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THE FAMILY AS A
We may become the last of the true family doctors in UNIT OF CARE
the world because the family is strong in
Asia…… in our society, the family of three Zorayda E. Leopando, MD
generations flourishes with the nuclear family which Annabelle Pabilona-Tiu, MD
nevertheless retains close …… ties with parents Angel Erich Sison, M.D.
and grandparents . The family in Asia transmit Arnel V. Herrera, M.D.
ethical and cultural values ; is a reliable source of Joseph A. Jao, M.D.
succor in adversity and provides loving care to their
Philippine Constitution, 1987
Gloria Peret- Clarion, M.D.
disabled and handicapped on the tiniest of Julie Tanchanco- Tiu, M.D.
resources. Ma. Lorena Lorenzo, M.D.
Jena Angela Perano, MD
M. K. Rajakumar,
1993

1987 Philippine Constitution

…The state shall protect and promote the right to
ROAD MAP OF SESSION
health of people….
Article 2 Section 15 Understanding the
family
The state shall adopt an integrated and
comprehensive approach to health development, - Classification of families
which shall endeavor to make essential goods, - Family as a system-
health and other social services available to all
the people at affordable cost - The Family as a unit of
Article 13 Section 2 care

The state recognizes the Filipino family as the Family Medicine

Philippine Constitution, 1987
foundation of the nation. Accordingly, it shall - Understanding the
strengthen its solidarity and actively promote its discipline that takes care
development. of the Family
Article 15, Section 1

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BIOSPHERE
SOCIETY

COMMUNITY
Understanding the
FAMILY
family:
PERSON The family and its
functions
Tissue
c
Organ
Human Body

G. Engel, 1979

THE FAMILY MINIMUM BASIC NEEDS TO

ATTAIN DECENT QUALITY LIFE
• Primary social agent in the promotion 1. Needs for survival
of health and well being→ greatest ally
in health care 2. Security
• Primary source of health beliefs, 3. Empowerment
health related behaviors, stress and
emotional support
• Strongly influences most health
behaviors and that family oriented
approach is the most effective and
efficient way to prevent disease and
promote health

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THE FILIPINO FAMILY THE FILIPINO FAMILY

1. Closely knit, bilaterally extended 1. Predominantly Catholic

2. Average household size is 4.6 2. Child –centered
3. Expenditure pattern mostly on 3. Health problems
food and rent/ housing
4. Environmental stresses
4. Life expectancy of 68.8 for men
and 74.3 for women 5. Economic
5. Functional literacy rate of 84.1 % 6. Political
6. Total fertility rate of 2.76% 7. Industrialization
7. Contraceptive prevalence rate of 8. urbanization
50.6%
Challenges to Filipino families Challenges to Filipino families

THE FILIPINO FAMILY THE FILIPINO FAMILY

AS A VERY SPECIAL UNIT AS A VERY SPECIAL UNIT
1. Societal expectations
1. Lifelong involvement 2. Sense of responsibility towards
2. Shared attributes
members and others
3. Basis of affection/ care
Genetics: Physical, Psychological
4. Built in problems
3. Developmental
5. Generation gap
• Home, lifestyle, social activities 6. Dependence of members
4. Sense of belonging 7. Emotional attachment/ involvement
5. Security/ defense against a potentially 8. The family endures in spite of
hostile environment problems
6. Companionship 9. Resource utilization
10. Authority
11. Individual sense of responsibility
Challenges to Filipino families Challenges to Filipino families

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FILIPINO CONCEPT OF HEALTH

WHY STUDY THE FAMILY? KALUSUGAN
Body

Malusog ang Mabuti ang Matipuno ang

kaatawan katawan katawan
1. Transmission of infectious diseases
Criteria : Criteria : All
2. Health behavior is acquired in the family Criteria : Mostly aspects:
3. Psychosocial stress can occur within the family exclusively emotional Physical,
4. Source of social support physical and mental mental, and
emotional
5. Defines health and illness Good
6. Makes health decisions Abled Body condition Physically,
7. Cause of illness or problem mentally and
socially sound
8. Resource for prevention or cure; solution of the
problem
KARAMDAMAN B. T Medina
Feelings 1992
WHO def health
Challenges to Filipino families

WHAT DOES HEALTH MEAN TO YOUR FUNCTIONS OF THE FAMILY :

FAMILY ?
Physical • Reproduction With other
• Biological institutions
maintenance • Economics
• Socialization • Citizenship and
• Welfare and political behavior
Health
protection • Religion
& • Education
Mental Well Being Social
and not merely the
absence of disease or Diminished functions in modern
infirmity times : political, religious, status
WHO Constitution
placement

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FAMILY STRUCTURE
CLASSIFICATION
1.Nuclear Family OF FAMILY
2.Extended Family
ACCORDING TO
3.Single Parent Family
4.Blended Family
HEALTH STATUS
5.Communal/ Corporate Grouping

Challenges to Filipino families

CLASSIFICATION OF FAMILY
ACCORDING TO HEALTH
STATUS :
1. Healthy Family
2. Family at Risk
3. Family with Problem
1. HEALTHY / WELL FAMILY
CHARACTERISTICS OF A HEALTHY FAMILY :
1. Open to change
2. High self worth
3. Functional defenses
4. Clear rules discussed
5. People take risk to express feelings
6. Can deal with stress
7. Welcomes life stages
8. Clear hierarchy
9. Affect is open

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FACTORS AFFECTING HEALTH

2. FAMILY AT RISK
Personal Gaps in Mental
Questions to identify the family at risk Genetic
Primary Health
1. What does the family need to maintain or restore Physiological Care Issues
its health ? Demographic Violence
Depression
2. What capacity does the family have to make Substance
healthy choices ? Health abuse

3. What does the family need from society to

optimize its health ?
Environmental Behavioral
Alcohol
4. How do we promote a balance between the Hazards in work, Societal
family’s needs and expectations and the constraints community,
Tobacco
of the health care system ? Home, Cultural Injury
Bersick, 2006 recreation Socio-
Unintended
pregnancy
economic Over nutrition

RISK FACTORS :
RISK FACTORS FOR DISEASE :
A risk factor increases your risk of developing
a disease or health problem
environment
behaviors and lifestyle 1. Environment

Genes

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RISK FACTORS : RISK FACTORS :

2. BEHAVIOR AND LIFE 3. GENES
Grandmother
STYLE
A. Lack of exercise Mother

B. Poor diet
C. Obesity
D. Smoking
Child

Government Agencies which has

3. FAMILY WITH PROBLEM:
given emphasis on role of
families in health
Agencies Initiatives
Economic

DOH Family Health Program, Sustainable

Development Goals; Philippine Health Agenda
and interventions at life stages
Psycho
Cultural Health DSWD Pantawid Pampamilya Pilipino Program
social

DOLE Family Welfare Program and Family Health

Program
Biological
Phil Health Family Registration for Primary Care Benefits

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PANTAWID PAMILYANG PILIPINO

PROGRAM (4’P)
BRIDGING PROGRAM FOR THE
FILIPINO
FILIPINO VERSION OF
CONDITIONAL CASH TRANSFER

DOH FHO, DOLE

National Objectives for Health, DOH 1999

Pantawid Pamilyang Pilipino Program (4P’s)

OBJECTIVES : (Filipino version of Conditional Cash Transfer)

1. Social assistance – provide

1. Pregnant women : pre- and post-natal care
cash assistance to address the and be attended by a trained health
short term financial needs professional during childbirth
2. Parents→ Family Development Sessions
3. 0-5 year old children → regular preventive
2. Social development – by health check-ups and vaccines
investing in capability building 4. 3-5 year old children→ attend day care or
pre-school classes at least 85% of their time
inorder to break intergenerational 5. 6-14 year old children→ enroll in
poverty cycle elementary or high school and must attend at
least 85% of their time; must receive
deworming pills twice year

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4P’s CASH GRANTS :

1. Health grant – PHP 500 per
household per month or a total of
PHP6,000 every year FAMILY AS A
2. Education grant – PHP 300 per child
every month for 10 months or a total of
SYSTEM
PHP 3000 every year

A household may register a maximum

of 3 children for the program

SYSTEM : FAMILIES
FAMILY SYSTEM THEORY :
Are systems of interconnected and
• an entity interdependent individuals, none of
composed of whom can be understood in
discrete parts isolation from the system. CHANGE→
which are • Parts or
connected in such It is the system in which each members • Circularity
a way that a member had a role to play and rules
change in one part to respect. • a change in
results in changes Members of the system are one part • Equilibrium
in all of the other expected to respond to each other results in
parts. in a certain way according to their changes in all
Allan Dionisio, 2013 role, which is determined by parts. • Homeostasis
relationship agreements.

Murray Bowen

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STRUCTURES OF FAMILY
DYNAMICS :
1. Rules of behavior
FAMILY AS A UNIT
2. Boundaries
OF HEALTH CARE
3. Roles played by different members

4. Coalition and power structures

FAMILY AND HEALTH FAMILY AND HEALTH :

1. Primary social agent in promotion
Social context of illness of health and well being
And recovery
2. Primary source of health beliefs/
Culture and Lifestyle related behaviors, stress and
religion Diseases emotional support

3. Family oriented approach →most

effective and efficient way to
Family Interventions prevent disease and promote health

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FAMILY PARTICIPATION IN
PREVENTION OF DISEASES
Primary prevention
Common lifestyle
diet, non-addictive
behavior, leisure activity,
basic living habits
Health maintenance
screening activities and
immunization
Family life education
sexuality, marriage,
prenatal care, personal
hygiene and sanitation,
health risk behavior and
disease prevention, care
of elderly
Secondary prevention
Health is shared
responsibility between
doctor, patient and family.
(i.e. monitoring of well-
being
Encouraging sick member
to seek appropriate help
Compliance monitoring
regarding management
Hennen et all
Tertiary prevention
Balanced support between
compliance monitoring and
independent activity of
members with chronic
iillness
Adjustment of all members
to changes necessitated by
chronic illness in one
patient
Coping with crisis created
by serious illness or a dying
family member
FAMILY ORIENTED PRIMARY
CARE :
1. Learning to “think family”
2. The importance of genogram
3. The family within a larger system – use
an Ecomap
4.Chronic illness and disability- family
caregivers
5. Working with family members – the
family conference
6. Identifying the family at risk
Graham Bresick, 2006

5 IMPORTANT QUESTIONS IN THINKING FAMILY :

THINKING FAMILY :

1. Has anyone else in the family had a similar

1. the patient’s family or household problem?
as integral part of information 2. What do family members believe caused the
gathering, clinical reasoning, and problem and how do they think it should be
treated?
patient care 3. Who in the family is most concerned about the
2. Role of family in health and problem?
illness 4. Have there been any other recent changes or
stresses in your life? Are you or any member of
3. Importance of communication your family experiencing any difficulties at
present?
skills, patient centeredness, 5. How can your family or friends help you in
principles of family medicine dealing with this problem

Graham Bresick, 2006

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FAMILY MEDICINE
• a component of primary care
• specialty of medicine concerned with
providing comprehensive care to individuals
FAMILY MEDICINE and families
AND THE • integrates biomedical, behavioral and social
sciences
FAMILY PHYSICIAN •an academic medical discipline that includes
comprehensive health care services,
research and education

Contribution of Family Medicine in Improving Health System , 2013

FAMILY MEDICINE – A SPECIALTY PRINCIPLES OF FAMILY

▪ Distinguishable Recognition of Family MEDICINE
core knowledge Medicine as
specialty/ academic Family Physician
▪ Unique field of
action
discipline skilled clinician
resources to defined population
▪ Intellectually • Philippine Medical Association
vigorous training • Department of Health Family Medicine
• Association f Philippine Medical
Colleges community based discipline
▪ Active area of
research
• Philippine Health insurance Centrality of doctor-patient relationship
Association
• Technical Committee o Medical
Education, Commission on Professor Ian R. McWhinney
Higher Education
• Philippine Regulatory Board of
Professor Ian Mac Whiney, Me Philippine Regulation
Commission
1968

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CORE VALUES IN FAMILY MEDICINE PRINCIPLES OF PRIMARY CARE

ADHERED TO IN FAMILY MEDICINE
Wes Fabb PSTFM , 2001 Rich Roberts PAFP EDUCATION AND TRAINING
1. Access or first contact care
2. Comprehensiveness
ãDoctor-patient Punctuality Relationship Compassion: 3. Continuity of care
relationship
ãPatient-centered,
Honesty Trust Altruism: 4. Coordination
Integrity Respect:
continuing care in Comprehensive 5. Prevention
context of the family, Initiative Excellence:
community and the Resourcefulness ness Solidarity: 6. Family-orientation
workplace
ãOpportunities for
Compassion 7. Community-orientation
various spectrum of care Caring 8. Patient centeredness
ãApproach to health Humaneness Wonca President
care utilizes systems 2010-2013
theory
ãWonca CEO
ã1975-2001 Contribution of Family Medicine in Improving Health System , 2013

What kind of doctors should a Family CHARACTERISTICS OF CARE GIVEN

Medicine specialist be? IN FAMILY MEDICINE :

Doctor of the sick 1. Comprehensive

Doctor for health 2. Continuing
3. Coordinated
4. Compassionate
5. Primary
6. Personalized (Patient centered)
7. Promotive /preventive
8. Participatory

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PRIMARY CARE PHYSICIANS / IMPLICATIONS TO

FAMILY DOCTOR/ FAMILY PHYSICIANS
FAMILY PHYSICIAN
1. Provide primary and continuing care for entire 1. Recognizes the pivotal role of the
families within the communities family in the healing process
2. Address physical, psychological and social 2. Power structure in health decision
problems
making
3. Coordinates comprehensive heath services with
other specialists 3.Rules on Medical Issues
4. Medical specialists trained to provide health 4. Medical Roles→ Hierarchy
services for all individuals regardless of age, sex, or
type of health problems 5. Neutrality in the midst of coalition
homeostasis and equilibrium vs
compliance issues
Contribution of Family Medicine in Improving Health System , 2013

ROLES OF FAMILY PHYSICIANS Family physicians give care in the clinic,

Undergraduate Residency hospital, home
Health Care Researcher/
Provider Lifelong learner

Teacher/ Teacher/
Educator Educator Counselor
Researcher

Health Care
Provider
……. To patients at various stages of life
….To families at various stages of family life cycle………

Social mobilizer Leader/ Social mobilizer Leader/

Manager/ Manager/

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Philippine Textbook of Family

Medicine
WHA62 IN
GENEVA,
22.05.09

Resolution

to train and retain adequate numbers of health workers,

with
appropriate skill-mix, including primary health care nurses,
midwives, allied health professionals and family physicians,
able to work in a multidisciplinary context, in cooperation
with non-professional community health workers in order to
respond effectively to people’s health needs;

References

Michael Kidd. Contribution of Family Medicine in Improving

Health System , 2013, World Organzation of Family Doctors.
 Belen T. Medina, The Filipino Family. University of the Philippines
Press. 1991. UP_ Diliman.
Graham Bresik. Family Oriented Primary Care. Handbook of Family
Medicine. Edited by Bob Mash. Oxford University Press. South Africa,
2006. pp 96-125.
Ian R McWhinney, Textbook of Family Medicine. Oxford University
Press. ______ London. Pp 202-231
Landa F. Jocano, Filipino Social Organization. Traditional Kinship and
Community
Professor Leela Karunaratne Family Organization. Punlad Research House Quezon City 1998. pp 1-
Family 150.
Physician Faculty of Medical Sciencephysician
University
of Sri Javawardenepura Landa F. Jocano, Folk Medicine in a Philippine Municipality. 1973.
Punlad Research House. Quezon City.
Wesley Fabb . Conceptual leaps in family medicine: Are there more to
come? Asia pacific Family Medicine 2002. Vol 1 pp 67-73

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REFERENCES

Zorayda Leopando, Alex Bienvenido Alip, Thelma Fernandez, Cynthia

Hipol, Irene Maglonzo, Reynaldo Olazo et al (Editors) Textbook of
Family Medicine Principles, Concepts, Practice, Context (Volume 1) 2014
Philippine Academy of Family Physicians and C and E Publishing, Quezon
City
Leopando, Zorayda E. Family Medicine History and Perspective: The Philippine
Experience. Pp 3-12
 Leopando, Zorayda E. and Maria Teresa Rosario Mercado. Integrating Family
Medicine and Community Medicine: Towards Family –Oriented and Community
Oriented Primary Care. Pp 36-44
 Alip, Alex. The Family as a Unit of Care. Pp 58-64 Every Filipino Family deserves a to be listed with a primary care
 Alip, Alex. The Family Life Cycle. Pp 65-70
 Nicodemus Leilani and Martha Jane Pauline Umali. Family Assessment Tools. Pp 76-
physician who can address majority of their undifferentiated health
87 problems when they see them, thereby receiving care which is
 Fernandez, Thelma. Wellness, Health Promotion, and Maintenance: Anticipatory
Guidance in Family Medicine. Pp 163-174. person-centered, comprehensive and continuing.
 Leopando, Zorayda, Aileen Pascual and Jardine Sta Ana. Family Medicine Values
and Professionalism. Pp 557- 565.
Duterte Health Agenda, 2016 .

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FAMILY STRUCTURE AND

FUNCTION LEARNING OBJECTIVES

ANNABELLE PABILONA-TIU, MD
LOURDES CARPENA-MEDALLA, MD
MA. TERESITA S. CHUA, MD
JULIE TANCHANCO-TIU, MD
GLORIA T. PERET-CLARION, MD
At the end of the session, the students should be able to:
1. Discuss family structure, organization and function
2. Identify unique stresses associated with families of varying
composition

JENA ANGELA PERANO, MD 3. Discuss social changes happening to the Filipino families

MACARIO F. REANDELAR, JR., MD

JOSEPH A. JAO, MD

FAMILY FAMILY
• Is a group of persons united by ties
• Is a group of people united by a common desire to exist
of marriage, blood or adoption
together, to meet the needs of its members and the
constituting a single household
family unit as a whole
interacting and inter-communicating
with each other in their respective • Is an intimate domestic group made up of people related
social roles of husband and wife, to one another by bonds of blood, sexual mating or legal
father and mother, son and ties
daughter, brother and sister, • Is the smallest and most basic social unit
creating a common culture
• Is the most important primary group in a society

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CHARACTERISTICS OF THE
FAMILY STRUCTURE FAMILY

• Includes the people who are considered part of the

1. A universal group 5. The primary organization of an
family.
individual
• The present members 2. Based on marriage
6. The most important group in the
• The important figures from the past 3. A source of nomenclature
society
• The quality of relationship among them 4. A group which descent and
7. Based on emotions, sentiments
ancestry can be traced
and economic cooperation
8. Made up of different social roles

BASIC FUNCTION OF THE FAMILY FORMS OF FAMILY

1.Biologic 1.Based on Birth

2.Economic a. Family of Orientation
• The family in which the
3.Education individual is born
4.Psychological/ Affection b. Family of Procreation
• The family where and
5.Sociocultural/ socialization individual sets up after his/her
marriage

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FORMS OF FAMILY FORMS OF FAMILY

3. Based on Residence
2. Based on Marriage a. Patrilocal
b. Matrilocal
a. Monogamous Family
c. Bilocal
b. Polygamous Family
d. Neolocal
a. Polygynous Family e. Avunculocal
b. Polyandrous Family
• Changing Residence

FORMS OF FAMILY FORMS OF FAMILY

4. Based on Ancestry or Descent 5. Based on Authority

a. Patrilineal a. Patriarchal Family
b. Matrilineal b. Matriarchal Family
c. Bilateral c. Equalitarian/ Egalitarian
d. Bilineal Family

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FORMS OF FAMILY FORMS OF FAMILY

7. Based on State or Structure

6. Based on Nature of Relations a. Nuclear Family
a. Conjugal b. Extended Family
• Family system of spouses and their c. Blended/ Step Families
dependent children d. Single Parent Family
b. Consanguineal e. Foster Parent Family
• Made up of members wherein blood relation f. Empty Shell Family
exists g. Communal Family

By Miriam Bobkoff, others - http://www.diggers.org/kaliflower/kf.htm, CC BY-SA 4.0,

https://commons.wikimedia.org/w/index.php?curid=58319606

BASIC TYPES OF FAMILY SYSTEMS ACCORDING TO

FORMS OF FAMILY FUNCTION

8. Based on Naming System

a. Patronymic 1. Open Type of Family
2. Closed Type Family
b. Matronymic
3. Random Type Family

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MARRIAGE MAIN POINTS OF FAMILY INTERACTION

1. Husband-Wife Relationship
• Legal, social or formal union A. Conjugal bond- permanency in marriage and intimacy. It is for
recognized between a man and sexual pleasure and protection. It is for procreation.

woman that unites their lives legally, B. Social pressure- the community expects the husband and wife to
economically, and emotionally with be loving and faithful to each other and to have a lasting and
permanent marriage
intimate, mutual long-term
obligations C. Economic cooperation- the husband is the main breadwinner
while the wife takes care primarily of the domestic needs of the
family

MAIN POINTS OF FAMILY INTERACTION MAIN POINTS OF FAMILY INTERACTION

2. Parent-Child Relationship 3. Children-Parent Relationship
• Very strong filial bond between parents and children
• Love, respect and obey their parents

• Parents and children are also bound together by the need

Parents: for economic cooperation

1. Loving, caring and protective of their children
2. Work hard and even plunge into debt to provide for their children
3. Train and discipline their children early in life with high hopes for
their bright future
4. Aspire to have their children attain a high level of education
Rural areas- division of labor based on age and sex provides
each family member a special work- role
• Sons are trained in farm work so that they may take over
the father’s responsibilities someday
• Daughters help their mother take care of the home

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MAIN POINTS OF FAMILY INTERACTION FUNCTIONS OF PARENTS

4. Siblings Relations
• Mutual love, protection and respect
• Brothers are expected to look after their sisters and protect
them from harm
• Older siblings are given the responsibility to take care of
the younger ones especially when the parents are away
• Younger siblings are in-turn need to obey their elders and
look up to them with respect
“ NO MATTER WHAT HAPPENS IN LIFE OR THE NEXT, I WILL ALWAYS BE HIS
MOTHER.”
PARENTING : IS THE PROCESS OF NURTURING, CARING FOR, SOCIALIZING
AND PREPARING ONE’S CHILDREN FOR THEIR EVENTUAL ADULT ROLES
1. Parents serve many functions that play a crucial role in the society’s endurance
and success at many levels
2. Parents function as caregivers to the children in their families
3. Parents function as agents of socialization for their children

FUNCTIONS OF PARENTS KINSHIP

“PARENTS PROVIDE PRIMARY SOCIALIZATION TO THEIR A network of people who are related by marriage,
CHILDREN. BEGINS AT BIRTH AND MOVE FORWARD UNTIL blood, or social practice or the state of being related
THE BEGINNING OF SCHOOL YEAR” to others culturally learned, not necessarily
determined by biological ties
4. Parents function as teachers
5. Parents function as guardians • Kinship is a means by which societies can
socialize children and transmit culture from one
6. Parents function as mediators generation to the next
• Kinship creates complex social bonds

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KINSHIP IS MADE UP OF: KINSHIP IS MADE UP OF:

1. Consanguineal Relatives 2. Affinal Relatives

• Relatives by blood • Relatives acquired through marriage

• All direct ascendants from great grand parents to all • Union of two consanguineal family
descendants from children to great grandchildren • Balae relationship
• Bilas relationship

KINSHIP IS MADE UP OF: THE FILIPINO FAMILY

3. Spiritual or Ceremonial Kin 1. Closely knit 6. High value on education

2. Bilaterally extended
• Acquired through baptism, confirmation, 3. Strong family orientation
wedding 4. Authority based on age
5. Externally patriarchal and
internally matriarchal
7. Predominantly Catholic
8. Child-centered
9. Average number of children is 3
10. Exposed to different
environmental stresses

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MARITAL INFIDELITY MARITAL INFIDELITY

Adultery Concubinage

• Committed by any woman who shall

have sexual intercourse with a man not • The cohabitation of a man
her husband and by the man who has and a woman without the
carnal knowledge of her knowing her to
be married even if the marriage be
full sanctions of legal
subsequently declared void marriage

MARITAL INFIDELITY MARITAL INFIDELITY

Differences Between Adultery and Concubinage

Bigamy
• Proof of sexual intercourse is enough in adultery
• The act of marrying again while the first marriage is still
• In concubinage, the prosecution must prove that the sexual subsisting
intercourse must be under scandalous circumstances
• It is defined as the contracting of a 2nd or subsequent marriage
• The law seeks to prevent the introduction of spurious heirs into before the former marriage has been legally dissolved, or
the family, which could happen in adultery, not in concubinage before the absent spouse has been declared presumptively
• Penalty: Imprisonment dead by means of a judgement rendered in the proper
proceeding
• Adultery- 2 years to 6 years (both)
• Concubinage: 6 months to 4 years (husband)
• Imprisonment lasting 15 years
• Distierro (mistress)

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MARITAL INFIDELITY THE MODERN FILIPINO FAMILY

Differences Between Bigamy, Adultery and Concubinage 1. Dual Earners

2. Changes in sex norms and
• In adultery/concubinage, the law requires that both are culprits
behaviors
• In bigamy, the second spouse could be charged only if she/he
1. Family ties diminished
had knowledge of the previous undissolved marriage of the
accused 2. Gender Roles
• Bigamy is a public offense and a crime against status, while 3. Fragility of marriage
adultery and concubinage are private offenses and are crimes
against chastity

FILIPINO FAMILY THROUGH THE YEARS

THE MODERN FILIPINO FAMILY

6. Child Rearing Patterns

7. Solo Parenthood 1800 1934 1950’s Late 1970’s

8. Mate Selection “The only rock I know that stays

steady, the only institution I know
that works, is the family”

Lee Iacocca
2008 2018

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OBJECTIVES:

 To define, describe and discuss the

different stages of family life cycle
Family
 To discuss the order of magnitude of
changes Community
 To discuss problems encountered and tasks
at each stage and its relevance to health
Nation
care.

World/Universe

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Individual Family Community

Unattached Healthy initiatives
In utero Newly married Maternal Care
Infancy, toddler, With young children Child Health, EPI
school age School Health

Adolescents With adolescents Adolescent programs

Young adult Launching CCD, NCDC

Middle age
Elderly Later years Programs for Older
people
Death Death

Why do we need to study the

family life cycle ? 1. It provides a predictable,
* It is a very important concept chronologic oriented sequence of
essential in understanding the health events in family life, which the family
and illnesses of patients and their physician and other health
families. professionals are familiar.

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2. It involves a sequence of 3. Events of Family Life Cycle

stressful changes that requires
compensating or reciprocal
readjustment by the family if it is to
maintain viability.
can be related to clinical events
and to health maintenance of
the family

◆ Is a series of stages families go

4. Understanding the stages in the
through as the structure of the
lifecycle of a family can help
family changes.
prepare parents and other family
members for the challenges and
demands each stage brings.

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◆It delineates various developmental

◆ Not every family follows the life stages in the status of families and
cycle in order or description describes the manner in which a family
because each family is unique. is functioning.

◆In each stage, a family projects various ◆The process which are undertaken
identities and roles, the fulfilment of involves transition, extension, and
which would ensure advancement to overlaps.
the next level.

4

The key element in studying the family is
that if they will be able to ADAPT...
 As one family member moves through
the different stages over a period of
time
 As one encounter challenges, learns
and even master new skills.
First Order Changes
- e.g.
A change that is present when a
family moves to a new resident.
3/27/2021
First Order Changes
✓ Involve increments of mastery and
adaptation
✓ A “need to do” something new
✓ Do not involve change in the main
structure of the family
✓ Do not involve a change in an
individuals identity and self-image
Second Order Changes
✓ Involve transformation of an individuals
status and meaning
A “need to be” something new
✓
✓ Change in the role and identity of family
members
✓ Change in the very basic attributes of the
family system.
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First Order Changes Second Order Changes

Second Order Changes

“need to do” “need to be”
Adjustment within the existing New way of seeing things
- e.g. family structure
A change that is present when a family
moves into the stage of the birth of the first child.
Doing more or less of something Shifting gear

Husband becomes the father and wife

becomes the mother of a dependent sibling Reversible Irreversible
New learnings not require Requires new learning

Non Transformational Transformational

NINE-STAGES NINE-STAGES EIGHT-STAGES SIX-STAGES FIVE-STAGES

NINE-STAGES NINE-STAGES EIGHT-STAGES SIX-STAGES CYCLE FIVE-STAGES
CYCLE CYCLE CYCLE CYCLE CYCLE
CYCLE CYCLE CYCLE CYCLE

Stage I: Stage I: Stage 1:

Stage III: Stage III:
Experiences The Young Independence
With pre-school With pre-school
with Family of Unattached children children
Origin Adult
Stage II:
Leaving Home Stage IV: Stage IV:
With School-age With School-age
children children
Stage III:
Pre-marriage
Stage V: Stage V: Stage VI: Stage IV:
Teenage or Family with Early Family with The Family at
Stage I: Stage IV: Stage II: Stage II: Adolescent Adolescent Adolescent Midlife with
Establishment Childless Couple Newly –married Coupling or Adolescent
(Newly-married Couple Marriage
couple)
Stage VI: Stage VI:
Late adolescent Family with Young
Adult
Stage II: Stage V: Stage III: Stage III:
New parents Family with The Family with Presenting Stage VII: Stage VII: Stage VII: Stage V: Stage IV:
(Infant to 3 young Children Young Children babies through Launching Family Launching Family Launching Family The Stage of Launching Adult
Launching with Children
years old ) adolescence

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NINE-STAGES NINE-STAGES EIGHT-STAGES SIX-STAGES FIVE-STAGES

CYCLE CYCLE CYCLE CYCLE CYCLE

 Stage I: The Young Unattached Adult

Stage VIII: Stage VIII: Stage VIII: Stage VI: Family Stage V:
Middle-aged Middle-aged Family in Later in Later Life Retirement or
Parents Parents Years Senior Years  Stage II: Newly –married Couple

Stage IX: Stage IX:  Stage III: The Family with Young Children
Aging Family Aging Family

 Stage IV: The Family at Midlife with

Adolescent
Source:
Duval 1957 Barnhill, Ang & Carter & Lauer & Lauer Various author  Stage V: The Stage of Launching
Longo 1978 McGoldrick 2004
1999 Goldberg
 Stage VI: Family in Later Life
Leopando et al, Textbook of Family Medicine, Vol 1, Principles, Concpts,
Practice , and Context

Emotional SECOND ORDER FIRST ORDER PROBLEMS

Process Of Changes In Family Changes Or Task ENCOUNTERED
- The start of the family life cycle Transition: Status Required To Involved At Each Stage Of
KEY Proceed The Cycles
- Acceptance of emotional and financial PRINCIPLE Developmentally “need to do”
responsibility for oneself “need to be”
- One’s own identity is developed Accepting Differentiation of self in Extend social contact MEDICAL:
- Beliefs and behavior are parts of this identity financial and relation to the family of outside of home 1. Episodic
- Intimate peer relationship are developed and emotional origin (WHAT YOU (dating, clubs and problems
financial independence is learned responsibility for WANT TO BE) recreation) 2. Sexually
- Health issues that need to be addressed , oneself transmitted
proper nutrition, physical fitness and safe sex Development of Job employment Infection
practice intimate peer 3. Unwanted
relationship Living pregnancy
(BOYFRIEND- accommodation 4. Pre-
GIRLFRIEND) employment
check up
Establishment of self in
work

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Emotional SECOND ORDER FIRST ORDER PROBLEMS

Process Of ENCOUNTERED
Transition:

EMOTIONAL: “ The joining of families through marriage”

1. Psychosomatic
problems secondary
to new jobs, role and
peer group
2. Depression
- The transition stage of the couple from
- life away from their lives as individual to life as couple
home
- diff. in finding
employment / life partner
/ parental expectation - Forming its own marital system
SOCIAL:
1. Peer group pressure
on acquiring vices
2. Fiancée pressure for
marriage and
premarital sex

STAGES EMOTIONAL ISSUES STAGE CRITICAL TASKS

Stages of Marriage
STAGES EMOTIONAL ISSUES STAGE CRITICAL TASKS
Stages of Marriage Middle Marriage stage Post-care Review a. Adjusting to mid-life
(10-26 years) changes
Honeymoon Commitment to the a. Differentiation from family b. Renegotiating
stage marriage origin relationship
(0-2 years) b. Making room for spouse with c. Renewing marriage
family and friends commitment
c. Adjusting career demands

Long-term Marriage Farewells and Planning a. Maintaining couple

stage (26+ years) functioning
Early Marriage Maturing of Relationship a. Keeping romance in the b. Closing or adapting
stage (2-10 marriage family home
years) b. Balancing separateness and c. Coping with death of
togetherness spouse
c. Renewing marriage
commitment

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Emotional SECOND ORDER FIRST ORDER Changes PROBLEMS

Process Of Changes In Family Or Task Involved ENCOUNTERED At Emotional SECOND ORDER FIRST ORDER PROBLEMS
Transition: Status Required Each Stage Of The Process Of ENCOUNTERED
KEY To Proceed “need to do” Cycles Transition:
PRINCIPLE Developmentally
5. Establishing a system EMOTIONAL/SOCIAL
“need to be”
of intellectual and 3. Emotional problem
emotional relating to new role
Commitment 1. Formation of 1. Establishing a homebase MEDICAL
communication as a spouse
to new system marital system in a place to call their 1. Episodic problems
6. Establish a workable 4. Problems related to
2. Realignment of own 2. Early pregnancy
relationship with in-laws, friends,
Adjustment relationship with 2. Establishing a mutually 3. STD
relatives peers and money
to living extended families satisfying system of 4. Job related PE
7. Establish ways of
together: and friends to getting and spending 5. Gynecologic
interacting with 5. Demand of new role
include spouse money problem
sex, marital 3. Establishing a mutually 6. Infertility
friends and 6. Problems of
chastity, associates in the adjustment to office
acceptable patter of
money, community or work
who does what and who EMOTIONAL/SOCIAL
lifestyle, 8. Facing the possibility
is accountable to whom 1. Depression due to
of children and
friends, 4. Establish continuity of forced early
planning for their
work, mutually satisfying marriage and
coming
religion sexual relationship unwanted
pregnancy
2. Jealousy to job,
friends and
previous fiancée

Becoming parents : “Defines a new family status“

EMOTIONAL SECOND ORDER FIRST ORDER PROBLEMS
PROCESS OF Changes In Changes Or Task ENCOUNTERED At Each
TRANSITION: Family Status Involved Stage Of The Cycles
KEY
PRINCIPLE
Required To
Proceed
Developmentally
- Defines a new family status
Accepting 1. Accepting 1. Supplying adequate PARENTS:
- Couples role as mother and father as well as husband new marital system space facilities and MEDICAL:
and wife members to make space equipment for the 1. Episodic medical
for children expanding family problems
- Marital satisfaction is likely to be low at this stage into a 2. Meeting predictable 2. Family Planning
system
- The child starts going to school 2. Taking on and unexpected 3. STD
parenting role costs of family life 4. Annual P.E
- Conflict with practices in the home and school • Less with small children 5. OB-GYN problem
regulations may occur couple 3. Realignment of 3. Sharing
time relationship responsibilities EMOTIONAL/SOCIAL
- Realignment of family system to make space for the • Less with extended within the extended 1. Peer pressure on
children, adopting and developing parenting roles personal family to family and between alcoholism and other
freedom include members of the vices
• New roles parenting and growing family (drugs/extramarital
grand 4. Maintaining affairs)
parenting roles mutually 2. Sexual inadequacies
satisfactory sexual 3. Spouse abuse
relationship and 4. Job related problems
planning for the 5. Problems in child rearing
future children

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EMOTIONAL SECOND FIRST ORDER PROBLEMS ENCOUNTERED

SECOND FIRST ORDER PROBLEMS PROCESS OF ORDER

EMOTIONAL ORDER ENCOUNTERED TRANSITION

PROCESS OF :
TRANSITION:

5. Creating and PARENTS:

Develop new Maintaining effective MEDICAL: CHILDREN: GRANDPARENTS :
relationship communication system
to extended in the family. MEDICAL:
EMOTIONAL/SOCIAL
MEDICAL:
family
6. Cultivating the full 1. Episodic medical
potentials of 6. Communication Problems 1. Episodic medical problems
relationship with problems 2. Degenerative
relatives within the 7. In-laws problems 2. Accidents diseases
extended family 3. Mental 3. Chronic debilitating
8. Taking care of the old retardation disease
7. Tapping resources, and sick parents or in-
serving needs and laws
4. Poisoning
EMOTIONAL/SOCIAL
enjoying contacts
outside the family 8. Financial difficulties 1. Psychosomatic
EMOTIONAL/SOCIAL problems related
8. Facing dilemmas to illness and
and reworking 1. Learning loneliness,
philosophies difficulties financial
2. Child abuse and difficulties
neglect

EMOTIONAL SECOND ORDER FIRST ORDER Changes Or Task PROBLEMS

Changes In Family Involved
PROCESS OF Status Required To ENCOUNTERED At Each
TRANSITION: Proceed Stage Of The Cycles
Developmentally

Challenge
ADOLESCENT :
• 1. Shifting of1. Providing
to parental parent- facilities for
authority MEDICAL:
- Requires increase in the flexibility of (negotiatin
child
relationshi
widely different
g) needs
family boundaries to include children's • "Middle-
essence"
p to
permit the 2. Working out • Drugs /
independence and grandparents weakness meets adolescen money matters in substance abuse
adolescenc t to move the family with • STD
e
• Less time
in and out teenagers • Acne, bad odor
with
of the 3. Sharing task of • Gynecologic
system responsibilities of
extended problem
family family living • Menstrual
2. Refocus
4. Putting marriage
on midlife
relationship into
problem
marital • Allergies / skin
and career focus
issues
disease
• Circumcision

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EMOTIONAL SECOND ORDER FIRST ORDER Changes Or Task PROBLEMS Emotional PROBLEMS
CHANGE Involved SECOND ORDER
PROCESS ENCOUNTERED Process of Changes FIRST ORDER ENCOUNTERED
OF Transition Changes

TRANSITION
PARENTS:
• Continued 1. Keeping the ADOLESCENT : MEDICAL:
mid-life 3. Beginning communication system
challenge shift towards open EMOTIONAL/SOCIAL • Common medical
concern for 2. Maintaining contacts
in problems
older with the worlds as a
marriage generation family and as a person • Sexual • Pre-menopausal
relationsh experimentation symptoms
ip and 7. Growing into the world • Homosexuality • Alcoholism/ vices
with as family and as a • OB-GYN problem
person • Conflict with
extended
family 8. Reworking and parents EMOTIONAL/SOCIAL
maintaining a • Juvenile
philosophy in life
delinquency • Middle life crisis
• Depression due to • Male climacteric
peer pressure • Extra marital affair
• Child prostitution • Insecurities
• Suicidal tendencies secondary to
changing appearance

EMOTIONAL SECOND ORDER FIRST ORDER Changes Or PROBLEMS

Changes In Family Task Involved
PROCESS Status Required To ENCOUNTERED At Each
OF Proceed Stage Of The Cycles
Developmentally
TRANSITION

• Renegotia 1. renegotiating 1. Adjustment to PARENTS

ting of marital physiologic Medical:
- Starts when the first child leaves home and couple system as changes of middle • episodic medical
dyad;
ends when the last child leaves home relationsh 2. Development
age; problems,
ip of adult to 2. Discover new • OB-Gyne,
- In the Philippines, this is prolonged • Caring for adult satisfaction with degenerative diseases
own relationship with
because unmarried children usually stay with parents
relationship
with children; spouse; Emotional:
parents • Extra 3. Realign
relationship to
3. Setting • Depression due to
financial comfortable death of spouse and
- Launched children start with their own burdens
include new in
law;
home; sickness
family life cycle. • Breaking
continuity
4. Deal with 4. Help adolescent
children to free
• Psychosomatic
problems due to
disabilities /
of family death of themselves; children leaving home
p0arents. 5. Re-examine living • Loneliness,
Grandparents arrangements • financial adjustment
with parents;

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EMOTIONAL SECOND ORDER FIRST ORDER Changes Or PROBLEMS

Changes In Family Task Involved
PROCESS Status Required To ENCOUNTERED At Each
OF Proceed Stage Of The Cycles
Developmentally
TRANSITION

6. Re-examine CHILDREN
living Medical:
arrangements • episodic medical -Begins with departure of last child and
problems ,
with parents;
• OB gyne problem
continues through retirement of one or both of the
7. Adjust to reality • menopause problem couple and ends when both are dead
of work
situation; Emotional problems - Coping with physiological decline
8. Assure security • Independence and
for later years; dependency problem; - Accepting the shift in generational roles
9. Participate in juvenile delinquency,
community • peer group pressure
on vices,
activities;
• conflict with parents,
10.Reaffirm values • problems in
in life with real adjustment to married
meaning life

FAMILY IN LATER YEARS FAMILY IN LATER YEARS

PROBLEMS PROBLEMS
SECOND ORDER
EMOTIONAL
SECOND ORDER Changes
ENCOUNTERED At Each EMOTIONAL Changes FIRST ORDER Changes ENCOUNTERED
In Family Status Required FIRST ORDER Changes Or
PROCESS OF To Proceed Task Involved Stage Of The Cycles PROCESS OF
Developmentally
TRANSITION: TRANSITION:
KEY KEY PRINCIPLE
PRINCIPLE
PARENTS &
ACCEPTING
THE SHIFTING
Loss of GRANDPARENTS
OF
1. Maintaining own 1. Adjusting to the PARENTS & energy, 3. Making room
GENERATIONA in the system for EMOTIONAL/SOCIAL
L ROLES and or couple physiologic GRANDPARENTS work, the wisdom and 1. Depression due to death
functioning and changes of later identity, experience of of spouse and sickness
interest in the life. MEDICAL:
health, the elderly 2. Psychosomatics
• Loneline face of 2. Re-examining their generation problems due to children
ss physiologic living 1. Episodic medical spouse and
without over- leaving the home
• Children decline, arrangements problem friends functioning 3. Loneliness
exploration of 3. Participating in 2. GYN problem them 4. Financial adjustment
returning new familial and group activities 3. Degenerative diseases
home social options 4. Maintaining 4. Urologic problems 4. Dealing with
• letting 2. Support for more contact with loss of spouse,
go- pain central role for younger siblings, and CHILDREN
of loss middle generations other peers and 1. Episodic medical
(evaluati generation preparation for problem
ng self own death, life 2. OB-Gyne problem
as review and 3. Menopausal problem
parent) integration

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Family Life Rewards

cycle stage
Unattached young Romance , Freedom
adults
Newly Married Couple time , Intimacy/belonging
Couple
Family with young Generativity , Joy in watching child develop ;
children Enriched identity as a family ; Shared responsibility in
the home; Mother's world expands
Family with Joy in watching child develop; Beginning of new kind of
adolescents relationships in family ; Increasing independence and
competence in children
Launching family Friendship with children; Entry of caretakers into new
arenas (career, volunteer) ; More time with spouse,
friends ; Freedom: finances and time ; Children settling in
Family at later Grandchildren , Back to "coupleness" ; Fulfilment in Life
years Decrease in tasks, free time ; New relationship with
widow/ers, friends

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The doctor of the future will give no

medicine, but will interest his patients in
the care of the human frame, in diet, and in
the cause and prevention of disease.
- THOMAS A. EDISON

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Family Dynamics • Motivation that direct all individuals involved

and the adaptive processes and mechanism
they utilize to fulfill the requirements needed
Gloria Peret-Clarion, MD for their proper functioning at the biological,
Macario Reandelar Jr., MD familial and social level of life.
Ronwaldo San Diego, MD
Joseph A. Jao, MD
Marie Ruth Echavez, MD
Angel Erich Sison, MD
Jena Angela Perano, MD Family Psychodynamics

• Nature of family relationship

• Having a particularly soft or strict parents
• Number of children in the family
• Personalities of family members
• An absent parent
• Levels and type of influence from
extended family
• Events which have affected family
members
• Family values, culture and ethnicity
• Dynamics of previous generation
• Broader system: social, economic,
political
• Family Personality
• Functional style of the family
• Each person provides emotional needs on each family
member
• Internal processes that provide a family a unique
personality
• Each family has its own attitude and beliefs, regarding
health, definition of health and how one should react
to it

What Influences Family Functional Family

Dynamics? Relationship

INSTRUMENTAL ROLE AFFECTIVE ROLE

• Recurrent patterns of behavior by which individuals
• Concerned with the • To provide emotional
fulfill family functions and needs
provision of physical support and
• Individual members of family occupy certain roles resources(food, encouragement to
such as child, sibling, grand child shelter, and clothing), family members
• A person’s role is always expanding or changing, decision making and
depending upon his age or family stage family management

Family Roles TYPES OF FAMILY ROLES

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Role Allocation
• Assignment of
responsibilities within a
family that enables the
family to function properly
• Make decisions on who will
be responsible for
completing a certain task or
fulfilling a particular
responsibility
Family
Accountability
• Refer to a family members
sense of responsibility for
completing the tasks of an
assigned role
• e.g. Parents in healthy families
understand that they are
responsible for disciplining their
children. When discipline is
needed they do not hesitate

Family Roles Family Roles

1. Provision of Resources 4. Maintenance and Management of the Family

System
• Money, food, clothing, shelter

• Leadership, decision making, handling family finances,

2. Nurturance and Support maintaining appropriate roles with respect to extended
family, friends and neighbors
• Providing comfort, warmth and reassurance for family • Maintaining discipline and enforcing behavioral
members standards

3. Life Skills Development

5. Sexual Gratification of Marital Partners
• Physical, emotional, educational and social development of
children and adults • Meeting sexual needs in a manner that is satisfying to
both partners

5 Essential Roles for Effective Family Functioning 5 Essential Roles for Effective Family Functioning

• Parental practices will be restrictive

• No single interpersonal relationship in a family
exists in isolation from other relationships within the
family.
• The more individual within the family system, the
more complex will be the interactional pattern, and
the greater opportunity for conflict.
• Parents will be authoritative
• Corporal punishment will be used
• One parent is dominant
• The father is the dominant parent
• Stress will characterize the role playing of parents
CONVERSELY, IT IS LESS LIKELY THAT:
• Children will exhibit a positive affect toward their parents
• Spouses will show positive affect toward each other

8 CONCEPTS RELATING TO THE IMPACT OF

FAMILY SIZE ON ROLES AND RELATIONSHIPS
Interpersonal Dynamics (Lye, Carlson and Garrett 1970)

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• Some families have a distinct style and

pattern of interaction which remain constant.

• THUS, it appears that the larger the

family, the less likely it is that affection
will be shown and perceived among
family members.
• Some of the pattern or style that can be
observed are:
• Who talks after whom within the family.
• Style of interacting and managing stress.
• Method of coping with problems.

Impact of Family Size on

Roles and Relationship Family Patterns

• Formed wherein 2 or more family members

• Created for the purpose
exclude the rest of the family.
of defending against
• Most subgroup consists of 2 individuals who
others.
pair up to form an entity called DYAD.
• Seriously disrupt a
• Purpose: maintaining discipline. family’s functional
• Alliance could be temporary or permanent. adaptive capacity.
• Disruptive and distorts
the normal balance of
family relationship.

Family Subsystem Permanent Alliance

• Family remains the central refuge where all its • Alcoholism

members feel secure and relax. • Drug abuse
• Financial difficulty
• Serves as a source of security in the midst of a fast • Serious illness
moving, stressful, and chaotic world. • Mental problem
• An essential feature of raising children to become • Marital discord
secure individuals. • Frequent absence of
• Family is the first level of support for individual father
family members in the attempt to cope with the
• A secure and supportive family gives comfort and
stresses of daily living. strength to its members in times of stress.

STRESSFUL FACTORS THAT

Family Stability WEAKEN FAMILY STABILITY

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• The capacity to maintain effective functioning under constantly

changing condition.

• A state of family homeostasis in which member interaction results in • Approach problem in a unified manner as a family.
emotional and physical nurturing, thus promoting growth of family
members and the family unit.
• Have a non-materialistic orientation.
FAMILY HOMEOSTASIS:
• Husband and wife frequently share tasks.
• Ability to maintain a constant state in the midst of a continuous interplay of
internal and external forces. • Perceive the nature of the problem accurately.
DISTURBED BY: • Have a democratic orientation, with diffusion of
- Sudden socio-cultural change leadership regarding problem solving tasks.
- immigration from one culture to another
- unexpected alteration in position on the social ladder
- Role change

CHARACTERISTICS OF FAMILIES BEST ABLE

TO WITHSTAND STRESS AND MAINTAIN
Equilibrium HOMEOSTASIS:

LOVE
• Provides an atmosphere of warmth, acceptance and support.

DISCIPLINE • Refers to adjustment by the family to

• Provides guidelines for acceptable activity as well as the ability to save
and prepare for future needs. stressors within and outside the family.
TOLERANCE
• Allows for individual freedom and development.
Example:
ADAPTABILITY
• Makes it possible to adjust and respond to sudden or relatively
unexpected changes. • Changes resulting from the illness of one of its
FREE COMMUNICATION members
• Contributes to the consistency of open and honest relationships
among members.

STABLE FAMILIES Coping

5 BASIC CHARACTERISTICS:
• An attitude of service – looking out for each other
• Clear separation of generation.
• Secure relationship between parents (or other
• Flexibility of family roles. guardian/authority figure)
• Effective and constant communication. • Parents teach and train – encourage each family
member to grow & develop as an individuals
• Tolerance for individuality.
• Attitude of honor: parents lead with love, children respect
and obey
• Have shared experiences/activities on a regular basis

CHARACTERISTICS OF FAMILY WHO • (from “Five Signs of a Functional family” by Gary Chapman)

MAKE SUCCESSFUL ADJUSTMENTS TO

SERIOUS ILLNESS: THE HEALTHY/SUPPORTIVE FAMILY

4

• The foundation of a well functioning family is a
balance of love and respect base on a shared set of
values/beliefs
• Rules, roles, and relationships work together to
meet the goals/purpose of the family
• A healthy family will more easily weather the
storms of life
• Family members accustomed to helping each other,
self sacrifice
• Open to share feelings and fears without being
threatened
• Easier time adjusting to new roles
• More likely to plan ahead and be prepared
THE HEALTHY/SUPPORTIVE FAMILY
DYSFUNCTIONAL
FAMILY
• Family Rules may be either too restrictive, too
loose, or not exist at all. Rules are harmful, not
helpful.
• Family Relationships are hurtful and bring each
other down. They may be too close (enmeshed, co-
dependent), too distant (cut-off, aloof), or
inappropriate (i.e. Child who has to take
responsibility due to depressed parent).
• Family Roles no longer exist for the “greater good”,
but to help each individual family member cope.
DYSFUNCTIONAL FAMILY
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• Each person tends to select a spouse most likely to provide
gratification and best satisfy his needs
• Harmony and stability within the family system are maintained
if the spouses’ personalities, goals, and expectations are
complimentary
• Relationships needs to be flexible and adjustable over time
• When complimentary function fails, anxiety, conflict, and
hostility result; equilibrium is disrupted and dysfunction occurs
COMPLIMENTARY NEEDS OF
THE FAMILY:
• The essence of a dysfunctional family is that the
parents are unable to meet the emotional needs of their
children. (Core Needs: Purpose, love/acceptance, value)
• Emotional problems and difficulties as adults can be
the result of individuals being raised in dysfunctional
families.
• A dysfunctional family is an unhealthy place where
family members adopt destructive behaviors in order to
cope with pain, suffering, fear and loneliness.
• Sometimes family members experience verbal,
emotional, physical, &/or sexual abuse.
• Maybe characterized by negative unwritten rules: “Don’t
Talk, Don’t Trust, Don’t Feel.”
• Troubles will be magnified in times of stress
DYSFUNCTIONAL FAMILY
THE ENABLER
• Has distorted thinking
and believes that they
are basically
responsible for the
other person’s
dysfunction.
DYSFUNCTIONAL FAMILY
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THE SCAPEGOAT THE HERO THE MASCOT

• Tends to blame others,
makes strong peer
alliances, and is often
disciplined by teachers or
other adults for breaking
rules.
• Always volunteering, very • Tends to be funny or
responsible and distracting and gets attention
manifests a drive, almost frequently. This student likes
a compulsion, to be on to hide, make faces, pull the
top. chair from someone else,
otherwise act out.

ROLES THAT CHILDREN IN ROLES THAT CHILDREN IN

DYSFUNCTIONAL FAMILIES DEVELOP DYSFUNCTIONAL FAMILIES DEVELOP

MARITAL CONFLICTS
• A result of disordered family dynamics.
THE LOST CHILD
• Child feels caught in the middle and forced to take
• Often gets lost in the shuffle. sides with one parent against the other
Adults sometimes can’t
remember the student’s name
because he/she is so quiet and
is seldom a behavior problem.

ROLES THAT CHILDREN IN

DYSFUNCTIONAL FAMILIES DEVELOP DYSFUNCTIONAL FAMILY

• Means the assigning of blame to a person or things for fault of

others
• The object of scapegoating is to draw off tension that cannot
be resolved in the usual manner and assign it to another
• Frequently occurs in a strict authoritarian family
• One in which the wife is dependent and
infantile and in which the husband’s self
esteem and fragile maturity depend on
keeping her that way

• Possible RESULTS in a child:

• School phobias,
• The husband’s ego strength and borderline
• Behavior problems, maturity rely upon the continuation of this
• Poor school performance.
relationship

SCAPEGOATING DOLL’S HOUSE FAMILY

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• The spouses are not merely unhappy but are openly hostile to
one another, often competing for loyalty of the children
• The mother in a schizophrenic family is typically described as
domineering, over protective and manipulative of both father
and child
• The father is usually weak, passive, and elusive, having little
interaction with the child
• Parental coalition is absent
• Parents are in chronic conflict
• Family members rarely make affirmative statements
• Comes from disordered family relationships
• Families of delinquent children lack a warm,
affectionate relationship between parents and
children
• Common among boys who have lost their father or
passed through an important formative years (ages
4 to 8) without a father figure present or with one
present who serves inadequately in the paternal
role.

SCHIZOPHRENIC FAMILY DELINQUENCY

• Children reared in emotionally nurturing

environments do well.

• Deprived of a supportive environment and raised

where care is impersonal and inadequate often
shows developmental difficulty, and high
susceptibility to diseases and can also affect the
child’s IQ.

EMOTIONAL DEPRIVATION EMOTIONAL DEPRIVATION

• More from large families

• A relationship has been shown between
incontinence in children and the strength of
maternal relationship during the early formative
years.
• Bedwetting is greatest if total disruption of the
family occurs through either divorce or
dissertion.
• Half of the family have either serious physical or
psychological illness.
• 1/3 from divorced, separated, or single parent
family.
• Dysfunctional home relationships were the most
common factors placing these children at high risk.
• Major cause of death in children over 1 y/o in
developed countries.

ENURESIS ACCIDENTAL INJURIES

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THERE ARE 5 MAJOR FORMS OF FAMILY

DISORGANIZATION

1. Uncompleted Family Unit

2. Willed Family Dissolution
3. Empty Shell Family
4. Externally Caused Crisis

TROUBLED FAMILY
5. Internal Catastrophe

TROUBLED FAMILY

Illegitimacy

• Potential mother and father fail to assume the role

obligations of marriage and parenthood.
Annulment,
• The out of wedlock pregnancy implies failure of the parents
of the families of orientation. Separation,
FOUR possible solution to illegitimacy: Divorce,
• Chastity PROHIBITS Dissertion
• Birth control PREVENTS
• Abortion DISRUPTS
• Coerced marriage PROVIDES Legitimacy

1. UNCOMPLETED FAMILY UNIT 2. WILLED FAMILY DISSOLUTION

• Unwilled absence of a
family member.
• Individuals may live together with minimal • Maybe lost to death,
contact and communication and fail to incarceration, or war.
provide for the basic personal and social • Loss of family member
needs of the family member. means that the
relationship between
• Families of professional and managerial remaining members
have to be rewoven to
men seem prone to this type of existence compensate for the lost
individual.

3, EMPTY SHELL FAMILY 4. EXTERNALLY CAUSED CRISIS

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• Unwilled major family failures.

• Severe mental, emotional, and
physiological disorders result in
role failures.
• While the individual is present, he
is unable to meet obligations
because of his disabilities.
• Acute episodes call for mobilization
of family resources to meet the
needs of the afflicted individuals.

FAMILY CRISIS
• Chronic disabilities present a
different problem- chronically ill
person must reshape his personal
and social needs so that they are
consistent with his capabilities.

5. INTERNAL CATASTROPHE

• Many crisis are major family disruption • Any event, past or present that changes the
which results from repeated subtle lifestyle or presents a significant strain upon
stresses that have been inadequately family organization.
managed and have weakened family
dynamics until they ultimately CATEGORIES:
culminate in a major threat to family • 1. Normative
stability. • 2. Non-normative

FAMILY CRISIS CRISIS

• LIFE events that are part of the planned,

• Due to unexpected or adverse life experiences
expected or normal process of family life.
that have greater impact on family function.

• Examples:
• Example:
• Birth, marriage, moving to a new community
• Infidelity, unplanned pregnancy, sudden fame

NORMATIVE NON-NORMATIVE

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ADDITION
EXTERNAL NON- INTERNAL NON-
NORMATIVE • A crisis identified with short and long
NORMATIVE term addition of one or more to the
• Manmade and • As in marital family structure.
infidelity, criminal • Example:
natural disasters • Adoption, birth, marriage, unplanned
activity pregnancy
• Usually leads to
transient dysfunction • May lead to ABANDONMENT
extended period of
• Rapid pooling of
dysfunction • Associated with the threat of loss or
resources actual departure of a family member
• Example:
• Planned departure, separation, death,
stow away

NON-NORMATIVE HILL’S TAXONOMY OF CRISIS

DEMORALIZATION 1. Assessing history of coping with problem

and stresses
• A crisis that occurs when a family • Coping and boiling point affected by unique factors
member initiated a change in a and external factors.
previously ordained family moral code

• School suspension, alcoholism,

• Family psychosocial history.
drug abuse, delinquency, infidelity • Quality of life.
• Stressors number and intensity.
STATUS CHANGE
2. Determine stage of family development
• Crisis involving gain or loss of wealth,
power, or position in the family or extra • Timeliness of illness or problems.
familial society • Anticipatory guidance.
• Loss of income, sudden fame,
expulsion, loss of freedom

HILL’S TAXONOMY OF CRISIS EVALUATING FAMILY CRISIS

1. Family stability returns to normal level.

3. Role of patient in the family
4. Monitoring role disruption.
• Assess and monitor effect.
• Identify gaps in family roles.
• Explore options for filling gaps.
2. Family improved after resolution.
3. Family stability suffers and never returns to its
former level.
• In order to obtain a good response pattern, an
essential feature in the family response is to have
adequate resources.
• Different families respond to the challenge of a
stressful life event in different ways.

FAMILY RESPONSES TO
EVALUATING FAMILY CRISIS STRESSFUL LIFE EVENTS:

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Family in functional equilibrium Stressful Life

(Functional or nurturing) event
Adaptation
• Developed as a (coping)

conceptual framework for

Resources
presenting an empirical adequate
view of the response that Intrafamilial Family in
disequilibrium
Resources
may result when a family
Resources
experience a stressful life inadequate Extra-
event. familial
Crisis resources

Maladaptation

Pathologic defense

THE CYCLE OF FAMILY FUNCTION

mechanism
Stressful
Terminal
disequilibrium Pathologic disequilibrium life event

EQUILIBRIUM STRESSFUL LIFE EVENT

State of family homeostasis
in which member • Life experience that
interaction results in requires the use of
emotional and physical
nurturing, thus promoting family resources for
growth of family members coping or adapting not
and the family unit.
usually required for
• The capacity to maintain
effective functioning under management of daily
constantly changing activities.
condition.
• FAMILY HOMEOSTASIS:
• Ability to maintain a
constant state in the midst
of a continuous interplay of
internal and external forces.

THE CYCLE OF FAMILY FUNCTION THE CYCLE OF FAMILY FUNCTION

DISEQUILIBRIUM RESOURCES
• State of impaired • Assets that serve to
functioning that occurs nurture an individual
when an individuals and those that supply
resources are the means for solving
stressor-induced
inadequate or problems.
unavailable to meet an • Familial, extra-familial,
intense stressor or an social, cultural,
accumulation of religious, economic,
stressor. environmental, and
medical support
systems.

THE CYCLE OF FAMILY FUNCTION THE CYCLE OF FAMILY FUNCTION

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COPING CRISIS
• Refers to adjustment Example: • State of family
by the family to disequilibrium that
stressors within and • Changes resulting results from the failure
outside the family. of an individual to
from the illness of
identify or use
one of its members resources to resolve a
stressor induced
problem.

THE CYCLE OF FAMILY FUNCTION THE CYCLE OF FAMILY FUNCTION

PATHOLOGIC TERMINAL
MALADAPTATION DISEQUILIBRIUM DISEQUILIBRIUM
• The use of pathologic ▪ State of impaired ▪ Family function is
defense mechanisms interaction or nurturing continuously
to escape from an within the family that deteriorating because
unresolved crisis, follows the use of of failure to resolve a
resulting in a state of crisis, may eventually
impaired emotional, abnormal defense lead to family
and social functioning. mechanisms to escape dissolution.
from anxiety of
unresolved family
crisis.

THE CYCLE OF FAMILY FUNCTION THE CYCLE OF FAMILY FUNCTION

• Ways to behave or think to protect or “defend”

ourselves from anxieties.
• How we distance ourselves from a full awareness of
unpleasant thoughts, feelings, and behaviors.
• While all defense mechanisms can be unhealthy,
they can also be adaptive and allow us to function
normally.

DEFENSE
• The greatest problems arise when defense
mechanisms are overused.

MECHANISMS Defense Mechanisms

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DENIAL DISPLACEMENT
◼ Seeing but refusing ◼ Involves purposeful,
to acknowledge unconscious shifting
what one sees and from one object to
hearing but another the interest of
negating what is solving a conflict.
actually heard

Defense Mechanisms Defense Mechanisms

IDENTIFICATION INTROJECTION
◼ Actually plays a crucial ◼ Differs from
role in ego identification in the fact
development, but can that this involves
be used as a defense internalization of the
mechanism when a characteristics of
person unconsciously another person or
incorporates the object, creating a
characteristics and radical shift or
qualities of another alteration in the
person or object into person.
his ego system.

Defense Mechanisms Defense Mechanisms

RATIONALIZATION REGRESSION
▪ Individual provides a ◼ Individual retreats to
plausible but an earlier
inaccurate justification developmental stage
for his or her failures. that was more secure
and pleasant and/or
▪ Attributes the use of less mature
achievements to their response in attempting
own qualities and to cope with stress.
skills;
▪ Failures are blamed on
other people or outside
forces

Defense Mechanisms Defense Mechanisms

13

REPRESSION
◼ Consist of expelling
and withholding from
conscious awareness
of an idea or feeling.
Defense Mechanisms
INTELLECTUALIZATION
• Taking an objective
viewpoint.
• Reduces anxiety by
thinking about
events in a cold
clinical way.
Defense Mechanisms
SOMATIZATION
• The defensive conversion of
psychic derivative of bodily
symptoms, tendency to react
with somatic rather than
psychic manifestations.
• Is among the most common
problems seen by physician.
• An expedient defense
mechanism because it places
individual in the sick role.
• The physical symptoms
usually are associated with:
• An existing health problem;
• Past personal or family
experience with illness;
• Previous family experience with
physical disability.
Defense Mechanisms
3/27/2021
TRANSFERENCE
▪ The redirection of
feelings and desires
and especially of those
unconsciously retained
from childhood toward
a new object.
▪ The inappropriate
repetition in the present
of a relationship that
was important in a
person's childhood.
Defense Mechanisms
PROJECTION
▪ Perceiving and reacting
to an unacceptable inner
impulse and their
derivatives as though
they were outside the
self.
▪ In the family, a child with
a health problem usually
may become the
identified patient onto
whom the unresolved
family problems are
transferred.
Defense Mechanisms
ACTING OUT REACTION FORMATION
▪ Performing an extreme ▪ Reduces anxiety by
behavior in order to
converting dangerous
express thoughts or thoughts, feelings,
feelings the person feels
behavior or impulses
incapable of otherwise
expressing. into their opposite
feelings, impulses or
▪ Acts as a pressure
release behavior.
▪ Often helps the individual
feel calmer and peaceful
once again.
Defense Mechanisms
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• Often most
constructive and
helpful to most adults,
but may require
practice and effort to
put to daily use
• More focus on helping
a person be a more
constructive
component of their
environment
SUBLIMATION
• “People with more • Redirecting or
acting out
mature defenses tend to unacceptable
be more at peace with impulses or “wrong”
themselves and those urges into socially
around them.” acceptable actions.
• Sign of maturity.
• Example: A person
experiencing extreme
anger may take up
boxing/kickboxing as a
means of venting out
frustration.

Mature Defense Mechanisms Mature Defense Mechanisms

SUPPRESSION COMPENSATION ALTRUISM

▪ Process of ▪ Satisfying internal
◼Consciously counterbalancing needs through helping
forcing the others
perceived weakness by
unwanted
information out of emphasizing strength in
conscious other areas
awareness

Mature Defense Mechanisms Mature Defense Mechanisms

• Reference:
• Zorayda Leopando, Alex Bienvenido Alip, Thelma
Fernandez, Cynthia Hipol, Irene Maglonzo,
Reynaldo Olazo et al (Editors) Textbook of Family
Medicine Principles, Concepts, Practice, Context • Time: An Impatient Young Mother Learns to Treasure
(Volume 1) 2014 Philippine Academy of Family Time with her Son//Viddsee.com
Physicians and C and E Publishing, Quezon City
• PRINCIPLES OF FAMILY PRACTICE by Robert E.
Rakel, M.D.
• Graham Bresik. Family Oriented Primary Care.
Handbook of Family Medicine. Edited by Bob
Mash. Oxford University Press. South Africa,
2006. www.psychologistworld.com
• https://en.m.wikipedia.org

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THANK YOU FOR LISTENING!!!

16
 5/12/2021

Tools for
Family Assessment
Arnel V. Herrera, MD
Ronwaldo San Diego, MD
Macario Reandelar Jr., MD
Jena Angela Perano, MD
Zorayda E. Leopando, MD
Ma. Teresita Chua, MD
Marie Ruth Echavez, MD
Desmond Tutu

Objectives:
At the end of the lecture the student should
be able to:
 discuss family system approach in clinical
practice
 enumerate the various tools for family
assessment and their indications/uses
 describe how each tool is made, and FAMILY SYSTEM APPROACH
analyzed
 demonstrate how tools are applied
IN CLINICAL PRACTICE

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Incorporating a Family Systems The five basic functions of family are:

Approach Into Clinical Practice
Steps
1. Families provide support to each other.
1. Recognize • Names of the individual family member
family structure • Place of residence 2. Families establish autonomy and independence for each
• Specific roles in the family person in the system, which enhance personal growth of
• Stage family life cycle individuals within the family.
• Significant dates in the family
3. Families create rules that governs conduct within the
2.Understanding • Families provide support to each other.
normal family • Families establish autonomy and independence family.
function for each person in the system 4. Families adapt to changes in the environment:
• Families create rules that governs conduct First order change - adaptation to environment.
within the family
• Families adapt to changes in the environment Second order change - fundamental changes in Family
• Families communicate with each other. structure
3. Learn To • Meet the family as a unit 5. Families communicate with each other.
Assess Family • Transfer clinical information from doctor to
Structure and family members
Function in • Should be able to listen more and talk less
Clinical Practice

Checklist To Assess Family Function Checklist To Assess Family Function, 2

 How are the major decisions made in the family

 How many are there in the family?
and by whom?
 Who lives at home?
 Are the in-laws and relatives helpful? Do they create
 In what phase of family life cycle is the family? problems for the family?
 What problems does this phase raise for them?  Do the family members have many friends in the
 What major problems has the family had in the past? neighborhood? To what groups or clubs do family
 Does the family feel these problems were dealt with members belong?
satisfactorily?
 Is there any history of alcoholism, drug abuse or
dependency?

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Checklist To Assess Family Function, 3

 What community resources has the family used? Would

the members use them again?
 Has this family not used community resources at times
when they would have been appropriate?
 What do the children expect of each parent? Are these
expectations realistic?

TOOLS FOR FAMILY

ASSESSMENT, HOW IT IS
MADE AND ANALYZED

Family Assessment Instruments

FAMILY ASSESEMENT TOOLS
1.Family Genogram
 Designed for family physicians to have a
2.Family APGAR by Smilkstein
systematic way of understanding the family
3. Family Circle
 Aid physicians in evaluating the impact of illness
4. Draw a Family Test (DRAFT)
on a person and his/her role in the family
5. ECO-MAP
6. SCREEM
7. Clinical Biographyand Life Events
8. FACES (Family Adaptability and
Cohesion Evaluation Scale)
9. FES by Moos (Family Environmental Scale)

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Five basic functions performed by all families

The Family Genogram
 Families provide support to each other Recognizes the family structure
 Families establish autonomy and independence for each
person in the system which enhance personal growth of Family Tree Family names; Three or more
individuals within the family generations; Names and age of
all members sequentially from
 Families create rules that govern the conduct of the
left to right; significant dates;
family and the individuals within the family
 Families adapt to changes in the environment Family Illnesses;
 Families communicate with each other background on causes of deaths,
health health risk behavior
Note: A dysfunctional family is a family with chronic Social and Members living together;
inability to respond to the needs of the members or to cope interactional possible source of stress;
with changes and stresses in the environment influences relationship

I. FAMILY TREE
II. FUNCTIONAL CHART
- - Must consist of 3 or more generations, each generation
 Gives more dynamic image of the family especially of the
is identified by Roman numerals
relationship of members.
-The family name is placed above each major family unit
 Allows one to judge the totality of the unit, its strengths,
- - First born of each generation is farthest to the left, weaknesses and its ability to withstand the future
with the siblings following to the right in the order of stressful situations.
birth
- Given names and ages are placed below each symbol.
- One member of the family with greater medical
significance is known as the INDEX PATIENT and is
identified with an arrow (↗️).
- Members of the family of the Index Patient living in the
house will be enclosed in a circle
- Finally indicate the date when the chart was developed.

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Genogram symbols
III. FAMILY ILLNESS/HISTORY

 Denotes the presence of inherited diseases or familial

tendencies indicating potential problems in the family

Genogram Cruzada Montereal

Cerrera – Sonio Family
August 18, 2017 MC SC
RM EM
I 75

CERRERA SONIO
I
II MJrC SC
LC VC 48 44
VM LM

II A
PTB HPN

BIENVENIDO CRISTINA 71
73 III LEGEND
Asthma MC 3, RC, MC, KC,
Heart disease 21 19 17 15

Adopted
A Dead
Strong bond
III RICARDO 49 MOISES 44 ERLINDA JOY 20 Smoking
35 Legend Obese Living together
Asthma Informant: SC
Date prepared
Sept 15, 2017

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Family Genogram: Uses FAMILY APGAR Part 1

❑ Quick overview on the family members and relationship ADAPTATION

❑ A way to visually overlay biomedical and psychosocial
information
❑ A study tool for gaining a comprehensive understanding
of multigenerational family systems
Note:
Excellent tool to use in learning about the family structure
BUT has a limited role in assessing family function.
 How resources are utilized and shared
 The degree to which a member is satisfied with the
assistance received when family resources are needed
PARTNERSHIP
 How decisions are shared
 This measures the satisfaction attained in solving
problems by communicating

FAMILY APGAR Part 1 FAMILY APGAR Part 1

GROWTH RESOLVE
 How nurturing is shared  How time, space and money are shared
 The member’s satisfaction with the freedom available  How the member’s satisfaction with the time
within the family to change roles and attain physical and commitment that has been made to the family by its
emotional growth or maturation members is achieved

AFFECTION
 How emotional experiences are shared
 The member’s satisfaction with the intimacy and
emotional interaction the exists in a family

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FAMILY APGAR PART 1

Palagi Minsan Bihira or hindi
I am satisfied….. Almost Some of Hardly (almost (some of (hardly ever)
always the time ever always) the time) 0
2 1 0 2 1

A that I can turn to my family for help when

something is troubling me

P with the way my family talks on things

with me & shares problems with me

G that my family accepts & supports my

wishes to take on new activities or
directions

A with the way my family expresses

affection and responds to my emotion
such as anger, sorrow & love

R with the way my family and I share time

together

APGAR SCORING FAMILY APGAR PART 2

Scoring: Delineates relationship with other family members.
Almost always (Palagi) 2 X __= Also it identifies persons who can give assistance to the
Some of the time (Paminsan-minsan) 1 X __ = patient.
Hardly ever (Halos Hindi) 0
Total score: And lastly, it indicates conflict not revealed in Part I.

A total score of
8-10 = highly functional family
4-7 = moderately functional family
0-3 = severely dysfunctional

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FAMILY APGAR PART 2

Who lives in your home? How well do you

If you do not stay with your family get along?
list the person / persons to whom
you turn to for help

Relationship Age Gender Well Fairly Poor

Family APGAR : Indications

❑ The family will be directly involved in caring for patient

❑ Treating a new patient
❑ Treating a patient whose family is in crisis
❑ A patient’s behavior makes you suspect a psychosocial
problem due to family dysfunction

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Brother
Family Circle
Nanny ME
 A big circle is drawn
 The patient is asked to draw smaller circles within the
big circle or outside. Mother
Each circle represents significant people in his/her life.
Distance and size vary according to degree of closeness Sister
and significance to the patient
Father
 Assessment is through interpretation by the one who
draws
 There are no right or wrong answers

Draw a Family Test: (D.R.A.F.T.) Community

Based Family Assessment Tools DRAFT
• DRAFT is a projective technique that can be
administered individually or in-group test

• It does not only provide clues on individual family

members with regard to their personalities but also
serves as a diagnostic device.

9

USEFULNESS OF D.R.A.F.T.
 Patients exhibiting evasiveness and guardedness are more
likely to reveal their underlying traits and psychodynamics
because subjects are more intellectually aware of what
they might expose through verbal communications.
 Drawing can be an expression of the unconscious label
that represents an adulterated basic needs.
 Drawings are first to show incipient psychopathology and
the last to loose signs of illness after patient recovers
The family within a larger system - Ecomap
Graham Bresick, 2006
5/12/2021
Projective drawing like DRAFT has been found to be useful
and revealing because of the following reasons:
- Patients who exhibit evasiveness and guardedness seem
more likely to reveal their underlying traits
- Psychodynamics is more revealed in the drawing
because through verbal communications subjects are
more intellectually aware of what they might expose.
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Family mapping

// Dysfunctional or conflict
Functional
Enmeshed or overinvolvement

Clear boundaries
Rigid boundaries

Diffuse boundaries

Family mapping Use of Family mapping

Lola Minda ❑ Reflects relationships and interaction

Mandy Shirley ❑ Provides schematic description whom to ask for

assistance in making decision for patient
Bianca
❑ Identifies possible source of somatic complaints
Nini
JR

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SCREEM SCREEM
 SCREEM acronym for
RESOURCES PATHOLOGY
Social
SOCIAL + communication, social Social Isolation
Cultural interactions
Religious CULTURAL Pride in ethnicity Feels cultural/ ethnic
Economic inferiority
RELIGIOUS Satisfying spiritual Rigid rituals
Educational experience
Medical ECONOMIC Stable financial status Financial Problems
 Helps families assess their resources to meet a crisis.
Lack of resources can cause pathology. EDUCATIONAL Adequate comprehension Handicapped

MEDICAL Available health care Not utilizing health

care facilities

Uses of SCREEM Family Lifeline

 To assess the family as to its capacity to participate in
provision of health care or to cope with crisis.
 Used when there is a need for long term care
 Used to assess resources of difficult and non-compliant
patients
 Summarizes the history of the family, significant
experiences chronologically sequenced and how family
copes with the stresses
 Arranges clinical events in the life of a patient or a
family chronologically with life events arranged parallel
to clinical events

12

Family Lifeline
 Assessment- detects any relationship between the
clinical and life events and its effect on health seeking
behavior
i.e. Attacks of headache would occur whenever Shirley
would hear her parents quarrel and became severe when
they separated
FACES
 One modality of conceptualizing the family is using the
cohesion, flexibility and communication constructs,
proposed by Olson as the Family Adaptability and
Cohesion Evaluation Scale (FACES)
5/12/2021
Family Lifeline: CLINICAL BIOGRAPHY and LIFE CHART
FACES
 FACES is useful for clinical evaluation, treatment, as well
as to evaluate the efficacy of marital and family
therapeutic intervention (Olson, 1993; Olson, 1996)
 It is comprised of 30 items, 16 of which evaluate
cohesion, and 14 of which evaluate adaptability (Olson
1993; Olson 1991; Ravi & Shirali, 1992; Rodick &
Henggeler, 1986)
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FES (Family Environment Scale) FES (Family Environment Scale)

 The Family Environment Scale (FES) gives counselors
and researchers a way of examining each family
member’s perceptions of the family in three ways—as it
is (real), as it would be in a perfect situation (ideal) and
as it will probably be in new situations (expected).
 90 item questionnaire developed by Bernice S. Moos &
Rudolf H. Moos
 The FES is made up of ten subscales measuring three
underlying dimensions of the family environment:
• Family Relationship
• Personal Growth
• System Maintenance and Change

FES (Family Environment Scale) FES (Family Environment Scale)

 The FES has been widely used in clinical settings, to  A choice of three forms to allow you to measure the
facilitate family counseling and psychotherapy, to teach family environment in three ways: Real (Form R), Ideal
clinicians and program evaluators about family systems, (Form I) and Expected (Form E).
and in program evaluation.
 It can be used for individual and family counseling, or
for research and program evaluation.

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Family assessment tools: indication for use:

TOOLS FOR FAMILY

ASSESSMENT AND ITS
INDICATIONS /USES

Thank you …….

APPLICATION OF TOOLS FOR

FAMILY ASSESSMENT

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According to a 38 year-old male patient “I’ve come for

a test doc.”
Normally Aim fit and well and works in an office.
But since coming back from Thailand my diarrhea
never stopped usually 2-3 bout per day, watery to
semi formed, no blood, no weight loss, no vomiting.
Usually I eat and drink well.
Sometimes I feel a bit tired, but I don't sweat. I had a
rash and sore throat few days ago, but rash now
improved.

PHx:
No medical problems. No regular medications.
Allergies: Penicillin - anaphylaxis

Sexual history:
1 contact in Thailand, female, vaginal no condom.
No other sexual partners for 2 years.

P/SHx
Non smoker. Alcohol at weekends with friends 10 units
Travel history - Thailand on 2 week holiday. Has taken malaria
prophylaxsis.
Was careful about what he was eating and drinking there.

PHYSICAL EXAMINATION:
BP 110/68 RR 18 CR 88 T 36.9 BMI 20
Truncal rash and generalised lymphadenopathy

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IMPACT OF ILLNESS
▪ Training in medical school should focus on treatment of
disease problems and management of illness
problems.

IMPACT OF ILLNESS ▪ Medical care should result in treatment of disease,

which is technologically brilliant as well as adequate
treatment of illness.

▪ Ancient form of healing focused on the experience of

the patient and his family providing them with meaning
and hope, relieving the sufferer’s sense of despair,
impatience and isolation should be revived.

WHY STUDY THE IMPACT OF WHY STUDY THE IMPACT OF

ILLNESS? ILLNESS?
✓ Sickness of patient causes suffering and severe ✓ Patient’s disease is embedded in a whole
disruption for the patient’s family (way of life and ability
to function).
matrix of difficult family problems that
Thus when a patient is sick, the whole family suffers.
contribute to the disease process itself
▪ Poverty
✓ Particular illness sets in motion processes that are
▪ Unemployment
disruptive of family life and hazardous to the health of ▪ Other sickness in the family
family members. ▪ Chronic family dispute
Thus there is role reversal, income loss and ▪ Poor nutritional habit
disruption of activities and danger of transmission ▪ Inadequate housing condition
▪ Part of structured inequality in society that he
cannot change

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WHY STUDY THE IMPACT OF WHY STUDY THE IMPACT OF

ILLNESS? ILLNESS?
✓ The interaction that takes place between ✓ Impact of illness minimized by
the health care system and the patient personalized care that is highly
and his family are dependent on: responsive and flexible to the patient and
the family members.
a. Setting of care
b. Type of care ✓ Prolonged and complicated illness
c. Ability to pay • results in structural change within family
d. Flexibility/ responsiveness of the health care system to the point that leads to different
system roles and functions.

WHY STUDY THE IMPACT OF

ILLNESS? DISEASE VS. ILLNESS
STUDIES HAVE SHOWN THAT ▪The two represent one phenomenon but
a. There are psychological and social effects two aspects of sickness
on the family of a patient with chronic or life
threatening illness DISEASE ILLNESS
Primary biologic and psycho-physiologic • Includes the sufferer’s experience of
disorder the disease and the broad range of
b. There are effects on parents and sibling of dislocations felt by both the sufferer
the illness of a child Clinical perspective and his family

• Deeply embedded in the social,

cultural and family context of the
c. Severe illness in parents place children of person who is ill.
family at greater risk.

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DISEASE VS. ILLNESS HOW IS INVESTIGATION DONE?

▪Discovering the meaning for the family THE PHYSICIAN:
✓Explores the patient’s explanatory models because
INVESTIGATE DISEASE INVESTIGATE ILLNESS the belief held by a person explains the nature of
illness
• Examining clinical and • Exploring the meaning of
laboratory evidences of illness to the patient and the ✓Explore the patient’s understanding of the
biologic and psycho- patient’s family following issues:
physiologic dysfunction
▪ Etiology of his illness
▪ Its pathophysiology
▪ Trajectory and outcome of his illness
▪ Appropriate treatment

HOW IS INVESTIGATION DONE? HOW IS INVESTIGATION DONE?

THE PHYSICIAN: THE PHYSICIAN:
This should be the basis for communication. This should be the basis for communication.

✓ Explores the patient’s ✓ Consider the concept of illness

• Perception • Individual
• Reaction to symptom • Family
• How and why he seeks medical advise and care • Ethnic group
• Follow-up regimen and care for himself • Social class
• Society

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HOW IS INVESTIGATION
HOW IS INVESTIGATION DONE? DONE?
THE PHYSICIAN:
THE PHYSICIAN:
▪ Investigate the broader set of experiences and
This should be the basis for communication. concerns that patients associate with their illness

✓ The belief ▪ Derived from past experience with therapy

• Scientific medicine ▪ Personal meaning associated with disease and
forms of therapy
• Religious beliefs
▪ Self-consciousness about tacit meanings of certain
• Ancient healing sciences diseases and disabilities
• Popular account ▪ Meaning of illness for other members of the family
• Healing groups and their vulnerability

HOW IS INVESTIGATION DONE?

Kleinman suggests the following questions to learn how
your patient sees his or her illness: THE FAMILY ILLNESS
1. What do you think caused your problem?
2. Why do you think it started when it did?
TRAJECTORY
3. What do you think your sickness does to you?
4. How severe is your sickness? Do you think it will last a long time,
or will it be better soon in your opinion?
5. What are the chief problems your sickness has caused for you?
6. What do you fear most about your sickness?
7. What kind of treatment do you think you should receive?
8. What are the most important results you hope to get from treatment?

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THE FAMILY ILLNESS TRAJECTORY
PASSAGE THROUGH SUFFERINGS
✓ Normal course of psychosocial aspects of
disease for the patient and the family
✓ Knowledge of trajectory allows the physician to
PREDICT, ANTICIPATE and DEAL with a
family’s response to illness
✓ Indicates NORMAL and PATHOLOGIC
responses thus enabling family physicians to
formulate special therapeutic plan
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE
I ONSET OF ILLNESS TO DIAGNOSIS
II IMPACT PHASE – REACTION TO DIAGNOSIS
III MAJOR THERAPEUTIC EFFORTS
IV RECOVERY PHASE – EARLY ADJUSTMENT TO OUTCOME
V ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
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THE FAMILY ILLNESS TRAJECTORY
Major illnesses involving loss of:
1. Body parts
2. Ability to carry out normal and treasured
activities
3. Sense of self-esteem
4. Dreams and plans for the future
5. Sense of invulnerability of one’s self and in
loved ones that keep existential fears of
impending death and separation at bay
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE I – ONSET OF ILLNESS
▪ Warning sign of malaise which initiates
preliminary stage of the illness trajectory
▪ Stage experienced prior to contact with medical
care providers. Medical beliefs and previous
experiences provide influence to meaning of
illness
▪ Nature of onset may play an important role on
impact of illness on a family and some meaning
of experiences are formulated here.
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STAGES IN THE FAMILY ILLNESS STAGE I – ONSET OF ILLNESS

TRAJECTORY NATURE OF
ILLNESS
NATURE OF
ONSET
CHARACTERISTICS OF
EXPERIENCE
IMPACT ON FAMILY

STAGE I – ONSET OF ILLNESS ACUTE:

Rapid illness
Rapid
clear onset
• Provide little time for physical
and psychological adjustment
• Caught up in the suddenness

• Deal with immediate decision

Accident • Short period between onset,
diagnosis and management
thereby leaving little time to
remain in state of uncertainty
• Often with little support from within
and outside the family unit
• If less threatening, may be dramatic
but less crisis oriented problem for
the family

CHRONIC: Gradual • Suffer from a state of • Vague apprehension and anxiety

onset uncertainty over meaning
Debilitating and symptom • Fearful fantasies over denial of
seriousness of symptoms and
problem implications

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE I – ONSET OF ILLNESS
Responsibilities of the physician
1. Explore routinely the explanatory model and
fear that patients bring into the clinic set-up
2. With inappropriate label of illness,
acknowledge and explore conflict the patient
may be experiencing
3. Explore several aspects of pre-diagnostic
phase of patients and families
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
✓ The physician who presents the diagnosis is
responsible for making a clinical judgment about
the amount of information the patient can absorb
given his present level of anxiety or shock.
✓ It is important that the physician elicits explanatory
model of diagnosis to patient if disease is not life
threatening and patient is liable to be unduly
harmed.

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STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
✓ Disease and appropriate treatment can be
described according to the patient’s level of
comprehension and understanding

✓ Unnecessary frightening anxiety may occur if

information is not understood

✓ Give small doses of information over time if the

diagnosis is particularly traumatic and the patient
and his family may be unable to receive so much.

STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
✓ If diagnosis is confusing and stressful and
shattering, the family physician must:

• Provide support, and continuously of care

• Interpret findings which are misunderstood
• Offer advise and encouragement
• And clarify meaning of specialist’s message and
outcome of illness and operation

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STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
EMOTIONAL PLANE(react)
During onset of illness, initially there is
DENIAL, DISBELIEF AND ANXIETY
• Protest diffuse directly over
unfairness (minutes to hours)
This is followed by emotional upheaval
characterized by strong emotions such
as ANGER, ANXIETY AND
DEPRESSION
• Depends on disrupted roles and
channels (period of weeks)
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
EMOTIONAL PLANE
COGNITIVE PLANE (think)
PHASE I: Initially there is TENSION and
CONFUSION with probable lack of
capacity for problem solving
• Threat sets in motion tension
reduction mechanism
PHASE II: repeated failure in deriving
the diagnosis may lead to
EXACERBATION of tension and
increase distress
• Resort to prayers
• Still earn capacity to problem solve
COGNITIVE PLANE
PHASE IV: eventual ACCEPTANCE
of diagnosis will enable them to
mobilize resources and recognize
the family
• Quality of family reorganization
• If there is no movement towards
this phase, family will be inefficient
in achieving healthy adaptation to
the crisis and reorganize at more
DYSFUNCTIONAL LEVEL
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STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
EMOTIONAL PLANE COGNITIVE PLANE
The last phase is ACCOMMODATION PHASE III: increasing assessment and
during which during which the patient RECEPTIVITY of family to new
and the family learn to accommodate approach for RELIEF OF DISTRESS
and accept the diagnosis ✓ Some go doctor shopping
✓ Some are willing and capable for
• This is very important for active participation
✓ Time for real opportunity for the
the implementation of physician and other health workers
therapeutic plans to assist family in realigning roles
and expectations, learn new skills
and make adjustment
✓ Willing to accept responsibility
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
Responsibilities of the Physician
✓ ANTICIPATE: number of problems and
help families to cope and adapt more
through family conference, discussion
with parents.
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STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
Responsibilities of the Physician
✓ ENCOURAGE:
▪ Make clear to each other and to the patient the nature
of the illness by helping family maintain openness that
allows sharing and support.
▪ Pattern of non-sharing/ silence limit the openness and
spontaneity of families and hampers their ability to
share and openly support each other.
▪ Process of isolation is more terrifying and may be
perceived as abandonment by the patient.
TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
Responsibilities of the Physician
✓KNOW
▪ That feeling of guilt is a natural response to
stress of grief and loss
▪ Family members may have the irrational
feeling that they personally caused the
patient’s disease.
▪ To anticipate such feelings and make realistic
efforts to relieve patient of self-blame through
careful explanation of etiology.

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY TRAJECTORY
STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE STAGE II – REACTION TO DIAGNOSIS: IMPACT PHASE
Responsibilities of the Physician Responsibilities of the Physician
✓ HELP ✓ OFFER
▪ Family assess the likely effect of the illness on
the family ▪ Alternative interpretation of proposed
▪ Predict problems likely to arise therapeutics
▪ Develop plans for realistically coping with ▪ Bolster family’s denial and inability to accept
them and assess the family capabilities to deal reality.
with such stress.
▪ Understand problems as well as benefits to be
expected from family and friends who offer
support

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STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE III – MAJOR THERAPEUTIC EFFORTS
▪ Management/ therapy represents one of the
MOST CHALLENGING AND REWARDING
part of medical practice
▪ The physician should deal with multiple
variables
▪ Works in harmony of the wishes of the patient
and family
▪ Coordinates all aspects of the therapy which
involve specialist and others.

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY TRAJECTORY
STAGE III – MAJOR THERAPEUTIC EFFORTS STAGE III – MAJOR THERAPEUTIC EFFORTS
▪ Critical issues in choosing therapeutic plan ▪ Assumption of responsibility for care very early
▪ Psychosocial state and preparedness of the patient and in the treatment plan.
family determine the choice of therapeutic plan as well as
▪ Establish and define responsibilities of each
the alternative choices
party.
▪ If the patient’s belief system and trust in therapeutic modality is
at variance with that of the physician, he may resist attempt at ▪ Give realistic role to everyone.
education and reassurance.
▪ Thus, the physician should investigate for signs of non-
compliance
▪ Some of patient’s families are not emotionally equipped to
undertake some form of therapy so other professional help
should be obtained

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STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY TRAJECTORY
STAGE III – MAJOR THERAPEUTIC EFFORTS STAGE III – MAJOR THERAPEUTIC EFFORTS
▪ Economy of therapeutic plan ▪ Lifestyle and cultural characteristics of a family
“of what good is therapy if family cannot afford it” are important in choosing a therapeutic plan
▪ The sickness will have devastating effects on the family ▪ Effects of hospitalization, surgery and other
economically speaking
major therapeutic method are emotionally
▪ DILIGENCE on the part of the physician in keeping costs down by involving
family in all major decisions which affect the patient. request for stressful for the patient’s family.
TESTS/REFERRALS which are really necessary ▪ Fear and concern in the families who are still
ECONOMIC IMPACT OF ILLNESS
essentially helpless
a. EMOTIONAL TRAUMA
b. SOCIAL DISLOCATION ▪ Unable to participate in the suffering or need to
c. ECONOMIC CATASTROPHE – WIPES OUT FAMILY SAVINGS relieve the constant discomfort or anguish.

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY TRAJECTORY
STAGE III – MAJOR THERAPEUTIC EFFORTS
STAGE III – MAJOR THERAPEUTIC EFFORTS
Responsibilities of the Physician
Hospitalization gives rise to stressful logistic pattern ✓ Remain open to the family, indicate they will NOT BE
FATHER – special economic burden ABANDONED, provide them information
MOTHER – greatest impact on other family members. ✓ Deal with multiple variables, CONSIDER ALL FACTORS IN
It poses high risk for family dysfunction PLANNING
✓ Work in HARMONY with patient and family
CHILDREN – special syndrome of emotional problems
✓ COORDINATE all aspects of therapy
of families. Hostility, abandonment
✓ ANTICIPATE pathologic response.
PARENTS – helpless, guilt, frustrated or hurt ▪ severe emotional symptom of deep depression
GERIATRIC – vulnerable to fears of death, rejection, ▪ psychological reaction and organic symptoms behavioral problem like
addiction to alcohol work inhibition and pathologic acting out.
abandonment, loneliness and helplessness

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STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE IV – EARLY ADJUSTMENT TO OUTCOMES
RECOVERY

▪Initiates a period of gradual movement from the role

of being sick to some form of recovery or adaptation,

▪Important phase for patients and families.

▪Varies according to the type of outcome anticipated

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE IV – EARLY ADJUSTMENT TO OUTCOMES
RECOVERY
Simplest outcome is RETURN to full health
▪ Gains from illness experience
▪ Patient nurtured and allowed to take over the
abandoned obligation, new responsibilities and
privileges when sick
TRAJECTORY
STAGE IV – EARLY ADJUSTMENT TO OUTCOMES
RECOVERY
PARTIAL RECOVERY
▪ Period of waiting to learn if disease will return or fear of
death, because of long period of waiting
▪ They maintain constant sense of vulnerability.
▪ Recovery is quite different if it requires acceptance of a
known permanent disability

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STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE IV – EARLY ADJUSTMENT TO OUTCOMES RECOVERY
Responsibilities of the Physician
✓ Deal with immediate EFFECTS of trauma
✓ ALLEVIATE anxiety and assure adequate rest
✓ Psychological SUPPORT can be given through
understanding and repeated assurance
✓ Explore level of UNDERSTANDING of patient and family.
✓ Call on other members of family for means of SUPPORT.
✓ Try to find out how members understand what
happened, what kind of LABELLING do they have.
▪ Do they label person as still ill or do they label him as
once again well or has returned to health.

STAGES IN THE FAMILY ILLNESS STAGES IN THE FAMILY ILLNESS

TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
▪ This points to the family’s adjustment to crisis
▪ SECOND CRISIS occurs as family realizes that they
must accept and adjust to a permanent disability.
▪ Family must BEGIN AND GIVE UP HOPE for the
patient’s full return to health.
▪ ACCEPT that life must go forward and pattern believed
to be temporary must be accepted as permanent.
▪ Physician should be aware that continued
unwillingness to incorporate that reality of the
permanency of the loss may be a sign of PATHOLOGY.
TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE
OUTCOME
▪Coping mechanism is developed during earlier
stage of family adjustment
▪ Person who is sick continued to be treated as sick
and he is treated as patient and not reintegrated
into the family
▪ Treat patient as recovered, full, responsible
person

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STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
ACUTE ILLNESS:
▪ There is potential for crisis especially when family routines are
suspended.
▪ Emotions are high and can lead to anger especially if the family
perceives that the care given by the doctor is not satisfactory.
▪ Because of suddenness of illness, family may find it difficult to
face the stress.
The family physician can facilitate healthy response or acceptance of
diagnosis and recognize danger signals such as delayed or prolonged
reaction
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
FOR TERMINAL ILLNESS
▪ This is HIGHLY EMOTIONAL and potentially devastating.
▪ The moment of diagnosis of a debilitating or terminal disease
is often remembered by patient in their families as the
SINGLE MOST DIFFICULT time of the entire illness
experience.
▪ Patient and his family anticipate GRIEF REACTION.
▪ If the family is FUNCTIONAL:members will be drawn close
together to provide care and support to the patient and to
each other
▪ if the family is DYSFUNCTIONAL: it can be the seed for
future family discord and breakdown.
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STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
CHRONIC ILLNESS:
▪ Because of prolonged fear and anxiety there is higher incidence of
illness in other members of the family.
▪ Additional burden and sometimes feeling of guilt especially if the sick
member was previously neglected
▪ The family becomes over-indulgent toward the sick member and this
will later result into feeling of overwork.
▪ Anger and resentment toward sick member sets in leading back to
feeling guilt later
The family physician can encourage ventilation of feelings, give reassurance
and reinforcement of care.
STAGES IN THE FAMILY ILLNESS
TRAJECTORY
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE OUTCOME
FOR TERMINAL ILLNESS
▪ The initial response is that of shock and overwhelming anxiety.
▪ As they respond to the pain with denial and disbelief, the patient
may say “This could not be happening to me.”
THE PHYSICIAN CAN:
▪ ASSIST THE PATIENT AND THE FAMILY IN RELATING TO HEALTH
CARE SYSTEM
▪ AID THE PATIENT AND THE FAMILY IN EFFICIENT AND
FUNCTIONAL ADJUSTMENT
▪ PROVIDE QUALITY CARE. HOME CARE IS THE BEST AND MOST
ACCEPTED AND THE LEAST DEMANDING, THUS IT SHOULD BE
FACILITATED
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STAGES IN THE FAMILY ILLNESS

TRAJECTORY FAMILY IN CRISIS
STAGE V –ADJUSTMENT TO THE PERMANENCY OF THE
OUTCOME
FAMILY REACTION TO DEATH
▪ In prolonged severe illness and adaptation and reaction
are already accomplished
▪ Death comes swiftly physician should assist family to
cope
▪ Stage of denial – few days to few weeks
▪ If prolonged – premorbid pattern of abnormal behavior
▪ Denial, Anger, Bargaining, Depression, Acceptance

Family in functional equilibrium

FAMILY IN CRISIS Adaptation

(Functional or nurturing)

(coping)

▪Family is in crisis when it moves into a Resources

adequate
state of disequilibrium in response to any Intrafamilial
Resources
Family in
disequilibrium
Stressful Life
event
situation or event that it cannot resolve by Resources

use of available problem-solving skills, inadequate Extra-

familial
behavior or resource. Crisis resources

▪When illness is perceived as threat to its Maladaptation

equilibrium, a crisis response is set in Pathologic defense

mechanism
motion. Terminal
Stressful life
event
disequilibrium Pathologic disequilibrium

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EVALUATING FAMILY IN CRISIS

EVALUATING FAMILY IN CRISIS
Assess family history of coping with problem and
stressor Determine style of family development
▪ Boiling point at which crisis response is set in ▪ Anticipatory guidance
motion
▪ Affected by uniqueness of internal and external factors ▪ Timeliness of illness or problem affects
▪ Stresses are sufficient in number or intensity to disturb family’s ability to cope
family equilibrium
▪ Family psychosocial history provides information
regarding capacity of family to cope with illness and other
missions
▪ Quality of Family Life mobilize their own strengths and
resources to cope adequately with stress

EVALUATING FAMILY IN CRISIS EVALUATING FAMILY IN CRISIS

Role of the patient in the family
▪ Member providing financial support financial
problem
▪ Member plays critical role in family emotional
life, ex: mom who nurtures, emotional support
most serious impact in family when she gets
sick. Impact: feelings of guilt and self blame
▪ Child other siblings deprived, develop
resentment towards the ill sibling
Monitoring role disruption
▪ Assesses and monitors effect of role
disruption
▪ Identifies gap in family role that exists or the
results of the illness and helps the family
explore options for filling those gaps from
within and outside of the family
▪ Sick role as perceived by patient and family

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Demos + graphein

Demography is scientific study

of human population

ARNEL V. HERRERA, MD
Family Medicine and Community
Health

Community medicine is vitally concerned with
population as the health of the people
depends upon:
➢ the number of people
➢ the space they occupy
➢ the skill that they have acquired
 Census
Total process of collecting, compiling and
publishing demographic, economic and
social data pertaining to all persons in a
country at a specified time.
 Vital registration
Continuous registration of vital events
(births, deaths, marriages)

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 Continuing
population registers
Continuous recording of
information about the population
 Description by specific
populations
Voters registration
School enrollment
Income tax returns
Social security system
Three phenomena in Demography
1. Changes in population size
2. Composition of population
3. Population distribution in space
5/12/2021
 Counts
Absolute number of a population or any
demographic event occurring in a specified
area during specified time period
 Ratios
A single number that represents the relative
size of 2 numbers
 Proportion
A special type of ratio in which the
numerator is part of the denominator
 Actual number of the population
 How many people live in a given
place at a given time
 Focus on rates of change and
describing trends
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 Basis for many vital statistics

There are two methods of making a census:
(a) de facto census : counting individuals
 Knowing the size of the population wherever they actually are on the day the
is done by enumeration of all census is conducted.
persons in the community, which is
(b):The de jure census : counting individuals
called “census”. at their legal permanent residence
regardless to whether or not they are
physically present at the time of the census

 Population density=
 Population density is midyear population
divided by land area in square kilometers.
Midyear population
Land area in sq km
 Population is based on the de facto definition
of population, which counts all residents Population is based on the de facto
regardless of legal status or citizenship. definition of population, which counts
all residents regardless of legal status
 Land area is a country's total area. or citizenship.

 Land area is a country's total area.

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 World (land only) – 58 person/sq.km.
 Macau (China) – 19,199 person/sq.km.
Philippines – 358 person/sq.km.

 Thailand – 136 person/sq.km.
 Canada – 4 person/sq.km.
Age & Sex composition
➢ Proportion of males & females in
different age-groups
➢ Direct bearing on social, economic,
health needs of communities
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 Measurable characteristics of the
people who make up a given
population like age, sex, marital
status, occupation and education
 Studying the composition includes:
◦ age and sex composition,
◦ sex ratio,
◦ age pyramid,
◦ dependency ratio
Sex Ratio
➢ Ratio of males to females in the population
➢ Sex Ratio = Number of Males X 1000
Number of Females
➢ Sex ratio of: Philippines (2015 est.)
Total: 1000 male/1000 female
At birth: 1050 male/1000 female
15-64 years: 1000 male/1000 female
65-over: 760 male/1000 female
➢ Factors affecting sex ratio:
1. Difference in mortality conditions of males
& females
2. Sex selective abortion and infanticide
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Age Pyramid
➢ It is a pictorial presentation (double
histogram) of the age-sex composition of
a population
➢ Male & Female are compared for age
➢ Under-developed/developing country: Broad
base & tapering top (pyramid shape)
➢ Developed countries: Bulge in the middle and
has a narrow base (spindle shape)

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Comparison between the Pyramids of Developing & Developed

Countries
Developed countries Developing countries Age Dependency Ratio
Dependency Ratio is the ratio of economically
Base Narrow ( Low BR) Wide (high BR)
▪
Side Not sloping (Straight ). Sloping.
(low mortality ) (high mortality)
dependent population to economically
Height Tall Short independent population
(high life expectancy). (Low life expectancy) ▪ Index of age induced economic drain on manpower
Apex Wide Narrow resources
(large numbers of people > (few people survive to old
60. age)
Median Age High (low birth) Low ( High births) ▪ Dependency Ratio
= Children (<15 yr) + Elderly (>65 yr) X 100
Old dependency
ratio
High Low
Working Age(15-64)
Young dependency Low High
ratio

 The arrangement of the population in

Fertility is the actual reproductive performance of a
space at a given time

woman or a group of women. A woman's
 Urban versus rural reproductive period is roughly from 15 to 49 years
of age.
 Major demographic processes that
affects the population: • Fertility indicators
1. Fertility • Crude birth rate
• General fertility rate
2. Mortality
• Age specific fertility rate
3. Migration • Total fertility rate
4. Marriage
5. Social Mobility

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1.Crude Birth Rate (CBR) - is the simplest
indicator of fertility.
CBR=Live Births x 1000/mid year population
Useful in:
- making annual comparisons
- to detect trends in fertility in a given
country and
- in comparing different populations
2.General fertility rate (GFR)
GFR = Live Births x 1000/mid year female
pop. (15-49yr)
Weakness of GFR :
(a) the marital status and
(b) the differences in fertility levels in various
age groups of reproductive period.
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Factors affecting the crude birth rate:
Factors affecting the Live births
• Number of females specifically those 15-49 years
• Level of infant and preschool mortality rates
• Socioeconomic level of the country
• Cultural and religious factors
• Knowledge, attitudes and motives for adopting or
rejecting family planning
Factors affecting the mid year population
• Epidemics
• Wars
• Famine
• Migration
3. Age specific fertility rates (ASFR)
Live births in specific age group x 1000
Midyear population of women in that age
group
The whole reproductive life of females (15-49
years) is divided into seven age groups, each of
five years duration (namely 15-19, 20-24
years, … etc). There are seven age specific
fertility rates.
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4. Total fertility rate (TFR) The expected number of births per

woman, at current fertility rate is:
TFR = 5 x ƩASFR  Africa 4.1
1000  Oceania 2.3
It is a hypothetical measure of fertility.  Asia 2.0
 Total fertility rate(TFR) gives an idea of total family  South America 2.0
size
 Total number of children borne by a woman during  North America 1.8
her child bearing age (15 to 49 years)  Europe 1.6
 TFR in Philippines: 2.58 (2018 est.) 6.5 (1968)

Family Size Reasons for High Birth Rate in Philippines

Family size depends upon:
➢ early marriage
✓Duration of marriage ➢ low standard of living
religion: 80% catholic
✓Education of couple ➢
➢ absence of family planning
✓No. of live births habit

✓No. of living children

✓Preference of male child

8

Net reproduction rate (NRR)
 The rate of replacement of females in
the population per generation
NRR = Number of girls born and survived
Number of the women survived
after the end of reproductive life
Measures of mortality describe
both the likelihood of dying in
any specific time interval and the
expectation of survival
 Crude death rate
 Specific mortality rates
5/12/2021
 Economic status is inversely
proportional to fertility
 Economic development is the best
contraceptive
 Education is inversely proportional
to fertility
 Well fed society has low fertility
 Poorly fed society has high fertility
 CRUDE DEATH RATE:
The total number of deaths in a year x 1000
midyear population in the same year
Utilized in deciding priorities for health action, in
designing intervention programs and in the
assessment of public health problems and plans
9

1. Age
 Infancy: high mortality levels
 Childhood: decline
 Adolescence & early adulthood:
remain at low level
 Adulthood & older ages: increase
The pattern is true for male and
female in developed and developing
countries
3. Race
4. Region / area
5. Morbidity preventable, fatal /
non fatal
6. Social and economic conditions
7. Public health measures
5/12/2021
2. Sex
Males have a higher risk of mortality in
developed and most developing
countries
Exceptions:
➢ Societies that value survival of male
offspring more than females
 Low levels of economic development
where childbearing increases risk of
mortality for females of reproductive
age
Movement of people involving a change
of residence between 2 clearly defined
geographic units
 Internal migration- movements by in-
migrants and out-migrants within
national borders
 External / international migration
Immigrants – those who enter
Emigrants – those who leave
10
 5/12/2021

Age at marriage  Socio-economic status

 Great impact on fertility  Differences in health experience due to

 Early marriages = increased

nutrition
occupation
births
exposure
 Age of marriage:Filipinos
accessibility to health care
1968’s : 23.4 years knowledge
2019 : 29 years - Male education
27 years - Female

The population grows according to two The growth rate takes into consideration
factors: birth rate and death rate. The birth, death & migration.
difference between these two is called the
rate of natural increase. Growth rate (GR) = RNI + Net migration rate

The rate of natural increase is expressed as a Net migration rate = Immigrants - emigrants
percent.
Rate of natural increase (RNI) =CBR – CDR
10

11
 5/12/2021

Relation between growth rate & population

Rating Annual rate of Population doubling

growth % time in years
Stationary Population No growth -
Slow growth Less than 0.5 More than 139
Moderate growth 0.5 to 1.0 139-70
Rapid growth 1.0 to 1.5 70-47
Very rapid growth 1.5 to 2.0 47-35
Explosive growth 2.0 to 2.5 35-28
Explosive growth 2.5 to 3.0 28-23
Explosive growth 3.0 to 3.5 23-20

Life expectancy
Reasons for increase life expectancy
▪ Expectation of life at a given age is the average number of years
which a person of that age may expect to live, according to the
mortality pattern prevalent at that age
1. Mass control of diseases
▪ Indicator of country development & overall health
▪ Expectation of life at birth – World 2. Advance in medical science
1950 : 46.5 years 3. Better health facility
2002 : 63 years 4. Impact of national programs
2010 : 67 years 5. Improvements in food supply
2018 : 72 years
6. International aid
7. Development of social
▪ Expectation of life at birth – Philippines
consciousness among masses
Year Males Females Ave

1960 51 55 53

2018 67 75 71

12
 5/12/2021

Population Demographic transition model

 Economic implications
 Demographic Implications
 Environmental / Ecological Each stage creates
population pyramids
Implications unique to that stage.

 Social / Political Implications

Population Demographic transition model Population Demographic transition model

Stage 1. Stage 1.
Birth rates are high because: Birth rates are high because:
➢ No birth control or family planning. ➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.

13

Population Demographic transition model
Stage 1.
Birth rates are high because:
➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.
➢ Many children needed to work in agriculture
Population Demographic transition model
Stage 1.
Birth rates are high because:
➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.
➢ Many children needed to work in agriculture
➢ Children expected to support parents in later
life in the absence of pensions.
➢ Children regarded as a sign of virility and
status in some societies.
5/12/2021
Population Demographic transition model
Stage 1.
Birth rates are high because:
➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.
➢ Many children needed to work in agriculture
➢ Children expected to support parents in later
life in the absence of pensions.
Population Demographic transition model
Stage 1.
Birth rates are high because:
➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.
➢ Many children needed to work in agriculture
➢ Children expected to support parents in later
life in the absence of pensions.
➢ Children regarded as a sign of virility and
status in some societies.
➢ Religious beliefs - Roman Catholics, Muslims,
Hindus, encourage large families.
14
 5/12/2021

Population Demographic transition model Population Demographic transition model

Stage 1. Stage 1.
Death rates are high because: Death rates are high because:
➢ Lack of access to medical science/supplies - few ➢ Lack of access to medical science/supplies - few
doctors, hospitals, drugs. doctors, hospitals, drugs.
➢ Poor hygiene

Population Demographic transition model Population Demographic transition model

Stage 1. Stage 1.
Death rates are high because: Death rates are high because:
➢ Lack of access to medical science/supplies - few ➢ Lack of access to medical science/supplies - few
doctors, hospitals, drugs. doctors, hospitals, drugs.
➢ Poor hygiene ➢ Poor hygiene
➢ Famine, uncertain food supplies, poor diets. ➢ Famine, uncertain food supplies, poor diets.
➢ Disease spread by lack of access to clean water

15
 5/12/2021

Population Demographic transition model Population Demographic transition model

Stage 1. Stage 2.
Natural increase (population growth) is low Birth rates remain high because of all
because although there are a lot of births the the same reasons as for Stage 1.
similarly high number of deaths effectively cancels
them out

Population Demographic transition model Population Demographic transition model

Stage 2. Stage 2.
Death rates begin to fall because: Death rates begin to fall because:
➢ Improved medical care ➢ Improved medical care
➢ Improved sanitation and water
supply systems reduces disease.

16

Population Demographic transition model
Stage 2.
Death rates begin to fall because:
➢ Improved medical care
➢ Improved sanitation and water
supply systems reduces disease.
➢ Improvements in agricultural
efficiency
Population Demographic transition model
Stage 2.
Natural increase (population growth)
is high because there is now a large
gap between births and deaths,
increasing the population rapidly.
5/12/2021
Population Demographic transition model
Stage 2.
Death rates begin to fall because:
➢ Improved medical care
➢ Improved sanitation and water
supply systems reduces disease.
➢ Improvements in agricultural
efficiency
➢ Improved communications to
transport food, doctors, medicines
etc.
Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Lower infant mortality
rate means less pressure to
have many children.
17

Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Lower infant mortality
rate means less pressure to
have many children.
➢ Widespread availability and
knowledge of family planning
Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Lower infant mortality
rate means less pressure to
have many children.
➢ Widespread availability and
knowledge of family planning
➢ Change from agrarian to an
industrial society and
mechanisation leads to a
reduction in workforce
requirements.
➢ Welfare systems pensions
5/12/2021
Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Lower infant mortality
rate means less pressure to
have many children.
➢ Widespread availability and
knowledge of family planning
➢ Change from agrarian to an
industrial society and
mechanisation leads to a
reduction in workforce
requirements.
Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Emancipation of women
and improved educational
opportunities
18

Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Emancipation of women
and improved educational
opportunities
➢ Large families increasingly
viewed as an economic and
social burden.
Population Demographic transition model
Stage 3.
Natural increase (population growth)
remains high due to the gap between
births and deaths but as this stage
progresses the increase gets less as
births and deaths match up again.
5/12/2021
Population Demographic transition model
Stage 3.
Birth rates begin to fall
because:
➢ Emancipation of women
and improved educational
opportunities
➢ Large families increasingly
viewed as an economic and
social burden.
➢ Increased desire to pursue
material lifestyles
Population Demographic transition model
Stage 3/4.
Death rates continue to fall
because of ongoing
developments in health and
hygiene already mentioned.
19
 5/12/2021

Population Demographic transition model Population Demographic transition model

Stage 3/4. Stage 3/4.

Death rates remain low because: Death rates remain low because:
➢ Continued advances in paediatric care further reduce ➢ Continued advances in paediatric care further reduce
infant mortality rates. infant mortality rates.
➢ Improved diets

Population Demographic transition model Population Demographic transition model

Stage 3/4. Stage 3/4.

Death rates remain low because: Death rates remain low because:
➢ Continued advances in paediatric care further reduce ➢ Continued advances in paediatric care further reduce
infant mortality rates. infant mortality rates.
➢ Improved diets ➢ Improved diets
➢ Continued advances in geriatric care increase ➢ Continued advances in geriatric care increase
life expectancy life expectancy
➢ Increase in preventive health care

20

Population Demographic transition model
Stage 3/4.
Death rates remain low because:
➢ Continued advances in paediatric care further reduce
infant mortality rates.
➢ Improved diets
➢ Continued advances in geriatric care increase
life expectancy
➢ Increase in preventative health care
➢ Enhanced public services for elderly -
specialised care workers, day-centres, residential
homes, sheltered housing, meals-on-wheels.
Population Demographic transition model
Stage 4.
Birth rates continue to fall for all the same reasons as
Stage 3.
5/12/2021
Population Demographic transition model
Stage 3/4.
Death rates remain low because:
➢ Continued advances in paediatric care further reduce
infant mortality rates.
➢ Improved diets
➢ Continued advances in geriatric care increase
life expectancy
➢ Increase in preventative health care
➢ Enhanced public services for elderly -
specialised care workers, day-centres, residential
homes, sheltered housing, meals-on-wheels.
➢ Universal state pension scheme
Population Demographic transition model
Stage 4.
Natural increase (population growth) is again low
as births and deaths virtually cancel each other
out, but now the population is high..
21
5/12/2021

22
 5/12/2021

• As future health workers, students should

be prepared to cope with ever changing
responsibilities and expectation.
• These changes are brought about by the
fact that the health situation continuously
Rates and Ratios change.
Joseph A. Jao, MD, FPAFP
Macario F. Reandelar, Jr., MD, MSPH, FPAFP • These changes are translated into statistical
Julie Tiu, MD, FPAFP
Gloria Peret-Clarion, MD. FPAFP terms.
FMCH Department, FCM, OLFU

Rates and Ratios

• Rates form the essential ingredients of vital

statistics method.
• Crude Rates • Specific Rates
• Actual summary rates • Homogenous subgroups
• Readily calculable for international
comparisons • Detailed rates useful for
• Since population vary in composition, epidemiological and public health
differences in crude rates makes it difficult purposes
to interpret

General Classification of
Rates General Classification of Rates

1
 5/12/2021

• Proportion
- a part of a whole in which the numerator is part of • Ratio
the denominator - A single number that represents the relative size of two
Form: a numbers
*k a
a+b
Form:
*k
b
where a= count where a=count
b=count b=count
k=factor size k= factor size

RATES AND RATIO RATES AND RATIO

• Rates
- Measures the amount of change (no. of new events) in a
given period of time
• Quotient of two numbers without taking a
Form:
particular considerations to time or place *k
t *n
where a= count
• Number of deaths per population N=no. of subjects
t=amount of time
k=factor size

Ratio RATES AND RATIO

2
 5/12/2021

Index Numerator Denominator

• Measures the probability of occurrence of some
Proportion People with the All people ( with
particular events
disease and without
• Count of measurement is observed over a period of disease)
time and then divided by its base or population of Ratio People with the People without
observation disease the disease
Rate People with the All people ( with
• Total deaths in 1989/midyear population of 1989 disease in a and without
given period disease )

Rate

• Realize the implications of certain data in our

practice
1. Approach to care for our patients
2. Understanding the health and health resources
needs

• Clear understanding of these rates and ratios and

their implications will better prepare us in starting and
managing our practice

Importance Morbidity Rate

3
 5/12/2021

• Incidence Rate
• Refers to newly diagnosed cases of a particular disease
• Designed to provide measures of the rate
• Also known as attack rate, case rate, sickness rate, morbidity rate
at which people without a disease during
• “How frequent do cases of a particular disease occur in a given period specified period of time
of time?”
• Used when dealing with acute conditions and accidents • Provides for statements about probability
No. of cases discovered during a given time period x factor
or risk
• High incidence-→ high risk of disease
Average population of that period

• High incidence rate – High risk of disease

Incidence Rate Incidence Rate

• Incidence rate, by person • “What proportion of the population or of a group of

• Number of people who developed disease (i.e.,colds) over a persons are actually ill with a particular disease at a
period of time point in time?”
• Incidence Rate by events
• Number of cases (i.e., colds) over a period of time • Used when dealing with chronic conditions and
• Denominator for both - Population at risk over the same disabilities
period of time
No. of cases new and old

Incidence Rate Prevalence Rate

4
 5/12/2021

• Low Prevalence Rate:

• High prevalence rate reflect increase in survival 1. Illness is of short duration
perhaps due to medical care 2. Recovery
3. Death
• Low prevalence and low incidence rate reflect 4. Migration
rapidly fatal process or rapid cure of disease
Importance of Prevalence Rate:
1. Determining workload, particularly in chronic disease
• Prevalence rate is dependent on:
2. Useful tool in planning of facilities and manpower need
1. How often disease occur
3. Monitoring control programs for chronic conditions such as
2. How long it lasts mental illness
4. Extent of disease problem

Prevalence Rate Prevalence Rate

• Measures the number of people in a population who have

the disease at one point in time
Number of existing cases at a point in time
= *100
Total population at a point in time
• Records old and new cases
• Fertility – actual level of performance in a population
based on numbers of live births that occur as in
frequency of births of population derived from statistics

Prevalence Rate Measures of Fertility

5

• A measure of one’s characteristics of the natural growth or
increase of a population
• Rough measure of the fertility of the population
Total Live Births in a Year x 1,000
Midyear Population
e.g. Crude Birth Rate of province M in 1988
7,113 x 1,000 = 29.41/1,000 population
241,882
• Rate is crude because:
1. Only Live Births are counted
2. Denominator is the total population
Crude Birth Rate
Mortality Rate
5/12/2021
Total registered births
= *1000
Midyear population of women 15−44 years of age
• Denominator restricts to potential mothers, excluded all
men and women not exposed to the risk
General Fertility Rate
Total number of deaths during a given year
= *100
Midyear population during the same year
• Takes no account of specific characteristics of the
population it is based
• Not useful for inter-areas comparison
• Population with older population higher CDR
compared to population with younger population
• Valid for comparison for the same area from year
to year
Crude Death Rate
6

• A measure of one mortality from all causes which
result in a decrease of population
• Measures the risk of dying from all causes in a
population
e.g. CDR of City Z in 1989 with a total pop of 155,511
1148 deaths x 1,000 = 7.38/1,000 population
155,511
Crude because:
• Does not take into account the differences in the risk
of dying among different age group
Crude Death Rate
• Age-Sex Specific Death Rate
Number of deaths in a specified age− sex group
=
Mid−year population in the same age−sex group
*1000
• Cause Specific Death Rate
Number of deaths from a particular cause
= *100,000
Midyear population of the same year
• Accuracy depends on standard of diagnosis and report
• Indicates the status of health, health facility, medical care,
socio-economic condition, and environmental sanitation of
the death occurrence
MORTALITY RATE
5/12/2021
• Age-Specific Death Rate
Number of deaths in particular age group
= *1000
Midyear population of the same age group
• Sex-Specific Death Rate
Total number of deaths in particular sex
= *1000
Midyear population of the same sex
MORTALITY RATE
• Cause Age and Sex Specific Death Rate
=Number ofmidyear
deaths from a particular causein a specific sex and age group
population of the same age and sex group
*
100,000
• Proportionate Mortality Rate
• Usually used for describing the relative importance of
different fatal diseases in the population
• Can be calculated from different age groups and are useful
for determining the order of importance of causes of deaths
in the different age groups.
Mortality Rate
7
 5/12/2021

• Proportionate Mortality Rate By Cause • Proportionate Mortality indicator

• Proportionate Mortality Rate by Age Group
• Proportionate Mortality Indicator or Swaroop’s Index
• Proportion of death of 50 yrs and over to the total
deaths
• Good indicator in comparing health status of
deferent countries
• The higher this rate, the better is the health status
of the population
• The higher this rate, the better is the health status of the
population because many are reaching older ages before
dying
• Good indicator in comparing health status of different
countries
Deaths all causes among 50 years
and above during a given time interval x 100
Total deaths all causes during the same
period

Mortality Rate Swaroop’s Index

High proportion of deaths 50 years and over

• Case Fatality Rate
• Success in the control of preventable deaths from Number of Deaths from a particular disease
communicable diseases = *100
Number of cases
• Low IMR • Represents risk of dying during a definite period of time
• Better sanitation for those individuals who had the particular disease.
• Longer life expectancy
• Better economic status

Swaroop’s Index Mortality Rate

8
 5/12/2021

• Infant Mortality Rate

Total number of deaths under 1 year
= *1000
Number of live births for the year
• Measure the killing power of the disease • One of the most sensitive indices of the health
conditions of general population

Case Fatality Rate Infant Mortality Rate

• Measures the risk of dying during the first year of life • Highest for babies with adolescent mothers and
women in their forties and older
• Good index of the general health condition of a
community
• Decreases with increasing maternal educational
• Used to measure the adequacy of health services as well
levels
as the state of environmental health
• IMR for unmarried mothers is often more than 83%
Total infant deaths in a calendar year x 1, 000
higher than the mortality rate for married mothers
Total Live Births During the Year

• Not a perfect index of the risk of dying, ONLY a • Higher for mothers who smoke than those who do
reasonable approximation not smoke

Infant Mortality Rate Infant Mortality Rate

9
 5/12/2021

Implications of Low IMR

Implications of Low IMR
2. Sanitarian’s Point of View
1. Health Officer’s Point of View a. Good environmental sanitation
b. Good water supply
a. Adequate immunization program c. Good housing facility
b. Sound Infant and Maternal nutrition
c. Satisfactory Pre- and Post-natal services 3. Social Worker’s Point of View
d. Good disease control program a. Illegitimates are not neglected
e. Strict laws governing the administration of health b. Female babies are not
programs unwelcome
c. High standard of living

Infant Mortality Rate Infant Mortality Rate

• For WHO, an IMR of 50/1000 live births make a country a

• Under 28 days
priority for international aid • Early neonatal – under 7 days
• Priority is given when it comes to programs for: • Late neonatal – 7 to less than 28 days
1. Sanitary improvement
2. Vaccination against diarrheal diseases • Implications
High IMR: • Health status of mother before and
during pregnancy
1. High incidence of communicable diseases
2. Poor state of sanitation • Risks of labor and delivery
3. Inadequate health facilities
4. Shorter life expectancy
5. Young population

Infant Mortality Rate Neonatal Mortality

10
 5/12/2021

• Measures pregnancy wastage

• Death of a product of conception occurs prior to its
complete expulsion, irrespective of duration of
pregnancy Late fetal deaths and early neonatal deaths
= *1000
Live births
• Measures the risk of dying before birth • Late fetal death – 28 weeks or more
Fetal Deaths x 1000
Live Births

• Ideal denominator: Total births

Fetal Death Rate Perinatal Mortality Rate

• Probability of dying (per 1000) under age five years

(under-5 mortality rate) • Probability of a child born in a specific year or period
• Under-5 mortality rate is a leading indicator of the level dying before reaching the age of five, if subject to age-
of child health and overall development in countries. specific mortality rates of that period.
• It is also a MDG indicator.

Under five Mortality rate Definition

11

• Under-5 mortality rate, is strictly speaking, not a rate
(i.e. the number of deaths divided by the number of
population at risk during a certain period of time) but a
probability of death derived from a life table and
expressed as rate per 1,000 live births.
Definition
• Maternal Mortality Ratio
Death among women directly due to pregnancy, labor, puerperium
= Live births
• Measures the risk of dying from causes associated with
childbirth
Maternal Mortality Ratio
5/12/2021
• Measures the risk of dying from causes directly related to
pregnancy, childbirth and puerperium (Old Definition)
• Index of the obstetrical care needed and received by the
women in a community
• Both sex and cause specific and in a way age specific death
rate
Deaths among women due to maternal cause x 1000
Live births during the year
• Ideal denominator- number of pregnant women
• Other data to use- Total births
Maternal Mortality Ratio
• Maternal mortality ratio (per 100 000 live births)
• Complications during pregnancy and childbirth are a
*1,000 leading cause of death and disability among women of
reproductive age in developing countries.
• The maternal mortality ratio represents the risk associated
with each pregnancy, i.e. the obstetric risk.
• It is a MDG indicator.
New Concepts
12
 5/12/2021

• To facilitate the identification of maternal deaths in

• Maternal death is the death of a woman while pregnant
or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental
causes.
circumstances in which cause of death attribution is
inadequate, a new category has been introduced:
Pregnancy-related death is defined as the death of a
woman while pregnant or within 42 days of termination
of pregnancy, irrespective of the cause of death.

New Definition New Definition

MMR 2010 est.: Population: 102,624,209 (July 2016 est.)

Age Structure: 0-14 years 33.71%

• Highest: 15-24 years 19.17%
25-54 years 36.86%
1. South Sudan: 2054 deaths/100,000 livebirths 55-64 years 5.89%
> 65 years 4.38%
2. Chad: 1100 deaths/ 100,000 livebirths
3. Somalia: 1000 deaths/100,000 livebirths
Median Age: Total 23.4 years
Male 22.9 years
• Philippines: 114 deaths/ 100,000 livebirths (2015 est.) Female 23.8 years

Population Growth Rate: 1.59 %

• Lowest:
Birth Rate: 24 births/1000
1. Estonia: 2 deaths/ 100,000 livebirths
2. Greece, Singapore: 3 deaths/ 100,000 livebirths) Death Rate: 6.1 deaths/1000
3. Belarus, Italy, Sweden, Austria: 4 deaths/ 100,000 livebirths)

Maternal Mortality Ratio Philippines Demographic Profile 2016

13
 5/12/2021

Sex Ratio at birth 1.05 male/female

Under 15 years 1.04 male/female
15-24 years 1.04 male/female
24-54 years 1.03 male/female
> 65 years 0.72 male/female
Total population 0.71 male/female

Life Expectancy at Birth

Total Population 69,2 years

Male 65.7 years
Female 72.9 years

Infant Mortality Rate 21.9 deaths/1000

Total Fertility Rate 3.02 children born/ women

Maternal Mortality Rate 114 deaths/100,000 live births

Philippines Demographic Profile 2016

MORBIDITY: 10 Leading Causes, Number and

Rate
2010*
Diseases
Number Rate
1. Acute Respiratory Infection ** 1,289,168 1371.3
2. Acute Lower Respiratory Tract Infection and
586,186 623.5
Pneumonia
3. Bronchitis/Bronchiolitis 351,126 373.5
4. Hypertension 345,412 367.4
5. Acute Watery Diarrhea 326,551 347.3
6. Influenza 272,001 289.3
7. Urinary Tract Infection** 83,569 88.9
8. TB Respiratory 72,516 77.1
9. Injuries 51,201 54.5
** 10.
ARIDisease
was includedof in the Heart
the list 37,589
of notifiable diseases in 2008 only, while UTI and Injuries are new in the list 40
*** Acute Febrile illness was included in the list of notifiable diseases in 2006 only, 3-year average only

14
5/12/2021

15
Donald E. Stout, Jr 5/12/2021

If you are running in a race and overtake the

person who is in second place, what place
will you be in? second place

If you overtake the person in last place, Can you name 3 days in row without using
what place will you be in? the words: Tuesday, Thursday or Saturday?

No one can’t
overtake the
person in last
place!

Yesterday, Today and Tomorrow

StatisticsQuality Basics 1
Donald E. Stout, Jr 5/12/2021

A father and his son are involved in a car
accident, as a result of which the son is
rushed to hospital for emergency
surgery. The surgeon looks at him and
says "I can't operate on him, he's my
son". Explain.
Measures of Central Tendency
Shape of the Distribution
Measures of Dispersion
Normal Curve
Measures of Relative Standing

The surgeon is the boy's mother

Statistics

Measures of Central Tendency What Is Mean?

◆ Describe the center position of the data
◆ Numbers that describe what is average or
typical of the distribution
◆ The goal is to come up with the one single
number that best describes a distribution of
scores.
◆ Mean Median Mode

StatisticsQuality Basics 2
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Mean (Arithmetic Mean)

Mean - Average
Affected by Extreme Values (Outliers)
◆ Most common measure of central tendency
◆ Arithmetic mean is defined as the sum of
all the observed values, divided by the
number of observations
◆ Best for making predictions 0 1 2 3 4 5 6 7 8 9 10 Balancing Point, Fulcrum

◆ Distribution is more or less normal Mean = 5

[symmetrical].
◆ It is calculated rather than determined 0 1 2 3 4 5 6 7 8 9 10 11 12 … 29

Mean = 9

Finding the Mean Finding the Mean

◆ X = (Σ X) / N ◆The average score for a class of 10
◆ If X = {3, 5, 6, 4, 5, 7} students was 50. The 5 female
X = (3 + 5 + 6 + 4 + 5 + 7) / 6
students averaged 40. The
= 30 / 6
= 5
remaining students averaged score
would be:
Answer: 60

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Donald E. Stout, Jr
What Is Median?
Median
◆ It is determined rather than calculated,
the observations are ranked in order from
the smallest to the largest
◆ If the number of observations is odd, the
median is the middle number, (N + 1) / 2
◆ If the number of observations is even, the
median is the average of the two middle
numbers, {N/2 + (N/2 + 1)} / 2
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Median
◆ Middle-most Value
◆ 50% of observations are above the
Median, 50% are below it
◆ It is the value that divides the distribution
of values into two equal parts
◆ The difference in magnitude between the
observations does not matter
◆ Therefore, it is not sensitive to outliers
◆ The ways for computing the median depend on
the distribution of scores.
• First, if you have an odd number of scores
pick the middle score. (N + 1) / 2
• 1, 4, 6, 7, 12, 14, 18
• Median is 7
• Second, if you have an even number of
scores, take the average of the middle two.
{N/2 + (N/2 + 1)} / 2
• 1, 4, 6, 7, 8, 12, 14, 16
• Median is (7+8)/2 = 7.5
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Median Example Median

◆ What is the median of the following
scores: ◆ Not Affected by Extreme Values
10 8 14 15 7 3 3 8 12 10 9 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 12 14

◆ Sort the scores:

Median = 5
15 14 12 10 10 9 8 8 7 3 3 Median = 5
◆ Determine the middle score: The median is computed when data
middle = (N + 1) / 2 = (11 + 1) / 2 = 6 are highly skewed.
◆ Middle score = median = 9

17

Median Outlier
◆ Find the Median A number that is extremely large or small in
comparison to the rest of the set of data.
4, 5, 6, 6, 7, 8, 9, 10, 12
Ans: 7 Outliers can greatly affect the measures of
◆ Find the Median and Mean central tendency.
5, 6, 6, 7, 8, 9, 10, 100,000
Ans: Median - 7.5
Mean – 12,506

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Find the outlier(s)

1. 12, 22, 40, 17, 29, 72, 38 Outliers
2. 90, 80, 75, 7, 67, 82 Mean The data has no outliers
Median The data has outliers
3. 101, 210, 184, 18, 156, 989, 204

What Is Mode? Mode

◆ Find the value that occurs most
frequently in a set of observations
◆ If no value is repeated within the set of

observations, then there is no mode

◆ Mode is determined rather than

calculated, determined by counting the

number of times each individual value
occurs
NOT THIS !

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Mode Mode
◆ The mode is not a very useful measure of central
◆ Not Affected by Extreme Values tendency.
◆ Used for Either Numerical or
◆ It is insensitive to large changes in the data set.
Categorical Data ◆ That is, two data sets that are very different from
each other can have the same mode.
7
120
6
100
5
80
4
60
3
40
2

0 1 2 3 4 5 6 1 20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
0 0
Mode = 8 No Mode 1 2 3 4 5 6 7 8 9 10 10 20 30 40 50 60 70 80 90 100

26

Mode
Multimodal Distributions
• A distribution may have more than one mode 6
• For the given example, what are the modes? • If a distribution has
more than 2 “modes,” 5

it is called multimodal 4
Frequency

5
3
4
Frequency

3 2

2 1

1 0
75 80 85 90 95
0
33 34 35 36 37 38 39 40 Score on Exam 1

Score
28

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The Mode: An Example Considerations for Choosing a

◆ Example: Number of Votes for Candidates for
President. The mode, in this case, gives you
the “central” response of the voters: the most
popular candidate.
Candidate A – 11,769 votes
Candidate B – 39,443 votes
Candidate C – 78,331 votes
Answer: Candidate C
Measure of Central Tendency
◆ For a nominal variable, the mode is the only
measure that can be used.
◆ For ordinal variables, the mode and the
median may be used. The median provides
more information (taking into account the
ranking of categories.)
◆ For interval-ratio variables, the mode, median,
and mean may all be calculated. The mean
provides the most information about the
distribution, but the median is preferred if the
distribution is skewed.

Questions:
Matching! What is the best measure of central tendency to be
used in the following cases:
Mean Middle 1. Enumerate the top ten cases of morbidity and
mortality in the Phil.

Median Average
2. What is the most sellable brand of rubber shoes in the
dept. store?
3. What is the favorite ice cream flavor of this class?
Mode Most 4. What is the representative wt. and ht. of this class?
5. What is the income of all the hospital personnel in
Fatima University Medical Center?
6. What is the IQ of this class?

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Donald E. Stout, Jr
Case:
• Consider a company that has nine employees with
salaries of 35,000 a year, and their supervisor
makes 150,000 a year.
• What is the typical salary in this company, which
measure of central tendency will be used?
• Answer:
IF THE DISTRIBUTION IS NORMAL
– Mean is the best measure of central
tendency
– Most scores “bunched up” in middle
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Symmetry in Data Sets
The analysis of a data set often depends on whether the
distribution is symmetric or non-symmetric.
Symmetric distribution: the pattern of frequencies from a
central point is the same (or nearly so) from the left and
right.
Symmetry in Data Sets
Non-symmetric distribution: the patterns from a central
point from the left and right are different.
Skewed to the left: a tail extends out to the left.
Skewed to the right: a tail extends out to the right.
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Skewed distributions Skewed distributions

A positively skewed distribution
median

40
35
30

No. of People
25
20
15
10
5
0
0 20 40 60
mode 80 100 120 140 160 180 200 220 240
Income in 1,000s
mean

Relations Between the Measures of

Skewed distributions Central Tendency
• A negatively skewed distribution • In symmetrical
median distributions, the median
and mean are equal
– For normal distributions,
7
6
mean = median = mode
5 • In positively skewed
No. of People

4
3 distributions, the mean is
2
greater than the median
1
0

• In negatively skewed
0 20 40 60 80 100

Test score

mean
mode
distributions, the mean is
smaller than the median
40

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Donald E. Stout, Jr
Questions:
The mean is 51.5, the median is 60.
Answer: negatively skewed
The mean is 36.1, the median is 30.
Answer: positively skewed
Desired result of your examination.
Answer: negatively skewed
Statistics
The Concept of Dispersion: Examples
◆ Typically, a large city will have more
diversity than a small town.
◆ Metro Manila are more racially diverse
than others (Cebu, Davao).
◆ Some students are more consistent than
others.
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Measures of Dispersion
Measures of Central Tendency don’t tell
us everything.
Dispersion/Deviation/Spread tells us a
lot about how a variable is distributed.
Dispersion shows us how much these
figures/variables differ from the
average.
◆ Measures of dispersion are descriptive
statistics that describe how similar a set
of scores are to each other
• The more similar the scores are to each
other, the lower the measure of dispersion
will be.
• The less similar the scores are to each
other, the higher the measure of dispersion
will be.
• In general, the more spread out a
distribution is, the larger the measure of
dispersion will be.
44
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Measures of Dispersion Measures of Dispersion

Dispersion
◆ Which of the 125
100
distributions of 75
Range Variance Standard Coefficient
50
scores has the 25 Deviation of Variation
0
larger dispersion? 1 2 3 4 5 6 7 8 9 10

The upper distribution has 125

more dispersion 100
◼ Measures of dispersion
because the scores are 75 give information on the
50
more spread out. 25
spread or variability of
That is, they are less similar
0 the data values.
1 2 3 4 5 6 7 8 9 10
to each other
Same center,
45 different variation

What Is Range? Range

◆ Difference between the largest and the smallest
observations:
Range = X Largest − X Smallest
◆ Ignores how data are distributed:

Range = 12 - 7 = 5 Range = 12 - 7 = 5

7 8 9 10 11 12 7 8 9 10 11 12

◆ Sensitive to extreme observations.

◆ Gives an idea of the variability very quickly.
◆ Suffers from a serious drawback considers only 2 values
and neglects all the other values of the series.

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Compute for the Range:

When To Use the Range
◆ The range is used when:
• you are presenting your results to Daily High Temperatures (for any given date) Over the Last Decade
people with little or no knowledge of 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
statistics. 59 50 49 13 40 46 50 53 58 47
◆ The range is rarely used in scientific
work as it is fairly insensitive.
◆ Usually used in daily temperature
59° - 13° = 46°
fluctuations or price movement.

49

Coefficient of variation Coefficient of Variation

◆ Is a measure of relative variability used
to: ◆ It indicates the spread of values
• measure changes that have occurred in a around the mean by a percentage.
population over time
• compare variability of two populations that
are expressed in different units of
measurement Standard Deviation x 100
Coefficient of variation =
• expressed as a percentage rather than in mean
terms of the units of the particular data
51

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Donald E. Stout, Jr
Things you need to know
◆ The higher the Coefficient of
Variation the more widely spread
the values are around the mean.
◆ The purpose of the Coefficient of
Variation is to let us compare the
spread of values between
different data sets.
Coefficient of Variation
◆ C.V.(day) = (3.4/27) x 100 = 12.6%
and C.V.(night) = (8/94) x 100 = 8.5%
◆ Which section has the greatest
variation or dispersion of scores?
◆ Answer: Day section
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Coefficient of Variation
◆ For example, Mark teaches two sections of
statistics. He gives each section a different test
covering the same material. The mean score on
the test for the day section is 27, with a standard
deviation of 3.4. The mean score for the night
section is 94 with a standard deviation of 8.0.
Day Section....................Night Section
Mean.........27....................................94
S.D............03.4.................................08.0
Variance
◆ Variance is defined as the average
of the square deviations:
 (X −  )
2
2 =
N
- Important Measure of Variation
- Shows Variation About the Mean
- Sensitive to Extreme Observation
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Properties Standard Deviation

◆ It has squared units … which leads to
defining the standard deviation.
◆ It is always nonnegative, and equals zero if
and only if all the observations are identical.
◆ The larger the variance is, the more the
scores deviate, on average, away from the
mean
◆ Most Important Measure of Variation
◆ Shows Variation about the Mean
◆ Has the Same Units as the Original Data
◆ It is simply the square root of the
variance
N

( X −)
2
◆ The smaller the variance is, the less the i

scores deviate, on average, from the mean = i =1

57

What does it measure? Standard deviation

◆ It measures the dispersion (or spread)
of figures around the mean.
• Standard deviation tells us a lot about
a distribution, particularly if that
◆ A large number for the standard
distribution is normally distributed.
deviation means there is a wide spread
of values around the mean, whereas a • It tells us that about 68% of all values
small number for the standard deviation will fall within 1 SD of the mean,
implies that the values are grouped close 95% fall within 2 SDs and 99.7% fall
together around the mean.
within 3 SDs.

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Properties of the Normal Distribution:

The Normal Curve:
1. It is bell-shaped and unimodal.

The Normal curve is a mathematical abstraction

which conveniently describes ("models") many
frequency distributions of scores in real-life.

2. It's symmetrical around the mean. Data

3. The mean, median and mode all
values concentrate around the mean.
have same value.

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Relationship between the normal curve

The standardized normal and the standard deviation:

=0
=1

frequency
68%

95%
x scale -3 -2 -  + +2 +3
99.7%
z scale -3 -2 -1 0 +1 +2 +3

-3 -2 -1 mean +1 +2 +3
Number of standard deviations either side of mean

SD and the Normal Curve SD and the Normal Curve

About 68% of About 68% of
scores fall X = 70 scores fall
X = 70 within 1 SD SD = 10 between 60
SD = 10 34.1% 34.1% of mean 34% 34% and 80

60 70 80 60 70 80

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SD and the Normal Curve SD and the Normal Curve

About 95% of About 95% of
X = 70 X = 70
scores fall scores fall
SD = 10 SD = 10
within 2 SD between 50
of mean and 90
34.1% 34.1% 34.1% 34.1%

13.6% 13.6% 13.6% 13.6%

50 60 70 80 90 50 60 70 80 90

SD and the Normal Curve SD and the Normal Curve

About 99.7% About 99.7%
X = 70 X = 70
of scores fall of scores fall
SD = 10 SD = 10
within 3 S.D. between 40
of the mean and 100
34.1% 34.1% 34.1% 34.1%

13.6% 13.6% 13.6% 13.6%

2.3% 2.3% 2.3% 2.3%

40 50 60 70 80 90 100 40 50 60 70 80 90 100

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Example: Example:
◆ The distribution of raw scores of second year
Fatima students is approximately normally ◆ Group of boy scouts with a mean weight
distributed with mean of 100 and standard of 30 kg. and SD of 4 kg. Get the
deviation of 10. Get the distribution of score in
68%, 95%, and 99.7%
distribution of weight in 68%, 95%, and
99.7%
◆ Ans: 68% - 26 to 34 kg
95% - 22 to 38 kg
99.7% - 18 to 42 kg

Measures of Relative Standing Measures of Relative Standing

A. Percentiles
◆ Measures of relative standing
B. Z scores tell us something about a given
score by reporting how it relates
to other scores.

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Measures of Relative Standing

- Percentiles - the distribution is divided into
Example
100 equal parts with the median at the 50th
percentile.
In a set of 200 observations, if
-The 50th percentile is that observation or a number X is larger than 150
number that has 50% of the observations of the observations, then X is at
below it and the other 50% above it ; this is
simply the ‘middle’ observation when the set the 75th percentile (150/200 =
of observations are arranged in order of 75th).
magnitude.
- The most commonly used percentiles are the
25th, 50th and 75th percentiles.
Statistics

The Z-Score
What is the
percentile ◆ Each group has a distribution—but in their original
rank for a form, the groups are not comparable
score of 6? ◆ Each original score can be converted to a z-score,
How many which is a standard score that can be compared
scores fall at across groups
or below a z=(x-mean)/s
6? • z=z-score
(9 scores) • x=score

9/15 = 60th • mean=mean of the distribution

• s=standard deviation of the distribution

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What is a z-score?
• A measure of an observation’s distance from
the mean. ◆ If a z-score is zero________________
• The distance is measured in standard
deviation units.
• If a z-score is zero, it’s on the mean.
• If a z-score is positive, it’s above the mean.
• If a z-score is negative, it’s below the mean.
• If a z-score is 1, it’s 1 SD above the mean.
• If a z-score is –2, it’s 2 SDs below the mean.

Statistics

◆ If a z-score is zero________________ ◆ If a z-score is zero,_____________

◆ If a z-score is positive,_____________ ◆ If a z-score is positive,_____________

◆ If a z-score is negative,_____________

Statistics Statistics

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◆ If a z-score is zero,_____________ ◆ If a z-score is zero,_____________

◆ If a z-score is positive,_____________ ◆ If a z-score is positive,_____________

◆ If a z-score is negative,_____________ ◆ If a z-score is negative,_____________

◆ If a z-score is 1,_________________ ◆ If a z-score is 1,_________________

◆ If a z-score is -2,_________________

Statistics Statistics

Characteristics, Continued
◆ Given the standard distribution of scores
within a normal curve, the following
statements are true:
• 84% of the scores fall below z-score of 1
• 16% of the scores fall above z-score of1
◆ The more extreme the z-score, the
farther it is from the mean

Statistics

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Example: Application
For instance, if Steph Curry scored a 70 on ◆ If Step Curry got a z score of 2 on that
a test with a mean of 50 and a standard test, what can we say about his score
deviation of 10, converting the test relative to others who took the exam?
scores to z scores, an X of 70 would be: A. it is above average
Ans: Z = (70 – 50) / 10 = 2 B. it is average
C. it is below average
D. I don’t know

Standard score example:

- You want to compare your performance on your
first and second prelims exams
- On the first exam you score 84, the class mean is
80 with SD of 4
- On the second exam you score 70, the class
mean is 60 with SD of 7
- Comparison of scores:
Exam 1: Z = (84 – 80) / 4 = 1
Exam 2: Z = (70 -60) / 7 = 1.43
Question: Which among these two exams did you
perform well?
Statistics

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Example two tests:

Test A: Fred scores 78. Mean score = 70, SD = 8.
Test B: Fred scores 78. Mean score = 66, SD = 6.

Did Fred do better or worse on the second test?

Statistics

Test A: as a z-score, z = (78-70) / 8 = 1.00

Test B: as a z-score , z = (78 - 66) / 6 = 2.00
Question:
◆ If a raw score is 8, the mean is 10 and
Conclusion: Fred did much better on Test B. the standard deviation is 4, what is the z-
score?
A. -1.0
B. -0.5
C. 0.5
D. 2.0

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Question: If we have 480 scores, normally

Exercise distributed with a mean of 60 and an SD of
On their third test, the class average was 45 and 8, how many percent would be a score of
the standard deviation was 6. Fill in the rest. 76 or above?

Test 3 Z-Score
Peter 57
John 39
Question: Same data above, how many
Paul -1.5 percent would be a score of 52 or less?
Mary 1.3

Statistics Statistics

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Question: Question:
If a distribution is normally distributed, ◆ What percentage of scores falls below
about what percent of the scores fall zero in the standard normal distribution?
below +1 SD? A. zero
A. 15 B. fifty
B. 50 C. seventy five
C. 84 D. one hundred

D. 99

Question: The standardized normal

◆ If the area under the curve =0
between X1 and X2 is 0.495, =1
what is the area between Z1
and Z2?
x scale -3 -2 -  + +2 +3
Answer: 0.495
z scale -3 -2 -1 0 +1 +2 +3

Statistics

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Questions about z scores

QUESTIONS OR COMMENTS??
• Any distribution of raw scores can be converted to a
distribution of z scores

the mean of a distribution has a z

zero
score of ____?

positive z scores represent raw scores

above
that are __________ (above or below) the
mean?
negative z scores represent raw scores
below
that are __________ (above or below) the
mean?

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At the end of the lecture the student is expected to

INFERENTIAL STATISTICS 1. Define the following terms

ARNEL G. SYQUIA, MD
1.1 Population
MA. LORENA LORENZO, MD
1.2 Sample
RONWALDO SAN DIEGO, MD 1.3 Parameter
BILLY A. GOCO, MD 1.4 Statistic
MARIE RUTH ECHAVEZ, MD 1.5 Statistical inference
JENA ANGELA PERANO, MD 1.6 Confidence interval
MACARIO REANDELAR JR., MD 1.7 Confidence limits
JENELL Y. OCZON, MD 1.8 Confidence coefficient

2. Discuss methods of estimation of population

4. Illustrate hypothesis testing for a given data
parameters
2.1 Point estimate 5. Explain the rationale for test of significance
2.2 Interval estimate 6. Apply z-test:
6.1. Testing a hypothesis concerning a population
3. Explain the following terms in relation to hypothesis mean
testing 6.2 Testing significance of the difference between 2
3.1 Statistical Hypothesis means
3.2 Null hypothesis
7. Interpret results of tests of significance
3.3 Alternative hypothesis
3.4 Statistical test 8. Differentiate alpha error from beta error in different
3.5 Level of significance situations
3.6 Critical region

1

9. Discuss chi-square test as to
9.1 sampling distribution of proportions and the
difference between 2 proportions
9.2 definition of contingency table, observed and
expected frequency
9.3 Assumptions, uses and limitations
9.4 Formula, computation and interpretation of results
Inferential Statistics
Because we only study a sample, we are prone to
making an error.
And we call this error, sampling error.
The magnitude of the error can be accurately
specified.
5/12/2021
Inferential Statistics
The process of generalizing and making conclusions
about a target population based on results from a
sample.
We rarely observe the general population.
We only take a sample from that population, collect
data from the sample and make conclusions about
the target population based on the results from the
sample.
Inferential Statistics
To understand how we come up with a
generalization notwithstanding sampling error, we
have to understand sampling distribution of means.
It forms the basis for Inferential Statistics.
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Sampling Distribution Of Means

Mean IQ Number of students
Sampling Distribution Of Means 92 1
93 2
Suppose we want to estimate the mean IQ of the 94 2
medical students of OLFU. 95 3
96 6
If we were to get a sample of 50 students, get the 97 8
98 9
IQ of each one and compute the mean, we can get 99 9
an estimate of the mean IQ. 100 11
101 11
If we repeat the process 100 times, i.e., get a 102 9
sample of 50 students, get the IQ of each one and 103 9
104 7
compute the mean, we would create a distribution of 105 5
mean IQ’s. 106 4
107 2
108 1
109 1
𝝁ഥ𝒙=100.5 N= 100

Sampling Distribution Of Means Characteristics of a Sampling Distribution of Means

The sampling distribution of means approximates a normal
The Table shows the distribution of the different
curve.
mean IQ’s for the 100 samples of 50 students.
true of all sampling distributions of means regardless of
The table looks like a frequency distribution; in fact it
the shape of the distribution of the population from
really is a frequency distribution.
which the means are drawn, as long as the sample size
But because what we have in the table is a is reasonably large (over 30).
distribution of sample means, it is more
If the population is normally distributed to begin with,
appropriately called the sampling distribution of
then the distribution of sample means is normal
means.
regardless of sample size.
This is known as the central limit theorem.

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Characteristics of a Sampling Distribution of Means Characteristics of a Sampling Distribution of Means

 The mean of a sampling distribution of means (the
mean of all means) is equal to the true population
mean.
The mean of the sampling distribution of means is
the same as the mean of the population from
which it was drawn.
 The standard deviation of the sampling distribution of
means is much smaller than the standard deviation of
the population.
The sample means are more stable, i.e., less variable,
than the individual scores in the population.

The mean of all sample means will be denoted by The standard deviation of the sampling distribution of
this symbol, means is known as the standard error of means, and
is symbolized by,
X X

Sampling Distribution of Means

Sampling Distribution of Means Mean IQ Number
92 1
93 2
Note that in the Sampling Distribution of Means, the 94 2
lowest IQ is 92 and the highest is 109. 95 3
96 6
In the total population of the medical students, there 97 8
are students whose IQ’s are much lower than 92 and 98 9
99 9
there are those that are much higher than 109. 100 11
The standard deviation therefore of the Sampling 101 11
102 9
Distribution of Means will be much smaller than the 103 9
population standard deviation. 𝝁𝒙ഥ =100.5 104 7
105 5
𝝈=5.19 106 4
107 2
108 1
109 1

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Sampling Distribution Of Means Sampling Distribution Of Means

Histogram of the Sampling Distribution of Means of A theoretical distribution, it is, normally distributed,
IQ's of 100 sets of Samples (first property)
12 Thus we can use the z score formula to find the
10 probability of occurrence of any one sample mean
8 under the curve.
6

Sampling Distribution Of Means Sampling Distribution Of Means

The standard deviation of the sampling distribution To illustrate, if we know that the population standard
of means, known as the standard error of the mean, deviation (σ) of IQ’s to be 36.7, we can derive the
can be derived by dividing the population standard standard deviation of the sampling distribution of
deviation by the square root of the sample size. means or the standard error, in a sample of 50
students,

X = 𝜎 36.7
n 𝜎 = =
𝑛 50
𝜎 = 5.19

5
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Inferential Statistics Applications of the Sampling Distribution of Means

Two main problems that are tackled in inferential ESTIMATION

statistics
The process of computing for measures of population
Estimation attributes or estimating the value of a parameter
1.1 Point estimate based on data from a sample
1.2 Interval estimate
Hypothesis testing
2.1 Qualitative data
2.2 Quantitative data

Point Estimate Applications of the Sampling Distribution of Means

Estimation (Mean)
A single numerical value used to estimate the
corresponding population parameter
No associated probability indicating how likely the
result is obtained
We can estimate the mean IQ of the medical
students of OLFU, by collecting say a sample of
50 medical students from the University.
Suppose we find the mean to be 98. We then
say the mean IQ of the medical students is 98.
We are giving a point estimate of the mean
IQ.
The point estimate is a single numerical value
used to approximate the population parameter.

6
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Interval estimate
Applications of the Sampling Distribution of Means
An estimate of a parameter which is expressed as a
Levels of Confidence Intervals and their corresponding
range of numbers
z-value
Confidence Interval z-value
In an interval estimate the parameter is specified as
being between two values 90% 1.64

95% 1.96
The estimate has an upper limit and a lower limit
defining an interval which is expected to include 99% 2.58
the parameter being estimated according to varying
degrees of confidence

Confidence levels
Purpose of interval estimate

To indicate the precision / imprecision of the sample

study estimates as population values

Imprecision is indicated by the width of the

confidence interval (CI)

The wider the interval, the less precise

7

Confidence Limit
The range within which the population value of
some measure falls with a certain degree of
certainty
Factors that determine the width of the Confidence
interval
1. Sample size
A larger sample size will give more precise results with
narrower confidence interval
2. Variability of the characteristics being studied
The less variable the characteristics, the more precise.
3. Degree of confidence required
the greater the confidence, the wider the interval
Note: The interval however may or may not contain the
parameter
5/12/2021
Confidence Coefficient / Confidence Level
The degree of reliability one may place in the estimate
of the parameter
The probability that the interval estimate will contain
the parameter assuming that a large number of
samples are selected and the estimation process on
the same parameter is repeated
Applications of the Sampling Distribution of Means
Estimation (Interval Estimate)
How confident are we in making our estimate?
Knowing that Z=  1.96 standard deviations about the
mean comprises about 95% of the total population, we
can make a computation and say that the mean IQ of
the students of OLFU ranges from for example 87.8 to
108.2 and we are 95% sure of the figures.
We use z-test to estimate the confidence interval when
the population standard deviation is known.
8
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Confidence Interval Applications of the Sampling Distribution of Means

Formula for calculating Confidence Interval (CI)
Estimation
𝐶𝐼 = 𝑥ҧ ± 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐𝑎𝑙 𝑡𝑒𝑠𝑡 𝑥 𝑆𝐸 Standard error
The range of values that we give is what we call
𝜎
𝐶𝐼 = 𝑥ҧ ± 𝑧
𝑛
an Interval Estimate.
36.7 An interval estimate consists of two numbers, a
𝐶𝐼 = 98 ± 1.96 50 lower limit and an upper limit, within which the
𝐶𝐼 = 98 ± 1.96(5.19) parameter is expected to lie with a certain degree
𝐶𝐼 = 98 ± 10.2 (margin of error) of confidence, in the above example, 95%
confidence.
𝐶𝐼 = 87.8 − 108.2

Estimation and the t-Distribution Estimation and the t-Distribution

To illustrate, suppose a researcher does not know the
When we do not know the population standard
population standard deviation of the IQ’s of the medical
deviation, we use the t-test rather than the z-test .
students.
We estimate the standard error of the mean by using
He gets a mean IQ of 98 from a sample of 50 students
the sample standard deviation
and a standard deviation of 18.
Thus for cases in which the standard error of the
He can then construct the 95% confidence interval of the
mean is estimated, we can construct confidence
mean estimate, using the t-test.
intervals using an appropriate t value from the t
table.

9
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Estimating Proportions Estimating Proportions

Proportions too have their sampling distributions. PQ

p =
Like the sampling distribution of means, the sampling n
distribution of proportions is normally distributed. where σP = standard error of the proportion
Just as we can derive the standard error of the mean, P = a sample proportion
so too can we derive the standard error of the
proportion σP by the formula Q=1–P
PQ n = sample size
p =
n

Estimating Proportions Standard error of the Proportion

To illustrate,
PQ
Suppose another researcher is interested in p =
determining the proportion of Medical Technology n
students who are positive for Hepatitis B surface
antigen (HbsAg). p =
0.12 * 0.88
He takes a sample of 50 students and finds 6 50
students to be positive, proportion = 0.12, (6/50).  p = 0.0460

10

Estimating Proportions
We used the t distribution previously in constructing
the confidence interval for the population mean
when the standard deviation was unknown.
When dealing with proportions we use the z-test for
constructing confidence intervals for the population
proportion.
Hypothesis Testing
Ideas that researchers have on the nature of disease
or disease determinants are what we call hypotheses
Frequently expressed in a statement of relationship
between at minimum two variables, an independent
variable and a dependent variable.
5/12/2021
Estimating Proportions
Thus the 95% confidence interval for the proportion
of medical technology students positive for HbsAg is
95% Confidence Interval = P  z (σP)
95% Confidence Interval = 0.12  1.96(0.0460)
= 0.12  0.09 (margin of error)
= 0.03 to 0.21
Steps in Hypothesis Testing
1. Stating the null hypothesis Ho and the alternative
hypothesis Ha;
2. Stating the level significance, ; and the critical
region
3. Choosing the statistical test; Computing the test-
statistic;
4. Making a decision;
5. Drawing a conclusion about the population.
11

Steps in Hypothesis Testing
Step 1. Stating the null hypothesis Ho and the alternative
hypothesis Ha
Two hypotheses are normally made regarding a
supposed relationship:
 the null hypothesis, denoted as Ho, and
 the alternative hypothesis, denoted as Ha.
Hypothesis Testing - Null Hypothesis (Ho)
Any observed difference that may arise between two
independent variables being compared can be
regarded as a chance occurrence resulting from
sampling error alone.
Therefore, an obtained difference between two
sample means does not represent a true difference
between their population means.
5/12/2021
Hypothesis Testing - Null Hypothesis (Ho)
The hypothesis of no difference.
A statement of “no difference” or “no effect”
between a parameter and a specific value or
that there is no difference between 2 parameters
Hypothesis Testing – Alternative Hypothesis (Ha)
The alternative hypothesis is the hypothesis that the
researcher hopes to prove.
It states that there exists a difference in the two
sample means and the difference is not just due to
sampling variability alone.
There are two ways of stating an alternative
hypothesis: a two-tailed Ha and a one-tailed Ha.
A two-tailed Ha is also known as a non-directional
alternative hypothesis and a one-tailed Ha,
directional alternative hypothesis.
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One-tailed test (Directional Test)

The purpose is to test only whether the sample value is
 indicates that the null hypothesis should be larger (right sided) or smaller (left sided) than the mean
rejected when the test value is in the critical in the population
region on one side of the mean

used when investigators have an expectation

about the sample value

Two-tailed test (Non-directional Test)

indicates that the null hypothesis should be rejected

when the test value is in either of the two critical
regions

Appropriate when investigators do not have prior

expectation for the value in the sample

They want to know if the sample mean differs from

the population mean in any direction

13

Example
Objective: To determine the relationship between sex
and IQ.
One-tailed Ha: Females are more intelligent than
males. Or Females have higher IQ than males.
Two-tailed Ha: (?)
Answer: There is a difference in IQ between females
and males
One-tailed test (Directional Test)
5/12/2021
Two-tailed test (Non-directional Test)
indicates that the null hypothesis should be rejected
when the test value is in either of the two critical
regions
Appropriate when investigators do not have prior
expectation for the value in the sample
They want to know if the sample mean differs from
the population mean in any direction
 One-tailed test (Directional Test)
 indicates that the null hypothesis should be rejected
when the test value is in the critical region on one
side of the mean
used when investigators have an expectation about
the sample value
14
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Steps in Hypothesis Testing

The purpose is to test only whether the sample value
is larger (right sided) or smaller (left sided) than the
mean in the population
Step 2. Stating the level of significance , the critical value
and critical region
The level of significance  is the level of probability at
which the null hypothesis can be rejected with
confidence.
We decide to reject the null hypothesis if the probability
that the difference between two sample means is just
due to sampling error alone, is very small, say 5 out of
100 or 0.05, i.e., probability = < 0.05.

The 0.05 level of significance can be graphically

depicted in the Figure below

As shown, the 0.05 level of significance is found in

the small areas of the tails of the distribution of
mean differences.
Region of non
rejection These are the areas under the curve that represent a
distance of ±1.96 SD from a mean difference of zero
Region of
rejection

Critical value Critical value

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The level of significance , critical value and the critical The level of significance , critical value and the critical
region region

Critical value separates the critical (rejection ) region

from the non critical (non-rejection) region
Areas of acceptance and rejection are determined by
the value chosen for α
The critical region is the area in either tail determined
by the alpha level of significance.
It indicates that there is a significant difference and
That the null hypothesis should be rejected

Thus in the Figure below the areas equal to and beyond

±1.96 constitute the critical region of rejection.
In probability terms the areas equal to or less than 0.05
represent the area where we reject the null hypothesis. The non critical or non-rejection region
The range of values that indicates that the difference
was probably due to chance and
That the null hypothesis should not be rejected
Region of non
rejection

Region of
rejection

Critical value Critical value

16

The level of significance  and the critical region
The level of significance  can be set up for any
degree of probability, 0.01, 0.05, 0.10.
The 0.01 level of significance is represented by the
area that lies 2.58 standard deviations in both
directions from a mean difference of zero.
A more lax alpha can be setup, 0.10 and is
represented by the area that lies 1.64 standard
deviation in both direction from the mean difference
of zero.
Alpha Error
If we reject the null hypothesis at the 0.05 level of
significance and conclude for example that there is a
difference in IQ between females and males, then
there are 5 chances out of 100 that we can be
wrong.
In other words, P = 0.05 that we can commit Type I
error, and that there is really no difference in IQ
between females and males.
5/12/2021
The level of significance  and the critical region
Whenever we decide to reject the null hypothesis at
a certain level of significance, we open ourselves to
the chances of making the wrong decision.
Rejecting the null hypothesis when we should have
accepted it is known as Type I error.
A Type I error can only arise when we reject the null
hypothesis, and its probability varies according to the
level of significance we choose.
Alpha Error
Likewise, if we choose the  = 0.01 level of
significance, there is only 1 chance out of 100
(P=0.01) of making the wrong decision regarding the
difference in IQ between genders.
Obviously, the more stringent our level of
significance (the farther out in the tails it lies), the
less likely we are to make Type I error.
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Beta Error
Decision
The smaller the level of significance alpha we choose Accept Ho Reject Ho
Reality
however, the greater the risk of making another kind
Type I error
of error known as Type II error. Ho is true Correct Decision
P (Type I error) = 
This is the error of accepting the null hypothesis Type II error
when it should be rejected. Ho is false Correct Decision
P (Type II error) = 
One method for reducing the risk of committing Type
II error is to increase the sample size.
The probability of Type II error is denoted by 
(beta).

Steps in Hypothesis Testing

Four possible outcomes in hypothesis testing
1. The null hypothesis is False and is rejected
2. The null hypothesis is True and is not rejected α = the probability of incorrectly rejecting the null
hypothesis when it is actually true (Type I error)
3. The null hypothesis is true and it is rejected (Type I α
error)
Arbitrary significance levels: 0.10 0.05 0.01
4. The null hypothesis is false but is not rejected (Type II When α = 0.10, there is 10% chance of rejecting a true
β error) null hypothesis
When α = 0.05, there is a 5% chance of rejecting a true
null hypothesis
An “error” in an observation does not refer to an error in
When α = 0.01, there is a 1% chance of rejecting a true
the sense of a mistake but rather to the deviation of
null hypothesis
the individual observation from the typical

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Steps in Hypothesis Testing

Step 3. Choosing the statistical test; Computing the test
statistic
For greater validity
Statistical test uses the data obtained from a sample
to make a decision about whether the null
If the difference is significant, the null hypothesis is rejected;
if it is not, then the null hypothesis is not rejected hypothesis should be rejected

The numerical value obtained from the statistical test

is called the test value

Statistical Test
Test for quantitative data (Parametric data)
The z – test is used for quantitative variables when
the population standard deviation is known. Tests used for hypothesis concerning means
The t – test is used for quantitative variables when
the population standard deviation is unknown. These are tests for the difference between 2
For qualitative variables, chi-square test is used. means

Examples: z-test, t-test

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Steps in Hypothesis Testing Making The Decision

Step 4. Making a decision to reject or not to reject the null
hypothesis
The decision to be made is whether we reject the
null hypothesis or we don’t.
If the value of the statistical test (or the calculated
statistical test) equals or exceeds the critical region
(or the tabulated statistical test), we reject the null
hypothesis.
Otherwise we don’t.
With statistical software, making a decision whether
to reject or not to reject the null hypothesis can be
seen in the p-value that stat software shows.
If the p-value is equal to or less than the level of
significance alpha which the investigator has chosen
(either 0.01, 0.05, 0.10), then we decide to reject
the null hypothesis .
Otherwise we don’t.

Statistical significance
Guideline for judging the statistical significance of a
p - value
p – value
If 0.01 < p < 0.05 The difference is significant
 The probability of getting a sample statistic or a more Reject the null hypothesis
extreme sample statistic in the direction of the
alternative hypothesis when the null hypothesis is true 0.001 < p < 0.01 The difference is highly significant
Reject the null hypothesis
 The probability that the observed result is due to
chance alone p < 0.001 The difference is very highly
significant Reject the null
hypothesis

20

0.05 < p < 0.10 The difference is not statistically
significant . Consider the consequences of
type I error before rejecting the null hypothesis
p > 0.10 The difference is not significant.
Do not reject the null hypothesis
 Rejection or non-rejection of the null hypothesis is
made on the basis of the value obtained from the
statistical rest
 If the test value falls in the region of rejection, the null
hypothesis is rejected
 If the test value falls in the region of acceptance, the
null
hypothesis is not rejected
5/12/2021
*These are not hard and fast rules.
Some researchers do not choose an α but report the p-
value and allow the reader to decide whether the null
hypothesis should be rejected
Others decide on the α value in advance and use the p-
value to make the decisions
Steps in Hypothesis Testing
Step 5. Drawing a conclusion about the population
The conclusion that we make is based on the
decision that we reach.
If our decision is to reject the null hypothesis, then
we say that there is enough evidence to suggest that
there is a difference in the independent variables
that we compare.
 Otherwise we say there is not enough evidence to
say that there is a difference.
21
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Applications Test of Two Means – Population

Standard Deviation Known
 A researcher is interested in finding out whether there
exists a difference in the mean IQ of females and males.
 He took a sample of 50 females and 50 males.
 The mean IQ for females was calculated to be 102 and
that of the males, 98.
 Suppose that population standard deviation σ was
known to be 15 for both males and females.
 Test the hypothesis that there exists a difference in the IQ
between sex.

Test of Two Means – Population Test of Two Means – Population

Standard Deviation Known Standard Deviation Known
Following the steps enumerated above, we now The alternative hypothesis stated above is a
test the hypothesis. two-tailed alternative hypothesis.
Ho: There is no difference in the IQ between females Thus the critical region is equal to or beyond 
and males. 1.96 on either tail of the curve.
Ha: There exists a difference in the IQ between
And since the population standard deviation σ
females and males.
is known, the test statistics to be used in this case
Level of Significance,  = 0.05
is the z-test
Statistical Test: z-test
Critical Region: z >= 1.96

22
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Statistical test calculation Test of Two Means – Population

Standard Deviation Known
𝑥Ӗ 1−𝑥Ӗ 2 A difference of 4, (102 – 98) between the means
𝑧 =
𝜎𝑥ഥ −ഥ𝑥
1 2
for IQ of females and males falls +1.333 standard
deviation from the mean difference of zero in
the distribution of differences between means.
 where 𝜎𝑥ҧ 1−𝑥ҧ 2 is the standard error of the difference of 2
means A z-value of 1.333 is less than the critical region
𝜎12 𝜎2 152 152
of rejection of 1.96.
 𝜎𝑥ҧ 1−𝑥ҧ 2= + 𝑛2 = +
𝑛1 2 50 50 In probability terms, p-value=0.1836

102−98
𝑧 = = 1.33
3

Test of Two Means – Population Test of Two Means – Population

Standard Deviation Known
 Thus we accept the null hypothesis or we do not reject
the null hypothesis
 Conclusion: there is no sufficient evidence to suggest
that there is a difference in IQ between females and
males.
Standard Deviation Unknown
 Example: we use the same data previously on the
difference in IQ between females and males but here
the population standard deviation is unknown.
 Thus we use the sample standard deviation.
 Suppose that the sample SD s for females and males are
10 and 15 respectively.
 We compute for the standard error for the difference
between means.

23
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Test of Two Means – Population Test of Two Means – Population

Standard Deviation Unknown Standard Deviation Unknown
 We now use the steps in hypothesis testing.  The alternative hypothesis is two tailed.
 We test the hypothesis if there is difference in IQ  The test statistic to use is t test, and at α=0.05 and df = 50
between females and males. + 50 – 2 = 98, the critical region from the t table is t = 2.00.
 We said that the mean IQ for females is 102 with a
standard deviation s of 10 and for males, mean of 98
and a standard deviation s of 15.
 Use level of significance α = 0.05.

Test of Two Means – Population Test of Two Means – Population

Standard Deviation Unknown Standard Deviation Unknown
 49 *10 2 + 49 *15 2
 Statistical test to use is t-test
 Formula: t = x1 − x 2( ) (
s x1 − x2 = 

 50 + 50 − 2
)*(5050+* 5050)
( s x1 − x 2 )
s x1 − x 2 = 2.55
 s 2 (n − 1) + s2 2 (n2 − 1)   n1 + n2 
s( x1 − x2 ) =  1 1 *
  nn 

 n1 + n2 − 2   1 2 

24
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Test of Two Means – Population Test of Two Means – Population

Standard Deviation Unknown Standard Deviation Unknown
 Calculating now the t ratio for our data we get  The t value of 1.57 is much smaller than the critical
t=
(102 − 98) region of 2.00.
2.55  In probability terms, the p-value >0.05
 We therefore decide to accept the null hypothesis or
t = 1.57 not to reject the null hypothesis.
 And we conclude that there is not enough evidence to
say that there exists a difference in the IQ between
females and males.

Paired t-test Paired t-test

Subject Before After Difference
1 300 312 -12
 A Researcher wants to test the hypothesis that swimming 2 201 242 -41
can increase the Peak Expiratory Flow rate (PEFR) of 3 232 340 -108
asthmatic individuals. Thus he randomly selects 9
4 312 388 -76
asthmatics, takes the baseline PEFR then asks them to
swim for about 30 minutes. He takes another PEFR 5 220 296 -76
measurement post swimming. Level of significance is 6 256 254 2
0.05. Below is the table of the results. 7 328 391 -63
8 330 402 -72
9 231 290 -59
Mean 267.8 323.9 -56.1
SD 34.17

25
 5/12/2021

Paired t-test Paired t-test

 We then obtain the standard deviation of the difference  Test statistics used here is the t- test with this formula:
(d) for the distribution of before and after measurement
scores:

Is the standard error with the formula below:

Paired t-test Paired t-test

Level of significance is 0.05 Decision: Reject the Ho

The alternative hypothesis is one tailed. Conclusion: There is sufficient evidence to say
Critical region of rejection taken from the t-table that swimming can increase the PEFR of
is = 1.860 asthmatic patients.
Calculated t-test value is 4.93

26

Chi-Square
In the previous discussion we dealt with
outcomes (dependent variables) that are
quantitative.
Thus we compared means.
In the following discussion , we deal with
qualitative outcomes.
And we test the association between an
independent variable and a dependent
variable using chi-square (x2).
Chi-Square-One Way
Treatment Observed Frequency
A 22
B 28
C 18
D 15
E 17
Total 100
5/12/2021
Chi-Square-One Way
Suppose you want to test five levels of treatment
to 100 patients. You ask a research assistant to
make the randomization to the patients.
The research assistant hands out to you a
frequency distribution of the randomization.
Chi-Square-One Way
The table shows that 22 of the 100 patients
received Treatment A, 28, Treatment B, and so
on.
These are called the observed frequencies (o).
Observed frequencies refer to the set of
frequencies obtained in an actual frequency
distribution, that is, when we actually do a
research or conduct a study.
27

Chi-Square-One Way
You suspect that the research assistant did not
do the randomization properly.
You think that he probably has a preference for
one or two treatment levels
Chi-Square-One Way
Hypothesis Testing
Ho: The research assistant shows no tendency to
assign any particular treatment level from A to E.
Ha: He shows a tendency to assign a particular
treatment level from A to E.
5/12/2021
Chi-Square-One Way
Can you generalize from the distribution he
hands to you that he has a preference for one
particular treatment level or two?
Are the departures from an even distribution of
treatment levels large enough to indicate a real
preference for a particular choice?
Chi-Square-One Way
How will the distribution look like if there is
homogeneity in the allocation of the five
treatment levels?
28

Chi-Square-One Way
Expected Frequencies For an Even Distribution
Choices Expected Frequency
A 20
B 20
C 20
D 20
E 20
Total 100
Chi-Square-One Way
Chi-square statistic focuses directly on how close the
observed frequencies are to what they are
expected to be under the null hypothesis. The
formula for chi-square thus is:
( o − e) 2
x2 = 
e their
where o = observed frequency at any level
e = expected frequency at any level
5/12/2021
Chi-Square-One Way
Chi-square (X2) allows us to test the significance
of the difference between a set of observed
frequencies (o) and expected frequencies (e).
Obviously, the greater the differences between
the observed and the expected frequencies,
the more likely we have a significant difference
suggesting that the null hypothesis must be false.
Chi-Square-One Way
Notice that if all the observed frequencies were
equal to their respective expected frequencies,
as the null hypothesis suggests, chi-square value
will be equal to zero.
If all the observed frequencies were close to
respective expected frequencies,
consistent with the null hypothesis except for
sampling error, chi-square value will be small.
29

Chi-Square-One Way
The more the set of observed frequencies
deviates from the expected frequencies,
the larger the chi-square value.
At some point, the discrepancies of the
observed from the expected frequencies
can become larger than can be
attributed to sampling error alone.
At that point, chi-square is so large that
we are forced to reject the null
hypothesis and accept the alternative
hypothesis.
Chi-Square-One Way
In our example, the computed chi-square value
= 5.3
The tabulated chi-square value at 4 df and at
alpha of 0.05 is = 9.49.
The computed value is smaller than the
tabulated value.
The p-value = 0.258*.
*Note: This value is taken from a computer output.
5/12/2021
Chi-Square-One Way
Just how large the chi-square value is to
reject the null hypothesis?
The chi-square value must be compared
with a tabular chi-square at certain
degrees of freedom df and at a
particular alpha, level of significance.
If the chi-square value exceeds the
tabulated value, then we say, the chi-
square value is large enough to reject the
Ho.
Chi-Square-One Way
Thus we say that the value is not large enough
so as to reject the Ho.
The differences in the observed from the
expected frequencies are what we might
attribute to sampling variability or sampling error
alone.
30
 5/12/2021

Two Way Chi-Square Chi-Square

 Fortunately the principles behind one way chi-square
can well be applied to two way chi-square.
 The formula is basically the same.
 The only difference is now we will be dealing with an
independent variable and a dependent variable.
For example, suppose we want to find out if
there is a difference in the proportion of cases
with heart disease (dependent variable) among
those with various levels of snoring behavior
(independent variable).

Chi-Square Chi-Square
Relationship between Snoring and Heart Dse
Ho: There is no difference in the proportion of
Heart Snoring Behaviour
cases with heart disease across levels of snoring
behavior. Dse Nver Ocas Freq Alw Total
Ha: There is a difference in the proportion of cases
with heart disease across levels of snoring Yes 4 10 20 24 58
behavior.
No 196 190 180 176 742

Total 200 200 200 200 800

31
 5/12/2021

Chi-Square Chi-Square

Expected Frequencies Computed Chi-Square value = 18.66

Heart Snoring Behaviour Tabulated Chi-Square value = 7.815

Dse P-value = <0.001*
Nver Ocas Freq Alw Total

Yes 14.5 14.5 14.5 14.5 58 *Note: Taken from computer output
No 185.5 185.5 185.5 185.5 742

Total 200 200 200 200 800

Chi-Square Computer Output Chi-Square Computer Output

32

Chi-Square Computer Output
Note the footnote below the table that says 0%
of cells have expected count less than 5.
This is desirable. Because if more than 20% of
cells have expected count less than 5, then
computation of chi-square value becomes
unstable, making chi-square test not valid.
Chi-Square
In that case, levels may have to be combined
into some meaningful groupings so a two by two
table can be constructed.
The study on snoring is a 2 by 4 table. Snoring
has 4 levels. This can be made dichotomous by
combining never with occasional and frequent
with always.
5/12/2021
Chi-Square
When that happens, Fischer’s Exact test will be
used when both the independent and
dependent variables are dichotomous, i.e., a
two by two table.
Fischer’s Exact test cannot be used if either one
variable has more than two levels, (not
dichotomous).
Exercise #1
 You wanted to determine if there was a difference in the
fasting blood glucose (FBS) among apparently healthy
adults residing in the urban and in the rural areas. A
sample of 50 urban adults and 50 rural adults were
studied and the mean FBS for urban adults was 106 and
the rural adults, 102. Supposed that the population
standard deviation σ was known to be 15 among urban
adults and 10 among rural adults. Test the hypothesis
that there existed a difference in the FBS of urban and
rural adults. Use level of significance α = 0.05.
33

Exercise #1
Q: What kind of alternative hypothesis was
used?
A: Two-tailed alternative hypothesis
Q: What test statistics do you use?
A: Since the Population standard deviation is
known, statistical test to use is z-test.
Exercise #1
 Q: What is your conclusion?
 Choose the correct answer.
 A. There is no sufficient evidence to say that mean FBS in
the urban areas differs from that in the rural areas.
 B. There is no sufficient evidence to say that there is a
difference in mean FBS in the urban areas and in the
rural areas.
 A: B
5/12/2021
Exercise #1
Q: Critical region of rejection is 1.96 and
statistical test is calculated to be 1.57. What is
your decision?
A: Since the calculated statistical test is lower
than the critical region of rejection, we do not
reject the null hypothesis
Exercise #2
An examination was given to two Biostatistics
classes Sections A and B, consisting of 40 and 50
students respectively. In the Section A, the mean
grade was 78 and the standard deviation s of 7,
while in Section B, the mean grade was 74 with
a standard deviation s of 8. Test the hypothesis
that there was a difference in the performance
of the two sections. Use level of significance α =
0.05.
34

Exercise #2
Q: What kind of alternative hypothesis was
used?
A: Two-tailed alternative hypothesis
Q: What test statistics do you use?
A: Since the Population standard deviation is
unknown, statistical test to use is t-test.
Exercise #2
Q: What is your conclusion?
Choose the correct answer.
A. There is no sufficient evidence to say that the
mean grade in Section A differs from that in
Section B.
B. There is no sufficient evidence to say that
there is a difference in mean grade in the two
sections.
A: B
5/12/2021
Exercise #2
Q: Critical region of rejection is 2.0 and statistical
test is calculated to be 0.53. What is your
decision?
A: Since the calculated statistical test is lower
than the critical region of rejection, we do not
reject the null hypothesis
Exercise #3
An oriental form of massage was thought to
decrease the Blood Pressure of patients with Pre-
hypertension. Blood pressure of 6 patients was
taken before the massage and another one 5
minutes after the massage. Test the hypothesis
that the massage decreased the blood pressure
of these patients. Use alpha=0.05.
35

Exercise #3
Q: What kind of alternative hypothesis was
used?
A: One-tailed alternative hypothesis
Q: What test statistics do you use?
A: Paired t-test.
Exercise #3
Q: What is your conclusion?
Choose the correct answer.
A. There is sufficient evidence to say that
the massage decreases blood pressure
among patients with pre-hypertension.
B. There is sufficient evidence to say that
there is a difference in the blood pressure
of patients before and after a massage.
A: A
5/12/2021
Exercise #3
Q: Critical region of rejection is 2.02 and
statistical test is calculated to be 2.19. What is
your decision?
A: Since the calculated statistical test is higher
than the critical region of rejection, we reject
the null hypothesis.
Exercise #4
In a university, 200 staff members who go to
work report the kind of transportation they use
as well as whether they are ‘morning people’ or
‘night people’. Table below shows the summary
of results. Test the hypothesis that there is a
difference in the mode of transportation
between ‘morning people’ and ‘night people’.
Use level of significance =0.05.
36
 5/12/2021

Exercise #4 Exercise #4

Bus Carpoo Own Totals Q: What test statistics do you use?
l car
A: Chi-square test.
Mornin 60 30 30 120
g
Night 20 20 40 80
Totals 80 50 70 200

Exercise #4 Exercises #4

Q: Critical region of rejection is 5.99 and
statistical test is calculated to be 16.07. What is
your decision?
A: Since the calculated statistical test is higher
than the critical region of rejection, we reject
the null hypothesis
Q: What is your conclusion?
A. There is sufficient evidence to say that there is
a difference in the use of the mode of
transportation among morning and evening
people.

37
 6/24/2021

GOOD MORNING !

DISEASE OUTBREAK / EPIDEMIC

INVESTIGATION
ANGEL ERICH R. SISON, MD
MA. LORENA LORENZO, MD
DISEASE OUTBREAK / EPIDEMIC
FRAULEIN P. TORMON, MD INVESTIGATION
BILLY A. GOCO, MD
ARNEL V. HERRERA, MD
JENA ANGELA T. PERANO, MD
GLORIA PERET-CLARION, MD Original prepared by:
RENATO A. CARASIG, MD IMELDA MARIBETH F. GARCIA, MD, MMedPH, FPAFP

1
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Chain of Infection

A process that begins when an agent leaves its

reservoir or host through a portal of exit, and is
transported by some mode of transmission, then
enters through an appropriate portal of entry to
infect a susceptible host.

Epidemiology of Communicable Diseases 6/24/2021 8

Chain (Cycle) of infection

Incubation Period
Agent ▪ The period from exposure to infection to the
onset of symptoms or signs of infectious
disease.
Susceptible Host Reservoir The length of incubation period depends on:
IP o The portal of entry.
PC o The rate of growth of the organism in the host.
Portal of Entry Portal of Exit o The dosage of the infectious agent.
o The host resistance.
Mode of transmission
Epidemiology of Communicable Diseases 6/24/2021 9 Epidemiology of Communicable Diseases 6/24/2021 10

Broad Street Pump

Dr. John Snow
Period of Communicability Father of Modern Epidemiology

 The time during w/c an infectious agent may

be transmitted directly or indirectly from an
infected person to a susceptible person or
animal.

 Its length varies from one disease to another

Epidemiology of Communicable Diseases 6/24/2021 11

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OUTBREAK
▪ occurs when there has been no cases of a disease for EPIDEMIC
some time then suddenly a case or a few cases appear.
▪ The occurrence in a community or
region of cases of an illness clearly in
▪ the disease may be absent then suddenly there is a
excess of normal expectancy &
remarkable number of cases seen.
derived from a common or
propagated source.
▪ An epidemic occurs when there are
significantly more cases of the same
disease than past experience would
have predicted for that place at that
time among the population.

EPIDEMIC How/Why epidemics occur?

▪ Epidemics occur when:
▪ The disease is initially endemic then there is a sudden 1. An agent & susceptible hosts are present in
increase in the number of cases. adequate numbers
▪ “Excessive” Prevalence 2. The agent can be effectively conveyed from a
source to the susceptible hosts

Chain (Cycle) of infection Factors w/c may trigger an epidemic:

Agent ▪ A recent increase in the virulence of the agent

▪ The recent introduction of the agent into a
setting where it has not been there before
Susceptible Host ▪ An enhanced mode of transmission so that
Reservoir more susceptible persons are exposed
IP ▪ A change in the susceptibility of the host
response to the agent
PC
▪ Factors that increase host exposure
Portal of Entry Portal of Exit ▪ Involved introduction of agent through new
portals of entry

Mode of transmission
Epidemiology of Communicable Diseases 6/24/2021 17

3

Why investigate ?
▪ Characterize a public health problem
▪ Identify preventable risk factors
▪ Provide new research insights into disease
▪ Train health department staff in methods of
public health investigations & emergency
response
▪ To address public, political or legal concerns
Principal considerations:
▪ If cases are continuing to occur:
- Goal is most probably to prevent occurrence of
additional cases
- The objective of the investigation would be to
assess the extent of the outbreak, the size, &
characteristics of the population at risk
- These information is important in designing &
implementing the appropriate control
measures
Reasons for investigating:
3. How much is known about the causative
agent, the source, & the mode of
transmission of the agent?
4. The decisions regarding whether & how
extensively to investigate an outbreak are
influenced by the characteristics of the
problem itself:
- severity of illness
- source/mode of transmission
- availability of prevention & control
measures
6/24/2021
Reasons for investigating :
▪ Prevention & Control
1. Primary public health reason for
investigation
2. Principal considerations
- what is the stage of the epidemic?
- are cases occurring in increasing numbers?
- Is the outbreak just about over?
Principal considerations:
▪ If an outbreak appears to be
almost over:
- Goal may be to prevent similar outbreaks in the
future
- To identify factors w/c contributed to the
outbreak in order to design & implement
measures that would prevent similar
occurrences in the future
Components of investigation
▪ Diagnostic (research)
▪ Directed action
▪ Not “mutually exclusive”
4
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Components of investigation Components of investigation

1. Define the Problem
- Confirm diagnoses
- Show that epidemic exists
2. Describe the epidemiology of the outbreak
- Time: determine dates & times of onset;
draw epidemic curve; determine attack rates
overtime
- Place: draw spot map of cases; consider
environments of home, work, recreational, &
special meeting places
- Person:
- calculate attack rates by age, sex,
occupation, ethnic group, & other
personal factors
- consider rates of infection, disease &
death; note possible means of
transmission
- address both common denominators &
notable exceptions

Components of investigation
3. Formulate Hypotheses Initial Detection of Epidemics &
Outbreaks
- source of infection
1. Epidemiologic surveillance
- method of contamination & spread systems
- possible control mechanisms - Organizations & structures
4. Test Hypotheses - Surveillance methods
- conduct special epidemiologic,
laboratory & environmental 2. Individuals directly/indirectly
investigations affected by the outbreak
5. Draw conclusions & devise practical
applications
- long-term surveillance
- prevention

Who Investigates ?
1. Local Health Department
- 1st line
2. National/Federal agencies
- Requires further resources
- Attracts substantial public
concern
- Associated w/ a high attack rate
- Serious complications
(hospitalizations/death)
3. Center for Disease Control (CDC)
- Outbreaks of national importance

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6/24/2021

6
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I. Preliminary Analysis
- check records & seasonal incidence
Steps in Outbreak / Epidemic Investigation
- review routine information & clinical cases
- community information & reports
I. Preliminary Analysis
- surveillance

7
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2. Identification of cases & other characteristics

1. Verification of the diagnosis

Diagnostic criteria / Case definition

- profile of those w/ the disease
Name of disease
- case history (experience common to those affected)
Most frequent & occasional signs & symptoms
- clinical examination
Circumstances responsible for occurrence of disease
- laboratory investigation
Confirmatory laboratory test

Criteria for cases 3. Definition & investigation of the population at risk

Suspect cases
▪ Characterize the population who would most likely be
(+) signs & symptoms afflicted by the disease
(-) laboratory evidence of ▪ Determine whether an excess number have occurred
infection
▪ Check whether it is true epidemic, its extent or size, by
comparing the incidence of the disease w/ the usual
Presumptive case incidence in the community
(+) signs & symptoms ▪ comparison of the incidence of the disease w/ the
inconclusive laboratory incidence for the past 5 years
evidence ▪ comparison may be made w/ the same month every year.
▪ Extent & severity of epidemics in terms of rates
Confirmed case ▪ Attack Rate measures the “infectivity”
Definite laboratory evidence of ▪ Case Fatality Rate measures the “virulence”
infection
(+) or (-) signs & symptoms

Measures of extent and severity:

4. Formulation of a hypothesis as to:

# of persons acquiring a dse reg in a given yr
- source of transmission
PrimaryAtt ack rate = x 100
# of population at risk in same yr - mode of transmission
- duration of the outbreak

# of persons acquiring a dse after the Primary

Secondary Attack rate = x 100
# of population at risk in same yr

Total number of deaths due to the disease

Case fatality rate = x100
Total number of cases of that disease

8

4.1. Time
▪ Determine the chronological distribution of the dates of onset
▪ basic aspect of epidemiological analysis
▪ Disease occurrence is usually expressed hourly, daily, weekly,
monthly or yearly basis
▪ usually related to time of onset rather than time of diagnosis.
▪ those cases w/ known time of exposure & date of onset of the
disease, tabulate the incubation period & estimate the range &
median incubation period.
▪ help in making differential diagnosis of the disease under
investigation & in eliminating other diseases
▪ A graphical illustration of the epidemic curve is also important in
knowing the type or nature of the epidemic.
Epidemic Curve for Point Epidemic
Time: Prolonged progressive epidemic
Source: Propagated epidemic
▪ Epidemic extends over a number of cases in each
successive time period
▪ result from transmission (directly or indirectly) of an
infectious agent from one susceptible person to another.
▪ There are multiple peaks
▪ Wave after wave of infection spreads throughout a
population
▪ When all the susceptibles are exhausted, the outbreak
ends
6/24/2021
Time: Point epidemic
Source: CommonSource Epidemic
▪ Exposure is brief
▪ All cases developed w/in one incubation period
▪ epidemic curve rises & fall rapidly, usually skewed to the
right.
▪ All members of the population at risk are exposed to the
causal agent over a short period of time (common source)
▪ In common source epidemic w/ somewhat prolonged
exposure (few days or weeks) the curve is usually
symmetrical.
Identifying the source of the etiologic agent & its mode of transmission
Common Source Epidemic
▪ due to exposure of a group of persons to a common source of
infection.
▪ Cases occur more or less at the same time.
▪ There may be more than 1 peak but still there is clustering.
Epidemic Curve for Prolonged Progressive / Propagated
Source Epidemic
9
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Identifying the source of the etiologic agent & its mode of transmission

Continuous source epidemic

Propagated Source Epidemic

▪ Exposure occurs over multiple incubation
▪ Cases do not come at the same time.
periods

▪ Source is being continuously exposed to a

contaminant

Curve for Continuous Source Epidemic

Classification as to mode of transmission

▪ Single exposure
▪ Continued exposure
▪ Person to person spread
▪ Arthropod vector
▪ Animal reservoir

4.2. Place Community Characteristics of Epidemiological

- Determine the geographical distribution of cases Significance:
- Spot map ▪ geographical location
- Evaluate characteristics of the environment that favors ▪ climate condition
the spread of the disease ▪ socio-economic condition
▪ sanitation standards
▪ water distribution
▪ sewage collection
▪ food supply
▪ recent outbreaks
▪ population movement

10
 6/24/2021

4.3. Person

- Determine age, sex, race, occupation. etc

- Alternatively, association of illness w/ the
vehicle may be shown by comparing the
percentage of persons exposed to the
vehicle among those ill & those not ill.

II. Further investigation & analysis

Steps in Outbreak / Epidemic Investigation 1. Search for additional cases w/c may have been
recognized or reported
I. Preliminary Analysis 2. Determine what additional information is necessary
II. Further Investigation & to answer any question formulated & to test
Analysis tentative hypothesis.
III. Implement Control  Plan & conduct a detailed epidemiological
Measures investigation of all cases or a representative
IV. Prepare Report for Epidemic sample of cases using the suitable epidemiological
case form.
Investigation
 Arrange for any special investigation needed to
V. Continued Surveillance of establish collateral circumstances using laboratory
the Population facilities, engineering & other expert
consultations.

3. Analyze details derived from case investigation, Considerations:

comparing attack rate among various pertinent
groupings.
1. General Information Bias:
 Try to identify the group selected for attack & - has there been a change in the
discover the common source or vehicle to w/c they reporting procedure or case
are exposed, if any. definition ?
 Assemble results of collateral investigation. - artifactual increase?
4. Test various hypothesis w/c have been suggested to - does the increase represent a
fad or false alarm?
ascertain w/c one is consistent w/ the known facts.
 Base conclusions on all pertinent evidence, not 2. Change in population size
relying upon any single distribution with only one - can a sudden increase in
hypothesis. population size, in a resort
 Formulate conclusions as to the source, mode of area, college town, farming
transmission & all other features of the epidemic that area w/ migrant labor → reflect
require explanation. on increase on the rate of
5. Make a decision about the hypothesis considered & population increase vs change
in rate of disease?
tested.

11
 6/24/2021

Considerations:

3. Diagnostic suspicion bias:

- improved diagnostic
Steps in Outbreak / Epidemic Investigation
procedures
- new physician I. Preliminary Analysis
- new infection control nurse II. Further Investigation &
- change of outlook Analysis
III. Implement Control
4. Publicity bias:
- when media attention Measures
stimulates the reporting of IV. Prepare Report for Epidemic
cases that would have gone Investigation
unnoticed? V. Continued Surveillance of
the Population

III. Implement Control Measures

1. Attack the source

2 . Protect the susceptible
- Treat cases, carriers - Immunization
- Isolate cases until no longer infectious
- Quarantine for maximum incubation period - Chemoprophylaxis
- Surveillance of suspects / contacts
- Control of animal reservoirs - Better nutrition
- Notification of cases
- Contact case tracing - Personal protection
- Immediate cessation of sale of food, withdrawal of a drug
- closure of a facility

3. Interrupt transmission
- Hygiene : personal & environmental

- Vector control

- Disinfection & sterilization

- Restriction of population movement

12
 6/24/2021

Stage 2. Confirmation of AI
Most important control measure –
Infection
▪ Infected Premises – any poultry holding facility in which AI is
confirmed to exist HEALTH INFORMATION
HEALTH EDUCATION
3 km
INFECTED
PREMISES

CONTROL
ZONE
7 km

QUARANTINE
ZONE Level 2

▪ Control Zone – seven (7) kilometer zone from the edge of

▪ Quarantine
Quarantine Zone 2Level
Zone Level 2 that
– three serves as azone
(3) kilometer buffer between
from the
the Infected
Quarantine
Premises. Zone
This covers alland the Disease
poultry holding Free Areasincluding major
facilities
markets, processing plants and general service areas

www.birdflufreephilippines.com
Public information and
report@birdflufreephilippines.com
communication
• Pre-pandemic prepared IEC materials
• Communication links at both national and local
level -telephone lines, internet
• Public advisories, IEC materials, press briefing,
hotlines, Designated spokesperson,
• Speakers’ Bureau
• Regular information to doctors at all levels -health
updates
• Linkages with the media at the national and local
level

Brochures, Flyers and How To /

Community Education Posters

13
 6/24/2021

Steps in Outbreak / Epidemic Investigation IV. Preparation of report of investigation

I. Preliminary Analysis ▪ Layperson – general

II. Further Investigation & ▪ Health Authority – technical
Analysis ▪ Medical Journal – scientific
III. Implement Control
Measures
IV. Prepare Report for Epidemic
Investigation
V. Continued Surveillance of
the Population

Steps in Outbreak / Epidemic Investigation V. Continued surveillance of the population

- Detect further rises in incidence
I. Preliminary Analysis - Ensure the effectiveness of control measures
II. Further Investigation &
Analysis
III. Implement Control
Measures
IV. Prepare Report for Epidemic
Investigation
V. Continued Surveillance of
the Population

The ideal outcome of the investigation is a complete

picture of the following: CASE 1
▪ Philippine Airlines flight PR
168 has a total number of
▪ The critical changes that led to the epidemic 165 persons on board; this
includes 156 passengers, 6
flight attendants, 2 pilots,
▪ The source and a navigator.
▪ This plane was scheduled to
▪ The transmission & mode of entry of the disease agent leave Ninoy Aquino
International Airport on 01
May 2009 for Beijing with a
▪ The characteristic of the disease 3-hour stopover at Xiamen
International Airport.
▪ The varying susceptibility of the individuals in the ▪ All seats were booked on
the flight.
population

14

▪ An hour into the flight, Dr Pol
Medina, Jr noticed that there
were numerous passengers
who were coughing and some
who were sneezing but were
mostly dismissed as it was
attributed to the dustiness of
Manila at that time.
▪ A gentleman seated beside
him was noticeably feverish,
and he also noticed that a flight
attendant was blowing his nose
while checking on the
overhead baggage.
▪ A public health
manager who was part
of the medical team
was able to obtain the
passenger manifest of
the plane and mapped
out the seating
arrangement of the
quarantined persons.
▪ He then informed the chief
▪ In all there were 35 other
6/24/2021
▪ Upon arriving at Xiamen, a medical
team from the Chinese Ministry of
Health boarded the plane and
conducted a quick check-up of the
passengers and crew using a
thermal scanner.
▪ It was found that 25 passengers, 3
flight attendants, and the
navigator registered temperatures
above 38°C.
▪ This included the passenger
seated beside Dr Medina.
▪ All of them were immediately
quarantined while the rest were
allowed to stay in the airport
awaiting their connecting flight.
health officer to include
the people seated beside
the affected ones to also
be quarantined.
passengers who were
quarantined. The rest of
the passengers were
marked for follow-up in
case the signs and
symptoms of any disease
occurs.
15
 6/24/2021

Compute for the Primary

▪ During the observation Attack Rate
period, 3 passengers
died, thereby extending
the quarantine period of ▪
the persons involved.
▪ Concurrently, the sera of
the quarantined persons
were obtained for study,
and it was confirmed
that there was an
outbreak of Swine Flu
H3N2.

Compute for the Secondary Compute for the Case

Attack Rate Fatality Rate
▪ ▪

Case 2 Case 2
 University belt dormitory w/ 50 occupants; all students  5 were admitted & the rest were treated &
from the different institutions. subsequently sent home w/ prescriptions.

 All took dinner at the dorm cafeteria, owned by a
caterer who serves other dorm cafeterias of 5 other
dorm building.
 After dinner: some occupants of bldg 1 began to have
abdominal pains, vomiting & LBM.
 20 students were rushed to a secondary hosp;
Epidemiology of Communicable Diseases
 Dx. Acute Food Poisoning
 Investigation: meal component
 Squash, embotido, hopia, bottled water, rice
 Labs: culture of food & water samples
 Self administered questionnaire
 What is the probable source?
6/24/2021 97 Epidemiology of Communicable Diseases 6/24/2021 98

16
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Case 2 Case 2
Served Did Did not w/ s/sx w/o s/sx
Served Did Did not w/ s/sx w/o s/sx Attack
Food eat eat Food eat eat Rate
Squash 27 23 18 9 Squash 27 23 18 9 56%
Hopia 22 28 20 2 Hopia 22 28 20 2 91%
Embutido 40 10 35 5 Embutido 40 10 35 5 88%
Rice 30 20 10 20 Rice 30 20 10 20 33%
Bottled 45 5 40 5 Bottled 45 5 40 5 89%
Water Water
Table 1. Number of dorm residents who ate or did not eat food served during dinner and who
Table 1. Number of dorm residents who ate or did not eat food served during dinner and who exhibited signs and symptoms of food poisoning.
exhibited signs and symptoms of food poisoning.

Epidemiology of Communicable Diseases 6/24/2021 99 Epidemiology of Communicable Diseases 6/24/2021 100

THANK YOU !

17
 Epidemiology of Non- Communicable versus
Definition of Epidemiology
Communicable and Communicable Non-communicable diseases
Diseases Epidemiology – science concerned Communicable diseases Non-communicable
JENA ANGELA T. PERANO, MD diseases
with various factors and conditions • Sudden onset • Gradual onset
JULIE TANCHANCO-TIU, MD that influence the occurrence and • Single cause • Multiple causes
GLORIA PERET-CLARION, MD
distribution of health, disease, • Short natural history • Long natural history
JENELL Y. OCZON, MD • Short treatment schedule • Prolonged treatment
defect, disability and death among • Cure is achieved • Care predominates
MACARIO REANDELAR JR., MD
groups of individuals. • Single discipline • Multidisciplinary
ARNEL V. HERRERA, MD • Short follow up • Prolonged follow up
LOURDES C. MEDALLA, MD • Back to normalcy • Quality of life after
treatment
MARIE RUTH ECHAVEZ, MD

Global Trends in Mortality

NCDs Comm. Dis. Injuries

Deaths (millions)
40
30
20
10
0
1990 2000 2010 2020
Global Burden of Disease

1
 Noncommunicable diseases: Noncommunicable diseases:
DALYs (Globally) Current status and trends in risk Current status and trends in risk
factors factors
1990 2020
 Common, preventable risk factors underlie most  Several risk factors have the highest
NCDs. These risk factors are a leading cause of the prevalence in high-income countries. These
death and disability burden in nearly all countries, include:
regardless of economic development. 1. physical inactivity among women,
 The leading risk factor globally for mortality is: 2. total fat consumption,
1. raised blood pressure (responsible for 13% of
3. raised total cholesterol.
deaths globally),
2. followed by tobacco use (9%),
 Some risk factors have become more common
in middle-income countries. These include:
3. raised blood glucose (6%),
1. tobacco use among men,
4. physical inactivity (6%),
Comm. Disease NCDs Injury
5. overweight and obesity (5%). 2. overweight and obesity.
8 9

The causal chain explains the risk factor

Life course approach for the prevention Rationale of the risk factor approach for
approach for surveillance of non
of non communicable diseases non communicable diseases
communicable diseases
Fetal Infancy and Adolescence Adult Life
life childhood • Non communicable diseases are slowly
•Obesity
•Established adult risk factors
(behavioural/biological)
evolving
Behavioral
•Lack of
Physiological Disease ▪ Early recognition difficult
•SES
activity risk factors
•Nutrition
•Diet risk factors outcomes • A number of risk factors influence one or
•Alcohol, Range of

•SES
•Diseases
•Linear
•Smoking
individual
risk
• Tobacco • Heart disease more non communicable diseases
• Alcohol • Body mass index
•Maternal
nutritional
growth
•Obesity • Physical • Blood pressure •
•
Stroke
Diabetes
• Risk factors have the greatest impact on non
status & Accumulated
Accumulated
risk
inactivity •
•
Blood glucose
Cholesterol • Cancer communicable diseases mortality and
obesity, • Nutrition
•Fetal risk • Respiratory diseases morbidity
growth
• Effective modification of risk factors is
possible through primary prevention
Age

2
 Noncommunicable diseases: Communicable Disease
Risk factors under surveillance
Prevention and Control of NCDs
• Tobacco use - is an illness due to a specific
• Alcohol consumption • Millions of deaths can be prevented by stronger infectious (biological) agent or its
• Raised blood pressure implementation of measures that exist today.
▪ Systolic and diastolic • These include policies that promote government-
toxic products that is transmitted
• Obesity wide action against NCDs: to a susceptible host by direct or
▪ Height, weight, body mass index, waist circumference
• Diet
1. stronger anti-tobacco controls indirect contact, through a vehicle
2. promoting healthier diets,
▪ Low fruit, high fat, added salt to served food
3. physical activity,
or vector, or as an airborne
• Physical inactivity infection.
• Diabetes mellitus 4. reducing harmful use of alcohol;
▪ Fasting plasma glucose 5. along with improving people's access to essential
• High serum cholesterol health care.
14

Factors Influencing
Epidemiologic Triad Disease Transmission Chain of Infection
Agent
• Infectivity
Environment A process that begins when an agent
• Weather
Disease is the result of • Pathogenicity • Housing
leaves its reservoir or host through a
• Virulence
forces within a • Immunogenicity
• Geography
• Working condition
dynamic system • Air quality portal of exit, and is transported by
consisting of: • Disaster/War
some mode of transmission, then enters
agent of infection
host
Host • Age through an appropriate portal of entry to
• Sex

environment • Behaviour
infect a susceptible host.
• Nutritional status
• Health status 18
()

3
 Chain (Cycle) of Infection
Incubation Period Period of Communicability
Agent
• The period from exposure to infection to the ▪ The time during which an infectious
onset of symptoms or signs of infectious
agent my be transmitted directly or
Susceptible Host Reservoir disease.
IP • The length of incubation period depends on: indirectly from an infected person to a
PC o The portal of entry. susceptible person or animal.
Portal of Entry Portal of Exit o The rate of growth of the organism in the host.
o The dosage of the infectious agent. ▪ Its length varies from one disease to
o The host resistance. another
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Mode of transmission 19 6/24/2021 20 6/24/2021 Epidemiology of Communicable 21
Diseases

1. Agent Infectivity: Pathogenicity:

The ability of an agent to invade and multiply
• Microorganisms are responsible for disease (produce infection) in a susceptible host. Is the ability of the organisms to produce specific
clinical reaction after infection
production (viruses, bacteria, protozoa, yeast) Secondary Attack Rate It refers to the proportion of infected persons who
• Agent factors that affect disease transmission: • The proportion of exposed susceptible persons develop clinical disease.
who become infected.
o Infectivity Examples:
o Pathogenicity Secondary attack rate =
Numberof sec ondary cases
x100 • High pathogenicity: Measles, Chickenpox
Numberof susceptibles • Low pathogenicity: Polio, Tuberculosis, Hepatitis A
o Virulence
It can be measured by:
• Examples: High infectivity: Measles, Chickenpox
o Immunogenicity Ratio of clinical to sub-clinical case =
Low infectivity: Leprosy
Clinical cases
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Diseases Diseases

4
 Virulence: Immunogenicity: 2. Source or Reservoir
It refers to the ability of organisms to produce severe • The reservoir of an agent is the habitat in
pathological reaction.
• Ability of an organism to produce an which an infectious agent normally lives, grows,
immune response that provides and multiplies.
It is the proportion of persons with clinical disease
who become severely ill or die (mortality). protection against re-infection with • “any person, animal, arthropod, plant, soil, or
substance, or a combination of these, in which
Examples: Rabies, Hemorrhagic fevers caused by the same or similar agent. an infectious agent normally lives and
Ebola and Marburg viruses. multiplies, on which it depends primarily for
• Can be life long or for limited periods. survival, and where it reproduces itself in such
Case fatality rate a manner that it can be transmitted to a
susceptible host. It is the natural habitat of the
Total number of deaths from a disease • Important information for infectious agent.”
Case fatality rate = x100
Total number of cases of that disease development of vaccines.
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Diseases Diseases

Types of Reservoirs Humans are

the most
important
Human Reservoir
Reservoir reservoir of
human
infectious
disease.

Human Animal Non-living Cases Carriers

reservoir reservoir reservoir

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Diseases Diseases Diseases

5
 Cases Cases Cases
❖ Index – the first case identified
Cases are classified as ❖ Primary – the case that brings the infection into a pop.
❖ Secondary – infected by a primary case
A case is defined as “a person in the • Primary case
• Index case
population or study group identified as • Secondary cases
S
having the particular disease, health According to spectrum of disease: SC

• Clinical cases: (mild/severe- Susceptible P

S
disorder, or condition under typical/atypical) Immune
I IM
• Sub-clinical cases Sub-clinical
S
investigation” • Latent infection cases Clinical
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Diseases Diseases

Carriers are dangerous because: Types of Carriers:

Carriers
• A person or animal without apparent disease
who harbors a specific infectious agent and is
capable of transmitting the agent to others.
• It occurs either due to inadequate treatment
or immune response, or the disease agent is
not completely eliminated, leading to a
carrier state.
6/24/2021 Epidemiology of Communicable 34
Diseases
• They do not show any clinical manifestation so
they carry normal life.
• The carrier and his contacts are not aware of
their condition, so they take no precautions.
• They can remain infectious for a long time
leading to repeated introduction of the
disease to contacts.
6/24/2021 Epidemiology of Communicable
Diseases
1. In-apparent carrier:
The carrier state that may occur in an individual with
an infection that is in-apparent throughout its course
2. Incubatory and Convalescent carriers:
The carrier state may occur during the incubation
period and convalescence of an individual with a
clinically recognizable disease.
3. Healthy (chronic) carriers:
They continue to harbour an agent for an extended
time (months or years) following the initial infection.
35 6/24/2021 Epidemiology of Communicable 36
Diseases

6
 Animal reservoirs Zoonoses are Zoonoses
Human Reservoir in non-living things
• Zoonosis is an infection that is transmissible Diseases with
under natural conditions from vertebrate animals Animal
to man. Reservoirs. • Water, Soil and inanimate
• There are over a 100 zoonotic diseases that can matter can also act as reservoir
be conveyed from animal to man.
of infection.
➢ brucellosis (cows and pigs),
➢ anthrax (sheep),
• Pools of water are the primary
reservoir of Legionnaires’
➢ plague (rodents),
bacillus.
➢ rabies (dogs and bats).
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Diseases Diseases

3. Portal of Exit 4. Mode of Transmission: Modes of Transmission

- Once a pathogen exited the reservoir, it • Direct Contact
• Portal of exit is the path by which an agent needs a mode of transmission to the host
through a receptive portal of entry. -Requires close
leaves the source host.
- Types of Transmission
association
• Examples: between infected
1. Horizontal Transmission
1.1 Direct Contact and susceptible
• Respiratory tract
1.2 Indirect Contact host
• GIT a) Vehicle Borne - Skin-to-skin
b) Vector Borne contact, kissing,
• Skin and mucous membrane 1.3 Airborne
sexual intercourse
2. Vertical Transmission
6/24/2021 Epidemiology of Communicable 40
Diseases

7
 Modes of Transmission Droplet Transmission Modes of Transmission
Indirect Contact
• Direct Contact (Droplet Transmission) - Vehicle Borne Transmission: vehicle is any
substance that serves as an intermediate
- Large droplets within ~1 meter (3 feet) means to transport and introduce an infectious
transmit infection via: agent into a susceptible portal of entry
▪ Coughing, sneezing, talking - Transmission by an inanimate reservoir
(food, water, soil, fomites)
▪ Medical procedures

6/24/2021 Epidemiology of Communicable 44

Diseases

Vector Borne Transmission Vectors Airborne Transmission

• An insect or any living carrier that transports an Very small particles of evaporated
infectious agent from an infected individual or its droplets or dust with infectious agent
wastes to a susceptible individual or its food or
immediate surroundings. may…
• Arthropods, especially fleas, ticks, and mosquitoes
▪ Remain in air for a long time
• Transmit disease by 2 general methods:
▪ Travel farther than droplets
▪ Mechanical transmission: Arthropod carries pathogen ▪ Become aerosolized during
on feet or appendages
procedures
▪ Biological transmission: Pathogen reproduces in vector

8
 Airborne Transmission
Vertical Transmission 5. Portal of entry
An agent enters a susceptible host through a portal
1. Transplacental
of entry.
2. During delivery
- The portal of entry must provide access to
tissues in which the agent can multiply or a toxin
can act.

Mycobacterium - Often, organisms use the same portal to

tuberculosis?
enter a new host that they use to exit the source
host.
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Diseases Diseases

6. Susceptible Host Susceptibility of a host depends on Two types of immunity

• A susceptible host is the final link
in the chain of infection.
• The host is a person or other
living organism that can be
infected by an infectious agent
under normal conditions.
1. Innate (non-adaptive)
1. Genetic factors ▪ first line of immune response
▪ relies on mechanisms that exist before infection
2. General factors 2. Acquired (adaptive)
▪ Second line of response (if innate fails)
relies on mechanisms that adapt after infection
3. Host defense (Specific acquired immunity) ▪
▪ handled by T- and B- lymphocytes
▪ one cell determines one antigenic determinant

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Diseases Diseases

9
 General factors which defend against Acquired immunity
infection (Innate Immunity):
Specific (acquired) immune
system
• Skin • 1. Humoral immunity (Antibody- 1. Active
mediated immune system) - B a) Naturally acquired
• Mucous membranes - acquire the disease
cells
• Gastric acidity • 2. Cell mediated immunity – - subclinical immunity
• Cilia in the respiratory tract Cytotoxic T cells b) Artificially acquired
- vaccination
• Cough reflex
6/24/2021 Epidemiology of Communicable 55
Diseases

Acquired immunity Herd Immunity

It is the state of immunity of a group or a
2. Passive – not coming from the
person community.

a) Naturally acquired Also it is;

- maternal antibodies “The resistance of a group or a community to
- colostrum an infectious agent, based on the immunity
b) Artificially acquired of a high proportion of individual members
- injection of of the group”.
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Diseases
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Diseases
60

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Diseases
c. maintain nutrition and encourage
rest and sleep to promote tissue
repair and production of
lymphocytes and antibodies
d. educate patient about
immunization
Herd Immunity Preventing Infection
If the herd immunity is sufficiently high, the 1. Decrease host susceptibility
occurrence of an epidemic is highly unlikely a. maintain skin and mucous
High level of immunity (by high vaccination coverage) membrane as first line of defense
------- makes elimination of a diseases possible. b. reinforce or maintain natural
It was crucial in polio and diphtheria protective mechanisms such as
Herd immunity may be determined by serologic
coughing, pH of secretions,
survey.
resident flora
61 6/24/2021 Epidemiology of Communicable 62
Diseases
Preventing Infection Relative Resistance of Microbes
2. Limit or eliminate the microbiologic agent • Highest resistance
• Physical and Chemical methods to destroy or ▪ bacterial endospores, prions
reduce undesirable microbes in a given area • Moderate resistance
• Primary targets are microorganisms capable of
▪ Pseudomonas sp.
▪ Mycobacterium tuberculosis
causing infection or spoilage:
▪ vegetative bacterial cells and endospores ▪ Staphylococcus aureus
▪ protozoan cysts
▪ fungal hyphae and spores, yeast
▪ protozoan trophozoites and cysts • Least resistance
▪ worms
▪ most bacterial vegetative cells
▪ viruses
▪ prions ▪ fungal spores and hyphae, yeast
▪ enveloped viruses
▪ protozoan trophozoites
11
 Terminology and Methods of Control
• Sterilization – a process that destroys all viable
microbes, including viruses and endospores;
microbicidal
• Disinfection – a process to destroy vegetative
pathogens, not endospores; inanimate objects
• Antiseptic – disinfectants applied directly to
exposed body surfaces
• Sanitization – any cleansing technique that
mechanically removes microbes
• Degermation – reduces the number of microbes
Pattern of Occurrence and
Distribution of Diseases
1. Sporadic
2. Endemic
3. Epidemic/Outbreak
4. Pandemic
Prevention of Transmission: Hand-washing
• HANDWASHING (FOR EVERYONE) -is the • Elements of hand-washing: friction, soap
single most important procedure for and water – to loosen and flush
preventing the transfer of microorganisms & microorganisms
therefore preventing the spread of • Medical vs Surgical Hand-washing
nosocomial infections.
• CDC (Centres for Disease Control and
Prevention) recommends at least 20 seconds
hand washing. This will remove most
transient organisms from the skin.
Sporadic
Endemic
• The word sporadic means “scattered
about”. The cases are few and separated • It refers to the constant presence
widely in time and place that they show no
or little connection with each other, nor a of a disease or infectious agent
recognizable common source of infection. within a given geographic area or
population group. It is the usual or
• However, a sporadic disease could be the
starting point of an epidemic when the expected frequency of disease
conditions are favorable for its spread.
within a population.
12
 Hyperendemic and Holoendemic
• The term “hyperendemic” expresses that the
disease is constantly present at high incidence
and/or prevalence rate and affects all age
groups equally.
• The term “holoendemic” expresses a high level
of infection beginning early in life and affecting
most of the child population, leading to a state
of equilibrium such that the adult population
shows evidence of the disease much less
commonly than do the children
Pandemic and Exotic
• Pandemic affects a large proportion
of the population, occuring over a
wide geographic area such as a
section of a nation, the entire
nation, a continent or the world.
• Exotic diseases are those which are
imported into a country in which
they do not otherwise occur.
Epidemic
Endemic vs Epidemic
• “The unusual occurrence in a
community of disease, specific
Number of Cases of a
health related behavior, or other
Disease
health related events clearly in
excess of expected occurrence”
• Epidemics can occur upon endemic
states too.
Endemic Epidemic
Time
Eradication and Elimination
• Termination of all transmission of infection by IF YOU THINK
the extermination of the infectious agent
through surveillance and containment.
Eradication is an absolute process, an “all or IS EXPENSIVE, TRY
none” phenomenon, restricted to termination
of infection from the whole world.
• The term elimination is sometimes used to
describe eradication of a disease from a large
geographic region.
HOSPITALIZATION
13
14
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Objectives

At the end of the lecture, the students must be

able to:
GENETICS & EPIDEMIOLOGY 1. Explain the role of genetics and environment
in disease causation.
2. Discuss the importance of screening
measures for evaluation of diseases
3. Discuss measures to prevent occurrence of
diseases.
1 2

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION

GENETICS & EPIDEMIOLOGY GENETIC EPIDEMIOLOGY

• Two disciplines • Epidemiologic techniques are used to
• Depend on collection of data study genetic risk factors and
• Draw heavily on application of interactions:
statistics and mathematics to analysis Genetic susceptibility
of patterns of disease distributions
and disease frequency in man Environmental factors

3 4

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IN DISEASE CAUSATION IN DISEASE CAUSATION
INTERACTION OF GENES AND ENVIRONMENT
General Rule:
1. Within a certain range of genetic
GENES ENVIRONMENT background, environmental factors
 Factors  Things one is determine its occurrence.
transmitted in the exposed to after 2. Within a certain range of
chromosomes conception environmental condition, the trait is
received from
genetically determined.
one’s parents
5 6

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IN DISEASE CAUSATION IN DISEASE CAUSATION
MECHANISM OF INTERACTION MECHANISM OF INTERACTION

Mother with Phenylketonuria (Gene) Pregnancy in older maternal age

Phenylalanine crosses transplacental barrier Trisomy 21 & 22 defect (Gene)

Fetus
Fetus

Mental Retardation (Effect)

7
Down’s Syndrome (Effect)
8

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
IMPLICATIONS
FAMILIAL DISEASE
1. The epidemiologist should distinguish if the • Is hereditary, passed on from one
occurrence of a disease is likely due to: generation to the next.
Genetics • Resides in a genetic mutation that is
Environment transmitted by one or both parents through
2. Prevent the abandonment for the search of the gametes to their offspring.
environmental causes of diseases that may • Not all genetic disorders are familial,
appear to be solely caused by genetic because the mutation may arise for the first
factors time during the formation of the gametes or
9 during the early development of the fetus.
10

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
FAMILIAL DISEASE MENDELIAN OR SINGLE-GENE INHERITANCE

• If found to conform to the pattern expected • A Mendelian trait is one that is controlled
for a single major gene: strong evidence of by a single locus in an inheritance pattern.
genetic origin • A mutation in a single gene can cause a
● Failure to conform: suggest environmental disease that is inherited according to
explanation Mendel's principles.
• Dominant diseases manifest in
heterozygous individuals.
• Recessive ones are sometimes inherited
Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
unnoticeably by genetic carriers.

Medical Epidemiology,
114th Edition 12

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IN DISEASE CAUSATION IN DISEASE CAUSATION

MENDELIAN OR SINGLE-GENE INHERITANCE Autosomal Dominant

• The expression of the mutated allele with respect • Each affected person has an affected parent.
to the normal allele can be characterized as • Occurs in every generation.
dominant, co-dominant, or recessive.
• There are five basic modes of inheritance for
single-gene diseases:
• autosomal dominant
• autosomal recessive
• X-linked dominant
• X-linked recessive
• mitochondrial 13 14

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION

AUTOSOMAL DOMINANT AUTOSOMAL RECESSIVE

• Huntington’s disease • Both parents of

an affected
• Neurofibromatosis person are
• Achondroplasia carriers.
• Familial hypercholesterolemia • Not typically
seen in every
• Myotonic Dystrophy generation.
• Polycystic Kidney Disease

15 16

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION

AUTOSOMAL RECESSIVE X-linked Dominant

• Females more frequently affected
Tay-sachs disease • Can have affected males and females in same generation
Sickle cell anemia
Cystic fibrosis
Phenylketonuria (PKU)
Hurler Syndrome
Hereditary Hemochromatosis
Beta- thalassemia

17 18

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IN DISEASE CAUSATION IN DISEASE CAUSATION

X-linked Dominant X-linked Recessive

• Hypophatemic rickets (vitamin D-resistant • Males more frequently affected
rickets) • Affected males often present in each generation
• Ornithine transcarbamylase deficiency
• X-linked Hypophosphatemia
• Dermal Hypoplasia (Focal)
• Coffin Lowry Syndrome
• Alport Syndrome
• Child Syndrome
19 20

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION

X-linked Recessive Mitochondrial Inheritance

• Can affect both
• Hemophilia A
males and
• Duchenne Muscular Dystrophy females, but only
• Wiskott-Aldrich Syndrome passed on by
• G6PD Deficiency females.
• Lesch-Nyhan Syndrome • Can appear in
• Hunter Syndrome every generation.
• Fabry Disease

21 22

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IN DISEASE CAUSATION IN DISEASE CAUSATION
TWIN STUDIES
Mitochondrial Inheritance
• Single most powerful method of
• Leber’s Hereditary Optic Neuropathy detecting genetic etiology in human
• Kearns-Sayre Syndrome disease
• Myoclonic Epilepsy and Ragged Red Fiber • Most studies found no difference
Disease between disease rate in twins vs. single
pregnancy except for the following:
• Prematurity
• Danger of delivery
 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
23 Medical Epidemiology,
244th Edition

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IN DISEASE CAUSATION IN DISEASE CAUSATION
TWIN STUDIES TWIN STUDIES

BASIC PREMISE BASIC PREMISE

• Monozygotic twins • Monozygotic twins
• Division of a single fertilized ovum carry • Division of a single fertilized ovum carry
identical twin identical twin
• Dizygotic twins • Dizygotic twins
• Fertilization of 2 ova by spermatozoa • Fertilization of 2 ova by spermatozoa
• Genetically not similar like 2 siblings • Genetically not similar like 2 siblings
born after separate pregnancy born after separate pregnancy

 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).  Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
254th Edition Medical Epidemiology,
264th Edition

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
TWIN STUDIES TWIN STUDIES

Monozygotic twins
Monozygotic twins Dizygotic twins • Similarity in disease or trait: evidence of
existence of a genetic component
• Certain characteristics become more alike
as twins age, such as IQ and personality.
• Consistent for a particular disease more
frequently than dizygotic sets

 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
27 Medical Epidemiology,
284th Edition

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
TWIN STUDIES TWIN STUDIES

DISCORDANT MONOZYGOTIC  Dizygotic

Twinning:
• Any manifestational difference between
them must be due to differences in  6x higher for
environmental experience maternal age
group 35-39
years

 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
294th Edition 30

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IN DISEASE CAUSATION IN DISEASE CAUSATION
TWIN STUDIES BIRTH ORDER
Dizygotic twins • Parental genes are distributed to their
• Do not share the same genetic material and are
offspring independently of the order of birth
not identical.
• Can be different sexes. • First and early born children usually have
• Higher among women who are overweight or close to exclusive attention of parents
have fraternal twins already in their family. • Late born children forced to compete with
• In some rare instances, dizygotic twins can have siblings over resources from birth.
different fathers. This happens when one egg is • Studies shows that late born children to be
fertilized by sperm from one father, while the
at greatest risk of mental health problems
second egg is fertilized by sperm from another
father. and increased risk of suicide.
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ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
NATAL ENVIRONMENT NATAL ENVIRONMENT
Prenatal Environment Prenatal Experiences
• Maternal nutrition • Prolonged and difficult labor
• Affects maternal antibody system • Anoxia, trauma, prolonged anesthesia,
• Late pregnancies and other factors connected with
• Fetal exposure to drugs confinement
• Nutritional supplements • Patent ductus arteriosus in prematures

33 34

ROLE OF GENETICS & ENVIRONMENT ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION IN DISEASE CAUSATION
NATAL ENVIRONMENT NATAL ENVIRONMENT

Postnatal Environment • Frequency and timing of exposure to

• Psychological differences infectious agents
• Parental psychology • Hypertrophic pyloric stenosis (6 weeks from
• Child-rearing practices birth)
• Age of Mother at the time of pregnancy

 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
354th Edition 36

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NATAL ENVIRONMENT
MULTIFACTORIAL INHERITANCE
• Down’s Syndrome
• Heredity is not a factor in trisomy 21 • Genetic and environmental factors
(nondisjunction). • Genetic predisposition to malformation
• Prevalence = <1/1000 in infants with • Environmental factors push the threshold
mothers under 30 years • 1-5% recurrence for every succeeding
• > 1/1000 in infants with mothers over pregnancy
40y
• People with Down syndrome all look the
same but with different abilities.
37 38

ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION

MULTIFACTORIAL INHERITANCE
Importance of
Cleft lip and cleft palate
•
• Pyloric stenosis
Screening Measures
• Epilepsy for Evaluation of Diseases
• Mental retardation
• Neural tube defects (spina bifida and
anencephaly)
• Hip dysplasia

39 40

IMPORTANCE OF SCREENING MEASURES IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES FOR EVALUATION OF DISEASES

PRENATAL DIAGNOSIS
1. Amniocentesis – between 16 and 18
weeks of gestation
AMNIOCENTESIS
2. Ultrasound
ALPHA FETO PROTEIN TEST

3. Alpha fetoprotein
4. Fetoscopy – a highly invasive procedure
done on pregnant women by using highly
flexible app. to get placental tissues
41 ULTRASOUND 42 FETOSCOPY

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IMPORTANCE OF SCREENING MEASURES IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES FOR EVALUATION OF DISEASES

CRITERIA FOR EVALUATING SCREENING TOOLS CRITERIA FOR EVALUATING SCREENING TOOLS

INTERNAL VALIDITY EXTERNAL VALIDITY

• VALIDITY
▪ Refers to how accurately a method  extent where  extent where
measures what it is intended to results of results of study
measure. investigation are applicable to
accurately reflects other populations
true situation of
study population
43 44

IMPORTANCE OF SCREENING MEASURES IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES FOR EVALUATION OF DISEASES

CRITERIA FOR EVALUATING SCREENING TOOLS CRITERIA FOR EVALUATING SCREENING TOOLS

• VARIABILITY
• YIELD
▪ Spread of a data set
▪ Amount of screening the test can
▪ Vary from the average value, as well as
accomplish in a time period
the extent to which these data points
▪ How much disease it can detect in the
differ from each other.
screening process

 Merrill, R.M., (2009). Introduction to Epidemiology, 5th Edition

45 46

IMPORTANCE OF SCREENING MEASURES IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES FOR EVALUATION OF DISEASES

CRITERIA FOR EVALUATING SCREENING TOOLS
SENSITIVITY
• Measures how often a test correctly
generates a positive result for people who
have the condition that’s being tested for
(the “true positive” rate).
• A test that’s highly sensitive will flag almost
everyone who has the disease and not
generate many false-negative results.
47
CRITERIA FOR EVALUATING SCREENING TOOLS
SPECIFICITY
• Specificity measures a test’s ability to
correctly generate a negative result for
people who don’t have the condition that’s
being tested for (the “true negative” rate).
• A high-specificity test will correctly rule out
almost everyone who doesn’t have the
disease and won’t generate many false-
positive results.
48

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IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES

CRITERIA FOR EVALUATING SCREENING TOOLS

• PREDICTIVE VALUE
▪ Directly address the estimation of
probability of disease
▪ Positive predictive value
True-positives x 100
True-positives + False-positives
▪ Negative predictive value
True-negatives x 100
True-negatives + False-negatives
 Greenberg, R.S., Daniels,
49 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004). 50
Medical Epidemiology, 4th Edition

IMPORTANCE OF SCREENING MEASURES

FOR EVALUATION OF DISEASES

90 20
CRITERIA FOR EVALUATING SCREENING TOOLS

• SCREENING TEST
▪ Sensitive and specific
Acceptable to the target population
80
▪
10 ▪ Associated with minimal risk
▪ Diagnostic work-up for a positive test
result must have acceptable morbidity,
given the number of false-positive results
51  Greenberg, R.S., Daniels,
52 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology, 4th Edition

MEASURES OF PREVENTION OF
OCCURRENCE OF DISEASE

Measures to Prevent 1. Identify high risk individuals

Occurrence of Diseases 2. Screen the population at risk
3. Detect disease at its earliest stage
4. Educate for primary prevention
5. Eliminate harmful agents from work
place and environment

53  Greenberg, R.S., Daniels,

54 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology, 4th Edition

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MEASURES OF PREVENTION OF MEASURES OF PREVENTION OF

OCCURRENCE OF DISEASE OCCURRENCE OF DISEASE

1. Identify high risk individuals 2. Screen the population at risk

• Identify Risk Factors
• Age, sex, parity NEWBORN SCREENING
• Parental risk factors Rationale:
1961 - first introduced
Dr. Carmelita Domingo by–
early
Dr.
was Robert
diagnosis
Training in Guthrie
inspired the of
toUS certain
convince
when
• Medical history
congenital
Philippine
screening in
conceived disorders
policy
for PKU
1996 makers
was→
• Teratology (infection, drug, exposures) early
and
just
in treatment
local
being
the funding
introduced
Philippines →
• Occupational history reversal
agenciesoftoresultant poor
have a pilot
• Signs and symptoms medical
newbornoutcomes
screening
• Environment
 Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).  David-Padilla, C.M, Gutierrez-Tayag, J.P. (2016). Celebrating
55 56
Medical Epidemiology, 4th Edition 20 Years of Newborn Screening; Challenges and Successes

MEASURES OF PREVENTION OF MEASURES OF PREVENTION OF

OCCURRENCE OF DISEASE OCCURRENCE OF DISEASE

3. Detect disease at its earliest stage 4. Educate for primary prevention

• Identify Risk Factors • Genetic counseling
• Age, sex, parity • Communication process –
• Parental risk factors • Between trained health
• Medical history
• Teratology (infection, drug, exposures)
professional and patient
• Occupational history
• Signs and symptoms
• Environment
 Greenberg, R.S., Daniels,
57 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).  Greenberg, R.S., Daniels,
58 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology, 4th Edition Medical Epidemiology, 4th Edition

MEASURES OF PREVENTION OF MEASURES OF PREVENTION OF

OCCURRENCE OF DISEASE OCCURRENCE OF DISEASE

GENETIC COUNSELING 5. Eliminate harmful agents from work

Help an individual to: place and environment
4. Choose course
1. Comprehend of action
medical suited for their
facts • Identify Risk Factors
-individual
diagnosis,needs
natureand goals
and cause of disorder, • Age, sex, parity
5. Make the best
available possible family adjustment
treatment • Parental risk factors
2. to the disorder
Understand of affected
genetic member
and non-genetic • Medical history
aspect of disorder and risk of recurrence • Teratology (infection, drug, exposures)
3. Understand alternatives for subsequent • Occupational history
family planning - prenatal diagnosis, • Signs and symptoms
adoption, artificial insemination • Environment
59  Greenberg, R.S., Daniels,
60 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology, 4th Edition

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ROLE OF GENETICS & ENVIRONMENT

IN DISEASE CAUSATION
MECHANISM OF INTERACTION
CAN IT BE ALTERED?
“Identify the group
Maternal history of Rubella that is most susceptible
in order to allocate the measures and
to concentrate on them
Virus crosses transplacental barrier
who are in need of services”
Fetus (Environment)

(deafness, cataract, PDA

result of GF and Environment)
61 62

THANK YOU FOR

LISTENING

63

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REFERENCES
EVIDENCE BASED
MEDICINE
• Rosenberg W, Donald A. Evidence based medicine: an approach to
clinical problem-solving. BMJ 1995; 310: 1122–1126.
• Crumley, E, Koufoglannakis, D, Stobart, K. Teaching EBP, part 1. Case
J E N A A N G E L A T. P E R A N O , M D scenarios and the well-built clinical question. Bibliotheca Medica
M A . L O R E N A L O R E N Z O, M D Canadiana 2000: 22(2):80-84.
F R A U L E I N P. TO R M O N , M D
M AC A R I O R E A N D E L A R J R . , M D
RO N WA L D O S A N D I E G O, M D
M A R I E R U T H E C H AV E Z , M D
B I L LY A . G O C O , M D
J E N E L L Y. O C Z O N , M D

DEFINITION EBM AND ITS VALUE IN PATIENTS’

CARE

• Evidence Based Medicine (EBM) is the • Clinicians

process of systematically reviewing,
–Best of patients’ clinical research
appraising and using clinical research findings
to aid the delivery of optimum clinical care to Assessments evidence
patients.
• It is a systematic approach to the acquisition, assist in patients’ care
appraisal and application of research
evidence to guide healthcare decisions.

EBM AND ITS VALUE IN PATIENTS’ THE EBM CYCLE

CARE
Ask
• Defines strength of evidence
supporting a practice
• Ranking interventions Assess Acquire

• CPGs Patient

–Minimizes variation of the standards of

practice
Apply Appraise

1

EBM
• There are basically three steps to utilize EBM
as a tool for clinicians in their practice:
– Step One: Search and Acquisition of
Evidence
– Step Two: Critical Appraisal of
Evidence
– Step Three: Application of Evidence
ACQUIRE
In searching for evidence, consider the following:
• 1) Develop an initial strategy
a) Precise question (use PICOM)
b) Key concepts in the question
c) Broaden key concept to account for
differences in terminology
d) Narrow down yield by using the “intersect”
(use of OR or AND)
ACQUIRE
6/24/2021
ACQUIRE
• MEDLINE/PubMed
– Full Text online
– Abstracts
• EBM at the point-of-care
– Online availability and accessibility of
the appropriate article that will provide
timely answer to a clinical dilemma
ACQUIRE
• Boolean Logic - Using the words and, or,
and not will help refine your search.
Connecting your keywords with AND
AND tells the search tool that all the words
must be present.
Connecting your keywords with OR tells
the search tool that any of the words can
OR
be present.
Using NOT in front of a key word tells
the search tool to exclude any page
NOT contaning that word. Some engines
require you to use AND NOT
ACQUIRE
•Phrase Searching
–Enclose in quotation marks the
phrase you are searching for
• The quotation marks - the words within
must be exactly as they were typed,
and in the same order.
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ACQUIRE ACQUIRE

•Let’s try combining Boolean

logic and using Quotation
marks

ACQUIRE ACQUIRE

APPRAISE I. SEARCH AND

• Critical Appraisal guides
– 3 parts
• Validity questions
• Summary of results
• Applicability in practice
ACQUISITION OF EVIDENCE
• The clinical problem
• As in all researches, EBM begins with a
clinical problem
• And the clinical problem is normally
translated as a clinical question.

3

I. SEARCH AND
ACQUISITION OF EVIDENCE
• Four components are tackled in the formulation of a
focused clinical question
– P: Participants or Patients or Population of
Interest
– I : Intervention (Exposure/Diagnostic Procedure)
– C: Comparison
– O: Outcome of Interest
P = PATIENT/POPULATION OF
INTEREST
• Who are the patients of interest?
• Is there a particular age group, gender
or population?
• What is the health concern?
• Example: For persons entering a health
care facility…
C = COMPARISON OF
INTEREST
• Is there a comparison to be evaluated against
the intervention?
• Only used if more than one intervention or if
no intervention is a factor.
• Example: For persons entering a health care
facility, is hand rubbing with a waterless,
alcohol-based solution, as effective as
standard hand washing with antiseptic soap…
6/24/2021
“PICO” MODEL
• The focused Clinical Question:
• Patient / Population / Problem (among ____)
• Intervention / Exposure (does ____)
• Comparison (versus _____)
• Outcome (affect ______)
I = INTERVENTION OR
EXPOSURE
• What therapeutic, diagnostic, preventive or
other health care interventions are you
interested in knowing more about?
• What health care management strategies are
you interested in comparing?
• Example: For persons entering a health care
facility, is hand rubbing with a waterless,
alcohol-based solution…
O = OUTCOME OF INTEREST
• What is the desired outcome to be evaluated?
• How will the patient or population be
affected, or not affected, by the intervention?
• Example: For persons entering a health care
facility, is hand rubbing with a waterless,
alcohol-based solution, as effective as
standard hand washing with antiseptic soap
for reducing hand contamination?
4

TT MODEL
• In addition to the PICO elements of your
clinical question, it’s important to know:
– What TYPE of question are you asking?
– What is the best STUDY DESIGN to
search for to find evidence to answer your
clinical question?
WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE
SUPPORT?
Therapy/Treatment questions:
Evidence supports how to select
treatments to offer your patients
that do more good than harm and
that are worth the efforts and costs
of using them.
WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE
SUPPORT?
Prognosis questions:
Evidence supports how to estimate
your patient’s likely clinical course
over time and anticipate likely
complications of the disorder.
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P.I.C.O. (T.T.) MODEL
FOR CLINICAL QUESTIONS
WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE
SUPPORT?
Diagnosis questions:
Evidence supports how to select
and interpret diagnostic tests, in
order to confirm or exclude a
diagnosis, based on considering
their precision, accuracy,
acceptability, expense, safety, etc.
WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE
SUPPORT?
Harm/Etiology questions:
evidence supports how to
identify causes for disease
(including its iatrogenic forms).
5

ISSUES FOR EACH CLINICAL
SCENARIO
• What is your clinical question in PICO
format?
• What type of clinical question is this?
• What is the best study design to answer
this type of clinical question?
CLINICAL SCENARIO #1
• What is your clinical question in PICO format?
• What type of clinical question is this?
• What is the best study design to answer this
type of clinical question?
6/24/2021
CLINICAL SCENARIO #1
• On morning rounds in the Hem/Onc unit, a
first year resident turns to you for
consultation. She wants to discuss options for
managing moderate nausea and vomiting
that result following chemotherapy. She
shares an experience a relative had taking
ginger when prochlorperazine didn’t provide
effective relief and asks for your input.
ANSWERABLE CLINICAL
QUESTION: PICO TT MODEL
• P – In patients receiving chemotherapy who are
experiencing moderate nausea and vomiting
• I – is the use of ginger
• C – as effective as prochlorperazine
• O – in reducing nausea and vomiting?
• Type of Question: Therapy/Treatment
• Type of Study/Methodology: Double-Blind
Randomized Controlled Trial; Systematic Review/Meta
Analysis of RCT
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CLINICAL SCENARIO #2 CLINICAL SCENARIO #2

• Traditionally, clinicians have used a conservative approach
to the diagnostic evaluation of head-injured infants, • What is your clinical question in PICO format?
arguing that infants are at increased risk of intracranial
injury (ICI) and that symptoms or signs of brain injury • What type of clinical question is this?
may not be reliably present in those with ICI. A number • What is the best study design to answer this type of
of previous studies have reported that a significant clinical question?
fraction of ICIs in infants occur in patients with a normal
neurological status and with no signs or symptoms of
brain injury. You want to see how well clinical features
predict ICI in infants.
Adapted from: Greenes D, Schutzman S. Clinical Indicators of Intracranial Injury in Head-injured Infants. Pediatrics 1999; 104 (4):
861-867.

ANSWERABLE CLINICAL CLINICAL SCENARIO #3

QUESTION: PICO TT MODEL • A 2-year-old patient presents with a 12-month history of
recurrent wheezing, cough, dyspnea, and mucopurulent
• P – Among children with minor head injury nasal discharge. There are no smokers in the household,
and all pets have been removed. Antibiotics and
• I – will clinical features antihistamines have been tried without sustained benefit.
• C – compared to CT scan Physical examination demonstrates normal growth and
normal vital signs. Thick yellow nasal discharge is noted,
• O – predict ICI? and bilateral expiratory wheezes are heard on chest
• Type of Question: Diagnosis auscultation. This scenario raises multiple questions, and
the focus here will be: When is antibiotic therapy
• Type of Study/Methodology: Controlled Studies; indicated?
Systematic Review/Meta Analysis of Controlled Adapted from: http://pedsinreview.aappublications.org/cgi/reprint/24/8/265.pdf
Studies

CLINICAL SCENARIO #3 ANSWERABLE CLINICAL

QUESTION: PICO TT MODEL
• What is your clinical question in PICO format? • P – Among toddlers with recurrent nasal discharge
• What type of clinical question is this? • I – does the use of antibiotics
• What is the best study design to answer this type of • C–
clinical question? • O – affect the probability of recurrence?
• Type of Question: Prognosis
• Type of Study/Methodology: Cohort Studies

7

CLINICAL SCENARIO #4
• The traditional view of withholding feeds in VLBW
infants has recently been challenged. Provision of
trophic feeds has been found to result in faster
maturation of the gut, making it much more
receptive for subsequent enteral feeds. You’ve been
asked to find the evidence on whether feeds should
be administered fast or slow to this vulnerable
population.
CLINICAL SCENARIO #5
• Working on the Developmental Assessment Team for
school-aged children of mothers who used cocaine
during their pregnancy, you are interested in learning
the developmental outcomes for these children as
they begin school compared to children not exposed
to cocaine during pregnancy.
ANSWERABLE CLINICAL
QUESTION: PICO TT MODEL
• P – Do otherwise healthy children
• I – born from mothers exposed to cocaine during
pregnancy,
• C – compared to those not exposed to cocaine
• O – have increased incidence of learning disabilities?
• Type of Question: Harm/Etiology
• Type of Study/Methodology: Cohort Studies
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ANSWERABLE CLINICAL
QUESTION: PICO TT MODEL
• P – Among very low birth weight infants,
• I – are slow enteral feeds
• C – vs. fast enteral feeds
• O – better tolerated?
• Type of Question: Therapy/Treatment
• Type of Study/Methodology: Systematic
Review/Meta
• Analysis of Double-Blind Randomized Controlled Trials
CLINICAL SCENARIO #5
• What is your clinical question in PICO format?
• What type of clinical question is this?
• What is the best study design to answer this type of
clinical question?
CLINICAL SCENARIO #6
• Forced use, or constraint-induced movement therapy
(CIMT) has shown some efficacy in the rehabilitation
of adults with chronic hemiparesis as a result of
stroke. You are asked to provide a Lunch and Learn
for your department on the use of CIMT versus
conventional PT/OT therapy to improve outcomes for
the management of hemiparesis associated with
cerebral palsy in pediatric patients.
8

CLINICAL SCENARIO #6
• What is your clinical question in PICO format?
• What type of clinical question is this?
• What is the best study design to answer this type of
clinical question?
II. CRITICAL APPRAISAL OF
EVIDENCE
• The process of systematically examining the research
evidence to assess its validity, results, and relevance
before using it as a basis of clinical decision-making.
II. CRITICAL APPRAISAL OF
EVIDENCE
• CLINICAL PICO = Research PICO: Appraising
Directness
• A research article, however well made, is useless if it
will not answer the clinical question.
• The first step to critical appraisal is to evaluate the
article’s directness.
• This essentially means checking if the clinical
question is similar to the research question.
• This is done by matching the PICO of the research
question with that of the clinical question.
6/24/2021
ANSWERABLE CLINICAL
QUESTION: PICO TT MODEL
• P – Among cerebral palsy pediatric patients with
hemiparesis
• I – does constraint movement induced therapy,
• C – compared to conventional PT/OT therapy
• O – improve outcomes (motor skills / function)?
• Type of Question: Therapy/Treatment
• Type of Study/Methodology: Double-Blind
Randomized
• Controlled Trial
II. CRITICAL APPRAISAL OF
EVIDENCE
• Bad Evidence = Bad Clinical Decision
• There are research studies whose methodological
flaws lend them to a number of biases.
• These biases compromise the validity of evidence.
• A clinical decision made based on flawed evidence is
in itself flawed.
II. CRITICAL APPRAISAL OF
EVIDENCE
• More Flaws = More Biases = Less Valid
Evidence: Appraising Validity
• In the evaluation of internal validity, one must
examine the study’s methodology.
• Methodological flaws result to biases, which then
lead to invalid results (over or under-estimations).
• For example, a biased study may conclude
effectiveness of treatment when in truth it is not.
9

II. CRITICAL APPRAISAL OF
EVIDENCE
• More Flaws = More Biases = Less Valid
Evidence: Appraising Validity
• The way in which evidence is critically appraised
differs slightly according to the study design being
appraised (e.g. RCTs, meta-analysis, observational
studies).
III. APPLICATION OF
EVIDENCE
• After the study has been deemed direct and valid,
and after the result has been appraised, the next
step is to apply the evidence to the clinical scenario
or actual patient’s situation.
• Application of evidence involves evaluation of
applicability and individualization of results.
III. APPLICATION OF
EVIDENCE
• The Study Population and Setting is NOT
Always Similar to the Actual Patient and
Clinical Situation: Evaluating Applicability
• Differences often do exist between the study setting
and real world scenario.
• It is important to assess whether these differences
will affect the applicability of the study findings in
actual clinical practice.
• For example in a study population comprised of
Caucasian subjects; will the findings of such study
affect the applicability to Asian patients?
6/24/2021
II. CRITICAL APPRAISAL OF
EVIDENCE
• Numbers can be Deceiving: Appraising the
Result
• Appraising results involves not only determining the
statistical significance but also understanding and
determining other numeric expressions of
effectiveness or accuracy such as risk ratio, relative
risk reduction, sensitivity, specificity, likelihood ratio,
etc.
III. APPLICATION OF
EVIDENCE
• The Study Population and Setting is NOT
Always Similar to the Actual Patient and
Clinical Situation: Evaluating Applicability
• In assessing the applicability of a research finding,
several issues must be addressed.
• Patient related issues include biologic issues such as
age, sex, race, pathology and comorbidities.
• Socio-economic issue is also very important to
consider.
III. APPLICATION OF
EVIDENCE
• What is True for Many is NOT Always True for
One: Individualizing the Results
• The conclusion of the study is based on the overall
effect of an intervention or procedure on an entire
study population.
• It is the average effect of a treatment or procedure
on an average patient.
• In clinical practice however, the patient often does
not fit the category of an “average” patient.
• It is important therefore that the results are
individualized to the specific patient.
10

ARTICLES ON TREATMENT
APPRAISING VALIDITY OF A
TREATMENT
• The validity of trials comparing two therapies
depends almost entirely on how fair the comparisons
are between patients in the treatment and control
groups.
• There are criteria used for assessing the validity of
therapy.
• These criteria are phrased as questions.
EIGHT QUESTIONS
FOR ASSESSING VALIDITY
Question #1: Were patients randomly assigned to
treatment groups?
Question #2: Was allocation concealed?
Question #3: Were baseline characteristics similar at the
start of the trial?
Question #4: Were patients blinded to treatment
assignment?
Question #5: Were physicians blinded to treatment
6/24/2021
REFERENCE
• Dans AL, Dans LF, Silvestre MA. Painless Evidence-Based Medicine.
John Wiley & Sons Ltd; 2008
APPRAISING VALIDITY OF A
TREATMENT
• A ‘yes’ answer to a question means that the criterion
is satisfied.
• The more ‘yes’ answers there are, the more sure we
become that the comparisons are fair.
WERE PATIENTS RANDOMLY
ASSIGNED TO TREATMENT
GROUPS?
• Random assignment of patients to treatment groups
in a trial is the best technique to ensure that
treatment groups are truly comparable.
• If patients are not assigned to treatment groups at
random, then allocation may become unfair.
• Cases with poorer prognosis may end up being
assigned to one treatment group.
11

WAS ALLOCATION
CONCEALED?
• The random order by which patients are assigned to
treatment groups is referred to as the allocation
sequence.
• Researchers must ensure that the allocation
sequence is not altered by clinicians who consciously
or unconsciously tend to distort the balance.
• Such measures are called allocation concealment
strategies.
WERE BASELINE
CHARACTERISTICS SIMILAR
AT THE START OF THE TRIAL?
• With proper randomization, baseline characteristics
of treatment groups tend to be very similar.
• There are instances however where dissimilarity in
the characteristics between treatment groups may
arise.
• Look for comparison in the baseline characteristics
between the treatment and control groups.
• If there are differences in the characteristics, check if
they are adjusted in the analysis.
WERE PHYSICIANS BLINDED
TO TREATMENT ASSIGNMENT?
• When physicians are aware of the treatment group to
which patients are assigned, they may treat the
patients in the two groups differently.
• For example, a clinician who knows his patient is on
a placebo may worry and decide to take better care
of that patient.
• Conversely, a clinician who knows the patient is on
treatment may decide to monitor more frequently
just in case there are side effects.
• These changes in care may make a treatment appear
better or worse than it really is.
6/24/2021
WAS ALLOCATION
CONCEALED?
• It is important that the randomization scheme be
unpredictable, meaning which treatment group a
participant will be randomized to cannot be
predicted.
• Unpredictability is assured through the process of
allocation concealment.
• Such scheme can in prevent selection bias – that is,
the potential for investigators to manipulate who gets
what treatment.
WERE PATIENTS BLINDED
TO TREATMENT ASSIGNMENT?
• Patients may respond to a treatment even the
treatment has no therapeutic value.
• This phenomenon called the ‘placebo effect’ can
happen more frequently for symptoms that are
subjective in nature like headaches or body aches.
• Patients need to be informed that they can either be
given a placebo or an experimental drug in 50% of
the time; but they will not know what they will be
taking.
WERE OUTCOME ASSESSORS
BLINDED TO TREATMENT
ASSIGNMENT?
• Outcome assessors can be the patients themselves,
or their caregivers.
• They are sometimes directly involved in assessing
outcomes or therapy response.
• For example, patients may be asked if they feel
better and caregivers may be asked if they think their
patients are doing well.
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WERE ALL PATIENTS ANALYZED IN WAS FOLLOW-UP RATE

THE GROUPS TO WHICH THEY WERE
ORIGINALLY RANDOMIZED?
ADEQUATE?
• Many times patients in clinical trials may not complete the • Adequacy of follow-up refers to minimization of the
treatment protocol that they were assigned to, either because number of patients who drop out from a study.
of intolerable side effects, or loss to follow up.
• A dilemma arises: should all be analyzed in their original
• The greater the number of patients lost to follow-up,
treatment group (intention-to-treat analysis, ITT) or only those the more the study validity is threatened.
who completed the treatment protocol (per protocol analysis)? • The crucial issue is ascertaining when to worry about
• Reason for doing ITT analysis is that when patients develop the number of drop-outs.
intolerable side effects and they are removed from the analysis,
these side effects will not be reported.

WHEN TO WORRY ABOUT THE WHEN TO WORRY ABOUT THE

NUMBER OF DROP-OUTS? NUMBER OF DROP-OUTS?
• Assessing if there are too many drop-outs in a
• Assessing if there are too many drop-outs in a study
study
• Step 1: Count the number of drop-outs in each
• In this hypothetical RCT, patients with severe pneumonia
treatment group
are randomized to receive either active treatment (n=30)
or placebo (n=30). There are 13 drop-outs in the study, 6 • Step 2: Count the number of patients with bad
on treatment and 7 on placebo. outcomes in each treatment group, and express this
as a fraction of the number of patients analyzed.
Measure Treatment Placebo
Taken from: Dans AL, Dans LF, Silvestre MA. Painless Evidence-Based Medicine. John Wiley & Sons Ltd;
2008 No. of Participants 30 30
Drop outs 6 7
Deaths 5/24 9/23

WHEN TO WORRY ABOUT THE WHEN TO WORRY ABOUT THE

NUMBER OF DROP-OUTS? NUMBER OF DROP-OUTS?
• Assessing if there are too many drop-outs in a Measure Treatment Placebo
study
No. of Participants 30 30
• Step 3: Create a worst scenario for the treatment
group by assuming all the drop-outs in this group 5+6 9+0
had the bad outcome, and all the drop-outs in the Worst Scenario 24 + 6 23 + 7
control group had a good outcome.
5+0 9+7
• Step 4: Create a best scenario for the treatment Best Scenario 24 + 6 23 + 7
group by assuming the opposite, i.e. all the drop-
outs in this group had a good outcome, and all the
drop-outs in the control group had the bad outcome

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WHEN TO WORRY ABOUT THE WHEN TO WORRY ABOUT THE

NUMBER OF DROP-OUTS? NUMBER OF DROP-OUTS?
Measure Treatment Placebo
• Step 5: Were the conclusions of the best and worst
No. of Participants 30 30 scenarios significantly different?
• If yes, then there were too many drop-outs!
36.7%(Harm) 30.0%
Worst Scenario

16.7%(Benefit) 53.3%
Best Scenario

WHEN TO WORRY ABOUT THE WHEN TO WORRY ABOUT THE

NUMBER OF DROP-OUTS? NUMBER OF DROP-OUTS?
Measure Treatment Placebo
No. of Participants 30 30 • Drop-out formula

Worst Scenario 36.7%(Harm) 30.0%

Best Scenario 16.7%(Benefit) 53.3%

• The best-case scenario showed fewer bad events for

treatment (benefit), while the worst-case scenario showed
more bad events for treatment (harm).
• Therefore, there were too many drop-outs in this
hypothetical study.

EXERCISE EXERCISE

• If the deaths on treatment were 1/24 and the deaths • Answer: No, the treatment group would have fewer
on placebo were 16/23, would the same drop-out deaths in both the best and worst scenarios.
rates still be worrisome? • Drop-out formula

14

QUESTIONS ON VALIDITY
• The eight questions on the validity of a study have
now been discussed.
• While it is tempting to be strict and insist that all
eight criteria be satisfied, we must be pragmatic and
remember that we sometimes need to make medical
decisions based on less than perfect information.
APPRAISING THE RESULTS
• Question #1: How large was the effect of
treatment?
• Question #2: How precise was the estimate of
the treatment effect?
HOW LARGE WAS THE
EFFECT OF TREATMENT?
• For quantitative outcomes, the effect of treatment is
simply expressed as the ‘mean difference’.
• For qualitative outcomes, relative risk (RR), absolute
risk reduction (ARR), relative risk reduction (RRR),
and number needed to treat (NNT) are calculated.
6/24/2021
QUESTIONS ON VALIDITY
• If you feel that errors are small or that this is
probably the best study you will find that addresses
your clinical question, read the results.
• If you feel the errors are too great and that there are
better studies, then don’t waste your time with the
article.
HOW LARGE WAS THE
EFFECT OF TREATMENT?
• The magnitude of the treatment effect may be
expressed by comparing outcomes in the treatment
and control groups.
• Outcomes can be reported either as: Quantitative
(Blood Pressure in mmHg, cholesterol levels,
reduction in weight) or Qualitative, (Cured, not
cured, dead or alive, with complication or without
complication)
HOW PRECISE WAS THE ESTIMATE
OF THE TREATMENT EFFECT?
• Interval estimate is another way of looking into the
significance of the effect size.
• An interval estimate consists of two numbers, a lower
limit and an upper limit, within which the parameter
is expected to lie with a certain degree of confidence,
known as confidence interval (CI)
• Conventionally, confidence intervals are reported as
90%, 95% or 99%.
• But the 95% CI is most commonly used.
15

HOW LARGE WAS THE
EFFECT OF TREATMENT?
• When the 95% CI excludes 1 in a Relative Risk, the
effect of treatment is statistically significant.
ASSESSING APPLICABILITY
• We can also look at treatment effects in subgroups of
patients that more closely approximate the individual
patient we are trying to help (subgroup analysis).
• Because data from subgroups are limited, healthcare
providers must decide on the applicability of trial
results to individual patients, based on the general
information available to them.
• To do this, biologic as well as socioeconomic issues
may be considered.
BIOLOGIC ISSUES
AFFECTING APPLICABILITY
• Consider co-existent conditions that could affect
applicability.
• Studies show that response to measles vaccination is
reduced in malnourished children
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ASSESSING APPLICABILITY
• After evaluating validity and analyzing the results of a
trial, the next step is to decide if the results can be
applied to our own patients.
• For example, we can check if our patients’
characteristics satisfy the inclusion and exclusion
criteria.
BIOLOGIC ISSUES
AFFECTING APPLICABILITY
• Consider physiological, hormonal or biochemical
differences between sexes that might affect the
effectiveness of an intervention.
• For example, women have greater reduction in stroke
incidence compared to men when treated with
aspirin.
BIOLOGIC ISSUES
AFFECTING APPLICABILITY
• Racial differences may affect applicability. For
example, black hypertensives are more responsive to
diuretics than whites.
• East Asians are more likely to develop the adverse
effect of cough from angiotensin converting enzyme
inhibitors compared to whites
16

BIOLOGIC ISSUES
AFFECTING APPLICABILITY
• Age differences commonly affect response to a
treatment.
• For example, flu vaccines lead to smaller reductions
in the risk of influenza in older people
SOCIOECONOMIC ISSUES
AFFECTING APPLICABILITY
• Most trials are carried out under ideal conditions,
which are difficult to apply in everyday life.
• This is as much a problem of provider compliance as
it is a problem of patient compliance.
SOCIOECONOMIC ISSUES
AFFECTING APPLICABILITY
• Some therapies present both types of compliance
problems.
• Warfarin administration for atrial fibrillation, for
example, requires not only strict patient compliance
with monitoring, but also availability of resources for
prothrombin time determination and emergency
management of life-threatening bleeds.
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BIOLOGIC ISSUES
AFFECTING APPLICABILITY
• Consider differences in the disease under study itself.
• At times, diseases we refer to by the same name are
actually conditions with slightly different pathology.
• This can lead to significant variations in response to
treatment.
• For example, malaria in Zimbabwe is different from
malaria in the Philippines and this is manifested as
differences in treatment response
SOCIOECONOMIC ISSUES
AFFECTING APPLICABILITY
• Patient compliance problems often relate to markers
of socioeconomic disadvantage such as poverty and
lack of education.
• Provider compliance problems, on the other hand,
are often related to skill in the implementation of
certain procedures and availability of necessary
facilities.
INDIVIDUALIZING THE
RESULTS
• Once satisfied that biologic and socioeconomic
factors will not compromise effectiveness, the next
step is to individualize the benefit, risks and costs to
your patient.
• While studies report effectiveness of a treatment in a
population as a whole, the benefits, risks and costs
will vary slightly from patient to patient.
• The main source of this variation is the patient’s
baseline risk for the event you are trying to prevent.
17

ARTICLES ON DIAGNOSIS
DIAGNOSTIC TESTS
• Diagnostic tests help physicians revise
disease probability for their patients.
• All tests should be ordered by the physician
to answer a specific question.
• The 5 main reasons for a diagnostic test are
as follows:
DIAGNOSTIC TESTS
• Screen for disease in asymptomatic patients.
– For example, a prostate-specific antigen
(PSA) test in men older than 50 years.
• Provide prognostic information in patients
with established disease.
– For example, a CD4 count in patients with
HIV.
6/24/2021
REFERENCES
• Dawson B, Trapp R. Basic & Clinical Biostatistics.
Fourth Edition. McGraw-Hill Companies, Inc., 2004.
• Abram E, O’Connor R, Valesky W. Screening and
Diagnostic Tests. Medscape Reference. Available at
http://emedicine.medscape.com
DIAGNOSTIC TESTS
• Establish a diagnosis in symptomatic patients.
– For example, an ECG to diagnose ST-
elevation myocardial infarction (STEMI) in
patients with chest pain.
DIAGNOSTIC TESTS
• Monitor therapy by either benefits or side
effects.
– For example, measuring the international
normalized ratio (INR) in patients taking
warfarin.
• A test may be performed to confirm that a
person is free from a disease.
– For example, a pregnancy test to exclude
the diagnosis of ectopic pregnancy.
18

CRITERION TEST
• The criterion (reference) standard test
definitively decides either presence or
absence of a disease.
– Examples of criterion standard tests
include pathological specimens for
malignancies and pulmonary angiography
for pulmonary embolism.
ALTERNATIVE TESTS
• These issues usually compel most physicians
to choose other diagnostic tests as
surrogates for their criterion standard test.
ALTERNATIVE TEST
• The price most diagnostic tests pay for their
ease of use compared with their criterion
standard is a decrease in accuracy.
• How to account for this trade-off between
diagnostic accuracy and patient acceptability
is the subject of this discussion.
6/24/2021
CRITERION TEST
• However, criterion standard tests routinely
come with drawbacks.
• They are usually expensive, less widely
available, more invasive, and riskier.
ALTERNATIVE TESTS
• For example, venography, the criterion standard
for vein thrombosis, is an invasive procedure
with significant complications including renal
failure, allergic reaction, and clot formation.
• These risks make venography less desirable than
the alternative diagnostic test—venous duplex
ultrasonography.
PRETEST AND POSTTEST
PROBABILITY
• Every clinical encounter begins with an initial
clinical impression, a subjective pretest
probability of disease.
• The ultimate goal of all diagnostic testing is
to refine this pretest probability to the point
where the physician can confidently make a
treat or no-treat decision.
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PRETEST AND POSTTEST MEASURES OF ACCURACY

PROBABILITY
• Each diagnostic test whether it is a laboratory, or • Clinical studies of diagnostic tests measure
radiological examination results in a change in the the accuracy of the test against its criterion
physician’s probability of disease, the posttest
standard.
probability.
• The degree to which a diagnostic test increases or
decreases the probability of disease from pretest to
posttest represents the clinical utility of the test.

SENSITIVITY AND
SENSITIVITY
SPECIFICITY
a
Disease • Sensitivity = 100
a+c
Test
Yes No
Positive a b
• The ability of the test to detect those who have the
Negative c d disease.
Total a+c b+d • True positive = those persons with the disease and
Disease whose findings are abnormal
Test
Yes No • False negative = Those persons who have the disease but
Positive TP FP whose findings are normal
Negative FN TN
Total

SPECIFICITY MEASURES OF ACCURACY

d
• Specificity =  100 • Different diagnostic tests for the same disease often
b+d trade sensitivity for specificity or vice versa.
• The ability to test negative if the disease is truly • In general, the more sensitive a test is for a disease,
absent
the higher its false-positive rate, lowering its
• True negative - those persons who do not have the
disease and whose findings are normal specificity.
• False positive rate refers to the percentage of all • A test with a higher specificity will usually sacrifice
positive results that occur in those in whom the sensitivity by increasing its false-negative rate.
disease is absent.

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MEASURES OF ACCURACY PREDICTIVE INDICES

• This makes a highly sensitive test ideal for a • Predictive value of a Positive test (PVP)
screening examination. • Predictive value of a Negative test (PVN)
• While, highly specific tests are best in a
confirmatory role.

PREDICTIVE VALUE OF A PREDICTIVE VALUE OF A

POSITIVE TEST POSITIVE TEST
• The probability that the patient has the • PVP is dependent on the prevalence of the disease
disease given a Positive test. and the specificity.
a • The higher the prevalence of the disease, the higher
PVP = 100 will the PVP be.
a+b
• However if the specificity is 100%, the PVP is also
100% regardless of the prevalence of the disease

PREDICTIVE VALUE OF A PREDICTIVE VALUE OF A

NEGATIVE TEST NEGATIVE TEST
• The probability that the patient does not have • The PVN is dependent on the prevalence of
the disease given a Negative test. the disease and the sensitivity.
d • The lower the prevalence of the disease is,
PVN = 100 the higher will the PVN be.
c+d
• However, if the sensitivity is 100%, the PVN
is also 100% regardless of the prevalence of
the disease.

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BAYES' THEOREM BAYES' THEOREM

• Adapting a theory of conditional probability
from the 18th century statistician Thomas
• Posttest Odds = Pretest Odds X Likelihood Ratio
Bayes solves the problem of calculating
posttest disease probability.
• This theory allows pretest probability to be
separated from a term that describes the
strength of the diagnostic test—likelihood
ratio.

LIKELIHOOD RATIO POSITIVE LIKELIHOOD RATIO

• A likelihood ratio for a positive test result (LR+) is
the ratio of the true positive rate (sensitivity) divided
• Both PVP and PVN are dependent on the prevalence by the false-positive rate (1 - specificity).
of the disease.
• LR+ then can be thought of how much more likely
• There is one other index that we use to calculate the the patient is to actually have the disease after a
likelihood of the disease that are not affected by the positive test result.
prevalence of the disease.
• Likelihood ratios are proportions of probabilities Test
Disease
Yes No
Positive TP FP
Negative FN TN
Total

NEGATIVE LIKELIHOOD LIKELIHOOD RATIOS

RATIO
• The likelihood ratio for a negative test result (LR-) is
calculated by dividing the false-negative rate (1 -
• A LR of 1.0 is a useless test.
sensitivity) by the true negative rate (specificity) • LR+ are always greater than 1.0; the larger
• The LR- provides the strength of a negative test the number, the more likely is the patient to
result that the patient is indeed free of disease. have the disease after a positive test result.
Disease • LR- are always less than 1.0, with the smaller
Test
Yes No numbers signifying a lower risk for disease.
Positive TP FP
Negative FN TN
Total

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STRENGTH OF THE TEST BY USING BAYES' THEOREM

LIKELIHOOD RATIO
Qualitative Strength LR+ LR-
• Posttest Odds = Pretest Odds X Likelihood Ratio
Excellent 10 0.1 • This form of Bayes’ theorem using likelihood ratios
Very Good 6 0.2 requires the conversion of pretest probability to odds
Fair 2 0.5 multiplied by the appropriate LR and then
reconverted to the posttest odds, back into posttest
Useless 1 1
probability.

BAYES' THEOREM STEPS

1. Convert pretest probability to odds.
Odds = Probability / (1 - Probability)
• What is the probability of Alzheimer’s Disease
Pre-test odds = 0.70/(1 – 0.70) = 2.333
in a patient after a positive MOCA test whose
2. Calculate LR+.
sensitivity is 75% and its Specificity is 85% if
LR+ = Sensitivity / (1 - Specificity)
the patient has a pretest probability of 70%?
LR+ = 0.75/ (1 – 0.85) = 5
• Bayes' theorem:
Posttest Odds = Pretest Odds X Likelihood Ratio

STEPS BAYES THEOREM

3. Calculate Bayes' Theorem.
Posttest Odds = Pretest Odds X LR
• Thus a Pre-test probability of 70%, after a positive
Posttest Odds = 2.333 x 5 = 11.67
MOCA test will yield a Post-test probability of
4. Convert posttest odds to probability. 92.1%
Probability = Odds / (1 + Odds)
Probability = 11.67 / (1 + 11.67) = 0.921
or 92.1%

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NOMOGRAM NOMOGRAM

• This method requires multiple steps and is

inconvenient for bedside use.
• In 1975, Fagan published a nomogram for
the graphical calculation of Bayes' theorem.

BAYES THEOREM MORE EXAMPLES

• ESR as test for diagnosis of Spinal Malignancy in a
patient presenting with low back pain, getting
progressively worse for the past 6 weeks .
• MIA method
• It has a Sensitivity of 78% and a Specificity of 67%.
• Use Bayes theorem to calculate the probability of the
Spinal Malignancy with a pre-test probability of 50%.
• Suppose the test turns out to be positive, calculate
the probability that the patient has Spinal Malignancy

BAYES THEOREM EXAMPLES

• MIA method
• A 65 year old man complained of
urinary frequency and urgency for
several months. On history taking no
loss of weight nor loss of appetite was
noted. DRE was done which revealed
nodules with asymmetry and difference
in the texture. PSA result was 4.2 ng/ml

24

EXAMPLES
• DRE and PSA combined Sensitivity and
Specificity is 38% and 87.9% respectively
• Supposed the index of suspicion of patient
having Prostatic CA is 60%.
• What is the probability that the patient have
Prostatic malignancy after a positive DRE and
PSA?
• MIA method
EXAMPLE
• Age 40-49 years – 0-2.5 ng/mL
• Age 50-59 years – 0-3.5 ng/mL
• Age 60-69 years – 0-4.5 ng/mL
• Age 70-79 years – 0-6.5 ng/mL
• MIA method
6/24/2021
EXAMPLE
• The standard prostate-specific antigen (PSA)
reference range of 0.0-4.0 ng/mL does not account
for age-related volume changes in the prostate that
are related to the development of benign prostatic
hyperplasia (BPH).
• Oesterling et al proposed that the use of age-related
reference ranges would improve cancer detection
rates in younger men and increase the specificity of
PSA testing in older men.
• They reported an overall specificity of 95% with the
following reference ranges:
QUESTIONS?
25
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MEDICAL INFORMATICS 1.What is the advantage of modern

technology in the practice of medicine?
Ronwaldo San Diego, MD
Jenell Y. Oczon, MD
Billy A. Goco, MD
Joseph A. Jao, MD 2. What patient data is the most
Angel Erich R. Sison, MD important to you and why?
Gloria Peret-Clarion, MD
Arnel V. Herrera, MD
Fraulein P. Tormon, MD

1
 6/24/2021

INFORMATICS

Informatics is an emerging discipline that has been

defined as the study, invention, and implementation of
structures and algorithm

To improve communication, interpretation,

understanding and management of information in order
to help solve application-specific problems

In our case , the application is

healthcare

ALGORITHM

A process for carrying out a complex task broken

down into simple decision and action steps.

Often assists the requirements analysis process

carried out before programming.

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MEDICAL INFORMATICS MEDICAL INFORMATICS

• Rapidly developing scientific field that
deals with the:

• storage
• retrieval
• optimal use of biomedical
information/data
• knowledge for problem solving and
decision making.

Health Informatics covers the organization and
management of information in the areas of patient
care, research and administration.
It focuses on the structuring of health data and
knowledge to support data analysis and decision-
making in medicine and health care with the use of
information systems.
It covers a wide spectrum of applications, from
computer-based patient records in general
practices and hospitals to electronic communication
between health care providers, from signal analysis
and image processing to decision support systems.
Effective delivery of healthcare requires correct
decision-making based on proper management of
health information.

WHY HEALTH INFORMATICS IMPORTANT

? WHY HEALTH INFORMATICS IMPORTANT ?

Work stress can arise from many sources, but the most
commonly reported ones

1. Heavy workload, lack of collegial support, ‘compassion

fatigue’ or burnout, and boundary issues
2. Difficulties with colleagues, criticism, discrimination,
harassment, bullying and racism
3. Making mistakes
4. Dealing with a complaint

3
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WHY HEALTH INFORMATICS IMPORTANT

?

Helps doctors with their decisions and actions, and

improves patient outcomes by making better use of
information—making more efficient the way patient data
and medical knowledge is captured, processed,
communicated, and applied

WHY HEALTH INFORMATICS IMPORTANT WHY HEALTH INFORMATICS IMPORTANT

? ?

APPLICATION APPLICATION
Mrs Smith is a 58 year old teacher was diagnoses with
15 year history of renal impairment caused by childhood
pyelonephritis.

She now came in for consult due to tiredness and muscle

cramps. She had previous consult for similar problems in
the past.

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APPLICATION
5

Heath informatics during routine clinical tasks

1
4 Since WHEN?
HOW many days?
WHAT do you think
causes?
WHAT did you do?
2 WHAT meds taken?
WHERE did you last
consulted?
WHO was your MD?
WHAT was the
diagnosis?
6 3
WHO is your previous
MD?

WHY HEALTH INFORMATICS IMPORTANT

?

LOST CHART

WHY HEALTH INFORMATICS IMPORTANT

?

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WHY HEALTH INFORMATICS IMPORTANT

?

WHY HEALTH INFORMATICS IMPORTANT ? IMPORTANCE OF PATIENT DATA

6
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IMPORTANCE OF PATIENT DATA

7
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IMPORTANCE OF PATIENT DATA IMPORTANCE OF PATIENT DATA

IMPORTANCE OF PATIENT DATA IMPORTANCE OF PATIENT DATA

IMPORTANCE OF PATIENT DATA WHY HEALTH INFORMATICS IMPORTANT ?

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INTERNET INTERNET
Ms Amulya Patel is a 48 year old accountant whose mother has recently died of breast
cancer. Ms Patel wonders about her own level of risk, and uses the internet to search for
patient resources

ADVANCE SEARCH ADVANCE SEARCH

• Allow specific phrases, languages, and times to be defined.

• Reduces the hits to a more manageable number.

• Narrows down the results by eliminating irrelevant ones.

• Skip unnecessary information by giving directions in ‘not to

include’ section

• Be more organized

• Allow users to save time and get maximum output in limited

time.

ACCESS TO MEDICAL LITERATURE

• Medical literature intended for professional use

• Jargon may make the information resource

impenetrable to non-professionals

• Prefer professional help to translate the information

that they have found.

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 6/24/2021

ACQUIRE
ACCESS TO MEDICAL LITERATURE
• MEDLINE/PubMed
The New England Journal of Medicine and JAMA are notable in this
regard, although subscriptions are needed to access many of these
–Full Text online
services. –Abstracts
Therefore, they may be available only if accessed by the health • EBM at the point-of-care
professional on the patient’s behalf
–Online availability and accessibility of the
appropriate article that will provide timely
answer to a clinical dilemma

ACQUIRE ACQUIRE
• Boolean Logic - Using the words and, or, and
not will help refine your search.
Connecting your keywords with AND tells
AND the search tool that all the words must be
present.
Connecting your keywords with OR tells
the search tool that any of the words can
OR
be present.
Using NOT in front of a key word tells the
search tool to exclude any page contaning
NOT that word. Some engines require you to use
AND NOT

ACQUIRE ACQUIRE
•Phrase Searching
–Enclose in quotation marks the phrase
you are searching for
• The quotation marks - the words within
must be exactly as they were typed, and in
the same order.

10
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ACQUIRE ACQUIRE

•Let’s try combining Boolean

logic and using Quotation marks

ACQUIRE

WHY HEALTH INFORMATICS IMPORTANT ?

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TELECONSULTATION TELECONSULTATION

• Patients and doctors can submit and receive

responses at their convenience
• Easy exchange of follow-up information
• Patient education (by attaching leaflets or links
to websites)
• Automatic documentation of consulting
behaviors or service requests.
• Email can be given by general practitioner
• Follow a website link to a specialist.

TELECONSULTATION WHY HEALTH INFORMATICS IMPORTANT ?

Regulation of teleconsultation varies between

countries, and guidelines are available.

Webcams or other video messaging techniques allow

real time, albeit virtual, face to face consultations.

APPLICATION
Mr Edward Evans is a 49 year old, recently unemployed,
pharmaceutical company representative who presents with
headaches. He also has symptoms of early morning
wakening and erectile dysfunction

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EXPERIENCED
Experienced doctors use hypothetico-deductive reasoning
methods when assessing patients’ problems.

An initial clinical feature, headache

perhaps, prompts a doctor to recall an
“illness script” derived from his or her
experience and education that seems to
explain a patient’s problems.

The doctor hypothesises that the diagnosis is, in this

case, possibly depression, and tests this hypothesis by
asking further questions, examining the patient, or doing
laboratory tests to confirm or rule out the diagnosis.

EXPERIENCED

LESS EXPERIENCED
Less experienced doctors may use a checklist or, when an
unusual presentation occurs, they may return to inductive
reasoning learnt as an undergraduate or trainee.

This more exhaustive process involves taking a complete history,

carrying out a full systematic examination, and then developing a
RESPECT OLD DOCTORS FOR THEY CURE PATIENTS WITH OUT GOO
differential diagnosis list. The process may be made more efficient
by using a reference folder that contains checklists describing a
clinical examination for headache, for example.

These checklists or protocols may be stored on

desktop computers or other devices.

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WHY HEALTH INFORMATICS IMPORTANT ?

PAPER RECORD EHR

Electronic version of a patients medical history
Health practitioners use record to capture
their clinical findings and conclusion Maintained by the provider over time
Include all of the key administrative clinical data relevant to that
persons care under a particular provider including
Medical records have been recorded on paper
and are within the property of the records demographics
section progress notes
problems
medications
“To Err Is Human”- many problem arise due vital signs
to lapses in patient care past medical history
immunizations
laboratory data
radiology reports

DISADVANTAGE OF PAPER DISADVANTAGE OF PAPER

RECORDS RECORDS

Paper charts are neither interactive nor

No data sharing, written records remains
intuitively designed
in the providers office
Printed reminders and cautions can be easily
overlooked Take a lot of space

Physicians are notorious for illegible Disorganization or disaster in office can

handwriting result to loss of information
Less than 65% of the written medical charts can
be fully read

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ADVANTAGE OF EHR ADVANTAGE OF EHR

Intuitive formatting and enhanced Provides alerts to the doctor to health

interaction needs or relevant research
Eliminating unnecessary procedures Improve decision on part of the clinician
reducing health care expenditures Empowers patient in self management of
Greater coordination and data sharing chronic diseases
No data loss Helps track past medical history and
Provide patient specific feedback in treatment of the patient
realtime Collaboration between patient and doctor

DISADVANTAGE OF EHR WHY HEALTH INFORMATICS IMPORTANT ?

Expensive software and computer

purchase
Software maintenance expense
Dependent upon reliable operation

APPLICATION APPLICATION

Patrick Murphy is a 6 year old boy who has been

brought to the accident and emergency department
with status asthmaticus. He is cyanosed with a poor
respiratory effort

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APPLICATION

Paper or electronic records, or other information tools,

may make it easier to record items of data that can be
aggregated and analyzed after the event.

The data can improve efficiency when they are entered into
clinical records and made available to other members of
the clinical team.

Wireless networks allow data to be transmitted to and from

handheld computers, laptops, or desktop computers.

This Acute asthma management flow chart for children >5

years in accident and emergency department.

APPLICATION

An improved standard of record keeping probably

means better data in the electronic patient record,
which increases knowledge about the range of
problems seen in clinical practice.

This new knowledge informs decisions made at several

levels, and contributes to better outcomes for patients.

CONCLUSION CONCLUSION

The patient’s story need not be repeated, and

An effective consultation instils trust and
develops the relationship between doctor and
patient.
Patients will probably consider returning to the
team who dealt with his problems on this occasion
for further care.
When a patient sees the same doctor over time in
a general practice surgery or outpatient clinic, it
makes the consultation more efficient for both
parties.
clinical examinations provide data that are
comparable.
When personal continuity of care is not possible,
the electronic patient record provides some
organizational continuity.
Complete and accurate recording of data by
clinicians becomes more important when a
different member of the healthcare team needs to
know what information is already known, or
deduced, about the patient.

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