1. SupattraSrivanichakorn ASEAN Institute for Health Development, Mahidol University Introduction andRole of Epidemiology

2. What is Epidemiology ? The study of the distribution and determinants of diseases and injuries in human population.(Mausner&Bahn) the study of the distribution and determinants of health related states or events in specified populations, and the application of this study to the control of health problems. (dictionary of epidemiology)

4. The Traditional Model of Disease Host Agent Environment Source: G.E. Alan Dever, 1980

6. Healthy People in Healthy Communities. Source: U.S Department of Health and Human Services, 2000

7. Health, Healthy peopleHealth concept model Definition of Health Health concept model

8. Epidemiological Model for Health Policy Analysis COMPLEX INTERNAL SYSTEMS HUMAN BIOLOGY GENETIC INHERITANCE MATURATION AND AGING SOCIAL RESTORATIVE AN EPIDEMIOLOGICAL MODEL FOR HEALTH POLICY ANALYSIS ENVIRONMENT SYSTEM OF HEALTH CARE ORGANIZATION PSYCHO-LOGICAL CURATIVE PREVENTIVE PHYSICAL LEISURE ACTIVITY RISK EMPLOYMENT PARTICIPATION AND OCCUPATIONAL RISKS LIFE STYLE (SELF-CREATED RISKS CONSUMPTION PATTERNS Source: G.E. Alan Dever, Social Indicator research 2,1976,455.

9. Multi-dimension of health Psychological Social Physical Spiritual Health:A state of complete physical, mental, and social well being - not merely the absence of disease or infirmity (WHO1948)

12. Domains in Epidemiological data? TIME - PERSON - PLACE - Distribution and Determinants of Problems

13. สถานการณ์สุขภาพ อัตราเกิด อัตราตาย อัตราป่วย ความชุกในการป่วยประเภทต่างๆ ความชุกของความพิการ การทำงานไม่ได้ตามภาวะปกติ ความชุกของพฤติกรรมเสี่ยงในการเกิดปัญหาสุขภาพ ลักษณะปัจจัยที่มีผลต่อปัญหาสุขภาพ ทุนและปัจจัยที่มีผลบวกต่อสุขภาพ

14. เงื่อนไข และเป้าหมายการพัฒนาบริการสาธารณสุข สาธารณสุข แนวใหม่ ที่ยังไม่บรรลุผล ภาระเก่า สิ่งแวดล้อม กายภาพ สังคม เศรษฐกิจ สิ่งแวดล้อม กายภาพ สังคม เศรษฐกิจ อาการ โรค ป่วย + สุขภาพ

15. The Mandala of Health culture community Life style Personal Behavior Economic- social Env. Family Health service system spiritual Work/Occupation Body Mind Physical Environment Biology Human invented Environment Biological world

16. Alma-Ata Declaration WHO, Geneva,1978Primary Health CareHealth for All by the Year 2000 Ottawa Charter for Health Promotion (1986): Birth of the “new” public health Health - a resource for living, not the objective of living; emphasis on social and personal resources, as well as physical capacities

18. Work

19. School

21. Family Life cycle

22. Life cycle

23. Family of origin

26. Ideas

27. Function

29. Why we need Epidemiology ? To understand the nature of diseases/health problems. To find out root causes of health problems To identify options for effective interventions to control/prevent health problems in clinical setting and in the population. To evaluate the output/outcome/effect after the interventions

30. อนาคต Sentinel information of risk groups for AIDs infection การดูแลรักษา ผู้ติดเชื้อเอดส์ Drug injector Male user at STD clinics % % 14 70 โจทย์ 12 10 50 8 6 30 4 10 2 โจทย์ 0 0 Direct Prostitutes Indirect Prostitutes % % 40 40 โจทย์ 30 30 20 20 โจทย์ 10 10 โจทย์ 0 0 ’33 ’35 ’37 ’39 ’41 ’43 ’45 ’33 ’35 ’37 ’39 ’41 ’43 ’45 Bangkok Central North North-east South

31. How we use Epidemiology ? Epidemiological tools: Surveillance, Out-break investigation Epidemiological studies Descriptive study Analytical study Experimental study

32. Application of Epidemiology To identify the etiology or causes of a diseases and risk factors. To determine the extent of disease found in the community . To study the natural history and prognosis of diseases To evaluate both existing and new preventive and therapeutic measures and mode of health care delivery. To provide the foundation for developing public policy and making regulatory decisions relating to environmental problems.

33. National Household Survey 2001 STATISTICS Area Specific Demographics and Selected Planning Indicators

34. NUMBER OF POPULATION National Household Survey 2001 REPORTED EVER USED SUBSTANCES STATISTICS Stimulant and muscle relaxant Number of substance user population x 1000 AREA Yaba Ecstacy Ketamine Cocaine 143.7 17.2 17.4 Bangkok 36.2 36.7 3.1 1.8 Peripheral province 7.5 402.4 7.8 10.6 Central region 66.0 283.1 0.7 4.1 Northern region 71.3 2,564.9 8.6 11.9 Northeastern region 161.5 60.8 3.4 7.1 Southern region 17.6 3,491.6 40.7 52.8 Total 360.1 Yaba: An illicit stimulant commonly contains methamhetamine, ephedrine and/or caffeine.

35. National Household Survey PERCENTAGE OF SUBSTANCE USER per AREA 2001 STATISTICS Stimulants and muscle relaxant Percentage of user per area population(%) AREA Yaba Ecstasy Ketamine Cocaine Bangkok 0.4 0.4 0.9 3.5 Peripheral province 0.1 0.2 0.4 2.0 Central Region 0.1 0.1 0.8 4.8 0.1 0.0 0.8 3.3 Northern Region Northeastern Region 0.1 0.1 1.0 16.1 Southern Region 0.1 0.1 0.3 1.1 7.8 Total 0.1 0.1 0.8 Yaba: An illicit stimulant commonly contains methamhetamine, ephedrine and caffeine.

36. AREA SPECIFIC PREVALENCE National Household Survey OF EVER USE SUBSTANCES 2001 STATISTICS % 45 MALE RESPONDENTS 40 35 30 25 20 15 10 5 0 Ganja Kratom Heroin Inhalant Yaba Bangkok Central Region Northeastern Reg. Bangkok/ Suburb Northern Region Southern Reg.

37. Epidemiology for health service management and policy development The foundation for problem identification When and how to use epidemiology for policy development Describe the situations: HR, quality of services Identify risks Evaluation performance and outcome of health services Use for assessing planning, forcasting, projecting health needs of population groups Numerators/Denominator Monitor and evaluate process management

38. Ecology of Medical Care Adult population Age 16+ yrs 1000 Illness or injury a month 750 Consulting MD in PC a month 250 9 Admitted a month 5 Referred TC a month 1 Referred medical center a month White KL. NEJM 1961;265(18):885-892

39. Ecology of Medical Care : Revisited 1000 All Ages Report Symptoms a month 800 327 Consider Seeking Medical Care 217 Consulting MD in PC Visit CAM provider 65 Visit OPD Hospital 21 Receive HHC 14 Admitted 8 1 Admitted medical center Green LA. NEJM 2001;344(26):2021-5

40. รพ.รัฐ (26.1) กิน/อยู่ รพ.เอกชน (6.4) หมอพื้นบ้าน /สมุนไพร (3.8) ทำงาน ป่วยเรื้อรัง ศูนย์แพทย์ (26.1) พึ่งตนเอง ผู้ใหญ่ ไม่ป่วย พึ่งบริการ พักผ่อน คลินิคเอกชน (26.1) ซื้อยากินเอง (10.2) ฯลฯ ปล่อยให้ หายเอง (1.3)

41. รพ.รัฐ (7.4) รพ.เอกชน (1.5) หมอพื้นบ้าน /สมุนไพร(0.5) กิน/อยู่ ศูนย์แพทย์ (25.4) ทำงาน คลินิคเอกชน (21.1) children พึ่งตนเอง Not sick พึ่งบริการ Mild sickness พักผ่อน ซื้อยากินเอง (31.9) ฯลฯ ปล่อยให้หายเอง (31.9)

42. H EALTH CARE REFORM THE CONCEPTUAL FRAMEWORK OF PRIMARY CARE in Thailand SERVICE DEMAND SELF-CARE Development direction Development direction Health Behaviors Service provider PRIMARY SERVICE Eating Sleeping Working Resting Exercise Alternative healers Village Health Volunteers Health centers Private clinics Private hospitals Public hospitals etc. PERSONAL HEALTH CARE etc. SECONDARY SERVICE Resting Self-prescription Physical remedies SELF-TREATMENT ON ILLNESS TERIATIARY SERVICE (bathing/cleansing/ message/etc.) Socio-economic & environmental context, Area-based & population specific demands and service capacity

43. Figure 5.20 Incidence of Sexually Transmitted Infections and Condom Use Rate among Female Commercial Sex Workers (CSWs), Thailand, 1977-2003

44. Top ten mortality in 2004 Source: Thai Working Group on BOD % of Total national deaths 63.9 56.0

45. Share of public and private financing sources from total health expenditure in Thailand,1994 - 2005

46. Epidemiology for Population Health To describe situations and trend of human population To investigate the process beneath the surface To interpret, analyze, to find meaning and use for the future

48. ความชุกของโรคเบาหวาน6.9 % ผู้ป่วยส่วนใหญ่ได้รับ การดูแลที่โรงพยาบาล ทราบว่าป่วย 43% ควบคุมได้ 12.2 % 2547

49. Microvascular complications Macrovascular complications Postprandial plasma glucose Glucose production Glucose transport TG HDL Lipogenesis Obesity Waist-hip ratio Hypertension Stage III Type 2 Diabetes mellitus Stage II Impaired glucose tolerance Insulin secretory deficiency Stage I Normal glucose tolerance Atherogenesis Hyperinsulinemia Insulin resistance Diabetes Genes เบาหวาน General Population : no risk