Community Medicine

Prepared by Prince, Vaibhav

 1. Define health and describe the concept of Holistic health
The widely accepted definition of health is that given by the World Health
Organization (1948) in the preamble to its constitution, which is as follows :
"Health is a state of complete physical, mental and social well-being and
not merely an absence of disease or infirmity"

1¥
The holistic approach implies that all sectors of society have an effect on
health, in particular, agriculture, animal husbandry, food, industry, education,
housing, public works, communications and other sectors (6). The emphasis
is on the promotion and protection of health.

Holistic approaches to health are derived from ancient healing traditions that
help to achieve higher levels of wellness and prevent disease. These
approaches include use of traditional medical systems, mind-body-spirit
interventions, manipulative and body-based approaches, biological based
therapies and energy therapies

Holistic health is an approach to life that considers multidimensional aspects

of wellness. It encourages individuals to recognize the whole person:
physical, mental, emotional, social, intellectual, and spiritual.
 2. Describe the concept of spiritual health

Spiritual health in this context, refers to that part of the individual which
reaches out and strives for meaning and purpose in life. It is the
intangible "something" that transcends physiology and psychology.

Spiritual health includes a purposeful life, transcendence and actualization

of different dimensions and capacities of human beings. Spiritual health
creates a balance between physical, psychological and social aspects of
human life.
“The most important and essential component of spiritual health is
communication with God”.
Characteristics of Spiritual Health
1) It has different definitions.
2) It affects physical, mental, and social health.
3) It is preferred over the other aspects of health.
4) There are religious and existential approaches to it.
5) It is presented in individuals’ behavior.
6) It is a dynamic state and can be promoted.
Some Studies also show that spirituality is a way through which one
communicates with oneself, others, the nature and everything that is sacred
(holy entities) ,
 3. Define and describe the concept of public health

The term "public health" came into general use around 1840. It arose from
the need to protect "the public" from the spread of communicable
diseases. Later, it appeared in 1848 in the name of a law, the Public Health
Act in England to crystallize the efforts organized by society to protect,
promote, and restore the people's health.

The WHO Expert Committee on Public Health Administration , adapting

Winslow's earlier definition, has defined it as (122):

• "the science and art of preventing disease includes following -

• prolonging life,
• and promoting health and
• efficiency through organized community efforts for the sanitation of the
environment,
• the control of communicable infections,
• the education of the individual in personal hygiene,
• the organization of medical and nursing services for early diagnosis and
preventive treatment of disease,
• and the development of socio/ machinery to ensure for every individual a standard
of living adequate for the maintenance of health,
so organising these benefits as to enable every citizen to realize his birthright of
health and longevity".

Public health, in its present form, is a combination of scientific disciplines

(e.g., epidemiology, biostatistics, laboratory sciences, social sciences,
demography) and skills and strategies (e.g.. epidemiological investigations.
planning and management, interventions, surveillance, evaluation) that are
directed to the maintenance and improvement of the health of the people
With the adoption of the goal of "Health for All'', a new public health was
evident worldwide, which may be defined as:
"the organized application of local, state, national and international
resources to achieve "Health for All", i.e., attainment by all people of the
world by the year 2000 of a level of health that will permit them to lead a
socially and economically productive life".
 Now a days the public health is widely used in the name of preventive
medicine, social medicine, community medicine
Public health is not only a discipline but has become a "social institution" (33)
created and maintained by society to do something about the death rate and
sanitary conditions and many other matters relating to life and death (125) . In
this sense public health is both a body of knowledge and also a means to
apply that knowledge.

4. Define and describe relativeness of health

An alternative approach to positive health conceptualizes health not as an

ideal state, but as a biologically "normal" state, based on statistical averages
(3). For example, a newborn baby in India weighs 2.8 kg on an average
compared to 3.5 kg in the developed countries, and yet compares favourably
in health. The height and weight standards vary from country to country, and
also between socio-economic groups. Many normal people show heart
murmurs, enlarged tonsils and X-ray shadows in the chest and yet do not
show signs of ill-health. Thus health is a relative concept (7) and health
standards vary among cultures, social classes and age-groups. This implies
that health in any society should be defined in terms of prevailing ecological
conditions. That is, instead of setting universal health standards, each country
will decide on its own norms for a given set of prevailing conditions and then
look into ways to achieve that level (19).
5. Define and describe determinats of health

Health is multifactorial. The factors which influence health lie both within the
individual and externally in the society in which he or she lives. It is a truism
to say that what man is and to what diseases he may fall victim depends on
a combination of two sets of factors - his genetic factors and the
environmental factors to which he is exposed. These factors interact and
these interactions may be health- promoting or deleterious. Thus,
conceptually, the health of individuals and whole communities may be
considered to be the result of many interactions. Only a brief indication of
the more important determinants or variables are shown in Fig.
The context of people’s lives determine their health, and so blaming
individuals for having poor health or crediting them for good health is
inappropriate. Individuals are unlikely to be able to directly control many of the
determinants of health. These determinants—or things that make people
healthy or not—include the above factors, and many others:

Income and social status - higher income and social status are linked to
better health. The greater the gap between the richest and poorest people, the
greater the differences in health.

Education – low education levels are linked with poor health, more stress and
lower self-confidence.

Physical environment – safe water and clean air, healthy workplaces, safe
houses, communities and roads all contribute to good health. Employment
and working conditions – people in employment are healthier, particularly
those who have more control over their working conditions

Social support networks – greater support from families, friends and

communities is linked to better health. Culture - customs and traditions, and
the beliefs of the family and community all affect health.

Genetics - inheritance plays a part in determining lifespan, healthiness and

the likelihood of developing certain illnesses. Personal behaviour and coping
skills – balanced eating, keeping active, smoking, drinking, and how we deal
with life’s stresses and challenges all affect health.

Health services - access and use of services that prevent and treat disease
influences health

Gender - Men and women suffer from different types of diseases at different
ages.
6. Describe the characteristics of agent, host and environments
factors in health and disease and multifactorial etiology of disease.

The agent is the cause of disease; the host is an organism, usually a

human or an animal, that harbours the disease, the environment is
those surroundings and conditions external to the human or animal
that cause or allow disease transmission; and time accounts for
incubation periods, life expectancy of the host or the pathogen, and
duration of the course of illness or condition.

Agents of infectious diseases include bacteria, viruses, parasites, fungi,

and molds. With regard to non-infectious disease, disability, injury, or death,
agents can include chemicals from dietary foods, tobacco smoke, solvents,
radiation or heat, nutritional deficiencies, or other substances, such as
poison. One or several agents may contribute to an illness.
A host offers subsistence and lodging for a pathogen and may or may not
develop the disease. The level of immunity, genetic makeup, level of
exposure, state of health, and overall fitness of the host can determine the
effect a disease organism will have on it. The makeup of the host and the
ability of the pathogen to accept the new environment can also be a
determining factor because some pathogens thrive only under limited ideal
conditions. For example, many infectious disease agents can exist only in a
limited temperature range.

Environmental factors can include the biological aspects as well as

social, cultural, and physical aspects of the environment. The surroundings
in which a pathogen lives and the effect the surroundings have on it are a
part of the environment. Environment can be within a host or external to it
in the community.
The concept that disease is due to multiple factors is not a new one.
Pettenkofer of Munich (1819-1901) was an early proponent of this concept.
But the "germ theory of disease" or "single cause idea" in the late 19th century
over- shadowed the multiple cause theory.
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7. Describe and discuss the natural history of disease

The term natural history of disease is a key concept in epidemiology. It

signifies the way in which a disease evolves over time from the earliest stage
of its prepathogenesis phase to its termination as recovery, disability or
death, in the absence of treatment or prevention. Each disease has its own
unique natural history, which is not necessarily the same in all individuals, so
much so, any general formulation of the natural history of disease is
necessarily arbitrary.
The natural history of disease is best established by cohort studies . As these
studies are costly and laborious, our understanding of the natural history of
disease is largely based on other epidemiological studies, such as cross-
sectional and retrospective studies, undertaken in different population
settings, both national and international.

1. Prepathogenesis phase
This refers to the period preliminary to the onset of disease in man. The disease
agent has not yet entered man, but the factors which favour its interaction with the
human host are already existing in the environment. This situation is frequently
referred to as "man in the midst of disease" or "man exposed to the risk of
disease". Potentially we are all in the prepathogenesis phase of many diseases,
both communicable and non-communicable.
 2. Pathogenesis phase
The pathogenesis phase begins with the entry of the disease "agent'' in the
susceptible human host. The further events in the pathogenesis phase are
clear-cut in infectious diseases, i.e., the disease agent multiplies and
induces tissue and physiological changes, the disease progresses through a
period of incubation and later through early and late pathogenesis. The final
outcome of the disease may be recovery, disability or death. The
pathogenesis phase may be modified by intervention measures such as
immunization and chemotherapy.

8. Describe the application of interventions at various levels of prevention

The goals of medicine are to promote health, to preserve health, to restore
health when it is impaired, and to minimize suffering and distress.
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 of and development of procedures applied.

Levels of prevention:
1. primordial prevention
2. primary prevention
3. secondary prevention
4. tertiary prevention
5. Quaternary Prevention
Primordial prevention, a new concept, is receiving special attention in the
prevention of chronic diseases. This is primary prevention in its purest sense,
that is, prevention of the 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.

Primary prevention – preventing a disease from occurring, e.g., vaccination

to prevent infectious diseases, advice to stop smoking to prevent lung
cancer.
Secondary prevention – making an early diagnosis and giving prompt and
effective treatment to stop progress or shorten the duration and prevent
complications from an already existing disease process, e.g., screening for
hypertension or cancer of cervix and colorectal cancer for early case finding,
early care and better outcomes.
•
Tertiary prevention – stopping progress of an already occurring disease, and
preventing complications, e.g., in managing diabetes and hypertension to
prevent complications; restoring and maintaining optimal function once the
disease process has stabilized, e.g., promoting functional rehabilitation after
stroke and myocardial infarction with long-term follow-up care.
Quaternary Prevention —
In this new proposal, quaternary prevention is defined as an ‘action taken to
protect individuals (persons/patients) from medical interventions that are likely
to cause more harm than good.’
Like it check the risk of overmedicalization, to protect him from new medical
invasion, and to suggest to him interventions, which are ethically acceptable.
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9. Describe and discuss the concepts, the principles of health Promotion

and education,IC and BCC- behavlour change communication.

Health is a basic human right and is essential for social and economic
development. Increasingly health promotion is being recognized as an
essential element of health development. Health promotion, through
investment and action, has a marked impact on the determinants of health so
as to create the greatest health gain for people, to contribute significantly to
the reduction of inequities of health, and to further human rights. The ultimate
goal is to increase health expectancy.
The Ottawa charter incorporates five key action areas in health promotion.
They are :
a. build healthy public policy,
b. create supportive environment for health,
c. strenghthen community action for health,
d. develop personal skills, and e. re-orient health services

Guiding Principles of Health Promotion

1.Empowering individuals and communities.

2. Participatory (involving all).

3. Holistic (all four dimensions of health).

4. Intersectoral (collaboration of all agencies)

5. Equitable (equity and social justice)

6.Sustainable (changes are maintained)

7.Multi-strategy (variety of approaches)

10. Enumerate and describe health Indicators

Indicators are required not only to measure the health status of a

community, but also to compare the health status of one country with that
of another; for assessment of health care needs; for allocation of scarce
resources; and for monitoring and evaluation of health services, activities,
and programmes.
Indicators help to measure the extent to which the objectives and targets of
a programme are being attained.
They are defined as variables which help to measure changes. Often they
are used particularly when these changes cannot be measured directly. as
for example health or nutritional status.
If measured sequentially over time, they can indicate direction and speed of
change and serve to compare different areas or groups of people at the
same moment in time
Characteristics o f indicators
Indicators have been given scientific respectability; for example ideal
indicators
a. should be valid, i.e., they should actually measure what they are
supposed to measure;
b. should be reliable and objective, i.e., the answers should be the same if
measured by different people in similar circumstances;
c. should be sensitive, i.e., they should be sensitive to changes in the
situation concerned,
d. should be specific, i.e., they should reflect changes only in the situation
concerned,
e. should be feasible, i.e., they should have the ability to obtain data
needed, and;
f. should be relevant, i.e., they should contribute to the understanding of the
phenomenon of interest.
• There is no single comprehensive indicator of nation’s
health.
• Each of the available indicators reflects an aspect of
health.
11. Demonstrate the role of effective communication skill In health.

Health is the concern of everyone for everyone. Health communication is

therefore an important area of communication. The term "health
communication" is often used synonymously with health education, which
itself suggests "outward and downward" communication of knowledge (6).
Health education is the foundation of a preventive health care system
Functions of health communication
Health communication has to cater to the following needs:

1.Information
2. Education
3. Motivation
4. Persuasion
5. Counselling
6. Raising morals
7. Health development
8. Organization
In the medical domain, communication represents a fundamental clinical skill
that involves the establishment of the therapeutic relationship, understanding
the patient's perspective, exploring thoughts and emotions, and guiding them
towards improving their health. The quality of the information obtained by the
doctor during consultations is closely linked to the communication skills of
the doctor and the patient. In literature, it is mentioned that the listening,
explaining, and empathizing skills of the clinician can have a profound effect
on the patient’s health status and functioning, as well as on their satisfaction
regarding health care in the medical establishment [16] [17].
In the communication with the patient, listening and time (availability) are
elements that must maintain attention to the speaker, regardless of the
affective status, mode of cognitive operation. “Knowing to listen” is the first
rule of the dialogue [18]. A number of rules have to be met for the listening to
be efficient and profitable for the doctors. It needs to be active, total,
empathic, receptive and with a certain criticism [19].
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12. Describe family types, its role in health and disease.

The family is a primary unit in all societies. It is a group of biologically
related individuals living together and eating from a common kitchen. The
term family differs from household in that all the members of a household
may not be blood relations, e.g., servants. As a biological unit, the family
members share a pool of genes : as a social unit, they share a common
physical and social environment. As a cultural unit, the family reflects the
culture of the wider society of which it forms a part and determines the
behaviour and attitudes of its members. The family is also an
epidemiological unit, and a unit for providing social services as well as
comprehensive medical care. The family therefore has engaged the
attention of sociologists, anthropologists, demographers,
epidemiologists, medical scientists, and in fact all those who are
concerned with family welfare.
The word, family, which is used in popular term, has made a good deal of
confusion among the professionals. It is used in very many different
senses. To avoid confusion, social scientists have used the term : (1)
Family of origin or the family into which one is born, and (2) Family of
procreation or the family which one sets up after marriage.

Types Of Family
Nuclear (elementary) family: It consists of a married couple and their
dependent children. A “new family” is a nuclear family within first 10 years
of formation (marriage).

Joint (extended) family: It consists of a number of married couples and

their children living in the same household. All the men in the household
are related by blood and the women are their wives, unmarried daughters
or widows.

Three generation family: It occurs when the married children of a couple

continue to stay with their parents and have their own children. Hence,
three generations related by direct descent live together.

Household: A “household” is usually a group of persons who normally

live together and take their meals from a common kitchen unless the
exigencies of work prevent any of them from doing so. Persons in a
household may be related or unrelated or a mix of both.