Topic 1: Health effects of environmental pollution

Definition:
Persistent organic pollutants (POPs) are organic compounds that are resistant to
environmental degradation via chemical, biological and photolytic processes.
Persist in the environment, bioaccumulate in humans and animals
Capable of long range transport, significant impact on human health and
environment
Biomagnify in food chains
Some were used as pesticides, others used in industrial setting
3 groups of chemicals:
Polychlorinated biphenyls PCBs
Polychlorinated dibenzodioxins PCDDs
Polychlorinated dibenzoflurans PCDFs

PCBs 2 benzene rings + 2-10 chlorides

Biological activity & environment persistence dependent on degree of chlorination
Production started in the 30s and until 1980s, 1 million tons were produced
Since 1980 withdrawal in use, still persist in environment

Used in Capacitors, transformers, medical equipment (X-Ray machines) & old

household electronics like refrigerators
Major source Contaminated food via food chain, released from coating & direct
contamination
Minor source industrial & municipal effluents, discharge from accidents,
transformer & capacitor fires, occupational exposure

Yusho disease: Mass PCB poisoning in Japan.

Rice bran oil was contaminated which resulted in chloracne (acne like
eruptions in cheeks, behind ears, armpits & groin, associated with
halogenated compounds
Yu-Chan disease: Taiwan version of the same.

Transplcental exposure: Dark brown pigmentation, facial edema, IUGR, pigmented

nails, dental abnormalities

Dioxins: highly toxic compounds that are POPs

Byproducts of various industrial processes Incomplete combustion of chlorinated
organic compounds, chemical bleaching, wood burning and hospital waste
PCDDs (-benzo)
o Dioxins. (76 different; 7 are extremely toxis)
PCDFs (-furans) & PCBs
o Dioxin-like properties
Source: Byproducts of chlorinated phenols & herbicides.
Major Source: Contaminated food (98%); waste incineration

Agent Orange: used in Vietnam war

Contains dioxin developmental abnormalities in Vietnamese
Increase incidence of Non-Hodgkins & basal cell carcinoma
Seveso, Italy: Industrial accident
Highest known exposure to TCDD in residential populations.
Chloracne in children, increase liver enzymes, hepatomegaly
Gave rise to many scientific studies & safety standardizations in
industry
SEVESO II DIRECTIVE EU industrial safety regulation

Carcinogenic effects of Dioxin:

Increase soft tissue tumors
TCDD is a group 1 carcinogen
Topic 2: Physical and chemical examination of drinking water and food
In order to prevent exposure to health-related chemical contamination, public water suppliers
have a legal responsibility to provide safe drinking water for population

Basic parameters of drinking water are examined by routine analysis that includes
measurements of:
NH4+, Cl-, NO2-, NO3-, Fe2+, Mn2+,
pH value,
Chemical O2 demand,
Hardness Unit: German Degree (d) 1d=10 mg/l CaO =17,8 mg/l CaCO3

NH4+: ammonia: due to ground & surface water contaminated by domestic & agricultural
waste water.
Not an immediate risk; but can be oxidized to NO2- & NO3-

NO2- & NO3-: result of nitrogen cycle & chemical contamination. NO2- also comes from
oxidation of ammonia by microorganisms.
CYANOSIS Methemoglobinemia (worst for < 4 month olds)

Cl-: natural source (geological) or contamination by sewage

Not an immediate threat. High concentrations indicate sewage contamination.

Fe2+ & Mn2+: ground water or corrosive action of water in iron pipelines
Air oxidation soluble iron/Mn insoluble oxides hydroxides yellow, orange, brown
precipitates
Dont cause serious problems

pH: One of the most important parameters

- no direct impact on consumers
- pH must be controlled to minimize corrosions of pipelines metal contamination
- taste & odor problems

COD (chemical O2 demand): gives info on O2 required for oxidation of almost water soluble
organic substances (except nitrogen containing compounds & slightly soluble hydrocarbons)
Quantifies the amount of organic substances in water which can decreases quality of taste and
odor.

Hardness: Dissolved Ca2+ & Mg2+ salts

- Stone depositions excessive soap consumption
- Not dangerous
Topic 3: Bacteriological and mycological examination of water and food

1. For checking Milk

Methylene Blue is a redox indicator dye
Oxidized form: Blue
- 1-2 drops of methylene blue in a milk sample Reduced form: Colorless
- incubate for 30 mins at 37C
- Positive results:
o Lower 2/3 of milk becomes white MB is reduced (colorless) by bacterial
reductases
o Upper 1/3 of milk is still blue, the O2 content has reoxidized the dye (NOT
IMPORTANT)

Most frequent pathogens in milk

Pneumonia Staph, strep,
Food poisoning Salmonella, Shigella, Listeria, C. Jejuni

2. Trichinella Spiralis Larva in pig meat

Transmission: consumption of raw/undercooked pork

Primary diagnosis:
- Acute fever, pronounced weakness
- Myalgia, diarrhea, facial edema
- CV, pulmonary, neurological and renal complications can be LETHAL
Rx: Mebendazole, Corticosteroids
No treatment after larval invasion and encapsulation!

Prevention: cook meat properly, freezing meat for 10 days in -25C

High dose gamma radiation and veterinary examination

3. Drinking water
Diagnostic methods:
- Microscopic evaluation after gram staining
- Examine physical feature of colonies with agars
- Chemical reaction methods (agglutination, AB resistance assay)

Incubation:
20C incubation for 48h growth of normal flora (Actinomyces, Streptomyces etc.)
37C incubation for 96h Human pathogen growth ( E.coli, Pseudonomas, Enterococci)
usually enteral pathogens

Evaluation: in 1ml of water

1. > 50/ml: suitable for drinking
2. 50-100/ml: suitable for drinking after 10 mins of boiling
3. >100/ml NOT suitable for drinking
 4. Analysis of eggs freshness by floating test

Put eggs in 10% NaCl solution, then distilled water

Evaluation:
- sinking in both Totally fresh, can be used raw
- floating in NaCl, sinking in water 1-2 weeks old, good if cooked
- Floating in both Rotten eggs

Bacterial content within the egg means increased gas production that reduces egg density
Topic 4: Diagnosing occupational diseases
Definition: Occupational disease have a strong relation to an occupation, usually one
causative agent is responsible for the disease

Criteria:
- Effect: Fit the disease description
- Exposure: Needs to be documented; occupational history, examination, investigation
- Time sequence: identify cause leading to a specific effect
- Competing causes

Criteria by EU commission:
- Minimum intensity of exposure
- Minimum duration of exposure
- Maximum latency period
- Minimum induction period

Workplace Hazards:
- Physical noise, vibration, radiation, light, heat/cold, pressure, electricity
- Chemical metals, solvents, gases, plastics, pesticides, particles
- Biological bacteria, viruses, fungi, insects, parasites
- Mechanical Manual work, repetitive movements, safety
- Psychological pressure/stress, morale/motivation

Proper History taking is very important!!!

What is your work, Have you been exposed to, Are your symptoms better/worse at work, Do
you think your problem is to do with work, etc.

Top 5 occupational diseases

Lung asbestosis, silicosis, coal workers pneumoconiosis, lung cancer, asthma

Musculoskeletal back, trunk, upper extremity, neck, lower extremity
Cancers Leukemia, mesothelioma, bladder, nose, liver
Injuries Amputations, fractures, blindness, lacerations, death
CVD HTN, CAD, AMI
Topic 5: Hypothesis testing and interval estimation
Methods to quantify the precision of a study

Hypothesis testing:
- Proposed explanation based on limited evidence
- Starting point of an investigation
- Keep in mind:
o Does the experiment prove the null hypothesis?
o Any difference between expectation and actual outcome?

Null Hypothesis The Appropriate null hypothesis (H0) is that there is no relationship!
- No effect, difference, association, relationship

Hypothesis There is a relationship!

- Effect, Difference, Association, Relationship

P-Value How strong is your evidence against the null hypothesis. Smaller the better!
- Usually p < 0.05 is statistically significant which means congratulations, you dont
have to reject your hypothesis. But it doesnt mean that you can accept that your
hypothesis is true either. You can only the null hypothesis is very unlikely. I know
right, science!

Confidence Interval True mean of your population is expected to fall between certain
values. It is a range.
Lets explain! You have 2 populations with 2 different CIs. If the CIs of your 2 groups are
completely different from each other, a statistically significant difference exists which is
GOOD! If the CI ranges are overlapping, then there is no significant difference.
It is also much more informative than p value since it is a range and gives size of the measure.

Standard deviation This one depends on how varied your data is. Standard deviation is
how much your mean can be wrong.
For example, you have the numbers 10,18,19,20,21,22,22,24,26,36.
Mean= 21.8
SD= 6.58
My mean is 21.8 but since my SD is 6.58, the range is 15.22 28.38.
Smaller SD is always better!

Standard error derived from standard distribution. Used on a specific value. For example,
our standard error here is 2.08 with the formula written on the slides S/root of number of
values. So pick a value and add/deduct this number from it. 192.08

Point of estimate Point estimate gives the most likely value of the association measure,
estimating the population value based on a sample. This is uncertain information.
Topic 6: Validity of epidemiological studies
- The general issue of whether or not there are imperfections in the
o Study design
o Methods of data collection
o Methods of data analysis
May distort the conclusion made about exposure disease relationship

- If no imperfections study is valid

- If imperfections study is biased (extent of the distortion of the results from the
correct conclusions)

Types of bias Selection, Information and Confounding

General approaches for addressing bias:

1. Design decisions prior to study
2. Decisions during analytic stage
3. Discussion during publication

Selection Bias:
- Systematic error due to the way subjects are selected into a study.
- Occurs in any kind of epidemiological study.
- Solve it by Randomization.

Information bias:
- Systematic error in a study arising from incorrect info obtained about variables
measured in the study.
- Imprecise measurement, subjective self-report

Confounding:
- Important problem for health and medical researchers when they conduct a study to
assess relationship between exposure and outcome
- Bias that occurs when we forget to take other variables into account (e.g. Age,
gender, smoking etc.) in attempt to assess an exposure to outcome relationship
- Solve it by Randomization, matching, restriction, stratified analysis, multiple
variable regression analysis

Reliability how many times you get the same results with same condition
PRECISION
Validity how many times a test measures what its supposed to measure
ACCURACY

The accuracy of a measurement system is how close it gets to a quantity's actual (true) value
The precision of a measurement system is the degree to which repeated measurements give the same
results
Topic 7: Types of epidemiological studies
2 types of epidemiological studies:

1. Observational studies non experimental

a. Case report study

b. Case series study
c. Cross sectional study
Asses frequency of disease at a particular point in time (What is happening?)
Measures disease prevalence and risk factor association with disease
d. Case control study
Compare people with disease to people without disease (What happened?)
Measures Odds ratio
e. Cohort Study (incidence study) relative risk; attributable risk
Compare a group with a certain risk factor/exposure to a group without
Measure incidence and relative risk

2. Experimental studies clinical trials

a. Randomized controlled
i. Double blind
ii. Cross-over
b. Field study
c. Community based study

Relative risk Risk of developing disease in group exposed to risk factor divided by the
group unexposed to risk factor

Attributable risk Difference in risk between exposed and unexposed

Odds Ratio Odds of people getting the disease who are exposed divided by odds of getting
the disease without being exposed
Topic 8: Using research results in clinical practice (basics of quantitative
medicine)
Empirical Medicine
- Books, lectures, experiences, colleagues etc.
o Subjective
o Qualitative
o Cannot be reproduced

Evidence based medicine

- Medical research
o Relevant, objective
o Quantitative
o Reproducible

Harm of treatment:
Health loss in non-diseased person due to
treatment. Scoring systems can help to determine severity
Also Risk of death during a routine surgery & need for medical/surgical intervention
e.g. Alvarado score
Benefits of treatment:
Net health gain in diseased persons due to
treatment
Topics 9: Using epidemiological measures in practice (DEALE method,
frequency measures, association measures)

DEALE Method (Declining exponential approximation of life expectancy)

- Life expectancy prediction model; MOST USED IN CLINICAL SETTING

- Easy format
- LE= 1/ mortality rate
- LE for a constant hazard is 1/M (M for mortality which is sum of hazards)
-
- Hazard
o A: natural hazard; according to age sex & race. Death due to natural causes
o D: constant disease- specific hazard
- Its assumed that both disease- specific & natural hazards remain a constant over time.
Therefore: life expectancy with a disease
o LEd=1/(A+D)
- Overall mortality is calculated by a sum of the disease specific mortality rates (e.g.
M= d1+d2+d3.)

- For example, consider a 45 y.o. man, whose life expectancy based on his age, sex and
race is 27.8 years. His adjusted mortality rate is 1/27.8 or 0.036 per year. If the same
man had a disease, producing an excess mortality of 0.179 per year, then his overall
mortality rate would be 0.036 + 0.179 = 0.215 per year. For each disease the man
suffers from, the disease specific mortality rates are added.

- The DEALE enables the physician to collect various survival data with information on
morbidity to form a management plan. This approximation makes it possible to
translate data from various literature sources (life expectancy, 5-year survival rate,
survival curves, median survival) into a single, unified mortality scale.

- NOT AN EXACT MODEL: It assumes a constant mortality rate across time which is
not true. Diseases can alter mortality rate of each other.

Frequency measures:

- Cumulative incidence new cases/all at risk

o Range: 0-100%
o Timespan should be specified
o Measures the absolute risk
o Useful in acute condition

- Incidence density new cases/ total amount of observed as people-time

o Measures absolute hazard (spread of disease)
o Useful in chronic conditions
o Dimension is inverse of time (1/t)

- Prevalence all cases/population

o Depends on length of disease and its incidence
o Range 0-100%, dimensionless
Association Measures:

1. Relative risk


= + =

+
- RR >1 risk factor
- RR= 1 no association
- RR<1 protective factor

2. Attributable risk
AR= Incidence in exposed incidence in unexposed
AR= DE/ALL DN/ALL

3. Odds Ratio
Odds of people getting the disease who are exposed divided by odds of getting the
disease without being exposed
/
=
/

4. Number needed to treat (NNT)

- Inverse of AR
- For every X number treated, 1 case is prevented

5. Number needed to harm

- Same but here we say for every X people exposed, one case occurs
Topic 10: Clinical trials (basic concept)

In health care, a clinical trial is a comparison test of a medication or other medical

treatment, versus a placebo, other medication or devices, or the standard medical
treatment for a patients condition.
Clinical trials vary greatly in size: from a single researcher in one hospital or clinic to an
international multicenter study with several hundred participating researchers on several
continents.

Preparation of a trial:
1. Identification of the medication or device to be tested.
2. Decide what to compare it with (one or more existing treatments or a placebo).
3. What kind of patients might benefit from the medication/device.

During the clinical trial, the investigators recruit patients with the predetermined
characteristics, administer the treatment and collect data on the patients health for a defined
time period. Data collected includes vital signs, amount of study drug in the blood and
whether the patients health improves or not.
The researchers send the data to the trial sponsor, who then analyses the pooled data using
statistical tests.

Types of committees
Steering committee: responsible for general operating policy, procedures and related
matters affecting all the other participants. They lead the study, set the type and
coordinate the others.
Randomization committee: chooses the method, performs randomization and reports to
the steering committee.
Data entry committee: sums up the results.
Data analytic committee: analyses the accumulated data.
Execution committee: prepares and administers the treatment, tests mental performance.

A randomized controlled trial is the study design that can provide the most compelling
evidence that the study treatment causes the expected effect on human health.
Currently, some phase II and most phase III drug trials are designed as randomized, double
blind and placebo-controlled.
Randomized each study subject is randomly assigned to receive either the study drug or
placebo.
Blind the subject does not know which treatment they are receiving.
Double blind both the subject and researcher do not know who is receiving the drug and
who is receiving the placebo.
Cross over study all subjects receive the trial drug and placebo in alternating periods.
Placebo controlled allows the researchers to isolate the effect of the study treatment.
Phase I trials
Determination of the safety, tolerability, pharmacokinetics and pharmacodynamics.
A small group (20-80) of healthy volunteers.

Phase II trials
Determination of safety and efficacy.
Performed on a larger group (20-300) of healthy and patients with the relevant disease.
Phase III trials
Definitive assessment of efficacy in relation to the current gold standard treatment.
Randomized, controlled, multicenter trials on a large patient group (300-3000 or more).
Phase IV trials
Post marketing surveillance trial.
Safety, technical support and additional rare side effects.

Clinical trials are closely supervised by the appropriate regulatory authorities. All studies that
involve a medical or therapeutic intervention on patients must be approved by a supervising
ethics committee before permission is granted to run the trial.
Institutional review board.
Data safety and monitoring board.
Topic 11: Preventive strategies
Primary prevention
Provided to individuals to prevent the onset of targeted condition when they are healthy.

Secondary prevention
Identify and treat asymptomatic persons who have already developed risk factors or
preclinical disease but in whom the condition is not clinically apparent.

Tertiary prevention
Involve the care of an established disease, which attempts to resolve the highest function,
minimize the negative effects of the disease and prevent disease-related complication

Particular Approach Why did these patients get the disease at this time? What is the cause
of the case? FOCUS ON SICK INDIVIDUALS

General Approach How and why does this disease happen? What is the cause of
incidence? FOCUS ON SICK POPULATIONS

Comparison of preventive strategies:

High-Risk Approach Population Approach

- Individual already has the
problem
- Greater motivation for patient and
doctor
- Cost effective
- Impacts on total burden of
disease is relatively small
- Screening to identify high-risk
individuals is difficult and costly
- Favorable benefit-risk ratio
- Intervention is palliative and
temporary
- Radical
- Poor motivation
- Prevention Paradox: Great
benefit to population but little
advantage to individual
- Behaviorally appropriate (Dont
expect individuals to behave
differently than their peers. It is
more appropriate to seek a general
change in behavioural norms which
facilitate their adoption)
- Shift the whole distribution of
exposure in a favorable direction
- Advantages of the range of
variation doesnt change with
increasing population average (e.g.
BP)

Middle Road approach

- Good if the range of variation increases as the population average increases (e.g. body
weight)
Topic 12: Screening programs

Screening: Initial examination of asymptomatic people in order to classify them as likely

or unlikely to have early stage or precursor of a disease. If people appear likely for a
disease, they need to be investigated further to gain a final diagnosis.

Goal of screening Reduce progression of preclinical disease to clinical phase. To find risk
factors or disease

- Initiative comes from the doctor on asymptomatic, apparently healthy people

- Rapid and inexpensive tests, examinations and other procedures
- Applied to large group of people
- NOT diagnosis; just tell the likelihood of a disease before symptoms
- Beware of false positives and negatives effect on the people
- Has to be very sensitive and specific

Sources of bias in screening programs

- Lead time bias
- Length bias
- Patient self-selection bias

Diseases appropriate for screening

- Detectable preclinical phase
- Severity
- Prevalence of preclinical disease
 Screening Disease
Positive Negative
Positive TP FP PPV
Negative FN TN NPV
Sensitivity Specificity

Sensitivity true positive TP/(TP+FN)*100

Specificity true negative TN/(TN+FP)*100
These have fixed properties

Positive predictive value TP/(TP+FP)*100

Negative predictive value TN/(TN+FN)*100
These depend on prevalence, sensitivity and specify.
Topic 13: Outbreak investigation (dynamics of infection, surveillance,
Epiinfo)
Questions to answer
- What is the infectious agent?
- Who is the source and the infected?
- Where does the infection occur?
- When do the infections occur?
- How are the infections transmitted?

Incubation period:
- Subclinical or inapparent pathologic changes following exposure
- Ends with onset of symptoms of infectious disease
Latent period:
- Interval from infection to development of infectiousness
Period of infectiousness:
- Time the host could infect others

Index case 1st case patient in a group to come to attention

Primary case Individual that introduces the disease into a group got the disease from the
original exposure
Secondary case Cases that occur after primary case
Serial interval Generation time of infections

Confirmed case verified by lab

Probable case clear clinical picture or linked to a confirmed case
Possible case indicative clinical picture without being confirmed

Endemic constant incidence and prevalence over time

Epidemic sharp and significant rise over a time period
Pandemic world wide epidemic

Epidemic Curves

Explosive epidemic
(point source)

Person to person spread

(extended source)

Combination
Net case reproduction rate (R0) = Basic reproductive rate
- Average number of secondary cases per case (number of successful transmissions)
- function of transmissibility, contact pattern and intensity
- R>1 outbreak epidemic
- R=1 endemic
- R<1 elimination/eradication
Attack rate
- cumulative incidence type measure
- number of new cases amongst those at risk during an outbreak
- mainly used in small communities
- more transmissible more rapid spread
Herd Immunity
- % of population needed to be immune for a disease to become stable
- important index in formulation of vaccine strategies
- % needed to avoid endemic or epidemic

Steps of outbreak investigation

- Prepare field work
- Establish the existence of an outbreak
- Verify diagnosis
- Define and identify cases
- Describe the data
- Develop hypothesis
- Evaluate hypothesis
- Refine hypothesis and carry out additional studies
- Implement control and prevention measures
- Communicate findings

Surveillance An important feature of disease monitoring and control.

Continuous and systematic collection, processing and analysis of health
data collected from:
- Vital records (birth and death certificate)
- Administrative data system (medical care, hospital, insurance records)
- Notification systems (mostly infectious diseases)
- Registries (individuals with chronic disease)
- Lab examinations (only if we can take specimen)
- Sentinel surveillance (monitoring of predefined key health events
- Surveys (assessing self-reported behaviors or health practices)

Epiinfo
- Series of database managing and statistical programs for use of public health
professionals.
- Developed by the CDC, free
- Applications:
o Outbreak investigation or epidemiological surveys
o Implantation of public health surveillance and other tasks
o General database management
o Statistical application
- Used to develop a questionnaire or a form, customize the data entry process and
enter and analyse data.
Topic 14: Concept and methods of health monitoring
- Health monitoring is continuous and systemic collection, processing & analysis of
health data for the public.
- Indicators are used for the constant monitoring & analysing the etiology of diseases.

1. Mortality Indicators measured by incidence

- Age specific (neonatal, premature)
- Cause specific (cancer, CVD, AIDS)
- Sex specific
Mortality is a fundamental factor in population dynamics.
Mortality patterns change over time

2. Morbidity indicators measured by incidence and prevalence

- Age specific
- Cause specific
- Sex specific

3. Quality of life/functionality
4. Global burden of disease quantified by DALY
5. Health/ risk behavior Absolute & Relative risk

Pay attention to age, gender, race, income, education at local, regional, country and global
level in time

Surveillance is an important feature of disease monitoring and control.

Continuous, regular collection of information.
Collected from:
- Vital records (birth and death certificate)
- Administrative data system (medical care, hospital, insurance records)
- Notification systems (mostly infectious diseases)
- Registries (individuals with chronic disease)
- Lab examinations (only if we can take specimen)
- Sentinel surveillance (monitoring of predefined key health events
- Surveys (assessing self-reported behaviors or health practices)
Topic 15: Priority setting in public health
Priority setting is decision making about the most
important issues in health. It rates the importance
of the different health services.

Based on intervention/prevention
Based on disease burden

Indices used used to measure disease burden:

1. Mortality figures
a. Measured by incidence
b. Cause/age/sex specific
c. Premature Mortality
i. Causes of disease greatly influenced by quality of health care below 65
years
ii. Deaths that might have been prevented with adequate measures
iii. PYLL (potential years of life lost) 65 (x+ 0.5) years where x=age
2. Measures of morbidity
a. Measured by incidence and prevalence
b. Cause/age/sex specific
3. Composite measures (mortality + reduction in quality of life)
a. Healthy life expectancy
b. Similar to life expectancy at birth but it shows average number of expected
healthy years
c. DALY (disability adjusted life years) = YLL (years of life lost) + YLD
(year lost due to disability)
i. Extends the concept of potential years of life lost due to premature
death to include equivalent years of healthy life lost by virtue
of individuals being in states of poor health or disability
ii. Combines mortality and morbidity into a common metric
(expressed as the number of years lost due to ill-health, disability or
early death)
4. Economic burden
a. Direct costs
i. Hospital care expenditures
ii. Drug, physician care
iii. Other institutions
iv. Cost borne by patients
b. Indirect costs
i. Mortality
ii. Morbidity & disability
iii. Time lost from work & leisure activities by family members
Topic 16: Health education in primary care, health education techniques

Ideal CV health
- No smoking
- BMI <25 kg/m2
- Physical activity at goal levels
- Proper healthy diet
- Untreated total cholesterol <5.2 mmol/l
- Untreated BP <120/80 mmHg
- Fasting blood glucose <5.6 mmol/l (100 mg/dL)

Health education on smoking cessation

- Screen adults and pregnant women for tobacco use
o Fagerstrom nicotine dependence test
- Form of tobacco use
o Current everyday smoker
o Current some day smoker
o Former smoker
o Never smoker
5. Intervention of tobacco uses Brief counseling of 5 As
5 As
1. Ask about and document tobacco use at every visit
2. Advise to quit through clear personal messages (link to personal problems)
3. Asses willingness to quit. If no stop. If yes continue with As
4. Assist to quit offer medications, counseling, additional treatment
5. Arrange follow up and support within the 1st week after quitting

Reference range of nicotine metabolism

- < 2 ng/ml either person who doesnt smoke or person quit smoking >2 weeks ago
- 30-50 ng/ml of nicotine, 200-800 ng/ml of cotinine person is smoking

Alcohol misuse screening (adults + pregnant women)

CAGE questionnaire. 2+ positive answers mean alcohol misuse +5 As
1. Have you felt you should CUT down?
2. Have people ANNOYED you by criticizing your drinking?
3. Have you felt GUILTY about your drinking?
4. Drink to treat a hangover? (EYE OPENER)

Physical activity (Fact sheet for professionals)

Moderate 150 minutes a week
o Slight increase in respiratory rate, moderate perspiration
o Slight muscle pain
o You can talk but not sing during exercise
Vigorous 75 minutes a week
o Significant increase in respiratory rate and marked muscle pain
o Can only say few words without pausing for a breath
Muscle strengthening activities that involve all major muscle groups on 2 or more
days per week.
Older adults limiting chronic conditions, avoid inactivity as much as their conditions allow
Topic 17: Introduction to health policy

Policy decisions taken by those with responsibility for a particular area

Health care policy Covers the actions of institutions and organizations, and funding
of the health care system
Healthy public policy characterized by explicit concern for health and equity in all areas of
policy and accountability for health impact

Steps of the policy process

- Problem identification and issue recognition
- Policy formulation
- Policy implementation
- Policy evaluation

Policy Instruments
- Legislation
- Taxation
- Information
- Provision of direct service

Values in health policy

- Quality
- Choice right of patients
- Solidarity guaranteed package of health care services
- Equity
o Horizontal give equal resources to equal health needs
o Vertical give different resources to different levels of health needs
No discrimination for access to health care services
- Efficiency

Basic actors of Health system

- Consumer
- Providers of health care (doctors, nurses etc.)
- Health insurance funds (insurance companies, charities)
- Health care policy makers (government, ministries, parliament etc.)

Health as a policy value

- The right to health is an inclusive right
o Safe food, adequate nutrition, health working and environmental conditions,
health related education, gender equality
- The right to health contains freedoms
o Right to be free from non-consensual medical treatment, cruel, inhuman or
degrading treatment or punishment
- The right to health contains entitlements
o Right to prevention, treatment and control of disease
o Access to essential medications
 Health is a prerequisite for economic development
Good genetics, education, lifestyle, healthcare, wealth and environment Increase health
Increase productivity, labor supply, capital formation INCREASED ECONOMIC
OUTCOME increase health

Inequalities in health Differences that are un-needed and avoidable and judged to be unjust
or unfair
- Professionals or more skilled people better health state
- Infant mortality rate is higher in less skilled people

Social determinants
- Education
- occupation
- income
- gender
- ethnicity

Main goal of WHO

- improving health of the population
- responsiveness to expectations of the population
- fair financial contribution

Explosion of health care cost

- Increased demand
- developing technology
- aging of population
Topic 18: Health systems financing

Elements of health system financing

- Revenue collection
o Mobilization of money from primary sources (households, firms) and
secondary sources (government, charities)
- Fund pooling
o Accumulation of revenues for the common advantage of participants
- Purchasing
o Process through which revenues are allocated to institutional or individual
providers to deliver a set of interventions

OECD countries allocate 9.6% of their GDP to health

- 17% in USA
- 2.4% in Indonesia

Main types of health system

- Tax financed
- Social health insurance
- Private health insurance
- Out of pocket
- Donation based
Most countries are a mix!

1. Tax financed health care system universal coverage = ALL!

- Based on taxes
- Collected and set by national, regional or local bodies
- Market elements have appeared (private providers, insurers, competition etc.)
- Access open for ALL

2. Social health insurance system Partial Coverage!

- Contribution is mandatory for all or part of the population, independently from
risk
- Third party payer
- Proportion of income
- Employers and employees share
- Single national/ multiple funds
- Advantages solidarity, non-profit

3. Private health insurance system part of population! Full coverage!

- Offered for profit or non profit (but lets get real usually for profit)
- Dominant in USA (thanks Trump)
- Can be complementary to social health insurance system
- Compulsory in Switzerland
- When its supplementary double coverage (it covers the same things your social
health insurance system covers
 4. Out of Pocket
- Used to decrease unnecessary, expensive and excessive use of services
- Used to raise additional revenues
- Direct payment no covered at all
- Cost sharing/user charges partial payments
- Informal payment under the table

Progressivity of the funding system

- Progressive (Taxation) Rich pay more than poor
- Proportional (Social) Everyone pays the same
- Regressive (Private/voluntary) rich pay less than poor (relatively)

Major forms of reimbursement in primary, secondary and tertiary care

- Primary care
o Line budget
o Salary
o Per capita a fixed prepayment, per patient covered, to a healthcare provider
to deliver medical services to a particular group of patients
o Fee-of-service physicians or other providers bill separately for each patient
encounter/service they provide
- Secondary care
o Global budget
o Fee of service
o Per diem
o Diagnosis related groups

Gatekeeper
Person (primary care provider; GP) who controls patients access to healthcare services
and other specialists
- Intended to decrease costs by increasing coordination, prevent and decrease
duplicate work
Topic 19: Assessing and improving quality of health services

Health Quality The degree to which health services increase the likelihood of desired
health outcome and are consistent with current professional knowledge

Why do we assess quality?

- Facilitate greater accountability
- Helps to improve quality

How do we assess quality?

- Inspection of hospitals
- Indicators measurable dimension of quality in health care
- 3rd party assessments
o Accreditations
o ISO standards
o Peer reviews
- Clinical audit Improve patient care through systematic review of care against
explicit criteria.
- Patient satisfaction surveys

What do we assess?
- Structure the characteristics of the care setting
- Process what is done for the patient
- Outcome how the patient responds to care

Improvement of care
- Structure better equipment and training
- Process doing the right things better
- Outcome
Good structure increases the likelihood of good progress which increases the
likelihood of good outcome!!!

Measurement tools
Standards documented agreements containing technical specifications or other precise
criteria
- Guideline a set of systematically developed steps which assists in the basic clinical
approach to each patient.
- Protocol a set of practice parameters which the clinician must adhere to for the
best outcomes
Criteria measurable item which describes quality.
Medical Errors (Quality problem)
- Underuse of services (health technologies) - Dont use smt when you better had
vaccination
- Overuse of services (health technologies) - Harm > benefit antibiotics
- Misuse of services (health technologies) -Preventable complication leading to less
efcacy of technology and potential benet partial course antibiotics
- Communication problems
- Lack of using evidences
- Dissatised patients
- unequal access to health care services
- waiting lists
- waste from poor quality

Components of Quality Management

Includes all the activities that organizations use to direct, control and coordinate their quality
policy
- Quality planning develop an adequate healthcare system
- Quality control meeting healthcare goals
- Quality improvement achieve even higher level of performance

Determinants of health quality by WHO

- technical quality
- economical efciency
- risk management
- patient satisfaction

Aims of healthcare improvement safe, efficient, patient-centered, timely, equitable

Plan, do, study, act