADIENT → the lower and individual’s socioeconomic position, the worse their
health. Where people are in the social hierarchy affects the conditions in which they grow,
learn, live, work and age, their vulnerability to ill health and the consequences of ill health.
GRADIENT ALSO IN: ILLNESS LEVELS AND DETERMINANTS OF HEALTH
ILLNESS LEVELS DETERMINANTS OF HEALTH

Hospitalization for mental illness among 37% of women with medical cards smoke
unskilled workers is 6x higher than for during pregnancy vs. 12% mothers without
skilled
The average suicide rate in economically 27% of babies born to unemployed mothers
deprived areas is 2x that of non-deprived were breastfed vs. 67% of babies born to
areas in N. Ireland higher professional women
Children in first year of life have more ear, Cervical screening uptake >60% in most
chest and GIT infections (Dundee study) affluent EDs, <40% in least affluent EDs in
Limerick
NOT ASKED IN THE EXAM‼
WHAT CAN BE DONE? → THREE APROACHES

Taking into account the complexities around health inequalities, academics suggest three
interlinked approaches which all need to be addressed but will require different aims and
actions:
- Targeting worst off
o Examples of actions: employability, services for vulnerable children…

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- Closing the gap

o Examples of actions: increase minimum wage, re-allocation of resources from
affluent to poor areas…
- Reducing the gradient → reducing systematic inequalities for income, gender,

ethnicity, disability…
o For example: improve access and opportunities, inequalities sensitive
practices…
WHAT CAN BE DONE? → EARLY LIFE IS KEY TO THE FUTURE

- Healthy early years development is the foundation for later school achievement,
economic productivity, responsible citizenship and successful parenting
- Very early life is crucial but different skills mastered at different stages are equally
important
- Interventions important at all stages

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APPROACHES TO SOLVING HEALTH INEQUALITIES.

Two major approaches to tackling inequalities in health:
- COLLECTIVIST APPROACH
o Based on the view that differences in health are beyond the ability of the
individual change
o The view is that differences in health are due to major economic and social
problems in society (e.g. poor housing stock, unemployment, inflation)
§ These problems impact on different people in different ways → but
poorer social classes suffer most
o Idea first found favor in the Black Report (1980) and Acheson Report (1998)
o Subscribers to this view feel that improvements will only come by concerted
government action centering on anti-poverty strategies
- INDIVIDUALIST APPROACH
o Based on the belief that health results of how individuals choose to lead their
lives
o There seems to be differences in health habits between different social classes
§ People of lower social class seem to: smoke and drink alcohol more
often, exercise less and have less healthy diets
o Idea is that people should be largely responsible for monitoring own health
o Government action should center on high-profile health advertising
campaigns…
INTERVENTIONS
Whitehead (2005) suggests a typology of actions to reduce health inequalities:
- Strengthening individuals
- Strengthening communities
- Improving working and living conditions
- Promoting healthy macro-policies

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TOPIC 37. PREVENTION – SCOPE AND LEVELS OF

PREVENTION. PRIMORDIAL PREVENTION. PRIMARY
PREVENTION – POPULATION AND HIGH RISK STRATEGY.
PREVENTION
The goals of medicine are to promote health, to preserve health, to restore health when it is
impaired, and to minimize suffering and distress.
These goals are embodied in the word “PREVENTION”.
Actions aimed at eradicating, eliminating or minimizing the impact of disease and disability,
or if none of these are feasible, retarding the progress of the disease and disability.
The concept of prevention is best defined in the context of levels, traditionally called primary,
secondary and tertiary prevention. A fourth level, called primordial prevention, was later
added.
DETERMINANTS OF PREVENTION
Successful prevention depends upon:
- Knowledge of causation
- Dynamics of transmission
- Identification of risk factors and risk groups
- Availability of prophylactic or early detection and treatment measures
- An organization for applying these measures to appropriate persons or groups
- Continuous evaluation of and development of procedures applied
PREVENTABLE CAUSES OF DISEASE

BEINGS
- Biological factors and Behavioral factors
- Environmental factors
- Immunologic factors
- Nutritional factors
- Genetic factors
- Services, Social factors, and Spiritual factors

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SCOPE AND LEVELS OF PREVENTION.
PRIMORDIAL Before appearance of risk Total population

PREVENTION factors Selected groups
PRIMARY Total population
Risk factors
PREVENTION Selected groups
SECONDARY
Early stage of disease Patients
PREVENTION
TERTIARY Late stage of disease
Patients
PREVENTION (treatment, rehabilitation)
LEVEL OF
STAGE OF DISEASE TYPE OF RESPONSE
PREVENTION
Health promotion and
Pre-disease Primary prevention
Specific protection
Pre-symptomatic diagnosis
Latent disease Secondary prevention
and treatment
Disability limitation for
early symptomatic disease
Symptomatic disease Tertiary prevention
Rehabilitation for late
symptomatic disease

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PRIMORDIAL PREVENTION.
- Primordial prevention consists of actions and measures that inhibit the emergence of
risk factors in the form of environmental, economic, social, and behavioral conditions
and cultural patterns of living etc.
- Primordial prevention consists of actions to minimize future hazards to health.
o It addresses broad health determinants rather than preventing personal exposure
to risk factors, which is the goal of primary prevention.
- It is the prevention of the emergence or development of risk factors in countries or
population groups in which they have not yet appeared.
o For example, many adult health problems (e.g., obesity, hypertension) have
their early origins in childhood, because this is the time when lifestyles are
formed (for example, smoking, eating patterns, physical exercise).
- In primordial prevention, efforts are directed towards discouraging children from
adopting harmful lifestyles.
- The main intervention in primordial prevention is through individual and mass
education ≈ health promotion
PRIMARY PREVENTION – POPULATION AND HIGH RISK

STRATEGY.
- Primary prevention can be defined as the action taken prior to the onset of disease,
which removes the possibility that the disease will ever occur.
- It signifies intervention in the pre-pathogenesis phase of a disease or health problem.
- Primary prevention may be accomplished by measures of “Health promotion” and
“specific protection”.
- It includes the concept of “positive health”, a concept that encourages achievement
and maintenance of "an acceptable level of health that will enable every individual to
lead a socially and economically productive life".
- Primary prevention may be accomplished by measures designed to promote general
health and well-being, and quality of life of people or by specific protective measures.

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APPROACHES FOR PRIMARY PREVENTION

The WHO has recommended the following approaches for the primary prevention of chronic
diseases where the risk factors are established:
- POPULATION (MASS) STRATEGY
- HIGH-RISK STRATEGY
Population (mass) strategy

“Population strategy” is directed at the whole population irrespective of individual risk levels.
- For example, studies have shown that even a small reduction in the average blood
pressure or serum cholesterol of a population would produce a large reduction in the
incidence of cardiovascular disease
The population approach is directed towards socio-economic, behavioral and lifestyle
changes
High-risk strategy
The high-risk strategy aims to bring preventive care to individuals at special risk.
This requires detection of individuals at high risk by the optimum use of clinical methods.

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TOPIC 38. SECONDARY PREVENTION – SCREENING.

CRITERIA FOR SCREENING. SENSITIVITY, SPECIFICITY AND
PREDICTIVE VALUES OF SCREENING TEST. SCREENING
PROGRAMS.
SECONDARY PREVENTION.
SECONDARY PREVENTION → It is defined as “action which halts the progress of a

disease at its incipient stage and prevents complications”.
- The specific interventions are:
o Early diagnosis (screening tests, case finding programs…)
o Adequate treatment
Secondary prevention attempts to arrest the disease process, restore health by seeking out
unrecognized disease and treating it before irreversible pathological changes take place,
and reverse communicability of infectious diseases.
- It thus protects others from in the community from acquiring the infection and thus
provide at once secondary prevention for the infected ones and primary prevention for
their potential contacts.
SCREENING.
SCREENING → Process in which we use a test to determine whether an individual likely has
a particular health indicator or not or is likely to develop a particular health indicator or not.
- Screening is not the same as diagnosis:
o Screening tests give us information about whether the disease is likely to be
present.
A screening test assesses the presence of an underlying marker that is associated with
outcome of interest.
EXAMPLES:
- Women receive regular screening tests beginning in young adulthood for cervical
cancer (Pap smear)
- Physicians assess blood pressure and cholesterol as screening tools for the
development of cardiovascular disease

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CRITERIA FOR SCREENING.

We screen for disease when we have the opportunity to reduce costs and risk associated with
diagnosis on large proportions of at-risk individuals.
1. We screen for health indicators that affect population health principally, not for rare
diseases (although there are exceptions for rare diseases screen in utero).
2. There should be sufficient time between biological onset of disease and appearance
of signs and symptoms of the disease exist so that screening could detect the presence
of the disease earlier than it would come to clinical attention.
3. There should be available treatment for the disease so that early detection improves
the lives of affected.
4. Screening tests should be cheaper and less invasive than best available diagnostic
tool.
SENSITIVITY, SPECIFICITY AND PREDICTIVE VALUES OF

SCREENING TEST.
SCREENING TEST EVALUATION

1. SENSITIVITY
2. SPECIFICITY
3. POSITIVE PREDICTIVE VALUE
4. NEGATIVE PREDICTIVE VALUE
SENSITIVITY AND SPECIFICITY

To assess the validity of a screening tool in establishing the presence of disease we compare
with a gold standard
- Sensitivity → Whether individuals with disease are correctly identified by the
screening test as having the disease.
- Specificity → Whether individuals without the disease are correctly identified by the
screening test as not having the disease.

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Sensitivity and specificity tradeoffs

- Test cut-off is very sensitive → all those who have the disease will be captured by the
test
- Test cut-off is very specific → individuals who do not have the disease will not be
screened positive
- High sensitivity/low specificity tests are common in practice

o I.e., we will not miss many individuals with disease but we also will screen
positive those who do not have disease
RAMIFICATIONS OF FALSE POSITIVES VS. FALSE NEGATIVES

Low rate of false negatives preferred
- Infectious diseases critical to maintain low rate of false negative
- When disease can be readily remediated if caught early but devastating if not
Low rate of false positives preferred

- When subsequent diagnostic test is invasive and expensive procedures
- Screening is done routinely on low burden diseases

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TOPIC 39. HEALTH PROMOTION – DEFINITION,

DEVELOPMENT OF THE CONCEPT AND PRACTICE OF
HEALTH PROMOTION, BASIC PRINCIPLES.
DEFINITIONS FOR HEALTH PROMOTION.

- It is the process of enabling people to increase control over and improve their
health (Ottawa H.P. Charter).
- It is a process which empowers families and communities to improve their quality of
life, and achieve and maintain health and wellness.
- It emphasizes not only prevention of disease but the promotion of positive good
health ≠ primordial prevention.
- It is a positive concept emphasizing personal, social, political and institutional
resources, as well as physical capacities.
- Health promotion is any combination of health, education, economic, political,
spiritual or organizational initiatives designed to bring about positive attitudinal,
behavioral, social or environmental changes conducive to improving
the health of populations.

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- Health promotion is directed towards action on the determinants or causes of health.

- Health promotion, therefore, requires a close co-operation of sectors beyond health
services, reflecting the diversity of conditions which influence health.
- Government at both local and national levels has a unique responsibility to act
appropriately and in a timely way to ensure that the ‘total’ environment, which is
beyond the control of individuals and groups, is conducive to health.
Tannahill’s model of health promotion:
- Health protection → legal or fiscal controls, other regulations or policies, or voluntary

codes of practice aimed at the prevention of ill-health or the positive enhancement of
well-being.
DEVELOPMENT OF THE CONCEPT.

- “Any combination of health education and related organizational, economic and
political interventions designed to facilitate behavioral and environmental changes
conducive to health”. (Green LW 1979)
- “Health promotion is the science and art of helping people change their lifestyle to
move toward a state of optimal health. Optimal health is defined as a balance of
physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be
facilitated through a combination of efforts to enhance awareness, change behavior

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and create environments that support good health practices. Of the three, supportive
environments will probably have the greatest impact in producing lasting
change”. (American Journal of Health Promotion, 1989,3,3,5)
- Process enabling individually and collectivelly increase control over determinants

of their health, and improve health status. (WHO, 1998)
- It does not mean only responsibility of the health care system, but also individual
responsibility for health expressed via life style. (Kebza, 2005)
PRACTICE OF HEALTH PROMOTION, BASIC PRINCIPLES.

OTTAWA CHARTER (1986)
- Health promotion should be a part of public policy, documents and measures.
- Health promotion should be a part of a community policy and practice.
- Environment should enable and promote health.
- People should be able to gain information, knowledge and skills enabling development
of health.
- Health services should be more oriented on health promotion and support.
IMPORTANT AREAS FOR CONSIDERATION IN HEALTH PROMOTION

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A FRAMEWORK FOR HEALTH PROMOTION
WHO IS RESPONSIBLE FOR HEALTH PROMOTION.

- Individuals
o What role do individuals play in health promotion?

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- Communities (community groups and schools)

o They are important settings for health promotion, after all these are the places
where we live, work and play.
o Communities should be able to contribute to discussion and participate in the
setting of health policies.
- Non-government organizations
o Many organizations such as universities conduct health research into the

prevention, detection, and treatment of disease. While other NGO’s contribute
in various ways, including raising funds for research, running educational and
health promotion programs, providing support services and coordinating
voluntary care.
- Government
- International organizations

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TOPIC 40. HEALTH EDUCATION – DEFINITION, OBJECTIVES,

CONTENT, PRINCIPLES. COMMUNICATION IN HEALTH
EDUCATION. PRACTICE OF HEALTH EDUCATION.
HEALTH EDUCATION – DEFINITION, OBJECTIVES, CONTENT,

PRINCIPLES.
HEALTH EDUCATION → Communication process that determines knowledge, believes,

behavior, related to the promotion or restauration of health.
OBJECTIVES
- Motivating people to adopt health-promoting behaviors by providing appropriate
knowledge and helping to develop positive attitude.
- Helping people to make decisions about their health and acquire the necessary
confidence and skills to put their decisions into practice.
CONTENT
Health education combines the science of medicine with the principles and practice of
education.
It aims at change of behavior. Therefore, multidisciplinary approach is necessary for
understanding of human behavior as well as for effective teaching process.
PRINCIPLES
Certain principles have to be followed in the establishment and implementation of health
education programs and the development of health educational materials:
1. Interest
2. Participation
3. Known to unknown
4. Comprehension
5. Reinforcement
6. Motivation
7. Scientific precision and credibility
8. Attractive way of presentation
9. Good relation to the audience

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COMMUNICATION IN HEALTH EDUCATION.

METHODS OF HEALTH EDUCATION
TRADITIONAL METHODS
1. Oral methods
o Health talks
o Lectures
o Group discussion
o Demonstration
o Role play
2. Written methods
o Printed methods
o Visual materials
o Audio and audio-visual materials
MODERN METHODS
1. Social learning → observation of healthy life-style of famous people.
2. Diffusion of innovation → to apply it we work with leaders to teach small

communities.
3. Social immunization → useful during the childhood (teach children in favor of

healthy life-styles).
4. Mass-media → using advanced technologies.
PRACTICE OF HEALTH EDUCATION.

MODELS OF HEALTH EDUCATION
1. BEHAVIOURAL CHANGE MODEL
o The goal is to change people’s lifestyle and to make them responsible of their
own health.
2. SELF EMPOWERMENT MODEL

o The goal is to teach people how can they control their own health-states.
3. COLLECTIVE ACTION MODEL

o The goal is to improve community structures, and to make people be aware of
public/community health.

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SOCIAL MEDICINE - NOTES

Social Medicine (Medical University-Pleven)

StuDocu is not sponsored or endorsed by any college or university

Cristina Ribera Soler

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TOPIC1. SOCIAL MEDICINE AS A SCIENCE. SUBJECT

SOCIAL MEDICINE AS A SCIENCE.

THE DISCIPLINES OF SOCIOLOGY, DEMOGRAPHY,

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- Social physiology – the way the society functions as an organized unit

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DESCRIPTIVE AND PRESCRIPTIVE PARTS OF SOCIAL

METHODS OF SOCIAL MEDICINE.

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- Abu Ali Ibn-Sina (980 – 1037)

- Bernardino Ramazzini (1633 – 1714)

- Rudolf Virchow (“Die Medicinische Reform, 1848)

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§ In 1903, Alfred Grotjan began publishing a magazine on social hygiene.

THE EDUCATION IN SOCIAL MEDICINE.

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- Contribute to health systems’ performance as a member of the health team in the

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TOPIC 2. THE CONCEPT OF HEALTH AND DISEASE.

THE CONCEPT OF HEALTH AND DISEASE.

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HEALTH AS A RELATIVE CONCEPT.

NEW PHYLOSOFPHY OF HEALTH.

In medico-social researches, at health estimation, it is accepted to point out four levels:

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CONCEPT OF PUBLIC HEALTH

- Alan Gregg: “Maladjustment of the human organism to the environment”.

- Susser: “A physiological dysfunction”.

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FACTORS INFLUENCING HEALTH.

FACTORS OF COMMUNITY HEALTH FACTORS OF INDIVIDUAL HEALTH

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TOPIC 3. SOCIOLOGICAL APPROACHES IN SOCIAL MEDICINE

SOCIOLOGICAL APPROACHES IN SOCIAL MEDICINE –

SOCIOLOGY AS APPLIED TO MEDICINE AND HEALTH CARE SYSTEM

Important field of study because:

Sociologists use the following methods:

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QUESTIONNAIRE DESIGN – QUESTIONS AND

SURVEY RESEARCH → Method in which subjects respond to a series of statements or

DESIGN THE QUESTIONNAIRE

The major decisions in questionnaire design:

1. CONTENT – Questions must meet 5 requirements

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2. WORDING – How should the questions be asked?

Open ended questions

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o Leading questions – that suggest or imply certain answers

o Loaded questions – suggest social desirability, or are emotionally charged

o Ambiguity and vagueness:

o Double-barreled questions → Questions that refer to two or more issues

o Making implicit assumptions

o Burdensome questions → that may tax the respondent’s memory

o Using double negatives

o Embarrassing, sensitive, or threatening questions:

3. SEQUENCE → Question sequence & Layout decisions

Basic – Difficult and complicated questions

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