Social Medicine: 1. Social Medicine As A Science - Subject, Objectives and Methods

Social Medicine 2017
Social Medicine
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1. Social medicine as a science – subject, objectives and methods

The subject of social medicine:
Social medicine’s subject is to study the social aspects of health. It is to study how social and
environmental factors impact health and disease.
The WHO definition of health is: ‘Health is a state of complete, physical, mental and social
well-being and not merely an absence of disease or infirmity and is the ability to lead a socially
economically productive life.’
The WHO has sequence of states leading to disability and handicap due to diseases:
Diseases – Impairment – Disability – Handicap
● Impairment – ‘Any loss of psychological, physiological or anatomical structure or function.

● Disability – ‘Any restriction or lack of ability to perform an activity in the manner or within
the range considered normal for a human being.
● Handicap – ‘A disadvantage for a given individual, resulting from an impairment or a
disability that limits or prevents the fulfilment of a role that is normal for that individual.
Interviews:
Interviews are a far more personal form of research than questionnaires.
Types of interviews include:
1) Individual and group interviews

2) Telephone interview
3) Structured interviews – when the interview is standardised and the questions are already
set for every interviewee in which the choice of answers to the questions are often closed
ended in advance.
4) Unstructured interviews – method of interviews where questions are changed based on the
interviewee’s intelligence, understanding or belief.
Observations:
Sociological observation is used for collecting information for elements from the behaviour of the
researched persons.
Types of observations include:
1) According to who makes the observation:

● Self-observation
● External observation – observation from an explorer.
2) According to the conditions:
● An observation is natural conditions
● An observation in controlled conditions (i.e. laboratory conditions)
3) According to the level of anonymity:

● Overt observations – where the researcher being open about her presence and
given permission by the group to conduct his/her research.
● Covert observations – where the researcher is participating fully without informing
the group/individual being observed of his/her presence, thus carried out secretly or
covertly.
Objectives and methods of social medicine – Historical method (2)
Through the social history of health of the patient, the physician aims at revealing the influence of
different factors on the patient’s health. The historical method ensures that information such as
genetic predisposition is collected in order to identify the cause of disease or condition of the
patient. It also helps to create a plan to minimize the risk of any future diagnosis (i.e. grandparents
had hypertension so patients are advised to carry out actions that prevent hypertension).
These factors have different natures and are often connected with:
● Personality of the patient

● Environment of the patient
● Social history of the patient based on genetic history
The other element of the historical method allows for future scientists to look further into the works
of physicians and scientists before in order to further develop the approach and hypothesis. For
example, Robert Koch’s discoveries in physiology and medicine allowed for modern medicine to
develop. This is because he was the founder of modern bacteriology where he identified the specific
causative agents of: Cholera and tuberculosis.
Objectives and methods of social medicine – Statistical (3)
Statistical method includes the common trends of diseases demographically. This essentially means
that different areas in the world have different susceptibilities for specific diseases and infections.
This figure shows Hepatitis A prevalence in 2005. The statistical method will analyse this information
and base a plan in which population requires vaccinations and which individuals require vaccinations
for Hepatitis A when travelling.
Objectives and methods of social medicine – Epidemiological method (4)
Epidemiology is the branch of medicine that deals with incidence, distribution and possible control
of disease and other factors relating to health. This in turn provides a broader understanding of the
causes and natural history of diseases. Modern methods of epidemiological enquiry was first
developed in the course of investigating outbreaks of infectious diseases in the 19th century. The
epidemiological approach will allow to identify the risk factors of the disease and provide data for
prevention, control and treatment of the disease.
Epidemiology has three main aims:
1) To describe the distribution of a disease

2) To identify risk factors (if they are exposed to certain harmful agents)
3) To provide data for prevention, control and treatment of disease.
2. Historical development of social medicine

The birth of social medicine began during the development of the industrial revolution in the 18th
century. This is due to the subsequent increase in poverty and disease among workers due to
socio-economic conditions.
The birth began during the outbreak of cholera epidemics across Europe in 1854. Cholera is an
infection of the small intestine. Cholera epidemics caused hundreds of deaths. The reason of this
outbreak was due to poor socio-economic conditions for the workers and also their families.
John snow also known as the ‘father of public health’ realised the main significant reason was due
to poor access to healthcare and clean water (sanitization). Following this Edving chadwick then
improved sanitary conditions and public health. This then led to further research in which the ‘germ
theory of disease’ was proposed by Pasteur and Koch in which stated that some diseases are caused
by microorganisms such as pathogens.
In the 19th century, due to the germ theory of disease and previous significant figures, many
discoveries were made. In 1977, the WHO decided that the main social target of governments
should be that all people of the world by 2000 should receive a level of health allowing them to lead
a social and economic productive life as a minimum to which they can work and participate actively
in the social life of the community in which they live.
3. Basic methods of social medicine.

Basic methods of social medicine include:
1)Historical method:The historical method allows for future scientists to look further into the works
of physicians and scientists before in order to further develop the approach and hypothesis.
2)Statistical method:Statistical method includes the common trends of diseases demographically.

This essentially means that different areas in the world have different susceptibilities for specific
diseases and infections.
3)Economic method:This studies the interrelation between the economy and health care. For
example, in Bangladesh, the economy is very low and due to this, there is poor access to healthcare
for the major public.
Indicators that can show basic access to healthcare for individuals include:
● GDP (Gross Domestic Product)

● Income and wages
● Unemployment rate
● Consumer price index (inflation)
● Corporate profit (private healthcare or public)
4)Experimental method: The experimental method involves the studying of a specific variable to
calculate their dependence. Thus, the experimental method involves manipulating one variable to
determine if a change in one variable causes changes in another. For example, if there is a study on
fertility within a population in a given area, the natural method will be used.
Methods of birth control:
Natural method – type of birth control that relies on observations about the woman’s body and
menstrual cycle.
Artificial method – type of birth control that relies on external factors to prevent unwanted
pregnancy (i.e. contraception).
4)Epidemiological
5)Sociological
4. Health and disease – upto date definitions

The analysis of the concept of health according to the study of different authors allows to
differentiate types of definitions:
● The health as a status

● The health as a property
● The health as a process
● The health as a measure of vitality
● The health as a new category (quality)
Health defined by the WHO:
● ‘Health is a state of complete, physical, mental and social well-being and not merely an
absence of disease or infirmity.’ This was later modified and an addition was added which
was the ability to a socially and economically productive life. This means that disease is the
opposite of health.
The new philosophy of health:
The new philosophy of health involves not only the wellbeing in the conception of health but also
new dimensions to what health is:
● Health is a fundamental human right

● Health is the essence of productive life
● Health is quality of life
● Health involves individual governmental and international responsibility
● Health is world-wide social goal
Disease:
There have been many attempts to define the term ‘disease’. The simplest way to define diseases is
to state that it is just the opposite of health.
Concept of disease:
● ‘A condition in which body health is impaired, a departure from a state of health, an
alteration of the human body interrupting performance of vital functions.’ (Webster)
● ‘A condition of the body or some part or organ of the body in which its functions are
disrupted or deranged.’ (Oxford English Dictionary)
● ‘A state of social dysfunction, a role that the individual assumes when ill.’ (Susser)
● ‘A physiological dysfunction.’ (Susser)
The WHO has sequence of states leading to disability and handicap due to diseases:
Diseases Impairment Disability Handicap
● Impairment – ‘Any loss of psychological, physiological or anatomical structure or function.

● Disability – ‘Any restriction or lack of ability to perform an activity in the manner or within
the range considered normal for a human being.
● Handicap – ‘A disadvantage for a given individual, resulting from an impairment or a
disability that limits or prevents the fulfilment of a role that is normal for that individual.
5. Social factors of health and disease. Classification

There is both a positive and negative definition of health in which interlinks with social factors of
health and disease.
● Negative definition of health:

- Where an individual believes they have a good state of health and
well-being because they have nothing wrong with them (i.e. no physical
illness, disease, injury mental stress from pain and discomfort).
- Individuals with this view regard good health as normal and do very little to
maintain their health and wellbeing (i.e. not visiting a GP for years with no
encouragement from family, friends and the community to have a checkup).
● Positive definition of health:
- Where an individual is achieving and maintaining a healthy lifestyle by being
physically fit and having a good mental health. Ensuring to only drink clean
sanitized water and work in safe hygienic working conditions and visiting the
GP regularly for check-ups.
Many factors combine together to affect the health of individuals and communities. Whether
people are healthy or not, is determined by their circumstances and environment. To a large
extent, factors such as: where we live, the state of our environment, genetics, our income and
education level, and our relationships with friends and family all have considerable impacts on
health, whereas the more commonly considered factors such as access and use of health care
services often have less of an impact.
Social factors of health and disease:
Other than genetics, age and gender, health is also affected by social factors. Social factors are
things that affect lifestyle, such as religion, family or wealth. These can change over time.
Social factors include:
● Social and Economic background – higher income and social status are linked to better
health. The greater the gap between the richest and poorest people, the greater the
differences in health.
● Education – low education levels are linked with poor health, more stress and lower
self-confidence.
● Environment – safe water and clean air, healthy working conditions in work places, safe
houses, communities and roads all contribute to good health. Employment
● Health care/services – access and use of services that prevent and treat diseases or
potential infections influence health. For example, vaccination in the UK is carried out for
hepatitis A ensuring positive health and defence against the disease.
● Social support networks – greater support from families (upbringing), friends and
communities is linked to better health. Culture, and beliefs of family and community also all
affect health.
Classification:
● Social factors that act on a population level :

- This includes general regulations and laws that are put in place to minimize
risk and ensure immunity to specific types of diseases. For example,
vaccination for hepatitis A in schools are carried out to ensure that the
population as a whole are immune to this disease.
● Social factors that act on an individual level:
- This includes the effects social factors have on an individual. For example,
the socioeconomic background of an individual. The salary of the individual
can determine the positive health and well-being of the individual. With a
higher salary, there will be a greater access to: privatised healthcare, clean
and sanitized water, hygienic working conditions etc.
6. Socio-medical approach in medical doctor’s activity – social history of Health

Through the social history of health of the patient, the physician aims to identify the influence of
different factors that has affected the health of the patient. These factors are connected with the
personality of the patient and the environment he/she lives and works.
The more complete the social history, the higher degree the physician is able define the socio-medial
needs of the patient and make a plan for their managing.
The doctor collects the necessary information/date for the social history usually from the patient
himself or his relatives etc. Information can be taken via medical interviews, observations, medical
examinations, document analysis and medical tests etc.
The key information required are:
1) Somatic status – Gender, Age, Height, Weight, Style, Facial Expression, Smoker, Drinker
2) Objective status – Complaints, symptoms – pain; type of pain; duration, Occurrence

a. Genetic predispositions – Family history of genetically important diseases
b. Diagnosis – Identification of a condition/illness at the time of consultation.
c. Past illnesses – health status of patient throughout the course of his life
3) Personal characteristics
a. Education
b. Religion
c. Lifestyle – Drug abuse, alcoholism, smoking, exercise
4) Occupation
a. Where? Type? Duration? Relationship with Colleagues?Factors affecting health
5) Family
a. Members - age and sex
b. Housing conditions – rooms, pollution, noise, animals, flat/house, elevator
c. Relationship – with family members
d. Social Class – Wealth, disposable income
e. Health Problems – Chronic diseases, old people, disabilities
6) Public Environment
a. Relationship with neighbours
b. Relationship with Friends
c. Reliance and confiding
d. Problems
7) Health Care
a. Visits to health service
b. Hospitalisation
c. Attitude towards health care service
d. Attitude to receiving medical intervention
8) Medico-social conclusions – These are the conclusions of the physician based on the risk factors
and protective factors of patient health. Patients medico-social needs are defined.
9) Plans for the Future – Plan including activities and propositions for solutions and potential
referrals to other patients. Fundamental towards the health status of the patient.
7. Sociological method. Essence. Types. Application in medical practice.
Sociology studies the social interrelations among people.
Medical Sociology is studying health, health behaviour and health institutions.
Sociological methods are used for research by doctors. This is used to study behaviour and
background of patient.
Applications of Medical Sociology include:
▪ Field of Public Health

▪ Clinical Medicine
▪ Field of Epidemiology (incidence, distribution and control)
Types of Methods in Sociology:
▪ Inquiry Methods – e.g. Questionnaires, Surveys

o Direct Inquiry – Group, Individual, Mail filled out by researched individual(s)

o Indirect Inquiry – Questionnaire is filled out by the researcher/inquirer
▪ Interview
o Individual and Group Interviews
o Telephone Interview
o Structured Interview – Generally closed questions that are fixed not changed
o Unstructured Interview – Questions changed and adapted to meet intelligence
o Semi-structured Interview – Limited set of questions but can introduce new.
▪ Observation
o Objective to person making observation – Self or external observation
o Dependent upon conditions – Laboratory or natural conditions
o Covert (secret)/Overt (aware) Observation
▪ Documentary Method
o Written, Pictures, Films, Clothes – Can be reviewed later repeatedly
Requirements of Questionnaires in Medical Sociology (Basic use your brain, chat crap ☺ !!!)
Must have specific objective, indicate name and purpose of study, positive statements (do not start
with ‘ don’t you smoke…”), grammatically correct, simple, answers should cover all possible options,
Similar questions should be grouped together, pilot the survey
Types of Questions
1. Open-ended Questions: Response can be whatever the respondent wants

2. Close-ended Questions: Response is restricted to selected options
3. Filtered Questions: When an initial question is asked to see if the respondent is qualified to
answer subsequent questions. E.g Have you smoked Marijuana→ how many times?
Advantages vs Disadvantages – For a GP
Direct inquiry may be the best sociological method as the patient is being asked directly and are
asked to fill out a questionnaire on only relevant questions. However, the disadvantage to this is that
the patient may lie. Indirect inquiry may be beneficial, as only information based on medical history
will be written which are facts. The disadvantage is that haven’t gathered present information on the
patient. An interview format may be advantageous or disadvantageous dependent on the behaviour
of the patient (anxious etc). Observation can cause problems as covert observation are based on
criminal activity which is not correct. Also, even in open observation, the patient may act in a
different way due to the presence of the observer.
8. Epidemiological method. Essence and application in medical practice.

Epidemiology: covers incidence, distribution, cause, control of disease and other factors relating to
health and health events.
History: The modern methods of epidemiological enquiry were first developed whilst investigating
outbreaks of infectious diseases in the 19th century. The epidemiological approach allows us to
identify risk factors of the disease and provide data for prevention, control and treatment of the
disease.
Role: Provides a broader understanding of the causes and natural history of diseases.
Epidemiology is very helpful in the application of medicine as the recorded experiences of many
doctors and patients greatly assist in diagnosis and aid in patient management.
Epidemiology has three main aims:
1. Describe the Distribution of a Disease – Epidemic, Pandemic, Prevalence

2. Identify risk factors – e.g. exposure to harmful agents
3. Data for Prevention, Control and Treatment of Disease
Risk and Cause
Cause can be either:
➢ External Agents (microbe, chemical agent) which results in a disease

➢ Determinants are attributes or circumstances that an individual is predisposed to
(Hereditary, Environmental)
Risk is the dangers from exposure to potentially harmful agents and the chance a particular
intervention will benefit an outcome.
Population Risk is a group of people at risk of disease rather than individuals.
Measurement of Epidemiology
Measurements in epidemiology can be expressed as:
▪ Rate
▪ Proportion
▪ Ratio
Examples of Measurements: Morbidity, Mortality, Disability, Birth
Epidemiological Studies
1. Descriptive – Description of the occurrence of a disease in a population

2. Analytical – Analyses relationship between health status and other variables
a. Cohort
b. Case-Control
3. Experimental – experimentally active attempt to change a disease and its progress
9. Descriptive epidemiological method. Essence and application in medical

practice.
Descriptive epidemiological investigations are a description of the patterns of distribution of a
disease in populations.
Informative Value: First phase of an epidemiological investigation. Advantages include cheap and
quick to complete giving initial overview of the investigation and the next step.
Procedures in Descriptive studies are:
1. Define Population to be studied

2. Define Disease being studied
3. Describing the Disease by time, place and person
4. Measurement of Disease
5. Comparing with known indices
6. Formulation of etiological hypothesis (causes)

Categories of Variables in Descriptive Studies
1. Time
a. Long term trends
b. Periodic Changes
c. Epidemics, Pandemics
2. Place
a. Broad geographical differences
b. Local differences
3. Personal Characteristics
a. Age, Gender, Marital Status, Ethnic Groups
Sources of Information used by Descriptive Studies
▪ Population Census
▪ Vital Data
▪ Hospital Statistics
▪ National data for: food, alcohol, medical drugs consumption
Types of Descriptive Studies
▪ Population Studies
▪ Case Report or Case Series
▪ Cross-sectional studies
▪ Advantages and disadvantages of descriptive studies
▪ Importance of descriptive studies result in clinical practice
This can be applied in medical practices to understand and identify the statistics of certain diseases
in a population in a certain time zone and location.
10. Analytical epidemiological method. Case-control studies. Risk assessment

(relative, absolute and population risk)
Case-Control Study is a comparison of the characteristics of ill people (cases) in a population with
those people at risk from the illness within the same population.
Design
Advantages vs Disadvantages
ADVANTAGES DISADVANTAGES
Study rare health outcomes Not suitable to study rare theories
Quick, cheap and easy to conduct Greater potential for bias
Study more than one risk factor at same Cannot measure incidence rates
time
Suitable for diseases with long latent period Cannot measure absolute or relative risks
Data Analysis
▪ Statistical Tables
▪ Odds Ratio Calculation
With Disease Without

Exposed a b
Not exposed c d
OR = ad/bc
▪ Odds Ratio Interpretation

o 0R < 1 - incidence in exposed persons is less than incidence in non-exposed
o 0R = 1 - No link between considered exposition and the disease
o 0R > 1 - Association with risk factor and disease
11. Analytical Epidemiological Method. Cohort Studies. Risk Assessment

(relative, absolute and population risk)
The analytical epidemiological researches study the relationship between an exposure and the risk of
developing disease.
Cohort Studies
Its an observational epidemiological study which attempts to study the relationship between a exposure
and the risk of developing disease. The cohort study follows a group of healthy people with different
levels of exposure and assesses what happens to their health over time. This type of study allows direct
estimation of the risk of developing disease and how risk varies with time since exposure.
Advantages of Cohort Studies:

➢ They offer the possibility of studying the full range of effects of the suspected etiological factor.
➢ They directly measure the incidence rates within exposed and non-exposed people.
➢ They provide direct estimates of the risk of disease for each exposure group separately.
➢ They enable us to study rare expositions.
➢ The are less bias because exposure is evaluated before the health status is known.
Disadvantages of Cohort Studies

➢ They are time consuming and expensive.

➢ They are not suitable for studying rare diseases.
➢ They require standardised diagnostic methods and criteria.
➢ There could be analytical problems due to loss from follow-up, migration or gradual deterioration of
interest in participation.
Design of the Cohort Study
Risk Assessment
Risk Difference (RD)

The RD measures the over-incidence in the group of exposed people that is due to the influence of the
considered exposition and identifies the additional risk of diseases outcome exposed people in
comparison with non-exposed people.
RD = the absolute distinction between the incidence among the exposed and non-exposed people
Ie and CIe = incidence among exposed people

Io and Clo = incidence among the non-exposed people
Etiological Fraction of Exposed (EF)

EF measure the share of diseases among the exposed people that is due to the considered the risk factor.
EF shows what part of diseases among exposed people could be prevented by the omission of the risk
factor.
Population Attributive Risk (PAR)

PAR measure the share of diseases among the whole population that is due to the risk factor, as well as
what could be preventable part of diseases among the whole population if the risk factor influenced was
excluded.
Ip and CIp = incidence among the whole population
Relative Risk (RR)

The RR is the ratio of incidence in expose and non-exposed people. The RR assesses how strong the
association between the exposure and the diseases is.
The RR can be calculated only in cohort studies. It varies between 0 and ∞

RR < 1 = the incidence in exposed people is smaller than the incidence in non-exposed people. In such a
case the exposure has protective effect.
RR = 1 = there is no link between the exposition and the disease.
If RR increases more stronger connection between risk and diseases
12. Evaluation of Public Health
Incidences of PH:
1. Demographic data
2. Morbidity
3. Physical development
The study of the massive events and processes related to the population as number, condition,
movement and production, plays an important role not only for analysis of socio-economic relations
but they are also directly related to the whole society including public health.
Good planning will have built-in evaluation to measure the performance and effectiveness and for
feed-back to correct deficiencies or fill up gaps discovered during implementation. In the words of
the WHO Expert Committee on National Health Planning in Developing Countries, evaluation
“measures the degree to which objectives and targets are fulfilled and the quality of the result
obtained. It measures the productivity of available resources in achieving clearly-defined objectives.
It measures how much output or cost-effectiveness is achieved. It makes possible the reallocation of
priorities and of resources on the basis of changing health needs”.
Measurement of negative health - types and method of calculation

The aspects of morbidity are commonly measured by morbidity rates, namely frequency, duration
and severity. There are two types of measures of illness or morbidity. They are incidence and
prevalence.
➢ Incidence: The number of new cases of a disease and registered occurring per unit of population
per unit time.
➢ Point prevalence: The number of people with a disease in a defined population at a point in
time.
➢ Period prevalence: The number of people with a disease in a defined population over a period
of time.
Incidence measures the rate at which new cases occur in a population.
Measurement of positive health - types and methods of calculation

Demographic characteristics are the basic components for the evaluation of the populations public
health and they are important factors for its development. Studying the population takes place in 2
direction:
→ status = includes the number and condition of the population
→ dynamics = mechanical and natural movement of the population
Live birth is “the complete expulsion or extraction from its mother of a product of human
conception, irrespective of the duration of pregnancy, which, after such expulsion or extraction,
breathes or shows any other evidence of life, whether or not the umbilical cord has been cut or the
placenta is attached”.
Health index - life expectancy at birth expressed as an index using a minimum value of 20 years and
a maximum value of 85 years.
Quality of life (QOL) is the general well-being of individuals and societies, outlining negative and
positive features of life. It observes life satisfaction, including everything from physical health,
family, education, employment, wealth, religious beliefs, finance and the environment.
13. Sources and Methods of Assessing Public Health Indicators
Census - information
Census is a massive undertaking to contact every member of the population in a given time and
collect a variety of information. Most developed countries undertake regular and detailed censuses
of their populations in order to provide information to assist in social planning. The modern system
of censuses was introduced in Europe during the late 18th and early 19th centuries. The first regular
census in India was taken in 1881 ad others took place at 10-year intervals. The census contain a lot
of information on subjects not only demographic but also social and economic characteristics of the
people, the condition which they live in, how they work, their income and other basic info. All
information is kept confidential.
The size and demographic characteristics of the population in non-census years is estimated by
deducting deaths and emigrants from numbers recorded in the census, and adding births and
immigrants. At the same time, the age distribution of the people remaining is adjusted. These are
known as intercensal estimates.
Error in intercensal estimates arise through inadequate recording of immigration and emigration.
After a census, the figures of years since the last census are recalculated, taking account of the info
provided by the new census. These are called postcensal estimates.
Definitions of the International Classification of Diseases

Live birth is “the complete expulsion or extraction from its mother of a product of human
conception, irrespective of the duration of pregnancy, which, after such expulsion or extraction,
breathes or shows any other evidence of life, whether or not the umbilical cord has been cut or the
placenta is attached”.
Pregnancy usually lasts 40 weeks, beginning from the first day of the woman's last menstrual period,
and is divided into three trimesters, each lasting three months.
For coding and reporting purposes the perinatal period is defined as before birth through the 28th
day following birth.
For coding and reporting purposes, the perinatal period is defined as before birth through the 28th
day after birth.
Death occurring during pregnancy, childbirth and the puerperium is the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death (obstetric
and non-obstetric). Maternal death.
Registration of morbidity - document types
1. Through registered cases of diseases in health facilities:

- Cases subject to general reporting
- Cases subject to special reporting:
- Very dangerous infections
- Acute infectious diseases
- Infectious no epidemic diseases
- Incidence with temporary disability
- Incidence with permanent disability
- Hospitalized incidence
2. Through the data for causes of death

3. Through the data from prophylactic examinations
In considering how a particular source of morbidity data describes the disease problem in a
population, it is helpful to bear in mind the “iceberg” concept. The phenomenon whereby only a
proportion of patients make contact with health services, and in particular with hospital services, is
often referred to as the tip of the iceberg.
Registration of Death
The certificate that the doctor is required to complete and sign is one of the cause (or causes) of
death. After giving the deceased’s name, age, data and place of death and detail of how far the
death was investigated, the doctor is required to state the “immediate cause” of death.
Death registration data are collected and analysed by an official organisation.
The methods for elaboration of a social history are medical interview, observation and medical
examination. The medico-social conclusions are based on the risk factors revealed by the physician,
as well as on the protective factors of the patients health.
Registration of vital events keeps a continuous check on demographic changes. If registration of

vital events is complete and accurate, it can serve as a reliable source of health information. The
time limit for registering the event of birth is 14 days and that of death is 7 days.
Cancer
A cancer registry is a systematic collection of data about cancer and tumor diseases. The data are
collected by Cancer Registrars. Cancer Registrars capture a complete summary of patient history,
diagnosis, treatment, and status for every cancer patient.
Hospital cancer registries aim at the improvement of cancer therapy. Therefore they have to collect
detailed data about diagnosis and therapy. Improvements can be achieved by:
→comparison of therapy - which therapy is the best
→comparison of therapists - which hospital, which physician has the best results under the same
conditions (quality management)
→support of treatment - registries can improve information about a patient and help to provide an
optimal treatment by planning therapies and generating reminders
14-Demographic Indicators of Public Health - static and dynamics of population.

Modern trends
Demography as a science
Demography is the science of populations. Demographers seek to understand population dynamics
by investigating three main demographic processes: birth, migration, and aging (including death). All
three of these processes contribute to changes in populations, including how people inhabit the
earth, form nations and societies, and develop culture.
Structure of demographic processes

Demographic processes are extremely dynamic. They depend on specific rules. They are also
interrelated and influence each other. Knowing the development of these processes is the basis for
polices’ regulation and prognosis.
Composition of the population

➢ Studying of the populations takes place in two basic directions:
Status - includes the number and condition of the population
Dynamics - mechanical and natural movement of the population.
➢ Despite the presence of many serious endemic diseases and the occurrence of major epidemic
and wars, the populations of most European countries increased substantially during the past
300-400 years. There has been a reduction in the rate of increase in recent decades and today
the populations in most European and North American countries are relatively stable.
Throughout the past 400 years, people have emigrated in large numbers mainly to the
Americas, Australia and to parts of Africa. The majority of the present populations of North
America and Australia are descendants of migrants. The population in most other parts of the
world began to increase much more recently and their rate of increase has reached that
prevailing in Europe. It is forecast that if the prevailing rates of growth are sustained, the
world’s population, now more than 7 billion people, will double within the next 40 years.
Mechanical movement of the population

Urbanization - At the end of the 20th century more than half of the world population lived in the
towns. The increase of the towns means more difficulties which has an influence over life style. In
the big cities, there are issues with water and food supply, assuring home security , lack of living
territories which in turn increases the amount of homeless people, drug addicts and street crime.
Positive features = good living conditions, wide possibilities for electricity, broad assortment of
goods, developed system of health care, higher possibility for spending free time.
Negative features = difficulties adapting to life in towns, air pollution, irregularities of the
supplement, psychic disorders, lack of time for friends, increase non-social activities.
Natural movement of population

The natural movement of the population includes processes, involved with the vital events within
the population, as birth and death.The reliability of information characterizing the vital events
depends on the competence and conscientiousness of the physician in filling out the relevant
documentation.Together with the good professional skills and the good knowledge of the sense of
notions for birth and death is a necessary condition for the reliability of the primary information.
Birth rate: This entry gives the average annual number of births during a year per 1,000 persons in
the population at midyear; also known as crude birth rate. The birth rate is usually the dominant
factor in determining the rate of population growth. It depends on both the level of fertility and the
age structure of the population.
Death rate: This entry gives the average annual number of deaths during a year per 1,000 population
at midyear; also known as crude death rate. The death rate, while only a rough indicator of the
mortality situation in a country, accurately indicates the current mortality impact on population
growth.
The growth of a population and changes in its age structure are closely related to trends in birth and
death rates and changes in life expectancy. In the world, birth rates have trended down since 1950,
and the gap with respect to death rates has narrowed sharply, leading to a slowdown in population
growth. At the same time, life expectancy has improved significantly and has contributed to the
ageing of populations.
The decrease in birth rates around the world is linked to a number of factors. These include social
trends, such as the decline in marriage rates and the movement away from the family as a core living
arrangement, and economic forces, such as the rising cost of raising children, the growing number of
women in college and in the labor force, urbanization and, with the emergence of social insurance,
the reduced need for children as a support mechanism in old age. Development of the contraceptive
pill and its widespread adoption starting in the 1960s is also a factor. Government policies, such as
China’s imposition of a one-child policy in 1979, also may have played a role.35
15. Mechanical Movement of Population. Impact of the Migration Processes on the

Health of the Population.
The study of the massive events and processes related to the population as number, condition,
movement and reproduction, plays an important role not only for the analysis of socio-economic
relations, but they are also directly related to the whole society, including the public health.
Studying of populations takes place in 2 directions:

→ static = means number and condition of the population
→ dynamic = means mechanical and natural migrations of populations
Internal Migration
Urbanization - At the end of the 20th century more than half of the world population lived in the
towns. The increase of the towns means more difficulties which has an influence over life style. In
the big cities, there are issues with water and food supply, assuring home security , lack of living
territories which in turn increases the amount of homeless people, drug addicts and street crime.
Positive features = good living conditions, wide possibilities for electricity, broad assortment of
goods, developed system of health care, higher possibility for spending free time.
Negative features = difficulties adapting to life in towns, air pollution, irregularities of the
supplement, psychic disorders, lack of time for friends, increase non-social activities.
Dislocation: disturbance from an original, or usual place or state.
External Migration
Immigration is the international movement of people into a destination country of which they are
not natives or where they do not possess citizenship in order to settle or reside there, especially as
permanent residents or naturalized citizens, or to take-up employment as a migrant worker or
temporarily as a foreign worker. As for economic effects, research suggests that migration is
beneficial both to the receiving and sending countries. Between 2000 and 2015, Asia added more
international migrants than any other major area in the world, gaining 26 million. Europe added the
second largest with about 20 million. In most parts of the world, migration occurs between countries
that are located within the same major area.
Emigration is the act of leaving one's resident country with the intent to settle elsewhere.There can
be a desire to escape negative circumstances such as shortages of land or jobs, or unfair treatment.
People can be pulled to the opportunities available elsewhere. Fleeing from oppressive conditions,
being a refugee and seeking asylum to get refugee status in a foreign country, may lead to
permanent emigration.
Influence of Migration
In the long term, both high and low-skilled workers who migrate bring benefits to their new home
countries by increasing income per person and living standards. High-skilled migrants bring diverse
talent and expertise, while low-skilled migrants fill essential occupations for which natives are in
short supply and allow natives to be employed at higher-skilled jobs.
Conditions affecting health in the country of origin and during the journey may include war, torture,
loss of relatives, long stays in refugee camps (which may have poor sanitation and overcrowding),
imprisonment, and socio-economic hardship. After arriving in the host country migrants may
experience imprisonment, long-lasting asylum seeking processes, language barriers, lack of
knowledge about health services, loss of social status, discrimination and marginalisation.
Migration may also affect risk perception and risk behaviour. Feelings of loss and psycho-social
issues related to lower social positions, unemployment and being in a minority may lead to a feeling
of lack of connection between current risk behaviour and future health effects (i.e. migrants may be
forced to focus on their current feelings rather than the future health effects of their current health
behaviour). For example, a new migrant, separated from friends and family in an urban environment
(feeling more anonymous and less constrained by social norms) may turn to prostitution or drugs as
a way to escape loneliness, frustration and social isolation. Migration also has health implications for
the country migrants have left. Individuals who emigrate for economic opportunities may cause a
“brain drain” in their country of origin, when a large number of individuals with technical skills or
knowledge leave, potentially depleting the local infrastructure.
16.Natural movement of population. Indicators. The role of medical doctor in vital

events registration
The natural movement of population includes processes, involved with the vital events within the
population,as birth and death. These vital events allow to calculate the most important demographic
indicators,which are used for the assessment of demographic situations and projections of
population development, as well as for evaluation of population health status.
The reliability of information charectarizing the vital events depends on the competence and
conscientiousness of physician in filling out the relevant documentation. Together with the good
professional skills and the good knowledge of sense of notions for birth and death is a necessary
condition for reliability of primary information.
It is a condition for the united approach of physicians in the registration of these events, and on
other hand, it gives an opportunity for comparision of statistical data for health from international
aspect.
● Natural movement of a population includes processes related to birth and death of man.
Birth rate
= Number of life births per 1000 estimated mid-year population in a given year.
· 1950s = 35 ‰
· 1960s = 30 ‰
· nowadays = 25 ‰ as a world average.
Death rate
=number of deaths during the year per 1000 estimated mid-year population in a given year.
In last 50 years we can notice decreasing tendency.
· nowadays, average death rate of the world is approximately 10 ‰. The critical rate is 20 ‰.
· in Europe, average death rate is 6-13 ‰.
Population growth
If birth rate exceeds death rate of a population => natural increase of a population
If death rate exceeds birth rate of a population => natural decrease of a population
17.Natural movement of population. Age-structures and pyramids types of the

reproduction of population.
Reproduction of population
The reproduction of the population refers to a change of a generation into a new one. Reproduction
is measured by gross reproduction rates or net reproduction rates that generally indicate the ratio
between the sizes of the daughter's and mother's generations. The fertility and mortality of the
mother's generation before the end of the childbearing age is taken into account in the calculation
of the net reproduction rate. In the gross reproduction rate this mortality is not taken into
consideration. If the net reproduction rate calculated per one woman is less than one, the
daughter's generation is smaller than the mother's generation and the mother's generation has not
reproduced itself.
Age structures and pyramids

The Three Basic Shapes of Population Pyramids
Expansive(Progressive)
Expansive population pyramids

are used to describe populations
that are young and growing. They
are often characterized by their
typical ‘pyramid’ shape, which has
a broad base and narrow top.
Expansive population pyramids
show a larger percentage of the
population in the younger age
cohorts, usually with each age
cohort smaller in size than the one
below it. These types of
populations are typically
representative of developing
nations, whose populations often have high fertility rates and lower than average life expectancies.
Stationary
Stationary, or near stationary,

population pyramids are used to
describe populations that are not
growing. They are characterized by
their rectangular shape, displaying
somewhat equal percentages across
age cohorts that taper off toward the
top.
Regressive pyramid
A declining birth rate and a low mortality rate.

18.Birth rate--status,trends,international comparisons,family planning and

reproducting behaviour
The birth rate the total number of live births per 1,000 of a population in a year.
The rate of births in a population is calculated in several ways: live births from a universal
registration system for births, deaths, and marriages; population counts from a census, and
estimation through specialized demographic techniques.
The birth rate (along with mortality and migration rate) are used to calculate population growth.
The crude birth rate is the number of live births per year per 1,000 midyear population.
Another term used interchangeably with birth rate is natality.
When the crude death rate is subtracted from the crude birth rate, the result is the rate of natural
increase (RNI).
This is equal to the rate of population change (excluding migration).
General fertility rate- the '' number of the live births per 1000 women in the population of
childbearing age (15-49 years) in a given year.
Age-specific fertility rate- measures the annual number of births to women of a specified age or age
group per 1,000 women in that age group
Total Fertility Rate: The number of children that would be born per woman if she were to live to the
end of her child-bearing years and bear children at each age in accordance with prevailing
age-specific fertility rates.
Developed countries have a lower birth rate than underdeveloped countries .

A parent's number of children strongly correlates with the number of children that each person in
the next generation will eventually have.
Factors generally associated with increased fertility include religiosity, intention to have children,
and maternal support. Factors generally associated with decreased fertility include wealth,
education, female labor participation, urban residence, intelligence, increased female age and (to a
lesser degree) increased male age.
Many of these factors however are not universal, and differ by region and social class. For instance,
at a global level, religion is correlated with increased fertility, but in the West less so: Scandinavian
countries and France are among the least religious in the EU, but have the highest TFR, while the
opposite is true about Portugal, Greece, Cyprus, Poland and Spain.
Child custody laws, effecting fathers parental rights over their children from birth until child custody
ends at age 18, has an effect on the birth rate.
Strict in enforcing child support have up to 20 percent fewer unmarried births than states that are
lax about getting unmarried dads to pay, the researchers found.
Moreover, according to the results, if all 50 states in the United States had done at least as well in
their enforcement efforts as the state ranked fifth from the top, that would have led to a 20 percent
reduction in out-of-wedlock births.
19.Mortality Rate-status,trends,international comparisons;infant mortality

rates,life expectancy at birth.
Mortality rate, or death rate, is a measure of the number of d
eaths (in general, or due to a specific
cause) in a particular population, scaled to the size of that population, per unit of time.
Mortality rate is typically expressed in units of deaths per 1,000 individuals per year; thus, a
mortality rate of 9.5 (out of 1,000) in a population of 1,000 would mean 9.5 deaths per year in that
entire population, or 0.95% out of the total.
revalence or incidence of a
It is distinct from "morbidity", a term used to refer to either the p
disease, and also from the incidence rate (the number of newly appearing cases of the disease per
unit of time).
● Crude death rate – the total number of deaths per year per 1,000 people.The crude death
rate can be misleading. The crude death rate depends on the age (and gender) specific
mortality rates and the age (and gender) distribution of the population.
● Infant mortality rate- probability of dying between birth and exact one year of age expressed
per 1000 live births.
● Perinatal mortality rate – the sum of neonatal deaths and fetal deaths (stillbirths) per 1,000
births.
● Infant deaths- deaths under 1 year of age
● Neonatal death- a live-born infant that dies within 28 days
● Early neonatal death- a live-born infant that dies within 7 days
● Late neonatal death- a live born that dies after 7 days but within 28 days
● Post neonatal death- deaths from 1 month to 1 year of age.
● Stillbirth: a fetus that dies before birth but after presumed 24 weeks of gestation
● Perinatal death: Stillbirth + Early neonatal deaths
● NEONATAL MORTALITY RATE:Number of deaths in the first 28 days of life per 1000 live
births per annum
● EARLY NEONATAL MORTALITY RATE:Number of deaths in the first week of life per 1000 live
births per annum
● LATE NEONATAL MORTALITY RATE:Number of deaths between the 7 and 28 day of life per
1000 live births per annum
● POST NEONATAL MORTALITY RATE:Number of deaths after 28 days but before end of the
first year of life per 1000 live births per annum
● STILLBIRTH MORTALITY RATE:Number of stillbirths per 1000 live births per annum
● POSTNEONATAL MORTALITY RATE:Number of stillbirths together with deaths in the first
week of life per 1000 total births per annum.
MAIN CAUSES OF NEONATAL DEATHS ARE:
● PRETERM
● SEVERE INFECTION
● ASPHYXIA
● CONGENITAL ANOMALIES
● NEONATAL TETANUS
● DIARRHOEAL DISEASES
● SOME OTHER NEONATAL CAUSES are also.
(Other measures of mortality used to provide indications of the

relative success or failure of medical treatment or procedures (for life-threatening illnesses, etc.)
include:
● Early mortality rate – the total number of deaths in the early stages of an ongoing treatment, or
in the period immediately following an acute treatment.
● Late mortality rate – the total number of deaths in the late stages of an ongoing treatment, or a
significant length of time after an acute treatment.)
==Life expectancy at birth is defined as how long, on average, a newborn can expect to live, if
current death rates do not change. However, the actual age-specific death rate of any particular
birth cohort cannot be known in advance. If rates are falling, actual life spans will be higher than life
expectancy calculated using current death rates.
Life expectancy at birth is one of the most frequently used health status indicators.
Gains in life expectancy at birth can be attributed to a number of factors, including rising living
standards, improved lifestyle and better education, as well as greater access to quality health
services.
This indicator is presented as a total and per gender and is measured in years.
20.The physical development as an indicator of health. Accelaration_ medico-social

problems
Nature of physical development: Physical development is the process that starts in human infancy
and continues into late adolescent concentrating on gross and fine motor skills as well as
puberty. Physical development involves developingcontrol over the body, particularly muscles
andphysical coordination.
1-Anthropometric (related to measuring structure/anatomy): height, weight, chest

measurement, length of limbs, etc.;
2-Physiometric (related to measuring physiological processes): vital capacity, muscular

strength, reactivity and accuracy of the movement;
3-Somatoscopic (related to assessing external manifestations): build, muscular development,

chest and legs shaping, level of development of the male genitals, secondary sexual characteristics,
time of onset of puberty.
Main physical growth indicators
● Height – the most stable indicator, characterizing the rate of plastic processes in the
organism and to some extent its maturity.
● Weight – contrary to height a very responsive indicator, quick to react to a variety of stimuli
of exogenous and endogenous nature. Weight reflects the level of development of the
skeletal and muscular systems, inner organs and subcutaneous fatty cells.
● Head measurement
● Chest measurement – an important indicator, reflecting the level of development of the

chest, muscular apparatus, the subcutaneous fatty layer of the chest, all of which closely
correlate to the functional indicators of the pulmonary system.
● Body surface – one of the important physical growth indicators as well. It helps to assess not
only the morphological, but also functional state of the organism.
● Sexual maturity
ACCELERATION
Acceleration (from Latin: аcceleratio) is the accelerated development of the human organism,
manifesting in early sexual maturation, increased height and weight, as well as changes in other
anthropometric and physiometric indicators.
21. The morbidity as an indicator of public health. Basic notions. International

Classification of diseases
Morbidity is the condition of being diseased. Main aspects of morbidity are commonly measured by
morbidity rate, duration and severity.
There are two types of morbidities: Incidence and Prevalence.
Incidence: the number of new cases occurring per unit of population per unit time. Incidence
measures the rate at which new cases occur and registered in a population.
Incidence rate= (total number of new cases of a given disease during a given period of time /total
population at risk during the time period of time) x 1000
Prevalence: disease prevalence refers to al the current and existing cases in a given population.
Calculation of all old and new cases.
Period Prevalence: The number of people with a disease in a defined population over a period of
time.
Point Prevalence: The number of people with a disease in a defined population at a point in time.
Prevalence rate= (all new and preexisting cases of a specific disease during a given time period /
total population during the same time period) x 1000
2) Iceberg of Morbidity:
The iceberg phenomenon is a metaphor emphasizing that for every health problem the number of
cases of disease is outweighed by those that remain undiscovered (such as increased heart rate, type
2 diabetes and depression), much as unseen part of an iceberg is much larger that the part visible
above water.
Reasons for hidden morbidity:
-Patient-Led Barriers: for example, not giving full information about the psychological and behavioral
changes about the patient suffering from a chronic disease.
-Profession-Led Barriers: for example: false or premature reassurance.
Double Burden of Disease:
Concept of Double Burden of disease is characterized by coexistence of centuries old communicable

diseases such as malnutrition, or other infectious diseases along with modern non-communicable
diseases such as obesity with in population.
International Classification of disease (ICD):
According to WHO
-Purpose and Meaning:
ICD is the international standard diagnostic tool for epidemiology, health management and clinical
purposes.
This includes the analysis of general health situation of population groups defining universe of
disease, disorders, injuries and other health related conditions.
Main purpose of ICD is, easy storage, retrieval and analysis of health info for evidenced-bases
decision making as well as sharing and allowing comparison of health info between hospitals, regions
and countries.
-Number of Revisions of the ICD:
ICD has been translated in 17 different languages and used by 117 countries worldwide. Currently
ICD 10 established in 1994 is used worldwide with ICD under revision through ongoing revision
process and to be released in 2018.
-Way of coding diseases in ICD10:
The information about coding a disease is done by the general practitioner.
GP is required to code information depending on external causes of the disease and condition of the
disease if it is acute or chronic along with providing information about all other conditions observed
during the course of examination.
22. Sources of Information and methods of studying morbidity.

Sources of Information:
A wide variety of morbidity data are collected locally, nationally and on an ad hoc basis for a specific
purpose.
Source of information about morbidity is based upon hospital patient, general practice patient and
people in general population and disease registers.
In considering how a particular source of morbidity data describes the disease problem in a
population, it’s helpful to be aware of the iceberg phenomenon of the morbidity whereby on a
proportion of patients make contact with the health services and particular with hospital services
(the tip of the iceberg)
Methods of studying morbidity:
1) Through registered cases of diseases in health facilities:
-Cases subject to general reporting
-Cases subject to special reporting:
● Very dangerous infections

● Acute infections
● Infections non-epidemic disease

-Incidence with temporary disability
-Incidence with permanent disability
-Hospitalized incidence
2) Through the data for cause of disease
3) Through the data from prophylactic examinations (preventive examination)
23. Ability to work, inability to work, invalidity. The medial doctor as an expert.
Preserved and impaired ability to work:
-Preserved ability to work: this is the healthy state of person where the person is prevented from any
disease which can in one way or the other cause a person to be in an impaired state of health
preventing him to work.
-The medical expertise of ability to work is organized and directed by Ministry of health.
-Impaired ability to work: also can be classed as having a disability, which makes a person unable to
work and dependent.
Temporary inability to work:
It is temporary absence of legal capability to perform an act. It’s curable impairment of mental or
physical state that may prevent the affected person from functioning normally only as far as he/she
is under treatment
-Hospital list for temporary disability: It’s the source of studying of morbidity with temporary
disability. They are issued only of health provided and working people.
Sick leave is calculated in calendar days and not working days.
-Types of Hospital list:
1) Primary Hospital list: issued for every new illness with temporary disability.
2) Extension of Hospital list: issued for repeated visit to the doctor on the occasion of the same
illness.
-Reasons for temporary inability to work can be: injuries, surgery, short-term medical conditions
such as broken limb or injured hand, looking after a healthy child, because of a quarantine in the
kindergarten, urgent accompany of a sick family member for a medical examination and looking
after a diseased family member.
Expertise of temporary inability for work- who is taking part, number of days of the issued hospital
lists.
The number of days of the issued hospital list depends on the incubation period of the temporary ill
(such as infections) and the infectivity.
Temporary:
-The role of treating physicians in the expertise of temporary disability: the treating physician can
issue a hospital list for temporary disability for 14 consecutive days and for no more than 40
non-consecutive days in a calendar.
-The role of LKK (physician Consulting Commission) in the expertise of temporary inability for work:
LKK can issue a hospital list for temporary disability for 30 calendar days without interpretation and
fro no more than 6 months in one calendar year.
Permanent:
-The role of TELK (Territorial expert physician Commission) in the expertise of temporary inability of
work: allow sick leave because temporary disability over 6 months.it takes part in expertise of
disability but doesn’t issue hospital list.
-The role of NELK (National expert physician Commission) in the expertise of temporary inability of
work: Decides over controversial points of the expertise of inability to work.
Permanent inability to work: (invalidity)
This is the condition of being invalid to perform any task. It is a form of dependency where an
individual is unable to work. This is defined as a percentage lost ability for work compared to the
abilities of the healthy person.
Expertise of permanent disability to work:
1) Extent of the permanent disability in percentage compared to healthy person
2) The need for somebody else’s assistance
3) The initial date of becoming disabled
4) The duration of permanent inability to work and final date of it
5) The contra-indicated work conditions and the necessity for a transfer to a more appropriate job.
The expertise of permanent disability to work is carried by TELK and NELK
Types of Invalidity (as a percentage of loss of ability to work):
1) First group permanent disability- over 90% lost of ability to work (with/without right to
somebody else’s assistance)
2) Second group permanent disability- from 71% to 90% lost of ability to work
3) Third group permanent disability- from 50 to 70% lost ability to work
24. Integral indicators of public health assessment.

The philosophy behind the emergence of integral indicators:
For many years, life expectancy in almost every country has slowly been increasing with a rise in
chronic diseases among already people in many countries (an increase in morbidity).
As a consequence, increasing efforts have been focused on constructing a novel health indicators
that take into account both mortality and morbidity.
The concept of integrated health indicator was first proposed by Sander in 1964. In 1971, Sullivan
developed a simple computational technique for a (HLE) health expectancy index, showing how
many years people could expect to live in good health.
To calculate the life expectancy, information on both mortality and morbidity is combined.
Indicators:
Using data obtained from unified questionnaires proposed by WHO can calculate following
indicators:
-Perceived health expectancy
-Disability-free life expectancy
-Handicap-free life expectancy
Characteristics of health expectancy in different countries
Studies in different countries show that:
-Women have a longer life expectancy that men but they’re expected to spend more years in poor
health
-In economically developed countries the proportion of expected life in good heath is higher than in
less developed countries
-The poorest and least educated people not only have a shorter total duration of life but much
smaller part of it in good health
-Life expectancy in good health in urban countries is higher than in rural
Health Expectancy as a strategic goal of WHO (World Health Organization):
Evaluation of health status in quality of life is perceived as general situation in contemporary

philosophy and strategy of WHO.
According to annual report in 1197: World wide, life expectancy has increases dramatically during
last decades of 20th century. But in celebrating our extra years, we must recognize that increased
longevity without quality of life is an empty prize, i.e. health expectancy is more important than life
expectancy.
25. Epidemiology of socially important diseases.
Changes in pattern of morbidity in 20th century:
Dramatic increase in life expectancy achieved during the 20th century, combined with profound
changes in lifestyle is leading to global epidemic of chronic diseases.
These chronic diseases are responsible for half of 52 million or so deaths that occur every year. In
industrialized countries, infectious diseases are under control where as in developing countries if an
individual do manage to survive an infectious disease in childhood he’ll be exposed to a

non-infectious disease later in life.
The changing pattern of morbidity as well as health is called double pattern. Where about, on one
hand- an individual is in danger of infectious diseases such as tuberculosis and malaria, and on the
other hand in under the growing shadow of new non-infectious chronic diseases.
Criteria for socially significant disease:
1) High level of death rate and unfavorable dynamics, especially within people in activate age
2) High proportion in the structure of cause of death within the whole population and
especially within active people.
3) High level of incidence and prevalence and unfavorable dynamics of these indicators.
4) High proportion in structure of:
-General incidence and prevalence
-Incidence with temporary disability
-Primary permanent disability
-Hospitalized incidence
5) High proportion in structure of expenditures for hospital care and rehabilitation.
6) Significant social, medical, economical and psychological damages for patients and their
family.
7) Have burden on public funds and social services
Estimates of socially significant diseases in the world for 2020:
The estimated ranking of diseases as cause of death in 2020 is:
1) Ischemic Heart Disease

2) Cerebrovascular Disease
3) Chronic obstructive pulmonary disease
4) Lower respiratory infections
5) Cancer
Socially significant diseases in Bulgaria:
According to the data provided by *World Life Expectancy* top 10 socially significant diseases in
Bulgaria are:
1) Coronary Heart Disease
2) Stroke
3) Hypertension
4) Lung cancer and other lung diseases
5) Breast Cancer
6) Influenza and Pneumonia
7) Liver Diseases
8) Diabetes Mellitus
9) Prostate Cancer
10) Suicide
Socially significant diseases in developing and developed countries:
In Developed Countries: With growing progress in industrialized countries, number of people with
infectious diseases has decreases dramatically.
With increasing life expectancy and a better quality of life most people in developing countries suffer
from newly developed chronic diseases such as:
-Obesity
-Diabetes
-Cardiovascular Disorders
-Liver damage due to drinking
-Obstructive lung problems as a result of smoking
In developing countries: People living in developing countries with low or middle level of Health
Development Index are at a higher risk of suffering from infectious diseases such as Tuberculosis and
Malaria, mainly due to:
-Poor Sanitation
-Poor Diet
- Unsatisfactory health care system.
The outlook for most individuals in the developing countries is that, if they do manage to survive the
infectiousness of infancy and childhood, they will become exposed in later life to noninfectious
diseases.
26) Risk factors health and risk contingencies. Prevention and promotion programs.
1) Risk factors for health – classification:
▪ Primary and secondary risk factors:

● Primary: Inactivity, obesity, high blood pressure, high levels of cholesterol, stress and
tension, smoking.
● Secondary: fatigue, injury, overweight, pain, bowel/bladder problems.
▪ On the level of the individual and on the level of the public health:
● Individual health: state of health/fitness, our life styles, our posture and out work habits
● Public health: unsafe sex, unsafe water, sanitation and hygiene.
2) Life style and health:
▪ Nature of the lifestyle:

● Life style is the way in which a person lives.
● Health behaviour- action taken by an individual to maintain, attain good health and prevent
any illness. Such as exercising regularly, eating a balanced diet etc.

● Prevention health behaviour: activity undertaken by an individual who believes himself to be
healthy.
● Illness behaviour: an activity that under taken by an individual who perceives himself to be
ill.
▪ Types of risk factors from the lifestyle, Contribution of the lifestyle for the impairment of
health:
● Diet and nutrition: eating healthy helps maintain a good diet and reduces the chances of
becoming ill, excess weight puts strain in the entire circulatory system. Also make people
have high cholesterol; high blood pressure and diabetes, all of which cane increase stoke
risk.
● Physical Activity: regular physical activity will improve overall health and fitness, and reduce
the risk of chronic diseases.
● Tobacco use and smoking: s moking doubles the risk of stroke when compared to
non-smokers. Smoking increases clot formation thickens blood and increases the amount of
plaque build-up in the arteries.
● Alcohol: use has been linked to stroke in many studies. Drinking too much alcohol can
increase blood pressure and risk of stroke.
3) Heredity, as a risk factor for health- contribution:
● Family history is often one of the strongest risk factors for common disease complexes, such
as cancer, cardiovascular disease (CVD), diabetes.
● A person inherits a complete set of genes from each parent.
● Inherited genetic variation within families clearly contributes both directly and indirectly to
the pathogenesis of disease.
4) Risk factors from the environment- types, contribution for the impairment of health:
● Air pollution- leading to respiratory and breathing problems.

● Passive smoking – increases the risk of tobacco related diseases, such as lung cancer, heart
disease and stroke
● Radon- is the number one cause of lung cancer among non- smokers
● Living in unclean environment: increases the chances of becoming
● Poor sanitation and unclean water- unclean water contains many parasites increasing the
risk if obtaining parasitic disease.
5) Health care system as risk factor for health- contribution:
● Contaminated injections in health care can transmit diseases from one patient to another.
● When waiting to be examined patients waiting in the waiting area have a chance of being
infected from another patient, the longer the patients wait the more chance of being
infected
● Often in less developed countries there is a limitation of specialists, so delay in seeing a
specialist can further worsen the conditions.
6) Risk contingents from the population:
▪ Women, pregnant, women in child-birth, mothers: the common disease women share are
breast cancer as well as cervical cancer. Pregnant women on the other can feel anxieties
especially if they are pregnant for the first time or pregnant women are at a higher risk of
postpartum depression.
▪ New- born, babies and children: new born babies can be premature leading then to be
underweight. Very common diseases that most babies endure during their first few weeks of
life are jaundice, pink eye and hepatitis A. whilst most children are at high risk of chickenpox,
skin rash allergies, diarrhoea etc.
▪ Old people: elderly people tend to have dementia, Parkinson’s disease, poor vision and
hearing loss.
▪ Disabled people: tend to have musculoskeletal problems such as; arthritis, heart disease,
stoke etc.
▪ Mentally ill: tend to have depression, schizophrenic, lack of motivation, detached from
everyone else.
▪ Poor and homeless people, refugees, minority groups: they may be malnourished due to
lack of balanced diet, may be a risk of late diagnosis due to having financial problems. May
feel isolated from the society, unclean and lack of sanitation areas increases of the rick of
parasitic diseases.
7) Programs for prevention and promotion:
WHO programs:
● Cities for health promotion

● Schools for health promotion
● Work places for health promotion.
27) Health and Health care for mothers and children. Specific programs
implementation and the role of medical doctor
Maternity:
1) Medical and social problems of motherhood.
▪ Morbidity:
For adolescent girls (10 to 19) years:
● Unintentional injuries: injuries from road traffics are one of the leading causes of death for
adolescents girls
● Mental health: Unstable mind set, suicidal and mental health disorders play a great role in
morbidity.
● HIV/AIDs: Unsafe, unwanted and forced sex can lead to higher risk of HIV/AIDs.
● Adolescent Pregnancy: Are increasing globally, but due to unsafe abortions which are
carried out by unprofessional under hygienic condition lead to an increase death rate.
● Substance use: Drinking, Smoking over usage of drugs negatively influences on the health of
an individual, leading to further increase in pregnancy complications in later life.
Reproductive age (15 to 44 years) and Adult women (20-59 years):
● Increase of cancer frequency: Breast, lung and colon are among top ten causes of death for
older women globally.
● Cervical Cancer: second most common type of cancer among women. 80% of cases today an
even higher proportion of deaths from cervical cancer occur in low-income countries.
● HIV/AIDS
● Mental Health
● Tuberculosis: linked to HIV infection and the third leading cause of death among women of
ages 15 to 44 years.
● Violence: Women who are sexually or physically abused have a higher rate of mental illness.
● Depression and suicide.
Older women: (60 years and over)
● Cardiovascular disease: heart attracts and stroke: Women show different symptoms to men
and develop heart disease later in life than men.
▪ Abortion:
● Is a highly controversial topic and has many aspects related to it such as; cultural, ethical,
religious and political.
● Abortion procedure can be performed legally no later than the 24th week of pregnancy.
● The international practice law allows abortion up 24th week of pregnancy, if mother is under
at risk/ the foetus has serious abnormalities. Such circumstances must be declared by tow
specialist is the field of gynaecology.
▪ Fertility: is the quality of being able to conceive children
▪ Problems associated with birth: Often child birth cause no compilations, however under
certain circumstances a birth of a child not only cause a danger to the life of child itself but
also the mother these are;
● Premature labour
● Problem with umbilical cords
● Problems with the position of the baby
● Birth injuries
▪ Single motherhood
▪ Contraception: Is defined as an artificial method to prevent pregnancy.
2) Pregnancy, children birth and safe motherhood:
▪ Primary outpatient care:

● Defined as medical care which does not require the patient to stay overnight in the hospital.
● Surgical services, rehabilitation treatments and mental health services are available to
outpatient.
▪ Hospital obstetrics care:
● Is needed for the management of normal and complicated pregnancy, delivery and
postpartum period.
● Two types of obstetrics care; Basic essential obstetrics care and comprehension essential
obstetrics care.
● Basic essential obstetrics care: Are basic care services at the health centre level.
● Comprehensive essential obstetrics: Are services at district hospital level.
3) Tasks of GP for obstetrics primary care:
▪ Promotion: Encouraging and supporting good health

▪ Prevention: This is act of encouraging patients to prevent certain diseases of condition from
arising
▪ Dispensary method: location where patients can legally purchase or have access to medical
drugs.
▪ Target groups: Are group of patients that hospitals or business aim to market their
products/information on.
▪ Pregnant women with low risk pregnancies: Observed when woman is healthy:
● 18 to 34 years old
● Has visited gynaecologist at least once during the first 3 months of pregnancy.
● No more than 3 previous deliveries.
● No previous delivery or no children with disabilities
● Us not an alcohol, tobaccos and drug abuser
▪ Pregnant women with high risk pregnancies:
● Mothers below 18 years or over 35 years
● Previous delivery complications
● Malnutrition and poverty
● Poor living conditions
● Psycho-emotional stress
4) Disability expertise associated with pregnancy and motherhood:
● Child birth carries its own health risk for the child as well as the mother
● Such conditions and disabilities can be overcome via giving the patient he correct support
and treatment.
● Skilled care at childbirth: qualified and professional staff should carry child procedure.
● Antenatal care: Gives the opportunity for regular screening and check-up for the mother
and baby.
● Delivery care: Ensures that obstetric emergencies are effectively managed.
● Postpartum care: Important for detecting and treating infections and other diseases
5) Family planning and contraception- Types.
● Having a baby is a very personal decisions that coupe make.

● There are many factors involved when planning a family such as; social status (income and
living conditions), age of the partners, family pressure etc.
● Usage of contraception prevents unintentional pregnancy below is a list of few contraceptive
methods:
1. Coitus interrupts and the “calendar” method which are unreliable
2. Hormonal contraceptive medication- reliable but make provoke a latent hormone-sensitive
breast cancer, and not protective against sexually transmitted disease.
3. Post-coital contraceptive mediations.
6) Infertility:
● Affect about 15% of reproductive –aged couples worldwide.

● About 50% of the cases male infertility has been reason for the couple’s infertility.
1. Primary Infertility: Inability to conceive with two years of exposure to pregnancy is the
epidemiological definition recommended by the world health organisation (WHO , 1975;
WHO, 2001)
2. Secondary infertility: unable to conceive after an initial first pregnancy.
● Main cause of infertility in women:
1. Congenital abnormalities of the genital organs.
2. Hormonal disorders
3. Genetic causes
Medical and Social problems of childhood and social services for children.
1) Periods in childhood Development- Types and problems
Newborns:
● Promote and support early and exclusive breast feeding

● Help keep the new born warm
● Birth registration should be done and vaccination should be given on time according to
national schedule.
● Problems:
1) Low-birth weight babies
2) Sick new-borns
3) New-borns of HIV infected mothers.
Early child development:
● Brain and biological development during the early years are highly influenced by the
environment.
● Early experiences influence health, education and economic participation for the rest of the
life.
● Problems:
1) Malnutrition
2) Inadequate stimulation
3) Iodine deficiency
4) Iron deficiency anaemia
Adolescent:
● Period of preparation for adulthood

● Changes in the biology, physical and sexual maturation.
● Move towards social, economic and personal independence.
● Problems:
1) Pressure to fit into the society.
2) Peer pressure leading to carrying out activities such as; alcohol, drugs, tobaccos and forming
sexual relationships.
3) Making life changing decisions; university, moving or going into the world of work.
2) Organisation of paediatric care:
▪ Outpatient Paediatric care: Includes; diagnoses, observation, consultation, treatment,

innervation and rehabilitation centre.
▪ Hospital Paediatric care: Condition or diseases which require the child to stay in the hospital
in order to be treated.
28) Health and health care of elderly.
1) Classification of age:
▪ Classification according to WHO:

● The period that has elapsed since birth.
● The number of people reaching age 65 couples wth their increased life expectancy , has
expmaded the classification of those age 65 years and older to include three sub-
populations commonly referred to as:
1) The “young old” 65 to 74
2) The “old “74-84
3) The “oldest- old” 85+
▪ Classification for the purposes of education and health:
● Individuals are educated about: physical health, social health, emotional health intellectual
health and spiritual health.
2) Elderly as a specific heterogeneous group:
▪ With an active career

▪ Seniors in good health
▪ Sick and dependent people
▪ Identifying needs and potential interventions
3) Characteristics of health in older people:
● Multiple pathology
● Many different medicaments.
● Interaction between drugs.
● Not known bad side effects.
4) Particularities of the disease in the elderly:
● There are several distinct mechanism leading to unrecognised diseases:

1) Failure to report symptoms
2) Denial of symptoms
3) Under investigation by doctors
4) Poor diagnosis by doctors
▪ Older people as risk group :
● Injury- falls and injuries increase o the burden of disease and disability. Requiring
hospitalisation as well as expensive interventions.

● Risk factors of no communicable diseases- harmful behaviour which has been early
established in life , can reduce the quality of life and even premature- death.
● Poverty- Many older patients cannot afford to pay for health costs and treatment further
worsening their condition.
● Social isolation and exclusion, mental health disorder- affect all aspects of health and
wellbeing including mental health, dehydration or malnutrition.
5) Priority issues in the third adult
● Difficulty in health
● And problems in managing the disabled adults expenses
6) WHO: investing in “healthy aging”- Strategy and action plan for healthy aging in Europe.
2012-2016:
▪ Ensuring access to prevention

▪ The quality of health care
▪ Long-term care
▪ Protective from abuse
7) Health strategy “Europe 2020”:
▪ Promotion of good health in an aging Europe

▪ Innovations related to healthy and active aging
29- Family and health. Family Doctor.

1) Role of GP as a family physician.
● General Practical is a Medical Doctor who treats acute and chronic illnesses.
● Providing preventative care and health education to patients.
● Role of GP varies among countries
● Urban areas of development tend to be narrower as GP focus on care of chronic health
problems and treating acute non- life threatening conditions.
2) Elements of family environment:
▪ Structure of family:
1) Nuclear family- mother, father and their biological children.
2) Single parent- A Parent who cares for his/her children without the support of the other
biological parent
3) Step families – two different family comes together
4) Extended family –including, grandparents, grandmother, uncle aunties etc.
▪ Housing:
● Poor housing conditions can led to increases risk of health problems
● Lack of good ventilation can cause respiratory problems
● Poor house design can increase health related risk, if the house needs maintenance it may
be too cold in the winter or too hot in the summer.

▪ Psycho- social factors of family:
● If the family has low income may not be able to afford treatment , therefore further
worsening the disease/ the condition
● If the family has many visitors, these visitors may have flu or a cold, increasing the risk of
individuals in the family becoming ill.
▪ Relationship in the family:
● Impact greatly on how quickly a patient recovers
● If there is positivity and unity with in a family they will support each other
● Encourage one another to look out for each other.
▪ Health Status of family members- up to 6 age and over 60 age.
3) The role of promotion and prevention in the family:
● Promotion enable people to increase control over and improve their health
● Prevention is an active approach which reduces the likelihood that a disease or disorder will
affect an individual.
● Having promotion and prevention family programs are more likely to be affective, as often
people listen to their loved ones.
● Family members will encourage each other and certain positive changes in their life style
may become a habit, and reduce the risk of certain diseases and conditions.
30-Globalsation of public health problems – international health cooperation:

1) Globalisation and health:
▪ Cycle of impact of globalisation:

● Globalisation is a word wide movement towards, economic , financial , trade and
communication integration.
▪ Determining linkages between globalisation and health :

● Due to globalisation health care professional can travel to different countries and practise
medicine where needed.
2) Global health situation:
▪ Demographic trends:
● Population- global population was 2.8 billion and currently is 5.8 billion; it is expected to
reach up to 8 billion by the year 2025.
● Life expectancy- in 1955 average life expectancy was 48 years and in 1995 it was 65 years, by
2025 it will reach up to 73 years. By 2025 it is expected that no country will have life
expectancy of less than 50 years.
3) International health cooperation:
▪ Basic principles of international health cooperation:

● Develops standards, mechanism and procedures for international health cooperation
● Provides services related to mobilisation, coordination, management and assessment of
externally supported health projects and initiatives.
● Advises the secretary and undersecretary of health on matters pertaining to international
health programs projects an initiatives and externally supported international and local
health projects.
WHO (World Health Organization):
Head Quarter: Geneva, Switzerland.
Regional Main Cities:
African Region: Brazzaville
South-East Asia: New Delhi
Region of America: Washington
European Region: Copenhagen
Western Pacific: Manila
31. International health programs. The WHO conceptions and strategies.

1. International health cooperation at the global level. World Health Organization (WHO)
● Goal
The objective of the WHO is “the attainment by all peoples of the highest level of health”
which is set out in the preamble of the Consultation. The current objective of WHO is the
attainment by all 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 – also known as Health for All
by 2000 AD.
● Principles
o International health activities coordination;
o Providing help for the governments in developing their health systems;
o Preparing an international; standards for food, biological and pharmaceutical
products;
o Providing information and advises concerning the management and organization of
the public health
● Features
WHO also has specific responsibilities for establishing and promoting international standards
in the field of health, which comprise the following broad areas:
o Prevention and control of specific diaseases;

o Development of comprehensive health services;

o Family health;
o Environmental health;
o Health statistics;
o Bio-medical research;
o Health literature and information;
o Cooperation with other organizations.
● Structure and governing bodies
The WHO consists of three principal organs:
1. The World Health Assembly – this is the: “Health Parliament of Nations” and the supreme
governing body of the organization. It meets annually, usually in May, and generally at the
headquarters in Geneva, but from time to time in other countries.
The main functions of the Health Assembly are:
● a). to determine international health policy and programmes;

● b). to review the work of the past year;
● c). to approve the budget needed for the following year and
● d). to elect Member States to designate a person to serve for three years on the Executive
Board and to replace the retiring members.
2. The Executive Board – the board had originally 18 members, which designated by a
Member State. The Executive Board meet at least twice a year, generally in January and
shortly after the meeting of the World Health Assembly in May.
The main work of the Board is to give effect to the decisions and policies of the Assembly.
The Board also has power to take action itself in an emergency, such as epidemics,
earth-quakes and floods where immediate actions are needed.
3. The Secretariat – is headed by the Director General who is the chief technical
administrative officer of the Organization.
2. Objectives of the WHO Europe during the first two decades of the XXI century
● Strategic objectives of the Health 2020
Conception and strategies of the WHO
In recent years, two major policy developments have influenced the WHO.
First - the Alma-Ata Conference in 1978 on primary health care which provided both WHO and
UNICEF with a common charter for health.
Second - health promotion
Three - the Global Strategy for Health for All during the 21 century.
Both WHO and UNICEF are striving towards the goal of HFA during 21 century through health
system based on primary health care.
● Main objectives at EU level
Health21 is a European policy framework derived from the Health for All policy for the
twenty-first century adopted by the World Health Assembly in 1998.
Health21’s goal is to achieve full health potential for all people in the Region, with two main
aims: to promote and protect people’s health throughout their lives; and to reduce the incidence
of the main diseases and injuries and alleviate the suffering they cause. Three basic values form
its ethical foundation: health as a fundamental human right, equity in health and solidarity in
action and participation and accountability for continued health development.
3. International health cooperation at European level
● Health Strategy 2020 goals of the EC

● Health for AllIn 1977, it was decided in the World Health Assembly to launch a movement
known as “Health for All by the year 2000”. After 2000 it was renamed as a Global Strategy
for “Health for All during the 21 century”. The fundamental principle of HFA strategy is
equity, that is, as equal health status for people and countries, ensured by an equitable of
health resources.
● EUROPE 2020 – goals and priorities
The member countries of WHO at the 30th World Health Assembly defined Health for All as:
“Attainment of a level of health that will enable every individual to lead a socially and
economically productive life.”
32. Public health as an element of general socio-economical system of society.
1. Objectives of the national health system
Health systems are defined by the WHO as comprising all the organizations, institutions and
resources that are devoted to producing health actions: to promote, restore and maintain health. A
health action is defined as any effort, whether in personal health care, public health services or
through intersectoral initiatives, whose primary purpose is to improve health.
Health systems have three fundamental objectives:
● improving the health of the population they serve;

● responding to people’s expectations
● providing financial protection against the costs of ill health.
2. Classification of the prevailing health systems funding
● Public budgeting
1-The system of state monopolism:
o The state is owner of health institutions and resources;

o Budget financing through taxation;
o Polyclinical organization of the health service;
o Centralized by state management of resources;
2-Security Method:
System of liberal pluralism:
o Based on the economic freedom and pluralistic ownership of health resources;

o Private sector is predominant;

o Primary and secondary health care are privatized;
3-Private funding from voluntary insurance
Health-insurance system:
o State regulation through legislation;
o Pluralistic (public and private) ownership of health resources;
o Well developed market mechanisms;
o Orientated towards the demand of health services;
33. Health service – functions, objectives, organisation. Health establishment law.

1. Main functions and tasks of the health services
Public health systems are commonly defined as “all public, private, and voluntary entities that
contribute to the delivery of essential public health service within a jurisdiction.” This concept
ensures that all entities’ contributions to the health and well-being of the community or state are
recognised in assessing the provision if public health services.
● Education concerning prevailing health problems and the 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 the major infectious diseases
● Prevention and control of locally endemic diseases
● Appropriate treatment of common diseases and injuries
● Provision of essential drugs
2. Organisation of health care
● Primary health care – family medicine, specialised outpatient care, dispensary, emergency
Levels of health care
Health care services are usually described at three levels – primary, secondary and tertiary
care levels.
o Primary level: it is the first level of contact for the patient with the health system. It deals
with the most common health problems
o Secondary level: at this level more complex problems are dealt with.
o Tertiary care level: this is the most specialized level. It requires highly specialized health
workers and facilities
by Dr. Zachary Botchev. The idea was to establish a comprehensive and accessible for the entire
population system of healthcare to be financed by an insurance fund and to be managed in a
democratic and decentralized way with the wide participation of the public and of the professional
associations.
34. Health policy and health legislation.

1. Nature of health policy
● Tasks of health policy

o It defines a vision for the future
o It outlines priorities and the extended roles of different groups
o It builds consensus and informs people
● Role of health policy
Deals with organisation, financing and delivery of health care services. This includes training of
health professionals, overseeing the safety of drugs and medical devices, administrating public
programs and regulating public and private health insurance
2. Contemporary requirements for health policy
● Modern technologies used in health policy

o Health 2020 is the new European health policy framework. It aims to support action
across government and society to: “significantly improve the health and well-being
of populations, reduce health inequalities, strengthen public health and ensure
people-centred health systems that are universal, equitable, sustainable and of high
quality”.
35. Basic priorities of health legislation.

1. Strategic Management
● Health system – definition

o It is the organization of people, institutions, and resources that deliver health care
services to meet the health needs of target populations
● Systems approach to strategic management
In theory, management consist of four basic activities:
1. planning: determining what is to be done;
2. organizing: setting up the framework and making it possible for groups to do the work;
3. communicating: motivating people to do the work;
4.monitoring (controlling): checking to make sure the work is progressing satisfactorily.
● Elements of the strategic management
Management techniques are many. They are based on principles of behavioral sciences as
quantitative methods. These techniques have been developed by expert of management science to
help the managers of any organization to achieve the stated goals more efficiently. Efforts are being
made by WHO for making these techniques more popular for application in the health field.
2. Priority issues in health policy
Investing in health through a life-course approach and empowering people;

o Tackling the Region’s major health challenges of non-communicable and

communicable diseases
o Strengthening people-centred health systems, public health capacity and emergency
preparedness, surveillance and response
o Creating resilient communicating and supportive environments
3. Political Action Plan of the World Health Organisation – directions
Health 2020 sets out the strategic directions and priority policy action areas for Member States and
the WHO Regional Office for Europe. The Health 2020 policy framework has been developed through
a fully participatory process with Member States and a wide variety of other interested parties
across the European Region.
4. EU health policy
The aim of EU policies and actions in public health is to improve and protect human health, and to
support the modernisation of Europe's health systems, thereby contributing to the Commission's
2014-2019 priority on growth and jobs. In line with the principles of proportionality and subsidiarity,
the Commission's role is mainly to support the EU Member States' efforts to protect and improve
the health of their citizens and to ensure the accessibility, effectiveness and resilience of their health
systems.
36. Economical problems of public health. Sources of financing- modern

tendencies.
1. Health Systems are defined by the WHO as comprising all the organizations, institutions and
resources that are devoted to producing health actions: to promote, restore and maintain
health care.
2. Types of financing systems
Type Source of financing

Health insurance type Bismarck through Obligatory payment from the employer
social security (e.g. Germany, Japan, & employee for health funds or through
France, Austria, Belgium, Switzerland, social security.
Israel)
National health service type Beverage The government-fees & taxes
(e.g. GB, Norway, Sweden, Denmark, GB- national financing
Italy, Spain, Portugal, Greece) Scandinavian countries- mixed national,
regional & local taxation.
National health system type Semashko The government- fees & taxes
(e.g. the former Soviet union)
National health insurance type Douglas , Taxes, distribution of expenditures
realized through the government (e.g. between the local & federal
Canada, Australia) governments
Mixed private/public systems (e.g. USA, Private insurance through the employer
Columbia, Philippines & Nigeria) & public insurance through social
security for specific population groups.
3. Private funding of voluntary insurance

Voluntary health insurance (VHI) schemes are those where the decision to join and the
payment of a premium is voluntary.
Together with out-of-pocket payments, VHI premiums are considered a private revenue
source.
4. Methods of financing health systems:
Health systems have 3 fundamental objectives:
● Improving the health of the population they serve

● Responding to people’s expectations
● Providing financial protection against the cost of ill health
3 main systems of health care with their typical features:
(1) The system of state monopolism:

● The state is owner of health institutions & resources
● Budget financing through taxation
● Polyclinical organization of the health service
● Centralized by state management of resources
● Total lack of market elements & self-regulation of the system
● There is no adequate coverage of health needs
● Health services are oriented towards the supply, & not towards the demand of
health services
● The system is sustainable because of state ownership & centralized management,
but its development is unsustainable
● Typical for the former socialist countries.
(2) System of liberal pluralism
● Based on the economic freedom & pluralistic ownership of health resources
● Private sector is predominant
● Primary & secondary health care are privatized
● Market mechanisms are fully developed, but there are elements of state regulation
● The system is sustainable because of high resources & market orientation
● The system is oriented mainly towards the demand of health care
● The health care isfinanced through great number of sources
● Typical country: USA
(3) Health-insurance system and Health Insurance Funds
● Sate regulation through legislation
● Pluralistic (public & private) ownership of health resources.
5. Financing of emergency health care (by the government)

● Principles
● Practices
● Sources
37. Primary health care- objectives, organization, financing. The role of medical
doctor in primary health care delivery.
1. Health care – is the maintenance or improvement of health via the diagnosis, treatment, and
prevention of disease, illness, injury, and other physical and mental impairments in human
beings.
2. Medical care
● Medical care is the provision of what is necessary for a person's health and
well-being by a doctor, nurse, or other healthcare professional.
● Primary Level: It is the 1st level of contact for the patient with the health system. It
deals with the most common health problems.
Secondary level: at this level more complex problems are dealt with
Tertiary care level: This is the most specialized level. It requires highly specialized
health workers & facilities.
3. Primary health care as an integral system of primary medical care

● Core primary health activities:
- Education concerning prevailing health problems and the methods of preventing &
controlling them
- Promotion of food supply & proper nutrition
- An adequate supply of safe water and basic sanitation
- Maternal & child health care, including family planning
- Immunisation against the major infectious diseases
- Prevention & control of locally endemic diseases
- Appropriate treatment of common diseases & injuries
- Provision of essential drugs
● Primary health care is essential health care made universally accessible to individuals
& acceptable to them, through their participation and at a cost the community and
country can afford
4. Outpatient care
● Outpatient care is medical care
provided on an outpatient basis, including diagnosis, observation, consultation,

treatment, intervention, and rehabilitation services. This care can include advanced
medical technology and procedures even when provided outside of hospitals.
5. GP practice
● A general practitioner (GP) is a medical doctor who treats acute and chronic illnesses
and provides preventive care and health education to patients.
6. GP as a sole trader
● When a GP is a sole trader, they run their practice as a small business and are paid
on the basis of fee-for-service. They have to manage the financial, human and time
resources themselves.
7. Medical standards in general practice
● Standards for the unit
● Standards of practice staff
● Performance standards for clinical & non-clinical activities in the practice of primary
care
● Standards for information security
● Standards to respect patients’ rights and ensure confidentiality
8. Self management
9. Reforms in primary care
● Comparative analysis
● Past attempts
● The current focus
38. Hospital medical care- objectives, organization, financing.

1. A hospital is an institution providing medical and surgical treatment and nursing care for sick
or injured people.
2. Types of hospitals:
● According to function:
(1) Hospitals for active treatment- for patients with acute diseases, traumas,
aggravated chronic diseases, conditions requiring operative treatment in
hospital conditions as well as natal care and medical cosmetic services.
(2) Hospitals for long term treatment- this type of hospital admits persons needing
long recovery of health and persons with chronic diseases requiring long-term
care.
(3) Hospitals for rehabilitation- for persons in need of physical therapy, motor &
psychic rehabilitation, balneological, climatological and thalassotherapy.
● According to the specialization:
(1) Multi-profile hospitals- which have departments or clinics on different medical
specialities.
(2) Specialised hospitals- in which there are departments or clinics corresponding to
one basic medical speciality.
● According to the profit:
(1) Non-profit hospitals
(2) Private for-profit hospitals
3. Basic hospital activities:

● Diagnostics & treatment of diseases when the purpose of the treatment cannot be
achieved in the conditions of outpatient care
● Natal care
● Rehabilitation
● Diagnostics & consultations requested by a doctor, or a dental doctor or by othet=r
medical establishments
● Transplantation of organs, tissues & cells
● Medical cosmetic services
● Clinical tests of medicines & medical equipment
● Educational & scientific activity
4. Hospital structure
A Hospital consists of:
● Clinics or departments with beds

● Medical diagnostic and medical technical laboratories
● Departments without beds
● Hospital pharmacy
● Consulting rooms
● Units for administrative economic & servicing activities
5. Financing of the Hospital

Sources of financing of a hospital can be:
● Public health insurance funds

● Republican and municipal budgets
● Private health insurance funds
● Local & foreign corporate bodies & individuals
6. Indicators for assessing Hospital care

Quantitstive indicators:
● Hospital beds per 1000

● Average length of stay
● Utilization of beds
● Turnover of beds
Qualitative indicators:
● Surgical wound infection rate in % from all operations

● Hospital mortality
● Match of clinical diagnosis with the pathology diagnosis
39. Emergency medical care – objectives & organization.

1. Emergency medical services (EMS) systems form an integral part of any public health care
system: their primary function is to deliver emergency medical care in all emergencies,
including disasters.
2. Emergency medical condition means a medical condition manifesting itself by acute
symptoms of severity (including severe pain) such that a prudent lay person, who possesses
an average knowledge of health & medicine, could reasonably expect the absence of
immediate medical attention to result in:
(1) Placing the health of the individual in serious jeopardy
(2) Serious impairment of bodily functions
(3) Serious dysfunction of any bodily organ or part.
Emergency Services: Those services provided after the sudden onset of a medical condition
manifested by symptoms of sufficient severity, including severe pain, so that the absence of
immediate medical attention could reasonably be expected to result in placing the patients’
health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of
any bodily organ or part.
3. Basic Life Support (BLS)- The constellation of emergency procedures needed to ensure a
person’s immediate survival, including Cardio- Pulmonary Resuscitation (CPR), control of
bleeding, treatment of shock & poisoning, stabilization of injuries and/or wounds, and basic
first aid.
4. Out-of-hospital emergency medical services (O-H-EMS), also known as pre-hospital EMS,
typically refer to the delivery of medical care at the site of the adverse medical event
(1) Dispatch centers receive the initial request for ambulance services and organize the
appropriate response, the organization & management of ambulance services that
deliver on-site medical care & provide rapid transportation to health facilaties. Both
services are usually provided or at least coordinated and supervised by local, regional or
national government and can be accessed through a national (or regional) public
telephone number.
The emergency call number for the most of the European countries is 112, and in some
of them there is a national number as well (e.g. in Bulgaria 150)
DC is to get the right resources to the right patients in the appropriate amount of time.
(2) Ambulance services. Ambulance- vehicle or craft intended to be crewed by a minimum
of two appropriately trained staff for the provision of care and transport of at least one
stretched patient. According to the latest EU standards, road ambulances can be
categorized into 3 types:
● Type A- patient transport ambulance
● Type B- emergency ambulance
● Type C- mobile intensive care unit (ICU)
In-Hospital EMS
● The Emergency department (ED), sometimes called emergency room,

emergency ward, accident & emergency department or casualty department is
a hospital department that provides initial treatment to patients.

5. Legislation & Financing
● The legislative framework in the majority of EU Member States implies secured
funding mechanisms for EMS. Similarly, more than two thirds of countries
specify, within the legal framework, standards of care, equipment &
professional qualification in EMS.
● In reality, some countries or regions or even individual hospitals invoice patients
for emergency care. This usually effects non- EU residents and, occasionally,
persons from a ‘socially marginalized group’. However, co-payment for
emergency care is waived in the event of (life threatening) conditions.
● In most countries, EMS are purchased by the state or through a national health
insurance scheme according to the number & type of services delivered.
Payment systems rely mainly on classification of services e.g. diagnosis-related
groups.
40. Health management- basic notions.

‘Management’, It characterises the process of leading and directing all or part of an organization,
often a business, through the deployment & manipulation of resources.
Type of resources:- human, financial, material, time.
Management has 4 dimensions:
(1) The culture, principles & values of management

(2) The structure of management
(3) The techniques employed by managers
(4) The settings, or infrastructure, of management
Type of Organisation & style of managements
● Authoritarian organization. There is a ‘chain of commands’ orders are passed down from
above. The manager’s job is to do orders & to compel the workers to carry out their tasks.
● Participative organization. People accept responsibility for work to be done. They accept
that their job is to carry out a part of the company’s activities. The manager’s job is to help
his subordinate by removing obstacles from their path. It seems that leadership &
co-operation result in economic success.
Models of management:
● Traditional bureaucracy- with an emphasis on clear structure, hierarchical chains of

command, clear accountability for performance.
● New pubic management- with an emphasis on making organizations more like firms
operating in markets through the introduction of competition to improve performance.
● ‘Japanese’ organization model or ‘clan’ – ‘solidarity’ model of organization – i n which a
sense of identity with, & pride in, the organisation itself is the main source of motivation.
● Professionalism – shares the ‘Japanese’ models assumption that people work better when
they are trusted & their performance is not closely monitored, the sense of identity is with
the profession rather than with the organization.
41 – The role of medical doctor in managing process. Management of medical

practice. Management of disease/health. Evidence based medicine.
1 – The role of the physician in the management process
● Financial - offering sustainable, cost-effective treatment options for patients, improvisation,

reducing overall wastages in the health sector, and improving access to care.
● Material - Materials to be managed are quite varied and may include medical supplies,
consumables, equipment, and drugs among others.
● Human - Manpower resources are said to be the most important aspect of healthcare
systems. For a doctor to deliver high-quality service, it goes beyond mere clinical expertise, it
entails appropriate skills in human relations, and inter-and intra-professional relationships
and conflict management.
● Time - Proper time management is essential for high-quality health care delivery as patients
experience less waiting time, colleagues, and other health workers experience less
job-related stress as tasks are done promptly without impeding the work of others.
Evidence- Based Medicine
1. Definition - Evidence-based medicine (EBM) is an approach to medical practice intended to

optimize decision-making by emphasizing the use of evidence from well-designed and
well-conducted research.
2. Scope of the MBD
3. Hierarchy of evidence
4. Followers steps in the implementation of MBD

5. Key clinical activities related to the use of MBD
6. Meta-analysis for MBD - Evidence based medicine (EBM) is integrating individual clinical
expertise with the best available external clinical evidence from systematic research
7. Sources of information on MBD - Cochrane Library, Medline, Embase
42 – Health culture and health education of population

1 – Health culture – Definition A system of thoughts & behaviors shared by a group of people, which
may influence health
● Health motivation – types of motives
● Health knowledge and skills – Types; factors, influencing the health knowledge
o Education
o Income & Occupation – Ethnicity & Race
o Religion
o Political Affiliation
o Geographic Region
2 – Health education
● ealth education is any combination of learning

Definition of health education - H
experiences designed to help individuals and communities improve their health, by
increasing their knowledge or influencing their attitudes.
● Aims of health education –
o Early diagnosis and management
o Health promotion and disease prevention
o Utilization of available health services
● Phases of health education -
1. Stage of unawareness – not aware of new idea or practice
2. Stage of awareness – get some information but lacking
3. Stage of interest – show interest to know more listen, read
4. Stage of evaluation – Find out advantages and disadvantages
5. Stage of trial – puts into practice
6. Stage of Adoption – Accepts new idea as beneficial to him and adopts it.
3 – Models of health education
● Traditional model of health education

● Model of shared health education
● Promoting model of health education
4 – Methods of health education
● Classical methods –
o Verbal method – includes anything heard such as spoken words, health talk, music,
sounds etc.
o printed method – it generally involves the the exchange of facts, ideas and opinions
through a written instrument/material (posters, Leaflets, flipcharts)
o visual method – include something seen, for example models, real objects, and
photographs, written words are not included under visual methods. (real objects,
such as if you are displaying ‘family planning methods’ include condoms, IUD’s and
the pill.
o mixed method – Audio-visuals are multi-sensory materials combine both seeing and
listening.
● Modern methods – social learning, diffusion of innovations, social immunization, mass-
media strategies
43 - Prophylactics – Primary, Secondary and tertiary dispanserization.

1 – Prevention
Definition - guarding from or preventing the spread or occurrence of disease or infection
Aims - Disease prevention focuses on prevention strategies to reduce the risk of developing chronic
diseases and other morbidities.
2 – Types of Prevention
Primary prevention – Definition, expected benefits - aims to prevent disease or injury before it ever
occurs. This is done by preventing exposures to hazards that cause disease or injury, altering
unhealthy or unsafe behaviours that can lead to disease or injury, and increasing resistance to
disease or injury should exposure occur.
Secondary prevention – Definition, main instrument of secondary prevention - Secondary

prevention aims to reduce the impact of a disease or injury that has already occurred. This is done
by detecting and treating disease or injury as soon as possible to halt or slow its progress,
encouraging personal strategies to prevent re-injury or recurrence, and implementing programs to
return people to their original health and function to prevent long-term problems. Examples include:
• regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms
to detect breast cancer)
• daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks
or strokes
• suitably modified work so injured or ill workers can return safely to their jobs.
Tertiary prevention – Definition - Tertiary prevention aims to soften the impact of an ongoing
illness or injury that has lasting effects. This is done by helping people manage long-term,
often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order
to improve as much as possible their ability to function, their quality of life and their life expectancy.
3 – Screening
● Definition - in medicine, is a strategy used in a population to identify the possible presence

of an as-yet-undiagnosed disease in individuals without signs or symptoms
● Necessary conditions for screening
• Types of screening - Mass screening : Mass screening means, the screening of a whole
population or a subgroup. It is offered to all, irrespective of the risk status of the individual.
• High risk or selective screening : High risk screening is conducted among risk populations
only.
• Multiphasic screening : It is the application of two or more screening tests to a large
population at one time instead of carrying out separate screening tests for single diseases.
● When done thoughtfully and based on research, identification of risk factors can be a
strategy for medical screening.
44 – Health promotion – basic points & social medical importance

1 – Definition of health promotion
● Ottawa charter for health promotion – Defines health promotion as ‘the process of enabling
people to increase control over their health and its determinants, and thereby improve their
health’
● Prerequisites of achieving good health – income, housing, food, security, clean water, a
stable eco system, peace, employment and quality working conditions.
● Aims and meaning of health promotion –
o aims at making (political, cultural economic, social, environmental and biological
factors) favourable through advocacy for health.
o Demands coordinated action by all concerned, i.e. government, health services,
citizens, social and professional groups, managers, non-govermental organizations,
political.
2 – Main principles of health promotion
● Building a healthy public policy

● Establishing and strengthening a healthy living environment
● Increasing the public participation in health activities
● Developing the personal knowledge, skills and abilities for consolidation of health
3 – Difference between promotion of health prevention
Final aim of health promotion is improved healthy state of the population through creating a healthy
lifestyle of the person, the group and the society. Therefore health promotion will include actions
directed at both the determinants of health that are outside the immediate control of individuals.
Including social economic and environmental conditions and the determinants within the more
immediate control of individuals.
Disease prevention focuses on prevention strategies to reduce the risk of developing chronic
diseases and other morbidities.
4 – Projects of the WHO for health promotion
● Cities for health promotion

● Schools for health promotion – encourage students to eat healthily and follow a nutritional
diet, participate in physical activities as listed in the next point.
● Working-place for health promotion – encouraging workers to become more physically
active.
o Encouraging to walk, cycle, jog…
o Allowing flexible timing for workers to accommodate physical activity.
o Joining a corporate membership scheme with local leisure services.
o Encouraging participation in local and national events, such as sponsored walks.
5 – Approaches for health promotion
Geoffrey Rose proposed His ideas on the approach for health promotion based on the empirical
observation that many cases of disease arise in people who are not in a high-risk group. Moreover,
the number of cases arising from the population at average risk is often greater than the number
occurring in the population at high risk simply because there are so many more people in the
average-risk population.
● High-risk – health promotion in this group is targeted towards groups of individuals who are
at high risk of developing certain conditions.
● Population-based – Geoffrey Rose proposed that preventing disease by trying to shift the
entire population distribution of a risk factor can be more efficient than focusing
interventions solely on people at high risk.

Social Medicine: 1. Social Medicine As A Science - Subject, Objectives and Methods

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Social Medicine: 1. Social Medicine As A Science - Subject, Objectives and Methods

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Social Medicine 2017

1. Social medicine as a science – subject, objectives and methods

Diseases – Impairment – Disability – Handicap

● Impairment ​– ‘Any loss of psychological, physiological or anatomical structure or function.

Interviews are a far more personal form of research than questionnaires.

Types of interviews include:

1) Individual and group interviews

Types of observations include:

1) According to who makes the observation:

3) According to the level of anonymity:

Objectives and methods of social medicine – Historical method (2)

● Personality of the patient

Objectives and methods of social medicine – Statistical (3)

Objectives and methods of social medicine – Epidemiological method (4)

Epidemiology has ​three main aims​:

1) To describe the distribution of a disease

2. Historical development of social medicine

3. Basic methods of social medicine.

2)Statistical method:​Statistical method includes the common trends of diseases demographically.

● GDP (Gross Domestic Product)

Methods of birth control:

4. Health and disease – upto date definitions

● The health as a status

Health defined by the WHO:

The new philosophy of health:

● Health is a fundamental human right

Diseases​ ​Impairment​ ​Disability​ ​Handicap

● Impairment ​– ‘Any loss of psychological, physiological or anatomical structure or function.

5. Social factors of health and disease. Classification

● Negative definition of health:

Social factors of health and disease:

Social factors include:

● Social factors that act on a population level :

6. Socio-medical approach in medical doctor’s activity – social history of Health

The key information required are:

2) Objective status​ – Complaints, symptoms – pain; type of pain; duration, Occurrence

7. Sociological method. Essence. Types. Application in medical practice.

Sociology​ studies the social interrelations among people.

Medical Sociology​ is studying health, health behaviour and health institutions.

Applications of Medical Sociology include:

▪ Field of Public Health

▪ Inquiry Methods – ​e.g. Questionnaires, Surveys

o Direct Inquiry –​ Group, Individual, Mail filled out by researched individual(s)

1. Open-ended Questions: ​Response can be whatever the respondent wants

8. Epidemiological method. Essence and application in medical practice.

Epidemiology has three main aims:

1. Describe the Distribution of a Disease ​– Epidemic, Pandemic, Prevalence

Cause ​can be either:

➢ External Agents​ (microbe, chemical agent) which results in a disease

Measurements in epidemiology can be expressed as:

1. Descriptive ​– Description of the occurrence of a disease in a population

9. Descriptive epidemiological method. Essence and application in medical

Procedures in Descriptive studies are:

1. Define Population to be studied

6. Formulation of etiological hypothesis (causes)

10. Analytical epidemiological method. Case-control studies. Risk assessment

With Disease Without

▪ Odds Ratio Interpretation

11. Analytical Epidemiological Method. Cohort Studies. Risk Assessment

Advantages of Cohort Studies:

Disadvantages of Cohort Studies

➢ They are time consuming and expensive.

● Impairment – ‘Any loss of psychological, physiological or anatomical structure or function.

Epidemiology has three main aims:

2)Statistical method:Statistical method includes the common trends of diseases demographically.

Diseases Impairment Disability Handicap

● Impairment – ‘Any loss of psychological, physiological or anatomical structure or function.

2) Objective status – Complaints, symptoms – pain; type of pain; duration, Occurrence

Sociology studies the social interrelations among people.

Medical Sociology is studying health, health behaviour and health institutions.

▪ Inquiry Methods – e.g. Questionnaires, Surveys

o Direct Inquiry – Group, Individual, Mail filled out by researched individual(s)

1. Open-ended Questions: Response can be whatever the respondent wants

1. Describe the Distribution of a Disease – Epidemic, Pandemic, Prevalence

Cause can be either:

➢ External Agents (microbe, chemical agent) which results in a disease

1. Descriptive – Description of the occurrence of a disease in a population

The RR can be calculated only in cohort studies. It varies between 0 and ∞

Registration of vital events keeps a continuous check on demographic changes. If registration of

Developed countries have a lower birth rate than underdeveloped countries .

1-Anthropometric (related to measuring structure/anatomy): height, weight, chest

2-Physiometric (related to measuring physiological processes): vital capacity, muscular

3-Somatoscopic (related to assessing external manifestations): build, muscular development,

1) Through registered cases of diseases in health facilities:

2) Through the data for cause of disease

3) Through the data from prophylactic examinations (preventive examination)