Introduction To Public Health

Introduction to Public Health
By Dawit F. (MPH, Epidemiology)

E-mail: firdisadawt@gmail.com
School of Public Health
SPH1 FOR MEDICINE STUDENTS

Course contents
➢Introduction to public health
➢Health and Socio-economic factors
➢Ecology and environmental health
2 IPH Friday, April 12, 2024

Introduction to public health

Learning Objectives
After this course, you will be able to
➢ Describe health and the purpose of Public health
➢ Define key terms used in public health
➢ Recognize the core public health functions and services
➢ Describe the role of different stakeholders in the public health
➢ list some determinants of health
➢ Recognize how individual determinants of health affect population

health
4
Health
✓ Health is a highly subjective concept, Why?
✓ Good health means different things to different people.
✓ Lay Point of view: doing their activities with no apparent symptoms of

disease and the state of being free from illness or injury
✓ Professional points of view: state of the physical bodily Organs, and the
ability of the body as a whole to function and refers to freedom from
medically defined diseases.
✓ WHO definition of health; “a state of complete physical, mental, and
social well being and not merely the absence of disease or infirmity.”
✓ Is the ability to lead socially and economically productive life”

Health...
Positive health
⚫ Perfect continuing adjustment between the individual and
the environment.
⚫ This indicates that health is a positive dynamic interaction
between the individual and his surroundings with proper
acclimatization to maintain health.
Negative/marginal health
▪ If the individual is in a state of equilibrium, he looks
healthy, but he has no ability to adjust himself to his
surroundings, then he is going to fall ill on the slightest
adverse stimulus.

Disease
 Disease is a state of departure from normal to the extent that
the ordinary physiologic processes are not enough to restore

the body to its normal functions.
▪ Unapparent disease (also called pre-clinical) is not
recognized by the individual, but can be discovered through

screening tests.
▪ Apparent disease
 An individual is aware that s/he is suffering from an illness,
whether s/he seeks medical care or not.

Diseases are classified by Severity and Duration:
▪ Acute – disorder with sudden onset, relatively severe, and
short duration of symptoms (e.g. common cold)
▪ Chronic – develops slowly, lasting over long periods if not a

lifetime (e.g. tuberculosis)
▪ Subacute disease- intermediate between acute and chronic.
▪ Latent disease- agent remains inactive for a period of time,

but then activates to cause disease.
Public Health Definition and Key Terms
➢ Public Health “The science and art of preventing disease, prolonging

life, and promoting health through the organized efforts and informed
choices of society, organizations, public and private communities, and
individuals.”
➢ The concept of public health is not unique and has changed over the
years due to changes in the health status of the population and the
determining situations of health.
➢ This means that public health aims to create the right conditions in
order to provide the state of health for the benefit of society.
Public health…
➢ Public health works to ensure the equitable distribution of
health promotion and disease prevention efforts across and
within populations (e.g., race, gender, ethnicity,
community).
➢ It includes health communication campaigns, disease
monitoring and investigation, mobilization of
communities around health issues, development of health
policy and plans, and enforcement of laws to create
healthy environments.

PH…
➢ Public health is a science and art of saving the lives of
millions at once by single decision or intervention
Public Health Key Terms
➢Clinical/health care: prevention, treatment, and management of illness and

the preservation of mental and physical well-being through the services offered
by Medical and allied health professions.
➢Determinant: factor that contributes to the generation of a trait.

➢Epidemic or outbreak: occurrence in a community or region of cases of an
illness, specific health-related behavior, or other health-related event clearly in
excess of normal expectancy.
➢Both terms are used interchangeably; however, epidemic usually refers to a
larger geographic distribution of illness or health-related events.
➢Health outcome: result of a medical condition that directly affects the

length or quality of a person’s life.
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The Mission of Public Health
“Fulfilling society’s interest in

assuring conditions in which
people can be healthy.”
“Public health aims to provide

maximum benefit for the largest
number of people.”
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Goals of Public Health
1. Prevents epidemics and the spread of disease
2. Protects against environmental hazards
3. Prevents injuries
4. Promotes and encourages healthy behaviors
5. Responds to disasters and assists communities in recovery
6. Assures the quality and accessibility of health services

Comparison of Clinical Medicine and Public Health Practice
Clinical Medicine Public Health- Population Medicine
✓Take a history of the current illness Ask ✓Problem identification; anecdotes, focus
directed questions groups, basic population health indicators,
✓Review of symptoms ✓Surveillance statistics, Disease registries
✓Physical examination of the patient ✓Behavioral risk studies, observational
studies; cross sectional studies, case control
✓Develop a single or differential diagnosis ✓Develop a hypothesis

✓Conduct tests to confirm the diagnosis or ✓Case control studies, prospective cohort
reduce the number in the differential studies,
✓Evaluates possible modes of treatment- ✓Evaluates modes of treatment- Outcome
Clinical studies evaluation Cost-benefit analysis
✓Treat the problem ✓Select, modify and implement programs

✓Monitor results ✓Monitor outcome indicators
✓Adjust treatment plan as necessary ✓Revise programs as necessary

A Public Health Approach
Risk Factor Intervention

Surveillance Implementation
Identification Evaluation
16 IPH 16
Friday, April 12, 2024
Cholera — A Public Health Approach
Cholera, a fatal intestinal disease, was

rampant during the early 1800s in
London, causing death to tens of
thousands of people in the area.
Cholera was commonly thought to be
caused by bad air from rotting organic
matter.
Photo: TJ Kirn, MJ Lafferty, CMP Sandoe, and R Taylor,

Dartmouth Medical School

John Snow, Physician
John Snow is best known for his work tracing

the source of the cholera outbreak and is
considered the father of modern epidemiology.
Photo: London School of Hygiene

and Tropical Medicine

Epidemiology — What is the Problem?
Cluster of Cholera Cases, London — 1854
Image: The Geographical Journal
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Risk Factor Identification — What Is the Cause?
Cluster of Cholera Cases and Pump Site Locations
Image: The Geographical Journal

Intervention Evaluation — What Works?
➢Through continuous research, Snow understood what
interventions were required to

✓ stop exposure to the contaminated water supply on a
larger scale, and
✓ stop exposure to the entire supply of contaminated

water in the area

Implementation — How Do You Do It?
John Snow’s research convinced the

British government that the source of
cholera was water contaminated with
sewage
Photo: Justin Cormack

Basic Six Services of Local Public Health
1. Vital statistics—collection and interpretation.

2. Sanitation.
3. Communicable disease control, including immunization
4. Maternal and child health (MCH)
5. Health education
6. Laboratory services to physicians.

Three Core Functions of Public Health
Systematically collect, analyze,
Assessment and make available information
on healthy communities
Policy Promote the use of a scientific

Development knowledge base in policy and
decision making
Assurance Ensure provision of services to

those in need
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Ten Essential Public Health Services
1. Monitor Health
2. Diagnose and Investigate
3. Inform, Educate, Empower
4. Mobilize Community Partnership
5. Develop Policies
6. Enforce Laws
7. Link to/Provide Care
8. Assure a Competent Workforce
9. Evaluate
10. Research

Core Functions at Government Levels
Policy
Assessment Development Assurance
Smoking ban
Federal National tobacco Federal grants
on commercial
public health for antismoking
flights/public
surveillance research
Funding
Monitor state Increase
State tobacco use tobacco tax
for campaign
Resources to help
Report on local County laws smokers quit
tobacco use prohibiting in multiple
Local smoking in bars languages

Stakeholder Roles in Public Health
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Partners in the Public Health System
Clinical Care
Community Delivery System
Government Ensuring the Conditions Employers

Public Health for Population Health and Businesses
Infrastructure
Academia The Media

Nongovernmental Organization Examples
Organization Type Example

Professional membership Ethiopian Public Health
organizations Association
Associations related to a specific Ethiopian heart Society

health concern
Organizations of citizens focused XXXXX for Nonsmokers Rights

on health concerns
Foundations that support health Dipora Foundation

projects and influence public
policy development
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Health Care as a Partner in Public Health
Public Health Health Care
Population focus Individual patient focus
Public health ethic Personal service ethic
Prevention or public health emphasis Diagnosis and treatment emphasis
Joint laboratory and field involvement Joint laboratory and patient

involvement
Clinical sciences peripheral to Clinical sciences essential to
professional training professional training
Public sector basis Private sector basis

Other Partners in Public Health
• Vehicle for public discourse
Media • Health education and promotion
• Health communication
• Social media as catalyst
• Employer-sponsored health insurance programs
Employers • Wellness initiatives and benefits
and Businesses • Healthy workplaces and communities
• City planning
Government
• Education
Agencies • Health in all policies
• Education
• Training
Academia • Research
• Public Service
Determining and Influencing the Public’s
Health
33
Health Determinants
❖ Biological
❖ Health behaviors
❖ Environmental
❖ Social or societal characteristics
❖ Health services or medical care
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What Determines the Health of a Population?
Genes and Biology
Social/Societal
Characteristics;
Total Ecology Health Behaviors
Medical Care
35
Contemporary Concept of Health…
❖ Biologic or host factors include: ❖ Environmental Determinants:
– Genetics
Environment includes:
– Behaviors that determine the
– physical environment
susceptibility of the individual to disease
– conditions of living
❖ Social Determinants: – toxic agents
▪ Social factors include: – infectious agents
– Poverty
– Education
– Cultural environments (including
discrimination )
➢According to WHO, 40% of deaths
worldwide are due to these 10 risk factors
alone (behaviors).
➢Global life expectancy could be increased by

5-10 years if we reduce these risks.

Health Impact Pyramid
39
Health Impact Pyramid
40
Medical Care as a Determinant
❖Inadequate health care may account for 10%
of premature death
❖Health care receives by far the greatest share
of our resources and attention

Medical Care as a Determinant
❖ Missing routine or preventive medical care can lead to the need
for emergency care or even to preventable hospitalizations.
❖Lack of access to transportation due to:
– Not owning a vehicle,
– Not having a vehicle available via a friend or family member,
– Or not having access to public transportation can lead to
difficulty in seeking medical care.

Determinants of Health

Social determinants of Health

Social determinants of Health
 Health and health problems result from a complex
interplay of a number of forces.
➢ An individual’s health-related behaviors , particularly diet,
exercise, smoking,
➢ Surrounding physical environment,
➢ Health care( access and quality)
All contribute significantly to how long and how well we
live.
 These factors are collectively known as Social
determinants of Health.

Components of the SDH
There are four major components of SDH
1. Physical environment
2. social environment
3. life style and behaviors
4. economic environment

Components of the SDH

Core determinants of health

SDH…

Health disparity
Difference in health that is closely linked with social or
economic disadvantage.
Health disparities negatively affect groups of people who

have systematically experienced greater social or economic
obstacles to health.
These obstacles stem from characteristics linked to:
➢ discrimination or exclusion such as race or ethnicity, religion,
➢ socioeconomic status, gender, mental health,
➢ sexual orientation, or geographic location.
➢ Other characteristics physical disabilities,…etc.

WHO commission reports on the SDH
components contribution

SDH contribution in early death
Source: Schroeder SA. N Engl J Med 2007;357:1221-1228.

SDH/life stle and behaviors contribution in death

SDH vs health outcome

Brain storming?
Why is the life expectancy scored 80 years in some
countries and less than 50/45 in other countries?

Why such a huge gap? Reasons for health inequalities
➢ Variation in degrees of social disadvantage.
➢ The circumstances in which people grow, live, work, and
age, and the systems put in place to deal with illness.
➢ The conditions in which people live and die are, in turn,
shaped by political, social, and economic forces.
➢ The unequal distribution of power, income, goods, and
services, globally and nationally,

Reasons for health inequalities…
➢ the consequent unfairness in the immediate, visible
circumstances of peoples lives
➢ their access to health care, schools, and education,
➢ their conditions of work and leisure, their homes,
communities, towns, or cities
➢ their chances of leading a flourishing life.
➢ The planning and design of urban environments that has a
major impact on health equity through its influence on
behavior and safety.
➢ The daily conditions in which people live have a strong
influence on health equity
➢ Policies and investment patterns reflecting the urban-led
growth paradigm
 rural communities worldwide, including Indigenous Peoples
suffer from progressive underinvestment in infrastructure and

amenities.
 with disproportionate levels of poverty and
 poor living conditions.
 outmigration to unfamiliar urban centers.

➢ Urbanization poses significant environmental challenges,
particularly climate change

✓ greater in low-income countries and among vulnerable
subpopulations.
➢ The disruption and depletion of the climate system
✓ Greenhouse gas emissions (…transport and buildings,
agricultural activity)

Why is the healthy society needed?
➢ The development of a society, rich or poor, can be
judged by the quality of its population’s health.
➢ how fairly health is distributed across the social
spectrum and the degree of protection provided from

disadvantage as a result of ill-health.

Why is the healthy society needed?...
➢ The poorest of the poor have high levels of illness and
premature mortality.
➢ In countries at all levels of income, health and illness
follow a social gradient,

o the lower the socioeconomic position, the worse the health
conditions.

R/ship between income and Health
Higher income buys better quality healthcare
➢ More resources for goods/ services that results in
better health care outcomes.
➢ Parents adopt better health care practices also tend
to be “more productive” resulting in better

outcomes for their children.

Universal Health Care as a social determinants of health
➢ Access to and utilization of health care is vital to good
and equitable health.
➢ The health-care system is itself a social determinant of
health, influenced by and influencing the effect of other
social determinants.
➢ Gender, education, occupation, income, ethnicity, and
place of residence are all closely linked to people’s
access to, experiences of, and benefits from health care.
➢ Leaders in health care have an important stewardship
role across all branches of society to ensure that policies
and actions in other sectors improve health equity.
Recommendations for health inequalities
➢ 1. Communities and neighborhoods that ensure access to
basic goods, that are socially cohesive, that are designed to

promote good physical and psychological well-being and
that are protective of the natural environment are essential
for health equity.

Recommendation…
2. Build health-care systems based on principles of equity,

disease prevention, and health promotion.
➢ Build quality health-care services with universal coverage,
focusing on Primary Health Care(PHC).
➢ Strengthen public sector leadership in equitable healthcare
systems financing, ensuring universal access to care

regardless of ability to pay.

Recommendation…
3. Build and strengthen the health workforce, and expand
capabilities to act on the social determinants of health.
➢ Invest in national health workforces, balancing rural and
urban health-worker density.
➢ Act to redress the health brain drain, focusing on
investment in increased health human resources and
training and bilateral agreements to regulate gains and
losses.

Recommendation…
➢ Reducing the health gap in a generation requires that
governments build systems that allow a healthy standard of

living below which nobody should fall due to circumstances
beyond his or her control.
➢ Social protection schemes can be instrumental in realizing
developmental goals, rather than being dependent on

achieving these goals – they can be efficient ways to reduce
poverty, and local economies can benefit.

Recommendation…
5. Establish and strengthen universal comprehensive social

protection policies that support a level of income sufficient for
healthy living for all.
➢ Progressively increase the generosity of social protection
systems towards a level that is sufficient for healthy living.
➢ Ensure that social protection systems include those
normally excluded: those in precarious work, including

informal work and household or care work.

Recommendation…
6. Tackle the Inequitable distribution of Power, Money,

and Resources
➢ Inequity in the conditions of daily living is shaped by
deeper social structures and processes.
➢ The inequity is systematic, produced by social norms,
policies, and practices that tolerate or actually promote
unfair distribution of and access to power, wealth, and
other necessary social resources.
Recommendation…
7. Place responsibility for action on health and

health equity at the highest level of government, and
ensure its coherent consideration across all policies.

Recommendation…
8. Strengthen public finance for action on the social

determinants of health.
➢ Build national capacity for progressive taxation and
assess potential for new national and global public
finance mechanisms.
➢ Increase international finance for health equity, and
coordinate increased finance through a social
determinants of health action framework.
➢ Fairly allocate government resources for action on the
social determinants of health.

Recommendation…
9. Address gender biases in the structures of society – in laws and
their enforcement, in the way organizations are run and interventions
designed, and the way in which a country’s economic performance is
measured.
➢ Create and enforce legislation that promotes gender equity and
makes discrimination on the basis of sex illegal.
➢ Strengthen gender mainstreaming by creating and financing a
gender equity unit within the central administration of governments
and international institutions.
➢ Include the economic contribution of housework, care work, and
voluntary work in national accounts.
➢ Increase investment in sexual and reproductive health services and
programs, building to universal coverage and rights.
Recommendation…
10. Ensure that routine monitoring systems for health
equity and the social determinants of health are in place,
locally, nationally, and internationally.
✓ Ensure that all children are registered at birth without
financial cost to the household.
✓ Establish national and global health equity surveillance
systems with routine collection of data on social
determinants and health inequity

Recommendation…
11. Provide training on the social determinants of health to
policy actors, stakeholders, and practitioners and invest in
raising public awareness.
✓ Incorporate the social determinants of health
into medical and health training, and improve
social determinants of health literacy more
widely.
✓ Train policy-makers and planners in the use
of health equity impact assessment

Identifying Community Health Problems
Learning Objectives
After this session, you will be able to:
➢ Describe Community diagnosis, assessment and Analysis
➢ Recognize steps and Sources of information for

community health problems identification
➢ List and identify Indicators of health status of a population
➢ Recognize Major strategies of improving public health
➢ Natural history of disease and level of diseases prevention
77
Community Diagnosis
1

1. Community D….
❖ According to WHO definition--- it is “a quantitative and
qualitative description of the health of citizens and the
factors which influence their health.
❖ It identifies problems, proposes areas for improvement and
stimulates action”.
❖ It is Comprehensive assessment of health status of the
community in relation to its social, physical and biological
environment.

Comparing clinical diagnosis with
community diagnosis
Clinical diagnosis Community diagnosis
1. Obtain health awareness of the community by
1. Obtain a history of the patients’
symptoms. informal meeting and discussions.
2. Examine the patient and 2. Obtain measurable facts of causes through
observe sign. basic demographic survey. (indicator)
3. Perform laboratory test , x-ray 3.
Conduct specific survey based on finding of
and others. basic demographic survey.
4. To infer causation from the
history and test result to make the 4. Make inference from the data (indicator) to
diagnosis. make the community diagnosis.
5. Provide treatment. 5. Prescribe community treatment or community

health action as part of community health
6. Follow-up and assess effectiveness programme.
of the treatment.
6.Evaluate (follow-up) the effect of community
IPH
80 health action Friday, April 12, 2024
Dimensions of the Community
❖ Any community have three features:
✓Population,
✓Social system,
✓Location
Community Diagnosis use
45
❖ Identify trends in illness, injury, and death and the
factors, which may cause these events.
❖ Identify available resources and their application
❖ Identify unmet needs
❖ Identify community perceptions about health
❖ Collect data regarding specific populations….

2. CommunityAssessment and Analysis
43
❖CA is the regular collection, analysis and sharing of information
about health conditions, risks and resources in a community.
❖Community analysis is the process of examining data to

define needs, strengths, barriers, opportunities,
readiness, and resources.
✓The product of analysis is the “community profile”.

Types of Community diagnosis
❖Comprehensive community diagnosis

✓Aims to obtain general information about the
community
❖Problem Oriented community diagnosis
✓Responds to a particular need

❖Analyze the health status.
❖Evaluate the health resources, services, and systems of care.
❖Assess attitudes toward community health services and issues.
❖Identify priorities, establish goals, and determine courses of
action to improve health status.
❖Establish epidemiologic baseline for measuring improvement over
time.
❖Gets community members, stakeholders and a wide variety of
partners

Sources of Data
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❖Routine reporting from health facilities
❖Surveillance :active, passive.
❖Screening
❖Surveys
❖Contact tracing
❖Vital registration
❖A combination of several methods

Core activities performed during
conducting CD
a. Casual visit to the community (spot map, informal
discussion with community members)
b. Preliminary data from the respective community (secondary)
c. Tentative household survey schedule preparation and
pre- testing.
d. Making plan of action (emphasis on
dates/places/activities/group division/group coordinator etc.)

Core activities…
 Collect data:
a. Primary data (through household survey)
b. Secondary data (through records of different organizations)
c. Tools for data collection
d. Techniques for data collection
e. Data editing
f. Data analysis and interpretation
Finding presentation

Community Diagnosis steps :
76
1- Determine the objectives
2- Define the study population
3-Determine the data to be collected
4- Developing the instruments
Survey questionnaires
Interview guides
Observation checklist

Steps…..
78
5- Collecting the data

✓ Records review
✓ Surveys
✓ Interviews
✓ Observation(Participant and Non Participant)
6-Actual data gathering/collection

Steps……..
79
7-Data Analyses
8- Problem identification :
✓( Magnitude, Trend, Comparison )
✓ (Health Status , Health –related, Health Resource)

Steps….
80
9- Priority-setting
❖ Nature of the condition/problem presented
➢ Classified as health status, health resources or health
related problems
❖ Magnitude of theproblem
➢ Severity of the problem which can be measured in terms of

the proportion of the population affected by the problem
Steps ….
81
9- Priority-setting….
❖ Modifiability of the problem
◼ Probability of reducing, controlling or
eradicating the problem
❖ Preventive potential
◼ Probability of controlling or reducing the effects
posed by the problem
❖ Social concern
◼ Perception of the population or the community as
they are affected by the problem and their readiness
95 IPH
to act on the problem Friday, April 12, 2024
Health Indicators
❖Are quantitative or statistical measures or

instruments used for the measurement of health
status of individuals or defined group.

❖Valid: Measure what they are supposed to measure.
❖Reliable and objective: the same if measured by different
people in similar circumstances
❖Sensitive: to changes in the situation concerned
❖Specific: reflect changes only in the situation concerned
❖Feasible: Have the ability to obtain data needed
❖Relevant: Contribute to the understanding of the
phenomenon of interest.
❖ Mortality ❖ Social and mental health
❖ Morbidity ❖ Environmental
❖ Disability rates ❖ Socio-economic
❖ Nutritional status ❖ Health policy
❖ Health care delivery ❖ Quality of life
❖ Utilization rates

Mortality Indicators
Mortality Rates
-
✓ Crude death rates
-
✓ Specific death rates: age/disease
✓ Expectation of life
✓ Infant mortality rate
✓ Maternal mortality rate
✓ Proportionate mortality ratio
✓ Case Fatality rate

Morbidity Indicators
Morbidity rates
✓Incidence and prevalence
✓.Attendance rates: out-patient clinics or health centers.
✓Admission and discharge rates
✓Hospital stay duration rates

Disability Indicators
Disability rates
✓ No. of days of restrictedactivity
✓ Bed disability days
✓ Work/School loss days within a specified

period.
✓ Expectation of life free of disability

Nutritional Indicators
Nutritional Status
Indicators
➢ Anthropometrics measurements
➢ Height of children at school entry
➢ Prevalence of low birth weight
➢ Anemia, Hypothyroidism, Night blindness

Health Care Delivery Indicators
Health CareDelivery Indicators

• Reflect the Equity / Provision of health carre
❖Physician / Population ratio
❖Physician/ Nurse ratio
❖Population / Bed ratio
❖Population / Health center

Utilization Indicators
Health care utilization Rates
- Extent of use of health services ❖ Proportion of infants who are fully
- Proportion of people in need of service who st year of
actually receive it in a given period immunized in the 1
life. “immunization coverage”.
❖ Proportion of pregnant women
who receive ante-natal care.
❖ Hospital-Beds occupancy rate.

Social/MentalHealthIndicators
Indicators of Social and
Mental Health
- Valid positive indicators does not
often exist
- Indirect measures are commonly used
❖ Suicide &Homicide rates
❖ Road traffic accidents
❖ Alcohol and drug abuse.

Environmental Indicators
Environmental health Indicators
- Reflect the quality of environment
✓ Measures of Pollution
✓ Proportion of people having access to safe
water and sanitation facilities
✓ Vectors density

Socio-economicIndicators
Socio-economic Indicators
- Is not a direct measure of health status.
- For interpretation of health care indicators.
✓ Rate of population increase
✓ Per capita GNP
✓ Level of unemployment
✓ Literacy rates – females
✓ Family size
✓ Housing condition e.g. No. of persons
per room

Health Policy Indicators
Health Policy Indicators
- Allocation of adequate resources.
✓ Proportion of GNP spent on health services.

✓ Proportion of GNP spent on health related activities.
✓ Proportion of total health resources devoted to primary health care

Major strategies of improving public health
❖Formulating health policy
❖Investing on education
❖Implementing HEP
❖Supporting community based health service
❖Strong leadership
❖Strong partnership with private and NGOs
❖Health system and sustainable development
❖Evidence based and scientific information and …etc

Natural history of disease and levels of
prevention

Learning objectives
At the end of this session the student should be able
to:
 Define the natural history of disease and its
different stages
 Describe the levels of disease prevention
 Apply these concepts in relation to diseases/health
problems of public health importance in the country

Natural history of disease
 The “natural history of disease” refers to the
progression of disease process in an individual over
time, in the absence of intervention.
 The process begins with exposure to or

accumulation of factors capable of causing disease.
 Without medical intervention, the process ends with

recovery , disability, or death

Natural history of disease
 Each disease has its own life history, and thus, any
general formulation of this process is arbitrary.
 However, it is useful to develop a schematic picture of

the natural history of diseases as a frame work within
which to understand and plan intervention measures
including prevention and control of diseases.

Natural history of a disease
Usual time of
diagnosis
Onset of Non-diseased
Exposure
Pathologi symptoms - Immune
- Carrier
c changes - Dead
-- Recovered
Stage of Stage of
Stage of Sub-clinical Stage of
susceptibi recovery,
disease Clinical
lity disability
disease
or death

Cont.…
There are four stages in the natural history of a disease.
These are:
1. Stage of susceptibility
2. Stage of pre-symptomatic (sub-clinical) disease
3. Stage of clinical disease
4. Stage of disability or death

Cont.…
I. Stage of susceptibility
In this stage, disease has not yet developed, but the
groundwork has been laid by the presence of
factors that favor its occurrence.
Examples:
 A person practicing unprotected sex has a high risk
of getting HIV infection.
 An unvaccinated child is susceptible to measles.
 High cholesterol level increases the risk of coronary
heart disease.

Cont.…
II. Stage of Pre-symptomatic (sub-clinical) disease
 In this stage there is no manifestation of disease but
pathologic changes have started to occur.
 There are no detectable signs or symptoms.
 The disease can only be detected through special

tests.

Cont.…
Examples:
 Detection of antibodies against HIV in an apparently
healthy person.
 Ova of intestinal parasite in the stool of apparently

healthy children.
 The pre-symptomatic (sub-clinical) stage may lead to
the clinical stage, or may sometimes end in recovery
without development of any signs or symptoms.

Cont…
III. The Clinical stage
❑ By this stage the person has developed signs and
symptoms of the disease.
❑ The clinical stage of different diseases differs in
duration, severity and outcome.
❑ The outcomes of this stage may be recovery,
disability or death.

Cont…
Examples:
 Common cold has a short and mild clinical stage and
almost everyone recovers quickly.
 Rabies has a relatively short but severe clinical stage
and almost always results in death.
 HIV/AIDS has a relatively longer clinical stage and
eventually results in death.

Cont…
IV. Stage of disability or death
➢ Some diseases run their course and then resolve
completely either spontaneously or by treatment.
➢ In others the disease may result in a residual defect,

leaving the person disabled for a short or longer
duration. Still, other diseases will end in death.
➢ Disability is limitation of a person's activities

Cont…
Examples:
 Trachoma may cause blindness
 Meningitis may result in blindness or deafness. It may
also result in death.

Disease prevention
 Disease prevention means to interrupt or slow the

progression of disease.
 Disease prevention:- Primary, Secondary, Tertiary

Cont.…
1. Primary prevention is aimed at preventing healthy
people from becoming sick.
 The main objectives of primary prevention are

promoting health, preventing exposure and
preventing disease
 Primary prevention keeps the disease process from

becoming established by eliminating causes of
disease or increasing resistance to disease.

Cont…
 Health promotion: consists of general non-specific
interventions that enhance health and the body's
ability to resist disease.
 Improvement of socioeconomic status, provision of

adequate food, housing, clothing, and education are
good examples of health promotion.

Cont…
▪ Prevention of exposure: is the avoidance of factors
which may cause disease if an individual is exposed
to them.
▪ Examples can be provision of safe and adequate

water, proper excreta disposal, and vector control.

Cont…
Prevention of disease: is the prevention of disease
development after the individual has become
exposed to the disease causing factors.
 The timing is between exposure and biological

onset (mark initiation of disease process).
 Immunization can be taken as a good example.

Cont…
A. Active immunization involves exposing the host to a
specific antigen against which it will manufacture
its own antibodies after three weeks interval.
Example EPI
B. Passive immunization involves providing the host

with the antibodies necessary to fight the disease. It
is commonly given after exposure.
Examples: rabies, tetanus.

Cont…
Note:
 Both active and passive immunization act after
exposure has taken place.
 Immunization does not prevent an infectious

organism from invading the immunized host, but
does prevent it from establishing an infection.

Cont…
 Breast feeding is an example of an intervention
which acts at all three levels of primary
prevention:
 Health promotion: by providing optimal nutrition
for the young child.
 Prevention of exposure: by reducing exposure of
the child to contaminated milk.
 Prevention of disease after exposure: by the
provision of anti-infective factors, including
antibodies, WBCs, and others.

Cont…
 Early detection and treatment can also be

considered a primary prevention if you may treat
them to shorten the period during which they can be
source of infection to others.

Cont…
2. Secondary prevention involves detecting people who

already have the disease as early as possible and
treat them.
 It is carried out after the biological onset of the

disease, but before permanent damage sets in.

Cont…
 The objective of secondary prevention is to stop or
slow the progression of disease and to prevent or
limit permanent damage.
Examples:
 Prevention of blindness from trachoma
 Early detection and treatment of breast cancer to
prevent its progression to the invasive stage.
 These may be achieved through screening for early
detection and early treatment

Cont…
3. Tertiary prevention is targeted towards people with
chronic diseases and disabilities that cannot be
cured.
 Tertiary prevention is needed in some diseases

because primary and secondary prevention have
failed, and in others because primary and secondary
prevention are not effective.

Cont…
It has two objectives:
 Treatment to prevent further disability or death and
 To limit the physical, psychological, social, and

financial impact of disability, thereby improving the
quality of life.
➢ This can be done through rehabilitation, which is

the retraining of the remaining functions for
maximal effectiveness.
Levels of prevention: definition, timing, objectives
Levels of Definition Timing Objectives
prevention
Primary Promotion of health and Before the biological To promote
prevention of disease onset of disease health, prevent
(=promotive and exposure. And
preventive) prevent disease
Secondary Early detection and early After the biological To stop or slow
treatment of disease onset but before the the progression of
(=curative) onset of permanent disease so as
damage prevent or limit
permanent
damage
Tertiary Limitation of disability After the onset of limit the physical,
and rehabilitation permanent damage psychological,
(=rehabilitative) social, and
financial impact
of disability
(prevent further
disability or
death)
Cont…
Examples:
 Blindness due to vitamin A deficiency occurs when

primary prevention (adequate nutrition) and
secondary prevention (early detection of corneal
ulcers) have failed, and damage to the cornea
(keratomalacia) can not be treated.
 Tertiary prevention (rehabilitation) can help the

blind or partly blind person learn to do gainful work
and be economically self supporting.

Cont…
 Diabetes mellitus is a disease that can not really be
prevented or cured so primary and secondary
prevention are not effective.
 Hence, the goal of tertiary prevention in diabetics is to

control the level of their blood sugar using drugs and/
or diet, and to treat complications promptly in order to
improve the quality of life, prevent permanent
damages such as blindness, and prevent early death.

Trachoma:-
 Primary prevention:-improving basic sanitation,
including availability and use of soap and water,
avoid common use of towel
 Secondary prevention:-early detection and early

treatment to prevent blindness
 Tertiary prevention:-Rehabilitation for blind person

(limit the physical, psychological, social, and financial
impact of disability)

Goals and principles of communicable disease
control and prevention
Goals
 Eradication: reducing the incidence to zero level
 Elimination: reducing the incidence of disease to zero
level in specified geographic areas
 Control: reducing the incidence to the level where the
disease is no more of public health importance

Principles
1) Action on the reservoir of infection
a. Early detection and treatment: this is to stop
communicability of the disease process
b. Quarantine and isolation
 Isolation refers to the separation of persons who
have a specific infectious illness from those who are
healthy during its period of communicability

 Quarantine refers to the separation and restriction of
movement of persons or animals who, while not yet ill,
have been exposed to an infectious agent and therefore
may become infected
2) Interruption of transmission: it involves the control of
the mode of transmission from the reservoir to a
susceptible host. Eg. Control of vectors, improvement of
personal hygiene and environmental sanitation
3) Protection of the susceptible host
 At individual level: includes active and passive
immunization and chemoprophylaxis
 At the community level: host resistance at the community
(population) level is called herd immunity

Any QUESTIONS?

Introduction To Public Health

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Introduction To Public Health

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Introduction to Public Health

By Dawit F. (MPH, Epidemiology)

School of Public Health

SPH1 FOR MEDICINE STUDENTS

➢Health and Socio-economic factors

➢Ecology and environmental health

2 IPH Friday, April 12, 2024

3 IPH Friday, April 12, 2024

➢ Define key terms used in public health

➢ Recognize the core public health functions and services

➢ Describe the role of different stakeholders in the public health

➢ list some determinants of health

➢ Recognize how individual determinants of health affect population

✓ Good health means different things to different people.

✓ Lay Point of view: doing their activities with no apparent symptoms of

5 IPH Friday, April 12, 2024

6 IPH Friday, April 12, 2024

the ordinary physiologic processes are not enough to restore

▪ Unapparent disease (also called pre-clinical) is not

recognized by the individual, but can be discovered through

7 IPH Friday, April 12, 2024

▪ Chronic – develops slowly, lasting over long periods if not a

▪ Subacute disease- intermediate between acute and chronic.

▪ Latent disease- agent remains inactive for a period of time,

➢ Public Health “The science and art of preventing disease, prolonging

10 IPH Friday, April 12, 2024

➢Clinical/health care: prevention, treatment, and management of illness and

➢Determinant: factor that contributes to the generation of a trait.

➢Health outcome: result of a medical condition that directly affects the

“Fulfilling society’s interest in

“Public health aims to provide

14 IPH Friday, April 12, 2024

✓Develop a single or differential diagnosis ✓Develop a hypothesis

✓Treat the problem ✓Select, modify and implement programs

15 IPH Friday, April 12, 2024

Risk Factor Intervention

Cholera, a fatal intestinal disease, was

Photo: TJ Kirn, MJ Lafferty, CMP Sandoe, and R Taylor,

18 IPH Friday, April 12, 2024

John Snow is best known for his work tracing

Photo: London School of Hygiene

19 IPH Friday, April 12, 2024

Image: The Geographical Journal

Image: The Geographical Journal

interventions were required to

✓ stop exposure to the entire supply of contaminated

22 IPH Friday, April 12, 2024

John Snow’s research convinced the

Photo: Justin Cormack

23 IPH Friday, April 12, 2024

1. Vital statistics—collection and interpretation.

24 IPH Friday, April 12, 2024

Policy Promote the use of a scientific

Assurance Ensure provision of services to

26 IPH Friday, April 12, 2024

27 IPH Friday, April 12, 2024

Government Ensuring the Conditions Employers

Academia The Media

29 IPH Friday, April 12, 2024

Organization Type Example

Associations related to a specific Ethiopian heart Society

Organizations of citizens focused XXXXX for Nonsmokers Rights

Foundations that support health Dipora Foundation