COMMUNITY & PUBLIC HEALTH • Health status of a community is associated with

a number of factors such as health care access,

Community, defined (based on attributes)
economic conditions, social and environment
• A collection of people who interact with one issues as well as cultural practices.
another and whose common interests or
• OLOF (individuals, families, communities)
characteristics form the basis for a sense of
unity or belonging (Allender, 2009)

• Group of people who share something in

common and interact with one another and
may share a geographic boundary (Clark, 2008)

• A locality-based entity, composed of systems of

formal organizations reflecting society’s
institutions, informal groups and
aggregates(Goeppinger, 2008)

• A group or collection of locality-based

individuals , interacting in social units and
sharing common interests, characteristics,
values, and/or goals (Famorca,et al.,2013)

Two main types

• Geopolitical – defined or formed by both

natural and manmade boundaries and include
barangays, municipalities/cities, provinces,
regions, nations; congressional districts and
neighborhoods

• Phenomenological – relational, interactive

groups, in which the place or setting is more
abstract, and people share a group perspective
or identity based on culture, values, interests,
goals. Also described as functional; Examples
are schools, churches, groups/organizations

• Rural, Urban, Suburban; Rurban

Other related terms

• Population – group of people having common

personal/environmental characteristics

• Aggregates – subgroups or subpopulations that Characteristics of a Healthy Community

have some common characteristics or concerns
(Clark, 2008) 1. Awareness that “we are a community”

Health is the goal of Public Health 2. Conservation of natural resources

• State of complete physical, mental, and social 3. Recognition of and respect for the existence of sub
well-being and not merely the absence of groups
disease or infirmity (WHO, 1958)
4. Participation of subgroups in community affairs
• The extent to which an individual or group is
5. Preparation to meet crises
able, on the one hand, to realize aspirations and
satisfy needs; and, on the other hand, to change 6. Ability to solve problems
or cope with the environment.
7. Resources available to all
Health is therefore seen as a resource for everyday life,
8. Communication through open channels
not the objective of living; it is a positive concept
emphasizing social and personal resources, and physical 9. Settling disputes through legitimate mechanisms
capacities (WHO, 1986
10. Participation by citizens in decision making
Community Health
11. Wellness of a high degree among its members
Public Health Assure competent public
health and personal
“ science and art of preventing disease, prolonging life, healthcare workforce
and promoting health and efficiency through organized Evaluate effectiveness,
community effort”(Winslow, 1920) accessibility and quality of
personal and population-
Refer to p.5, Intro to Public Health by Schneider
based health services
“fulfilling society’s interest in assuring cnditions in
which people can be healthy” (IOM,1988)`` SERVING ALL FUNCTIONS Research for new insights
and innovative solutions to
“dedicated to the common attainment of the highest health problems
level of physical, mental , and social well-beng and
longevity consistent with available knowledge and
resources at any given time and place (Hanlon,1984)
Five step process of PH approach to health problems
What is Public Health? in the community

Core Functions of Public Health Define the health problem

• Assessment
Identify the risk factors associated with the
• Policy Development problem.
• Assurance
Develop and test community-level interventions to
Focus of Public Health control or prevent the cause of the problem.

• Prevention Implement interventions to improve the health of

the population.
• Intervention
Monitor those interventions to assess their
effectiveness.

TEN ESSENTIAL PUBLIC

HEALTH SERVICES Elected Features of Public Health
CORE FUNCTIONS SERVICES
• Basis in social justice philosophy
ASSESSMENT Monitor health status to
identify community health • Inherently political nature
problems
• Dynamic, ever-expanding agenda
Diagnose and investigate
health problems and health • Grounding in the sciences
hazards in the community.
• Use of prevention as a prime strategy
POLICY DEVELOPMENT Inform, educate, and
• Uncommon culture and bond
empower people about
health issues. Philippine Healthcare Delivery System

Mobilize community
partnerships to identify
and solve health problems.

Develop policies and plans

that support individual and
community health efforts.

ASSURANCE Enforce laws and

regulations that protect
health and ensure safety.

Link people to needed

personal health services
and assure the provision of
health care when
otherwise unavailable.
National Objectives for Health
2016-2022
• “All for Health towards Health for All”
(Lahat Para sa Kalusugan! Tungo sa Kalusugan Para sa
Lahat)
Elicit multi-stakeholder support for health
• All Life Stages & Triple Burden of Disease
Advance health promotion, primary care and quality
Pregnant, newborn, infant, child, adolescents, adults
and elderly
• Communicable diseases; Non-
communicable including malnutrition;
disease of rapid urbanization and
Industrialization
Health Goals to attain SDGs
• Financial Risk Protection
– Filipinos, especially the poor are
protected from high cost of health care
• Better Health Outcomes
– Filipinos attain the best possible health
outcomes with no disparity
• Responsiveness
– Filipinos feel respected, valued, and
empowered in all of their interaction
with the health system
Cover all Filipinos against financial health risk
VALUES
• EQUITABLE & INCLUSIVE TO ALL
• TRANSPARENT & ACCOUNTABLE
• USES RESOURCES EFFICIENTLY
• PROVIDES HIGH QUALITY SERVICES
SDN..Services are delivered by networks that are
• FULLY FUNCTIONAL (Complete Equipment,
Medicines, Health Professional)
• COMPLIANT WITH CLINICAL PRACTICE
GUIDELINES
• AVAILABLE 24/7 & EVEN DURING DISASTERS
• PRACTICING GATEKEEPING
• LOCATED CLOSE TO THE PEOPLE (Mobile Clinic
or Subsidize Transportation Cost)
• ENHANCED BY TELEMEDICINE
Health Strategy:
ACHIEVE
• Advance health promotion, primary care and
quality
• Cover all Filipinos against financial health risk
• Harness the power of strategic HRH
• Invest in eHealth and data for decision making
• Enforce standards, accountability and
transparency
• Value clients and patients
• 1. Annual health visits for all poor families
• 2. PhilHealth to contract with functional
networks* of PCB providers and DOH provide
additional resources*
• 3. Transform selected DOH hospitals into multi-
specialty, end referral “mega-hospitals”, i.e.
teaching/training, reference laboratory
• 4. Enact/enforce measures to improve access to
lifesaving interventions and reduce exposure to
risk factors for premature deaths and disability
• 5. Establishing expert bodies for health
promotion (Public Health Philippines) and
surveillance and response (Philippine CDC)
– *District hospital paired up with 10+
RHUs or private clinics *HFEP,
deployment vaccines, medicines,
trainings
• .1. Mobilize more funds Sin Tax | PAGCOR,
PCSO | Increase Premium | Collection Efficiency
• 2. Enroll remaining 8% from non-formal sector
into PhilHealth
• 3. Expand PhilHealth benefits Outpatient
diagnostics, drugs, blood & blood products
• 4. Recalculate case rates & link payment to
quality
• 5. Improve contracting and enforce terms
Primary care trust fund | Network-based
contracting
• 1. Publish information that can trigger better
performance • Prices of common drugs and
services • Non-compliant / erring providers •
National Objectives for Health to guide
strategies and investments by different
stakeholders
• 2. Set up dedicated performance monitoring
unit • Ghost patients and/or surprise visits •
Medical audits or third-party monitoring
• 1. Publish information that can trigger better
performance • Prices of common drugs and
services • Non-compliant / erring providers •
National Objectives for Health to guide
 strategies and investments by different
stakeholders
• 2. Set up dedicated performance monitoring
unit • Ghost patients and/or surprise visits •
Medical audits or third-party monitoring
Harness the power of strategic HRH
• 1. Make health professions curricula responsive
to local and global needs
• 2. Review government HRH compensation
package such that ARMM, IP, GIDA will have
highest pay
• 3. Shift to competency versus profession-based
frontline complement
• 4. Provide scholarships, financial incentives
• 5. Institute return service schemes *clinicians
and allied health professionals, managers,
researchers and policymakers
Invest in eHealth and data for decision making
• 1. Require online data* submission as
requirement for licensing & contracting of
health facilities and drug outlets
• 2. Mandate the use of Electronic Medical
Records (EMR) in all health facilities
• 3. Invest in nation-wide surveys, administrative
data and disease registries
• 4. Automate major business processes
• 5. Facilitate open access to anonymized data
* clinical and administrative
Enforce standards, accountability and transparency
1. Publish information that can trigger better
performance
– Prices of common drugs and services
– Non-compliant / erring providers
– National Objectives for Health to guide
strategies and investments by different
stakeholders
2. Set up dedicated performance monitoring unit -
Ghost patients and/or surprise visits
- Medical audits or third-party monitoring
Value clients and patients especially the poor and
vulnerable
• 1. Focus all efforts on the poorest 20 million
Filipinos
• 2. Make all health entitlements simple and
explicit
• 3. Set up participation & redress mechanism 4.
Significantly reduce turnaround time and
improve transparency of processes
Elicit multi-sector, multi-stakeholder support for health
1. Harness and align Private Sector in planning SDN,
intervention, and supply side investments
2. Ensure convergence with other government
agencies in delivering services (DOH, DENR, DSWD,
DepEd)
– Advocate for Health in All Policies
– Multi-sectoral work with different
agencies to build healthy living,
working, schooling environments,
healthy cities, and Health in All Policies
– Mandate Health Impact Assessment for
large-scale, high-risk development
projects, e.g. mining, power plants, oil
rigs
3. Governance
- Budget Development
- Monitoring and Evaluation
Elicit multi-sector, multi-stakeholder support for health
1. Harness and align Private Sector in planning SDN,
intervention, and supply side investments
2. Ensure convergence with other government
agencies in delivering services (DOH, DENR, DSWD,
DepEd)
– Advocate for Health in All Policies
– Multi-sectoral work with different
agencies to build healthy living,
working, schooling environments,
healthy cities, and Health in All Policies
– Mandate Health Impact Assessment for
large-scale, high-risk development
projects, e.g. mining, power plants, oil
rigs
3. Governance
- Budget Development
- Monitoring and Evaluation
History of Public Health, US
Major Eras
• Prior to 1850 – Battling Epidemics
• 1850-1999 - Building State and Local
Infrastructure
• After 1999 - Preparing for and responding to
community health threats
WEEK 2: Models and Frameworks of Public Health

Understanding Influences of
Public Health

HEALTH FIELD CONCEPT

BIOLOGY

ENVIRONMENT

LIFESTYLE (HUMAN BEHAVIOR)

HEALTHCARE ORGANIZATIONS

OLOF
Law of Supply

Like the law of demand, the law of supply demonstrates

the quantities that will be sold at a certain price. But
unlike the law of demand, the supply relationship shows
an upward slope. This means that the higher the price,
the higher the quantity supplied. Producers supply
more at a higher price because selling a higher quantity
at a higher price increases revenue.

• Health Care Economics

– Law of Supply and Demand

– Managed Care Reimbursements

– Gatekeeping

Law of Demand When supply and demand are equal (i.e. when the
supply function and demand function intersect) the
• if all other factors remain equal, the higher the
economy is said to be at equilibrium. At this point, the
price of a good/SERVICE, the less people will
allocation of goods is at its most efficient because the
demand that good. In other words, the higher
amount of goods being supplied is exactly the same as
the price, the lower the quantity demanded.
the amount of goods being demanded.
• People will naturally avoid buying a product
Thus, everyone (individuals, firms, or countries) is
that will force them to forgo the consumption
satisfied with the current economic condition.
of something else they value more.
At the given price, suppliers are selling all the goods
• Demand curve is a downward slope.
that they have produced and consumers are getting all
the goods that they are demanding
 Disease Causation

• Miasmic theory – poor environmental

conditions (polluted water, improper human
waste/garbage disposal); unspecific

• Germ theory – specific microrganism found in

the environment which can be
isolated/identified from the affected host;
specific

• Epidemiological triad – disease occurs in the

presence of three iter-related factors: agent,
host, environment

HEALTHCARE ECONOMICS

Reimbursement in Managed Care

Epidemiological Disease Triad

Understanding Clients (Individual, Family and

Community)

• General Systems Theory

– Open system

– Client is considered as a set of

interacting elements that exchange
energy, matter or information with
external environment to exist

– Individual is a set of several dimensions

that are interdependent and
Drivers interrelated
• Consumer health economics – Family/group/aggregate are sets of
– More practitioners in urban centers interrelated individuals

– Philhealth Reimbursement and Healthcare Behavior

Capitation • Health Belief Model (Hockbaum; Rosenstock)
– HC is both capital and labor intensive – Behavior is a function of health beliefs
– Technology driven care – Influence of different variables on the
• Obsolescence individual’s health related behavior

• Innovation • Perceived Susceptibility, P

Severity, P Benefits, P Barriers;
– Healthcare behavior Cues to Actions and, Self-
efficacy

• Learning theories

– Behavioral: conditioning
 – Cognitive: perceptual thinking,
information processing; metacognition

– Social (Bandura) : behavior adopted

through imitation and modeling but
with cognitive awareness

Community Health Practice

• Primary Health Care

– Concepts and Principles

• Voluntary Community
cooperation/involvement

• MBN as a common social goal

(food, clothing, shelter,
environment, livelihood, health
education Health and Human Development

• PHC --- better quality of Life; as
a strategy differ from village to
village thus must be in
harmony with existing
institutions and daily life; as a
public service
• Services are Accessible,
Acceptable, Available and
Affordable;
Partnership/Linkages between
community and agencies (Gos
and NGOs); Community
Participation and Self reliance;
Social Mobilization;
Decentralization
– E-L-E-M-E-N-T-S
Community Health Practice
• Public health model –
• Ecological Models: Health, Human Development
and Community Ecosystem (evolving…)
• Integration of social sciences with
natural sciences
a) Mandala of Health (Hancock, Perkins and
Welsh, 1980s) major determinants of health as
bases for teaching
b) Model of Human Development (Hancock, 1989)
- 2 principles of PH for “socially sustainable
development”: ecological sanity and social
justice
- Economic activity must not only preserve the
environment but also preserve and enhance
the social system and strengthen the social
resources of a community
- c. Health and Community Ecosytem (Hancock,
1993)

– use of epidemiological concepts but - d. Human Ecosystem model (Hancock, 2000)

with little attention on analyzing social
Community Planning and Development
conditions
• Precede-Proceed Model (Green and Kreuter)
• Health as a Multi-factorial Phenomenon
– HP focused systematic planning that
Disease Prevention
seeks to empower individuals with
• Health Promotion Model (Pender,1996) knowledge, motivation, skills and active
community participation . Copar
– Biopsychosocial influences of health
behavior

• Individual Characteristics and

Experiences

• Behavior-specific cognitions
and affect

• Behavioral Outcome
Human Ecology, Demography and Epidemiology
Human Ecology
 Interrelationship of organisms and their
environments
 Totality of pattern of relations between
organisms (human beings) and their
environment
Environment
 Circumstances, objects or conditions by which
one is surrounded
 Complex of physical, chemical and biotic factors
(climate, soil, and living things) that act upon an
organism or an ecological community and
ultimately determine its form and survival
 Aggregate of social and cultural conditions that
influence the life of an individual or community
Human Demography
 Statistical study of human populations
especially with reference to its size and density
Epidemiology
 Deals with the incidence, distribution and
control of disease in a population
 The sum of the factors controlling the presence
or absence of a disease or pathogen
Historical background
 Hippocrates’ observation that environmental
factors influence the occurrence of disease
(2000 years back)
 John Snow studies (1848-1854)
 Richard Doll and Andrew Hill –relationship
between tobacco use and other possible factors
to lung cancer using long term cohort studies.
Scope and Importance
 Focus on population – one selected from
specific area or country at a specific time
 Tool for improving public health, backbone of
disease PREVENTION
Epidemiology
Uses (Morris)
 Study history of a health population and rise
and fall of diseases and changes in their
character
 Diagnose health of community and condition of
people to measure distribution of illness in
terms of incidence, prevalence, disability and
mortality, to set health problems in
perspectives and to identify groups needing
special attention.
 Study work of health services with a view of
improving them
 Estimate risk of disease, accidents, defects and
chances of avoiding them
 Identify syndromes by describing distribution
and association of clinical phenomena in
population
 Complete clinical picture of chronic diseases
and describe their natural history
 Search for causes of health and disease by
comparing experience of groups and clearly
defined by their composition, inheritance,
experience, behavior and environments
EPIDEMIOLOGY
 Deals with
◦ Distribution of disease/health status of
populations in terms of age, gender,
race, geography and time
◦ Causation of disease – explanations of
the patterns of causal factors
◦ Natural history of disease
◦ Evaluation of health interventions
Epidemiology and Surveillance
 Established in regional and some local health
agencies
 Mainly responsible for providing timely and
accurate information on diseases within a
locality
◦ Infectious diseases with outbreak
potential
◦ Assisting LGUs during outbreak
(control)
◦ Providing information package and
technical assistance
 Types of Surveillance
1. Public health – on-going systematic collection,
analysis , interpretation and dissemination of
health data
2. Surveillance system – information loops or
cycles involving healthcare providers, public
health agencies and the public;
- reporting of cases and feedback of
surveillance information
Epidemiological Studies
Classification
A. Approach to Observation
1. Prospective
Forward, vertical perspective; e.g. cohort study
Show cause and effect
Study certain groups over a period of time
2. Retrospective
past events, records of past epidemiological
investigation
Not show cause and effect
3. Cross-sectional
horizontal, e.g. Prevalence study
Show level of occurrence
4. Case control
Has positive and negative exposure to dse agents
Combination e.g. experimental, quasi-experimental
Diseases under Surveillance
A. Laboratory diagnosed – cholera, Hep A and
Hepa B, malaria, typhoid fever
B. Clinically diagnosed – dengue hemorrhagic
fever, diptheriae, measles, meningococcal dse,
neonatal tetanus, pertussis, rabies, leptospirosis
and poliomyelitis (acute flaccid paralysis)
B. Dses based on pattern of occurrence and distribution
1. Sporadic – intermittent occurrence of few
isolated and unrelated cases in a given locality;
e.g. rabies in the Phils.
2. Endemic – continuous occurrence throughout a
period of time of the usual number of cases in a
given locality; e.g. Schistosomiasis
3. Epidemic – unusually large number of cases in a
relatively short period of time
4. Pandemic – simultaneous occurrence of disease
epidemic in several countries; of international
perspective
Epidemiological triangle
Three (3) components
Agent,
Host,
Environment
Epidemiology Variables
 Time – epidemic period, year
 Persons – age, sex and occupation
 Place – urban/rural, socio-economic areas
Factors that contribute to epidemic occurrence:
1. Agent – new, changes in the number of living
organisms
2. Host – lower resistance during disasters; water
and milk supply; sewage disposal, changes in
eating habits
3. Environment – changes in physical environment
including temperature, humidity, rainfall which
directly or indirectly influence equilibrium of
the agent and host
Basic determinants and Health Problems
Health Profile
 Demographic data to determine the nature and
extent of public health problems-
Info on who are affected; whereabouts
◦ 62.8% rural in 1980 distributed among
13 regions including NCR
◦ Urban population grew from 37.2% in
1980 to 48.60% in 1990 and 54.1% in
1995
◦ 1/3 of the population can be found in
key cities including Cebu, Iloilo, CDO,
Davao, General Santos, NCR
◦ Areas proximal to these cities are also
urbanizing such as northern and
southern Luzon
◦ Morbidity and mortality data (adult,
infant and maternal forms
◦ Morbidity and mortality indicate the state of
health of a community and success or failure of
health interventions
◦ Age and sex distribution
◦ As reported by DOH, influenza,
pneumonia, diarrhea and bronchitis
remain the top 5 leading causes of
morbidity
◦ Malaria is re-emerging
◦ Infectious but preventable dses of
poverty and underdevelopment
Non-communicable (dses of the heart and malignant
neoplasms are on the rise)
VITAL STATISTICS
STATISTICS – systematic approach in obtaining,
organizing and analyzing numerical facts so that
conclusion may be drawn from them
  Births
 Marriages, divorce and separation
 Illnesses (reportable or under surveillance
 Deaths
Uses
 indices of community health status
 for planning, implementing, monitoring and
evaluation of public health programs/projects
Sources of data-
 Population census
 Registration of vital data
 Health surveys
 Studies and researches
Key terms and indices in Vital Statistics
Rate – relationship between a vital event and those
persons exposed to the occurrence of the vital event
within a given area and during a specified period of
time. Ex: prevalence rate
Ratio – relationship between two numerical qualities or
measures of events without taking particular
considerations to the place and time
Crude or general – refer to the total living population
presumed to be exposed to the risk of occurrence of an
event
Specific – relationship for specific class or population
group
Crude Birth Rate (CBR) - measurement of the natural
growth or increase of the population
Crude Death Rate (CDR) – measurement of mortality
from all causes which may result in a decrease in
population
Infant Mortality Rate (IMR) – a measure of the risk of
dying during the first year of life; good index of the
general condition of a community because it reflects
the changes in the environment and medical condition
of a community
Maternal Mortality Rate (MMR) – a measure of the risk
of dying from causes related to pregnancy, childbirth
and purpuerium; index of obstetrical care needed and
received by women in a community
Fetal Death Rate (FDR) – measures pregnancy wastage
or death of a product of conception occurring prior to
its complete expulsion, irrespective f duration of
pregnancy
Neonatal Death Rate (NDR) – measures risk of dying
during the first month of life; serves as an index of the
effects of prenatal care and obstetrical management of
the newborn
Specific Death Rate – describes more accurately the risk
of exposure of certain class/group of population to
particular diseases; render more comparable and thus
reveal the real problem of public health
Incidence Rate (IR) – measures the frequency of
occurrence of the phenomenon during a given period of
time
Prevalence Rate (PR) – measures the proportion of the
population which exhibits a particular disease at a
particular time; determined through a survey of the
population concerned
Attack Rate (AR) – more accurate measure of the risk of
exposure
Swaroop’s Index –proportion of deaths of people aged
50 years and up; estimate of chronic disease.
-The higher the Swaroop’s index of a population, the
greater the proportion of the deaths among those who
were able to reach the age of 50 years.
Proportionate Mortality (PM) – death ratios which
shows the numerical relationship between deaths of all
causes (or group of causes), age (or group of age) and
the total number of deaths from all causes in all ages
taken together
Case Fatality Ratio (CFR) – index of the killing power of
a disease; influenced by incomplete reporting or poor
morbidity data
Adjusted or Standardized Rate – done to render the rate
of 2 communities comparable; adjustment for the
differences in age, sex and other factors which influence
the vital events; employ these methods:
- by applying observed specific rates to standard
population
- by applying specific rate of std population to
corresponding classes or groups of the local population
Ways of presenting data
 Tabular
 Textual
 Graphical
line graph…. Trends over a period of time
bar graph…. Expresses quantity in terms of
rates or % of a particular observation
pie chart….. Shows the relative importance of
parts to the whole
Assignment:
Formulas; Process of Tabulations

 Formulas

 Parts of a table

 Grouping

◦ Number of groups

◦ Grouping by age

◦ Establishing class intervals; upper and

lower limits

◦ Cross classification

◦ Arrangement of tables