Transcript DETERMINANTS OF HEALTH

DETERMINANTS OF HEALTH
Biological determinants
Behavioral & Socio-cultural condition
Environmental Social –economic conditions
Health services
Aging of population
Gender
Other factors
DETERMINANTS OF HEALTH
Biological determinants
Physical, mental ,genetic make up
Behavioral & Socio-cultural condition
lifestyle ,cultural, behaviour ,personal
habits & addiction(eg smoking,alcohol)
Environmental Social –economic conditions
Internal
External
DETERMINANTS OF HEALTH
 Social –economic conditions
economic status, education, occupation,
political system
Health services
family welfare services,treatment of diseases
Prevention of illness, promotion of health
Immunization “Primary health care”
DETERMINANTS OF HEALTH
Aging of population
increases chronic diseases & disability
Gender
Nutrition , reproductive health , violence,
aging , lifestyle condition
Other factors
mass media, health related system(Food
agriculture, education , industry, rural
development)
DETERMINANTS
OF HEALTH
Biological
Human rights
Behavioural
Equity and social
justice
Environmental
Communities
Families
Gender
V
Health
Health
Societies
Socio-economic
Individuals
Information &
communication
Health system
Science &
technology
Socio-cultural
Aging of the population
• Indicator ?
Health care Indicators
variable which help to measure changes (WHO)
• How healthy is a given community?
• Indicators requires - to know health status of
country
- to compare health status with
another
- to assess the health care need
- for allocation of scarce resources
- monitoring & evaluation of health
services, activities & programmes
Health Indicators Vs
Health index(indice)
In relation
to health trend
Amalgamation of
health indicators
Characteristics of Indicators
Ideal indicator should be
Valid
Reliable & objective
Sensitive
Specific
Feasible
Relevant
Classification on indicators
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Mortality indicators
Morbidity indicators
Disability rates
Nutritional status indicators
Health care delivery indicators
Utilization rate
Indicators of social and mental health
Environmental indicators
Socio-economic indicators
Health policy indicators
Indicators of quality of life
Other indicators
Mortality indicator
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Crude death rate
Expectation of life
_ at birth
_ at age of 1
_ at age of 5
Infant mortality
Child mortality rate
Under-5 proportionate mortality rate
Maternal(puerperal) mortality rate
Disease –specific mortality
Proportional mortality rate
Morbidity indicators
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Incidence & prevalence
Notification rate
Attendance rate at OPD, health centers etc.
Admission ,readmission & discharge rate
Duration of stay in hospitals
Spell of sickness or absence from work or
school
Disability rates
A) Event type indicators
1) number of days of restricted activity
2) bed disability days
3) work loss days (or school loss days)
with in a specific period
B) person type indicators
1)limitation of mobility
2)limitation of activity
Sullivan’s index (expectation of life free of disability)
HALE
DALY
QALY
Nutritional status indicators
• Anthropometric measurement of preschool
children
• Height (or weight)of children at school entry
• Prevalence of low birth weight (<2.5kg)
Health care delivery indicators
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Doctor- population ratio
Doctor –nurse ratio
Population- bed ratio
Population per health / sub center
Population per traditional birth attendant
Utilization rates
• Proportion of infant fully immunized against
6EPI diseases
• Proportion of pregnant women who receive
antenatal care
• Percentage of population using the various
methods of family planning
Indicators of social & mental health
• Suicide , homicide, violence ,alcohol ,drug
abuse, smoking
• Family violence ,battered baby or battered
wife syndrome
Environmental indicators
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Air & water pollution
Radiations
Solid waste
Exposure to toxic
Access to safe water & sanitation
Socio –economic indicators
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Rate of population increase
Per capita GNP
Level of unemployment
Dependency ration
Literacy rate
Family size
Housing : number of person per room
Per capita calorie availability
Developed & developing region
• Social & economic
• Demographic characteristics
• Contrast in health (health gap)
Amount & pattern of burden Ds in Developing & developed countries
Intentional injury
Unintentional injury
Cardiovascular ds
Neuropsychiatric disorder
Chronic respiratory Ds
Nutritional defeciencies
Respiratory Ds
Maternal & perinatal condition
Infectious & parasitic Ds
Developing
countries-high
mortality
Developing
countries-low
mortality
Developed
countries
Selected health & socio-economic indicators
Lest
developed
countries
Other
developing
countries
Developed
countries
1.Life expectancy at birth (2004)
52
65
79
2.IMR(per 1000 live birth)(2004)
98
52
5
3.Under 5 mortality/1000live birth
(2004)
155
87
6
4.Matarnal mortality /100000live birth (2000)
890
440
13
5.Doctor -population ratio per 10000
(1993)
1.4
8.4
25.2
6.Nurse –population ratio /10000
2.2
9.6
74.2
7.GNI per capita (US$) 2004
345
1524
32232
8.Per capita public expenditure on health ,US$ in 5
% of GDP (1999)
4
14
9.Adult literacy (%) 2004
54
77
97
10.Access to safe water % population 2002
58
79
100
11.Per capita calorie(1997)
2099
2663
3371
Health services philosophies
• Health care : “multitude of services rendered to
individuals ,families or communities by the
agents of the health services or professions, for
the purpose of promoting, maintaing, or
restoring health.”
• Health care include -“medical care” refers chiefly
to those personal services that are provided
directly by physicians or rendered as a result of
the physician’s instruction”
Characteristics of health care
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Appropriateness
Comprehensiveness
Adequacy
Availability
Accessibility
Affordability
Feasibility
Health system
• To deliver health services
• Constitute the management sector & involve
Organizational matters e.g. planning ,
determining priority, mobilizing &
allocating resources, translating policies in
services, evaluation &health education.
Components of health system
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Concepts
Ideas
Objects
Persons
Aim of health system- health development
Levels of health care
• Primary health care
“Essential” health care
PHC, Sub centers
• Secondary health care
mostly curative services
CHC, District hospitals
• Tertiary health care
super-speciality care
provide manangerial skill
teaching specialized staff
Health team concept
• Group of persons who shares common health
goals & objectives, determined by community
need & toward the achievement of which each
member of the team contributes in accordance
with her/his competence & skill,and the
respecting the functions of others.
• Health team
In hospital
In community
Health for all
• May 1977-World health assembly
• “Attainment by all the people of world by the
year 2000 AD of level of health that will permit
them to lead socially & economically
productive life”
• Health for all by 2000- essential principle is
concept “equity in health”
Primary health care
• 1978-Alma-Ata,USSR
Essential health care based on practical, scientifically sound &
socially acceptable methods & technology made universally
accessible to individuals & families in the community through
their full participation & at the cost that the community and
the country can afford to maintain at every stage of their
development in the spirit of self-determination
• Accepted to achieve the goal of “Health for all by 2000”
• “Health by people” “placing peoples health in people’s hands”
Declaration of Alma Ata
Primary health care include at least
• Education about prevailing health problems and methods of
preventing & controlling them
• Promotion of food supply & proper nutrition
• An adequate supply of safe water basic sanitation
• Maternal & child health care ,including family planning
• Immunization against infectious diseases
• Prevention & control of endemic diseases
• Appropriate treatment of common diseases & injuries
• provision of essential drug
Millennium Development Goal
Sep 2000 ---Govt set date of 2015
GOALS areEradicate extrime poverty & hunger
Achieve universal primary education
Concept of Disease
• Disease ?
• Oxford English dictionary: a condition of the body or same part or organ
of the body in which its function are disrupted or deranged.
• Webster: a condition in which body health is impaired, a departure from a
state of health, an alteration of the human body interapting the
performance of vital fufncions
• Ecological view : a maladjustment of the human organism to environment
• Sociology view: disease is considered as social phenomenon, occurring in
all societies & define & fought in terms of the the perticular cultural forces
prevalent in society
• Simplest definition is : any deviation from normal functioning or state of
completeness physical & mental well-being- since health & disease is
mutually exclusive .
Concept of Disease
Disease – is physiological/psychological
dysfunction
Illness – is a subjective state of the person who
feels aware of not being well
Sickness – is a social dysfunction , i.e. the role
that the individual assumes when ill
(sickness roll)
Concept Of Causation
Supernatural theory of disease, theory of humors, concept of
contagion,miasmatic theory of disease, theory of
spontaneous generetion
• Germ theory of disease
• Epidemiological triad
Environment
Agent
• Multifactorial causation
• Web causation
Host
Web of causation for Myocardial infarction
Changes in life style
Stress
Smoking
Abundance of food
lack of
physical
exercise
Emotional
disturbances
Aging &
other factor
Obesity
Hyperlipidaemia
Coronary atherosclerosis
Hypertension
Increase catacholamines
thrombotic tendency
coronary occlusion
Myocardial ischaemia
Myocardial infarction
Changes in walls of arteries
Natural History Of Disease
• Prepathogenesis phage
disease agent not yet entered but the factors which
favour its interaction with human host already existing in
environment
i.e the process in environment
• Pathogenesis phage
this phage begins with the entry of the disease Agent in
the susceptible human host
i.e. the process in the man
Prepathogenesis phage
Epidemiologic concept of interaction of Agent
,Host and Environment
Agent factors
 Biological agent
Infectivity
Pathogenicity
Virulence
 Nutrient agent
 Physical agent
 Chemical agent
 Mechanical agent
 Absence or insufficiency or excess of a factor necessary to
health
Host factor
• Demographic characteristics-e.g. age, sex, ethnicity
• Biological characteristics –genetic, blood group,
enzymes, cellular constitute of blood
• Social & economic characteristics- socio-economic
status, education, occupation , stress, marital status
• Life style factor – personality trait ,living habits,
nutrition ,physical activity, smoking, use of alcohol
Environmental factors (extrensic)
• Physical environment – non –living things & physical
factors (air,water,soil,housing,climate etc.)
• Biological environment – living
things(viruses,bacteria,insect etc.) surrounding man, including
man himself
• Psychosocial environment –those factors affecting personal
health ,health care and community wellbeing that stem from
the psychosocial make up of individual & function of social
group. It include cultural values, customs,habits,beliefs.
PERIOD OF PRE-PATHOGENESIS
DISEASE
PROCESS
PERIOD OF PATHOGENESIS
Before man is involved
Agent
Host
environmental factors
(known & unknown)
Bring agent & host together
or produce a disease
provoking stimulus
In the
Human
host
LEVELS OF
PREVENTION
PRIMARY PREVENTION
SECONDARY
PREVENTION
MODES OF
INTERVENTION
HEALTH
SPECIFIC DISABILITY
PROMOTION
LIMITATION
PROTECTION
TERTIARY
PREVENTION
REHABILITATION
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Risk
factors
Where the disease agent is not firmly established ,the etiology is generally
discussed in terms of “risk factor”
• 2 meanings
a. an attributes or exposure that is significantly associated with the
development of disease
b.a determinant that can be modified by intervention, thereby reducing
the possibility of occurrence of disease or other specified outcome
Disease
Risk factors
Heart disease
Smoking,high blood pressure,elevated serum
cholesterol,diabetes,obesity,lack of exercise
Cancer
Smoking,alcohol,solar radiation,ionising
radiation,work site hazards,environmental
pollution,infectious agent ,dietary factors
Stroke
High blood pressure,elevated
cholesterol,smoking
Motor vehicle
accidents
Alcohol ,non-use of seat belts,speed, roadway
desing,automobile desing
Diabetes
Obesity,diet
Cirrhossis of
liver
alcihol
Risk groups
guideline for defining “at-risk” group
a.Biological situation:
- Age group e.g.Infants(LBW),toddlers,elderly
- Sex eg females in reproductive age group
- Physiological state pregnancy,cholesterol level
- Genetic factors –family h/o genetic disease
- Other health conditions(disease,physical functioning,unhealthy behaviour)
b.Physical situation :
-rural,urban slums
-living conditins,overcrowding
-environment : water supply,proximity to industry
c.Sociocultural & cultural situatiion:
-social class
-ethnic & cultural group
-family disrruption ,education
Spectrum of disease
Subclinical
infection
Mild ,moderate ,severe
cases
Fatal
illness
Iceberg Of Disease
Symptomatic disease
What physician sees
What
physician
does not
sees
Pre-symptomatic disease
CONCEPTS OF CONTROL
• AIM IS REDUCE
1. The incidence of disease
2. The duration of disease & risk of
transmission
3.The effect of infection , including both
physical & psychosocial complication
4.the financial burden to the community
Control Elimination Eradication
disease agent is permitted to persist in
community at a level where it ceases to be a public health
problem according to the local population.
A state of equilibrium between
Agent
Host
e.g. Malaria control
Environment
Control Elimination Eradication
Interruption of transmission of disease from
large geographical region or area
It is intermediate goal
e.g. Measles, Polio , Diphtheria
Control Elimination Eradication
Termination of all transmission of infection
by extermination of the infectious agent .
Cessation of infection or disease from whole
world
“Tear out by roots”
e.g. Smallpox
In future – Polio , Measles , Dracunculiasis
Monitoring & Surveillance
• The performance & analysis of routine measurements aimed
at detecting changes in environmental or health status of
population
• In management – the continuous oversight of activities to
ensure that they are proceeding according to plan. It keeps
track of achievements, staff movements and utilisation
,supplies & equipment & the money spent in relation to the
resources available so that if any thing goes wrong ,immediate
corrective measures can be taken.
Monitoring & Surveillance
• The continuous scrutiny of the factor that determined the
occurrence & distribution of disease & other condition of
illness.
• Objectives:
1.To provide information about new & changing trend in health
status of population .e.g. morbidity .mortality ,nutritional
status, environmental hazards .
2.To provide feed-back which expected to modify the policy &
system itself &lead to redefinition of objective.
3. Timely warning of public health disasters so that intervention
can be modify.
“Sentinel surveillance”
CONCEPTS OF PREVENTION
Successful prevention depends on
-Knowledge of causation
-Dynamics of transmission
-Identification of risk factor & groups
-Availability of prophylactic or early
detection & treatment
-An organization to apply these
measures
LEVELS OF PREVENTION
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention
Modes of Intervention
• Health promotion
• Specific protection
• Early diagnosis & treatment
• Disability limitation
• Rehabilitation
Health promotion
- Health education
- Environmental modification
- Nutritional intervention
- Lifestyle & behavioral changes
Specific Protection
 Immunization
 Use of specific nutrients
 Chemoprophylaxisis
 Protection against occupational hazards
 Protection against accidents
 Protection from carcinogens
 Avoidance of allergens
 The control of general environment e.g.air pollution, noise
control
 Control of consumer product quality safety of food, drugs,
cosmetic
Early diagnosis & treatment
• Early detection of health impairment- “the
detection of disturbance of homoeostatic &
compensatory mechanism while biochemical,
morphological & functional changes are still reversible.”
(WHO)
• MASS TREATMENT APPROCH
Disability limitation
• Disease
Impairment
Disability
Handicaps
Impairment
“Any loss or abnormality of psychological, physiological or
anatomical structure or function”
e.g. loss of foot, defective vision , mental retardation
Impairment may
Visible or invisible
Temporary or permanent
Progressive or regressive
One may leads to other
Disability
• “Any restriction or lack of ability to perform an
activity in the manner or within the range
considered normal for human being”
HANDICAP
• “A disadvantage for a given individual,
resulting from an impairment or adisability
,that limits or prevents the fulfilment of a role
that is normal for (depending on age ,sex,
social & cultural factors)for that individual”
Example--Accident
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Accident……..Disease( or disorder)
Loss of foot…………impairment(extrinsic 0r intrensic)
Can not walk …………Disability(objectified)
Unemployment ……………Handicap(socialized)
Rehabilitation
• Medical rehabilitation- restoration of function
• Vocational rehabilitation- restoration of the
capacity to earn
• Social rehabilitation- restoration of family and
social relation
• Psychological rehabilitation-restoration of
personal dignity & confidence
Cause of death
CHANGING PATTERN
Pneumonia
OF DISEASE
Tuberculosis
Developed Country
The leading cause of
death in the United
Stastes 1900 & 1994
% death from cause
1900
11.8
11.3
8.3
8.0
6.2
4.7
4.2
3.7
3.6
2.3
Diarrhoea & enteritis
Heart disease
Cerebrovascular disease
Chronic nephritis
Accidents
Cancer
Certain disease of infancy
Diphtheria
1994
32.1
Heart disease
Cancer
23.5
Cerebrovascular disease
6.8
Accidents
3.9
COPD
4.5
Pneumonia & influenza
3.6
Diabetes
2.4
Suicide
1.4
Chronic liver Ds & cirrhosis of liver 1.1
HIV infection
1.8
All other cause
18.9
CHANGING PATTERN
OF DISEASE
• Developing Country
In typical developing country 40% Deaths
from infectious , parasitic and respiratory
disease .
Diarrhoeal disease is wide spread.
CHANGING PATTERN
OF DISEASE
Devloped country
“Silent epidemic”
e.g. Alzheimer’s disease,
Mental disorders
Developing country
Mixture of old & “Modern”
• Knowledge about human health & disease
classified as
Basic Sciences
Clinical Sciences
Population Medicine
POPULATION MEDICINE
-Public Health
-Preventive Medicine
-Community Health
-Social Medicine
-Community Medicine
Public Health
• The science & art of preventing disease, prolonging life &
promoting health & efficiency through organized community
effort for the sanitation of the environment ,the control of
communicable infection, the education of the individual in
personal hygiene, the the organization of medical & nursing
services for early diagnosis & preventive treatment of diseases
& the development of social machinery to ensure every
individual a standard of living adeqaute for the maintanance
of health,so organizing these benefits as to enable every citizen
to realize his birthright of health & longevity.
(WHO,Winslow 1920)
Preventive Medicine
• Not only the organized activity of community
to prevent occurrence as well as progression of
disease,disability ,mental &physical,but timely
application of all means to promote the health
of individual ,and the community as the the whole ,
including prophylaxisis, health education & similar work
done by good doctor in looking after individuals &
families.
Social Medicine
• Social medicine stands up on two pillars,medicine & sociology
.social medicine, by derivation is concerned with the health of
group of individual & individuals within these group with a view to
create ,promote, preserve and maintain health optimum health.the
laboratory to practice social medicine is the whole whole
community; tool for diagnosis community llness is epidemiology &
biostatastics:and social therapy does not consist in administration
of drug but social &political action for the betterment of condition
of life of man. Social medicine is one more link in the chain of
social organizations of civilized community ,
Community medicine
Hospital & Community