Preventive and Social Medicine

Preventive, Family and Community Medicine

Roles of a Physician:1. Health Care Provider 2. Social Mobilizer 3. Teacher 4. Administrator 5. Researcher

Concepts of Health and DiseaseDefinitions of Health 1. Bio-medical scientist - the harmonious functioning of all parts of the body or the physical ability of components of the body to self heal 2. Social scientist - the well functioning biological state that provide the body with physical capacities to fulfill all higher order task 3. W.H.O. - is a state of complete physical, mental, and social well being not merely the absence disease or infirmity.

Concepts of HealthHealth 1. Successful Adaptation to Stress - Types of stress a. Eustress - helpful b. Dystress - harmful 2. Satisfactory Functioning - the ability of the individual to function in manner acceptable to himself and to the group to which he is a part

Concepts of DiseaseBiologic laws of disease causation 1. Disease results from an imbalance between a disease agent and man. 2. The nature and extent of the imbalance depends on the nature of the host and agent. 3. The characteristics of the host and the agent are influenced considerably by their environment.

Lever of Disease CausationAgent Host

Environment

I.

The Agent Factor of Disease

Agent - anything whose presence or absence can initiate or perpetuate a disease process Types of agents a. Biologic b. Nutrient c. Chemical d. Physical e. Mechanical

1. Inherent characteristicsa. Physical features - morphology b. Biologic requirements - aerobic or anaerobic c. Chemical make-up d. Viability e. Resistance

2. Characteristics directly related to mana. Pathogenecity - the ability of the agent when lodge in the body to set up specific reaction. b. Virulence - severity of the reaction produced, measured in terms of fatality c. Antigenecity - the ability to stimulate the host to produce antibodies.

3. Characteristics related to the environmenta. Source of infection - anything from which an is agent passes immediately to a host b. Modes of transmission - mechanisms by which an agent is transported from reservoir to a susceptible host c. Vehicle of infection - inanimate objects contaminated by the agent d. Vectors - arthropods or other invertebrates which transmit infection e. Airborne spread

II.

The Host Factor of Disease

1. Age - certain diseases have a predilection for specific age groups 2. Sex - certain diseases are sex-linked 3. Race - certain diseases are peculiar to certain race 4. Habits, customs and religion - the presence or absence of certain diseases are influenced by habits, customs, and religion. 5. Exposure to agents

Defense Mechanism of the Host1. Specific anatomical defenses 2. Immunity - resistance associated with antibodies 3. Inherent insusceptibility - ability to resist disease independently of antibodies 4. Resistance - include both immunity and inherent insusceptibility 5. Tolerance - a form of carrier state 6. Premunition - refractoriness to further infection of already sick individual 7. State of nutrition

1. Physical environment1. Climate a. Certain diseases have seasonal distribution b. Distribution of vectors are adversely or favorably affected c. Disease agents are adversely or favorably affected 2. Humidity - most vectors thrives best in higher humidity 3. Geography a. Geologic structure may facilitate transport of diseases b. Fertility of the soil influence food habits c. Topography affects the ability to utilize health care services

2. Biologic environment- All living things that may serve as reservoir, sources, and vectors of diseases agents a. Plants b. Animals c. Human beings

3. Socio-economic environment1. Factors arising out of social environment aside from economic status and its social stratification. 2. Factors that are essential concomitants and results of the economic systems of the era. 3. Factors that are inherent in the nature of specific diseases which are particularly subject to general as well as specific economic and social conditions 4. Factors arising out of the maladjustments in the production and distribution of curative and preventive services 5. Factors that essentially are psychological

Requirements for the occurrence of infection1. Conditions in the environment must be favorable to the infectious agent or the agents must be able to adopt to the environment 2. Suitable receivers must be present 3. The host must be susceptible and within reach 4. Satisfactory portal of entry into the host 5. Accessible portal of exit from the host 6. Appropriate means of dissemination and transmission to a new host

Factors that affects disease process manifestation1. Characteristics and dosage of the agent, and the duration of exposure of the host to it. 2. Reaction of the tissues of the host to the introduction of the agents 3. Portal of entry tissues affected

Host reaction to disease agent1. The host successfully ward off the pathogen - by virtue of its natural resistance or weak agent 2. Balanced equilibrium - host is a healthy carrier 3. Subclinical conditions - very mild reactions that they escape detection but may lead to carrier state. 4. Full-blown clinical cases - cases may be typical or atypical

1. Primary Level1. Promotion of General Health a. Development of good habits and hygiene b. Proper nutrition c. Proper attitude toward sickness d. Proper an prompt utilization of health and medical facilities 2. Specific Protection a. Segregation of the reservoir or source of infection by isolation or quarantine b. Control of means of spread of disease agents c. Increasing the resistance of host by specific immunization

2. Secondary Level1. Early diagnosis - arrest disease process in its earliest possible state 2. Prompt treatment of disease - give appropriate medicines to cases to eradicate human reservoirs of disease agents 2. Immediate destruction of animal reservoir of fatal diseases. - animal reservoir should not be treated.

3. Tertiary Level1. Disability Limitation - indicates failure of prevention - requires treatment of more ore less advanced disease 2. Rehabilitation - maximizing the affected individuals remaining capacity 3. Intensive, periodic follow-up and treatment - done to prevent relapses - to affect complete cure

Preventive ,Family, and Community Medicine

Health IndicatorsRussell F. Bernabe, MD

Ratioa single number that represents the relative size of two number formula: a ______ (k) b k is usually assigned a value of 100; 1,000; 10,000 and so on the numerator in ratio may or may not be a subgroup or part of the denominator Sex Ratio = Number of males X 100 Number of females Age-Dependency Ratio = no. of persons aged 0 14 y.o. + no. of persons aged 65 years and over X 100 no. of person 15 64 years old -

Proportiona special type of ratio which the numerator is part of the denominator formula: a ______ (k) a+b Proportionate Mortality Ratio for Measles, which relate the number of deaths from measles to the total deaths from all causes.

-

Rates-the frequency of occurrence of events over a given interval of time. it measures amount of changes categorized into: I. Crude rates - the denominator is the total population II. Specific rates - events happening to a specified group are related only to the corresponding segment of the population - used when making comparisons between and among populations which differ in distribution according to the different variables.

I. Crude Rates1. Crude Birth Rates 2. General Fertility Rates 3. Crude Death Rates 4. Cause-of-Death Rates

1. Crude Birth Rates- measures how fast people are added to the population through births. - formula: no. of registered livebirths in a year CBR = ______________________________________________ X 1000 midyear population - can be made specific by computing for the different variables - it is affected by: a) fertility/marriage patterns and practices of a place b) sex and age composition of a population c) birth registration practices

2. General Fertility Rates- births are related to the segment of the population deemed to be capable of giving birth no. of registered livebirths in a year GFR =_______________________________________________________________

X 1000

midyear population of women 15 44 years of age - it can be made specific by computing it for different categories of maternal variables

3. Crude Death Rates- gives the rate with which mortality occurs in a given population no. of of deaths in a year CDR = __________________________________ X 1000 midyear population - it affected by: a. peace and order situation b. adverse environmental and occupational conditions c. age and sex composition

4. Cause-of-Death Rates- gives the rate of dying secondary to specific causes no. of of deaths from a certain causes in a year CofDR = ___________________________________________________________ X 1000 midyear population - it can be made specific by relating the deaths from a specific cause and group to the midyear population of that specified group - it is affectd by: a. completeness of registration of deaths b. composition of the population c. diseae ascertainment level in the community

II. Specific Rates1. Specific Mortality Rates- shows the rate of dying in specific population groups. - general formula: no. of of deaths in a specified in a year SMR = ___________________________________________________________ X 1000 midyear population of the same specified group - much more valid to use than CDR when comparing mortality experiences between groups. - types: 1. Infant Mortality Rates 4. Swaroops Index 2. Maternal Mortality Rates 5. Case Fatality Rates 3. Proportionate Mortality Rates

1. Infant Mortality Rates- a sensitive index of the level of health in a community - it can be artificially lowered by improving the registration of births - formula: no. of deaths under 1 year old in a specified in a year IMR = _____________________________________________________________________ X 1000 number of livebirths in the same year - affected by: a. maternal and child health care c. environmental sanitation b. malnutrition d. health service delivery - subdivisions: a. Neonatal Mortality Rate b. Post-neonatal Mortality Rate

a. Neonatal Mortality Rates- deaths are due to prenatal or genetic factor no. of deaths among those under 28 days in a year NMR =________________________________________________________________

X 1000

no. of live births in the same year

b. Post-neonatal Mortality Rates- deaths are due to environmental, genetic, nutritional and/or infectious factors. no. of deaths among those 28 days to less than 1 year of age in a year PnMR = 1000_____________________________________________________________________________________

X

no. of live births in the same year

2. Maternal Mortality Rates- measures the number of deaths due to diseases directly related to pregnancy, delivery and puerperium per 1,000 livebirth - formula: no. of deaths due to pregnancy, delivery, puerperium in a year MMR = ____________________________________________________________________________ X 1000 no. of livebirths in the same year - affected by a. maternal health practices b. diagnostic ascertainment c. completeness of registration of births

3. Proportionate Mortality Rates- is the proportion of total deaths occurring in a particular population group or from a particular cause - formula: no.of deaths from a particular cause or population group in a year PMR = _______________________________________________________________________________ X 100 total deaths in same year

4. Swaroops Index- a special kind of proportionate mortality ratio - a sensitive indicator of the standard oh health care - formula: no. of deaths among those 50 years and over in a year S.I. = ____________________________________________________________________ X 100 total number of deaths in the same year - develop countries have higher Swaroops Index than less developed ones

5. Case Fatality Rates- is the proportion of cases which end up fatally - it tells how much of the afflicted die from the disease - formula: no. of deaths from a specified cause CFR = ______________________________________________ X 100 number of cases of the same disease - high CFR means more fatal disease - it depends on : a. nature of the disease itself b. diagnostic ascertainment c. level of reporting in the population

Morbidity Rates1. Incidence Rates 2. Prevalence Rates

1. Incidence Rates (Incidence Density)- measures the development of a disease in a group exposed to the risk of the disease in a period - useful than PR in determining etiologic factors of diseases. - formula: no. of new cases of a disease developing in a period of time ____________________________________________________________________________ IR = X 100 population at risk of developing the disease during the same period of time - Cumulative Incidence rates - measures the proportion of persons in a population who are initially free of the disease of interest and who develop the disease within specified time interval

2. Prevalence Rates- measures the proportion of existing cases of a disease in a population - more use than the incidence measure in describing the occurrence of chronic conditions and as an indicator or basis for making decisions in the administration of health services. - formula: no. of existing cases of a specified disease PR = ________________________________________________________ X F population examined - influenced by: a. diagnostic capabilities b. levels of notifications c. age and sex composition of the population

Other measures used in Public HealthLife Expectancy - a very useful and commonly used method of describing a population trait. - defined as the average of years an infant is expected to live under the mortality conditions for a given year. - life expectancy of a female child is always higher that her female counterpart for the years indicated. Ave. length of Stay in the Hospital - measures the mean length of time a specific group of patients spend in the hospital continuously. - computing by adding up the duration of stay of all patients dan dividing the sum by the number of patients.

Department of Preventive, Family and Community Medicine

Data PresentationRussell F. Bernabe, MD

Types of Scales1. Nominal - represents name or identifiers of persons status, category, or attribute that do not represent quantity or amount 2. Ordinal - represents an ordered series of relationship 3. Interval scale - represents quantity, meaningful comparison of one number to the another number is possible, no meaningful zero 4. Ratio scale - represents quantity, meaningful comparison of one number to the another number is possible, it has meaningful zero

Types of VariablesVariables - used interchangeably with attribute, are specific characteristics of anything which can be assessed. 1. Qualitative - are attributes that yield observations that can be categorized according to some characteristics or quality 2. Quantitative - are variables that yield observations that can be measured. a. Discrete expressed as integers b. Continuous expressed as fraction

Types of Data Presentation1. Narrative Presentation 2. Tabular Presentation 3. Graphical Presentation

1. Narrative Presentation- also known as the Textual Method of data presentation - the data is simply narrated in a story like fashion - tendency to get confused - usually used as research abstract or summaries of study/research.

II. Tabular Presentation of Data- numerical data are presented in a logical fashion usually in form of tables - provide a compact and orderly way of presenting large sets of detailed information - can readily point out trends and comparison - show the interrelationships among variables

Parts of a Tables1. Table number - consecutively place on the left most potion of the table, 2. Title - give the what, who, where, and when of a table - a headnote may be placed as a secondary caption and serves to clarify items in the main title or body 3. Column headings - indicate the basis of classification of columns or vertical series of figures 4. Row headings - indicate the basis of classification of the rows or horizontal series of figures 5. Body -composed of cell (intersection of a row and a column) 6. Footnotes - placed immediately below the bottom rule of the table 7. Source of data - place immediately after the footnotes of unoriginal data.

Characteristics of a Properly Constructed Table1. Simplicity - tables should exhibit a clean, professional and uniform look 2. Clarity - table should jive with the textual discussion - can be achieved by: i. clear, concise headings or captions ii. uncluttered footnotes iii. minimum variables present iv. well spaced columns and rows 3. Directness - implies that what is only necessary should be included in the table

Pointers in Table ConstructionA. Positioning of the table - a table should be placed immediately after the text where it was first cited B. Uniformity in style - standardize a particular style of a table format for a single report C. Number of variables presented - minimized the variables presented on a table. - if data in a master table must be presented, it should be broken down into simple tables with a maximum of 3 variables presented D. Every table should be self explanatory - the reader should be able to understand the content of the table without referring to textual explanations.

Pointers in Constructing a Self-Explanatory Table1. Title must be complete but concise. 2. All units of measure should be indicated in the table. 3. Uncommon abbreviations should be explained in the footnote 4. Each row and column should have a clear and concise heading 5. Double rule lines should only be used in the top rule succeeding rule lines should be single rule lines. Rule lines should always be used for closely-spaced figures

Classification of tables according to number of variables1. One-way tables - a table which present distribution for a single variable 2. Contingency table (.Two- way table) - a table which shows the distribution of two variables 3. Multi-way table - a table which shows the distribution of three or more variable

1. One-way tableTable 1. Selected Reportable Diseases, Philippines 1997 Diseases Number of Cases 1. Tuberculosis 240,509 2. Influenza 574,748 3. Malaria 69,248 4. Diarrhea 899,409 5. Measles 37,857 6. Diphtheria 53 7. Malignant Neoplasm 4,723 Source:1997 Annual Report of the Health Intelligence Center, Department of Health

2. Contingency table (.Two- way/2 X 2)Disease E x p o s u r e

+ +-

bd

ac

3. Multi-way table (Master/Dummy)Table 1 Total Number of First Year Medical Students, AUF-SOMa, A.Y. 2007-2008

Ae < 20 21-30 31- 0 > 1

Se M ale Female M ale Female M ale Female M ale Female

as

Fili ino Installment

as

Forei ner Installment

Footnote: aAngeles University Foundation-School of Medicine

III. Graphic Presentation of DataAdvantages 1. Simpler to read 2. Appeal to a greater number of people 3. Large complex masses of data can be presented in simpler language 4. Significant trends or patterns can be made to stand out more clearly 5. Offers a wider point of view of the data set, when precision is not required Disadvantages 1. Can be used to misrepresent facts 2. Twist facts 3. Oversimplify situations

General Principles1. Should be completely self explanatory. 2. The scales should be properly labeled. 3. Trend lines and curves in the chart should be properly identified by labels or a legend 4. Grid or guide rulings may be used in a graph to guide the eye, but they should be kept at a minimum 5. Graphs should be simple, neat, and businesslike 6. Basis of classification is generally represented on the horizontal scale, while, frequencies are placed along the vertical scale 7. The vertical scale should always start with zero. 8. Use color for emphasis or to differentiate between items in a diagram 9. On an arithmetic scale, equal distances between tick marks on the axis should represent equal numerical units

Most Common Graphics used in Presentation of Data1. Bar Graph 2. Pie Chart 3. Component Bar Diagram 4. Histogram 5. Frequency Polygon 6. Line Graph 7.Scatterpoint Diagram

1. Bar Graphs- for comparison of absolute or relative counts, rates, etc. between categories of a qualitative or discrete quantitative variable - Qualitative variables are represented using the horizontal Bar graph - Discrete quantitative variables are represented using the vertical bar graph

1. Bar Graph1Dseases of the Heart Pneumonia Vacular Sytem Tuberculosis Malignant Neoplasm Accidents Septicemia Diarrheal Disease Nephritis Fetus and Infant Resp. Diseases

L a

a

r a

h pp

1

1

1Rate per 100,000 Population

2. Pie Chart- shows the breakdown of a group or total where the number of categories of qualitative variable is not too many - the percentage of contribution of each component is multiplied by 3.6 - the area of each sliced is proportional to the relative contribution of the component to the whole pie

2. Pie Chartsi 2 ater a eaths ai Ca ses Phi i2 %

i es

Other complicatons Hypertension Abortion Hemorrhage

2%

2 %

%

3. Component Bar Diagram- shows the breakdown of a group or total where there are several number of categories of qualitative variable

3. Component Bar DiagramFig. 3100 90 80 70 60 50 40 30 20 10 0

Births by Type of Attendant: NCR vs. Region 10, 1984

Others Hilot Midwife Nurse Physician

NCR

Region 10

Source: Health Intelligence Service, DOH, Philippine Health Statistics, 1984

4. Histogram- graphic representation of the frequency distribution of a continuous quantitative variable or measurement including age group - horizontal axis is a continuous scale showing the units of measurement of variable under consideration - vertical scale shows absolute or relative frequencies - rectangle are drawn over the true limits of the groupings - comparisons between groupings is made on the basis of the areas of rectangle an not the height

Frequency DistributionTable 4 Lengths in Centimeters of 84 Infants at Birth Lengths (cms) No of Infants 43 1 44 3 45 6 46 11 47 12 48 16 49 14 50 8 51 6 52 4 53 2 54 1

4. HistogramFig. 4 Length of 84 Infants at Birth in Centimeters 20 18 16 No. of Infants 14 12 10 8 6 4 2 0 43 44 45 46 47 48 49 50 Length in Centimeters 51 52 53 54 55

5. Frequency Polygon- same function as the histogram - use to depict more than one distribution in a single graph - the frequencies are plotted against the corresponding midpoint of the classes - can be constructed from a Histogram by simply connecting the midpoints of the upper bases of each bar and closing the figure

5. Frequency PolygonFig. 5 Length of 84 Infants at Birth in Centimeters 20 18 16 No. of Infants 14 12 10 8 6 4 2 0 43 44 45 46 47 48 49 50 Length in Centimeters 51 52 53 54 55

5. Frequency PolygonFig. 5 Length of 84 Infants at Birth in Centimeters 20 18 16 No. of Infants 14 12 10 8 6 4 2 0 42.5 43.5 44.5 45.5 46.5 47.5 48.5 49.5 Length in Centimeters 50.5 51.5 52.5 53.5 54.5 55.5

6. Line Diagram- shows trend data or changes with time or age with respect to some other variable - changes in growth of population, temperature readings, birth and death rates morbidity and mortality rate are best portrayed using Line graph

6. Line Diagramig. 6 r i i Ra e ree i i ine1600 1400 1200 1000 800 600 400 200 0 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 ai n

i ia e Di ea e

Diarrhea Measles TB, all forms

Ra e er

ear

7. Scatterpoint Diagram- show correlation between two quantitative variables - gives a rough estimate of the type and degree of correlation between two variables - usually made as a preliminary step towards more detailed mathematical analysis

7. Scatterpoint Diagramig. 7 Scatterp ot o100 90

ge

. Dia to ic

oo

re

re

mm g

80 70 60

15

20

25

30

35

40

45

50

Age in years

Preventive, Family, and Community MedicineSampling

Russell F. Bernabe, MD

Selection of SampleSampling - is a procedure of drawing a fraction or segment of a population - purpose: a) to determine certain characterisitics of the population. b) to determine the occurrence of some events in the population - advantages: a) economy b) greater speed in getting results c) greater accuracy is achieved d) more information can be obtained e) more intensive and careful data collection and analysis can be done

Methods of SamplingI. Non- Probability Sampling Methods - the process of obtaining a sample where the probability of inclusion of a unit is of known or specified, thus the reliability of a sample results can not be assessed.

II. Probability Sampling Methods - procedure of obtaining a sample where each unit of a population has a known non-zero probability of being included. - results using probability samples can be assessed for precision.

I. Non-Probability Sampling Methods1. Haphazard/Accidental Sampling - the inclusion into a sample of whatever units are at hand or available, based on the assumption, often incorrect, that units picked this way are typical of the population they came from. - often used in the social and biological fields 2. Judgment/Purposive Sampling - inclusion or exclusion of units depends on an experts judgment or opinion. 3. Quota Sampling - process of picking units from various subgroups in proportion corresponding to those of the population

II. Probability Sampling Methods1. Random Sampling 2. Systematic Sampling 3. Stratified Sampling 4. Cluster Sampling 5. Multistage Sampling

1. Random Sampling- Method of selecting a number of subjects from a population such that every member has an equal chance of being drawn into the sample. - The units are drawn unit by unit

2. Systematic Sampling- This is a method where every Kth unit is selected from a population which is arranged in some definite way to obtain a sample of units - Complete enumeration or list of the sampling population is a prerequisite at the start.

3. Stratified Sampling- Population is divided into subpopulations or strata, then a samples from each stratum are then selected either by random or systematic sampling as if each strata is a population itself - It ensures proportionate representation into the sample of the different classes in the population.

4. Cluster Sampling- Cluster sampling should be resorted to if a. complete list of the sampling unit does not exist b. an up-to-date list is not available c. other sampling technique cannot be done - The sampling unit consists of a group or cluster of similar units

5. Multistage Sampling- Used only when dealing with extremely large population where complete list of final sampling units are not available from the outset. - process: 1. Population is divided into first stage sampling units ( primary sampling units) and a sample of these units is selected. 2. Each of these selected first stage sampling units is further subdivided into a second stage units - Different sampling methods may be used at any stage of the sampling

Determination of Adequate Sample Size1. Problems dealing with counts a) Descriptive study or one population problem K2pq ______________ n= d2 where: n = sample size k = reliability coefficient based on the level of confidence p = estimate of frequency of event q=1p d = maximum amount of deviation from true frequency

Determination of Adequate Sample Size1. Problems dealing with counts b) Analytic study comparing two frequencies from different population K22pq ______________ n= d2 where: n = sample size k = reliability coefficient based on the level of confidence p = ave. of estimates of frequencies of the event in the 2 population q=1p d = minimum difference between the frequencies to be detected

Determination of Adequate Sample Size2. Problems dealing with measurements a) Analytic study comparing two frequencies from different population K22SD2 n=______________

d2 where: n = sample size k = reliability coefficient based on the level of confidence SD = estimate of standard error of difference d = minimum difference between means to be detected.

Demography

Russell F. Bernabe, M.D.

Definition of TermsDependency Ratio - ratio of economically dependent part of the population to the productive part Doubling Time - number of years required for the population of an area to double its present size given the current rate of population growth Fecundity - physiological capacity of a woman, or couple to produce a live child Fertility - actual reproductive performance of an individual, a couple, a group or a population.

Definition of TermsGrowth Rate - rate at which the population is increasing or decreasing at a given time. Life Expectancy - average number of additional years a person would live if the current mortality trends were to continue Life Span - maximum age that human beings could reach under optimum condition Sex Ratio - the number of males per 100 females in a population multiplied by100 Population Pyramid - special type of bar chart that shows age and sex composition of a population.

DemographyScope of Demography A. Focuses on 3 human phenomenon 1. Population size 2. Composition of the population 3. Distribution of population in space B. Seek reasons or explanations why such conditions are changing the way they are, given the rate of change they exhibit.

Definition of TermsDemography the scientific study of human population including their size, composition, distribution, density and other demographic and socio-economic characteristics and the causes and the consequences of changes in theses factors.

Population Size3 major dynamic processes 1. Natality 2. Mortality 3. Migration

Population CompositionMeasurable characteristics 1. Age 2. Gender 3. Marital status 4. Occupation 5. Education

Population DistributionPopulation density - population per unit of land - expressed as: a) Person per square mile b) Person per square kilometer

Uses of Demography1. 2. 3. Identify and characterize health problems. Control and prevent health problems Predict future developments and possible consequences

Sources of Demographic Data1. Census - population information which includes, age, gender, ethnicity, number of children ever born, literacy/educational attainment, place of birth, occupation. - de jure - de facto Surveys - information collected from only a subset of population Vital registration systems - continuous recording of vital events such as birth, death, stillbirth, marriages, divorces/annulments, and adoption Continuing Population Registers - continuous recording of information about a population

2. 3.

4.

Tools of Demography1. Ratio - single number that represents the relative size of 2 numbers - (a / b) x k Proportion - special type of ratio in which the denominator is a part of the denominator - (a / a + b) x k Rate - frequency of occurrence over a given interval of time. - e.g. Incidence Rate

2.

3.

Describing the Population CompositionA. 1. SEX COMPOSITION number of males Sex Ratio = --------------------------- X 100 number of females In 1990 census of the Phils. 30,443,187 males and 30,115,929 females were enumerated. What is the sex ratio? 30,443,187 Sex Ratio = ------------------- X 100 = 101 30,115,929 In 1990 there were 101 males for every 100 females in the Philippines

Describing the Population Composition2. Sex Structure Table1. Population Distribution by Age and Gender,Cavite,1990 Age Male Female 6,050 7,879 All ages 574,156 576,302 Sex ratio 106.6 105.7 106.4 102.6 100.4 96.8 95.1 100.0 101.4 101.8 96.8 94.6 90.2 88.6 81.9 74.1 76.8 99.6

Describing the Population CompositionB. 1. AGE COMPOSITION Age Composition - in the Philippines the median age has been increasing from 15.8 years in1970 to 16.4 years in 1975 to 18.6 years in 1980 and 19 years in 1990. Age Dependency Ratio - index of age induced economic drain on manpower resources - vital indicator of human resources and resource allocation

2.

# of persons 0-14 y.o. + 65 y.o. and over Age Dependency Ratio= ------------------------------------------------------# of persons 15-64 y.o.

Describing the Population CompositionTable 2 Population Distribution the by Age Group Phils. 1990 Age group 0 - 14 15 - 64 65 - 0ver Total Number 24,004,586 34,629,959 2,063,445 69,697,994 Percent 39.5 57.1 3.4 100.0

Factors that affect population age composition 1. Fertility level 2. Peace and order situation 3. Urban-rural differences

Describing the Population CompositionC. AGE AND SEX COMPOSITION (Population Pyramid) Types of Population: 1. Young Population - 45% of the population are children - median age is 15 19 - FR > 30 livebirths/1,000 - 1: 1 dependency ratio 2. Median Population - 30-40% of the population are children - FR = 25 - 30 livebirths/1,000 Old Population - 10 minutes g) palpitations d) Nausea/vomiting

Limits/Over-exercisingSymptoms of over-exercising 2. Delayed a) Prolonged fatigue b) insomnia c) Weight gain d) persistent rapid heart beat

Exercise Program Suspension- development of any of the following: 1) Persistent chest pain or progression of heart disease 2) Recurrent illness 3) Hypertension 4) Orthopedic problem 5) Dizziness 6) Swelling or sudden weight gain

Waste Management


Waste(a) any substance which constitutes a scrap material or an effluent or other unwanted surplus substance arising from the application of any process (b) any substance or article which requires to be disposed of as being broken, worn out, contaminated or otherwise spoiled. However, this does not include a substance, which is an explosive.

Waste ClassificationI. Controlled Waste a) Household Waste b) Industrial Waste c) Commercial Waste d) Clinical Waste e) Hazardous Waste Non-Controlled Waste a) Agricultural Waste b) Mines and Quarries

II

Types of Waste1. Solid - refuse 2. Liquid or sewage - water carried including human excreta 3. Gaseous - air pollutants (e.g. CO)

TYPES of REFUSE1. garbage - organic solid wastes that are putrescible wastes resulting from the handling of food; considered the most valuable component of refuse because it is used for animal feeding, home feedings, fertilizers and soil conditioners 2. Rubbish - non-putrescible wastes except ashes - both combustible (papers, woods, cardboard)and non-combustible (cans, scrap metals) - useful; converted for packing materials

3. Ashes - waste products that result from the use of coals or other fuels 4. Street sweepings - e.g. leaves, dirt, sand, animal manure 5. Dead animals 6. Solid industrial wastes

Sources of human wastes1. Mouth-saliva 2. 3. 4. 5. Respiratory system - mucus, phlegm, sputum, etc. Skin- sweat Genito-urinary- urine , secretions Gastrointestinal- stools

WASTE MANAGEMENTworks toward reduction, reuse and recycling of all resources. a) reduction of energy consumption b) water conservation c) the purchase of reused and recycled products d) the reusing and recycling of products e) alternate transportation methods

Waste Hierarchy in Waste Management1. Waste reduction 2. Waste Re-use 3. Waste recovery a. Recycling b. Composting c. Energy recovery from waste 4. Waste Disposal

1.

Waste reductionprevention of waste at source or an overall waste management strategy that seeks to reduce the amount of waste generated at each stage of a product's life span.

The objective of waste reduction is to: a) ensure efficient use of resources within existing processes through tighter management control b) reduce the hazardousness of materials or products which become waste

2.-

Waste Re-useinvolves putting an item to another use after its original function has been fulfilled. Two types of re-use. a) conventional re-use - products are used a number of times before they are discarded. e.g. milk, bottles, cardboard craters, etc. b) alternative reuse - uses are found for products once they have served their original purpose. e.g. discarded tyres used as boat fenders

3.

Waste recovery- the process by which waste is converted either into a usable form or energy is derived out of the waste. 3 sub-categories: a. Recycling - involves processing waste to produce a usable raw material or product. - Potential advantages 1. Extending the life and maximizing the value extracted from raw materials. 2. Energy savings 3. Reduced disposal impacts b. Composting - aerobic processing of biologically degradable organic wastes to produce a reasonably stable, granular material, usually also containing valuable plant nutrients c. Energy recovery from waste - is a process by which energy stored in the waste is extracted in the form of fuel or electric power, which can then be used as power source for various applications

4.

Waste Disposal- the last option in the waste hierarchy - disposal options : i. Land Filling ii. Incineration iii. Permanent storage

METHODS OF REFUSE DISPOSAL1. Burial - 1m x 1m pit 2. Open Burning - rural areas only 3. Feeding to Animals 4. Composting - aerobic and anaerobic decomposition 5. Sanitary Landfill - large scale burying, associated with problem of ground water source 6. Incineration - controlled burning of refuse, associated with problem of air pollution

Major Types of Refuse Disposali. Land Filling Type of waste that can be landfilled safely: - inert wastes , biodegradable waste, aqueous liquids (in limited quantities) , sludges , and certain special wastes Waste type which should not be landfilled include : - Volatile liquids (solvents) - Wastes which would introduce unacceptable contamination into leachate - Wastes which would interfere with the biological processes in a landfill site Hazardous wastes disposal to landfill : Deep disposal - waste are placed in deep undergrounds in old mines until a new use can be found. Mono-landfill - no mixing of wastes and these are robustly designed engineered barriers. they are not co-disposed with other wastes.

Major Types of Refuse Disposal

ii.

Incineration - disposal of waste particularly clinical waste by exposing them to high temperature that will render them sterilized.

iii. Permanent storage - this is a last resort and it provides no amelioration of hazard. Any hazardous wastes disposed by permanent storage will remain hazardous indefinitely.

WASTE MANAGEMENTproper disposal of waste management of processes in order to achieve objectives 1. to prevent contamination of : -surface soil -surface water -ground water 2. to prevent the creation of breeding place 3. to prevent odors and unsightly conditions 4. to prevent contamination of fomites and other objects

METHODS OF EXCRETA DISPOSALCategory I - most acceptable form of excreta disposal - disposal unit equipped with water and transport facilities - advantages: 1) excellent health benefits 2) convenience - Disadvantages 1) large water requirements 2) high construction and maintenance cost - e.g. Cistern flush toilet connected to sewerage system

METHODS OF EXCRETA DISPOSALCategory II - acceptable form of excreta disposal - disposal unit equipped with water supply - advantages: 1) excellent health benefits 2) convenience - Disadvantages 1) large water requirements 2) moderate construction cost 3) requires dislodging every 1 - 5 years - e.g. Cistern flush toilet connected to septic tank, Aqua privy, Pour-flush latrine, Vault privy

METHODS OF EXCRETA DISPOSALCategory III - unacceptable form - disposal unit equipped with transport facilities only. - advantages: 1) minimal water requirement 2) minimal construction cost - Disadvantages 1) periodically emptied by night soil laborer/scavenger 3) problems of odor, insect, spillage - e.g. Bucket Latrine

METHODS OF EXCRETA DISPOSALCategory IV - most unacceptable method of excreta disposal - disposal unit not equipped with water nor transport facilities - advantages: 1) convenience 2) very minimal construction cost - Disadvantages 1) Associated with problem of environmental contamination that can be detrimental to health - e.g. Pit latrine, Bored-hole latrine, Compost Latrine

Methods of excreta disposal or water-carried waste1. For rural areas -pit privy e.g.. sanitary pit privy with water seal (recommended) others: -bored-hole -latrines e.g. trench latrines, overhung latrines -box and carry -can privy-->no chemical use like in chemical toilet -flying saucer (not recommended) 2. For sub-urban -septic tank 3. For urban areas -sewerage system (best or acceptable way of waste disposal) -Imhoff tank -chemical toilet- consists of a tank, containing 5 -10 -15 gallons of water with 25 lbs. of caustic soda 4. For vehicles -(e.g. airplane)-chemical toilet

Sewerage SystemProcess/Steps 1. Removal of large solid-screening(bars) 2. Sedimentation-inside tanks 3. Anaerobic decomposition-inside tanks 4. Aerobic decomposition -trickling filter 5. Drying of sludges- in-sludge beds 6. Disinfection of effluent-uses lime-before and after final disposal

Solid Waste DisposalHousehold1. burning 2. burying 3. composting

Community1. incineration 2. sanitary landfill 3. Composting

Housing Sanitation


HOUSING SANITATIONFunction of a home: 1. Shelter 2. Secure place 3. Center of family activity 4. Decent place for caring and rearing 5. Satisfies physiological and psychological needs of man

HOUSING SANITATIONBasic Principles of Standard Housing I Fundamental Physiologic needs II Fundamental Psychologic needs III Protection against Contagion IV Protection against accidents

I

Fundamental Physiologic needs1) Maintenance of appropriate temperature that will allow Adequate heat loss or prevent undue heat loss from the human body. 2) Provision of unpolluted environment 3) Provision of adequate natural illumination 4) Provision of adequate artificial illumination and avoidance of glare 5) Protection from excessive noise 6) Provision of adequate space for exercise and play of children

II

Fundamental Psychologic needsProvision of adequate privacy Provision of opportunities for normal family life Provision of opportunities for normal community life Provision of facilities that will enable performance of household task with adequate ease. 5) Provision of facilities for maintenance of cleanliness 6) Concordance with the prevailing social standard of the local community 1) 2 3) 4)

III

Protection against Contagion1) 2) 3) 4) 5) 6) 7) 8) Provision of a safe and sanitary water supply Protection of the water supply systems against pollution Provision for toilet facilities Protection against sewage contamination of the interior surface Avoidance of unsanitary condition Exclusion of the dwelling area from vermin Provision of sufficient space in sleeping areas Provision for sanitary food storage

IV

Protection against accidents1) Construction of house should conform with the prevailing standards to prevent/avoid accidents: a) falls b) electrocution c) fire d) vehicular accidents 2) Provision of adequate emergency exit

Essentials of Housing1) 2) 3) 4) 5) 6) Access to safe and adequate water supply: at least 20 gallons/person/day Proper waste disposal (refuse and excreta) Protection against vermin invasion Doors: minimum of 2 egress should be constructed Minimum standard of Basic Equipment a) Food preparation, storage and cooking b) Bathroom, Toilet and Lavatory Minimum Standard for a) Light for general lighting 5-10 foot candle, for reading 14 foot candle b) Ventilation- for adequate air circulation (air movement within 10 to 15 min) c) Temperature 20 to 30 Celsius d) Noise insulation maintain sound level to 20 dB in sleeping quarters Vermin proofing a)Safe storage for drugs and poisons. Adequate Space: -150 square feet of space for first occupant -100 square feet additional space for each succeeding occupant -minimum of 7 feet floor to ceiling clearance

7) 8)

Types of Dwelling units1) 2) 2) 3) 4) Single Houses single dwelling unit in one lot and one roof Duplex- two dwelling units in one lot under one roof Apartments several dwelling units in one lot under one roof Condominium/Townhouse- several dwelling units on several levels in one big lot under one roof Temporary dwelling units: a) Hotel/Motel b) Lodge/Inn c) Dormitories Special dwelling units: a) Camps b) Convents/seminaries c) Institutional hospitals

5)

Food Sanitation


Food SanitationControl measure employed in food handling, preparation and storage to ensure the safeness of food from contamination of poisonous substances and invasion of disease causing microorganisms.

OBJECTIVES:1. 2. 3. 4. 5. 6. To educate each individual, the family and community on proper way of handling, preparing and storing of foods. To provide protective measures on foods against unrelated agents that alter it's value. To ensure consumption of safe wholesome food. To prevent sale of food of poor quality or offensive to purchaser. To protect consumer against adulteration and misrepresentation. To cut down spoilage and wastage.

Aspects/Areas of Consideration1. Food Control 2. Food Management 3. Food Technology 4. Food Handling/Handlers

Primary Health Significance1. Transmit pathogens 2. Transfer parasites 3. Incite allergic reactions

Occurrence of Food Contamination1. Production/Processing 2. Transport Storage 3. Distribution and Retailing

Food-borne DiseasesFOOD POISONING: Ingestion of food that contains toxins that are produced by microbial growth or toxins that are cause by substances that contaminated the food FOOD-BORNE INFECTION: The contaminating microorganisms infects the person who ingests contaminated food. As the pathogen grow in the host , it produces damaging toxins.

Prevention1. 2. 3. 4. 5. 6. healthy food handlers care in food handling clean environment sufficient amount of clean water proper storage/refrigeration of perishable food don't keep cooked food too long under warm temperature

Conditions that predispose to food-borne disease1. Food itself a. ingredients used b. freshness c. source d. methods of preparation, preservation and storage. 2. Food handler a. Free from infection and disease. b. Cleanliness and personal hygiene. 3. Environment / Food Establishment a. Cleanliness b. Sanitary maintenance of the equipment, utensils and the area where the food is being prepared.

Agents through which food may cause or transmit infectionA. Animal parasites - pork and beef tapeworm B. Bacteria - Salmonella C. Bacterial toxins - food intoxication due to toxins of streptococcus, staphylococcus and botulism. D. Poisons - deliberately added to food as preservatives, coloring or accidentally added by mistake. E. Poisonous animals, fish or plants F. Chemically decomposed foods. G. Idiosyncrasies to certain foods. H. Dietary indiscretions, eating too little or too much.

METHODS OF FOOD PROCESSING:1. Food cleaning 2. Food preservation a. High Temperature b. Pasteurization c. Blanching d. Canning e. Freezing f. Drying g. Fermentation and Pickling 3. Chemical Preservation

1. Food cleaninga. Physical - removal of visible soil b. Chemical - use of chemical substances to remove chemical residues. c. Bacteriological - to eliminate organism d. Radiological - treat with UV or IR rays

2. Food preservationa. High Temperature - best method by cooking b. Pasteurization - utilizes mild heat with sufficient holding time to destroy pathogens responsible for fermentation and spoilage Methods of Milk Pasteurization: i. Low Temp Holding Time - use 140 - 153 oF for 30 minutes - cool rapidly to 50 oF ii. High temp. Short Time - flush method - use 161 oF for 15 seconds then cool rapidly to 50 oF

Continuation of Food preservationc. Blanching - scalding with hot/boiling water d. Canning - food put in cans, sterilized and sealed under pressure - Signs of unsatisfactory canning process i leaks ii Swelling/lid puffers iii Springer/flicker - causes : iii.1 overfilling iii.2 insufficient vacuum

Continuation of Food preservatione. Freezing - not effective as high temperature - storage of food at 20 - 30 oF f. Drying - dehydration of food to reduce moisture content to 10 - 15% which will inactivate enzymes that produces putrefaction. g. Fermentation and Pickling - alcoholic fermentation - vinegar and sugar immersion of food

3. Chemical Preservation- the addition of chemicals additives to food as preservatives Types of Additives a. Intentional - added to enhance food value - e.g. vitamins, mold inhibitors, bactericides, emulsifiers, minerals, flavors, etc b. Permitted - added to protect the nutrient in food, add flavor, and improve physical qualities - e.g. anti-oxidants and sequestrants c. Prohibited - preservatives such as formaldehyde, salicylates, boric acid

Food Adulteration1. Mixing/addition of substance that lowers the quality food. 2. Substitution of a cheaper additive in place of a more expensive but effective additives 3. Abstraction of valuable constituents of food 4. Food coloring to conceal inferiority of food 5. Addition of poison 6. Misbranding and mislabeling

Water Sanitation


Water1. Characteristics : a. water- colorless, transparent, odorless and palatable; neutral pH, very good solvent b. potable water -free from harmful substances, chemicals and organisms 2. Uses a. drinking b. cooking c. bathing d. power generation

e. laundry f. cleaning g. recreation h. means of transportation

Water Diseases- diseases that occur due to ingestion of contaminated water e.g. cholera, typhoid water washed - diseases that occurs due to insufficient hygiene secondary to insufficient water supply e.g. scabies water related - diseases transmitted by vectors whose life cycle is partially dependent on water e.g. malaria, dengue water-based - diseases transmitted by vector that lives in water e.g. schistosomiasis water disperse- diseases which are spread by water e.g. leptospirosis water borne

Water ImpuritiesTypes 1. physical - solids colloids 2. chemicals (dissolved) - permissible (Na+, Ca, Mg but not in excess) - non-permissible 3. biological (planktons) - algae - small animals 4. micro-organism - bacteria, virus - protozoa 5. radioactive Laboratory analysis 1. physical exam - pH, threshhold odor number, cloudiness 2. chemical exam Removal Process 1. coagulation - sedimentation and & filtration 2. for hardness - filtration process; ion exchange

3. microscopic exam

3. filtration aeration

4. bacterial exam: E. coli

4. chlorination

5. test for radioactivity

5. elimination of source

QUALITY OF WATERA safe drinking water should meet the following CRITERIA: 1. Aesthetic quality 2. Biological quality 3. Chemical quality

AESTHETIC QUALITYThe aesthetic quality requirements are in respect of substances and characteristics affecting the acceptability of water for domestic use. 1. color - transparent 2. odor - odorless 3. taste - tasteless 4. suspended matter (turbidity) - clear 5. pH 6. Soft These aesthetic quality standards are made to ensure the acceptability of water for domestic use and should not be regarded as a basis for rejection of a water supply.

BIOLOGICAL QUALITY:The greatest danger in a drinking water supply is contamination by sewage fecal wastes. 1. use of coliform bacteria as indicator organisms. 2. presumptive test for coliform organisms indicative of fecal pollution. If coliform organisms are found in water sample, then it is presumed that the water is polluted with sewage or fecal wastes. Confirmatory test for E.coli - undoubtedly of fecal origin. If E.coli is not found, a further test for streptococous faecalis is carried out. Bacterial quality for drinking water The proper and efficient treatment of a raw water with chlorination or disinfection should ensure the absence of any coliform organisms.

3.

4.

WHO: International Standards for Drinking Watertreated & chlorination water should have a zero count of Coliform organism in any 100 ml. sample

For water in the distribution system, WHO recommends that, a) 95% of water samples collected from the distribution system should not contain any coliform organisms in 100 ml. throughout the year. no sample should contain E. coli in 100 ml. no sample should contain more than 10 coliform organism in 1000 ml. coliform organisms shall not be detectable in 100 ml of any 2 consecutive samples.

b) c) d)

3. CHEMICAL QUALITY:1. Toxic substances 1.1 Arsenic (As) 0.05 mg/L 1.4 Lead (Pb) 0.01 1.2 Cadmium (Cd) 0.01 1.5 Mercury (Hg) 0.001 1.3 Cyanide (Cn) 0.05 1.6 Selenium (Se) 0.01 2. Pesticides - Insecticides Ex. chlorinated hydrocarbon (DDT, Aldrin, Lindane) - Herbicides - Fungicides 3. Fluorides - may occur naturally in water - they may cause FLUOROSIS and skeletal damage to humans. - Fluoride - 0.6 - 0.8 mg/l with a temperature range of 26.3oC- 32.6oC 4. Nitrates - > 45 mg/l (NO3) may cause methemoglobinemia in infants

SOURCES OF WATERConventional sources of water 1. Rain water 2. Ground water 3. Surface water II. Non-conventional sources of water 1. Desalinated water 2. Reclaimed waste water I.

1. RAIN WATERcollected from roof and artificial catchment areas and stored in cisterns and tanks soft and of high quality has been a traditional source of water supply for rural areas not a very reliable source of supply because: 1. the rainfall pattern for any one area is seldom constant 2. the area of catchment can be extensive and costly for large populations

2. GROUND WATERfrom springs, wells and infiltration galleries cool, uncontaminated and of good quality due to the percolation and passage of water through various geological strata in the ground, there can be undesirable minerals in solution such as Ca++, Mg++, Fe, Mn Ca++and Mg++, ions cause hardness in water. Fe and Mn forms tiny particles of iron rust & oxide of manganese usually requires very little treatment other than chlorination. a good source for both urban and rural water supplies.

3. SURFACE WATERfrom streams, rivers, ponds, and lakes usually contaminated with various organic and inorganic impurities and will require treatment to render it suitable and safe for drinking treated by slow sand filtration and chlorination

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II. NON-CONVENTIONAL SOURCES OF WATER1) Desalinated water - demineralization and removal of salts specially from brackish or salty water - Demineralization processes include: 1.1 distillation 1.3 electrodialysis 1.2 ion exchange 1.4 reverse osmosis - Disadvantages 1. costly 2. requires complicated equipment and highly trained personnel

II. NON-CONVENTIONAL SOURCES OF WATER2) Reclaimed waste water the reuse of treated waste water like sewage effluents after treatment processes and disinfection additional treatment processes include: 2.1 rapid filtration 2.2 use of activated carbon to reduce further the fine suspended and dissolved solids and disinfected with chlorine Uses of reclaimed waste water 2.2.1 for industrial processes and as industrial cooling water 2.2.2 for flushing toilets

WATER TREATMENTObjective of Water treatment: To provide a potable water supply A. Household Method - boiling, filtration and/or chlorination B. Municipal - purification system Standard Water Treatment Process: 1. Coagulation 2. Flocculation 3. Sedimentation 4. Filtration: a. sand filter b. pressure filter 5. Disinfection: a. Chlorine b. Iodine

WATER PROTECTIONWater Protection 1. Watershed (catchment area) - protection from human habitation 2. Proper waste disposal 3. Proper construction and protection of wells and springs 4. Proper distribution

Factors affecting the quantity of water required for domestic purposes:1. its availability 2. the water pressure in the distribution system 3. the number of plumbing fixtures in the house Recommended water tank capacity: 1. Residential area: 10 - 15 gal/day 2. Industrial area: 100 - 150 gal/day The following rates of water usage are recommended: 1. For urban areas - 180 liters/person/day 2. For rural areas: a) water from public taps - 25 liters/person/day b) in households with water pipe connection - 150 liters/person/day

Health Education


Health Education- a compound word, Health and Education - should be viewed within a. the changing context of health and disease b. the changing health picture where lifestyles play an important role c. accepted definition of health

Health Educationit is leading out what people already know and believe and do about their health; modifying those that are undesirable, and developing desirable behaviors that are conducive to health. it is a process of providing experiences to people in order that they may be able to define their health problems, personal, family and community-and to take the needed actions for solving these problems plays an important role in the Primary level of prevention and is an essential part of the other levels of prevention

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Other definitions1. Presidents Committee on Health Education - a process that bridges the gap between health information and health practices. 2. Simmonds - a process of bringing about behavioral changes individuals, groups and larger populations from behavior that are presumed to be detrimental to health, to behaviors that are conducive to present and future health.

Other definitions3. Green - any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health 4. National Task Force on the Preparation and Practice of Health Educators - the process of assisting individuals, acting separately or collectively to make informed decisions about matters affecting personal health and that of others

Health Behavior- central concern of Health Education - 3 categories 1. Preventive Health Behavior - for preventing or detecting illness in an asymptomatic state 2. Illness Behavior - define state of health and to discover suitable remedy 3. Sick Role Behavior - perception of illness and how to get well - generally involves a whole range of dependent behaviors and leads to some degree of exemptions of ones usual responsibilities

Foundations of Health Education1. Philosophical Foundation - serves as proper guide for health educators 2. Biomedical Foundation - provides content of health education programs 3. Behavioral Science Foundation - theories or methods to bring about behavioral changes

1. Philosophical Foundation1. Health Education should bring about improved health and well being for all through promotion of healthful lifestyle, community actions for health and conditions that make it possible to live healthful lives While health is obviously the goal, ultimately the end should be human development. Health education is working with rather than for the people. Intervention strategy should be tailored to address the circumstances of a given population, person or situation Effective health education planning and application involves anticipation of the emerging challenges of the future not just understanding the current health challenges The most effective health education is planned and developed by both the health educator and the people involved. Appropriately planned health education program yield results.

2. 3. 4. 5.

6. 7.

1. Philosophical Foundation8. Requirements of successful health education includes: a. financial, political and management support b. careful planning, monitoring and evaluation c. intersectoral collaboration d. application of multiple theories and methods e. participant involvement and qualified personnel 3 principal strategies to effectively achieved health education: a. Advocacy b. empowerment c. social support

9.

2. Biomedical Foundationexplains illness in terms of biological malfunction rather than multifactorial causes

Basic Assumptions: a. The definition of disease as deviation from normal biologic functioning. b. c. The doctrine of specific etiology. The conception of generic diseases, that is the universality of disease taxonomy.

d. The scientific neutrality of medicine.

Contributions of Biomedical Foundation1. 2. 3. Identification and repair of biological problems using surgery or medicine Reduction of deaths from infectious diseases Increased life expectancy because of discoveries of sophisticated technologies

3. Behavioral Science Foundationa. b. attributes the decline in mortality to rising standard of living which gave rise to better nutrition and improved environment or personal hygiene. it includes The socio-economic and cultural factors associated with health and disease The psychological factors associated with health behavior i. learning process ii. Communication process iii. Change process Strategies/interventions to bring about change to include individual, interpersonal and group intervention models

c.

Processes of Health EducationI. II. III. Learning Process Communication Process Change Process

I.

Learning Process

Elements of Learning 1. Goal - must be relevant to the needs and concern of the person 2. Readiness - require physical, mental, and emotional preparedness 3. Situation - provide the learner with viable alternatives 4. Interpretation - acceptance or rejection depends on previous experience 5. Response - actions depends on the perception and expectation of best results 6. Consequence - result of the response would either be a confirmation or contradiction of expectations 7. Reaction to thwarting - unfavorable consequences leads to exploration of other alternatives (changes in behavior) or lose hope (give up)

Theories of Learning1. Behaviorist theories 2. Cognitive theories 3. Humanist theories

1. Behaviorist theories- Learning results from the association between stimuli and responses. Example: a. Pavlovs Classical Conditioning - pairing of natural stimulus with neutral stimulus will result to a conditioned response b. Thorndikes Law of Exercise and Law of Effects i. Law of Exercise - > frequency of stimulus-response connection is used > the association and vice-versa ii.Law of Effects stimulus connection is strengthened with reward and weakened with punishment c. Skinners Operant Conditioning - learning takes place when it is followed by reinforcement

2. Cognitive theoriesA reorganization of a number of perceptions percolating in the mind of the learner

Example: a. Tolmans Cognitive Mapping - learning is goal directed and needs a semblance of structure

3. Humanist theoriesWhile some form of stimulus-response is also present, they feature the analyses of the nature of personality and society Active role of the learner is highlighted

Example: a. Banduras Social Cognitive Theory - reciprocital determinism of individual and environment

Parts of Learning Process1. Content - relevant and meaningful issues are quickly learned 2. Learning Situation - learning is easy in an appropriate circumstances 3. Method - learning is effective if real learning situations or those which closely resemble them are provided for. 4. People - learning is effective if the individual participation is enhanced by identifying motivations and skillful usage of motivations of the learner

II.

Communication Process

Definitions: 1. The process by which information is exchanged and understood by two or more people (Daft) 2. The creation or exchange of understanding between and a receiver; both verbal and nonverbal. (Rackick) 3. A process by which people attempt to share meaning via transmission of symbolic message. (Porter and Roberts)

Elements of Communication Process1. Source/Sender - initiates the process of communication 2. Message - physical form into which the information/idea are encoded 3. Channel - mode of transmission of the information/idea 4. Receiver - target of the senders message 5. Feedback - reaction of the receiver

Steps in the Communication Process1. Thinking - framing of ideas in senders mind 2. Encoding - putting thought into some form 3. Transmitting - broadcasting the message via some medium 4. Perceiving - incoming communication sensed by senses 5. Decoding - incoming communication transform into some form 6. Understanding

Communication Theories1. The Two Step Flow Theory 2. The Diffusion Process 3. Communication-Behavior Change Model

Communication Theories1. The Two Step Flow Theory - ideas are disseminated through mass media are received mostly opinion leaders in the community, who in turn play relay or reinforcement roles to influence others and spread ideas through their interpersonal relationship.

Communication Theories2. The Diffusion Process - acceptance of an idea goes through five stages: a. Awareness b. Interest c. Evaluation d. Trial e. Adoption

Communication Theories3. Communication-Behavior Change Model - based on an input output factors relevant for communication programs in health a. Input factors i. awareness ii. interest iii. evaluation iv. trial v. adoption

Communication Theories3. Communication-Behavior Change Model a. Output factorsi. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. exposure to the message Attending to it liking, becoming interested in it comprehending it skill acquisition acceding to it memory stage of content or agreement to both information search and retrieval deciding on basis of retrieval behaving in accord with decision reinforcement of desired acts post behavioral consolidating

Principles of Communication1. People select what they see or hear. 2. Interpret selectively what they see and hear. 3. Choose what they want to remember and what they want to forget. 4. Words do not have meanings 5. Meanings are in the people. 6. Meaning are in contexts 7. Meanings are in relationship

Barriers to Communicationa. Environmental Barriers i. noise ii. competition for attention iii. time b. Terminology and Complexity of the Message - Familiar terminology tend to minimize misunderstanding - more complex message the greater the misunderstanding c. Personal Barriers - encoding and sending or decoding and receiving message depends on: i. frame of reference ii. Beliefs iii.selective perception

Ways to Overcome Barriers to Effective Communicationa. Regulate the flow of information b. Encourage feedback c. Simplify message language d. Listen actively e. Restrain emotions f. Use nonverbal cues

III. Change Processa. Cognition change - a change in knowledge and/or perception of a person b. Attitude change - a change in individuals belies, predispositions, intentions and tendencies c. Behavior change - an alteration in an individual/groups knowledge, attitude and practices

Levels of Change Occurrencea. Individual - a change in knowledge , attitudes, values and behavior of the individual b. Group - a change in normative beliefs, values and behaviors of the group. c. Society - can be accomplished by a major or pervasive change, such as legislation, technical innovations and massive movements.

Elements of Change Occurrencea. Innovation - idea, behavior, new technology to affect change b. Targets of change - an individual, group of people, or a community c. Change agent - a person or group of person introducing the innovation d. Strategies of change - deliberate actions, set of activities, approaches, tactics, or processes designed to effect change

Motivation to Changea. Desire for Prestige - emulation of behavior of prestigious individuals b. Desire for Economic Gain - economic gain is the most important consideration c. Competitive Situation - competition motivates change d. Obligation of Friendship - usually a friend cannot be turn down e. Play Motivation - satisfaction is derived from innovation in the form of play f. Religious Appeal - provide emotional attachment to it as sacred undertaking

Strategies/Methods of Health EducationDominant Dichotomies of Health Education: 1. Stress on environmental versus individual change. - environmentalist places emphasis on the structural factors - individualist place emphasis on the responsibility of the individual 2. Stress on high risk individuals versus whole population where risk is evened out - emphasize the prevention paradox: a large number of people at small risk may give rise to more cases of disease than a small number who are at high risk

Classification of Strategies/Methods of Health EducationDominant Dichotomies of Health Education: 1. Stress on environmental versus individual change. - environmentalist places emphasis on the structural factors - individualist place emphasis on the responsibility of the individual 2. Stress on high risk individuals versus whole population where risk is evened out - emphasize the prevention paradox: a large number of people at small risk may give rise to more cases of disease than a small number who are at high risk

Family Medicine


Family Medicinea discipline in Medicine with distinct core knowledge and characteristics of care which refers to individuals, family and community; functions with economic, cultural and social environments and resources

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Characteristic Family Medicine Care1. 2. Primary care - first contact Continuing care - chronologically - geographically - interdisciplinary - interpersonal Comprehensive - ecologic factors

3.

Characteristic Family Medicine Care4. 5. 6. Prevention - emphasis on health education Curative - relieve symptoms through early diagnosis and prompt treatment Rehabilitative - enable highest possibility for the patient to return to their usual routine.

Family Medicine as a Specialty1. Distinguishable body of knowledge - integration of biological, clinical, and behavioral sciences - curricular framework integrates the elements of traditional clinical disciplines - emphasis on : a. prevention b. modern epidemiology c. physiological medicine d. socio-cultural factors

Family Medicine as a Specialty2. Unique field of action - patients cases are undifferentiated and not categorized - encompasses: a. all ages b. both genders c. each organ systems

Family Medicine as a Specialty3. Active area of research - Potential areas for research a. Clinical Epidemiology of common diseases Screening for diseases Alternative treatment for common diseases b. Health Care Delivery Cost effectiveness of care Utilization of health services

Family Medicine as a Specialtyc. The Family in Family Medicine Family epidemiology Impact of Illness in the family Effect of family on illness Family Practice Approach Family therapy Patient education

d.

Family Medicine as a Specialty4. Intellectually vigorous training - emphasis on continuity - multi- and/or interdisciplinary orientation of training

Family Medicineas an academic discipline: 1. centered on the family as a basic social unit. 2. it is health oriented emphasizes on 1. disease prevention. 2. health maintenance 3. curative medicine

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Requisites for a Family Medicine Practitioner- personal attributes of Family Medicine practitioner are perhaps of equal importance to scientific knowledge 1. 2. 3. 4. 5. 6. Interest in people 7. Sensitivity Good judgment 8. Thinker and doer Broad interest 9. Flexibility Decisiveness 10.Ease w/ interpersonal relationship Assume responsibility 11.Comprehensive Stability

Misconceptions on Family Medicine1. Field of Family Practice a. Family practice is what any family-oriented practice specialist does b. Patients usually prefer a super specialist when they get sick c. The Family Medicine Practitioner is not well-respected by other specialists d. Anyone can practice good family medicine without residency training. c. Degrading attitude in university medical center towards primary and comprehensive care

Misconceptions on Family Medicine1. Field of Family Practice a. Family practice is what any family-oriented practice specialist does Family physician attends to all members at any stage of illness and refers to specialty consultants particular problems beyond his range of competence.

Misconceptions on Family Medicineb. Patients usually prefer a super specialist when they get sick. Patients evaluate doctors based on availability and personality rather than on certificates on the walls. Attributes patients look for in a Physician (4 Cs) 1. Compassion 3. Competence 2. Convenience 4. Cost

Misconceptions on Family Medicinec. The Family Medicine Practitioner is not well-respected by other specialists Respect can be earned and acquired. d. Anyone can practice good family medicine without residency training. c. Degrading attitude in university medical center towards primary and comprehensive care Reflects: 1. lack of awareness on major objective of medicine 2. relative isolation from the needs of the community

Misconceptions on Family Medicine2. Nature of Family Practice a. Family Medicine physician spends all his time with minor illness and has to refer the patient who really get sick b. The Family Medicine Physician will not be given hospital privileges c. It would be too busy in Family Medicine practice d. The Family Medicine Physician is for rural areas and not for larger communities e. Family Medicine Physician earn income below other specialist.

FAMILY LIFE CYCLErepresents: a. composite of the individual developmental changes of the family members b. evolution of the marital relationship c. the cyclic development of the evolving family unit. it provide a predictable, chronologically oriented sequence of events in family life. it involves a sequence of stressful changes that requires compensating or reciprocal readjustments by the family if it is to maintain viability.

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STAGES OF THE FAMILY LIFE CYCLEI. II. III. IV. V. VI. Unattached Young Adult The Newly Married Couple The Family With Young Children The Family With Adolescents Launching Family Family In Later Years

Family Health Care


Periodic Health ExaminationPeriodic Health Examination- a group of tasks designed either to determine the risk of subsequent diseases or to identify disease in its early, symptomless state - based on the premises that 1. asymptomatic individuals can harbor disease 2. examination can detect disease can decrease morbidity and mortality

Periodic Health Examination Protocol20 to 39 years old patients:1. Physical Examination 2. Blood Pressure 3. Cholesterol 4. Breast & Pelvic Exam 5. Pap Smear 6. Mammography 7. Immunizations - every 5 years - annually - every 5 years - every 3 years - every 3 years (after 2 yearly negatives) - baseline at 35 years old - Tetanus/Diphtheria every 10 years

Periodic Health Examination Protocol40 to 50 years old patients:1. Physical Examination 2. Blood Pressure 3. Cholesterol 4. Breast & Pelvic Exam 5. Pap Smear 6. Mammography 7. Occult Blood in stool - every 3 years - annually - every 5 years - annually - every 3 years (after 2 yearly negatives) - every 2 years - every 3 years

Periodic Health Examination Protocol51 to 69 years old patients: 1. Physical Examination 2. Blood Pressure 3. Cholesterol 4. Breast and Pelvic Exam 5. Pap Smear 6. Mammography 7. Occult Blood in stool 8. Proctosigmoidoscopy 9. Immunizations - every 2 years - annually - every 5 years - yearly - every 3 years (after 2 yearly negative) - annually - annually - every 3 years (after 2 yearly negative) - a) Influenza - yearly after age 65 years b) Pneumovax at age 65

Periodic Health Examination Protocol70 years old and over patients: 1. Physical Examination 2. Blood Pressure 3. Cholesterol 4. Breast & Pelvic Exam 5. Pap Smear 6. Mammography 7. Occult Blood in stool 8. Proctosigmoidoscopy - annually - annually - every 5 years - yearly - every 3 years after 2 yearly negative - annually - annually - every 3 years after 2 yearly negative

Family Health Care- A process encompassing: a. screening for abnormalities b. early detection of disorders c. prevention of ill-health

Principal Objectives of Family Health Care1. To alert and educate individuals about their roles and responsibilities in maintaining their own health. 2. To detect disease at an early stage to alter its progression. 3. To provide entry into health care system 4. To improve health care especially among socially disadvantage 5. To gain understanding of disease trends both in population and in individuals. 6. To make the best use of proven, cost-beneficial techniques, especially in screening and early detection.

Components of Family Health CareI. Prevention II. Screening III. Periodic Health Examination/Early Detection

PreventionCategories of Prevention:1. 2. 3. Primary Prevention Secondary Prevention Tertiary Prevention

Primary PreventionClinical manifestation of disease is prevented through health promotion and specific disease protection. 1. Life style - healthy diet - non-addictive behavior 2. Health maintenance - screening activities 3. Family life education - sexuality - prenatal care - personal hygiene and sanitation

- basic living habits - leisure activity - immunizations - marriage - problems of aged members

Secondary PreventionImplies early intervention to detect and treat asymptomatic disease 1. Monitoring of well-being by physician and patient. 2. Encouraging sick members to sick appropriate help 3. Compliance monitoring regarding specific management.

Tertiary PreventionConsists of intervention in the setting of established disease to avoid complications and disability and to assist in rehabilitation. 1. Balanced support between compliance monitoring and the appropriate independent activity of members with chronic illness. 2. Adjustment of all members to changes necessitated by chronic illness in one member. 3. Coping with crisis created by a serious illness such as congenital anomaly or by a dying family member.

Health Risk1. Health behavior a. Tobacco use e. b. Alcohol f. c. Caffeine g. d. Nutrition, diet, and obesity h. Family determinants - family history can help predict future problems Environmental and Community determinants a. Socio-economic factors b. Sanitation Injuries/accidents Exercise Infectious disease Stress

2. 3.

ScreeningPatients are well or asymptomatic individual. Criteria for Screening (Frame and Carlson) 1. The condition must have a significant effect on quality and quantity of life. 2. Acceptable methods of treatment must be available. 3. The condition must have an asymptomatic period during which detection and treatment significantly reduce morbidity and mortality. 4. Treatment in asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptom appear. 5. Tests that are acceptable to patients must be available at reasonable cost to detect the condition in the asymptomatic period. 6. The incidence of the conditions must be sufficient to justify cost of screening,

Medical Conditions Appropriate for Screening1. 2. 3. 4. 5. Hypertension Hypercholesterolemia Glaucoma Hearing deficit Carcinomas a. Breast b. Cervical c. Lung d. Colon Infectious Diseases a. Rubella b. Tuberculosis

e. Prostatic f. Endometrial g. Ovarian h. Testicular c. Hepatitis d. STIs

6.

Early DetectionEarly Detection 1. Case finding by survey and selective examination 2. use of all available laboratory procedures 3. use of consultant specialist in communicable disease 4. adequate notification of cases 5. examination of contacts

Impact of Illness on the Family


Disease versus IllnessDisease- primary biologic and psycho-physiologic disorder. Illness - includes the sufferers experience of the disease and the broad range of dislocations felt by both the sufferer and his family. - deeply embedded in the social, cultural and family context of the person who is ill.

Impact of Illness1. Sickness of patient causes suffering and severe disruption for the patients family. 2. Particular illness sets in motion processes that are disruptive of family life and hazardous to health of family member. 3. Patients disease is embedded in a whole matrix of difficult family problems that contribute to the disease process itself.

Meaning of Illness for the Family- To discover the meaning of illness: 1. Investigate disease examining of the clinical and laboratory evidences of biologic and psycho-physiologic dysfunction. 2. Investigate illness exploring the meaning of illness to the patient and patients family a. patients understanding of etiology of his disease b. its pathophysiology and appropriate treatment c. trajectory and outcome of his illness

The Family Illness Trajectorynormal course of the psychosocial aspects of disease for the patient and the family Uses : 1. Allows Family physician to predict, anticipate, and deal with a familys response to illness. 2. Indicates normal and pathologic responses thus enabling family physicians to formulate special therapeutic plan. -

The Stages in Family Illness TrajectoryI. II. III. IV. V. Onset of Illness Impact Phase Major Therapeutic Effects Recovery Phase Adjustment to the Permanency of the Outcome

I. Onset of IllnessAcute Disease 1. Nature of Onset - rapid and clear onset 2. Characteristics of Experience a. provide little time for physical and psychological adjustment b. short period between onset, diagnosis and treatment leaves little time to remain in a state of uncertainty 3. Impact on Family - caught up in suddenness to deal with immediate decision. Chronic Disease 1. Nature of Onset - gradual and insidious onset 2. Characteristics of Experience - suffer from state of uncertainty over meaning and symptom 3. Impact on Family - vague apprehension, anxiety and fearful fantasies over denial of seriousness of symptom and possible implication

Dysfunctional Family reaction to illness1. 2. Mistrust and Hostility toward the medical profession Issue on legitimacy of sufferers symptoms

Corrective measure: 1. Explore routinely the explanatory model and fear that patients bring to the clinic visits 2. With inappropriate label of illness, acknowledge and explore conflict the patient may be suffering. 3. Explore several aspects of pre-diagnostic phase of patients and families.

II. Reaction to Diagnosis: Impact PhasePlanes of Reaction 1. Emotional Plane a. Initial phase denial, disbelief, and anxiety b. Succeeding phase anger, anxiety, and depression c. Last phase accommodation and acceptance 2. Cognitive Plane a. Initial phase tension and confusion b. Succeeding phase exacerbation of tension and distress c. Last phase - acceptance

III. Major Therapeutic EffortsCritical Issues in Choosing Therapeutic Plan 1. Psychologic states of the patients and family determine the choice of therapeutic plans as well as the alternative choices. 2. Assumption of responsibility for care early in the treatment plan. 3. Economy of treatment plan. 4. Lifestyle and cultural characteristics of a family 5. Effects of hospitalization, surgery and other therapeutic methods a. Father special economic burden b. Mother greatest impact on other family members c. Children special syndrome of emotional problems i. children hostility, abandonment ii. Parents helpless, guilt, frustrated, hurt d. Geriatric vulnerable to fears of death, rejection, abandonment, loneliness

III. Major Therapeutic EffortsResponsibilities of the Attending Physician: 1. Openness of the Attending Physician to the family. 2. Deal with multiple variables 3. Work with harmony with patient and family 4. Coordinate all aspects of therapy 5. Anticipate pathologic response which occurs

IV. Early Adjustment to Outcome - RecoveryAdjustment varies according to the type of outcome anticipated 1. Return to full health - simplest outcome - gains from illness experience - patient nurtured and allowed to take over abandoned obligation, new responsibilities and privileges when sick. 2. Partial Recovery - constant sense of vulnerability due to long period of waiting. 3. Recovery is quite different if it requires acceptance of known permanent disability

IV. Early Adjustment to Outcome - RecoveryAppropriate reaction of the Attending Physician: 1. Deal with the immediate effect of trauma. 2. Alleviate anxiety and assure adequate rest 3. Provide psychologic support through understanding and repeated reassurance 4. Explore level of understanding of patient and family (labeling)

V. Adjustment to the Permanency of the Outcome1. 2. 3. The familys adjustment to the initial crisis. The second crisis occurs as family realizes that they have to accept and adjust to permanency of disability. Finally, the family begin and gives up hope for the patients full return to health and have to accept that life must go forward and the pattern believed to be temporary must be accepted as permanent.

Economic Impact of Illness1. 2. 3. Emotional trauma Social dislocation Economic catastrophe

Family in CrisisFamily is in crisis when it moves into a state of disequilibrium in response to any situation or event that it can not resolve by the use of available problem solving skills, behavior or response.

Evaluating Family in Crisis1. Assess family history of coping with problem or stressor. - boiling point at which crisis response is set in motion a. affected by uniqueness of internal and external factors b. stresses are sufficient in number or intensity to disturb family equilibrium c. family psychosocial history provides information regarding capacity of family to cope with illness and other missions d. quality of family life

Evaluating Family in Crisis2. Determine the style of family development a. Anticipatory guidance issue b. timeliness of illness or problem Role of patient in the family a. Member providing financial support b. Member plays a critical role in family emotional life Monitoring role disruption a. assesses and monitors effects of role disruption b. identifies gap in the family that exists or has resulted from illness c. sick role as perceived by patient and family

3.

4.

Evaluating Family in Crisis5. Nature of Illness a. For acute illness - potential for crisis especially when family routines are suspended b. For chronic illness - prolonged fear and anxiety leads to higher incidence of illness in other members of the family c. For terminal illness - highly emotional and devastating d. Hospitalization - conflict between the family and hospital staff (intrusion) e. Family reaction to death - initially denial , then anger, after which there is bargaining, then depression, finally acceptance

Segmental Phase of ReactionEmotional Plane a. Onset state of response of protective denial, disbelief and numbness b. Emotional upheaval strong emotion alternately express anxiety or rage, sadness, depression c. Accommodation phase emotional climate moves towards hopefulness and acceptance Cognitive Plane Phase I - tension may be observed objectively Phase II - result from proven method of tension reduction Phase III - increasing assessment and receptivity of the family to new approach for relief of distress Phase IV - quality of family reorganization

Tools in Family Assessment


Tools in Family AssessmentSteps: 1. Recognize Family Structure 2. Understanding Normal Family Function 3. Learn to Assess Family Structure and Function in Clinical Practice

Family Assessment ModelFamily Identification a. Composition b. Social History c. Community and Neighborhood II. Individual Family Data a. Health History b. Family Dynamics i. Techniques ii. Recording I.

OCCUPATIONAL MEDICINE


Luminaries of Occupational MedicineBernardino Raizzini - father of Industrial Medicine (Occupational Medicine)

Gregorio Dizon - father of Occupational Medicine in the Philippines

Important Conditions in O.H.Injury - a condition which has occurred after a short/single period of exposure to an unsafe act or condition. Illness - a condition which has occurred as a consequence of long exposure to unsafe act or condition.

DefinitionsOccupational Health - concerned with the promotion and maintenance of highest degree of physical, mental as well as the social well being of workers in all occupations. Occupational Medicine - a branch of Preventive Medicine concerned with adaptation of man to his job and the job to each man.

Occupational Hygienethe applied science concerned with 1. Identification risk factors 2. Measurement risk factors 3. Appraisal of risk and control to acceptable standards of physical well being 4. Chemical biologic

Preventive and Social Medicine

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