Health determinants and indicators

.
MBBS. DPH, Dip-Card, M.Phil, FCPS
Assistant Professor Community Medicine
Services Institute Of Medical Sciences
Lahore
Health For All PHC
Monday, February 22, 2016 DR MUHAMMAD TAUSEEF
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Concepts of Health and
Disease and Prevention
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WHO Definition
“Health is a state of complete physical, mental and social
wellbeing and not merely an absence of disease or infirmity.”
now added
“the ability to lead a socially and economically productive life.”
•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.
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• Traditionally health has been considered as an absence
of the diseases and if someone was free from disease,
then that person was considered healthy.
This concept is known as biomedical concept, and it has
a basis on the
“germ theory of the disease.”
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CHANGING CONCEPTS OF HEALTH
• Health is perceived in different ways giving rise to
various concepts of health. Health has evolved over
the centuries as a concept from an individual concern
to a worldwide social goal.
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.
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Ecological Concept
•Ecologists viewed health as a dynamic equilibrium
between man and his environment, and disease – a
maladjustment of the human organism to environment.
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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
•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.
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Health
Social economic
Envirnmental
Political
Health
promotion
Health
protection
Holistic concept
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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 othersMonday, February 22, 2016 DR MUHAMMAD TAUSEEF
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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.
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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.
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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.
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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,
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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.
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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.
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Positive health
Better health
Freedom from sickness
Unrecognised sickness
Mild sickness
Severe sickness
Death
SPECTRUM OF HEALTH
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DETERMINANTS OF HEALTH
Health
Biological
Gender Environment
Health services
Behavioral &
sociocultural condition
Socioeconomic
Aging
Other
factor
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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.
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.
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• 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
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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.
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.
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INDICATORS OF HEALTH
• Indicators should be valid, reliable and objective,
sensitive, specific, feasible and relevant.
• The indicators are:
1. Morbidity indicators
2. Disability rates
3. Nutritional status indicators
4. Health care delivery indicators
5. Utilization rates
6. Indicators of social and mental health
7. Environmental indicators
8. Socioeconomic indicators
9. Health policy indicators
10. Indicators of quality of life
11. Other indicators
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Mortality Indicators
•Mortality indicators represent the traditional measures of health
status:
● Crude death rate: It is defined as the number of deaths per
1000 population per year in a given community.
● Expectation of life: “the average number of years that will be
lived”
An increase in the expectation of life is regarded, inferentially,
as an improvement in health status. It can be considered as a
positive health indicator. It is a global health indicator.
● Infant mortality rate: It is the ratio of deaths under 1 year of
age in a given year to the total number of live births in the same
year; usually expressed as a rate per 1000 live births.
It is one of the most universally accepted indicators of healthMonday, February 22, 2016 DR MUHAMMAD TAUSEEF
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Child mortality rate: It is defined as the number of deaths at
ages 1-4 years in a given year, per 1000 children.
It is related to insufficient nutrition, low coverage by
immunization, etc.
Under-5 proportionate mortality rate: It is the proportion of total
deaths occurring in the under-5 age group. This rate can be
used to reflect both infant and child mortality rates.
Maternal mortality rate: Maternal mortality accounts to the
greatest proportion of deaths among women of reproductive
age.
Disease-specific mortality rate: Mortality rates can be computed
for specific diseases.Monday, February 22, 2016 DR MUHAMMAD TAUSEEF
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Morbidity Indicators
•Morbidity indicators supplement mortality data to describe
the health status of a population.
•Morbidity rates are incidence and prevalence, notification
rates, attendance rates at outpatient departments, health
centres, admission, readmission and discharge rates,
duration of stay in hospital, and spells of sickness or
absence from work or school etc.
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Disability Rates
•Disability rates related to illness and injury supplement
mortality and morbidity indicators.
•The commonly used disability rates are:
(i)event-type indicators:
(ii)person-type indicators.
.
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Sullivan’s index. It is calculated by subtracting from the life
expectancy the probable duration of bed disability and
inability to perform major activities.
HALE (Health adjusted life expectancy). HALE is based
on life expectancy at birth but includes an adjustment for
time spent in poor health.
DALY (Disability – adjusted life year). DALY is a measure
of the burden of disease in a defined population and the
effectiveness of the interventions.
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Nutritional Status Indicators
•Nutritional status is a positive health indicator.
•It consists of anthropometric measurements of preschool
children (e.g., weight and height, mid-arm circumference),
heights and weights of children at school entry and
prevalence of low birth weight (less than 2.5 kg).
Health Care Delivery Indicators
•Frequently used indicators of health care delivery are
doctor-population ratio, doctor-nurse ratio, population bed
ratio, population per health/subcentre and population per
traditional birth attendant.
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Utilization Rates
•Proportion of people in need of a service who actually
receive it in a given period, usually a year.
•Utilization rates give some indication of the care needed
by a population, and therefore, the health status of the
population such as immunization, deliveries supervised by
a trained birth attendant, methods of family planning etc.
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Indicators of Social and Mental Health
•Indirect measures
•These include acts of violence and other crime, road traffic
accidents, juvenile delinquency, alcohol and drug abuse,
smoking etc.
Environmental Indicators
•Environmental indicators reflect the quality of physical and
biological environment in which diseases occur and in
which the people live.
•They include indicators relating to pollution of air and
water radiation, solid wastes, noise, exposure to toxic
substances in food or drink.
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Socioeconomic Indicators
•indirect indicators of health.
•These include rate of population increase, level of
unemployment, dependency ratio, literacy rates, especially
female literacy rates, family size, etc.
Health Policy Indicators
•The most important indicator of political commitment is
“allocation of adequate resources.”
•The relevant indicators are proportion of gross national
product (GNP) spent on health services, proportion of GNP
spent on health-related activities and proportion of total
health resources devoted to primary health care.
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Health Care
• It is defined as “a multitude of services rendered to
individuals, families or communities by the professions,
for the purpose of promoting, maintaining, monitoring or
restoring health.”
• Health care should be appropriate, comprehensive,
adequate, available, accessible, affordable and feasible.
• It can be delivered by appropriate planning of health
systems with the aim of health development.
• Health systems are based on contemporary ideas and
concepts and available resources.Monday, February 22, 2016 DR MUHAMMAD TAUSEEF
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Levels of Health Care
• Primary health care. It is the first level of contact
between the individual and the health system where
essential or primary health care is rendered.
• Secondary health care. At this level, more complex
problems are dealt with. This care comprises essentially
curative services and is provided by the district hospitals
and community health centres.
• This level serves as the first referral level in the health
system.
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Tertiary health care.
• This level offers super specialist care.
• This care is provided by regional/central level institutions.
• These institutions provide not only highly specialized
care, but also planning and managerial skills and
teaching for specialized staff.
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Health Team Concept
• Practice of modern medicine has become team of many
groups of workers, both professional and non-professional.
• Health team has been defined as “a group of persons who
share a common health goal and common objectives,
determined by community needs and toward the
achievement of which each member of the team contributes
in accordance to her/his competence and skills.”
• The auxiliary is an essential member of the team. It is
recognized that many functions of the physician can be
performed by auxiliaries, given suitable training.
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Health for All
• In May 1977, World Health Assembly decided that the
main social goal of governments in the coming years
should be the “attainment by all the people of the world by
the year 2000 AD of a level of health that will permit them
to lead a socially and economically productive life.
• ” This goal has come to be popularly known as “Health for
all by the year 2000.”
• There was a growing concern about the low levels of
health status of the majority of the world’s population,
especially the rural poor
• the gross disparities in health between the rich and poor,
urban and rural population, both between and within
countries. The important principle in this concept is “equity
in health”, which means all people should have an
opportunity to enjoy good health.
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Primary Health Care
• The concept of primary health care came into limelight in
1978 following an international conference in Alma Ata,
erstwhile USSR. It has been defined as:
• “Essential health care based on practical, scientifically
sound and socially acceptable methods and technology
made universally accessible to individuals and families in
the community through their full participation and at a
cost that the community and the country can afford to
maintain at every stage of their development in the spirit
of self-determination.”
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• Primary health care approach is based on principles of
social equity, nationwide coverage, self-reliance,
intersectoraI coordination, and people’s involvement in the
planning and implementation of health programs in pursuit
of common health goals.
• Declaration of Alma Ata stated that primary health care
includes at least:
● Education about prevailing health problems and
methods of preventing and controlling them
● Promotion of food supply and proper nutrition
● An adequate supply of safe water and basic sanitation
• ● maternal and child health care, including family
planning
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● Immunization against infectious diseases
● Prevention and control of endemic diseases
● Appropriate treatment of common diseases and injuries
● Provision of essential drugs.
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Millennium Development Goals
• On September 2000, member states of the United Nations
Organization made a historic declaration that by 2015 they
would meet the ‘millennium development goals’:
● Eradicate extreme poverty and hunger
● Achieve universal primary education
● Promote gender equality and empower women
● Reduce child mortality
● Improve maternal health
● Combat HIV/AIDS
● Malaria and other diseases
● Develop global partnership for development.
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CONCEPTS OF PREVENTION
• Successful prevention depends upon a knowledge of
causation, dynamics of transmission, identification of risk
factors and risk groups, availability of prophylactic or
early detection and treatment measures; an organization
for applying these measures to appropriate persons or
groups, and continuous evaluation and development of
procedures applied.
• The objective is to intercept the “cause” and thereby the
disease process .
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Levels of Prevention
• Prevention can be achieved in terms of four levels:
(1)Primordial prevention
(2)Primary prevention
(3) Secondary prevention
(4) Tertiary prevention.
1. Primordial prevention: Prevention of emergence or
development of risk factors in countries or population
groups in which they have not yet appeared.
In primordial prevention, efforts are directed towards
discouraging children from adopting harmful lifestyles.
The main intervention in primordial prevention is through
individual and mass education.Monday, February 22, 2016 DR MUHAMMAD TAUSEEF
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Primary prevention:
A desirable goal relies on holistic approach that signifies
intervention in the prepathogenesis phase.
• “action taken prior to the onset of disease, which
removes possibility that a disease will ever occur.”
• Intervention, promote general health and wellbeing and
specific protective measures.
• It concerns an individual’s attitude towards life and
health and the initiative he takes about positive and
responsible measures for himself, his family and his
community.
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• WHO has recommended :
a. Population (mass) strategy: Take whole population
irrespective of individual risk levels and is aimed at
towards socioeconomic, behavioral and lifestyle
changes.
b. High-risk strategy: to bring preventive care to individuals
at special risk.
This requires detection of individuals at high risk by the
optimum use of clinical methods.
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Secondary prevention:
“Action which halts the progress of a disease at its
incipient stage and prevents complications.”
•Interventions are early diagnosis and adequate treatment.
•Health programs initiated by governments are usually at the
level of secondary prevention.
•Drawback of secondary prevention is that the patient has
already been subjected to mental anguish, physical pain, and
the community to loss of productivity.
•These situations are not encountered in primary prevention.
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Tertiary prevention:
“All measures available to reduce or limit impairments and
disabilities, minimize suffering caused by existing departure
from good health.”
Interventions are disability limitation and rehabilitation.
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Modes of Intervention
• Five modes of intervention have been described which
form a continuum corresponding to the natural history of
any disease:
(i) Health promotion
(ii)Specific protection
(iii)Early diagnosis and treatment
(iv) Disability limitation
(v) Rehabilitation.
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Health Promotion
•“The process of enabling people to increase control over and
improve health.”
•It is not directed against any particular disease, but is
intended to strengthen the host through a variety of
approaches such as :
● Health education: A large number of diseases could be
prevented with little or no medical intervention
if people were adequately informed about them
if they were encouraged to take necessary precautions
in time.
Targets for educational efforts may include general public,
patients, priority groups, health providers, community leaders
and decision makers.
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● Environmental modifications: Provision of safe water;
installation of sanitary latrines; control of insects and
rodents; improvement of housing, etc. promote health.
● Nutritional interventions: This refers to food distribution
and nutrition improvement of vulnerable groups; child
feeding programs; nutrition education, etc.
● Lifestyle and behavioral changes:
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Specific Protection
•Some of the currently available interventions aimed at
specific protection are: immunization, use of specific
nutrients, chemoprophylaxis, protection against accidents,
protection from carcinogens, avoidance of allergens,
control of specific hazards in general environment etc.
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Early Diagnosis and Treatment
•A WHO defined early detection of health impairment as
“the detection of disturbances of homeostatic and
compensatory mechanism while biochemical,
morphological, and functional changes are still reversible.”
•Early detection and treatment are the main interventions of
disease control. Earlier a disease is diagnosed and treated
the better it is from the point of view of prognosis and
preventing the occurrence of further cases or any long-term
disability.
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Disability Limitation
•Objective of this intervention is to prevent or halt the
transition of the disease process from impairment to
handicap.
•Intervention in disability will often be social, environmental
as well as medical. While impairment which is the earliest
stage has a large medical component, disability and
handicap which are later stages have large social and
environmental components in terms of dependence and
social cost.
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Rehabilitation
•“The combined and coordinated use of medical, social,
educational and vocational measures for training and
retraining the individual to the highest possible level of
functional ability.”
Rehabilitation includes
•Medical rehabilitation (restoration of function),
•Vocational rehabilitation (restoration of the capacity to earn a
livelihood),
•Social rehabilitation ( restoration of family and social
relationships),
•Psychological rehabilitation (restoration of personal dignity
and confidence).
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