BLOCK CBP

SEMESTER I
1. Stadium Generale and Humaniora
2. Medical Communication
3. The Cell as Biochemical Machinery
4. Growth and Development Prenatal and
Postnatal
 SEMESTER II
1. Medical Professionalism
2. Community-Based Practice
3. Health System-Based Practice
4. Evidence-Based Medical Practice
5. Special Topic
6. Elective Study 1
 SEMESTER III
1. The Hematologic System and Disorders
and Clinical Oncology
2. Immune System and Disorders
 SEMESTER IV
1. The Musculoskeletal System and
Connective tissue Disorders
2. Neuroscience and Neurological Disorders
3. Behavior Change and Disorders
4. The Visual System and Disorders
 SEMESTER V
1. The Alimentary and Hepatobiliary System
and Disorders
2. The Endocrine System, Metabolism, and
Disorders
3. Clinical Nutrition and Disorders
4. Special Topic
5. Elective Study 2
 SEMESTER VI
1. The Respiratory System and Disorders
2. The Cardiovascular System and Disorders
3. The Urinary System and Disorders
4. The Reproductive System and Disorders
 SEMESTER VII
1. Medical Emergency
2. Special Topic: Travel Medicine
3. Elective Study 3
Tahun lalu dilakukan perdebatan di Stasiun TV
Swasta Nasional dalam acara Indonesia Lawyers
Club (ILC) yang membahas UU Pembatasan
Penggunaan Tembakau antara kelompok yang anti
dan yang pro

Hampir semua kelompok anti UU mengemukakan

alasan sbb: “Ah, tidak benar merokok ada
kaitannya dengan kanker paru-paru. Buktinya,
saya dan teman-teman saya adalah perokok berat,
dan sudah merokok selama 30 tahun, toh sampai
saat ini tetap sehat-sehat saja”.

Pertanyaan: sebagai calon dokter  apa komentar

Sdr. dengan mengacu pada prinsip-prinsip CBP
APPROCHES OF CBP
 Prevention (not curative)
 Community
(not individual)
 Determinants
Genetic Physical
Social, cultural Stage
Environment
Biological, economical of
Behavior dis-
Clinical
Health Services
Presym- stage ability
tomatic
Susceptible stage
(at risk)
Tertiary prev.
Secondary prev. • Disability
Primary prevention
• Early detection limitation
• Health promotion & prompt
• Rehabilitation
• Specific protection treatment
TATA TERTIB

1. Selama kuliah 
HP dimatikan (bukan silent)
2. Dalam pleno pagi  bila
terlambat > 10 menit (jam di
dinding ruang kuliah)
mahasiswa tidak
diperkenankan ikut kuliah
BLOCK CBP RULE/REGULATIONS

(Community-based Medical Practice)

1. HP harus dimatikan selama kuliah dan SGD

2. Study Guide dan semua references agar selalu
dibawa saat kuliah, SGD, individual learning
3. Kehadiran dan keaktifan saat SGD dinilai
(5% dari nilai ujian)  INGAT ABSEN
4. Kehadiran saat kuliah dan feedback dihitung
(bila lebih dari 25% tidak ikut)  tidak bisa ujian
5. Pada saat plenary  mahasiswa presentasi

6. Wakil mahasiswa yang presentasi harus dipilih

pada saat SGD dan bukan di ruang kuliah
7. Wakil mahasiswa yang presentasi harus bergilir
(tidak boleh sama pada setiap hari)
8. Sesaat sebelum plenary dimulai, wakil
masing-masing kelompok yang akan presentasi
langsung duduk didepan
9. Narasumber akan memberi feedback
pada presentasi mahasiswa
REFERENCES & MANUAL
• Study Guide & Annexes
• Reference 1-6
• Manual
Please refer to each day
session/module
CURRICULUM  STUDY GUIDE
17 MODULES

DAY 1, 2, 3: MODULE-1

LEARNING MATERIALS:
Reference 1 and 2 ,movie, video clip,
websites (it is advice to download materials from the websites
before the lecture)
Learning Outcomes:
a) Describe several determinants (models)
of diseases and death occurring in the
population
b) Explain the applications of
understanding diseases and death
determinants (models)
c) Identify the strengths and weaknesses of
diseases models
d) Draw figure of the natural history of a
certain disease
e) Explain the applications of the natural
history of a disease for prevention
f) Explain the severity of diseases in a
population and its implication to
prevention
g) Describe the level of disease prevention
based on determinants and natural
history
h) Explain the Ice Berg Phenomenom and
its implication in diseases prevention
LEARNING SCHEDULE
(time table)
• STUDY GUIDE PAGE 7 (CLASS B)
• 08.00-09.00: Introductory lecture
• 09.00-11.00: Independent learning
 Reference 1 & 2
 Learning tasks page 18-21

• 11.00-13.00: SGD
• 14.00-15.00: Student presentation & feedback
LEARNING SCHEDULE
(time table)
• STUDY GUIDE PAGE 11 (CLASS A)
• 09.00-10.00: Introductory lecture
• 10.00-12.00: Independent learning
 Reference 1 & 2
 Learning task-1 & 2 page 18-21

• 13.00-15.00: SGD
• 15.00-16.00: Student presentation & feedback
APPROCHES OF CBP
 Prevention (not curative)
 Community
(not individual)
“Some of the people need health care
some of the time
BUT
All of the people need public health all
of the time."

C. Everett Koop, MD
former U.S. Surgeon General
MODULE-1
• Determinants of morbidity
and mortality in a population
• Natural history of the
disease
• Diseases prevention
 DAY 1

• Determinants of
morbidity and mortality
in a population
Several models/concept used to
analyzed determinants of morbidity
and mortality in a population
 The Epidemiologic Triad/ Triangle
(Teori Segi Tiga)  page 26 – 33

 Wheel Model (Teori Roda)  page 35-39

 Web Model (Teori Sarang Laba-laba) page 33

 Model Blum
 Model Mosley
 Model Segitiga (The Epidemiologic Triad/
Triangle)
HOST (intrinsic)
(age, sex, genotype, behaviour,
nutritional status)

AGENT ENVIRONMENT
(biologic, physic, mechanical, (Physical, Biological, Social)
chemical, nutrient)
 HUMAN HOST
AGENT Age, race, sex, habit
Biological, chemical, physical Genetic, personality
Mechanical, Nutrient Defense mechanism

ENVIRONMENT
Biological, chemical, physical
Mechanical, nutrient, social, psychologic
Triad epidemiologik
 Homeostatic Balance
H A
A H

E E
The proportion of susceptibles
Agent becomes more pathogenic A H in population decreases

E
At equilibrium
H Steady rate A
A H
E E
Environmental changes that
Environmental changes that favor the host
favor the agent
Model Roda (Wheel Model)
INTERNAL
(intrinsic)

Social
Biological HOST • politic,
Environ- Genetic • economic
ment • culture

Physical Environment

EXTERNAL (extrinsic)
 Contoh
WEB MODEL Kasus Kematian
(SARANG Ibu
LABA-LABA)

Modifikasi dari: FA Moeloek, 2010

 BLUM MODEL
Genetic

Morbidity and
Behavior Health
mortality in
services
a population

Environmental factors
(biological, physical, social, economical, politic)
CONCEPT (THEORY, MODEL)
INTRODUCED BY
DR. MOSLEY WHICH EXPLAINED
DETERMINANTS OF MORBIDITY AND
MORTALITY OF CHILDREN AGE
UNDER 5 YEARS IN A POPULATION
 Socioeconomic determinants

Maternal Environmental Nutrient

Injury
factors Contamination deficiency

Healthy Sick

Prevention
Treatment
Personal
Illness Growth
control Mortality
faltering
SOCIAL DETERMINANTS OF HEALTH
WHO- CSDH conceptual framework
UNDERSTANDING
CAUSALITY
Four types of Causal relationships
1. Necessary and Sufficient
2. Necessary but not Sufficient
3. Sufficient but not Necessary
4. Neither Sufficient nor Necessary

Necessary = without that factor disease never develops

Sufficient = in the presence of that factor disease always
develops
1. Necessary and Sufficient

Direct:
Factor A Disease

Indirect:
Factor A Step1 Step2 Disease

 rarely happens
2. Necessary but not Sufficient

Factor A
+
Factor B Disease
+
Factor C

Multiple factors required: initiator & promoter

(cancer, TB)
3. Sufficient but not Necessary

Factor A
or
Factor B Disease
or
Factor C

Leukemia = Exposure to radiation OR benzene

4. Neither sufficient nor necessary
(contributory causes)

Factor A + Factor B
or
Factor C + Factor D Disease
or
Factor E + Factor F

Most accurately represents causal relationships in most

chronic diseases
END OF DAY 1
 Plenary day 1
• Please refer to the plenary day 1 slides
DAY 2
MODULE-1
• Determinants of morbidity
and mortality in a population
• Natural history of the
disease
• Diseases prevention
 DAY 2

• Natural history of the

disease
• Disease prevention
 Natural History of Disease
• Natural history of disease:
progression of disease in an
individual over time WITHOUT
any intervention.
NATURAL HISTORY OF THE
DISEASE
 Page 6-9  reference 2
 Four stages
 Stage of susceptibility (population at risk)
 Stage of pre symptomatic (asymptomatic)
disease
 Stage of clinical (symptomatic) disease
 Stage of disability

 Everydisease has difference natural

history (example: HIV/AIDS, DHF)
 Stage of susceptibility
(population at risk)
Determinants (risk factors) (+), disease (-)
• Tired
• High cholesterol, high sugar, low fiber
• Smoking
• Multiple partners with unprotected sex
• Sharing needle
• Low physical activity
 Stage of pre symptomatic
(asymptomatic) disease

Disease (+), signs (+/-) symptoms (-)

• Aterosclerotic
• Antibodi (+)
• Pre-cancer lesion
• Lab marker >>>
– Uric acid, fasting glucose, LDL >>, creatinin
>>
 Stage of clinical
(symptomatic) disease
Disease (+), signs and symptoms (+)
Anatomical & functional changes (+)
Grouping:
1. Symptoms
2. Functional class
3. Localisation
4. Morfologic/ cell type
5. Theraphy
Ex:
• Cancer stadium
• Hearth disease 
– Functional class
High relationship
– therapy

REASON OF THE GROUPING:

1. Therapeutic reason
2. Epidemiological reason (homogenity,
specific rate)
 Stage of disability

Disease outcome
1. Total recovery (treatment, self limited)
2. Partly recovery
3. Scuele (+); disability
1. Physical (anatomical)
2. Social
3. Phsycological
PREPATOGENESIS PATOGENESIS

Agen Host Fase klinis

Sembuh
Cacat
Lingkungan Fase penyembuhan Mati
Kronis

Fase susceptible Fase subklinis

Perjalanan Alamiah Penyakit 56

 Natural history of disease
TIME
Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation
period
Latent Infectious Non-infectious

Exposure Onset
NATURAL HISTORY (PERJALANAN
PENYAKIT)
Meninggal
Contoh: Symptomatic
hepatitis stage Khronis

Carrier
Sembuh
Asymptomatic dengan cacat
stage Sembuh
tanpa cacat
 Perjalanan infeksi HIV
1000
Viral Load
Jumlah CD4
Jumlah CD4

200
Infeksi Akut Infeksi asimtomatik Simptomatik/AI
Window period DS
Serokonversi

0
Bulan 0 1 2 3 4Tahun
5 1 2 3 4 5 6 7
Prevention can be done when
determinants and natural history of
the disease are understood
LEVEL OF PREVENTIONS  IN BROAD
CONCEPT
 Primary prevention
 Health promotion
 Behavior change education
 Policy/regulation
 Specific protection
(specific to a certain disease)
 Secondary prevention
 Early detection and
prompt treatment/action

 Tertiary prevention Prolonging

 Disability limitation life/increase
 Rehabilitation quality of life
 Medical
 Psychological
 Social
 Economical
 Using Blum Model/Concept
Genetic Physical
Social, cultural Stage
Environment
Biological, economical of
Behavior dis-
Clinical
Health Services
Presym- stage ability
tomatic
Susceptible stage
(at risk)
Tertiary prev.
Secondary prev. • Disability
Primary prevention
• Early detection limitation
• Health promotion & prompt
• Rehabilitation
• Specific protection treatment
Natural History of Disease and
Level of Prevention
Riwayat Alamiah Penyakit 64
 LIMA TINGKAT PENCEGAHAN
Riwayat Alamiah Setiap Penyakit
Interaksi Agen, Pejamu dan Lingkungan  Reaksi pejamu terhadap RANGSANGAN PENYAKIT ->
Faktor  RANGSANGAN PENYAKIT
Patogenesis  Kerusakan  Penyakit  Konvalesens
awal awal jaringan lanjut
Periode Prepatogenesis Periode Patogenesis

Promosi kesehatan

Pendidikan kesehatan Perlindungan khusus

Gizi yang cukup sesuai dengan
perkembangan
Perumahan, rekreasi dan tempat
kerja
Perkembangan kepribadian
Konseling perkawinan dan
pendidikan seks
Genetika
Pemeriksaan kesehatan secara
berkala
Imunisasi
Kebersihan perorangan
Sanitasi lingkungan
Perlindungan terhadap kecelakaan
akibat kerja
Perlindungan terhadap kecelakaan
Penggunaan gizi tertentu
Perlindungan terhadap zat yang
dapat menyebabkan kanker
Menghindarkan zat-zat allergen
Diagnosis dini dan pengobatan Rehabilitasi
segera
Penemuan kasus, individu dan masal Pembatasan ketidakmampuan Penyediaan fasilitas untuk pelatihan
hingga fungsi tubuh dapat
dimanfaatkan sebaik-baiknya
Skrining Pengobatan yang cukup untuk Pendidikan pada masyarakat dan
menghentikan proses penyakit dan industriawan agar menggunakan
Pemeriksaan khusus mencegah komplikasi mereka yang telah direhabilitasi
Tujuan: Penyediaan fasilitas untuk Penempatan secara selektif
Menyembuhkan dan mencegah membatasi ketidakmampuan dan
penyakit berlanjut mencegah kematian Mempekerjakan sepenuh mungkin
Mencegah penyebaran penyakit Terapi kerja di RS
menular
Penggunaan koloni yang terlindung
Mencegah komplikasi dan akibat
lanjutan

Memperpendek masa ketidakmampuan

Pencegahan primer Pencegahan sekunder Pencegahan tertier
Tingkat Penerapan Upaya Pencegahan
• ICE-BERG PHENOMENA
• SEVERITY OF DISEASES
 ICE BERG PHENOMENA
(FENOMENA GUNUNG ES)
 TWO CONSEQUENCIES
(DUA KONSKUENSI)
Semakin lebar dasar gunung es:
• Semakin sulit penanggulangan penyakit
(control of the disease)
• Bila memakai data sekunder, data
(statistik penyakit) akan semakin tidak
akurat
CONTOH: DBD dan RABIES
 Epidemiological Iceberg
• Only the tip of the iceberg is
easily observable
• Dog bite example
– 3.73 dog bites annually
– 451,000 medically
treated
– 334,000 emergency
room visits
– 13,360 hospitalizations
– 20 deaths
THE VARIATION OF SYMPTOMATIC
DISEASES SEVERITY
100 CASES

Mild (ringan) Moderate

Severe
Fatal
 The film presentation
showed to you
Contribution (peran) of: scientific
foundations, clinical skill, communication
skill, information management, critical
thinking, professional values and attitudes,
community health

Meneliti kausa suatu penyakit (AIDS)

dan pencegahannya
 DIFFERENCES BETWEEN
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

1. Focus: population 1. Focus: individual

2. Responsibilities: 2. Responsibilities:
all people in certain all people who come
geographical area, health and to the health facilities.
sick, those who come and They usually passive.
those who do not come to
health facilities. They must
actively provide diseases
prevention to all people who
are at risk
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

3. Function: to mobilize all 3. Function:

stakeholders and using to cure and to
management principles to increase the
plan, implement and
patient’s quality
evaluate primary,
secondary, tertiary of life
preventions
4. Place of works: health 4. Place of works:
centre, heath department, private practices,
community clinics, etc hospitals, etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

5. Diagnostic tools: 5. Diagnostic tools:

epidemiology, statistics, stethoscope, ECG, lab
demography examinations kits , CT
Scan, etc
6. Diseases 6. Diseases
measurements in the measurements for
community: individual patient: level
proportion, prevalence, of blood pressure, blood
incidence, ratio sugar, level of
hemoglobin, etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

7. Treatment at the 7. Treatment for

community level individual patient
(prevention): public (diagnosis and
health program such as care):
education program, medical
immunization program, treatments,
nutrition program, surgery,
family planning radiation,
program, etc physiotherapy,
etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

8. Indicators for 8. Indicators for

evaluating community evaluating the result
health program: percent of patient’s
treatments:
decrease of under
decrease of blood
nutrition, percent pressure of the
increase of contraceptive individual patient,
use for family planning, increase of
etc hemoglobin
“FIVE STARS DOCTOR”
(WHO = World Health Organization)
 Care provider (clinical dr)
 Communicator (clinical & PH dr)
 Manager (PH dr)
 Community leader (PH dr)
 Decision maker (clinical & PH dr)
 SOAL-SOAL
PEMANASAN
SEBELUM UJIAN
As shown in the film ”And The Band Played On”
which was presented to you, there were several
sciences involved in investigation the cause of AIDS.
Those sciences are:

A. Social, economic, politic, epidemiology, statistic,

virology, clinical medicine
B. Social, politic, epidemiology, statistic, virology,
clinical medicine, health education
C. Social, epidemiology, statistic, virology,
clinical medicine, health education
D. Clinical medicine, epidemiology, statistic, social, politic
E. Social science, epidemiology, statistic,
virology, clinical medicine
Dalam film dengan judul ”And The Band Played
On” yang telah Sdr. saksikan pada waktu
pertemuan pertama Blok Community-Based
Practice, ada beberapa metode yang dipergunakan
untuk mengungkapan penyebab AIDS, yaitu:

1. Contact tracing
2. Cohort
3. Case-control
4. Cross-sectional
Bila dilihat dari waktunya, urutan cabang
ilmu yang membantu mengungkapan
penyebab AIDS, yaitu:

A. Paling awal virologi, lalu epidemiologi dan terakhir ilmu klinik

B. Paling awal ilmu klinik, lalu virologi dan terakhir epidemiologi
C. Paling awal ilmu klinik, epidemiologi/statistik/ilmu sosial, lalu
virologi
D. Paling awal virologi, statistik/epidemiologi lalu ilmu klinik
E. Paling awal statistik/epidemiologi, ilmu klinik lalu virologi
Pada Gambar-1 berikut ini adalah kompetensi
(kemampuan) yang harus dikuasai oleh seorang
dokter. Kompetensi untuk memahami statistik
kasus-kasus AIDS dalam film dengan judul
”And The Band Played On” termasuk:

1. Scientific foundations
2. Information management
3. Professional values
4. Population health
 Clinical
skill

Critical Information
Community thinking management Scientific
Health (Pu- foundations
blic Health)
Communication
skill

CBP
Professional,
values,
attitudes
Salah seorang mahasiswa (inisial “X”) yang kuliah di
fakultas non-kesehatan mengatakan sebagai berikut:
“Ah, tidak benar merokok ada kaitannya dengan
kanker paru-paru. Buktinya, paman saya adalah
perokok berat, dan sudah merokok selama 30 tahun,
toh sampai saat ini dia sehat-sehat saja”.

Pertanyaan: berikan komentar Sdr. terhadap

pernyataan mahasiswa “X” seperti pada soal di
atas (dengan mengacu pada prinsip-prinsip
epidemiologi).
Dalam suatu program interaktif yang
membahas topik wabah HIV/AIDS di sebuah
stasiun radio di Bali, banyak pendengar
dengan berapi-api mengatakan melalui
telepon sebagai berikut:

“Lho, kenapa pelacur yang sudah jelas-jelas

dijumpai HIV+ tidak dikarantina. Mereka ..kan
dengan bebas masih menularkan HIV-nya pada
orang lain. Kenapa pada saat terjadi wabah
SARS, yang dicurigai saja sudah langsung
diisolasi?”
Anggota DPRD Provinsi Bali tahun lalu mengatakan
sebagai berikut: “Kami sudah mengalokasikan
dana APBD yang cukup besar untuk
penanggulangan HIV/AIDS di Bali. Kenapa jumlah
orang yang HIV+/AIDS kok terus bertambah
banyak. Harusnya kan berkurang. Kalau begitu
percuma dana yang kami alokasikan tersebut”.

PERTANYAAN: Seandainya Sdr. menjadi petugas

kesehatan, bagaimana Sdr. menjawab pernyataan
anggota DPRD tersebut
Pertanyaan pendengar dalam
program interaktif di sebuah
stasiun radio di Bali

Tempat tidur pasien demam berdarah

yang dirawat di rumah sakit kok tidak
pakai kelambu? Kalau pasien digigit
nyamuk Aedes kan bisa menularkan
penyakitnya kepada petugas di RS atau
kepada pasien lain?