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PRIMARY HEALTH
PHYSICIAN / FAMILY
DOCTOR
AND PUBLIC HEALTH

DEPT. OF PUBLIC HEALTH & PREVENTIVE MEDICINE


FACULTY OF MEDICINE
PADJADJARAN UNIVERSITY

THE PRIMARY CARE DOCTOR IS WELL


PLACED TO PARTICIPATE:
DESCRIPTIVE
EPIDEMIOLOGY
EXPERIMENTAL
EPIDEMIOLOGY
THE CONTROL
OF DISEASE
EPIDEMIOLOGY

CONTROL OF NONCOMMUNICABLE DISEASES


CONTROL OF
COMMUNICABLE DISEASES

OUTBREAK
INVESTIGATION

PREVENTIVE
SERVICES

SPESIFIC PROTECTION
EARLY DETECTION
PROMPT TREATMENT

General Principles of Preventive Practice


Preventive practice has been divided into three
categories:
1.Primary prevention increase a persons ability to
remain free of disease.
2.Secondary prevention is the early detection of
disease/ precursors of disease
treatment
can be started before irreversible damage
3.Tertiary prevention is the management of
established disease
minimize disability

the promotion of
health and the
prevention of illness,
e.x.,immunisation
and making physical
environments safe

the early detection and


prompt intervention
to correct departures
from good
health or to treat the
early signs of disease
ex .,cervical screening,
mammography,
blood pressure monitoring
and blood cholesterol
checking

reducing impairments
and disabilities,
minimising suffering
caused by existing
departures from good
health or illness, and
promoting patients
adjustment to chronic
or irremediable
conditions,
e.x.,prevention of
complications

PREVENTIVE SERVICES ( CANADIAN MEDICAL


ASSOCIATION/ CMA, 1995)

1.

HEALTH ENHANCEMENT: COUNSELING AND INFORMATION

2.

RISK AVOIDANCE: ENSURING THAT PEOPLE AT LOW RISK


REMAIN AT LOW RISK (IMMUNIZATION, ACCIDENT PREVENTION)

3.

RISK REDUCTION: IDENTIFICATION OF INDIVIDUALS AT HIGH


RISK IN ORDER TO HELP THEM REDUCE THE RISK

4.

EARLY IDENTIFICATION OF DISEASE AT PRESYMPTOMATIC


STAGE (~ SECONDARY PREVENTION)

5.

COMPLICATION REDUCTION IN PATIENS WITH ESTABLISHED


DISEASE (~ TERTIARY PREVENTION)

Why prevention???
Population pyramid : Indonesia

USA

b
a
nd WHO
Point
subregion
prevalence
,: 2002
(000s) for selected causes: by sex, age and WH

Cause
Females

AFRO

AMRO

EMRO

18389 HIV/AIDS
26200
2866
826
Tropical diseases
5442
Chagas
0 disease 10137
0
443 Leprosy
110
91
85
Nutritional deficiencies
c
malnutrition
112245 Protein-energy
54700
9375
25500
d
291462 Iodine
103414
49487
deficiency 14506
e
9996 Vitamin
5800
2359
A deficiency 63
587027 Iron-deficiency
157649
100696f
108904
anaemia
95841Diabetes
8452
mellitus
35011
16410
Neuropsychiatric disorders
g
95023 Unipolar
12408
25019
12083
depressive
disorders
affective disorder
14112 Bipolar
2433
3999
2030
12539 Schizophrenia
1869
3789
1798
18605 Epilepsy
6991
8509
2755
use disorders
14135 Alcohol
3550
28212
8
dementias
14632 Alzheimer
572 and other
4678
589
2786 Parkinson
150 disease 1145
193
sclerosis
1357 Multiple
164
363
157
use disorders 4789
3489 Drug 3211
1644
stress
disorder
16700 Post-traumatic
2071
3007
1748
disorder
15825 Obsessive-compulsive
4091
5137
2827
disorder
19348 Panic2803
4143
2270
17069 Insomnia
2224(primary) 5505
1541
232236 Migraine
11396
58381
15530
Respiratory diseases
26661 Chronic
1299
obstructive
13222
pulmonary disease
3185
105215 Asthma
27459
52768
14951
Musculoskeletal diseases
16322 Rheumatoid
1055
arthritis
4482
1242
89711 Osteoarthritis
9024
21156
5765
Injuries Long-term sequelae j
6704
Injured
1566 spinal cord
3525
2148
7882
Intracranial
1691
injury
2434
2505
2051
Amputated
986
arm 662
640
7106
Amputated
3048
foot/leg
1191
1764

Both sexes
SEARO

EURO

Males
WPRO

Females

1781

39395
5703

210062019

0
1

101370
903
581

5223
140968
259
92091
34174

231798
101500
505792
169077
19926
8004
1049407
381365
181699
50930

119553
35500 11224
214330
28341 29146
99303441
999
462381
208702 58702
85858
36722 9584

24035
4321
4324
4076
21680
7236
1913
454
3222
3467
5176
4194
6082
76395

154012
39775
28315
6832
25262
5835
38574
9286
91073
7704
22541
2591
5004
635
2380
547
14946
1257
23056
6022
27513
5452
29396
7423
29392
7763
313311
66463

58989
40691 9502
142038700 1411
127237646 1253
199696955 1860
76938
29919 1413
79096875 1463
2217 968
278
1022 694
135
11457 822
348
63556741 1670
116884831 1582
100488562 1934
123246278 1706
81075
85145 23223

11514
28593

62462
14212
227693
43397

35801
19031 2666
122479
60525 10521

6079
39400

22732
4102
143668
25598

64105771
53957
42726

1632
8971

2356
1916
549
1238

19359
5284
18715
5772
5578
1836
15141
6215

126564480
108334397
3526 903
80351686

670
788
205
710

4695
460

0
35

1838

544
44

Estimated annual incidence (000s) for selected causes: by sex, age and WHO subregion a, 2002
Cause

SEX
Both sexes

Tuberculosisb
c
Syphilis
Chlamydiad
Gonorrhoeae
HIV
AIDS
Diarrhoeal diseases
Childhood diseases
Pertussis
Poliomyelitis
Diphtheria
Measles
Tetanus
Meningitis

Streptococcus pneumoniae
Haemophilus influenzae
Meningococcaemia without meningitis

Hepatitis B
Hepatitis C
Malaria
Tropical diseases
Chagas diseasef
Leprosy
Dengue
Respiratory infections
Lower respiratory infections

Males

Females

AFRO

AMRO

EMRO

EURO

SEARO

WPRO

7629
9355
43555

4884
4261
30916

2745
5094
12639

1528
2682
7118

311
2465
6011

504
711
5743

559
257
4740

2777
2516
15236

1949
724
4707

37907
5190
3160
4512989

24581
2827
1683
2299612

13326
2363
1477
2213377

9572
3290
2388
838857

5307
262
113
541350

3761
99
71
441096

2905
356
48
205532

13463
763
448
1231056

2898
420
92
1255097

42711
13
21
33072
549

21360
7
10
16522
276

21351
6
10
16550
273

13056
1
5
13891
220

4416
1
1
8
2

5938
2
1
3686
108

2768
0
0
936
0

9803
6
13
9182
186

6730
4
0
5370
33

170
141
137
914
683
408389

85
72
70
680
465
204419

85
69
67
234
218
203970

44
34
43
110
46
357180

39
15
16
59
141
3584

30
51
21
74
35
17261

8
4
11
87
111
0

31
17
23
319
124
28519

17
19
23
265
226
1844

217
175
73

103
89
34

114
85
39

0
21
4

217
17
0

0
17
7

0
0
0

0
112
53

0
7
9

450989

231522

219467

125608

36398

47569

25769

149512

66133

SEARO
Respiratory infections
Lower respiratory infections
Maternal conditions
Maternal haemorrhage
Maternal sepsis
Hypertensive disorders
Obstructed labor
Nutritional deficiencies
Protein-energy malnutrition
Wasting
Stunting
Developmental disability
Iodine deficiency
Vitamin A deficiency
Malignant neoplasms
Mouth and oropharynx cancers
Oesophagus cancer
Stomach cancer
Colon/rectum cancer
Liver cancer
Pancreas cancer
Trachea/bronchus/lung cancers
Melanoma and other skin cancers
Breast cancer
Cervix uteri cancer
Corpus uteri cancer
Ovary cancer
Prostate cancer
Bladder cancer
Lymphomas, multiple myeloma
Leukaemia
Diabetes mellitus

450989

231522

219467

125608

36398

47569

25769

149512

66133

11719
5084
8272
3776

0
0
0
0

11719
5084
8272
3776

2628
1101
1826
1044

1113
564
800
122

1645
712
1168
481

621
272
399
0

3692
1573
2481
1771

2020
862
1597
359

10431
35922
7617
1085
169

5341
18567
3892
16
86

5090
17355
3724
1069
82

2227
8717
2424
238
69

267
1597
190
45
0

1335
3773
918
116
19

261
784
75
341
2

5173
15118
2796
275
65

1167
5932
1215
71
13

418
470
992
1065
641
236
1433
211
1033
450
321
233
557
380
485
367
11638

265
300
605
544
437
124
954
119
0
0
0
0
557
277
240
194
5540

153
170
387
522
203
111
479
91
1033
450
321
233
0
103
245
172
6098

23
24
41
30
48
9
19
12
56
71
10
16
61
19
48
17
801

36
34
87
218
39
53
252
104
290
71
103
40
220
90
104
67
2058

27
15
24
22
15
5
29
4
52
15
11
12
14
34
31
29
1129

71
51
184
396
68
90
396
67
317
54
129
74
176
123
110
79
2009

185
84
69
91
66
20
185
6
153
177
23
49
41
58
131
65
3391

77
261
586
309
404
60
553
18
166
62
45
42
46
57
61
109
2251

SEARO
Leukaemia
Diabetes mellitus
Cardiovascular diseases
Cerebrovascular diseaseh
Respiratory diseases
Chronic obstructive pulmonary disease
Asthma
Unintentional injuriesi
Road traffic accidents
Poisoning
Falls

367
11638

194
5540

172
6098

17
801

67
2058

29
1129

79
2009

65
3391

15251

7797

7454

858

1438

622

3901

2964

5378
17817

3111
11279

2267
6538

202
2842

901
4023

254
1389

770
1764

1244
3665

20768
2227
32864

12890
1096
17400

7878
1131
15464

4378
270
2610

2055
302
2972

2429
244
3289

1687
321
4993

6308
572
11459

The health enhancement


continuum

Pre-pathogenesis phase
Environmenta
l and Social
policies

-Housing
-Electricity
-Clean water
-Park & recreation
-Nutrition
education
-Food insp.
-Occupational
health and safety
-Insect control
-Accident
prevention
-Child support &
protection
-Health education

Assessment
of General
Resistance
Resources
(GRR)
-Self-assessed
health status

Enhancement
of GRR

-Support

-Coping ability

-Health
education and
counseling

-Social support

-Immunization

-Family
function

-Family
planning

-Work
Satisfaction

-Prenatal care

-Confidence

Pathogenesis phase
Risk
Assess
ment

-Smoking
related
disease

Risk
Reductio
n

-Smoking
cessation

-Substanc
e abuse

-Reduction
alcohol
intake

-Coronary
heart
disease

-Reduction
of serum
cholesterol

-Family
violence

-Nutrition
edu.

-Exercise

-STD

-Immunization
status

-Occupati
on

-Accident
prevention

-Income
security

-Teenage
pregnancy

-Knowledge of
hygiene

-Child care

-Refer to
social
service
counseling

Presympt
omatic
diagnosis

Early
Diagno
sis

-Screening
and case
finding

-Preventi
on of
complica
tion by
early
diagnosi
s of
serious
treatable
disease

Rehabilit
ation to
enhance
recovery

Care and
support to
maintain
function
and
reduce
further
complicati
ons

The health enhancement


continuum

Pre-pathogenesis phase
Environmenta
l and Social
policies

Assessment
of General
Resistance
Resources
(GRR)

Enhancement
of GRR

Pathogenesis phase
Risk
Assess
ment

Health promotion & Spesific protection

Risk
Reductio
n

Presympt
omatic
diagnosis

PREVENTIVE

Care and
support to
maintain
function
and
reduce
further
complicati
ons

Disability Th/ &


Rehabilitation

CURATIVE
REHABILITATIVE

PREVENTIVE
CURATIVE

PRIMARY HEALTH CARE/FAMILY


PHYSICIAN

Rehabilit
ation to
enhance
recovery

Early detection &


prompt treatment

PROMOTIVE
PROMOTIVE

Early
Diagno
sis

REHABILITATIVE

SPECIALIST

Why a GP solution?
General practitioners are at the forefront of the
provision of primary medical care and have
enormous potential to encourage patients to
take greater responsibility for their health.
Through a range of proven strategies, GPs may
be able to influence patients to:
change their lifestyle
undergo screening for the early detection of a range
of conditions
present for health protecting vaccinations
manage chronic conditions to improve quality of life

ONE OF PUBLIC HEALTH


PROGRAM IN PRIMARY HEALTH
SERVICES ~ FAMILY DOCTOR IS:

IMCI

WHAT IS IMCI ?

IMCI (INTEGRATED MANAGEMENT OF


CHILDHOOD ILLNESS) IS AN INTEGRATED
APPROACH TO CHILD HEALTH THAT
FOCUSES ON THE WELL-BEING OF THE
WHOLE CHILD AND AIMED TO REDUCE
DEATH, ILLNESS AND DISABILITY, AND TO
PROMOTE IMPROVED GROWTH AND
DEVELOPMENT AMONG CHILDREN 5
YEARS OF AGE.

THREE COMPONENT WORKING IN IMCI

1. FIRST LEVEL HEALTH CARE


PROVIDERS
2. THE LOCAL HEALTH CARE
DELIVERY SYSTEM
3. FAMILIES AND COMMUNITIES

CHILD SURVIVAL PROBLEM: 7 IN 10 OF THE CHILDREN < 5


YEARS DIE CAUSE OF PREVENTABLE AND TREATABLE
CONDITIONS (ARI, DIARRHOEA, MALARIA, MEASLES AND
MALNUTRITION)

A SERIOUS
CHALLENGE

IMCI (WHO, UNICEF)

MANY SICK CHILDREN ARE NOT PROPERLY ASSESSED AND


TREATED BY HEALTH CARE PROVIDERS
THEIR PARENTS ARE POORLY ADVISED
DIAGNOSTIC SUPPORT ARE INADEQUATE
DRUGS AND EQUIPMENT ARE OFTEN SCARCE

WHY IS IMCI BETTER THAN SINGLE


CONDITION APPROACHES ?
THE MOST IMPORTANT REALISATION ABOUT CHILD
SURVIVAL IS THAT KILLER DISEASES OPERATE IN THE SAME
ENVIRONTMENT OF POOR NUTRITION AND LACK
IMMUNISATION TO PROTECT THE CHILD
MAKING A
SINGLE DIAGNOSIS IS IMPOSSIBLE

IMCI

- INTEGRATED STRATEGY WHICH TAKES INTO


ACCOUNT THE VARIETY OF FACTORS THAT PUT
CHILDREN AT SERIOUS RISK
- IT ENSURES THE COMBINED TREATMENT OF THE
MAJOR CHILDHOOD ILLNESSES, EMPHASIZING
PREVENTION OF DISEASE THROUGH
IMMUNIZATION AND IMPROVED NUTRITION

WHAT DOES THE IMCI PROGRAMME STRIVE TO DO ?


STRATEGY:
1.
IN THE HEALTH CARE PROVIDERS
TO PROMOTES
THE ACCURATE IDENTIFICATION OF CHILDHOOD
ILLNESSES IN OUTPATIENT SETTING, COMBINED
TREATMENT ALL MAJOR ILLNESSES, STRENGTHENS THE
COUNSELLING OF CARETAKERS AND SPEEDS UP THE
REFERRAL OF SEVERELY ILL
2.

IN THE HEALTH CARE DELIVERY SYSTEM


MANPOWER TRAINING, MATERIAL AND BUDGET

3.

IN THE HOME SETTING


TO PROMOTES
APPROPRIATE CARE SEEKING BEHAVIOURS, IMPROVED
NUTRITION AND PREVENTIVE CARE, AND CORRECT
IMPLEMENTATION OF PRESCRIBED CARE

HOW IS IMCI IMPLEMENTED ?


PHASE I :

INTRODUCTION OF IMCI IN A COUNTRY


(ORIENTATION OF DECISION MAKERS, THE
ESTABLISHMENT OF NATIONAL MANAGEMENT AND
COORDINATION GROUP, TRAINING OF KEY MINISTRY
OF HEALTH STAFF.

PHASE II : GAINING EXPERIENCE THROUGH EARLY


IMPLEMENTATION, DEVELOPMENT OF NATIONAL
PLAN, SELECTION OF INITIAL DISTRICTS FOR
IMPLEMENTATION, ADAPTATION OF CLINICAL
GUIDELINES AND MATERIALS, TRAINING
FACILITATORS AND PLANNING AT DISTRICT LEVEL.
PHASE III: EXPANSION OF ACTIVITIES AND COVERAGE