Documente Academic
Documente Profesional
Documente Cultură
Nairobi 2011
(copyright page)
Tina Okulo designed the cover.
Acknowledgements
The idea of writing this book started because, within the then department of community
health, there was no basic textbook for medical undergraduates or students of public
health. Initially, it seemed a simple matter of putting a few notes together. Never did it
occur to me that the project would require two years to complete.
The manuscript has benefited from immense contributions provided by the school of
public health university of Nairobi staff members. They include: Dr. Dismus Ongore,
Director school of public health, university of Nairobi Rose Opiyo, Prof Mutuku Mwanthi,
Lambert Nyabola, Erastus Njeru, Prof. Elisha Muchunga Dr. Peterson Muriithi, Mary
Kinoti, Faith Thuita, Dr. Peter Njoroge, Prof. Joyce Olenja, Prof. Violet Kimani and Prof.
Elizabeth Ngugi.
The anonymous peer reviewer who went through the entire manuscript provided
valuable comment.
Judie Lynn Rabar and Dr. Sally Wanjohi read through the manuscript as it was being
developed. I am also indebted to the following for their invaluable contributions:
Emmanuel Odemba for his editorial work and Hudson Kubasu who did the design
and layout of the book. The pair pushed me when I faltered to keep on writing to
the end.
Mrs. Rosemary Kinyua for useful tips on manuscript preparation.
Tyler Ayah for helping compile the index and Craig Ayah for his steadfast
encouragement.
4i
Preface
Public health is one of the major avenues to achieve socio-economic development in
society. Clinical medicine practiced on its own in isolation from the community becomes
a never-ending queue of the same preventable problems, managed expensively with
relatively poor outcomes because then, it is often too late to effectively alter the course of
the condition afflicting the patient. Public health science includes various disciplines which
together are more than the individual parts. This synergistic approach of public health is
what gives it the unique perspective to be able to tackle complex health issues in society.
Within the medical and public health schools in sub-Saharan Africa, theory and principles
have fallen behind practice and much of what is done in the name of public health is often
done using weak justification with attendant poor results at the end. When practicing
medicine there has to be a direct link with the general population. Public health is that
interface. This book attempts to provide such a link, by outlining the principles in public
health that, when practiced, would lead to improved health status by reducing morbidity
and mortality. This book is divided into Four major parts namely: basic tools for public
health, the individual and public health, individual health and the environment and making
a community diagnosis. Each part has several chapters that cover individual subject areas
in public health. Combined the chapters provide an overview of each subject.
It must be recognized that each subject area is a specialty on its own with practioners. The
idea is not to make the reader an expert epidemiologist or an environmental scientist but
to give the learner the tools necessary to begin to have an understanding of each subject
area.
5ii
List of tables
Table 2.1: Survey results of H1N1 cases in school A and B
Table 2.2: Calculating specific rates
Table 2.3: A relationship between cigarette smoking and Incidence
Table 2.4: Host factors in disease transmission
Table 2.5: Environmental factors in disease transmission
Table 2.6: Types of study designs
Table 2.7: Calculating relative risk
Table 2.8: Appropriate use of observational studies
Table 2.9: Comparing qualitative and quantitative
Table 2.10: Comparing sensitivity and specificity in a screening Test
Table 2.11: Possible outcome of diagnostic test
Table 3.1: Calculating the mode
Table 3.2: Calculating variance
Table 3.3: Grouping data into classes
Table 3.4: Accepting the null hypothesis
Table 3.5: Classification of men admitted to a hospita; by educational attainment
Table 3.6: Calculating chi-square
Table 3.7: Blood pressure readings of selected patients
table 3.8: Blood pressure readings from two sample groups
Table 4.1: Population growth rate of select countries
Table 4.2: Dependency ratios for select regions
Table 4.3: Possible errors in a census
Table 4.4: Comparisons of census and sample errors
Table 4.5: Contraceptive methods
Table 4.6: Reasons for migration
Table 5.1: Food requirements
Table 5.2: Daily requirements for dietary rehabilitation
Table 5.3 Nutritional management of common conditions in HIV/AIDS
Table 5.4:Gomez classification
Table 5.5: Waterlow classification
Table 5.6: Wellcome classification
Table 5.7: Minimum nutrient requirements
Table 5.8: Risk factors of vitamins A deficiency
Table 5.9: Recommeded iodine intake
Table 5.10: Stepwise implementation for: prevention of childhood obesity
Table 5.11: Z - score classification
Table 5.12: BMI classification
Table 6.1: Characteristics of an effective vaccine
Table 6.2: Causes of morbidity and mortality in displaced populations
Table 6.3: Major causes of diarrhoeal diseases
Table 6.4: Diagnosis of amoebiasis
Table 6.5: Risks in HIV/AIDS transmission
iii
6
7iv
List of Figures
Fig. 1.1: Evidence based approach to public health
Fig. 2.1: Interaction between disease and disease determinant
Fig. 2.2: Stages in the natural history of disease
Fig. 2.3: The causes of tuberculosis
Fig. 2.4: Case control study design
Fig. 2.5: Cohort study design
Fig.3.1: Bar graph showing height of students
Fig. 3.2: Pie chart showing tobacco use by type
Fig. 3.3: A Histogram of discrete data
Fig. 3.4: Different types of distribution curves
Fig. 3.5: Calculating standard deviation
Fig. 3.6: Bar chart showing all possible scores from two dice
Fig. 4.1: World Population : 1950-2050
Fig. 4.2: Age/sex structure for Kenya and Italy
Fig. 4.3: The demographic transition
Fig. 4.4: Motivation for migration
Fig. 5.1: A food pyramid
Fig. 5.2: Conceptual framework: Causes of malnutrition
Fig. 5.3: An algorithm for the diagnosis and management of of acute malnutrition
Fig. 5.4: Kwashiokor and marasmus
Fig. 5.5: Use of MUAC
Fig. 5.6: Conceptual model of pathways to death and disability from malnutrition
Fig. 5.8: Determinants of food consumption and nutritional status: a conceptual
framework
Fig.6.1: Equilibrium between the Population, Infectious Agent, and the environment
Fig. 6.2: Life cycle of the malaria parasite
Fig. 6.3: A summary of factors affecting the prevention and control of malaria
Fig. 6.4: Prevention and control of diarheal diseases
Fig. 6.5: Life course of HIV/AIDS infection
Fig. 6.6: Life cycle of schistosomiasis
Fig. 7.1: Framework: determinants of non-communicable diseases
Fig. 7.2: Use of seat belt prevents fatalities
Fig. 8.1: The doctor-patient interaction
Fig. 8.2: The individual within a complex world
Fig. 8.3: gender distribution in healthcare delivery
Fig. 9.1: Relationship between health and the environment
Fig. 9.2: The DPSEEA model
Fig. 9.3: The steps that food undergoes from production to consumption
Fig. 9.4: Urban housing in the slums
Fig 9.5: Examples of safety gear
Fig. 10.1: A framework for occupational health
v8
9vi
Content
Acknwledgement
Preface
List of tables
List of figures
i
ii
iii
iv
11
12
17
37
54
72
73
94
125
148
149
162
179
193
194
201
208
223
249
2.1. Nutrition
2.2. Communicable diseases control
2.3. Non-communicable disease
References
Appendix
Index 273
Glossary
261
262
270
272
The definition of public health as expressed by C.E.A Winslow in 1920 endures today.
He defined public health as the science and art of preventing disease, prolonging life
and promoting health through the organized efforts and informed choices of society,
organizations, communities and individuals. He believed that the barrier between public
health and clinical medicine is an artificial one and that the far-sighted physician is equally
eager to link up his science with the public health program, because on his side he realizes
that medicine can never attain its full potentialities of service unless it is made really
preventive, through some type of effective professional and social coordination. This
observation is true especially in sub-Saharan Africa where health professionals are scarce.
Waiting to manage patients when they arrive late at health facilities is a strategy (whether
by design or otherwise) that has not and will never succeed in improving the health of
people in society.
The World Health Organization (WHO) defines health as a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity. The
goal of public health is to improve health status through the prevention and treatment of
disease. It does this by focusing on disease surveillance and promotion of health behaviour
at population level and not at individual level.
Whereas there is a clear link between public health and socio-economic development, it
is only in the late 90s that African governments began to pay serious attention to public
health. The starting point however, was the landmark Alma-Ata conference on primary
health care that took place in September 1978. That conference was followed by the 32nd
World Health Assembly in Geneva in 1979 which endorsed the Alma-Ata declaration and
approved a resolution that primary health care was the key to attaining an acceptable
level of health for all.
Despite the initial enthusiasm, it was difficult to implement primary health care thereafter.
The declaration was viewed by many as being too broad, idealistic and having an
unrealistic timetable. The slogan Health for All by 2000 went unrealized. The major
reason was lack of clear financing mechanism in place to achieve the goals set. It was
expected governments would adjust their health budgets to incorporate this new thinking.
International organizations too did not offer much funding to assist the process.
The turn of the century therefore offered a chance for world leaders to review progress
made and set new goals. A total of 189 world leaders met in September 2000 at the
United Nations headquarters to discuss the role of the UN in the 21st century. The
Millennium Summit declaration agreed upon undertook to help the people living in the
worlds poorest countries achieve a better life by the year 2015.
11
The millennium development goals (MDGs) are derived from the Millennium Summit
and provide a framework for monitoring the progress of the goals set. Unlike previous
attempts at the global level to improve health in developing countries, the MDGs have
been accompanied by h significant funding from global organizations. The emergence
of several large disease-specific global health initiatives (GHIs) has changed the way in
which international donors provide assistance to public health initiatives. More than 100
global health initiatives exist today including The Global Fund to fight AIDS, Tuberculosis
and Malaria(Global Fund), Global Alliance for Vaccines and Immunization (GAVI) and
the US Presidents Emergency Plan for AIDS Relief (PEPFAR). These global initiatives
have capitalized on the momentum generated by the adoption of the MDGs to mount
a concerted response to fight various diseases such as HIV/AIDS, malaria and neglected
tropical diseases. There has been heavy promotion of the use of effective health
interventions and technologies such as vaccines, anti-retroviral drugs for HIV/AIDS, and
insecticide-treated bednets for malaria prevention.
Importantly, these initiatives have increased the involvement of the private sector, civil
society and philanthropic trusts in health care. Philanthropic organizations such as the Bill
& Melinda Gates Foundation (which has committed more than $1 billion per year since
2000 to global health) have changed the way in which public health is financed in developing
countries. The importance of these global initiatives cannot be underestimated. In 2007,
investment through these GHIs accounted for two-thirds of all external funding for HIV/
AIDS, 57% for tuberculosis and 60% for malaria in developing countries.
In the developed world, major gains in health status were achieved through provision of
safe water and food, sewage treatment and disposal, tobacco use prevention and cessation,
injury prevention, immunization and other population based interventions. In sub-Saharan
Africa, much of this basic but necessary public health promotion and development has not
been sufficiently realized.
There is a need to practice public health using an evidence based approach. Such an
1. Community
assessment
2. Quantifying the
issue
7. Evaluating the
program or policy
6. Developing
an action
plan and
implementing
interventions
3. Developing a concise
statement of the issue
5. Developing
and
prioritizing
program and
policy options
12
4. Determining what is
known through the
scientic literature
approach involves the use of the best available scientific evidence, using data and
information systems systematically, applying program-planning frameworks, engaging
the community in decision-making, conducting sound evaluation, and disseminating what
is learned for action.
An evidence-based approach has several benefits including efficient use of resources,
improved chances of health programs succeeding coupled with greater workforce
productivity. Poor countries pay a huge opportunity cost when interventions which
would yield the highest health return on investment are not implemented. This means
that ideally, public health practitioners should always start from a scientific evidencebased perspective in developing policy, selecting and implementing programs and then
monitoring and evaluating success. However there are challenges to this approach. The
political environment must be one able to allow sober evaluation and absorb in a timely
manner the available information generated from research.
The information system requires investment to ensure it is able to generate information
for policy making. The type of information needed include epidemiologic data, results of
program or policy evaluations and qualitative data from the population. Results of studies,
and pilots done need to be widely disseminated. For this to happen, health workforce
training needs to incorporate at an early stage of training the principles of public health.
Much of the capacity building that has been conducted in the last twenty years has been
done on an emergency basis (post training).
One major barrier of disseminating information can be potentially overcome relatively
easily when compared historically. The extensive use of mobile phones by the general
population and health-service personnel and the spread of internet use offer a way to scale
up primary health services rapidly in a cost effective manner. However, these remains the
weak health systems with limited capacity to absorb and implement the huge amount of
resources available to change health status. Not enough investment has gone into building
the physical infrastructure of clinics and hospitals and the training and salaries of health
workers.
Going back to the beginning, real public health starts with determining what the health
problems affecting people are. The problem must be identified but equally important is
the context within which the problem is occurring and peoples behaviour in relation to
the problem.
The next step is to analyze how significant these problems are, then identify a possible
solution that will solve the identified problems in conjunction with the affected population.
Initially, public health was about what the public health practioner told the public to do
such as getting vaccinated or washing hands. Today, it is recognized that behaviour change
is an important part of health improvement.
Overeating, reduced physical activity and cigarette smoking are examples of individual
13
behaviour that require thinking about what the conditions are necessary to cause
behaviour change. It is important to note that most health communication interventions
have failed to elicit desired change in behaviour because of over emphasis on attitude
change. Researches have shown that attitude does not necessarily influence behaviour in
a linear fashion. In addition, the trend of the problem needs to be carefully monitored and
the interventions applied evaluated for effectiveness and efficiency. Preventing ill-health
from breathing polluted air from vehicle exhausts requires possibly several different types
of interventions targeted at different levels. Different segments of the population will have
contradictory views on the magnitude of the problem and what should be done about it.
These diverse views must be accommodated while solving the health problem. Emerging
problems need to be identified as early as possible and possible risk factors managed.
Risk factors can be at either individual or population level, and the approach to managing
them will vary accordingly. Much depends on the education levels, culture and socioeconomic well being of the community. However, public health practitioners must have
the sense of responsibility for safeguarding population health and looking out for factors
and behaviour that lead to poor health. This is the concept of primary prevention where
disease is avoided through preventive measures. If the disease exists, then secondary
prevention can be applied. This is where early signs of the disease are detected and action
is taken to minimize disease progression. Tertiary prevention is when the disease already
exists but action can be taken to minimize complications and disability assigned by the
disease. Clinical medicine and public health meet at the secondary and tertiary levels.
Effective public health measures almost always include interventions at the policy level,
For example, for many years it has been known that cigarette smoking leads to cancer
and other illnesses. Having doctors and other health practioners announce that cigarette
smoking is bad has had little effect on peoples smoking habits. Reduction in smoking
requires a coalition of health and non-health forces in a concerted effort. Reducing smoking
requires a two-pronged approach, strategies to reduce first time uptake among youth and
secondly to encourage cessation of smoking for those already addicted.
The first prong envisions strengthening traditional tobacco control measures that are
known to be effective such as strong comprehensive government tobacco control
programs, increased excise taxes, stringent public smoking restrictions, limiting youth
access to tobacco products and intensifying prevention interventions. Restricting access
to cigarettes by not selling them in kiosks, banning tobacco advertising and enforcement
of laws against sales to school children are examples of such interventions.
Tobacco companies tend to argue against such control using a variety of arguments especially
free market arguments either that the cost of tobacco consumption can be simply priced
and the consumer will therefore pay for the healthcare costs incurred or that high tobacco
pricing encourages tobacco smuggling and therefore government will loose tax revenue.
Western Europe has the highest tobacco prices in the world yet smuggling is on average
14
lower than in other regions of the world. Controlling tobacco smuggling is therefore not a
market problem but weak government control problem. Tobacco smuggling occurs where
it is easy to evade taxes. At this point, tobacco smuggling becomes a public health problem
because it brings tobacco on to markets cheaply, making cigarettes more affordable and
thus stimulates consumption. The struggle to control tobacco consumption is one example
where the policy battles can extend for many decades before success. However before
embarking on policy issues there is a requirement that there be an understanding of the
epidemiology of the disease.
15
Public health, as a branch of medicine, is concerned with general aspects of health within
the public domain. There are three broad basic tools in the study of public health, namely
epidemiology, biostatistics and demography. By the end of this section, the reader will
be able to:
understand the fundamentals of epidemiology
differentiate between the different types of study designs in epidemiology
understand the concepts of specificity, sensitivity and positive predictive value
outline the measures used to describe the frequency of disease in the population and
their uses in public health
understand the concept of an ideal sample
describe the different classes of data and how they can be presented
describe the characteristics of a normal distribution within a population
understand the different types of decision errors and the implications for stating
results
enumerate the main sources of demographic data
identify the likely errors in collecting, analyzing and publishing data from the various
sources and strategies to minimize such errors.
understand the factors that determine family size and therefore population size and
growth
understand the theory of demographic transition and how it applies to health
planning.
16
EPIDEMIOLOGY
Introduction
Environmental
determinant 1
(social)
Environmental
determinant 2
(physical)
Specic disease
agent
determinant 1
Host
determinant 1
Specic disease
agent determinant 2
Host
determinant 2
Disease
in the
population
Environmental
determinant 3
(other)
Fig. 2.1: Interaction between disease and disease determinant
Measuring mortality
Mortality can be measured in terms of:
Counts
Proportions or percentages
Ratios
Rates
120
240
1000
Males = 200
Females = 400
Total population = 600
The ratio of males to females is 1: 2
1000
For this disease we can say that the mortality rate is low.
However the case fatality rate is high and can be calculated as
follows;
No of people infected with disease = 20 of which 18 die,
therefore 18/20 = 90% case fatality.
Once the person has the disease, the chances of dying are high
(90%)
Population
Number of
cases
Rates (%)
Males
500
80
16%
Females
500
40
8%
Total
1000
120
12%
(X10n)
Period prevalence =
Measuring Morbidity
Morbidity measures disease occurrence in
the population. If we measure the number
of cases at any given point in time or
during a specific time period, then we are
determining the disease prevalence.The
disease prevalence is a good measure of
disease burden and is useful for planning
health services especially at the evaluation
stage. However, if we measure the number
of new cases of the diseases, then we
have determined the disease incidence. A
rapidly increasing incidence would indicate
the outbreak of a disease or epidemic. The
prevalence can be further refined.
(X10n)
Cumulative incidence =
Number of
cases
of stroke
Personyears of
observation (over 8
years)
Stroke
incidence
rate (per 100
000 person
years)
Never smoked
Ex-smoker
Smoker
70
65
139
395,594
232,712
280,141
17.7
27.9
49.6
Total
274
908,447
30.2
Recovery stage
Susceptible stage
Clinical stage
Sub-clinical
Causes of disease
One of the general themes in the philosophy
of science is that of cause and effect
and it always follows that if the causes
are present then the disease will follow.
It is termed sufficient when it inevitably
produces or initiates an outcome. Some
diseases are caused almost completely
by genetic factors while others are a
result of interplay between genetic and
environmental factors.
22
prevention often
23
TB
infection
Fig. 2.3: The causes of tuberculosis
Example
Age
Race
Sex
Immunity
24
Environmental Determinant
Example
Physical
Temperature,
humidity, Insects, animals,
water quality
Interventions
An intervention is an action taken with
the goal of modifying the natural history
of a disease. An effective intervention
changes the natural history of the disease
for the better of the population health.
The intervention can aim to either control
or eradicate the disease in question.
Depending on what can be achieved and
remembering that disease causes are
usually multiple, different segments of the
population can be targeted.
Study Designs
Observational
Experimental
Quasi-experimental studies
POPULATION
Cohort Studies
This study starts with people who do not
have the disease. Cohort study populations
are divided into two groups; those with
exposure to potential causes of the disease
and those without exposure. They are then
followed up to see how they develop the
disease under study.
(a)
(b)
(c)
(d)
Figure 2.5: Cohort study design
Absent
(a) 20
(b) 80
Teetotaller
(c) 2
(d) 98
RR
c
(c+d)
20
100
2
100
a
(a+b)
10
Objective
Ecological
Cross
section
Case
control
Cohort
Y - Yes
28
W - Weak
N - No
Experimental Studies
In experimental (intervention) studies,
there is an active attempt to change
a disease determinant through some
intervention such as treatment. Examples
of interventions include drugs, vaccine
trials, health
education and food
supplements. In the examples provided,
we could be asking whether the procedure
or drug is effective. The determinant
can be exposure, behaviour or disease
progression. In this regard, experimental
studies are similar in design to experiments
done in other sciences.
Community trials
Community trials are similar to a
randomized control study in design.
The difference is that the subject is the
community rather than an individual.
They are useful for conditions which are
influenced by social circumstances and
for which prevention involves targeting
behaviour change. However, there are
difficulties in the methodology as it may be
very difficult to find two communities that
are similar enough yet are far apart enough
to be isolated from each other so that there
is a true experimental and control group in
place. As a result of this, it is often difficult
to state categorically that a communitywide intervention has been shown to be
effective.
Sampling
Quantitative
Qualitative
Philosophical
foundation
Deductive eductionist
Inductive, holistic
Aim
Explore complex
human issues
Study Plan
Step-wise predetermined
Iterative, exible
Position of
researcher
Aims to be detached
and objective
Integral part of
research process
Assessing
quality of
outcomes
Indirect quality
assurance methods
of trustworthiness
Measuring of
utility of ults
Generalizability
Transferability
Screening tests
Disease
Sensitivity
Specicity
Test positive
True Positive
False positive
Test negative
False negative
True negative
Diagnostic tests
Using the same principals as a screening
test, a diagnostic test should help confirm
the presence of disease that is suggested
by the present symptoms and clinical signs.
The value of the test is how correctly
it predicts the presence or absence of
disease. In performing the test, there are
four possible results that can be obtained
as shown in table 2.9.
Negative
Absent
true
positive
False
positive
False
negative
True
negative
35
Questions Section
1. What are the main purposes for which epidemiological studies are carried out?
2. What is the difference between cohort study and case control study?
3. Define specificity, sensitivity and positive predictive value
4. What are the measures used to describe the frequency of disease in the population
and their uses in public health
5. What is the relative risk (RR)? From which type of epidemiological studies can RR be
calculated?
Further Reading
1. Concato J. What is a screening test? Misclassification bias in observational studies of
screening for cancer. Journal of general internal medicine. 1997 ;12(10):607-12.
2. De Vreese L. Epidemiology and causation. Medicine, health care, and philosophy.
2009 ;12(3):345-53.
3. Fletcher, RH, Fletcher SW, Clinical epidemiology: the essentials, 4th ed,
(Philadelphia: Lippincott, Williams & Wilkins, 2005.)
4. Mayer D, Essential evidence-based medicine, (Cambridge, Press Syndicate of the
University of Cambridge, 2004)
36
BIOSTATISTICS
Introduction
Descriptive Statistics
Location
Ordinal
This where the order matters but there is
no sensible arithmetic difference between
the different values, e.g. asking people to
rank pain on a scale of 1 to 5. Where 1
=not painful and 5 = unbearable pain. The
relationship between the response 1 and 5
cannot be related mathematically.
Measures of Location
Measures of location (central tendency),
give us an idea of where our observation
lies on the scale of measurement. The
three most commonly used measures of
location are the arithmetic mean, median
and mode.
Interval
This where order matters and the
difference in value has meaning, but the
zero is arbitrary, e.g. temperature and
dates in calendar.
Ratio
Has all the properties of an interval variable
but a fixed known zero exists. Age, weight
and height are examples.
Organizing Data
Imagine having the blood pressure data
for a village population of 5,000 people.
Ultimately we want to describe the
characteristics of the given population
rather than each individual.
Example 1:
To find the median of 4, 5, 7, 2, and 1.
(Odd)
Step 1: Count the total numbers given.
There are 6 elements or numbers in the
distribution.
Step 2: Arrange the numbers in ascending
order. 1, 2,4,5,7
Step 3: The middle position can be
calculated using the formula.
(n+1)
2
6
2
(4+5)
=
2
Hand Size
= 3
No. of Staff
61/2
71/2
Example 2
To find the median of 4,5,7,2,1,8 (Even)
Step 1: Count the total numbers given.
There are 6 elements or numbers in the
distribution.
Step 2: Arrange the numbers in ascending
order. 1, 2, 4,5,7,8
Step 3: The total elements in the distribution
(6) is even.
As the total is even, we have to take average
of numbers at n and (n) + 1
2
2
6
Thus the positions are n =
=3
2
2
and 4
Measures of Variability
The other major way of describing data is
to measure the variability or dispersion.
Important measures of variability are the
range and standard deviation (variance):
Range
The range is the difference between the
maximum and minimum value. It is based
on only two observations, the smallest
and the largest. Even though it is easy to
calculate and understand, extreme values
can distort the range. To help limit the
effects of the extreme values at the end,
we can divide the population of interest
into equal groups or ranges.
Two commonly used ranges are interquartile range (4 equal parts) and percentile
range (100 equal parts). Having ordered
the data from least to highest, using the
percentile range, the 25th percentile would
include all data that is less than twenty five
percent of all the data.
MAD =
(Xi - X
n
(Xi - X)2
n
The formula would give the standard
deviation for a given population, but in
almost all cases, we deal with samples of
the population. The appropriate formula
for the standard deviation (sd) is thus:
11
13
)2 = variance
22.8 = 2.28
10
[Xi - X ] =
n
sd
(Xi - X)2
n-1
X2i - (Xi)2
n-1
Grouped Data
Faced with a mass of data, it is often better
to group them rather than work with
individual values. For example, below are
Qualitative Data
Discrete data is best presented graphically
using either, a pie-chart, a bar graph or a
histogram as illustrated in figure 3.1.
(Height)
165
160
155
150
145
140
0
1
Class
mid-point
Frequency (f)
(Students)
Fig.3.1: Bar graph showing height of students
Cigarette smokers
Cumulative
Pipe smokers
Quantitative Data
As discussed earlier, data can be either
discrete or continuous. Discrete or
category data such as a disease group or
presence or absence of specific symptom,
can be summarized as frequencies and
percentages. However, percentages alone
can be confusing, as the denominator may
be unclear. Rarely is it necessary to present
Presentation of Data
In presenting data, we must find a way that
communicates the maximum amount of
information efficiently. The most common
41
Bimodial distribution
f(z)
0.3
Frequency
0.2
-3
0.1
-2
-1
1.45 2
Statistical Inference
Skewed Distribution
Not all populations have a bell-shaped
curve and not all bell-shaped curves are
normal as illustrated below.
42
19
That is, 20 + 20 = 1
The third law states that the average of
the results obtained from a large number
of trials should be close to the expected
value, and will tend to become closer as
more trials are performed.
Normal distribution
A normal distribution is defined as normal if
the area under the curve between it and the
x-axis is equal to one. Between the mean
and is 0.34 (one standard deviation).
Area = Q
q
Signicance level
43
Binomial distribution
Binomial distribution is applicable where
we know that the probability of an event
occurring is p and therefore the probability
of it not occurring is q, where p -1 = q.
We can use two dice; one black the other
white to explain this. Suppose we were to
roll both dice at the same time, what is the
probability that each would give a score of
4? Because each dice has 6 surfaces, the
probability is 1/6 for each dice. For both
since they are independent of each other,
1
1 1
it would be 6 x 6 = 36 .
The rolling of the dice to give a 4 means
its not possible to score 1,2,3,5 or 6
i.e. each outcome is mutually exclusive of
the other. If we were to draw a bar graph
of all the possible scores from two dice,
we would have a graph that is very similar
to a normal distribution curve as shown in
fig. 3.6.
SD =
nX pXq
5/
6
=
=
Z=
=
500/
36
3.73
(16.6 -2)
3.73
-3.91
6
5
4
3
2
1
Fig. 3.6: Bar chart showing all possible scores from two dice
Suppose that p= 5 .
For each patient p+q =1. If there are 3
patients then (p+q)3
The probability that all three patients have
URTI would be:
2
2
2
5 X 5 X 5
2
=( 5 )3
8
= 125
3
5
Standard Error
If we have a true random sample, rather
than look at each individual sample measure
we can use various parameters such as the
mean, for study. Just like when we looked
at individual scores earlier we assume that
the populations are normally distributed,
the mean is known and so is the standard
deviation. But now we look at the mean
of a sample of the scores. It is crucial to
realize that for any given population, there
is a very large number of samples that can
be obtained that have the same mean and
SD.
Testing Samples
A random sample refers to a set of measures
each one of which is no more likely to
occur in the population from which the
sample is drawn than is any other similar
45
Sd x = sdx
n
Where Sdx is the sample standard
deviation and n is the sample size.
In biostatistics, the standard deviation of
the sample mean is called the standard
error (SE).
SE =
Where
is standard deviation
n is the sample size
Z = xm - x
SE
Where Xm is sample mean
X is the population mean
The Null Hypothesis
A hypothesis is a statement about
population parameters like expected value
and variance For example, Number of sex
partners of HIV positive clients is high or
the duration of the hospitalized stay for
HIV/AIDS patients is longer than that of
malaria patients.
In looking at new treatments or
interventions, we must always have in mind
the fact that not only can the intervention
be ineffective but it can actually cause
harm. Therefore, in research we adopt
a pessimistic attitude and assume that
the new treatment we are researching at
worst will not be harmful.
(Null Hypothesis)
Test decision
H0 true
H0 False
Accepted (TRUE)
OKay
Type II
Rejected (FALSE)
Type I
OKay
Levels of significance
In a one-tailed test if the Z-score from our
sample mean is associated with a probability
less than , then we reject H0 and accept
47
Hypothesis testing
and SEy = y
ny
2
Chi-Square
We often want to compare a discrete
variable found in two different sample
populations. Chi square test can be used to
determine if the differences in nominal or
categorical data are statistically significant.
The test examines the observed frequencies
Some primary
education
16
22
Completed
primary
25
21
46
Some
secondary
education
39
34
73
Completed
secondary
42
49
91
More than
secondary
education
31
25
56
Total
153
135
288
is the sum of
(O-E)2
E
Expected Numbers
Medical
Ward
(3)
O-E
Surgical
Ward
(4)
Medical
Ward
(5)
(O-E)2
E
Surgical
Ward
(6)
Medical
Ward
(7)
(4.31)
1.59
1.80
total
Surgical
Ward
(2)
11.7
10.3
22.0
4.31
24.4
21.6
46.0
0.56
(0.56)
0.01
0.01
38.8
34.2
73.0
0.22
(0.22)
0.00
0.00
Completed
secondary
48.3
42.7
91.0
(6.34)
6.34
0.83
0.94
More than
secondary
education
Total
29.8
26.3
56.0
1.25
(1.25)
0.05
0.06
153
135
288
2.49
2.82
Some
primary
education
Completed
primary
Some
secondary
education
2
= 2.49+2.82 = 5.13
Degree of freedom = 4
2
From the
table 5.31 lies between 3.357 and 7.779. The corresponding probability is: 0.50>P>0.10. This is well above the conventionally signicant
level of 0-05, or 5%. So the null hypothesis is not disproved.
49
From the
table (Appendix) entering at
4 degrees of freedom and reading along the
2
row we find that
of 5.31 lies between
3.357 and 7.779.
= 72.16
Confidence Limits
Paired Samples
In a clinic, we can take the blood pressure
of a patient using a digital or a manual BP
machine. Assume ten patients had their
blood pressures taken using both machines.
The results are as shown in table 3.7.
10
= 1.10
The interval extends either side of the
mean. AZ-value of 1.96 is associated with
50
Digital reading
Manual Reading
Difference d
Difference 2 d2
80
85
25
78
80
74
75
73
75
99
100
90
95
25
82
85
81
84
77
80
10
75
78
Total
mean
The standard deviation of the d-values is:
SD =
d2- d 2
28
10
= 63.3
17.6
9
1.956
SD =1.398
Independent Samples
In the above case, the samples were
dependent since we were measuring the
same person in different ways.
96
1.398
n
n-1
SD = 96 - 28
10
9
28
2.8
1
d
SD
n
51
Table 3.8
X
Men
x2
Men
X
Y
Men
x2
y2
women
85
90
100
100
115
115
118
120
122
125
135
22500
7225
8100
10000
10000
13225
13225
13924
14400
14884
15625
18225
1375
161333
1
2
3
4
5
6
7
8
9
10
11
12
100
110
115
120
122
125
135
140
140
145
150
10,000
12,100
13,225
14,400
14,884
15,625
18,225
19,600
19,600
21,025
22,500
150
Total
1402
181,184
Mean
127.45
114.58
SD
15.79
15.53
women
y2
D
Therefore SD = 17.28
Confidence Intervals
The interval in which the population
interval should lie can be calculated using
the following formula. Using the sample of
women blood pressure:
Standard error (SE)
= sd/n
= 15.53 12
= 4.48
52
Questions Section
1.
2.
3.
4.
Further Reading
1. Devane, D., Begley, C. M., & Clarke, M. (2004). How many do I need? Basic
principles of sample size estimation. Journal of Advanced Nursing, 47(3), 297-302.
2. Florey, Charles V. Sample size for beginners. British Medical Journal 306 (1993):
1181-4.
3. Overholser, B. R., Sowinski, K. M., Overholser, B. R., &Sowinski, K. M. (2007).
Biostatistics Primer : Part I. Nutrition In Clinical Practice, 22, 629-635.
53
DEMOGRAPHY
Introduction
9 billion
8 billion
7 billion
6 billion
5 billion
4 billion
2050
2040
2030
2020
2010
2000
1990
1980
1970
3 billion
1960
9
8
7
6
5
4
3
2
1
0
1950
Population (Billions)
10
YEAR
Source: U.S Census Bureau, International Data Base, June 2010 update
Country
Current
Population
2011
(millions)
Current
growth rate
Estimated
population
2025
(millions)
Kenya
41
2.5%
51
Uganda
34
3.6%
56
South Africa 49
-0.4%
48
Italy
58
-0.1%
56
Indonesia
245
1.1%
279
Brazil
203
1.1%
232
PT+ n
= PT + B - D + M
Where;
(Pt + n)
Pt
B
D
M
Population
change
= population today
= Population at a presence Pt in time
= Births
= Deaths
= Migrations
=Natural Increase (Birth, deaths) + Migration
(Net)
Age/Sex Structure
Dependency ratio
Northern America
0.49
South America
0.51
0.49
Eastern Africa
0.88
56
Stage 1
Stage 2
Stage 3
Stage 4
Birth Rate
Level of Technology
Population Growth
Pre-Industrial
Very Slow
Early
Industrial
Mature
Industrial
Rapid
Slowing
58
Post-Industrial
Very Slow
Description
Under-enumeration
Double enumeration
Misclassication of
information
Census
This is a complete enumeration of all
persons living in the country at a specified
time called the reference period. The
census is the source of benchmark statistics
on population size and age-sex structure.
Additional data collected include data
on social and economic factors such as
housing, environment, health, income, and
education and disease, such as HIV/AIDS.
Enumerating
non-eligible persons
Coverage area
Political interference
Obsolete results
Demographic variables
Sample Survey
NGOs sponsors
Source of
bench-mark statistics on size, spatial,
spread, density, fertility, mortality,
migration, HIV/AIDS, Orphan load,
therefore Population and Housing
census
Sampling population
which should be
representative of the
wider population not
covered. Avoid bias
Flexibility
techniques,
questionnaires to
methods used and
Sampling error
Biological factors
The oldest age to which a human being
can live is termed as lifespan. Lifespan is
almost entirely determined biologically
i.e. genetic. The oldest authenticated age
to which anyone ever lived is 122 years,
but the average age to which people live is
about 66 years.
This average is measured by life expectancy
and is greatly influenced by where in the
world we live. Longevity, which is the
ability to remain alive from one year to
60
Measures of Mortality
The mortality rate measures the extent
to which people are unable to live to their
full biological potential. The measure most
often used is the crude death rate (CDR).
CDR = total deaths in a year X 1000
mid year population
Urbanization
During the time of the industrial revolution,
cities were dangerous places to live.
Overcrowding and poor sanitation meant
that communicable diseases spread easily.
Today, urbanites in developed countries
tend to be better off with better access to
facilities and therefore lower mortality.
Social Status
Income has long been observed to be
a determinant of mortality. In addition,
a persons status in society has a bearing
on mortality such that the higher your
in society the longer you are likely to
live. Marmot studied civil servants in the
United Kingdom and identified the inverse
gradient of health with lower grade of job.
Education
The risk of death declines markedly with
increasing education. A post secondary
education halves the risk of dying when
compared to primary level. Education
gives women the knowledge to demand
and seek proper health care.
Occupation
Mortality rates for manual workers tend
to be higher than that of professional
workers. Certain jobs which are inherently
dangerous will have a higher mortality
rate.
Gender
Women generally live longer than men with
an average difference of 2-3 years. This is
important because it has several implications
for women. Married women tend to marry
men older than themselves artificially
increasing the time a woman outlives her
spouse. For individual women, this often
means living alone under poorer economic
conditions with fewer resources.
Fertility control
Fertility control is often thought of as being
synonymous with contraception. This is not
necessarily true. There are three phases to
fertility. namely; intercourse, conception
and gestation. For conception to occur,
fertilization must take place and for a baby
to be born, there must be a successful
gestation.
Fertility
Fertility refers to the number of children
born to women. The fertility rate in a
society is the accumulation of millions of
individual decisions on whether or not to
have children. This decision is influenced
both, biological and societal factors.
Biological factors begin with the physical
Female
Male
Couple
Barrier
Diaphragm
Cervical cap
Vaginal sponge
Female condom
Intra Uterine
Device (IUD)
Male
condom
abstinence
Chemical
(Precoital)
(normal)
Oral
contraceptives
Implants
Injectables
Chemical
(postcoital)
(normal)
Oral
contraceptives
Levonorgesterel
withdrawal
Fertility
awareness
Oral/anal
intercourse
Natural
Surgical
Tubal ligation
vasectomy
Measuring Fertility
In measuring fertility, we are measuring
the number of children that each woman
is capable of producing. The data for this
is usually obtained from a combination of
census, vital statistics sources and sample
surveys.
CWR=
X 1000
ASFR =
X 1000
X 1000
CBR =
Fertility control
What motivates people to control their
fertility? One hypothesis is that, if
individuals want to limit their fertility, then
three pre-conditions would have to apply:
I. the acceptance of calculated choice as a
valid element in marital fertility
2. the perception of advantages from
reduced fertility
3. Knowledge and mastery of effective
techniques of control. These factors
can exist even in the absence of a
mortality decline.
X 1000
Fertility transition
High fertility in a country is often explained
as a result of high mortality. Couples
have many children because they do not
expect all of them to survive to adulthood.
Children in such societies may be seen as
labour and eventually as old age security.
Migration
Globalization, the process by which the
world becomes more integrated in terms of
trade, travel, communication and education,
has led to increased travel and mobility
of the world population. The reasons for
population movement have become more
varied and the demographic make up of
these populations has also become less
homogeneous. The relationship between
health and migration is complex but can be
simplified into two broad processes.
Measuring migration
A
part from difficulties in defining
migration, further problems arise when
we try to measure migration. Unlike the
other two determinants of population,
there is neither natural limit to migration
nor a pre-determined pattern that people
follow. Many countries keep records of legal
immigrants. Obviously, illegal immigrants
are difficult to measure and countries
rarely have records of emigrants.
(total out-migrants)
Total mid year population
X 1000
X 1000
X 1000
Push-Pull theory
Older people
Divorced separated or
widowed at every age group
Married people
Ownership of property
women
69
Modifying
this theory, a household
approach argues that people will make
decisions at the household or family level
so that some members of the family may
migrate and remit some of their money
back home.
The dual labour market theory suggests
that, in developed countries, there are
two kinds of jobs. A primary market that
employs well educated people and pays
them well and a secondary market that
offers lowly jobs that pay poorly. The latter
jobs are unattractive to the locals but will
attract migrants. No single theory explains
migration fully.
Questions Section
1. What are the differences between a census and a sample survey. What are the main
errors likely to occur in collecting, analyzing and publishing data from either source.
How can such errors be minimized.
2. What are the advantages of sampling from a population
3. What is the theory of demographic transition.
How valid is the theory in understanding current population dynamics?
4. What are the main sources of demographic data
5. What are the factors that determine family size?
6. List 4 factors that distinguish migration from mortality & fertility.
7. What are the advantages and disadvantages of the defacto and dejure method of
enumeration during census
Further reading
1. Kenya Demographic and Health Survey (1998) Ministry of Planning and Development
2. The Demography of Health and Health Care. By. Louis G. Pol and Richard K.
Thomas. Kluwer. Academic/Plenum Publishers, New York, 2001.
4. UNFPA. The state of world population 2009 Facing a changing world : women,
population and climate. 2009 ;104
5. Sclar ED, Garau P, Carolini G. The 21st century health challenge of slums and cities.
Lancet. 2007 ;365(9462):901-3.1. The Demography of Health and Health Care. By.
Louis G. Pol and Richard K. Thomas. Kluwer. Academic/Plenum Publishers,
New York, 2001.
71
Human beings depend on a continuous supply of nutrients to survive. Having these nutrients in
the right quantities and the right balance is a prerequisite for good health. The consequences of
malnutrition in children can be irreversible if the condition begins before the age of two years.
Malnutrition increases vulnerability to disease and can make worse an already existing disease
such as malaria, diarrheoa and pneumonia. Conversely, good nutrition can help sick people
recover from poor health more quickly. Globally, more than one-third of post-neonatal child
deaths are attributable to under-nutrition.
Pregnant and breastfeeding women are especially prone to malnutrition disorders, as their bodies
need extra nutrients. Maternal malnutrition, involving a poor diet leading to anemia and other
micronutrient deficiencies contribute to high maternal and neonatal mortality rates. HIV-infected
mothers risk of dying is ten times higher than that of HIV negative mothers. Poor nutrition is a
major contributing factor.
Over nutrition is one of the contributing risk factors to the emerging epidemic of noncommunicable diseases (NCD). Many governments remain relatively complacent about the
existing levels of NCDs. A greater challenge is the future increases in prevalence of obesity,
diabetes, cardiovascular diseases and other complications that arise from NCDs. Some of these
increases can be attributed to lifestyle choices made by individuals and communities today. The
implications for the health system are huge.
This section will focus on the nutritional needs of vulnerable populations, the various diseases
(communicable and non-communicable), their causal factors, control and preventive interventions.
Thus, the section is divided broadly into nutrition, communicable and non-communicable
diseases. By the end of this section, the reader will be able to:
a) understand the nutritional requirements of vulnerable populations, infants, children,
pregnant women and people with HIV/AIDS
b) promote the role of breast-feeding as part of infant nutrition
c) understand the causes and consequences of malnutrition and be able to take steps to
prevent malnutrition
d) understand the public health management of micro-nutrient deficiencies
e) understand the concept of nutritional surveillance
f) understand the principles of communicable diseases control
g) outline the main measures taken to control an infectious disease
h) discuss the major ways to prevent an outbreak of a communicable disease
i) enumerate the major communicable diseases of public health concern
j) outline the common risk factors for non communicable diseases and
how they interact
k) enumerate the major non-communicable diseases of public health concern
l) understand the concept of risk factor surveillance (WHO Stepwise approach)
72
NUTRITION
Introduction
73
Nutritional requirements
Meats, poultry,
Fish, dried beans,
eggs, nuts
2-3 servings
Vegetables
3-5 servings
Notes
Energy
Fats
Proteins
Fibre
Water
Breastfeeding
For the first six months of an infants life,
breast milk is the perfect and complete food.
Breast milk is easy to digest and protects the
child against infections. Breastfeeding costs
less than artificial feeding. and is the natural
default for feeding infants. Breastfeeding
has several benefits :
It helps a mother bond with the baby.
Breast fed babies are less likely to
cry and more likely to have emotionally
satisfied and affectionate mothers
Breastfeeding for the recommended
six months helps in birth spacing
It reduces the incidence of uterine,
ovarian and breast cancer
Children who have been breast fed
perform better in intelligence tests in
Minimum requirement
Calories
Proteins
Iron
60mg /day
Folic acids
Potassium
1-2 g / day
Magnesium
250 mg 1g daily
Vitamin A
100,000 IU
Nutrient Malabsorption
Nutrient absorption can be impaired
especially during infection such as diarrhoea.
In almost all stages, malabsorption of fats
and carbohydrates is common. Patients
tend to be vitamin deficient compounding
the problem. There is increased oxidative
stress due to the absence of vitamins A, C,
B and Zinc.
6 12 months
There are several development milestones
to indicate an infant is ready to eat solid
foods. These include:
- The birth weight has doubled
- The baby has good control of head and
neck
- The baby can sit up with some support
- The baby can show fullness by turning
the head away or by not opening the
mouth
- The baby begins showing interest in
Strategy
Anorexia
Constipations
Bloating and
Heartburn
Diarrhoea
Anaemia
Nausea
Outcome
Inadequate dietary
intake
Insufficient
household
food security
Disease
Inadequate
health services & unhealthy
environment
Inadequate maternal
& child care
78
Immediate
underlying
determinant
Malnutrition in children
Malnutrition is a major health problem
in developing countries. Out of the 2
million children under 5 years who die
each year in developing countries, 55%
can be attributed directly or indirectly to
malnutrition.
Malnutrition
Macronutrient deficiency
Protein and energy malnutrition (PEM)
occurs when there is a deficiency in intake
of proteins and energy over a period of
time. Clinically, manifestations reflect a
79
Severe
WH < 70% or MUAC < 110 mm
Moderate/ severe
medical conditions
Moderate
WH 70-80% or MUAC 110-125 mm
No/minimal medical
conditions
In patient/stabilization care
with F75 & F100
No Oedema
Feeding well (good
appetite
Clinically stable
Supplementary feeding
Fig. 5.3: An algorithm for the diagnosis and management of of acute malnutrition
Marasmus
Prominent bones(ribs)
Skinny limbs
Loose skin (on lifting))
Loose skin around the
buttocks (buggy pants)
Severe PEM impairs mental and cognitive development. School-age children who suffered from early child-hood
malnutrition have generally been found to have poorer IQ levels,with reduced cognitive function, lower school
achievement and greater behavioural problems than matched controls and to a lesser extent, siblings. (A Review of
Studies of the Effect of Severe Malnutrition On Mental Development, Sally Grantham-McGregor )
80
Classification of PEM
PEM can be classified either by taking into
account only severe forms or by dividing
the cases into mild, moderate and severe.
Using weight for age, Gomez (1965),
classified PEM into three levels as shown
in table 5.4
Normal
90-110%
First degree
malnutrition
76-90%
Second degree
malnutrition
61-75%
Third degree of
malnutrition
< 61%
Height of age
(stunting)
Normal
>90
>95
Mild
80-90
90-95
Moderate
70-80
85-90
Severe
>70
>85
Oedema absent
80-60%
Kwashiorkor
Under malnourished
<60%
Marasmus
Marasmus
Proteins
2-5-g/-kg/ day
Iron
Folic acids
Potassium
1-2 g / day
Magnesium
250 mg 1g daily
Vitamin
A100,000 IU
Calories
Dietary Rehabilitation
Prevention and management of malnutrition
is complex. At community and policy level,
focus has been on:
Immunization
Girl child education
Promotion of growth monitoring for
child upto 5years
Micronutrient deficiency
Micronutrients are essential dietary
elements needed only in small quantities.
They include the trace elements such iron,
copper, zinc, iodine, selenium, magnesium,
cobalt chromium and vitamins. Most
micronutrients are classed as Type I, which
includes iodine, iron, Vitamins A and C.
83
Hyper vitamin A
Vitamin A
Vitamin A is a fat-soluble vitamin found
in meats, livers, dairy products and eggs,
fruit, green leafy vegetables and red palm
oil. Vitamin A has multiple roles within
the body. It is found in rhodopsin within
the retina and is needed for vision. It
also plays a role in foetal development,
hearing, the immune response, growth and
maintainance of healthy epithelial tissues.
Cause
occurs when there is
ingestion of repeated large
doses (>100,000 IU) very
closely spaced together
2) Chronic
occurs when there is
recurrent ingestion
of excessive doses of
Vitamin A over a period of
several weeks
3)Teratogenic occurs due to excessive
intake of Vitamin A during
pregnancy.
Vitamin A deficiency
84
Reason
Infants
Inadequate breastfeeding
School children
Poor diet
Seasonality
Infection
Prevention Strategies
Prevention is through health education.
Women of child bearing age should be
encouraged to eat a diet with plenty of
vitamin A.
Iodine
Twenty-nine percent of the worlds
population, living in approximately 130
countries, is estimated to live in areas
of deficiency. One billion people in the
world suffer from iodine deficiency. Iodine
deficiency occurs primarily in mountainous
regions where iodine has been washed
away through glaciation and flooding and in
lowland regions far from the oceans, such
as Central Africa and Eastern Europe.
Daily requirement
Infants
50g
Children
2-6years-
90g
7-12years
120g
12years
150g
200g
Maternal Nutrition
Malnutrition is an intergenerational
problem. Failure to tackle the problem
of malnutrition in the mother can lead to
not just the mother begin affected but her
children as well.
Obesity
Steps
Change physical environmnet to support active commuting and space for recreational activity
Ensure walking, cycling and other forms of physical activity are accessible and safe
Improve sports, recreation and leisure facilities (sports for all)
Increase safe spaces for active play
Desired
88
Nutritional Surveillance
Intrauterine
growth
retriction
Infections
Poverty
Social and
political contexts
Micronutrients
deciences
Disability
Increased
exposure to
infections
Food security
Poor access to
or update of
services
Chronic
undernutrition
(Stunting)
Reduced
energey
intake
Severe acute
malnutrition
Breastfeeding
Death
Infection
Fig. 5.6: Conceptual model of pathways to death and disability from malnutrition
90
Nutritional
status
Z score
Wasting
Stunting
Underweight
BMI(kg/m2)
Principal cut-off
points
Additional cut-off
points
Underweight
<18.50
Severe thinness
<16.00
<18.50
Moderate thinness
16.00 - 16.99
16.00 - 16.99
Mild thinness
17.00 - 18.49
17.00 - 18.49
Normal range
18.50 - 24.99
18.50 - 22.99
23.00 - 24.99
Overweight
25.00
Pre-obese
25.00 - 29.99
Obese
30.00
Obese class I
30.00 - 34.99
30.00 - 32.49
32.50 - 34.99
Obese class II
35.00 - 39.99
35.00 - 37.49
37.50 - 39.99
40.00
<16.00
25.00
25.00 - 27.49
27.50 - 29.99
30.00
40.00
Oedema
91
Food security
SOCIO-ECONOMIC
AND POLITICAL
ENVIRONMENT
National Level
Population
Education
Macro economy
Policy environment
Natural resources
Agricultural sector
Market conditions
Sub-national level
House hold
characteristics
Livelihood systems
Social institutions
Cultural attitudes
CARE PRACTICES
Child care
Feeding practices
Nutritional education
Food preparation
Eating habits
Intra-household food
distribution
FOOD
AVAILABILITY
Trends & level)
Production
Imports (net)
Utilization
Stocks
STABILITY OF FOOD
SUPPLIES AND ACCESS
(Variability)
Food production
Incomes
Markets
Social/cultural
ACCESS TO FOOD
(Trends & levels)
Purchasing power
Market integration
Access
FOOD
CONSUMPTION
Energy intake
Nutrient intake
HEALTH &
SANITATION
Health care
practices
Hygiene
Water quality
Sanitation
Food safety &
quality
NUTRITIONAL
STATUS
FOOD
UTILIZATION
BY BODY
Health status
Fig. 5.8: Determinants of food consumption and nutritional status: a conceptual framework
92
Questions Section
Further reading
93
COMMUNICABLE DISEASES
Introduction
POPULATION
age
genetic susceptibility
nutritional status
previous exposure
immunisation status
physical condition
AGENT
Virulence
Infectious dose
Susceptibility to drugs
mode of transmission
ability to adapt to
change
vector
ENVIRONMENT
Shelter
attitude
Humidity
Sanitation
Food supply
water supply
temperature
overcrowding
essential services
Agent Transmission
On escaping from the reservoir, the
agent has to be transmitted to a new
host. Transmission can either be direct
or indirect. For many agents, this period
of transmission is a vulnerable period and
the shorter the period of transmission the
greater the chances of survival.
Control Measures
immunity is achieved.
The herd immunity threshold is the
proportion of a population that must be
immunized in order to cease an epidemic
and impart indirect protection to those
without personal immunity, thereby
preventing the spread of a disease. For
example, measles is highly infectious and so
the level of vaccination required to provide
herd immunity in the population is 95%.
In the reservoir
If the reservoir is non-human, then the
entire reservoir can be destroyed, e.g. rats
in case of plague or wild dogs in the case
of rabies. If the reservoir is human, then
treating the person eliminates the agent
e.g. in TB treatment. In a disease such as
TB the reservoir and the host are one and
the same.
Characteristic
Desired quality
Safety
Protection
Cost
Administration
97
Surveillance of communicable
diseases
Displaced Populations
Displaced populations often have high
level of risk factors for communicable
diseases. According to the International
Committee of Red Cross between 5195% of deaths in refugee populations can
be attributed to communicable disease.
The displaced population also increase the
risk of communicable disease spread to the
Acute emergency
phase
Post emergency
phase
Predisposing factors
insufcient shelter,
indoor air pollution
(smoke from cooking
fuel and cigarettes),
overcrowding,
poor access to health care
tuberculosis, meningitis
98
Host
age (<2 years and > 65
years),
low birth weight,
breast-feeding, poor
practices, malnutrition,
vitamin A deciency,
incomplete immunization,
Low maternal education.
Epidemic thresholds
The importance of having a good
survelliance system is to be able to predict
when an epidemic has began. This can be
done by:
keeping track of weekly incidence rates
and comparing them to those of the
previous month or season may
improve prediction.
Comparing the disease incidence rate
or attack rate (the proportion of
those exposed to an infectious agent
who become clinically ill) to the
epidemic threshold (the minimum
number of cases indicating the
beginning of an outbreak of a
particular disease).
Registration of case
Standard case definitions are used to
diagnose and record common health
problems affecting the population. This
helps to accurately monitor the disease
trends and make better estimates of
required resources. If standard case
definitions are used at several locations
or by different relief agencies, disease
trends among different populations can be
compared.
Notification
Standard case definitions are used to alert
national health authorities about outbreaks
of notifiable diseases (diseases for which
regular, frequent, and timely information
on individual cases is considered necessary
for the prevention and control of the
disease).
Malaria
100
Human liver
stages
1 schizont
Mosquito stages
9 Mosquito stages ruptured
Oocyst
10
Mosquito takes a
blood meal (injects
sporozites)
2 Ruptured
schizont
8
Oocyst
7
Mosquito takes a blood
meal
(injects gametocytes)
Human blood
stagses
3
schizont
4
Gamotocytes
Ruptured
schizont
5
Fig. 6.2: Life cycle of the malaria parasite
More than 250 million people suffer from malaria and it is responsible for more than one million deaths per year, most
of them children in sub-Saharan Africa. A major initiative to eradicate malaria was the launch of the Global Fund to
Fight AIDS, Tuberculosis and Malaria which was created in 2002 following a UN General Assembly Special Session
on AIDS in June 2001. Its mandate is to provide signicant amounts of new resources to allow affected countries to
respond forcefully to the formidable challenge caused by AIDS, TB and Malaria cause six million deaths every year.
From 2002 until 2007 a total of US$ 7.6 billion for 136 countries have been approved to combat the three diseases. In
2011 it had approved funding of US$21.7 billion for more than 600 programs.
Global: www.theglobalfund.org/en/about accessed 15.2.2011.
101
Differential
immunity in
human
population
Climate
Incidence and
parasitemia
in human
population
Regional
climate
% of bites on
% of mosquitoes
infected humans that surviving
infmosquito
sporogony
Local habitat
suitability
Vector control
Human vector
exposure
Vector control
Personal
protection
measures
No. of bites
per human
per day
ma
Housing &
socio-economic
variables
a/g
R0
No. of
human
bites per
mosquito
l/r
Duration of
human infection
Medical systems
and services
Personal
protection
measures
Housing &
socio-economic
variables
% of bites by
infectious mosquitoes Differential
that infect a human
immunity in
human
population
Transmission parameters
Incidence and parasitemia
in the mosquito population
102
Amoebiasis
Entamoeba histolytica, a protozoa, has a
worldwide distribution but is prevalent in
the tropics where there is poor sanitation.
It exists either as a trophozoite or in cyst
form. Its main habitat is the large intestine.
Diarrhoeal diseases
Infective food
poisoning
Protozoa
Clostridia
Rotavirus
Giardiasis
Bacillus cereus
Campylobacter
Amoebiasis
Staphylcoccus
Salmonella
Cryptosporidium
Rotavirus,
Amoebiasis
(Entamaoeba
Histolytica) and typhoid (Salmonella typhi)
are the three major causes of diarrhoeal
disease.
Reservoir
Humans are important reservoirs but
Entamoeba histolytica can also be found in
raw unwashed vegetables and in untreated
water. Transmission can therefore occur in
a number of ways including:
Through cysts which are passed in the
stool of a healthy carrier.
Direct person-to-person
- through contaminated fingers into
contaminated food.
Water borne, through untreated water.
The cysts can survive ordinary chlorination
of water and therefore treatment should
include water filtration.
Pathogenesis
The trophozoites can either be
in
vegetative or invasive forms. The invasive
form invades tissues of the intestines causing
minute ulcerative lesions particularly in the
caecum and ascending colon. Following an
incubation of 8 to 10 days, infection runs a
variable course and may be asymptomatic
or may start with abdominal discomfort,
mild looseness of bowels developing into
severe amoebic dysentery with recurrent
bouts of bloody mucoid stool.
103
Carriers (no
dysentery)
Dysentery
Trophozoite
Cysts
104
106
Asymptomatic
phase
Cholera
Cholera is an acute diarrhoeal disease
characterized by painless, effortless
watery diarrhoea and subsequent vomiting
with rapid onset of dehydration. The
agent is Vibrio cholerae and there are
two main biotypes, Classical and El-tor.
They have slightly different epidemiology
presentation with El-tor being responsible
for most current epidemics. They are more
resistance to treatment and therefore have
more carriers.
The seventh pandemic started in 1961
spreading via the Middle East to become
endemic in Africa. It reached South America
in 1990. A new serotype 0139 established
itself in Bangladesh in 1992 thereby possibly
starting a new pandemic.
107
Helminths
Reservoir
Ascaris lumbricoides (Round worms)
are the most common especially in the
developing countries where sanitation is
poor. Ascaris is a large worm and measures
15 to 35cm in length with the female on
average being larger. It inhabits the small
intestines and eggs are laid and passed out
as immature ova containing un-segmented,
undifferentiated embryo.
Development of the embryo takes places
over a period of three weeks in damp soil
and is temperature dependent. The eggs
do not hatch in soil and human beings are
the sole reservoir, usually children.
Pathogenesis
Infection is via ingestion of eggs from
contaminated soil. Viable eggs have been
found in soil after more than 10 years.
108
Reservoirs
Humans are the reservoirs and transmission
is normally acquired via the skin from
infective filiariform larvae. In rare cases,
eating uncooked meat containing larvae
can cause infection. Human milk is a very
rare source of infection. This occurs when
migrating larvae are arrested in their
development and migrate to the mammary
glands in a lactating mother.
Hookworm
Two species with different geographical
spread occur commonly. Necator americanis
predominates in Central, Eastern and
109
110
HIV/AIDS
Risk of Transmission
>90%
15-40%
0.5 1%
0.2 0.5%
<0.1%
Writing together in the New England Journal of Medicine the two state Many lessons can be drawn from this early
intense period, and most suggest that science requires greater modesty. Our experience with AIDS underscores the
importance of basic research, which gave us the technical and conceptual tools to nd the cause less than three years
after the disease was rst described It has also become clear that nding the cause of an infectious disease is the
alpha but not the omega of its eradication. The identication of HIV has allowed us to eliminate transmission of the
disease through the transfusion of blood and blood products, create rational policies for prevention, and design efcient
antiretroviral therapies. These therapies are not a cure, however, and the epidemic is still growing in many countries for
lack of accessible treatments and preventive vaccines. Moreover, we must recognize that we are still far from having
exhausted the list of potential new pathogens. Finally, one lesson that should be clear is that effective collaboration
among groups of scientists and clinicians is essential and that it is possible to achieve such collaboration without
excluding a certain dose of the competitive spirit as a stimulant .
The Discovery of HIV as the Cause of AIDS, Robert C. Gallo, M.D., and
Luc Montagnier, M.D., N7 Engl J Med 2003; 349:2283-228
112
The world HIV epidemic peaked in 1996. More than 25million people have died of AIDS since 1981.As at 2009,the
number of people living with HIV globally stands at 33.4 million and lthough 2.7 million people became newly infected
with HIV in 2008, this is a decrease by 17% over the last eight years.
Source: UNAIDS 2010
113
Tuberculosis (TB)
Reservoir
The human body is the reservoir for
mycobacterium tuberculosis while for
mycobacterium bovis it is both human and
cow. The bacilli are transmitted through
air droplets. Infection usually occurs when
people are in close proximity.
Repeated closeness is usually required
for infection to occur, for example, in
overcrowded poor quality housing. The
organisms can remain suspended in air
for several hours and TB therefore usually
spreads among family members, close
friends and work mates.
Transmission in an aeroplane has been
documented but is rare.
Pathogenesis
The probability that tuberculosis will be
transmitted depends on a number of
factors including the:
quantity of bacilli inhaled
Environment in which exposure
occurs;
Duration of exposure; and,
Virulence of the organism.
There are two major patterns of the
disease. In the first degree tuberculosis, the
initial infection is usually seen in children.
114
UNAIDS and Millennium Villages Project taking steps toeliminate mother-to-child HIV transmission in Africa On
January 11th 2010 Michel Sidib, Executive Director of UNAIDS, and Jeffrey Sachs, Director of the Earth Institute
and Special Advisor to United Nations Secretary-General Ban Ki-moon, visited one of the Millennium Villages in
Sauri (western Kenya) to witness rst-hand efforts to virtually eliminate mother-to-child HIV transmission. UNAIDS
and the Millennium Villages Project joined forces in September 2009 to strengthen prevention of mother-to- child HIV
transmission (PMTCT) services at the village level with the aim of creating MTCT-free zones. In the Millennium
Villages, PMTCT services are integrated within the maternal-child health package and a continuum of care is offered to
the mother from the antenatal period through delivery and the postnatal period. Levels of HIV testing among pregnant
women in the Millennium Village siteshave increased from 10% at baseline to over 60% in three years. The UNAIDSMVP partnership will further improve on these gains by decreasing the incidence of HIV among women, meeting needs
for modern contraceptives and blocking transmission from mothers to their babies.
www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/
2010/january/20100111prunaidsmvp/ accessed 15.2.2011
115
Schistosomiasis
Reservoir
S. Haematobium is and S. intercalatim
confined to Africa and Middle East while
S.Mansoni is found in Africa, the Middle
East and South America. S. haematobium
is principally a human parasite while
S. Mansoni is common to humans and
baboons. S. japonicum and S. intercalatim
have a wide range of hosts including
humans and domestic animals.
Pathogenesis
Transmission is by penetration of intact skin
by cercaviae. For transmission to occur
three conditions must be met. First, there
must be contamination of fresh water with
urine or faeces containing schistosomal
eggs. Secondly, the right snail species must
be present in which miracidium are capable
of development. Thirdly, there must be
human contact with the water. The main
forms where humans come into contact
with water where snails are present are in
irrigation schemes and domestic use.
The life cycle consists of two alternating
generations in the host and in fresh water
snails.The adult fluke worm is flat and
leaf-like with an oral sucker with which
it attaches itself to the wall of the vessel
where it lives within the human body. The
male is folded to form a gynaecopheric
116
+
Adult
male/female
schistosomes
Egg laying
S. japonicum (A)
S. mansoni (B)
S. Haematobium
Skin penetration of
denitive host
(see right panel)
Cercariae
released from
snail
Sporocyst
(replication in
snail)
Migrate against
blood ow to inferior mesentric
veins
Eggs released
in stool
Miracidium
Skin residence
(hours to days)
Penetration of veins
Travel to pulmonary
capillaries (lung stage)
(48-72 hours)
119
Geography
Reservoir
Notes
B. abortus
Africa, Asia,
South America
Cattle
Cause of
spontaneous
abortion
in animals
B.
melitensis
Middle East,
Africa, India,
Central Asia,
South America
Goats and
sheep
Causes
most
severe
disease
B. suis
South Asia
Pigs
Associated
with abscess
formation
Reservoir
In Africa, the first two species are the
principal agents. The disease is zoonosis
from animals with goats (B. melitensis) and
cattle (B. Abortus) as the main reservoirs.
The pregnant animal is the most susceptible
and in cattle, the organism lodges in the
uterus causing abortion hence its name.
Pathogenesis
Transmission to humans is by ingestion of
un-pasteurized milk or via respiratory tract
or ocular route by direct contact. Once in
the body, it localizes in the regional lymph
glands where they proliferate causing
necrosis.
Once in the blood, they are carried into the
liver, spleen and lymph glands. Following
an incubation period of 7 to 21 days, there
are symptoms of weakness, fatigue, fever
and chills. The most characteristic feature
is temperature that rises and falls in a step
like fashion when charted over 7 -10 days.
Pathogenesis
Ebola and Marburg are considered the
most severe VHFs; with mortality rates
ranging from 25 to 100%. Approximately
1% of individuals exposed to the RVF virus
120
Example
Area found
Host
Transmission
Arenavirus
West Africa,
Small eld
rodents
Filoviruses
Central Africa
Vector unknown
Bunyaviruses
Mosquito bite
Flaviviruses
Karnataka, India
121
122
Questions Section
Further reading
123
NON-COMMUNICABLE DISEASES
Introduction
124
Individual
Background, age, education,sex, genetic
Behavioural, smoking, diet, physical
inactivity
Intermediate, cholesterol, obesity
Community
Socio-economic status (SES) (the poor
dont seek healthcare have poor diet
etc), poverty and unemployment,
Environment includes, climate, air
pollution, heavy metals such as lead in
petrol and paint and water pipes
Culture, practices, norms, values
Urbanization, type of housing, access
to foods/ products
Workforce composition, less women at
home.
The risk factors are interactive, addictive
and synergistic.
126
127
Diabetes mellitus
Type II diabetes:
Formerly called adult-onset diabetes, is the
most common form of diabetes. It usually
develops in middle age and begins with
peripheral tissues like muscle and fat cells
developing insulin resistance. Initially, the
pancreas is able to produce the additional
insulin required but eventually it loses the
ability to keep up and diabetes develops.
Type 3 diabetes:
This develops in some women during
the late stages of pregnancy. Usually, the
diabetes resolves with the birth of the baby.
However, gestational diabetes predispose
to the development of type II diabetes
later in life.
Burden of disease
Diabetes is a major cause of premature
mortality, stroke, cardiovascular disease,
peripheral vascular disease, renal failure
as well as long and short-term disability.
In addition, persons with diabetic
complications have a lower quality of life
compared to persons without diabetes.
World Health Reports put diabetes in fifth
place in terms of cause of death ranking after
communicable diseases, cardiovascular
disease, cancer, and injuries.
Even in the poorest countries, at least
one in twenty adult (3564 years of age)
deaths is diabetes related, and in most
countries, the proportion is substantially
higher. In developing countries, mortality
due to diabetes is dominated by infections
and renal failure rather than the coronary
artery disease and cerebrovascular disease
experienced in developed countries .
Risk factors
The diabetes epidemic closely parallels the
worldwide epidemic of obesity. Numerous
epidemiologic studies have suggested that
128
Symptoms
Classical symptoms of hyperglycemia polyuria (excessive urination); polydipsia
(thirst); nocturia (nocturnal urination);
lethargy; weight loss. Type I classically
presents in younger age groups with an
acute onset.
130
131
Cancers
132
133
Detection method(s)
Evaluation goal
Basic
Limited
Enhanced
Maximal
Lifestyle risks
Anthropometric measures specifically
height, obesity and high body mass index
are risk factors especially in postmenopausal
women. Alcohol and diets rich in saturated
fat raises the risk while smoking does not
appear to affect the risk.
Radiation exposure
Exposure to ionizing irradiation increases
the risk of developing breast cancer.
Patients receiving radiotherapy and X-ray
technicians have been noted to have a
higher incidence of breast cancer.
Genetics
A family history of breast cancer increases
a womans risk of developing the disease.
134
135
Beneciaries/Target Groups
Process Indicators
Smokers
Potential smokers (especially the
youth)
Smokers
Smokers
number of ex-smokers
137
The FCTC, WHOs rst international treaty, was adopted by WHO member countries in May 2003. It commit all
countries that ratify it to: eliminate all tobacco advertising, promotion and sponsorship within 5 years (with a narrow
exception for nations whose constitutions prohibit a complete ban); require warning labels occupying at least 30% of
the area of cigarette packs (and suggests 50% or more); prohibit misleading tobacco product descriptors such as light
and mild; and protect nonsmokers from tobacco smoke in public places. The FCTC also urges strict regulation of
tobacco product contents; higher tobacco taxes, global coordination to ght tobacco smuggling, and promotion of
tobacco prevention, cessation and research programs.
WHO framework on Tobacco control. (2005)
138
Complications
Cardiovascular diseases, including ischemic
heart disease and cerebro-vascular disease,
are leading causes of morbidity and
mortality worldwide. Cigarette smoking is
the leading cause of fatal household fires.
Tobacco agriculture causes substantial
environmental damage from provision
of farmland for growing tobacco and
deforestation for curing the product.
Prevention and control
Efforts to reduce smoking face formidable
obstacles mainly nicotine addiction
combined with social pressures, aggressive
cigarette marketing and promotion. Other
pressing health problems cause affected
individuals and communities to relegate
tobacco related illnesses. Policy makers
overestimate the economic importance of
tobacco.
Many smokers want to quit and while
most quit without help, nicotine addiction
makes quitting very without. Quit rates can
be substantially increased through advice
from health care providers, telephone
quit lines, formal and informal supportgroups, and cessation therapies including
nicotine-replacement (NRT). Over-thecounter(non-prescription) sales improve
access to NRT. In addition, there exists
many potential opportunities for cessation
advice and support within the health
system.
Costs
Tobacco does not serve any basic human
need therefore, the purchase price of
tobacco is an immediate cost to the user
without corresponding benefit. Employers
bear an economic burden from employee
smoking through more employee
absenteeism
decreased
on-the-job
productivity (presenteeism) increased
139
140
141
Speed calming
142
This
includes
physiotherapy
and
occupational therapy. Many victims require
lifelong care to prevent infection and
psychosocial support.
Costs
Nantulya, Muli-Musiime (2001), suggested
that the cost to the economy as a result of
RTAs is approximately 1-2% of countrys
Gross National Product (GNP). Directly,
individuals suffering from injuries and
disabilities will incur costs of medication.
They are not economically productive and
most of the times incapacitated to work.
Indirect costs include those arising from
the resulting disabilities, both physical
and psychosocial which can be a very
high burden to the patient, family and the
community.
In developing countries, the cost of
improving vehicles may be high, relative to
expenditure on health cares, so the effect
of including such activities in the definition
of the health system may be greater.
As mentioned above, unsafe roads also
contribute greatly to the vehicular toll in
poorer countries.
However, the cost of improving roads could
be much larger than the cost of making cars
safer. Behavioural changes such as using
seat belts once installed, and respecting
speed limits, are nearly costless and could
save many lives; they are very likely to
Mental illness
143
144
145
146
Questions
1. Describe the major non-communicable diseases of public health importance.
2. Identify the major risk factors that non-communicable diseases have in common.
3. Outline the major public health strategies to control non-communicable disease risk
factors.
4. Discuss why developing countries suffer from a quadruple disease burden.
5. Why is the WHO stepwise methodology ideal for poor resource settings?
Further reading
1. Anderson BO, Yip C, Ramsey SD, Bengoa R, Braun S, Fitch M, et al. Breast cancer
in limited-resource countries: health care systems and public policy. The breast
journal. 2006 ;12 Suppl 1S54-69.
2. Brown ML, Lipscomb J, Snyder C. The burden of illness of cancer: economic cost
and quality of life. Annual review of public health. 2001 ;2291-113.
3. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annual
review of public health. 2008 ;29273-95.
147
PART III:
The environment describes everything that makes up our surroundings both living and nonliving.
Concerns about environmental health date from ancient times. Access to clean water was
evidenced by archaeological remains of water and sewage lines date back more than 4,000 years.
Today we are aware of the continued threat to public health from various environmental hazards.
The impacts of these hazards can be local or global. Climate change, poor sanitation, pollution of
water supplies and food safety are the major areas of concern. Different societies have developed
different ways of adapting environmental impact on health. The most important factors that
determine health are hereditary, environmental, lifestyle and medical care.
The social environment, how society is organized and the social and community networks that an
individual has influence their health status, how, when and what type of healthcare they access.
For example Gender discrimination, low levels of female education, and lack of empowerment
prevent women from seeking care, having the autonomy to make decisions, and accessing the
best choices for themselves and their childrens health, resulting in critical delays and unnecessary
deaths. Educated women are less likely to die in childbirth. Adults will spend a great deal of their
life at the workplace. The work environment therefore needs to be conducive to maintaining
and possibly improving health status. The safety of the workplace is therefore a key concern.
Identifying then understanding the occupational risks and interventions that will reduce these risks
is the major concern of occupational health practioners. Much of the effective work in promoting
worker safety is done through policy and law.
Understanding the linkages between the environment and health and what is needed to predict,
prevent and monitor the environmental hazards is of great importance. By the end of this part
the reader should be able to:
a) list and describe the factors that influence health seeking behaviour
b) describe the characteristics of the sick role
c) discuss the difference between anthropological and biomedical models of health
d) explain the role of culture in health care
e) understand the role of gender in health care
f) appreciate the role of the environment in determining health status.
g) outline the relationship between water and good health
h) understand the concepts in providing proper sanitation
i) outline the principles of food hygiene
j) discuss the growing problem of environmental pollution and how it affects health
k) explain how urbanisation affects health status appreciate the nature and scope of
occupational health.
l) outline the approaches to occupational health
m) list the major occupational risk factors and hazards
n) discuss the challenges in ensuring occupational and health safety standards in a
developing country
148
MEDICAL SOCIOLOGY
Introduction
149
Expression
Discovery
methods
Artefacts &
behaviour
expressions of
tradition, clothing,
customs
Observation
Interview &
survey
Assumptions
often unspoken or
unconscious
Inference &
interpretation
Anthropological
Health and illness are largely previewed
as cultural phenomena, based on cultural
ideas of disease causation that are largely
personas. e.g. attributes of ill-health
to witchcraft, the evil eye, taboos and
transgression (e.g. of child malnutrition
and HIV/AIDS in selected communities and
supernatural falsest (leading to fatalism and
resignation).
151
152
LD
Fig. 8.3:
154
155
156
Gender
157
158
159
160
Questions
1. Debate the role of culture in health. What models help explain health seeking
behaviour?
2. Describe the sick role and explain the importance of the concept.
3. Explain the difference between anthropological and biomedical models of health.
4. Summarize the health belief model.
5. Describe the doctor-patient interaction in the context of how it affects patients
wellbeing
Further reading
161
Introduction
IC
EMon
H
s
i
C Po ins s
ox rgie
T lle
A
Environmental
health
incorporates
the evaluation and control of those
environmental factors that affect health. It
is aimed at creating healthy surroundings
that prevent disease According to WHO
environmental hazards are responsible
for about a quarter of the total burden of
disease worldwide, and nearly 35% in subSaharan Africa.
As many as 13 million deaths can
be prevented every year by making
our environments healthier. Proper
environmental management is the key
to avoiding the quarter of all preventable
illnesses which are directly caused
by environmental factors. Whereas
environmental science tends to address
how human beings affect the rest of the
biosphere, environmental health focuses
on how the environment affects human
health.
PS
S YCH
B tress OLO
GI
D ored
CA
A iscomom
L
nxi
ety fort
HEALTH
SOCIOLOGY
Overcrowding
Isolation
PHYSICAL
Vibration, Radiation
Noise, Humidity
Thermal
Stress
Illumination
ENVIRONMENTAL HEALTH
BIOLOGICAL
Animal
Insects
Microbiological
Vegetation
162
163
State
(Natural hazards,
resource, pollution)
Exposure
(External exposure,
absorbed dose)
Action
Economic and
social policies
Clean technologies
Risk management
and communication
Environmental pollution
monitoring and control
Education/ awareness
Treatment/
rehabilitation
Effect
Morbidity, mortality, well being, etc
Fig. 9.2: The DPSEEA model
165
166
167
168
Description
Effects on
health
Radioactive
radon
Formaldehyde
Asbestos
Combustion gases
carbon monoxide
Lung damage
Colourless,tasteless gas, formed during combustion
Long exposure lung disease
Nitrogen dioxide
169
170
Types of spoilage
Causative microorganisms
Fresh meat
Putrefaction
Souring
Fish
Discoloration
Putrefaction
Pseudomonas
Chromobacterium, Halobacterium, Micrococcus
Poultry
Odour, Slime
P. alcaligenes
Eggs
Green rot
Colourless rot
Black rot
Fungal rot
P. uorescens
P. alcaligenes
Pseudomonas
Proteus
Penicillium spp,
Pseudomonas spp.
Botryitis cinerea
Rhizopus nigrican
Penicillium spp
Aspergillus niger,
Saprophytic bacteria
Sugar products,
Honey, Syrups
Pink syrup
Green syrup
Mouldy
Aerobacter aerogenes
Saccharomyces, Torula,(yeast)
Pseudomonas uorescens
Aspergillus, Penicillium
Bread
Rhizopus stolonifer
Penicillium
Bacillus spp.
171
Example
Chlorinated pesticides
Organochlorines
Classied as persistent
organic pollutants
DDT(insecticide)
Endrin (rodent control)
Dieldrine (insecticide)
Carbamates
(Household insecticides)
Carbofuran
Aldicarb
organ phosphorous
Organophosphates
(Agricultural insecticides)
Malathion
Parathion
Fumigants
(Agricultural fumigant
pesticide)
Methyl bromide
Neurotoxic.
Readily absorbed through lungs.
Is a cumulative poison. Because it is an odorless gas victim may
not realize exposure. Under US law Methyl bromide is a Class 1
ozone-depleting substance.
Botanicals
(natural insecticides
produced by chrysanthemum
plant)
Pyrethrines
Pyrethroids (semisynthetic
derivatives)
Food Preservation
172
In 2008, melamine poisoning was reported to have occurred in China. Six babies died and more than 300,000 children
were affected. China recalled more than 170 tons of milk powder after authorities found some batches of tainted dairy
products ordered to be destroyed in 2008 had instead been redistributed.
Ningxia Tiantian Dairy Co. was shut after a police investigation found it had repackaged and sold more than 164 tons of
milk powder tainted with the chemical melamine, the China Daily newspaper reported, citing the local government.
Melamine is a chemical used in the production of plastics that can also be used to make the protein levels of watereddown milk appear higher.Ningxia Tiantian, based in the northwestern province of Ningxia, was a small company and
couldnt afford to buy a machine needed to test for melamine, the English-language China Daily reported, citing Zhao
Shuming, Secretary-General of the Ningxia Dairy Industry Association.
Dairy companies in the province, which depend on selling their products to other regions, are in panic about how the
recall will affect their businesses, the newspaper cited Zhao as saying
http:// www.businessweek.com/news/2010-02-08/ china-recalls-more-melamine-tainted-milk-in-crackdown- update1.html.Accessed 11.10.2010
Fig. 9.3: The steps that food undergoes from production to consumption
Monitoring observations,
measurements of control
parameters to assess whether
a ccp is under control
Collective action-action to
be taken when monitoring if
results indicate loss of ccp
6. Establish verication
procedure
Verication-application
methods ,procedure
compliance with HACCP
modication
7.Establish determination
procedures
174
Urbanization
Environmental pollution
177
Questions
1. Illustrate how the DEEPSEA model can be used to analyze an environmental health
problem
2. Outline the relationship between water and health
3. Describe the process of solid waste management in urban and rural areas
4. Explain the principles of food hygiene
5. Discuss the role of housing standards in maintaining good health status
6. Outline the concept of HACCP. Apply the priciples to a common food that you buy
Further Reading
178
Introduction
In 1775, Percival Pott of Saint Bartholomews Hospital in London described scrotal cancer as an occupational cancer in chimney
sweeps. At that time chimney sweeps were small boys who could t in the chimneys. The soot to which they were exposed has
similar carcinogens to those found in tobacco smoke. Evidence that radiation exposure causes cancer came from an observed higher
incidence of cancer among radiologists. Certain injuries like repetitive stress injuries are more common among ofce workers sitting
at computers.
179
following:
All workers have rights. Workers as
well as employers have rights that must
be protected. To the worker, these
include the right to work in a safe and
health working environment.
In each workplace occupational health
and safety policies must be established.
Such polices must be communicated to
all parties concerned.
Prevention and protection must
be the aim of occupational health and
safety programs
Compensation, rehabilitation and
curative services must be made
available to workers who suffer
occupational injuries, accidents and
work related disease.
Education and training are vital
components of a safe healthy
working environment
Workers, employers and government
have certain responsibilities, duties
and obligations. For example, workers
should follow established safety
procedures, employers must provide
safe workplaces and government
must communicate and review policy
as appropriate.
Policies must be enforced.
There must be consultation among all
stakeholders
Challenges in occupational
health and safety
180
181
PHYSICAL
Vibration
Radiation
Noise
Humidity
Thermal
Stress
Illumination
CHEMICAL
Poison
Toxins
Allergens
Health
hazard
c. determining the population that is
at risk of the hazard
d. Devising strategies and interventions
to ensure prevention. These include
hazard/risk elimination, substitution
or containment. In addition, the
time that a worker spends exposed
to the risk can be reduced
e. Monitoring and evaluating the
effectiveness of preventive measures
put in place (health surveillance
programs)
2. Protecting workers with disability
or pre-existing illness. This involves:
a. Pre-employment assessment.
Having clear previous medical history
b. Indentifying pertinent risk factors
c. Designing appropriate job
placement and work modifications
e.g. a person with chronic bronchitis
or asthma should not be place in an
environment where attacks will be
triggered.
3. Promoting health in the workplace.
This involves:
a. Specific health promotion related to
that workplace. For example, the
dangers of working in a factory
with machinery that can cause injury
b. General health advice as the
workplace offers a captive audience.
For example bank, workers need
182
advice on non-communicable
diseases as their jobs are relatively
sedentary.
Occupational hazards
Chemical hazards
There are thousands of toxic chemicals
associated with work and environments.
These chemicals can exist in either, solid,
working liquid or gas. Exposure can lead
to development of acute or chronic health
conditions. The exposure can be either a
large dose at once or cumulative in small
doses over time.
Exposure to low doses of various toxic
chemicals can lead to accumulation in
various tissues and is associated with
development of chronic conditions. For
example, exposure to dust can lead to
pneumoconiosis.
The response to a chemical hazard can be
either acute or chronic. This depends on a
number of factors such as the:
dose-response relationship
genetic make up
sex
age, children and the elderly tend to
be more affected
chemical substance
Biohazards
Health
outcome
Mode
of transmission
Healthcare workers
Blood-borne pathogens
(HIV/AIDS, hepatitis,
Haemarraghic viruses)
Infection
injection
Farmers, slaughterers,
veterinary
workers, sugarcane
plantation
workers
Brucellosis
Anthrax
Byssonosis
Inhalation
skin contact
Leptospirosis
inhalation contact
183
route of exposure
duration of exposure.
Lead
Lead has been in use for thousands of
years. However, it is only in the second half
of the 20th Century that there has been
understanding of how little lead is needed
to cause harm. Routes of exposure to lead
include air, water, soil, food, and consumer
products. Lead has many uses in industry. It
is included in the manufacture of batteries,
paint, ceramics and glass. At the beginning
of the 1920s, Lead was added to petrol as
a catalyst to aid combustion.
Accidents
An occupational accident is defined as one
that occurs either at the workplace or on
the way or from the workplace. Accidents
have causes and do not occur naturally. An
accident may occur when work is being
undertaken and a proper risk assessment
has not been done. Accidents are classified
as fatal (leads to death), major, (Worker is
off duty for long and lost some body part
or minor. By law, all fatal or major accidents
should be reported to the authorities. For
example in Kenya to the directorate of
occupational services in the Ministry of
Labour.
Accidents can be caused through
carelessness or due to the inherent
processes being undertaken. There is
an interaction between the individual
and the environment, which includes the
organizational culture. Carelessness can be
due to faulty machines, which are either
not manufactured properly or not serviced
184
186
Db
Effects
150
120
Human pain
thresholds
100
Temporary hearing
loss
Vuvuzela
127
associated
with permanent
noise-induced
hearing loss
Vacuum cleaner
70
INTERVENTION
SOURCE
PATHWAY
RECEIVER
Prevention
Because hearing loss can be irreversible,
prevention of accidents and ill health in
the workplace requires innovative and
constant health promotion and education.
Medical examinations
Annoying
STIs Test
Family history
Social history
Physical examination
Respiratory function
tests
CXR
Cardiac Function
tests
ECG
SGPT, SGOT,
Others
Work
involving
risks to
health
Medical
examination
required
Examination
intervals
Indications
for redeployment
and
notication
to the director
OHS
Handling
animals,
animals
products,
eterinary
work
Clinical
examination
Reemployment
and annually
All case of
denite or
suspected
zoonotic
disease
Where
asbestos is
handled
Medical
examination
and clinical
examinations
Lung function
Full sized
chest X-ray
Sputum
cytology
Reemployment
and annually
Progressive
deterioration
in chest x-ray
ndings and
suspected or
diagnosed case
of asbestosis
Handling
fossil fuel
Clinical
examination
Reemployment
and annually
Those with
any abnormal
dermatological
or respiratory
symptoms
Work where
ionizing and
non ionizing
radiation
Clinical
examination
Reemployment
and annually
Arboreal
visual
or clinical
signs
Work
involving
exposure
to lead bits
compounds
Clinical
examinations
Blood lead
level
Reemployment
and annually
Repeat
depending on
the blood
lead
level
Cases of
suspected
lead poisoning
especially with
lead levels
of >70 ug
/ 100 ml for
males and
>50um/100ml
for females
Cases of
suspected
lead
poisoning
especially
with
lead levels
of >70 ug
/ 100 ml for
males and
>50um/
100ml
for females
Audiometric
examinations
Reemployment
and annually
Denition or
suspected
noise induced
deafness and/
or cases with
deterioration
of hearing loss
of 20dbor
more in two
successive
examinations
within two
weeks
188
Photosensitivity
This is an abnormal reaction of the skin
to sunlight and it exits in two forms;
photo toxicity and photo allergens. Photo
toxicity can affect anyone but occurs more
frequently in Caucasians. Photo allergens
occur because of an abnormal skin immune
response resulting from exposure to
chemicals.
Personal protection
The use of Personal protective equipment
(PPE) by workers minimizes occupational
risks or hazards. However, there must be
continual health education and supervision
to ensure that PPEs are used properly at
all times. Workers must understand the
risks involved and this can be done through
provision of material safety data sheets.
These outline how to deal with specific
hazardous materials and what to do in the
Workers with dry skin are likely to adsorb chemical such as solvents, disinfectants than those with oily skin.
Perspiration
If one sweats a lot, they are more predisposed to skin infection due to breakages in the skin when itching is
most common at armpits and genital areas.
Seasons and
humidity
If temperatures at working areas are high there will be a lot of people with skin disease. Humidity comes
with itching and rashes with cause skin disease.
Poor personal
hygiene
Causes of occupational and non occupational skin disease where humidity is a problem, provided showers
for workers.
Hereditary allergy
(atrophy )
People prone to allergies are more likely to get occupational skin disease.
190
Use
Ear muffs
Protects feet
Gloves
191
Discussion questions
1.
2.
3.
4.
5.
Further Reading
192
Health is a right. Therefore, the way in which healthcare is provided to everybody in society
is a crucial element in the development process of the country. Healthcare encompasses
both clinical individual care and care at the population level. Provision of healthcare includes
taking care of those who are already ill and preventing those who are healthy from falling ill.
The healthcare provided should be equitable, effective and efficient and this is influenced by
how the health services are financed and structured. Health care services can eliminate risk
factors, reduce disease incidencesprolong life and postpone death, thus leading to improved
quality of life in society. Provision of healthcare encompasses a broad spectrum of issues which
include: mapping and needs assessments to ascertain levels of healthcare needs, development
and implementation of a sustainable health policy that will promote effective management of
health services and facilities in the country. This section is divided into the following chapters
where the main issues of health care provision are discussed in details: health policy, health
economics, management of health services and health promotion. By the end of this section,
the reader should be able to:
a) describe the steps in the health policy process
b) identify and list t he key factors taken into consideration formulating health policy
c) outline a framework for policy analysis
d) describe the components of a health system
e) describe the elements needed to have a responsive health system able to deliver quality
healthcare
f) define the terms demand, supply, market and how they relate to healthcare
g) discuss market failure in healthcare
h) equity in health and how it can be applied in health services
i) list the different methods of health care financing and understand the comparative
advantages of each method
j) enumerate methods of economic evaluation
k) outline the management process and the role of a manager
l) enumerate the steps in the planning cycle
m) apply different decision making models to the management process
n) appreciate the importance of organizational structure in delivering on set goals
o) understand the essentials in human resource management
p) understand the principles of monitoring and evaluation
q) list the different approaches to health promotion
r) outline the different models of health promotion theories
s) discuss the risk approach to health promotion
t) discuss the role of health education in a community
u) outline the role of school health in health improving population health status
193
HEALTH POLICY
Introduction
What is Policy?
194
Policy
formulation
Policy
evaluation
Policy
implementation
Fig. 11.1:The policy cycle
Policy Analysis
CO NTENT
Fig. 11.2: Policy analysis triangle.
196
PROCESS
Micro -process
Private sector
stakeholders
Civil society
stakeholders
Bureaucracy
(civil servants
and various
departments)
Companies
Organized
religion /churches
Elected
representatives
(members of
parliament,
senators,
councilors)
Business
associations
Universities/
schools
Political parties
Professional
associations
Trade unions
Local
government
Individuals
International
NGOs
Military
Community
organizations
Judiciary (courts)
Media
Multinational
bodies (world
bank, UN)
197
High
Keep satised
Engage closely
and inuence
actively
POWER
Monitor
(minimum effort)
Keep informed
Low
Low
INTEREST
High
198
grouped as follows.
SITUATIONAL. The size of the
economy of a country or a particular
region has great influence on health.
How economic incentives are
structured and how much money is
allocated to the health sector;
structural. The political and
economic structure in place who has
the economic power, who controls
the income, the media, etc;
cultural. Denotes the values of
society. Where the society is culturally
heterogeneous, it is often difficult
to have uniform societal values; and,
exogenous. Includes factors such as
international agreements, international
donors that may influence, affect
the power of actors and political and
economic systems to act in certain
ways.
199
Questions
Further Reading
1. Walt, Gill, Health Policy, An Introduction to Process and Power, fourth Impression
2000,(Johannesburg, Witwatersrand University Press, 2000)
2. Gilson, Lucy, and Nika Raphaely. The terrain of health policy analysis in low
and middle income countries : a review of published literature 1994 2007. Health
Policy and Planning (2008): 294-307.
3. Gwatkin, Davidson R. 10 best resources on . . . health equity. Health policy and
planning 22 (2007): 348-351.
4. Ministry of Public Health and Sanitation. Kenya Health Policy Framework 1994 2010 Analysis of Performance Health Situation trends & distribution : 1994-2010 ,
And Projections for 2011 2030. Nairobi, 2010.
5. World Health Organization. Who pays for health systems? In: World Health Report
2000 chapter 5. Geneva: 2000.
200
Introduction
Health policies are formulated and
implemented to direct the health system
of a country. How good or poor the health
system is defines how successful a country
is in improving the health status of its
citizens. Individual interventions known to
work such as immunization can fail when
the various components of the health
system are not functioning properly. Poor
health systems have been cited as one of
the major factors causing poor health in
developing countries despite considerable
investment in vertical programs such as
HIV/AIDS and malaria.
It is therefore important not only to
have an understanding of individual
components of the health system but also
an understanding as to how the system is
organized and interlinked. Today, there are
growing expectations that every person is
entitled to access to healthcare and that
there should be ways in which the sick and
the very poor are protected against the
financial costs of ill health.
This concept of entitlement to healthcare
and financial protection against ill health is
relatively new and involves a considerable
shift in the economic burden of ill health.
Where a person has no access to healthcare
and has no form of insurance against ill
health, when they fall ill, it is the household
that bears the burden. This burden is both
direct in terms of lost income and indirect
as people have to take care of those family
members who are unwell, sometimes
having to sell family assets. In such a
scenario where it takes time to access care
201
Stewardship
People entrust their health and their money
to the health system with little recourse if
service is of poor quality. The level of trust
between the consumer of health services
and the provider therefore needs to be
high. This is why the ultimate responsibility
for health services in a country has to be
with the government.
The care and management of the health
of the population is a core mandate of any
government. The ministry of health must
therefore be the institution responsible
for stewardship of the health system.
Financing
As discussed earlier how the health system
is financed has a significant bearing on
how well the system performs in terms
of its core objectives. Financing has three
aspects to it. The system must be able to
collect the financial resources it needs to
meet its objectives.
On the flip side, it must be able pay the
various providers efficiently and in a manner
that aligns health providers to meet the set
goals and ensures equity for all. Thirdly, it
must be able to protect the health system
users against financial catastrophe arising
from ill health.
202
System building
blocks
Over goals/
outcomes
Health workforce
Improved health
(level and equity
Information
Medical products,
vaccines and
technologies
Financing
Leadership /
governance
Responsiveness
Quality
safety
Improved
efciency
203
Human resources
204
205
206
Questions
Further Reading
1. Lee, T. H. Turning Doctors into Leaders. Harvard Business Review, April 2010
2. Managers who lead: a handbook for improving health services.
Management sciences for health 200De Savigny, Don. Systems Thinking for Health
Systems Strengthening. Alliance For Health Policy And Systems Research,
World Health Organization, Geneva, 2009.
3. World Health Organization. HEALTH SYSTEMS AND SERVICES Annual Report
2009. World Health. 2009 ;
4. World Health Organization. The World Health Report 2000 Health systems:
improving performance. World Health. 2000 ;215.
5. Zaleznik A. Managers and leaders. Are they different? Harvard Business Review.
January 2004 ; 74-81.
6. Longest, Beaufort B.,Darr, Kurt, Managing Health Services Organizations and
Systems, 5th Ed., (Health Professions Press, 2000)
207
HEALTH ECONOMICS
Introduction
Scarcity of resources
208
209
convention, the price is on the vertical yaxis while the quantity is plotted on the
horizontal x-axis.
A demand schedule such as the one above
assumes that all the other factors that
could affect the demand are being held
constant.
20
50
16
100
12
150
200
250
Supply
Supply is the amount of goods that sellers
are willing and able to sell. Just like in
demand, the price is a key determinant of
how much will be supplied.
As the price goes up, the quantity supplied
will increase and as the price falls so will
the quantity supplied. This relationship is
called the law of supply.
Market equilibrium
When the supply curve and demand curve
are put together, there is a point when
the two curves intersect. This point is the
market equilibrium or market clearingprice. At this point (price), the quantity of
goods that suppliers are willing and able
to sell matches the quantity of goods that
buyers are willing and able to buy.
The interaction of demand and supply
determine the equilibrium prices of goods
and services and by doing so resolve the
three basic questions: what, how and for
whom. The market thus decides on how
much of a commodity is to be produced
by providing or setting the price at which
quantity demanded is equal to quantity
supplied. The market tells us who the
goods are being produced for and who
is willing and able to pay the equilibrium
price. The graph can be used to predict
market prices.
211
212
Health economics
Demand
Gross (1972), produced a formula that
sort to explain the demand for health.
In the formula he hypothesized various
factors that would influence health care
seeking behaviour and therefore in effect
the demand for health.
Defining health
Health is difficult to define in concrete
universally acceptable terms. The world
health organization, WHO defines
health as: a state of complete physical,
mental, social, economic well being of an
individual and not just absence of disease
of infirmity (WHO 1948). This is a clear
definition but difficult to measure.Different
communities have different perceptions of
what constitutes health. As
discussed earlier the doctor may have a
different view of health from the general
population.
Factors that influence an individuals health
status can be grouped into four.(Lalonde
Report) These are
1. Genetic factors (biology)
2. Lifestyle choices
3. Environment the individual lives in,
4. Consumption of health services &
goods.
Health economics tends to focus on looking
at health services rather than health. This
is partly because it is so difficult to agree
on a measurable definition of health. The
assumption is that, since we each know
about our health, when it is not there
100% then we will seek health services, to
restore us back to full health. By studying
the demand and supply of health services
214
Occupation hazard
Working in an occupation that is high risk
healthwise would lead to an increased
demand for healthcare.
Demand for health services
While the above factors influence how
much health a person demands, there are
barriers that can prevent a person from
accessing healthcare. The most obvious
barrier is the cost of healthcare and in
almost all countries public health systems
are built around the tenet that demand
for health should be based on need, not
on willingness to pay. Demand for health
will then differ in definition from the classic
definition for demand found in classic
economics. The cost of healthcare incurred
by a patient can be divided broadly into
three:
1. The fee charged by the health provider;
2. Costs incurred by the patient in
accessing the care including travel
and time away from work
3. Intangible costs such psychological
costs and pain. These can be quite
difficult to quantify. There are other
barriers to accessing healthcare.
In any structured health system, formal
barriers exist.
Referral policies exist.
Referral policies are necessary in
order to have a planned functional
health system but can have the effect
of denying a patient a particular service
at a particular time.
Principal-agency relationship.
Unlike in classic economics, rarely
do patients access healthcare directly.
Often, the patient is aware of the
symptoms but requires someone else,
the doctor, to interpret the symptoms
and signs.
The type and quantity of healthcare
demanded therefore depends on the
215
Moral hazard
In healthcare systems where the payer for
the health services consumed is someone
other than the patient, there is a problem
of excess demand. Such an instance
arises, for example in an insurance based
scheme and is known as moral hazard.
More healthcare is demanded than would
be the case in a perfect market. This is
because the consumer does not incur any
cost in demanding additional healthcare as
it is covered by insurance. Moral hazard
has two sides to it.
The consumer moral hazard arises because
insurance lowers the cost of being ill thus
the incentive be healthy is reduced.
Additionally at the point of service, care is
free and so expensive health services can
be ordered and the patient is happy with
this. The price of healthcare at this point
has no meaning.
Provider moral hazard occurs when the
provider is paid based on a fee for service.
The more services provided the more
money the provider makes. This holds
where the price of the service is higher
than the competitive price. Where the fee
is below the competitive price there is an
incentive to under provide care.
This means expensive city-based doctors
have a tendency to induce excess demand
for health services among their patients
while poorer rural health service have
a tendency to reduce demand for health
services.
Supply for healthcare
The supply of healthcare is dependant on
how the healthcare system is organized
operationally and how it is financed.
In a classical market, the suppliers and
consumers of goods communicate through
216
217
218
As part of structural adjustment programs in the 1980s a number of countries including Kenya introduced cost sharing as a way to help
mitigate falling government nancing. Apart from generating additional revenue the funds would be used by the facility to improve the
quality of care and reduce frivolous demand for healthcare. However over time it has been shown that cost sharing denies access to the
very needy, is inefcient to collect cost of collecting the funds often more than the amount collected and encourages corruption.
(Ref HEALTH POLICY AND PLANNING; 11(1): 52-63 D COLLINS et al).
219
Cost sharing
The theoretical argument for cost sharing
follows from the earlier discussion on
markets and market failure. In a perfect
market, there is no need for insurance
as all the information that is needed by
the consumer is available at the time of
purchase. However, when the consumer
does not pay for healthcare costs, there is a
tendency to consume more than is actually
needed because treatment decisions
are made without regard to the financial
costs.
Care that is high cost and low or no benefit
may be chosen. In a fee for pay system
the care provider may have incentive to
inflate costs and therefore healthcare is
not cost-effective and excessive healthcare
may be provided. However, cost effective
care is only useful if people already use the
service. Where service utilization is low as
in many SSA countries, the major challenge
is to increase utilization.
WHO has recognized this need, and in its
World Health Assembly resolution 2005
WHA 58.33 called on all member states to
plan the transition to universal coverage
of their citizens. The difficulty for policy
makers is how to raise sufficient funds to
pay for the necessary services without
excluding the poor and vulnerable. In
the 1980s, developing countries found
themselves with reduced public sector
budgets due to donor-lead structural
adjustment programs (saps). Following the
publication of an influential World Bank
report by (Akin et al 1987), about financing
of health services, user fees seemed to be
a magic bullet. Introducing user fees would
see three major benefits:
1. Additional revenue would be generated
for the health sector, possibly upto
1520% of operating costs.
220
Income levels
Cost sharing has a disproportionate financial
impact on people with low income.
Health status
Cost sharing may cause those with chronic
conditions requiring repeated visits to cut
back on services. This can impact patients
such as HIV patients on anteretroviral
drugs. Cost sharing done across the board
reduces access to care and affects those
most vulnerable, the chronically ill and
those with low incomes.
221
Questions
1.
2.
3.
4.
Discuss the factors that affect demand and supply for health services
Illustrate with an appropriate health services example, a perfect market
Identify the factors that cause market failure in healthcare
Define the concept of equity as it applies to provision of health care system in a
country
5. List the different methods of financing health care
Further Reading
222
Introduction
Defining management
223
Control
Organizing
Leading
225
Informational
Tasks
Figurehead
Leader
Encourage employees
Liason
Monitor
Disseminator
Send memos
Spokesperson
Communicate with
external world
226
Skills needed
Diagnostic
Middle level
1st line
operation
Finance
Administration
Information ow
Conceptual
Top Strategic
Human Resource
Operational
Other
Technical
Ethics
227
5. Measuring
6. Evaluation
Are we there
yet?
Is there a better
way to get there?
Do we need to go
further?
How will we
know when we get
there?
2. Objectives
Where do
we want to go
Why do we
want to go
there?
What do
we need to
do to get
there?
Getting there-putting
all the talk into action
3. Actions
4. Implementation
228
Key information
Source
Geography
Area
Climatic conditions
Noteworthy? E.g.
mountainous, by the
sea.semi-arid
Routine data
Demography
Population numbers
Age, sex,
Fertility rate, birth/
death rate (IMR,
MMR)
Census,
Demographic
Health Survey
(DHS)
Structure of
the economy,
employment,
income levels and
distribution,
Economic survey
Socioeconomic
situation
Key informat
interviews
Education/ literacy
levels
General
infrastructure
Education/ literacy
levels
Roads, Transport
electricity/water
Communication
schools
Government
reports
survey
Health
infrastructure
facilities, type,
services offered
Health facility
data survey
Health
indicators
Staff(no/type of
nurses, doctors and
other medical )
Routine data,
DHS
MOH reports
Decision making
The breadth and depth of information
gathered depends on what type of decision
is needed. Decision making is about
choice. First, there must be sufficient
information to define the problem, then
have alternatives to choose from based on
a certain criteria.
Decisions
made can
be either
programmed,
that is fairly structured
and recur regularly e.g. continue treating
pneumonia with antibiotic. Some can be
non-programmed where the decision is
relatively unstructured and occurs less
frequently.
229
230
Disadvantages
Increased information/
knowledge available
Increased costs
Increased communication
of decision may result
Increased acceptance of
nal decision
Strategic planning
231
Weaknesses
Threats
Goal setting
Because a strategy is a three to five year,
plan those developing a strategic plan need
to think beyond their daily activities and
project their goals imagining success after
the plan is complete.
Having a brainstorming session to set
targets is an ideal way to start. Goals are
critical to organizational effectiveness
because:
They provide guidance and unified
direction
Effective goal setting result in to
good planning
They serve as source of motivation
Useful monitoring and evaluation.
Ideally, goals should be SMART. That is
Specific Measurable Achievable Realistic and
Time bound. Very often, people interpret
achievable or realistic to set low targets.
The impact of the pace of technology is
underestimated when setting goals to be
achieved in say 5 years time.
For example mobile telephony use has
increased exponentially in the last five
years. Having a strategic plan that does not
take into account the potential use of such
a tool is probably a waste of time. Doing
a good analysis helps overcome such
myopia.
Operational Planning involves the
development of a schedule of activities, the
resources required and the time needed.
The format of plan may sometimes vary
according to the organization undertaking
the activity or the organization funding
the activity. A budget is an example of an
operational plan.
232
Tactical Goals
Operational
plans
Measurable Indicators
Means of verication
Important assumptions
GOAL:
Wider problems the project
will help resolve
Quantitative ways of
measuring or qualitative
ways of judging timed
achievement of the goal
PURPOSE:
The immediate impact on the
project area or target group
i.e the change or benet to be
achieved by the project
Quantitative ways of
measuring or qualitative
ways of judging timed
achievement of the purpose
(Purpose to goal)
External conditions if
achieved project purpose is to
contribute to reaching project
goal
OUTPUTS:
These are specically
deliverable results expected
from the project to attain the
purpose
Quantitative ways of
measuring or qualitative
ways of judging timed
production of outputs
(Outputs to purpose)
Factors out of project control
which, if present, could
restrict progress from outputs
to achieving project purpose
ACTIVITIES:
These are tasks to be done to
produce the outputs
INPUTS:
This is the summary of the
project budget
(Activity to output)
Factors out of project
control which, if present,
could restrict progress from
activities to achieving outputs
233
234
Disadvantages
Job redundancies
235
236
By function
Hospital
Director
Finance
Department
Human Resource
Department
Inpatient
Department
By Client/purpose
Director
Child welfare services
Director
Reproductive Services
Director
Water & Sanitation
By geography
Medical Ofcer
East division
Medical Ofcer
West division
Medical Ofcer
South division
237
Leadership
A successful leader is one who can
understand peoples motivation and enlist
employee participation in accomplishment
of a goal. The ability to influence people
to perform towards a certain goal depends
on the amount of power that the leader
has. There are different sources of power.
table 14.6. In all cases for the power to be
legitimate it must flow from the persons
formal position within the organization.
Responses to use of power
How people respond to the use of power
depends on a number of factors. People
are more likely to follow influential and
strong leaders than weak and isolated
ones. Four organizational factors can affect
a managers power:
1. Rules inherent in the job(less rules
more power)
2. Reward for innovation (more means
more power)
3. External Contact (more means more
power)
4. Senior Contact (More means more
power)
Description
Personal
Positional
Reward Power
Authority to use
organizational resources
including support of seniors
Coercive Power
Forceful, insistent,
determination
Authority to invoke
norms and values of the
organization s culture
Expertise
(technical)
Expertise
Power
(administrative)
238
Description
Commentary
Internalization
Target internally
agrees with
decision or request
and makes great
effort to meet it
successfully
Usual most
successful outcome
from point of view of
inuencer, esp. if task
is difcult
Compliance
Target willing
to do task but is
apathetic & make
minimal effort
may be OK for
routine tasks, but for
complicated tasks
may be unsatisfactory
Resistance
Target is opposed
to request &
actively avoids
the task
Level 5: Executive
Builds enduring greatness through a
paradoxical combination of personal
humility and professional will.
Motivation
The purpose of behaviour is to satisfy
needs. A need is anything that is required,
desired, or useful. A need arises when there
is a difference in self-concept (the way I see
myself) and perception (the way I see the
world around me). A want is a conscious
recognition of a need. Motivation is the set
of processes that moves a person toward
a goal. It is important to understand what
motivates people in order to get people
to perform towards the goals set for an
organisation.
There are various factors that affect
motivation at work including:
individual differences - personal needs,
values, attitudes, interests and abilities
job characteristics - the aspects of the
position that determine its limitations
and challenges.
organizational practices-the rules,
human resources policies, managerial
practices, and rewards systems of an
organization
There are two primary approaches to
understanding motivation.
1. A content approach that focuses on
the assumption that individuals are
motivated by the desire to fulfil inner
needs.
2. Process approach that focuses on
external influences or behaviours
that people choose to meet their
needs. The emphasis is how and why
people choose certain behaviours in
order to meet their personal goals. An
example is Vrooms Expectancy Model.
Maslows hierarchy divides needs into
239
Maslows hierarchy
of needs
Motivators
Achievement
Recognition
Work itself
Responsibility
Advancement
Personal growth
Hygiene
(maintenance) factor
Status
security
Relation &
subordinates
Personal life
Relationship with peers
Salary
Work conditions
Relationships with
supervisor
Company policy &
administration
Supervision
Herzbergs motivators
and hygiene factors
240
Supervisors
Requests
(Stimulus)
Employees
Dehaviour
(Response)
Positive
Recognition
(Reward)
Future Positive
Behaviour from
request
(Reinforcement
Fig. 14.7: The Reinforcement Process
Routine Problem
Complex conditions
Implementation requires
learning new approaches and
practices and being exible
as new conditions emerge
Collaborative work by
several stakeholders is
required to achieve the
solution
241
242
2. Storming stage
Change management
243
Commitment.
Communicate
the urgency
by framing the
challenge clearly
Complacency, people will not be mobilized to change if they think that everything is ne the way it is. They
need to understand the challenge they are facing and how it affects their work and their organization
Going it alone. If there is not a group of early adopters who are committed to change, it will falter in
the face of oppositions. Include key stakeholders and authority gures on the change team in order to get
organizational buy in
Crate a shared
vision
Lack of commitment. If the vision is not created together with all of the stakeholders, there is no clear picture
of the path towards a desired future and energy and commitment will be dispersed. Be inclusive in creating the
vision
Include others in
planning
and
implementation
Lack of involvement. If the vision is not communicated clearly and regularly and used as a guide for shared
planning, it will not have an impact on organization activities. Engage others in creating the implementation
plan.
Overcome
the obstacles
together
Demoralization. When obstacles remain in place and little or no effort is made to remove them, people will not
be able to sustain the energy to continue. Work to identify the root cause of obstacles and overcome them
Focus on results
and crate short
term wins
Lack of sustained effort. When people o no see any positive results in the short term, it is hard to keep them
engaged. Focus on results and how to achieve them.
Maintain
support for
facing ongoing
challenges
Shifts in attention. While the rst positive results may be encouraging, they are not a substitute for lasting
change. The risk of declaring victory too soon is that peoples attention shorts to something else and the effort
to keep the change moving is lost. Continue to frame the new challenges.
244
245
Finally,
evaluations have limitations.
Having an evaluation done does not
guarantee change nor does it automatically
lead to wide disclosure of information.
An evaluation can often be a threat to
underperformers and can divert attention
on the necessary changes by focusing on
trivia. Ultimately it is the beneficiary who
can judge success
247
Questions Section
1. Define the key management processes
2. Describe the steps in planning health activities
3. Explain the steps in organizing
4. Interpret the role of power in being a successful leader
5. List the available methods for monitoring and evaluating health service programs
Further reading
1. World Health Report, 2006 WHO,
3. Economics of health care financing, the visible hand, Cam Donaldson and Karen
Gerard 2nd edition, 2005
Cost sharing: a blunt instrument, dahlia K. Remler, Jessica Greene, Annu. Rev.
Public Health 2009. 30:293-311
Private health insurance in developing countries Mark v. Pauly et al, Health Affairs
Vol 25, No 2, 2006
4. World Health Organization. The World Health Report 2000 Health systems:
improving performance. World Health. 2000
5. World Health Organization. HEALTH SYSTEMS AND SERVICES Annual Report
2009.
6. Managers who lead: a handbook for improving health services.
Thinking for Health Systems Strengthening. Alliance For Health Policy And
Systems Research, World Health Organization,
Geneva, 2009.
7. Lee, T. H. Turning Doctors into Leaders. Harvard Business Review, April 2010
8. Zaleznik A. Managers and leaders. Are they different? Harvard Business Review.
January 2004 ; 74-81. World health report, 2010, WHO
248
HEALTH PROMOTION
Introduction
249
250
Disease
prevention e.g.
seat belt legislation
for road users
Health
education e.g.
behaviour
Health protection e.g.
legislation
251
Relapse
Contemplation
(returns to previous
Contemplation
pattern of behaviour)
Contemplation
maintenance
Contemplation
(actively maintaining
(weighing the pros and cons)
change)
Preparation
(active changes
putting decision
into practice)
254
Population
approach
Risk estimate
Example
High
Mother to child
transmission
Moderate
Smoking ten
cigarettes per
day
Low
Road Accident
Very Low
Leukaemia
Minimal
Between 1:100,000
and 1:1,000,000
Vaccination
associated polio
Negligible
Over 1:1,000,000
Hit by lightning
Disadvantages
Intervention
appropriate to
individuals
Subject
motivation
usually high
staff (medical)
motivation
usually high
Limited potential
for population
population health
improvement
Can be a cost
effective use of
resource
Seeks to remove
the root cause of
the problem
Population
Only a small benet
for most individuals
(prevention paradox)
Poor motivation for
most subjects
Large potential
for population
improvement
Behaviourally
appropriate
as it seeks to
shift population
norms
Advantages
Health education
256
School health
257
In the mid 1990s WHO launched a global school health initiative, seeking to mobilize and strengthen health promotion and education activities at
the local, national, regional and global levels. The initiative is designed to improve the health of students, school personnel, families and other members
of the community through schools. The goal of the initiative is to increase the number of schools that can truly be called Health-Promoting Schools.
Although denitions vary a Health-Promoting School can be characterized as a school constantly strengthening its capacity as a healthy setting for
living, learning and working.
A global alliance including Education International, Centers for Disease Control and Prevention, Education Development Center, UNESCO, UNAIDS
and NGTZ has been formed to enable teachers representative organizations, worldwide, to improve health through schools.
258
259
Questions
1.
2.
3.
4.
5.
Further Reading
1. Davis RM, Wakefield M, Amos A, Gupta PC. The Hitchhikers Guide to Tobacco
Control: a global assessment of harms, remedies, and controversies. [Internet].
Annual review of public health. 2007
2. French J, Adams L. From analysis to synthesis: Theories of health education Health
Education Journal. 1986 ;45(2):71-74.
3. U.S. Department of Health and Human Services. Theory at a glance: A guide for
health promotion practice. 2005
260
Planning and implementing cost effective health programs and activities require an accurate
assessment of public health problems and priorities. This requires an in depth knowledge
of the community, that is a community diagnosis. Carrying out a community diagnosis
enables the collection of information that can be used to determine the epidemiology of
disease within the community and list the key factors that influence the identified disease
pattern. The health status of the community is then known allowing targeted health
interventions and the setting up of health services that are responsive to the needs to the
community that they serve.
By the end of this short section the reader will be able to create a community survey plan
be able to conduct a community survey.
261
Introduction
herbal medicine.
Perceived poor or excellent service.
One good clinician may motivate more
patients with a particular condition to
go use the facility. For example, a
diabetic clinic might have large
numbers but that does not mean
the prevalence of diabetes is high.
A neighboring health facility might well
have no patients with diabetes because
the attending clinician has poor public
relations. A health facility holding
a clinic on market days might be
popular as people take the opportunity
to trade and visit the nurse.
Lack of awareness of their health
status.
People in the community might
be unaware that they need
healthcare, for example, patients with
hypertension may present late.
Exclusion of certain segments of the
community. The very poor or
disadvantaged such as orphans and the
elderly may not be able to access the
health facility.
Having a good understanding of
epidemiologic principles is therefore
important. Understanding the health needs
requires a health needs assessment which
can be done at various levels including:
International e.g. by the WHO or
UNICEF
National e.g. to tackle a national
priority such as malaria or mental
health to idenfity gaps in service.
262
Community participation
263
Data
known
yes/no
What
does the
data say?
Priority
Rank
Maternal
deaths
at health
facility
yes
Above
national
average
Need to
identify all
causes
HIV rate
in
community
no
May or
may not
be higher
than
national
average
Assume
national
average and
implement
recommended
strategies
264
Question to ask
Person
Place
Time
Disease
Time
Conducting a survey
265
266
2. Data collection
Before beginning full scale data collection
it is important to carry out a pilot or pretest using a subset of the population that is
similar but will not be covered in the main
study. The pilot has two main objectives:
a. To discover possible
misunderstanding
and misinterpretation of the
questions being asked.
b. To identify possible problems in the
procedures to be used in data
collection.
Even the most experienced researcher
cannot foresee all the potential problems
that may occur when using new questions
or techniques. Every effort must be made
to ensure those within the sample are
reached.
A low response rate produces more
questionable results than a small sample,
since there is no scientifically valid way to
infer the characteristics of the population
that the non-respondents represent.
Therefore rather than simply ignore the
non-respondents, every attempt should
be made to get them to respond to the
survey.
High response rates are usually obtained by
employing rigorous follow-up procedures
as part of the survey methodology. If further
callbacks do not substantially increase the
response rate, weighting adjustments can
be used to help compensate for potential
non-response bias.
3. Data processing and analysis
The process of data entering, editing, and
analyzing the completed questionnaires
is subject to a great deal of human error.
Maintaining a high level of quality control
during these processes takes time and very
267
risks
Professionals need to support patients
in making choices by turning raw data
into information that is more helpful to
the discussions than the data
Framing manipulations of
information, such as using information
about relative risk in isolation of base
rates, to achieve professionally
determined goals should be avoided
Decision aids can be useful as they
often include visual presentations of
risk information and relate the
information to more familiar risks just
like any other activity, dissemination of
results requires planning.
Table 16.3 gives a summary communication
plan with key questions that can help
in formulating a dissemination or
communication strategy.
Table 16.3: Communication Plan Summary
Summary points
Patients often desire more information
than is currently provided
Communicating about risks should
be a two way process in which
professionals and patients exchange
information and opinions about those
268
Context
Content
audience
audience
Channels of communications
Tactics
Budget
Evaluation
Questions
1. List reasons why health facility data may not reflect the health status of the
community
2. Explain the importance of community participation in a community survey
3. Describe the sources of information in the community
4. Outline the steps in conducting a survey
5. Identify methods of disseminating results obtained from a community survey
Further reading
1. Etches, V., Frank, J., Ruggiero, E. D., & Manuel, D. (2006). Measuring Population
Health:
A review of indicators. Annual Review of Public Health, 27, 29-55.
2. Marshall MN. The key informant technique. Family practice. 1996 ;13(1):92-7.
3. Stevens A, Raferty J, eds. Health care needs assessment the epidemiologically based
needs assessment reviews. Oxford: Radcliffe Medical Press , 1994.
4. World Health Organization Outbreak Communication Planning Guide 2008. World
Health, 2008.
269
REFERENCES
1. Rothstein Ma. Rethinking the meaning of public health. The Journal of law, medicine & ethics. 2002
;30(2):144-9.
2. Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata : Rebirth and Revision 1 Alma-Ata
30 years on : revolutionary , relevant , and time to. Lancet, The. 2008 ;(372):917-927.
3. Breslow, Lester. MUSINGS ON SIXTY YEARS. Annual Review of Public Health 19 (1998): 1-15.
4. Lawn, Joy E, Jon Rohde, Susan Rifkin, Miriam Were, Vinod K Paul, and Mickey Chopra. Alma-Ata :
Rebirth and Revision 1 Alma-Ata 30 years on : revolutionary , relevant , and time to.
Lancet, The 372 (2008): 917-927.
5. Walley, J., Lawn, J. E., Tinker, A., Francisco, A. D., Chopra, M., Rudan, I., et al. (2008). Alma-Ata :
Rebirth and Revision 8 Primary health care : making Alma-Ata a reality. Lancet, The, 372, 1001-1007.
6. Scally, G., Womack, J., Scally, G., & Womack, J. (2004). The importance of the past in public health.
J Epidemiol Community Health, 58, 751-755.
7. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for
public health practice. Annual review of public health. 2009 ;30175-201.
8. Linden E. The exploding cities of the developing world. Foreign affairs (Council on Foreign Relations).
1996 ;75(1):52-65.
9. UN Millennium Project. Investing in Development: A practical plan to achieve the Millennium
development goals. Development. 2005 ;1-356.
10. Bonneux L. How to measure the burden of mortality? Journal of epidemiology and community health.
2002 ;56(2):128-31.
11. Rose G, Barker P. Epidemiology for the Uninitiated What is epidemiology ? British Medical Journal.
1978 ;2(September):803-804.
12. Breslow N. Design and Analysis of Case-Control Studies. Annual Review of Public Health. 1982 ;3(d):
29-54.
13. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for
public health practice. Annual review of public health. 2009 ;30175-201.
14. Etches V, Frank J, Di Ruggiero E, Manuel D. Measuring population health: a review of indicators.
Annual review of public health. 2006 ;2729-55.
15. Virnig BA, Mcbean M. Administrative data for public health surveillance and planning.
Annual Review of Public Health. 2001 ;2213-30.
16. Olsen J. What characterizes a useful concept of causation in epidemiology? Journal of epidemiology
and community health. 2003 ;57(2):86-8.
17. Bonneux L. How to measure the burden of mortality? Journal of epidemiology and community health.
2002 ;56(2):128-31.
18. Rose G, Barker P. Epidemiology for the Uninitiated What is epidemiology ? British Medical Journal.
1978 ;2(September):803-804.
270
19. Breslow N. Design and Analysis of Case-Control Studies. Annual Review of Public Health. 1982 ;3
(d):29-54.
20. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for
public health practice. Annual review of public health. 2009 ;30175-201.
21. Etches V, Frank J, Di Ruggiero E, Manuel D. Measuring population health: a review of indicators.
Annual review of public health. 2006 ;2729-55.
22. Virnig BA, Mcbean M. Administrative data for public health surveillance and planning. Annual Review
of Public Health. 2001 ;2213-30.
23. Olsen J. What characterizes a useful concept of causation in epidemiology? Journal of epidemiology
and community health. 2003 ;57(2):86-8.
24. Devane D, Begley CM, Clarke M. How many do I need? Basic principles of sample size estimation.
Journal of advanced nursing. 2004 ;47(3):297-302.
25. Bachmann LM, Puhan Ma, ter Riet G, Bossuyt PM. Sample sizes of studies on diagnostic accuracy:
literature survey. BMJ (Clinical research ed.). 2006 ;332(7550):1127-9.
26. Florey, Charles V. Sample size for beginners. British Medical Journal 306 (1993): 1181-4.
27. Overholser, B. R., Sowinski, K. M., Overholser, B. R., & Sowinski, K. M. (2007). Biostatistics Primer :
Part I. Nutrition In Clinical Practice, 22, 629-635. doi: 10.1177/0115426507022006629.
28. Devane, D., Begley, C. M., & Clarke, M. (2004). How many do I need? Basic principles of sample size
estimation. Journal of Advanced Nursing, 47(3), 297-302.
29. (2000). Informative Presentation of Tables , Graphs and Statistics. Biometrics. Reading.
30. Sterne, Jonathan A C, Ian R White, John B Carlin, Michael Spratt, Michael G Kenward, Angela M
Wood, James R Carpenter, et al. Multiple imputation for missing data in epidemiological and clinical
research : potential and pitfalls. British Medical Journal 338, no. July (2009): 2393. doi:10.1136/bmj.
b2393.
32. The Demography of Health and Health Care. By. Louis G. Pol and Richard K. Thomas. Kluwer.
Academic/Plenum Publishers, New York, 2001.
33. UNFPA. The state of world population 2009 Facing a changing world : women , population and
climate. 2009 ;104
34. Sclar ED, Garau P, Carolini G. The 21st century health challenge of slums and cities.
Lancet. 2007 ;365(9462):901-3.
P37. Schiff, M., & Valdes, A. (1990). The Link Between Poverty and Malnutrition. PRE Working paper
series. Washington.
38. Black, R. E., Morris, S. S., & Bryce, J. (2003). Child survival I Where and why are 10 million children
dying every year ? The Lancet, 361, 2226-2234.
39. The Bellagio Study group in child survival. Knowledge into action for child survival.
The Lancet. 2003 ;362323-327.
40. Willet, W. C., Dietz, W. H., & Colditz, G. A. (1999). Guidelines for Healthy Weight. New England
Journal of Medicine, 341(6), 427-434.
271
41. Bryce, J., Coitinho, D., Darnton-hill, I., Pelletier, D., Pinstrup-andersen, P., Undernutrition, C., et
al. (2008). Maternal and Child Undernutrition 4 Maternal and child undernutrition : effective action at
national level. Lancet, The, 371. doi: 10.1016/S0140-6736(07)61694-8.
42. Global Strategy for Infant and Young Child Feeding. World Health Organization/UNICEF, Geneva.
(2003).
43. Yew WW, Lange C, Leung CC. Treatment of tuberculosis guidelines 4th Edition, The World Health
Organization. : 2010 ;1-160.
44. Taylor, C. E. (1989). Control of diarrheal diseases. Annual Review of Public Health, 10, 221-44.
45. Grant, G. B., Campbell, H., Dowell, S. F., Graham, S. M., Klugman, K. P., Mulholland, E. K., et
al. (2009). Recommendations for treatment of childhood non-severe pneumonia. The Lancet
Infectious Diseases, 9(3), 185-196. Elsevier Ltd. doi: 10.1016/S1473-3099(09)70044-1.
46. Ministry of Health Government of Kenya. Malaria National Guidelines for diagnosis, treatment and
prevention for health workers in Kenya. Health (Nairobi)2006 ;1-43.
47. Mathers, Colin, and Cynthia Boschi-pinto. Global burden of cancer in the year 2000 : Version 1
estimates. Health Policy. Geneva, 2010.
48. Krug, Etienne G., Dahlbeg, Linda L., Mercy, James A., Zwi, Anthony B., Lozano, Rafael. World report
on violence. World Health Organization. Geneva, 2002.
49. Bleich, Sara N, David Cutler, Christopher Murray, and Alyce Adams. Why Is the Developed World
Obese ?. Annual Review of Public Health, no. 29 (2008): 273-95. doi:10.1146/annurev.publhealth.29.0
20907.090954.
50. Tuberculosis, Lessons From, and Control Then. Cardiovascular Disease and Global Health Equity.
American Journal of Public Health 98, no. 1 (2008): 44-54. doi:10.2105/AJPH.2007.110841.
51. Lim, Stephen S, Thomas A Gaziano, Emmanuela Gakidou, K Srinath Reddy, Farshad Farzadfar, Rafael
Lozano, and Anthony Rodgers. Chronic Diseases 4 Prevention of cardiovascular disease in high-risk
individuals in low-income and middle-income countries : health eff ects and costs. Lancet, The 370
(2007): 2054-62. doi:10.1016/S0140-6736(07)61699-7.
52. Asaria, P., Chisholm, D., Mathers, C., Ezzati, M., & Beaglehole, R. (2007). Chronic Diseases 3 Chronic
disease prevention : health effects and financial costs of strategies to reduce salt intake and control
tobacco use. Lancet, The, 370, 2044-2053. doi: 10.1016/S0140-6736(07)61698-5.
53.
54. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health
Education & Behavior. 1988 ;15(2):175-183.
55. Valente TW, Pumpuang P. Identifying opinion leaders to promote behavior change. Health education &
behavior : 2007 ;34(6):881-96.
56. von Wagner C, Steptoe A, Wolf MS, Wardle J. Health literacy and health actions: a review and a
framework from health psychology. Health education & behavior. 2009 ;36(5):860-77.
57. Wade DT, Halligan PW. Do biomedical models of illness make for good healthcare systems? BMJ
(Clinical research ed.). 2004 ;329(7479):1398-401.
58. Wensing M, Elwyn G. Methods for incorporating patients views in health care.BMJ (Clinical research
ed.). 2003 ;326(7394):877-9.
272
59. Tauxe RV. Foodborne Infections and the Global Food Supply : Improving Health at Home and
Abroad. Vanderbilt journal of transnational law. 2007 ;40(4):
60. Shaw M. Housing and public health. Annual review of public health. 2004 ;25397-418.
61. Porta D, Milani S, Lazzarino AI, Perucci CA, Forastiere F. Systematic review of epidemiological studies
on health effects associated with management of solid waste.Environmental health : Biomed Central. 2009
;860.
62. World Health Organization,Domestic Water Quantity, Service Level and Health. World Health
Organization Geneva . 2003 ;1-39.
63. Mcmichael, A J, S Friel, A Nyong, and C Corvalan. Global environmental change and health : impacts ,
inequalities , and the health sector. British Medical Journal 336, no. July 2009 (2008): 191-194. doi:10.1136/
bmj.39392.473727.AD.
64. Costello, Anthony, Mustafa Abbas, Adriana Allen, Sarah Ball, Sarah Bell, Richard Bellamy, Sharon Friel,
et al. Managing the health effects of climate change. Lancet, The 373 (2009): 1693-733.
65. Corvalan, Carlos, Simon Hales, and Anthony McMicheal. Ecosystems and Human Well-being Health
Synthesis. World Health. Geneva, 2005.
66. Shaw, M. (2004). Housing and Public Health. Annual Review of Public Health, 25, 397-418. doi: 10.1146/
annurev.publhealth.25.101802.123036.
67. Galea, S., & Vlahov, D. (2005). Urban Health: Evidence, Challenges, and Directions. Annual Review of
Public Health, 26, 341-65. doi: 10.1146/annurev.publhealth.26.021304.144708.
68. Department of Food Safety, Zonooses and foodborne disease. (2006). A guide to healthy food markets.
World Health Organization. Geneva.
69. Jaramillo, J. Guidelines for the design, construction and operation of manual sanitary landfills. CEPIS/
PAHO(2003).
70. Broughton E. The Bhopal disaster and its aftermath: a review. Environmental health :2005 ;4(1):
71. Morgan MT. The role of environmental health in the health care system. Journal of environmental
health. 72(6):62-3.
72. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate
change: Lancet and University College London Institute for Global Health Commission.Lancet. 2009
;373(9676):1693-733.
73. Ecology PH. Public Health Ecology. Journal of Environmental Health. 2010 ;(September 2009):53-56.
74. Galea S, Vlahov D. Urban health: evidence, challenges, and directions. Annual review of public health.
2005 ;26341-65.
75. Batterman S, Eisenberg J, Hardin R, Kruk ME, Lemos MC, Michalak AM, et al. Sustainable control
of water-related infectious diseases: a review and proposal for interdisciplinary health-based systems
research.Environmental health perspectives. 2009 ;117(7):1023-32
76. Gottret, P., Schieber, G. J., Waters, H. R., & Editors. (2008). Good Practices in Health Financing Lessons
from reforms in low and middle income countries. Washington.
77. Johns, B., Torres, T. T., Johns, B., & Torres, T. T. (2005). Costs of scaling up health interventions : a
273
systematic review. Health Policy and Planning, 20(1), 1-13. doi: 10.1093/heapol/czi001.
78. Ensor, T. I., Cooper, S., Ensor, T., & Cooper, S. (2004). Overcoming barriers to health service access :
influencing the demand side. Health Policy and Planning, 19(2), 69-79. doi: 10.1093/heapol/czh009.
79. Yates, R. (2009). Universal health care and the removal of user fees. The Lancet, 373(9680), 2078-2081.
Elsevier Ltd. doi: 10.1016/S0140-6736(09)60258-0.
80. Pauly, M. V., Zweifel, P., Scheffler, R. M., S, A., & Bassett, M. (2006). Private Health Insurance In Developing
Countries. Health Affairs, 25(2), 369-379. doi: 10.1377/hlthaff.25.2.369.
81. World Health Organization. Strengthening Health Systems to improve health outcomes. WHOs
framework for action. Production. 2007 ;1-56.
82. Ministry of Health Government of Kenya. Kenya national health accounts 2005/06. Nairobi. 2009
83. Gold MR, Stevenson D, Fryback DG. HALYS and QALYS and DALYS, Oh My: similarities and differences
in summary measures of population Health. Annual review of public health. 2002 ;23115-34.
84. Carrin G. Social health insurance in developing countries: A continuing challenge International Social
Security Review. 2002 ;55(2):57-69.
85. Ministry of Health Republic of Rwanda. Rwanda National Health Accounts 2003 Prepared by : Ministry of
Health Republic of Rwanda. 2006 ;1-107.
86. Yates R. Universal health care and the removal of user fees The Lancet. 2009 ;373(9680):2078-2081.
87. Davis, R. M., Wakefield, M., Amos, A., & Gupta, P. C. (2006). The hitchhikers guide to tobacco control:
A global assessment of harms, remedies and controversies. Annual Review of Public Health, 28, 171-94. doi:
10.1146/annurev.publhealth.28.021406.144033.
88. Mcleroy, K. R., Bibeau, D., Steckler, A., Glanz, K., Bibeau, D., Glanz, K., et al. (1988). An ecological
perspective on health promotion programs. Health Education Quarterly, 15(4), 351-378. doi: 10.1177/
109019818801500401.
89. Howze, E. H., Auld, M. E., Woodhouse, L. D., Gershick, J., C, W., Howze, E. H., et al. (2009). Health
Education & Behavior 60 Years of Experience in the United States. Health Education & Behavior, 36(3), 464475. doi: 10.1177/1090198109333825.
90. Valente, T. W., & Pumpuang, P. (2007). Identifying Opinion leaders to promote behaviour change. Health
Education & Behavior, 34, 881. doi: 10.1177/1090198106297855.
91. Wagner, C. V., Steptoe, A., Wolf, M. S., Wardle, J., Wagner, C. V., Steptoe, A., et al. (2008). Health Literacy
and Health Actions : A Review and a framework from Health Psychology. Health Education & Behavior, (36),
860. doi: 10.1177/1090198108322819.
92. Richter ED, Laster R. The Precautionary Principle, epidemiology and the ethics of delay. International
journal of occupational medicine and environmental health. 2004 ;17(1):9-16.
93. French J, Adams L. From analysis to synthesis: Theories of health education Health Education Journal.
1986 ;45(2):71-74.
94. U.S. Department of Health and Human Services. Theory at a glance: A guide for health promotion
practice. 2005.
274
95. Victorian Government Department of Human Services, Integrated health promotion resource kit.
Melbourne, 2003 (updated 2008)
96. Butchart, Alexander, Alison Phinney Harvey, Etienne Krug, David Meddings, Margie Peden, Yussof
Fadhli, Wu Fan, Margaret Herbert, Jaffar Hussain, and Pierre Maurice. Preventing injuries and violence A
guide for Ministries of Health. World Health. Geneva, 2007.
97. Davis, R. M., Wakefield, M., Amos, A., & Gupta, P. C. (2006). The hitchhikers guide to tobacco control:
A global assessment of harms, remedies and controversies. Annual Review of Public Health, 28, 171-94.
doi: 10.1146/annurev.publhealth.28.021406.144033.
98. Mcleroy, K. R., Bibeau, D., Steckler, A., Glanz, K., Bibeau, D., Glanz, K., et al. (1988). An ecological
perspective on health promotion programs. Health Education Quarterly, 15(4), 351-378. doi: 10.1177/
109019818801500401.
99. Howze, E. H., Auld, M. E., Woodhouse, L. D., Gershick, J., C, W., Howze, E. H., et al. (2009). Health
Education & Behavior 60 Years of Experience in the United States. Health Education & Behavior, 36(3),
464-475. doi: 10.1177/1090198109333825.
100. Valente, T. W., & Pumpuang, P. (2007). Identifying Opinion leaders to promote behaviour change.
Health Education & Behavior, 34, 881. doi: 10.1177/1090198106297855.
101. Wagner, C. V., Steptoe, A., Wolf, M. S., Wardle, J., Wagner, C. V., Steptoe, A., et al. (2008). Health
Literacy and Health Actions : A Review and a framework from Health Psychology. Health Education &
Behavior, (36), 860. doi: 10.1177/1090198108322819.
102. Richter ED, Laster R. The Precautionary Principle, epidemiology and the ethics of delay. International
journal of occupational medicine and environmental health. 2004 ;17(1):9-16.
103. French J, Adams L. From analysis to synthesis: Theories of health education Health Education
Journal. 1986 ;45(2):71-74.
a. 6. Marshall MN. The key informant technique. Family practice. 1996 ;13(1):92-7. 7. Gessner BD,
Chimonas MR, Grady SC. It takes a village: community education
predicts
paediatric
lowerrespiratory infection risk better than maternal education.
Journal of epidemiology and
community health. 2010 ;64(2):130-5.
275
Appendix Z - Table
Normal distributions are symmetrical, bell-shaped distributions that are useful in describing real-world data.
The standard normal distribution, represented by the letter Z, is the normal distribution having a mean of
0 and a standard deviation of 1. Since probability tables cannot be printed for every normal distribution,
(there are infinite), it is common practice to convert a normal to a standard normal, and use a Z table to find
probabilities
0.03
0.0120
0.0517
0.0910
0.1293
0.1664
0.2019
0.2357
0.2673
0.2967
0.3238
0.3485
0.3708
0.3907
0.4082
0.4236
0.4370
0.4484
0.4582
0.4664
0.4732
0.4788
0.4834
0.4871
0.4901
0.4925
0.4943
0.4957
0.4968
0.4977
0.4983
0.4988
0.4991
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
0.04
0.0160
0.0557
0.0948
0.1331
0.1700
0.2054
0.2389
0.2704
0.2995
0.3264
0.3508
0.3729
0.3925
0.4099
0.4251
0.4382
0.4495
0.4591
0.4671
0.4738
0.4793
0.4838
0.4875
0.4904
0.4927
0.4945
0.4959
0.4969
0.4977
0.4984
0.4988
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
0.05
0.0199
0.0596
0.0987
0.1368
0.1736
0.2088
0.2422
0.2734
0.3023
0.3289
0.3531
0.3749
0.3944
0.4115
0.4265
0.4394
0.4505
0.4599
0.4678
0.4744
0.4798
0.4842
0.4878
0.4906
0.4929
0.4946
0.4960
0.4970
0.4978
0.4984
0.4989
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
0.06
0.0239
0.0636
0.1026
0.1406
0.1772
0.2123
0.2454
0.2764
0.3051
0.3315
0.3554
0.3770
0.3962
0.4131
0.4279
0.4406
0.4515
0.4608
0.4686
0.4750
0.4803
0.4846
0.4881
0.4909
0.4931
0.4948
0.4961
0.4971
0.4979
0.4985
0.4989
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
276
0.07
0.0279
0.0675
0.1064
0.1443
0.1808
0.2157
0.2486
0.2794
0.3078
0.3304
0.3577
0.3790
0.3980
0.4147
0.4292
0.4418
0.4525
0.4616
0.4693
0.4756
0.4808
0.4850
0.4884
0.4911
0.4932
0.4949
0.4962
0.4972
0.4979
0.4985
0.4989
0.4992
0.4995
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
0.08
0.0319
0.0714
0.1103
0.1480
0.1844
0.2190
0.2517
0.2823
0.3106
0.3365
0.3599
0.3810
0.3997
0.4162
0.4306
0.4429
0.4535
0.4625
0.4699
0.4761
0.4812
0.4854
0.4887
0.4913
0.4934
0.4951
0.4963
0.4973
0.4980
0.4986
0.4990
0.4993
0.4995
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999
0.09
0.0359
0.0753
0.1141
0.1517
0.1879
0.2224
0.2549
0.2852
0.3133
0.3389
0.3621
0.3830
0.4015
0.4177
0.4319
0.4441
0.4545
0.4633
0.4706
0.4767
0.4817
0.4857
0.4890
0.4916
0.4936
0.4952
0.4964
0.4974
0.4981
0.4986
0.4990
0.4993
0.4995
0.4997
0.4998
0.4998
0.4999
0.4999
0.4999
277
278
279
280