Concepts of Community Health and Determinants

Albaha University
faculty of Applied Medical Sciences
public health department
Concepts of Community Health
Dr.Abdalla Hasballa Elmanna Albaha
University email:dr.abdalla.sd@gmail.com
1

Lecture one
• Objectives:
1. The students should be able to:
• Define community
• Know the functions and features of
community
• Understand the characteristics and types of
community
2

Definition of Community
• A community is a collection of people who
• interact with one another and whose common interest
or characteristics gives them a sense of unity and
belonging
• A community is a group of people in define
• geographical area with common goal and
• objective.
• Communities are “systems composed of
• individual members and sectors that have
• a variety of distinct
• characteristics and interrelationships
3

Definition of the community
• Community(WHO)
• Is the social group determined by geographical
boundaries and or common values and interests.
• Its member known and interact with each others.
• Community is defined as any group of people who
share geographic space, interests, goals or history.
• Community is the group of people who have
common characteristics.
4

Function of community
• The function of any community includes its
members’ sense of belonging and shared
identity, values, norms, communication, and
supporting behaviors.
• Some communities who may share almost
everything, while other communities (large,
scattered and composed of individuals) who
may share only there common interests and
involvement in certain goals.
5

The Three Features of a Community
• Location: every physical community carries out its daily
• existence in a specific geographical location. The health
of the community is affected by this location, including
the placement of the service, the geographical features…
• Population: consists of specialized aggregates, but all of
the diversed people who live with in the boundary of the
community.
• Social system: the various parts of communities’ social
• system that interact and include the heath system, family
• system, economic system and educational system.
6

Characteristics of Community
1.commninity is contiguous geographical area.
2.it is compose of people living together.
3.there are common organizations, eg., markets,
schools, banks, hospitals.
4.A community associated with specific name.
5. A community is created spontaneously over a
long period of time.
6. A community is a net work of human
relationships. It is place where our home is located,
children are educated, sick people are treated.
7

Three types of Communities
There are special characteristics for each type
Urban Suburban Rural
8

Urban Community ( Cities)
Tall Buildings
Skyscrapers
• many people living close
together
• small amount of space
• not very much open space or
natural areas
Walk
taxi
Train
Bus
9

Urban Community
•One kind of community is an urban area. An
urban area is a city and the places around it.
•Examples:
–New York City
–Chicago
–Jedda
10

Suburban Community
• Close to, but not in, cities
• Fewer People Live in Houses or small
apartment buildings
not skyscraper
• many people have yards
• many natural areas.
Usually drive
Sometime walk or take the bus
Use the train
to get to the
city
11

Suburban Community
•A suburb is a community that is near a city.
The word part "sub" means near. The word
part "urb" means city. Most suburbs are not as
busy as cities. They have many parks and
fields.
12

Rural Community
“the country” or farmland
•Fewer people
•A few buildings spread out over large
distances
•Lots of open space and natural areas
- Must drive
because it is
too far to walk
- Roads are not
paved, so people
need special
vehicles,
- Farms have
special types
of vehicles
(tractors)
13

Rural Community
• A rural area is mostly farmland. You can see
more land than houses. It resembles the
characteristics of the country or country life.
• Examples:
14

Lecture two
• Concepts of health
• Objectives
• The students should be able to
• Define health and understand the concepts
and determinants of health
15

Concept of Health
• Health is derived from the old Anglo-Saxon word
health, meaning safe, sound, or whole. Over the
years health has variety of meanings including
freedom from disease and quality of life.
• In the Oxford English Dictionary health is defined
as: ‘the state of being free from sickness, injury,
disease, bodily conditions; something indicating
good bodily condition’.
16

Continuous -Concept Of Health
• An understanding of health is the basis of all
the health care.
• Health is not perceived the same way by all
the members of a community including
various professional groups (like biomedical
scientists, social scientists, health
administrators, ecologists) giving rise to
confusion about the concept of health.
17

Continuous –Concepts of health
• Health has evolved over the centuries from the
concept of individual concern to a worldwide social
goal.
• The various changing concepts of health as follows:
1. Biomedical concept
2. Ecological concept
3. Psychosocial concept
4. Holistic concept
5. Physical concepts of health
6. Cognitive concept of health
7.Emotional concepts of health
18

1. Biomedical concept
• Traditionally health has been considered as an
absence of the diseases and if someone was
free from disease, then that person was
considered healthy.
• This concept is known as biomedical concept,
and it is based on the “germ theory of the
disease.”
19

• Health means “absence of disease.”
• The medical profession viewed the human body
as a machine and disease is an outcome of the
breakdown of the machine, and one of the
doctor’s tasks was to repair the machine.
• This concept has minimized the role of the
environment, social and cultural determinants of
the health.
Continuous -Biomedical concept
20

• Developments in medical and social sciences
led to the conclusion that the biomedical
concept of health was inadequate
Continuous -Biomedical concept
21

2. Ecological Concept
• Deficiencies in the biomedical concept gave rise
to other concepts.
• The ecologists put forward the concept of
ecological concept.
• Ecologists viewed health as a dynamic equilibrium
between man and his environment, and the
disease as a maladjustment of the human
organism to environment.
22

3. Psychosocial Concept
•Advances in social sciences showed that health is
not only a biomedical phenomenon, but one which
is influenced by social, psychological, cultural,
economic and political factors of the people
concerned.
•These factors must be taken into consideration in
defining and measuring health.
•Thus health is both a biological and social
phenomenon
23

4. Holistic Concept
• The holistic model is a synthesis of all the above
concepts.
•Holistic concept recognizes the strength of
social, economic, political and environmental
influences on health.
•It has been variously described as
multidimensional process involving the wellbeing
of the person as a whole.
•The emphasis is on the promotion and
protection of health.
24

• The holistic approach implies that all sectors of
the society have an effect on health, in particular,
agriculture, animal husbandry, food, industry,
education, housing, public works and other
sectors.
25

5. Physical concepts of health
• To understand physical health (Figure 1.2) you
need to know what is
• Considered to be physically unhealthy so that
you can contrast the two. Even though this
young person has a physical problem he may
still is healthy according to a wider definition
of health.
26

27

Defining physical health
• Physical health could be defined as the ability to
perform routine tasks without any physical
restriction.
• The following examples can help you to
understand someone who is physically unhealthy:
• A person who has been harmed due to a car
accident.
• A farmer infected by malaria and unable to do
their farming duties.
• A person infected by tuberculosis and unable to
perform his or her tasks.
28

6. Cognitive concepts of health
The cognitive component of mental health is
really to do with thinking and being able to
work things out. It includes the ability of an
individual to learn, to have awareness
(consciousness) and to perceive reality. At a
higher level it also involves having a memory
and being able to reason rationally and solve
problems, as well as being able to work
creativity and have a sense of imagination.
29

7. Emotional component
• When you are implementing a health
extension program you may encounter various
feelings or emotions in households in your
community such as happiness, anger or
sadness. People might cry or laugh. The
emotional component of health is the ability
and skill of expressing emotions in an
‘appropriate’ way. Appropriate means that the
type of response should be able to match the
problem.
30

Definition of health
• The World Health Organization (WHO) defines
health as a “state of complete physical, mental,
and social well-being, not merely the absence of
disease or infirmity” (WHO, 1947).
31

Limitation of the world health organizations
definition of health
1. Health is dynamic not state
2. The dimensions are in adequate
3. The definitions is subjective
4. Measurement is difficult
5. The definition is idealistic rather than realistic
6. Health is not an end but a means
7. The definition lack community orientation
32

What is the definition of community health?
• Community health, a field of public health,
is a discipline which concerns itself with the
study and improvement of the health
characteristics of biological communities.
While the term community can be broadly
defined, community health tends to focus on
geographical areas rather than people with
shared characteristics.
33

Concept of Community Health
• Community Health concerned with the health status of
individuals affected and the extent of the health
problems and the quality of health services for the
community.
• To assess the state of health of this community has to
be knowledge and full understanding of the nature of
that society and its components, which include :.
1-study population: census of population distribution
by age and sex - immigration - births and infant
mortality rates.
2-study environmental characteristics: housing-work
environment-education-drinking water-economic and
social situation. Dr.Abdalla Hasballa Elmanna Albaha
34

35

Foundations of Community Health
• The foundations of community health include the
history of community health practice, factors that
affect community and population health, and the tools
of community health practice. These tools include
epidemiology, community organizing, and health
promotion and disease prevention planning,
management, and evaluation.
36

What is the purpose of a Community
Health Assessment?
• Community health assessment is a systematic
examination of the health status indicators for a
given population that is used to identify key problems
and assets in a community. The ultimate goal of a
community health assessment is to develop
strategies to address the community's health needs
and identified issues
37

• Community organizing is a process by which the
problem-solving capacity of communities is enhanced
• Community organizing is another term for
"community development," which involves a high
level of community involvement in all aspects of
intervention activities.
• Community action entails a lower level of
community involvement than does community
organizing, but includes some measure of community
control over the implementation of interventions.
38

Lecture three
Determinants of Health
The range of personal, social, economic, and
environmental factors that influence health
status.
39

40

ADD Picture of Tree
41

Determinants of health
Individuals determinants of
health
• Biological status (age,
gender, ethnicity, genetics)
Socio-economic status
(education, employment,
income) Cognitive factors
(knowledge, attitudes,
values and beliefs)
Behaviors – (physical,
mental, social, spiritual
Environmental determinants of
health
• Social environment
• Cultural environment
• Economic environment
• Political environements
• Built environment
• Natural environment
42

Determinants of health fall under
several broad categories
1. Policymaking
2. Social factors
3. Health services
4. Individual behavior
5. Biology and genetics
43

1. Policymaking
• Policies at the local, province, and national level
affect individual and population health.
Increasing taxes on tobacco sales, for example,
can improve population health by reducing the
number of people using tobacco products.
• Some policies affect entire populations over
extended periods of time while simultaneously
helping to change individual behavior.
44

2. Social Factors
• Social determinants of health reflect the social
factors and physical conditions of the
environment in which people are born, live,
learn, play, work, and age. Also known as
social and physical determinants of health,
they impact a wide range of health,
functioning, and quality-of-life outcomes.
45

Social Determinants of Health
Life-enhancing resources, such as food supply,
housing, economic and social relationships,
transportation, education and health care,
whose distribution across populations
effectively determines length and quality of
life.
Reference: James S. (2002)
46

Why Are Social Determinants of Health
Important?
Addressing the social determinants of health is important because:
• These factors underlie preventable disparities in health status
and disease outcomes.
• Poor health outcomes are often the result of the interaction
between individuals and their social and physical environment.
• Policies that result in changes to the social and physical
environment can affect entire populations over extended periods
of time, while simultaneously helping people to change
individual-level behavior.
• Improving the conditions in which people are born, live, work,
and age will ensure a healthier population, thereby improving
national productivity, security, and prosperity through a healthier
workforce. Dr.Abdalla Hasballa Elmanna Albaha
47

Examples of social determinants include:
1. Availability of resources to meet daily needs (e.g., safe housing and local food markets)
2. Access to educational, economic, and job opportunities
3. Access to health care services
4. Quality of education and job training
5. Availability of community-based resources in support of community living and
opportunities for recreational and leisure-time activities
6. Transportation options
7. Public safety
8. Social support
9. Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
10. Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of
cooperation in a community)
11. Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that
accompany it)
12. Residential segregation
13. Language/Literacy
14. Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social
media)
15. Culture
48

Examples of physical determinants include:
1. Natural environment, such as plants, weather, or
climate change
2. Built environment, such as buildings or transportation
3. Worksites, schools, and recreational settings
4. Housing, homes, and neighborhoods
5. Exposure to toxic substances and other physical
hazards
6. Physical barriers, especially for people with disabilities
7. Aesthetic elements, such as good lighting, trees, or
benches
49

Each of these five determinant areas reflects a
number of critical components/key issues that
make up the underlying factors in the arena of
SDOH.
1. Economic Stability
• Poverty
• Employment
• Food Insecurity
• Housing Instability
50

Continuous
2. Education
• High School Graduation
• Enrollment in Higher Education
• Language and Literacy
• Early Childhood Education and Development
3. Social and Community Context
• Social Cohesion
• Civic Participation
• Discrimination
• Incarceration
51

Cont…
4. Health and Health Care
• Access to Health Care
• Access to Primary Care
• Health Literacy
5. Neighborhood and Built Environment
• Access to Foods that Support Healthy Eating
Patterns
• Quality of Housing
• Crime and Violence
• Environmental Conditions
52

3. Health Services
• Both access to health services and the quality of
health services can impact health. Healthy People
2020 directly addresses access to health services
as a topic area and incorporates quality of health
services throughout a number of topic areas.
• Lack of access, or limited access, to health
services greatly impacts an individual’s health
status. For example, when individuals do not have
health insurance, they are less likely to
participate in preventive care and are more likely
to delay medical treatment.
53

Barriers to accessing
• health services
include:
• Lack of availability
• High cost
• Lack of insurance
coverage
• Limited language
access
• Unmet health needs
• Delays in receiving
appropriate care
• Inability to get
preventive services
• Hospitalizations that
could have been
prevented
Lead
to
54

4. Individual Behavior
• Individual behavior also plays a role in health
outcomes. For example, if an individual quits
smoking, his or her risk of developing heart
disease is greatly reduced.
• Many public health and health care interventions
focus on changing individual behaviors such as
substance abuse, diet, and physical activity.
Positive changes in individual behavior can
reduce the rates of chronic disease in this
country.
55

Examples of individual behavior
determinants
• Diet
• Physical activity
• Alcohol, cigarette, and other drug use
• Hand washing
56

5. Biology and Genetics
Some biological and genetic factors affect specific populations more than
others. For example, older adults are biologically prone to being in
poorer health than adolescents due to the physical and cognitive effects
of aging
Examples of biological and genetic social determinants of health
include:
• Age
• Sex
• HIV status
• Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic
fibrosis
• Carrying the BRCA1 or BRCA2 gene, which increases risk for breast
and ovarian cancer
• Family history of heart disease
57

Lecture four
• History of public Health
58

Objectives
• At the end of this lecture, the students are expected to:
• Discuss the history of public health
• Define public health and list its core activities.
• Be aware of the definition of key terms in public
• health
• Recognize the principal disciplines of public
• health
• Describe the difference and similarities between
• clinical medicine and community health.
• Discuss the ethical issues and challenges in
• public health.
59

History of public Health
Thehistoryofpublichealthgoesbacktoalmostaslongashistoryofcivilization.
IntheAncientSocieties(before500BC)thehistoryisthatofarcheologicalfindings
fromtheIndusvalley (NorthIndia)around2000BCwiththeevidenceof
bathroomsanddrainsinhomesandsewerbelowstreetlevel.Therewasevidenceof
drainagesystemsinthemiddlekingdomofancientEgyptinthetime2700-2000
BC.Therewerewrittenrecordsconcerningpublichealth,codesofHamurabiof
Babylon,3900yearsago.TheBookOfLeviticus(1500BC)hadguidelinesfor
personalcleanliness,sanitationofcampsites,disinfectionofwells,isolationof
lepers,disposalofrefusesandhygieneofmaternity.
60

Continuous
• In The Classical Cultures (500 BC - 500 AD)
public health was practiced as Olympics for
physical fitness, community sanitation and
water wells in the era golden age of ancient
Greek; and aqueducts to transport water,
sewer system, regulation on street cleaning
and infirmaries for slaves by Romans.
61

Continuous
• In the middle ages (500 - 1500 AD), health
problems were considered as having spiritual
cause and solutions. They were supernatural
powers for pagans and punishments for sins
for Christians. Leprosy, plague (Black Death)
during the 14th century and syphilis were
some of the deadliest epidemics resulted from
failure to consider physical and biological
cause.
62

continuous
• The era of renaissance and exploration (1500
– 1700 AD) was the rebirth of thinking of
about nature of the world and humankind.
There was a growing belief that diseases were
caused by environment, not by spirits and
critical thinking about disease causation
e.g."malaria" - bad air.
63

Continuous
• In the eighteen century, there were problems
of industrialization, urban slums leading to
unsanitary conditions and unsafe work places.
Edward Jenner (1796) demonstrated
vaccination against smallpox.
64

continuous
• In the nineteenth century there were still
problems of industrialization but agricultural
development led to improvements in nutrition
and there was real progress towards
understanding the causes of communicable
diseases towards the last quarter of the
century. The Luis Pasture's germ theory (1862)
and Koch's Postulate (1876) were remarkable
progresses.
65

Continuous
• Twentieth century has been the period of
health resources development (1900-1960),
social engineering (1960 - 1973), health
promotion (Primary Health Care), and market
period (1985 and beyond)
66

HISTORICAL MARKERS in the development
of Public Health (selected)
1700 BC :
The Code of Hammurabi – Rules governing medical
practice
1500 BC :
Mosaic Law – Personal, food and camp hygiene,
segregating lepers, overriding duty of saving of life
(Pikuah Nefesh) as religious imperatives.
67

400 BC Greece –
Personal hygiene, fitness, nutrition, sanitation,
municipal doctors, occupational health; Hippocrates
clinical and epidemic observation and environmental
health.
500 BC to AD 500 :
Rome – aqueducts, baths, sanitation, municipal
planning, and sanitation services, public baths,
municipal doctors, military and occupational health.
68

500 – 1000
Europe – destruction of Roman society and the rise
of Christianity; sickness as punishment for sin,
mortification of the flesh, prayer, fasting and faith as
therapy; poor nutrition and hygiene pandemics;
antiscience; care of the sick as religious duty.
1348 – 1350
Black Death – origins in Asia, spread by armies of
Genghis Khan, world pandemic kills 60 million in
fourteenth century, 1/3 to 1/2 of the population of
Europe.
69

1300 :
Pandemics – bubonic plague, smallpox, leprosy,
diphtheria, typhoid, measles, influenza,
tuberculosis, anthrax, trachoma, scabies and
others until eighteenth century.
1673 :
Antony van Leeuwenhoek – microscope,
observes sperm and bacteria.
1796 :
Edward Jenner – first vaccination against smallpox.
1830 : Sanitary and social reform, growth of science.
70

1830
Sanitary and social reform, growth of science.
1854
John Snow – waterborne cholera in London: the
Broad Street Pump.
1854
Florence Nightingale, modern nursing and hospital reform –
Crimean War
1858
Louis Pasteur proves no spontaneous generation of life.
1859
Charles Darwin publishes On the Origin of Species.
1862
Louis Pasteur publishes findings on microbial causes of
disease.
71

1876
Robert Koch discovers anthrax bacillus.
1879
Neisser discovers gonococcus organism.
1882
Robert Koch discovers the tuberculosis
organism, tubercle bacillus.
1880
Typhoid bacillus discovered (Laveran);leprosy
organism (Hansen); malaria organism (Laveran).
72

1883
Robert Koch discovers bacillus of cholera.
1883
Louis Pasteur vaccinates against anthrax.
1884
Diphtheria, staphylococcus, streptococcus, tetanus organisms
identified
1890
Anti-tetanus serum (ATS)
1892
Gas gangrene organism discovered by Welch and Nuttal
1894
Plague organism discovered (Yersin, Kitasato); botulism
organism (Van Ermengem).
73

1923
Health Organization of League of Nations
1926
Pertussis vaccine developed
1928
Alexander Fleming discovers penicillin
1929 – 1936
The Great Depression – wide spread economic collapse,
unemployment, poverty, and social distress in industrialized
countries.
1946
World Health Organization founded.
1977
WHO adopts Health for all by the year 2000
1978
Alma-Ata Conference on Primary Health Crae
74

1979 WHO
declares eradication of smallpox achieved
1981
First recognition of cases of acquired immune deficiency syndrome (AIDS).
1989
International Convention on the Rights of the Child.
1990
W.F. Anderson performs first successful gene therapy.
1992
United Nations Conference on Environmental and Development,
Rio de Janiero
1992
International Conference on Nutrition.
1993
World Conference on Human Rights, Vienna.
75

1994
International Conference on Population
and Development, Cairo.
1998
WHO Health for All in the Twenty-first Century
adopted.
76

Lecture No 5
continuous in -Public Health
77
77

Learner Objectives
• By the end of this lecture,
students will be able to…
1. Define public health
2. List the determinants of health
3. Identify one example of local or
province public health practice
78

What is Public Health?
• Definitions vary
79

What is Public health?
Charles-Edward Amory Winslow (1877 – 1957)
defined Public Health as : the science and art of
preventing disease, prolonging life, and promoting
physical health and efficiency through organized
community efforts for the sanitation of the
environment, the control of community infections,
the education of the individual in principles of
personal hygiene, the organization of medical and
nursing services for the early diagnosis and
preventive treatment disease, and the development
of the social machinery which will ensure to every
individual in the community a standard of living
adequate for the maintenance of health.Dr.Abdalla Hasballa Elmanna Albaha
80

• John M. Last’s Dictionary of Public
Health (2001) gives the following:
• Public Health is one of the efforts
organized by society to protect,
promote, and restore the peoples’
health.
81

• Public health is the combination of
sciences, skills, and beliefs that is
directed to the maintenance and
improvement of the health of all the
people through collective or social
actions.
82

• The programs, services, and institutions
involved emphasize the prevention of
disease and the health needs of the
population as a whole.
83

• Public health activities change with
changing technology and social values,
but the goals remain the same: to
reduce the amount of disease,
premature death, and disease-produced
discomfort and disability in the
population.
84

• Donald Acheson Report, 1988, UK
• The Acheson Report (1988) defines
Public health more succinctly as:
• The science and art of preventing
disease, prolonging life, and promoting
health through organized efforts of
society.
85

Public Health vs. Medicine
86
• Public Health
– Population
– Disease Prevention
– Health Promotion
– Interventions
• Environment
• Human behavior
– Government (Some private)
• Medicine
– Individual
– Diagnosis
– Treatment
– Intervention
• Medical care
– Private (Some public)
Source: Brandt, AM and Gardner, M. 2000. American Journal Public Health. 90:707-715 .

Characteristics of Public Health
87
1. A broad social initiative or system.”
2. A body of knowledge and techniques
that can be applied to health-related
problems.”
3. Public health is literally (actually) the
health of the public as measured in
terms of health and illness.”
4. Social justice is said to be the
cornerstone of public health.”Dr.Abdalla Hasballa Elmanna Albaha

Why public health is Important
1. Public Health Saves Money and Improves Quality of Life.
A healthy public gets sick less frequently and spends less money on health
care; this means better economic productivity and an
improved quality of life for everyone.
2. Improving Public Health Helps Children Thrive.
Healthy children become healthy adults. Healthy kids attend school more
often and perform better overall.1 Public health professionals
strive to ensure that all kids grow up in a healthy environment with
adequate resources, including health care.
3. Public Health Prevention Reduces Human Suffering.
Public health prevention not only educates people about the effects of
lifestyle choices on their health, it also reduces the impact
of disasters by preparing people for the effects of catastrophes such as
hurricanes, tornadoes and terrorist attacks.
88

Public Health Aims:
1. Prevents epidemics and the
spread of disease
2. Protects against environmental
hazards
3. Responds to disasters and assists
communities in recovery
89

Public Health aims:
1. Prevents injuries
2. Promotes healthy behaviors
3. Assures the quality and
accessibility of health services
90

A Public Health System
• Who?
– Public entities
– Private entities
– Voluntary entities
• What?
– A network
91

92

Public health workforce:
• Diverse and Multidisciplinary
• Examples…
 Biostatisticians
 Dieticians
 Environmental Health Specialists
 Behavioral Health Specialists
93

A Public Health Approach
Surveillance
Risk Factor
Identification
Intervention
Evaluation
Implementation
94
94

Public health Core Components:
ASSESSMENT
of the health of the
community
ASSURANCE
of the public’s health
POLICY
DEVELOPMENT
in the public’s
interest
95

The 10 Essential Public Health Services
1. Preventing epidemics
2. Protecting the environment, workplaces, food and water.
3. Promoting healthy behavior
4. Monitoring the health status of the population
5. Mobilizing community action
6. Responding to disasters
7. Assuring the quality, accessibility, and accountability of medical
care
8. Reaching out to link high risk and hard to reach people to needed
services
9. Researching to develop new insights and innovative solutions
10. Leading the development of sound health policy and planning.Dr.Abdalla Hasballa Elmanna Albaha
96

Public Health Approach
Public Health
Model
Medical
ModelVersus
97

Achievements in public health
1. Vaccination
2. Safer Workplaces
3. Safer & Healthier Food
4. Motor Vehicle Safety
98

Achievements
5. Control of Infectious
Diseases
6. Family Planning
7. Decline in Deaths from
Heart Disease & Stroke
99

Achievements
8. Recognition of Tobacco
Use as a Health Hazard
9. Healthier Mothers
and Babies
10.Fluoridation of Drinking
Water Dr.Abdalla Hasballa Elmanna Albaha
100

Public Health Functions:
1. Prevents epidemics and the spread of disease
2. Protects against environmental hazards
3. Prevents injuries
4. Promotes and encourages healthy behaviors
5. Responds to disasters and assists
communities in recoveries
6. Assures the quality and accessibility of health
services
101

Public Health Fundamentals
1. Prevention (individual and community-
focused)
2. Promotion (voluntary, education, advocacy)
3. Protection (policies/regulations; enforcement)
4. Population-based (communities, groups)
5. Preparedness (e.g., bioterrorism, natural
disasters, pandemics)
• Closely linked to Environmental Health
102

Lecture 6
• Indictors of health
• Objective's
• Understand the variety of health indicators
and its measurements
103

What are Health Indicators? (1)
With the goal of good health in mind, think of
an indicator as
“…a measure that helps quantify the
achievement of a goal.”
-Mark Friedman
Health Indicators, Part I
104

What are Health Indicators? (2)
Power of indicators is comparisons
- over time (trends)
- geographic areas
- groups of people
and the focus on the most essential domains of
health.
105

What are the bases for health
indicators?
Health indicators are based upon conceptual models for what
influences health status, based upon scientific research.
Models have evolved over time, as have definitions of health,
but trace historical improvements in health, e.g., increases in life
expectancy, declines in mortality due to infectious diseases.
106

How are health indicators used?
Indicators are powerful tools for monitoring and communicating
critical information about population health.
Indicators are used to support planning (identify priorities, develop
and target resources, identify benchmarks) and track progress toward
broad community objectives.
Engagement of partners into civic and collaborative action (build
awareness of problems and trends, generate interventions).
Inform policy and policy makers, and can be used to promote
accountability among governmental and non-governmental agencies.
107

INDICATORS OF HEALTH
• A variable which helps to measure changes ,
directly or indirectly (WHO,1981).
• A statistic of direct normative interest which
facilitates concise , comprehensive, and balanced
judgments about conditions of major aspects of
the society (H.E.W./USA,1969).
• The health indicators are defined as those
variables which measures the health status of an
individual and community.
108

Classification of Indicators of
Health
• Mortality Indicators
• Morbidity Indicators
• Disability Rates
• Nutritional Indicators
• Health Care Delivery
Indicators
• Utilization Rates
• Indicators of Social And
Mental Health
• Environmental
Indicators
• Socio-economic
Indicators
• Health Policy Indicators
• Indicators of Quality of
Life
• Other Indicators
109

Mortality Indicators
• Crude Death Rate
• Age Specific Death Rates
• Expectation of life
• Infant mortality rate
• Under-5 Proportionate Mortality rate
• Child Mortality Rate
• Maternal Mortality Rate
• Disease Specific Death Rate
• Proportional Mortality Rate
• Case fatality rate
• Year of potential life lost
110

• Mortality Indicators: Crude Death rate, Life
Expectancy, Infant mortality rate, Child
mortality rate, Under five mortality rate,
Maternal mortality ratio, Disease specific
mortality, proportional mortality rate etc.
• Morbidity Indicators: Incidence and prevalence
rate, disease notification rate, OPD attendance
rate, Admission, readmission and discharge
rate, duration of stay in hospital and spells of
sickness or absence from work or school.
111

Prevalence
• The total number of all individuals who have
an attribute or disease at a particular time
divided by population at risk of having
attribute or disease at this point of time or
midway through the period.
• Ex: Prevalence of TB (sputum+ve in
population) is 249 per 100000 population
112

• Disability Indicators: Sullivan's index, HALE (Health
Adjusted Life Expectancy), DALY (Disability Adjusted
Life Year).
• life expectancy at birth but includes an adjustment
for time spent in poor health.
• •Number of years in full health that a newborn can
expect to live based on current rates of ill-health
and mortality.
113

Disability Indicators
• Sullivan's index is a expectation of life free from
disability.
• HALE (Health Adjusted Life Expectancy)is the
equivalent number of years in full health that a
newborn can expected to live based on the
current rates of ill health and mortality.
• DALY ((Disability Adjusted Life Years))
expresses the years of life lost to premature
death and years lived with disability adjusted
for the severity of disability.
114

MAJOR MEASURES USED ARE
• ( DALY = YLL+ YLD)
• 1. YEAR OF LIFE LOST: no of death at each age
multiplied by the expected remaining years of
life a/c to a global standard life expectancy.
• 2. Years lost to disability: no of incident cases
due to injury and illness is multiplied by the
average duration of disease and a weighing
factor reflecting the severity of disease on a
scale from 0 (perfect health) and 1(dead).
115

• Disability Indicators: Disability Rates are of two
categories
• Event type Indicators
• - number of days of restricted activity - bed
disability days - work-loss days within a specified
period
• Person type Indicators
• - limitation of mobility
• - limitation of activity: basic activity of daily living
116

• Nutritional Status Indicators:
• Positive health indicator
Anthropometric measurement of preschool
children, Prevalence.
i. Weight
ii. Height
iii. Mid-arm circumference
• Growth Monitoring of children
• Prevalence of low birth weight
117

• Health Care Delivery Indicators: Doctor-
population ratio, Bed-nurse ratio, Population-bed
ration, Population per health facility etc.
• Doctor-population Ratio – 1/1700 (Norm 1/1000)
• Nurse-population ratio – 0.8/1000 (Norm 1/500)
• Doctor- nurse ratio
• Population-bed Ratio – 8.9/10000
• Population per PHC/sub center
118

Health System Performance Indicators
• Access (additional)
– Trends in health insurance enrollment, range of benefits, exclusions,
premiums
– Rural health provider supply, linguistic or cultural barriers to getting care
• Cost
– Total health expenditures
– Health as share of Gross Domestic Product (GDP)
– Prescription drug costs
– Payments to hospitals, facilities
– Comparisons of resources used per patient between hospitals/areas
• Quality of care
– Effective care – receipt of recommended screenings, treatment, readmission
rates.
– Patient Safety – medical error
119

• Utilization Rates:
o Actual coverage is expressed as the proportion of people in
need of a service who actually receive it in a given period,
usually a year.
• Depends on availability & accessibility of health services
and the attitude of an individual towards health care
system
• Direct attention towards discharge of social responsibility for
the organization in delivery of services
• immunization coverage, ANC coverage, % of Hospital
Delivery, Contraceptives prevalence rate, Bed occupancy
rate, average length of stay in hospital and bed turnover
rate etc.
120

• Indicators of social and mental health: Rates of
suicides, homicides, violence, crimes, RTAs, drug
abuse, smoking and alcohol consumption etc.
• Environmental indicators: proportion of population
having access to safe drinking water and improved
sanitation facility, level of air pollution, water
pollution, noise pollution etc.
• Socio Economic Indicators: rate of population
increase, Per capita GNP, Dependency ratio, Level of
unemployment, literacy rate, family size etc.
121

Social Indicators (1)
Physical environment:
• Area-based measures, e.g., income/poverty, population density
• Access to public transportation, housing
• Environmental pollution, e.g., air and water quality.
Social environment:
• Income (individual/family)
• Education (e.g., high-school graduation rates, students
reading/doing math at grade level)
• Social support and connectedness.
122

Social Indicators (2)
Child and family focused:
• Parental educational attainment
• Parent practices (e.g., breastfeeding, reading to child, regular
meal/bedtimes)
• Access to services such as early developmental screening
• Family social environment (e.g. parent stress, depression)
123

• Health policy Indicators: proportion of GNP
spent on health services, proportion of GNP
spent on health related activities including
safe water supply, sanitation, housing,
nutrition etc. and proportion of total health
resources devoted to primary health care.
124

Indicators of Quality of Life:
• PQLI, IMR, Literacy rate, Life Expectancy at age
one etc.
• Commonly used to measure the cost
effectiveness of health interventions .
• Number of years of life added by a successful
treatment or adjustment for quality of life.
• Each year in perfect health is assigned a value
of 1 down to a value of 0 for death.
125

Community participation
Objectives :
By the end of
this lecture the
students
should be able
to:
understand the concept of community participation
Be aware of the principles of community participation
Know the characteristics of community participation
Lecture 7
126

The modern affirmation that citizen and community participation is
pivotal to health and is critical in primary health services goes back to
the UN Declaration at Alma Ata, U.S.S.R. in 1978. World leaders there
agreed that
“The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care. PHC
(Primary Health Care) requires and promotes maximum community and
individual self-reliance and participation in the planning, organization,
operation, and control of primary health care…”. World Health
Organization, 1978, p. 6
The concepts of community participation
127

Community participation :
Defined as “an on-going relationship
between citizens, health care
providers and other community
members and organizations to
improve health through dialogue”
Community participation/community
engagement
128

It is a social entity made of people or families who have the following characteristics:
Live in the same geographical area
Share common goals or problems
Share similar development aspirations
Have similar interests or social network or relationship at local level
Have a common leadership and tradition
Have common system of communication
Share some resources-water, school, etc
Are sociologically and psychologically linked.
CHARACTERISTICS OF COMMUNITY
129

The ultimate goal of community participation is for the community
and the health system
“to work as partners to have an impact on conditions that influence
the health of that community and improve population health”.
AIMS :
• The community develops self-reliance
• The community develops critical awareness
• The community develops problem solving skills
Community participation/community engagement
GOALS
130

• Community participations has three
• dimensions;
1. Involvement of all those affected in decision
making about what should be done and how
2. Mass contribution to the development
efforts to the implementation of decision
3. Sharing in the benefits of the program
DMENSIONS OF COMMUNITY
PARTICIPATION
131

1. Relevance and accountability
2. Education status of the community
3. Community infrastructure (including
communication network)
4. Economic factors
5. Social and cultural factors
6. The level of inter-sectoral collaboration
FACTORS WHICH INFLUENCE THE DEGREE OF COMMUNITY
PARTICIPATION POSITIVELY
132

7. Suppression of involvement and initiative by
projects which create dependency
8. Political stability
9. Good leadership
10. Motivated community
11. A sense of ownership
12. Locally available resources
FACTORS WHICH INFLUENCE THE DEGREE OF
COMMUNITY PARTICIPATION POSITIVELY
133

Critical values for effective
engagement include honesty,
•Respect,
•Authenticity,
•Openness and transparency,
•And trustworthiness.
The essential elements of participating
community
134

which include
1. diversity,
2. accessibility,
3. inclusivity, and capacity-building for all
participants;
4. integrity and accountability in engagement
practices;
5. outcomes that demonstrate genuine influence
and the impacts of the process;
6. and collaboration and improved governance.
Principles for participation
135

participation is premised on the existence of
certain organizational and community
capacities.
Organizational and community
capacities in participation
Community capacities
include:
• Leadership
• Networks
• Skills
• Power
• Resources
Organizational capacities
• Legitimating
• Rhetoric and policies, s
• Killed and educated staff,
• Managers who understand and
support engagement,
• And sufficient resources.
136

Evaluation of the results of any engagement
process is critical for on-going improvements in
community health . Immediate results such as:
1. The level of participation
2. Quality of communication
3. The influence of the engagement in shaping
policy and practice
4. Cost-effectiveness
EVALUATION OF ENGAGEMENT
137

Enabling conversations
Facilitating discussions
Collaborating and building partnerships
Community health assessment activities
Developmental evaluation of engagement in action.
The skill set for community
participation
138

Some potential benefits of
community participation are:
Value to Communities:
Value for Primary Health Providers:• Increased access – to decision-makers, to information,
to others’ opinions, to new processes for making
decisions, to other parts of the community and the
organization.
• Better information and understanding – improved
understanding of the complexity of health care and
greater opportunities to make informed input into a
plan, a policy or a proposal.
• Sense of involvement – the mutual sense of ownership
for all parties is enhanced through shared
responsibility. Ideally, this should result in increased
capacity and sustainability of the efforts in
communities.
• Better outcomes – outcomes can be achieved that
utilize existing resources and more fully reflect the
aspirations of the client and the community.
• An increased range of ideas – community contributions
may surface ideas not apparent to service providers;
avenues are opened for the community to raise issues
incorporating local knowledge, resources, and expertise.
• Credibility and accountability is increased for primary
health with communities through dialogue and working
together. There are also increased opportunities for
explanation - a venue to give an account of the reasons
for the organization’s policies and actions.
• Networks, relationships and processes are established in
the local community that can benefit current and future
projects.
• A deeper understanding is developed around issues
through public information sharing, discussion and
deliberation.
• Improve democratic outcomes, including the equity or
fairness of a policy or project.
• Better decisions are achieved that incorporate the
communities’ aspirations, have less duplication, and are
sustainable.Dr.Abdalla Hasballa Elmanna Albaha
139

• Concern for the common good
• Resources - education, health, recreation, socialization
- available and easily accessible to all
• Sustainable resource use and a healthy environment
• Connections and linkages vertically and horizontally in
the community
• Adequate incomes; no big gaps between rich and poor
• Good housing and safe neighborhoods
• Robust political debates where everyone is involved;
responsive governance
• Intergenerational caring
A more participated community might
be characterized by:
140

• Loss of hope
• Lack of trust
• No sense of a future
• Unhealthy individual behaviors and poor self-care
• A blaming, punishment mentality
• Poverty
• High rates of preventable illness
• Physical and psychological barriers to services
Characteristics of Less participated communities
141

142

Lecture 8
• Objectives
• By the end of this lecture the students will be
able to
• Understand Community health needs
assessment
143

Community health needs assessment
• What is a community health needs
assessment?
Community health needs assessment is
“a process that describes the state of health of
local people; enables the identification of the
major risk factors and causes of ill health; and
enables the identification of the actions needed
to address these.
144

Profiling the population
Think about what you want to find out about your local
population. What information will help you define and
describe the community and its health needs? You may
find it helpful to ask yourself the following questions.
1. What are the key characteristics of the population?
2. What is the health status of the people?
3. What local factors are affecting their health and what
impact do they have (good and bad)?
4. What services are currently being provided?
5. What do local people see as their health needs
6. What are the national and local priorities for health?
145

1- Characteristics of the population
• A number of elements will enable you to describe
the community you work in:
1. Geography: which area/population does this
profile cover?
2. Numbers: how many people?
3. Age distribution: what age are they?
– pre-school children
– school-age children and young people
– adults
– elderly people
146

Characteristics of the population
• Gender distribution: how many males and
females?
• Ethnicity and religion
• Language and literacy
147

2-The health status of the population.
There are different ways of finding out about the
health status of the community:
1. people’s own views of their health
2. statistical information
3. qualitative surveys
4. the knowledge of local health care workers and
other agencies.
148

There are a number of measures commonly
used to identify the health of a population.
• Mortality data
• Morbidity data
• Behavior measures
• Quality of life” measures
• Use of service information
• Health inequalities
– Who is disadvantaged in this community?
– Why are they disadvantaged?
– What can I do about it?
– Who has unmet needs in this community?
– Who does not access care in this community?
149

3- Local factors affecting health
• Work and employment
• Poverty and income
• Environment
• Pollution.
• Sanitation
• Housing.
• Social cohesion
– Networks.
– Migration
– Marginal groups.
– Pleasure and leisure
• Destabilizing factors
• Resources, formal and informal
150

4-What services are currently being provided?
• What illnesses do I see most of?
• What problems occupy most of my time?
• Do people I meet see themselves as sick?
• What do people tell me about their worries and health?
• What is the interventions am I using and how well do they
work?
• How many people are using the public health services?
• Are they from across all sections of the community?
• Do I see those whose needs are greatest?
• What changes have I seen take place in the community and
in the services I
• provide?
151

5- What do local people see as their health needs
• Local people’s views of their health needs and resources.
• Involving local people will ensure that any service developed
will be based on need and be more likely to be acceptable to
the population.
• There will always be a great deal of expertise and knowledge
to draw on among the local population, in particular on what
assets exist, the factors that influence their health, what is
most important, local health beliefs and solutions to
problems.
• It is important that people are able to describe health
problems and solutions in their own terms.
• This may involve using less conventional methods such as
photographs, drawings or personal stories.
152

6- Local and national priorities
• National priorities are often set by governments and
influenced by the political and economic agenda.
• Local priorities will reflect national priorities as well as
issues identified by local groups, practitioners and
communities.
• When undertaking a needs assessment you will need to
discover what these priorities are in relation to health.
• Sometimes there can be
• a conflict between the national top-down agenda and
the needs identified locally.
153

Section Two: How do you find out?
• The previous slides described the type of health information
you may need in order to identify health needs; the next stage
is to collect this information.
1. Describing the community
• Local views
• These can be obtained using a variety of methods that allow
for different perspectives.
• Professional views
• Local surveys
• Newspaper reports
154

2. Measures of health and of health inequalities:
• To obtain a full picture of health, information about
health should come from a variety of sources.
– A public health department
– Local health and social care managers
– Government departments
– work information
– own knowledge
• What am I seeing?
• What can I hear and smell?
• What, if anything, is missing?
• What is this telling me?
155

• Record the observations made.
• Casework information.
• The family health assessment
– The information that families provide about their
community at micro level is of good quality and can build
into an overall picture of the community if a sufficient
number of assessments are completed.
156

Profile information
1. Characteristics of the population
• Geography
• Numbers
• Age distribution
• Gender distribution
• Ethnicity and religion
• Population trends
• Language and literacy
2. Health status of the population
• Measures of health
157

3. Local factors affecting health
(positive and negative)
• Work and employment
• Poverty and incomes
• Environment
• Social cohesion
• Destabilizing factors
• Resources, formal and informal
4. Current public health officer work
5. Local people’s views of their
health needs and health services
6. Local and national priorities
Profile information
158

Section Three: What to do with the
information
1. What is the information telling you?
o compare your population with a larger group to ascertain
whether a health issue or disease rate is higher or lower
than expected;
o compare current information with that collected in
previous years to identify trends over time;
o identify significant gaps in the information;
o compare and contrast different types of information e.g.
statistics, client and professional views, surveys and
questionnaires; and
o look for positive features as well as problems; even the
most disadvantaged communities have strengths that can
form the building blocks for change.
159

information
2.Deciding on priorities
– How many people are affected?
– What is this information telling you about
equity?
– What is the impact on people’s lives?
– Are there appropriate and effective
interventions?
– Are the services adequate?
– Is the expertise and training available?
160

information
• 3. Planning what to do:
• Being creative
• Involving the community
• Collaboration
• Health promotion
 creating healthy public policies
 building supportive environments
 strengthening community action
 developing personal skills
 reorganizing health services
 addressing inequalities.
161

information
• Prevention
– Primary prevention
– Secondary prevention
– Tertiary prevention
• Measuring success
– where you are now (baseline measures)
– where you are going (aim and objectives)
– how to get there (action plan)
– how you will know you have arrived
(evaluation/outcome measures).
162

information
4. Taking action
You should now put your plans into action
163

Record of action plans
Health problem to
be addressed
objectives Action to be
taken
Who will do
it
Time scale Evaluation
and
measurement
Health problem to
be addressed
objectives Action to be
taken
Who will do
it
Time scale Evaluation
and
measurement
164

Models and Approaches to
Health Promotion
Lecture No 9
165

Concepts of health promotion
• The Ottawa Charter of Health Promotion
As discussed, health promotion is part of what is referred
to as the ‘new public health’. One of the most significant
events in the emergence of the ‘new public health’ was the
Ottawa Charter for Health Promotion that was formulated
at the first international conference on health promotion
that was held in Ottawa, Canada in 1986. Many people
regard the Ottawa Charter as the formal beginning of the
“new public health” movement. The “new public health”
movement is based on a social model of health rather than
on a medical model, which promotes dealing with health
problems at the root of their cause rather than just dealing
with the disease when, it arises
166

Concepts of health promotion
• A social view of health:
“implies that we must intervene to change those
aspects of the environment which are promoting
ill health, rather than to continue to simply deal with
illness after it appears, or continue to extort
individuals to change their attitudes and lifestyles
when, in fact, the environment in which they
live and work gives them little choice or support for
making such changes”
167

According to the Ottawa Charter, the core
activities of health promotion are:
1. Advocating:
to make political, economic, social, cultural, environmental,
behavioral and biological conditions favorable for health
2.Enabling:
to make people achieve the fullest health potential,
addressing in particular, issues of equity – i.e. providing access
to information, life skills and a supportive environment.
4. Mediating:
with government and non-government agencies, industry and
media to achieve coordinated action.
168

The Five Principles of the Ottawa
Charter
The development and adoption of the Ottawa
Charter, saw a framework emerge that consisted
of five essential components;
1. Build Healthy Public Policy
2. Create Supportive environments
3. Strengthen Community Action
4. Develop Personal Skills
5. Reorient Health Services
169

1. Build Healthy Public Policy
This puts health on the agenda of policy makers in
all sectors and at all levels and it directs them to be
aware of the health consequences of their
decisions. It includes legislation, fiscal measures,
taxation and organizational change. The aim of
having policy in health promotion is to make the
healthier choice the easier choice not only for
individuals and the wider community but for policy
makers as well.
Examples: Smoke free policies, compulsory wearing
of helmets, seatbelt legislation
170

2. Create Supportive Environments
There are inextricable links between people and their
environment and this constitutes the basis for a socio-
ecological approach to health. Individuals, communities,
regions and nations need to recognize that living and
working conditions should promote health. These are
closely linked through the establishment of healthy public
policy.
Examples: Create user friendly, accessible breast feeding
areas in public areas, create user
friendly, accessible counseling services at schools and
places where young people gather. Shade
creation in schools.
171

3. Strengthen Community Action
Health promotion acts to empower communities to
recognize that they can and must take ownership and
control in order to determine their health. Communities
themselves should determine what their needs are and
how they can best be met. In order to strengthen public
participation in health matters there needs to be access
to education, information, learning opportunities and
funding. Community development is a process that by
which this can be achieved.
Examples: Create consumer organizations such as Nursing
Mothers Association of Australia, encourage the
development of support groups and community demands
for support services.
172

4. Develop Personal Skills To help
people
make effective decisions about their health they
need information, education and skills. This enables
people to use their knowledge and skills to take
control over their health and their environment.
This process needs to be facilitated in a range of
settings including school, home, work and the
community in order to be effective.
Examples: Education programs. Skill development.
173

5. Reorient Health Services
The health system must be beyond clinical and curative services and needs to
focus on promoting health and preventing disease. Health services need an
expanded mandate that opens links between the health sector and the broader
social, political, economic and physical environments. There needs to be a much
greater balance between health promotion and curative services and the health
care system needs to work more closely with other sectors whose work impacts
on .The whole area of health care provider education needs also to be
examined to ensure that there is a focus on promoting health and preventing
disease as well as on clinical and curative services.
• Examples: Train staff to prevent, and recognize and manage early warning
signs of disease.
• Implement the policies of a Breast Feeding Promoting Hospital so that staff
encourage new
• mothers to breast-feed
174

Settings Approaches to Health
Promotion
1. Places:
Cities, towns, villages, neighborhoods
1. Organizations:
Schools, worksites, hospitals, daycares,
universities (most relevant to you)
1. Sectors:
Health services and regions, transport,
environment
175

Ethical considerations in health
promotion
1. Address the social determinants of health as the underlying
processes that influence the health and wellbeing of individuals
and communities;
2. Achieve community health through respect of the rights of
individuals and groups within the community;
3. Develop and evaluate policies, programs and priorities through
processes that ensure an opportunity for input from community
members;
4. Advocate and work for the empowerment of disenfranchised
community members, aiming to ensure that the basic resources
and conditions necessary for health are accessible to all;
5. Seek the information and evidence needed to implement effective
policies and programs that protect and promote health;
176

Continuous -Ethical considerations in
health promotion
6.Provide communities with relevant
information that they need to make informed
decisions on policies and programs while
obtaining the community’s consent for their
implementation;
7. Act in a timely manner on the information
they have within the resources and the mandate
given to them by the public;
177

Continuous -Ethical considerations in
health promotion
8. Incorporate a variety of approaches that anticipate and
respect diverse values, beliefs and cultures in the
community;
9. Implement policies and programs in a manner that
most enhances the physical and social environment;
Protect the confidentiality of information that can bring
harm to an individual or community if made public;
11. Ensure the professional competence of their
employees; and
12. Engage in collaborations and affiliations in ways that
build the public’s trust
178

Main approaches to health promotion
• Medical or preventative
• Behavioral change
• Educational
• Empowerment
• Social change
179

These approaches have different
objectives
• To prevent disease
• To insure that people are well informed and
are able to make health choices
• To help people acquire the skills and
confidence to take greater control over their
health
• To change polices and environments in order
to facilitate healthy choices
180

TOP-DOWN VS. BOTTOM-UP
•Priorities set by health
promoters who have
the power and
resources to make
decisions and impose
ideas of what should be
done
•Priorities are set by
people themselves
identifying issues they
perceive as relevant
181

The medical or preventative approach
182

Aims
• Reduce morbidity and premature mortality
• Target: whole populations or high risk groups
• Promotion of medical intervention to prevent
ill-health
183

Levels of interventions
• Primary prevention – prevention of onset of
disease, e.g. immunization; encouraging non
smoking
• Secondary prevention – preventing
progression of disease, e.g. Screening
• Tertiary prevention – reducing further
disability and suffering in those already ill; e.g.
rehabilitation, patient éducation, palliative
care
184

Popularity of medical approach
• Uses scientific methods, e.g. epidemiology
• Prevention and early detection of disease is
cheaper than treatment
• Top-down approach, i.e. led by experts, this
kind of activity reinforces authority of health
professionals who are viewed as having
necessary knowledge to achieve results
• Highly successful examples in the past, e.g.
eradication of smallpox
185

Disadvantages
• Focuses on the absence of disease rather than
on promoting positive health
• Based on a medical definition of health
• Ignores the social and environmental
dimensions of health
• Encourages dependency on medical
knowledge and compliance with treatments
• Removes health decisions from
nonprofessional people
186

Methods
• Preventive procedures need to be based on a
sound rationale derived from epidemiological
evidence
• Having an infrastructure capable of delivering
screening or immunization programs, e.g.
Trained personnel, equipment and laboratory
facilities, record keeping facilities, effective
and safe vaccine
187

Evaluation of medical approach
• Short term evaluation
– Increasing in percentage of target population
being screened or immunized
• Long term evaluation
– Reduction in disease rates and associated
mortality
188

Behavior change approach
189

Aims
• Encourages individuals to adopt healthy
behaviors which improve health
• Views health as a property of individuals
• People can make real improvements to their
health by choosing to change lifestyle
• It is people’s responsibility to take action to look
after themselves
• Involves a change in attitude followed by a
change in behavior
190

Disadvantages
• Depends on person’s readiness to take action
• Complex relationship between individual
behavior and social and environmental factors
• Behavior may be a response to a persons’ living
conditions which may be beyond individual
control (e.g. Poverty, unemployment)
191

Methods
• Campaigns to persuade people e.g.
– Not to smoke
– To adopt a healthy diet
– To undertake regular exercise, etc.
• Targeted towards individuals
• May use mass-media to reach them
192

Evaluation
• Theoretically it would appear simple by asking:
“Has the health behavior changed after the
intervention?”
• However, there are two main problems
– Change may become apparent only after a long
period
– Difficult to determine whether behavior change
was due to health promotion intervention
193

The educational approach
194

Aims
• To enable people to make an informed choice
about their health behavior by
– providing knowledge and information
– developing the necessary skills
• Not similar the behavioral approach, it does NOT
try to persuade or motivate change in a particular
direction
• OUTCOME is client’s voluntary choice which may
be different from the one preferred by health
promoter
195

Disadvantages
• ASSUMES THAT:
Increase in knowledge change in attitudes
behavior change
BUT:
• Voluntary behavior change may be restricted
by social and economic factors
• Health related decisions are very complex
196

Methods
• Aspects of learning:
–Cognitive Aspect (information and
understanding)
–Affective Aspect (attitudes and feelings)
–Behavioral Aspect (skills)
197

Aspects of learning
• Cognitive Aspect - Provision of information
about causes and effects of health-related
behaviors
– Provision of leaflets/booklets
– Visual displays
– One-to-one advice
198

Aspects of learning (Cont.)
• Affective Aspect - Provision of opportunities
for clients to share and explore their attitudes
and feelings
– One-to-one counseling
– Group discussions
199

Aspects of learning (Cont.)
• Behavioral Aspect - Helping clients develop
decision-making skills required for healthy
living
– Exploring Real life situations
– Role Play
– Examples: reaction when offered a drink /
cigarette / drugs; negotiating contraception use
200

Evaluation
• Increase in knowledge is easy to measure
(exam, pre-post questionnaire..)
• HOWEVER, Knowledge alone is insufficient to
change behavior
• Knowledge is rarely translated into behavior
201

Empowerment approach
202

• WHO defined health promotion as “enabling
people to gain control over their lives”
(empowerment)
203

Aims
• Helps people identify their own concerns and
gain the skills and confidence necessary to act
upon them
• This is the only approach to use a ‘bottom-up’
(rather than ‘top-down’) approach
204

Aims (Cont.)
• Clients have the right to set their own agenda
• Health promoter plays the role of a facilitator
rather than that of an expert, he/she Initiates
the process but then withdraws from the
situation
205

Aims (Cont.)
• Empowerment may involve both self-
empowerment and community empowerment
• Self-empowerment:
– Based on counseling
– Uses non-directive ways
– Increase person’s control over his/her own live
206

Aims (Cont.)
• For people to be empowered they need to:
1. Recognize and understand their
powerlessness
2. Feel strongly enough about their situation to
want to change it
3. Feel capable of changing the situation by
having information, support and life skills
207

Disadvantages
• Results are vague and hard to quantify
compared with those of other approaches
• Health promoter may feel uncomfortable in
handing over his expert role
208

Methods
• Examples of methods used in empowerment
approach:
– Nurses working with patients to develop a care
plan
– Teachers working with students to raise their self-
esteem
209

Evaluation
• Outcome evaluation: the extent to witch specific aims have
been met
• Process evaluation: The degree to which the group has
been empowered as a result of the intervention
• Evaluation includes qualitative methods that reveal
people's perceptions and beliefs ,
• Quantitative methods that demonstrate the outcome such
as behavioral change
• HOWEVER,
• Usually empowerment is a long term process
• Difficult to conclude that changes are due to the
intervention rather than some other factor
210

Social change approach
211

Aims
• Radical approach which aims to change
society not individual behavior
• Aims to bring changes in the physical,
economic and social environment
• Healthy choice to become the easier choice in
terms of cost, availability and accessibility
• Targeted towards groups and populations
212

Disadvantages
• It may require major structural changes
• Vulnerable to official disapprovals
• Requires political support from the highest
level, e.g. through legislation
• Needs support of the public
213

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