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Unit I: Concept of Health and
Disease
Presented By: Sirjana Tiwari
School of Health and Allied Sciences
Pokhara University
Unit I: Concept of Health and Disease
( 18 hours)
 Concept of health and disease (concept and definition of health, wellbeing, illness,
sickness and disease; philosophy of health; concept and definition of disease; changing
concepts of health; dimensions of health; spectrum of health; iceberg phenomenon of
disease; responsibility for health: Individual, community, state and international)
 Concept of causation (germ theory of disease; epidemiological triad; multi-factorial
causation; web of causation; natural history of disease: pre-pathogenesis and
pathogenesis phase)
 Determinants of health
 Prevention, its levels in line with phases of disease concurrent to natural history
 Concept of modes of intervention in different levels of prevention
 Burden of disease (concept of burden of disease; measurements used in burden of
 disease: DALY, QALY, YLL, YLD)
 Indicators of Health (Concept and characteristics of health indicator; Different types of
mortality and morbidity indicators: mortality Indicators-crude death rate; age-specific
death rate; infant mortality rate; maternal mortality rate and ratio; Morbidity indicators:
incidence and prevalence)
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Definition of Health
Traditionally health has been considered as an
absence of the diseases and if someone was free
from disease, then that person was considered
healthy.
Health is a state of complete physical, mental and
social wellbeing and not merely an absence of
disease or infirmity.” “the ability to conduct
socially and economically productive life.” (WHO)
Definition of Health from different
perspectives
Theoretical perspectives
Biomedical model
Social model
Bio-psychosocial model
Holistic model
Layman perspectives
Cultural perspectives
Understanding across the life span
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 Medical model:
 Absence of disease or abnomility
 Basis of germ theory of disease
 Health is derieved from biology- biological
factors
 Social model:
 Health is influenced by different factors as
political, economic, social, psychological,
cultural, environmental.
 Causes of ill health are attributed to factors
outside the human body-the wider structural
causes such as inequality, poverty as well as
social interaction and behavior.
Theoretical perspectives
Medical model Vs Social model
Medical model
 Narrow concept
 Doesn’t take into
account outer
influences on health
 Influenced by
scientific and expert
knowledge
 Emphasize on
personal and
individual
responsibility on
health
Social model
 Broader concept
 Takes into account
outer influences on
health
 Takes into account
layman knowledge and
understanding
 Emphasize collective
and social
responsibility on health
 Integrated approach- biological, psychological and
social factors influence health
 Sound mind in sound body, sound family in sound
environment
 Strength: Spiritual health into consideration
 Criticism: It is more individualistic and doesn’t
take wider social factors into account
Holistic model:
 Takes into account biological, psychological
and social factors and their interaction
Biopsychosocial model
The findings of a major UK study in which people
were asked what it was like to be healthy. The
five categories of responses were as follows:
Health as not- ill
Health as physical fitness, vitality
Health as social relationships
Health as function
Health as psychosocial well- being
- (1990 in Blaxter, 2004)
Layman perspective
 The younger children (aged 5 –11 years) defined
health in terms of diet, exercise and rest, hygiene and
dental hygiene
 The older children (over the age of 12 years)
included things like smoking and drinking behaviors,
having
a healthy mind, feeling happy and confident and self-
acceptance.
 Interestingly the older children also linked looking
good, being happy and feeling confident with being
healthy.
Chapman et al. (2000)
Young people perspective
 Blaxter’s (1990) Health and Lifestyles study
found that older people tended to define health
more in terms of being able to function and do
things or care for themselves.
 being 'independent’ is strongly linked to ideas
about being healthy (Lloyd, 2000).
Older people perspective
Proposed Definition of
Health : WHO
12/13/2021 12
https://www.ncbi.nlm.nih.gov/pmc/article
s
Physical Health
 It means adequate body weight,
height and circumference as per age
and sex with acceptable level of
 “ vision, hearing, movements,
acceptable levels of pulse rate, blood
pressure, respiratory rate, chest
circumference, head circumference,
waist hip ratio”.
 The body structure and functions
confirming to laid down standards
within the range of normal
development and functions of all the
systems
 Mental health is defined “as a state of well
being in which the individual realized his or
her own abilities, can cope with normal
stresses of life, can work productively and
fruitfully and is able to make a contribution
to his or her community”.
Mental Health
 A mentally normal person has the ability to
mix up with others, he/she makes friendship,
behaves in a balanced manner, keeps himself
tidy and observes adequate personal hygiene,
well oriented to time, place and person and
environments and he is unduly not
suspicious of others.
 He is cheerful and happy and
enjoys life with a purpose and he thinks positively
and has normal development and contributes fully
and is useful and productive to society and nation.
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Spiritual Health
 Spiritual health is
achieved when you
feel at peace with
life. It is when you
are able to find hope
and comfort in even
the hardest of times
chronic disease.
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Definition of Public Health
 Sir Donald Acheson in 1988 defined it as
‘the science and art of preventing disease,
prolonging life, promoting, protecting and
improving health through the organized community
efforts’
 The field pays special attention to the social
context of disease and health, and focuses on
improving health through society-wide measures
like vaccinations, the fluoridation of drinking
water, or through policies such as seatbelt and
non-smoking laws.
Donald Acheson Report, 1988, UK
Leading Differences Between Basic,
Clinical and Public Health Activities And
Research
Characteristics Basic Clinical Public Health
Who/What
is studied
Cells, tissues,
animals
laboratory
Patient seeking for
health services
attendance
Populations or
communities
Activity or research
goal
Understand the
mechanisms of
disease and the
effects of toxic
substances
Improve the
diagnosis and
treatment of
disease
Prevention of
disease and health
promotion
Examples Toxicology,
inmunology
Pediatric and
clinical nursing
Epidemiology,
Environment
Sciences
CONCEPT OF WELLBEING
Standard of Living
 As per WHO, “Income and occupation, standards of
housing, sanitation and nutrition, the level of
provision of health, educational, recreational and
other service and collectively as an index of the
‘standard of living’.”
Level of Living
 As per United Nations documents “level of living”
consists of nine components: health, food
consumption, education, occupation and working
conditions, housing, social security, clothing,
recreation and leisure, and human rights.
Quality of Life
 Quality of life as defined by WHO, “The condition of
life resulting from combination of the effects of the
complete range of factors such as those
determining health, happiness , education, social
and intellectual attainments, freedom of action,
justice and freedom of expression.”
Physical Quality of Life Index
 It includes three indicators such as
Infant mortality
Life expectancy at age one
Literacy.
For each component, performance of individual
countries is placed on a scale of 0 to 100,
Human Developmental Index
It includes
longevity (life expectancy at birth)
knowledge (adult literacy rate)
income (real GDP per capita)
The HDI value ranges from 0 to 1.
What is Disease
 Disease is a disorder or malfunction of mind or
body, which leads to a departure from good
health can be a disorder of a specific tissue or
organ due to a single cause. E.g. malaria
 May have many causes often referred to as
multifactorial. E.g. heart disease
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Disease Illness and sickness
 An illness is a general term that people will use to
describe themselves when they do not feel well.
 They may or may not have been diagnosed by a
doctor.
 A disease is more specific and is determined by a
physician or health worker.
 The term sickness is usually applied if people miss
work or cannot function normally in society.
In general, "illness" is more general then "disease",
which in turn is more general than "sickness".
 Sickness is a generic term referring to a condition
you experience when do not feel well.
 Sickness may refer to being nauseated (e.g.
motion sickness) or just being unwell because
you are ill or tired.
 Illness is very similar to disease, in everyday
speech a disease is typically perceived as a
problem more serious or incurable (e.g. a genetic
disease).
 While an illness, on the other hand, is simply the
cause of a temporary state of ill health (e.g. the
flu).
.
• The concept of health as defined by WHO is
broad and positive in its implications; it sets
out the standard, the standard of “positive”
health.
• Health has evolved over the centuries as a
concept from an individual concern to a
worldwide social goal.
CHANGING CONCEPTS OF HEALTH
Biomedical Concept
 Health means “absence of disease.”
 It was felt that human body is a machine and
disease is an outcome of the breakdown of the
machine, and one of the doctor’s tasks was to
repair the machine.
 Developments in medical and social sciences led
to the conclusion that the biomedical concept of
health was inadequate.
CHANGING CONCEPTS OF HEALTH
Ecological Concept
Ecologists viewed health as a dynamic
equilibrium between man and his environment,
and disease ( a maladjustment of the human
organism to environment).
Psychosocial Concept
Advances in social sciences showed that
health is not only a biomedical phenomenon,
but one which is influenced by social,
psychological, cultural, economic and political
factors of the people concerned.
Thus health is both a biological and social
phenomenon.
Holistic concept recognizes the strength of social,
economic, political and environmental influences
on health.
It has been variously described as
multidimensional process involving the wellbeing
of the person as a whole
The emphasis is on the promotion and protection
of health.
Holistic Concept
Health
Health promotion
Health
protection
Holistic concept
DIMENSIONS OF HEALTH
 Health is multidimensional and are interrelated, each has its
own nature
Physical Dimension
 “Perfect functioning” of the body.
 It conceptualizes health biologically as a state in which
every cell and every organ are functioning at optimum
capacity and in perfect harmony with the rest of the body.
Mental Dimension
 Ability to respond to many varied experiences of life with
flexibility and a sense of purpose.
 Mental health has been defined as “a state of balance
between the individual and the surrounding world, a state of
harmony between oneself and others
Social Dimension
Harmony and integration with the individual,
between each individual and other members of
society, and between individuals and the world in
which they live.
“quantity and quality of an individual’s interpersonal
ties and the extent of involvement with the
community.”
Spiritual Dimension
Spiritual health refers to “something” that
transcends physiology and psychology.
Emotional Dimension
Relates to “feeling.” it reflects emotional aspects
of humanness.
Vocational Dimension
Work often plays a role in promoting both physical
and mental health.
Physical work is usually associated with an
improvement in physical capacity, while goal
achievement and self-realization in work are a
source of contentment and enhanced self-esteem.
Others
A few other dimensions have also been suggested
such as philosophical dimension, cultural
dimension, socioeconomic dimension,
environmental dimension, educational dimension,
nutritional dimension, and so on.
36
Spectrum of Health
 The graphic
representation of
variation in the
manifestation of disease.
 It is similar to spectrum
of light where the colors
vary from one end to the
other, but difficult to
determine where one
color ends and the other
begins.
 Likely it is very difficult to
differentiate one state
from other in the
definition of health and
SPECTRUM OF HEALTH
 This concept of health emphasizes that health of
an individual is a dynamic phenomenon and a
process of continuous change, subject to repeated,
fine variations
 Transition from optimum health to ill health is often
gradual, and where one state ends and other
begins is a matter of judgment.
 Different stages are positive health, better health,
freedom from sickness, unrecognized sickness,
mild sickness, severe sickness, and death.
H
E
A
L
T
H
39
Contd…
 Health and disease lie in
continuum and there is no
single cut off point.
 At one end of the spectrum,
there are sub-clinical cases
which are not ordinarily
identified and at the other end
there are fatal illnesses.
 In the middle of the spectrum,
there is ranging of illness from
mild to severe.
 The shifting from optimum
health to ill health is often
gradual, where one state ends
and another begins is a matter
of judgment. Mary Mallon/ Cook
Contd…
 The lowest point in the spectrum is death
and the highest point corresponds to the
WHO definition of health.
 Health fluctuates within the range of
optimal well-being to the various levels of
dysfunctions.
 Spectral concept emphasizes that the
health of an individual is not a static , but
rather it is dynamic phenomena of
continuous adjustment.
Spectrum of disease
 The spectrum of disease is, primarily, a
population concept
 Diseases may be mild or even ‘silent’-one
of the many explanations for undiagnosed
disease in the community.
 This phenomenon is described by the
metaphor of the iceberg of disease.
41
Contd….
◦ The onset of symptoms marks the transition
from subclinical to clinical disease.
◦ Most diagnoses are made during the stage of
clinical disease.
◦ In some people, however, the disease
process may never progress to clinically
apparent illness.
◦ In others, the disease process may result in
illness that ranges from mild to severe or
fatal.
◦ Ultimately, the disease process ends either in
recovery, disability or death.
◦ This range is called the spectrum of
 Spectrum of health and diseases identifies and
analyzes the scope of intervention for prevention and
disease control.
 It facilitates the understanding of health and
productivity spectrum
Epidemiological importance of
Spectrum of Health and Disease
 Environmental factors range from housing, water
supply, psychosocial stress and family structure
Socioeconomic Conditions
● Economic status: Economic situation in a country is an
important factor in morbidity, increasing life expectancy
and improving quality of life, family size and pattern of
disease
● Education: Illiteracy correlates with poverty,
malnutrition, ill health, high infant and child mortality
rates.
● Occupation: Productive work provides satisfaction,
promotes health and improves quality of life.
● Political system: timely decisions concerning, resource
Iceberg Phenomenon
of Disease
 A concept is closely related to
the spectrum of disease
 According to this concept,
disease in a community may
be compared to the Iceberg
 The floating tip of the iceberg
represents what the physician
sees in the community i.e.
clinical cases.
 The vast submerged portion of
the iceberg represents pre-
symptomatic and undiagnosed
cases and carriers in the
community
 The waterline represents the
demarcation between apparent
and in apparent disease in the
community
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Iceberg Phenomenon of
Disease
 The submerged portion of the
iceberg represents the
unknown morbidity of chronic
disease for example,
Hypertension, Diabetes,
Anemia , Malnutrition ,
mental illness.
 Thus the submerged /hidden
part of iceberg is thus
constitute an important,
undiagnosed reservoir of
infection or disease in the
community and its detection
and control is a challenges for
the modern medicine.
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Responsibility for Health
1. Individual Responsibility (Self Care)
2. Community Responsibility
3. State Responsibility
4. International Responsibility
12/13/2021 48
Individual Responsibility for Health
 Health generating activities must be undertaken by the
person themselves
 It means individual should be responsible for the
promotion of their own health, preventing their own
disease and limiting their own illness and restoring their
own health.
 Individual respondibility include “self care” for example
 Maintaining healthy behaviour relating to died, sleep,
exercise, weight, alcohol, smoking and drug
 Attention to personnel hygiene, healthful behaviour and
lifestyle, self medical examination and screening, ,
accepting immunization and reporting diseasee and
prevention of spread of disease.
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Community Responsibility for Health
1. The individual and community responsibility for
health is complementary.
2. This implies a more active involvement of
families and community members in planning,
implementation, utilization , operation and
evaluation of health service
3. The concept of primary health care has major
mottos “community participation” in their own
activities
4. The community can raise fund, can provide
manpower and logistic support for utilization of
certain health service.
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Community Responsibility for Health
(Henry Sigerist, the medical historian) stated that The people’s
health ought to be the concern of the people
themselves. They must struggle for it and plan for it.
The war against disease and for health cannot be
fought by physicians alone. It is a people’s war in
which the entire population must be mobilized
permanently.”
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State Responsibility for Health
The constitution of Nepal 2072 states that health is the fundamental human
right and has formulate national health policy2071 which cover following
area
1. provide basic health services free of cost
2. develop skilled human resources
3. Develop Ayurvedic system of medicine
4. utilization of quality medicine and medical products
5. improve quality of health research
6. Give priority to HEIC
7. Minimize prevalence of malnutrition
8. provision of quality health service
9. making health related professional councils
10. collaboration with multi-sector stakeholders in health
11. Control environmental pollution
12. improve governance
13. Promote public private partnership
14. Gradually increase state 's investment in health sector
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International Responsibility for Health
1. The health of mankind require the co-operation of
government, individual people and national and
international organization for achieving our health
goal.
2. This co-operation covers different international
conference (ICPD), Comprehensive and selective
PHC , Health for all by the year 2000, MDGs, SDGs
etc.
3. The eradication of smallpox, Campaign against
smoking and AIDS, polio elimination etc are some of
the example of international responsibility for health.
4. The WHO and other UN agencies (Multilateral and
Bilateral) organizations are the leading organization
for fostering international health with others.
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Concept of Causation
12/13/2021 54
Different theory of disease
causation
before Germ theory
 Supernatural Theory of disease: disease is
due to super power of god, evil sprit.
 The theory of humors (Tridosha): Disease is
due to imbalance between Vatta (wind),
pitta(gall) and kaph(mucus)
 The theory of contagion: spreading disease by
being close contact with people.
 The maismatic theory: Disease is due to
noxious air or vapour.
 Theory of spontaneous generation: ???? HW
Germ Theory of Disease
 Louis Pasteur (1873) demonstrated the presence of
bacteria in air and he advanced the germ theory of
disease
 Robert Koch 1843-1910 showed anthrax is caused
by bacteria.
 These theory prove the germ theory of disease
 Likewise gonococcus, typhoid bacillus,
pneumococcus, tubercle bacillus , cholera vibrio ,
diphtheria bacillus were discovered which turn the
century into aetiological concept and all these
attention focus on the microbes role in disease
causation.
Germ Theory of Disease
Germ theory of disease is the revolutionary concept,
now it is recognized that disease is not caused by
single agent only but rather it depends upon a number
of factor which contribute to the occurrence.
Disease
Agent
Disease
Epidemiological
Triad
 It is based on , not everyone exposed to TB develop
TB but the susceptible person/undernourished person
may result in clinical cases of TB.
 Not everyone exposed to beta-haemolytic streptococci
develops acute rheumatic fever
 Epidemiological traid is especially used in infectious
disease but in case of chronic disease, this model is not
able to explain the pathogenesis of disease adequately.
Agent Host
Environment
Epidemiological Triad
 The agent is the cause of disease: Bacteria, Viruses,
Parasite, Fungi for communicable disease and
dietary chemical, tobacco smoking, radiation, heat,
dust and other substance such as poison.
 The host is an organism usually man or animal that
harvour the disease : the level of immunity, genitic
makeup, level of exposure and overal health status
determine the effect of disease .
Multi-factorial Causation
 Germ theory of disease was overshadowed by multi-
factorial cause of disease as advancement of public
health and human civilization the communicable
diseases are decline and raise number of non-
communicable disease for example: lung cancer,
coronary heart disease, mental illness.
 For this , multiple factors were responsible for disease
causation where there is no clear agents. Some factors
in the etiology of disease are socio-economic, genetic,
cultural, environmental, behavioral etc.
 The purpose of knowing multifactorial causation is to
quantify and arrange those disease in priority setting
for the prevention and intervention of particular
disease.
Web of Causation
 multiple factors causing a disease cannot be explained using a
linear causal relation as, there are complex precursors to each
causal component in the chain that have their respective
complex interactions that overlap each other.
Web of Causation
 This model of disease causation was suggested by Mac
Mohan and Pugh
 This model is ideally suited in the study of chronic disease
where the disease agent is often not known, but the outcome
of interaction of multiple factors.
 The web of causation considers all the predisposing factors of
any type and their complex interaction with each other.
 The web of causation dose not imply that the disease can not
be controlled until and unless all the multiple causes or chain
of causation are controlled.
 Sometimes removal of any one link may be sufficient to
control disease.
Natural History of Disease
Natural history of disease has two
phases:
 Pre-pathogenesis: It is the period before
the onset of disease but presence of
favorable environment for entrance of agent
and man is exposed to risk of disease.
 Pathogenesis: Pathogenesis begins with
the entry of disease causing agent and
multiplication of disease agent in the host. It
alters the physiology of host.
Natural history: applications
• Natural history is vital for disease prevention
policies.
• It underlies secondary prevention based on
screening
• It provides a rationale for all health care.
• Purpose of health care, including medicine, is to
influence the natural history of disease by
reducing and delaying ill-health.
• When achieved through deliberate actions by
societies the collective endeavour is public health.
DETERMINANTS OF HEALTH
Health
Biological
Gender Environment
Health
services
Behavioral &
sociocultural
condition
Socioeconomic
Aging
Other
factor
Biological Determinants
Physical and mental traits of every human being are to
some extent determined by the nature of his genes at the
moment of conception. (for example: genetic disease)
Behavioral and Sociocultural Conditions
Health requires promotion of healthy lifestyle. Modern
health problems especially in the developed countries and
in developing countries are mainly due to changes in
lifestyles.
Healthy lifestyle includes adequate nutrition, enough
sleep, sufficient physical activity etc.
Environment
Environment has a direct impact on the physical, mental
and social wellbeing of those living in it i.e. (Person
internal and external environment, person lifestyle,
occupational environment, socio-economic environment
etc)
Health Services
To be effective, the health services must reach the
masses, equitably distributed, accessible at a cost the
country and community can afford and social acceptable.
Example: supply of quality health care service,
immunization, safe water supply, maternal and child
health services )
Aging of the Population
A major concern of rapidly aging population is increased
prevalence of chronic diseases and disabilities that
deserve special attention.
Gender
Women’s health is gaining importance in areas such as
nutrition, health consequences of violence, aging,
lifestyle related conditions and the occupational
environment.
There is an increased awareness among policy makers
of women’s health issues, and encourages their inclusion
in all development as a priority.
Prevention and its levels
What is Prevention?
 The management of those factors that
could lead to disease so as to prevent the
occurrence of the disease. (Mosby dictionary)
 Prevention is an attempt to create a
blockade/barrier between the source of
health problem and the host.
Contd…
 Goals of the health care are to promote,
preserve and restore health.
 Disease prevention includes the measures that
are applied not only to prevent the occurrence of
disease but it is also applicable to arrest its
progress and reduce its consequences.
Implication for disease prevention
and health promotion
Levels of Prevention
 Primordial
prevention
 Primary prevention
 Secondary
prevention
 Tertiary prevention
Primordial prevention
 “Primordial prevention is defined as prevention
of risk factors themselves, beginning with change
in social and environmental conditions in which
these factors are observed to develop, and
continuing for high risk children, adolescents and
young adults.
 It is the prevention of emergence of risk factors
in populations, in which they have not yet
appeared.
Contd…
◦ It deals with underlying conditions leading to
exposure to causative factors.
◦ INTERVENTIONS: The main intervention in
primordial prevention is through individual
and mass health education.
Primary prevention
 Primary prevention can be defined as action taken
prior to the onset of disease, which removes the
possibility that a disease will ever occur.
• The purpose of primary prevention is to limit the
incidence of disease by controlling causes and risk
factors.
 It focuses on the whole population with the aim of
reducing average risk or on people at high risk as a
result of specific exposure.
 It denotes the interventions applied in the pre-
pathogenesis phase
This level of prevention applies
A. Population (mass) strategy: It is directed at the
whole population irrespective of an individual risk
levels.
B. High risk strategy : It 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.
Interventions for primary preventions
Interventions Activities
Health
promotion
• Health education
• Environmental modifications
• Nutritional interventions
• Lifestyle and behavioural changes.
Specific
protection
• Use of Specific immunization (BCG,
DPT,MMR vaccines)
• Chemoprophylaxis (tetracycline for Cholera,
dapsone for Leprosy, Chloroquine for
malaria,etc.,)
• Use of specific nutrients (vitamin A for Children,
iron-folic acid tablets for Pregnant mothers)
• Protection against accidents (Use of helmet,
seatbelt ,etc.,)
• Protection against occupational hazards.
• Avoidance of allergens.
• Protection from air pollution
Secondary prevention
It is defined as “ actions which halts the progress of a
disease at its incipient stage and presents complications”
 It aims to cure patients and reduce the more
serious consequences of disease through early
diagnosis and treatment.
 It aims to reduce the prevalence of disease.
 Secondary prevention can be applied only to
disease with a natural history including an early
period when the disease is easily identified and
treated, so that progression to a more serious stage
can be stopped.
Interventions for Secondary
preventions
Modes of intervention Services / measures to be taken
3. Early diagnosis and
treatment
Early detection : screening and
diagnosis
Individual and mass treatment
Tertiary prevention
It is defined as “ all measures available to reduce or
limit impairments and disabilities, minimize
sufferings caused by existing departure from good
health and promote the patient’s adjustment to non
reversible conditions”
◦ It signifies the interventions at the late pathogenesis phase.
◦ The purpose of tertiary prevention is to reduce the progress
or complications of established disease and is an important
aspect of therapeutic and rehabilitative medicine.
◦ Services provided at this stage are either disability
limitation measures or rehabilitations (psychosocial,
vocational, medical and educational)
Modes of intervention Services / measures to be taken
4. Disability limitation By immunization, treatment,
support
5. Rehabilitation Medical, vocational, educational
and psychosocial supports
Interventions for Tertiary Preventions
Modes of Intervention
 Definition
◦ Intervention can be defined as any attempt to
intervene or interrupt the usual sequence in the
development of disease in man
◦ A health intervention is an effort that promotes
behaviours that improves mental and physical health,
or discourages or reframes those with health risks.
Sum up Modes of health interventions and Levels
of prevention
Modes of
intervention
Services / measures to be taken Levels of prevention
1. Health
promotion
Health education, Environmental
modification, Nutritional
interventions
Lifestyle and behavior change
Primordial and primary
2. Specific
protection
Immunization, Use of specific
nutrients
Chemoprophylaxis, Protection
against occupational hazards,
Avoidance of allergens, Protection
against the accidents,
Protection against the
carcinogens,
Control of environmental hazards,
Preservation of quality of
products for consumers
Primary
Contd….
Modes of
intervention
Services / measures to be
taken
Levels of prevention
3. Early
diagnosis and
treatment
Early detection : screening and
diagnosis
Individual and mass treatment
Secondary
4. Disability
limitation
By immunization, treatment,
support
Tertiary
5. Rehabilitation Medical, vocational,
educational and psychosocial
supports
Tertiary
Burden of Disease
12/13/2021 87
1.What are the top 10 Global Burden of Disease??
2. List out disability weighting for different
disease
Concept of Burden Of Disease
 Disease burden is the impact of a health problem as
measured by financial cost, mortality, morbidity, or
other indicators.
 It is often quantified in terms of quality-adjusted
life years (QALYs) or disability-adjusted life
years (DALYs).
 Both of these metrics quantify the number of years
lost due to disability (YLDs), sometimes also
known as years lost due to disease or years lived
with disability/disease
YLL
 The years of life lost (YLL) is a summary measure of
premature mortality.
 YLL estimates the years of potential life lost due to
premature deaths.
 YLL can be used to calculate the YLL due to a specific
cause of death as a proportion of the total YLL lost in
the population due to premature mortality.
 Such indicator can be used in public health planning to
compare the relative importance of different causes of
premature deaths within a given population, to set
priorities for prevention, and to compare the premature
mortality experience between populations.
YLD
 “Years lived with disability” (YLD) is a measure
reflecting the impact an illness has on quality of
life before it resolves or leads to death.
 YLDs account for the severity of a disability that a
subject lives with some disease.
 Chronic disease disables an individual once disease
is diagnosed, and the years that he or she lives until
death are the number of years lived with disability.
DALY
 The disability-adjusted life year is a societal measure of
the disease or disability burden in populations.
 DALYs are calculated by combining measures of life
expectancy as well as the adjusted quality of life during
a burden of some disease or disability for a population.
 The disability-adjusted life year (DALY) is a measure of
overall disease burden, expressed as the number of years
lost due to ill-health, disability or early death.
 It was developed in the 1990s as a way of comparing
the overall health and life expectancy of different
countries.
DALY
DALY
QALY
 The quality-adjusted life year (QALY) is a generic
measure of disease burden, including both the quality
and the quantity of life lived.
 It is used in economic evaluation to assess the value
of medical interventions.
 One QALY equates to one year in perfect health.
 QALY scores range from 1 (perfect health) to 0 (dead).
 QALYs can be used to inform health insurance
coverage determinations, treatment decisions, to
evaluate programs, and to set priorities for future
programs.
QALY
INDICATORS OF HEALTH
 What is indicator??
◦ Indicators are the summary value which
help to measure the extent to which the
objectives and targets of a program are
being attained.
 Importance of Indicators:
◦ To measure the health status of the
community;
◦ To assess the health care needs;
◦ To allocate scarce resources; and
◦ To monitor and evaluate health services,
activities and programs.
INDICATORS OF HEALTH
 Characteristics of Indicators:
1. Should be valid: - they should actually measure
what they are supposed to measure.
2. Should be reliable and objective: - the
answers should be the same if measured by different
people in similar circumstances.
3. Should be sensitive: - they should be sensitive to
change in situation concerned.reflect small changes in
health status
4. Should be specific: - they should reflect changes
only in situation concerned.
5. Should be feasible: - they should have the ability
to obtain data needed.
6. Should be relevant: - they should contribute to
the understanding of the phenomena of interest.
12/13/2021 98
1. Mortality indicators
1. Death Rates (Crude Death Rate
(CDR),Standardized Death Rate (SDR), (age,
sex or Disease) Specific Death Rate
2. Life expectancy
 Perinatal Mortality Rate:
 Neonatal Mortality Rate:
 Infant Mortality Rate (IMR):
 Maternal Mortality Rate (MMR):
 Disease/ Cause-specific Death Rate:
 Case-fatality Rate:
 Child Mortality Rate (CMR):
 Under – 5 Mortality Rate (U5MR):
2. Morbidity indicator
Morbidity: -
Deviation subjective or objective
from a state of wellbeing.
◦ Severity: - by case fatality rate
◦ Duration: - disability rate, loss of
working days
◦ Frequency: - prevalence, incidence
2. Morbidity indicators
1. Incidence rate:
 The numbers of new cases occurring in a
defined population during a specified period of
time.
2. Prevalence rate:
 All current cases (old and new) existing at a
given point in time, or over a period of time.
3. Attendance at OPD
4. Duration of hospital stay
5. Admission at OPD
6. Notification rate:
The proportion of detection (or even suspect) of
infectious disease and the notification to the local ,
national, regional and international authority.
3. Fertility indicators
1. Birth Rates (Net Reproduction Rate
(NRR) ,Child Woman Ratio (CWR),
Pregnancy Rate, Abortion Rate,
Abortion Ratio, Marriage Rate, Growth
Rate)
• Crude Birth Rate (CBR)
• General Fertility Rate (GFR)
• General Marital Fertility Rate (GMFR)
• Age Specific Fertility Rate (ASFR)
• Age Specific Marital Fertility Rate
(ASMFR)
• Total Fertility Rate (TFR)
• Total Marital Fertility Rate (TMFR)
• Gross Reproduction Rate (GRR)
4. Nutritional status indicators
 % of budget Expended on
Nutritional Sector
 Number of nutritional
programs Conducted by HFs.
 % of Vit-A distribution
 % of IFA distribution
 % of Alb distribution
 % of MNP distribution
 % Iodized salt distribution
Nutrition status outcomes
 % Stunting
 % Wasting
 % of underweight
 Prevalence of overweight
 % LBW
 Prevalence of Anemia
(among children, women,
adolescent girls)
 Prevalence of Goiter
 Prevalence of night
blindness
5. Health care delivery indicators
 Doctor population ration
 Doctor nurse ration
 Population bed ratio
 Population per health institute
 Population per SBA
6. Utilization rates
 Immunization rate,
 ANC (Antenatal check up) attendance rate,
 CPR(contraceptive prevalence rate)
 Bed occupancy rate
 Average length of stay, and
 Bed turn-over ratio
7. Environmental indicators
 No of ODF (Open defecation free) districts
 % of households having toilet
 Reduction in amount of solid waste (in kg)produce
by per person per day.
 No of drinking water supply system treated with
chlorine.
 No of industries supplying PPE (personnel
protective equipment's) to their workers
 No of no horn area declared
8. Socioeconomic indicators
 Rate of population increase
 Per capita gross national product (GDP)
 Level of unemployment
 Dependency ratio
 literacy rates, especially female literacy
rate
 Family size
 Housing: the numbers of person per room;
and
 Per capita calorie available.
9. Indicators of quality of life
 Physical quality of life
index (PQLI):
◦ Composite index from a
number of health
indicators.
◦ It consolidates three
indicators
 Infant mortality,
 Life expectancy at age one,
and
 Literacy
◦ Scaled 0 to 100.
◦ It measures results of
social, economic and
political policies.
◦ The ultimate objective is
to attain a PQLI of 100
 Human development
index (HDI):
◦ A composite index
combining indicators
representing three
dimensions – longevity (life
expectancy at birth);
knowledge (adult literacy
and mean years of
schooling); and income (real
GDP per capita in
purchasing power parity in
us dolor).
◦ The HDI values range
between 0 to 1.
◦ To construct the index, fixed
minimum and maximum
values have been
established for each of
10. Health Policy Indicator
 Proportion of GNP spent on health services,
 Proportion of GNP spent on health related
activities (including water supply and sanitation,
housing and nutrition, community development)
and
 Proportion of total health resources devoted to
primary health care.
Concept of health and disease

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Concept of health and disease

  • 1. Unit I: Concept of Health and Disease Presented By: Sirjana Tiwari School of Health and Allied Sciences Pokhara University
  • 2. Unit I: Concept of Health and Disease ( 18 hours)  Concept of health and disease (concept and definition of health, wellbeing, illness, sickness and disease; philosophy of health; concept and definition of disease; changing concepts of health; dimensions of health; spectrum of health; iceberg phenomenon of disease; responsibility for health: Individual, community, state and international)  Concept of causation (germ theory of disease; epidemiological triad; multi-factorial causation; web of causation; natural history of disease: pre-pathogenesis and pathogenesis phase)  Determinants of health  Prevention, its levels in line with phases of disease concurrent to natural history  Concept of modes of intervention in different levels of prevention  Burden of disease (concept of burden of disease; measurements used in burden of  disease: DALY, QALY, YLL, YLD)  Indicators of Health (Concept and characteristics of health indicator; Different types of mortality and morbidity indicators: mortality Indicators-crude death rate; age-specific death rate; infant mortality rate; maternal mortality rate and ratio; Morbidity indicators: incidence and prevalence) 12/13/2021 2
  • 3. Definition of Health Traditionally health has been considered as an absence of the diseases and if someone was free from disease, then that person was considered healthy. Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity.” “the ability to conduct socially and economically productive life.” (WHO)
  • 4. Definition of Health from different perspectives Theoretical perspectives Biomedical model Social model Bio-psychosocial model Holistic model Layman perspectives Cultural perspectives Understanding across the life span 12/13/2021 4
  • 5.  Medical model:  Absence of disease or abnomility  Basis of germ theory of disease  Health is derieved from biology- biological factors  Social model:  Health is influenced by different factors as political, economic, social, psychological, cultural, environmental.  Causes of ill health are attributed to factors outside the human body-the wider structural causes such as inequality, poverty as well as social interaction and behavior. Theoretical perspectives
  • 6. Medical model Vs Social model Medical model  Narrow concept  Doesn’t take into account outer influences on health  Influenced by scientific and expert knowledge  Emphasize on personal and individual responsibility on health Social model  Broader concept  Takes into account outer influences on health  Takes into account layman knowledge and understanding  Emphasize collective and social responsibility on health
  • 7.  Integrated approach- biological, psychological and social factors influence health  Sound mind in sound body, sound family in sound environment  Strength: Spiritual health into consideration  Criticism: It is more individualistic and doesn’t take wider social factors into account Holistic model:
  • 8.  Takes into account biological, psychological and social factors and their interaction Biopsychosocial model
  • 9. The findings of a major UK study in which people were asked what it was like to be healthy. The five categories of responses were as follows: Health as not- ill Health as physical fitness, vitality Health as social relationships Health as function Health as psychosocial well- being - (1990 in Blaxter, 2004) Layman perspective
  • 10.  The younger children (aged 5 –11 years) defined health in terms of diet, exercise and rest, hygiene and dental hygiene  The older children (over the age of 12 years) included things like smoking and drinking behaviors, having a healthy mind, feeling happy and confident and self- acceptance.  Interestingly the older children also linked looking good, being happy and feeling confident with being healthy. Chapman et al. (2000) Young people perspective
  • 11.  Blaxter’s (1990) Health and Lifestyles study found that older people tended to define health more in terms of being able to function and do things or care for themselves.  being 'independent’ is strongly linked to ideas about being healthy (Lloyd, 2000). Older people perspective
  • 12. Proposed Definition of Health : WHO 12/13/2021 12 https://www.ncbi.nlm.nih.gov/pmc/article s
  • 13. Physical Health  It means adequate body weight, height and circumference as per age and sex with acceptable level of  “ vision, hearing, movements, acceptable levels of pulse rate, blood pressure, respiratory rate, chest circumference, head circumference, waist hip ratio”.  The body structure and functions confirming to laid down standards within the range of normal development and functions of all the systems
  • 14.  Mental health is defined “as a state of well being in which the individual realized his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community”. Mental Health
  • 15.  A mentally normal person has the ability to mix up with others, he/she makes friendship, behaves in a balanced manner, keeps himself tidy and observes adequate personal hygiene, well oriented to time, place and person and environments and he is unduly not suspicious of others.  He is cheerful and happy and enjoys life with a purpose and he thinks positively and has normal development and contributes fully and is useful and productive to society and nation.
  • 17. Spiritual Health  Spiritual health is achieved when you feel at peace with life. It is when you are able to find hope and comfort in even the hardest of times chronic disease. 12/13/2021 17
  • 18. Definition of Public Health  Sir Donald Acheson in 1988 defined it as ‘the science and art of preventing disease, prolonging life, promoting, protecting and improving health through the organized community efforts’  The field pays special attention to the social context of disease and health, and focuses on improving health through society-wide measures like vaccinations, the fluoridation of drinking water, or through policies such as seatbelt and non-smoking laws. Donald Acheson Report, 1988, UK
  • 19. Leading Differences Between Basic, Clinical and Public Health Activities And Research Characteristics Basic Clinical Public Health Who/What is studied Cells, tissues, animals laboratory Patient seeking for health services attendance Populations or communities Activity or research goal Understand the mechanisms of disease and the effects of toxic substances Improve the diagnosis and treatment of disease Prevention of disease and health promotion Examples Toxicology, inmunology Pediatric and clinical nursing Epidemiology, Environment Sciences
  • 20.
  • 21. CONCEPT OF WELLBEING Standard of Living  As per WHO, “Income and occupation, standards of housing, sanitation and nutrition, the level of provision of health, educational, recreational and other service and collectively as an index of the ‘standard of living’.” Level of Living  As per United Nations documents “level of living” consists of nine components: health, food consumption, education, occupation and working conditions, housing, social security, clothing, recreation and leisure, and human rights.
  • 22. Quality of Life  Quality of life as defined by WHO, “The condition of life resulting from combination of the effects of the complete range of factors such as those determining health, happiness , education, social and intellectual attainments, freedom of action, justice and freedom of expression.” Physical Quality of Life Index  It includes three indicators such as Infant mortality Life expectancy at age one Literacy. For each component, performance of individual countries is placed on a scale of 0 to 100,
  • 23. Human Developmental Index It includes longevity (life expectancy at birth) knowledge (adult literacy rate) income (real GDP per capita) The HDI value ranges from 0 to 1.
  • 24. What is Disease  Disease is a disorder or malfunction of mind or body, which leads to a departure from good health can be a disorder of a specific tissue or organ due to a single cause. E.g. malaria  May have many causes often referred to as multifactorial. E.g. heart disease 12/13/2021 24
  • 25. Disease Illness and sickness  An illness is a general term that people will use to describe themselves when they do not feel well.  They may or may not have been diagnosed by a doctor.  A disease is more specific and is determined by a physician or health worker.  The term sickness is usually applied if people miss work or cannot function normally in society. In general, "illness" is more general then "disease", which in turn is more general than "sickness".
  • 26.  Sickness is a generic term referring to a condition you experience when do not feel well.  Sickness may refer to being nauseated (e.g. motion sickness) or just being unwell because you are ill or tired.  Illness is very similar to disease, in everyday speech a disease is typically perceived as a problem more serious or incurable (e.g. a genetic disease).  While an illness, on the other hand, is simply the cause of a temporary state of ill health (e.g. the flu).
  • 27. . • The concept of health as defined by WHO is broad and positive in its implications; it sets out the standard, the standard of “positive” health. • Health has evolved over the centuries as a concept from an individual concern to a worldwide social goal. CHANGING CONCEPTS OF HEALTH
  • 28. Biomedical Concept  Health means “absence of disease.”  It was felt that human body is a machine and disease is an outcome of the breakdown of the machine, and one of the doctor’s tasks was to repair the machine.  Developments in medical and social sciences led to the conclusion that the biomedical concept of health was inadequate. CHANGING CONCEPTS OF HEALTH
  • 29. Ecological Concept Ecologists viewed health as a dynamic equilibrium between man and his environment, and disease ( a maladjustment of the human organism to environment).
  • 30. Psychosocial Concept Advances in social sciences showed that health is not only a biomedical phenomenon, but one which is influenced by social, psychological, cultural, economic and political factors of the people concerned. Thus health is both a biological and social phenomenon.
  • 31. Holistic concept recognizes the strength of social, economic, political and environmental influences on health. It has been variously described as multidimensional process involving the wellbeing of the person as a whole The emphasis is on the promotion and protection of health. Holistic Concept
  • 33. DIMENSIONS OF HEALTH  Health is multidimensional and are interrelated, each has its own nature Physical Dimension  “Perfect functioning” of the body.  It conceptualizes health biologically as a state in which every cell and every organ are functioning at optimum capacity and in perfect harmony with the rest of the body. Mental Dimension  Ability to respond to many varied experiences of life with flexibility and a sense of purpose.  Mental health has been defined as “a state of balance between the individual and the surrounding world, a state of harmony between oneself and others
  • 34. Social Dimension Harmony and integration with the individual, between each individual and other members of society, and between individuals and the world in which they live. “quantity and quality of an individual’s interpersonal ties and the extent of involvement with the community.” Spiritual Dimension Spiritual health refers to “something” that transcends physiology and psychology.
  • 35. Emotional Dimension Relates to “feeling.” it reflects emotional aspects of humanness. Vocational Dimension Work often plays a role in promoting both physical and mental health. Physical work is usually associated with an improvement in physical capacity, while goal achievement and self-realization in work are a source of contentment and enhanced self-esteem. Others A few other dimensions have also been suggested such as philosophical dimension, cultural dimension, socioeconomic dimension, environmental dimension, educational dimension, nutritional dimension, and so on.
  • 36. 36 Spectrum of Health  The graphic representation of variation in the manifestation of disease.  It is similar to spectrum of light where the colors vary from one end to the other, but difficult to determine where one color ends and the other begins.  Likely it is very difficult to differentiate one state from other in the definition of health and
  • 37. SPECTRUM OF HEALTH  This concept of health emphasizes that health of an individual is a dynamic phenomenon and a process of continuous change, subject to repeated, fine variations  Transition from optimum health to ill health is often gradual, and where one state ends and other begins is a matter of judgment.  Different stages are positive health, better health, freedom from sickness, unrecognized sickness, mild sickness, severe sickness, and death.
  • 39. 39 Contd…  Health and disease lie in continuum and there is no single cut off point.  At one end of the spectrum, there are sub-clinical cases which are not ordinarily identified and at the other end there are fatal illnesses.  In the middle of the spectrum, there is ranging of illness from mild to severe.  The shifting from optimum health to ill health is often gradual, where one state ends and another begins is a matter of judgment. Mary Mallon/ Cook
  • 40. Contd…  The lowest point in the spectrum is death and the highest point corresponds to the WHO definition of health.  Health fluctuates within the range of optimal well-being to the various levels of dysfunctions.  Spectral concept emphasizes that the health of an individual is not a static , but rather it is dynamic phenomena of continuous adjustment.
  • 41. Spectrum of disease  The spectrum of disease is, primarily, a population concept  Diseases may be mild or even ‘silent’-one of the many explanations for undiagnosed disease in the community.  This phenomenon is described by the metaphor of the iceberg of disease. 41
  • 42. Contd…. ◦ The onset of symptoms marks the transition from subclinical to clinical disease. ◦ Most diagnoses are made during the stage of clinical disease. ◦ In some people, however, the disease process may never progress to clinically apparent illness. ◦ In others, the disease process may result in illness that ranges from mild to severe or fatal. ◦ Ultimately, the disease process ends either in recovery, disability or death. ◦ This range is called the spectrum of
  • 43.
  • 44.  Spectrum of health and diseases identifies and analyzes the scope of intervention for prevention and disease control.  It facilitates the understanding of health and productivity spectrum Epidemiological importance of Spectrum of Health and Disease
  • 45.  Environmental factors range from housing, water supply, psychosocial stress and family structure Socioeconomic Conditions ● Economic status: Economic situation in a country is an important factor in morbidity, increasing life expectancy and improving quality of life, family size and pattern of disease ● Education: Illiteracy correlates with poverty, malnutrition, ill health, high infant and child mortality rates. ● Occupation: Productive work provides satisfaction, promotes health and improves quality of life. ● Political system: timely decisions concerning, resource
  • 46. Iceberg Phenomenon of Disease  A concept is closely related to the spectrum of disease  According to this concept, disease in a community may be compared to the Iceberg  The floating tip of the iceberg represents what the physician sees in the community i.e. clinical cases.  The vast submerged portion of the iceberg represents pre- symptomatic and undiagnosed cases and carriers in the community  The waterline represents the demarcation between apparent and in apparent disease in the community 12/13/2021 46
  • 47. Iceberg Phenomenon of Disease  The submerged portion of the iceberg represents the unknown morbidity of chronic disease for example, Hypertension, Diabetes, Anemia , Malnutrition , mental illness.  Thus the submerged /hidden part of iceberg is thus constitute an important, undiagnosed reservoir of infection or disease in the community and its detection and control is a challenges for the modern medicine. 12/13/2021 47
  • 48. Responsibility for Health 1. Individual Responsibility (Self Care) 2. Community Responsibility 3. State Responsibility 4. International Responsibility 12/13/2021 48
  • 49. Individual Responsibility for Health  Health generating activities must be undertaken by the person themselves  It means individual should be responsible for the promotion of their own health, preventing their own disease and limiting their own illness and restoring their own health.  Individual respondibility include “self care” for example  Maintaining healthy behaviour relating to died, sleep, exercise, weight, alcohol, smoking and drug  Attention to personnel hygiene, healthful behaviour and lifestyle, self medical examination and screening, , accepting immunization and reporting diseasee and prevention of spread of disease. 12/13/2021 49
  • 50. Community Responsibility for Health 1. The individual and community responsibility for health is complementary. 2. This implies a more active involvement of families and community members in planning, implementation, utilization , operation and evaluation of health service 3. The concept of primary health care has major mottos “community participation” in their own activities 4. The community can raise fund, can provide manpower and logistic support for utilization of certain health service. 12/13/2021 50
  • 51. Community Responsibility for Health (Henry Sigerist, the medical historian) stated that The people’s health ought to be the concern of the people themselves. They must struggle for it and plan for it. The war against disease and for health cannot be fought by physicians alone. It is a people’s war in which the entire population must be mobilized permanently.” 12/13/2021 51
  • 52. State Responsibility for Health The constitution of Nepal 2072 states that health is the fundamental human right and has formulate national health policy2071 which cover following area 1. provide basic health services free of cost 2. develop skilled human resources 3. Develop Ayurvedic system of medicine 4. utilization of quality medicine and medical products 5. improve quality of health research 6. Give priority to HEIC 7. Minimize prevalence of malnutrition 8. provision of quality health service 9. making health related professional councils 10. collaboration with multi-sector stakeholders in health 11. Control environmental pollution 12. improve governance 13. Promote public private partnership 14. Gradually increase state 's investment in health sector 12/13/2021 52
  • 53. International Responsibility for Health 1. The health of mankind require the co-operation of government, individual people and national and international organization for achieving our health goal. 2. This co-operation covers different international conference (ICPD), Comprehensive and selective PHC , Health for all by the year 2000, MDGs, SDGs etc. 3. The eradication of smallpox, Campaign against smoking and AIDS, polio elimination etc are some of the example of international responsibility for health. 4. The WHO and other UN agencies (Multilateral and Bilateral) organizations are the leading organization for fostering international health with others. 12/13/2021 53
  • 55. Different theory of disease causation before Germ theory  Supernatural Theory of disease: disease is due to super power of god, evil sprit.  The theory of humors (Tridosha): Disease is due to imbalance between Vatta (wind), pitta(gall) and kaph(mucus)  The theory of contagion: spreading disease by being close contact with people.  The maismatic theory: Disease is due to noxious air or vapour.  Theory of spontaneous generation: ???? HW
  • 56. Germ Theory of Disease  Louis Pasteur (1873) demonstrated the presence of bacteria in air and he advanced the germ theory of disease  Robert Koch 1843-1910 showed anthrax is caused by bacteria.  These theory prove the germ theory of disease  Likewise gonococcus, typhoid bacillus, pneumococcus, tubercle bacillus , cholera vibrio , diphtheria bacillus were discovered which turn the century into aetiological concept and all these attention focus on the microbes role in disease causation.
  • 57. Germ Theory of Disease Germ theory of disease is the revolutionary concept, now it is recognized that disease is not caused by single agent only but rather it depends upon a number of factor which contribute to the occurrence. Disease Agent Disease
  • 58. Epidemiological Triad  It is based on , not everyone exposed to TB develop TB but the susceptible person/undernourished person may result in clinical cases of TB.  Not everyone exposed to beta-haemolytic streptococci develops acute rheumatic fever  Epidemiological traid is especially used in infectious disease but in case of chronic disease, this model is not able to explain the pathogenesis of disease adequately. Agent Host Environment
  • 59. Epidemiological Triad  The agent is the cause of disease: Bacteria, Viruses, Parasite, Fungi for communicable disease and dietary chemical, tobacco smoking, radiation, heat, dust and other substance such as poison.  The host is an organism usually man or animal that harvour the disease : the level of immunity, genitic makeup, level of exposure and overal health status determine the effect of disease .
  • 60. Multi-factorial Causation  Germ theory of disease was overshadowed by multi- factorial cause of disease as advancement of public health and human civilization the communicable diseases are decline and raise number of non- communicable disease for example: lung cancer, coronary heart disease, mental illness.  For this , multiple factors were responsible for disease causation where there is no clear agents. Some factors in the etiology of disease are socio-economic, genetic, cultural, environmental, behavioral etc.  The purpose of knowing multifactorial causation is to quantify and arrange those disease in priority setting for the prevention and intervention of particular disease.
  • 61. Web of Causation  multiple factors causing a disease cannot be explained using a linear causal relation as, there are complex precursors to each causal component in the chain that have their respective complex interactions that overlap each other.
  • 62. Web of Causation  This model of disease causation was suggested by Mac Mohan and Pugh  This model is ideally suited in the study of chronic disease where the disease agent is often not known, but the outcome of interaction of multiple factors.  The web of causation considers all the predisposing factors of any type and their complex interaction with each other.  The web of causation dose not imply that the disease can not be controlled until and unless all the multiple causes or chain of causation are controlled.  Sometimes removal of any one link may be sufficient to control disease.
  • 64. Natural history of disease has two phases:  Pre-pathogenesis: It is the period before the onset of disease but presence of favorable environment for entrance of agent and man is exposed to risk of disease.  Pathogenesis: Pathogenesis begins with the entry of disease causing agent and multiplication of disease agent in the host. It alters the physiology of host.
  • 65.
  • 66. Natural history: applications • Natural history is vital for disease prevention policies. • It underlies secondary prevention based on screening • It provides a rationale for all health care. • Purpose of health care, including medicine, is to influence the natural history of disease by reducing and delaying ill-health. • When achieved through deliberate actions by societies the collective endeavour is public health.
  • 67. DETERMINANTS OF HEALTH Health Biological Gender Environment Health services Behavioral & sociocultural condition Socioeconomic Aging Other factor
  • 68.
  • 69. Biological Determinants Physical and mental traits of every human being are to some extent determined by the nature of his genes at the moment of conception. (for example: genetic disease) Behavioral and Sociocultural Conditions Health requires promotion of healthy lifestyle. Modern health problems especially in the developed countries and in developing countries are mainly due to changes in lifestyles. Healthy lifestyle includes adequate nutrition, enough sleep, sufficient physical activity etc. Environment Environment has a direct impact on the physical, mental and social wellbeing of those living in it i.e. (Person internal and external environment, person lifestyle, occupational environment, socio-economic environment etc)
  • 70. Health Services To be effective, the health services must reach the masses, equitably distributed, accessible at a cost the country and community can afford and social acceptable. Example: supply of quality health care service, immunization, safe water supply, maternal and child health services ) Aging of the Population A major concern of rapidly aging population is increased prevalence of chronic diseases and disabilities that deserve special attention. Gender Women’s health is gaining importance in areas such as nutrition, health consequences of violence, aging, lifestyle related conditions and the occupational environment. There is an increased awareness among policy makers of women’s health issues, and encourages their inclusion in all development as a priority.
  • 71. Prevention and its levels What is Prevention?  The management of those factors that could lead to disease so as to prevent the occurrence of the disease. (Mosby dictionary)  Prevention is an attempt to create a blockade/barrier between the source of health problem and the host.
  • 72. Contd…  Goals of the health care are to promote, preserve and restore health.  Disease prevention includes the measures that are applied not only to prevent the occurrence of disease but it is also applicable to arrest its progress and reduce its consequences.
  • 73. Implication for disease prevention and health promotion
  • 74. Levels of Prevention  Primordial prevention  Primary prevention  Secondary prevention  Tertiary prevention
  • 75. Primordial prevention  “Primordial prevention is defined as prevention of risk factors themselves, beginning with change in social and environmental conditions in which these factors are observed to develop, and continuing for high risk children, adolescents and young adults.  It is the prevention of emergence of risk factors in populations, in which they have not yet appeared.
  • 76. Contd… ◦ It deals with underlying conditions leading to exposure to causative factors. ◦ INTERVENTIONS: The main intervention in primordial prevention is through individual and mass health education.
  • 77. Primary prevention  Primary prevention can be defined as action taken prior to the onset of disease, which removes the possibility that a disease will ever occur. • The purpose of primary prevention is to limit the incidence of disease by controlling causes and risk factors.
  • 78.  It focuses on the whole population with the aim of reducing average risk or on people at high risk as a result of specific exposure.  It denotes the interventions applied in the pre- pathogenesis phase This level of prevention applies A. Population (mass) strategy: It is directed at the whole population irrespective of an individual risk levels. B. High risk strategy : It 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.
  • 79. Interventions for primary preventions Interventions Activities Health promotion • Health education • Environmental modifications • Nutritional interventions • Lifestyle and behavioural changes. Specific protection • Use of Specific immunization (BCG, DPT,MMR vaccines) • Chemoprophylaxis (tetracycline for Cholera, dapsone for Leprosy, Chloroquine for malaria,etc.,) • Use of specific nutrients (vitamin A for Children, iron-folic acid tablets for Pregnant mothers) • Protection against accidents (Use of helmet, seatbelt ,etc.,) • Protection against occupational hazards. • Avoidance of allergens. • Protection from air pollution
  • 80. Secondary prevention It is defined as “ actions which halts the progress of a disease at its incipient stage and presents complications”  It aims to cure patients and reduce the more serious consequences of disease through early diagnosis and treatment.  It aims to reduce the prevalence of disease.  Secondary prevention can be applied only to disease with a natural history including an early period when the disease is easily identified and treated, so that progression to a more serious stage can be stopped.
  • 81. Interventions for Secondary preventions Modes of intervention Services / measures to be taken 3. Early diagnosis and treatment Early detection : screening and diagnosis Individual and mass treatment
  • 82. Tertiary prevention It is defined as “ all measures available to reduce or limit impairments and disabilities, minimize sufferings caused by existing departure from good health and promote the patient’s adjustment to non reversible conditions” ◦ It signifies the interventions at the late pathogenesis phase. ◦ The purpose of tertiary prevention is to reduce the progress or complications of established disease and is an important aspect of therapeutic and rehabilitative medicine. ◦ Services provided at this stage are either disability limitation measures or rehabilitations (psychosocial, vocational, medical and educational)
  • 83. Modes of intervention Services / measures to be taken 4. Disability limitation By immunization, treatment, support 5. Rehabilitation Medical, vocational, educational and psychosocial supports Interventions for Tertiary Preventions
  • 84. Modes of Intervention  Definition ◦ Intervention can be defined as any attempt to intervene or interrupt the usual sequence in the development of disease in man ◦ A health intervention is an effort that promotes behaviours that improves mental and physical health, or discourages or reframes those with health risks.
  • 85. Sum up Modes of health interventions and Levels of prevention Modes of intervention Services / measures to be taken Levels of prevention 1. Health promotion Health education, Environmental modification, Nutritional interventions Lifestyle and behavior change Primordial and primary 2. Specific protection Immunization, Use of specific nutrients Chemoprophylaxis, Protection against occupational hazards, Avoidance of allergens, Protection against the accidents, Protection against the carcinogens, Control of environmental hazards, Preservation of quality of products for consumers Primary
  • 86. Contd…. Modes of intervention Services / measures to be taken Levels of prevention 3. Early diagnosis and treatment Early detection : screening and diagnosis Individual and mass treatment Secondary 4. Disability limitation By immunization, treatment, support Tertiary 5. Rehabilitation Medical, vocational, educational and psychosocial supports Tertiary
  • 87. Burden of Disease 12/13/2021 87 1.What are the top 10 Global Burden of Disease?? 2. List out disability weighting for different disease
  • 88. Concept of Burden Of Disease  Disease burden is the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators.  It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs).  Both of these metrics quantify the number of years lost due to disability (YLDs), sometimes also known as years lost due to disease or years lived with disability/disease
  • 89. YLL  The years of life lost (YLL) is a summary measure of premature mortality.  YLL estimates the years of potential life lost due to premature deaths.  YLL can be used to calculate the YLL due to a specific cause of death as a proportion of the total YLL lost in the population due to premature mortality.  Such indicator can be used in public health planning to compare the relative importance of different causes of premature deaths within a given population, to set priorities for prevention, and to compare the premature mortality experience between populations.
  • 90. YLD  “Years lived with disability” (YLD) is a measure reflecting the impact an illness has on quality of life before it resolves or leads to death.  YLDs account for the severity of a disability that a subject lives with some disease.  Chronic disease disables an individual once disease is diagnosed, and the years that he or she lives until death are the number of years lived with disability.
  • 91. DALY  The disability-adjusted life year is a societal measure of the disease or disability burden in populations.  DALYs are calculated by combining measures of life expectancy as well as the adjusted quality of life during a burden of some disease or disability for a population.  The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death.  It was developed in the 1990s as a way of comparing the overall health and life expectancy of different countries.
  • 92. DALY
  • 93. DALY
  • 94. QALY  The quality-adjusted life year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived.  It is used in economic evaluation to assess the value of medical interventions.  One QALY equates to one year in perfect health.  QALY scores range from 1 (perfect health) to 0 (dead).  QALYs can be used to inform health insurance coverage determinations, treatment decisions, to evaluate programs, and to set priorities for future programs.
  • 95. QALY
  • 96. INDICATORS OF HEALTH  What is indicator?? ◦ Indicators are the summary value which help to measure the extent to which the objectives and targets of a program are being attained.  Importance of Indicators: ◦ To measure the health status of the community; ◦ To assess the health care needs; ◦ To allocate scarce resources; and ◦ To monitor and evaluate health services, activities and programs.
  • 97. INDICATORS OF HEALTH  Characteristics of Indicators: 1. Should be valid: - they should actually measure what they are supposed to measure. 2. Should be reliable and objective: - the answers should be the same if measured by different people in similar circumstances. 3. Should be sensitive: - they should be sensitive to change in situation concerned.reflect small changes in health status 4. Should be specific: - they should reflect changes only in situation concerned. 5. Should be feasible: - they should have the ability to obtain data needed. 6. Should be relevant: - they should contribute to the understanding of the phenomena of interest.
  • 99. 1. Mortality indicators 1. Death Rates (Crude Death Rate (CDR),Standardized Death Rate (SDR), (age, sex or Disease) Specific Death Rate 2. Life expectancy  Perinatal Mortality Rate:  Neonatal Mortality Rate:  Infant Mortality Rate (IMR):  Maternal Mortality Rate (MMR):  Disease/ Cause-specific Death Rate:  Case-fatality Rate:  Child Mortality Rate (CMR):  Under – 5 Mortality Rate (U5MR):
  • 100. 2. Morbidity indicator Morbidity: - Deviation subjective or objective from a state of wellbeing. ◦ Severity: - by case fatality rate ◦ Duration: - disability rate, loss of working days ◦ Frequency: - prevalence, incidence
  • 101. 2. Morbidity indicators 1. Incidence rate:  The numbers of new cases occurring in a defined population during a specified period of time. 2. Prevalence rate:  All current cases (old and new) existing at a given point in time, or over a period of time. 3. Attendance at OPD 4. Duration of hospital stay 5. Admission at OPD 6. Notification rate: The proportion of detection (or even suspect) of infectious disease and the notification to the local , national, regional and international authority.
  • 102. 3. Fertility indicators 1. Birth Rates (Net Reproduction Rate (NRR) ,Child Woman Ratio (CWR), Pregnancy Rate, Abortion Rate, Abortion Ratio, Marriage Rate, Growth Rate) • Crude Birth Rate (CBR) • General Fertility Rate (GFR) • General Marital Fertility Rate (GMFR) • Age Specific Fertility Rate (ASFR) • Age Specific Marital Fertility Rate (ASMFR) • Total Fertility Rate (TFR) • Total Marital Fertility Rate (TMFR) • Gross Reproduction Rate (GRR)
  • 103. 4. Nutritional status indicators  % of budget Expended on Nutritional Sector  Number of nutritional programs Conducted by HFs.  % of Vit-A distribution  % of IFA distribution  % of Alb distribution  % of MNP distribution  % Iodized salt distribution Nutrition status outcomes  % Stunting  % Wasting  % of underweight  Prevalence of overweight  % LBW  Prevalence of Anemia (among children, women, adolescent girls)  Prevalence of Goiter  Prevalence of night blindness
  • 104. 5. Health care delivery indicators  Doctor population ration  Doctor nurse ration  Population bed ratio  Population per health institute  Population per SBA
  • 105. 6. Utilization rates  Immunization rate,  ANC (Antenatal check up) attendance rate,  CPR(contraceptive prevalence rate)  Bed occupancy rate  Average length of stay, and  Bed turn-over ratio
  • 106. 7. Environmental indicators  No of ODF (Open defecation free) districts  % of households having toilet  Reduction in amount of solid waste (in kg)produce by per person per day.  No of drinking water supply system treated with chlorine.  No of industries supplying PPE (personnel protective equipment's) to their workers  No of no horn area declared
  • 107. 8. Socioeconomic indicators  Rate of population increase  Per capita gross national product (GDP)  Level of unemployment  Dependency ratio  literacy rates, especially female literacy rate  Family size  Housing: the numbers of person per room; and  Per capita calorie available.
  • 108. 9. Indicators of quality of life  Physical quality of life index (PQLI): ◦ Composite index from a number of health indicators. ◦ It consolidates three indicators  Infant mortality,  Life expectancy at age one, and  Literacy ◦ Scaled 0 to 100. ◦ It measures results of social, economic and political policies. ◦ The ultimate objective is to attain a PQLI of 100  Human development index (HDI): ◦ A composite index combining indicators representing three dimensions – longevity (life expectancy at birth); knowledge (adult literacy and mean years of schooling); and income (real GDP per capita in purchasing power parity in us dolor). ◦ The HDI values range between 0 to 1. ◦ To construct the index, fixed minimum and maximum values have been established for each of
  • 109. 10. Health Policy Indicator  Proportion of GNP spent on health services,  Proportion of GNP spent on health related activities (including water supply and sanitation, housing and nutrition, community development) and  Proportion of total health resources devoted to primary health care.