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Evolution of the concepts, ideas and functions of Public

Health. Social medicine – areas of investigation,


content. Concepts of health and disease. Determinants
of health of the population. Public Health information
sources and evaluation of public health

Assoc. Prof. Skirmantė Starkuvienė MD, MPH, PhD


Department of Health Management
What is meant by Public Health?
Public health is the science and art of:
 preventing disease
 prolonging life
 promoting health and efficiency through organized community efforts
(Acheson report, 1988)
 sanitation of environment
 control of communicable diseases
 education of the individual in personal hygiene
 organization of medical and nursing services
 development of the social machinery to ensure everyone a standard of living
adequate for the maintenance of health
(Winslow,
WHO, 1951)
The essential elements of Modern
Public Health theory and practice
 Emphasize collective responsibility for health and the prime role of
the state in protecting and promoting the public’s health.
 A focus on whole populations.
 An emphasis on prevention, especially the population strategy for
primary prevention.
 A concern for the underlying socioeconomic determinants of health
and disease, as well as the more proximal risk factors.
 A multi-disciplinary basis which incorporates quantitative and
qualitative methods as appropriate.
 Partnership with the populations served.

(Beaglehole, Bonita, 1997)


Essential Public Health functions
These functions are a set of fundamental and
indispensable activities to protect the population’s
health and treat diseases, targeted at the
environment and the community. They are vital
for maintaining and improving health. Countries
at all levels of development should ensure that
these services are performed at least to minimum
standards, and their implications should be
monitored by government agencies.
(Health for all in the 21st century, 1998)
Essential Public Health functions
 Assessment and monitoring of the health of communities and
populations at risk to identify health problems and priorities.
 Formulating public policies, in collaboration with community
and government leaders, designed to solve identified local and
national health problems and priorities.
 Assuring that all populations have access to appropriate and
cost-effective health promotion and disease prevention
services, and evaluation the effectiveness of that care.
Scientific basis of Public Health
 Biomedical sciences
 Epidemiology

 Health psychology

 Health sociology

 Health economics

 Health ethics

 Health law
Historical development of health
problems and Public Health actions
Time Health Problems Public Health
Actions
-1700 Infectious diseases, epidemics Isolation, quarantine

1910 Tuberculosis, sexually Personal prevention,


transmitted diseases hygiene
1930-1950 Chronic non-communicable Preventive medicine,
diseases (CNCD) hospital technologies

1970-2000 CNCD, accidents; Primary health care,


health education
Our days AIDS, aging problems, Modern public health
CNCD, drugs, mental health
Public Health vs Medicine (1)
 Primary focus on population  Primary focus on individual
 Public service ethic, tempered by  Personal service ethic,
concerns for the individual
conditioned by awareness of
 Emphasis on prevention, health
promotion for the whole community social responsibilities
 Public health paradigm employs a  Emphasis on diagnosis and
spectrum of interventions aimed at treatment, care for the patient
the environment, human behavior
and lifestyle, and medical care
 Medical paradigm places
 Multiple professional identities with
predominant emphasis on
diffuse public image medical care
 Well-established profession
with sharp public image
Public Health vs Medicine (2)
 Variable certification of specialists  Uniform system for certifying
beyond professional public health specialists beyond professional
degree medical degree
 Biologic sciences central, stimulated  Biologic sciences central, stimulated
by major threats to health of by needs of patients; move between
populations; move between laboratory and bedside
laboratory and field  Social sciences tend to be an
 Social sciences an integral part of elective part of medical education
public health education
 Clinical sciences an essential part of
 Clinical sciences peripheral to professional training
professional training
What is meant by Social Medicine?

Social Medicine is part of the Public


Health science, which analysis the
impact of social, economical and
cultural environment on the health of
the population.
What is health?
Categories of definitions of
health (1)
 Biomedical
 Sociological

 Psychological

 Mental

 Environmental

 Economic

 Holistic
Categories of definitions of
health (2)
 Positiveconcepts of health
 Negative concepts of health

 Professionalconcepts of health
 Lay concepts of health
Holistic health definition
 Healthis a state of complete
physical, mental and social well-
being, and not merely the absence of
disease or infirmity.

(World Health Organization, 1946)


Population health
 The health of population as measured by
health status indicators and as influenced by
social, economic and physical environments,
personal skills, human biology, early
childhood development, and health services.

(Health Canada, 1997)


Two major aspects of health
■ Feeling well.
People who feel well and have a positive attitude
are more likely to actually be healthy as well.
■ Ability to function.
The ability to carry out minimal requirements for
independent living. It may be difficult to feel
healthy when we cannot function independently.
Quality of life
 Is defined as an individual’s perception of their
position in life in the context of the culture and
value systems in which they live and in relation to
their goals, expectations, standards and concerns.
It is a broad ranging concept affected in a complex
way by the person’s physical health, psychological
state, level of independence, social relations, and
their relations to salient features of their
environment
(WHOQOL Group, 1993)
Quality of life is represented by:
 Demographic developments
 Physical & mental health & illness
 Educational & occupational achievement
 Development in the science & the arts
 Production & consumption
 Wealth & income
 Conditions of housing
 Conditions of the natural environment
 Patterns of recreation
 Patterns of social participation
 Patterns of social mobility
 Social deviance & alienation
What are determinants of health?
Determinants of health are factors or
characteristics that bring about a change in
health, either for the better or the worse.
 Proximal (downstream) determinants of health
– ones, which are near (directly) to the change
in health status.
 Distal (upstream) determinants of health –
ones, which are distant either in time or place
(indirect) from the change in health status.
Epidemiological triangle
HOST

AGENT ENVIRONMENT
Case study
Judy, a small, three-year-old child, was playing with her
siblings outside her home in a small, semi-urban, slum area.
While chasing her older brothers she trod on a nail. Her mother
washed the wound and bandaged it. The wound remained red
and ‘angry’. Over a week the wound did not heal, the area
remained red and ‘angry’, with flaring up the leg. Judy began
to complain that she had pain in her groin, she became weak
and febrile. Judy was taken to hospital when her mother could
not control her fever and she died within a few days of
admission.
What are the possible determinants of Judy’s death?
The (possible) determinants of
Judy’s death
 Septicaemia (diagnosis)
 The nail (environmental – proximal)
 The environment – no playground (environmental, social – proximal
and distal)
 Lack of footwear (social – distal)
 Poverty (social – distal)
 Poor housing (social – distal)
 Poor wound management (biological – proximal)
 Poor knowledge about wound management (social – distal)
 Lack of education of parents (social – distal)
 Poor health care facilities (social, environmental – proximal and distal)
 Lack of antibiotics (biological – proximal)
Determinants of health and
disease
Enviroment
20%

Biological
factors
20%

Behavioral
factors and
Health care
lifestyle
services
50%
10%
Behavioural factors and lifestyle
 Smoking
 Alcohol abuse
 Drugs
 Nutrition
 Physical activity
 Stress
 Etc.
Factors influencing lifestyle
 Knowledge

 Attitudes, beliefs
 Habits, skills

 Social, environmental support

 Influence of different organizations

 Health policy of the state


Risk factors common to major
chronic diseases
Risk factor CVD Diabetes Cancer COPD
Smoking    
Alcohol  
Physical activity   
Nutrition   
Obesity    
Raised blood pressure  
Dietary fat/blood lipids   
Blood glucose   
Biological factors
 Genes, genetic diseases
 Gender
 Age
 Race and ethnicity
 Body size
 Special abilities
 Disease resistance
 Diseases susceptibility
 General robustness
Physical environment
1) Macro – environment:
- Food and water
- Air pollution
- Radiation
2) Micro – environment:
- Home
- Workplace
Social environment
- Religion, culture
- Race
- Place of residence
- Marital status
- Socioeconomic status
- Education
- Occupation
- Work related groups, colleagues
Social environment: poverty
 2.6 billion of people has
less than 2$ per day;
 1.2 billion – less than 1$
per day;
 8 from 100 newborns will
died before theirs five
year birthday.

Women work in a house-


building. India.
(HDR, 2000)
Social environment: education

 9 from 100 boys and


14 from 100 girls will
never go to school;
 The health status is
better among educated
people comparing with
no educated ones.

Bus - library. Chile. (HDR, 2000)


Social environment: occupational
status  Health is better among
white-collar workers
vs. blue-collar ones.
 Unemployment is
physical and mental
stress, which increase
the risk for many
diseases.

(Bartly M, 1994)
Social environment:
unemployment
Cause of death RR with 95% CI
Lung cancer 1.43 (1.12-1.85)
Acute myocardial infarction 1.36 (1.18-1.56)
Other ischemic heart disease 1.77 (1.44-2.17)
Cerebrovascular disease 1.54 (1.21-1.96)
Other circulatory diseases 2.08 (1.59-2.72)
Diseases of respiratory system 3.32 (2.14-5.13)
Alcohol related diseases 5.24 (4.21-6.52)
Suicide 1.92 (1.62-2.27)
Traffic accidents 1.88 (1.47-2.40)
Alcohol poisonings 4.62 (3.59-5.95)
Other accidents and violence 3.01 (2.54-3.56)

(Martikainen PT, 1990)


Health care services
■ Structure
■ Material resources

■ Human resources

■ Technologies

■ Professional’s knowledge, etc.


Disease, illness, sickness
 Disease is a state that in certain culture and
time can be diagnosed as a disease by the
medical science.
 Illness is defined as subjective symptoms
experienced by an individual and identified
as ill health. The symptoms can comprise
physical, psychological and social factors.
 Sickness is a social role given to or taken
by an individual in a certain social context
and normally in combination with illness
and/or disease.
Top risk factors leading to
disease, disability or death
■ Poorest countries ■ Developed countries
1. Underweight 1. Tobacco
2. Unsafe sex 2. High blood pressure
3. Unsafe water, sanitation & 3. Alcohol
hygiene
4. Indoor smoke from solid 4. High cholesterol
fuels 5. High BMI
5. Zinc deficiency 6. Low fruit & vegetable
6. Iron deficiency intake
7. Vitamin A deficiency 7. Physical inactivity
8. High blood pressure 8. Illicit drugs
9. Tobacco 9. Unsafe sex
10. High cholesterol 10. Iron deficiency
Indices used for measurement of
the population health
 Biomedical public health indices
- Demographic indicators
- Morbidity indicators

 Behavioral indices

 Sociomedical public health indices


- Education
- Occupation
- Income
- Living conditions
- Marital status
- Place of residence
- Religion
- Opportunities to spend leisure time, etc.
Some groups of health indicators
A. NEGATIVE HEALTH IND. B. NEGATIVE/POSITIVE HEALTH IND.
1. Epidemiological indicators 3. Behavioral indicators
- mortality - coping stress
- morbidity - smoking, alcohol, drug abuse
- disability - oral hygiene
2. Subjective indicators - sexual behavior
- complaints - use of protective measures/devices
- perceived health

C. POSITIVE HEALTH IND.


- quality of life
- well-being
- physical fitness
Health care is vital to all of us
some of the time but public
health is vital to all of us all the
time

C. Everett Koop

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