a close view of the various models of public health

1. Public Health Model
Dr Soumya Swaroop Sahoo

2. Contents
• Public health-introduction
• What is a public health model (PHM)
• Types of PHM
• PHM examples
• PHM in India
• References

3. What is public health
• Public health refers to all organized measures to
prevent disease, promote health, and prolong life
among the population as a whole
-WHO
• Its activities aim to provide conditions in which
people can be healthy and focus on entire
populations, not on individual patients or diseases.
• Thus, public health is concerned with the total
system and not only the eradication of a particular
disease.

4. What is public health
• The span of public health is to look at
some notable public health
campaigns:
– Vaccination and control of infectious
diseases
– Safer and healthier foods
– Safe drinking water
– Healthier mothers and babies and access
to family planning
– Decline in deaths from coronary heart
disease and stroke
– Recognition of tobacco use as a health
hazard.
– Motor-vehicle safety

5. Public health model(PHM)
• A model that addresses health or social problems in
a comprehensive way.
• It considers human factors, characteristics of the
source of harm, and the environment, identifies
causes and suggests possible interventions.
• The public health model takes a population
approach to health promotion and disease
prevention.

6. Public health model focuses not only on traditional
areas of diagnosis, treatment, and etiology, but also on
• epidemiologic surveillance of the health of the
population at large,
• health promotion,
• disease prevention, and
• access to and evaluation of services
Public health model(PHM)

7. Public Health Approach
Public Health
Model
Medical
ModelVersus

8. PHM
• Public health models aim to prevent problems
by
– targeting policies and interventions at the known risk
factors for the problem,
– quickly identifying and responding to problems if
they do occur, and
– minimising the long-term effects of the problems
-WHO, 2006
• In the public health model of disease prevention,
preventative interventions are described as either
primary, secondary, or tertiary interventions .

9. • The public health model is a concept with
application in many disciplines
 health,
 education
 social welfare.
• It is an epidemiological model that attempts to
prevent or reduce a particular illness or social
problem in a population by identifying risk
factors.
PHM

10. Steps in designing a PHM
Define the problem
Identify risk and protective factors
Develop and test intervention
strategies
Assure widespread adoption and
evaluation

11. "who", "what", "when",
"where" and "how"
associated with it.
• magnitude of the
problem by analyzing
data like number of
violence-related
behaviours, injuries, and
deaths
•Data demonstrates how
frequently violence
occurs, trends, and who
the victims and
perpetrators are.
Risk Factor - Characteristic
that increases the
likelihood of a person
becoming a victim or
perpetrator of violence.
•Protective Factor - that
decreases the likelihood
of a person becoming a
victim or perpetrator of
violence .
Research data and findings
from needs assessments,
community surveys for
designing prevention
programs.
• Once programs are
implemented, they are
evaluated rigorously to
determine their
effectiveness
programs having been
proved effective, must
be implemented and
adopted broadly.
• Communities are
encouraged to
implement programs
and to evaluate the
success.
• Dissemination
techniques to
promote widespread
adoption
PHM for violence prevention
Define the
Problem
Identify Risk
and Protective
Factors
Develop and
Test Prevention
Strategies
Assure
Widespread
Adoption

12. Public health pyramid
Tertiary
Provide
interventions for
those affected
Secondary
(Programs targeted at
families in need to alleviate
identified problems and
prevent escalation)
Primary (Universal)
(Programs targeted at entire
population in order to provide
support and education before
problems occur)

13. Primary prevention
– Primary prevention consists of activities that are targeted
towards the whole community.
– These activities are meant to impact families and communities
prior to any allegations of abuse and neglect. It includes:
– Parent education programs and support groups that focus on
child development,and the roles and responsibilities of
parenting
– Family strengthening programs that enhance a family’s ability
to access existing services and resources to support positive
interactions among family members
– Public awareness campaigns that provide information on how
and where to report suspected child abuse and neglect
PHM for child welfare services

14. Secondary Prevention
– consists of activities targeted to families that have one or
more risk factors such as poverty, mental health problems,
marital discord, alcohol and drug use .
They include:
– Parent support groups that help parents deal with their
everyday stresses and meet the challenges and
responsibilities of parenting
– Home visit programs that provide support and assistance
– Early screening of children with special needs
– Parent education programs focusing on teen parents, or
those undergoing substance abuse treatment programs
and problem families.
PHM for child welfare services

15. Tertiary prevention
– consists of activities targeted to families that have confirmed child
abuse and neglect reports.
– These families have already demonstrated the need for
intervention for services under child welfare programs.
They include:
– Parent mentor programs with stable, non-abusive families acting
as "role models" and providing support to families in crisis
– Intensive family preservation services with trained mental health
counsellors.
– Parent support groups that help parents transform negative
practices and beliefs into positive parenting behaviours and
attitudes
– Mental health services for children and families affected by
maltreatment to improve family communication and functioning
PHM for child welfare services

16. PHM: Uses
• Organize thinking
• Guide design of intervention
• Help us to evaluate the effects of intervention
for the benefit of the community at large

17. Types of public health models
• Health belief model
• Trans-theoretical model /Model of change
• Socio-ecological model
• PATCH model
• PERI model
• PRECEDE-PROCEED model

18. Health belief model
• Health Belief Model (HBM) is a psychological model that
attempts to explain and predict health behaviors.
• This is done by focusing on the attitudes and beliefs of
individuals.
• It was developed in response to the failure of a free
tuberculosis (TB) health screening program.
• Since then, the HBM has been adapted to explore a
variety of long- and short-term health behaviors,
including sexual risk behaviors and the transmission of
HIV/AIDS.

19. • The HBM is based on the understanding that a person
will take a health-related action (i.e., use condoms) if
that person:
– feels that a negative health condition (i.e., HIV) can
be avoided,
– has a positive expectation that by taking a
recommended action, he/she will avoid a negative
health condition (i.e., using condoms will be effective
at preventing HIV), and
– believes that he/she can successfully take a
recommended health action (i.e., he/she can use
condoms comfortably and with confidence).
Health belief model

20. CONCEPT
Perceived
susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Cues to action
Self efficacy
DEFINITION
One’s opinion of chances of
getting a condition
One’s opinion of how serious a
condition and its consequences
are
One’s belief in the efficacy
of the advised action to
reduce the risk
One’s opinion of the
tangible and psychological
costs of the advised action
Strategies to activate
readiness
Confidence in one’s ability
to take action
APPLICATION
Define population at risk, risk levels;
personalize risk based on a person’s
behaviour
Specify consequences of the risk and
the condition
Define action to take; how, where,
when; clarify the positive effects to
be expected.
Identify and reduce barriers through
reassurance, incentives, assistance.
Provide how-to do information,
promote awareness
Provide training, guidance in
performing action.

21. concept
Perceived
Susceptibility
Perceived Severity
Perceived Benefits
Condom use
education
example
Youth believe they can get STIs or
HIV or create a unwanted
pregnancy.
believe that the consequences of
getting STIs or HIV or creating a
pregnancy are significant enough
to try to avoid
recommended action of using
condoms would protect them
from getting STIs or HIV or
creating a pregnancy.
STI
screening or
HIV testing
Youth believe they may have
been exposed to STIs or HIV.
believe the consequences of
having STIs or HIV without
knowledge or treatment are
significant enough to try to
avoid.
believe that the recommended
action of getting tested for STIs
and HIV would benefit them —
by allowing them to get early
treatment or preventing them
from infecting others

22. concept
Perceived barriers
Cues to action
Self efficacy
Condom use
education
example
Youth identify their personal
barriers to using condoms (i.e.,
condoms limit the feeling or they
are too embarrassed to talk to
their partner about it) and
explore ways to eliminate or
reduce these barriers
Youth receive reminder cues for
action in the form of incentives
(such as with the printed
message "no glove, no love") or
reminder messages
Youth confident in using a
condom correctly in all
circumstances
STI
screening or
HIV testing
Youth identify their personal
barriers to getting tested (i.e.,
getting to the clinic or being seen
at the clinic by someone they
know) and explore ways to
eliminate or reduce these
barriers
receive reminder cues for action
in the form of incentives (such as
pencils that says, "Got sex? Get
tested!") or reminder messages
(that say, "25% of sexually active
teens contract an STI)
Youth receive guidance (such as
information on where to get
tested) ,counselling and training

23. Trans theoretical model
• The transtheoretical model of behaviour change assesses an
individual's readiness to act on a new healthier behaviour,
and provides strategies, or processes of change to guide the
individual through the stages of change.
• uses stages of change to integrate processes and principles of
change from across major theories of intervention, hence the
name 'Trans -theoretical’

24. Stages of change

25. It is common for people to change gradually —
from being uninterested, to considering a
change, to deciding and preparing to make a
change — over months and years.
Change is a Process Rather Than
an Event

26. Five Stages of Change
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
People in this Stage
1. No intent to change yet,
unaware or deny personal
relevance
2. Aware of the problem,
ambivalent about change
3. Getting ready to change,
choosing a plan
4. Trying to change, not yet
consistent in doing it
5. Practice being consistent,
avoid slipping back
1. “There’s nothing I
really need to change”
2. “It might be good for
me, but it’s too hard”
3. “I’ve started to make
small changes”
4. “I wish I was more
consistent”
5. “I’m working hard not
to lose the progress I’ve
made”
Stage of Change…Details

27. • Precontemplation- Stage of change in which people
are unwilling to change behaviour
• Contemplation- Stage of change in which people
consider to change behaviour
• Preparation- Stage of change in which people get
ready to make a change
• Action- Stage of change in which people are actively
changing a negative behaviour or adopting a new,
healthy behavior
Transtheoretical model

28. • Maintenance - Stage of change in which people
maintain behavioral change
• Termination/adoption stage-Stage of change in
which people have eliminated an undesirable
behaviour or maintained a positive behaviour
• Relapse-To slip or fall back into unhealthy
behavior(s) or fail to maintain healthy behaviours
Transtheoretical model

29. Example: Physical inactivity

30. Socio-Ecological Model
• A model of health that emphasizes the linkages
and relationships among multiple factors(or
determinants) affecting health.
• A rainbow-like figure of five bands represents
the SEM.
• At the core of the model is the
individual(intrapersonal), surrounded by four
bands of influence representing the
– interpersonal,
– organizational,
– community, and
– policy levels.

31. Socio-Ecological Model

32. individual
interpersonal
organizational
community
Public policy

33. PATCH Model
• P lanned
• A pproach
• T o
• C ommunity
• H ealth

34. • The Planned Approach to Community Health
(PATCH) was developed in 1983 by
the United States Centers for Disease
Control(CDC) in partnership with state and
local health departments and community
groups.
PATCH Model

35. PATCH: phases
• Phase I: Mobilizing the community
• Phase II: Collecting and organizing data
• Phase III: Choosing priorities
• Phase IV: Developing a comprehensive
intervention plan
• Phase V: Evaluating PATCH

36. PATCH Model: example
• In Baltimore, PATCH was implemented to improve the mental health
among elderly people living in urban public housing developments.
• Health workers were trained to identify and refer residents who may
need mental health care to a PATCH nurse.
• Psychiatric nurses, with consultation and supervision from psychiatrists,
provided psychiatric evaluation and treatment in the residents’ homes.
• Investigators evaluated the PATCH program to determine whether it is
more effective than usual care in decreasing levels of depression and
other psychiatric symptoms.

37. • A total of 945 (83%) of 1,195 residents in six public housing
sites were screened for psychiatric illness
• 342 screened positive.
• Residents in 3 building sites received the PATCH model
intervention; residents in the other 3 building sites received
usual care (comparison group).
• Results:
• Residents with mental disorders who lived in housing sites
where the PATCH program was available had significantly
fewer symptoms of depression and other psychiatric
symptoms at the end of 26 months than residents with mental
disorders who lived in the randomly-selected comparison
housing sites where the PATCH program was not available.
PATCH Model: example

38. PERI Model
• Problem- What is the health problem?
• Etiology- What is/are the contributory
cause(s)?
• Recommendations- What works to reduce the
health impacts?
• Implementation- How we get the job done?

39. PERI Model
Problem
Etiology
Recommendation
Implementation

40. PRECEDE –PROCEED Model
• PRECEDE/PROCEED is a community-oriented,
participatory model for creating successful
community health promotion interventions
• By Green and Kuerter(2005)
• PRECEDE: Predisposing, Reinforcing &
Enabling Constructs in Educational/Ecological
Diagnosis & Evaluation
• PROCEED: Policy, Regulatory &
Organizational Constructs in Educational and
Environmental Development

41. PRECEDE: :4 Phases
• Phase 1: Social diagnosis
• Phase 2: Epidemiological
diagnosis
• Phase 3: Educational and
ecological diagnosis
• Phase 4: Administrative and
policy diagnosis
PROCEED : 4 Phases
• Phase 5: Implementation
• Phase 7: Process evaluation
• Phase 8: Impact evaluation
• Phase 9: Outcome
evaluation
PRECEDE –PROCEED Model

44. PHM:INDIA’s SUCCESS STORY
Society for Education,
Action and Research in
Community Health
(SEARCH), Gadchiroli,
Maharashtra
• SEARCH was founded in
Gadchiroli district in 1986.
• Its founders, Dr Abhay
Bang and Dr Rani Bang,
received their medical
training in India and their
training in public health at
Johns Hopkins University.

45. • 3 Missions
i) providing health care to local populations,
ii) training and education in health
iii) research to help shape health policies.
SEARCH conducted a field trial in Gadchiroli on home-
based neonatal care from 1993 to 1998.
They trained village health workers (aarogyadoot) to
make home visits and manage birth asphyxia,
premature birth or low birth weight, hypothermia,
breast-feeding problems, in addition to diagnosing
and treating neonatal sepsis.
PHM:INDIA’s SUCCESS STORY

46. • 39 Intervention and 47 control villages were selected in Gadchiroli
district
• SEARCH's strategy to curb infant deaths relies on training community
health workers to diagnose and treat newborn diseases and has been
dramatically successful in reducing IMR.
• Over a span of 15 years, SEARCH has been able to reduce IMR in its
intervention area by 75% to 30, by providing home-based newborn care
(HBNC)
• A 1999 Lancet research paper by Abhay Bang and his colleagues at
SEARCH, based on their interventions in Gadchiroli, showed for the first
time how very sick newborn babies could be saved even in poor nations
with a novel cost-effective strategy. Bang's paper found a place in a 2005
compilation of "vintage papers" in the 180-year-old history of Lancet.
PHM:INDIA’s SUCCESS STORY

47. Gadhchiroli: Turning the tide

48. Selecting a Specific Model to apply will be
based on:
 The preferences of stakeholders (e.g., decision makers,
program partners, consumers);
 How much time is available for planning purposes;
 How many resources are available for data collection and
analysis;
 The degree to which clients are actually involved as partners
in the planning process or the degree to which your planning
efforts will be consumer-oriented (i.e., planning is based on
the wants and needs of consumers)

49. Criteria for implementation
 Fluidity: Steps in the planning process are sequential,
or that they build upon one another
 Flexibility: Planning is adapted to the needs of
stakeholders
 Functionality: the outcome of planning is improved
health conditions, not the production of a program
plan itself

50. Advantages
• Provides direction
• Non-biased approach
• Uncovers hidden problems
• Provides evaluation measures

51. Challenges
• Learning before doing
• Understanding theory/model
• Finding the data
• Create problems for un-experienced program
planners
• Takes time and resources before
implementation

52. References
• Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and
Health Education. Theory, Research and Practice. San Fransisco:
Wiley & Sons.
• www.cdc.gov/violenceprevention/overview/publichealthapproach.
html
• Prochaska, James O., and Carlo C. DiClemente. "Stages And
Processes Of Self-change Of Smoking: Toward An Integrative
Model Of Change.." Journal of Consulting and Clinical Psychology
51.3 (1983): 390-395.
• http://www.hindustantimes.com/news-feed/chunk-ht-ui-
trackinghunger-intro/gadchiroli-s-trudging-doctors-spell-
hope/article1-842172.aspx#sthash.BdWqznng.dpuf
• National Institutes of Health. Theory at a Glance: A Guide for
Health Promotion Practice. Bethesda, MD: National Institutes of
Health, National Cancer Institute; 1995.