CONCEPTS IN HEALTH &

DISEASE

K.SAGAR
Asso professor
Health is NOT mainly an issue
of doctors , social services &
hospitals.
It is an issue of social justice.
Oldest definition of health:
”absence of disease”
Health is often taken for
granted, & its value is not
fully understood until it is
lost.
Health has evolved over
centuries as a concept from an
individual concern to a
world – wide social goal.
CHANGING CONCEPTS
Biomedical concept
Ecological concept
Psychological concept
Holistic concept
 WHO DEFINITION OF HEALTH (1948)

Health is a state of
complete physical ,mental
& social well being not
merely an absence of
disease or infirmity.
In recent years it has been
amplified to include the
ability to lead a “ socially &
economically productive
life”
NEW PHILOSOPHY OF HEALTH
Health is a fundamental human right.
Health is the essence of productive life.
Health is intersectoral.
Health is integral part if development.
Health involves individuals , state & international
responsibility.
Health is a major social investment.
Health is world wide social goal.
 DIMENSIONS OF HEALTH
Physical dimension
Mental dimension
Social dimension
Spiritual dimension
Emotional dimension
Vocational dimension
 PHYSICAL DIMENSION
Perfect functioning of the body.
Every cell and every organ functioning
at optimum capacity and perfect
harmony with the rest of the body.
Signs of Physical Health
 
Good complexion
Clean skin
 Bright eyes
Lustrous hair
Body well clothed with firm flesh
Not too fat
A sweet breath
 Signs of Physical Health
Good appetite
 Sound sleep
 Regular activity of bowels and bladder
 Smooth, easy, co- ordinated bodily movements
All the organs are of unexceptional size and
functioning normally
All special senses are intact
Resting pulse rate, BP and exercise tolerance are
within normal range .
 Evaluation of Physical Health
•  

Self assessment of overall health

Inquiry into symptoms of ill health and risk factors
Inquiry into medication
Inquiry into levels of activity
Inquiry into use of medical services
Std quest., of CVS, RS,
 Clinical Examination
 Nutrition
dietary assessment
Biochemical and Laboratory Investigations
ASSESSMENT AT COMMUNITY LEVEL
Death rate
IMR
Expectation of life
 Mental Dimension
Mental Dimension Is not mere absence of mental
illness .
Good mental health is the ability to respond to varied
experiences of life with flexibility & a sense of
purpose.
“ a State of Balance between the individual and
surrounding world, a state of harmony between
oneself and others
 Conditions caused due to mental illness
Essential hypertension
Peptic ulcer
Bronchial asthma
 Qualities of mentally healthy person
Free from internal conflicts
Well- adjusted
Searches for identity
Strong sense of self esteem
Knows him self
Good self control
Coping with stress & anxiety
 Assessment of mental health
By administering questionnaires
Assessment of mental well being
Assessment of mental function
 Social Dimension
 
Harmony and integration
a) within the individual
b) between each individual and other members of the
society
c) between individuals and world in which they live .
Definition :- Quantity and quality of an individual’s
interpersonal ties and the extent of involvement with
the community
 Social dimension
Levels of social skills,
social functioning ,
Ability to see oneself as a member of a larger society.
 Focuses on social and economic conditions & well
being of the “whole person”.
 Spiritual Dimension
 
Spiritual Dimension Refers to that part of individual
which reaches out and strives for meaning and
purpose in life.
 Something that transcends Physiology and
Psychology.
 Includes integrity, principles, ethics, purpose of life,
commitment .
 
Emotional Dimension

Mental Health = seen as Knowing or Cognition

Emotional Health = relates to feeling
 Vocational Dimension : 

When work is fully adapted to human goals,

capabilities and limitations work often plays an imp
role in promoting physical & mental health.
Importance is exposed when individuals suddenly
lose their Job / after Retirement.
 Other Dimensions
 
Philosophical
Cultural
Socioeconomic
Environmental
Educational
Nutritional
Curative
Preventive
Health – A Relative Concept : 

Health not as an ideal state , but as a biologically

Normal State based on Statistical averages .
NO Universal Health Standards Defined
in terms of Prevailing Ecological
conditions
CONCEPT OF WELL BEING
1. Objective Components:
Standard of Living
Level of Living
2. Subjective Component:
Quality of Life
 Standard of Living
Standard of Living Refers to Expenditure,
Goods we Consume Services we enjoy.
Varies among different countries.
Depends on per capita GNP.
 Standard of Living
Income
Occupation,
standards of housing, sanitation, nutrition,
level of provision of health,
educational, recreational and other services
may all be used individually as measures of socio –
economic status – collectively as an index called
“Standard of Living”.
 Level of Living
Health
Food Consumption
Education
Occupation & Working Conditions
Housing
Social Security
Clothing
Recreation & Leisure
Human Rights
Quality of Life :
Quality of Life Subjective component.
 RECENT DEFINITION
A composite measure of physical ,mental, social
well being as perceived by each individual or group
say happiness , satisfaction , gratification as it is
experienced in various life concerns as health ,
marriage , work , financial situation, education etc.
Evaluated by subjective feelings.
Physical Quality of Life Index : 

Infant Mortality
Life Expectancy at age One
 Literacy
 PQLI
For each component, the performance of individual
countries is placed on a scale of 0 to 100.
 0 represents "worst" performance.
100 represents "best" performance.
 PQLI
PQLI has not taken per capita GNP into consideration.
For example,
the oil-rich countries of Middle East with high per capita
incomes have in fact not very high PQLIs.

At the other extreme, Sri Lanka and Kerala state in India have
low per capita incomes with high PQLIs.
PQLI does not measure economic growth;
 It measures the results of social, economic and political
policies.
The ultimate objective is to attain a PQLI of 100.
Human Development Index
Longevity (life expectancy at Birth)
Knowledge (adult literacy rate and mean years of
schooling)
 Income (real GDP per capita in purchasing power –
parity Dollars)
 HDI
ADULT LITERACY INDEX +GER
INDEX=EDUCATION INDEX

LIFE
EXPECTANCY GDP INDEX
INDEX

HDI
 HDI
The HDI values ranges between 0 to 1.
Life expectancy at birth : 25 years and 85 years
 Adult literacy rate : 0 per cent and 100 %
Combined gross enrolment ratio : 0 % and 100%
 Real GDP per capita (PPP$) , $ 100 and $ 40,000
For any component of the HDI, individual indices can
be computed according the general formula :
Index = (Actual value) - (Minimum value) /
(Maximum value) - (Minimum value)
HPI – DEVELOPING COUNTRIES
 A long and healthy life- vulnerability to death at a
relatively early age, as measured by the probability at
birth of not surviving to age 40.
Knowledge-adult Literacy rate.
A decent standard of living
HPI – DEVELOPED COUNTRIES
A long and healthy life-vulnerability to death at a
relatively early age, as measured by the probability at
birth of not surviving to age 60.
Knowledge-adult Literacy rate.
A decent standard of living
Social exclusion
DETERMINANTS OF HEALTH
DETERMINANTS OF HEALTH
SPECTRUM OF HEALTH
 RIGHT TO HEALTH
The international level, the Universal Declaration of
Human Rights established a breakthrough in 1948, by
stating in Article 25:
"Everyone has the right to a standard of living
adequate for the health and well-being of
himself and his family.....".
The Preamble to the WHO Constitution
also affirms that it is one of the fundamental
rights of every human being to enjoy "the highest
attainable standard of health.
 RESPONSIBILITY FOR HEALTH
Health is on one hand a highly personal
responsibility
and
on the other hand a major public concern.
It thus involves the joint efforts of the whole social
fabric,
viz. the individual,
community
state to protect and promote health.
 RESPONSIBILITY FOR HEALTH
Individual responsibility (Self care )
Community responsibility
State responsibility
International responsibility
 Lessons from Kerala State

Kerala is the southern-most state of India.

With a population of 31.83 million, and a population
density of 819 per sq.km, the state of Kerala is
extremely crowded.
 Its annual per capita income of Rs.27048 (2004-05) is
almost equal to the national average of Rs. 28715.
Kerala has surpassed all the Indian states in certain
important measures of health and social development.
 Lessons from Kerala State

Kerala has demonstrated that, in a

democratic system with strong political
commitment to equitable socioeconomic
Development, high levels of health can be
achieved even on modest levels of income.
 Lessons from Kerala State

Kerala can therefore be considered a

yardstick for judging health status in the
country .
Literacy (especially female literacy) has
played a key role in improving the health
situation.
This was probably responsible for the high rate of
utilization of health facilities.
Kerala has demonstrated that good health at low cost is
attainable by poor countries, but requires major political
and social commitment .
 INDICATORS OF HEALTH
To measure the health status of a community,
To compare the health status of one country with that
of another;
For assessment of health care needs
For allocation of scarce resources; and for monitoring
and evaluation of health services, activities, and
programmes.
 To measure the extent to which the objectives and
targets of a programme are being attained.
 Characteristics INDICATORS OF HEALTH
should be valid
should be reliable
should be sensitive,
should be specific
should be feasible
should be relevant,
 INDICATORS OF HEALTH
1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Health care delivery indicators
6. Utilization rates
7. Indicators of social and mental health
8. Environmental indicators
9. Socio-economic indicators
10. Health policy indicators
11. Indicators of quality of life, and
12. Other indicators
 Mortality indicators

Crude death rate

Expectation of life
Infant mortality rate
Child mortality rate
Under-5 proportional mortality rate
Maternal (puerperal) mortality rate
Disease-specific mortality rate
Proportional mortality rate
 Morbidity indicators

incidence & prevalence

notification rates
attendance rates at out-patient departments, health
centres. etc.
admission, readmission and discharge rates duration
of stay in hospital and
spells of sickness or absence from work or school.
 Disability rates
a)Event-type indicators :
i) Number of days of restricted activity
ii) Bed disability days
iii) Work-loss days (or school loss days) within a
specified period
 b)Person-type indicators :
i) Limitation of mobility:
Eg: confined to bed,
confined to the house, special aid in getting around
either inside or outside the house.
ii) Limitation of activity:
Eg: limitation to perform the basic activities of
daily living (ADL)-
eg: eating, washing, dressing, going to toilet,
moving about, etc;
limitation in major activity:
 ability to work at a job, ability to housework
 Sullivan's index
 This index (expectation of life free of disability)

is computed by subtracting from the life

expectancy , the probable duration of bed
disability and inability to perform major
activities.
 HALE
life expectancy at birth but includes an
adjustment for time spent in poor health.

 It is most easily understood as the equivalent

number of years in full health that a newborn can
expect to live based on current rates of ill - health
and mortality.
DALY (Disability - Adjusted Life Year)
years of life lost to premature death and years
lived with disability adjusted for the severity of
the disability.

One DALY is "one lost year of healthy life".

 Nutritional status indicators
Nutritional status is a positive health indicator.
1)anthropometric measurements of preschool
children,
e.g., weight and height, mid-arm circumference;
2)heights (and sometimes weights) of children
school entry;
3) prevalence of low birth weight (less than 2.5
kg).
 Health care delivery indicators

a. Doctor-population ratio

b. Doctor-nurse ratio
c. Population-bed ratio
d. Population per health/sub centre
e. Population per traditional birth attendant
 Utilization rates
proportion of infants who are "fully immunized"
against the 6 EPI diseases .
proportion of pregnant women who receive antenatal
care, or have their deliveries supervised by a trained
birth attendant
percentage of the population using the various
methods of family planning.
bed-occupancy rate (i.e., average daily in-patient
census/average number of beds).
average length of stay
bed turn-over ratio (i.e., discharges/average beds).
Indicators of social and mental health
suicide,
homicide,
other acts of violence and other crime;
road traffic accidents,
 juvenile delinquency;
alcohol and drug
abuse;
smoking;
consumption of tranquillizers
 Environmental indicators
pollution of air and water,
radiation,
solid wastes,
noise,
exposure to toxic substances in food or drink
proportion of population having access to safe water
and sanitation facilities,
 Socio-economic indicators
A. rate of population increase
b. per capita GNP
c. level of unemployment
d. dependency ratio
e. literacy rates, especially female literacy rates
f. family size
g. housing: the number of persons per room
h. per capita "calorie" availability.
 Health policy indicators
The single most important indicator of political
commitment is "allocation of adequate
resources".
(i) proportion of GNP spent on health services
(ii) proportion of GNP spent on health-related
activities (including water supply and sanitation,
housing and nutrition, community development)
(iii) proportion of total health resources devoted
to primary health care.
 Indicators of quality of life
PQLI:
infant mortality,
Life expectancy at age one,
literacy.
 Social indicators
population; family formation, families and households;
learning and educational services;
earning activities; distribution of income,
consumption, and accumulation;
social security and welfare services;
Health services and nutrition;
housing and its environment;
Public order and safety;
time use; leisure and culture;
Social stratification and mobility
 Basic needs indicators
calorie consumption;
access to water;
life expectancy;
deaths due to disease
illiteracy,
doctors and nurses per population;
rooms per person;
GNP per capita.
 Health for AII indicators
Health policy indicators
Social & economic indicators related to health
indicators for the provision of health care
Health status indicators
 DEVELOPED AND DEVELOPING
REGIONS

Social and economic characteristics

Demographic characteristics
Contrasts in health (Health gap)
 "epidemiological transition”
Developed & developing countries differ substantially
in their disease patterns.
 This phenomenon reflects what is known as the "
"epidemiological transition”.
As life expectancy increases, the major causes of
death and disability in general shift from
communicable, maternal and peri natal causes to
chronic, non-communicable ones.
Health care has many characteristics; they
include:
appropriateness (relevance)
comprehensiveness
Adequacy
Availability
Accessibility
Affordability
feasibility
 Levels of health care
Primary health care
Secondary health care
Tertiary health care
 Primary health care
"Essential health care which is made universally

accessible, affordable to individuals and families

in the community through their full participation
and at a cost that the community and the country
can afford .
 Elements of primary health care
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 diseases;
prevention and control of endemic diseases;
appropriate treatment of common diseases and
injuries
provision of essential drugs.
 CONCEPT OF DISEASE
WHO has defined health but not disease.
Disease is a physiological/psychological dysfunction;
Illness is a subjective state of the person who feels
aware of not being well;
Sickness is a state of social dysfunction, i.e., a role
that the individual assumes when ill ("sickness role").
CONCEPT OF CAUSATION
Up to the time of Louis Pasteur (1922-1895), various
concepts of disease causation were in vogue,
supernatural theory of disease,
 the theory of humors,
The concept of contagion,
miasmatic theory of disease,
 the theory of spontaneous generation, etc.
 Discoveries in microbiology marked a turning point
in our etiological concepts .
Germ theory of disease:
1860 Louis Pasteur demonstrated the presence of
bacteria in air.
1877 Robert Koch showed anthrax was caused by
bacteria.
These discoveries confirmed Germ theory of
disease.
 CONCEPT OF CAUSATION
Germ theory of disease:
one-to one relationship between causal agent and
disease.

Disease
man Disease
agent
Epidemiological triad

AGENT

HOST ENVIRONMENT
 Multifactorial causation(Pettenkofer of
Munich)
excess of fat intake,
 smoking,
 lack of physical exercise
obesity
 are all involved in the pathogenesis of coronary heart
disease.
tuberculosis is not merely due to tubercle bacilli; factors
such as
 poverty,
 overcrowding
 malnutrition contribute to its occurrence
WEB OF CAUSATION(MacMahon and Pugh)