Evidence-Based Periodic

Health Examination and

promotion health FM
dr. Titiek Hidayati M. Kes.
Bag. Epidemiology
Ilmu Kedokteran Masyarakat dan keluarga (IKM/IKK)
Fakultas Kedokteran Umum dan Ilmu kesehatan UMY

LO
Pemeriksaan kesehatan berkala yang
berdasarkan pada bukti bukti
kesehatan (Evidence Based)
Tentang berbagai tes kesehatan yang
tepat guna sesuai waktu dan
kegunaannya
Task Forces on Prevention and Health
Screening
Natural course of disease and five level
prevention
2

Periodic health examination

(PHE)
Periodically, patients visit physicians office not
because they are unwell, but because they want a
check-up. Such visits are referred to as health
maintenance or the PHE.
The PHE is an opportunity to relate to an
asymptomatic patient for the purpose of case
finding and screening for undetected disease and
risky behavior. It is also an opportunity for health
promotion and disease prevention.
The decision to include or exclude a medical
condition in the PHE should be based on the burden
of suffering caused by the condition, the quality of
the screening, and effectiveness of the intervention.
3

Pencegahan lebih baik dari

pada pengobatan
An ounce of Prevention equals to
pounds of Cure

Task Forces on Prevention

The US Preventive Services Task Force

(1984, 1996, 2002)

The Canadian Task Force on Periodic
Health Examination (1997)
The Task Force on Philippine Guidelines
Periodic Health Examination (2004)
- Sie Promosi kesehatan, Sie P2M dan PTM
(Puskesmas, Dinkes kabupaten, Dinkes
propinsi dan Depkes)

Health Screening as a Strategy

for Preventive Medicine
(Task Force on Philippines Guidelines on PHEX, 2004)

In the last half century, health care has seen

a major shift in philosophy
from curative medicine to preventive medicine

Four major strategies used in the rapidly growing field

of Preventive Medicine:
1. Health Screening
(doing tests for early detection of disease or risk factors
for disease)
2. Lifestyle change
(avoidance of unhealthy habits)
3. Risk factor control
(treatment of factors that predispose to disease)
4. Vaccination programs
(immunization against infectious diseases)

creening (WHO, 1994):

he use of presumptive methods to detect unrecognize
ealth risks or asymptomatic disease in apparently
ealthy individuals in order to permit prevention &
.
mely prevention

reening (WHO, 1994):

enggunaan metode-metode yang dianggap bisa
endeteksi risiko kesehatan yang tidak dikenal atau
enyakit yang asimptomatik pada individu-individu yan
mpak sehat dalam rangka membolehkan dilakukannya
encegahan atau pencegahan yang tepat pada waktuny

Screening (executive
medical check up)
is performed to categorize
members of the general
public into:

Higher
probability
of disease

Lower
probability
of disease

This group is
urged to seek
further medical
attention for
definitive
diagnosis &
treatment

Pitfalls of Screening & Other Preventive

Medicine Strategies:
Things that ought to work do not always so

Lifestyle changes such as salt restriction:

have failed to lead to appreciable changes in the incidence
of stroke & coronary disease in the general population
Most dietary maneuvers, like high fiber diet,
have not been proven effective in cancer prevention

Risk factor control has failed as well, and in some instances

has even led to an increase in deaths:
The cholesterol lowering drug clofibrate, was removed from
the market because a trial by WHO showed more deaths
among patients who received treatment

Many screening tests, such as ECG:

have been found to be inaccurate for detection of
early coronary disease

.Consequently, many asymptomatic patients are wrongly

labeled as being ill (false labeling)

nstead of improving the quality of life of people,

false labeling has been found to wreak havoc on the social,
psychological, physical & even financial stability of
unfortunate individuals

oductive people have been denied insurance or employme

have resigned from work because of depression

Many times, the side effects of screening

have been far worse than the effects of the diseases which
we were trying to prevent in the first place

Although treating early disease may be cheaper & easier,

the savings are often offset by the costs of having to do
the screening tests on large numbers of
apparently healthy individuals

urative surgery for a case of coronary artery disease (CAD)

may cost half a million pesos (Rp 100juta) in the Philippines

contrast, primary prevention of a single death from

rdiovascular disease may entail treating at least 143 patien
r high cholesterol with a statin for 5 years.
pending on the statin used , this may costs as much as
million pesos (Rp 4 milyar)

eed, sometimes,

ounds of prevention translates to just an ounce of cur

Criteria for the use of screening test

(Blueprints Family medice, Martin S. Lipsky)
Criteria for the use of screening tests include the
following :
- The disease is common and significantly affects
individuals and society
- Effective treatments for the disease are available
- The screening tests or procedures are accurate
and reasonable in terms of cost, comfort and
complications
- Characteristics that measure the accuracy of
screening tests include sensitivity, speciticity,
positive and negative predictive values
15

Criteria for Screening

(Task Force on Philippines Guidelines on PHEX, 2004)

B
. ecause health screening carries the potential
for harm & because it can lead to huge increments,
criteria need to be set on when screening for
early disease should be done
Four criteria

1. Treatment for the asymptomatic condition must have been

evaluated using well-designed randomized controlled trials
(RCTs) that observed effects on clinical outcomes

. The burden of illness from asymptomatic condition must have

2.

been measured accurately in locally-conducted community-based

studies (disease prevalence or its impact on peoples lives)

3. Accuracy of the screening test for the asymptomatic

condition must have been evaluated in validation studies

done in the community (false positive & false negative errors)

4. Cost-effectiveness of the screening test, as well as

treatment for the disease, should have been evaluated

locally in properly conducted economic analysis (studies that
evaluate costs, risks & benefits of treatment)

Communitybased
Studies

Hospitalbased
Studies:
Hospitalized patients tend
VS to have more advanced
illness (easier to detect):
Exaggerate the
prevalence of the
condition

19

20

Screening for Hypertension

(Task Force on Philippines Guidelines on PHEX, 2004)

ommendations:
.

creening for hypertension is recommended

he auscultatory method using a mercury

phygmomanometer is recommended for the diagnosis
hypertension as well as for the monitoring of blood
ressure

mbulatory blood pressure monitoring is not

ecommended for screening

Screening for Dyslipidemia

(Task Force on Philippines Guidelines on PHEX, 2004)

mmendations:

eening for dyslipidemia using a non-fasting total

olesterol level alone should be done in individuals
ed 40 or above with no other risk factors

reening for dyslipidemia using a complete lipid profile

otal Cholesterol, Low Density Lipoprotein (LDL), High
nsity Cholesterol (HDL) & Triglycerides) should be
ne in:

Patients with two or more of the following risk factors

smoker, obese, post-menauposal)
Patients with evidence of familial dyslipidemia
xanthoma, family history of early cardiovascular
disease)

Screening for Diabetes

(Task Force on Philippines Guidelines on PHEX, 2004)

mmendations:
.

lective screening using fasting plasma glucose is

commended for high-risk individuals (patients 40 y.o.
nd above, smokers, obese, patients, with a family
story of DM, patients with evidence of familial
yslipidemia & those with history of delivery of babies
rge for gestatitional age

ass screening for DM using fasting plasma glucose

PG) levels or the oral glucose tolerance test (OGTT)
not recommended

Screening for Obesity

(Task Force on Philippines Guidelines on PHEX, 2004)

mmendations:

reening for obesity using the waist-to-hip ratio (WHR

body mass index (BMI) is recommended for
pparently healthy individuals

Screening for Sedentary Lifestyle

(Task Force on Philippines Guidelines on PHEX, 2004)

.
Recommendations:
Screening with regard to sedentary lifestyle is
recommended (Level 4)

26

Health Promotion &

Disease Prevention
Strategies

27

Health Promotion Strategies

.

The Ottawa Charter

for Health Promotion (WHO, 1986)

Health promotion is the process of enabling

people to increase control over, and
o improve their health
To reach a state of complete physical, mental &
social well-being, an individual or group must
be able to identify and to realize aspirations,
o satisfy needs, and to change or cope with
he environment.
Health is, therefore, seen as a resource for
everyday life, not the objective of living.

Health is a positive concept emphasizing socia

.
and personal resources, as well as physical
apacities.
Therefore, health promotion is not just
he responsibility of the health sector,
but goes beyond healthy life-styles
o well-being.

The fundamental conditions and resources for health:

. peace,
shelter,
education,
food,
income,
a stable eco-system,
sustainable resources,
social justice, and equity.
Improvement in health requires a secure foundation
in these basic prerequisites.

Health Promotion
Health Promotion is a term that has been applied
to a wide range approaches to improving health of
people, communities and populations

Health Promotion Circle

Health Promotion Cycle

Health Promotion: Best Practice Intervention

Prevention & Health Promotion Strategy

in Diabetes

Republic of Philippine Department of Health

Health Promotion & Disease Prevention at Stages
of Life
Various
Stages
of Life

Leading Causes
of Deaths

Mothers &
Unborn

Maternal Deaths:
Postpartum
hemorrhage
Hypertension &
complications
Sepsis
Obstructed labor
Fetal Deaths:
Congenital
cretinism
Spina bifida
Rubella baby
syndrome

Health Promotion & Disease

Prevention Strategies

Antenatal registration
Tetanus Toxoid immunization
Nutrition (including vitamin A, iron
& folate supplementation)
Treatment of existing conditions of
diseases
Recognition, early detection and
management of complications
before, during & after pregnancy
Clean & safe delivery
Promotion of breastfeeding
Information service for family
planning
STD/HIV prevention & management
Dental care

Various
Stages
of Life
Newborn &
infants

Leading Causes
of Deaths
Pneumonia
Diarrhea
Septicemia
Meningitis
Measles
Respiratory
conditions of
newborn & fetus
Congenital
anomalies
Avitaminosis &
other nutritional
deficiencies
Birth injury
Difficult labor

Health Promotion & Disease

Prevention Strategies
Resuscitation
Routine eye prophylaxis
Prevention & management of
hyperthermia
Newborn screening
Immediate & exclusive breastfeeding
Complementary breastfeeding at 6
months
Prevention & management of
infection
Birth registration
Birth weight and growth monitoring &
promotion
Full immunization
Micronutrient supplementation
Dental care
Developmental milestone screening
Advice on psychosocial stimulation

Various
Stages
of Life
Early
childhood

Leading Causes
of Deaths
Pneumonia
Diarrhea
Measles
Meningitis
Combination of
above with
underlying
malnutrition

Health Promotion & Disease

Prevention Strategies
Growth monitoring & promotion
Nutritional screening
Micronutrient supplementation
Developmental milestone screening
Disability detection
Management of common childhood
illness
Dental care
First Aid

Various
Stages
of Life
Middle
childhood

Leading Causes
of Deaths
Pneumonia
Accidents
Diarrhea
Measles

Health Promotion & Disease

Prevention Strategies
Integrated management of
childhood illness
Accident prevention
Nutrition & diet counseling
Dental care

Various
Stages
of Life

Leading Causes
of Deaths

Health Promotion & Disease

Prevention Strategies

Adolescent &
Youth

Accidents & other

forms of violent
deaths
Pneumonia
Tuberculosis
Rheumatic heart
disease
Carcinomas

Management of illness
Counseling on substance abuse,
sexuality & reproductive tract
infections
Nutrition & diet counseling
Mental health
Family planning & responsible
sexual behavior

Various
Stages
of Life
Adults

Leading Causes
of Deaths
Cardiovascular
diseases
Tuberculosis
Pneumonia
Malignant
neoplasm
Chronic
obstructive lung
diseases

Health Promotion & Disease

Prevention Strategies
Nutrition & diet counseling
Screening & management of
degenerative diseases
Dental care
Counseling on substance abuse,
Family planning & responsible
sexual behavior
Reproductive health
Mental health

Concepts of Prevention
The objective of preventive medicine
is to intercept or oppose the cause
and thereby the disease process.
Levels of Prevention:
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention

 Five levels of Prevention (Rao, 2005)

Primary Prevention / Prevention of disease
occurrence (true prevention), Prepatogenesis
1. Health promotion:
good nutrition, safe water supply
2. Specific protection:
immunization, mask, glove

Secondary Prevention/ Patogenesis

3. Early detection & prompt treatment:
screening for asymptomatic disease, oral dehydration
therapy, physiotherapy

Tertiary Prevention Treatment of symptomatic

disease to minimize complications (morbidity
reduction)
4. Disability limitation:
bed rest, chemotherapy
5. Rehabilitation:
wearing spectacles, leg prosthesis,

Pencegahan
PRIMARY PREVENTION
Ths is the measure undertaken in the period of
prepathogenesis (i.e.before the development of the
disease) which removes the possibility of occurence
of the diseases,for which removes the possibility of
occurrence of the disease.

Specially,it is all the more important in those

diseases, for which no treatment is available, e.g.
AIDS, cancer, rabies, carries tooth, etc.

Primary prevention can be adopted by two modes

of interventionnamely health promotion and
Specific protection.

 Secondary Prevention
Actions which halts the progress of a
disease at its incipient stage and
prevents complications.
Intervention in early pathogenesis phase.Early
diagnosis and adequate treatment.

Largely the domain of a clinical medicine.

Drawbacks:Already there is suffering of
mental anguish, pain.
Loss of productivity
More expensive and less effective

 Tertiary Prevention
All measures available to reduce or
limit impairments and disabilities,
minimize suffering caused by
existing departures from good health
and to promote the patients
adjustment to irremediable
conditions.
Intervention in late pathogenesis
phases to prevent sequelae and limit
disability.

Modes of Intervention
Any attempt to intervene or interrupt
the usual sequence in the
development of disease.
Modes of intervention:Health promotion
Specific protection
Early diagnosis and treatment
Disability limitation
Rehabilitation

PRIMARY PREVENTION
Health Promotion
This consist of General measures, which will strengthen the
individual/host and prevents the occurrence of the disease by
interrupting the interaction among the three factors of epidemiological
triad.
The various measures of health promotion are:
Health education (on personal hygiene, oral hygiene, nutrition
education, life-style, etc.).
Sex education.
Adequate nutrition.
Improvement in the environmental sanitation (such as control of
insects, provision of protected water supply, sanitary disposal of
sewage, etc.).
Promotion of breast feeding and proper weaning.
Family planning and spacing of births.
Genetic counseling (premarital and marriage counseling)
Efficient ante-natal care and post natal care.
Recreation facilities (sports, games, cultural activities, etc.).
Improvement in the literacy level.

Specific Protection
This consist of specific measure,which prevent specific diseases.
The various measures are:
Immunization against vaccine preventable diseases,
Silver nitrate or Penicillin eye drops against ophthalmia
neonatorum,
Condom against AIDS
Use of specific nutrients (Vit. A against nutritional blindness, IFA
against nutritional anemia, Iodised salt against Iodine
Deficiency Disorders),
Helmet against head-injury,
Masks against pneumoconiosis,
Ear plugs against noise induced deatness,
Lead apron against radiation hazards,
Visor against welding keratitis,
Barrier cream against occupational skin cancer,
Avoidance of allergens and carcinogens,
Sterilization procedures of surgical instruments,
Pasteurization of milk,
Traffic signals against road accidents,

 Specific Protection
Immunization e.g. Vaccine
preventable diseases.
Specific nutrient e.g. Iron.
Protection against injuries (seat belt)
Chemoprophylaxis e.g. against
Malaria.
Control of consumer product quality
and safety of foods, drugs, cosmetics
etc.

Secondary prevention
Early diagnosis and Treatment
The detection of disturbances of
homoeostatic and compensatory
mechanism while biochemical,
morphological and functional
changes are still reversible.
Important in reducing high morbidity
and mortality.

Secondary prevention
This helps in the following ways:
Helps in recovery from the disease (restoration)
Reduces the duration of illness in the individual,
Minimizes the suffering,
Prevents the development of complications,
Prevents further spread of the diseases in the
community,
Prevents or postpones the deaath of the
individual.

Tertier prevention

Disease

Impairment

Disability

Handicap

Accident

Loss of foot

Inability to
waalk

Loss of job

Vit A deficiency

Corneal xerosis

Blurring of
vision

Blindness and
loss of job

Leprosy

Involvement of
nerves

Inability to work Unemployment

because of claw
hand

Tertier prevention
Rehabilitation
The combined and coordinated use of medical,
social, educational and vocational measures
for training and retraining the individual to
the highest possible level of functional
ability.
Medical rehabilitation
Vocational rehabilitation
Social rehabilitation
Psychological rehabilitation

 Example rehabilitation care:

1. Establishing the schools for the blind
2. Providing aids for crippled, such as
artificial limb
3. Reconstructive surgery in leprosy
4. Graded exercises in paralysis
5. Intraocular implantation of learn
among cataract patient.

Functions of a doctor:
The care of the individual
The care of community Community
diagnosis & Community treatment
As a teacher

Ringkasan pencegahan

Natural History of Disease

.

Ringkasan pencegahan

Terima ka
sih
Dr. Titiek Hidayati M.
Kes

Terima kasih