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LEARNING OBJECTIVES

CONCEPT OF HEALTH & DISEASE • At the end, Learner will be able to:
• Discuss the terms of Health, Disease, Well-
being.
• Describe the concept of causation.
• Explain Types of causal relationships
Akash Samuel
• Discuss Factors in causation.
Nursing Instructor
• Explain Guidelines for causation
AFNC • Describe the Health indicator.

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INTRODUCTION OF
H E A LT H
• Health is a state of dynamic balance of an
individual ability to perform personally
According to WHO, “Health is a state of valued roles and responsibilities to deal and
complete physical, mental, and social being cope with physical biological psychological
and not merely an absence of diseases or and social stresses and challenges
infirmity” throughout the life while continuing to
maintain sense of wellbeing .
• Wellness: the quality or state of being in good
health especially as an actively sought goal

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• Illness: is a feeling, an experience of unhealthy

which is entirely personal, interior to the person of
the patient. • Carrier: A person or animal that shows no
• Sickness: It is a state of Social Dysfunction. symptoms of a disease but harbors the infectious
• Disease: Disease, on the other hand, is defined as a agent of that disease and is capable of transmitting
condition that is diagnosed by a physician or other it to others
medical expert.
• Ideally, this would include a specific diagnosis
according to standardized and systematic diagnostic
codes.

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C O N C E P T OF D I S E A S E Theories of Disease Causation

C A U S AT I O N
• Old Theories
• Germ Theory of Disease
• Biomedical Model
• Theory of multifactorial Causation
• Epidemiological Triad
• Lazaru’s theory of stress response
• Wolff’s theory of stress, organ maladaptation and
disease
• Holmes and rahe’s theory of life changes and the
onset of illness

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Old theories
• Till the end of 18 th century, various theories
were in vogue, e.g.
• supernatural theory of disease (e.g. curse of
God; an evil eye). The Ayurveda considers
that the disease is due to imbalance of the
‘tridosha’. These are vata(air), pitta(bile), and
kapha(mucus).
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Germ Theory
• The discoveries in microbiology at the turn of
18 th century became a turning point in the
etiological concept of disease.
• Louis Pasteur (1860) demonstrated the
presence of bacteria in the air. Robert Koch
(1877) showed that anthrax caused by bacteria.
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• These theories of pasture and Koch confirmed the
germ theory of disease.
• Thus, the emphasis has shifted from empirical
causes (like bad air as a cause in malaria) of the
old theories to microbes of Germ theory.
• But now it is recognized that a disease is rarely
caused by a single agent alone, but depends upon
a number of contributory factors.
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The Biomedical model
• This model explains the disease as a result of
malfunctioning organs or cells, e.g. diabetes is
caused by malfunctioning of pancreas. But the
drawback with it is focuses on cause and effect
relationships, and ends to ignore the psychosocial
component of the disease.
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Theory of multifactorial causation

• Now it is recognized that a disease is not caused • This theory of multifactorial causation was put
by an organism but also predisposed by many forth by Pettenkofer Munich (1819-1901). This
factors contributing to its occurrence, specially theory deemphasizes the “Germ theory” (or single
‘modern diseases’ of civilization like lung cancer, cause idea).
diabetes, coronary heart disease, mental illness
etc. These predisposing factors are social,
economic, cultural, genetic psychological factors,
etc. (including poverty, illiteracy, ignorance and
poor living conditions).

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Epidemiological Triad
• The Germ theory of disease has many
limitations. For example, it is well known that
not everyone exposed to tuberculosis develops
tuberculosis.
• The same exposure, however in an
undernourished or otherwise susceptible person,
may result in clinical disease.
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• Similarly, not everyone to beta-hemolytic
streptococci develops acute rheumatic
environment, which are equally important to
determine whether or not disease will occur in
the exposed host.
• This demanded a broader concept of disease that
synthesized the basic factors of agent, host and
environment.
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Lazaru’s theories of stress

response
• According to him, in the process of coping, the
individual shapes as well as responds to a demand
or stress, which can have an impact on the client’s
resistance to disease.

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Wolff’s theory of stress, organ
maladaptation and disease
• He studied people’s response to chronic stressors,
like a frustrating job or an unhappy home life. He
believed that a person’s total life situation
profoundly affects a person’s susceptibility to
disease.
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Holmes and rahe’s theory of life changes
and the onset of illness
• They explored the relationship between the
amount of change in a person’s life and
subsequent illness. They discovered that the
higher a person’s life changes score, the greater is
the like hood that an illness would develop.
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Natural History of Disease

• It means the evolution of a disease process in an

individual, from its early stage to final stage of
recovery or death, in the absence of any
intervention such as prevention or treatment. This
differs from disease and from person to person.
• The natural history of an infectious disease occurs
in two phases
• prepathogenesis and pathogenesis.

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Pre- Pathogenesis Phase

Stages in the Natural History of Disease
• This phase refers to the period before the onset
of disease. During this phase, interaction is
taking place among the three components of
epidemiological triad namely Agent, Host, and
Environment.

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pathogenesis phase
• The pathogenesis phase begins with the entry of the disease
‘agent’ in the susceptible human host.
• The further events in the pathogenesis phase are clear cut in • The infection may be clinical or sub-clinical, and
infectious disease, i.e. the disease agent multiple and induces when it is subclinical, the person will not have
tissue and physiological changes, the disease progresses recognizable signs and symptoms but may spread
through a period of incubation and later through early and the disease agent to others, acting as a ‘carrier’, as
late pathogenesis. the final outcome of disease may be
in typhoid and diphtheria.
recovery, disability, or death.
• The pathogenesis phase may be modified by intervention • When the person develops clinical signs and
measures such as immunization and chemotherapy. symptoms, he is called a ‘clinical case’.

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3. ICEBERG PHENOMENON OF
DISEASE
• According to this concept, the disease in the
community is compared to an iceberg. When a
piece of ice is allowed to float on water, a small
portion is visible and a major portion is
submerged in the water. The visible tip of ice is
compared to clinical cases, which the physician
sees in the community
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• The major submerged portion of ice corresponds
to the hidden mass of unrecognized disease such
as latent cases, in apparent, carriers,
asymptomatic, and undiagnosed cases in the
community, which are all responsible for the
constant prevalence of the disease in the
community.
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INTRODUCTION

• A major goal of epidemiology is to assist in the

prevention and control of disease and in the
promotion of health by discovering the causes of
disease and the ways in which they can be
modified.

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CONCEPT OF CAUSE
• An understanding of the causes of disease is
important in the health field not only for
prevention but also in diagnosis and the
application of treatment.
• A cause of a disease is an event, condition,
characteristic, or combination of these factors
which plays an important role in producing the
disease.
• A cause could be sufficient or necessary
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TYPES OF CAUSAL RELATIONSHIPS
• A causal pathway can be either direct or
indirect.
• In direct causes a disease without any
intermediate step.
• In indirect causation, a factor causes a disease,
but only through an intermediate step or steps.
In human biology, intermediate steps are
virtually always present in any causal
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• If a relationship is causal, four types of causal

relationships are possible:
(1) necessary and sufficient;
(2) necessary, but not sufficient;
(3) sufficient, but not necessary; and
(4) neither sufficient nor necessary.

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• Necessary and Sufficient • Factor A is both necessary and sufficient.

• In the first type of causal relationship, a factor is
both necessary and sufficient for producing the
disease. Without that factor, the disease never
develops (the factor is necessary), and in the
presence of that factor, the disease always
develops (the factor is sufficient) For example,
in most infectious diseases, a number of people
are exposed, some of whom will manifest the
disease and others who will not.

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• Necessary, But Not Sufficient

• In another model, each factor is necessary, but
• Each factor is necessary, but not sufficient.
not, in itself, sufficient to cause the disease.
Thus, multiple factors are required, often in a
specific temporal sequence. For example
Again, in tuberculosis, the tubercle bacillus is
clearly a necessary factor, even though its
presence may not be sufficient to produce the
disease in every infected individual

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Sufficient, But Not Necessary

• Sufficient, But Not Necessary
• In this model, the factor alone can produce the
disease, but so can other factors that are acting • Each factor is sufficient, but not necessary.
alone.
• Thus, either radiation exposure or benzene
exposure can each produce leukemia without the
presence of the other. Even in this situation,
however, cancer does not develop in everyone
who has experienced radiation or benzene
exposure, so although both factors are not
needed, other cofactors probably are.

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• Neither Sufficient Nor Necessary

• In the fourth model, a factor, by itself, is neither
sufficient nor necessary to produce disease. This
is a more complex model, which probably most
accurately represents the causal relationships that
operate in most chronic diseases.

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• A given disease can be caused by more than
one causal mechanism, and every causal
mechanism involves the joint action of a
multitude of component causes.
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FACTORS IN CAUSATION
• Four types of factor play a part the causation of
disease. All may be necessary but will rarely be
sufficient to cause a disease.
• PREDISPOSING FACTORS: A predisposing
factor is a condition or situation that may make a
person more at risk or susceptible to disease
include heredity, age, gender, environment, and
lifestyle.
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• ENABLING FACTORS: environmental
conditions which favor the development of
disease. E.g. low income, poor housing, poor
nutrition, inadequate medical facility.
• PRECIPITATING FACTORS: specific or
noxious agent, exposure to which can be
associated with the onset of a disease. E.g.
pollens in asthmatic attack.
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• REINFORCING FACTORS: factors which
aggravates an already established disease or
state. e.g. repeated exposure and unduly hard
work.
• The term Risk factors are those factors that have
a direct link to the cause of the disease but are
not sufficient to cause the disease i.e. they
heighten the chance of contacting a disease
condition but themselves not enough. e.g.
Refined sugar, time, bacteria for caries
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ESTABLISHING THE CAUSE OF A

DISEASE
• Causal inference is the term used for the
process of determining whether observed
associations are likely to be causal; the use of
guidelines and the making of judgments are
involved.
• Before an association is assessed for the
possibility that it is causal, other ,explanations
such as chance, bias and confounding have to
be excluded.

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GUIDELINES FOR CAUSATION

• Bradford Hill (1965) suggested that the following TEMPORAL RELATIONSHIP
aspects of an association be considered in
attempting to distinguish causal from non-causal • refers to the necessity for a cause to precede an
associations: effect in time.
✓Temporal relation
• It is clear that if a factor is believed to be the
✓Plausibility
cause of a disease, exposure to the factor must
✓Consistency have occurred before the disease developed.
✓Strength
• It is often easier to establish a temporal
✓Dose response relationship relationship in a prospective cohort study than in
✓Reversibility a case control study or a retrospective cohort
✓Specificity of the Association study.
✓Judging the evidence

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PLAUSIBILITY
• In epidemiology and biomedicine, the
term biological plausibility refers to the
proposal of a causal association —
• a relationship between a putative cause
and an outcome — that is consistent with
existing biological and medical
knowledge.
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CONSISTENCY
• Refers to the repeated observation of an
association in different populations under
different circumstances obtained from
different studies.
• Lack of consistency, however, does not rule out
a causal association, because different exposure
levels and other conditions may reduce the
impact of the causal factor in other causes.
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• If studies conducted by….
– different researchers
– at different times
– in different settings
– on different populations
– using different study designs
……all produce consistent results,
this strengthens the argument for causation
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STRENGTH
• Hill’s argument is that strong association between
possible cause and effect are more likely to be
causal than weak associations .
• The strength of the association is measured by the
relative risk (or odds ratio). The stronger the
association, the more likely it is that the relation
is causal.
• The fact that an association is weak does not
rule out a causal connection. example would
be passive smoking and lung cancer.
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• Dose-response (‘biological gradient’)

– the relationship between the amount of exposure
DOSE-RESPONSE RELATIONSHIP (dose) to a substance and the resulting changes in
outcome (response)
• If an increase in the level of exposure increases the
• A dose-response relationship occurs when risk of the outcome
changes in the level of a possible cause are – this strengthens the argument for causality
associated with changes in the prevalence or R
R
R I
incidence of the effect R
I
I
I
S
S S
S
K
K
K K > 20 cigs/day
0 cigs/day < 5 cigs/day 5 - 20 cigs/day

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REVERSIBILITY
• when the removal of a possible cause results in
a reduced disease risk, the likelihood of the
association being causal is strengthened.
• Cessation of smoking reduces the risk of
developing lung cancer
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• SPECIFICITY OF THE ASSOCIATION.
• An association is specific when a certain exposure
is associated with only one disease; this is the
weakest of all the guidelines and should probably
be deleted from the list.
• Cigarette manufacturers have pointed out that the
diseases attributed to cigarette smoking do not
meet the requirements of this guideline, because
cigarette smoking has been linked to lung cancer,
pancreatic cancer, bladder cancer, heart disease,
emphysema, and other conditions.
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STUDY DESIGN
JUDGING THE EVIDENCE Relative ability of different types of study to
‘prove’ causation
• There’s no completely reliable means of
establishing a causal relationship and sometimes Type of Study Ability to ‘prove’ causation
evidence can be conflicting. To make a causal
inference, all available evidence must be 1) Randomised strong
considered. Controlled Trial
• Correct Temporal relationship is very essential
before other criteria are considered (plausibility, 2) Cohort Study Moderate
consistency and dose- response relationship). 3) Case-control study Moderate
The likelihood of a causal association is
heightened when many different types of 4) Cross-sectional study Weak
evidence lead to the same conclusion
5) Ecological study Weak

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Is this association causal? Is this association causal?

Does consumption of French fries by preschool
Does consumption of French fries by preschool children cause breast cancer?
children cause breast cancer?
Strength Weak: OR = 1.27
Strength
Consistency No
Consistency
Temporality Yes
Temporality
Dose response No
Dose response
Biological plausibility Biological plausibility Yes
Study design Study design Case Control

Is this association causal?

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Is this association causal? Is this association causal?

Does consumption of French fries by preschool
children cause breast cancer?
Does cigarette smoking cause lung cancer?
Strength Weak: OR = 1.27
Strength Strong: OR, RR = 4 - 20
Consistency No
Consistency Yes
Temporality Yes Temporality Yes
Dose response No Dose response Yes
Biological plausibility Yes Biological plausibility Yes
Study design Case Control Study design Ecological, C/S, CC, Cohort

Is this association causal? Is this association causal?

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CONCLUSION
• The knowledge of causation is an integral part of
epidemiology as it enables us to make the proper
diagnosis, formulate the correct treatment plan
and take necessary measures in the prevention of
a certain disease.
DETERMINANTS OF DISEASE
• Determinant is any characteristic that affects the
health of a population.
• Determinants can be classified in three ways, as:
1. Primary and Secondary
2. Intrinsic and Extrinsic
3. Associated with Host, Agent or Environment.

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HEALTH INDICATORS
• Primary determinants are factors whose variations
exert a major effect in inducing disease. Eg
• 1. Mortality Indicators:
distemper virus is a primary determinant of canine
distemper. • Crude Death Rate
• Secondary determinants correspond to • Life Expectancy
predisposing, enabling and reinforcing factors. Eg • Infant Mortality Rate
Nutritional Status. • Child Mortality rate
• Intrinsic(endogenous) determinants are internal to • Under-5 proportionate mortality rate
the host for example, genetic constitution etc. • Maternal Mortality rate
• Extrinsic(exogenous) determinants are external to • Disease Specific Mortality
the host; for instance, transportation.
• Proportional Mortality rate

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2. Morbidity Indicators 3. Disability rates

• Incidence & prevalence a. Event type indicators

• Notification rates • Numbers of days of restricted activity
• Attendance rates at outpatient departments • Bed disability days
• Admission and discharge rates • Work loss days
b. Person type indicators
• Limitation of mobility
• Limitation of activity

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4. Nutritional Status Indicators 5. Health Care Delivery Indicators

• Anthropometric Measurements • Doctor-Population ratio

• Heights • Doctor-Nurse ratio
• Prevalence of LBW(low birth weight babiese.g. • Population-bed ratio
less than 2.5kg0 • Population-TBA(Trained Birth Attendant) ratio.

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6. Utilization rates 7. Indicators of Social and Mental Health

• Proportion of infants who are fully immunized • Suicide

against EPI Diseases • Homicide
• Percentage of population using the various • RTA’S
methods of family planning
• Smoking
• Bed Occupancy rate: Ideally it should be 85% but
• Juvenile Delinquency
in Pakistan it is 93%

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8. Environmental Indicators 9. Health Policy Indicators

• Air Pollution • Allocation of adequate Resources

• Radiations • Proportion of GNP spent on Health Services
• Noise • Proportion of Total health Sources devoted to
• Solid waste PHC(Primary Health Care)

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10. Socio-Economic Indicators 11. Indicators of Quality of Life

• Rates of Population Increase • Infant Mortality

• Per Capita GNP • Life expectancy at age one
• Unemployment • Literacy
• Dependency ratio
• Literacy rates
• Family size
• Per capita calorie availability

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12. Other Indicators
• Social Indicators
• Basic Needs indicators
• Health for all indicators
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Reference
• Gordis, L. (2009). Epidemiology.
Saunders. Philadelphia, PA.
• Last JM, editor. Dictionary of epidemiology. 4th
ed. New York: Oxford University Press; 2001. p.
61
• Alam,N & Hussain, A. (2017). Community
Medicine. Faislabad,Punjab:Excel Publishers
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