BLOCK CBP

SEMESTER I
1. 2. 3. 4. Stadium Generale and Humaniora Medical Communication The Cell as Biochemical Machinery Growth and Development Prenatal and Postnatal

SEMESTER II
1. 2. 3. 4. 5. 6. Medical Professionalism Community-Based Practice Health System-Based Practice Evidence-Based Medical Practice Special Topic Elective Study 1

SEMESTER III
1. The Hematologic System and Disorders and Clinical Oncology 2. Immune System and Disorders

SEMESTER IV
1. The Musculoskeletal System and Connective tissue Disorders 2. Neuroscience and Neurological Disorders 3. Behavior Change and Disorders 4. The Visual System and Disorders

SEMESTER V
1. The Alimentary and Hepatobiliary System and Disorders 2. The Endocrine System, Metabolism, and Disorders 3. Clinical Nutrition and Disorders 4. Special Topic 5. Elective Study 2

SEMESTER VI
1. 2. 3. 4. The Respiratory System and Disorders The Cardiovascular System and Disorders The Urinary System and Disorders The Reproductive System and Disorders

SEMESTER VII
1. Medical Emergency 2. Special Topic: Travel Medicine 3. Elective Study 3

Tahun lalu dilakukan perdebatan di Stasiun TV Swasta Nasional dalam acara Indonesia Lawyers Club (ILC) yang membahas UU Pembatasan Penggunaan Tembakau antara kelompok yang anti dan yang pro Hampir semua kelompok anti UU mengemukakan alasan sbb: Ah, tidak benar merokok ada kaitannya dengan kanker paru-paru. Buktinya, saya dan teman-teman saya adalah perokok berat, dan sudah merokok selama 30 tahun, toh sampai saat ini tetap sehat-sehat saja. Pertanyaan: sebagai calon dokter apa komentar Sdr. dengan mengacu pada prinsip-prinsip CBP

APPROCHES OF CBP
Prevention (not curative)
Community (not individual)

Determinants
Genetic Environment Physical Social, cultural Biological, economical

Behavior Health Services

Susceptible

(at risk)

Presymtomatic stage

Clinical stage

Stage of disability

Tertiary prev.

Primary prevention Early detection limitation Health promotion & prompt Rehabilitation Specific protection treatment

Secondary prev. Disability

TATA TERTIB
1. Selama kuliah HP dimatikan (bukan silent) 2. Dalam pleno pagi bila terlambat > 10 menit (jam di dinding ruang kuliah) mahasiswa tidak diperkenankan ikut kuliah

BLOCK CBP

RULE/REGULATIONS

(Community-based Medical Practice)

1. HP harus dimatikan selama kuliah dan SGD
2. Study Guide dan semua references agar selalu dibawa saat kuliah, SGD, individual learning 3. Kehadiran dan keaktifan saat SGD dinilai (5% dari nilai ujian) INGAT ABSEN 4. Kehadiran saat kuliah dan feedback dihitung (bila lebih dari 25% tidak ikut) tidak bisa ujian

5. Pada saat plenary mahasiswa presentasi 6. Wakil mahasiswa yang presentasi harus dipilih pada saat SGD dan bukan di ruang kuliah 7. Wakil mahasiswa yang presentasi harus bergilir (tidak boleh sama pada setiap hari)

8. Sesaat sebelum plenary dimulai, wakil masing-masing kelompok yang akan presentasi langsung duduk didepan
9. Narasumber akan memberi feedback pada presentasi mahasiswa

REFERENCES & MANUAL

Study Guide & Annexes Reference 1-6 Manual

Please refer to each day session/module

CURRICULUM STUDY GUIDE 17 MODULES

DAY 1, 2, 3: MODULE-1

LEARNING MATERIALS: Reference 1 and 2 ,movie, video clip, websites (it is advice to download materials from the websites
before the lecture)

Learning Outcomes:
a) Describe several determinants (models) of diseases and death occurring in the population b) Explain the applications of understanding diseases and death determinants (models) c) Identify the strengths and weaknesses of diseases models d) Draw figure of the natural history of a certain disease

e) Explain the applications of the natural history of a disease for prevention

f) Explain the severity of diseases in a population and its implication to prevention g) Describe the level of disease prevention based on determinants and natural history h) Explain the Ice Berg Phenomenom and its implication in diseases prevention

LEARNING SCHEDULE
(time table)
STUDY GUIDE PAGE 7 (CLASS B)

08.00-09.00: Introductory lecture 09.00-11.00: Independent learning

Reference 1 & 2 Learning tasks page 18-21

11.00-13.00: SGD 14.00-15.00: Student presentation & feedback

LEARNING SCHEDULE
(time table)
STUDY GUIDE PAGE 11 (CLASS A)

09.00-10.00: Introductory lecture 10.00-12.00: Independent learning

Reference 1 & 2 Learning task-1 & 2 page 18-21

13.00-15.00: SGD 15.00-16.00: Student presentation & feedback

APPROCHES OF CBP
Prevention (not curative)
Community (not individual)

Some of the people need health care some of the time BUT All of the people need public health all of the time."

C. Everett Koop, MD former U.S. Surgeon General

MODULE-1
Determinants of morbidity and mortality in a population Natural history of the

disease

Diseases prevention

DAY 1

Determinants of morbidity and mortality in a population

Several models/concept used to analyzed determinants of morbidity and mortality in a population

The Epidemiologic Triad/ Triangle (Teori Segi Tiga) page 26 33

Wheel Model (Teori Roda) page 35-39

Web Model (Teori Sarang Laba-laba) page 33

Model Blum Model Mosley

Model Segitiga (The Epidemiologic Triad/ Triangle)

HOST (intrinsic)
(age, sex, genotype, behaviour, nutritional status)

AGENT
(biologic, physic, mechanical, chemical, nutrient)

ENVIRONMENT
(Physical, Biological, Social)

AGENT Biological, chemical, physical Mechanical, Nutrient

HUMAN HOST Age, race, sex, habit Genetic, personality Defense mechanism

ENVIRONMENT Biological, chemical, physical Mechanical, nutrient, social, psychologic

Triad epidemiologik

Homeostatic Balance
A
E
Agent becomes more pathogenic

H
E
A E

The proportion of susceptibles in population decreases

H
A E

At equilibrium
Steady rate

A H

E
Environmental changes that favor the host

Environmental changes that favor the agent

Model Roda (Wheel Model)

INTERNAL (intrinsic)
Social politic, economic culture

Biological Environment

HOST
Genetic

Physical Environment

EXTERNAL (extrinsic)

Contoh Kasus Kematian Ibu WEB MODEL (SARANG LABA-LABA)

Modifikasi dari: FA Moeloek, 2010

BLUM MODEL
Genetic
Morbidity and mortality in a population

Behavior

Health services

(biological, physical, social, economical, politic)

Environmental factors

CONCEPT (THEORY, MODEL)

INTRODUCED BY DR. MOSLEY WHICH EXPLAINED DETERMINANTS OF MORBIDITY AND MORTALITY OF CHILDREN AGE UNDER 5 YEARS IN A POPULATION

Socioeconomic determinants

Maternal factors

Environmental Contamination

Nutrient deficiency

Injury

Healthy
Prevention Treatment Growth faltering

Sick

Personal Illness control

Mortality

SOCIAL DETERMINANTS OF HEALTH

WHO- CSDH conceptual framework

UNDERSTANDING CAUSALITY

Four types of Causal relationships 1. Necessary and Sufficient 2. Necessary but not Sufficient 3. Sufficient but not Necessary 4. Neither Sufficient nor Necessary

Necessary = without that factor disease never develops Sufficient = in the presence of that factor disease always develops

1. Necessary and Sufficient

Direct: Factor A Indirect: Factor A

Disease

Step1

Step2

Disease

rarely happens

2. Necessary but not Sufficient

Factor A + Factor B + Factor C

Disease

Multiple factors required: initiator & promoter (cancer, TB)

3. Sufficient but not Necessary

Factor A or Factor B or Factor C

Disease

Leukemia = Exposure to radiation OR benzene

4. Neither sufficient nor necessary (contributory causes)

Factor A + Factor B or Factor C + Factor D or Factor E + Factor F

Disease

Most accurately represents causal relationships in most chronic diseases

END OF DAY 1

Plenary day 1
Please refer to the plenary day 1 slides

DAY 2

MODULE-1
Determinants of morbidity and mortality in a population Natural history of the

disease

Diseases prevention

DAY 2
Natural history of the

disease Disease prevention

Natural History of Disease

Natural history of disease: progression of disease in an individual over time WITHOUT any intervention.

NATURAL HISTORY OF THE DISEASE

Page 6-9 reference 2 Four stages
Stage of susceptibility (population at risk)

Stage of pre symptomatic (asymptomatic) disease Stage of clinical (symptomatic) disease Stage of disability
Every

disease has difference natural history (example: HIV/AIDS, DHF)

Stage of susceptibility (population at risk)

Determinants (risk factors) (+), disease (-) Tired High cholesterol, high sugar, low fiber Smoking Multiple partners with unprotected sex Sharing needle Low physical activity

Stage of pre symptomatic (asymptomatic) disease

Disease (+), signs (+/-) symptoms (-) Aterosclerotic Antibodi (+) Pre-cancer lesion Lab marker >>>
Uric acid, fasting glucose, LDL >>, creatinin >>

Stage of clinical (symptomatic) disease

Disease (+), signs and symptoms (+) Anatomical & functional changes (+) Grouping: 1. Symptoms 2. Functional class 3. Localisation 4. Morfologic/ cell type 5. Theraphy

Ex: Cancer stadium Hearth disease

Functional class therapy
High relationship

REASON OF THE GROUPING: 1. Therapeutic reason 2. Epidemiological reason (homogenity, specific rate)

Stage of disability
Disease outcome 1. Total recovery (treatment, self limited) 2. Partly recovery 3. Scuele (+); disability
1. Physical (anatomical) 2. Social 3. Phsycological

PREPATOGENESIS
Agen Host

PATOGENESIS
Fase klinis
Sembuh

Lingkungan

Cacat Fase penyembuhan

Mati Kronis

Fase susceptible

Fase subklinis

Perjalanan Alamiah Penyakit

56

Natural history of disease

TIME
Death Infection Susceptible host No infection Clinical disease Recovery

Incubation period Latent Infectious Exposure Onset

Non-infectious

NATURAL HISTORY (PERJALANAN PENYAKIT) Contoh: hepatitis

Meninggal Symptomatic stage

Khronis
Carrier

Asymptomatic stage

Sembuh dengan cacat Sembuh tanpa cacat

Perjalanan infeksi HIV

1000

Viral Load Jumlah CD4 Jumlah CD4

200

Infeksi Akut
Window period Serokonversi

Infeksi asimtomatik

Simptomatik/AI DS 4 5 6 7

5 Bulan 0 1 2 3 4 Tahun

Prevention can be done when determinants and natural history of the disease are understood
LEVEL OF PREVENTIONS IN BROAD CONCEPT
Primary prevention
Health promotion Behavior change education Policy/regulation Specific protection
(specific to a certain disease)

 Secondary prevention
Early detection and prompt treatment/action

Tertiary prevention
Disability limitation Rehabilitation
Medical

Prolonging life/increase quality of life

Psychological

Social Economical

Using Blum Model/Concept

Genetic Environment Physical Social, cultural Biological, economical

Behavior Health Services

Susceptible

(at risk)

Presymtomatic stage

Clinical stage

Stage of disability

Tertiary prev.

Primary prevention Early detection limitation Health promotion & prompt Rehabilitation Specific protection treatment

Secondary prev. Disability

Natural History of Disease and Level of Prevention

Riwayat Alamiah Penyakit

64

LIMA TINGKAT PENCEGAHAN Riwayat Alamiah Setiap Penyakit Interaksi Agen, Pejamu dan Lingkungan Faktor RANGSANGAN PENYAKIT Reaksi pejamu terhadap RANGSANGAN PENYAKIT -> Patogenesis awal Periode Prepatogenesis
Promosi kesehatan Pendidikan kesehatan Gizi yang cukup sesuai dengan perkembangan Perumahan, rekreasi dan tempat kerja Perkembangan kepribadian Konseling perkawinan dan pendidikan seks Genetika Pemeriksaan kesehatan secara berkala Perlindungan khusus Imunisasi Kebersihan perorangan Diagnosis dini dan pengobatan segera Penemuan kasus, individu dan masal Rehabilitasi Pembatasan ketidakmampuan Penyediaan fasilitas untuk pelatihan hingga fungsi tubuh dapat dimanfaatkan sebaik-baiknya Pendidikan pada masyarakat dan industriawan agar menggunakan mereka yang telah direhabilitasi Penempatan secara selektif Mempekerjakan sepenuh mungkin Terapi kerja di RS Penggunaan koloni yang terlindung Mencegah komplikasi dan akibat lanjutan Memperpendek masa ketidakmampuan

Kerusakan Penyakit awal jaringan lanjut Periode Patogenesis

Konvalesens

Sanitasi lingkungan Perlindungan terhadap kecelakaan akibat kerja Perlindungan terhadap kecelakaan Penggunaan gizi tertentu Perlindungan terhadap zat yang dapat menyebabkan kanker Menghindarkan zat-zat allergen

Skrining Pemeriksaan khusus Tujuan: Menyembuhkan dan mencegah penyakit berlanjut Mencegah penyebaran penyakit menular

Pengobatan yang cukup untuk menghentikan proses penyakit dan mencegah komplikasi Penyediaan fasilitas untuk membatasi ketidakmampuan dan mencegah kematian

Pencegahan primer

Pencegahan sekunder Tingkat Penerapan Upaya Pencegahan

Pencegahan tertier

 ICE-BERG PHENOMENA

SEVERITY OF DISEASES

ICE BERG PHENOMENA (FENOMENA GUNUNG ES)

TWO CONSEQUENCIES (DUA KONSKUENSI)

Semakin lebar dasar gunung es: Semakin sulit penanggulangan penyakit (control of the disease) Bila memakai data sekunder, data (statistik penyakit) akan semakin tidak akurat CONTOH: DBD dan RABIES

Epidemiological Iceberg
Only the tip of the iceberg is easily observable Dog bite example 3.73 dog bites annually 451,000 medically treated 334,000 emergency room visits 13,360 hospitalizations 20 deaths

THE VARIATION OF SYMPTOMATIC DISEASES SEVERITY

100 CASES

Mild (ringan)

Moderate

Severe Fatal

The film presentation showed to you

Contribution (peran) of: scientific foundations, clinical skill, communication skill, information management, critical thinking, professional values and attitudes, community health

Meneliti kausa suatu penyakit (AIDS) dan pencegahannya

DIFFERENCES BETWEEN
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

1. Focus: individual 2. Responsibilities: all people who come all people in certain geographical area, health and to the health facilities. They usually passive. sick, those who come and those who do not come to health facilities. They must actively provide diseases prevention to all people who are at risk

1. Focus: population 2. Responsibilities:

PUBLIC HEALTH DOCTOR

CLINICAL DOCTOR

3. Function: to mobilize all stakeholders and using management principles to plan, implement and evaluate primary, secondary, tertiary preventions 4. Place of works: health centre, heath department, community clinics, etc

3. Function: to cure and to increase the patients quality of life

4. Place of works: private practices, hospitals, etc

PUBLIC HEALTH DOCTOR

CLINICAL DOCTOR

5. Diagnostic tools: 5. Diagnostic tools: epidemiology, statistics, stethoscope, ECG, lab demography examinations kits , CT Scan, etc

6. Diseases measurements in the community: proportion, prevalence, incidence, ratio

6. Diseases measurements for individual patient: level of blood pressure, blood sugar, level of hemoglobin, etc

PUBLIC HEALTH DOCTOR

CLINICAL DOCTOR

7. Treatment at the community level (prevention): public health program such as education program, immunization program, nutrition program, family planning program, etc

7. Treatment for individual patient (diagnosis and care): medical treatments, surgery, radiation, physiotherapy, etc

PUBLIC HEALTH DOCTOR

CLINICAL DOCTOR

8. Indicators for evaluating community health program: percent decrease of under nutrition, percent increase of contraceptive use for family planning, etc

8. Indicators for evaluating the result of patients treatments: decrease of blood pressure of the individual patient, increase of hemoglobin

FIVE STARS DOCTOR

(WHO = World Health Organization)

Care provider (clinical dr) Communicator (clinical & PH dr) Manager (PH dr) Community leader (PH dr) Decision maker (clinical & PH dr)

SOAL-SOAL PEMANASAN SEBELUM UJIAN

As shown in the film And The Band Played On which was presented to you, there were several sciences involved in investigation the cause of AIDS. Those sciences are:
A. Social, economic, politic, epidemiology, statistic, virology, clinical medicine
B. Social, politic, epidemiology, statistic, virology, clinical medicine, health education C. Social, epidemiology, statistic, virology, clinical medicine, health education D. Clinical medicine, epidemiology, statistic, social, politic E. Social science, epidemiology, statistic, virology, clinical medicine

Dalam film dengan judul And The Band Played On yang telah Sdr. saksikan pada waktu pertemuan pertama Blok Community-Based Practice, ada beberapa metode yang dipergunakan untuk mengungkapan penyebab AIDS, yaitu: 1. 2. 3. 4. Contact tracing Cohort Case-control Cross-sectional

Bila dilihat dari waktunya, urutan cabang ilmu yang membantu mengungkapan penyebab AIDS, yaitu:
A. Paling awal virologi, lalu epidemiologi dan terakhir ilmu klinik B. Paling awal ilmu klinik, lalu virologi dan terakhir epidemiologi C. Paling awal ilmu klinik, epidemiologi/statistik/ilmu sosial, lalu virologi D. Paling awal virologi, statistik/epidemiologi lalu ilmu klinik E. Paling awal statistik/epidemiologi, ilmu klinik lalu virologi

Pada Gambar-1 berikut ini adalah kompetensi (kemampuan) yang harus dikuasai oleh seorang dokter. Kompetensi untuk memahami statistik kasus-kasus AIDS dalam film dengan judul And The Band Played On termasuk: 1. Scientific foundations 2. Information management 3. Professional values 4. Population health

Clinical skill

Critical Community thinking

Health (Public Health)

Information management Scientific

foundations
Communication skill Professional, values, attitudes

CBP

Salah seorang mahasiswa (inisial X) yang kuliah di fakultas non-kesehatan mengatakan sebagai berikut: Ah, tidak benar merokok ada kaitannya dengan kanker paru-paru. Buktinya, paman saya adalah perokok berat, dan sudah merokok selama 30 tahun, toh sampai saat ini dia sehat-sehat saja. Pertanyaan: berikan komentar Sdr. terhadap pernyataan mahasiswa X seperti pada soal di atas (dengan mengacu pada prinsip-prinsip epidemiologi).

Dalam suatu program interaktif yang membahas topik wabah HIV/AIDS di sebuah stasiun radio di Bali, banyak pendengar dengan berapi-api mengatakan melalui telepon sebagai berikut: Lho, kenapa pelacur yang sudah jelas-jelas dijumpai HIV+ tidak dikarantina. Mereka ..kan dengan bebas masih menularkan HIV-nya pada orang lain. Kenapa pada saat terjadi wabah SARS, yang dicurigai saja sudah langsung diisolasi?

Anggota DPRD Provinsi Bali tahun lalu mengatakan sebagai berikut: Kami sudah mengalokasikan dana APBD yang cukup besar untuk penanggulangan HIV/AIDS di Bali. Kenapa jumlah orang yang HIV+/AIDS kok terus bertambah banyak. Harusnya kan berkurang. Kalau begitu percuma dana yang kami alokasikan tersebut.

PERTANYAAN: Seandainya Sdr. menjadi petugas kesehatan, bagaimana Sdr. menjawab pernyataan anggota DPRD tersebut

Pertanyaan pendengar dalam program interaktif di sebuah stasiun radio di Bali

Tempat tidur pasien demam berdarah yang dirawat di rumah sakit kok tidak pakai kelambu? Kalau pasien digigit nyamuk Aedes kan bisa menularkan penyakitnya kepada petugas di RS atau kepada pasien lain?