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Community Diagnosis and Epidemiology in Community Medicine

By Ricky H Hipolito, MD

Part 1 Community Diagnosis

A Scientific inquiry Determining


The collective health status of the members of a community Factors affecting health present in the community Health problems present in the community Health problem/s that can be dealt with most efficiently using the present resources, and under present circumstances.

Part 1 Community Diagnosis


A. Dimensions Secondarily Related to Health 1. Background/ Setting 1.1 Local history 1.2 Geography
Part of which Region, Municipality/ City Boundaries whether land locked, coastal or both Land area Subdivisions, political, economic or social

1.3 Climate

Part 1 Community Diagnosis


2. Demography 2.1 Geographic distribution Age sex structure (Population pyramid) 2.2 Factors such as: Migration; Age dependency (18-49 yr); Birth/death rate; Ethnic dist; Density 3. Economic life 3.1 Sources of income 3.2 Indications of economic status: Employment; Income per capita; Poverty level; Economic organizations

Part 1 Community Diagnosis


4. Social Indicators Education Housing, Communication, Transportation Recreation Sources of health care and health information Public assistance Leadership pattern

Part 1 Community Diagnosis


B. Community Dimensions Directly Related to Health 1. Health Status of the Community Top Mortality Top Morbidity 2. Environmental Indices Water Supply Excreta Disposal Vermin/ Insect Control Sanitation, Garbage Collection

Part 1 Community Diagnosis


3. Food / Nutrition Sources of food: Backyard gardens/ Markets/ Public eating establishments Prevalence of Malnutrition 4. Health Resources Manpower / Health officer: Brgy health worker, Brgy nutritionist, Midwife, Nurse, Doctor Health facilities Health financing: Public funds versus private funding Health related legislations: National; Local

Part 1 Community Diagnosis


5. Organized Community health programs Expanded program on Immunization Maternal and Child health Reproductive health Nutrition programs

Part 1 Community Diagnosis

C. Situational Analysis

Involves organizing the data presented in the preceding parts in order to decide on the health problem to be addressed and the type of interventions to be employed.
The following concepts are helpful guide in the conduct of situational analysis.

Factors affecting health and well being Protective factors Psychosocial Effective health factors services Participation in Provision of civic activities preventive and social services engagement Access to Strong social culturally networks appropriate Supportive health services family structure Community participation in the planning and delivery of health services

Healthy lifestyles

Decreased use of tobacco and drugs Regular physical activity Balanced nutritional intake Positive mental health Safe sexual activity

Factors affecting health and well being Protective factors Healthy Conditions and Environments Safe physical environments Supportive economic and social conditions Regular supply of nutritious food and water Restricted access to tobacco and drugs Healthy public policy and organizational practice Provision of meaningful paid employment Affordable housing

Risk Conditions Poverty Low social status Dangerous work Polluted environment Natural resource depletion Discrimination (age, sex race, disability)

Risk factors Psychosocial risk Behavioral risk factors factors Isolation Lack of social support Poor social networks Low self esteem Abuse Smoking Poor nutritional intake Substance abuse Poor hygiene Overweight Unsafe sexual activity

Physiological risk factors High blood pressure High Cholesterol

Adapted from: Labonte R (1998), A community development approach to health promotion: a background paper on practice, tensions, strategic models and accountability requirements for health authority work on the broad determinants of health, Health Education Board of Scotland, Research Unit on Health and Behavior Change, University of Edinburgh, Edinburgh.

Part 1 Community Diagnosis


C. Situational Analysis 1. Selection of a Target Area Usually for pilot programs: Brgy subunit; Brgy; Municipality Criteria: Feasibility; Need 2. Selection of problem to be addressed Top causes of mortality or morbidity Factors to consider Magnitude: How many affected Feasibility and Sustainability: probability of developing a sustainable health program Impact to community: Potential of disease to cause long term disability or mortality Concern of the community: Perception of the community of the seriousness of the health problem.

Part 1 Community Diagnosis


Decision Matrix Scores (Weight) Highest = 3 Factors Total

Magnitude Feasibility/ Impact to Concern of (30%) Sustainabili Community the ty (30%) (20%) Community (20%)
High Blood 2 (0.6) Pressure Parasitism 3 (0.9) 1 (0.3) 2 (0.4) 3 (0.6) 1.7

3 (0.9) 2 (0.6)

3 (0.6) 1 (0.3)

2 (0.4) 1 (0.2)

2.8 1.5

Overweight 1 (0.3)

Part 1 Community Diagnosis


3. SWOT Analysis A strategic planning tool that enables you to refine a certain health program. It allows you to focus your resources on activities with higher probability of success. Strength: Advantages present in the community; Resources that the community have; Weakness: Areas that need improvement Opportunities: Changes in technology and policy that makes it easier to carry out programs; Changes in social patterns and trends; Threats: Potential obstacles to your health project

Part 1 Community Diagnosis


4. Formulating the Problem Tree and the Objective tree There are no specific rules in the creation of these conceptual frameworks The following pointers are helpful

Part 1 Community Diagnosis


Problem Tree 1. The center is the health problem identified 2. Downward are the causes. Arrange the causes with the more immediate causes in the proximal areas and the underlying causes more downward 3. Upward are the effects. Arrange the effects with the more immediate in the proximal and the long-term in the distal areas

Part 1 Community Diagnosis

Part 1 Community Diagnosis


Objective Tree 1. The Center is the General Objective 2. Downward are the activities in order to meet the G.O. Arrange the concepts with the more immediate activities in the proximal and the preparatory activities in the more distal 3. Upward are the effects of the intervention. Arrange the concepts with the more immediate at the proximal and the long term effects at the more distal

Part 1 Community Diagnosis

Part 1 Community Diagnosis


5. General objectives The SMART principle is used in the formulation of the General objectives S - Specific M - Measurable A - Attainable R - Relevant T - Time-bound

Part 1 Community Diagnosis


Examples of General objectives: To decrease by 20% the consults for URTI in Brgy Sampiro within 10 months By the end of 2010, there would be a reduction in infant mortality rates in Pagsanjan by 75-80%

Part 1 Community Diagnosis


Workshop 1: Formulation of Health Program Objectives Objective: At the end of the allotted time, the participants will be able to formulate and present health program objectives using the SMART framework.

Part 1 Community Diagnosis


Mechanics: Participants will be grouped into 10. Each of the ten groups will be given 20 min to formulate Health program objectives which include: General objective Specific objectives After 20 min the groups will be given 5 min each to present their work and another 5 min for critiquing.

Part 1 Community Diagnosis


Workshop 2: Creation of the Problem Tree Objective: At the end of the alloted time, the participants will be able to present a problem tree based on the guidelines and example previously given.

Part 1 Community Diagnosis


Mechanics:
Participants will use the previous grouping (10 groups) They will use the health problem, gen objectives and specific objectives they used in the previous presentation They will be given 20 min to formulate their problem tree After 20 min, they will be given 5 min to present and another 5 min for critiquing

Part 1 Community Diagnosis 6. Health project plan


Specific Strategy Objective To collect Survey information on the health situation of the community Resources Budget Activity Conduct of survey in all households Time Frame Feb 13-15 2003 Persons Involved Students Barangay council

Survey forms Pens

200

Evaluation: Method Comparison with the census of 2000

Evaluation: Indicator Covering 85% of the households

Part 2 Data Gathering


1. Primary sources of data Data collected by the researcher specifically for his purpose. Interviews, focus group discussions, surveys conducted by the researchers

Part 2 Data Gathering


2. Secondary sources of data Data collected for purposes other than the researchers Sources:
Vital statistics Birth and Death certificates Disease registries National Surveys Hospital data

Part 2 Data Gathering


Sources
Hospital data Previous or ongoing research studies Data bases

Uses
Disease surveillance, estimating incidence and prevalence Cross sectional studies Retrospective studies Determining the natural history of disease

Part 2 Data Gathering


Advantages of Primary vs Secondary Data
Primary
Exact data elements are collected Interventions can be tested using an RCT The Collection process is controlled to ensure internal validity The sample maybe selected to what the researcher requires

Secondary
Less expensive Less time consuming Pooled data from secondary sources are more practical if the effect size sought is small Less ethical considerations

Part 3 Top Mortality and Morbidity Causes

Part 2 Top Mortality and Morbidity Causes

Part 2 Top Mortality and Morbidity Causes

Part 4 Epidemiology in Community Medicine


1. Introduction Epidemiology A Basic Medical Science dealing with patterns of disease occurrence. Aims to determine the distribution and determinants of disease occurrence in a given population. Disease distribution is characterized as to Person, Place, Time These data is used for:
Disease surveillance

Part 4 Epidemiology in Community Medicine


1. Introduction These data is used for:
Determining causes and/or risk factors Evaluating diagnostics and screening methods Observing the natural history of disease Designing population based interventions including preventive measures Evaluating current treatment options Determining prognosis of disease

Part 4 Epidemiology in Community Medicine

2. Relevance and purposes Primary Health Care (PHC)


Tailored to the unique needs and resources of the community and entails their full participation in the planning and implementation. With some modifications, the concepts of PHC is still an important guiding principle in how we serve the health needs of our people. National Objectives for Health 2005 2010: Health services delivery are intended to improve the accessibility and availability of basic and essential health care for all.

Part 4 Epidemiology in Community Medicine


3. Primary care epidemiology
Epidemiological principles applied in health problems encountered in primary health care (PHC). Aims to improve management by studying disease etiology, prevention and diagnosis Old concept with increasing scope in terms of information sought and personnel involved. Integrates the knowledge of different professions

Part 4 Epidemiology in Community Medicine


3. Primary care epidemiology
Studying the determinants and outcomes of consultations in primary care Studying the nature of symptom, signs or illnesses occurring in the community and the factors influencing decisions to consult or not to consult. Outcomes considered include the duration, severity and impact of signs and symptoms or illnesses. The perspective in studying disease should be attuned to that of the community.

Part 4 Epidemiology in Community Medicine

Primary Care Epidemiology Purposes


1. Improving understanding of patterns and clinical significance of common symptoms and conditions seen in primary care. 2. Providing information that can optimise the efficient use of primary care services. 3. Providing a framework for the design and targeting of feasible and acceptable interventions.
From: Hannaford PC, et al. Primary care epidemiology: its scope and purpose. Fam Practice 2006

Part 4 Epidemiology in Community Medicine


Some questions that primary care epidemiology can answer through studies at different health care levels
Health care level A. Community Patterns of illness

What are the frequency, severity, and impact of illnesses in the community? What is the natural history (duration and recurrence if untreated) of different illnesses? Does the occurrence and characteristics of illness vary with time, person, place? How are different symptoms and signs related to each other? What are the factors that influence the occurrence and characteristics of illness? How do people manage their illnesses? What factors influence people in their response to their illnesses? Does it matter that some people have illnesses, for which they do not seek health care?

Patterns of response

Part 4 Epidemiology in Community Medicine


Some questions that primary care epidemiology can answer through studies at different health care levels
Health care level B. Primary care Patterns of illness What is the range of illnesses seen by different primary care professionals? Is this range changing? What is the predictive value of symptoms, seen by different primary care professionals? Patterns of response Is primary care meeting the health care needs of the population served? What is the effectiveness of health care services given? Are investigations and referrals to secondary care optimal?

How do management decisions now affect patients' future patterns of response?

Part 4 Epidemiology in Community Medicine


Some questions that primary care epidemiology can answer through studies at different health care levels
Health care level C. Secondary care Patterns of illness What is the proportion of patients with a particular condition referred to secondary care?

Does the proportion of referred patients vary according to the age, gender, ethnicity or other characteristic of the patient or referrer?
Pattern of response Is secondary care meeting the health care needs of the population served? Could primary care be taking over some of the work of secondary care?

Part 4 Epidemiology in Community Medicine

4. Rates
Rate

Compares number of actual cases with potential cases


Actual cases (Numerator) Potential cases (Denominator) X Factor (usually 100,000)

Part 4 Epidemiology in Community Medicine

Denominator defines who is at risk. Rates are generally multiplied by a factor such as 1,000
Crude rate Rates computed with number of whole population as denominator Specific Rates computed with number specific population as denominator

Example: When computing for rate of breast cancer it is more logical to include only females, the same is true for prostate cancer

Part 4 Epidemiology in Community Medicine


Crude Birth Rate (CBR) Philippine CBR: 23.1 per 1,000 pop (2000)
# Births in 1 year Mid year population X 1,000 40 25,000 X 1000 = 1.6 births per 1000 population

Part 4 Epidemiology in Community Medicine


Crude Death Rate (CDR): Philippine CDR: 4.8 per 1,000 pop (2000)
# Deaths in 1 year X 1,000 7 X 1000 = 0.28 deaths per 1000 population

Mid year population

25,000

Part 4 Epidemiology in Community Medicine


Morbidity rates
# Diseases cases in 1 year
Mid year population

X 1,000

Part 4 Epidemiology in Community Medicine


5. Incidence and Prevalence 5.1 Incidence New events in a population The denominator includes only individuals at risk At the start of observation period, only those without the event of interest is included as the population to be studied (denominator) Only individuals that developed the event during the study period are included in the numerator

Part 4 Epidemiology in Community Medicine


Incidence
# NEW Cases in the period of observation
# of People at risk during observation

Part 4 Epidemiology in Community Medicine


5.2 Prevalence All persons that have the event in a population The numerator includes all persons with the event whether old or new cases The denominator includes all individuals observed (the dead at the beginning of the period are excluded)
# Cases in the period of observation # Total number observed

Part 4 Epidemiology in Community Medicine Practice Excercises

What are the prevalence, incidence and point prevalence

Part 4 Epidemiology in Community Medicine A. Prevalence

(All cases) 6/ 9 (Pop observed)

Part 4 Epidemiology in Community Medicine B. Incidence

(New cases) 3/ 6 (Pop at risk)

Part 4 Epidemiology in Community Medicine C. Point Prevalence

(All cases seen on June 2004) 1/ 9 (Pop observed)

Part 4 Epidemiology in Community Medicine 6. Common Measures Used in Community Health Assessment
Name Crude Birth Rate Significance Measure of population growth Effectiveness of population intervention programs Crude Death Rate # Deaths in 1 year/ Mid General index of the delivery of year population preventive and curative health care Infant Mortality Rate # of death under 1 year High IMR is associated with the of age registered in the following population/ # Registered Poor antenatal and delivery care live births in the same Low maternal education year Mothers aged below 20 yr and above 40 yr Short interval between births (less than 2 years) Formula # Births in 1 year/ Mid year population

Part 4 Epidemiology in Community Medicine


Name Maternal Mortality Rate Formula # of Deaths from Maternal causes for a given year/ # Live births in the same year Significance Measure of the delivery of maternal health care Index of the delivery of antenatal and delivery care Greater spacing between births improves health of mother and child Reduction in the number of births leads to reduction in resource allocation for obstetric care, immunization, and maternal and child interventions Given as a National data Number of people expected to reach old age General index of the delivery of preventive and curative health care

Total fertility rate

Life expectancy at birth

Part 5. Data presentation and Interpretation


1. Text Used if there is 1 to 2 results to be presented. Must be clear and concise. It should have a clear explanation of what was measured, where the data was collected and when. When whole numbers are written in text, numbers less than or equal to 9 should be written as words and numbers from 10 upwards should be written as digits.

Part 5. Data presentation and Interpretation


1. Text Example: In Britain in 1948, when surveys of smoking began, smoking was extremely prevalent among men: 82% smoked some form of tobacco and 65% were cigarette smokers. From: Smoking-statistics. News and resources. Cancer research UK. Available online through: http://info.cancerresearchuk.org/cancerstats/types/l ung/smoking/

Part 5. Data presentation and Interpretation


2. Tables Structured numeric information. Most commonly used for presenting counts or frequencies resulting from surveys. Should be self-explanatory. Includes a concise text description of the data being presented. Must have an informative title, the rows and columns should be labeled. May also be used to make comparisons between groups. In such cases, the groups should define the rows and measured variables define the columns. Reduce the number of significant decimal places.

Part 5. Data presentation and Interpretation


Table 2b: Mean growth rate and intakes of supplement, milk and water for 4 diets.
Supplement Growth rate (g/day) 145 Sesbania Leucaena None 132 128 89 Supplement intake (g/day) 450 476 364 0 Milk intake (ml/kg0.75) 10.5 9.2 8.9 9.8 Water intake (ml/kg0.75) 144 128 121 108

From: Informative presentation of tables, graphs and statistics. Statistical Good Practice Guidelines. University of Reading. Last updated on 24 April 2003 Available online through: http://www.reading.ac.uk/ssc/publications/guides/toptgs.html

Part 5. Data presentation and Interpretation


3. Graphs Useful for presenting trends, broad comparisons and relationships. Includes a concise text description of the data being presented. Must have an informative title, the axes should be labeled. Use line graphs if the horizontal (or one of the axes) axis presents a continuous variable such as time or quantity Use bar graphs if the horizontal (or one of the axes) axis is a qualitative factor such as gender or ethnic group

Part 5. Data presentation and Interpretation

From: Smoking-statistics. News and resources. Cancer research UK. Available online through: http://info.cancerresearchuk.org/cancerstats/types/lung/smoking/

Part 5. Data presentation and Interpretation

From: Smoking-statistics. News and resources. Cancer research UK. Available online through: http://info.cancerresearchuk.org/cancerstats/types/lung/smoking/

Part 6. Research in Community Medicine


Study type Case-control Design With or without disease in the beginning Looking retrospectively for the risk factors With or with risk factors in the beginning Looking prospectively if disease will develop Random sample (or whole population) Looking for the risk factors and disease at the same time Measures/ example Odds ratio Patients with lung cancer have a higher odds of a history of smoking Relative risk Smokers have a higher risk of developing lung cancer than non-smokers Disease prevalence rates Risk factor association only

Cohort

Cross-sectional study

Research Title
Subjects (Population) Key Variables: Dependent and Independent Suggests a relationship between the key variables 15-20 words

Research Objectives
Think of a research topic first Action words: To Determine; To Compare; To Evaluate; To Describe Coherent and Logical General Specific

Research in Community Medicine


Workshop 3: Formulation of Research Title; General and Specific Objectives Mechanics:
Same groupings Same Disease problems Each group is Given 20 min to come up with
Research Title Gen Objectives Specific objectives (2)

Groups will be given 5 min to present and 5 min for critiquing

Part 6. Research in Community Medicine


Disease (+) Test (+) (-) A C (-) B D

Sensitivity a/(a+c) 1 False Neg NPV d/(c+d)

Specificity d/(d+b) 1 False Pos PPV a/(a+b)

Community Diagnosis and Epidemiology in Community Medicine


References: 1. Medical Epidemiology. Greenberg ,et al. 2003 2. Field Work Report for Public Health 195. R Hipolito et al, Faculty preceptor: Prof R R Quizon. College of Public Health, University of the Philippines Manila. 2003

Community Diagnosis and Epidemiology in Community Medicine


References: 3. Using Secondary Data. Romano PS. 2005 4. National Objectives for Health. Health Status of the Filipinos. Available online through: http://www2.doh.gov.ph/noh2007/NOHWeb3 2/NOHperSubj/Chap1/HealthStat.pdf

Community Diagnosis and Epidemiology in Community Medicine


References: 5. Hannaford PC, Smith BH, Elliott AM. Primary care epidemiology: its scope and purpose. Family Practice 2006 23(1):1-7; doi:10.1093/fampra/cmi102 6. Handbook of Reproductive Health Indicators. Economic and Social Commission for Asia and the Pacific, United Nations. 2003. Available online through: http://www.unescap.org/esid/psis/publications/han dbookhealth/handbook.pdf

Community Diagnosis and Epidemiology in Community Medicine 7. Informative presentation of tables, graphs and statistics. Statistical Good Practice Guidelines. University of Reading. Last updated on 24 April 2003. Cited on 16 March 2010. Available online through: http://www.reading.ac.uk/ssc/publications/guides/t optgs.html 8. Smoking-statistics. News and resources. Cancer research UK. Last updated on 9 December 2009. Cited on 16 March 2010. Available online through: http://info.cancerresearchuk.org/cancerstats/types/l ung/smoking/