Theories and Models of Disease Causation

The earliest attempt to attribute a cause to illness occurred during the religious Era (2000 BC to 600 BC). During this period the disease was thought to be Caused by the divine power as punishment for sins as bad deeds or considered as fate. This theory is referred as supernatural theory.

1) The Germ Theory:

popular during 19th century and in earlier 20th century. This theory attributes micro-organisms as the only cause of diseases. Acc. to this theory there is one single specific micro-organism (causative agent) to every disease. This refers to one to one relationship between the causative agent and the disease. This is also called as Single Cause Theory.

For example: - diphtheria due to coryne bacterium diphtheria, cholera due to vibrio chlorae. The Single Cause Theory was further supported by the identification of other specific agents as causative agents for certain health problems. It is now recognized that a disease is rarely caused by a single agent alone, but rather depends on a number of factors which contribute to its occurrence.

Single Cause Theory:

2) THEORY OF EPIDEMIOLOGICAL TRIAD:

It was experienced that everyone exposed to the disease agent did not contract the disease. For example- Tuberculosis, all those who were exposed to he tuberculosis organisms, did not suffer from tuberculosis. Only those who were undernourished, lived in dark places and who did not have immunity against tuberculosis get the disease

This means it was not only the causative agent that was responsible for causing disease but there were other factors related to man and environment which contributed to the occurrence of disease. This leads to the theory of epidemiological triad.

This model is also called as ecological model and is involved through the study of infectious diseases. According to this there are three elements or major factors which are responsible for particular disease causation. These are agent, host and environment.

The agent is considered to be the primary factor (e.g. amoeba. Bacteria, fungi, virus) without which a particular disease cannot occur. The host refers to human beings who came in contact with the agent. The host related factors which play an important role are genetic makeup, age, sex, race, immunity, health behavior etc.

the environment includes all that is external to the host and agent but that may influence interaction between them. These three factors as long as they remain in equilibrium or balance disease will not occur and is referred as state of health equilibrium.

3) Multifactorial Causation Theory:

The epidemiological triad model is applicable to infectious diseases only. It is not applicable to non infectious and chronic diseases like mental illness, coronary heart disease; rheumatoid arthritis etc because they are not linked with specific causation agent and these cannot be prevented and controlled by immunization, isolation and quarantine techniques. These diseases are caused by multiple factors.

E.g.: coronary heart disease is caused with certain life style activities such as: smoking, ingestion of food containing high level of cholesterol, lack of exercise, increased mental and emotional stress and environmental pollution etc.

control of diet and regular exercise and use of effective stress management techniques have shown to reduce the risk of experiencing myocardial infarction. This leads to the theory of multi factorial causation.

This theory thus stresses the multiplicity of interactions between host and environment. This model is equally applicable to infectious diseases except that specific agents causing infectious and non infectious diseases. The multi factorial causation model helps epidemiologist to understand the various associated causative actors, prioritize these and plan preventive and control measures for a particular disease.

Multi Cause\Single Effect Model:

several causative factors produce many observed effects e.g. air pollution; smoking, specific form of radiation (causes) may produce lung cancer, emphysema and bronchitis (effects).

4) Web of Causation:

According to this concept, disease (effect) never depends upon single isolated cause. Rather it develops as a result of chains of causation in which each link itself is the result of complex interaction of preceding events.

This model is particularly applicable to chronic diseases where the causative agent is unknown and which are due to interaction of multiple factors e.g. cardiovascular diseases, cancer.

5) Devers Epidemiologic Model:

another approach to conceptualize interaction of various factors involved in the development of a particular condition. This model is composed of four major categories of factors such as human biology, life style, environment and health care system.

Human biological factors are host related factors of epidemiological triad and include genetic inheritance, complex physiologic systems, factors related to maturation and ageing.

Life style factors include

daily living activities, customs, traditions, health habits and behavior etc.

environmental factors include

physical, biological, social and spiritual components and are similar to environment epidemiological triad.

aspects

of

Health care system factors include

availability, accessibility, adequacy and use of health care services at all levels.

All these factors influence health status either positively or negatively.

Natural history of disease

It signifies the way in which a disease evolves over time from earliest stage of its prepathogenesis to its termination as recovery, disability or death, in the absence of treatment or prevention

Phases of natural history of disease

Prepathogenesis ( process environment) Pathogenesis( Process in man)

in

the

Natural history of disease contd..

Prepathogenesis phase: The interaction of agent host and environment to initiate the disease process in man

Pathogenesis Phase: Begins with the entry of agent in susceptible host and ends with recovery, disability or death

Agent Factors
A substance living or non living

Biological agents: viruses, bacteria, fungi, protozoa etc Nutrient agents: proteins, vitamins, fats etc Physical agents: heat cold

Chemical agents: Endogenous or Exogenous Mechanical agents Social agents

Absence, insufficiency or excess of a factor necessary for health

Iceberg phenomenon of disease

Epidemiologists and others - find that the pattern of disease in hospitals is quiet different from that in the community. larger proportion of disease is hidden form view in the community then is evident to the physician or the general public.

Concept of screening
It is defined as The search for unrecognized disease or defect by means of rapidly applied tests, examinations or other procedures in apparently healthy individuals.

Screening differs from periodic examinations in the following aspects:

health

Capable of wide application. Relatively inexpensive. Requires little physician time. Physician is not required to administer the test, but only to interpret it.

Screening is testing for infection or disease in population or in individuals who are not seeking health care; for example, serological testing for AIDS virus in blood donors, neonatal screening, premarital screening for syphilis

Screening and Diagnostic test

Screening
Done on apparently healthy Applied to groups Test results are arbitrary and final Based on one criterion or cut off point Less accurate

Diagnostic test
Done on those with indications or sick Applied to single patients all diseases concerned Diagnosis is not final but modified in the light of new evidence, diagnosis is the sum of all evidences Based on evaluation of a number of symptoms, signs and laboratory findings More Accurate

Less Expensive
Not a bias for treatment The initiative comes from the investigator or agency providing care

More expensive
Used as a bias for treatment The initiative comes from a patient with a complaint

Aims and objectives

to sort out of large group of apparently healthy persons those likely to have disease or at increased risk of the disease under study, to bring those who are apparently abnormal under medical supervision and treatment

Uses of Screening
Four Main uses

Case Detection Control of Disease Research purposes Education opportunities

i. Case detection: it is also called prescriptive screening. It is defined as presumptive identification of unrecognized disease, which does not arise from a patients request, e.g. neonatal screening.

Diseases sought by this method are bacteriuria in pregnancy, breast cancer, cervical cancer, diabetes mellitus, iron deficiency anemia, PKU, pulmonary tuberculosis etc. In this it is made sure that the treatment is started early.

ii. Control of disease: it is also called prospective screening. The people are examined for the benefit of others, e.g., screening of immigrants from infectious diseases such as tuberculosis and syphilis to protect home population. It leads to early diagnosis, permit more effective treatment and reduce the spread of infectious disease.

iii. Research purposes: For example, there are many chronic diseases whose natural history is not fully known e.g. cancer, so screening may be done in obtaining basic knowledge about the natural history of such disease. The participants should be informed that no follow-up therapy will be provided.

iv. Educational opportunities:

Screening programmers provide public awareness and education to other health professionals.

Types of Screening
Three types of screening:

Mass Screening High Risk or Selective Screening Multiphasic Screening

a. Mass screening:

in this screening of the whole population or a subgroup whether or not exposed to the risk of having the disease under study. It is not advisable under limited sources.

b. High risk or selective screening: in this screening only those who are at high risk to have a particular problem or disease e.g. women 35+ and lower socioeconomic group have more chances of cancer cervix and if they are screened for that, then more chances of detecting the cases. Similarly people having family history of diabetes, breast cancer should be screened

c. Multiphase screening: it is the application of two more screening tests in combination to large number of people at one time than to carry out separate screening tests for single disease. For e.g. test for lung diseases, CV diseases, anaemia, kidney diseases, cancer of breast and uterus, visual and audio defects are grouped together. But it is an expensive venture and its benefits are under question.

Criteria for Screening

Before a screening programme is initiated, a decision should be made whether it is worthwhile, which requires ethical, scientific and if possible financial justification.

The criteria is based on two things

Disease to be screened Test to be applied

Disease to be Screened

should be an important health problem

should be a recognizable latent or early asymptomatic stage

test that can detect the disease prior to the onset of signs and symptoms Facilities should be available for the confirmation of diagnosis

There should be and agreed- on policy concerning whom to treat as patients There is good evidence that early detection and treatment reduces morbidity and mortality The expected benefits of early detection exceed the risks and costs

Test to be applied
the test must satisfy the criteria of acceptability, repeatability and validity,

besides others such as yield, simplicity, safety, rapidity, ease of administration and cost.

Acceptability:

The test should be acceptable to people it is aimed. The tests are usually painful, discomforting or embarrassing and are not likely to be acceptable to the population in mass campaigns

Repeatability

An attribute of an ideal screening test is that the test must give consistent results when repeated more than once on a same individual or material under similar conditions It depends on three factors

Observer variation Biological variation Errors relating to technical methods

Observer variation
Intra observer variation: If a single observer takes two measurements in the same subject at the same time and each time he obtained a different result. It may be minimized by taking the average Inter- observer variation: The variation between different observers on the same subject or material, also known as between observer variation

Biological Variation

There is biological variability associated with many psychological variables such as BP, BS, Sr. Cholesterol The change may be due to

Changes in the parameters observed Variations in way patients perceive their symptoms and answer

Errors relating to technical methods

defective instrument, faulty reagents, or the test itself might be inappropriate.

Validity (Accuracy)
it refers to what extent accurately measures which it purposes to measure. It must have the ability to separate those who have a disease from those who do not have. It has two components

Sensitivity Specificity

Sensitivity and Specificity

Sensitivity

The ability of a test to identify correctly all those who have disease, that is true positive
Specificity

The ability of a test to identify correctly all those who do not have the disease, that is true negative

Evaluation of Screening programmes

Randomized controlled trials:

Ideally evaluation should be done by randomized controlled trail in which one group receives the screening test, and a control which receives no such test

Uncontrolled Trials: Other Methods: