Concept of Health and Disease

Gautam  Sarker; Palash  Das

Concept of Health and DiseaseChapter 1

Q1. Define health. Describe limitation in WHO definition. Discuss with reasons one such definition of health, which you feel acceptable?

(BNMU 2002, WBUHS 2012)

Ans: The widely accepted definition of health is given by the World Health Organization (1948) in the preamble to its constitution, which is as follows—‘Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity’. This is desired to lead a socially and economically productive life.

WHO definition of health has the following defects:

The WHO definition of health has been criticized as being too broad.
Health cannot be a state and also not static.

Some argue that health cannot be defined as a state at all, but must be seen as a continuous adjustment to the changing demands of living and of the changing meanings we give to life. The WHO definition of health is not an operational definition, because it does not lend itself to the direct measurement. Studies of epidemiology of health have been hampered because of our inability to measure health and well-being directly. In this connection, an operational definition of health has been devised by a WHO study group. In this definition, the concept of health is being viewed as being of two orders. In a broad sense, ‘health can be seen as a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental’.

This can be explained in the following way: There is no obvious evidence of disease and the person is able to function in comparison with a similar person in respect of age, sex, community in that location. The organs of the body will function harmoniously with good equilibrium or homoeostasis in presence of certain internal and external stimuli. This can be taken as an alternative operational definition of health.

Q2. Enumerate and discuss the different determinants of health?

(BNMU 2002, 2004,2012, 2013, RGUHS 2004, 2009, 2014, SAMU 2004, BUMP 2008, WBUHS 2008, 2011, SMU 2010, 2011, SSUHSA 2011, KIMS 2017, RUJH 2018)

Ans: The different determinants of health are enumerated below:

Biological or heredity: The physical and mental traits of every human being are to some extent determined by the nature of his genes at the moment of conception. A number of diseases are known to be genetic in origin, e.g. chromosomal abnormalities, errors of metabolism, mental retardation. The state of heath depends partly on the genetic constitution of man.
Behavioral and socio-cultural conditions: It is composed of cultural and behavioral patterns and lifelong personal habits (e.g. smoking, alcoholism) that have develop through process of socialization. Lifestyles are learnt through social interaction with parents, peer groups, friends and siblings and through school and mass media. Many health problems in developed countries (e.g. coronary heart disease, obesity, lung cancer and drug addiction) are associated with life style changes. In developing countries traditional lifestyle still persists, lack of sanitation, poor nutrition, personal hygiene, customs and cultural patterns.
Environment: It is classified as internal and external. Internal environment of man pertains to each and every component part, every tissue, organ and organ system and their harmonious functioning within the system. It is the domain of internal medicine.

The external or macro environment consists of those things to which man is exposed after conception. It can be divided into physical, biological and psychosocial components, any or all of which can affect the health of man and his susceptibility to illness.
Socio-economic condition: For majority of world's people, health status is determined primarily by their level of socioeconomic development, e.g. per-capita GNP, education, nutrition, employment, housing, political system of the country.2
Economic status: GNP is the most accepted measure of economic performance. Economic progress is the major factors in reducing morbidity, increasing life expectancy and improving quality of life. The economic status determines the purchasing power, standard of living, quality of life, family size and disease pattern.
Education: A second major factor influencing health status is education especially female. The world map of illiteracy closely coincides with maps of poverty, malnutrition, high infant and child mortality. A major factors in lowest infant mortality in India is its high female literacy.
Occupation: Productive work promotes health vis-a-vas unemployment show higher incidence of ill-health and death.
Political system: Percentage of GNP spent on health is a quantitative indicator of political commitment. Decisions concerning resource allocation, manpower policy, choice of technology depend upon political will. According to WHO, target of at least 5% expenditure of country's GNP on health care budget should be allocated. But India spent less in amount on that. Political people and administrators should be motivated to increase the budget allocation.
Health services: The purpose of health services is to improve the health status of the population. Immunization of children protect from 7 vaccine preventable diseases. Provision of safe water prevents mortality and morbidity from water borne diseases.
Aging of population: By the year 2020, the world will have more than one billion people aged 60 years and above and more than two-thirds of them living in developing countries. They are enjoying better health than before concerned of chronic disease and disabilities.
Gender: In 1993, Global Commission on women's health was established. The commission drew up an agenda for action on nutrition, reproductive health, violence and aging.
Other factors: Coordination of outside formal health care system such as food and agriculture, education, industry, social welfare, rural development.

How do socioeconomic condition act as one of the determinant of health?

(WBUHS 2011)

Influence of socioeconomic condition in health: In majority of world's people, health status is determined primarily by their level of socioeconomic development, e.g. per capita GNP, education, nutrition, employment, housing, political system of the country.

Economic status: GNP is the most accepted measure of economic performance. Economic progress is the major factor in reducing morbidity, increasing life expectancy and improving quality of life. The economic status determines the purchasing power, standard of living, quality of life, family size and disease pattern. As health is becoming a purchasable commodity day by day, economic status of general people will determine the status of health to some extent.
Education: Education leads a person to adopt a correct behavior in health issue and other decisive issues which have influence on health. So poor education or no education will increase the ill health of the community where education is unreached by the people.
Nutrition: Nutrition is directly related to the health of a person. Poor nutrition means poor immunity; poor immunity means repeated infection and disease which is leading poor health.
Employment: Employment helps earn money by the individual or family. Employment provides confidence and honour to the person or family. Thus purchasing capacity of the requirement including health will be guiding force to lead a good health of the individual and or family.
Housing: Housing provides care, safety, security of the family member(s). This protects family from rain, sun, cold and hot weather, robbery, provides comfort, cool and calm mind to work and many more things which indirectly provide health. So housing plays its role in maintaining health in the society.
Political system of the country: Political system of the country is real existence in the country where people live. Capitalistic system differs from socialistic system in proving commodity for day to day use and its impact will fall over all other factors which directly or indirectly induce health system with other activities of the country. Commitment of the political leaders in relation to the health system is often seen average or poor compared to the demand of the community. Advocacy by technical people from health sector is one very important area to uplift the health in any political system.

Now we can conclude that socioeconomic condition acts as one of the determinants of health.

Q3. What do you mean by the term “Indicator of health”?

(BNMU 1018)

Ans:

INDICATOR OF HEALTH

Indicators are variables which help to measure changes. As the name suggest, indicators are only an indication of a given situation or a reflection of that situation.3

Characteristics of an ideal indicator:

(WBUHS 2018)

It should be valid, i.e it should be actually measure what it supposed to measure.
It should be reliable and objectives, i.e. the answer should be same if measured by different people in similar circumstances.
It should be sensitive, i.e. it should be sensitive to changes in the situation concerned.
It should be specific, i.e it should reflect changes only in the situation concerned.
It should be feasible, i.e. they should have the ability to obtain data needed, and
It should be relevant, i.e. they should contribute to the understanding of the phenomenon of interest.

List of various indicators of health.

(BNMU 2004, 2013, BUMP 2008, SSUHSA 2011, RUJH 2010, SMU 2012, 2013, WBUHS 2015, 2018, DU 2009, NU 2011, 2017)

The various indicators of health are listed below:

Mortality indicators:
- Crude death rate
- Expectation of life
- Infant mortality rate
- Child death rate
- Maternal mortality ratio
- Proportional mortality rate
Morbidity indicators:
- Incidence rate
- Prevalence rate
- Hospital attendance rate (OPD)
- Admission rate in hospital
Disability rates:
- Event type indicators
- Number of days of restricted activities
- Bed disability days
- Work loss days
Nutritional status indicators:
- Weight and height, MUAC
- Prevalence of low birth weight
Health care delivery indicator:
- Doctor population ratio
- Population nurse ratio
- Doctor-nurse ratio
- Population-bed ratio, etc.
Utilization rates:
- Vaccination coverage
- Population proportion using methods of family planning
Indicator of social and mental health:
- Suicide
- Homicide
- Act of violence and crime
- Drug abuse
- Smoking
- Alcohol consumption
Environmental indicator:
- Solid waste
- Liquid waste
- Other biomedical waste
Socioeconomic indicators:
- Overcrowding
- Per capita GNP
- Dependency ratio
Health policy indicators:

Proportion of GNP spent on health
Indicator of quality of life:

Physical quality of life index is one such example.4

Q4. List the various indicators of health which directly assess ill health in a community.

(BNMU 2018)

Name the health indicator which is considered as the most important indicator of health of the community. Why is it so considered?

(RGUHS 2001, TRIU 2014)

Ans: Mortality indicators do not reveal the burden of ill health of the community. From these data we can make plan and also take action to prevent any disease in future. Morbidity indicators are used to supplement mortality data to describe the health status of a population.

DIRECT INDICATORS OF HEALTH

Morbidity indicators are the direct indicators of health status of a community. The commonly used morbidity indicators are incidence and prevalence rate.

The incidence rate includes:

Numerator
Denominator
Time specification
Multiplier is usually 1000
Incidence rate is not influence by the duration of disease.
It is generally used for acute condition. This is measured on incident cases for a time period usually a year.

Prevalence rate: It is usually expressed in percent. This is measured on both the incident cases and previous all cases. All current cases are included in prevalence.

Q5. Describe the meaning and concept of disease control, elimination and eradication with examples?

(BNMU 2004, 2013, BUMP 2008, SSUHSA 2011, RUJH 2010, SMU 2012, 2013, WBUHS 2015, 2018, DU 2009, NU 2011, 2017)

Ans:

DISEASE CONTROL

In disease control, the agent persists in the community at a level it is no longer a public health problem. A state of equilibrium becomes established between disease agent, host and environment component of disease process. It focuses on primary and secondary prevention.

Concept of Disease Control

It is an ongoing process of reducing the incidence of disease, duration of disease as well as risk of transmission. Reducing physical and psychological components of disease and also reduce the financial burden of the community. Example can be cited as control of malaria, control of filaria, etc. Here the presence of medical or health problem is observed but it does not become public health problem.

Elimination

(BNMU 2002)

Disease elimination is between control and eradication. It is better to say “regional elimination.” The term elimination is used to describe the interruption of transmission of diseases. Certain diseases are targeted for elimination like Neonatal Tetanus, Measles and Diphtheria. Several strategies are adopted for elimination of certain diseases under different national programs. Regional elimination is now seen as an important precursor of eradication. Guinea worm disease, Poliomyelitis have been eliminated from our country.

Eradication

Eradication means “tearing out from root”. On the other hand eradication implies termination of all transmission of infection by extermination of infectious agents. It is an absolute process. It is all or none phenomenon. The disease has passed through all stages of control, elimination and eradication. No patient of smallpox is seen in the world at present and WHO declared its eradication in early eighties of last century. This is an absolute term considering globe, no germ found in the environment, no suffering from the disease for long time. Smallpox had already been eradicated from the globe.5

Q6. Write down the different disability rates with example. What is the concept of disability limitations?

(WBUHS 2015, DU 2009, NU2011, 2017)

Ans:

DISABILITY RATES

(DU 2013, RGUHS 2012, 2013, 2015)

To supplement morbidity and mortality indicators, disability rates have come in the scene. This is the proportion (percentage) of population unable to perform the expected, routine daily activities due to injury or illness. Different disability rates are the number of days of restricted activities, bed disability days, and work loss days as event type indicators and confined to bed, confined to house, limitation to perform the basic activities of daily livings are person-type indicators.

Examples of Disability Rate

Sullivan's index

(RGUHS 2010, 2012, TDMGRMU 2009, 2011, 2015, NIMSUR 2015)

This index is calculated by subtracting the duration of bed disability (whole life) from the expectation of life at birth. Say, average life expectancy of a female 64.5 years and she suffered from disability for 7.5 years, then Sullivan's index will be (64.5–7.5) years = 57 years.
Health adjusted life expectancy (HALE): This is taken as years. It is number of years a newborn is expected to live in full health based on current morbidity and mortality.
Disability adjusted life years (DALY): This is the number of years lost in the healthy life of an individual due to disability. DALY measures the burden of disease in a population and effectiveness of intervention. Necessary data are not available to measure the DALY readily.

Concepts of Disability Limitations

Disability is inability to perform certain routine and expected activity considered normal for that age, sex in good health. This is often the sequel of a disease or an accident. So disability limitation is an intervention to halt further worse condition of the diseased person (complication at end of the disease). This intervention may be intensive or aggressive treatment when the patient comes to health care provider at the advance stage of disease.

Disease or disorder (accident) produces impairment (loss of foot) which leads to disability (unable to walk). This disability may lead to handicap of the individual (discharge from employment or unable to work). So at the stage of impairment, action should be taken to develop disability. Thus limitation of disability will be possible in diseased individual to stop further problem in people.

Q7. What is concept of primordial prevention? Describe different levels of prevention and mode of interventions.

(BNMU 2002, 2013, 2014, SSUHSA 2009, 2010, 2012, RGUHS 2011, 2013, SAMU 2009, TDMGRMU 2010, ABKUB 2005, TRIU 2013, BUMP 2013)

Ans: There are four levels of prevention of disease. Interventions are taken to prevent and control the disease, to treat the case, to limit disability and rehabilitate one such crippled case. The four levels are termed as (1) Primordial prevention, (2) Primary prevention, (3) Secondary prevention and (4) Tertiary prevention.

Primordial prevention: This is prevention of population groups from risk factors which have not yet appeared. Obesity in childhood, when lifestyles are formed (eating habit, smoking and physical exercise) can be prevented in the community. Efforts are directed towards discouraging children from adopting harmful habits/lifestyles. The main intervention is through mass education. The prevention of hypertension, diabetes mellitus thus will be exercised in reducing the obesity.
Primary prevention

(WBUHS 2007, RGUHS 2004, SAMU 2011, 2012, TDMGRMU 2013, SMU 2013, NU 2007)

Action taken prior to the onset of disease. It signifies intervention in pre-pathogenic phase of a disease. It includes the concept of positive health. In broad sense “an acceptable level of health that will enable every individual to lead a socially and economically productive life.” WHO recommended two approaches for prevention of chronic diseases—population strategy and high-risk strategy. Population strategy directed towards whole population, studies have shown even in small reduction in average blood pressure or serum cholesterol would reduce incidence of cardiovascular diseases. High-risk strategy aim is to elimination of communicable diseases like cholera, typhoid, plague, leprosy and tuberculosis, not by medical intervention but mainly raised the standard of living.
Secondary prevention: Action which halts the process of disease at its incipient stage and prevents complications. Specific interventions are early diagnosis and adequate treatment, example screening test and case finding program.6
Tertiary prevention

(NU 2012)

It signifies the intervention in late pathogenesis phase. It defined as, all measures available to limit the impairments and disabilities, minimize suffering and patient's adjustment to present situation. Disability limitation and rehabilitation play an important role. Rehabilitation is based on medical, vocational, social and psychological.

MODES OF INTERVENTION

Health Promotion

Health education, lifestyle and behavioral change, environmental modification, nutritional interventions are examples of action in health promotion. It is the process of enabling people to increase control over and to improve health. It can be achieved through health education. Environmental modifications such as provision of safe water, installation of sanitary latrines, controls of insects and rodents, etc. nutritional interventions like food fortification, nutrition education, etc. lifestyle and behavioral changes.

Specific Protection

Specific diseases are addressed here. Vaccinations against specific diseases like measles are examples of specific protection. The following are some examples of specific protection: Immunization, use of specific nutrients, chemoprophylaxis, protection against accidents, protection from carcinogens, avoidance of allergens, etc.

Early Diagnosis and Treatment

Detection of abnormality in bodies both physique and mind is the mainstay of disease control. Early detection of a case may reverse the health situation or medical condition of the affected person(s) if he gets the right treatment at earlier time.

Disability Limitation

Sequence of events in disease may be recovery or death or recovery with complication(s) i.e. disability. If proper management is not done here in time, it may lead to handicapped situation of the persons.

Rehabilitation

To get functional ability a disabled person is trained and retrained with combined and coordinated use of medical, social, educational and vocational measures. Thus a disabled person will be suitably reemployed.

These are the related issues of modes of intervention which can be apples to improve the health of people.

Q8. Define community medicine and internal medicine. Compare and contrast the relation between them?

(BNMU 2006, 2008)

Ans: Definition of community medicine and internal medicine can be achieved from the following table described hereunder.

Community medicine	Internal medicine
Made by Epidemiologist and group of doctors	Made by doctor
Concerned with defined population	Concerned with individual case
Concerned with both sick and healthy person	Concerned with only sick people
Epidemiologist conducts survey	Doctor examines the patient
Arrived at based on natural history of disease	Arrived at based on signs and symptoms
It involves epidemiological investigation	It involves laboratory investigation
Epidemiologist decides the plan of action	Doctor decides the treatment
Prevention and promotion is the main aim	Treatment is the main aim
It involves the evaluation of program	It involves follow-up of case
Epidemiologist is interested in statistical value	Doctor is interested in technological advantages

Comparison and contrast between clinical medicine and community medicine:

Approaches	Clinical medicine	Community medicine
Focus	Individual	Community
Concern	Sick person	Sick and healthy people both
Responsibility	For those who come to seek help	Whole community7
Goal	To relieve symptoms, signs and to cure patient	To eradicate disease and to reduce incidence and prevalence of disease
Skills/component	Clinical skill	Epidemiological- biostatistic and managerial skill
Treatment	Treat patients with drugs, injections, surgical treatment, etc.	Treat causes through national health programmes Treat environment through safe water and safe excreta disposal Raises community immunity by mass immunization, etc.
Teaching-training	Bedside	In community
Diagnostic and evaluation tool	Uses clinical parameters	Uses epidemiological tools
Requirement	Patient compliance and cooperation	Community participation
Results	Quickly achieved and visible	Takes longer time to see the results
Laboratory	Hospital-words	Community

Q9. Explain by diagram, natural history of disease, discuss how do you apply different modes of interventions in the natural history of disease?

(BNMU 2002, 2005, 2008, 2011, 2016, RGUHS 2001, 2008, 2010, ABKUB 2009, 2014, SMU 2010, TDMGRMU 2015, NU 2015, SSUHSA 2017)

Ans:

Fig. 1.1: Diagram of natural history of disease.

MODES OF INTERVENTION

Primary Level at Pre-pathogenesis State

Health promotion: This is an intervention in primary level of prevention. Health education, lifestyle and behavioral change, environmental modification, nutritional interventions are examples of action in health promotion. In presence of agent, host and environment health promotion is applied to prevent the development of disease process in pre-pathogenesis state.
Specific protection: Specific diseases are addressed here. Vaccinations against specific diseases like measles are examples of specific protection. This is primary level of prevention. Disease is not yet developed and disease will not be seen after this intervention in this pre-pathogenesis state.
Secondary Level at Pathogenesis State
Early diagnosis and treatment: Detection of abnormality in bodies both physique and mind is the mainstay of disease control. Early detection of a case may reverse the health situation or medical condition of the affected person(s) if he (they) gets the right treatment at earlier time. Pathogenesis process has been completed here with discernible signs and symptoms of the disease. So cases will be given relief from the physical problem. General people will be protected from development of similar disease of infectious origin.

Tertiary Level at Pathogenesis State

Disability limitation: Sequence of events in disease may be recovery or death or recovery with complication(s) i.e. disability. If proper management is not done here in time, it may lead to handicapped situation of the persons. So disability will be prevented at this level of intervention. Disease is advanced here with complication(s). Medical rehabilitation may be applied at this level.8
Rehabilitation: To get highest possible functional ability a disabled person is trained and retrained with combined and coordinated use of medical, social, educational and vocational measures. Thus a disabled person will be suitably reemployed. This is really adopted to get patient's confidence and social honour at last stage of pathogenesis. The victims are made confident to appear in the mainstream of community life. Thus a life will be fruitful from a stage of disability.

Q10. What do you mean by “Multifactorial Causation” of disease? Describe with suitable examples?

(BNMU 2011, WBUHS 2013, 2017, SAMU 2015)

Ans: It is an important concept in causation of disease. Before this concept, various other types of concepts came to our mind and those are described in the following ways:

Germ theory of disease: This concept gained momentum during the 19th and early part of the 20th century. The concept of cause embodied in the germ theory of disease is generally referred to as a one to one relationship between causal agent and disease. As an example we can cite the disease leprosy which is caused by Mycobacterium leprae.
Epidemiological triad: The germ theory has many limitations. For example, it is well known that everyone exposed to M. tuberculosis does not develop the disease tuberculosis. The same exposure, however, in an undernourished or otherwise susceptible patient may result in tuberculosis in favorable environment. Beta-hemolytic streptococci also behave in similar way. So some other factor plays its role in causation of disease in presence of agent and host. This may be simply taken as environment. The interplay of agent, host and environmental factors are responsible for causation of disease. This theory has been used for many years.
Multi-factorial causation of disease is a revolutionary concept where Pettenkofer of Munich (1819-1901) was an early proponent of this concept. As a result of advances in public health, chemotherapy, vector control, antibiotics, communicable diseases began to decline and it was replaced by new types of diseases, e.g. lung cancer, coronary heart disease, chronic bronchitis, mental illnesses, etc. These diseases could not be explained on the basis of germ theory of diseases nor could they be prevented by the traditional methods of isolation, immunization or improvement in the sanitation. The realization began to dawn that the single cause idea was an oversimplification and there are other factors in the etiology of diseases. These are social, economic, cultural, genetic and psychological and they are equally important for disease causation. As already mentioned, tuberculosis is not merely due to tubercle bacilli, factors such as poverty, overcrowding, malnutrition also contribute to its occurrence.

Example: Coronary heart disease occurs due to interplay of multiple factors like excess fat intake, obesity, smoking, physical inactivity, alcoholism, stress, etc. This has deemphasized the concept of disease agent between host and environment. An identification of multiple factors helps take action to reduce the burden of diseases caused by multiple factors. Multiple approaches can be adopted to reduce the burden. Prioritization can be done from these factors involved in disease development.

Q11. Discuss briefly how the knowledge of natural history of diseases helps us to prevent and control of a disease in the community.

(ABKUB 2009)

Ans: Natural history of diseases—already discussed in Long Essay Type Question 9.

In the pre-pathogenesis phase of natural history of diseases, level of intervention is health promotion and specific protection.

The various measures of health promotion are:

Health education
Sex education
Adequate nutrition
Improvement of sanitation
Promotion of breastfeeding
Family planning
Genetic counseling
Recreation facilities
Yoga exercise

In specific protection various measures are:

Immunization
Use of condom to prevent STI/RTI
Vitamin A prophylaxis
Use of helmet9
Lead apron against radiation hazards
Pasteurization of milk

In early pathogenesis phase early diagnosis and treatment is the intervention.

Screening procedure for early diagnosis
Investigation in pregnant mother
Contact tracing and cluster testing for STIs
Blood examination to detect diabetes
Periodic examination of industrial workers
PAP smear for carcinoma cervix.

Treatment modalities

Chemotherapy
Surgery
Radiotherapy
Psychotherapy
Oral rehydration therapy

In late pathogenesis phase intervention are disability limitation and rehabilitation.

In disability limitation modalities are:

Intensive or aggressive treatment
Treatment of corneal xerosis to prevent blindness

Types of rehabilitation are:

Physical, vocational, social, psychological.

Examples are:

School for blinds
Artificial limbs, crutches, wheel chair, hearing aids, intraocular lens implant, reconstruction surgery in leprosy.

Q12. Justify the role of healthy lifestyle in promotion of health. Give two examples of lifestyle factor that promote health and two examples that cause disease. Describe how can you influence lifestyle changes that promote health.

(RGUHS 2003, SMU 2009)

Ans: Role of healthy lifestyle in promotion of health:

Health requires promotion of health lifestyle.
It is composed of cultural and behavioral patterns and personal habits developed through the process of socialization, i.e. learnt through social interaction with parents, peer groups, friends, and siblings and through school and mass media.
Lifestyle pattern in developing countries like poor nutrition, lack of sanitation, poor personal hygiene, customs and cultural patterns are the risk factors for illness and also death.
Due to lifestyles in developed countries prevalent health problems are obesity, coronary heart disease, lung cancer and drug addiction, etc.
All lifestyle factors are not harmful, examples are adequate nutrition, enough sleep, and sufficient physical activity may promote health.

So, in conclusion, adoption of healthy lifestyle helps to achieve promotion of health.

Lifestyle factor promoting health: Adequate nutrition, physical exercises, meditation, adequate sleep

Lifestyle factors causing disease: Use of alcohol, drugs, tobacco, sedentary lifestyle.

Importance: Health education is the pivot of all health activity. Change of lifestyles towards health promotes health. Health education is a holistic approach which is the responsibility of individual, community, health workers and also physician at large.

Q13. How will you compare the health situation in two communities? What are the other uses of “Indicators of Health”?

(RGUHS 2008)

Ans: According to WHO, health status of a community can be measured and compared by comparing various health indicators.

However, there is no single indicator which can be used to compare the health status amongst the two communities because health is multidimensional and each dimension is influenced by numerous factors. 10Some of them are known and many are unknown. It must be conceived in terms of a profile, employing many indicators, which may be classified as follows:

Mortality indicators
Morbidity indicators
Disability rates
Nutritional status indicators
Health care delivery indicator
Utilization rates
Indicator of social and mental health
Environmental indicator
Socioeconomic indicators
Health policy indicators
Indicator of quality of life.

Significance

To compare the health status of two communities, various health indicators are available but there is no single comprehensive indicator of a community health.

An ideal index which combines the effect of the number of components measured independently is yet to be developed.

Currently the important health indicators proposed to measure the health status of a community, selected health and socioeconomic indicators are taken to compare with others.

Few indicators are given below:

Indicator	Low income countries	High income countries
Life expectancy at birth (2011)	60	80
IMR (2011)	63	5
Under 5 mortality (2011)	95	6
Maternal mortality per 100000 live birth (2010)	410	14
Doctor population ratio per 10000 (2005–12)	5.1	27.1
GNI per capita US $ (2011)	1313	38690
Adult literacy rate (2005–2011) %	63	97
Access to safe water (%)	67	99
Access to adequate sanitation (%) 2011	37	100
(Source: World Health Statistics 2013)

The other uses of “Indicators of Health” are:

To measure the health status of the community
To assess the health care needs and fixing of priorities
To compare heath status in different states, districts and also other countries
To plan and implement health care services and distribution of resources accordingly
To measure health care services
To evaluate health care services
Lastly impact of above services delivered.

SHORT NOTES AND RELEVANT QUESTIONS

Q1. Rehabilitation.

(BNMU 2005, 2010, 2012, TDMGRMU 2008, 2009, ABKUB 2013, BUMP 2008, SMU 2014, NU 2013)

Ans: Rehabilitation can be defined as combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability. It includes all measures aimed at reducing the impact of disabling and handicapping conditions and enabling the disabled and handicapped to achieve social integration.

Rehabilitation involves different disciplines at the same time in different combination such as physical medicine or physiotherapy, occupational therapy, speech therapy, audiology, psychology, education, vocational guidance and placement services.11

The following areas of concern in the rehabilitation has been identified:

Medical rehabilitation performs restoration of function. Reconstructive surgeries in leprosy, provision of aids for the crippled are medical rehabilitation.
Vocational rehabilitation performs restoration of the capacity to earn a livelihood. Establishing schools for the blind, muscle reduction or graded exercise in neurological disorder, changes of profession for a most suitable one are examples of vocational rehabilitation.
Social rehabilitation performs restoration of family and social relationship through re-employment.
Psychological rehabilitation performs restoration of personal dignity and confidence.
Purpose of the rehabilitation is to make productive people out of nonproductive people.

It is now recognized that rehabilitation is a difficult and demanding task that seldom gives totally satisfactory results but needs enthusiastic cooperation from different segments of society as well as expertise, equipment and funds not readily available for this purpose even in affluent societies.

Q2. Social rehabilitation.

(BNMU 2004, SAM 2015)

Ans: Rehabilitation involves disciplines such as physical medicine or physiotherapy, occupational therapy, speech therapy, audiology, psychology, education, vocational guidance and placement services. Rehabilitation are of different types—medical, vocational, social and psychological.

Social rehabilitation means restoration of family and social relationship. It is particularly important for diseases of social stigma, like leprosy, HIV, mental illness, etc.

Purpose: Social rehabilitation is adopted to make productive people out of nonproductive people.

It is now recognized that social rehabilitation is a difficult and demanding task that seldom gives totally satisfactory results but needs enthusiastic cooperation from different segments of society as well as expertise, equipment and funds not readily available for this purpose even in affluent societies.

Q3. Vocational rehabilitation.

(BNMU 2011)

Ans: Rehabilitation involves disciplines such as physical medicine or physiotherapy, occupational therapy, speech therapy, audiology, psychology, education, vocational guidance and placement services. There are different types of rehabilitation like medical, social, vocational and psychological.

Vocational rehabilitation means restoration of capacity to earn a livelihood, so that the person remains or becomes an economically productive person.

Example: Suppose after a road traffic accident loss his one foot, so he cannot drive and temporarily may become a jobless and economically dependent person. But if any alternative job like clerical job is offered to him and recruited in this new post, vocational rehabilitation can be done. Comparison and contrast will clear the concept of clinical medicine and community medicine and this is given here under in tabular form.

Q4. Measurement of morbidity.

(BNMU 2014)/ Morbidity indicators (RGUHS 2001, 2008, TDMGRU 2008, 2010, WBUHS 2018, DU 2013, 2012, NU 2009, 2006)

Ans: Indicators are used to measure health status of a community of a certain area. Measurement of morbidity is such an indicator. This reveals the burden of diseases in a community. These are used to supplement the mortality rates.

The following morbidity rates are used for assessing the health status:

Incidence rate
Prevalence rate
Notification rate
Outpatient attendance rate
Hospital admission and discharge rate
Duration of stay in hospital

For calculating any rate we need numerator, denominator, time specification and a multiplier.

Incidence rate: It is the number of new cases of a particular disease occurring per 1000 (unit) population in a year.
Prevalence rate: It is the total number of both old and new cases existing in the population during a given period of time. It is expressed in percentage i.e. percentage of the population suffering from a particular disease.

Q5. Medical care and health care not synonymous.

(WBUHS 2008)

Ans: Health care implies more than medical care. Health care means multitude of services provided to individuals or communities by the agent of health services or professions for the purpose of promoting, maintaining, monitoring or restoring health. Since health is influenced by a number of factors such as adequate food, housing, sanitation, healthy lifestyles, protection against environmental hazards and communicable diseases, the frontiers of health extend beyond the narrow limits of medical care.12

The term medical care refers chiefly to those personal services that are provided directly by physicians or rendered as the result of physician's instruction. It ranges from domiciliary care to resident hospital care. Thus health care and medical care is not synonymous.

Q6. Primary health care basically the responsibility of the state.

(WBUHS 2008)

Ans: The Alma-Ata conference in USSR in 1978 defined, “Primary health care is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford.” India participated the conference and was one of the signatories.

PRINCIPLES OF PRIMARY HEALTH CARE

Equitable Distribution

According to this principle, health services must be shared equally by all people, irrespective of their ability to pay and all must have access to health services. If the health services are mainly concentrated in major towns and cities, it results an inequality of care to the people in rural areas. Even among the rural areas, many people in tribal, hilly or difficult to reach area cannot reach the health center due to inaccessibility. Primary health care aims to redress the imbalance by shifting the center of gravity of health care system from cities to rural area, and within rural area, it is distributed in different areas, according to needs.

Example: Sub-centers are located every 5000 people in normal area and every 3000 people in tribal, hilly and difficult to reach areas.

Community Participation

Countries are now conscious of the fact that universal coverage of primary health care cannot be achieved without the involvement of community.

Examples: ASHA, CHG, trained Dai are selected by the local community and trained locally in the delivery of primary health care to the community, they belong, free of charge. By overcoming cultural and communication barrier, they provide primary health care in ways that are acceptable to the community. They play their role in decision, planning of health care delivery in the belonging community.

Inter-sectoral Coordination

Primary health care involves various sectors other than health for efficient delivery of health care like agriculture, animal husbandry, food, industry, education, housing etc. there is an increasing realization of the fact that the components of primary health care cannot be provided by the health sector alone.

Examples: IPPI requires the involvement of different sectors like health, transport, railway, panchayat, school, college, NGO, media, police, military, etc. to make it successful.

Appropriate Technology

It has been defined as ‘technology, that is scientifically sound, adaptable to local need, acceptable to those who apply it and those for whom it is used, and that can be maintained by people themselves keeping with the principle of self-reliance with the resources the community and country can afford.’

Examples: Preparation of ORS: Implementation of these principles are chiefly of states. Health care delivery is done through state as it is considered as state chapter. These principles are applied during service delivery among the general population. If these are technically followed in proper way, the success of health care delivery can be achieved. This health care cannot be delivered through private sector for all people. This delivery requires motivation of staff of health sector, requires huge finance, requires community involvement, requires proper planning and decision of activities dedicated for people and so on. This is seriously thought for only by government.

So we can come to the conclusion that primary health care is the responsibility of the state.

Q7. Primary health care.

(BNMU 2006, SAMU 2016, BUMP 2010, 2012, SSUHSA 2013, 2015, BUMP 2010, 2012, MU 2019)

Ans: Definition of The Primary Health Care

Alma-Ata conference in USSR in 1978 defined, “Primary health care is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford.”

Essential health care based on practical, scientifically sound and socially acceptable methods and technology to the individual and communities through their full participation and at a cost, that community and country can afford.13

Principles of primary health care:

Equitable distribution
Community participation
Inter-sectoral coordination
Appropriate technology

Elements of primary health care:

Health education regarding prevailing diseases.
Food supply and proper nutrition.
Water supply and basic sanitation.
Immunization against infectious diseases.
Maternal and child health care including family planning.
Prevention and control of locally endemic diseases.
Appropriate treatment of common diseases and injury.
Provision of essential drugs.

Delivery of primary health care:

Through community health center: Located every 120000 population in normal; area/80000 population in tribal, hilly and difficult to reach areas. It provides OPD, IPD, antenatal, intranatal, postnatal care, family planning services, counseling services, immunization, etc.
Through primary health center: Located every 30000 population in normal; area/20000 population in tribal, hilly and difficult to reach areas. It provides OPD, IPD, family planning services, immunization, etc.
Through sub-center: Located every 5000 population in normal; area/3000 population in tribal, hilly and difficult to reach areas. It provides OPD, family planning services, immunization, drug distribution to the TB and leprosy patients etc.
Through village: Located every 1000 population. Services are provided through ASHA, AWW, community health guide etc.

Q8. Elements of primary health care.

(WBUHS 2009, BNMU 2011, 2017, 2018, RGUHS 2013, 2014, TRIU 2013, 2014, 2015, 2016, SAMU 1999, 2011, 2012, 2016, TDMGRMU 2010, 2011, ABKUB 2006, 2010, 2016, BUMP 2010, 2016, SSUHSA 2013)

Elements of primary health care

Health education regarding prevailing diseases: Education imparts knowledge and knowledge catalyses practices. Healthy practice can be motivated giving knowledge to the people through health education.
Food supply and proper nutrition: Health is not only dependent on health department people and their activities. Nutrition is essential to make a person nutritionally fit and this will lead or help to keep the health of an individual normal.
Water supply and basic sanitation: Potable water will reduce water and food born diseases. Sanitation is also doing for health. Safe and wholesome water along with proper sanitation will create an environment of good health.
Immunization against infectious diseases: Specific protection against certain diseases can be adopted through vaccination. Infectious diseases are essentially taken in this intervention.
Maternal and child health care including family planning: Mothers and children are major number of beneficiaries in any country. Their health should be taken care of to prevent complications, to control problems. Good socio-economic status will be seen if family planning is taken by the couple.
Prevention and control of locally endemic diseases: Prevention and control measures are available for endemic diseases in all countries including India. So programmes protocol should be properly followed.
Appropriate treatment of common diseases and injury: Appropriate treatment will reduce morbidity (sufferings), complications and mortality.
Provision of essential drugs: This is the responsibility of a state. These drugs are cheaper, easy to make these available.14

Q9. Principles of primary health care.

(WBUHS 2010, 2016, BNMU 2016, 2017, RGUHS 2001, 2003, 2006, 2012, TRIU 2013, 2014, 2015,SAMU 2007, 2015, 2016, TDMGRMU 2009, 2010, 2012, 2013, 2014, SSUHSA 2010, 2015, BUMP 2010, KIMS 2016, NU 2016)

Ans: The definition of primary health care was widely accepted in a conference in Alma-Ata USSR in 1978 as “Primary health care is an essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford.”

This primary health care should follow certain principles which will help the country to do their best for most of their population. Principles of primary health care are described hereunder.

Equitable distribution [Equitable distribution of health services–an important principle of primary health care–justify].

(WBUHS 2013, ABKUB 2007)

It is the first principle of primary health care. According to this principle, health services must be shared equally by all people, irrespective of their ability to pay and all (rich or poor/urban or rural people) must have access to health services. If the health services are mainly concentrated in major towns and cities, it results an inequality of care to the people in rural areas. Even among the rural areas, many people in tribal, hilly or difficult to reach area cannot reach the health center due to inaccessibility. The worst hit are the needy and vulnerable group of population in rural areas and slums. This has been termed as social injustice. Primary health care aims to redress the imbalance by shifting the center of gravity of health care system from cities to rural areas (where three quarters of the people live), and within rural area, it is distributed in different areas, according to needs.

Example: Sub-centers are located for every 5000 people in plain area and for every 3000 people in tribal, hilly and difficult to reach areas. These are established for all residing in rural area both rich and poor. Every individual has an access to these service centers.

CHCs are located for every 1,20,000 people in plain area and every 80,000 people in tribal, hilly and difficult to reach areas.
Community participation.

(DU 2000, BUMP 2013, SSUHSA 2010)

Countries are now conscious of the fact that universal coverage of primary health care cannot be achieved without the involvement of community. The community should voluntarily come in all levels of service delivery and decision making.

ASHA, CHG, trained Dai, AWW are selected by the local community and trained locally. Their participation is utmost important for the delivery of primary health care to the community. By overcoming cultural and communication barrier, they are the people who can provide primary health care in ways that are acceptable to the community.
Inter-sectoral coordination.

(WBUHS 2008, BNMU 2013, RGUHS 2001, 2015, ABKUB 2004)

There is an increasing realization of the fact that the components of primary health care cannot be provided by the health sector alone. The declaration of Alma-Atta states that Primary health care involves various sectors other than health for efficient delivery of health care like agriculture, animal husbandry, food, industry, education, housing, public work, communication, etc. To achieve such cooperation, countries may have to review their administrative system, reallocate their resources and introduce suitable legislation to ensure that coordination can take place. This requires strong political will to translate values into action. An important element of the intersectoral approach is the planning—planning with other sectors to avoid unnecessary duplication of activities.

Examples: IPPI requires the involvement of different sectors like health, transport, railway, panchayat, school, college, NGO, media, police, military, etc. ICDS workers and ASHA work together in proper coordination in the working field.
Appropriate technology [ORS is an example of appropriate technology].

(WBUHS 2018)

It has been defined as ‘technology, that is scientifically sound, adaptable to local need, acceptable to those who apply it and those for whom it is used, and that can be maintained by people themselves keeping with the principle of self-reliance with the resources the community and country can afford.’ ORS is scientifically sound drug, adaptable and acceptable by local people; community and country can afford it. This appropriation in technology should be thought for primary health care.

Q10. What are the determinants of primary health care?

(RGUHS 2003)

Ans: The determinants of primary health care based on four principles of it are community participation, appropriate technology, inter-sectoral coordination and equitable distribution. Though the mode of delivery of primary health care is different from country to country and within the country from place to place and time to time, these are common and important.15

The determinants of primary health care depends on:

Type of illness prevalent
Availability of resources (money, manpower and resources)
Set up of objectives and fixing priorities
Active participation of the community at large.

Q11. Health promotion.

(BNMU 2011, RGUHS 2007, BUMP 2010, DU 2011, MU 2019)

Ans: Health promotion is “process of enabling people to increase over, and to improve health.” The well-known interventions in this area are:

Health education: This is one of the most cost-effective interventions for health. In primary health care approach, health education has been positioned at the beginning. There are many diseases (both communicable and non-communicable) which can be prevented applying the knowledge in real field. Practice is followed by knowledge. If individuals possess knowledge, then they can apply it in real life situation with positive attitude. Health issues are selected first for a particular group of people depending upon their age, sex, occupation, education, society etc. If practice is properly adopted by individuals, reduction of disease incidence will be observed in the population.
Environmental modifications: Provision of potable water in its absence, installation of sanitary latrine, improvement of houses are examples of intervention of environmental modification. This will reduce incidence of common food and water borne diseases.
Nutritional intervention: Food distribution and nutrition improvement of vulnerable groups (child, mothers), nutrition education to mothers, food fortification etc are examples of nutrition intervention which will minimize nutrition disorders.
Lifestyle and behavioral changes: The life-style and behavioral pattern play their role in determination of many health problems and keep health normal in favorable behavior. Tobacco use, alcohol use, lack of exercise, overeating etc can cause medical problems providing health burden. On the contrary no tobacco, no alcohol, regular exercise, optimum eating will help the individuals for maintenance of good health.

Setting goals, objectives and targets organization of these interventions in the society will improve the health or protect health from evil events.

Q12. Prevention of disease. (BNMU 2015)/Levels of prevention

(WBUHS 2008, TRI U 2016. TDMGRMU 2009, 2011, SSUHSA 2008, SMU 2012, KIMS 2015, 2017, DU 2013, NU 2013)

Ans: Primordial prevention: This is prevention of population groups from risk factors which have not yet appeared. Obesity in childhood, when lifestyles are formed (eating habit, smoking and physical exercise) can be prevented in the community. Efforts are directed towards discouraging children from adopting harmful habits/lifestyles. The main intervention is through mass education. The prevention of hypertension, diabetes mellitus thus will be exercised in reducing the obesity.

Other 3 levels of prevention:

Primary prevention
Secondary prevention
Tertiary prevention

Construct the answer from long essay question 7.

Q13. Principle of prevention.

(BNMU 2016, 2017)

Ans: Principle of prevention mostly depends upon:

Knowledge of causation
Dynamics of transmission
Identification of risk factors and risk groups
Availability of prophylactic or early detection and treatment measures
Need for appropriate organization/ groups/ person for applying these measures
Continuous evaluation of procedure applied.

The objective of prevention is to intercept or oppose the cause as well as disease process. Sometimes it was observed that removal or elimination of a single known essential cause may sufficient to prevent a disease.

Then describe 4 levels of prevention.16

Q14. Primordial prevention.

(BNMU 2014, TRIU 2016, TDMGRMU 2011, 2012, SSUHSA 2011, SMU 2015, ABKUB 2018)

Primordial prevention is a subject of primary prevention only–Justify

(WBUHS 2015)

Ans: Primordial prevention: This is prevention of population groups from risk factors which have not yet appeared. Obesity in childhood, when lifestyles are formed (eating habit, smoking and physical exercise), can be prevented in the community. Efforts are directed towards discouraging children from adopting harmful habits/lifestyles. The main intervention is through mass education. The prevention of hypertension, diabetes mellitus thus will be exercised in reducing the obesity.

The diseases are prevented before disease develops in any individual. This prevention level is truly primary prevention where disease development will be prevented. Primordial prevention is also trying to fulfil the same objective. So primordial prevention is a subset of primary prevention.

Q15. Disability limitation (WBUHS 2015) or concept of disability.

(RGUHS 2009, TDMGRMU 2014)

Ans: Disability limitation: Sequence of events in disease may be recovery or death or recovery with complication(s) i.e. disability. If proper management is not done here in time, it may lead to handicapped situation of the persons. So disability will be prevented at this level of intervention. Disease is advanced here with complication(s). Medical rehabilitation may be applied at this level.

Q16. Dependency ratio.

(ABKUB 2016, RUJH 2012)

Ans: It is the ratio between the adults, who are in the age of economically productive life, 15-65 years and the dependents such as children below 15 years and elderly above 65 years. It is expressed per 100 adults.

Young age dependency ratio is considered when 0-14 years children are taken.

Old age dependency ratio when above 65 years people are considered.

An increase in dependency ratio will effect the economic and social burden of the country.

The old age dependency ratio was 7.7 percent during 2001 and increased to 8.1 percent in 2011 and is on the increase.

Q17. Spectrum of disease.

(WBUHS 2007, RGUHS 2008, SAMU 2011, BUMP 2008)

Ans: Health and disease lie along a continuum and there is no single cut-off point. The lowest point on the health-disease spectrum is death and the highest point corresponds to the WHO definition of positive health. It is obvious thus health fluctuates within a range of optimum well-being to various level of dysfunction, including the state of total dysfunction, namely the death. The transition from optimum health to ill health is often gradual.

The spectral concept of health emphasizes that health of the individual is not a static, it is a dynamic phenomenon and a process of continuous change, subject to frequent subtle variations. What is considered maximum health today may be minimum tomorrow. It implies that health is a state not to be attained once and for all, but ever to be renewed. Spectrum of health can be described as follows:

Positive health
Better health
Freedom from sickness
Unrecognized sickness
Mild sickness
Severe sickness
Death

Q18. Disease dynamics.

(BUMP 2008)

Ans: As a point of departure the following definitions are proposed: Health is a dynamic state of well-being characterized by a physical, mental and social potential, which satisfies the demands of a life commensurate with age, culture, and personal responsibility.17

Q19. Early diagnosis and treatment are the main intervention of disease control–Explain.

(BNMU 2014)

Ans: Early diagnosis and treatment are the main intervention in disease control. The earlier a disease is diagnosed and better treatment and good prognosis, preventing the occurrence of secondary cases or any long term disability can be done. It is like the stamping the “spark” rather than calling the fire brigade to put out of fire.

Early diagnosis and treatment though not as effective and economical as primary prevention may be critically important in reducing the high morbidity and mortality in certain diseases. Essential hypertension, cancer cervix and breast cancer, etc. can be taken in this line. For other diseases like tuberculosis, leprosy and STD early diagnosis and treatment are only effective mode of intervention. Early diagnosis helps the patient reduce sufferings after getting proper treatment thus prevent spread of the disease to susceptible population. And at the same time the patient will be cured. Early effective therapy shorten period of communicability and reduce the mortality from acute communicable diseases. Proper treatment at right time will control the diseased situation i.e. early recovery and no further secondary case.

So, early diagnosis and treatment are the main intervention of disease control.

Q20. Iceberg phenomenon of a disease.

(WBUHS 2008, 2017, 2019, RHUHS 2010, 2012, 2013, TRIU 2011, 2015, SAMU 2007, TDMGRMU 2010, 2014, ABKUB 2004, 2007, 2017, SMU 2012, 2014, UUO 2013, DU 2008, 2012, NU 2007, 2012, 2014, 2015, SSUHS 2017)

Sub-merged part of the disease iceberg has immense importance to an epidemiologist–Explain.

(WBUHS 2009)

Ans: The iceberg of disease is closely related to spectrum of disease. The disease of the community is compared with an iceberg. The floating tip of the iceberg represents what physician sees in the community (clinical case). The vast submerged portion of iceberg represents the hidden mass of disease, i.e., latent, inapparent, presymptomatic and undiagnosed cases and carriers in the community. The waterline represents the demarcation between apparent and inapparent disease. In some diseases (e.g. hypertension, diabetes, anemia, malnutrition and mental illness), the unknown morbidity (submerged portion of iceberg) far exceeds known morbidity (floating tip). The hidden part of iceberg thus constitutes an important undiagnosed reservoir of infection or disease in the community. Its detection and control is a challenge to modern medicine.

Fig. 1.2: Iceberg of disease.

Q21. Quality of life.

(WBUHS 2008)

Ans: It defined as composite measure of physical, mental and social well being as perceived by each individuals or group of individuals. Governments (all over the world) are concerned about improving the quality of life by reducing morbidity, mortality, improved primary health care and enhancing physical, mental and social well-being. For measuring physical quality one such index used as PQLI is frequently utilized. Indicators of PQLI are infant mortality, life expectancy at age one and literacy rate. PQLI is independent of per capita GNP.

Q22. What is PQLI.

(RGUHS 2002, 2008, 2010, 2011, 2013, 2014, 2015, TDMGRMU 2010, 2014, ABKUB 2006, SAMU 2016, BUMP 2013, SMU 2010, 2012, 2014, DU 2010, NIMSUR 2015, NU 2009, 2012)

Ans: Physical Quality of Life Index (PQLI).

Three indicators are being used to determine the PQLI. These are infant mortality, Life expectancy at age one and literacy. The performance of each country is expressed in 0 to 100 scale, where 0 denotes absolutely worst performance and 100 denotes best performance. By averaging the three indicators the composite index is being calculated, giving equal weightage to each of them. The resulting PQLI thus also is scaled 0 to 100.

Per capita GNP is not considered for determining the PQLI. For example, the Middle East (Oil rich countries) is with high per capita incomes but with a very low PQLI. On the other hand, the country like Sri Lanka and Kerala, the state of India, with lower per capita income have high PQLI.

So, PQLI does not represent economic growth rather it is the results of social, economic and political policies. The ultimate objective is to attain a PQLI of 100.18

Q23. Human development index.

(WBUHS 2011, RUJH 2009, RHUHS 2004, 2010, 2013, 2015, SAM 2011, 2012, TDMGRMU 2010, 2016, KIMS 2015, DU 2012, ABKUB 2018)

Ans: Human development index (HDI) is a composite index combining three indicators. There are three dimension of HDI - longevity (life expectancy at birth), educational attainment as knowledge (adult literacy rate and mean years of schooling) and income (real GDP per capita in purchasing power-parity dollars).

The concept of HDI really reflects the achievement of basic needs (capabilities) leading to a long healthy, knowledgeable life with decent standard of living.

Income is only a means to human development, not an end. Nor is it a sum total of human lives. HDI provides a more comprehensive picture of human life than income does. This HDI can be calculated and its value ranges from 0 to 1. This value can be utilized in international comparison.

To construct the index, for each of these components minimum and maximum values have been established and their summation will be treated as HDI. Depending upon the value of HDI, the countries can be graded in different levels. The different grades are ‘low’ with HDI value < 0.5, ‘medium’ with HDI value 0.79 to 0.5 and ‘high’ with value ≥ 0.8.

HDI of 187 countries have been constructed for the year 2012. India's rank was seen at 136 in median category. High category countries are Norway, Australia and United States of America, etc.

Q24. Healthy lifestyles.

(WBUHS 2010)

Ans: Maintenance of healthy lifestyle is required to maintain good health and this is a good actionable example of health promotion. As the age advances, problems of communicable disease begin to decline due to advancement in chemotherapy, vector control, immunization, etc. but various types of lifestyle related non-communicable and chronic diseases are increasing like hypertension, diabetes, cardiovascular diseases, mental illness, accident etc. If the healthy lifestyles are adopted by majority of the population, it will substantially reduce morbidity and mortality from various non-communicable and chronic diseases.

Life style should be such that it will promote health and it will never cause harm. Examples of healthy lifestyles include avoidance of tobacco smoking, regular physical activity (at least 30 minutes/day) like running, fast walking, swimming, playing, etc. Consumption of alcohol should be reduced as much as possible.

Low consumption of fatty food and junk food, regular consumption of fruits and vegetables are good practice in relation to food. Maintenance of body weight, maintenance of personal and genital hygiene, use of protective device during driving and driving at low speed, adequate rest and sleep, avoidance of regular late night, etc. are other important issues as healthy lifestyle for health improvement.

Q25. Lifestyle and healthy aging.

(SSUHSA 2016)

Ans: Healthy ageing is about enabling older people to enjoy a good quality of life. Healthy regarding aging and beliefs regarding healthcare among older adults.

Menopause is a normal part of ageing. With increasing age the risk of many common illnesses increases. Optimizing health at menopause may help to improve.
Healthy lifestyles for seniors’ is an important part of the aging process. Healthy eating, keeping up on medications and tests, and regular exercise can help.
Being physically active, eating well, socializing and improving your health can help you live a healthy, happy and active life as you get older.
Plan for healthy aging and improve your odds of living a long and active life by following the choice guide to healthy habits and targeted screenings.

Q26. Age specific indicator of health.

(SSUHSA 2015)

Ans: Age specific indicators of health: Death rate is crude indicator which cannot be compared to assess the status of health of two or multiple areas or states or countries. In particular when light on etiology is concerned, then specific death rate is primarily required in terms of age, disease, gender, age and gender, time, etc.

Let us take the example of age specific death rates.

Death rate can be expressed for specific age group in a defined population. An age specific death rate is defined as total number of deaths occurring in a specific age group of population (20-24 years) in a defined area during a specific period per 1000 estimated total population of the same age group in the same area during the same period.

Similarly disease specific death rate, sex-specific death rate are also calculated to see the cause for death or proportion of cause of death.

Q27. Standardized mortality ratio [SMR].

(WBUHS 2018)

Ans: It is simplex and most useful form of indirect standardization. The standardized mortality ratio is a ratio (usually expressed in percent) of total number of deaths that occur in study group.

To the number of deaths that would have been expected to occur if that study group had experienced the death rate of a standard population (or other reference population). In other words, SMR compares the mortality in a study group (e.g. an occupational group) with a mortality that the occupational group would have had if they had experienced national mortality rates.

In this method of study, the more stable rates of study population are applied to the smaller study groups. It gives a measure of the likely excess risk of mortality due to the occupation.

If the SMR is greater than 100, the occupation would appear to carry a greater mortality risk than that of whole population. If SMR less than 100 then the occupation risks of mortality would seem to be proportionally less than that of whole population.

Table 1.1 Calculation of the SMR for coal workers.

Age	National population death rates per 1000	Coal worker population	Observed deaths	Expected deaths
24–34	3.0	200	*	0.6
35–44	5.0	400	*	2.0
44–54	8.0	300	*	2.4
55–64	25.0	100	*	2.5
		1000	9	7.5
*It is not necessary to know these values; only the total for the whole age range is required.

SMR = 9/7.5 × 100 = 120

The Table 1.1 shows that the mortality experience of coal workers was 120%, which meant that their mortality was 20% more than that experienced by the national population. If the values more than 100% indicates unfavorable mortality experience and those below 100% relatively favorable mortality experience.

Advantage of SMR: SMR has the advantage over the direct method of age adjustment in that it permits adjustment for age and other factors where age-specific rates are not available or unstable because of small numbers. Only requirement is, the number of persons in each group in the study population and age-specific rates of the national population.

Q28. Crude death rate.

(RGUHS 2009)

Ans: Crude death rate (CDR) is defined as the number of death per 1000 population per year in a given community. It indicates the rate at which people are dying.

Crude death rate (CDR) in India is 7.0 per 1000 mid-year population [SRS Bulletin, 2014]. This is used to assess the health situation of the area. The causes of the death also can be identified by this CDR. Age-specific death rate is better and most useful single measures of mortality.

Total mid-year population: Population size changes daily due to births, deaths and migration, hence, the mid-year population is commonly chosen as a denominator, the mid- point refers to the population estimated as on the first of July of a year.

Q29. Life expectancy.

(RGUHS 2010)

Ans: Life expectancy at birth is “the average number of years that will be lived by those born alive into a population if the current age-specific mortality rates persist.” It is influenced by infant mortality rate. When we say life expectancy at age 1, this excludes the influence of infant mortality and life expectancy at age 5, this excludes the influence of child mortality.20

It is estimated separately for both sexes. It is very good indicator of socioeconomic development of a country. It is a positive health indicator, hence adopted for global health indicator.

Q30. Proportional mortality rate.

(TDMGRMU 2009)

Ans: This is the number of deaths for a particular disease among all deaths in a population. It is the simplest measure of estimating the burden of a particular disease in a community. The proportional mortality rate from communicable diseases has been suggested as a useful health status indicator. It may indicate the magnitude of preventable mortality.

Proportion of death of mothers due to hemorrhage in one year in a hospital among all deaths of mother in same time period is one of proportional mortality rate. Ante-natal or post-natal hemorrhage can be prevented in many cases of mortality.

The calculation of proportional mortality rate can be seen in the following way:

Q31. Secondary attack rate.

(BNMU 2005, RGUHS 2013, TDMGRMU 2010, SMU 2010, BUMP 2012, RUJH 2010)

Ans: Secondary attack rate (SAR) is defined as the number of exposed persons developing the disease within the range of the incubation period, following exposure to the primary cases. It is given by the formula:

The denominator consists of all persons who are exposed to the primary case. Most specifically, the denominator may be restricted only to susceptible contacts. The primary case is excluded from both the numerator and denominator.

The following example may clarify the matter. Say, there is a family of 6 members consisting of 2 parents and 4 children who are susceptible to a specific disease like measles. There occurs a primary case and within a short time 2 secondary cases among the remaining children. Here the first case will be kept aside from the calculation. 2 cases will be the number of exposed susceptible persons developing the disease and susceptible persons will be 3 putting as denominator. Thus, secondary attack rate is 2/3 × 100 or 66.6 percent. Secondary attack rate is limited in its application to infectious diseases in which the primary case is infective for only short period of time measured in days. When the primary case is infective over a long period of time, duration of exposure is an important factor in determining the extent of spread. It is indicated by the formula for tuberculosis.

An additional advantage of the secondary attack rate is that vaccines and non-vaccines from several families can be added to determine the overall attack rates in the vaccinated and unvaccinated populations.

Use of secondary attack rate: It measures the spread of an infection from first case to susceptible population. It can be used to evaluate the effectiveness of control measures in some disease. It can be useful in determination of communicability of a disease of unknown etiology.

Q32. Case fatality rate and its significance.

(TDMGRMU 2008, WBUHS 2018)

Ans: Case fatality rate (CFR) measures the risk of persons dying from a certain disease within a given period of time. It is calculated as number of deaths from a specific disease during a specific time period divided by total number of cases of the disease during the same time period expressed in percent.

The calculation of case fatality rate can be seen in the following way:

Significance:

It is used to link mortality and morbidity
It can measure pathogenicity, severity or virulence
It is used in poisonings, chemical exposure and other short term non-disease cause of death.

Limitation of CFR:

Time interval is not specified.

Q33. Survival rate.

(TDMGRMU 2011)

Ans: Survival rate (SR): It is proportion of survivors in a group of patients, studied/followed up over a period of time (example 5 years). It is used to understand prognosis of a disease under study like cancer.

Survival period is calculated from date of diagnosis or start of treatment.

Q34. What is community diagnosis?

(RGUHS 2003, 2009, SAMU 2009, SMU 2013, 2015)

Ans: Community diagnosis may be defined as the pattern of disease in a community described in terms of the important factors which influence this pattern. It is concerned with both sick and healthy people in a defined population.

Objectives: Identification of health problems and felt need of the community.

Strategies: It is based on collection and interpretation of important data like:

Age and sex distribution of a population
Vital statistics rates such as birth and death rates, etc.
Incidence and prevalence of the important diseases of that area
Social distribution of the population.

Community diagnosis at primary health center

It is based on collection, analysis and interpretation of following data:

Age and sex distribution of a population
- It is collected from the census reports of the area
- It helps to understand the structure of the community
Vital statistics
- Vital statistics like crude birth rate, crude death rate, age specific death rate, etc. are the indicators of the health and morbidity of the community.
- Morbidity data is preferred but mortality data is widely used because it is easily available
Incidence and prevalence of the diseases of that area
- It identifies the risk groups for various illnesses, character of diseases prevalent, nutritional, environmental and sanitation status of the community, etc.
- Identification of felt need of the community
- Intervention measures are adopted from above information
Social distribution of the population
- It involves the study of social groups, their relationships and socioeconomic status of the community.

Q35. Definition of community treatment.

(TDMGRMU 2013)

Ans: Community treatment is the steps taken to meet the health need of the community in respect to resources available as revealed by community diagnosis.

Community treatment should have following actions:

Optimum use of available resources in terms of money, manpower and materials.
Full participation of the community
Coordination of the efforts of other agencies

Thus the principle of primary health care as laid down in “Alma-Ata Declaration” is fulfilled.

Examples of some of the community action:

Improvement of safe water supply.
Health education
Immunization for vaccine preventable diseases
Control of specific diseases
Follow the health legislation.22

These actions are implemented at three levels:

At individual level
At family and
At community level.

Q36. Web causation of disease.

(RGUHS 2008, 2014, TRIU 2014, SMU 2013, DU 2012)

Ans: Web causation of disease was described by McMahon and Pugh.

According to them, disease occurs due to complex interaction of various predisposing factors. To control them sometimes removal of just one key link helps in control of disease. There is no need to control of all factors associated in the disease causation.

Individual factors do not carry much effect but one crucial factor may very important role in disease causation. Model is ideally suited for study of chronic disease.

Fig. 1.3: Web causation.

BEINGS model of disease causation: These are different factors which interact in various directions with different strength and ultimately they lead the development of a disease.

Behavioral and biological factors (Virus, bacteria, fungi)
Environmental factors (physical, biological)
Immunological factors (immunity, vaccination, susceptibility)
Nutritional factors (under nutrition, over-nutrition)
Genetic factors (damilial disease)
Social, services and spiritual factors (culture, customs, habits)

Q37. Concept of positive health.

(TDMGRMU 2009, NU 2013, RUJH 2010)

Ans: The concept of positive health is the perfect functioning of the body and mind in a person.

Components of positive health are given below.

Biological: A state where every cells and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body.
Psychological: A state where the individual feels a sense of perfect well-being and of mastery over his environment.
Social: A state where the individual's capacities for participation in the social system are optimum.

Finally, the concept of positive health will always remain a mirage because everything in our life is subject to change.

Q38. International classification of diseases [ICD].

(TRIU 2013, 2016, TDMGRMU 2010, 2012, SMU 2014, DU 2008, ABKUB 2018)

Ans: World Health Organization introduced International Classification of Diseases (ICD) in 1993 which has been accepted by National and International countries in the following years. In the year 1948, in its 6th revision the scope of ICD was expanded, hence forth it covered morbidity from illness and injury. ICD is revised once in every 10 years. The latest 10th version was introduced on the 1st January 1993 by WHO. India has accepted this ICD 10 in 2000.

ICD can be adapted for use of other field like dentistry, oncology and ophthalmology.

ICD-10 is arranged in 21 major chapters. This classification has been taken as alphanumeric one. Any one disease is identified with alphabet and numeral figure. All the alphabets are taken for classification of diseases except ‘U’ and numeral figures are added after alphabet from 00 to 99.

First character: Alphabet (Range: A-Z except U)
Other characters: Numeric: 2–4 digits
For example: A37.1
A37 = Whooping cough
A37.1 = Whooping cough caused by B parapertussis.

Here ‘A’ is placed as alphabet and 37 as numeric figure as 2 digits. You have already understood ‘whooping cough caused by B parapertussis’ has been expressed as ‘A37.1’ which is alphanumeric classification.23

Q39. Global Hunger Index.

(SAMU 2015)

Ans: The Global Hunger Index (GHI) is a multidimensional statistical tool used to describe the state of countries’ hunger situation. The GHI measures progress and failures in the global fight against hunger. The GHI is updated once a year.

It shows that the world has made progress in reducing hunger since 2000, but still has a long way to go, with levels of hunger still serious or alarming in 50 countries. This year's report hails a new paradigm of international development proposed in the United Nations’ 2030 Agenda for Sustainable Development, which envisages Zero Hunger by 2030, as one goal among 17, in a holistic, integrated, and transformative plan for the world.

Calculation of the Index

The Index ranks countries on a 100-point scale, with 0 being the best score (no hunger) and 100 being the worst, although neither of these extremes is reached in practice. Values less than 10.0 reflect low hunger, values from 10.0 to 19.9 reflect moderate hunger, values from 20.0 to 34.9 indicate serious hunger (Pakistan), values from 35.0 to 49.9 reflect alarming hunger (Zambia), and values of 50.0 or more reflect extremely alarming hunger levels.

The GHI combines 4 component indicators: 1) the proportion of the undernourished as a percentage of the population; 2) the proportion of children under the age of five suffering from wasting; 3) the proportion of children under the age of five suffering from stunting; 4) the mortality rate of children under the age of five.

Q40. Explains briefly dimensions of health.

(RGUHS 2008, 2012, 2014, TRIU 2014, BNMU 2017)

Ans:

Physical: Perfect functioning of body cells and organs.
Social: Interpersonal ties and involvement with community.
Mental: Balance between self and surrounding world.
Emotional: Feeling towards self and others.
Spiritual: Meaning and purpose in life.
Socioeconomic: Financial and societal placing.
Environmental: Harmony with physical, biological, chemical surroundings.
Nutritional: Nourishment status of body.
Cultural: Customs, beliefs and practice in family.
Others: Philosophical, vocational.

[Each item may be elaborated from Textbook]

Q41. Spiritual dimension of health.

(ABKUB 2018)

Ans: Proponents of holistic health believe that the time has come to give serious consideration to the spiritual dimension and which plays a role in health and disease.

So, spiritual health refers to that part of the individual which reaches out and strives for meaning and purpose in life. It is the intangible something that transcends physiology and psychology. As a relatively new concept, it seems to defy concrete definition. It includes integrity, principles and ethics, the purpose in life, commitment to some higher being and belief in concepts that are not subject to “state of the art” explanation.

Q42. Family medicine.

(ABKUB 2009, SMU 2012)

Ans: Family medicine has been defined as “a field of specialization in medicine which is neither disease nor organ oriented”. It is family oriented medicine or health care centered on the family as the unit from first contact to the ongoing care of chronic problems. The recognition of family as a focal point of health care and right place for integrating preventive, promotive and curative services.

When these cares are being provided to patients and their families through application of the knowledge of family medicine then it is called family practice. The speciality of family practice is to deliver primary care.

Q43. Family physician.

(WBUHS 2018)

Ans: Family physicians, through education and residency training, possess distinct attitudes, skills, and knowledge which qualify them to provide continuing and comprehensive medical care, health maintenance and preventive services to each member of the family regardless of sex, age, or type of problem, be it biological, social.

Family physicians possess unique attitudes, skills and knowledge which qualify them to provide ongoing, comprehensive medical care to each member of the family. The cornerstone of family medicine is an ongoing, personal patient-physician relationship focused on integrated care.24

Responsibilities:

Family practice doctors, as primary care physicians, are often the first person whom a patient sees when seeking healthcare services. They examine and treat patients with a wide range of conditions and refer those with serious ailments to a specialist or appropriate facility.

Q44. Socialized medicine.

(TDMGRMU 2014, ABKUB 20050)

Ans: Socialized medicine is provision of medical services and professional education by state but the program is operated and regulated by professional groups rather than by government.

It is different from social medicine
It is the policy of providing complete medical care, preventive and curative to all members of a society usually a whole nation as governmental commitment but out of public finance.
Russia was the first country to socialize medicine completely.

Advantages: It ensures social equity that is universally operated by the professional health services.

Significance: It requires community participation though it offers free treatment to all but it alone cannot ensure increased utilization of health services.

Q45. Public health.

(ABKUB 2005, 2008)

Ans: In 1920, Winslow defined Public Health as “the science and art of preventing disease, prolonging life and promotion of health and efficiency through organized community effort for sanitation of environment, the control of communicable infections, the education of individual in personal hygiene, the organization of medical and nursing services for early diagnosis and preventive treatment of disease and development of social machinery to ensure for every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birth right of health and longevity.”

Presently public health is a combination of scientific discipline which includes epidemiology, biostatistics, laboratory medicine, social sciences, demography. It also includes epidemiological investigations, planning, management, interventions, surveillance and evaluation.

Q46. Phases of public health.

(TDMGRMU 2009, 2011)

Ans: There are 4 phases of public health:

Disease control phase (1880–1920): Public health during the 19th century was limited to sanitary legislation and sanitary reforms like water supply, sewage disposal, etc. These activities were not sufficient to control specific diseases. Technical knowledge was deficient in those days.
Health promotional phase (1920–1960): At the beginning of 20th century, new concept in public health was health promotion. It was realized that State had a direct responsibility for the health of an individual. For the health promotion of the individuals few services were came into action like child health services, school health services, industrial health services, mental health and rehabilitation services.

In 1920, Winslow, great public health expert defined Public health as “the science and art of preventing disease, prolonging life and promotion of health and efficiency through organized community effort”.

In the middle of 20th century, provision basic health services in rural and urban areas. In 1946, in India, the Bhore Committee recommended the establishment of health centers for providing integrated curative and preventive services.

The second great movement was community development programme to promote village development through active participation of the whole community.
Social engineering phase (1960–1980): With the advancement of preventive medicine, some of the acute health problems were solved like diarrheal diseases.

New health problems began to emerge like cancer, diabetes, cardiovascular diseases, alcoholism and drug addiction, etc. These diseases could not be explained on the basis of germ theory nor tracked by traditional approaches like isolation, immunization and disinfection.

The concept of risk factors as determinants was highlighted.

Reorientation of public health for control of chronic diseases on social perspectives was also described. 1n 1960, social engineering phase started on social and behavioral aspect of diseases, then the term community health was introduced as a new concept.
“ Health for all” Phase (1981–2000 AD): Most people in developed countries and 20% population in developing countries are enjoying the determinants of good health like adequate income, nutrition, education, sanitation, safe drinking water. Consequently, it was revealed that 80% world population have equal right to health care. Against the background, in 1981, the members of WHO pledged themselves to an ambitious target of “ Health for all” by 2000 AD and attainment of a level of health that will permit all people “to lead a society and economically productive life”.25

Q47. Write the contribution to medical science of the following person:

(BNMU 2018)

Edward Jenner (Vaccination against smallpox 1796)
Roland Ross (Plasmodium)
Louis Pasteur (Pasteurization)

Ans:

Edward Jenner

Edward Jenner, (17 May 1749–26 January 1823) was an English physician and scientist who was the pioneer of smallpox vaccine, the world's first vaccine. The terms “vaccine” and “vaccination” are derived from Variolae vaccine (smallpox of the cow), the term devised by Jenner to denote cowpox. He used it in 1796 in the long title of his Inquiry into the Variolae vaccine known as the cowpox, in which he described the protective effect of cowpox against smallpox.

Jenner is often called “the father of immunology”, and his work is said to have “saved more lives than the work of any other human”. In Jenner's time, smallpox killed around 10 percent of the population, with the number as high as 20 percent in towns and cities where infection spread more easily. In 1821 he was appointed physician extraordinary to King George IV, and was also made mayor of Berkeley and justice of the peace. A member of the Royal Society, in the field of zoology he was the first person to describe the brood parasitism of the cuckoo. In 2002, Jenner was named in the BBC's list of the 100 Greatest Britons.
Roland Ross

Sir Roland Ross (13 May 1857–16 September 1932), was a British medical doctor who received the Nobel Prize for Physiology or Medicine in 1902 for his work on the transmission of malaria, becoming the first British Nobel laureate, and the first born outside Europe. His discovery of the malarial parasite in the gastrointestinal tract of a mosquito in 1897 proved that malaria was transmitted by mosquitoes, and laid the foundation for the method of combating the disease. He was a polymath, writing a number of poems, published several novels, and composed songs. He was also an amateur artist and natural mathematician. He worked in the Indian Medical Service for 25 years. It was during his service that he made the groundbreaking medical discovery. After resigning from his service in India, he joined the faculty of Liverpool School of Tropical Medicine, and continued as Professor and Chairman of Tropical Medicine of the Institute for 10 years. In 1926 he became Director-in-Chief of the Ross Institute and Hospital for Tropical Diseases, which was established in honour of his works. He remained there until his death.
Louis Pasteur

Louis Pasteur (27 December 1822–28 September 1895) was a French biologist, microbiologist and chemist renowned for his discoveries of the principles of vaccination, microbial fermentation and pasteurization. He is remembered for his remarkable breakthroughs in the causes and prevention of diseases, and his discoveries have saved many lives ever since. He reduced mortality from puerperal fever, and created the first vaccines for rabies and anthrax. His medical discoveries provided direct support for the germ theory of disease and its application in clinical medicine. He is best known to the general public for his invention of the technique of treating milk and wine to stop bacterial contamination, a process now called pasteurization. He is regarded as one of the three main founders of bacteriology, together with Ferdinand Cohn and Robert Koch, and is popularly known as the “Father of Microbiology”.

Pasteur was responsible for disproving the doctrine of spontaneous generation. He performed experiments that showed that without contamination, microorganisms could not develop. Under the auspices of the French Academy of Sciences, he demonstrated that in sterilized and sealed flasks nothing ever developed, and in sterilized but open flasks microorganisms could grow. Although Pasteur was not the first to propose the germ theory, his experiments indicated its correctness and convinced most of Europe that it was true. Today, he is often regarded as one of the fathers of germ theory. Pasteur made significant discoveries in chemistry, most notably on the molecular basis for the asymmetry of certain crystals and racemization. Early in his career, his investigation of tartaric acid resulted in the first resolution of what is now called optical isomers. His work led the way to the current understanding of a fundamental principle in the structure of organic compounds.

He was the director of the Pasteur Institute, established in 1887, until his death, and his body was interred in a vault beneath the institute. Although Pasteur made groundbreaking experiments, his reputation became associated with various controversies. Historical reassessment of his notebook revealed that he practiced deception to overcome his rivals.

Chapter Notes

Concept of Health and DiseaseChapter 1