Introduction to community

medicine

DR.SOURAB
KUMAR DAS
Community
The definition of “community” accepted by WHO Expert Committee is
“A community is a social group determined by geographical boundaries
and/or common values and interests’.

OR,
Community can be defined as “a collection of a group of persons in
social interaction in a geographical area and sharing a common social
and cultural life’.
Characteristics of community
1. The community is a contiguous geographical area.
2. It is composed of people in living together.
3. People co-operate to satisfy their basic needs.
4. There are common organizations, e.g. markets, schools, stores,
banks, hospitals.
5. Economic status.
6. Specific functions or occupations or pursuits as a whole for the
community.
7. A group dependence or belongingness.
8. An interdependent behavior.
Community medicine
It is the successor of what was previously known as public health,
community health, preventive and social medicine.

Definition:
The study of health and disease in the population of defined
communities or groups in order to identify their health needs and to
plan, implement, and evaluate health programs to effectively meet these
needs.
Or
A WHO technical committee(1972) defined community medicine as
“a system of delivery of comprehensive health care to the people by a
health team to improve the health of the community’.
Objective of community medicine

1. To provide comprehensive health care.(preventive, promotive,

curative and rehabilitative).
2. To provide primary healthcare to the community.
3. To conduct epidemiological survey about common health problems.
4. To conduct health education programs among the people.
5. To participate the national health programme.
6. The final objective is to extend the scope of health disciplines
involved indirectly in health care, such as economists, social
scientists.
Importance of community medicine
1. To provide knowledge, skillness and attitude regarding the delivery
of comprehensive health care to the people.
2. To give knowledge about screening, diagnosis, treatment, referral
and follow-up.
3. To give knowledge on immunization e.g. EPI.
4. To provide knowledge on planning, reporting and supervision.
5. To give knowledge of control of communicable disease, e.g.
Diphtheria, Diarrhea, Measles etc.
6. To give knowledge on health education.
MODERN MEDICINE

1. Curative medicine
2. Preventive medicine
3. Social medicine
Curative medicine
Its primary objective is the removal of disease from the patient(rather than
from the mass).
It employes various modalities to accomplish this objective eg, diagnostic
techniques, treatment.
By the indroduction of antibiotic agents and other drugs ,which produces a
reaction which itself neutralizes the disease.
Prventive medicine

Preventive medicine can be define as art and science of

health promotion , disese prevention, disability
limitation and rehabilitation .
Social medicine
The field of social medicine seeks to:
understand how social and economic conditions impact health, disease and the
practice of medicine and
foster conditions in which this understanding can lead to a healthier society.
Salient components of community medicine

A. Community:
Healthy person
Unhealthy person
B.Comprehensive healthcare
Preventive care
Promotive care
Curative care
Rehabilitative care
C.Health team
Health professionals
Auxiliaries
Team leader.
Health team
Health tem has been defined as “ a group of persons who share a
common health goal and common objectives , determined by
community needs and toward the achievement of which each member
of the team contributes is accordance with his/her competence and
skills, and respecting the functions of the others”.
Population medicine
Population medicine is referred to as hygiene, public health, preventive
medicine, social medicine or community medicine. All these share
common ground in their concern for promotion of health and
prevention of disease.
 Public health

Public Health is the Science

and Arts of prevention, preservation, promotion
and rehabilitation of health through organized
community effort (WHO, 2004).
Public Health Cont……
An alternative Definition of Derek
Wanless is : "the science and art of
preventing disease, prolonging life and
promoting health through the
organised efforts and informed choices
of society, organisations, public and
private,Communities and individuals.“
(February 2004)
Community health
Community health can be define as “all the personal health and enviromental
services in any human community,irrespective of whether such services were
public or private ones.”

The term ‘community health “ has replaced in some countries the terms public
health.
How Community Medicine differs from other branches of Medicine?

“Community Medicine reaches out to people to provide services for prevention

of disease (such as immunization, pre-natal care, health screening etc.),
 Promotion of health (such as safe water supply and sanitation, vector control
measures, tobacco control policy etc.) and
 Provision of primary medical (health) care (treatment of common ailments
such as diarrhea, pneumonia, TB, leprosy, malaria, hypertension etc.)

Whereas other branches of medicine largely provide diagnostic and treatment

services to patients who seek treatment. 
 Changing concept of public health
4 Phases of public health:
1. Disease control phase(1880-1920)
Goals: control of disease
Aims: Control of man`s physical environment.
Target:
To provide clean surroundings
To provide clean and safe water
To provide wholesome condition of house.
To control offensive trades.
Approach:
Regulatory approach: e.g. sanitary legislation.
Service approach: e.g. disinfection of water and disposal of excreta.
Educational approach: Cleanliness.
Changing concept of public health
2.Health promotion phase(1920-1960AD):
Goal: Promotion of individual as well as community health.
Aims:
To decrease mortality and morbidity.
To increase life expectancy.
Approach:
Personal health services:
• Mother and child health services(MCH)
• School health services(SHS)
• Industrial health services(HIS)
• Mental health and rehabilitation services.
Community development programme:
• Immunization.
• Provision of adequate food and proper nutrition.
 Changing concept of public health
3.Social engineering phase(1960-1980 AD):
Goals:
Prevention of disease.
Promotion of health.
Prolongation of life.
Aims: Prevention, treatment and rehabilitation of chronic disease and
behavioral disorder.
Approach:
Health education.
Modification of life style and human behavior.
Changing concept of public health
4.Health for all phase(1981-200 AD): Attainment by all the people of the
world by the year 2000 AD of a level of health that will permit them to lead a
socially and economically productive life.
Main themes of health for all:
Equity of health
Universal coverage
Community participation
Integration between health and health related sectors.
Targets:
Provision of right kind of food
Provision of essential drugs.
Providing adequate supply of drinking water
Providing adequate basic sanitation
Immunization of children against six common disease.
Basic human need
Food
Clothing
Residence
Education
Medical support
Basic human needs
Implementation of equitable distribution of health resources:
Health care should be equitably distributed. That means health services
must be shared equally by all people irrespective of their ability to pay
and all(rich, poor, urban or rural) must have access to health services.
Basic human needs
Abraham Maslow`s need hierarchy:
Maslow`s hierarchy of needs is a theory in psychology, proposed by
Abraham Maslow in his 1943 paper A theory of human motivation.
Maslow subsequently extended the idea to include his observations of
human`s innate curiosity.
Basic human needs
Construction:
Maslow`s hierarchy of needs is often portrayed in the shape of
pyramid, with the largest and most fundamental level`s of need at the
bottom, and the need for self- actualization at the top.
Concept of health:

Health:
A state of complete physical, mental
and social well-being and not merely the absence of disease or
infirmity (WHO 1948).

Now spiritual wellbeing has been added in this definition.

Concept of health

Changing concept of health:

1.Biomedical concept: A person was considered as healthy if he was free from
disease or absence of disease. This concept is known as biomedical concept.
This concept is based on germ theory of disease.
Criticism: role of environmental, social, psychological and cultural
determinants of health are ignored.
2.Ecological concept: the ecologists viewed health as a dynamic equilibrium
between man and his environment and disease a maladjustment of the
human organism to environment. The ecologist concept raises two issues:
Imperfect man.
Imperfect environment.
Concept of health
 Changing concept of health:
 3.Psycological concept: health is not only a biomedical phenomenon, but one
which is influenced by social, psychological, cultural, economic & political
factors of the people concerned.
 Social factor:
 Poverty
 Illiteracy
 Habits and life style(smoking, drugs, multiple sex partner etc.)
 Psychological factors:
 Anxiety
 Tension
 Emotional breakdown.
 4.Holistic concept: the holistic model is a synthesis of all the above concepts.
The holistic approach implies that all sectors of society have an effect on
health(in particular agricultural, animal husbandry, food, industry, education,
housing, public works, communication and other sectors.)
New philosophy of health
1. Health is a fundamental human right.
2. Health is the essence of productive life and not the result of ever
increasing expenditure on medical care.
3. Health is intersectoral.
4. Health is an integral part of development.
5. Health is central to the concept of quality of life.
6. Health involves individuals, state and international responsibility.
7. Health and its maintenance is a major social investment.
8. Health is world-wide social goal.
 Dimension of health
A) Major dimensions:
1. Physical dimension.
2. Mental dimension.
3. Social dimension.
4. Spiritual dimension.
B)Minor dimension:
5. Emotional dimension.
6. Vocational dimension.
7. Others.
Philosophical dimension.
Cultural dimension.
Socio-economic dimension.
Environmental dimension.
Nutritional dimension.
Curative dimension
Preventive dimension.
Dimension of health
Physical dimension:
Perfect functioning of the body.
Every cell and organ is functioning at optimum capacity.
Signs of physical health:
Good complexion
Clean skin
Bright eyes
Good appetite
Sound sleep
Regular activity of bowel and bladder.
Smooth, easy and co-ordinated movement.
All the special sense are intact.
 Dimension of health
2. Mental dimension:
Mental health: “A state of balance between the individual and the
surrounding world, a state of harmony between oneself and other, a co-
existance between the realities of the self and that of other people that
of the environment.”
Criteria of a mentally healthy person:
I. Is free from internal conflicts.
II. Is well adjusted with family and community.
III. Awareness of one`s identity.
IV. Has a strong sense of self-esteem.
V. Known himself;his needs, problems & goals.
VI. Has good self-control.
VII. Faces problems and tries to solve them intelligently.
Dimension of health
Tools and techniques for the evaluation of physical health:
1. Self-assessment of overall health.
2. Inquiry into symptoms of ill health and risk factors.
3. Inquiry into medications.
4. Inquiry into level of activity.
5. Inquiry into use of medical services.
6. Dimension of health for cardio vascular disease.
7. Dimension of health for respiratory disease.
8. Clinical examination.
9. Nutrition and dietary assessment.
10. Bio-chemical and laboratory investigations.
Positive health
The state of health implies the notion of “perfect functioning” of the
body and mind. It conceptualizes health biologically, psychologically
and socially.
A person who enjoys health at three planes, ie. Good physical,, mental
and social well-being is said to be in a state of positive health.
Concept of wellbeing
Wellbeing: In point of fact, there is no satisfactory definition of the
term “well-being”.
Recently psychologist have pointed out that the well-being’ of an
individual or group of individuals have objective and subjective
components. The objective components relate to such concerns as are
generally known by the term “standard of living” or “level of living”.
The subjective component of well-being( as expressed by each
individual) is referred to as “quality of life”
Concept of wellbeing
1.Standard of living(objective component)
It refers to the usual scale of our expenditure, the goods we consume and
the services we enjoy. It includes the level of education, employment
status, food, clothing, house, amusements and comforts of modern
living.
WHO definition: Income and occupation, standard of housing,
sanitation and nutrition, the level of provision of health, educational,
relational and other services may all be used individually as measures
of socioeconomic status and collectively as an index of the “standard of
living”.
Concept of wellbeing
2.Level of living: (objective component) It consist of 9 components-
1. Health
2. Food consumption
3. Education
4. Occupation and working conditions
5. Housing
6. Social security
7. Clothing
8. Recreation and leisure
9. Human rights.
Concept of wellbeing
3.Quality of life (subjective components) WHO define as-
The condition of life resulting from the combination of the effects of
the complete range of factors such as those determining health,
happiness(including comfort in the physical environment and satisfying
occupation), education, social and intellectual attainments, freedom of
action, justice and freedom of expression.
 PQLI
Physical quality of life index. It is an index for measuring quality of life of a nation.
Components: It consolidates three indicators-
1. Infant mortality
2. Life expectancy at age one
3. Literacy.
Calculation: for each component , the performance of individual countries is placed
on a scale of 0 to 100. ‘0’ represents an absolutely defined ‘worst’ performance
and ‘100’ represents an absolutely defined ‘best’ performance. The composite
index is calculated by averaging the 3 indicators, giving equal weight to each of
them. The resulting PQLI thus is scaled 0 to 100.
Example: In Bangladesh:
4. Infant mortality=57/1000/year
5. Life expectancy at age one=60 years
6. Literacy=43%
So PQLI of Bangladesh is=(57+60+43)/3= 53.3
Human development index(HDI)

HDI defined as ‘a composite index combining indicators representing

three dimensions-longevity(life expectancy at birth), knowledge(adult
literacy rate and mean year schooling ) and income(real GDP per capita
in purchasing power parity in US dollars)”.
HDI value ranges from 0-1.
Health sickness spectrum:
The spectral concept of health denotes that the health of an individual is
not static. It fluctuates within a range varying from optimum wellbeing
to various levels of dysfunction including the state of total
dysfunction(death).
The transition from good health to ill health is often a gradual one and
where one step ends the other being as matter of judgment.
The systematic representation of these different levels of health
constitutes the health-sickness spectrum.
Health sickness spectrum:

Positive health
Better health
Freedom from sickness

Unrecognized sickness
Mild sickness
Severe sickness
Death

Figure: the health sickness

“Health for All”
In 1981, the members of the WHO pledged themselves to an ambitious
target to provide ‘health for all’ by the year 2000, that is attainment of a
level of health that will permit all peoples to lead a socially
economically productive life.
Health for all means that health is to be brought within the reach of
every one in a given community.
“Health for All”
It implies the removal of obstacles to health- that is to say, the
elimination of malnutrition,ignorence,disease, contaminated water
supply, unhygenic housing etc.

It depends on continued progress in medicine and public health.

Global indicators for HFA by 2000AD :
1. Endorsement of HFA strategy as a policy at the highest political level.
2. At least 5% of GNP is spent on health.
3. Equitable distribution of health resources.
4. Availability of primary health care to the entire population at least
with the followings-a)Safe water at home or within 15 minutes
walking distance and adequate sanitation , B)immunization against 6
EPI diseases. C)availability of at least 20 essential drugs within an
hour travels or walk .d) Antenatal care and child birth.
5. Reduction of infant mortality rate( IMR) from 125 to 50.
6. Life expactancy at birth is over 60 years.
7. Adult literacy rate for both sexes exceeds 70%.
8. The GNP per capital exceeds US $ 500.
9. At least 90% of newborn have birth weight of at least 2500gm.
The millennium development goals
In September 2000, representative from 189 countries met at millennium
summit in new york to adop the United Nations Millennium Decleration.
To eradicate extreme poverty and hunger
To achieve universal primary education.
To promote gender equality.
To reduce child mortality.
To improve maternal health.
To combat HIV/AIDS, malaria and other diseases.
To ensure environmental sustainability.
To develop a global partnership for development
Levels of health care
Primary health care
Essential healthcare based on practical, scientifically sound and
socially acceptable methods and technology made universally
accessible to individuals and families in the community and the
country can afford to maintain at every stage of their development in
the spirit of self determination.”
Levels of health care
Primary health care includes
Education about prevailing health problems and methods of preventing
and controlling them.
Promotion of food supply and proper nutrition.
An adequate supply of safe water and basic sanitation.
Maternal and child health care, including family planning.
Immunization against infectious disease.
Levels of health care
Essential Components of Primary Health Care
Prevention and control of endemic disease.
Appropriate treatment of common disease and injuries; and.
Provision of essential drug.
Levels of health care
Principles of primary health care:
Primary health care based on 4 principles
1. Equitable distribution of health services
2. Community participation at all level
3. Inter-costal co-ordination/multi-sectoral approach.
4. Appropriate technology.
Levels of health care
Secondary health care: At this level , more complex problems are dealt with.
This care comprises essentially curative services and is provided by the district
hospital and community health centres. This level serves as the first referral
level in the health system.
 Levels of health care
Tertiary health care: This level offers super-specialist care. This care is provided
by the regional/central level institutions. These institutions provide not only
highly specialized care, but also planning and managerial skills and teaching for
specialized staff. In addition, the tertiary level supports and complements the
actions carried out at the primary level.
Concept of prevention
The goals of medicine are to promote health, to preserve health, to restore
health when it is impaired, and to minimize suffering and distress. These goals
are embodied in the word “Prevention”.
Succeesful prevention depends upon

a knowledge of causation
Dynamics of transmission
Identification of risk factor and risk groups
Concept of prevention
Availability of prophylactic or early detection
Tratment measure

Level of prevention:
1. primodial prevention
2.primary prevention
3.secondary prevention
4.tertiary prevention
Level of prevention
Primodal prevention: prevention of emergence or development of risk factor
in countries or population groups in which they have not yet appeared.
Example: Many adult health problem(e.g.o obesity, hypertension) have their
early origins in childhood.
Level of prevention
Primary prevention: primary prevention can be define as “action taken prior
to the onset of disease”, which removes the possibility that the disease will ever
occur.
Example; the concept of primary prevention is now being applied to the
prevention of chronic heart disease such as coronary heart disease,
hypertension and cancer based on elimination or modification of” risk factors.”
Level of prevention
Seconary prevention: It can be define as “action which halts the progress of a
disease at its incipient stage and prevent complications.”
The specific interventions are:
Early diagnosis(eg;screening tests , case finding programmes).
Adequate treatment.
Level of prevention
By early diagnosis and adequate treatment secondary prevention attempts
to
arrest the disease process,
Restore health by seeking out unrecognized disease, and
Treating it before irreveersible pathological changes have taken place,
Reverse communicability of infectious disease,

It may also protect others in the community from acquiring the infection .
Level of prevention

Tertiary prevention: It can be define “All measures available to reduce or limit

imparirments and disabilities, minimise suffering caused by exsisting departures
from good health and to promote the patient’s adjustment to irremediable
condition.”
Eg; treatment, even if undertaken late in the natural history of disease may
prevent sequelae and limit disability.
Tertiary prevention extends the concept of prevention into fields of
rehabilitation.
Family medicine
Formerly family practice (FP), is a medical specialty devoted to
comprehensive health care for people of all ages; the specialist is named
a family physician, family doctor, or family nurse practitioner.
In Europe the discipline is often referred to as general practice and a
practitioner as a General Practice Doctor or GP.
It is a division of primary care that provides continuing and
comprehensive health care for the individual and family across all ages,
genders, diseases and parts of the body,
Determinants of Health
The range of personal, social, economic, and environmental factors that
influence health status are known as determinants of health.
Determinants of health are:
1. Biological determinants
2. Behavioral and socio-cultural conditions
3. Environmental services
4. Aging of the population
5. Gender
6. Other factors
Determinants of Health
1.Biological determinants: the physical and mental traits of every
human being are to some extent determined by the nature of his genes
at the time of conception. A number of diseases are now known to be
genetic origin, e.g. chromosomal anomalies, errors of metabolism,
mental retardation, some types of diabetes, etc.
2.Behavioural and socio-cultural conditions:
The way people live
Cultural pattern.
Personal habits.
Life style:
Harmful life style e.g. smoking
Healthy life style e.g. adequate nutrition, enough sleep, sufficient
physical activities.
 Determinants of Health
3.Environment:
A)internal-tissue, organ and organ system.
B) external- the things to which man is exposed after conception.
Physical environment:
Air pollution
Water pollution
Soil pollution
Heat ,light, radiation sound.
Food, excreta, refuse.
Biological:
Human being
Plants
Animal
Micro-organisms
Insect, birds
Housing.
Determinants of Health
Psychological:
Customs
Belief moral
Occupation
Religion
Education.
4.Socio-economic conditions:
a. Economic status: A community with a high per capita GNP has a better
health status then one with a low GNP.
b. Education: Illiteracy-poverty-malnutrition-ill health-increased maternal and
infant mortality.
c.Occupation: employment- promote health, unemployment-ill health.
d.Political system: In absence of strong political commitment, allocation for
health development is probably the lowest.
 Determinants of Health
5.Health services:
Criteria:
I. Comprehensive health care
II. Equitable distribution
III. Health care must reach periphery.
IV. Accessible to all
V. Socially acceptable and affordable.
.
Determinants of Health
6. Aging of the population:
The elderly enjoy better health
Rapid population aging increase prevalence of chronic illness and
disabilities.
7.Gender: women's health is an important issue for the society.
8. Other factors: Health related systems e.g.
Food and agriculture
Education
Industry
Social welfare
Rural development
DEFINITION OF HYGIENE
HYGEIA = The Goddess of Health
DEFINITION : “hygiene refers to conditions and practices that help to maintain
health and prevent the spread of disease.”(WHO)

• The aim is to impart knowledge and teach the means of improving one’s
health

• Deals with individuals as well as the community as a whole

SANITATION
Sanitation is the hygienic means of promoting
health through prevention of human contact with
the hazards of wastes as well as the treatment and
proper disposal of sewage or wastewater.
Hazards can be either physical, microbiological,
biological or chemical agents of disease.
Wastes that can cause health problems include
human and animal excreta, solid wastes, domestic
wastewater (sewage, sullage, greywater), industrial
wastes and agricultural wastes.
SANITATION
Hygienic means of prevention can be by using
engineering solutions e.g.,
sanitary sewers
sewage treatment
surface runoff management,
solid waste management
excreta management.
.
Simple technologies
e.g.,
pit latrines
dry toilets
septic tank
or even simply by personal hygiene practices e.g.,
hand washing with soap, behavior change.
 Determinants of Health
About Determinants of Health
The range of personal, social, economic, and environmental factors that
influence health status are known as determinants of health.
 
Determinants of health fall under several broad categories:
 
Policymaking
Social factors
Health services
Individual behavior
Biology and genetics
Policymaking
Policies at the local, state, and federal level affect
individual and population health.
for example, Increasing taxes on tobacco sales,, can
improve population health by reducing the number of
people using tobacco products.
Social Factors
Social determinants of health reflect the social factors
and physical conditions of the environment in which
people are born, live, learn, play, work, and age. Also
known as social and physical determinants of health,
they impact a wide range of health, functioning, and
quality-of-life outcomes.
Examples of social determinants include

Availability of resources to meet daily needs, such as educational

and job opportunities, living wages, or healthful foods
Social norms and attitudes, such as discrimination
Exposure to crime, violence, and social disorder.
Social support and social interactions
Exposure to mass media and emerging technologies, such as the
Internet or cell phones
Socioeconomic conditions, such as concentrated poverty
Quality schools
Transportation options
Public safety
Residential segregation
Examples of physical determinants include:

Natural environment, such as plants, weather, or climate

change
Built environment, such as buildings or transportation
Worksites, schools, and recreational settings
Housing, homes, and neighborhoods
Exposure to toxic substances and other physical hazards
Physical barriers, especially for people with disabilities
Aesthetic elements, such as good lighting, trees, or
benches
Examples of physical determinants include:

Poor health outcomes are often made worse by the

interaction between individuals and their social and
physical environment.
For example, In counties where ozone pollution is high,
there is often a higher prevalence of asthma in both
adults and children compared with state and national
averages. Poor air quality can worsen asthma
symptoms, especially in children.
Health Services
Both access to health services and the quality of health
services can impact health.
For example, when individuals do not have health
insurance, they are less likely to participate in
preventive care and are more likely to delay medical
treatment.
Barriers to accessing health services include:

Lack of availability
High cost
Lack of insurance coverage
Limited language access
 These barriers to accessing health
services lead to
Unmade health needs
Delays in receiving appropriate care
Inability to get preventive services
Hospitalizations that could have been prevented
Individual Behavior
Individual behavior also plays a role in health outcomes.
For example, if an individual quits smoking, his or her
risk of developing heart disease is greatly reduced.
Many public health and health care interventions focus
on changing individual behaviors such as substance
abuse, diet, and physical activity. Positive changes in
individual behavior can reduce the rates of chronic
disease in the country.
Individual Behavior

Examples of individual behavior determinants of

health include:
Diet
Physical activity
Alcohol, cigarette, and other drug use
Hand washing
 Biology and Genetics
Some biological and genetic factors affect specific
populations more than others. For example, older adults
are biologically prone to being in poorer health than
adolescents due to the physical and cognitive effects of
aging.
Sickle cell disease is a common example of a genetic
determinant of health. Sickle cell is a condition that
people inherit when both parents carry the gene for
sickle cell.
Biology and Genetics
Examples of biological and genetic social determinants of
health include:
Age
Sex
HIV status
Inherited conditions, such as sickle-cell anemia,
hemophilia, and cystic fibrosis
Carrying the BRCA1 or BRCA2 gene, which increases risk
for breast and ovarian cancer
Family history of heart disease
Health indicators
Indicators are required not only to measure the health
status of a community, but also to compare the health
status of one country with that of another,
indicatorsHealth
It may be classified as –
1.Mortality indicator:
a) Crude death rate: It indicates the rate at which
people are dying.
b) Life expectency indicator: It can be cosidered as
positive health indicator.
c) Infant mortality rate:Infant mortality rate is the ratio
of deaths under 1 year of age in a given year to the
total number of live births in the same year, usualy
expressed as rate per 1000 live births.
indicatorsHealth

D)Child mortality rate: The number of deaths at the

ages 1-4 years in a given year , per 1000 children in
that age group at the mid-point of the year
concerned.
E)Under 5 proportionate mortality rate: It is the
proportion of total deaths occuring in the under 5 age
group.
F) Maternal mortality rate: It accounts the propotion
of deaths among women of reproductive age.
indicatorsHealth
G) disease specific mortality rate: Mortality rate can be
computed for specific diseases.
H)Porportional mortality rate: The simplest measure of
estimating the burden of a disease in the community is
the proportional mortality rate.
2)Morbidity indicator: Mobidity indicators are used to
supplement mortality data to describe the health status
of a population.
 Indicators Health
The following morbidity rates are used for assessing ill
health in the community.
I. Incidence and prevalence
II. Notification rates
III. Attendence rates at out patient departments, health
centres, etc.
IV. Admission, readmission and discharge rates
V. Duration of stay in hospital, and spells of sickness or
absences from work or school.
Indicators Health
3)Disability rates: disability rates related to illness and
injury have come into use to supplement mortality and
morbidity indicators.
Commonly used diasbility rates fall into two groups:
A. Event type indicators
B. Person type indicators
indicatorsHealth
Event- type indicators:
Number of days restricted activity
Bed disability days
Work-loss days (or school loss days) within a specified
period.
Person -type indicators:
Limitation of mobility-eg. Confined to bed, confined to
house.
Health indicator
4.Nutritional status indicators: It is a positive health
indicator. Three nutritional status indicator are
important as indicator of health status, they are
a) Anthropometric measurements of preschool
children, e.g, weight and height, mid-arm
circumference;
b) Height and sometimes weights of children at school
entry; and
c) Prevalence of low birth weight(less than 2.5 kg)
Health indicator
5. Health care delivery indicators: the frequently used
indicators of health care delivery are:
a) Doctor-population ratio
b) Doctor-nurse ratio
c) Population-bed ratio
d) Population per health/subcentre, and
e) Population per traditional birth attendant.
Health indicator
5. Health care delivery indicators : Is expressed as propotion of
people in need of a service who actually receieve it in a given
period, usually a year.
E,g;
a) Propotion of infants who are ‘fully immunized” against the 6 EPI
diseases.
b) Proportion of pregnant women who receive antenatal care or
have their deliveries supervised by a trained birth attendant.
Percentage of population using various methods of family
planning.
c) Bed ocupancy rate.
d) Average length of stay.
e) Bed turn over ratio.
Health indicator
7.Indicator of social and mental health: These includde
Sucide
Homocide
Road traffic accident
Juvenile deliquency
Alchol and drug abuse
Smoking
Conumption of tranquillizers
Obesity
Family violence
Battered- baby and battered wife syndroms
Neglected and abandoned youth in the
neighbourhood. Etc.
These social indicators provide a guide to social
action for improving the health of the people.
Health indicator
◦ 8. Enviromental indicators: it reflects the quality of
physical and biological enviroment in which disease
occur and in which people live. They include:
Pollution of air and water
Radiation
Solid waste
Noise
Exposure to toxic substances in food or drink.
Health indicator
9.Socio economic indicators: These indicator do not
directly measure health. Neverthelesss , they are of
great importance in the interpretation of the indicators
of health care. These include:
a) Rate of population increase
b) Per capita GNP
c) Level of unemployment
d) Dependency ratio
e) Literacy rate, specially female literacy rate
f) Family size
g) housing: the number of persons per room.
 Health indicator
10. health policy indicator:
I. Propotion of GNP spent on health services,
II. Propotion GNP spent on health- related
activities( including water supply and sanitation,
housing and nutrition, community development)
III. Propotion of total health resources devoted to
primary health care.
 Health indicator
11. Indicator of quality of life: It consolidates three
indicator-
I. Infant mortality
II. Life expectancy
III. Literacy.
More work is needed to develop indicators of quality of
life.
 Health indicator
12. Other indicators:
A. Social indicator; they are ( according to United Nations Statistical office) divided
inti 12 categories:
i. Population
ii. Families and households
iii. Learning and educational service
iv. Earning activities
v. Distribution of income
vi. Consumption and accumulation
vii. Social security and welfare service
viii. Health service and nutrition
ix. Housing and its enviroments
x. Public order and safety
xi. Leisure and culture, social statification and mobility.
Health indicator
B) basic need indicators: include
Calorie consumption
Acces to water
Life expectancy
Death due to disease
Illiteracy
Doctor and nurse per population
Rooms per person
GNP per capita
C) health for all indicators,
D)millinium devopmental goal indicator.
Importance of health indicators

1. To measure the health status of a community

2. To compare the health status of one country with the that of another
3. To assess the health need of the people.
4. To allocate the health resources
5. To monitor and evaluate of health services, activities and
programmes.
6. To provide feedbacks for reprogramming for better use of resources
and accelerating progress in health development.
 Health care
It may be define as “a multitude of services rendered to individuals, families or
communities by the agents of the health services or professions, for the purpose of
promoting, maintaining , monitoring or restoring health”.
Characteristics of ideal health care:
1. Appropriateness(relevance), i.e whether the service is needed at all in relation
to essential human needs, proprieties and policies.
2. Comprehensiveness, i.e whether there is an optimum mixture of prevention,
curative and promotional services.
3. Adequacy, ie if the services is proportionate to requirement.
4. Availability, ie. Ratio between the population of an administrative unit and the
health facility(e.g. population per center, doctor-population ratio).
5. Accessibility, i.e this may be geographic accessibility, economic accessibility
or cultural accessibility.
6. 6.affordability. i.e the cost of the health care should be within the means of the
individual and the state.
7. Feasibility, i.e. operational efficiency of certain procedures, logistic support,
manpower ans material resources.
Comprehensive health care
The term “comprehensive health care”was first used by bhore
committee in 1946.

Comprehensive healthcare may be define as “the provision of

integrated preventive, curative, promotive and rehabilitative health
care from the womb to the tomb to every individual residing in defined
geographic are.”
Criteria of comprehensive health care:

1. Provide adequate preventive, curative and promotive health

services.
2. Be as close to the beneficiaries as possible.
3. Has the widest co-operation between the people, the service and the
profession.
4. Available to all irrespective of their ability to pay.
5. Look after specifically the vulnerable and weaker sections of the
community.
6. Create and maintain a healthy environment both in homes as well as
working places.
Objective of comprehensive health care:
1. Reduction of premature death.
2. Reduction of disease
3. Reduction of discomfort.
4. Reduction of delinquency.
5. Reduction of disruption.

Requirements of comprehensive health care:

6. Maximum utilization of all available skills in order to ensure the most economic
provision of health services.
7. Co-operation and active involvement of the community with the staff of medical
institutions providing the services.
8. A change in tradition pattern of living and availability of basic sanitary amenities.
9. The available doctors should be concerned not only with the illness of the
individual but also with the factors, which govern the well-being of the whole
community.
10. Awareness and acceptance of modern concepts in health and sickness.
Examples of each components of
comprehensive health care:
1. Preventive health services: prevention of diseases by vaccines, e.g.
Prevention of poliomyelitis.
2. Curative health services: treatment of disease, e.g. Anti-tubercular
drug therapy for tuberculosis
3. Promotional health services: e.g. health promotion by environment
and personal sanitation.
4. Rehabilitative health care:
 Medical rehabilitation: restoration of function
 Social rehabilitation: restoration of family and social relationships.
 Vocational rehabilitation: restoration of the capacity to earn a
livelihood.
 Psychological rehabilitation: Restoration of personal dignity and
confidence.
Domiciliary health care
This is the primary health care in a package which includes activities,
such as-
Health education
MCH and family planning
Nutrition
Sanitation
Communicable disease control and treatment of minor ailments.
Bhore committee
It was the “health survey and development committee appointed by the
government of India in 1943 under the chairmanship of sir Joseph
Bhore. The members of the committee met regularly for 2 years and
submitted in 1946 its famous report which runs into 4 volumes.
The committee observed,” If the nations health is to be built, the
programme should be developed on a foundation of preventive health
work and such activities should proceed side by side with those
concerned with treatment of patients.”
Bhore committee
Some of the recommendations of the committee were:
1. Integration of preventive and curative services at all adminstratative
levels.
2. Development of primary health care in two stages-
a) As a short term measure: each primary health center in the rural
areas cater to a population of 40,0000 with secondary health center
to serve as a supervisory, co-ordinating and referral institution.
b)Long term programme: Setting up primary health units with 75
bedded hospitals , again 10,000-20,000 population and secondary
units with 650 bedded hospital, again recognalized around district
hospitals with 2500 beds.
3. Three months training in preventive and social medicine for medical
students to prepare "social physician.”