Concepts of community health nursing.pptx

Unit I in the subject of Community Health Nursing of Semester V as per the INC, MUHS syllabus

1. Unit 1: Concepts of Community Health and Community Health Nursing S emester 5 B.Sc. Nursing Mrs. Angela Braver, Professor Community Health Nursing

2. Learning objectives Define public health, community health and community health nursing Explain the evolution of public health in India and scope of community health nursing Explain various concepts of health and disease, dimensions and determinants of health Explain the natural history of disease and levels of prevention Discuss the health problems of I ndia.

3. CONTENT Definition of public health, community health and community health nursing Public health in India and its evolution and Scope of community health nursing Review : Concepts of Health & Illness/ disease: Definition, dimensions and determinants of health and disease Natural history of disease Levels of prevention: Primary, Secondary &tertiary prevention – Health problems (Profile) of India

4. Definitions : According to the  American Public Health Association , “Public Health is the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries.” According to the  World Health Organization   (WHO), “Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” The Public Health System  - According to the  Centers for Disease Control and Prevention  (CDC), “Public health systems are commonly defined as ‘all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction."

5. Public health in India and its evolution With the advent of the British in India, the system of medicine known as western medicine or modern medicine was introduced in this country . At first the aim was largely to train apprentices to help the army medical personnel, the qualification required of such trainees being elementary.  It was in the year 1835 that a more comprehensive system of training was instituted in India. The evolution of public health in colonial India has been chronicled earlier .  The Calcutta Medical College was established by an order in 1835 to fulfill the growing need for health professionals .

6.  In 1846, a two-year course, later extended to three years, was started for the training of Hospital Assistants. This enabled them to join the subordinate medical services in the Army and in the civil cadres in British India. After the establishment of the three Universities of Calcutta, Bombay, and Madras, in 1857, medical education was taken over by Universities, which granted the qualifications of a Licentiate in Medicines and Surgery (the L.M.S.) and the Bachelor of Medicine and Master of Surgery (M.B.C.M. degree).

7. The entrance qualification for the former course was a pass in the Matriculation examination and for the latter course, the Intermediates were eligible. Subsequently , the Licentiate qualification was abolished and the degree M.B.B.S. was awarded by the Universities .  The qualification of M.B.B.S. granted by the different Universities was recognized by the General Medical Council of Great Britain and the standards were in conformity with the requirements laid down by the General Medical Council for such recognition. The Indian Medical Services was formed in 1896 and the subsequent transfer of public health, sanitation, and vital statistics to the provinces took place in 1919. A new department to cater to education and health was constituted in 1912, with public health physicians in medical colleges entrusted with teaching hygiene .

8.  A School of Tropical Medicine was established in 1922 at Kolkata in eastern India. The establishment of this school marked a conscious shift from medical to a public health school. In 1933, the Medical Council of India was constituted, which took over the functions hitherto exercised by the General Medical Council of Great Britain for the maintenance of uniform standards for medical education in the country.

9. Formal public health activities in pre-independence India were backed by the introduction of physicians with both clinical and public health responsibilities. The public health workforce constituted personnel from a medical and nonmedical background that included ANMs, nurses, midwives, traditional birth attendants, sanitary inspectors, sanitary assistants, health officers, and physicians . The establishment of The All India Institute of Hygiene and Public Health (AIIH and PH), Kolkata, in December 1932, making it the oldest school of public health in southeast Asia  was a welcome development toward imparting public health education in India.

10. The institute was established with a generous donation from the Rockefeller Foundation with an objective to develop health manpower by providing postgraduate (training) facilities of the highest order and to conduct research directed toward the solution of various problems of health and diseases in the community, thus prompting an application of knowledge to a large community and training students in these methods.

11. Public health and medicine have been mutually dependent and interact with each other, in the past as well as in modern times .  Such an interaction can be seen in the history of development of the discipline in India as well where there was a healthy mix of clinical and public health responsibilities. The Health Survey and Development Committee ( Bhore committee) not only dealt with professional education in health under the following heads: Medical education, Dental education, Nursing education, The training of certain types of public health personnel, Pharmaceutical education, Training of technicians, and training of hospital social workers but also laid the foundation for community service by advocating for the institution a three-month training in preventive and social medicine for physicians as part of the medical education system.

12. The WHO Expert Committee on Professional and Technical Education of medical and ancillary personnel in its report in 1952 stressed the relationship between the basic and clinical sciences and the necessity for internship after completion of the formal course . The First World Medical Education Conference that met in London in August 1953 reviewed the requirements of entry into medical schools, the aim and content of the medical curriculum, the technique and method of education, and the importance of preventive and social medicine in the training of physicians. The southeast Asia Regional Office of the W.H.O., in their analytical study of Medical Education, recommended the reorientation of medical teaching from the predominantly individual and curative approach to a more community-minded and a preventive one .

13.  The Medical Education Conference organized by the Government of India in 1955 after the World Medical Education Conference recommended major reforms in medical education in India. This Conference made several suggestions in regard to selection of students, entrance qualifications, including premedical studies, curriculum of medical education, examinations, fulltime teaching units, and so on. The Medical Education Conference agreed that the present methods of examinations and assessment were unsatisfactory, that written examinations required considerable modification and that great importance should be given to the day-to-day assessment of the student during his medical course. It was recommended that each medical college should have a Preventive and Social Medicine Department with fulltime staff.

14. The teaching of Preventive and Social Medicine should start from the very beginning and continue throughout the period of training including the period of internship. The functions of the Preventive and Social Medicine Department should be integrated with the teaching of the other departments along with a co-ordinated outpatient service. This department should have rural and urban health centers which will give the necessary facilities for rural training. A separate examination in Preventive and Social Medicine should be made part of the final M.B.B.S. The Indian Public Health Association was formed in 1956 with the main objective of "promotion and advancement of public health and allied sciences in their different branches in India, protection and promotion of public and personal health of the people of the country and promotion of co-operation and fellowship among the members of the Association." This association solicited membership from different cadres of public health professionals across the country.

15. The Mudaliar Committee further sought to strengthen public health education in the country by recommending schools of public health in every state to train medical officers, public health nurses, maternity and child welfare workers, public health engineers and sanitarians, dieticians, epidemiologists, nutrition workers, malariologists , and field workers.

16. The Indian Association of Preventive and Social Medicine,  which was founded in 1974, is a "not for profit" professional organization dedicated to the promotion of public health by bringing its members′ expertise to the development of public health policies, an advocate for education, research, and programs of Community Medicine and providing a forum for the regular exchange of views and information. The Shrivastava committee report in 1975 went on to advocate for a change in the structure of medical education to meet the changing requirements of health care and plan adequately for the future.  The committee noted that the role of the general practitioner is far from the treatment of sickness and the prevention of disease, but extends to include the social and cultural problems that contribute to the fabric of health. It went on to recommend the content, structure, and process of change in order to orient the medical education across the country.

17. The ROME scheme was planned to impart community-oriented training to medical undergraduates in primary health care. The Government of India launched the Re-orientation of Medical Education (ROME) scheme in 1977 to involve medical colleges by encouraging the adoption of preventive, promotive , and curative health care in Community Development Blocks across the country. In the same year, the National Institute of Health and Family Welfare was set up for promotion of Health and Family Welfare programs in the country through education, training, research, evaluation, consultancy, and specialized services.

18. The Medical Education Review Committee of 1983 was set up for suggesting measures aimed at bringing about overall improvement in the undergraduate and postgraduate medical education, paying due attention to institutional goals; content, relevance, and quality of teaching and training and learning settings; and the evaluation systems and standards. The Bajaj committee was formulated in 1987 suggest remedial measures consequent to a dichotomous growth of health services and manpower, thereby affecting the planning, production, and management of allied health professionals. It provided an assessment of existing and projected national health manpower requirements primary and the intermediate level health care programs and also to recommend the essential educational institutions and facilities to facilitate the production of appropriate categories of health manpower.

19. The expert committee on public health systems of 1996 stated that there is a need to open new schools of public health where more public health professionals and paraprofessionals could be trained. The existing public health schools must also be appropriately strengthened. The committee recommended that at least four more regional schools of public health be set up in Central, Northern, Western, and Southern regions. The Calcutta Declaration of 1999 stressed upon the primacy of creating career structures at the national, state, provincial, and district levels and mandating competent background and relevant expertise for persons responsible for the health of populations. The resolution also stressed upon the need to strengthen and reform the public health education, training and research, as supported by the networking of institutions and the use of information technology for improving human resources development.

20. The Task Force on Medical Education was set up in 2005 with the context of an increased sense of urgency in contextualizing the medical education to the National Rural Health Mission (NRHM). The Task Force on Medical Education for the NRHM  has recommended reformative and remedial action in medical education and health manpower development. The Public Health Foundation of India was setup in 2006 with the mandate of establishing new institutes of public health, assist the growth of existing public health training institutions, establish a strong national research network, generate policy recommendations, and develop a vigorous advocacy platform. The Indian Institutes of Public Health established by the Foundation are not only engaged in the delivery of long-term academic programs in vital public health areas, but also in health system strengthening through short-term trainings and research. Recently , there have been networking of institutions with the initiation of collaborative academic programs (PGDPHM partnership), Indian Public Health Education Institution Network, and the Public Health Education and Research Consortium

21. Scope of community health nursing 1.Home care A large number of clients can be adequately cared for at home by extending certain hospital services . The hospital takes up the responsibility in coordinating these services by providing personnel or equipment. In order to carry out this responsibility, the nurse requires certain additional skills like history taking and recognition of physical signs for proper treatment.  2.Nursing homes The nursing homes are privately run. They have better medical care facilities than the government hospitals because they charge more fees. The nursing component in nursing homes is generally well catered for.  3.MCH and Family planning The public health nurse plays a major role in the MCH and family planning services. It comprises antenatal , postnatal and child care services. During pregnancy or illness, people listen to the suggestions and advices for their welfare. Since nurses are directly in touch with patients, they should be trained to give proper and correct advice.

22. 4.School Health Nursing  The School Health Nurse renders services to promote and protect the health of the school children. She provides her services in the areas like, health education, first-aid, early education of diseases ,immunization, dental health, school sanitation maintenance of health records, follow up and referral services . 5. Community health nursing Community health nursing includes nursing care of the family in sickness and health . The Community health nurses must be able to To provide primary health care in the community To conduct routine antenatal and postnatal visits and to conduct deliveries when required. To carry out immunization To promote the health of the children by conducting under five clinics and referring cases who requires medical care To assess the social, environmental and nutritional needs of the help of social workers to meet these needs

23. 6.Industrial Nursing Services  Nurses are employed in industries. There is provision for appointment of medical and  nursing staff in factories where 500 or more workers are employed. The broad areas of nursing in this are: pre-employment and periodic health check-up, care of sick, first aid, industrial sanitation  and safety , organizations of service o women and children, rehabilitation of the ill and disabled workers and administration. 7. Domiciliary Nursing Services The areas where domiciliary nursing is practiced in this country are maternity services, health supervision disease prevention services and services for illness and accidents. The scope is limitless for organizing domiciliary visits. 8. Mental health nursing services Many developing countries have mental health services today. These services include early diagnosis and treatment, rehabilitation, psychotherapy, use of modern psychotropic drugs and aftercare services .

24. 9. Rehabilitation centers Rehabilitation means restoration of all treated cases to the highest level of functional ability. Nursing is an important component in the rehabilitation of the disabled. 10 . Geriatric nursing services The number of old people is increasing in the world today. The need of the old is different and they need more care than the younger age groups. In many countries the old people are visited by the nurses and other health workers.

25. 12 Principles of Community Health Nursing 1. The recognized need of individuals, families and communities  provides the basis for CHN practice. Its primary purpose is to further apply public health measures within the framework of the total CHN effort. 2. Knowledge and understanding of the objectives and policies of the agency facilities goal achievement.  The mission statement commits Community Health Nurses to positively actualize their service to this end. 3. CHN considers the family as the unit of service.  Its level of functioning is influenced by the degree to which it can deal with its own problems. Therefore the family is an effective and available channel for the most of the CHN efforts. 4. Respect for the values, customs and beliefs  of the clients contribute to the effectiveness of care to the client. CHN services must be available sustainable and affordable to all regardless of race, creed, color or socio-economic status. 5. CHN integrated health education and counseling as vital parts of functions.  These encourage and support community efforts in the discussion of issues to improve the people’s health. 6. Collaborative work relationships with the co-workers and members of the health team facilities accomplishments of goals.  Each member is helped to see how his/her work benefits the whole enterprise.

26.   7. Periodic and continuing  evaluation  provides the means for assessing the degree to which CHN goals and objectives are being attained. Clients are involved in the appraisal of their health program through consultations, observations and accurate recording. 8. Continuing staff education program quality services to client and are essential to upgrade and maintain sound nursing practices in their setting. Professional interest and needs of Community Health Nurses are considered in planning staff development programs of the agency. 9 . Utilization of indigenous and existing community resources maximizing the success of the efforts of the Community Health Nurses. The use of local available ailments. Linkages with existing community resources, both public and private, increase the awareness of what care they need what are entitled . 10. Active participation of the individual, family and community in planning and making decisions for their health care needs, determine, to a large extent, the success of the CHN programs. Organized community groups are encouraged to participate in the activities that will meet community needs and interests. 11 . Supervision of nursing services by qualified by CHN personnel provides guidance and direction to the work to be done. Potentials of employees for effective and efficient work are developed. 12. Accurate recording and reporting serve as the basis for evaluation of the progress of planned programs and activities and as a guide for the future actions. Maintenance of accurate records is a vital responsibility of community as these are utilized in studies and researches and as legal documents.

27. CONCEPT OF HEALTH Definitions: “Absence of disease” In some cultures, health and harmony are considered equivalent, Harmony: "being at peace with the self, the community, god and cosmos". (Indian Ayurveda and Greek) Modern medicine: Studies disease, and neglects the study of health. In 1977, the 30th World Health Assembly decided that the main social target of governments and WHO "the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”, “Health for All”

28. Biomedical concept: "Absence of disease" based on "germ theory of disease“ It was felt that human body is 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. Developments in medical and social sciences led to the conclusion that the biomedical concept of health was inadequate Drawback : minimized the role of the environmental, social, psychological and cultural determinants of health Ecological concept: According to ecologists: Health is a dynamic equilibrium between man and his environment, and Disease is a maladjustment of the human organism to environment

29. Psychosocial concept: Health is not only a biomedical phenomenon, but one which is influenced by social , psychological , cultural , economic and political factors of the people concerned. Holistic concept : It recognizes the strength of social, economic, political and environmental influences on health. Implies that all sectors of society have an effect on health Ancient view: Sound mind, in a sound body, in a sound family, in sound environment. Emphasis is on promotion and protection of health

30. DEFINITION OF HEALTH: Health is a state of complete physical, m ental and s ocial wellbeing and Not merely an absence of disease or infirmity .To be able to lead a "socially and economically productive life New philosophy of health Health is a fundamental human right Health is the essence of productive life, and not the result of ever increasing expenditure on medical care Health is intersectoral Health is an integral part of development Health is central to the concept of quality of life Health involves individuals, state and international responsibility Health and its maintenance is a major social investment Health is a worldwide social goal

31. Dimensions of health The good health or healthy life is composed of five dimensions and these dimensions are: physical, intellectual, emotional, social and spiritual. With the passage of time many more dimensions have been added in understanding the composite nature of health. The additional dimensions are emotional, vocational, intellectual and political

32. Physical dimension The physical dimension of the health is directly related with the perfect functioning of the body . It is related with the functioning of the body cells and organs at the optimum level. However , there is a ambiguity at the level of defining the optimum level of functioning. Some people view physical health in terms of colour of the skin, height and body weight and other physical features. The conception of health is reflected in the form of fair colour , bright eyes, long, black and silky hair, not to fat, a good appetite, sound sleep, capacity to do hard work and no tiredness even after doing hard work . The health is also viewed in terms of well functioning of the different organs of the body and proper working of sense organs. Physical dimension of health also includes the normal pulse rate, required level of blood pressure according to age and sex of individual.

33. Thus, we conclude that physical health refers to the state of the body, its composition, development, functions and maintenance of its vital organs. Since health is related with the functioning and maintenance of the body organs therefore, it is necessary to keep oneself healthy by doing physical exercises, eating nutritious food to keep the body and mind energized

34. Mental dimension Mental health is not mere absence of mental illness. Good mental health is the ability to respond to the many varied experiences of life with flexibility and a sense of purpose . More recently, mental health has been defined as a state of balance between oneself and others, a coexistence between the realities of the self and that of other people and of the environment. A few short decades ago, the mind and body were considered independent entities. Recently, however, researchers have discovered that psychological factors can induce all kinds of illness, not simply mental ones.

35. They include conditions such as essential hypertension, peptic ulcer and bronchial asthma. Some major illnesses such as depression and schizophrenia have a biological component. The underlying inference is that there is behavioral, psychological or biological dysfunction and that the disturbance in the mental equilibrium is not merely in the relationship between the individual and society. Although mental health is an essential component of health, the scientific foundations of mental health are not yet clear. Therefore, we do not have precise tools to assess the state of mental health unlike physical health. Psychologists have mentioned the following characteristics as attributes of a merely healthy person. A mentally healthy person is free from internal conflicts; he is not at “war” with himself; He is well adjusted, i.e. he is able to get along well with others. He accepts criticism and is not easily upset. He searches for identity; He has a strong sense of self-esteem; He knows his needs, problems and goals (this is known as self actualization); He has good self-control- balance rationality and emotionally; He faces problems and tries to solve them intelligently i.e. coping with stress and anxiety

36. SOCIAL DIMENSION Man is a social animal. He is surrounded by network of social relationships. These relationships are reciprocal and satisfy various needs in the society. Various ideas and interactions take places and therefore, we also share our emotions. There are diverse cultures in the society and these cultures are regulated by various forms of norms and practices. Although, these cultures are different by they are shared and by community people and cultural diffusion also takes place. The normal individual is a part of all these function and he is capable of sharing the traits of culture and maintains the harmony. This sharing process builds the positive image and enhances the interpersonal communicational skills. This is utmost necessary to be involved in the community as well as in the society at large. The more the personal is involved in the process of integration, more he is regarded as the healthy person.

37. Thus, the social dimension of the health includes the level of social skills, social functioning of the individual and one’s ability to see one self as a member of whole society. Overall the social dimension of health is primary related with individual as a family member, he is part of society and above all he is member of larger group. It also focuses on social and economic conditions and well- being of the society which is ultimately related with the network of social relationships. There is a importance of positive human environment and positive material environment which in turn related with the social network and financial and material conditions of the individual

38. SPIRITUAL DIMENSION Besides being a social being spiritualism is also necessary part of healthy life. Spiritual life makes you to turn to you goals in the life and to achieve these goals one strives for them . A spiritual personal sets his own meanings, personal beliefs, his own acceptance or rejection of the creation . Spiritualism is related with one’s inner self, therefore, there are no objective meanings attached to it. There are no universal laws which define the meaning to attain the goals, rather it is one’s own understanding of existence and creation. To get released from these complexity one needs to have spiritualism which in turn affect the health . The thought of spiritualism directs the mind to think or reaches out for the constructive meaning of the life. Without considering the meaning of life one is worthless. The worth in the life ultimately transcends into good physical well-being and healthy life. This is not a old philosophy of health, rather it has emerged in the contemporary time looking to the complexity in the life .

39. In sum, spiritualism includes integrity, principles, ethics and the purpose in life. It also includes commitment to some higher being.

40. EMOTIONAL DIMENSION Emotional dimension of health is the domain under psychology. Since human being is not only a social being but at the same time he is also a emotional being. Therefore , emotional elements are indispensable from a healthy human being. Emotional well-being is the ability in the human being to adjust and cope with our own and others feelings. Emotions are present in all human beings in different periods of time, in different situations . At various times emotions are visible, but at times in the situation of hopelessness, depression, anxiety etc. they are not easily and therefore, can lead to the mental illness and ultimately affect the health. Therefore , one should be aware of one’s weaknesses and strength which can be helpful in the coping situation of emotional disturbing situations. It will caution before hand and one can seek help so that situation can be altered. Further, it can be altered by building strong cushion of relationships with the family, peer groups and community.

41. Emotional health is related to ones feeling whereas mental health can be seen as “knowing” or “cognition”. Thus, in the present time, the mental and emotional aspects of human being should be viewed separately particularly in the context of human health

42. VOCATIONAL DIMENSION Vocational dimension is related with the work one does. Every human being who has come in the world is supposed to do some or other type of work for human existence. It may vary from person to person, but should be adaptable according to human capacity. Work also depends on ones capacity and limitations to perform. The performance of work is directly elated with the physical and mental health of the individual. Physical work is related with one’s capacity to perform work, while its goal is associated with self realization of satisfaction and enhanced self-esteem. Its actual potential is realized only when the person is without work or he is out of work or may be retired. This situation immediately affects his health.

43. As people think that vocational dimension is related with the economic aspects or it is values in the form of source of incomes, but it represents the persons’ ability in the form of success to prove his worth in the society and does not become burden on others

44. INTELLECTUAL DIMENSION Intellectual dimension is related with one’s ability to develop skills and knowledge to make life more meaningful. Intellectual capacity gives ability to think rationality and in turn it translates into the idea of creativity and insight in decision making . Intellectual leanings gives ability to plan the things in such a manner that will go long way and will make life successful. The mind is able to think with openness and act accordingly. It will not be influenced by any subjectivity or other external pressure to influence your decision. Additionally, positive intellectual thinking will automatically contribute to the good health. It is also helpful in the conflicting situation for arriving at the rational arguments. A few other dimensions are also important while discussing the health. These are: philosophical, cultural, socio-economic, environmental, educational, nutritional, curative and preventive. A glance on these dimensions shows that there are many non-medical dimensions of health which are equally important for the purpose of health.

45. Determinants of health What makes some people healthy and others unhealthy? How can we create a society in which everyone has a chance to live long healthy lives?

46. The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health. Determinants of health fall under several broad categories: Social factors Health services Individual behavior Biology and genetics

47. Policymaking Policies at the local, State, and Federal 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. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn, reduced rates of injuries and deaths from motor vehicle accidents.

48. S ocial Social determinants of health reflect social factors and the physical conditions in 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. Examples of social determinants include: Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods Exposure to crime, violence, and social disorder, such as the presence of trash Social support and social interactions Exposure to mass media and emerging technologies, such as the Internet or cell phones Socioeconomic conditions, such as concentrated poverty Quality schools Transportation options Public safety Residential segregation

49. P hysical determinants Examples- Natural environment, such as plants, weather, or climate change Built environment, such as buildings or transportation Worksites, schools, and recreational settings Housing, homes, and neighborhoods Exposure to toxic substances and other physical hazards Physical barriers, especially for people with disabilities Aesthetic elements, such as good lighting, trees, or benches Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment. For example, millions of people live in places that have unhealthy levels of ozone or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of asthma in both adults and children compared with State and national averages. Poor air quality can worsen asthma symptoms, especially in children

50. Health services Both access to health services and the quality of health services can impact health. 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 . Barriers to accessing health services include: Lack of availability High cost Lack of insurance coverage Limited language access These barriers to accessing health services lead to: Unmet health needs Delays in receiving appropriate care Inability to get preventive services Hospitalizations that could have been prevented

51. 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. Examples of individual behavior determinants of health include: Diet Physical activity Alcohol, cigarette, and other drug use Hand washing

52. 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. Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition that people inherit when both parents carry the gene for sickle cell. The gene is most common in people with ancestors from West African countries, Mediterranean countries, South or Central American countries, Caribbean islands, India, and Saudi Arabia. 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

53. Social Determinants of Health Social determinants of health are economic and social conditions that influence the health of people and communities. These conditions are shaped by the amount of money, power, and resources that people have, all of which are influenced by policy choices. Social determinants of health affect factors that are related to health outcomes. Factors related to health outcomes include: How a person develops during the first few years of life (early childhood development) How much education a persons obtains Being able to get and keep a job What kind of work a person does Having food or being able to get food (food security) Having access to health services and the quality of those services Housing status How much money a person earns Discrimination and social support

54. What are determinants of health and how are they related to social determinants of health? Determinants of health are factors that contribute to a person’s current state of health. These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature. Scientists generally recognize five determinants of health of a population: Genes and biology: for example, sex and age Health behaviors: for example, alcohol use, injection drug use (needles), unprotected sex, and smoking Social environment or social characteristics: for example, discrimination, income, and gender Physical environment or total ecology: for example, where a person lives and crowding conditions Health services or medical care: for example, access to quality health care and having or not having insurance Other factors that could be included are culture, social status, and healthy child development. Scientists do not know the precise contributions of each determinant at this time.

55. In theory, genes, biology, and health behaviors together account for about 25% of population health. Social determinants of health represent the remaining three categories of social environment, physical environment/total ecology, and health services/medical care. These social determinants of health also interact with and influence individual behaviors as well. More specifically, social determinants of health refer to the set of factors that contribute to the social patterning of health, disease, and illness.

56. Why is addressing the role of social determinants of health important? Addressing social determinants of health is a primary approach to achieving health equity. Health equity is “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance.” Health equity has also been defined as “the absence of systematic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages—that is, different positions in a social hierarchy.” Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities.

57. Natural History and Spectrum of Disease Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. For example, untreated infection with HIV causes a spectrum of clinical problems beginning at the time of seroconversion (primary HIV) and terminating with AIDS and usually death. It is now recognized that it may take 10 years or more for AIDS to develop after seroconversion . Many , if not most, diseases have a characteristic natural history, although the time frame and specific manifestations of disease may vary from individual to individual and are influenced by preventive and therapeutic measures.

58. The process begins with the appropriate exposure to or accumulation of factors sufficient for the disease process to begin in a susceptible host. For an infectious disease, the exposure is a microorganism. For cancer, the exposure may be a factor that initiates the process, such as asbestos fibers or components in tobacco smoke (for lung cancer ) After the disease process has been triggered, pathological changes then occur without the individual being aware of them. This stage of subclinical disease, extending from the time of exposure to onset of disease symptoms, is usually called the  incubation period  for infectious diseases, and the  latency period  for chronic diseases . During this stage, disease is said to be asymptomatic (no symptoms) or in apparent. This period may be as brief as seconds for hypersensitivity and toxic reactions to as long as decades for certain chronic diseases. Even for a single disease, the characteristic incubation period has a range. For example, the typical incubation period for hepatitis A is as long as 7 weeks. The latency period for leukemia to become evident among survivors of the atomic bomb blast in Hiroshima ranged from 2 to 12 years, peaking at 6–7 years.

59. Although disease is not apparent during the incubation period, some pathologic changes may be detectable with laboratory, radiographic, or other screening methods. Most screening programs attempt to identify the disease process during this phase of its natural history, since intervention at this early stage is likely to be more effective than treatment given after the disease has progressed and become symptomatic. The onset of symptoms marks the transition from subclinical to clinical disease. Most diagnoses are made during the stage of clinical disease. In some people, however, the disease process may never progress to clinically apparent illness. In others, the disease process may result in illness that ranges from mild to severe or fatal. This range is called the  spectrum of disease . Ultimately, the disease process ends either in recovery, disability or death. For an infectious agent,  infectivity  refers to the proportion of exposed persons who become infected.  Pathogenicity  refers to the proportion of infected individuals who develop clinically apparent disease.  Virulence  refers to the proportion of clinically apparent cases that are severe or fatal.

60. Because the spectrum of disease can include asymptomatic and mild cases, the cases of illness diagnosed by clinicians in the community often represent only the tip of the iceberg. Many additional cases may be too early to diagnose or may never progress to the clinical stage. Unfortunately , persons with in apparent or undiagnosed infections may nonetheless be able to transmit infection to others. Such persons who are infectious but have subclinical disease are called  carriers . Frequently , carriers are persons with incubating disease or in apparent infection. Persons with measles, hepatitis A, and several other diseases become infectious a few days before the onset of symptoms. However carriers may also be persons who appear to have recovered from their clinical illness but remain infectious, such as chronic carriers of hepatitis B virus, or persons who never exhibited symptoms. The challenge to public health workers is that these carriers, unaware that they are infected and infectious to others, are sometimes more likely to unwittingly spread infection than are people with obvious illness.

61. Natural history of a communicable disease The  natural history  of a communicable disease refers to the sequence of events that happen one after another, over a period of time, in a person who is not receiving treatment. Recognizing these events helps understand how particular interventions at different stages could prevent or control the disease.  Events that occur in the natural history of a communicable disease are grouped into four stages: exposure, infection, infectious disease, and outcome

62. 1. Stage of exposure: In the  stage of exposure , the susceptible host has come into close contact with the infectious agent, but it has not yet entered the host’s body cells. Examples of an exposed host include: a person who shakes hands with someone suffering from a common cold a child living in the same room as an adult with tuberculosis a person eating contaminated food or drinking contaminated water. 2. Stage of infection At this stage the infectious agent has entered the host’s body and has begun multiplying. The entry and multiplication of an infectious agent inside the host is known as the  stage of infection . For instance, a person who has eaten food contaminated with  Salmonella typhii  (the bacteria that cause typhoid fever) is said to be  exposed ; if the bacteria enter the cells lining the intestines and start multiplying, the person is said to be  infected . At this stage there are no  clinical manifestations  of the disease, a term referring to the typical symptoms and signs of that illness.  Symptoms  are the complaints the patient can tell about (e.g. headache, vomiting, dizziness).  Signs  are the features that would only be detected by a trained health worker (e.g. high temperature, fast pulse rate, enlargement of organs in the abdomen).

63. 3 . Stage of infectious disease At this stage the clinical manifestations of the disease are present in the infected host. For example, a person infected with  Plasmodium falciparum , who has fever, vomiting and headache, is in the  stage of infectious disease  – in this case, malaria. The time interval between the onset (start) of infection and the first appearance of clinical manifestations of a disease is called the  incubation period . For malaria caused by  Plasmodium falciparum  the incubation period ranges from 7 to 14 days. Remember that not all infected hosts may develop the disease, and among those who do, the severity of the illness may differ, depending on the level of immunity of the host and the type of infectious agent. Infected hosts who have clinical manifestations of the disease are called  active cases . Individuals who are infected, but who do not have clinical manifestations, are called  carriers . Carriers and active cases can both transmit the infection to others. 4. Stage of outcome At this stage the disease may result in recovery, disability or death of the patient. For example, a child who fully recovers from a diarrhoeal disease, or is paralyzed from poliomyelitis, or dies from malaria, is in the  stage of outcome .

64. Levels of prevention

65. Prevention includes the actions required to eradicate, eliminate or minimizing the impact of diseases. The various countries are using this strategy to control the prevalence of many major diseases throughout . There are different levels of prevention. 

66. 1. Primordial prevention It is a new concept in the prevention of chronic diseases. This is primary prevention in its pure sense, that is prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. For example- many adult health problems ( eg - hypertension, obesity ) have their origins in childhood because this is the time when lifestyle are formed. ( eg - smoking, eating patterns, physical exercise) In primordial prevention, efforts are directed towards discouraging children from adopting harmful lifestyles. The main intervention in primordial prevention is through individual and mass education.

67. 2. Primary prevention It can be defined as “ action taken prior to the onset of disease, which removes the possibility that a disease will even occur” It signifies intervention in the pre pathogenesis phase of a disease or health problem ( eg - low birth weight) or other departures from health. Primary prevention is far more than averting the occurrence of a disease and prolonging life. It includes the concept of “ positive health” a concept that encourages achievement and maintenance of an “acceptable level of health that will enable every individual to lead a socially an economically productive life” It concerns an individuals attitude towards life and health and the initiative he takes about positive and responsible measure for himself, his family and community. The WHO has recommended the following approches for the primary prevention of chronic diseases where the risk factors are established. Population (mass )strategy High risk strategy

68. a. Population (mass) strategy : it is directed at the whole population irrespective of individual risk levels. For eg - studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease. The population approach is directed towards socio economic ,behavioral and lifestyle changes. b. High risk strategy: aims to bring preventive care to individuals at special risk. This requires detection of individuals at high risk by optimum use of clinical methods. Industrialized countries succeeded in eliminating a number of communicable diseases like cholera , typhoid, and dysentery, and controlling several others like plague, leprosy and TB not by medical interventions but mainly by raising the standards of living. In summary primary prevention is a holistic approach Fundamental public health measures and activities such as sanitation, infection control, immunization, protection of food , milk and water supplies, environmental protection , protection against occupational hazards and accidents are also basic to primary prevention The safety and low cost of primary prevention justifies its wider application. Primary prevention has become increasingly identified with “health education” and the concept of individual and community responsibility for health

69. Secondary prevention Can be defined as action which halts the progress of a disease at its incipient stage and prevents complications. The specific interventions are early diagnosis and adequate treatment. By early diagnosis and early treatment secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes have taken place and reverse communicability of infectious diseases. It is largely the domain of clinical medicine. The health programmes initiated by the governments are usually at the level of secondary prevention. The drawback of secondary prevention is that the patient has already been subject to mental anguish , physical pain, and community loss of productivity. It is often more expensive and less effective than primary prevention

70. Tertiary prevention When the disease process has advanced beyond its early stages it is still possible to accomplish prevention by what might be called as tertiary prevention. It signifies intervention in the late pathogenesis phase It can be defined as all measures available to reduce or limit impairments and disabilities, minimize suffering caused by existing departures from good health and to protect the patient’s adjustment to irremediable conditions. When defect and disability are more or less stabilized, rehabilitation plays a preventable role. Modern rehabilitation includes psychosocial, vocational, and medical components based on team work of variety of professions. Tertiary prevention extends the concept of prevention into the fields of rehabilitation.

71. Health problems in India

72. Health problems in India

73. REFERENCES What is Public Health? | Capital Area (capitalareaphn.org) Negandhi , Himanshu1; Sharma, Kavya2; Zodpey , Sanjay P.3,. History and Evolution of Public Health Education in India. Indian Journal of Public Health 56(1):p 12-16, Jan–Mar 2012. | DOI: 10.4103/0019-557X.96950 Principles of Epidemiology | Lesson 1 - Section 9 (cdc.gov ) OLCreate : HEAT_CD_ET_1.0 Communicable Diseases Module: 1. Basic Concepts in the Transmission of Communicable Diseases: 1.3.4  Stage of outcome | OLCreate (open.edu ) K Park.2019.Preventive and social medicine. Bhanot .