PUB304 Public Health Resource Manual Draft 3 For 20

DEPARTMENT OF COMMUNITY HEALTH DEPARTEMENT VAN GEMEENSKAPSGESONDHEID
PUB 304
RESOURCE MANUAL FOR THE COURSE/ HULPBRON LER VIR DIE KURSUS
Department of Community Health/ Departement van Gemeenskapsgesondheid University of Free State/Universiteit van die Vrystaat
Resource manual: PUB 122
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Welcome: The Department of Community Health would like to welcome you to a most interesting field of study in your optometry course. In this course you will realise that an optometrist should take care of his/her patients and family but the community in which they live could not be ignored. Next time you see a patient in your consultation room, think about the community at large and not just about the patient/family. Presentation format: The course is structured to facilitate effective understanding of all the concepts used in Community Health. It consists of 12 contact sessions which should be very interactive and not just lecturing. Please share your experience/opinions with the rest of the class during the sessions. That is the best way to study and understand concepts used in the field of Community health. The sessions are structured to cover Community Health issues in a meaningful order. The program for the sessions is on the next page. Unfortunately there isnt a prescribed handbook but this resource manual will provide you with the necessary information. Additional reading (books, journals, Internet) is however recommended in order for you to fully understand and have meaningful discussion on critical Community Health issues. You will receive study goals for each session some of the study goals are already included in the resource manual and other will be discussed during the contact session. These study goals should guide you in studying and using the resource manual of each session. If dont have study goals, please ask the lecturer. Assessment: The assessment of students in this course consists of a written 3 hour closed book test of 100 marks in the second semester as indicated on the program. They will also be a project presentation contributing towards the module mark. The end of the year assessment (examinations) will be conducted according to the University's examination program (during the official University exam period). For further information, please read the criteria in the Year book of the Faculty of Health Science. Conclusion: It is important to note that Community Health is not an exact science. Therefore, the suggested frameworks that will be discussed during the contact sessions should be used to answer questions or to motivate arguments. If you differ from others, take notice of it and motivate your opinion with proper arguments. To get maximum gain from the course it is recommended that you participate in all activities with an open mind and eagerness to learn and to understand alternative view points.
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PUB304 (Public health and compulsory residency) Session * Session 1 Lecturer Prof. Kruger LECTURE PROGRAM - 2011 Subject Principles of Public Health/Community Health & PHC Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9 Session 10 Session 11 Session 12 Additional Additional Additional Prof Kruger Dr de Klerk Dr de Klerk Dr de Klerk Prof. Kruger Dr de Klerk Prof. Kruger Dr de Klerk Prof. Kruger Dr de Klerk Dr de Klerk Prof. Kruger Dr de Klerk Prof. Kruger Dr de Klerk Health care system in SA Levels of Care and Prevention Multi-causality of disease Health Promotion and Health Education 27/01/11 3/02/11 10/02/11 17/02/11 Date 20/01/11
Community and community participation 24/02/11 Community assessment Introduction to epidemiology Screening programs Disease surveillance Outbreak investigation Health personnel MAIN TEST Feedback test 1 03/03/11 10/03/11 17/03/11 24/03/11 14/04/11 5/05/11 19/05/11 26/05/11
N Naicker/ MG Community-based Service Learning Ramonyai Project Additional N Naicker /MG Submission of the report of CommunityRamonyai & based Service Learning Project Community health staff Additional Optometry & Project presentation by students 16/09 Community health staff *Please note that session schedule might change because of availability of lecturers Lecture: Place: Test 1: Exam: Thursday 14h00-15h00 Seminar room, Department of Community Health, University of Free State Sessions 1-11 See examination roster later this year sessions 1-12
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INTRODUCTION TO COMMUNITY/PUBLIC HEALTH INLEIDING TOT GEMEENSKAPS-/PUBLIEKE GESONDHEID
Session/sessie 1
Information and study materials Informasie en studie materiaal
Compiled by: Opgestel deur:
Prof. WH Kruger Chief Specialist/Hoof spesialis
Department of Community Health Departement van Gemeenskapsgesondheid
University of Free State
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A.
1. 1.1
INTRODUCTION TO COMMUNITY/PUBLIC HEALTH
DEFINITIONS Definition of community: Dennill et al ( 1995:56) described a community in terms of its geographic boundaries or its social boundaries, or both. They define a community as a group of people who live in a particular area and who have shared values, cultural patterns and social problems, as well as a group awareness which facilitates the residents interacting more intensely with each other than they would with outsiders. In respect of planned resources a community could also be defined geographically. Matters of culture, ethnicity and age, however, define, sometimes tightly and sometimes not, other communities, which are within the geographical community. All of these have to be taken into account in respect of a service, which is delivered sensitively, responsively and responsibly. According to Hennessy (1997:5) a dictionary definition reads something like this: [Community is] a collection of individuals composing a community of living under the same organisation or government, and the state or condition of living in association, company or intercourse with others of the same species; the system or mode of life adopted by a body of individuals for the purpose of harmonious co-existence or fur mutual benefit (The Shorter Oxford English Dictionary on Historical Principles).
1.2
Definition of Health There are several familiar descriptions of health and the definition given by Hennessy (1997:6) is in line with the definition given by the WHO. The definition regard health as a state of balance or harmony, of homeostasis between the emotional, mental, physical, social and spiritual aspects of a persons individual life. Definition of Care: According to Hennessy (1997:8) care is about having a concern for another/others; an appropriate regard; a preparedness to act; and, sometimes properly, not to act. Care, too, has to do with the balance, which assists in promoting independence and appropriate protection of the vulnerable form exploitation and abuse. Definition of Community Health Care: Community Health Care is all about comprehensive health care provision in a community both by the primary health care team and others organisations/people such as dentists, dieticians, pharmacists, ophthalmic workers, continence advisers, ext. (Hennessy, 1997:10). Hennessy (1997:11) also describe community health care as all the health care that is taking place and developing at the interface of hospitals and communities, and also all health care provision outside hospitals.
1.3
1.4
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B.
1.
PRINCIPLES USED IN COMMUNITY HEALTH
3 MAIN AREAS OF INTEREST Community Health focuses on the following three areas:
1.1
HEALTH ADMINISTRATION This is all about the health care systems including management of health care and health care institutions COMMUNICABLE AND NON-COMMUNICABLE DISEASE Focus on epidemiology and prevention of the above-mentioned diseases/epidemics/ endemic Environmental Health including water, sanitation, regulations, ext. Occupational Health including occupational medicine and hygiene EPIDIOMOLOGY AND STATISTICS Research
1.2
1.3
2. 2.1
PRIMARY HEALTH CARE (PHC) DEFINITION: PHC represents essential health care which is widely accessible to the individual and their families in the community, in a acceptable way to the clients, with their continuous co-operation at an affordable cost for the community and the country. It is also seen as part of the first contact a client or his family has with health care system (called primary care not the same as primary health care) that can be rendered by health care workers inside and outside of the hospital in the community.
2.2
COMPREHENSIVE IN NATURE: Essentially primary health care is part of a holistic approach to a patient and/or a community. Not only focusing on the problem but taking into consideration several other issues at hand. Several frameworks could be used in this regard and the levels of prevention is just one such an example: 2.2.1 Primary level of prevention Health promotion Specific prevention 2.2.2 Secondary level of prevention Early diagnosis and treatment Limitation of disability 2.2.3 Tertiary level of prevention Rehabilitation
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2.3
THE KEY WORDS: Key words use in PHC context as well as quality in health care are defined as follows: 2.3.1 Accessibility: Health care that is within easy reach of all citizens geographically, functionally, financially and culturally 2.3.2 Affordable: The level of health care which the community and authorities can afford 2.3.3 Equity The absence of subgroup variability and discrepancy 2.3.4 Acceptability A level of health care which is acceptable to the community and other health workers 2.3.5 Availability Services must be readily available to members of the community 2.3.6 Effectiveness It is the extent to which a specific intervention when employed in the field, does what is intended to do for a defined population 2.3.7 Efficiency The end results achieved in relation to the effort expended in terms of money, resource and time. It is a measure of the economy with which a procedure of known efficacy and effectiveness is carried out
2.4
PREREQUISITES: 2.4.1 2.4.2 2.4.3 2.4.4 Sufficient supportive and referral resources must exit It is a multi-professional team approach Environmental health plays an important role Although the medical practitioner fulfils the leading role in the team, the community health nurse, in her extended role, bears the responsibility for the greater workload
2.5
COMPONENTS OF PHC (ALMA ATA, WHO declaration): 2.5.1 2.5.2 2.5.3 2.5.4 2.5.5 2.5.6 2.5.7 2.5.8 2.5.9 Promotion of proper feeding Sufficient supply of safe water Basic sanitation Mother and child care Family planning Immunisation Prevention and control of local endemic diseases Education with regard to health problems and ways of prevention and control Appropriate treatment for general diseases and minor injuries
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2.6
PRINCIPLES OF PHC: 2.6.1 Promotion of health is important for sustained economic and social development 2.6.2 PHC is an integral part of a countrys comprehensive health care system 2.6.3 Emphasis should be on rendering PHC services at the lowest possible appropriate effective level 2.6.4 Community members have the right and duty to participate in planning and implementation of their health care 2.6.5 In determining the priorities for the rendering of health services, the felt and identified needs of the community must also receive consideration 2.6.6 A balance must be maintained between national standards and local needs and resources
2.7
RESEARCH AND PRIMARY HEALTH CARE: Research is an essential link in ensuring that PHC reaches its goals. Health research serves two functions: 2.7.1 To determine health problems, analyze their causes and assist in the choice of appropriate actions 2.7.2 To develop new knowledge and technology to cope with major unsolved health problems
3. 3.1
PREVENTIVE MEDICINE CONCLUSIONS Health promotion is also a function for the sector outside health (education, agriculture, housing). Specific prevention is mainly a function of those delivering primary care Prevention should be included into all levels of care Preventative medicine is not a separate discipline but should be delivered within the multi-professional team QUESTION: WHAT IS THE ROLE OF THE OPTOMETRIST IN THE COMPREHENSIVE HEALTH CARE SERVICE DELIVERY AND THE PRIMARY HEALTH CARE (PHC) SETTING?
3.2 3.3 3.4
3.5
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4.
DETERMINANTS OF A DISEASE (see Figure 2 for more details)
HOST
AGENT ENVIRONMENT
5. 5.1 INFECTIOUS DISEASE PROCESS AGENT BACTERIAL, VIRAL, FUNGI, PARASITES RESERVOIR HUMAN, ANIMAL, ENVIRONMENT PORTAL OF EXIT IN NORMAL BODY FUNCTIONS MODE OF TRANSMISSION DIRECT(FROM ONE PERSON TO ANOTHER) INDIRECT(VECTOR, VEHICLE) AIRBORNE ROUTE PORTAL OF ENTRY THROUGH NORMAL BODY FUNCTIONS SUSCEPTIBLE HOST IMMUNITY, LIFE STYLE, BARRIER, CHEMOPROPHYLAXIS INCUBATION PERIOD TIME FRAME FROM INFECTION UNTIL SYMPTOMS/SIGNS APPEARED BASIC CONCEPTS IN INFECTIOUS DISEASE EPIDEMIOLOGY
5.2
5.3
5.4
5.5
5.6
5.7
DISCUSSION:
These concepts or framework are not unique to only infectious diseases. It could also be used in describing any other disease and to develop preventative programs. Some of the heading will then only be not applicable. 5.1 AGENT BACTERIAL, VIRAL, FUNGI, PARASITES RESERVOIR HUMAN, ANIMAL, ENVIRONMENT This is where the agent normally lives and multiplies and where it depends mainly for survival. This may be man, e.g. chickenpox, animals, e.g. brucellosis, or the environment, e.g. tetanus. It is not necessarily the same as the source of infection in a particular incident.
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5.2
5.3
SOURCE OF INFECTION: Infection may arise from the organisms normally living on the person, or from another human being, an animal (zoonoses) or the environment. The source of an infection may sometimes be different from its reservoir. For example, in an outbreak of listeriois in Canada in 1981, the reservoir of infection was a flock of sheep, from which manure was used as fertilizer on a cabbage field. Contaminated cabbages from the field were used to make coleslaw, which became the source of infection for humans. When the source of infection is inanimate, e.g. food, water or fomites, it is termed the vehicle of infection PORTAL OF EXIT FROM RESERVOIR: IN NORMAL BODY FUNCTIONS MODE OF TRANSMISSION The routes by which an infectious agent passes from source to host can be classified as follows: 5.4.1 Food-, drink- or water-borne infection, e.g. typhoid and cholera. The term food poisoning is usually used of incidents of acute disease in which the agent has multiplied in the food vehicle before ingestion, (e.g. salmonella food poisoning), and where it may have produced toxins, e.g. botulism. Other agent such as virus gastro-enteritis agents may be carried on the food but do not multiply in it. 5.4.2 Direct of indirect contact. This includes spread from cases or carriers, animals or the environment to other persons who are 'contacts'. (A carrier is someone who is excreting the organism but who is not ill.) Within this category possible routes include: Faeces to hand to mouth spread, e.g. shigellosis Sexual transmission, e.g. syphillis Skin contact, e.g. wound infection and cutaneous anthraz 5.4.3 Percutaneous infection. This includes: Insect-borne transmission via the bite of an infected insect, either directly from saliva e.g. malaria, or indirectly from insect faeces contaminating the bite wound e.g. typhus. Inoculation of contaminated blood or a blood product, either by transfusion, by sharing intravenous needles, by contaminated tattoo needles or acupuncture needles, e.g. hepatitis B. The agent may pass directly through intact skin, e.g. schistosomiasis, or through broken skin, e.g. leptospirosis. 5.4.4 Air-borne: Infectious organisms may be inhaled as: Droplets and droplet nuclei, e.g. tuberculosis aerosols, e.g. legionnaires' disease Dust, e.g. ornithosis. 5.4.5 Mother to baby: Organisms may pass from the mother across the placenta to the baby before birth, e.g. rubella, or via blood at the time of birth e.g. hepatitis B.
5.3
5.4
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5.5
PORTAL OF ENTRY (HOST): THROUGH NORMAL BODY FUNCTIONS SUSCEPTIBLE HOST: IMMUNITY, LIFE STYLE, BARRIER, CHEMOPROPHYLAXIS While the environment affects human health in general, environmental health threats do not weigh evenly on all segment of the community. Unfortunately, there are many populations that are more vulnerable to the environmental health challenges than other. Among these populations are the following: 5.6.1 Children: Because of the childrens immature body organs and tissues, rapid changes in development and growth, higher levels of exposure (eat, drink and breath more air per pound of body weight), play more outside, and are less capable of protecting themselves. 5.6.2 The elderly: Because of their compromised immune system. 5.6.3 The immune-compromised: (e.g. HIV positive, people on steroids and chemotherapy, organ transplants, diabetes mellitus patients) Also because of their compromised immune system. 5.6.4 Minority populations & the Impoverished:
5.6
5.7
INCUBATION PERIOD: This is the time from infection to the onset of symptoms. For each organism there is a characteristic range within which the infection dose and the portal of entry, as well as other host factors, e.g. age and other illness, give rise to individual variability. For example, in rabies the incubation period is shorter the closer the bite would is to the head. The virus travels up the nerves to the brain and has less far to go the closer the bite to the head. COMMUNICABILITY: The infectious agent may be present in the host and passed to others over a long period of time, the period of communicability. Some infections can be passed on even when the host is well. These people are then known as temporary or chronic carriers e.g. typhoid carriers. In some diseases, transmission from person to person occurs before symptoms develop. For example, a person with hepatitis A is most infectious to others just before he or she becomes ill.
5.8
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5.9
OCCURRENCE: An infection that is always present in a population is said to be endemic. An increase in incidence above the endemic level is described as an epidemic or pandemic when the epidemic is world wide. Cases may be sporadic when they are not known to be linked to other cases, or clustered in outbreaks when two or more linked cases or infections occur, suggesting that there was a common source of there has been spread from person to person. Two commonly used measures of occurrence of disease or infection are the incidence rate, the number of new cases occurring in a defined population for the total population, e.g. 10 cases per 100 000 persons per year/ and prevalence, the proportion of the population which is susceptible to infection. The resistance of a population to the epidemic, because a sufficient proportion of the population is immune, is called herd immunity. The attack rate during an outbreak is the proportion of the population at risk who was ill during the period of the outbreak. The secondary attack rate is the attack rate in the contacts of primary cases due to person -to-person spread. Variables: Epidemiology involves measuring attributes or factors, which vary in quantity or character. Some variables are fixed, i.e. they are either present or absent, e.g. sex. Occupation and nationality; or they may be continuous, being possessed in different amounts, e.g. age, height and weight. Analysis of the distribution of fixed variables in a population will usually be by calculating the proportion of people who fall within certain categories, or the rates of occurrence of disease within sub-groups of the population, e.g. death rates by residence or occupational group. Analysis of continuous variables is more complicated since values obtained from a population will lie along a range, and these values are usually summarised by an average.
5.10
SURVEILLANCE: The process of monitoring disease and infection in population is called epidemiological or population surveillance. The stages of surveillance are: 5.10.1.1 5.10.1.2 5.10.1.3 5.10.1.4 5.10.1.5 systematic collection of data; analysis of the statistics to produce statistics interpretation of the statistics to provide information distribution of this information to all those who require it so that action can be taken; and continuing surveillance to evaluate the action
Data maybe collected especially for surveillance purpose (active systems) or use may be made of routine data (passive systems). Possible weaknesses in the quality and completeness of the data should always be borne in mind. Most active data collecting systems are based on a carefully designed standard case definition. Passive data collection systems are usually based upon a microbiological or clinical diagnosis, which is not precisely defined, and this may lead to problems of interpretation. Nevertheless, such data are invaluable for monitoring trends and for detecting episodes or cases for further study.
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Period of pre-pathogenesis
Period of pathogenesis
Period of rehabilitation
Death Complications Chronicity
Agent
Host Advanced disease.
Improvement and rehabilitation. Temporary disability. Permanent disability.
Interaction
Early recognizable disease.
Environment Stimulus Susceptible host and determinants. (Specific agent and contributing factors) Clinical horizon Clinical horizon
Early pathogenesis including incubation and latent period.
Healthy carrier
Complete recovery
COURSE OF TIME
FIGURE 1:
Resource Manual: PUB304
DEVELOPMENT OF A DISEASE
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DETERMINANTS OF DISEASE In-transit Environment

R R
e s i d e n t i a l
Housing, clothing, sport, recreation, hobbies, legislation, lifestyle, family life, occupations, training, income taxes, attitudes, beliefs, values, norms, socialization, politics, war, unrest, violence, crime, overpopulation, slums, squatting, theatres, prostitution, sexual offences, suicide, welfare, divorce, family disintegration Sosio-economical Environment
Climate, allergens and carcinogens, metals and minerals, rainfall, humidity, water, temperature, barometric, pressure, ozone, topography, earthquakes, smoke, smog, gasses, radio active radiation, sunlight, noise, vibration, ventilation, dust, chemical pollution, traffic, poisons, mechanical, electrical and Physico chemical Environment thermal processes.
e c r e a t i o n a l
Biological Environment Viruses, bacteria, fungi, protozoa, worms, arthropoda, vegetative and animal food allergens and carsinogens alcohol, tobacco, dagga, opium, cocane, vaccines and antibiotics.
Occupational Environment]
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FIGURE 2:
DETERMINANTS OF DISEASE
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Visiting doctor
Chief nursing service manager
iii
A Senior nursing service manager
ii
Nursing service manager
Decision-making level Chief professional nurse (senior tutor)
4
B Senior professional nurse (tutor)
Professional nurse
Health adviser Community level workforce
Community
FIGURE 3:
AN EXAMPLE OF A HEALTH CARE HIERARCHY IN A COMMUNITY Chimere-Dan (1996:30)
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REFERENCES: Chimere-Dan, G. 1996. Community involvement in urban health programmes. Johannesburg : Thomson Publishing. 109p. Dennill, K., King, L., Lock, M & Swanepoel, T. 1995. Aspects of primary health care. Halfway House : Southern Book Publishers. 146p. Hennesy, D. 1997. Community health care development. Hampshire : Macmillian Press. 270p. STUDY GOALS A student should be able to: 1. 2. 3. Define certain concepts used in Community Health and apply the definitions in practice Understand and apply the concepts of primary health care in practice Have meaningful discussions with peers and patients using the various frameworks used in Community Health
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HEALTH CARE SYSTEM IN SOUTH AFRICA/ GESONDHEIDSORG SISTEEM IN SUID AFRIKA
PUB 304
Information and study materials for Session 2 Informasie en studie materiaal vir Sessie 2
Compiled by: Opgestel deur: Dr GMC Louwagie Senior Specialist/Senior spesialis & Dr A de la Querra Registrar Department of Community Health/ Departement van Gemeenskapsgesondheid University of Free State/Universiteit van die Vrystaat
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A.
OVERALL STRUCTURE OF HEALTH AUTHORITIES AS ENVISAGED IN NATIONAL HEALTH ACT, 2004 (Act no.61 of 2003)
(Note that some of these structures, e.g. the advisory councils are not yet in place) 1. NATIONAL LEVEL National Cabinet
Minister of Health
National Health Council (advisory)
Director General Health National Health Departments 2. PROVINCIAL LEVEL (system of fiscal federalism). Free State Example Provincial Cabinet Member of Executive Council Health Provincial Head Health Health support Cluster Clinical Cluster (Health programs) (Hospitals and clinics) Financial Cluster (Financial/strategic issues) Provincial Health Council (advisory)
3. DISTRICT LEVEL (TYPE C AND A MUNICIPALITIES, with type B local municipalities)
MHS
NON-MHS
District Health Council: functional integration
District Councils (and for transitional period type B local municipalities) are responsible for Municipal Health Services, defined as Envirornmental Health Services in new National Health Act, 2004. The MEC Health establishes the District HEALTH Councils and ensures mutually agreed performance targets are set. Note that un the transitional period, many PHC services at clinics are rendered by type B local authorities. Some may be taken over by the province, others may continue to be rendered by the local authorities if they have the capacity.
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B.
1.
HEALTH CARE SYSTEM IN SOUTH AFRICA

INTRODUCTION The Department of Health is committed to providing quality health care to all South Africans, to achieve a unified National Health System, and to implement policies that reflects its mission, goals and objectives. STATUTORY BODIES Statutory bodies for the health service professions include the Health Professions Council of South Africa (HPCSA), the South African Dental Technicians' Council, the South African Nursing Council, the South African Pharmacy Council, Allied Health Service Professions Council of South Africa and the Council for Social Service Professions. HEALTH AUTHORITIES National Department of Health The Department of Health is responsible for: formulating health policy and legislation formulating norms and standards for health care ensuring appropriate utilisation of health resources co-ordinating information systems and monitoring national health goals regulating the public and private health-care sectors ensuring access to cost-effective and appropriate health commodities at all levels liaising with health departments in other countries and international agencies.
2.
3. 3.1
3.2
Provincial Department of Health The provincial health departments are responsible for: providing and/or rendering health services formulating and implementing provincial health policy, standards and legislation the planning and management of a provincial health information system researching health services rendered in the province to ensure efficiency and quality controlling the quality of all health services and facilities screening applications for licensing and the inspection of private health facilities co-ordinating the funding and financial management of district health authorities effective consulting on health matters at community level ensuring that delegated functions are performed.
4.
PRIMARY HEALTH CARE (PHC) The Government is committed to providing basic health care as a fundamental right. Assessment of recent policy developments and progress on service delivery suggest that substantial progress continues to be made in providing PHC. These services are now far more accessible: they have been made free at the point of use, and some 495 new clinics have been constructed and 2 298 upgraded. A comprehensive package of PHC services has been developed and costed, and is being progressively implemented.
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The services provided by PHC workers include immunisation; communicable and endemic disease prevention; maternity care; screening of children; Integrated Management of Childhood Illnesses (IMCI) and child health care; health promotion; youth health services; counselling services; chronic diseases; diseases of older persons; rehabilitation; accident and emergency services; family planning; and oral health services. Patients visiting PHC clinics are treated mainly by PHC-trained nurses, or at some clinics by doctors. Patients with complications are referred to higher levels of care, such as hospitals, if the conditions cannot be treated at PHC level. Persons who are members of a medical aid scheme are excluded from free services. The National Drug Policy is to a large extent based on the essential drugs concept, and is aimed at ensuring the availability of essential drugs of good quality, safety and efficacy to all South Africans. The Essential Drug List (EDL) for all levels consists of 693 medicines. Provincial governments determine which of the medicines applicable to each level of care are stocked in the different facilities. The Standard Treatment Guidelines and EDL for the different levels were developed using World Health Organisation (WHO) guidelines. They will be revised regularly to include new developments in the medical and pharmaceutical fields. 5. DISTRICTS The Department's health plan is based on the district model, which functions according to the PHC approach and implies the establishment of health districts in every part of the country. Forty-two health regions and 162 health districts have been demarcated nationally. The health districts have been realigned with the newlydemarcated municipalities. 6. HEALTH POLICY Some 40% of all South Africans live in poverty, and 75% of these stay in rural areas where health services are least developed. The core of government's health policy is to eventually provide health care that is affordable and accessible to all. In 1999, the Minister of Health published a reviewed strategic framework to guide work over the next five years. Relevant aspects identified in this 10-point plan are: reorganisation of support services improvements in the quality of care revitalisation of public hospitals further implementation of the district health system and primary care a decrease in the incidence of HIV/AIDS, sexually-transmitted infections (STIs) and tuberculosis (TB) resource mobilisation and allocation human resource development (HRD).
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In recent years, substantial developments took place in several of these areas: A unified National Health Laboratory Service (NHLS) was established to provide laboratory services to the public health sector. It came into operation as a public entity in the middle of 2001. The National Planning Framework, provincial health plans and costing of services have progressed substantially, enabling a longer-term focused rehabilitation and revitalisation programme in the Department. Significant progress in HRD included the submission to Cabinet of a draft human resource plan for the sector and the negotiated abolition of rank and leg promotions. Community service was extended to dentists and pharmacists. 7. 7.1 LEGISLATION National health Act The National Health Bill was passed by Parliament in 2003. The Act, which provides a legal framework for a national health system that encompasses public, private, nongovernmental and other providers of health services, also sets out the rights and duties of health-care providers, health workers, establishments and users. It aims to promote the progressive realisation of South Africans' rights to health services and an environment that is not harmful to their well-being. It will also promote the right to basic health-care services for children. 7.2 Mental Health Act The Act provides for the care, treatment, rehabilitation and administration of persons who are mentally ill. It also sets out the different procedures to be followed in the admission of such persons. 7.3 Traditional Healers Bill The Traditional Healers Bill was drafted in 2002. It will provide for the registration of traditional healers and the establishment of a statutory body for the regulation of this area of practice. Medicine and Related Substances Amendment Bill The Bill makes provision for, among other things: the definition of the search-and-seizure powers of the inspectorate of the Medicines Control Council in a way that is consistent with the Bill of Rights. the appointment of a Deputy Registrar or Registrars for the Council to assist the Registrar as the workload increases. the extension of regulations applicable to pharmacists to cover other health practitioners licensed to dispense and compound medicines. These include professional fees and the obligation to inform the patient about generic drug options. The Bill further states that any party appealing against a decision of the DirectorGeneral on the granting of dispensing licences must approach the Minister directly. Any party appealing against a decision of the Council on medicine registration will have recourse to an appeal committee established by the Minister.
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7.4
7.5
Other health legislation The recommendations of a task team comprising the Department of Health and officials from the HPCSA and the South African Nursing Council is expected to lead to amendments of the Health Professions Act, 1974 (Act 56 of 1974), and Nursing Act, 1978 (Act 50 of 1978), in 2002/03. The process of revising the regulations of the Medicines and Related Substances Control Amendment Act, 1997 (Act 90 of 1997), is almost complete. The regulations were published for comment in the latter half of 2001. The Medical Schemes Amendment Act, 2001 (Act 55 of 2001), amended the Medical Schemes Act, 1998 (Act 131 of 1998), to extend certain rights of members to their dependants. In addition, the Act, among other things: broadens the definition of a complainant explicitly prohibits discrimination on the basis of age regulates the practice of reinsurance regulates the circumstances under which waiting periods may be applied improves the powers of the Council and the Registrar to act in the interest of beneficiaries
8. 8.1
HEALTH CARE FACILITIES Clinics A network of mobile clinics run by government forms the backbone of primary and preventive health care in South Africa. Clinics are being built or expanded throughout the country. Between 1994 and 2002, health services were brought within easier reach of about six million people through the building of some 500 clinics.
8.2
Hospitals Provincial hospitals play a vital role in the training of physicians, nurses and supplementary health personnel. According to the Department of Health there were 357 provincial public hospitals in 2002. Ongoing programmes are in place to improve the quality of hospital services. A charter of patients' rights has been developed, as well as complaint and suggestion procedures. A service package with norms and standards has been developed for district hospitals and is being extended to regional hospitals. Funding for tertiary health services has been reformed with the introduction of the new National Tertiary Services Grant, which will fund 27 hospitals in all the provinces in 2002/03. The National Planning Framework and provincial strategic position statements have progressed substantially, providing a sound basis for health service planning and a firmer base for the Health Facilities' Revitalisation Grant. The Hospital Revitalisation Programme (with a budget of some R528 million) and the Hospital Management Grant (amounting to R129 million) deal with some substantial elements of quality of care. It also targets the management systems and the skills needed by managers to drive a process of quality improvement. By February 2002, the Revitalisation Programme had funded 936 projects aimed at physical repairs and rebuilding. Four hundred and forty-four of these projects had
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been completed and 241 were on site. The Programme has R528,5 million to spend in 2002/03, which will bring the total expenditure since 1998 to R1,2 billion. According to the National Health Accounts (March 2001), there were 200 private hospitals and a total of 23 076 beds in use in South Africa in 1999. Many of these hospitals are owned and managed by consortia of private physicians or by large business organisations. Private hospital fees are generally higher than those of provincial hospitals. 8.3 Emergency medical services Emergency medical services, which include ambulance services, are the responsibility of the provincial departments of health. Emergency care practitioners receive nationally standardised training through provincial colleges of emergency care. Some technikons also offer diploma and degree programmes in emergency care. Personnel can receive training to the level of advanced life-support. These services also provide aero-medical and medical rescue services. The national Department of Health plays a co-ordinating role in the operation formulation of policy and guidelines, and development of government emergency medical services. Private ambulance services also provide services to the community, mainly on a private basis. Some of these services also provide aero-medical services to the private sector. The South African Health Services of the South African National Defence Force plays a vital supporting role in times of emergencies or disasters. 8.4 National Health Laboratory Service The NHLS is a single national public entity that consists of personnel from provincial Personnel working in this field are required to register with the HPCSA, which has a Professional Board for Emergency Care, health departments and from the South African Institute for Medical Research's (SAIMR) laboratory service. Unification of laboratories will provide cost-effective and efficient health laboratory services to all public-sector health-care providers, private health-care providers and to any government institutions that may require such service. 8.5 South African Vaccine Producers and State Vaccine Institute The South African Vaccine Producers and State Vaccine Institute play a crucial role in the control and prevention of communicable diseases, by producing human vaccines and antiserum against diseases affecting the developing world. At present, the South African Vaccine Producers is not operational, owing to restructuring that aims for a strategic equity partnership with the private sector.
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9.
THE ROLE OF LOCAL GOVERNMENT Local government has been recognised as a separate sphere of government, thereby endorsing its constitutional status. Some of the services rendered at this level include the following: preventive and promotive health, with some municipalities rendering curative care environmental health services, including the supply of safe and adequate drinking water, sewage disposal and refuse removal regulation of air pollution, municipal airports, fire-fighting services, licensing and abattoirs.
10.
ANCILLARY SERVICES Various independent organisations, most of them voluntary, also provide vital health services. The South African Red Cross renders emergency, health and community services and offers training in first aid and home-nursing. It also operates an ambulance service, medical supply points, old-age homes, an air ambulance and airrescue service, and comprehensive youth programmes. The St John's Ambulance Foundation operates in major centres around South Africa and offers training in first aid and home care to individuals, schoolchildren, and commerce and industry. It operates eye-care clinics around the country aimed at underprivileged communities. Centres stock a range of first-aid kits for factory, office and home environments, as well as hiring out mobility aids. Various community service projects in the field of PHC are undertaken. Medic Alert is a world-wide medical identification system. All members wear an identification emblem on which their medical condition and membership number are engraved. Health personnel have 24-hour telephonic access to this register. Medic Alert also serves as a register for organ, tissue and body donors, as well as for people with pacemakers. The South African First Aid League provides first aid at sports meetings, civil protection and training in first aid. It also provides first-aid kits. Poison centres are staffed 24 hours a day. These centres also provide vital advice on antidotes and treatment for doctors, pharmacists, hospitals and the public. Life Line provides a 24hour telephone counselling service for those in distress. Similar confidential services are Child Line, Rape Crisis and Suicides Anonymous. Alcoholics Anonymous is a nonprofit organisation aimed at helping addicts deal with alcoholism. Hospices improve the quality of life of the terminally ill through care, support and love. Nursing staff look after the physical, social, emotional and psychological needs of the patients and their relatives.
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Transnet's health-care train, known as Phelophepa (good health), offers a unique service, bringing accessible and affordable health-care facilities to rural communities. Since its inception five years ago, Phelophepa's education programme has broadened existing services, which include eye, dental, health and psychological clinics, and an X-ray and a pharmacy service. The train is run by qualified permanent staff. The basic health education programme gives volunteers from local communities the opportunity to enhance their basic health-care knowledge. Topics such as baby care, how to keep one's environment and body clean, and the prevention of STIs and AIDS, have been included in a five-day course presented weekly in the educlinic. It is estimated that more than 25% of South Africa's population is in need of some form of primary eye care. The primary eye-care programme, Sight Africa, is the brainchild of Lions Club International of South Africa and the South African Optometric Association. It aims to provide primary eye care to disadvantaged or indigent people who are visually impaired. The Bureau for the Prevention of Blindness performs 4 000 cataract operations each year to restore eyesight. 11 COSTS AND MEDICAL SCHEMES Tariffs for admission to private and provincial hospitals differ. Cost differences also exist between various provincial hospitals depending on the facilities offered. All provincial hospital patients pay for examinations and treatment on a sliding scale in accordance with their income and number of dependants. If a family is unable to bear the cost in terms of the standard means test, the patient is classified as a hospital patient. His or her treatment is then partly or entirely financed by the particular provincial government or the health authorities of the administration concerned. By April 1999, 168 private medical schemes were registered in terms of the provisions of the Medical Schemes Act, 1967 (Act 72 of 1967). The Medical Schemes Amendment Act, 2001 (Act 55 of 2001) improves the regulatory capacity of the Registrar for Medical Schemes and regulates reinsurance. A review of medical schemes was published in the Registrar's annual report. The complaints division of the Council for Medical Schemes dealt with 1 327 complaints in 2000/01. The Act seeks to strengthen the Medical Schemes Act, 1998 in the following ways: improving protection for members. The Act addresses the problem area of insurance, by revisiting the provision on waiting periods, and specifically protecting against discrimination on grounds of age. reducing unnecessary red tape that imposes unduly heavy conditions on medical schemes. promoting efficient administration and good governance of medical schemes by, among other things, insisting on the independence of individuals in key positions. introducing mechanisms to address problematic practices in the marketing of medical schemes and brokerage of services. The consumer is further protected by additional powers that are assigned to the Minister in terms of the Act. These include the power to:
regulate managed health-care contracts impose penalties on medical schemes or administrators for the late payment of claims.
B.
DISTRICT HEALTH SYSTEM

African National Congress District Action Research and Education District Health System Member of the Executive Council Medical University of South Africa Health Minister and nine Members of the Executive Council non-government organisation National Health System Provincial Health Authority Provincial Health Advisory Committee primary health care primary school nutrition programme Reconstruction and Development Programme University of Cape Town University of Western Cape World Health Organisation University of Witwatersrand
ACRONYMS ANC DARE DHS MEC MEDUNSA MINMEC NGO NHS PHA PHAC PHC PSNP RPD UCT UWC WHO Wits 1.
INTRODUCTION
In the 1990s South Africa is one of the few countries in the world where wholesale transformation of the health system has begun with a clear political commitment to, inter alia, ensure equity in resource allocation, restructure the health system according to a 'district health system' (DHS) and deliver health care according to the principles of the primary health care (PHC) approach. The paper will explain why the DHS was adopted and what progress has been made to date in its implementation. The paper ends by proposing next steps on the path to the establishment of well functioning health districts. 2. LEGACIES OF THE PAST
The Government of National Unity elected in 1994 inherited a highly fragmented and bureaucratic system that provided health services in a discriminatory manner (see for example Ntsaluba and Pillay, 1998). Services for whites were better than those for blacks, those in the rural areas were significantly worse off in terms of access to services compared to their urban counterparts. Expenditure on tertiary services were prioritised above PHC services.
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In order to address the problems within the health sector the Department of Health developed policies on a wide range of issues that are contained in the White Paper for the Transformation of the Health Sector in South Africa released in April 1997. The White Paper lays out the vision of the Department and the Ministry of Health. The White Paper presents what needs to be done to correct the ills of the health system and proposes how the Department intends to go about the process of reconstruction. A significant departure from the past is the decision to create a unified but decentralised national health system based on the DHS model. One of the main reasons for this is the belief that this system is deemed to be the most appropriate vehicle for the delivery of PHC. In addition, the decision to decentralise the delivery of health care is consistent with the overall policy to decentralise government. 3. 3.1 WHAT IS MEANT BY DECENTRALISATION AND THE DHS Decentralisation and health sector reform The Government of National Unity has adopted decentralisation as the model for both governance and management. Decentralised governance is embodied in the Constitution in the form of the powers and functions of the three spheres of government. The powers and functions of the local sphere of government bears testimony to the importance of this sphere in particular. In trying to understand what the concept 'decentralisation' means a definition is required. In general terms the concept implies the shift of power, authority and functions away from the centre. It is seen as a mechanism to achieve the following: greater equity and efficiency; greater involvement of and responsiveness to communities; the reduction in the size of the bureaucracy far removed from the communities being served; and greater coordination between social sectors. The World Bank views the decentralisation of public health services as potentially the most important force for improving efficiency and responding to local health conditions and demands (World Bank, 1993). According to Bossert (1996) decentralisation can take many forms. One set of typologies is the following: Deconcentration: Deconcentration is defined by Bossert as 'shifting power from the central offices to peripheral offices of the same administrative structure' Devolution: Is the shifting of power and responsibility to separate administrative structures but that are still within the public sector Delegation: Represents the shifting of responsibility to semi-autonomous 'agencies' Privatisation: As a form of decentralisation 3.2 Rationale for and principles underlying DHS development in South Africa Unger and Criel (1995) note that the ...district concept derives from two rationales:... the implementation of the PHC strategy, requiring a decentralised management, (and) the organisation of integrated systems which implies that one single team manages simultaneously the district hospital and the network of dispensaries' (p. 125). In terms of the developments post Alma Ata there was a clear recognition that unless one creates a coherent vehicle to manage the delivery of PHC the objectives set at Alma Ata would not be met. This recognition resulted in the
development of the DHS concept that has been promoted by the World Health Organisation (WHO). Tarimo (p. 4, 1991) defines a DHS as follows: 'A DHS based on PHC is a more or less self-contained segment of the national health system. It comprises first and foremost a well-defined population living within a clearly delineated administrative and geographic area. It includes all the relevant health care activities in the area, whether governmental or otherwise'. The WHO views the DHS as a vehicle for the delivery of integrated health care (WHO Technical Report Series, 1996). This is an important consideration given the Department of Health's policy decision, reflected in the White Paper on the Transformation of the Health System in South Africa, that service delivery must be both integrated and comprehensive (p. 14). The White Paper also notes that the establishment of the DHS is a key health sector reform strategy that is also based on the Reconstruction and Development Programme (RDP): 'The health system will focus on districts as the major locus of implementation, and emphasise the primary health care (PHC) approach' (p. 12). There is national consensus on the principles underlying the establishment of the DHS and what the DHS should strive for. These include: overcoming fragmentation; equity; provision of comprehensive services; effectiveness; efficiency; quality; improved access to services; local accountability and community participation; decentralisation; developmental and intersectoral approach; and sustainability (White Paper, 1997, p. 28). The role of the DHS within the National Health System (NHS) is also spelled out in the White Paper: 'This level of the health care system should be responsible for the overall management and control of its health budget, and the provision and/or purchase of a full range of comprehensive primary health care services within its area of jurisdiction. Effective referral networks and systems will be ensured through cooperation with the other health districts. All services will be rendered in collaboration with other governmental, non-governmental and private structures' (p. 30). The following aspects of the role of the DHS in South Africa should be emphasised: delivery of comprehensive and integrated services up to and including district hospital services; decentralised management responsibility, authority and accountability; the planning and management of services delivered at district level; the need for effective referral mechanisms within and between districts and levels of care; the need to deliver care in the most efficient and effective manner possible; the option of purchasing services; and the importance of utilising all district resources effectively, whether public, private or non-government organisation (NGO).
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4. 4.1
PROGRESS IN DHS IMPLEMENTATION IN SOUTH AFRICA Implementing the DHS: achievements and challenges, 1994-2000 A formal study of the process and some of its outputs was conducted in 1995 as part of a WHO multi-county study. This investigation identified the following weaknesses (Gilson et al., 1995): regions may become an obstacle to district development; implementation strategies may have overlooked some critical groups; top-down implementation runs counter to the PHC approach; the linear strategy adopted is inflexible; there is little change in the management style of provincial and national managers; lack of management capacity and skills; and there is no monitoring and evaluation system. Despite barriers the Albany district in the Eastern Cape province, for example, has been able to document the processes and benefits of functional integration which included: curative services being introduced in all municipal clinics; staff redeployment strategies finalised; duplication of services rendered by both the province and the municipality within a single clinic was rationalised; and all facilities, Many barriers to the institutionalisation of the DHS remain. These include: the determination of the health rendering function of municipalities; the transfer of resources; and the building of capacity of municipalities to enable them to render comprehensive health care. Many organisations (NGOs and universities) have worked with the national and provincial departments of health to implement the DHS. While an exhaustive list of organisations and their areas of assistance is beyond the scope of this document a few will be listed: Health Systems Trust and the Initiative for Sub-district Support have worked in several health districts in all nine provinces and produced a number of publications which may be found on their website (www.hst.org.za); The EQUITY Project which initially focused its efforts in the Eastern Cape Province but has since expanded to become a national project has produced a range of documents (www.msh.co.za); The Centre for Health Policy and the Women's Health Project based in the School of Public Health at the University of the Witwatersrand (Wits); The Public Health Programme at the University of the Western Cape (UWC); The Health Information System Project based at the Universities of the Western Cape and Cape Town (UCT); The various schools of public health and training programmes (Medical University of South Africa (MEDUNSA), University of Pretoria, Wits, UCT, UWC).
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The national Department of Health, with the concurrence of the Departments of Finance and Provincial and Local Government have yet to define municipal health services as provided for in the constitution (see later sections for the decisions adopted by the Health Ministers and nine Members of the Executive Council (MINMEC)). While the Department of Health favours a situation where municipalities (district councils and metropolitan councils) take responsibility for rendering a comprehensive package of PHC services, the Departments of Finance and Provincial and Local Government appear to favour a narrow definition of municipal health services. The latter argue that municipalities are currently not, and would not for the short term, doing a reasonably efficient and effective job of rendering their core functions and that they should not be burdened with additional responsibility until they can demonstrate that they can perform their core functions adequately. While the national departments sort out their differences, municipalities are undergoing a process of restructuring following the determination of new boundaries and the election of a new set of councilors in December 2000. It may be argued that this presents the country with a unique opportunity to obtain consensus on the role of local government with respect to the delivery of health services so that municipalities may plan accordingly. The Department of Health has decided to reduce the number of health districts in line with the changes in the number of municipalities. Each metropolitan municipality and each district municipality would constitute a health district. This implies that there will be 48 health districts a reduction from the 174 demarcated in early 1999. It has also been proposed that local municipality boundaries may be used to designate sub-districts one or more local municipalities may therefore become sub-districts. A few scenarios are possible with regard to the role of municipalities in the delivery of health services. The scenarios are wholly dependent on how municipal health services are defined. Firstly, municipal health services may be defined as the comprehensive package of PHC services. If this is the case a further determination needs to be made, i.e., should metropolitan councils and district councils or local councils be responsible for the delivery of these services. A further issue that would need to be resolved is how these services will be funded would they be funded from the revenues generated by municipalities from rates and taxes, or by the provinces or directly from the national fiscus?
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Secondly, if municipal health services are defined narrowly, say as environmental health services and preventive and promotive health as preferred by the Departments of Finance and Provincial and Local Government who would render the remainder of the PHC services and how would integration be secured? An option could be that whilst the primary responsibility of municipalities is the funding and rendering of a narrowly defined basket of services, municipalities should be provided with the resources and support to render the remainder of basket of PHC services as well and that the relationship between the province and individual municipalities be regulated via performance agreements. Given the differences in current health services rendering capacity of municipalities it is possible that a one size fits all strategy may not be feasible or desirable. It may be better to build on the current capacity of municipalities even if in the short term some health districts have more than one health rendering authority. However, this possibility should only be entertained if, via negotiation and joint planning, services are perceived to be seamless to the users and that there is an absence of duplication of services. 5. KEY LESSONS FROM INTERNATIONAL EXPERIENCES In order that South Africa may learn from the experiences of other countries the literature was explored to seek out the lessons learnt by countries that have a head start with respect to the implementation of a DHS. In a review the WHO notes that following five important issues that need to be considered (quoted in Tollman et al., 1993): organisation, planning and management; financing and resource allocation; development of human resources; community involvement; and intersectoral action. While an exhaustive literature review is beyond the scope of this paper lessons from the following countries will be described: Mexico; the Gambia; Tanzania; Sweden; Norway; the Sudan; and Philippines. The experiences of these countries will be illustrated under the following three headings: political commitment; decentralised management: process, skills and systems; and financing decentralised health systems.
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6.
CRITICAL NEXT STEPS IN DHS DEVELOPMENT The Health MINMEC meeting on 13 February 2001 took the following decisions regarding the implementation of the DHS and the role of local government in health service delivery: District and the Metropolitan Council areas shall be the focal point for the organisation and coordination of health services. Provincial Departments of Health will be responsible for coordinating the planning and delivery of district health services within the District and Metropolitan areas, in collaboration with local government Each Member of the Executive Committee (MEC) for Health shall establish a Provincial Health Authority (PHA) in her/his province by the 30 June 2001 whose function will be to advise the MEC for Health; The PHA shall comprise the MEC for Health and the councillors responsible for health for each District or Metropolitan Council in the province; The Head of the provincial Department of Health will establish a Provincial Health Advisory Committee (PHAC) by 30 June 2001 whose functions will be to coordinate the planning and delivery of health services and to advise the Provincial Health Authority; The PHAC will be composed of the Heads of Health of the provincial Department of Health and each District Council and Metropolitan Council; The MEC for Health will facilitate the establishment of District Health Authorities and community health committees within the District municipalities and Metropolitan areas, using the criteria and guidelines agreed to by the PHA, with the participation of local government; District Health Services will be provided in every District municipality and Metropolitan area; Although the long-term vision is to capacitate municipalities to deliver comprehensive PHC services, in the short-term, these services will exclude services provided by district hospitals. Municipal Health Services should be defined to include the following: environmental health services; provision of clean water and sanitation; prevention of infectious or communicable diseases; health promotion and education; provision of community rehabilitation services; treatment of minor injuries and diseases; and provision of essential medicines for primary care. After conducting an audit of services provided in each municipality, the MEC for Health may delegate the delivery of PHC services to a Metropolitan or District Council, a local municipality, or a group of local municipalities, with the appropriate capacity, support and resources and this relationship will be managed through a service agreement signed between the province and the municipality, with clearly outlined performance indicators. The MINMEC has provided clear direction with regard to what needs to be done and, in some instances, some timeframes. The task remains a large one which must be done in the context of limited financial and other resources. As expressed
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in numerous policy documents, the South African government is committed to the establishment of the DHS but needs to provide clear leadership in a few areas so that progress can be accelerated. There are many lessons from the international experience in establishing decentralised system and South Africa is well placed to learn from these experiences. Suggested reading Arden, N. African Spirits Speak: A White Woman's Journey into the Healing Tradition of the Sangoma. Rochester, Vermont (USA): Destiny Books, 1999. Baldwin-Ragaven, L., De Gruchy, J. and London, L. An Ambulance of the Wrong Colour: Health Professionals, Human Rights and Ethics in South Africa. Cape Town: University of Cape Town Press, 1999. Bayer, R and Oppenheimer G.M. AIDS Doctors: Voices from the Epidemic. Cape Town: Oxford University Press, 2002. Campbell, S. Called to Heal: Traditional Healing Meets Modern Medicine in Southern Africa. Halfway House: Zebra Press, 1998. Kibel, M. and Wagstaff, L. eds. Child Health for All: A Manual for Southern Africa. Cape Town: Oxford University Press, 1992. Crewe, M. AIDS in South Africa: The Myth and the Reality. London: Penguin, 1992. De Haan, M. Health of Southern Africa. 6th ed. Cape Town: Juta, 1988. De Miranda, J. The South African Guide to Drugs and Drug Abuse. Cresta, Randburg: Michael Collins Publications, 1998. Dennil, K. and others. Aspects of Primary Health Care. Halfway House, Gauteng: Southern Book Publishers, 1995. Dreyer, M. and others. Fundamental Aspects of Community Nursing. 2nd ed. Halfway House: International Thomson Publishing, 1997. Engel, J. The Complete South African Health Guide. Halfway House, Gauteng: Southern Book Publishers, 1996. Gumede, M.V. Traditional Healers: A Medical Doctor's Perspective. Johannesburg: Skotaville, 1990. Hammond-Tooke, W.D. Rituals and Medicines: Traditional Healing in South Africa. Johannesburg: Donker, 1989. Hattingh, S. and others. Gerontology: A Community Health Perspective. Johannesburg: International Thomson Publishing, 1996. Holland, H. African Magic: Traditional Ideas that Heal a Continent. Sandton: Penguin, 2001. Booysens S.W. ed. Introduction to Health Services Management. Kenwyn: Juta, 1996. Kok, P. and Pietersen, J. Health. Pretoria: Human Sciences Research Council, 2000. (National Research and Technology Project). Mashaba, T.G. Rising to the Challenge of Change: A History of Black Nursing in South Africa. Kenwyn: Juta, 1995. Mbuya, J. The AIDS Epidemic in South Africa. Johannesburg: The Author, 2000. Mendel, G. A Broken Landscape: HIV and AIDS in Africa. Johannesburg: M & G Books, 2002. Nadasen, S. Public Health Law in South Africa: An Introduction. Durban: Butterworths, 2000. Reddy, S.P and Meyer-Weitz, A. Sense and Sensibilities: The Psychosocial and Contextual Determinants of STD-related behaviour. Pretoria: Medical Research Council and Human Sciences Research Council, 1999. South African First Aid Manual: The Authorised Manual of the St John's Ambulance and the South African Red Cross Society. 3rd ed. Cape Town: Struik, 1997.
Felhaber, T. ed.South African Traditional Healers' Primary Health Care Handbook. Traditional aspects compiled by I. Mayeng. Cape Town: Kagiso, 1997. Couvadia, H. M. and Benatar, S. eds. Tuberculosis With Special Reference to Southern Africa. Cape Town: Oxford University Press, 1992. Van Rensburg, H.C.J. Health Care in South Africa: Structure and Dynamics. Pretoria: Academica, 1992. Van Wyk, B.E. and Gericke, N. Medicinal Plants of South Africa. Pretoria: Briza Publications, 1999. Webb, D. HIV and AIDS in Africa. London: Pluto; Cape Town: David Philip, 1997. Whiteside, A. and Sunter, C. AIDS: The Challenge for South Africa. Cape Town: Human & Rousseau, 2000. REFERENCES Abdel Rahim IM, Elkaki BA, Ali MMA, Elsayd AH, Nalder S and Gorosh M (1992) Smaller health areas for better service. World Health Forum, 13:31-37. Ahmed AM, Desta A, Tekle K and Mweta E (1993) Pursuing better health care delivery at district STUDY GOALS A student should be able to: 1. 2. 3. 4. Explain the overall structure of health authorities in South Africa Discuss the functions of each level of authority as stipulated in the Health Act of South Africa Explain the purpose of each health related Act Explain the concept of a district health system in South Africa
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LEVELS OF CARE AND PREVENTION VLAKKE VAN SORG EN VOORKOMING
PUB 304
Information and study materials for session 3 Informasie en studie materiaal vir sessie 3
Dr B de Klerk PMO Department of Community Health Departement van Gemeenskapsgesondheid
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Levels of Prevention
The scope of prevention The decline in death rates that occurred during the nineteenth century in the United Kingdom, was principally due to a decrease in deaths from infectious disease. A similar decline is now being seen in many developing countries, mainly as a result of general improvements in standards of living, especially in nutrition and sanitation. Significant control of certain diseases has been achieved through specific preventive measures (for example, immunization against poliomyelitis), but in general the role of specific medical therapies has been less important. Changes over time are influenced by the changing age structure of the population, as well as by the waxing and waning of epidemic diseases. The changes in mortality rates over time in developed countries have been particularly dramatic in the youngest age groups, where infectious diseases used to account for most mortality; traffic accidents are now the leading cause of death in children in many developed countries. The increase in proportionate mortality due to heart disease, cancer and stroke is explained in part by an increase in the number of old people in the population. An analysis of age-specific or age-standardized data is required in order to assess trends properly. The continuously changing patterns of mortality and morbidity over time in countries indicate that the major causes of disease are preventable. Other evidence of this comes from geographical variation in disease occurrence within and between countries, and from the observation that migrants slowly develop the patterns of disease of host populations. For example, the rates of stomach cancer in people born in Hawaii to Japanese parents are lower than those in Japan (Haenszel et aI., 1972). The fact that it takes a generation for the rates to fall suggests the importance of an exposure, such as diet, in early life. Epidemjology, by identifying modifiable causes of disease, can play a central role in prevention. The many epidemiological studies of coronary heart disease conducted over the past 50 years have identified the size of the problem, the major causes and the appropriate strategies for its prevention and control, thereby contributing to decline in mortality in several countries. In a similar way, epidemiology has helped to reduce the incidences of occupational disease, food-borne disease and injuries sustained in road accidents. In addition to epidemiologists, other specialists are involved in prevention, among them sanitary engineers, pollution control experts, environmental chemists, public health nurses, medical sociologists, psychologists and health economists. The need for prevention is gaining acceptance in all countries as the limitations of modern medicine in curing disease become apparent and the costs of medical care escalate. Levels of prevention Four levels of prevention can be identified, corresponding to different phases in the development of disease: primordial; primary; secondary tertiary. All are important and complementary, 'although primordial prevention and primary prevention have the most to contribute to the health and well-being of the whole population.
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Primordial prevention This level of prevention, the most recent to have been recognized, was identified as a result of increasing knowledge about the epidemiology of cardiovascular diseases. It is known that coronary heart disease occurs on a large scale only if the basic underlying cause is present, i.e. a diet high in saturated animal fat. Where this cause is largely absent, as in China and Japan, coronary heart disease remains a rare cause of mortality and morbidity, despite the high frequencies of other important risk factors such as cigarette smoking and high blood pressure (Marmot & Smith, 1989). However, smoking-induced lung cancer is on the increase and strokes induced by high blood pressure are common in China and Japan. The aim of primordial prevention is to avoid the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to an elevated risk of disease. Mortality from infectious diseases' is declining in many developing countries and life expectancy is increasing. Consequently, non-communicable conditions, especially unintentional injuries, cancer and coronary heart disease, take on a greater relative importance as public health problems even before the infectious and parasitic diseases have been fully controlled. In some developing countries, coronary heart disease is becoming important in the urban middleand upper-income groups, which have already acquired high-risk behaviour. As socioeconomic development occurs, the risk factors can be expected to become more widespread, leading to major increases in cardiovascular disease. Primordial prevention is also needed in respect of the global effects of air pollution (the greenhouse effect, acid rain, ozone-layer depletion) and of the health effects of urban smog (lung disease, heart disease). For example, the particulate matter and the sulfur dioxide concentrations in the atmosphere in several major cities exceed the maximum recommended by the World Health Organization and the United Nations Environment Programme (UNEP) (Fig. 6.3). Public policies aimed at avoiding the underlying reasons for the development of these hazards are needed in most countries to protect health. Regrettably, the importance of primordial prevention has often been realized too late. In many countries the basic underlying causes of specific disease are already present, even' though the resulting epidemics may still be developing. Cigarette smoking is increasing rapidly in many developing countries, while the overall consumption of cigarettes in many developed countries is dropping. The epidemic of lung cancer may take 30 years to develop in countries newly exposed to cigarette sales promotion. It has been estimated that by 2010 there will be over two million deaths per year in China from smoking related diseases if a major effort is not made now to reduce smoking (WHO, 1997c). Effective primordial prevention in this field requires strong government regulatory and fiscal action to stop the promotion of cigarettes and the onset of smoking. Few governments have had the political will to act to prevent epidemics caused by smoking. All countries need to avoid the spread of unhealthy lifestyles and consumption patterns before they become ingrained in society and culture. The earlier the interventions, the more cost-effective they will be. (Manton, 1988). Primordial prevention for coronary heart disease should include: national policies and programmes on nutrition involving the agricultural sector, the food industry, and the food import/export sector; comprehensive policies to discourage smoking; programmes for the prevention of hypertension; and programmes to promote regular physical activity. The example of smoking indicates that a high level of government commitment is required for effective primordial prevention.
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Primary prevention The purpose of primary prevention is to limit the incidence of disease by controlling causes and risk factors. The high incidence of coronary heart disease in most industrialized countries is due to the high levels of risk factors in the population as a whole, not to the problems of a minority. A relationship between serum cholesterol and the risk of coronary heart disease excist. Only a small minority of the population have a serum cholesterol level above 8 mmol, i.e. a very high risk of coronary heart disease. Most of the deaths attributable to coronary heart disease occur in the middle range of the cholesterol level, where the majority of the population lies. In this case, primary prevention depends on widespread changes that reduce the average risk in the whole population. The most practical way to do this is to shift the whole distribution to a lower level. This approach is supported by a comparison of the distributions of serum cholesterol in Japan and Finland. There is little overlap: people with high cholesterol levels in Japan would be considered to have low levels in Finland; the death rate from coronary heart disease in Japan is about onetenth of the rate in Finland. Practical targets for mean serum cholesterol for the purpose of primary prevention have been proposed. Another example of primary prevention aimed at virtually the whole population is the reduction of urban air pollution through limitation of sulfur dioxide and other emissions from cars, industry and domestic heating. A series of air quality guidelines have been developed (WHO, 1987c) that would lead to primary prevention if enforced. In many cities the guideline values are exceeded. A similar approach is applicable in industry, where primary prevention means the reduction of exposure to levels that do not cause ill-health. Ideally, hazards should be totally eliminated; for example benzene, a cancer-causing solvent, has been banned from general industrial use in many countries. If this is not possible, maximum occupational exposure limits can be established and, indeed, have been in most countries. Further examples of primary prevention are the use of condoms in the prevention of HIV infection, and the development of needle exchange systems for intravenous drug users to prevent the spread of hepatitis Band HIV infection. Education programmes to make people aware of how HIV is transmitted and what they can do to prevent its spread are an essential part of the primary prevention of this disease. Another important way of preventing communicable diseases is to employ systematic immunization, as hi the eradication of smallpox. Primary prevention involves two strategies that are often complementary and reflect two views of etiology. It can focus on the whole population with the aim of reducing average risk (the population strategy) or on people at high risk as a result of particular exposures (the high-risk individual strategy). Epidemiological studies have demonstrated that, although the high-risk individual strategy, which aims to protect susceptible individuals, is most efficient for the people at greatest risk of a specific disease, these people may contribute little to the overall burden of the disease in the population. In this event the population strategy or a combination of both strategies should be applied. The advantages and disadvantages of the two strategies are summarized in Table 6.2. The major advantage of the population strategy is that it does not require identification of the highrisk group. Its main disadvantage is that it offers little benefit to individuals because their absolute risks of disease are quite low. For example, most people will wear a car seat-belt while driving for their entire life without being involved in a crash. The widespread wearing of seat-belts has produced benefits to many societies but little apparent benefit to most individuals. This phenomenon has been called the prevention paradox (Rose, 1985).
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With regard to the high-risk strategy, smoking cessation programmes are very appropriate since most smokers wish to abandon the habit and individual smokers and the physicians concerned are usually strongly motivated. The benefits of intervention directed at high-risk individuals are likely to outweigh any adverse effects, such as the short-term effects of nicotine withdrawal. If the highrisk strategy is successful it also brings benefit to nonsmokers by reducing their passive smoking. The disadvantage of the high-risk individual strategy is that it usually requires a screening programme to identify the high-risk group, something that is often difficult and costly. . Secondary prevention Secondary prevention aims to cure patients and reduce the more serious consequences of disease through early diagnosis and treatment. It comprises the measures available to individuals and populations for early detection and prompt and effective intervention. It is directed at the period between onset of disease and the normal time of diagnosis, and aims to reduce the prevalence of disease. Secondary prevention can be applied only to diseases in which the natural history includes an early period when it is easily identified and treated, so that progression to a more serious stage can be stopped. The two main requirements for a useful secondary prevention programme are a safe and accurate method of detection of the disease, preferably at a preclinical stage, and effective methods of intervention. Cervical cancer provides an example of the importance of secondary prevention and also illustrates the difficulties of assessing the value of prevention programmes. Another example is screening for phenylketonuria in newborn children. If children with this condition are identified at birth they can be given a special diet that will allow them to develop normally. If they are not given the diet they become mentally retarded and require special care throughout life. In spite of the low incidence rate of this metabolic disease (2-4 per 100000 births), secondary prevention screening programmes are highly cost-effective. Other examples of secondary prevention measures that are widely used are: blood pressure measurements and treatment of hypertension in middle-aged and elderly people; testing for hearing loss and advice concerning protection against noise in industrial workers; skin testing and chest X-rays for diagnosis of tuberculosis and subsequent treatment. Tertiary prevention Tertiary prevention is aimed at reducing the progress or complications of established disease and is an important aspect of therapeutic and rehabilitation medicine. It consists of the measures intended to reduce impairments and disabilities, minimize suffering caused by departures from good health, and promote patients' adjustment to incurable conditions. Tertiary prevention is often difficult to separate from treatment since the treatment of chronic disease has; as one of its central aims, the prevention of recurrences. The rehabilitation of patients with poliomyelitis, strokes, injuries, blindness and so on is of great importance in enabling them to take part in daily social life. Tertiary prevention can mean a great improvement in individual well-being and family income, in both developed and developing countries. Screening Screening is the process by which unrecognized diseases or defects are identified by tests that can be applied rapidly on a large scale. Screening tests sort out apparently healthy people from those who may have a disease. Screening is not usually diagnostic and it requires appropriate investigative follow-up and treatment. Safety is of paramount importance, since the initiative for screening usually comes from the health service rather than from the people being screened.
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There are- different types of screening, each with specific aims: mass screening involves the screening of a whole population; multiple or multiphasic screening involves the use of a variety of screening tests on the same occasion; targeted screening of groups with specific exposures, e.g. workers in lead foundries, is often used in environmental and occupational health; case-finding or opportunistic screening is restricted to patients who consult a health practitioner for some other purpose. The costs of a screening programme must be balanced against the number of cases detected and the consequences of not screening. Generally, the prevalence of the preclinical stage of the disease should be high in the population screened, but occasionally it may be worthwhile to screen even for diseases of low prevalence which have serious consequences, such as phenylketonuria. The disease must have a reasonably long lead time, i.e. the interval between the time when the disease can be first diagnosed by screening and that when it is usually diagnosed in patients presenting with symptoms. Hypertension has a very long lead time and so has noiseinduced hearing loss; pancreatic cancer usually has only a short one. A short lead time implies a rapidly progressing disease and treatment initiated after screening is unlikely to be more effective than that begun after the more usual diagnostic procedures. Early treatment should be more effective in reducing mortality or morbidity than treatment begun after the development of overt disease, as, for example, in the treatment of cervical cancer in situ. A treatment must be not only effective, but also acceptable to people who are asymptomatic, and it must be safe. If treatment is ineffective, earlier diagnosis only increases the time period during which the participant is aware of the disease; this effect is known as length bias or length/time bias. When targeted screening is carried out in groups with particular exposures, the criteria for screening are not necessarily as strict as for general population screening. The health effect that is prevented may be minor (for instance, nausea or headache), but screening may be of high priority if the effect reduces the work capacity and well-being of the patient. This type of screening is common in workplaces. In addition, many health effects arising from exposure to environmental hazards are graded, and the prevention of a minor effect may at the same time prevent more serious effects. Targeted screening is a legal requirement in many countries, for instance, for people working with lead or asbestos, miners, victims of major environmental pollution, and other groups. After the initial screening process more precise tests are used as appropriate. The screening test itself must be cheap, easy to apply, acceptable to the public, reliable and valid. A test is reliable if it provides consistent results, and valid if it correctly categorizes people into groups with and without disease, as measured by its sensitivity and specificity. Sensitivity is the proportion of truly ill people in the screened population identified as ill by the screening test. who are
Specificity is the proportion of truly healthy people who are so identified by the screening test. Although it would obviously be desirable to have a screening test that was both highly sensitive and highly specific, a balance has to be struck between the two.
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TABLE 1: LEVEL SUBLEVEL Specific activities and/or items requiring attention
THE LEVELS OF PREVENTION/INTERVENTION
PRIMARY
HEALTH PROMOTION Natural environment Population growth Socialization Education Diet Housing Exercise Rest/Relaxation Transport Occupation
PREVENTION SPECIFIC PREVENTION
SECONDARY
PREVENTION LIMITATION OF DISABILITY Provision of sufficient facilities and trained manpower to treat disease, complications and prevent death.
EARLY DIAGNOSIS AND TREATMENT Protection of endangered species Periodic individual Health education & Family planning examinations. Personal hygiene & Sanitation Active disease Protection against infectious diseases surveillance Food hygiene & Foodstuffs Continued disease Protection against allergens screening Protection against carcinogens Mass screening. Water purification & control Active personal Protection against occupational surveillance diseases. Prevention of accidents.
TERTIARY PREVENTION REHABILITATION
Provision of sufficient facilities and trained manpower to optimize rehabilitation. Motivating the community and industries to participate in rehabilitation actively.
Aims
Responsibility
To obtain maximum Protect individuals and the community To resist the To prevent physical, social and against specific diseases. duration and complication/ psychological welldegree of morbidity. death. being for all to Prevent spread of To improve improve quality life. communicable existing diseases. disability. The individual The individual personally. Comprehensive Comprehensive The community, All health workers at Primary Health health care in health care in volunteers and Care level and comprehensive health private and public private and political associations care. sector. public sector. or bodies. (Environmental Health Officer) Outside the public sector. PREP A T H 0 G E N E S I S P A T H O G E N E S I S
To get the worker back at work as soon as possible. Find a suitable job for temporary and permanent disabled The individual. Community through volunteer organisation. Comprehensive health care in private and public sector. REHABILITATION
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MULTI-CAUSALITY OF DISEASE MULTI-OORSAAKLIKHEID VAN N SIEKTE
PUB 304
Dr B de Klerk PMO Department of Community Health Departement van Gemeenskapsgesondheid

MULTI-CAUSALITY OF DISEASE
Study goals
At the end of the session students must be able to do the following: 1. Understand the multi factorial factors that influence health (determinants of disease) 2. Describe the interaction between environment, host and agent. 3. Understand the guidelines to causation 4. Understand the different factors such as predisposing, modulating and precipitating factors in the host, which are related to illness. 5. Explain why a factor is a cause of a disease 6. Understand concept of macro and micro-environment
Lecture (1 hour)
Multi-causality of disease Causation Is a concept which is just as controversial in epidemiology as it is in other sciences. Cause of a disease Is an event, condition, characteristic or a combination of these factors, which plays an important part in the development of disease. It is called sufficient when it inevitably produces or initiates disease. It is called necessary if a disease cannot develop in its absence.
Kochs postulates for determining whether a specific organism caused a particular disease Koch stated that these postulates should be met before a causative relationship can be accepted between a particular bacterial parasite or disease agent and the disease in question. 1. The agent must be shown to be present in every case of the disease 2. The agent must be able to be isolated and grown in pure culture 3. Once isolated, the agent must be capable of reproducing the disease in susceptible animals. 4. The agent must be recovered from this experimental animal. Robert Koch (1843 1910) was one of the founders of microbiology and an important contributor towards our understanding of infectious disease epidemiology. His major contributions were the life cycle of anthrax, the etiology of traumatic infection and the discovery of the tubercle bacillus.
Temporal relationship Plausibility Consistency Strength of association Dose-response relationship Reversibility Study design Judging the evidence
Guidelines to causation Does the cause precede the effect? (essential) Is the association consistent with other knowledge? (mechanism of action; evidence from experimental animals) Have similar results been shown in other studies? What is the strength of association between cause and effect? (relative risk) Is increased exposure to the possible cause associated with increased effect? Does removal of a possible cause lead to a reduction of disease risk? Is the evidence based on a strong study design? How many lines of evidence lead to the conclusion?
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DETERMINANTS OF A DISEASE / DETERMINANTE VAN N SIEKTE

HOST/GASHEER
AGENT
ENVIRONMENT/OMGEWING
THE PRESENT APPOACH: AGENT, HOST, AND ENVIRONMENT:
The present epidemiologic approach is based upon the interaction of the host, the causative agent, and the environment. Among these factors there exists a dynamic situation in which efforts to prevent and/or control disease are constantly challenged: populations are highly mobile and tend to live longer, thereby creating circumstances of increased risk of exposure and infection; urbanization and sub-urbanization have exerted greater and greater pressures on the environment; biological agents of disease have shown remarkable adaptability to modern control measures; non-biological agents are often introduced into the milieu despite precautions of interested groups. The science of epidemiology emerged and evolved from the study of infectious diseases. However, it application has extended to the study of noninfectious diseases and to the study of health conditions in general. We may, therefore, speak of the apidemiology of heart disease, accidents, cancer, and hypertension. The same principles of interaction among the agent (s), host, and environment apply.
1.
AGENT FACTORS
The current scope of epidemiology requires an expansion in perception of the causative agents of disease. Causative (etiologic) agents are not limited to biological agents; they may also be chemical or physical: Biological Agents Protozoa Metazoa Bacteria Viruses Rickettisa Fungi Chemical Agents Pesticides Food additives Pharmacologics Industrial chemicals Physical Agents Heat Light Ionizing-radiation Noise Vibration Speeding objects
2.
HOST FACTORS
Host factors include a wide variety of characteristics. Examples of Host Factors Predisposing factors Modulating factors (born with it) (change during life) Sex Age Race Marital status Genes Lifestyle Ethnic Medication Blood group Nutrition Immunity Previous diseases Socio-economic status
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Precipitating factors (push you over edge) Death partner / family etc Overdose medication Crisis
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All of the preceding host factors, and some others, are important to the extent that they affect, first, the risk of exposure to a source of infection,, and second, the hosts resistance or susceptibility to infection and disease. Age usually is the single most important host factor related to disease occurrence. The influence of malnutrition both under and over nutritionis gaining more importance even in the relatively affluent and apparently well-fed populations of the United States. The connection between malnutrition and decreased general and specific host-resistance is slowly being disclosed.
3.
ENVIRONMENT FACTORS
Micro environment a. biological b. psycosocial c. Physical/chemical Macro environment a. recreational b. transport c. residential d. work
Some of the numerous environmental factors area: Water Housing conditions Milk Noise Meteorological conditions and effects Food Plants Environmental pollutants Animals The agent-host environment factors interrelate in extremely varied combinations to produce disease in humans. Investigators should be aware of this fact of assist them in analyzing disease problems and to reach proper conclusions regarding prevention and control measures.
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DETERMINANTS OF DISEASE In-transit Environment

R e s i d e n t i a l R e
Housing, clothing, sport, recreation, hobbies, legislation, lifestyle, family life, occupations, training, income taxes, attitudes, beliefs, values, norms, socialization, politics, war, unrest, violence, crime, overpopulation, slums, squatting, theatres, prostitution, sexual offences, suicide, welfare, divorce, family disintegration Socioeconomical Environment
Climate, allergens and carcinogens, metals and minerals,
rainfall, humidity, water, temperature, barometric, pressure, c ozone, topography, earthquakes, smoke, smog, gasses, radio active radiation, sunlight, noise, vibration, ventilation, dust, chemical pollution, traffic, poisons, mechanical, electrical and Physico chemical Environment thermal processes. r e a t i o n a l
Biological Environment Viruses, bacteria, fungi, protozoa , worms, arthropoda, vegetative and animal food allergens and carcinogens alcohol, tobacco, dagga, opium, cocaine, vaccines and antibiotics.
Occupational Environment
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Epidemiology in health care - Barbara Valanis Appleton & Lange 1992 CAUSALITY A Statistical Approach to Causality As commonly used, the term cause is understood to mean a stimulus that produces an effect or outcome. In epidemiology, cause deal with the production of an effect or outcome effected by a change in the host-agent-environment balance. A cause can be any of a large number of characteristics relating to time, place, person, or events. A health condition is likely to have multiple causes. Because an epidemiologist must rely on statistical measures of association to investigate and present causal relationship between a stimulus and an outcome, it is important to understand ways in which events or circumstances may be related in statistical terms. One operational definition of cause for such statistical investigations is a factor whose frequency varies with that of the health condition of interest. An increase or decrease in the amount of frequency of the causal factor produces a parallel increase or decrease in the frequency of the health condition. Statistical Relationships: The first question to be addressed is "does a statistical relationship exist between two factors?" Stated another way, the first in investigating statistical relationship between two factors or events is to determine whether any relationship (association) that does exit can be expected to occur by chance alone or whether the two factors occur together with a frequency greater than would be expected by chance. This is determined by applying one of a variety of statistical tests for independence or association, such as the chi-square test or a correlation coefficient. If such a test is statistically significant, then the two factors are not independent---they do have a statistical relationship that is not explained by chance alone. A table presents rates of developing complications after mastectomy for women with and without anxious personalities. A chi-square test on these data is statistically significant at p<0.05. This implies that at least 95 times out of 100, one would not expect to find such differences in complication rates between the two personality types by chance alone. Thus, the two factors--personality and complication rates--are not independent; they have a significant statistical association. The presence of a statistically significant association does not mean, however, that personality type causes complications. Determination of a statistically significant association is only the first step in assessing whether a relationship is causal. A strong statistical association between two factors or events. However, may suggest the possibility of a causal association. Note that statistical associations are determined for categories or groups and not for individual instances. In the previous example, although groups of women with anxious personalities are more likely to have complications after mastectomy than are women not undergoing mastectomy, it is not possible to say that any individual with an anxious personality will have complications, although if the association is causal, an individual with an anxious personality will be more likely to have complication that an individual without. Causal Relationships. Once it has been determined that two factors are not independent (i.e., that they have a statistically significant association), the next step is to determine whether the relationship is causal. Statistically significant (non-independent) factors may be causal or non-causally related. A non-causal relationship can be statistically significant because or the hypothetical causal factor varies systematically with the actual causal variable. When uncontrolled, its effect cannot be distinguished from that of a causal variable with it is highly correlated.
Paternal age, for example, shows a statistically significant relationship with infant birth weight. This association occurs because paternal age is highly correlated with maternal age, the actual causal variable; most husbands and wives are close in age, so the two vary together. In this instance, it is difficult to derive any logically biological explanation for why a father's age should affect the birth weight of a child, so a researcher finding this association would suggest that it is not causal and would search for an explanation for the association. It is possible in the process of epidemiological investigation to identify such factors or variables through appropriate analysis. However, it is important for clinical practitioners to bear in mind when reading the epidemiological literature that in the early stages of epidemiological investigation of a problem, published reports may not yet have identified such non-causal relationships. Guidelines to facilitate the process of interpreting the epidemiological literature in regard to the validity of causal evidence are presented later in this chapter. Causal relationship may be of two types: direct and indirect. It is important to distinguish between direct and indirect relationships to understand the natural history of a disease. Direct causal associations are those in which a factor causes a disease with no other factor intervening Causal factor Outcome An example of a direct cause would be the tubercule bacillus or any other infectious organism. Tubercule bacillus Tuberculosis Apparent directness depend on the limitations of current knowledge; what is considered a direct association may be identified as indirect when information arising from further studies of a causal mechanism reveals a new, more direct cause for the association. An historical example is the association of certain water sources with the outbreaks of cholera observed by Dr. John Snow in England in 1853 (Snow, 1855). Subsequent intervention to ban the identified sources of water self, but rather the cholera vibrio in the water that was the direct cause of the cholera epidemics. For public health practitioners interested in reducing or eliminating onset of disease, the distinction between direct and indirect cause is often not crucial. The available information may be a sufficient basis for initiating intervention, as in the example of cholera where restricting access to the suspect water supplies controlled the spread of the disease. Because clinicians more often deal with patients having signs or symptoms of disease already present, for them the distinction is more crucial. Toxic shock syndrome (TSS) provides a useful example. A direct cause of this contributing) cause. Public health officials were able to intervene even before the staphylococcal organism was identified as the direct cause. Education programs were aimed at eliminating use of tampons or changing the way tampons were used to reduce the risk of developing toxic shock; specifically, it was suggested that women avoid super absorbent tampons, change tampons frequently using good hygienic practices, and avoid leaving tampons in overnight (Centers for Disease Control, 1980). Clinicians, however, needed to know that the organism was the cause of the symptoms to treat patient appropriately with antibiotics. Knowledge of the role of tampons, however, is also useful to clinicians who need to prevent future episodes.
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In indirect causal associations, a third variable an intervening variable occupies an intermediate stage between the cause and effect. I, in the model below, A is causally related to D (A is the cause and D the effect), but only through the interposition of one or several linked factors such as B and C, the association between A and D is one of an indirect causal relationship. A B D
One example of an indirect causal association is the relationship of cigarette smoke to chronic bronchitis. Breathing air polluted by cigarette or other smoke (A) causes damage to the respiratory epithelium (B); this damage increases the susceptibility of the epithelium to infection (C); which results in chronic bronchitis (D). In this example, knowledge about B and C is not essential to primary prevention of chronic bronchitis; eliminating the inhalation of cigarette smoke may greatly reduce the frequency of occurrence of chronic bronchitis. For purposes of secondary and tertiary prevention, however, understanding B and C is important. Awareness of the role of epithelial damage on the development of chronic bronchitis offers an opportunity to test for early epithelial changes in high-risk individuals. Although it may not be possible to reverse the damage, counseling these individuals with epithelial damage are more susceptible to infection. They should be advised to avoid close contact with individuals known to have acute respiratory infections and to seek early treatment to avoid further damage in the event that they develop an infection. In the previous example of TSS, tampons are an indirect cause of the disease. The direct cause is that they create an ideal environment for proliferation of the organism (Centers for Disease Control, 1980). From the standpoint of primary prevention, the disease could be prevented by eliminating tampon use or changing the way in which they are used. Theoretically, it could also be prevented by treating women who are vaginal carriers of staphylococcal organisms with antibiotics, but this is less practical because of the expense and difficulty of identifying carriers and the possibility that the organism will recur again after treatment. From the stand-point of treatment (tertiary prevention), however knowing that Staphylococcus is the direct cause is useful because the physician can treat the disease with antibiotics to eliminate the source of the infection. The Concept of Multiple Cause Thus far for simplicity of presentation, we have discussed causality as if each disease had a single cause, although this is certainly not the case. Historically, since early epidemiology focused on outbreaks of diseases with infectious origins, the idea of single cause was quite workable for control of the disease. Cholera outbreaks could be controlled by eliminating the source of the cholera vibrio. Diphtheria could be eliminated through vaccination programs. Scarlet fever could be kept from spreading by imposing a quarantine on all exposed individuals. These measures were effective because infectious agents were necessary to produce the disease. Therefore, elimination or isolation of the agent and elimination of host susceptibility through vaccination were effective measures. With the advent of chronic diseases of noninfectious origin as major causes of morbidity and mortality, however, modern epidemiology has been force to move from the single cause conceptualization of causality to one that recognizes the presence of multiple causes in any biological phenomena, including infectious conditions. Staphylococcus for instance, was identified as the cause of TSS because this organism must be present for the disease to occur. This does not mean that it will always cause a clinically recognizable disease. Circumstances do exist when an organism is present and no disease occurs.
The host to e susceptible to the organism; susceptibility reflects previous exposure to the organism, immune response, and so on. If the host is not susceptible, no disease occurs. The environment is also important because the likelihood of exposure to an organism may vary greatly in different geographical areas; if temperature and moisture conditions are not ideal for proliferation of an organism, exposure is less likely. With diseases caused by noninfectious agents, the single cause model has limited usefulness because there is no single factor or agent that must be present to cause the disease. For example, even though smoking is recognized as a major cause of lung cancer, nonsmokers and individuals who have never been exposed to the cigarette smoke of others do get lung cancer. Clearly, there must be other sub-cancer. Furthermore, smokers who are exposed to substances such as asbestos. Exposure to multiple causal factors may have an additive or multiplicative effect. In a different example, automobile accidents may result form numerous factors, including speeding, faulty equipment, heavy traffic, poor visibility, driver inexperience, or drinking and driving. Any of these factors could cause an accident. All are amenable to intervention, as through public education, better engineering design, and better vehicle maintenance. Several of these factors together increase the risk of an accident. Such interrelationships between a multitude of factors, some known and some unknown, bur all bearing ultimately on the cause of the disease, constitute the web of causation. It is; fortunately, not necessary to understand completely the intricacy of relationships between factors to institute adequate preventive measures. Using our earlier definition of cause, numerous factors such as smoking, obesity, blood cholesterol level, and stress are causes of heart attack. The more of these factors present increases the risk for contracting a disease, we call them risk factors. Although we may not understand how these factors work or how they interact with each other, we can intervene and reduce the risk of heart attack by persuading individuals to give up smoking, lose weight, exercise regularly, or change their diet to reduce cholesterol. Establishing Causality Preliminary evidence of causality is provided through demonstration in multiple studies of statistical association between a factor and occurrence of a disease. The ultimate determination of the causality of an observed association is reached through an epidemiological experiment or a clinical trial. For factors whose presence appears to cause a disease, a factor is considered causal when reducing the amount or frequency of the suspected cause reduces the frequency of the effect, in this case, the illness of interest. If treating hypertensives to keep their blood pressure low reduces the frequency of stroke compared with the frequency of stroke in an equivalent, untreated group of hypertensives, hypertension would be considered a cause of stroke. Such experimental evidence of causality gives us an alternative operational definition of a cause. A factor is a cause when a reduction in the frequency of the factor produces a reduction in the frequency of occurrence of the related disease. In instances where the absence of a factor I associated with a higher frequency of disease and presence of the factor is associated with a lower frequency of disease, causality can be established by conducting a randomized clinical trial. A recent example of this was a series of trials conducted to confirm the protective role of betacarotene in preventing lung cancer. An extensive epidemiological literature review as well as in vivo and in vitro laboratoy studies and experiments with animal suggested a causal role for beta-carotene (an antioxidant) in preventing cancer occurrence. Three randomized clinical trials were conducted, two with high-risk population and one with male physicians. The latter found no benefit while the first two indicated possible harm in the form of increased rates of
lung cancer resulting from administration of beta-carotene (The Alpha-to copherol, Betacarotene Cancer prevention Study Group, 1994, Omenn et al, 1996; Hennekens et al, 1996). Criteria for Evaluating Causality in the Literature Studies reported in the literature may show conflicting results. An epidemiological experiment is not always feasible or desirable. In these instances, criteria based on available epidemiological data are needed for making decisions regarding intervention. Five criteria often accepted for assessing causality in such instances were used in the 1964 Surgeon General's Report (U.S. Department of Health, Education, and Welfare, 1964) for assessing the causal relationship between smoking and a variety of health outcomes. The five criteria are: (1) correctness of temporality; (2) strength of the association; (3) specificity of the association; (4) consistency of the association; and (5) biological plausibility. Correctness of temporality requires evidence that exposure to the causal factor did, in fact occur before initiation of the disease process. For diseases such as cancer, definitive proof that the exposure occurred before the first cell transformations may be difficult to obtain because there is a long period of latency during which cell replication and growth continues. This period may be as long as 20 to 40 years after the initial exposure to a causal agent before the tumor is diagnosed. Suppose someone with lung cancer has been smoking for 20 years. Did smoking initiate by an other agent? The answer cannot be definitely established, but it is much more likely that smoking is causal if a patient smoked for 10 years before diagnosis that if the patient smoked for only 18 months. Clearly, however, if the can be shown that exposure did not occur before the disease, the relationship cannot be causal despite a strong statistical association. Strength of the association is usually measured by a statistic called the relative risk ration or alternatively, the odds ration. In general the ration, the stronger the association and the greater the likelihood that the association is causal. Another aspect of strength of the association is dose effect. The strength of association should be stronger at higher doses, or levels of exposure, than at lower doses or levels. Specificity of the association refers to the uniqueness of the relationship between the putative causal factor and the disease occurrence. The terms necessary and sufficient can be used to clarify this concept. If the disease can occur without the presence of a particular agent, the agent is not necessary. Lung cancer can occur in nonsmokers; TSS, however, cannot occur without exposure to Staphylococcus. Sufficient refers to whether the agent is always able to produce the outcome. Although asbestos fibers are necessary to produce asbestosis, the fibers may not be sufficient; it is possible to be exposed to asbestos and not develop asbestosis. Prolonged exposure to flame is always sufficient to produce a burn, although severity may vary. Fire is not necessary to produce a burn, however, because burns may result from chemical exposures as well. A highly specific, therefore unique, association exists when an agent is both necessary for disease occurrence and sufficient, by itself, to produce the disease. Such a specific relationship would Be definitively causal. The closer an agent comes to meeting these criteria, the greater the likelihood of causality. As discussed in the next chapter, however, meeting both the necessary and sufficient criteria simultaneously is incompatible with the concept of multiple causes.
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Consistency of the association refers to the finding of various epidemiological studies. There may be conflicting results among reported studies on the association of a specific agent with a specific disease. Some studies may find no association, others an inverse (negative) association. Still others may find a positive association. The strength of the association may vary widely in the studies reporting a positive association. Barring major flaws in study designs, consistent findings of a positive association would be expected if the association is causal. Biological plausibility, sometimes called coherence, implies the presence of a reasonable biological mechanism to explain the physiological process by which an agent could produce the specific disease of interest. Documentation of biological plausibility is dependent on other scientific disciplines such as physiology, microbiology toxicology, and pharmacology. Causality demands a reasonable biological explanation for the observed association. Exposure of laboratory animals to an agent should, if an appropriated animal system is used, produce effects similar to those seen in humans.
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HEALTH PROMOTION AND EDUCATION GESONDHEIDSVOORLIGTING EN OPVOEDING
PUB 304
Compiled by: Opgestel deur: Dr. A. de la Querra Registrar Department of Community Health Departement van Gemeenskapsgesondheid
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1.
INTRODUCTION Health promotion has a number of different meanings, some based on different philosophies. The concept of health promotion started gaining importance since the 1980s. It is often compared and confused with the outmoded/ ineffective activities of health education. Health education forms only a small part of the wider concept of health promotion. In essence health promotion involves the empowerment of an individual on more than one level with the purpose of improving health.
1.1
Definitions
1.1.1 Health WHO definition of health: Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. This definition is much quoted but also criticized mostly because it is deemed unattainable and not of practical guiding value. Note the introduction of the concepts of positive and negative health. Positive health is encapsulated by the first part of the definition physical, mental and social well-being and negative health by the second part absence of disease or infirmity. Positive health is linked to health promotion while negative health is linked to disease prevention. 1.1.2 Health promotion (WHO) Health Promotion is a process of enabling people to increase control over their health and its determinants, and thereby improve their health.
HTTP://WWW.SEARO.WHO.INT/EN/SECTION1174/SECTION1458/SECTION2057.HTM
1.1.3 Health education (WHO) Health Education is a process comprising of consciously constructed opportunities for learning and communication designed to improve health information, health literacy, and health knowledge and developing life skills which are conducive to the promotion of an individual and communitys health including that of the environment.
HTTP://WWW.SEARO.WHO.INT/EN/SECTION1174/SECTION1458/SECTION2057.HTM
1.2
History of health promotion The Ottawa charter of 1986 forms the foundation of the health promotion movement. Five important principles were introduced in this charter: 1. build healthy public policy 2. create supportive environments 3. strengthen community actions 4. develop personal skills 5. reorient health services These principles were affirmed in 1997 at Jakarta. In 2005 the Bangkok charter was released. The Bangkok charter states that the global context of health promotion has changed significantly since the Ottawa charter. Some of the critical factors as follows: Increasing inequalities within and between countries New patterns of consumption and communication Commercialization Global environmental change, and Urbanization
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Four key commitments were made in the Bangkok charter to attain Health for All through health promotion: 1. Make health promotion central to the global development agenda. 2. Make health promotion a core responsibility for all of government. 3. Make it a key focus of communities and civil society. 4. Make it a requirement for good corporate practice.
2.
THE CONCEPT OF HEALTH PROMOTION It should be clear that health promotion is not merely an activity of health professionals. It involves the whole community including the government and local authorities, schools, hospitals, civil organizations, businesses and private individuals. It also involves more than one activity and definitely not simply health education. Downie, Fyfe and Tannahill created the following model of health promotion:
Health education
7 2 4
3 6
Health protection
Prevention
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ACTIVITY 1. 2. 3. 4. 5. 6. 7. Preventive services Preventive health education
EXAMPLE
Immunizations Influencing lifestyle e.g. wearing of sunglasses Preventive health protection Routine chloramphenicol drops at birth Health education for preventive Lobbying for seatbelt health protection legislation Positive health education Productive use of leisure time Positive health protection Workplace smoking policy Health education aimed at positive Awareness campaigns e.g. health protection HIV/AIDS
3.
APPROACHES TO HEALTH PROMOTION There are numerous health promotion approaches, some very complex. Kendall, Lask, Fordham and Baggaley describe three simple approaches:
3.1
The preventive approach: Health promotion is part of primary prevention. It entails reducing the risk for certain diseases in the community. It is not merely the education of the community but also involves among other things service delivery, housing and lifestyle changes. The empowerment approach: The aim is to enable the community to become involved in decisions regarding their lives and health. They must be able to make informed decisions, influence policies and decisions with an influence on their lives. The end result being that they can take control over their health. The radical approach: This is the community-based approach and is grounded in the Ottawa charter. It involves empowering the community to bring about social change ad improve health. Public health policy and intersectoral collaboration is important in this approach. HEALTH PROMOTION IN EYE CARE The following article describes health promotion approaches appropriate for use in promotion of eye care.
3.2
3.3
4.
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REFERENCES 1. Hatting, Dreyer, Roos. Aspects of Community Health, third edition, Oxford University Press. P. 49-53 2. Ottawa charter, WHO website 3. Bangkok charter WHO website
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COMMUNITY AND COMMUNITY PARTICIPATION GEMEENSKAP EN GEMEENSKAPSBETROKKENHEID
PUB 304
Compiled by: Opgestel deur: Prof. W.H. Kruger Chief Specialist Hoof spesialis Department of Community Health Departement van Gemeenskapsgesondheid
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1. 1.2
INTRODUCTION Definition of community: Dennill et al (1995:56) described a community in terms of its geographic boundaries or its social boundaries, or both. They define a community as a group of people who live in a particular area and who have shared values, cultural patterns and social problems, as well as a group awareness which facilitates the residents interacting more intensely with each other than they would with outsiders. In respect of planned resources a community could also be defined geographically. Matters of culture, ethnicity and age, however, define, sometimes tightly and sometimes not, other communities, which are within the geographical community. All of these have to be taken into account in respect of a service, which is delivered sensitively, responsively and responsibly. According to Hennessy (1997:5) a dictionary definition reads something like this: [Community is] a collection of individuals composing a community of living under the same organisation or government, and the state or condition of living in association, company or intercourse with others of the same species; the system or mode of life adopted by a body of individuals for the purpose of harmonious co-existence or fur mutual benefit (The Shorter Oxford English Dictionary on Historical Principles).
1.2
Definition of Health There are several familiar descriptions of health and the definition given by Hennessy (1997:6) is in line with the definition given by the WHO. The definition regard health as a state of balance or harmony, of homeostasis between the emotional, mental, physical, social and spiritual aspects of a persons individual life. Definition of Care: According to Hennessy (1997:8) care is about having a concern for another/others; an appropriate regard; a preparedness to act; and, sometimes properly, not to act. Care, too, has to do with the balance, which assists in promoting independence and appropriate protection of the vulnerable form exploitation and abuse. Definition of Community Health Care: Community Health Care is all about comprehensive health care provision in a community both by the primary health care team and others organisations/people such as dentists, dieticians, pharmacists, ophthalmic workers, continence advisers, ext. (Hennessy, 1997:10). Hennessy (1997:11) also describe community health care as all the health care that is taking place and developing at the interface of hospitals and communities, and also all health care provision outside hospitals.
1.3
1.4
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2.
DEMOGRAPHIC FACTORS IN COMMUNITIES A community is not a system without changes and Hennessy (1997:12) identifies four demographic factors that will have a profound effect on the changes in community health care provision in order to meet the required need: A declining fertility An ageing work-force More women in paid employment outside the home Growing numbers of elderly people.
3.
MATCHING DEMAND AND NEED According to Hennessy (1997:43) the need for health care indicates the potential to benefit from an intervention, and therefore requires a relevant intervention and a corresponding improvement in health. The need for health is on the other hand a more general term. Three factors should be considered in the definition of need Hennessy (1997:43): There is a health problem There is available an effective treatment or intervention for that health problem. People with that health problem believe that the resultant health gain is worth their input of time, effort, and/or money to receive that treatment. More information will be provided on needs and demands. Anybody can decide that someone has a health need. It is not only the individual that will take action but it can be done by several other people, for example his/her family or general practitioner, a community health care nurse, a paramedical worker, a teacher, a health care worker, ext. Hennessy (1997:44) identifies the following examples of these decisions: A grand mother advising her daughter that the grandchild needs to see a doctor. A social worker recognising non-accidental injury. A community nurse believing that one of her clients may be clinically depressed due to social isolation. A local authority councillor recommending that one of their constituents is rehoused on health grounds. Dennill et al (1995:57) mentioned three basic characteristics to take note of in the concept of community participation Participation must be active People have the right and responsibility to exercise power over decisions that affect their lives. There must be mechanisms available to allow the implementation of the decisions made by the community. In line with these basic characteristics. Rifkin et al. (1988:933) advocate that community participation is a social process whereby specific groups with shared needs living in ad defined geographic area actively pursue identification of their needs, take decisions and establish mechanisms to meet these needs.
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4. 4.1
COMMUNITY INVOLVEMENT Interpretation of community involvement and participation: Dennill et al (1995:59) summarised the various interpretations of community involvement and participation as follows: Peoples involvement in decision making Their involvement in implementation programmes and decisions by contributing various resources or cooperation in specific organisations and activities. Their sharing in the benefits of development programmes Their involvement in efforts to evaluate such programmes Community development: The following broad principles are suggested by Dennill et al (1995:59) as basic to the concept of community development: 4.2.1 Mutual involvement of government and the people is necessary to initiate community development. 4.2.2 Community co-operation must be stimulated and enhanced; not forced only project relevant to the needs of the community should be developed, as the community will be more willing to identify with such projects. 4.2.3 Human dignity must be respected by involving the people in decisions that affect them. 4.2.4 To ensure that projects can be sustained, attention must be given to the longterm changes that take place in the attitudes of people. 4.2.5 Existing grass-roots organisations should be utilised where possible. 4.2.6 Development must be accompanied by education of the people. 4.2.7 Central assistance may be required where needs cannot be met by small-scale action. 4.2.8 Both economic and social development should be attended to in community development initiatives. 4.2.9 Community development requires inter sectoral action, as it produces multidimensional effects. How should community involvement develop? A major aspect of community health care is the encouragement of more active involvement of individuals, families and groups in contributing to their own care. Communities should take more responsibility for their own health. It is costly for organisations to provide health care for each and others needs. Communities should therefore rely less on medical and organised public health services. Hennessy (1997:48) suggests that the public is less concerned with the effectiveness of health care than they are with being involved about the decisions that are taken when the treatment is unpleasant. They also wish to be heard and listened to in respect of when they want health care, and from whom they wish to receive it. Chimere-Dan (1996:11) anticipates that planners would face some problems in applying the concept of community involvement to health programmes. Rifkin (1990) suggested asking the following needed? Why is participation needed? Who will participate? How do people participate?
4.2
4.3
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4.4
Trends in community involvement: The following trends were mentioned by Chimere-Dan (1996:13) and it means that the approaches and implementation of programmes should be adopted accordingly: 4.4.1 Community involvement as an empowerment strategy: Focus communities on their damaging behaviour Change environmental conditions Authorities to be more involved Social actions where power is transferred from authorities to communities Give communities capacities to identify their own health problems 4.4.2 Community involvement as a programme instrument: Community involvement through volunteers or community health care workers Community involvement through community organisations Community involvement through leaders and community committees 4.4.3 Community involvement as a partnership: Feeling of community-managed self-help programmes Community perspectives should be the focal point Active participation
4.5
Obstacles to community participation: Dennill et al (1995:62) discussed the following obstacles to community participation: 4.5.1 Inadequate organisational support to involve the community in health care, as well as financial or geographic mal-distribution of health care services. 4.5.2 Community participation will not be successful unless the professional members of the multidisciplinary health team accept the community as active members of the team, and not as threat to their positions. 4.5.3 Community participation that could be used as a ploy by politicians to achieve political gain. 4.5.4 Differing cultural practices and communication problems between the community and the health care providers. 4.5.5 Obstacles to community participation are not only associated with the health professionals or the health care system. Many reasons for inadequate or ineffective participation can be attributed to the community for example: Inadequate or lack of leadership. Hesitancy by individuals to volunteer their time, money or energy. Incorrect assumptions about community participation. Not recognising the costs associated with participation.
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4.6
Advantages of community participation: Dennill et al (1995:64) used several sources and listed the following reasons why communities should participate: 4.6.1 Through community participation the health team can obtain first-hand information about local conditions and needs. 4.6.2 Community members will be more committed to community projects if they are involved in the planning preparation and maintenance of projects they consider important. 4.6.3 Community participation gives the community an opportunity too exercise its democratic right to be involved in its own development. 4.6.4 Through participation the community will become more self-reliant, selfsufficient, self-confident and independent. 4.6.5 Through joint discussions between the health planners and the people, power differences and potential corruption are reduced. 4.6.6 Planning is more likely to be done according to local circumstances and available resources if the community is involved. 4.6.7 Community participation supplements community services. 4.6.8 Community involvement is a basic right of all people. 4.6.9 Involvement in the decisions and actions affecting peoples health builds up self-esteem and encourages a sense of responsibility. 4.6.10 Through community involvement limited resources can be applied more can appropriately to satisfy needs as identified by the local community, and can complement and supplement formal health services. 4.6.11 Community involvement in health can help to create political awareness, encouraging people to get involved in other areas of development of the community.
4.7
Facilitating community participation: Several methods could be used to facilitate the process and Dennill et al (1995:68) considered the following factors before deciding on the most appropriate approach to establishing community participation in health: 4.7.1 Vital prerequisites for effective community participation such as: A clear, stable and supportive national policy and political framework. Community cohesion. Co-ordinated local inter-sectoral health programmes. Acceptance by all concerned of the multidimensional nature of the extended health team, which acknowledges the community as an active member of the team. Mutual support between the government and the community reinforced by mutual information feedback. Clarity about the health and related needs of the community. Effective integration of health into overall community development. Recognition of socio-economic contradictions. Involvement of the community in the control of financial, human and other resources necessary for the provision of health services. 4.7.2 Community-based research and data collection: Nature of community Its needs and priorities Available resources and facilities
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4.7.3 Initial contact and trust building: Spending enough time during initial contact stages. Reinforce during regular meetings and workshops with the community. 4.7.4 Identification of community representatives: Community decision-making bodies. Ensure commitment. 4.7.5 Leadership development: Assist local leaders to develop autonomy. 4.7.6 Getting the message across: Setting up workshops and public meetings 4.7.7 Identification of the strengths of the community: Increase the communitys sense of confidence in directing its own efforts. 4.7.8 Identification of, and corporation with, other projects in the community: Comprehensive approach 4.7.9 Ongoing education of community and health workers: By competent in participatory processes. Active player rather than passive recipients. 5. 5.1 COMMUNITY DEVELOPMENT Principles: The principles of community health involvement match the principles of community development. Their health care workers should create a climate and opportunities in a community where the individuals are empower and can therefore developed as a community. The following activities can be described as community development activities: assisting communities to identify their own needs mobilising neighbourhoods or communities to harness their own skills and resources supporting people to get involved in their communities and in decisions affecting their lives engaging with communities in influencing policies helping to build to healthy alliances between communities and people who can help them From the above mentioned, it is clear that each and every health care professional has a definite and important role to play in the development of his or her community. Important aspects such as changing the attitudes, behaviour and the environment of the community by means of participation in health promotion programmes leads to the development of the community. In South Africa there is an extensive usage of voluntary workers in many spheres of service deliveries including healthcare. A healthcare worker can concentrate on these lay workers and empower them to make meaningful contributions in their community.
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5.2
Summary: COMMUNITY DEVELOPMENT: Concept: Requires active involvement by community at large Stumbling blocks Basic principles: Empowerment Collaboration Participation Self-determination Equity Cooperation Process: Philosophy of action is formulated Community assessment of needs Priority needs identified Achievable objectives in place Strategies and plans in place Role of healthcare worker: Knowledge required Skills required
6.
SUMMARY Communities in South Africa today are more aware of their rights than in the past. They know they should be involved in decision-making process on factors affecting their health. The urgency to develop community participation in health care issues is highlighted in several statements made by the WHO. The importance and benefits of community participation are highlighted in this paper and every effort should be made to ensure its effective facilitation. Obstacles such as changing circumstances in South Africa should not be seen as a reason to stop the programme.
REFERENCES: Chimere-Dan, G. 1996. Community involvement in urban health programmes. Johannesburg : Thomson Publishing. 109p. Dennill, K., King, L., Lock, M & Swanepoel, T. 1995. Aspects of primary health care. Halfway House : Southern Book Publishers. 146p. Hennesy, D. 1997. Community health care development. Hampshire : Macmillian Press. 270p.
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STUDY GOALS A student should be able to: 1. 2. 3. 4. 5. Explain the concept of community and community health care Explain the differences between a need and a demand Apply the principles of community development in your community Recognise the obstacles to community participation Develop a plan to ensure community participation in decision making
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COMMUNITY ASSESSMENT GEMEENSKAPSEVALUASIE
PUB 304
Compiled by: Opgestel deur: Dr G Louwagie & Dr A de la Querra Senior Specialist & registrar Senior spesialis en kliniese assistent Department of Community Health Departement van Gemeenskapsgesondheid
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STUDY GOALS At the end of this session, students should be able to describe how to identify health needs of any population. In particular they should be able to: 1. 2. 3. 4. 5. Define Health needs assessment; Differentiate between needs, demands and supply; Understand basic epidemiological issues in health needs assessment; Understand the different approaches to needs assessment; Explain and apply all the necessary steps of a needs assessment to concrete examples and real situations in South Africa.
HEALTH NEEDS ASSESSMENT

1. DEFINITION OF & RATIONALE FOR HEALTH NEEDS ASSESSMENT Health needs assessment is a systematic method of identifying unmet health and healthcare needs of a population and making changes to meet these unmet needs. It involves an epidemiological and qualitative approach to determining priorities, which incorporates clinical and cost effectiveness and patients' perspectives. Health needs assessment is not the same as population health assessment, since it incorporates the capacity to benefit. It thus introduces the concept of effectiveness and of cost-effectiveness of interventions. Health needs assessments arose because of escalating costs of health services in the light of limited sources. In addition there is often inequitable access to health care, and the availability of this health care tends to be inversely related to the health needs of the population served. Another reason for health needs assessment is consumerism and public expectations about quality of care and about participation in decision making. 2. DEFINING NEED Need in health care is commonly defined as the capacity to benefit. If health needs are to be identified then an effective intervention should be available to meet these needs and improve health. There will be no benefit from an intervention that is not effective or if there are no resources available. Demand is what patients ask for; it is the needs that most doctors encounter. General practitioners have a key role as gatekeepers in controlling this demand. Demand from patients for a service can depend on the characteristics of the patient or on the media's interest in the service. Demand can also be induced by supply: geographical variation in hospital admission rates is explained more by the supply of hospital beds than by indicators of mortality; referral rates of general practitioners owe more to the characteristics of individual doctors than to the health of their populations. Supply is the health care provided. This will depend on the interests of health professionals, the priorities of politicians, and the amount of money available. Need, demand, and supply overlap, and this relation is important to consider when assessing health.
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Figure 1. Need, demand and supply
2 NEED
3 5 1 SUPPLY
DEMAND
Adapted from Stevens A, Raftery J, eds. Health Care Needs Assessment, the epidemiologically based needs assessment reviews. Oxford: Radcliffe Medical Press, Vo..1, 1994. Example for Home Based Care (HBC) for People with AIDS (1) Need and supply but no demand (e.g. need for HBC and caregivers available but patients prefer to go to the hospital) (2) Need but no supply or demand (e.g. need for HBC but no caregivers trained and no demand from clients) (3) Need and demand but no supply (e.g. clients want and need HBC, but there are no providers) (4) Supply and demand but no need: caregivers are available, patients want their service, but they do not need this service (hospital beds for terminal care are available and in demand, but the same service could be provided by HBC or step-down facilities) (5) Ideal relationship between need, supply and demand
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We also talk about Felt need, Expressed need (Demand) and normative need (Figure 2) Figure 2. Wants, demands, normative needs and supply
Study Method
Wants (felt needs) Consumer questionnaires, Participatory methods etc.
Demands (Expressed needs)
Need (Normative needs)
Epidemiological assessment
Met
Unmet
Supply
Effectiveness and distribution of services
Source: Adapted from Wright, Williams and Wilkinson, 1998
3.
APPROACHES TO NEEDS ASSESSMENT Epidemiological: combining epidemiological assessment with effectiveness and costeffectiveness of interventions Comparative: comparing levels of services between different populations Corporate and community based (PRA): canvassing the wishes and demands of various stakeholders
A combination of those could also be used.
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4.
FRAMEWORK FOR ASSESSING NEEDS
Questions to ask when assessing health needs: 4.1 What is the problem/health issue you want to perform a needs assessment on?
Perform a search of literature review and grey literature and decide whether needs assessment is justified. This search can for example give you case definitions, incidence and prevalence in this or a similar population, current service provision etc. This step will help you to formulate a clear purpose and objectives for your needs assessment. 4.2 What is the scope and nature of the problem? How many people in the study population are likely to suffer from the condition. What is the burden of disease attributable to this condition? We thus look at incidence, prevalence, morbidity, disability and death caused by this condition. What are their characteristics (time, place, person), including socio-economic conditions, since poorer people are more prone to illness and thus in greater need (greater potential to benefit)? In order to obtain this information, we can conduct surveys or we can use existing data, assess their applicability to our situation and make estimates for our specific situation (See attached article Epidemiological issues in health needs assessment by Williams and Wright, 1998). Routine data that can be useful at this stage (especially in resource constrained conditions): National census data can provide information on the age and sex distribution of a population. This information can be used to calculate crude birth rates and fertility rates Death certification and registers can provide information on the cause and place of death. Infant mortality rates can be calculated from the number of live born infants who die in the first 12 months of life Disease notification systems can provide information on important infectious diseases Maternity unit statistics can describe births rates, maternal ages and parity, numbers of low birth weight (<2500 g) babies, and maternal mortality Pharmaceutical information provides information on the use of essential and nonessential drugs Laboratories can provide information on the appropriate use of tests and numbers of positive tests (for example, sputum samples for pulmonary tuberculosis, malaria blood slides). Workplaces can provide data on absences due to illness, occupational injuries, etc. National surveys, e.g. the South African Demographic and Health Survey can give important information about the extent of health problems. District Health Information Systems; Hospital information systems. 4.3 What are the current services?
Make use of Hospital data, District Health Information System; compare actual utilisation rates with national or provincial norms. How equitably are these services distributed?
Example: Hospital inpatient records can be used to obtain numbers of admissions, cause of admission, and length of stay, and outpatient consultations can be used for numbers of patients and diagnoses. 4.4 What do stakeholders want?
A variety of methods can be used to assess what users, the community, carers, managers want: Focus group discussions In-depth interviews Questionnaires Community appraisal techniques Rifkin and Pridmore (2001) describe a variety of techniques that can be used in participatory community appraisals such as geographical mapping, time mapping, techniques for ranking and scoring, drama and forum theatre. They propose the following steps in a participatory needs assessment (Figure 3): Figure 3. Framework for participatory community appraisals 1. Reviewing the existing support 2. Assessing the available resources 3. Preparing the assessment team 4. Deciding what information is needed 5. Deciding how to get the information and who will get it. 6. Collecting the information 7. Analyzing the information 8. Reviewing the information with all needs assessment participants 9. Defining priorities and developing a plan of action
Source: Rifkin & Pridmore. Partners in Planning. Information, participation, and empowerment (2001:106)
The authors propose a useful information pyramid for step 4. 4.5 What are the most appropriate and effective (clinical and cost-effective) solutions?
Perform literature review. Ideally make use of systematic reviews or randomized controlled trials. Observational studies may also be helpful. If no information is available: consensus methods (e.g. nominal group techniques, delphi) are an alternative. 4.6 What are the resource implications?
Determine how resources are spent at present (programme budgeting) Define options for change (marginal analysis) - which services should get more resources - which services could be delivered at same level, but at reduced cost - which services should be reduced because these are less cost-effective Choose best option based on cost-effectiveness of different options
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4.7 What are the outcomes to evaluate change and the criteria to audit success? For example, if your needs assessment demonstrated inequity in delivery of a certain health service, you would want to measure your success in terms of changed distribution of health service delivery after your intervention.
5.

IMPLEMENTATION Write a report on the needs assessment Develop an implementation plan Develop monitoring and evaluation tools EXAMPLES
6.
An epidemiological health needs assessment in the UK

Objective: To assess whether the use of health services by people with coronary heart disease reflected need. Setting: Health authority with a population of 530 000. Methods: The prevalence of angina was determined by a validated postal questionnaire. Routine health data were collected on standardised mortality ratios; admission rates for coronary heart disease; and operation rates for angiography and angioplasty. Census data were used to calculate Townsend scores to describe deprivation for electoral wards. Prevalence of angina and use of services were then compared with deprivation scores for each ward. Results: Angina and mortality from heart disease was more common in wards with high deprivation scores. Treatment by revascularisation procedures was more common in more affluent wards. Conclusion: The use of revascularisation services was not commensurate with need. Steps should be taken to ensure that health care is targeted at those who most need it. Source: Williams and Wright, 1998
A needs-based assessment in Swaziland

Bacterial and tuberculous meningitis is an important cause of morbidity and mortality in developing countries despite the availability of effective treatment. Epidemiological assessment: A national study was undertaken in Swaziland to describe the epidemiology, clinical features and outcomes in each case of meningitis admitted to hospital. The overall case fatality was found to be 42% in all ages and 63% in adults. Significant association with a period of drought was found, and the increasing contribution of HIV infection was highlighted. The results also identified the age distribution and aetiology of meningitis in the country and allowed an assessment of the potential impact of immunisation programmes. Community appraisal: Semistructured interviews were carried out on a random sample of mothers attending a health centre. These were used as the basis of a focus group discussion with a purportedly selected group of health workers. The need for education about the awareness of symptoms and the importance of prompt referral and treatment was identified. Action: To reduce the high mortality from meningitis by reducing delays in treatment, a coordinated education campaign for the public and health workers, using posters and outreach teaching sessions, was undertaken.
Source: Wright and Walley, 1998
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A needs assessment of persons suffering from schizophrenia in South Africa This quantitative exploratory descriptive survey attempted to identify the needs of persons suffering from schizophrenia who live in the Mogoto Village, Zebediela District, Limpopo Province. Data obtained from 60 completed questionnaires indicated that these persons continued to be regarded as valued community members by their caregivers. Despite the apparent lack of community mental health services, the vast majority of the respondents reportedly took their medications regularly and would know when to seek help in case their symptoms deteriorated. Their greatest need related to a lack of employment opportunities. They could also benefit from counselling services for themselves and their families.
Source: Manamela KE, Ehlers VJ, van der Merwe MM, Hattingh SP, 2003.
REFERENCES Manamela KE, Ehlers VJ, van der Merwe MM, Hattingh SP. Curationis. 2003 ;26:88-97. Oxford Handbook of Public Health Practice, Chapter on Needs assessment and from series of articles on needs assessment in BMJ by Wright, Williams and Walley. Rifkin & Pridmore. Partners in Planning. Information, participation, and empowerment. London and Oxford: MacMillan 2001. Williams R, Wright J. Health needs assessment. Epidemiological issues in health needs assessment. BMJ 1998; 316:1379-82. Wright J, Walley J. Assessing health needs in developing countries. BMJ. 1998 ;316:1819-23. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. BMJ 1998 ;316:1310-13.
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INTRODUCTION TO THE EPIDEMIOLOGY INLEIDING TOT EPIDEMIOLOGIE
PUB 304
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SECTION 1
1. INTRODUCTION
INTRODUCTION
If you take the word epidemiology, it origins from epidemic are clear. The derivation of the word epidemiology itself is from the Greek word: epi upon demos - the people logia - study If you are combining the above mentioned, you can set samples set of questions to form the heart of epidemiology for example: What disease is present in excess and who is ill? Where do they live? When and why did they become ill? If one looks at the above paragraph it is evident that the target of a study in epidemiology is usually a human population. A common population used in epidemiology is one in a given area or country at a given time. This forms the basis for defining subgroups with respect to gender, age group, ethnicity etc. Epidemiology is a bit like detective work where we tried to find out why and how diseases occur. There are different sub-disciplines of epidemiology and it includes: public health epidemiology infectious disease epidemiology environmental epidemiology occupation or epidemiology clinical epidemiology Epidemiology is considered the basic science of public health, because epidemiology is: a quantitative basic science built on a working knowledge of probability, statistics, and sound research methods a method of causal reasoning based on developing and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality a tool for public health action to promote and protect the publics health based on science, causal reasoning, and a dose of practical common sense Knowledge of the epidemiology is important to the community health worker who wishes to establish the presence of a set of needs or conditions for a particular health service or program or to justify a request for funding. The primary purpose of epidemiological research should always be to solve a prioritised health problem in the community or to improve the quality of health services rendered. It can be concluded that the effective management of health services are not possible with out epidemiological studies.
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2. 2.1
DEFINITIONS Definition: A very simple definition is the science of epidemics. This was not very helpful and the new comprehensive definition end was established: The study of the distribution and determinants of health related conditions and events in populations. This definition was taken two steps further by broadening the scope to include health in general and not just diseases: Epidemiology is about measuring health, identifying the causes of ill-health and intervening to improve health
2.2
Explanation of the definitions: Study: Epidemiology is a scientific discipline, sometimes called the basic science of public health. It has sound methods of scientific inquiry. Distribution: Epidemiology is concerned with the frequency and pattern of health events in a population. Frequency includes not only the number of such events in a population, but also the rate or risk of disease in the population. The rate (number of events divided by size of the population) is critical to epidemiologists because it allows valid comparisons across different populations. The characterization of the distribution of health-related states or events is one broad aspect of epidemiology called descriptive epidemiology. Descriptive epidemiology provides the What, Who, When, and Where of health-related events. Determinants: Epidemiology is also used to search for causes and other factors that influence the occurrence of health-related events. Analytic epidemiology attempts to provide the Why and How of such events by comparing groups with different rates of disease occurrence and with differences in demographic characteristics, genetic or immunologic make-up, behaviors, environmental exposures, and other so-called potential risk factors. Under ideal circumstances, epidemiologic findings provide sufficient evidence to direct swift and effective public health control and prevention measures. Health-related states or events: Originally, epidemiology was concerned with epidemics of communicable diseases. Then epidemiology was extended to endemic communicable diseases and non-communicable infectious diseases. More recently, epidemiologic methods have been applied to chronic diseases, injuries, birth defects, maternal-child health, occupational health, and environmental health. Now, even behaviors related to health and well-being (amount of exercise, seat-belt use, etc.) are recognized as valid subjects for applying epidemiologic methods.
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Specified populations: Although epidemiologists and physicians in clinical practice are both concerned with disease and the control of disease, they differ greatly in how they view the patient. Clinicians are concerned with the health of an individual; epidemiologists are concerned with the collective health of the people in a community or other area. When faced with a patient with diarrheal disease, for example, the clinician and the epidemiologist have different responsibilities. Although both are interested in establishing the correct diagnosis, the clinician usually focuses on treating and caring for the individual. The epidemiologist focuses on the exposure (action or source that caused the illness), the number of other persons who may have been similarly exposed, and the potential for further spread in the community, and interventions to prevent additional cases or recurrences. Application: Epidemiology is more than the study of. As a discipline within public health, epidemiology provides data for directing public health action. However, using epidemiologic data is an art as well as a science. Consider again the medical model used above: To treat a patient, a clinician must call upon experience and creativity as well as scientific knowledge. Similarly, an epidemiologist uses the scientific methods of descriptive and analytic epidemiology in diagnosing the health of a community, but also must call upon experience and creativity when planning how to control and prevent disease in the community.
2.3
Assumptions: Epidemiology is based on two fundamental assumptions: Diseases do not occur by chance Diseases are not distributed randomly in population and therefore their distribution indicates something about how and why the disease process occurred It is therefore evident that the goals of the epidemiologist are to: identify factors that cause disease or disease transmission prevent the spread of communicable and non-communicable diseases and conditions The difference between an epidemiologists and a basic scientists is that the epidemiologist studies diseases in a population with many variables over which one has no control, while a basic scientist studies diseases in the laboratory modifying one variable at the time.
3.
THE EPIDEMIOLOGICAL APPROACH An epidemiologist determines What, When, Where, Who, and Why. However, the epidemiologist is more likely to describe these concepts in slightly different terms: case definition, time, place, person, and causes. Using the following principles, you can do the following: describe the data interpret the patterns that you observe use epidemiological measures to describe the situation
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3.1
Terms used in Epidemiology: The following terms are commonly used in the field of the epidemiology (pattern refers to the occurrence of health-related events):
3.1.1 Case definition:

It is a set of standard criteria for deciding whether a person has a particular disease or other health-related condition It consists of several set of criteria including clinical criteria and, sometimes, limitations on time, place, and person. The clinical criteria usually include confirmatory laboratory tests, if available, or combinations of symptoms (subjective complaints), signs (objective physical findings), and other findings Case definitions should not rely on laboratory culture results alone, since organisms are sometimes present without causing disease. An example of a case definition:
3.1.2 Personal characteristics:
It could include demographic factors such as age, race, sex, marital status, and socioeconomic status, as well as behaviors and environmental exposures. Inherent characteristics of people are usually used (of which age and sex/gender are most critical) but the following can also be used: o Their acquired characteristics (immune or marital status) o Their activities (occupation, leisure activities, use of medications/tobacco/drugs) o The conditions under which they live (socioeconomic status, access to medical care) A number of factors that also vary with age are reasons why age is such an important characteristic: o susceptibility o opportunity for exposure o latency or incubation period of the disease o physiologic response
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The gender-related difference is also important because of: o genetic o hormonal o anatomic o other inherent differences between the sexes that can affect the susceptibility or physiologic responses Ethnic and racial groups: o It is important to examine any group of people who have lived together long enough to acquire common characteristics, either biologically or socially. o Several terms are commonly used to identify such groups: race, nationality, religion, or local reproductive or social groups, such as tribes and other geographically or socially isolated groups. o Differences in racial, ethnic, or other groups may reflect differences in their susceptibility or in their exposure, or they may reflect differences in other factors that bear more directly on the risk of disease, such as socioeconomic status and access to health care. Socioeconomic status: o Socioeconomic status is difficult to quantify. It is made up of many variables such as occupation, family income, educational achievement, living conditions, and social standing. o The variables that are easiest to measure may not reflect the overall concept. o The most commonly used factors are occupation, family income, and educational achievement, while recognizing that these do not measure socioeconomic status precisely.
3.1.3 Place:
It could include geographic variation, urban-rural differences, and location of worksites or schools. One may use large or small geographic units: country, state, province, district, census tract, street address, map coordinates, or some other standard geographical designation. Sometimes, it may be useful to analyze data according to place categories such as urban or rural, domestic or foreign, and institutional or non-institutional. By analyzing data by place, one can get an idea of where the agent that causes a disease normally lives and multiplies, what may carry or transmit it, and how it spreads. If there is a possibility that the occurrence of a disease might be associated with a place, one can infer that factors that increase the risk of the disease are present either in the persons living there (host factors) or in the environment, or both.
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3.1.4 Time:

It could include annual occurrence, seasonal occurrence, and daily or even hourly occurrence during an epidemic. Disease rates change over time. Some of these changes occur regularly and can be predicted. Time data are usually presented as a graph. The number or rate of cases or deaths is put on the vertical, y-axis; and the time periods along the horizontal, xaxis. There could be an indication on a graph when events occurred that are believed to be related to the particular health problem described in the graph. Graphing the annual cases or rate of a disease over a period of years shows longterm or secular trends in the occurrence of the disease. By graphing the occurrence of a disease by week or month over the course of a year or more we can show its seasonal pattern, if any. Displaying data by days of the week or time of day may also be informative. Analysis at these shorter time periods is especially important for conditions that are potentially related to occupational or environmental exposures. To show the time course of a disease outbreak or epidemic, a specialized graph is used called an epidemic curve. As with the other graphs, the number of cases is placed on the vertical axis and time on the horizontal axis. For time, one should use either the time of onset of symptoms or the date of diagnosis.
4.
WHAT DOES EPIDEMIOLOGY OFFER? It must be remembered that epidemiology is a scientific study which can be descriptive, applied or analytical in nature. The focus is on groups rather than on individuals and epidemiologists uses various scientific data collection and analysis method. The following is a summarised version of what epidemiology can offer and what epidemiologists are doing: Description of health status of populations o By making use of descriptive studies in terms of person, place and time o This will provide frequency and distribution of health problems within populations Population or community health assessment: o This function is linked to the first function o To set policy and plan programs, public health officials must assess the health of the population or community they serve and must determine whether health services are available, accessible, effective, and efficient. To do this, they must find answers to many questions: What are the actual and potential health problems in the community? Where are they? Who is at risk? Which problems are declining over time? Which ones are increasing or have the potential to increase? How do these patterns relate to the level and distribution of services available?
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Causation and determinants of health problems o By using ideas generated by descriptive studies and testing it further by making use of analytical studies (retrospective and prospective studies) o Risk factors involved in health problems can also be identified o It has been said that epidemiology can never prove a causal relationship between an exposure and a disease. Nevertheless, epidemiology often provides enough information to support effective action. Evaluation of interventions o By evaluating new preventative measures, programmes or treatments that are designed to reduce ill-health or promote good health o By monitoring/evaluating the effectiveness of his intervention programmes after they have been implemented o The control of health problems can also be included under this heading Natural history and prognosis of a condition o by going back in time and do retrospective studies o by doing outbreak investigations
To summarise the uses of the epidemiology: 5. to identify factors that cause the disease to identify factors that can be used or modified to prevent the occurrence or spread of the disease to explain how and why diseases and epidemics occur to evaluate the effectiveness of interventions to establish a clinical diagnosis of the disease to identify the health needs of a community to evaluate the effectiveness of health programmes to predict the future health needs of a population
MEASURE OF THE FREQUENCY OF HEALTH EVENTS A basic task of a health department is counting cases in order to measure and describe morbidity. Reports should at least contain information on time (when the case occurred), place (where the patient lived), and person (the age, race, and sex of the patient). Then combines the reports and summarizes the information by time, place, and person as discussed above. Most epidemiological studies focus on the occurrence or frequency of disease or risk factors. The part of a population which is susceptible to a disease/condition is called the population at risk. It can be defined on the basis of demographic or environmental factors. Once, a condition is defined, it is necessary to study its occurrence and to measure how often it occurs. These measures formed the basis of descriptive epidemiology. Disease frequency can be measured by incidence or prevalence
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5.1
Prevalence: The prevalence of a disease stipulates what proportion of a population actually has the disease at the specific point in time. This is a snapshot of the situation at the single point in time, and it is called the point prevalence. This measures the proportion of the population that had the disease at any point during a specific period. That will include all their existing cases- old and newly diagnosed cases. Therefore prevalence focuses on existing cases at a specific time, regardless of when the disease onset was. Prevalence = the number of people with the disease at any given point in time total number of people in the population Please take note that: Cases that will have died or recovered by the time of the assessment are excluded from the calculations. The longer the duration of the disease, the higher its number of prevalent cases. If a disease is rapidly fatal it may have a lower number of prevalent cases. If treatment is success improves so that more cases survive but with some residual disease, the number of prevalent cases would increase even if incidence remained unchanged. To summarise - the following factors can influence the prevalence: this unity of the disease - if many people die because of the disease, the prevalence is decreased the duration of the disease if a disease lasts a short time its prevalence is lower than if it lasts a long time the number of new cases - if many people develop a disease it is prevalence is higher than if few people do so migration of cases - in and out migration of susceptible people - in and out improve diagnostic facilities Prevalence is sometimes referred to as prevalence rate - this is incorrect because it is not expressed per unit of time.
5.2
Incidence: The incidence of the disease stipulates the number of new cases for a specific time period. It is concerned with only new diseases that occur during a specific period for example one year. Incidents measures how quickly people are catching/developing the disease. Incidence = number of people who develop the disease in one year average number of people in the population in the same year
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5.3
Relationship between incidence and prevalence: If two diseases have the same incidence, but one lasts three times longer than the other then, at any point, you are much more likely to find people suffering from the more lasting disease. Therefore, the relationship between prevalence and incidence depends on how long the disease persists before it is cured or death occurs. P=IxD P = prevalence I = incidence D = average duration of the disease For example: Hepatitis A has a relative high incidence but people recover quickly. Therefore, the prevalence of hepatitis A infection at any point in time would be quite low. On the other hand hepatitis C infection is much less common, but once you are infected you are usually infected for life. Therefore, the prevalence of hepatitis C infection is much higher. Prevalence is useful for measuring diseases that have a gradual on set and long duration such as type 2 diabetes and or osteo-arthritis. It is of great value for describing the overall disease burden of a population and for assessing health care needs and planning health services.
5.4
Rates, ratios and proportions: Epidemiologists are concerned with numbers. If one looks at a disease, the starting point Is the number of cases (people who are sick) and the number of deaths. However, these numbers alone are not enough to provide a description of the extent of the disease in the community. A simple count of cases, however, does not provide all the information needed to make decisions on. To compare the occurrence of a disease at different locations or during different times, a health department converts the case counts into rates, which relate the number of cases to the size of the population where they occurred. Epidemiologists must also know the total number in the susceptible population so that the rates can be calculated. In order to compare the frequency of disease in different groups or in a group over time, one has to calculate rates since they relate: the number of cases to the size of the population at risk in a specific group in a specific period of time Rates are useful in many ways. By making use of rates, groups in the community can be identified to with an elevated risk of disease (so-called high-risk groups) and they can be further assessed and targeted for special intervention. The groups can be studied to identify risk factors that are related to the occurrence of disease.
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5.4.1 Ratio: A ratio is the expression of the relationship between the two items. In a ratio, the values of x and y may be completely independent, or x may be included in y. For example, the sex of children attending an immunization clinic could be compared in either of the following ways:
In the first option, x (female) is completely independent of y (male). In the second, x (female) is included in y (all). Both examples are ratios. 5.4.2 Proportion: A proportion, the second type of frequency measure used, is a ratio in which x is included in y. Of the two ratios shown above, the first (1) is not a proportion, because x is not a part of y. The second (2) is a proportion, because x is part of y.proportion is the expression of the relationship of one bite to the whole
5.4.3 Rate: A rate is often a proportion, with an added dimension: it measures the occurrence of an event in a population over time. The basic formula for a rate is as follows:
Take note of the three important aspects of this formula: o The persons in the denominator must reflect the population from which the cases in the numerator arose. o The counts in the numerator and denominator should cover the same time period o In theory, the persons in the denominator must be at risk for the event, that is, it should have been possible for them to experience the event Therefore it is the number of events in a given population over a given period or at a given point in time A rate is the expression of the probability of occurrence of a particular evening in a defined population using a specific period of time Rate is calculated by dividing the number of cases (numerator) by the population at risk and the period of observation (denominator). The calculation of rates is important because one can compare outbreaks that occurred at different times or in different places. Rates imply a change over time. For disease incidence rates, the change is from a healthy state to disease. The period of time must be specified.
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5.5
Uses of Ratios, Proportions, and Rates Ratios and proportions are used to characterize populations by age, sex, race, exposures, and other variables. It is also used to describe three aspects of the human condition: morbidity (disease) mortality (death) natality (birth).
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The following table shows some of the specific ratios, proportions, and rates used for each of the above-mentioned classes of events:
Key rates are categorised in birth, sickness and death rates and it includes the following: Birth rate: = Number of live births during the year Total population
x 1 000
Fertility rate: = Number of live births to women 15 to 49 years of age during the year x 1000 Number of women 15 to 49 years of age in the population Crude mortality rate: = Total number of deaths during the year x 1 000 Total population Crude mortality rate: = Total number of deaths due to a specific cause during the year x 100 000 Total population
5.6
Measuring diseases in epidemiological studies: There are three fundamental measures of disease occurrence (which is also called morbidity rates): prevalence incidents rate cumulative incidence To measure the prevalence of the disease, one needs to conduct a cross-sectional study or survey in which a random sample of the population is questioned to ascertain whether they had a particular condition at a particular point in time.
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To measure the incidence of the disease, one needs to start with the group (or cohort) of people who are currently free from the disease of interest, but who are at risk of developing it. They are followed up over a period of time to see who develops the disease. 5.6.1 Point & period prevalence: The amount of disease present in a population is constantly changing. Sometimes, sometimes it is necessary to know how much of a particular disease is present in a population at a single point in time - snapshot with regard to that disease. This is called the point prevalence for that disease. The numerator in point prevalence is the number of persons with a particular disease on a particular date. Please note that a point prevalence is not an incidence rate, because the numerator includes preexisting cases; it is a proportion, because the persons in the numerator are also in the denominator. On the other hand sometimes it's necessary to know how much of a particular disease is present in a population over a longer period. This is called the period prevalence. The numerator in period prevalence is the number of persons who had a particular disease at any time during a particular interval. The interval can be a week, month, year, decade, or any other specified time period.
5.6.2 Incidence: After two weeks of school, 16 pupils developed a cold. The incident rate is expressed as the number of cases per person time and is calculated as follows: = number of new cases in a specific time period total disease-free person time of observation in the a- risk population x 10 000
For each individual in the population, the time at risk is that during which that person under observation remains disease-free. The denominator is therefore calculated by the sum of all the disease-free time periods in the defined time period of the study. Sometimes it may not be possible to measure the disease-free period is precisely. In that case, the denominator is often calculated approximately by multiplying the average size of the study population by the length of the study period.
Depending on the circumstances, the most appropriate denominator will be one of the following: average size of the population over the time period size of the population (either total or at risk) at the middle of the time period size of the population at the start of the time period Since incidence is a measure of risk, when one population has a higher incidence of disease than another, it is said that the first population is at a higher risk of developing disease than the second, all other factors being equal. It can also be seen that the first population is a high-risk group relative to the second population.
5.6.3 Cumulative incidence of colds: This is a simpler measure of the occurrence of the disease or health status. By using this rate, the denominator is only measured at the beginning of the study. It (CI) measures the proportion of people who develop the disease during a specific period: CI = number of people who developed the disease in the specific period number of people at risk of developing the disease at the start of the period
Just another definition: CI = number of new cases in a specific period number of people in at-risk population at the start of the time period
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An example: A study was conducted in a primary school with a hundred pupils. On the first day of the new term, nine children had a cold. Over the next two weeks and now the seven children developed a cold. 9 out of a hundred children or 9% had a cold on the first day of term Out of 91 children at risk (100 -9 children who has the disease already) of developing a cold 7 or 7.7% develop one year in the first week of term. The nine children who have the disease already are not at risk and therefore the denominator is 91 children.
5.6.4 Comparison of prevalence and incidence: The prevalence and incidence of disease are frequently confused. They are similar, but differ in what cases are included in the numerator: Numerator of Incidence = new cases occurring during a given time period Numerator of Prevalence = all cases present during a given time period The numerator of an incidence rate consists only of persons whose illness began during a specified interval. The numerator for prevalence includes all persons ill from a specified cause during a specified interval (or at a specified point in time) regardless of when the illness began. It includes not only new cases, but also old cases representing persons who remained ill during some portion of the specified interval. A case is counted in prevalence until death or recovery occurs.
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5.6.7 Summary of morbidity measures: The following is a summary of the formulas that are used frequently for morbidity measures:
5.7
Mortality Rates: A mortality rate is a measure of the frequency of occurrence of death in a defined population during a specified interval/over a specified period of time.
When mortality rates are based on vital statistics (e.g., counts of death certificates), the denominator most commonly used is the size of the population at the middle of the time period.
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5.8
Case fatality: Case fatality is a measure of the severity of the disease and is defined/calculated as:
The case-fatality rate is the proportion of persons with a particular condition (cases) who die from that condition. 6. MEASURES OF MORTALITY RELATING TO CHILDBIRTH AND EARLY LIFE: Technically speaking, the following measures are proportions rather than true rates because they do not have units of time. However, they are commonly described as rates but don't be confused. All these measures just give an average picture for the whole population. It is not always possible to obtain an accurate figure for the number of people at risk (denominator) and therefore an approximation is sometimes used. Please note that there is not always as standard definition of what constituted a case. It is therefore important to be very careful when comparing measures of disease across different groups of people because many other factors can complicate this. 6.1 Maternal mortality rate: This rate calculates that deaths amongst women from causes relating to childbirth in one year (usually only days up to 42 days after birth are included) (numerator). The population at risk (denominator) is the number of live births in the same year. The denominator should include all pregnant women, but this information is not recorded routinely/directly. 6.2 Perinatal mortality rate: This rate calculates foetal deaths and deaths up to seven days of life. The population at risk is the live birth plus foetal deaths in the same year. This rate may be calculated as the ratio of the number of deaths to the number of live births and is called the perinatal death ratio. It may also include deaths up to 20 days of life. 6.3 Neonatal mortality rate: This rate calculates the deaths in children aged less than 28 days. The population at risk is the number of live births in the same year. Only live births are included in the denominator because only babies born alive are at risk of dying before the age of 28 days 6.4 Post neonatal mortality rate: This rate calculates deaths in children aged from 28 days to one year. The population at risk is the number of live births in the same year. The denominator should exclude children who died before age 28 days because they are no longer at risk.
6.5
Infant mortality rate: This rate calculates deaths in children up to one year of age. The population at risk these number of live births in the same year. This rate is probably the most widely used single indicator of the overall health of the community.
6.6
Child death rate: This rate calculates deaths in children aged 1-4 years. The population at risk is the number of children aged one to four years in the population. This is an example of an age specific mortality rate. Compare this to what is a crude death rate.
7.
SUMMARY: Counts of disease and other health events are important in epidemiology. Counts are the basis for disease surveillance and for allocation of resources. However, a count alone is insufficient for describing the characteristics of a population and for determining risk. Ratios, proportions, and rates as well as measures of central location and dispersion are useful for describing the characteristics of populations. Proportions and rates are used for quantifying morbidity and mortality. The two primary measures of morbidity are incidence rates and prevalence. Incidence rates reflect the occurrence of new disease in a population; prevalence reflects the presence of disease in a population. To quantify the association between disease occurrence and possible risk factors or causes, we commonly use two measures, relative risk and odds ratio. Mortality rates have long been the standard for measuring mortality in a population but other standards are used because they focus on premature, and mostly preventable, mortality.
8.
SUMMARISED ALGORITHM FOR RATES, PROPORTIONS AND RATIOS Ratio
Is numerator included in denominator?
Yes
No
Is time included in denominator?
Yes
No
Measure: Example:
Rate Incidence rate
Proportion Prevalence
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Ratio Maternal mortality ratio

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SECTION 2
1. INTRODUCTION
EPIDEMIOLOGICAL RESEARCH METHODS
Epidemiology is a science and therefore it follows mostly quantitative scientific research methods. One must remember that resource is extremely scarce and priorities must be set before the epidemiological research is carried out in health care services. Research problem should be one that is widely recognized as an absolute priority by healthcare professionals. The results of the research should have a significant effect on health services and also on the health of the community. 2. A RESEARCHABLE PROBLEM Once a research problem is identified the research statement of the epidemiological problem should fit the following criteria: Clear: The readers attention should be immediately drawn to the content of the statement and should not have any doubt about the statement.
Concise: Just me or where that scientific writing can be very difficult to read and visual presentations may be used to be more concise.
Simple: Try and address the following questions in your statement: o Who is the target group/people involved in the problem? o When did the problem occur? o When did it happen? o What does the problem entail? o What are the consequences of the problem? o How can the problem be solved? o Where is the problem?
3.
RESEARCH OBJECTIVES The development of research project is the next step after the development of a research problem statement. When setting objectives for a research problem, the following criteria should also be considered: Clarity: Use clear understandable language in order to avoid any possibility of misunderstanding.
Relevancy: The objectives should be relevant to the problem to be studied and ultimately the main goal should be to improve the health of the community
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Feasibility: Make sure that the planned research can actually be carried out
Logic: Internally consistent objectives.
Measurability: Ensure that the objective is scientifically measurable.
Collection of data: A number of designs can be used and make sure it is appropriate method.
Measurements and observations: 4. Make sure that you do have access to the necessary data or specify how did the data will be collected.
TEAM WORK Epidemiological research cannot be performed by an individual. It is of such a nature that team work is necessary. In addition to the epidemiologist, the healthcare worker could assist with the following: Collect data as specified in the research protocol/as required by the specific research methodology. Defining the data to be collected because the health professional knows the community being studied. Assisting with input on how the date that should be interpreted. Supplying additional data on the community being studied that may be necessary and that could be helpful in the research process. Monitoring the appropriate epidemiological indicators as stipulated in the research methodology
5.
INTRODUCTION TO EPIDEMIOLOGICAL RESEARCH METHODS Epidemiology is rarely an experimental science. It consists usually of measuring the rate of occurrence of the disease or other health outcome or will compare patterns of exposure and diseases to identify particular risk factors associated with the disease. The epidemiologists will play purely an observational role and the researcher does not intervene in any way. However, they do make use of the intervention studies where the investigator actively attempts to change something to see what effect it has on the disease occurrence. These experimental epidemiological studies are analogous to experiments in other sciences, because investigators control of who is exposed and who was not.
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Therefore epidemiological studies fall into two categories: experimental and observational: In the more commonly used observational study, the epidemiologist just observes the exposure and outcome status of each study participant. In an experimental study, the epidemiologist determines the exposure status for each individual (clinical trial) or community (community trial); then do some followups of the individuals or communities to detect the effects of the exposure. The following types of study designs are used in epidemiological studies: Observational/Descriptive studies: o Case report and case series o Surveillance - routine data collection o Prevalence surveys o Migrant studies Analytical studies: o Ecological or correlation studies o Cross-sectional or prevalence studies o Case-control or case-reference studies o Case-crossover studies o Cohort or follow up studies o historical cohort studies o Nested case-control studies o Case cohort studies o Record linkage Experimental/intervention studies: o Randomised controlled trials or clinical trials o Preventative trials or field trials o Community trials community intervention studies
To summarise:
The purpose of an epidemiologic study is to quantify the relationship between an exposure and a health outcome. The hallmark of an epidemiologic study is the presence of at least two groups, one of which serves as a comparison group. In an experimental study, the investigator determines the exposure for the study subjects but in an observational study, the subjects determine their own exposure.
6.
DESCRIPTIVE STUDIES TYPES These studies can consist anything from a description of a disease in a single person to the description of patterns and trends seen amongst routine data collected at a population level or a survey. In descriptive epidemiology, data are organized and summarized according to time, place, and person. These three characteristics are sometimes called the epidemiologic variables.
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It can also usually be a simple description of the health status of a community based on routinely available data or on data obtained in a special survey. Researchers use descriptive studies to describe the frequency, natural history and possible determinants of a condition. These results of these studies show how many people develop a disease or condition at the time, describe the characteristics of the disease and those affected, and generate hypotheses about the cause of the disease. The hypothesis can be assessed through more research such as analytical studies or randomised controlled trials. 6.1 Case reports and case series: This is the starting point of any scientific study and it consists of naming and describing the phenomenon of interest. It is usually a detailed objective description/report of a clinical characteristic or outcome from a single clinical subject or event. For a case report a single noteworthy event first must be identified and data collection is being done in the retrospectively. This is followed by a review and the descriptive summary of the subject or event. No statistical analysis is included in the design. A case series report is an objective report of a clinical characteristic or outcome from a group of clinical subjects. Unfortunately, these types of studies provide little evidence of causality and cannot say much about patterns of disease occurrence. It should not be ignored because it can help identify potential health problems and stimulate further research. Incidence and prevalence studies actually are a type of case series report in which the entire study population is well defined and being uniformly surveyed regarding the parameters in question. It is all about the occurrence of the disease, but it can also address the rate of other events. 6.2 Surveillance/routine data: Some healthcare authorities collect data and then analyse it at a later stage. 6.3 Prevalence (cross-sectional studies) surveys: A survey can be conducted to measure the prevalence of a wide variety of aspects of health and it doesn't always just focus on the disease. These are purely descriptive studies with the aim to describe their health of the population as well as to determine the prevalence of specific factors in the community. These studies provide a snapshot of the population at the particular time With this study, both exposure and outcome are ascertained at some time. However because exposure and outcome are identified at one point time, the temporal sequence is often impossible to work out. 6.4 Migrant studies: Migrant studies are used to interpret the differences in disease rates between countries.
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7.
ANALYTICAL STUDIES It is evident that with descriptive epidemiology several characteristics of persons with disease can be identified but the question may be whether these features are unusual. Descriptive epidemiology does not answer that question. Analytic epidemiology provides a way to find the answer: the comparison group. Comparison groups, which provide baseline data, are a key feature of analytic epidemiology. Analytic epidemiology is concerned with the search for causes and effects, or the why and the how. Analytic epidemiology is used to quantify the association between exposures and outcomes and to test hypotheses about causal relationships.
7.1
Ecological studies: In an ecological study, the unit of analysis are populations or groups of people rather than individuals. These types of study usually rely on data collected for other purposes and the data can be used from populations were widely differing characteristics. It can also provide a meaningful start for more detailed epidemiological work.
7.2
The cohort study - looking forward in time: This studies also call a follow-up study because the researcher begins with individuals who are all free of the outcome of interest/disease. This research follows both the exposed and unexposed groups through time and compares the incidence of the outcome in each of the groups. The researcher will therefore detect new or incident cases of the outcome. A cohort study may contain more than two comparison groups. The measure of association that is calculated depends on the type of cohort data. The design of a cohort study: Develop outcome of interest Exposed Do not develop outcome of interest Study population without the outcome of interest Develop outcome of interest Unexposed Do not develop outcome of interest
Time (period of follow up)
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Types of cohort studies: There are two types of cohort studies - prospective and retrospective. In a prospective cohort study of the researcher identifies the study population at the beginning of the study and observes them through the calendar time to see whether the disease does or does not develop. A retrospective cohort study shortens the time needed to conduct a cohort study as it makes use of historically or previously compiled data. Strengths: The risk of developing the disease and incident rate can be directly measured in a cohort study A range of disease associated with an exposure can be studied
Weaknesses: 7.3 It can be long and expensive A large sample is necessary if the disease is being studied is rare Information bias may be a problem
Case-control study - thinking backwards in time: In a case-control study, the researcher begins with cases -these are individuals from an identified population who have developed the outcome of interest. A suitable control group is then selected from this source population who do not have the outcome of interest. Once cases and controls have been identified the researcher collects exposure measurements and compares them between the two groups. The design of the case-control study: Exposed Cases (with a disease) Unexposed Population Exposed Controls (without a disease) Unexposed
Time
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Strengths: The researchers can assess a range of different exposures associated with a single outcome The odds ratio calculated from a case-control study can be interpreted in a similar way to risk ratio or rate ratio, under certain circumstances These studies do not require prospective follow up of exposed and unexposed participants It requires less time, effort and fewer resources than cohort studies it is more efficient than cohort studies in that they involve smaller number of participants in utilising all the cases but only a sample of controls useful for outcomes that are rare or take a long time to develop
Weaknesses: 7.4 Selection of an appropriate control group can be very difficult Inappropriate control group will result in selection bias and the results of this study will be invalid Some studies are vulnerable to recall bias because it relies on interviews for data collection and the exposure status is determined after the occurrence of the disease in the cases The measurement of association that can be calculated from case-control study is usually restricted to the odds ratio
Cross-sectional study: Cross sectional studies can be descriptive or may include an analytical component. In their study, the researcher does not assess and compare the occurrence of new cases of a disease in two groups. It assesses and compares the prevalence of a disease or exposure across the two groups. It is also sometimes called prevalence studies. The researcher usually selects the sample without reference to exposure or the disease. The sample is therefore drawn at random from a defined population. The researcher then measures the presence of a disease and exposure in each participant in the study. Finally, the researcher compares the prevalence of the disease among those who are exposed and those are not exposed to determine if there is a difference in the prevalence of disease, according to exposure status.
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Design of a cross-sectional study: Defined population
Sampling from defined population (not focus on disease or exposure) (done randomly)
Collect data on outcome (disease) and exposure(risk factors) at one point in time
Exposed with disease
Not exposed with disease
Exposed No disease
Not exposed No disease
Strengths: easy and economical to conduct useful for evaluating the relationship between exposure that are relatively fixed characteristics of individuals useful for assessing the healthcare needs of populations used as an important first step in assessing the possibility of the relationship between an exposure and the disease
Weakness: 7.5 experienced difficulty distinguishing between factors that cause the disease and those which prolong the period with the disease establishing the correct temporal relationship between exposure and disease is difficult provide weaker evidence about causation of disease
Difference between cohort and case-control studies: In an observational cohort study, subjects first are enrolled on the basis of their exposure, and then are followed to document occurrence of disease. In an observational case-control study, subjects first are enrolled according to whether they have the disease or not, then are questioned or tested to determine their prior exposure.
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8.
POTENTIAL ERRORS IN EPIDEMIOLOGICAL STUDIES It is not always possible to measure accurately the occurrence of the disease or other outcomes. Much attention is devoted to minimise errors which could be a random or systematic: Random error: o It is a diversion due to change a loan of an orb's ovation on the sample from the blue population value leading to a lack of precision in the measurement of an association and there are three major sources, (a) individual biological variation, (b) sampling error, and (c) measurement error. Sample size calculation: the desirable size of a proposed study can be assessed using standard formulations. Systematic error: o It occurs when there is a tendency to produce results differs in a systematic manner from the true values and there are two major sources, (a) selection bias, and (b) measurement/classification bias. Confounding: o Confounding occurs when the association between exposure to a cause or a risk factor and the occurrence of the disease are being studied and another exposure exists in the study population. This specific exposure is also associated with both the disease, and the exposure being studied.
9.
SUMMARY As a discipline within public health, epidemiology includes the study of the frequency, patterns, and causes of health-related states or events in populations, and the application of the information gained to public health issues. In epidemiology, the patient is the public at largethe communityand in treating the patient the epidemiologists perform several tasks, including public health surveillance, disease investigation, analytic epidemiology, and evaluation. With surveillance, they epidemiologists constantly monitor the health of a community to detect any changes in disease occurrence. This requires regularly collect, analyze, interpret, and disseminate data, with the intention of taking prompt and appropriate public health action should we identify a problem. Epidemiology provides us with a systematic approach for determining What, Who, Where, When, and Why/How. Epidemiologists rely on standard case definitions to determine What, that is, whether a specific person has a particular disease. Epidemiologists use descriptive epidemiology to describe disease occurrence by person (Who), place (Where), and time (When). Epidemiologists also use descriptive epidemiology to portray the characteristics and public health of a population or community.
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Two essential concepts in this systematic approach are population and rates. Epidemiologists identify the populations in which cases occur, and calculate rates of disease for different populations. Epidemiologists use differences in disease rates to target disease intervention activities and to generate hypotheses about possible risk factors and causes of disease. Epidemiologists then use analytic epidemiology to sort out and quantify potential risk factors and causes (Why). As epidemiologists carrying out these tasks, they must be part of a larger team of institutions and individuals, including health-care providers, government leaders and workers, laboratorians, and others dedicated to promoting and protecting the publics health. 10. SUMMARISED ALGORITHM FOR EPIDEMIOLOGICAL RESEARCH CLASSIFICATION OF TYPES OF
Did the researcher assign exposure? Yes No
Experimental study
Observational study
Random allocation?
Comparison group?
Yes
No
Yes
No
Randomised Descriptive controlled trial
Non-randomised controlled trial
Analytical study study
Direction (time)?
Exposure
Outcome
Exposure and outcome at the same time Outcome
Exposure
Cohort study
Case-control study
Cross sectional study
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STUDY GOALS A student should be able to: Explain the definition of Epidemiology 2. Explain the concept of epidemiological approach 3. Motivate the necessity of using epidemiology in Optometry 4. Apply and explain the various methods used to measure the frequency of health events in a community 5. Identify the strengths and weaknesses of the various research methods. 6. Use the appropriate research method in a research project in Optometry
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SCREENING PROGRAMMES SIFTINGSPROGRAMME
PUB 304
Compiled by: Opgestel deur: Dr B de Klerk Principle medical officer
Department of Community Health Departement van Gemeenskapsgesondheid
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See Appendix 1 Screening part 1 See Appendix 2 Screening part 2
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DISEASE SURVEILLANCE SIEKTE TOESIGHOUDING
PUB 304
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SECTION 3.1
1. 1.1 INTRODUCTION
SURVEILLANCE SYSTEMS - INTRODUCTION
Definitions of health and disease The most ambitious definition of health is that proposed by WHO in 1948: "health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". This definition, although criticized because of the difficulty of defining and measuring well-being, remains an ideal. More practical definitions of health and disease are, of necessity, required; epidemiology concentrates on aspects of health that are relatively easily measurable and are priorities for action. In communities where progress has been made on the prevention of premature death and disability, increased attention is being devoted to positive health states. Definitions of health states used by epidemiologists tend to be simple, e.g. "disease present" or "disease absent". The development of criteria to establish the presence of a disease requires definition of normality and abnormality. However, it is often difficult to define what is normal, and there is often no clear distinction between normal and abnormal. Diagnostic criteria are usually based on symptoms, signs and test results for example hepatitis can be identified by the presence of antibodies in the blood, asbestosis by symptoms and signs of specific changes in lung function as well as radiographic demonstration of fibrosis of the lung tissue or pleural thickening, and a history of exposure to asbestos fibres. A diagnosis can be made on the basis of several of the manifestations of the disease, some signs being more important than others. However in some situations very simple criteria are justified.
1.2
Definition of disease surveillance A public health system without information on the ever-changing health problems means that public health is paralysed. Date is needed for health planning as well as the allocation of resources. These much needed data can only be gathered through population health surveillance systems. Surveillance is therefore the eyes and the use of public health and is the most important sensory organ. Disease surveillance is defined as the systematic collection, collation and analysis of outcome-specific data, and timely dissemination to those who need to know, especially those who can use this information to improve the health of communities. Surveillance has also been referred to as the collection of data for action. It is a type of ongoing observational study that involves continuous monitoring of disease occurrence within a population.
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2. 2.1
THE SURVEILLANCE SYSTEMS - METHODS AND USAGE Methods of surveillance Surveillance data is typically obtained through health provider-initiated reports, such as notification forms filled in by nurses (passive surveillance) or health departmentsolicited reports. Passive surveillance is good for conditions that have clear symptomatology (and few asymptomatic infections), such as measles. Active surveillance is useful for diseases which can be easily missed - it reminds health care providers to be on the lookout for these conditions. A good example of a disease that needs active surveillance is malaria, where it is important in controlling malaria to detect asymptomatic malaria carriers, in order to reduce the prevalence of parasite carriers. Passive surveillance is much less costly than active surveillance and is therefore used most often. Methods of disease surveillance include routine reporting, sentinel reporting, special surveys or programs, and outbreak investigations. Several surveillance systems may be used to support or complement each other.
2.2
Usage of surveillance The primary use of surveillance systems is to establish the long-term trends and patterns in disease occurrence at local, regional, and national levels. The immediate use of surveillance data is to trigger disease control efforts. Surveillance data is useful in evaluating intervention measures. The main purposes of surveillance are summarized below. Morbidity and mortality reporting Documenting distribution and spread of diseases Establishing long-term trends in disease occurrence Detection of epidemics Identifying high-risk groups or areas Estimation of magnitude of the health problem Facilitating planning of control and prevention measures Evaluation of intervention measures Resource allocation in public health planning Setting research priorities Archival information for describing the natural history of diseases. Surveillance data can also be used to direct resources for swift and effective control, as well as to estimate the magnitude of the health problem (in the long term).
2.3
Goals and objectives of a surveillance system Any surveillance system should have goals and objectives and should be used as a starting point. The following should be the focus of the surveillance system: Is the system detecting what it is supposed to detect? Is the system producing data in time for appropriate responses? And this system cope with and anomalies and changes? Is this system as simple and cheap as possible? Are the public health responses timely and appropriate?
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3. 3.1
TYPES OF SURVEILLANCE SYSTEMS Active surveillance This system is based on specific collection of data from healthcare providers or institution and is based on certain health needs. It is a process of active gathering of data such as outbreak of food borne pathogens or measles and it can include household surveys to detect ongoing transmission of infections. Active surveillance systems can produce more complete data of better quality than that provided by other systems. It is however resource intensive.
3.2
Passive surveillance A surface surveillance system depends on the discretion of the health care provider who should report cases. The notifiable diseases system as required by law is an example of a passive surveillance system.
3.3
Routine surveillance Epidemiologists often begin the investigation of the health experience of a population with information that is routinely available. The notifiable disease reporting system is a form of routine surveillance and it means that every case of a particular condition seen must be reported and counted. Routinely reported data is typically obtained via passive surveillance. The main reason for making diseases notifiable is to control those diseases which constitute a danger to public health. Notifiable disease reporting is the main routine system for morbidity data collection in South Africa. If a condition is notifiable, the notification to health authorities is a statutory obligation, the regulations of which are contained in the previous Health Act (63 of 1977). A notification may be submitted by any person who is legally competent to diagnose the condition, not necessarily a medical practitioner. The Act stipulates that if the condition is a serious communicable disease, it must be reported without delay orally/telephonically and confirmed in writing within 24 hours. The notification is made to the health section of the local authority, or to the provincial department of health, in areas where no local authority exists. If a death occurs, the authorities must be notified separately to allow estimation of case fatality rates. Each local authority is required to submit, on a weekly basis, a summary of all notifications (including nil returns, which are blank: forms indicating that no cases were seen) and deaths to the provincial department of health for processing and analysis. Laboratory-based surveillance is another method of routine surveillance. This system uses biological specimens sent to state laboratories by health providers. Laboratorybased surveillance is particularly important in infectious disease surveillance and data from this system is often tied into the notifiable disease reporting system. Its potential in this country has been largely unexplored and its role therefore needs to be expanded. The laboratory is useful in finding the etiological agent. Some diseases, such as typhoid, salmonellosis, and shigellosis can only be notified after laboratory confirmation, because of the non-specificity of the clinical syndrome. Laboratorybased surveillance becomes essential when it comes to the eradication of diseases that can be clinically confused with others. For example; polio can be confused clinically with other causes of acute flaccid paralysis (such as Guillain- Barre syndrome or transverse myelitis).
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3.2
Sentinel surveillance Sentinel surveillance uses data from a few selected sites rather than data from all sites. Most sentinel surveillance systems are passive surveillance systems. Since it is much easier to monitor and improve information collection at a few sites, it is possible to get accurate and more complete data on the sentinel population using sentinel surveillance rather than with total population passive surveillance. Data from well-selected sites such as specific hospitals or health centers is available more quickly, is more reliable, and costs much less than data for a whole region. This information can act as an early warning system. For diseases with a relatively high incidence, such as tuberculosis, health centers (TB clinics) could be selected as sentinel reporting sites. Other sentinel surveillance systems include the influenza surveillance system, trauma surveillance system, and the National Cancer Registry.
3.3
Special surveys/special surveillance programs Periodically, new or unusual disease problems require special surveillance programs to be set up. With the emergence of multi-drug resistance and the greater risk of tuberculosis among those with HIV/AIDS, a national tuberculosis program was initiated to document cases and treat tuberculosis more accurately. A National TB Register was initiated in 1994 to document information on every case of TB in South Africa. The Malaria Control Program was developed to address this problem in certain regions of South Africa. The malaria program is one of the few examples of active surveillance undertaken by the Department of Health in South Africa. Another example is sewer pads for active surveillance for cholera in water sources. To find out whether cholera is present in the community, it is more cost -effective to place a pad which retains microorganisms from sewage than it is to screen members of the community. Another example is the data use from antenatal and sexually transmitted diseases clinics, to estimate the prevalence of HIV.
3.4
Outbreak surveillance Many epidemics can go undetected if no surveillance is in place because: the baseline prevalence of disease is not known, No trends to compare The main aim of an outbreak investigation is to quickly control the outbreak with targeted interventions. This topic will be discussed in detail at a later stage.
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4. 4.1
MEASURES OF DISEASE FREQUENCY Population at risk Several measures of disease frequency are based on the fundamental concepts of prevalence and incidence. Unfortunately, epidemiologists have not yet reached complete agreement on the definitions of terms used in this field. It is important to note that the calculation of measures of disease frequency depends on correct estimates of the numbers of people under consideration. Ideally these figures should include only people who are potentially susceptible to the diseases studied. Clearly, for instance, men should not be included in calculations of the frequency of carcinoma of the cervix. That part of a population which is susceptible to a disease is called the population at risk. It can be defined on the basis of demographic or environmental factors. For instance, occupational injuries occur only among working people so the population at risk is the workforce.
4.2
Prevalence and incidence Measuring prevalence and incidence basically involves the counting of cases in defined populations at risk. The number of cases alone without reference to the population at risk can occasionally give an impression of the overall magnitude of a health problem, or of short-term trends in a population, for instance during an epidemic. There are different ways of measuring occurrence of a disease and the relation between prevalence and incidence varies between diseases. There may be a high prevalence and low incidence, as for diabetes, or a low prevalence and high incidence, as for the common cold; colds occur more frequently than diabetes but last only a short time, whereas once contracted diabetes is permanent. Data on prevalence and incidence become much more useful if converted into rates. A rate is calculated by dividing the number of cases by the corresponding number of people in the population at risk, and is expressed as cases per 10" people. Some epidemiologists use the term "rate" only for measurements of disease occurrence per time unit (week, year, etc.). However, with this definition only incidence rate would be a true rate.
4.3
Prevalence rate See Session 8 for information
4.4
Incidence rate See Session 8 for information
4.5
Cumulative incidence rate or risk See Session 8 for information
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4.6
Case-fatality See Session 8 for information
5. 5.1
USAGE OF AVAILABLE INFORMATION Mortality data In South Africa important information such as age, sex, date of birth and place of residence as well as the cause of death are recorded on a standard death certificate. The data are open to various sources of error but, from an epidemiological perspective; often provide invaluable information on trends in a population's health status. The usefulness of the data depends on many factors, including the completeness of records and the accuracy with which the underlying causes of death are assigned, especially in elderly people for whom autopsy rates are often low. Where national registers exist they may not be complete; poorer segments of populations may not be covered, deaths may not be reported for cultural or religious reasons, and the age at death may not be given accurately. The provision of accurate death data is a priority for epidemiologists. Internationally agreed classification procedures, which are given in the International statistical classification of diseases and related health problems (WHO, 1992) and revised at regular intervals to take account of the emergence of new diseases and changes in criteria for established diseases, are used for coding causes of death. The coding of causes of death is quite complex and is not yet a matter of routine in all countries. The mortality data are usually expressed as death rates. The death rate or crude mortality rate is calculated as follows: Number of deaths in a specified period Average total population during that period x 10n The main disadvantage of the crude mortality rate is that it takes no account of the fact that the chance of dying varies according to age, sex, race, socio-economic class, and other factors. It is usually not appropriate to use it for comparing different time periods or geographical areas. Comparisons of mortality rates between groups of diverse age structure are usually based on age-standardized rates. Death rates can be usefully expressed for specific groups in a population which are defined by age, race, sex, occupation or geographical location, or for specific causes of death. For example, an age- and sex-specific death rate is defined as follows: Total number of deaths occurring in a specific age- and sex-group of the population in a defined area during a specified period Estimated total population of the same age- and sex-group of the population in the same area during the same period
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6.
SOME PROBLEMS EXPERIENCED WITH SURVEILLANCE SYSTEMS Lack of accurate, timely data in a useful form as well as the rapid access to such data. Health care providers, health officials and policy-makers could then be involved in poor planning, unnecessary illness, mortality, and economic costs. Under-reporting has often been cited as the major problem with passive surveillance Poor knowledge of conditions that are notifiable Who should notify and to whom? The notification form is too complicated, as too many details are requested There is lack of feedback on reported cases There is lack of training in surveillance at undergraduate level and continuing medical education Doctors are too busy to spend a lot of time filling in the notification form Incompleteness of reporting Surveillance programs are very seldom subject to regular evaluation or validation High cost involved in active surveillance
7.
CONCLUSION There are major criticisms of passive surveillance including under-reporting but it is not always critical to obtain complete counts of most diseases in order to plan and undertake disease control interventions. When the incidence of a disease is high, the trends instead of the complete counts of the cases are adequate to plan and institute disease control efforts. While the technology for good surveillance systems is available, the necessary commitment to apply these for the benefit of public health is not always present. Surveillance systems should be evaluated to assess the accuracy and completeness of reporting, as well as the timeliness of results and the usefulness of the results to policymakers. .
REFERENCE: Katzenellenbogen, J.M., Joubert G. & Abdool Karim, SS. 1997. Epidemiology a manual for South Africa. Cape Town : Oxford University Press Beaglehole, R., Bonita, R. & Kjellstrom, T. 2003. Basic epidemiology. WHO : Gevena. STUDY GOALS A student should be able to: 1. 2. 3. 4. 5. 6. 7. Describe the definitions, concept and methods used in disease surveillance systems Identify and motivate for the usage of the various types of surveillance systems Discuss the 4 types of surveillance system as well as the role of the GP in detail Explain the difference between prevalence, incidence and the rates being used Calculate simple surveillance and risk ratios Discuss the most important mortality data and rates used in surveillance systems Identify the some common problems experienced with surveillance systems and how to address it
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INVESTIGATION OF DISEASE OUTBREAK ONDERSOEK VAN SIEKTE UITBREEK
PUB 304
Compiled by: Opgestel deur: Dr B de Klerk PMO Department of Community Health Departement van Gemeenskapsgesondheid
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See Appendix 3 Outbreak investigation
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HEALTH PERSONNEL GESONDHEIDSPERSONEEL
PUB 304
Compiled by: Opgestel deur: Dr B de Klerk PMO Department of Community Health Departement van Gemeenskapsgesondheid
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See health care personnel slides & Session 2 (section on health care personnel) no additional information
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DEPARTMENT OF COMMUNITY HEALTH DEPARTEMENT VAN GEMEENSKAPSGESONDHEID

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INTRODUCTION TO COMMUNITY/PUBLIC HEALTH INLEIDING TOT GEMEENSKAPS-/PUBLIEKE GESONDHEID

Information and study materials Informasie en studie materiaal

Compiled by: Opgestel deur:

Prof. WH Kruger Chief Specialist/Hoof spesialis

Department of Community Health Departement van Gemeenskapsgesondheid

University of Free State

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INTRODUCTION TO COMMUNITY/PUBLIC HEALTH

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PRINCIPLES USED IN COMMUNITY HEALTH

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3.2 3.3 3.4

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DETERMINANTS OF A DISEASE (see Figure 2 for more details)

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Death Complications Chronicity

Host Advanced disease.

Improvement and rehabilitation. Temporary disability. Permanent disability.

Early recognizable disease.

Early pathogenesis including incubation and latent period.

DETERMINANTS OF DISEASE In-transit Environment

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Chief nursing service manager

A Senior nursing service manager

Decision-making level Chief professional nurse (senior tutor)

Health adviser Community level workforce

AN EXAMPLE OF A HEALTH CARE HIERARCHY IN A COMMUNITY Chimere-Dan (1996:30)

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HEALTH CARE SYSTEM IN SOUTH AFRICA/ GESONDHEIDSORG SISTEEM IN SUID AFRIKA

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National Health Council (advisory)

3. DISTRICT LEVEL (TYPE C AND A MUNICIPALITIES, with type B local municipalities)

District Health Council: functional integration

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HEALTH CARE SYSTEM IN SOUTH AFRICA

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DISTRICT HEALTH SYSTEM

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LEVELS OF CARE AND PREVENTION VLAKKE VAN SORG EN VOORKOMING

Compiled by: Opgestel deur:

Dr B de Klerk PMO Department of Community Health Departement van Gemeenskapsgesondheid

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