BLOCK 1:

S1: Health
S2: Public Health
S3: Evidence-Based Public Health
S4: Primary Health Care
S5: MDGs, SDGs and Public Health

Dr. Md. Mobarak Hossain Khan

Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
 Section 1
Perceptions and dimensions
of Health
Dr. Md. Mobarak Hossain Khan
Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
 Learning Objectives
• At the end of this presentation, students will be able to explain:
• Perceptions of health
• Importance of health
• WHO definition of health
• Dimensions of health
• WHO Index for assessing mental wellbeing
• Questions/discussions
 Perceptions regarding health

• Health means sound body, sound mind and sound body function
• Health means absence of disease or infirmity
• Health is a fundamental human right
• Health is wealth and root of all happiness
• Health an integral part of socio-economic development
• Health is central to the concept of quality of life
• Health is multidimensional concept and depends on various factors

• Note: Health is an amorphous word that lacks a single definition

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 Importance of Health
• Can be reflected by our:
• Greetings?
• Daily activities?
• Your sickness?

• If you are asked, what things do you desire to have in your life?
• The possible answer could be:
• Property
• Name and fame
• Health
• Power
• ……….
• Which one is the most important?
 Determinants of Health

• Determinant of health: Factor associated with or which influences a

health outcome. Determinants include social, cultural, environmental,
economic, behavioral, biological, and other factors.

Brownson et al (2003) Evidence-Based Public Health. New York: Oxford University Press, 2003

6
 Determinants of Health

Infrastructure
Germs/ Environmental/ (healthcare,
biomedical factors Ecological factors insurance, etc.)

Socioeconomic and
Determinants of …. …..
demographic
Health
factors

Social and
psychological Political factors Cultural factors
factors
 WHO definition of health (continued)

• In 1948 the World Health Organization (WHO) conceptualised health as

“a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity” (Larson, 1999).
(Infirmity means weakness, opposite to firmness)

• How many dimensions are included in WHO definition of health?

......................
• Are all dimensions of health included?
..............................

Larson JC. The conceptualization of health. Med Care Res Rev 1999; 56(2): 123-136

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 Limitations/criticisms of WHO health definition

• Health is dynamic, not a state

• The dimensions are inadequate
• The definition is subjective
• Measurement is difficult
• The definition is idealistic rather than realistic (because ‘complete’ is
neither operational nor measurable)
• The definition lacks a community orientation
Source: Sharma M and Romas JA (2012) Theoretical Foundations of Health Education and Health Promotion (2nd Ed). Jones and Bartlett
Learning, Sudbury, MA, USA.

9
 Dimensions of Health

Physical Mental Social

health health health

Environmental
health Health …. health

Reproductive Spiritual Vocational

health health health

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 Physical health
• Definition: Simply means perfect functioning of the body in which
each organ is working in harmony with the maximum/optimum
capacity.

• Physical health is achieved by (e.g.):

• Regular exercise
• Healthy diet
• Adequate rest and sleep
• Good lifestyles (no smoking or no alcohol drinking)
• Safety precautions
• Regular medical checkups

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 Mental health
• Definition: Simply means an absence of a mental disorder.
It is also defined as an well adjusted and balanced
personality with psychological well-being.

• Some possible questions to assess mental health:

• Is the person having a perfect state of balance with the
surrounding world?
• Is the person having harmonious relation with others?
• Is the person cheerful, clam and relaxed, etc.?

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 Social health
• Definition: The ability of a person to adjust with others in his/her social life, at home, at
work place and with people.

• A person is socially healthy if:

ü He is able to maintain harmonious relationship with other members of society in
which he lives
ü He/she is accepted, respected and loved by his surroundings

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 Vocational health
• A person is said to be vocationally healthy when the person is:
• Doing something exactly according to plan
• Comfortable with future plan
• Capable to earn sufficiently to lead the peaceful life

• Vocational dimension of health can be assessed by assessing:

ØJob satisfaction
ØJob facilities
ØRelationship with managers, administrators and colleagues

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 Subjective versus objective measurement
• Objective: Fact-/evidence-based, measurable, observable and reliable.
• Independent of individual experiences
• Agreement among observers is at maximum or observer variance is at minimum
• Subjective: Based on personal awareness, experience, opinions, interpretations,
viewpoints, emotions and judgment

• Situation: Patients can be asked whether they have difficulty going up an down
stairs. The answers can be obtained by two ways:
• By patients self-reports (Subjective) or an observer can visits their homes to observe
whether they can climb stairs or not (Objective).

• Which one is better and why?

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 Exercise: WHO Well-being Index
Over the past 2 weeks……..
• ... I have felt cheerful and in good spirits (5 4 3 2 1 0)
• ... I have felt calm and relaxed (5 4 3 2 1 0)
• ... I have felt active and vigorous (5 4 3 2 1 0)
• ... I woke up feeling fresh and rested (5 4 3 2 1 0)
• ... my daily life has been filled with things that interest me (5 4 3 2 1 0)

• Scoring: 5 = All of the time, 4=Most of the time, 3=More than half the time,
2=Less than half the time, 1= Some of the time, 0= At no time

• Exercise: Find the total score for you and see your mental well-being based on following interpretation

Interpretation: A score below 13 indicates poor wellbeing and is an indication for testing for depression under ICD-10.

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 Section 2

Overview of Public Health

Dr. Md. Mobarak Hossain Khan
Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
 Learning objectives
• After this lecture, students will be able to:
• Define public health
• Contributions of public health (US example of life expectancy)
• Mention mission and obligations of public health
• Six major eras of public health
• Importants milestones of public health
• Unique features/characteristics of public health
• Recognize core disciplines of public health
• Distinguish between public health and medical care
• Questions and discussions

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 Definition of Public Health
• “The science and the art of preventing disease,
prolonging life, and promoting physical health
and efficiency through organized community
efforts” (Edward A Winslow, 1920)

• “The totality of all evidence-based public and

private efforts that preserve and promote health
and prevent disease, disability and death”
(Riegelman, 2010)
Charles-Edward Amory Winslow
American bacteriologist
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 Contributions of public health to life
expectancy in USA

• Public health contributes more to the population health than medicine does

• Example: Life expectancy of US citizen has increased from 45 to 75 years over the
20th century. Only 5 of those 30 additional years can be attributed to the work of
medical care system.
• This gain can be attributed to health determinants such as better nutrition, housing,
sanitation, environmental problems, control of infectious diseases (vaccination), and
occupational safety.

Tulchinsky et al (2009): The New Public Health

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 Mission and Obligations of Public Health
• Mission
• “Fulfilling society’s interest in assuring conditions in which people
can be healthy” (IOM, 1988)

• Fundamental obligations
• Prevent epidemics and the spread of disease
• Protects against environmental hazards
• Prevent injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Assures the quality of and accessibility to health services
Goldsteen et al (2011), P-79
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 Major Public Health Eras
• Health protection (antiquity – 1830s)
• Miasma control (1840s – 1870s)
• Contagion control (1880s – 1930s)
• Preventive medicine (1940s – 1960s)
• Primary health care (1970s – 1980s)
• Health promotion (1990s – present)

Awofeso (2004): What‘s new about the „New Public Health“?

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 Major Public Health Eras (D)
• Health protection (antiquity – 1830s)
• Action frameworks (AF): spiritual practices, community taboos, quarantine
• Miasma (unpleasant/unhealthy smell) control (1840s – 1870s)
• AF: Centralized actions for environmental sanitation, legislation to maintain
minimum standards of drainage and garbage disposal
• Contagion (a disease spread by close contact) control (1880s – 1930s)
• AF: Interuption of disease transmission through improved water filtration
processes, vaccination, outbreak control measures, etc.
• Preventive medicine (1940s – 1960s)
• AF: environmental interventions for vector controls, identification of
microorganisms, enhanced medical care for „high-risk“ groups and
foundations of modern clinical pathology
Awofeso (2004): What‘s new about the „New Public Health“? 23
 Major Public Health Eras (D)
• Primary health care (1970s – 1980s)
• AF: Establishement of global cooperation and peace, adapting health services
to countries and communities, links between health care and socioeconomic
development, intersectoral cooperation in health promotion and disease
prevention, equity in health care
• Health promotion (1990s – present)
• AF: Adoption of Ottawa Charter‘s five key actions for health promotion: (i)
Build healthy public policy, (ii) Create supportive environments, (iii)
Strengthen comunity action, (iv) Develop personal skills, and (v) Reorient
health services
Awofeso (2004): What‘s new about the „New Public Health“?

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EPI in Bangladesh
Goldsteen et al (2011), P-121
Immunization successes in USA: Measles

Goldsteen et al (2011), P-145

Immunization successes in USA: Mumps

Goldsteen et al (2011), P-145

Immunization successes in USA: Polio

Goldsteen et al (2011), P-146

Immunization successes in USA: Rubella

Goldsteen et al (2011), P-146

Immunization successes in USA: Hepatitis A

Goldsteen et al (2011), P-147

Immunization successes in USA: Hepatitis B

Goldsteen et al (2011), P-147

Immunization successes in USA: Smallpox

Goldsteen et al (2011), P-148

 Selected Milestones of Public Health (I)
• 1796 Edward Jenner Vaccinates 24 children against smallpox
• 1842 Edwin Chadwick Sanitary commissions links poverty and disease
• 1848 UK parliament passes Public Health Act
• 1854 John Snow Waterborne cholera in London (Father of
epidemiology)
• 1867 Joseph Lister Describe use of carbolic spray for antisepsis
• 1872 American Public Health Association founded
• 1882 Robert Koch Tuberculosis organism was discovered
• 1883 Robert Koch Discovered bacillus (a rod-shaped bacteria) of cholera
• 1885 Escherich Discovered coli bacillus
• 1895 Luis Pasteur Developed rabies vaccine
• 1895 Wilhelm Roentgen Developed X rays for diagnostic imaging
•
Tulchinsky et al (2009): The New Public Health
34
Cholera data in London

Tulchinsky and Varavikova (2009), P-13

 Selected Milestones of Public Health (II)
• 1895 Emil von Behring Develop diphtheria vaccine (Nobel prize, 1901)
• 1897 London School of Hygiene and Trop. Med. founded
• 1915 John Hopkins and Harvard School of PH founded
• 1928 Alexander Fleming Discoverd penicilin
• 1946 World Health Organization founded
• 1954 Richard Doll Established link between smoking and lung cancer
• 1977 WHO adopts Health for All by the Year 2000
• 1978 Alma-Ata Conference on Primary Health Care
• 1979 WHO declares eradication of smallpox achieved
• 1994 International Conference on Population and Development
• 2000 United Nations Millennium Development Goals (MDGs) (8 goals/21 targets)
• 2015 United Nations Sustainable Development Goals (SDGs) (17 goals/169 targets)

Tulchinsky et al (2009): The New Public Health 36

 Unique features/characteristics of public
health
• Social justice philosophy
• Inherently politocal nature Turnock (2001):
• Dynamic, ever expanding agenda Essentails of Public
Health
• Link with government
• Grounded in science
• Focus on prevention
• Focus on population
• Uncommon culture (multidisciplinarity and
interdisciplinarity approach)
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 10 Essential Services of Public Health (I)

• Monitor health status to indentify community health problems

• Diagnose and investigate health problems and health hazards in the
community
• Inform, educate, and empower people about health issues
• Mobilize community partnerships to identify and solve health
problems
• Develop policies and plans that support individual and community
health efforts
Turnock (2001): Essentails of Public Health
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 10 Essential Services of Public Health (II)
• Enforce laws and regulations that protect health and ensure safety
• Link people to needed personal health services and assure the
provision of health care when otherwise unavailable
• Assure a competent public health and personal health care
workforce.
• Evaluate effectiveness, accessibility, and quality of personal and
population-based health services
• Research for new insights and innovative solutions to health problems

Turnock (2001): Essentails of Public Health

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 Public health-related disciplines
• Core public health disciplines • Other disciplines
• Epidemiology • Medicine
• Biostatistics • Nutrition
• Environmental health • Demography
• Social and behavioral sciences • Sociology
• Health management and policy • Anthropology
• Urban planning
• Toxicology
• Molecular biology, etc.

Savitz et al (1999): Reassessing the Role of Epidemiology in Public Health

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 Social and behavioral science

• Social and behavioral science in public health primarily aims to

understand, predict, and influence health behaviors of individuals,
groups, and entire populations.

• The main goals are to prevent morbidity (disease and health problems)
and premature mortality, especially as they are caused by unhealthy
behaviors.

Andresen and Bouldin (2010): P- 70

 Environmental health
• Environmental health is the branch of public health that protects against
the effects of environmental hazards that can adversely affect health or
the ecological balances essential to human health and environmental
quality.

• Environmental health is the discipline that focuses on the

interrelationships between people and their environment, promotes
human health and well-being, and fosters a safe and healthful
environment.

Frumkin (2010): Environmental Health: From Global to Local MKIN

EDITOR
 Public health versus medical care
• Public health focuses on community. Medicine is concerned with individual
patients
• PH focuses on preventing illness. Medicine focuses on healing ill patients.
• Public health-like doctors- assesses the health of a population, diagnoses its
problems, and seeks causes of these problems and develop strategies to
prevent them
• Public health actions need political support to implement, whereas doctor’s
recommendation for patient's treatment depends on patient’s desire.
Government plays an important role for public health.

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 Section 3
Primary Health Care
Dr. Md. Mobarak Hossain Khan
Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
 Outline
• Primary health care (PHC)
• Historical Background
• Health for All by the year 2000
• Goals
• Levels of care
• Definition of PHC
• Major Elementes of PHC
• Major Services of PHC
• Major Principles of PHC
• Requirements of PHC
• Discussions and conclusions
 Background (I)
• Health is a fundamental human right and governments have the
responsibility for the health of their people.
• The existing gross inequality in the health status of the people is
politically, socially, and economically unacceptable.
• Economic and social development is of basic importance to the fullest
attainment of health and the health of the people is essential to
sustained economic and social development and contributes to a
better quality of life and to world peace.
• The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.
 Background (II)
• WHO Target: Health for All by the year 2000
• It means “attainment of a level of health that will enable every individual
to lead a socially and economically productive life”.
• Primary health care (PHC) is the key to attaining this target as part of
development in the spirit of social justice.
• Primary healthcare is cornerstone of universal health coverage
• WHO and UNICEF organized an international conference in 1978 at
Alma-Ata (former USSR)
• Participants: The governments of 134 countries and many voluntary
organizations
 Goals to be achieved by 2000

• Reduce excess mortality, IMR, CDR and CBR (focus:

vulnerable/marginalized population)
• Reducing the leading risk factors to human health
• Developing Sustainable Health Systems
• Raise life expectancy
• Achieve a NRR of 1
• To provide potable water to entire rural population
 Levels of Care
• Primary health care
• Secondary health care
• Tertiary health care

• Primary health care

• The “first” level of contact between the individual and the health system.
• Essential health care (PHC) is provided.
• A majority of prevailing health problems can be satisfactorily managed.
• The closest to the people.
• Provided by the primary health centers.
 Definition of PHC (I)
• Primary health care means essential health care based on practical,
scientifically sound, culturally appropriate and socially acceptable
methods that is:
• universally accessible to people in their communities
• involves community participation
• integral to, and a central function of health system
• the first level of contact with our health system.

King (2001)
 Secondary and tertiary health care
Secondary and tertiary health care
• More complex problems are dealt with.
• Comprises curative services
• Provided by the district hospitals
• The 1st referral level
Tertiary health care
• Offers super-specialist care
• Provided by regional/central level institution.
• Provide training programs
 Eight Services of PHC
Promotive 1. Education concerning prevailing health problems and the methods of
services preventing and controlling them
2. Promotion of food supply and proper nutrition
3. An adequate supply of safe water and basic sanitation
Preventive 4. Maternal and child health care, including family planning
services 5. Immunization against the major infectious diseases
6. Prevention and control of locally endemic diseases
Curative care 7. Appropriate treatment of common diseases and injuries
services 8. Provision of essential drugs
Elements/Features of PHC
• Universal coverage and access (responsiveness to people health needs)
• First contact
• Comprehensive, integrated, and continuing care
• Family- and community-based
• Emphasis on promotion and prevention
• Appropriate technology and quality care
• Active participation mechanisms
• Sound policy, legal, and institutional framework
• Pro-equity policies (social justice) and programs
• Optimal organization and management
• Appropriate human resources
• Adequate and sustainable resources
• Intersectoral/multisectoral approach

Bryant and Richmond (2008)

The Basic Requirements for Sound PHC (the 8 A’s
and the 3 C’s)

• Appropriateness • Assessability
• Availability • Accountability
• Adequacy • Completeness
• Accessibility • Comprehensiveness
• Acceptability • Continuity
• Affordability
 Section 4
Evidence-Based Public Health

Dr. Md. Mobarak Hossain Khan

Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
 Evidence-based public health: Definition
• Evidence-based public health: Process of integrating science-based
interventions with community preferences to improve the health of
populations.

• Quality of the evidence: Quality refers to the appropriateness and

integrity of the information obtained. High-quality data are reliable,
valid, and informative for their intended use.

Brownson et al (2003) Evidence-Based Public Health. New York: Oxford University Press, 2003.

56
 Evidence-based public health (EBPH)
framework
• Following five questions provide a general framework for defining,
analyzing, and addressing a wide range of public health issues
• Problem: What is the health problem?
• Etiology: What is/are the contributory cause(s)?
• Recommendation: What works to reduce the health impacts?
• Implementation: How can we get the job done?
• Evaluation: How well does/do the intervention(s) work in practice?
• This framework is called P.E.R.I.E. – A public health approach

Riegelman R and Kirkwood B. Public Health 101: Healthy people – Healthy Populations. 2nd ed. Burlington, MA: Jones and Bartlett Publishers.

57
 P.E.R.I.E. approach – A circular process

1. Problem

5. Evaluation 2. Etiology

4. Implementation 3. Recommendations

Riegelman R and Kirkwood B. Public Health 101: Healthy people – Healthy Populations. 2nd ed. Burlington, MA: Jones and Bartlett Publishers.

58
 Recommendations: What works to reduce
the health impacts?
• Evidence-based recommendations are based on two criteria:
• The quality of evidence
• The magnitude of the impact

• Question 1: What is the quality of the evidence for the intervention?

• In EBPH, the quality of the evidence is divided into there categories:
• Good, fair and poor (poor means insufficient evidence)

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Recommendations: Two important questions
• Question 2: What is the impact of intervention in terms of benefits
and harms?
• Both potential benefits and harms of interventions are considered to measure
the impact
• The magnitude of the impact = net benefits = benefits – harms
• Net ffects can be categorized into four groups:
• Substantial
• Moderate
• Small
• Zero/negative

60
 Classifications of evidence-based
recommendations
• Question: What grade should be given indicating the strength of the
recommendatoon?
• Recommedations are garded into five categories: A, B, C, D, and I
(Classification of recommendations given in table)
Magnitude of the impact (net benefits)
Quality of evidence Substantial Moderate Small Zero/negativ
e
Good A B C D
Fair B B C D
Poor I I I I

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 Meaning of recommendations:
A, B, C, D and I
• A = Must – A strong recommendation
• B = Should – In general, the intervention should be used unless there
are good reasons or contraindications for not doing so
• C = May – The use of judgement is often needed on an individual-
by-individual basis (situation, risk-taking attitudes, and values)
• D = Don‘t – There is enough evidence to recommend against using
the intervention
• I = Indeterminant, insufficient, or I don‘t know – The evidence is
inadequate to make a recommendation for or against the use of the
intervention at the present time

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 Implementations: How can we get the job
done?
• WHEN – WHO – HOW Approach
• Questions:
• WHEN asks: When should the implementation occur?
• Example: Before, after (initial) or later stage of disease
• WHO asks: At whom should the intervention be directed
• Example: Everyone, community as whole or vulnerable group
• HOW asks: How should the intervention(s) implemented?
• Example of options:
• Information (education): Aims to change behavior through individual encounters, group
interactions, or the mass media
• Motivation (incentives): Tangible reward for changing or maintaining behavior
• Obligation (requirements): Relies on laws and regulations requiring specific behaviors

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 Section 5

MDGs, SDGs and Public

Health
Dr. Md. Mobarak Hossain Khan
Professor and Chairperson
Department of Social Relations
East West University
Dhaka, Bangladesh
Thank you