INTRODUCTION TO COMMUNITY HEALTH (COH 322)

Definitions:
Community health is that part of medicine which is concerned with the health of the whole
population and with the prevention of diseases. Community health, a field of public health, is a
discipline which concerns itself with the study and improvement of the health characteristics of
biological communities.

Public health is the approach to medicine that is concerned with the health of the community as
a whole. Public health is community health. It has been said that “Health” care is vital to all of us
some of the time, public health is vital to all of us all the time.

U.S. Public Health Expert, C.E. A. Winslow, defined ‘Public Health’ as- “the science and art of
preventing disease, prolonging life and promoting physical health and efficiency through
organized community efforts for the sanitation of environment, the control of community
infections, the education of individuals in provision of personal hygiene, the organization of
medical and nursing services for early diagnosis and preventive treatment of disease, and the
development of social machinery which will ensure every individual in the community a standard
of living adequate for the maintenance of Health” (Winslow 1920:23)

Clinical medicine is the science and “art” of maintaining and/or restoring human health
through the study, diagnosis, and treatment of patients.

The mission of public health is to “fulfill society’s interest in assuring conditions in which
people can be healthy”. The here core public health functions are:

 The assessment and monitoring of the health of communities and populations at risk to
identify health problems and priorities;
 The formulation of public policies designed to solve identified local and national health
problems and priorities;
 To ensure that all populations have access to appropriate and cost-effective care including
health promotion and disease prevention services and evaluation of the effectiveness of
the care.

There are many distinctions that can be made between public/community health and the clinical
health professions. While public health is comprised of many professional disciplines such as
medicine, dentistry, optometry, nutrition, social work, environmental sciences, health education
and behavioural sciences, its activities focus on entire population rather than on individual
patients.

For example, doctors usually treat individual patients one-on-one for a specific disease or injury.
Public health professionals monitor and diagnose the health concerns of entire communities and
promote healthy practices and behaviours to ensure populations stay healthy.

(A).EPIDEMIOLOGY
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0.0 INTRODUCTION TO EPIDEMILOGY
1.1 Concept of Epidemiology- History
The Greek physician Hippocrates is known as the father of medicine. Hippocrates sought logic to
sickness; he is the first person known to have examined the relationships between the occurrence
of disease and environmental influences. Hippocrates believed sickness of the human body to be
caused by an imbalance of the four Humors (air, fire, water and earth “atoms”). The cure to the
sickness was to remove or add the humor in question to balance the body. This belief led to the
application of bloodletting and dieting in medicine. He coined the terms endemic (for diseases
usually found in some places but not in others) and epidemic (for diseases that are seen at some
times but not others).

One of the earliest theories on the origin of disease was that it was primarily the fault of human
luxury. This was expressed by philosophers such as Plato and Rousseau, and social critics like
Jonathan Swift.

In the middle of the 16th century, a doctor from Verona named Girolamo Fracastoro was the first
to propose a theory that these very small, useable, particles that cause disease were alive. They
were considered to be able to spread by air, multiply by themselves and to be destroyable by fire.
In this way he refuted Galen's miasma theory (poison gas in sick people). In 1543 he wrote a
book De contagione et contagiosis morbis, in which he was the first to promote personal and
environmental hygiene to prevent disease. The development of a sufficiently powerful
microscope by Anton van Leeuwenhoek in 1675 provided visual evidence of living particles
consistent with a germ theory of disease.

Another pioneer, Thomas Sydenham (1624–1689), was the first to distinguish the fevers of
Londoners in the later 1600s. His theories on cures of fevers met with much resistance from
traditional physicians at the time. He was not able to find the initial cause of the smallpox fever
he researched and treated.

John Graunt, a haberdasher and amateur statistician, published Natural and Political
Observations ... upon the Bills of Mortality in 1662. In it, he analysed the mortality rolls in
London before the Great Plague, presented one of the first life tables, and report time trends for
many diseases, new and old. He provided statistical evidence for many theories on disease, and
also refuted some widespread ideas on them.

1.2 Concept of Epidemiology-Modern era

Dr. John Snow is famous for his investigations into the causes of the 19th century cholera
epidemics, and is also known as the father of (modern) epidemiology. He began with noticing the
significantly higher death rates in two areas supplied by Southwark Company. His identification
of the Broad Street pump as the cause of the Soho epidemic is considered the classic example of
epidemiology. Snow used chlorine in an attempt to clean the water and removed the handle; this
ended the outbreak. This has been perceived as a major event in the history of public health and

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regarded as the founding event of the science of epidemiology, having helped shape public
health policies around the world. However, Snow’s research and preventive measures to avoid
further outbreaks were not fully accepted or put into practice until after his death.

Other pioneers include Danish physician Peter Anton Schleisner, who in 1849 related his work
on the prevention of the epidemic of neonatal tetanus on the Vestmanna Islands in Iceland.
Another important pioneer was Hungarian physician Ignaz Semmelweis, who in 1847 brought
down infant mortality at a Vienna hospital by instituting a disinfection procedure. His findings
were published in 1850, but his work was ill received by his colleagues, who discontinued the
procedure. Disinfection did not become widely practiced until British surgeon Joseph Lister
'discovered' antiseptics in 1865 in light of the work of Louis Pasteur.

In the early 20th century, mathematical methods were introduced into epidemiology by Ronald
Ross, Janet Lane-Claypon, Anderson Gray McKendrick and others. Another breakthrough was
the 1954 publication of the results of a British Doctors Study, led by Richard Doll and Austin
Bradford Hill, which lent very strong statistical support to the suspicion that tobacco smoking
was linked to lung cancer.

1.3 Definition

Epidemiology is defined as the study of distribution and determinants of health related states or
events in specified populations and, the application of the study to address or control health
related problems (Lilienfeld, 1976). The study of the distribution and determinates of disease
frequency in man (MacMahon and Pugh, 1970).This emphasizes that epidemiologists are
concerned not only with death, illness and disability, but also with more positive health problems
and the means to improve health.

Epidemiology, literally meaning "the study of what is upon the people", is derived from Greek
epi, meaning "upon, among", demos, meaning "people, district", and logos, meaning "study,
word, discourse", suggesting that it applies only to human populations. The target of a study in
epidemiology is a human population. Population can be defined in geographical or other terms
for example, a specific group of hospital patients or factory workers could be the unit of study.
The most common population used in epidemiology is that in a given area or country at a given
time. This forms the base for defining subgroups with respect to sex, age group, ethnicity, and so
on.

Epidemiology is the study (or the science of the study) of the patterns, causes, and effects of
health and disease conditions in defined populations. It is the cornerstone of public health, and
informs policy decisions and evidence-based practice by identifying risk factors for disease and
targets for preventive healthcare. Epidemiologists help with study design, collection and
statistical analysis of data, and interpretation and dissemination of results (including peer review
and occasional systematic review). Epidemiology has helped develop methodology used in
clinical research, public health studies and, to a lesser extent, basic research in the biological
sciences.

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The term epidemiology is now widely applied to cover the description and causation of not only
epidemic disease, but of disease in general, and even many non-disease health-related conditions,
such as high blood pressure and obesity. Therefore, this epidemiology is based upon how the
pattern of the disease cause changes in the function of everyone.

1.4 Objectives of Epidemiology

The aims or objectives of epidemiology include knowledge of the distribution of disease in order
to:

 Explain casual mechanisms,

 Identify local disease occurrence,
 Describe the natural history of a disease,
 Provide guidance in the administration of health services.

Epidemiological practice and the results of epidemiological analysis make a significant

contribution to emerging population-based health management frameworks. Population-based
health management encompasses the ability to:

 Assess the health states and health needs of a target population;

 Implement and evaluate interventions that are designed to improve the health of that
population; and
 Efficiently and effectively provide care for members of that population in a way that is
consistent with the community's cultural, policy and health resource values.

1.4.1 Purpose of Epidemiology

The purpose of epidemiology is to obtain, interpret, and use health information to promote
health and reduce disease.

The human characteristics that are of concern to epidemiologists are:

 Biological characteristics, e.g. physiological function of different organ systems of the

body.
 Demographic characteristics such as age, sex, race, and ethnic groups.
 Social and socio-economic characteristics such as socio-economic status, education,
occupation and nativity.
 Personal living habits such as tobacco use diet and exercises.

1.4.2 Uses of epidemiology

 To complete the clinical picture of chronic diseases and describe their natural history.

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  To study the history of the health of populations and the rise and fall of diseases and
changes in their character. Explain the etiology of diseases by determining factors that
“cause” specific diseases or trends
 To diagnose the health of the community and the conditions of people; to measure the
distribution and dimension of illness in terms of incidence, prevalence, disability and
mortality, to set the health problems in perspective and to define their relative importance
and identify groups needing special attention. Describe the health status of populations by
enumerating the occurrence of diseases, obtaining relative frequencies within groups and
discovering important trends.
 To study the working health services with a view to their improvement. To estimate the
risks of disease, accident and defect and chances of avoiding them. Control the
distributions of disease in the population by prevention of new occurrences, eradication
of existing cases, prolongation of life for those with disease, or otherwise improving the
health status of afflicted persons.
 To search for causes of health and disease by comparing the experience, behavior and
environments. Predict the number of disease occurrences and the distribution of health
status within populations.

Uses of epidemiology can be demonstrated in a diagrammatic form as shown below:

1.4.2.1 Causation: Causation of some diseases can be linked exclusively to genetic factors, but
is more commonly the result of an interaction between genetic and environmental factors.
In this context, environment is defined broadly to include any biological, chemical,
physical, psychological and other factors that can affect health. Behaviour and lifestyle
are of graet importance in this connection, and epidemiology is increasingly used to study
both influence and preventive intervention through health promotion.

Causation:- Good health Genetic factors Ill health

Environmental factors
(Including lifestyle)

1.4.2.2 Concerned with natural history of disease: Epidemiology is concerned with the course
and outcome of disease in individuals and groups.
Death
Good health Sub- Clinical
clinical disease Recovery

1.4.2.3 Health status: Epidemiology is often used to describe the health status of population
groups. Knowledge of the disease burden in population is essential for health authorities
who seek to use limited resources to the best possible effect by identifying priority health
programs for prevention and care.

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 Good health

Ill health Time

Proportion with ill health change over time, change with age, etc.

1.4.2.4 Evaluation of intervention: Epidemiologists have become involved in evaluating the

effectiveness and efficiency of health services, by determining the appropriate length of
stay in hospital for specific conditions.
Treatment
Medical care

Good health
Ill health
Health promotion
Preventive measures
Public health services

1.0 NATURAL HISTORY OF DISAESE

2.1Natural History of Disease refers to a description of the uninterrupted progression of the

disease in an individual from the moment of exposure to the causal agents until recovery or
dearth. The knowledge of the natural history of disease ranks alongside causal understanding in
importance for prevention and control of disease.

2.2 The stages of disease: The two important stages of disease are the sub-clinical and clinical.

2.2.1 Sub-clinical stage: In the sub clinical stage there are no signs or symptoms and the person
does not know about the presence of any disease. With many infectious diseases, the infectious
agent (the bacterium) infects the person without causing any symptoms or signs of disease.

The only way we can know that a person has had a sub clinical infection is to be a special test,
examine the blood, urine or stool. Trace of antibodies in the blood for a particular disease e.g.
polio virus is suggestive of a sub clinical infection some time back.

The sub clinical stage of disease may lead to the clinical stage, or an individual may recover
without developing any signs or symptoms of the disease.

The following diagram shows the stages:

Health person

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 Sub clinical disease

Recovery
Clinical disease

2.2.2 Clinical stage: In the clinical stage the person has signs and symptoms of the disease. If
the symptoms become severe, the person may seek help. The clinical stage of different diseases
differs in duration, severity and outcome. Some diseases, such as cold have a clinical stage which
is short and mild and almost everyone recovers quickly. Other diseases are very serious, like
polio, most people who become infected with polio become paralyzed and may be disabled for
the rest of their lives.

Outcomes of clinical disease:

Health person

Sub clinical disease

Recovery Clinical disease

Recovery Permanent disability Death

2.3 Levels of Disease Prevention

There are three levels of disease prevention:

Death
Healthy person Early signs Disease
Recovery

Primary Secondary Tertiary

Prevention Prevention Prevention

2.3.1 Primary prevention

The purpose of primary prevention is to keep health people healthy and prevent them from
getting disease. It involves public health measures such as;

Control methods through people: Environmental control methods:

 Immunization -Safe water supply
 Chemoprophylaxis -Good food hygiene
 Good nutrition - Safe excreta and rubbish disposal
 Good personal hygiene -Disinfection and sterilization

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  Good behaviour -Vector control
 Child spacing -Good living and working conditions

2.3.2 Secondary prevention

Secondary prevention is the name given to interventions at early stage of a disease that is in the
sub-clinical stage. It is important to ensure that the community can recognize early signs of
disease and go for treatment before the disease becomes serious or in the clinical stage, like
Tuberculosis can be cured if it is known at an early stage. Peaople do home remedies or self
medication, consulting family members and healers before consulting the health worker, such
actions are called illness behaviours.
(Stage in illness behaviour)

Becoming aware of symptoms

Consulting others in family

Self-medication

Decision to go for treatment

(Either to local healer or doctor)

Doctor-patient consultation

Following advice and taking prescribed drugs

Returning for follow-up

There are two main methods of detecting a disease early;

 Screening for subclinical disease using special tests. The pap-smear test can find sub-
clinical cancer of the cervix.
 Case- finding for people with early clinical disaese, using clinical examinations with
laboratory tests if necessary. For example, vision screening can find people who are blind
due to cataracts.

2.3.3 Tertiary prevention

Tertiary prevention is aimed at reducing the progress or complications of established disease and
is an important aspect of therapeutic and rehabilitation medicine. It consists of the measures
intended to reduce impairments and disabilities, minimize suffering caused by departure from
good health and promote patient’s adjustment to incurable conditions.

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The rehabilitation of patients with poliomyelitis, stroke, blindness and so on is of great
importance in enabling them to take part in daily social life. Tertiary prevention can mean a great
improvement in an individual well-being and family income, in both developed and developing
countries.

2.0 SCREENING
3.1Definition
Screening is the process of surveying a community with tests to detect diseases at an early stage
before people feel symptoms. Screening tests sort out apparently healthy people from those who
may have a disease. Screening is not usually diagnostic and it requires appropriate investigative
follow-up and treatment.

A good example of this is growth monitoring of young children, it is not easy to tell just by
looking at a child if he or she is malnourished. However, if the child is regularly weighed and the
weights are plotted on a growth chart, you can see from the chart if there is a slowing-down of
growth. Advice can then be given to the parents to prevent the child becoming malnourished.

3.2Types of screening
 Mass screening: This involves the screening of a whole population
 Multiple or multiphasic screening: Involves the use of variety of screening tests on the
same occasion.
 Targeted screening of groups with specific exposures, like workers in lead foundries and
X-ray departments.
 Case-finding or opportunistic screening is restricted to patients who consult a health
practitioner for other purposes.

3.3 Criteria for starting a screening programme

 Disease: Serious
High prevalence of preclinical stage
Understanding the natural history
Long periods between first signs and overt disease
 Diagnostic/
Screening test: Sensitive and specific
Simple and cheap
Safe and acceptable
Reliable
 Diagnostic and
Treatment: Facilities are adequate
Effective, acceptable and safe treatment available

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3.4 The screening test itself must be cheap, easy to apply, acceptable to the public, reliable and
valid. A test is reliable if it provides consistent results, and valid if it categorizes people into
groups with and without disease, as measured by its sensitivity and specificity.

 Repeatability/Reliability- is the ability of the test to produce results that are identical
or closely similar each time it is conducted.
 Validity- is the degree to which a measurement actually measures or detects what it is
supposed to measure.
 Sensitivity- is the proportion of truly ill people in the population who are identified as
ill by the screening test.
 Specificity- is the proportion of truly healthy people who are identified by the
screening test.

Table 1: Validity of a screening test

Test outcome Disease status

Present Absent Total
Positive a b a+b
Negative c d c+d
Total a+c b+d a+b+c+d

a = no. of true positives

b = no. of false positives
c = no. of false negatives
d = no. of true negatives

Sensitivity; probability of a positive test in people with the disease = a/(a +c)

Specificity; probability of a negative test in people without the disease = d/(b + d)

Positive predictive value; probability of the person having the disease when the test is positive
= a/(a + b)

Negative predictive value; probability of the person not having the disease when the test is
negative = d/(c + d)
Three key biases in screening

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  Healthy screener effect- most people who are screened tend to be healthier than those
that do not go for screening.
 Lead time bias- those screened with early detection of the disease tend to seek medical
attention very quick. Survival (duration from diagnosis to death) will erroneously appear
increased among the screened when compared. Interval between time of diagnosis at
screening and expected time of diagnosis after development of symptoms. E.g. cancer
 Length bias- screening is best at picking up long lasting, slow growing diseases. This
pulls good prognosis. Overrepresentation among the screen-detected cases of those with a
long preclinical phase of disease and therefore a favorable prognosis. E.g. diabetes, BP.

3.0 EPIDEMIOLOGICAL STUDIES

4.1 Approaches to epidemiological studies: The types of studies used in epidemiology are;

4.1.1 Descriptive epidemiology; It asks what is the problem and its frequency, who is involved,
where and what? It is therefore, concerned with disease distribution and frequency. It is the
description of disease distribution. It describes occurrence of an outcome. In other words it looks
at the person, time and place.

The first stage in understanding a health problem or disease from an epidemiological perspective
is to describe it by the characteristics or variables of who? Where? and when? after all the
information has been assembled. The second stage is an attempt to explain all the facts.

Who?- The most important variables are age, sex, education, occupation, income, cultural and
religious grouping, family size, nutritional state and immune status.

Where?- The place where the people live or work may be partly determine which health
problems and diseases they may suffer from and what use they make of the available health
services. For example the variables might be:
 Town, village or isolated dwelling
 High or low altitude
 Proximity to rivers, forests, wild animals or sources of toxic substances
 Distance from dispensary, health centre or hospital

When?- It is important to know when health problems are most severe, or when the incidence of
new cases is greatest. To show this, cases, episodes can be grouped according to new cases per
day, week, month or year. The time period depends on what is being analyzed. For instance:
 New cases of cholera per day
 New cases of measles per week

Descriptive studies therefore, measure disease frequency- quantify disease and assess
distribution of disease- What is the problem and its frequency? Who is getting disease or
involved? Where is disease occurring?, and When is disease occurring? Examples of descriptive

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studies are: Ecological study (correlational studies) and cross sectional survey (Descriptive
studies).

4.1.2 Analytical epidemiology; It attempts to analyze the causes, or determinants, of diseases by

testing hypotheses to answer such questions as: how is the diseases caused and why is it
continuing? It is the analysis of relationships between possible causal factors and disease
occurrence. It describes the potential association between exposure and outcome.

It is concerned with the questions of cause and effect. It answers the questions: How is the
disease caused? Why is the disease continuing? Examples of analytical studies are: cohort and
case control (Observational studies).

4.1.3 Intervention or experimental epidemiology; this is where clinical and community trials
are used to answer questions about the effectiveness of new methods for controlling diseases or
for improving underlying conditions. It is concerned with questions such as: What is the
effectiveness for new methods of controlling diseases or improvement for underlying conditions?
It is the study of disease occurrence after removal of possible causal factors. Examples of
interventional studies are: clinical trials and field/community studies (Experimental studies).

4.1.4 Evaluation epidemiology; It attempts to measure the effectiveness of different health

services and programs and to answer the very important questions, so what? Have there been any
improvements in the health status? Was the type of intervention undertaken worthy
implementing?

4.0 EPIDEMIOLOGICAL CALCULATIONS

5.1 Morbidity
Morbidity is ill health. It is the occurrence of disease frequency and trends in a population over
time. Morbidity: measure rate of illness/time. Attack rate: cumulative incidence (e.g., the
proportion of people who got sick in an outbreak)

5.2 Mortality
Mortality is the death rate expressed as a percentage or a ratio per 1000 population.
Mortality: measure rate of death/ time
 Crude mortality rate: mortality from all causes for a specified population over a
specified period of time (usually a year)
Crude mortality rate = # of all deaths in a given time X 100
Total population in a given time

 Cause-specific mortality rate: mortality rate from a specified cause for a specified
population (usually a year)
 Age-specific mortality rate: a mortality limiting numerator and denominator to an age or
age group (usually a year)
 Infant mortality rate: number of deaths among <1 yr. children in a given time period
divided by number of births during same time period (usually a year)

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 IMR = # of deaths among infants <1 year of age (defined place & time period) X 100
# of live births (same place & time period)

Calculate the IMR for Zambia 2010 Census

# of infant deaths – 19,882
# of live births – 442,998
Answer:
IMR= 19,882 x 1000
442,998
= 44.9 per 1000 in 2010

5.3 Incidence rate

Measure of new cases of illness or occurrences of a condition. Incidence rate is the basic
measure of disease occurrence, which is defined as number of new cases that occur in a
population during a period of time over the total sum of individuals in the population at risk of
getting the disease at a specific period of time.

Proportion of people who develop the disease (new cases) over a specified period of time.

Incidence rate = # of new cases over a specific period of time X 100

Population at risk during same period of time

Incidence = Number of new cases in a fixed time period / Number of people at risk. Usually the
period of study is chosen to be one year, in which case we speak of the annual incidence. The
incidence rate is the number of new cases per population at risk in a given time period. When
the denominator is the sum of the person-time of the at risk population, it is also known as the
incidence density rate or person-time incidence rate.

5.4 prevalence rate

Proportion of individuals in a population who have the disease (or condition) at a given time.
Includes all of the people with the condition, whether or not they just developed it or have had it
for years and is often reported as a percent (%). Proportion of individuals in a population who
have the disease (or condition) at a given time.

Prevalence is a rate or proportion. It is defined as number of individuals having the disease at a

specific tine, over total number of individuals in the population at that point in time.

Prevalence = # of people with the disease at a given time X 1000

Total population at a given time

It is thus a proportion, rather than a rate, although you may sometimes see it called a "rate."
Prevalence is influenced by the incidence and by the duration of the condition, and provides a
good way to indicate the burden of disease in a population.

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Prevalence is a term which means being widespread and it is distinct from incidence. Prevalence
is a measurement of all individuals affected by the disease at a particular time, whereas incidence
is a measurement of the number of new individuals who contract a disease during a particular
period of time.

Incidence should not be confused with prevalence, which is the proportion of cases in the
population at a given time rather than rate of occurrence of new cases. Thus, incidence conveys
information about the risk of contracting the disease, whereas prevalence indicates how
widespread the disease is. Prevalence is the proportion of the total number of cases to the total
population and is more a measure of the burden of the disease on society with no regard to time
at risk or when subjects may have been exposed to a possible risk factor. Prevalence can also be
measured with respect to a specific subgroup of a population. Incidence is usually more useful
than prevalence in understanding the disease etiology: for example, if the incidence rate
population of a disease increases, then there is a risk factor that promotes the incidence.

When the incidence is approximately constant for the duration of the disease, prevalence is
approximately the product of disease incidence and average disease duration, so prevalence =
incidence × duration. The importance of this equation is in the relation between prevalence and
incidence; for example, when the incidence increases, then the prevalence must also increase.
Note that this relation does not hold for age-specific prevalence and incidence, where the relation
becomes more complicated. Prevalence = Incidence X Duration of illness

Incidence vs. Prevalence

Characteristic Incidence Prevalence

Numerator New Cases All Cases
Denominator Susceptible (at risk) All cases + non-cases
Time Duration Single point
How measured Cohort Cross-sectional

5.5 Case fatality rate

Case fatality rate. The proportion of people with a specified condition who die within a
specified time. The time frame is typically the period during which the patient is sick from the
disease. This works for an infectious disease but can be problematic for a chronic disease like a
cancer that may remit for a period and then prove fatal after a recurrence. In such instances we
tend to speak of mortality or survival rates rather than case fatality.

Case fatality rate = # of cases who die within given time X 100
# of all cases within given time

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6.0 INTEGRATED DISEASE SURVEILLANCE
6.1Epidemiology of infectious and non-infectious diseases
Surveillance is:
• On-going systematic collection, analysis and interpretation of data
• Timely dissemination of the resulting information to those who need them for action
• Essential for planning, implementation and evaluation of public health practices.

The functions of surveillance are:

• Identify cases or events

• Report suspected cases or conditions or events
• Analyze and interpret findings
• Investigate and confirm suspected cases
• Prepare for response
• Respond
• Provide feedback or communicate
• Evaluate and improve system

Integrated disease surveillance is a strategy for strengthening surveillance, laboratory and

response capacities at each level of the health system. Its core functions are to identify report,
analyze, investigate, prepare, respond, communicate and evaluate.

The purpose of integrated disease surveillance is to reduce morbidity, disability and mortality
through rational basis for decision making and implementing public health interventions that are
efficacious in responding to communicable and non-communicable diseases.

Epidemiology of infectious diseases

Infectious diseases are communicable. Communicable diseases are illnesses which are
transmitted indirectly or directly from an infected person to another or from an animal to man
including anthropoids. Eg TB, HIV/AIDS, malaria, STDs, measles, tetanus, rabies, cholera,
yellow fever, plague, dysentery etc.

What is an outbreak?

• Greater than expected number of cases

• Unusual presentation of cases
• Unusual event

Steps in Outbreak Investigation

1. Verify existence of outbreak
2. Institute immediate control measures
3. Prepare for field work (Teams & logistics)
4. Confirm diagnosis (Lab diagnosis)
5. Define case (Clear case definition)
6. Identify cases (Actively find cases)

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 7. Orient data in terms of person, place, time
8. Develop & Evaluate hypotheses
9. Implement control and prevention measures
10. Communicate findings

Notifiable diseases in Zambia

Diptheria, scarlet fever, chicken, small pox, STDs, acute conjunctivitis, trachoma, rabies,
meningitis, whooping cough, yellow fever, plague, typhoid and paratyphoid, ring worm, cholera,
mumps, poliomyelitis, typhus fever, T.B, measles, scabies. HIV/AIDS, AFP, NNT, dysentery,
VHF, leprosy, pandemic H1N1 Aivian influenza.

International notifiable diseases

Cholera, small pox, yellow fever, plague, typhus fever, relapsing fever.

Control of communicable diseases

 Recognition of the infection

 Notification of the diseases
 Identification of the source of infection
 Assessment of the extent of the disease

Methods of controlling the communicable diseases

 Elimination of the reservoir: isolation and quarantine

 Interruption of transmission. Eg sanitation barrier
 Protection of the host. Eg immunization.

Epidemiology of non-infectious diseases

Non-infectious diseases are not communicable, and usually are chronic in nature. These are
diseases which are not transmitted from an infected person to another. Eg cancer, malnutrition,
tumour, asthma, ulcers, diabetes etc.

6.2Community diagnosis
6.2.1 Definition
A community is a cluster of people with at least one common characteristic (geographic location,
occupation, ethnicity, housing condition etc). A group of people with a common characteristic or
interest living together within a larger society comprises a community. A group of people living
in a certain locality with similar interests.

Diagnosis is the process taken to arrive at the rightful final decision.

A community diagnosis is a comprehensive assessment of health status of the community in

relation to its social, physical and biological environment.

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6.2.2 Purpose of community diagnosis
 To define the existing problems, determine available resources and set priorities for
planning, implementing and evaluating health action, by and for the community.
 To help in the identification and quantification of health problems in a community as a
whole in terms of mortality and morbidity rates and ratios, and identification of their
correlates for the purpose of defining those at risk or those in need of health care.
 To act as a means of examining aggregate and social statistics in addition to the
knowledge of the local situation, in order to determine the health needs of community.

6.2.3 The importance of Community Diagnosis

 It helps to find the common problems or diseases, which are troublesome to the people
and are easily preventable in the community
 Brings solutions and sets priorities in the community
 It suppresses public opinions
 It is a pioneer step for betterment of rural community health
 It is a tool to disclose the hidden problems that are not visible to the community people
but are being affected by them
 It helps to access the group of underprivileged people who are unable to use the available
facilities due to poverty, prevailing discriminations or other reasons
 It helps to find the real problems of the community people which might not have
perceived by them as problems
 It helps to impart knowledge and attitudes to turnover people’s problems towards the
right solution.

Indications:
1. Making a general diagnosis of the community
2. Promoting community health
3. Fostering community participation
4. Promoting research.

Principles:
1. Identify the target population and the key leaders
2. Apply the ethics procedure
3. Have all necessary requirements available
4. Have a topic guide at hand
5. Use local language
6. Involve the community and its leaders throughout the process

6.2.4 The process of community diagnosis involves four stages: Initiation; Data collection and
analysis; Diagnosis and Dissemination

1.Initiation

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In order to initiate a community project a dedicated committee or working group should be set up
to manage and coordinate the project. The committee should involve relevant parties such as
government departments, health professionals and non-governmental organizations.

At an early stage it is important to identify the available budget and resources to determine the
scope of the diagnosis. Some of the common areas to be studied may include health status,
lifestyle, living conditions, socioeconomic conditions, physical and social infrastructure,
inequities, as well as public health services and policies. Once the scope is defined, a working
schedule to conduct community diagnosis, production and dissemination of report should be set.

2.Data collection and analysis

The project should collect both quantitative and qualitative data. Moreover, population census
and statistical data e.g. population size, sex, and age structure, medical services, public services,
public health, social services, education housing, public security and transportation etc, can
provide background of the district. As for the surveys through self-administered questionnaires,
face-to-face interviews, focus group and telephone interviews.

In order to ensure reliability of the findings, an experiences organization such as an academic

institution can be employed for conducting the study. The sampling method should be carefully
designed and the sample size should be large enough to provide sufficient data to draw reliable
conclusions. Therefore, study results derived can truly reflect the local community.

Collected data can then be analyzed and interpreted by experts. Here, are some practical tips on
data analysis and presentation;
 Statistical information is best presented as rates or ratios for comparison
 Trends and projections are useful for monitoring changes over a time period for future
planning
 Local district data can be compared with other districts or the whole population
 Graphical presentation is preferred for easy understanding.

3.Diagnosis
Diagnosis of community is reached from conclusions drawn from the data analysis. It should
preferably comprise three areas;
 Health status of the community
 Determinants of health in the community
 Potential for healthy city development.

4.Dissemination
The production of community diagnosis report is not an end in itself; efforts should be put into
communication to ensure that targeted actions are taken. The target audience for the community
diagnosis includes policy makers, health professionals and the general public in the community.

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The report can be disseminated through the channels:
 Presentation at meetings of health committees, forums or development committees
organized for voluntary organizations, local community groups and the general public
 Press release
 Thematic events (such as health fairs and other health promotion programmes).

It is important to realize that community diagnosis is not an one-off project but is part of a
dynamic process leading to health promotion in the community. There, community diagnosis
should be conducted at regular intervals to allow the HCP continuously improved.

A flowchart describing the community diagnosis process

Describe the scope/areas to be studied

Population census and statistical data concerns or views from the local people

Retrieve from GRZ departments or conduct surveys to obtain data

relevant organizations

Collect and analyze

From a community diagnosis and disseminate

the report via different channels

Establish and prioritize areas for improvement

Set work plans and indicators for evaluation

Requirements:
1. Questionnaire (topic guide)
2. Trained human resource
3. Community mobilization, awareness and acceptability
4. Transport and other facilities; community, leaders, key informers, cultural beliefs
5. Time
6. Pens/pencils/paper

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Method:
Before the procedure
1. Have all necessary requirements available
2. Supply questionnaires to interviewers
3. Divide interviewers into small groups of three or five
4. Allocate the directions

Actual procedure
1. Greet the house hold
2. Self introduction
3. Explain the mission of the visit
4. Obtain permission to conduct the interviews
5. Administer the questionnaire (topic guide). Pay attention to probing areas
6. Thank the house hold for the co-operation and allow them to ask you a few questions
before you leave.

After the procedure

1. Analyze the questionnaires to see the findings and write the report. Give incentives
2. Disseminate the information to community and other stake holders
3. Give appropriate health education to the community
4. Encourage the community to plan and start the community based projects to solve the
health problems in the area.

(B). DEMOGRAPHY
1.0 INTRODUCTION TO DEMOGRAPHY
1.1 Definition

Demography is the statistical study of human populations. It can be a very general science that
can be applied to any kind of dynamic living population, i.e., one that changes over time or space.
It encompasses the study of the size, structure, and distribution of these populations, and spatial
and/or temporal changes in them in response to birth, migration, aging and death. “Demo” means
“the people” and “graphy” means “measurement”.

Sources of demographic data or population information are;

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 1. Census- nationwide counting of the population by direct canvas of each person in a
household. Total process of collecting, evaluating, analyzing, and publishing of
demographic, economic, ad social data pertaining at a specified time to all persons in a
2. Vital registration- recording of vital events pertaining to births, adoptions, deaths,
marriages, divorces, legal separations.
3. Surveys- systematic selection of segments of the population to represent the entire
population. E.g sample surveys; Demographic and Health Surveys (ZDHS) done every 6
years, Reproductive Health Survey etc.:

Direct data come from vital statistics registries that track all births and deaths as well as certain
changes in legal status such as marriage, divorce, and migration (registration of place of
residence). In developed countries with good registration systems (such as the United States and
much of Europe), registry statistics are the best method for estimating the number of births and
deaths.

Population density is the average number of persons per square kilometer (km2). The density
can vary markedly between different districts and even within districts. Density tends to be
higher in areas with large towns, fertile soil and more advanced development. Migration can be
an important factor in areas with rapidly increasing or decreasing population density.

1.2 Objectives
To measure the health indicators of the population. Indicators are measures that can be used to
help describe a situation that exists and to measure changes or trends over a period of time.
These health indicators include:
Nutritional status
Morbidity
Mortality

1.3 Population distribution

Suppose that a country (or other entity) contains Populationt persons at time t. What is the size of
the population at time t + 1 ?

Natural increase from time t to t + 1:

Net migration from time t to t + 1:

This basic equation can also be applied to subpopulations. For example, the population size of
ethnic groups or nationalities within a given society or country is subject to the same sources of

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change. However, when dealing with ethnic groups, "net migration" might have to be subdivided
into physical migration and ethnic identification. Individuals who change their ethnic self-labels
or whose ethnic classification in government statistics changes over time may be thought of as
migrating or moving from one population subcategory to another.

A stable population, one that has had constant crude birth and death rates for such a long period
of time that the percentage of people in every age class remains constant, or equivalently, the
population pyramid has an unchanging structure.

A stationary population, one that is both stable and unchanging in size (the difference between
crude birth rate and crude death rate is zero).

A stable population does not necessarily remain fixed in size. It can be expanding or shrinking
1.4 Population pyramid
Population pyramid. A bar graph depicting the numbers or percentages of males and females in
each age group.
1.5 Census
Census. A national enumeration of a population at the same time.
De facto census. A census that counts people at their locations on the night of the census.
De jure census. A census that counts people where they usually live.

A census is the other common direct method of collecting demographic data. A census is usually
conducted by a national government and attempts to enumerate every person in a country.
However, in contrast to vital statistics data, which are typically collected continuously and
summarized on an annual basis, censuses typically occur only every 10 years or so.

Censuses do more than just count people. They typically collect information about families or
households in addition to individual characteristics such as age, sex, marital status,
literacy/education, employment status, and occupation, geographical location. They may also
collect data on migration (or place of birth or of previous residence), language, religion,
nationality (or ethnicity or race), and citizenship.

Vital statistics. Statistics on events that change the composition of the population, especially
births and deaths. Other events – marriages, divorces, adoptions and migration – are sometimes
included as well. The statistics are products of official registration systems.

Population surveys. These collect data from a sample of the population on an aspect of
demography such as fertility, mortality, migration, employment, families, health and housing.
Compared with a full census, they can provide more detailed data on certain subjects and are less
costly to conduct.
1.5 Population growth
Growth rate is the annual rate of change in the size of a population. Estimates of population
growth can be derived from the size of the population at two or more points in time. The simplest

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way of estimating population growth is to obtain the difference between the population size at
two points in time and then to divide this difference by the number of years’ interval between
them. E.g if pop. Is estimated to be 7830 on 31 March 2005 and 8450 on 30 September 2009,
then the average increase per year is estimated to be (8450-7830) divided by 4.5 = 138 people.
The estimated pop. On 30 September 2009 is therefore 8450 + 138 = 8588.

Population growth in a district depends on the balance between the number of births and people
migrating into the district on one hand, and the number of deaths and people migrating out on the
other. Populations can change through three processes: fertility, mortality, and migration.
Fertility involves the number of children that women have and is to be contrasted with fecundity
(a woman's childbearing potential). Mortality is the study of the causes, consequences, and
measurement of processes affecting death to members of the population.

Migration refers to the movement of persons from a locality of origin to a destination place
across some pre-defined, political boundary. Migration researchers do not designate movements
'migrations' unless they are somewhat permanent. Thus demographers do not consider tourists
and travelers to be migrating. While demographers who study migration typically do so through
census data on place of residence, indirect sources of data including tax forms and labor force
surveys are also important.

2.0 DEMOGRAPHIC RATES

2.1 Crude birth rate
The crude birth rate, the annual number of live births per 1,000 people. The crude birth rate
(CBR) is usually estimated from the census or special demographic surveys and is given by the
formula:

CBR = total births in one year X 1000

total midyear population (all ages, same year)

E,g In a district of 200,000 people with a CBR of 45 births per 1000, there would be about 9000
births per year.

2.2 Fertility rate

The general fertility rate, the annual number of live births per 1,000 women of childbearing age
(often taken to be from 15 to 49 years). Fertility rate is an age-sex specific rate usually derived
from the census or special demographic surveys. This rate is a measure of how frequently
women in the fertile age range (15-49 years) are having babies, so where the CBR is high the FR
will also be high. Fertility rate is calculated by the formula:

FR = total live births in one year X 1,000

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 Total midyear women population (15-49 years)

2.3 Crude death rate

The crude death rate, the annual number of deaths per 1,000 people. The crude death rate (CDR)
is calculated as:

CDR = total deaths in one year X 1000

Total midyear population (all ages, same year)

2.4 Infant mortality rate

The infant mortality rate, the annual number of deaths of children less than 1 year old per
1,000 live births. Infant mortality rate (IMR) is the proportion of all live born infants who die in
the first twelve months of live. It is commonly considered a good measure of health status. It is
usually calculated from the census or special demographic surveys. It is calculated using the
formula:

IMR = total infant (<1 year) deaths during one year X 1000
total births in the same year

Most of the infant deaths occur during the first month of life, these deaths are called neonatal
mortality

E.g in a district with a population of 200,000, 9,000 births per year and an IMR of 100,
estimated number of infant deaths would be:
100 X 900 = 900 per year.
1,000

2.5 Child mortality rate

Child mortality rate (CMR) is based on the deaths between 1 and 4 years of age and is important
because malnutrition and infectious diseases are common in this age group. It is usually
calculated from a census or special surveys since it is not easily calculated with sufficient
accuracy from district health information. It is calculated as:

CMR = total children (<5 years) deaths during one year X 1000
total children <5 years in the same year

2.6 Maternal mortality rate

MMR is the number of deaths in maternal pregnancy related in one year compared to the number
of births during the same year. MMR is calculated as:

MMR = maternal pregnancy-related deaths in one year X factor (1,000 or 100,000)

total births in same year

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(C). APPLIED RESAERCH
1.0 INTRODUCTION TO APPLIED RESEARCH
1.1 Definition of research
1.2 Selecting of research topic
1.3 Problem statement and justification
1.4 Literature review
1.5 Hypothesis and objectives
1.6 Methodology including study design selection
1.7 Sampling and sample size determination
1.8 Data collection tools/techniques
1.9 Pilot study
1.10 Data collection
1.11 Data processing
1.12 Analysis
1.13 Interpretation
1.14 Reporting

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1.15 Dissemination

(D). EPIDEMICS
1.0 INTRODUCTION TO EPIDEMICS
1.1 Definition
1.2 Speed of spread
1.3 Prevalence
1.4 Mode of transmission
1.5 Management and control of epidemic diseases

(E) PRIMARY HAELTH CARE

1.0 INTRODUCTION TO PRIMARY HEALTH CARE (PHC)
1.1 Definition
1.2 Concept of PHC
1.3 Elements of PHC
1.4 Principles of PHC
1.5 Primary Health Care in Zambia
1.5.1 Training of CHWs and TBAs
1.5.2 Ethical considerations for community health programmes
1.5.3 Types of PHC

(F) ENVIRONMENTAL HEALTH

1.0 WATER SUPPLY
1.1 Sources of water
1.2 Protection of water sources
1.3 Water purification
1.4 Storage
1.5 Water borne diseases
1.6 Prevention of contamination in the homes

2.0 SOLID WASTE MANAGEMENT

2.1 Definitions
2.2 Types of solid waste
2.3 Generation, collection, storage and disposal
2.4 Methods of disposal
2.5 Health risks associated with poor disposal

3.0 SANITATION
3.1 Definition
3.2 Excreta disposal systems
3.3 Health risks associated with poor disposal

(G) SCHOOL HAELTH SERVICES

1.0 Concept of school health services
1.1 Definitions
1.2 Objectives
1.3 Organization of school health services in Zambia

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2.0 Preventive
3.0 Curative
4.0 Nutrition services
4.1 School health nutrition services
4.2 Micronutrients supplementation
4.3Vitamin A supplementation
4.4Information, Education and Communication (IEC)

5 Reproductive health
5.1HIV/AIDS/STIs
5.2 Malaria
5.3 Nutrition
5.4 Gender
6 drug abuse
6.1Immunisation
6.2 Child To Child Program
6.3 Adolescent health services
6.4 Accident prevention- home, road, school.

7 dental health services

7.4 Oral examination
7.5 Oral health education
7.6 Referral

(H) OCCUPATIONAL HEALTH

1.0 INTRODUCTION TO OCCUPATINAL HEALTH
1.1 Concept of occupational health
1.2 Main services of occupational health
1.3 Common work related hazards
1.4 Management and control of hazards

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