Basic Concepts of Public Health

1. Public health
and
Public health interventions
Amita Kashyap
Professor (Com. Medicine)

2. Objectives
By the end of these lessons you will
be able to understand:-
• Why Community Medicine
• How Community Medicine is different
then Clinical Medicine
• Its evolution
• Basic Concepts of Community Medicine/
Public Health/ Preventive and Social
Medicine

3. Importance of Preventive and
Social Medicine/ Public Health
What is common in:-
• Swine flu
• HIV
• Typhoid
• Malaria
• Malnutrition
• Cancer
• Addiction

4. Public health movements
• Started in mid-nineteenth century by Edwin
Chadwick in UK
(report on an inquiry into the sanitary
conditions of the labouring population in
great Britain, 1842) and
• Around the same time in USA in 1850 by Lemuel
Shattuck
(Report of the sanitary commission of
Massachusetts)

5. Renewal of Interest in Prev.
Prom. And Protection of Health!!
Due to:-
• Continued Emergence and Resurgence of
Communicable Diseases and increase in Life-
Style Diseases
• Realization that investment in Clinical Care;
though necessary, bring diminishing results.
• Implementing Public Health Methods;
may be difficult, time-consuming but
bring maximum gains.

6. Contributions of Community
Medicine
• A major driving force in furthering the
cause of human health and development!
• Simple Public Health measures like
Safe Water Supply, Sanitary Excreta
Disposal, Vaccination and Vector control
measures has saved many more lives
than would have been saved by all the
dazzling advancement of curatives and
diagnostics put together.

7. Contributions of Community
Medicine
• Smallpox Eradication
• Guinae worm Eradication
• Polio Eradication
• Elimination of Leprosy
• Elimination of Neonatal Tetanus
• Control of Maternal and Child Mortality and Morbidity
• Control of IDD, Vit A deficiency, Iron Deficiency and so on…..
• Improved health planning (policies and system)

8. Clinical vs Preventive
Medicine Medicine
• Cater to individual patient
• Abstract, invisible
• Focus on cure of diseases
and immediate sufferings
• Bring immediate
gratification form patient;
his family and friends and
the community at large.
• Cater to Masses (community)
• Concrete, visible
• Focus on promotion and
protection of health and
prevention of diseases
• Results are not easily
recognizable, measurable
and quantifiable!!
< 1% of national health budget is spent on public health

9. Definition of Public Health
• Public health is the science and art
of Preventing disease, Prolonging
life, and Promoting health through
the organized efforts of society.
• Goal is – biologic, physical, mental
and social well being of all.

10. Functions of Public Health
I. Use of technology, social science
and politics to-
a) Identify and quantify current problems
b) Identify appropriate strategies and to
implement these with community
participation
c) Evaluate their effectiveness
d) Anticipate, Plan Mid Term Corrections
and prevent future problems

11. II. Identify Measure to Monitor
health outcomes via Surveillance
of Disease & RFs
III.Formulate, Promote, and Enforce
sound health policies– e.g. Notifying
highly transmissible diseases,
environmental threats.
IV.Influencing politics especially in
democracy is an essential function
of public health
V. Plan Equity for Equality

12. – To ensure a healthy environment
• education of the public,
• formulation of sound regulations, and
• influencing policy,
– Disaster preparedness and prediction
and prevention of natural disasters since it’s
prediction is not possible
–The quality of Public Health is
dependant on the competence and
vision of the public health workforce

13. Main causes of Death and Global Burden
of Disease (DALYs)
30%
30%
9%
9%
13%
7% 2%
Deaths
39%
10%
13%
28%
5%
4%
1%
DALYS
Injuries
Communicable diseases,
maternal and perinatal
conditions, and nutritional
deficiencies
Communicable diseases,
maternal and perinatal
conditions, and nutritional
deficiencies
CVDs
Injuries
CVDs
Other chronic
diseases Other chronic
diseases
Cancer
Chronic Resp.
Disease
Diabetes Diabetes
Chronic Resp.
Disease
Cancer
Source: WHO, Preventing chronic disease: A vital investment. (online). 2005
http://whqlibdoc.who.int/publications/2005/9241563001_eng.pdf.

14. An important task for PH Experts
• Raise the anxiety of the public about the
problem, to the level; at which they
are willing to take an appropriate action
• This requires “judgment about
Level” ! If its too high it can stigmatize
and may be fatal; HIV/AIDS !!

15. Most Successful PH Intervention
so far….
• An improved standard of living including
provision of clean water, and safe
disposal of wastes
• Unfortunately these interventions are
beyond reach to many
• Underlying almost all of the public
health problems is poverty and
ignorance

16. Public Health Interventions
• Social, Biologic &/or Environmental
Interventions
• Behavioral Interventions
• Political Interventions
• Structural Interventions

17. Social, Biologic &/or Environmental
Interventions:
• Immunization – most cost effective, in
part bcz it requires minimal behavioral
change & usually only a single action
• Utilization strategies of vaccines are more
important than development and production of
vaccine
• Eliminate vector of diseases - DDT !
• Early Dx and Treatment of Diseases -

18. Behavioral interventions
• Personal Level – promoting healthy habits and
avoiding damaging actions
(e.g. smoking, alcohol, and drug use).
• Modifying community norms – acceptable
sexual behavior, stigmatizing diseases, dependency
disorders, to promote a healthy lifestyle including
all segments of the society
• Using natural leaders as change agents !

19. Political Intervention
• Public Health is Politics
• Any process which involves obtaining public
support involves politics and differing point of
views e.g. strong apposition of antismoking
campaign by tobacco industry
• Political support in order to pass laws and
regulations limiting smoking, placing health
warnings on cigarette pack and raising tax was
required to counter the efforts of industry
• Political support to safeguard Envt!!

20. Structural Intervention
• The end result of Political Process is
passage of Laws & regulations
• If implemented; can have tremendous
impact on the health of the public
• Use of helmets lead to reduction in brain
injuries & deaths.
• Reduction in incidence of Lung cancer &
Heart disease after laws regulating smoking
& raised Taxes

21. Future of Public Health
• We could add years to life but Alziemers has
taken away the quality of life!
• Emerging infections- H5N1 Influenza
may mutate to cause human to human
transmission
• Environmental degradation
• Unchecked population growth
• Widening gap between rich and poor
• Injuries and violence
• WAR

22. 0
10
20
30
40
50
60
Trends in global years of life lost (YLL)
PER 1000 Population
Series1
Series2
Series3
2005
2015
2030

23. Ten leading causes of deaths & DALYS, Projection from 2002 to 2030
World wide Disease or injury
Percent of
Total Deaths Rank Disease or injury
Percent of Total
DALYS 2030
Ischemic Heart Disease 13.4 1 HIV/AIDS 12.1
CVD 10.6 2
Unipolar depressive
disorders 5.7
HIV/AIDS 8.9 3 Ischemic Heart Disease 4.7
COPD 7.8 4 Road Trafic Accidents 4.2
Lower RTI 3.5 5 Peri natal Conditions 4
Trachia, Bronchus,
Lung Cancers 3.1 6 CVD 3.9
Diabetes mellitus 3 7 COPD 3.1
Road Trafic Accidents 2.9 8 LRTI 3
Peri natal Conditions 2.2 9 Hearing loss adult onset 2.5
Stomach Cancer 1.9 10 Cataract 2.5

24. High Income
Countries
Ischemic Heart
Disease 15.8 1
Unipolar depressive
disorders 9.8
CVD 9 2
Ischemic Heart
Disease 5.9
Trachia,
Bronchus, Lung
Cancers 5.1 3
Alzimers & other
Dementias 5.8
Diabetes mellitus 4.8 4
Alcohol use
disorders 4.7
COPD 4.1 5 Diabetes mellitus 4.5
Lower RTI 3.6 6 CVD 4.5
Alzimers & other
Dementias 3.6 7
Hearing loss adult
onset 4.1
Colon & other
rectal cancers 3.3 8
Trachia, Bronchus,
Lung Cancers 3
Stomach Cancer 1.9 9 Osteoarthritis 2.9
Prostate cancer 1.8 10 COPD 2.5
Ten leading causes of deaths & DALYS, Projection from 2002 to 2030

25. Ten leading causes of deaths & DALYS, Projection from 2002 to 2030
Middle Income Countries
CVD 14.4 1 HIV/AIDS 9.8
Ischemic Heart
Disease 12.7 2
Unipolar
depressive
disorders 6.7
COPD 12 3 CVD 6
HIV/AIDS 6.2 4
Ischemic Heart
Disease 4.7
Trachia,
Bronchus, Lung
Cancers 4.3 5 COPD 4.7
Diabetes
mellitus 3.7 6
Road Trafic
Accidents 4
Stomach Cancer3.4 7 Violence 2.9
Hypertensive
heart disease 2.7 8 Vision disorders 2.9
Road Trafic
Accidents 2.5 9
Hearing loss adult
onset 2.9
Liver cancer 2.2 10 Diabetes mellitus 2.6

26. Low Income
Countries
Ischemic Heart
Disease 13.4 1 HIV/AIDS 14.6
HIV/AIDS 13.2 2
Peri natal
Conditions 5.8
CVD 8.2 3
Unipolar depressive
disorders 4.7
COPD 5.5 4
Road Trafic
Accidents 4.6
Lower RTI 5.1 5
Ischemic Heart
Disease 4.5
Peri natal
Conditions 3.9 6 LRTI 4.4
Road Trafic
Accidents 3.7 7 Diarhoeal disease 2.8
Diarhoeal
disease 2.3 8 CVD 2.8
Diabetes mellitus2.2 9 Diabetes mellitus 2.8
Malaria 1.8 10 Malaria 2.5
Ten leading causes of deaths & DALYS, Projection from 2002 to 2030

27. Health Equity
• The absence of unfair and avoidable or
remediable differences in health among
population groups defined socially,
economically, demographically or
geographically (WHO 2004)
• Alma Ata declaration on Primary Health
Care 1978
• The Ottawa Charter on Health Promotion –
1986 health equity as a Policy Goal emerged
strongly

28. Framework for
Determinants of Health
• Where do health differences among social
group originate- root causes?
• What pathways lead from root causes to
the stark differences in health status
observed at Population Level?
• Where & How should we intervene
to reduce health inequities?

29. Evidence for the Role of Social
Organization
• Whitehall study (Marmot et al 1978)
social gradient in health status is
reflected across all segments of
socioeconomic spectrum- not just rich vs
poor
• Robert Virchow 1985 (1948) wrote – “Do
we not always find the disease of
the populace traceable to defects in
society ”

30. Evidence for the Role of Social
Organization
• “A given model of social
organization -determines and
shapes to a significant extent the
options individual have and then
possibility for their change ”

31. Paradigms for health Determinants
• Biomedical – since late 1800
• Individual lifestyle and behavior –
1970s (Lalonde Report to Govt. of Canada,
1974 stated four major influences on health
:- Human biology, Environment, Lifestyle &
Healthcare organizations). Unfortunately its
interpretation got mislead!
• Social Approach to Health – patterns of
disease within populations are socially
produced (increasing clarity by
Epidemiological evidence)

32. Concepts of Health and Disease
• Biomedical Concept – “germ theory”
• Ecological Concept – “health as a
dynamic equilibrium between man and
his environment”
• Psychosocial concept – “influence of
social, psychological, cultural, economic
and political factors on health”
• Holistic Concept – All sectors of
society influence health
32

33. Disease?
• A condition where health is impaired
• Departure from health
• A deviation in performance of normal
body functions
But this requires defining health
33

34. Health?
Seeking perfect definition
continues… Few prevalent are:
Webster- “The condition of being sound
in body, mind or sprit, especially
freedom from disease or pain ”
Oxford Dictionary – “Soundness of
body & mind, that condition in which
its functions are duly and efficiently
discharged ”
34

35. Health?
• Perkins – “A state of relative
equilibrium of body form and its
functions which results from successful
dynamic adjustment to the forces tending
to disturb it.
• It is not passive interplay between body
and forces impinging upon it but an
active response of body forces working
towards readjustment.

36. 36
Health? WHO Definition…
……………………………………idealistically
‘A state of Complete Physical, Mental, and
Social Wellbeing; Not merely the absence of
Disease or Infirmity.’
A positive phenomenon
A dynamic State
The ability to lead a “socially and economically
productive life”

37. Health?
WHO; (Operational definition) –
Broader view:
“A condition or the quality of human
organism expressing the adequate
functioning of the organism in given
conditions; Genetic & Environmental”
• Ctd….
37

38. Operational Definition of Health
• Narrow down for measuring
purposes: health means;
– No obvious evidence of disease,
functioning is within normal limits of
variation to the standards of health
criteria as per one’s age, sex, community
& geographic region
–Organs of the body are functioning
adequately in themselves & in relation
to other organs
38

39. Philosophy of Health
• Health is a fundamental human right
• ..is essence of productive & quality life; you
can’t be buy health
• ..is intersectoral
• ….is an integral part of development
• ….involves individual, State, Nation and
International responsibility
• ….is world wide social goal
39

40. Dimensions of Health
• Physical
• Social
• Mental
• Spiritual
• Psychological
• Vocational
• Political etc
40
Positive Health: Hard to achieve;
Ultimate Goal
Health- A Relative Concept: Health
Standards can never be universal
because “Normal” vary from country
to country and also within
socioeconomic groups.

41. Determinants of Health
• Intrinsic Factors
–Age, sex, genetic pool,
immunological status, health
related behavior
• Extrinsic Factors
–Physical Env., Biological Env.,
Social Env.,

42. Concept of “Wellbeing”
• Wellbeing has two components-
I. Objective: Standard of living/ Level of
living(USA)
II. Subjective: Quality of Life
I. Objective: Standard of living :
Refers to the usual scale of expenditure,
the goods we consume & the services we
enjoy. Measured as per capita GNP ctd…
42

43. WHO Def:
“Income & occupation, Standards of
housing, Sanitation & nutrition,
Level of provision of health,
Education, Recreational and other
services may all be used individually
as measures of socioeconomic
status & collectively as an Index of
the ‘Standard of Living”

44. Contd…
Level of living - has 9 component –
Health,
Food consumption,
Education,
Occupation & working conditions,
Housing,
Social security,
Clothing,
Recreation &
Human rights.

45. II- Subjective: Quality of life-
WHO definition- “The condition of life resulting
from the combination of the effects of the complete
range of factors determining health, happiness
(including comfort in physical environment and a
satisfying occupation), education, social and
intellectual attainments, freedom of action, justice
and freedom of expression”.
This means increased emphasis on social policy
and on reformulation of societal goals to make
life more livable for those who survive.
45

46. Measures of Quality of Life -
1. Physical Quality of Life Index (PQLI):
consolidate three indicators - giving each equal
weight i.e. from ‘0-100’
• Infant Mortality
• Life Expectancy at Age One &
• Literacy
• Resulting PQLI (Composite Indicator)
thus is also placed on ‘0 to 100’ scale.
These components measure output rather
than inputs
• GNP is not included? – 46

47. Measures of Quality of Life (contd…)
2.Human Development Index (HDI)
A composite Index combining indicators representing three
dimensions –
Longevity (life expectancy at birth);
Knowledge (adult literacy rate and mean years of
schooling); and
Income (real GDP Per Capita in Purchasing Power
Parity in US dollars).
Indicating - Leading a long life, being knowledgeable
and enjoying a decent standard of living
HDI values range between ‘0 to 1’
47

48. How to calculate HDI:
To construct the Index;
fixed MINIMUM & MAXIMUM values are set for each of
these Indicators- longevity, knowledge & income
For Longevity: MIN. MAX
Life Expectancy at Birth: 25 yrs and 85 yrs
For Knowledge:
Adult Literacy Rate (AL): 0 % and 100%
Combined Gross enrolment ratio(CGE): 0 % and 100%
For Income:
Real GDP per capita (PPP$): $ 100 and $ 40,000
48

49. General formula for calculating any component of
the HDI Index = (Actual X1 value) – (Minimum X1 value)
(Maximum X1 value) - (Minimum X1 value)
Example:
1. If LE at birth in India is 64 yrs, then
LE index = 64-25/ 85-25= 0.65
2. For Education Index-
First calculate an index for Adult Literacy And Combined
Gross Enrollment AND then
Combine these two to create Education Index giving 2/3
weight to AL & 1/3 wt to CGE.
If AL Rate in India is 67 % Adult Literacy Index; = 67-0/100-0= 0.67
If Combined Gross enrolment Ratio in India is 58% Combined Gross
enrolment Index, = 58-0/100-0 = 0.58
So education Index = 2/3 * 0.67 + 1/3 * 0.58 = 0.6449

50. • GDP Index is calculated using adjusted GDP/ capita
(PPP$). This serve as a substitute for all those
component in HDI which are not reflected by life
expectancy and knowledge.
• If the real GDP per capita (PPP$) for India is 1670,
then GDP Index = log (1670)- log (100)/
(log40000- log 100) = 0.47
• HDI now is simple Average of all these three
i.e. HDI for India = 0.65 + 0.64 + 0.47/ 3 = 0.587
Interpretation
• High HDI = > 0.800, (Canada, USA, Norway etc)
• Medium HDI = 0.500-0.790 (India….)
• Low HDI= < 0.500 (Ethiopia…) 50

51. • Positive Health
• Good Health
• Freedom from Sickness
• Unrecognized Sickness
• Mild Sickness
• Severe Sickness
• Death
51
Spectrum
of
Health
Health is a process of continuous change

52. Determinants of Health
• Interaction of Genetic & Environmental Factors
• Biological Determinants
• Environment
• Internal
• External
• Socio-economic conditions (education, income,
occupation, political system, aging population)
• Socio-cultural & behavioral conditions (Gender)
• Health Services
• Others
52

53. Framework for Determinants of Health
• Central challenges for PH today –
not just improving Average
Health Indicators, but reducing
the unfair differences in health
among social groups between &
within countries.

54. ?
• Where do health differences among
social group originate- root causes?
• What pathways lead from root
causes to the stark differences in
health status observed at Pop.
Level?
• Where & How should we intervene
to reduce health inequities?

55. Social Determinants of Health & Health Policies
Socioeconomic
Political Context
Governance
Macroeconomic
Policies
Social Policies
(Labour market,
Housing, Land)
Public Policies,
(Education, Health,
Social protection)
Culture & Societal
Values
Material Circumstances
(Living & Working
Condition, Food
Availability, etc.)
Socio-economic Position
Social Structure – Social
Class
Education
Income
Occupation
Psychosocial Factors
Behaviors & Biological
Factors
Social Determinants of
Health
Gender Ethnicity
(Racism) Social cohesion & Social Capital
Social Determinants of Health Inequities
Health System
Impact
on
Equity
In
Health
&
Well-
Being

56. Tier System for Health Provision
• Primary Level – SC and PHC
(first contact)
• Secondary Level – CHC and DH
(first referral level)
• Tertiary Level – Medical College
and Super-specialty Hospitals
(Second referral level)

57. HFA
“Attainment by all people of the World;
a level of health that will permit them
to lead a Socially and Economically
productive life” BY 2000

58. Concept of HFA
• Alma-Ata Declaration 1978 (134
countries approved)
–HFA Is achievable by 2000
–‘Primary Health Care’ is the Key
Strategy
–Government is responsible

59. NEW Global HFA Policy –
“ Health For All in 21st Century”
10 global Health Targets under three sub
heads :-
1. Target for Health Outcome (4)
2. Target for Determinants of Health (2)
3. Targets for Health Policies and
Sustainable Health Systems (4)

60. 1. Target for Health Outcome
1. Use of “childhood stunting” as indicator of Equity by 2005
2. Survival – by 2020 MMR of <100/100000 LB, U5CMR
<45/1000LB and LE at Birth of > 70 years to be achieved
3. Reversal of global trends in 5 major pandemics caused by
TB, HIV/AIDS, Malaria, Tobacco related diseases, and
violence/ trauma by 2020
4. Eradication and Elimination of certain Diseases by
2020 (eradication of measles and Elimination of lymphatic
filariasis; trachoma, Vit A and Iodine Deficiency), Leprosy
will be Eliminated by 2010 and Transmission of Chagas
disease will be interrupted by 2010

61. 2. Target for Determinants of Health
5. Improved access to water, sanitation,
food, shelter and manage major Env.
Risk to health by 2020 via intersectoral
action
6. Measures to promote health by 2020 via
a combination of Regulatory, Economic,
Educational, Organizational and
Community based programs

62. Targets for Health Policies and
Sustainable Health Systems
7. Development, implementation and
monitoring of national “HFA” policies by
2005
8. Improved access to comprehensive
essential health care by 2010
9. Implemetation of global and national
health information and surveillance
system by 2010
10. Supporting research for health by 2010

63. Primary Health Care
(as Strategy)
Essential health care based on
scientifically sound, practical,
socially acceptable methods and
technology, made universally
available through community
participation at a cost that the
community and country can afford.

64. Components of PHCare
1. Health Education
2. MCH including FP
3. Promotion of proper nutrition
4. Immunization
5. Adequate supply of Safe water
6. Basic Sanitation
7. Prevention and Control of Endemic Diseases
8. Appropriate treatment for common diseases and
Injuries

65. Indicators of Health
To compare health of people of different
locations or of same location at different times.
Characteristics of indicators:
Valid
Reliable & Objective
Sensitive
Specific
Feasible
Relevant
65