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Introduction to Public Health

A textbook for medical students and public health students

Dr. Richard Ayah

Nairobi 2011

(copyright page)
Tina Okulo designed the cover.

Dedicated to Craig, Hawi and Baba.


Thank you for your unwavering support and encouragement through all the
difculties.

Acknowledgements
The idea of writing this book started because, within the then department of community
health, there was no basic textbook for medical undergraduates or students of public
health. Initially, it seemed a simple matter of putting a few notes together. Never did it
occur to me that the project would require two years to complete.
The manuscript has benefited from immense contributions provided by the school of
public health university of Nairobi staff members. They include: Dr. Dismus Ongore,
Director school of public health, university of Nairobi Rose Opiyo, Prof Mutuku Mwanthi,
Lambert Nyabola, Erastus Njeru, Prof. Elisha Muchunga Dr. Peterson Muriithi, Mary
Kinoti, Faith Thuita, Dr. Peter Njoroge, Prof. Joyce Olenja, Prof. Violet Kimani and Prof.
Elizabeth Ngugi.
The anonymous peer reviewer who went through the entire manuscript provided
valuable comment.
Judie Lynn Rabar and Dr. Sally Wanjohi read through the manuscript as it was being
developed. I am also indebted to the following for their invaluable contributions:
Emmanuel Odemba for his editorial work and Hudson Kubasu who did the design
and layout of the book. The pair pushed me when I faltered to keep on writing to
the end.
Mrs. Rosemary Kinyua for useful tips on manuscript preparation.
Tyler Ayah for helping compile the index and Craig Ayah for his steadfast
encouragement.

4i

Preface
Public health is one of the major avenues to achieve socio-economic development in
society. Clinical medicine practiced on its own in isolation from the community becomes
a never-ending queue of the same preventable problems, managed expensively with
relatively poor outcomes because then, it is often too late to effectively alter the course of
the condition afflicting the patient. Public health science includes various disciplines which
together are more than the individual parts. This synergistic approach of public health is
what gives it the unique perspective to be able to tackle complex health issues in society.
Within the medical and public health schools in sub-Saharan Africa, theory and principles
have fallen behind practice and much of what is done in the name of public health is often
done using weak justification with attendant poor results at the end. When practicing
medicine there has to be a direct link with the general population. Public health is that
interface. This book attempts to provide such a link, by outlining the principles in public
health that, when practiced, would lead to improved health status by reducing morbidity
and mortality. This book is divided into Four major parts namely: basic tools for public
health, the individual and public health, individual health and the environment and making
a community diagnosis. Each part has several chapters that cover individual subject areas
in public health. Combined the chapters provide an overview of each subject.
It must be recognized that each subject area is a specialty on its own with practioners. The
idea is not to make the reader an expert epidemiologist or an environmental scientist but
to give the learner the tools necessary to begin to have an understanding of each subject
area.

5ii

List of tables
Table 2.1: Survey results of H1N1 cases in school A and B
Table 2.2: Calculating specific rates
Table 2.3: A relationship between cigarette smoking and Incidence
Table 2.4: Host factors in disease transmission
Table 2.5: Environmental factors in disease transmission
Table 2.6: Types of study designs
Table 2.7: Calculating relative risk
Table 2.8: Appropriate use of observational studies
Table 2.9: Comparing qualitative and quantitative
Table 2.10: Comparing sensitivity and specificity in a screening Test
Table 2.11: Possible outcome of diagnostic test
Table 3.1: Calculating the mode
Table 3.2: Calculating variance
Table 3.3: Grouping data into classes
Table 3.4: Accepting the null hypothesis
Table 3.5: Classification of men admitted to a hospita; by educational attainment
Table 3.6: Calculating chi-square
Table 3.7: Blood pressure readings of selected patients
table 3.8: Blood pressure readings from two sample groups
Table 4.1: Population growth rate of select countries
Table 4.2: Dependency ratios for select regions
Table 4.3: Possible errors in a census
Table 4.4: Comparisons of census and sample errors
Table 4.5: Contraceptive methods
Table 4.6: Reasons for migration
Table 5.1: Food requirements
Table 5.2: Daily requirements for dietary rehabilitation
Table 5.3 Nutritional management of common conditions in HIV/AIDS
Table 5.4:Gomez classification
Table 5.5: Waterlow classification
Table 5.6: Wellcome classification
Table 5.7: Minimum nutrient requirements
Table 5.8: Risk factors of vitamins A deficiency
Table 5.9: Recommeded iodine intake
Table 5.10: Stepwise implementation for: prevention of childhood obesity
Table 5.11: Z - score classification
Table 5.12: BMI classification
Table 6.1: Characteristics of an effective vaccine
Table 6.2: Causes of morbidity and mortality in displaced populations
Table 6.3: Major causes of diarrhoeal diseases
Table 6.4: Diagnosis of amoebiasis
Table 6.5: Risks in HIV/AIDS transmission
iii
6

Table 6.6: Species implicated in Brucella infection


Table 6.7: VHF classifcation by agent
Table 7.1: Prevention of breast cancer
Table 7.2: Strategies to reduce tobacco use
Table 8.1: Discovering culture
Table 9.1: Types of Indoor pollution
Table 9.2: Types of Food Spoilage with causative organisms
Table 9.3: Types of chemical contaminants
Table 9.4: 7 Principles of HACCP
Table 10.1: Types of occupational bio hazards
Table 10.2: Effects of the different sounds levels
Table 10.3: Elements in pre-employment medical exams
Table 10.4: Indications for medical exams
Table 10.5: Use of personal protection equipment
Table 10.6: Use of personal protection equipment
Table 11.1: The different groups of stakeholders in health policy
Table 13.1: Demand schedule for chocolate
Table 14.1: Different leadership roles
Table 14.2: Data required for Situational Analysis
Table 14.3: Group decision- making
Table 14.4: Types of Plans
Table 14.5: Logical framework
Table 14.6: Job Specialization
Table 14.7: Response to use of power
Table 14.8: Outcome to use of power
Table 14.9: Routine vs complex problems
Table 14.10: Why change fails
Table 15.1: Terms describing and quantifying risk
table 15.2: Approaches to health promotion interventions
Table 16.1: Example of prioritization
Table 16.2: Health assessment; Questions to ask
Table 16.2: Questions to ask
Table 16.3: Communication Plan Summary

7iv

List of Figures
Fig. 1.1: Evidence based approach to public health
Fig. 2.1: Interaction between disease and disease determinant
Fig. 2.2: Stages in the natural history of disease
Fig. 2.3: The causes of tuberculosis
Fig. 2.4: Case control study design
Fig. 2.5: Cohort study design
Fig.3.1: Bar graph showing height of students
Fig. 3.2: Pie chart showing tobacco use by type
Fig. 3.3: A Histogram of discrete data
Fig. 3.4: Different types of distribution curves
Fig. 3.5: Calculating standard deviation
Fig. 3.6: Bar chart showing all possible scores from two dice
Fig. 4.1: World Population : 1950-2050
Fig. 4.2: Age/sex structure for Kenya and Italy
Fig. 4.3: The demographic transition
Fig. 4.4: Motivation for migration
Fig. 5.1: A food pyramid
Fig. 5.2: Conceptual framework: Causes of malnutrition
Fig. 5.3: An algorithm for the diagnosis and management of of acute malnutrition
Fig. 5.4: Kwashiokor and marasmus
Fig. 5.5: Use of MUAC
Fig. 5.6: Conceptual model of pathways to death and disability from malnutrition
Fig. 5.8: Determinants of food consumption and nutritional status: a conceptual
framework
Fig.6.1: Equilibrium between the Population, Infectious Agent, and the environment
Fig. 6.2: Life cycle of the malaria parasite
Fig. 6.3: A summary of factors affecting the prevention and control of malaria
Fig. 6.4: Prevention and control of diarheal diseases
Fig. 6.5: Life course of HIV/AIDS infection
Fig. 6.6: Life cycle of schistosomiasis
Fig. 7.1: Framework: determinants of non-communicable diseases
Fig. 7.2: Use of seat belt prevents fatalities
Fig. 8.1: The doctor-patient interaction
Fig. 8.2: The individual within a complex world
Fig. 8.3: gender distribution in healthcare delivery
Fig. 9.1: Relationship between health and the environment
Fig. 9.2: The DPSEEA model
Fig. 9.3: The steps that food undergoes from production to consumption
Fig. 9.4: Urban housing in the slums
Fig 9.5: Examples of safety gear
Fig. 10.1: A framework for occupational health
v8

Fig. 10.2: Controlling noise


Fig. 11.1:The policy cycle
Fig. 11.2: Policy analysis triangle.
Fig. 11.3: A framework for analyzing power and interest
Fig. 12.1: Objectives of the health systems
Fig. 12.2: Building blocks of the health systems
Fig. 13.1: A demand curve
Fig. 13.2: Market equilibrium
Fig.14.1 : The Management Process
Fig. 14.2: Levels of management
Fig. 14.3: The planning cycle
Fig. 14.4: SWOT analysis
Fig. 14.5: An organization can be structured by function, geography or client. as shown
Fig. 14.6: A comparison of Herzbergs model and Maslows Hierarchy
Fig. 14.7: The Reinforcement Process
Fig.14.11: Response to change
Fig. 15.1: Spheres of health promotion
Fig. 15.2: The TTM model
Fig 14.6 Comparing Herzbergs and Maslows theories of motivation

9vi

Content
Acknwledgement
Preface
List of tables
List of figures

i
ii
iii
iv

1.0 PART I: Basic tools for public health

11
12

1.1. Introduction to Public Health


Defining public health
Public health today
Evidence approach to public health
Importance of policy in achieving public health goals
1.2. Epidemiology and determinants of health
1.3. Biostatistics
1.4. Demography

17
37
54

2.0 PART II: The individual and public health

72
73
94
125

3.0 PART III: How the community interacts with health

148
149
162
179

4.0 PART IV: Provision of health

193
194
201
208
223
249

2.1. Nutrition
2.2. Communicable diseases control
2.3. Non-communicable disease

3.1. Medical sociology


3.2. Environmental health
3.3. Occupational health

4.1. Health policy


4.2. Health systems management
4.3. Health economics
4.4. Health services management
4.5. Health promotion

5.0 PART V: Making a community Diagnosis


5.1 Conducting a community survey

References
Appendix
Index 273
Glossary

261
262
270
272

INTRODUCTION TO PUBLIC HEALTH

Defining Public Health

The definition of public health as expressed by C.E.A Winslow in 1920 endures today.
He defined public health as the science and art of preventing disease, prolonging life
and promoting health through the organized efforts and informed choices of society,
organizations, communities and individuals. He believed that the barrier between public
health and clinical medicine is an artificial one and that the far-sighted physician is equally
eager to link up his science with the public health program, because on his side he realizes
that medicine can never attain its full potentialities of service unless it is made really
preventive, through some type of effective professional and social coordination. This
observation is true especially in sub-Saharan Africa where health professionals are scarce.
Waiting to manage patients when they arrive late at health facilities is a strategy (whether
by design or otherwise) that has not and will never succeed in improving the health of
people in society.
The World Health Organization (WHO) defines health as a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity. The
goal of public health is to improve health status through the prevention and treatment of
disease. It does this by focusing on disease surveillance and promotion of health behaviour
at population level and not at individual level.

Public health today

Whereas there is a clear link between public health and socio-economic development, it
is only in the late 90s that African governments began to pay serious attention to public
health. The starting point however, was the landmark Alma-Ata conference on primary
health care that took place in September 1978. That conference was followed by the 32nd
World Health Assembly in Geneva in 1979 which endorsed the Alma-Ata declaration and
approved a resolution that primary health care was the key to attaining an acceptable
level of health for all.
Despite the initial enthusiasm, it was difficult to implement primary health care thereafter.
The declaration was viewed by many as being too broad, idealistic and having an
unrealistic timetable. The slogan Health for All by 2000 went unrealized. The major
reason was lack of clear financing mechanism in place to achieve the goals set. It was
expected governments would adjust their health budgets to incorporate this new thinking.
International organizations too did not offer much funding to assist the process.
The turn of the century therefore offered a chance for world leaders to review progress
made and set new goals. A total of 189 world leaders met in September 2000 at the
United Nations headquarters to discuss the role of the UN in the 21st century. The
Millennium Summit declaration agreed upon undertook to help the people living in the
worlds poorest countries achieve a better life by the year 2015.
11

The millennium development goals (MDGs) are derived from the Millennium Summit
and provide a framework for monitoring the progress of the goals set. Unlike previous
attempts at the global level to improve health in developing countries, the MDGs have
been accompanied by h significant funding from global organizations. The emergence
of several large disease-specific global health initiatives (GHIs) has changed the way in
which international donors provide assistance to public health initiatives. More than 100
global health initiatives exist today including The Global Fund to fight AIDS, Tuberculosis
and Malaria(Global Fund), Global Alliance for Vaccines and Immunization (GAVI) and
the US Presidents Emergency Plan for AIDS Relief (PEPFAR). These global initiatives
have capitalized on the momentum generated by the adoption of the MDGs to mount
a concerted response to fight various diseases such as HIV/AIDS, malaria and neglected
tropical diseases. There has been heavy promotion of the use of effective health
interventions and technologies such as vaccines, anti-retroviral drugs for HIV/AIDS, and
insecticide-treated bednets for malaria prevention.
Importantly, these initiatives have increased the involvement of the private sector, civil
society and philanthropic trusts in health care. Philanthropic organizations such as the Bill
& Melinda Gates Foundation (which has committed more than $1 billion per year since
2000 to global health) have changed the way in which public health is financed in developing
countries. The importance of these global initiatives cannot be underestimated. In 2007,
investment through these GHIs accounted for two-thirds of all external funding for HIV/
AIDS, 57% for tuberculosis and 60% for malaria in developing countries.
In the developed world, major gains in health status were achieved through provision of
safe water and food, sewage treatment and disposal, tobacco use prevention and cessation,
injury prevention, immunization and other population based interventions. In sub-Saharan
Africa, much of this basic but necessary public health promotion and development has not
been sufficiently realized.

Evidence-based approach to public health

There is a need to practice public health using an evidence based approach. Such an
1. Community
assessment

2. Quantifying the
issue

7. Evaluating the
program or policy

6. Developing
an action
plan and
implementing
interventions

3. Developing a concise
statement of the issue

5. Developing
and
prioritizing
program and
policy options

12

4. Determining what is
known through the
scientic literature

approach involves the use of the best available scientific evidence, using data and
information systems systematically, applying program-planning frameworks, engaging
the community in decision-making, conducting sound evaluation, and disseminating what
is learned for action.
An evidence-based approach has several benefits including efficient use of resources,
improved chances of health programs succeeding coupled with greater workforce
productivity. Poor countries pay a huge opportunity cost when interventions which
would yield the highest health return on investment are not implemented. This means
that ideally, public health practitioners should always start from a scientific evidencebased perspective in developing policy, selecting and implementing programs and then
monitoring and evaluating success. However there are challenges to this approach. The
political environment must be one able to allow sober evaluation and absorb in a timely
manner the available information generated from research.
The information system requires investment to ensure it is able to generate information
for policy making. The type of information needed include epidemiologic data, results of
program or policy evaluations and qualitative data from the population. Results of studies,
and pilots done need to be widely disseminated. For this to happen, health workforce
training needs to incorporate at an early stage of training the principles of public health.
Much of the capacity building that has been conducted in the last twenty years has been
done on an emergency basis (post training).
One major barrier of disseminating information can be potentially overcome relatively
easily when compared historically. The extensive use of mobile phones by the general
population and health-service personnel and the spread of internet use offer a way to scale
up primary health services rapidly in a cost effective manner. However, these remains the
weak health systems with limited capacity to absorb and implement the huge amount of
resources available to change health status. Not enough investment has gone into building
the physical infrastructure of clinics and hospitals and the training and salaries of health
workers.
Going back to the beginning, real public health starts with determining what the health
problems affecting people are. The problem must be identified but equally important is
the context within which the problem is occurring and peoples behaviour in relation to
the problem.
The next step is to analyze how significant these problems are, then identify a possible
solution that will solve the identified problems in conjunction with the affected population.
Initially, public health was about what the public health practioner told the public to do
such as getting vaccinated or washing hands. Today, it is recognized that behaviour change
is an important part of health improvement.
Overeating, reduced physical activity and cigarette smoking are examples of individual
13

behaviour that require thinking about what the conditions are necessary to cause
behaviour change. It is important to note that most health communication interventions
have failed to elicit desired change in behaviour because of over emphasis on attitude
change. Researches have shown that attitude does not necessarily influence behaviour in
a linear fashion. In addition, the trend of the problem needs to be carefully monitored and
the interventions applied evaluated for effectiveness and efficiency. Preventing ill-health
from breathing polluted air from vehicle exhausts requires possibly several different types
of interventions targeted at different levels. Different segments of the population will have
contradictory views on the magnitude of the problem and what should be done about it.
These diverse views must be accommodated while solving the health problem. Emerging
problems need to be identified as early as possible and possible risk factors managed.
Risk factors can be at either individual or population level, and the approach to managing
them will vary accordingly. Much depends on the education levels, culture and socioeconomic well being of the community. However, public health practitioners must have
the sense of responsibility for safeguarding population health and looking out for factors
and behaviour that lead to poor health. This is the concept of primary prevention where
disease is avoided through preventive measures. If the disease exists, then secondary
prevention can be applied. This is where early signs of the disease are detected and action
is taken to minimize disease progression. Tertiary prevention is when the disease already
exists but action can be taken to minimize complications and disability assigned by the
disease. Clinical medicine and public health meet at the secondary and tertiary levels.

Importance of policy in achieving public health goals

Effective public health measures almost always include interventions at the policy level,
For example, for many years it has been known that cigarette smoking leads to cancer
and other illnesses. Having doctors and other health practioners announce that cigarette
smoking is bad has had little effect on peoples smoking habits. Reduction in smoking
requires a coalition of health and non-health forces in a concerted effort. Reducing smoking
requires a two-pronged approach, strategies to reduce first time uptake among youth and
secondly to encourage cessation of smoking for those already addicted.
The first prong envisions strengthening traditional tobacco control measures that are
known to be effective such as strong comprehensive government tobacco control
programs, increased excise taxes, stringent public smoking restrictions, limiting youth
access to tobacco products and intensifying prevention interventions. Restricting access
to cigarettes by not selling them in kiosks, banning tobacco advertising and enforcement
of laws against sales to school children are examples of such interventions.
Tobacco companies tend to argue against such control using a variety of arguments especially
free market arguments either that the cost of tobacco consumption can be simply priced
and the consumer will therefore pay for the healthcare costs incurred or that high tobacco
pricing encourages tobacco smuggling and therefore government will loose tax revenue.
Western Europe has the highest tobacco prices in the world yet smuggling is on average
14

lower than in other regions of the world. Controlling tobacco smuggling is therefore not a
market problem but weak government control problem. Tobacco smuggling occurs where
it is easy to evade taxes. At this point, tobacco smuggling becomes a public health problem
because it brings tobacco on to markets cheaply, making cigarettes more affordable and
thus stimulates consumption. The struggle to control tobacco consumption is one example
where the policy battles can extend for many decades before success. However before
embarking on policy issues there is a requirement that there be an understanding of the
epidemiology of the disease.

15

PART I: BASIC TOOLS FOR PUBLIC HEALTH

Public health, as a branch of medicine, is concerned with general aspects of health within
the public domain. There are three broad basic tools in the study of public health, namely
epidemiology, biostatistics and demography. By the end of this section, the reader will
be able to:
understand the fundamentals of epidemiology
differentiate between the different types of study designs in epidemiology
understand the concepts of specificity, sensitivity and positive predictive value
outline the measures used to describe the frequency of disease in the population and
their uses in public health
understand the concept of an ideal sample
describe the different classes of data and how they can be presented
describe the characteristics of a normal distribution within a population
understand the different types of decision errors and the implications for stating
results
enumerate the main sources of demographic data
identify the likely errors in collecting, analyzing and publishing data from the various
sources and strategies to minimize such errors.
understand the factors that determine family size and therefore population size and
growth
understand the theory of demographic transition and how it applies to health
planning.

16

EPIDEMIOLOGY

Introduction

Epidemiology is the study of the distribution


and determinants of health related states
or events in specified population, and
the application of this study to control
health problems. In public health, unlike
clinical medicine, the focus is on the
population and not the individual patient.
Epidemiology helps to determine the
probability of a certain disease occurring in
a given population.

its effects on the individual patient and the


population as a whole. At all times, the
population being studied must be carefully
and appropriately described and defined.
Disease is any impairment of the normal
physiological function affecting all or part
of an organism. It is a specific pathological
change caused by infection producing
characteristic symptoms illness or sickness
in general.

The population is a defined group of people


under study. It could be geographically
defined, for example, a country or defined
by age, say children under five years. The
population at risk or target population
is usually composed of both healthy and
unhealthy individuals. In practice, it is often
not possible to study every individual in
the population, thus we limit ourselves to
a subset of the population that is a typical
representation of the entire (target)
population.

Epidemiology is divided into two broad


categories namely, descriptive and
analytical. In descriptive epidemiology,
we look at the distribution of the disease,
that is, the patterns of the disease
occurrence in the population in terms
of who is affected where and when the
disease occurs. We can then determine the
prevalence and incidence of the disease.
The prevalence is the percentage of the
population that has the existing cases of
the disease at a given time. The incidence
of a disease is the number of new cases of
the disease for a given population in a given
unit of time.

Thus, a study can be conducted in a village


believed to have similar characteristics to
the study population. This generalization
of people in Village X which is similar to
the people in District Y, is non-statistical.
However, when we finally have to select
the actual people who enter the study, then
we use statistical methods such as random
sampling as discussed later in this book.

In analytical epidemiology, we study


the disease determinants or causes of the
disease in a population. A determinant
is any variable that directly or indirectly
influences disease distribution or the
frequency of occurrence of the disease.
These determinants can be related to
the host disease agent or environment.
The first step is to understand the natural
history of the disease.

From definition, epidemiology is concerned


with diseases such as malaria, HIV/AIDS,
and health problems such as injuries from
motor vehicle crashes. We need to have
a basic understanding of the disease and
17

Environmental
determinant 1
(social)
Environmental
determinant 2
(physical)

Specic disease
agent
determinant 1

Host
determinant 1

Specic disease
agent determinant 2

Host
determinant 2

Disease
in the
population

Environmental
determinant 3
(other)
Fig. 2.1: Interaction between disease and disease determinant

a particular health service. Differentiating


between need and demand allows for
prioritization of health services. By looking
at the changing patterns of morbidity and
mortality, we can evaluate the effectiveness
of health services in meeting health goals.

That is, how the disease behaves and in the


absence of an intervention the interactions
between the various determinants in
disease causation. Such an understanding
helps in disease diagnosis and in planning
preventive programs. Once interventions
are in place, there is need to find out if
these preventative measures are effective
both in the short and long term.

Measuring mortality
Mortality can be measured in terms of:
Counts
Proportions or percentages
Ratios
Rates

The Role of Epidemiology

The study of the distribution and


determinants of health problems in a
given population is essential for planning
and evaluation of health care services. As
part of health research, epidemiology is
used in identifying the providers as well
as seeking measures to control or prevent
the occurrences of illness in human
populations. Therefore, epidemiology
must be part of the foundation for the
organization, administration and control of
health programs.

Counts involve enumerating the number


of events occurring. Events can be the
number of disease cases, number of deaths
or number of accidents. It is the simplest
measure and establishes the magnitude of
the problem. For example, assume there
is an outbreak of swine flu in school A and
school B. A survey done simultaneously in
both schools to determine the number of
cases of swine flu found the following:

Measures used in Epidemiology


Diseases cause illnesses or even death and
therefore the two key measures used in
epidemiology are morbidity (illness) and
mortality (death). By understanding these
two measures in a given population, the
need for health services can be determined.
Need refers to people with a health
condition or disease and is different from
demand for health services which refers
to the people who actually access and use

Table 2.1: Survey results of H1N1 cases in school A and B


School

Number of H1N1 cases

120

240

While this information is useful, a simple


count does not allow for comparison
between the two populations. In order
to be able to compare, we need to have
a denominator, that is, the population at
risk. We then have a proportion which is
18

We can also calculate a Cause Specific


Mortality Rate (CSMR) where the deaths
are caused by a particular disease or event.
For example, in a district with a total
population of 1,000, the number of deaths
due to pneumonia in 2009 is 120. The rate
is therefore 12 %.

an expression where the number of cases


of a disease or condition is divided by the
population number from which the cases
were derived as shown below.
School A = 120 cases of H1N1 u in a population of 4,000
The proportion is 120
4,000
B = 240 case of H1N1 u in a population of 7,200

The case fatality rate is a measure


of disease severity and is calculated as
follows:

The proportion is 240


7, 200

A ratio is used where the numerator and


the denominator are separate and neither
is included in the other. For example, we
can compare the ratio of males to females
in a given population as shown below.

Case fatality rate =

Rates are used to describe or discover the


disease patterns when compared. Rates
can be crude, specific or standardized
(adjusted). The Crude Rate (CR) is
a summary rate calculated using the
actual number of events occurring in the
population over a specific period of time.
The crude death rate is calculated using
the formula:
No. of deaths in a year
Total population at mid year

No. of diagnosed cases of


that disease (in the same
time period)

1000

The rate is usually expressed as a


percentage. The case fatality rate can also
be used to measure benefits of a new
therapy as it would be expected to decline
if the therapy was successful. However,
it has to be used with caution where the
disease develops over a long period of time.
Under such circumstances, the numerator
may be higher than the denominator for
any given period of time.

Males = 200
Females = 400
Total population = 600
The ratio of males to females is 1: 2

Crude Death Rate =

No. of deaths from disease


(in a given period)

We have diseases where the case fatality


is high but the mortality rate is low. The
difference between case fatality and crude
death rate (CDR) is illustrated in the
example.

1000

In population of 100,000 persons, 20 have disease x. In a


year, 18 people die from disease x. the crude death rate = 18 /
100,000 = 0.018%

According to the UN population division


report, (2008) Kenya has a CDR of 11.8
while Malaysia has a rate of 4.5. CDR allows
for comparison and since crude rates are
easy to calculate, they are widely used for
international comparisons. However, they
have major limitations as they do not
take into account differences in population
structure such as age, sex and occupation.

For this disease we can say that the mortality rate is low.
However the case fatality rate is high and can be calculated as
follows;
No of people infected with disease = 20 of which 18 die,
therefore 18/20 = 90% case fatality.
Once the person has the disease, the chances of dying are high
(90%)

A specific rate is calculated using the


number of events occurring for a subgroup of the population over time.
19

Common categories used include age, sex


and occupation.

No. of existing cases at the


begining of specied period
+ No. of new cases that
develop during the period
Point prevalence =

Table 2.2: Calculating specic rates


Sex

Population

Number of
cases

Rates (%)

Males

500

80

16%

Females

500

40

8%

Total

1000

120

12%

total population at middle of


period

(X10n)

Period prevalence looks at the number


of cases at the beginning of the defined
period plus the number of new cases that
developed the disease during the period.

Adjusted rates are useful when comparing


populations. The rates are adjusted for the
effect of some particular variable such as age
or sex to allow valid comparisons between
groups. For example, suppose we want to
look at the relationship between alcohol
consumption and lung cancer, we will find
that some people who take alcohol also
smoke cigarettes.

Period prevalence =

No. of existing cases (C)


in a given point of time
total population multiply
by K

Where K is a constant e.g.=100, 1000, 10,000,100, 000


(10n)

While this is more informative than crude


rates, the major limitation with point
prevalence is in the large numbers needed
for comparisons to be useful.

We have to find a way to adjust the rate


so as to take into account those cases of
lung cancer which arise due to cigarette
smoking only.

We can also measure morbidity by


determining the number of new cases
occurring within the population. The
Incidence rate refers to the rate at which
new cases occur in a population. From the
incidence rate, we are able to derive the
risk of developing the disease.

Measuring Morbidity
Morbidity measures disease occurrence in
the population. If we measure the number
of cases at any given point in time or
during a specific time period, then we are
determining the disease prevalence.The
disease prevalence is a good measure of
disease burden and is useful for planning
health services especially at the evaluation
stage. However, if we measure the number
of new cases of the diseases, then we
have determined the disease incidence. A
rapidly increasing incidence would indicate
the outbreak of a disease or epidemic. The
prevalence can be further refined.

No. of new events in a


specied time period
Incidence rate (I) =

No. of persons at risk during


this period

(X10n)

However, to get an accurate incidence


rate, the disease free period for each
individual must be calculated. Since it is
rare for this to be done with precision,
the denominator is usually taken to be the
average population multiplied by the study
period. This is fairly accurate where the
average duration of the disease is long and
the population is stable. An easier measure
of disease occurrence is the cumulative

Point prevalence is the prevalence at


a given point in time and is calculated by
taking the total number of cases at a given
time and dividing by the total population.
20

incidence where the denominator is the


population at the beginning of the duration
of study.

Cumulative incidence =

and process data from various sources. The


information is then used for policy making
in the management of health services.
In studying the health of the population, the
first point of reference is to look at routine
data collected. If this is found inadequate,
then a survey can be done to fill in the
information gap. Research is needed when
there is a gap in the body of knowledge.
The main sources of routine data include:
a) Collection and analysis of vital
records such as:
Births
Deaths
Migration
How this data is collected is an integral part
of demography.
b) Collection and analysis of morbidity
data from:
Health facilities - Reviewing the
health records can yield useful
information. Often, though, the
record is of number of cases or visits
not the patients themselves. The use
of morbidity repeats can give a good
indication of disease management in a
given area. However, not all people
seek treatment and there might be
significant diagnostic deficiencies.
Records for laboratory tests can be
useful for information based on a
specific test that isolates an infectious
organism or confirms the diagnosis.
However, relatively few people have
direct access to laboratory services.
Community Health personnel such
as community health workers collect
useful data as they are involved in
vital registration, verbal autopsy
and follow up of patients. Traditional
healers and herbalists, are other
sources of community data.

No. of new cases in a specied


period
(X10n)
No. of persons free of the
disease in the population at
risk at the begining of the
period

The time period can be any length even a


life time.
Table 2.3: A relationship between cigarette smoking and
incidence rate of stroke in a cohort of 118,539
women.
Smoking
Category

Number of
cases
of stroke

Personyears of
observation (over 8
years)

Stroke
incidence
rate (per 100
000 person
years)

Never smoked
Ex-smoker
Smoker

70
65
139

395,594
232,712
280,141

17.7
27.9
49.6

Total

274

908,447

30.2

For certain diseases such as cholera which


spreads rapidly, the time of exposure to
a disease can be very short. Therefore, a
more useful measure is the attack rate (AR),
Where the incidence rate is expressed as
a percentage. A further refinement of the
attack rate is the secondary attack rate,
(SAR). This is the number of new cases of
a disease in a confined unit following the
first case (index case).
A confined unit is a closed group such as
a family or hospital. The secondary attack
rate gives a measure of how infectious a
disease is, e.g. Ebola which has a high
secondary attack rate.
Information Sources
Information
needed to solve health
problems should be readily available, reliable
and accurate. The health information
system (HIS) is the system used to collect
21

Employers either directly or through


their insurance schemes can be a
source of community data.
Another form of gathering data is
to carry out a survey. Such a survey
may involve:
a)Surveillance of disease or community
health problems.
b) Investigations of outbreaks or
epidemics leading to control or
prevention.
Information can also be gathered through
carrying out research in the form of;
a) Screening for disease - Identifying
individuals or sub-groups of the
general population at increased risks of
developing certain diseases.
b) Evaluation of the effectiveness of
existing or newly proposed
treatment methods or procedures
through clinical research studies or
trials.

b) Pre-symptomatic or sub clinical


stage
At this stage the disease is present in the
individual but symptoms or signs of the
disease are yet to appear.
c) Symptomatic or clinical stage
Organ and functional changes have
occurred leading to recognisable signs and
symptoms of the disease. There may be
partial or total disability at this stage.
d) Recovery stage
There may be total recovery or partial
recovery with residual disability or death.
Healthy stage

Recovery stage

Susceptible stage

The process of disease


transmission

Clinical stage

Understanding the natural history of a


disease allows us to work out the possible
points of intervention. Only then can we
begin to control and prevent the disease.

Sub-clinical

Figure 2.2: Stages in the natural history of disease

Depending on these stages of disease


progression, different prevention and
control strategies can be undertaken.

The natural history of a disease can be


defined as the course of the disease from
inception to termination when unaffected
by treatment or therapeutic process.

Causes of disease
One of the general themes in the philosophy
of science is that of cause and effect
and it always follows that if the causes
are present then the disease will follow.
It is termed sufficient when it inevitably
produces or initiates an outcome. Some
diseases are caused almost completely
by genetic factors while others are a
result of interplay between genetic and
environmental factors.

Four main stages can be identified as


follows:
a) Susceptible stage
In this initial stage, conditions necessary for
the disease to occur are present including
exposure to the disease causing agent.
However, the disease has not developed in
the individual.

22

need to be directed at more than one


factor at the same time. A look at the cause
of tuberculosis illustrates this concept.

This concept has been important in the


discovery of the causes of infectious
diseases. In Biology, Koch formulated
certain rules that determine whether a
specific living organism causes a certain
disease.
These include:
The organism must be present in
every case of the disease;
The organism must be able to be
isolated and grown in pure culture;
The organism must, when inoculated
into susceptible animal, cause the
specific disease; and,
The organism must then be recovered
from the animal and identified.

Tuberculosis (TB) is a disease caused by


a bacterium called M. tuberculosis. The
disease obeys Kochs postulate in that for
the disease to occur the individual must be
exposed to M. tuberculosis. However, many
people are exposed but do not succumb to
the disease.
There are other factors that play a
significant role to the extent that managing
these factors can lead to prevention of TB.
They play a critical role in influencing the
natural history of the disease.

Whereas this approach is useful in


determining certain diseases such as
Anthrax, Kochs postulate is inadequate
when we try to determine the cause of say
a motor vehicle crash.

The interactions of the various risk factors


determine the risk of disease. Some of the
risk factors can be termed proximal causes
of the disease while others are secondary
or tertiary causes. Looking at the condition
of low birth weight (LBW) illustrates this
point. The weight of a new born baby is
influenced by various factors.

Several elements can be identified such


as the state of the vehicle, behavior and
competnce of the driver and bad weather.
These elements can all be present and a
motor vehicle crash does or does not take
place. We therefore have to define causes
in epidemiology in a different way.

The most common cause of LBW is


pre-mature birth. This can be due to
intrauterine infection such as malaria, poor
nutritional status of the mother or multiple
pregnancies.

A cause of a disease or injury is an event,


condition, characteristic or combination of
these factors that play an important role in
producing the health outcome. We talk of
risk factors rather than cause. Rarely is the
cause of a disease due to a single factor.

The mothers socio-economic status has


a bearing on her nutritional status and the
healthcare she receives. This is in turn
influenced by her educational level directly
and or indirectly. The mothers age and use
of tobacco are other risk factors.

Unlike say Chemistry where a chemical


reaction follows a precise pathway, in
epidemiology it is more likely that several
factors are involved sometimes in a
hierarchy. Therefore we talk of proximal,
intermediate and distal causes of diseases.
Strategies for disease

These various factors act independently


and synergistically. In preventing LBW,
therefore it is necessary to look at all
the causes to design effective prevention
strategies.

prevention often
23

TB

infection
Fig. 2.3: The causes of tuberculosis

Dynamics of disease transmission


The manner in which risk factors interact
can often be complex and not well
understood. One framework we can use
is to divide these factors into:
Host determinants - those that are
inherent in the person affected.
Agent related - factors that are
related to the disease causing agent.
Environment related - factors
related to the hosts surrounding
The transmission process - methods
by which the agent accesses the host.

Why an infectious agent causes disease


now and not later depends on a number of
factors such as:
The pathogenicity of the agent, that is,
its ability to transmit disease. This is
measured by the ratio of the number
of persons who developed the clinical
disease, to the number exposed,
Virulence is a measure of the severity
of the disease which can vary from
very low to very high
Infective dose is the amount required
to cause infection in a susceptible
person,
The reservoir of the agent. (where its
natural habitat is)
The source of infection. For example,
certain diseases can be transmitted by
a carrier.

The host is the person or organism that


provides a suitable place for an infectious
agent to grow and multiply under natural
conditions. The reaction of the host can
range from severe clinical illness (low
resistance) to no apparent symptoms or
signs (high resistance) depending on the
specific host factor. Age, sex, race and
level of immunity are examples of host
factors as shown in table 2.4 below.

Environmental factors have an effect in


all the steps of disease transmission and
at all stages of the disease. We can group
environmental factors into physical,
biological and human factors.

Table 2.4: Host factors in disease transmission


Host factors

Example

Age

Inuenza ,more lethal in


the elderly and very young

Race

Skin cancer, more common


in Caucasians

Sex

Breast cancer more common in women

Immunity

Kaposi sarcoma, more


common in HIV/AIDS

Table2.5: Environmental factors in disease transmission

24

Environmental Determinant

Example

Physical

Temperature,
humidity, Insects, animals,
water quality

Man-made (including socioeconomic)

Living conditions, e.g.


crowding, sanitation,
pollution

Interventions
An intervention is an action taken with
the goal of modifying the natural history
of a disease. An effective intervention
changes the natural history of the disease
for the better of the population health.
The intervention can aim to either control
or eradicate the disease in question.
Depending on what can be achieved and
remembering that disease causes are
usually multiple, different segments of the
population can be targeted.

a major health problem. This is because,


while the disease exists, there is need to
continually carry out disease surveillance.

Study Designs

As discussed earlier, a number of factors


interact to bring about a particular health
outcome. In the study of a health problem,
choosing an appropriate study method
is therefore crucial in order to take into
account all sources of bias and confounding
and to make any sense of the results
obtained.

In primary prevention, the entire


population is the target. The objective is
to prevent onset of illness through health
education, immunization, sanitation and
good nutrition.

Each study design has its strengths and


weaknesses and the choice of which one
to use depends upon the purpose of the
study.

In secondary prevention, the target


population takes care of sick individuals.
By making an early diagnosis and providing
treatment, we try to prevent further
damage to the individual and the spread of
disease within the community. Screening
exercises of high risk individuals such as
those suffering from tuberculosis or breast
cancer falls in this category.

Epidemiological studies can either


be observational or experimental. In
observational studies, the investigator only
measures but does not interfere in any
way with nature. In experimental studies,
the investigator manipulates the events
or experience. Observational studies can
either be descriptive or analytical.
Table 2.6: Types of study designs

In tertiary prevention, the target population


are the sick people. The objective then is
to reduce further damage from disease by
clinical care and rehabilitation to regain
as much health as possible. Eradication
aims to eliminate the disease completely.
Usually, intensive effort is required for a
defined period of time to achieve success.
Examples include the eradication of Small
Pox and the campaign to eliminate Polio.
Though initially expensive, in the long run
there is no longer recurrent expenditure
once the disease is eliminated.

Observational

Experimental

Descriptive (Case series/


reports, cross-sectional studies,
ecological )

Clinical trials, Laboratory


experiments, Fields and
Community trials

Analytical (Case control


studies, cohort studies)

Quasi-experimental studies

In a descriptive study there is a description


of the occurrence of the disease in a
population. The study describes who is
affected, where and when it occurs. For
example, we may be concerned with
determining whether a condition affects
a particular age group or sex more than
another.

Control aims to reduce the disease to


acceptable low levels where it is no longer
25

Case control studies

A disease may have a seasonal variance


depending on weather. Geographical
differences e.g. rural vs. urban may also
play a role. It is useful where little is
known as to the occurrence, magnitude
or natural history of the disease. Because
the investigator is seeing both the outcome
and the possible causes at the same time,
no conclusion can be made as to the causal
factors of disease.
Descriptive studies are useful in anumber
of ways:
As the first study carried out to
generate a hypothesis as to the possible
relationship between cause and health
outcome;
To evaluate the trend in the occurrence
of health outcomes and exposure to
risk factors within a given population
or among sub-groups within the
population (or even across countries),
To provide a basis for the planning,
provision and evaluation of health
services for a given population or
community.

A case control study is a good way to test


a hypothesis concerning the relationship
between a health outcome and risk factors.
The magnitude of such a relationship can
be established. It is a relatively easy design
to investigate causes of diseases especially
for rare diseases. Comparison is made
between individuals who have a health
problem (outcome) and individuals who
do not have the health problem (control).
Unlike a cross sectional study, a case
control study is longitudinal. This is because
the investigator looks backward from the
disease to a possible cause, often called
retrospective studies. This terminology
can be confusing because at times the
terms retrospective and prospective are
also used to describe the timing of data
collection in relation to the current date. It
is therefore recommended not to refer to
this type of study as retrospective.
In designing a case controls study, there
are some key points that need to be taken
into account. The cases selected should
represent all the cases in the defined
population. Controls are people who do
not have the disease under study.

Descriptive studies offer certain advantages


in that they are easy and are not costly
to conduct both from time and financial
perspectives. The major disadvantage
however is that relationships cannot be
established and there is no comparison
between groups within the study. They are
generally unsuitable for acute conditions.

One of the major challenges is to find a


cost effective way to identify and enrol
controls. The choice of controls must be
similar for both control and subjects of
interest beyond the influence of exposure
status.

An analytical study analyzes the relationship


between health status and other variables
and they are useful in identifying risk
factors for a health condition or testing a
hypothesis generated from a descriptive
study. There are various types of analytical
studies namely:
Case control studies
Cohort studies.

The second major aspect is to determine the


start and duration of the exposure for both
case and control subjects. Often, because
the exposure is measured by interviewing
the affected person, the answers can be
skewed by the person having an idea about
the hypothesis under test.
26

POPULATION

Fig. 2.4: Case control study design

Case control studies have certain


advantages over other types of studies.
They are relatively cheap and can be
carried out over a short period. They can
be used to determine multiple exposure or
risk factors for a given disease or outcome.
They are suitable for a rare outcome and
are a good way to study a disease with a
long latency period such as Cancer.

Cohort studies provide useful information


on disease causation and the risk of
developing that disease. The major
disadvantage is that the actual study can
be difficult to carry out. The time between
exposure and disease occurring can be
years and it can also be difficult to find
people who are exposed in the case of
very rare diseases.

However, case control studies cannot be


used to determine risks and incidence
rates. Because of the way in which they
are conducted, problems with missing
information in terms of past records
and recall of past events becomes a big
challenge.

Nevertheless, cohort study has a number


of advantages.
Incidence or risk can be determined
Suitable for rare exposures
Multiple outcomes for given exposures
can be determined.
The disadvantages are significant though
and include:
Long time for follow up for certain
conditions e.g. cancer (possibly
decades)
Large number of subjects may be
required
Relatively expensive
Unsuitable for rare outcomes

Cohort Studies
This study starts with people who do not
have the disease. Cohort study populations
are divided into two groups; those with
exposure to potential causes of the disease
and those without exposure. They are then
followed up to see how they develop the
disease under study.

A cohort study allows us to calculate


relative risk (RR), which is defined as the
risk of an event (or developing a disease),
relative to exposure. The relative risk is
the probability of the event occurring in

Just like case control studies, the data


on exposure and disease are collected
at different times thus the studies can be
referred to as longitudinal studies.
27

(a)

(b)

(c)

(d)
Figure 2.5: Cohort study design

the exposed group compared to the nonexposed group.

of an adult population in Framingham,


Massachusetts.

Table 2.7: Calculating relative risk


Liver cirrhosis (Disease status)
Risk
Present

Absent

Heavy alcohol drinker

(a) 20

(b) 80

Teetotaller

(c) 2

(d) 98

RR

c
(c+d)

20
100
2
100

a
(a+b)

Depending on the objective, the


appropriate use of the different
observational studies can be summarized
as shown in table 2.8 .
Objectives:
1. Investigation of rare disease
2. Investigation of rare cause
3. Testing of multiple e ffects of cause
4. Study of multiple exposures and
determinants
5. Measurement of time relationship
6. Direct measurement of incidence
7. Investigation of long latent periods

10

The heavy alcohol drinker is ten times


more likely to develop liver cirrhosis when
compared to the non-drinker.

Table 2.8: Appropriate use of observational studies

In large cohort studies, expenses can


be reduced by using routine sources of
information such as disease registers as
part of the follow up.
The Framingham heart study that began in
1948 and ended in 2008 is an example. It
was set up to study the factors associated
with the development of cardiovascular
disease by employing long-term surveillance

Objective

Ecological

Cross
section

Case
control

Cohort

Y - Yes
28

W - Weak

N - No

Experimental Studies
In experimental (intervention) studies,
there is an active attempt to change
a disease determinant through some
intervention such as treatment. Examples
of interventions include drugs, vaccine
trials, health
education and food
supplements. In the examples provided,
we could be asking whether the procedure
or drug is effective. The determinant
can be exposure, behaviour or disease
progression. In this regard, experimental
studies are similar in design to experiments
done in other sciences.

be done properly. This ensures that any


differences between the two groups are
not due to bias.
Field trial
Field trials involve people who are healthy
but presumed to be at risk. The purpose
is to prevent disease. Data collection takes
place in the field as illustrated in the Salk
polio vaccine field trials of 1954.
Salk polio vaccine trial of 1954 are among the largest
and most publicized clinical trials ever undertaken.
Across the United States, 623 972 school children
were injected with vaccine or placebo, and more than a
million others participated as observed controls.

The main difference though is the fact that


we are dealing with human beings. The
main types of experimental study designs
are:
Randomized control trials (clinical trials)
Field trials
Community trials

The results, announced in 1955, showed good statistical


evidence that Jonas Salks killed virus preparation
was 80 to 90% effective in preventing paralytic
poliomyelitis.

Community trials
Community trials are similar to a
randomized control study in design.
The difference is that the subject is the
community rather than an individual.
They are useful for conditions which are
influenced by social circumstances and
for which prevention involves targeting
behaviour change. However, there are
difficulties in the methodology as it may be
very difficult to find two communities that
are similar enough yet are far apart enough
to be isolated from each other so that there
is a true experimental and control group in
place. As a result of this, it is often difficult
to state categorically that a communitywide intervention has been shown to be
effective.

Note: Almost invariably, informed consent


is required from the study participants. In
a single blinded study, the person in the
study does not know the treatment they
are on.
However, the investigator is aware of which
treatment each participant in the study is
receiving. In a double blinded study, both
the person in the study and the investigator
do not know the exact treatment that each
person is receiving. This minimizes bias.
Randomized Clinical Trials (RCT)
A randomized control trial is designed to
study the effects of a particular intervention.
Typically, subjects are allocated randomly
into two groups, an intervention group
and a control group. Because the results
are based on a comparison of the two
groups, the initial selection of subjects and
subsequent allocation to the groups must

Sampling

It is usually very expensive and impractical


when studying a health problem to study
an entire population. It is more practical
to carry out a sample survey. A sample
is defined as a selected subset of the
population.
29

Ideally, the sample should be representative


of the population and observations made
from the sample can be used to draw
conclusions about the larger population.
Sampling therefore is the procedure by
which individual units of a population are
selected from that population for study.

population from the list of all the clusters.


All the individuals within the selected
cluster are then selected. The selection
of individuals can be simple or stratified.
Stratification is done in order to get samples
representative of the population when
random sampling might be too expensive
or impractical. Stratification can be done
on the basis of geography, age or sex. A
random sample is then selected from each
stratum. For example, individuals within a
cluster can be sampled by locality in order
to ensure the sample is representative of
the population. We then have multi-stage
stratified sampling.

Samples can be random where every


individual has an equal chance of being
selected or non-random or convenience
samples. Convenience samples are chosen
for convenience for example patients
attending a health facility who agree to be
studied will likely not be representative
of the general population. Most published
clinical studies are not random but use
convenience samples.

Another common type of sampling method


is snowball sampling in which people are
selected using a non-random approach.
It is used when the desired population is
difficult to reach or access because they
feel disempowered, socially excluded, or
vulnerable. Common examples include
slum dwellers and migrants who are
typically under-represented in samples.

Probability sample is used when every


person has a known but not necessarily
equal chance of being selected. Probability
sampling is often more useful because it
allows inclusion of a sufficient number of
specific sub-groups of interest such as a
particular age group or people with certain
conditions.

Sampling begins by identifying someone


who meets the inclusion criteria for
the study. This person is then asked to
recommend others who might also be
eligible and like to be included.

If such sub-groups of interest comprise


a small proportion of the population, a
simple random sample may not include
enough of them for analysis.
Cluster sampling is used often to save
costs of random sampling when the study
population can be divided into natural
groupings called clusters. Such clusters
should be fairly similar to each other but
consist of heterogeneous individuals.

Sampling continues in this way, with the


next person providing recommendations
until the sample size is met. The sample
obtained may not be representative of the
general population but using a snowball
sample may be the only cost effective
sampling method available.

Clusters can be defined geographically, for


example Counties, villages or places around
which individuals cluster such as a school
or health facility. A random number of
clusters are then selected to represent the

Depending on how the sampling procedure


is done, the sample can end up being
representative or non-representative.
30

Four types of errors need to be accounted


for:
1. Sampling errors. These can be errors
arising from how the sample is selected
or errors arising due to non-response
of those being sampled. People may
not be present for interview or
decline to be interviewed. This is more
so where the information being gathered
is sensitive in nature or involves
discomfort to the respondent.
2. Errors of measurement
For example answers to questions may
be recorded incorrectly or during data
entry and analysis responses are
incorrectly entered.
3. Errors occurring during data
analysis such as inputting 1.0 as 10.
4. Errors due to changes in
population characteristic over time
(obsolete data).e.g. use of old census
data. At the time data is collected it
may be that the sample reflects the
population then. However the results
are used to inform future policy. At
that point in the future, the population
may have changed. For example in
Kenya in year 2000 there were
200,000 mobile phone users. In
2009 there were 17.5 million mobile
phone users. Basing policy on the year
2000 would definitely underestimate
the effects of mobile phone use.
Sample Selection
A good sample is one that will give the
desired result for the least amount of
resources. The major considerations are
to minimize the sampling errors and to
determine the desired levels of the result.

be. In a normal population, a standard


deviation of one includes 68% of the
population while a standard deviation of
three includes 99.7% of the population. If
the precision required is great, then great
care must be taken to reduce the sampling
errors in order to give meaning to the
results obtained.
For example, if preparing a drug requires
2mg of the active ingredient then we cannot
use a scale which measures kilograms to
the nearest 100 grams to weigh out the
active ingredient.
The technique used to select the sample
influences the types of errors that will
occur. The ideal is where every unit in the
population has an predetermined chance of
being selected into the sample (probability
sampling).
Simple random sampling is an example of
probability sampling. In order to draw a
probability sample, we need first to define
the population in terms of a sampling
frame. For example, in doing a study on
hypertension in urban areas, the goal is to
study individuals and determine how many
of them have hypertension. A sampling
frame can be constructed using a list of v
households in a particular district.
From this sampling frame, individuals are
randomly selected to participate in the
study. The households to be selected can
also be randomly selected and thereafter
the individuals. This process is referred to
as two-stage sampling.
The population can also be divided into
strata. Sometimes this is necessary because
results are to be published separately
for each stratum. Stratification can also
improve precision of results.

Most populations have a normal distribution


and therefore we can use standard error
to define how precise we would want to
31

answer why and how questions. For


example, why do women in a particular
community deliver at home and not in
health facilities? Quantitative research tries
to answer what questions. For example,
what percentage of women are delivering
in health facilities? Just like for quantitative
research the study sample depends on the
research question.

The exact size of each stratum needs to


be known and a sample is then obtained
independently from each stratum. To
select a sample, we need to number the
units from one to the last number.
The selected sample can be drawn by
one of two methods; simple random or
a systematic method. In a simple random
method we use a random numbers table to
generate random numbers which are used
to select the sample. In systematic sampling
we start by drawing a random number as
the starting point and then select every nth
unit until we have the desired sample size.

However there are a number of key


differences as shown in table 2.9.
Table 2.9: Comparing qualitative and quantitative

The size of the sample is determined by


the optimum number needed to enable
valid inferences to be made about the
population. For example, if the event
under observation is a rare one then a
larger sample size is required.
Also if there is to be a comparison between
two groups, intervention and control and
the difference is expected to be small
then a large sample size may be required.
The larger the sample size, that is the
closer it is to being the actual population
being studied, the smaller the chance of a
random sampling error.

Quantitative

Qualitative

Philosophical
foundation

Deductive eductionist

Inductive, holistic

Aim

To test pre set


hypothesis

Explore complex
human issues

Study Plan

Step-wise predetermined

Iterative, exible

Position of
researcher

Aims to be detached
and objective

Integral part of
research process

Assessing
quality of
outcomes

Direct tests of validity


and reliability

Indirect quality
assurance methods
of trustworthiness

Measuring of
utility of ults

Generalizability

Transferability

To obtain a true random sample it is


necessary to know before hand the
characteristics that make up the study
population. In addition, some informants
are often better than others in understanding
and interpreting observed behaviour.

However the sampling error is inversely


proportional to the square root of the
sample size, therefore there is very little to
be gained from having very large samples
beyond a certain point. This is why it is
important to calculate the correct sample
size to avoid wasting resources.

For example, it is better to ask a group of


medical students (or their lecturers) about
why students drink heavily rather than
ask a randomly selected group from the
general population.In a case like this, the
research aims to answer a question about a
particular group of students and the result
is not meant to be generalizable.

Qualitative research sampling


The decision whether to conduct
quantitative research or qualitative research
depends upon the research question.
Qualitative research tends to be done to

Three types of sampling techniques can


be used for qualitative research namely;
convenience, judgement and theoretical
samples.
32

Screening tests

Convenience sampling is the least rigorous


and involves the selecting subjects that are
easy to access. e.g patients attending your
clinic. It is often the least costly but may
lack credibility.

The aim of screening is to identify or detect


disease or risks factors in the early stages
of its development. By picking up the
condition as early as possible, we are in a
better position to intervene. Examples of
screening activities include antenatal clinics
or screening for breast cancer. Apart from
detecting diseases early, screening can aid
in assessment of the health of the general
population. There are different types of
screening depending on the objective:
Mass screening aimed at the whole
population;
Multi-phasic screening using several
screening tests at the same time;
Targeted screening of groups with
specific exposures, e.g. occupational
health;
Case finding or opportunistic screening
aimed at patients who attend clinic for
a different purpose.

Judgemental sampling is the most common


and involves the identification of the most
productive sample that answers that
research question. The development of
the criteria is based on literature or the
researchers practical knowledge of the
subject area. Identifying one or two such
subjects may lead to the identification of
others (snowball sample).
In interpreting the data, it is important
to consider how to handle subjects who
support certain explanations and those
who do not agree. It may therefore be an
advantage if a broad range of subjects are
included.
These include outliers, those subjects with
specific experiences to those with expertise
in a specific area (Key informants). Unlike
quantitative research where the sample
size is known before hand and steps in
data collection are performed in a rigid
step like fashion, quantitative research
requires a more flexible design approach
to accommodate such.

Screening can be carried out through


standardized
interviews,
physical
examination, laboratory tests or a
combination. The decision on whether
to screen for a disease or not should be
based on a number of factors. First, there
should be a high disease burden in terms of
morbidity and mortality.
The natural history of the disease should
be well understood and the prevalence
of detectable pre-clininical phase of the
disease must be high among the screened
population. Finally, the treatment given
before symptoms develop must be of
greater benefit than that given after a
person develops clinical manifestations of
the disease.

The theoretical approach in qualitative


research means that samples are usually
theory driven. As data emerges, an
interpretive theory is built up which then
informs the selection of a new sample.
Such sampling must take into account the
context of the study. A combination of
the various sampling techniques can also
be used to provide greater understanding.
E.g. use of focus groups, key informant
interviews and in-depth interviews of
selected subjects.

For a screening test to be useful, it must


satisfy certain requirements. Remember
that the population being screened
33

Screening for breast cancer with mammography


Screening with mammography uses X-ray to try to nd breast cancer before a lump can be felt. The goal is to treat
cancer early, when a cure is more likely. The review includes seven trials that involved 600,000 women who were
randomly assigned to receive screening mammograms or not. The review found that screening for breast cancer likely
reduces breast cancer mortality, but the magnitude of the effect is uncertain.
Screening will also result in some women getting a cancer diagnosis even though their cancer would not have led
to death or sickness. Currently, it is not possible to tell which women these are, and they are therefore likely to have
breasts or lumps removed and to receive radiotherapy unnecessarily. The review estimated that screening leads to a
reduction in breast cancer mortality of 15%and to 30%overdiagnosis and overtreatment. This means that for every
2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy
women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer
patients and will be treated unnecessarily.
Furthermore, more than 200 women will experience important psychological distress for many months because of
false positive ndings. It is thus not clear whether screening does more good than harm. Women invited to screening
should be fully informed of both the benets and harms.
Pc, Gtzsche, and Nielsen M. Screening for breast cancer with mammography ( Review ). the cochrance
collaboration, no. 4 (2009).

is negative it is unlikely that the person


concerned has the disease. In other words,
a very sensitive test rules out a disease.

is assumed to be healthy and so the


screening test needs to have the following
characteristics if it is to be useful:
Be acceptable to the people being
screened;
It should give immediate results;
It should be harmless;
It should be cost effective
The test should be reliable, that is, give
the same result if repeated under same
conditions.
In addition, the test should be valid,
that is, actually pick out the disease in
question and not some other similar
condition. Validity has two components
namely sensitivity and specificity.

Specificity of the test tells us the ability of


the test to correctly identify the disease. If
the result of a specific test is positive, it tells
us that the person has the disease. The test
is useful at picking out those people who do
not have the disease in a population where
the disease is absent. The test therefore
has very few false positives.
These two concepts are important in
screening because, if the result obtained in
screening is wrong, there can be devastating
consequences. These include psychological
trauma or possible wrong treatment. For
example, if a false positive result is given
in breast cancer screening, this may be
devastating where the treatment options
include mastectomy.

Sensitivity and Specificity


Sensitivity of a test is the ability of the
test to give a correct result where a person
with the disease is identified, that is, a
positive test compared to when it gives
a false negative result i.e. person has the
disease but is screened and the test result
is negative.

Table 2.10: Comparing sensitivity and specicity in a screening


test

For a screening exercise to be effective,


we need to minimize the number of
false negatives. If a screening test is very
sensitive, it means that when the result

Disease

Sensitivity

Specicity

Test positive

True Positive

False positive

Test negative

False negative

True negative

Ideally, we would like a test that is both


highly specific and highly sensitive. In reality
34

however, we have to balance between


the two. By increasing the cut-off point at
which we define a condition we increase
the specificity of the test, but we are also
likely to miss a few cases, false negatives
increase. In doing so, the sensitivity of the
test will go down.

The tests are accurate in only two of


these combinations (true positive and true
negative). In the other two categories,
there is a possibility of the test giving an
incorrect result.
The positive predictive value of a test is the
likelihood of disease if the test is positive.
The negative predictive value is the
likelihood that the disease is absent when
the test is negative.

Diagnostic tests
Using the same principals as a screening
test, a diagnostic test should help confirm
the presence of disease that is suggested
by the present symptoms and clinical signs.
The value of the test is how correctly
it predicts the presence or absence of
disease. In performing the test, there are
four possible results that can be obtained
as shown in table 2.9.

For the clinician, the problem lies in the


fact that truly accurate tests are usually
expensive and likely to be invasive
compared to cheaper tests that are used in
routine clinical practice.

Table 2.11: Possible outcome of diagnostic test


Present
Present
positive

Negative

Absent

true
positive

False
positive

False
negative

True
negative

35

Questions Section
1. What are the main purposes for which epidemiological studies are carried out?
2. What is the difference between cohort study and case control study?
3. Define specificity, sensitivity and positive predictive value
4. What are the measures used to describe the frequency of disease in the population
and their uses in public health
5. What is the relative risk (RR)? From which type of epidemiological studies can RR be
calculated?
Further Reading
1. Concato J. What is a screening test? Misclassification bias in observational studies of
screening for cancer. Journal of general internal medicine. 1997 ;12(10):607-12.
2. De Vreese L. Epidemiology and causation. Medicine, health care, and philosophy.
2009 ;12(3):345-53.
3. Fletcher, RH, Fletcher SW, Clinical epidemiology: the essentials, 4th ed,
(Philadelphia: Lippincott, Williams & Wilkins, 2005.)
4. Mayer D, Essential evidence-based medicine, (Cambridge, Press Syndicate of the
University of Cambridge, 2004)

36

BIOSTATISTICS

Introduction

Public health deals with populations and


relies on biostatistics to provide and
interpret data on the various populations.
Because health is determined by many
factors that interact in complex ways, it
is not always obvious which factors cause
what specific effect. By applying statistical
concepts and methods in a systematic way,
we can try to determine which particular
factor causes a particular health effect.
Before we determine there is an effect, we
need to determine that the occurrence or
perceived relationship between the cause
and effect is not purely due to chance.

the last few decades, biostatistics has


become more important in medicine as
we move more towards an evidence based
medicine approach.

Descriptive Statistics

Data is a collection of facts and figures


organized in such a way that conclusions
can be drawn from them. Data describes
the subjects we are interested in and can
broadly be classified into:
Qualitative data: This describes a
certain quality or characteristic that we
are interested in and therefore divides
the population into categories such as
sex, e.g. male or female.
Quantitative data: thus relates to
quantity data which can be further
broken down into discrete and
continuous data. Discrete data describe
values that can only be whole numbers.
For example you can have 2 or 3
children but not 2.5. Continuous data
has an infinite number of possible value
allowed and is usually associated with
measurement. For example a person
can weigh 70kg. Using a more accurate
scale, one can measure 70.255 Kg and
so on. The possibilities depend upon
the accuracy of the measuring device.
In general if data can take on values
that are fractions or decimals then it is
usually considered continuous data.
It is sometimes possible to obtain
approximate quantitative data from
qualitative data. For example, surveys
results that ask people to rate
perception on a Likert scale can be
summarized into continuous data.

Biostatistics helps us solve the problem that


we can rarely study every single individual
in a given population. We therefore have to
obtain a sub-set of the population. We need
to apply techniques that win to ensure the
results we get from studying the sample
can be applied to the larger population.
Biostatistics is therefore concerned with:
1. Collection and presentation of data
(descriptive statistics)
2. Drawing conclusion about population
based on the observation of the sample
(inferential statistics).
The field of statistics developed in the
18th century when governments began
to collect data about their populations for
planning purposes.
To make sense of the mass of data being
collected, concepts such as average
person were advanced using mathematical
calculations. Theories of probability also
developed formally around this time. Over
37

Four Classes of Data


Nominal
This is useful for mutually exclusive data
where we can label the data but there is
no order between the values, e.g. sex, race
and religion.

Location

By location we mean how close together


the various individual bits of data are and by
variability we want to know how different
this particular data is when compared to
the rest.

Ordinal
This where the order matters but there is
no sensible arithmetic difference between
the different values, e.g. asking people to
rank pain on a scale of 1 to 5. Where 1
=not painful and 5 = unbearable pain. The
relationship between the response 1 and 5
cannot be related mathematically.

Measures of Location
Measures of location (central tendency),
give us an idea of where our observation
lies on the scale of measurement. The
three most commonly used measures of
location are the arithmetic mean, median
and mode.

Interval
This where order matters and the
difference in value has meaning, but the
zero is arbitrary, e.g. temperature and
dates in calendar.

Arithmetic mean is an average that is


obtained by adding up all the values in the
sample and dividing by the total number of
values. For example, in an antenatal clinic,
five women have their weights checked.
We would like to know their mean weight
(represented as X ). The value for each
observation can be designated as X. Each
weight observation can then be designated
as X1 X2, X3. etc. A typical value of weight
is usually denoted Xi. To obtain the mean,
we can use the formula:

Ratio
Has all the properties of an interval variable
but a fixed known zero exists. Age, weight
and height are examples.
Organizing Data
Imagine having the blood pressure data
for a village population of 5,000 people.
Ultimately we want to describe the
characteristics of the given population
rather than each individual.

(X1+ X2 + X3+ X4+ X5)

For any given group of data, the arithmetic


mean is unique. While this is a very
useful measure and commonly used, the
arithmetic mean can be greatly affected by
extreme values at either end. In addition,
you could find that no single value in your
sample is the same as the mean. When
the observations are arranged in order of
magnitude, the median is the middle value.
That is, the median is the score above
which 50% of the other scores lie.

The first step is to look at the distribution


of the data. Arranging the data from the
least to the highest value can give us an
idea of how to describe the population of
interest.
In order to do this, we need to have the
ability to summarize the data. The data
can be described in terms of location and
variability.
38

Where the total count of values are even,


then the median is the average value of the
two middle values.

Find the median. The average is


Median = 4.5

If the number of values is odd, the


median will be the middle value of the
observations.

Example 1:
To find the median of 4, 5, 7, 2, and 1.
(Odd)
Step 1: Count the total numbers given.
There are 6 elements or numbers in the
distribution.
Step 2: Arrange the numbers in ascending
order. 1, 2,4,5,7
Step 3: The middle position can be
calculated using the formula.

If the number of observations is even, the


median will be average of the two middle
values.
The mode is the most frequently occurring
observation. For example, consider an
order for theatre gloves. The different
hand sizes of theatre staff are presented as
shown in table 3.1.

(n+1)
2

Table 3.1: Calculating the mode

Thus the middle position is,


(5+1)
2

6
2

(4+5)
=
2

Hand Size

= 3

The number at 3rd position


is = 4= Median

No. of Staff

61/2

71/2

The most commonly required glove size is


71/2 and this is the mode. In this case, this is
the size of glove that should be ordered in
larger quantities.

Example 2
To find the median of 4,5,7,2,1,8 (Even)
Step 1: Count the total numbers given.
There are 6 elements or numbers in the
distribution.
Step 2: Arrange the numbers in ascending
order. 1, 2, 4,5,7,8
Step 3: The total elements in the distribution
(6) is even.
As the total is even, we have to take average
of numbers at n and (n) + 1
2
2
6
Thus the positions are n =
=3
2
2
and 4

Measures of Variability
The other major way of describing data is
to measure the variability or dispersion.
Important measures of variability are the
range and standard deviation (variance):
Range
The range is the difference between the
maximum and minimum value. It is based
on only two observations, the smallest
and the largest. Even though it is easy to
calculate and understand, extreme values
can distort the range. To help limit the
effects of the extreme values at the end,
we can divide the population of interest
into equal groups or ranges.

The numbers at the 3rd and the 4th


position are 4,5.
Step 4
39

absolute deviations (MAD) as;

Two commonly used ranges are interquartile range (4 equal parts) and percentile
range (100 equal parts). Having ordered
the data from least to highest, using the
percentile range, the 25th percentile would
include all data that is less than twenty five
percent of all the data.

MAD =

(Xi - X
n

(Xi - X)2
n
The formula would give the standard
deviation for a given population, but in
almost all cases, we deal with samples of
the population. The appropriate formula
for the standard deviation (sd) is thus:

Table 3.2: Calculating variance


4

11

13

)2 = variance

To get the standard deviation we then


calculate the square root of the variance
as shown.

Variance (Standard Deviation)


By variance. we would like to know how
far the observations are from one another
with reference to the mean. Consider the
following set of values in table 3.2.

22.8 = 2.28
10

For mathematical reasons, rather than


using MAD as a measure of dispersion, we
use the standard deviation, where we
square each deviation. The formula then
becomes;

The 2nd quartile (Q2) is the 50th percentile


while Q3 is the 75% percentile and the
inter-quartile range is Q3-Q1. The 50th
percentile is the median. Grouping the data
in this way can give one an idea of how to
describe the population.

[Xi - X ] =
n

The mean X can be calculated by adding


up all the values and dividing by ten which
is 7.4. We could then work out how
much each value deviates from the mean.
For example, the first value 3 deviates
negatively from the mean by 4.4 and the
last value 13 deviates positively by 5.6.
In each case, the calculation done is
X -X .
i
adding up all the deviations to get an
average would give a figure of zero so we
take absolute values. This is indicated as:

sd

(Xi - X)2
n-1

This can be re-written as:


sd

X2i - (Xi)2
n-1

The final formula is usually easier to use


as we do not first have to calculate each
deviation. In biostatistics, the mean and
the standard deviation are known as
parameters and are the most commonly
used measures to describe data.

[ Xi - X ] which means the absolute value of Xi - X .

Grouped Data
Faced with a mass of data, it is often better
to group them rather than work with
individual values. For example, below are

To add up all the values, we get the equation


1 Xi - X . From adding up the absolute
deviations, we can calculate the mean of
40

heights in centimetres of students in a


class.

forms for presenting data are graphs and


tables.

180, 186, 123, 156, 221, 145, 158, 167,


171, 165, 144, 163, 155, 190 176, 177

Graphs give a general depiction of the


overall pattern while tables give more
specific detail about individual values. The
choice depends on the type of data.

The advantage of grouping data is that we


can quickly begin to make sense of the data
e.g. the mode and where the median might
lie and figures that are extreme (outliers).
In establishing the groupings, we create
class intervals. In doing so the following
rules are useful.

Qualitative Data
Discrete data is best presented graphically
using either, a pie-chart, a bar graph or a
histogram as illustrated in figure 3.1.
(Height)
165

The class limit of one class (right end point)


becomes the beginning point (left end
point) of the next class.

160
155

The mid points should be whole


numbers
There should be at least 6-10 class
depending on the sample
The class interval should be
between 1/10 and 1/20 of the
difference (i.e. the range).
Sturges rule can be used to determine
how wide to choose the bars when
visually representing data by a
histogram.

150
145
140
0
1

Class
mid-point

Frequency (f)

(Students)
Fig.3.1: Bar graph showing height of students

Cigarette smokers

Table 3.3: Grouping data into classes


Class
boundary

Smokers who chew


tobbacco

Cumulative

Pipe smokers

The mode can be seen as the most


frequently occurring value. The median
lies at the 50th percentile. To calculate the
mean we use the class midpoints.
ixi
Mean=
i

Fig. 3.2: Pie chart showing tobacco use by type

Quantitative Data
As discussed earlier, data can be either
discrete or continuous. Discrete or
category data such as a disease group or
presence or absence of specific symptom,
can be summarized as frequencies and
percentages. However, percentages alone
can be confusing, as the denominator may
be unclear. Rarely is it necessary to present

Presentation of Data
In presenting data, we must find a way that
communicates the maximum amount of
information efficiently. The most common
41

Bimodial distribution

the data beyond one decimal point. Tables


and text is the best way to display such
data.
For continuous data, the most commonly
used methods for presentation are
histograms,
cumulative
frequency
distributions and frequency polygons. A
large proportion of populations obey a
normal distribution where most of the
data cluster around the mean or average.
When plotted, the graph has a bell shape
with peak at its mean. In probability theory,
the normal distribution is a continuous
probability distribution.
For example, the height of people in any
population is normally distributed with a
few people being extremely tall and others
being extremely short and the majority
clustering around the average.

Fig. 3.4: Different types of distribution curves

Kurtosis is the degree of flatness or


peakedness of a distribution. Higher
kurtosis means more of the variance is the
result of infrequent extreme deviations,
as opposed to frequent modestly sized
deviations. Where the data distribution
follows the above curves, the mean is not a
good measure of distribution. The median
is usually a better measure of central
tendency.

f(z)
0.3

Frequency

0.2

-3

0.1

-2

-1

1.45 2

Statistical Inference

Very rarely do we get a chance to study


an entire population. More practical is to
obtain data of a sample of a population. In
drawing conclusions about a population
based on observing a sample, we need to
have an understanding of the mathematics
of chance. The question is how sure are
we that the result we have is not due
to chance? In otherwords, what is the
probability that the result we have is a true
result? To answer such questions we need
to have an understanding of statistical and
probability laws.

Fig. 3.3: A Histogram of discrete data

Skewed Distribution
Not all populations have a bell-shaped
curve and not all bell-shaped curves are
normal as illustrated below.

42

The first statistical law states that if two or


more events are such that not more than
one of them can occur in a single trial, then
they are said to be mutually exclusive.

19

That is, 20 + 20 = 1
The third law states that the average of
the results obtained from a large number
of trials should be close to the expected
value, and will tend to become closer as
more trials are performed.

Using the throwing of a dice as an example,


the probability of throwing a 3 is 61 . If we
roll the dice a second time and get a 4, the
chances of getting a 4 on the second roll
would be 61 . The result would not depend
on the result of the first throw and so the
events are mutually exclusive.

Normal distribution
A normal distribution is defined as normal if
the area under the curve between it and the
x-axis is equal to one. Between the mean
and is 0.34 (one standard deviation).

The second law states that two or more


events are said to be independent if the
probability of the occurrence of one of
them is not influenced by the occurrence
of the other. For example, suppose you had
a game where after rolling the dice in the
previous example, you are then required
to draw a black card from a pack of cards.
The probability of that event is 41 .

Because the curve is symmetrical around


the mean then the area under the curve
between - and is 0.68. the total area
under the curve between - 3 and 3 is
0.99 or 99%. If the population is normally
distributed then any value will fall within 3
standard deviations of the mean 99% of
the time.

The two events do not depend on each


other. Therefore, the probability of the first
event occurring than the second would be
1
1
1
6 X 4 which is 24 .

Area = Q

In real life a doctor suspects that a patient


has both malaria and an upper respiratory
tract infection (URTI). Assuming that the
cause of the illnesses are independent
events; what would be the probability
that both could occur in one person at
the same time? Suppose that the incidence
of Malaria is 51 of outpatient illnesses, for
URTI, it is 41 .

q
Signicance level

Fig. 3.5: Calculating standard deviation

We now need to relate the standard


deviation to probability. Suppose that we
have a student population with an average
weight of 70kg with a standard deviation
of 5. What would be the probability that
a student with a weight of 77kg or more
occurs in that distribution?

Therefore, the probability that the patient


1
. Put
had both conditions would be 41 X51 =20
the other way, 19 times out of 20 this would
not be the correct diagnosis. With respect
to any one event all the probabilities should
add up to one.

In this case the deviation from the mean is:


77 - 70 = 7 kg.
Z = (77 - 70)/ 5
= 1.4

43

come up (1/6) X 100 = 16.6 times. If it


were to come up just twice or come up
fifty times then we would have reason to
suspect a problem with the dice.

From the Z-table, we can look up the


area under the curve that corresponds
to a standard deviation of 1.4, in this case
0.9192 which subtracting from 1 = 0.808.
Thus there would be an 8% chance that
the student weighing 77kg is part of the
normal population.

This can be worked out statistically. For


binomial distribution the standard deviation
is calculated using the formula:

Binomial distribution
Binomial distribution is applicable where
we know that the probability of an event
occurring is p and therefore the probability
of it not occurring is q, where p -1 = q.
We can use two dice; one black the other
white to explain this. Suppose we were to
roll both dice at the same time, what is the
probability that each would give a score of
4? Because each dice has 6 surfaces, the
probability is 1/6 for each dice. For both
since they are independent of each other,
1
1 1
it would be 6 x 6 = 36 .
The rolling of the dice to give a 4 means
its not possible to score 1,2,3,5 or 6
i.e. each outcome is mutually exclusive of
the other. If we were to draw a bar graph
of all the possible scores from two dice,
we would have a graph that is very similar
to a normal distribution curve as shown in
fig. 3.6.

SD =

nX pXq

So the standard deviation for 5 in 100 dice


rolls is:
100 X 1/
6

5/
6

=
=
Z=
=

500/

36

3.73
(16.6 -2)
3.73
-3.91

That is, the chances of genuinely getting


5 only twice after rolling a dice 100 times
would be less than 1 in 100 (i.e. -3.91
chances ). If we had a null hypothesis (Ho)
which stated that the dice is normal and
we got such a score, then we would have
to reject the null hypothesis and conclude
that there is something wrong with the
dice.
Binomial Expansion
If we were dealing with more than one
patient, what would be the probability that
each has a URTI? We can work this out
algebraically. Let p be the probability that
the event happened and q the probability
that it did not.

6
5
4
3
2
1

Fig. 3.6: Bar chart showing all possible scores from two dice

Suppose that p= 5 .
For each patient p+q =1. If there are 3
patients then (p+q)3
The probability that all three patients have
URTI would be:

The graph gives us a kind of average, based


on probability.
On average, if we were to throw a single
dice 100 times, we would expect 5 to
44

2
2
2
5 X 5 X 5

2
=( 5 )3

measure in the population. Having a poor


sampling procedure can lead to bias, which
means that at the end of our research we
would be unable to generalize our findings
to the general population from studying
the sample because we would not be able
to show that the sample was similar to the
general population.

8
= 125

It is possible that two patients have URTI


and one does not.
( 25 )2 X

3
5

Each combination of circumstances is a


possible event and the probability of each
event occurring is not the same. A formula
that we use to express this is:

Standard Error
If we have a true random sample, rather
than look at each individual sample measure
we can use various parameters such as the
mean, for study. Just like when we looked
at individual scores earlier we assume that
the populations are normally distributed,
the mean is known and so is the standard
deviation. But now we look at the mean
of a sample of the scores. It is crucial to
realize that for any given population, there
is a very large number of samples that can
be obtained that have the same mean and
SD.

If there was only one patient then the


probability would be (p+q)1. If there are
two patients then (p+q)2
But (p+q)2
= (p+q)+(p+q)
(p+2q)+(p+q) = p(p2 q)+ q(p+q)
= p + pq +qp + q
In algebra, any expression that involves
adding or subtracting two different terms
like p and q is called a binomial. If we return
to our 3 patients then the equation would
be;
(p+q)3 = (p+q)(p2+2pq+q2)
= p(p2+2pq+q2)+q(p2+2pq+q2)
= p3 + 2p2q +pq2+qp2 +2pq2 +q3
= p3 +3p2q+ 3pq2 +q3

For example, in a country population of 35


million it is possible to get 35,000 distinct
samples of 1,000 people as long as there
is not a single element in common among
the different samples. But if one or more
persons appears in more than one sample
then the number of possible samples
increases.

The pattern that develops is that in


successive unlike terms in the expansion
the power of p drops by 1 and the power
of q gains by1. If the power of the binomial
is two then there are three terms and the
power is three then there are four terms
and so on.

Calculating the mean for each one of these


samples would create a distribution. The
total mean for all the sample means is the
same as the overall population mean.
However, we would expect that the
standard deviation for each sample would
be less than that of the larger population.
We can calculate the standard deviation of
sample means using the formula:

Testing Samples
A random sample refers to a set of measures
each one of which is no more likely to
occur in the population from which the
sample is drawn than is any other similar
45

to the patient. (The null hypothesis might


be written as H0: there is no difference
between the two treatments.) In doing
so, we should have to have a level of
probability known as the significance level,
alpha (). The significance level can be set
at say 0.01 which means that whatever
result is obtained there is a less than 1 in
100 possibility that it could have been due
to chance.

Sd x = sdx
n
Where Sdx is the sample standard
deviation and n is the sample size.
In biostatistics, the standard deviation of
the sample mean is called the standard
error (SE).
SE =
Where

For certain tests we are concerned with


either value being greater than the mean
or less than the mean. We refer to this as a
one-tailed test.

is standard deviation
n is the sample size

To test the sample mean using Z-score, the


formula is as shown:

At other times we are concerned with the


amount of deviation and therefore refer to
a two-tailed test. Special consideration is
given to the null hypothesis. This is because
it relates to the statement being tested,
whereas the alternative hypothesis relates
to the statement to be accepted if the null is
rejected. The results are therefore always
given in terms of the null hypothesis.

Z = xm - x
SE
Where Xm is sample mean
X is the population mean
The Null Hypothesis
A hypothesis is a statement about
population parameters like expected value
and variance For example, Number of sex
partners of HIV positive clients is high or
the duration of the hospitalized stay for
HIV/AIDS patients is longer than that of
malaria patients.
In looking at new treatments or
interventions, we must always have in mind
the fact that not only can the intervention
be ineffective but it can actually cause
harm. Therefore, in research we adopt
a pessimistic attitude and assume that
the new treatment we are researching at
worst will not be harmful.

We either Reject H0 in favor of H1 or Do


not reject H0; we never conclude Reject
H1, or even Accept H0. It is important
to note though that rejecting H0, does not
necessarily mean that the null hypothesis
is true, it only suggests that there is not
sufficient evidence against H0 in favor of
H0. Rejecting the null hypothesis then,
suggests that the alternative hypothesis
may be true.
Levels of significance
In a one-tailed test if the Z-score from our
sample mean is associated with a probability
less than , then we reject H0 and accept
H at the level of significance. Greater
than , then we accept H0 and reject H
at the level of significance. In a two-tailed

Therefore, we start off with a null


hypothesis (H0) which states that the new
treatment will not make any difference
46

test, if the Z-score from our sample mean


is associated with a probability Less than
/2, then we reject H0 and accept H at
the level of significance. Greater than
/2, then we accept H0 and reject H at
the level of significance.

P(type I error) = significance level =


The exact probability of a type II error is
generally unknown.
Table 3.4: Accepting the null hypothesis
H0

Decision errors - Type I and Type II


In testing a sample mean what we want
to know is how much does the sample
mean have to differ from the population
mean before we conclude that there is a
significant difference with this particular
sample? Suppose we are comparing a
group of patients receiving a new form
of treatment, how different should their
sample mean be before we can conclude
that the treatment works? Or might the
difference be a random one (chance)?

(Null Hypothesis)

Test decision

H0 true

H0 False

Accepted (TRUE)

OKay

Type II

Rejected (FALSE)

Type I

OKay

A hypothesis is a statement about a


population or populations for example;
Number of sex partners of HIV positive
clients is high or the duration of the
hospitalized stay for HIV/AIDS patients is
longer than that of malaria patients.
In looking at new treatments, we must
always have in mind the fact that not only
can new treatment be ineffective but it can
actually cause harm. Therefore, in research
we adopt a pessimistic attitude and assume
that the new treatment we are researching
at worst will not be harmful. Therefore,
we start off with a null hypothesis (H0)
which states that the new treatment will
not make any difference to the patient.

If we were to conclude that the difference


in means was random while in fact it is not,
we would be committing a type I error.
If on the other hand we conclude that
there is a difference between two samples
when in fact there is more then we have
a type II error. We are said to commit a
Type I error when we observe something
that is not really there and a Type II error
when we fail to observe something that
is there Committing a Type I error is
often considered to be more serious, and
therefore more important to avoid, than a
type II error. .For any given set of data, type
I and type II errors are inversely related;
the smaller the risk of one, the higher the
risk of the other.

In doing so, we have to have a level of


probability known as the significance level,
alpha (). The significance level can be set
at say 0.01 which means that whatever
result is obtained there is a less than 1 in
100 chance that it could have been due to
chance.For certain tests we are concerned
with either value being greater than the
mean or less than the mean. We refer to
this as a one-tailed test. At other times we
are concerned with the amount of deviation
and therefore refer to a two-tailed test.

The hypothesis test procedure is therefore


adjusted so that there is a guaranteed low
probability of rejecting the null hypothesis
wrongly; this probability is never 0. This
probability of a type I error can be precisely
computed as

Levels of significance
In a one-tailed test if the Z-score from our
sample mean is associated with a probability
less than , then we reject H0 and accept
47

H at the level of significance. Greater


than , then we accept H0 and reject H
at the level of significance.

in comparison to the expected frequencies


to determine if the categorical differences
that occurred are the same as would occur
by chance.

In a two-tailed test, if the Z-score from


our sample mean is associated with a
probability Less than /2, then we reject H0
and accept H at the level of significance.
Greater than /2, then we accept H0 and
reject H at the level of significance.

The test examines the observed frequencies


in comparison to the expected frequencies
to determine if the categorical differences
that occurred are the same as would occur
by chance. Below is an example of how to
calculate chi-square.

Hypothesis testing

Testing the difference of means of large


samples

Dr. Hawi wonders if there is a difference


in the characteristics of motor cycle riders
compared to other male patients admitted
to hospital. Over a period of one year she
has classified by level of education the men
aged 18-40 years admitted to the district
hospital as a result of a road crash. At the
same time she has likewise classified the
men of similar age admitted to a medical
ward with HIV/AIDS. She has used the
demographic survey method of classifying
education as attainment outlined in table
below.

It is common to want to know if means of


two large samples are significantly different
as to represent two different populations
or if the two samples have come out the
same or similar populations. A two-tailed
test is usually used because we want to
know if there is a difference either way.
As mentioned earlier, we can draw large
number of samples out of any given
population.
With two different populations we would
have to compare X1, X2, X1 being the
mean of samples from population X to
y1, y2, y3 being the mean of samples from
population y. For each pair, we would have
to consider the difference between each
pair of sample means. The formula to use
is:
x-y =SE2x + SE2y
SEx = x
nx

Table 3.5: Classication of men admitted to a hospita; by


educational attainment
Educational
Sample
total
attainment
Surgical Ward Medical Ward

and SEy = y
ny
2

Chi-Square
We often want to compare a discrete
variable found in two different sample
populations. Chi square test can be used to
determine if the differences in nominal or
categorical data are statistically significant.
The test examines the observed frequencies

Some primary
education

16

22

Completed
primary

25

21

46

Some
secondary
education

39

34

73

Completed
secondary

42

49

91

More than
secondary
education

31

25

56

Total

153

135

288

Dr. Hawi would like to know whether the


distribution of the patients by educational
attainment differs in these two wards.
She therefore has a null hypothesis that
there is no difference between the two
48

distributions. This is what she tests by chi2


2
square
. It is important to note that
.
Tests may be carried out for this purpose
only on the actual numbers of occurrences,
not on percentages, proportions, means of
observations, or other derived statistics.
2
Calculate
. Using the following steps:

in which the proportions are exactly the


same for two sample populations. This is
done in columns (2) and (3) of table 3.6.
The proportions are obtained from the
totals column in table and are then applied
to the totals row. For example, in table
above, column (2), 11.7= (22/288) x 153
for column (3) 10.3= =(22/288) x 153 and
so on. The sum of the expected numbers
for each sample must equal the sum of the
observed numbers for each sample. We
then subtract each expected number from
its corresponding observed number. The
results are given in columns (4) and (5)
(O-E)2
2
The value for
=
.
E
We then look up in a table of chi-square
( 2) distribution the probability attached to
it. However, we have to take into account
the degree of freedom. A simple rule is that
the degree of freedom equal (number of
columns minus ) x (number of rows minus
1). For Dr Hawis data in table above this
rule gives (2- 1) x (5 -1) =4.

For each observed number (O) in the


table find an expected number (E);
Subtract each expected number from
each observed number E (O-E)
Square the difference (O-E)2
Divide the squares so obtained for
each cell of the table by the expected
(O-E)2
number for that cell
E

is the sum of

(O-E)2
E

To calculate the expected number for


each cell of the table we consider the null
hypothesis. In this case it is that the numbers
in each cell are proportionately the same in
the surgical ward as in the medical ward.
We therefore construct a parallel table
Table 3.6: Calculating chi-square
Educational
attainment

Expected Numbers
Medical
Ward
(3)

O-E
Surgical
Ward
(4)

Medical
Ward
(5)

(O-E)2
E
Surgical
Ward
(6)

Medical
Ward
(7)

(4.31)

1.59

1.80

total

Surgical
Ward
(2)
11.7

10.3

22.0

4.31

24.4

21.6

46.0

0.56

(0.56)

0.01

0.01

38.8

34.2

73.0

0.22

(0.22)

0.00

0.00

Completed
secondary

48.3

42.7

91.0

(6.34)

6.34

0.83

0.94

More than
secondary
education
Total

29.8

26.3

56.0

1.25

(1.25)

0.05

0.06

153

135

288

2.49

2.82

Some
primary
education
Completed
primary
Some
secondary
education

2
= 2.49+2.82 = 5.13
Degree of freedom = 4
2
From the
table 5.31 lies between 3.357 and 7.779. The corresponding probability is: 0.50>P>0.10. This is well above the conventionally signicant
level of 0-05, or 5%. So the null hypothesis is not disproved.

49

a significance level of 5% and a confidence


level of 95% if we want to define our
interval level at a 95% then;

From the
table (Appendix) entering at
4 degrees of freedom and reading along the
2
row we find that
of 5.31 lies between
3.357 and 7.779.

70 m/ 1.10 =+1.96 or 70 m/ 1.10


= -1.96
m = 70 2.16 or m
= 70+2.16

The corresponding probability is:


0.50>P>0.10. This above the significance
level of 0.05 or 5% and therefore the null
hypothesis is not disproved. It is therefore
possible that in the distribution of patients
by educational attainment the population
from which patients in surgical ward were
drawn did not differ significantly from the
population from which patients in the
medical ward was drawn.

= 72.16

The interval is 67.84 to 72.16, that is we


have a 95% probability that the mean of
the general population is at this interval
assuming normal distribution.
The t-test
Using the Z-table (appendix) to work
out probabilities only works if the sample
size is greater than 30. As the sample size
becomes smaller there is likelihood that a
single extreme value will distort the sample
parameters. William S. Gosset1 worked
out a method of modifying the Z ratio so
that it could be applied to small samples of
less than 30.
The method is therefore widely known as
the Students t-test. The student t-test can
be used to determine:
1. Whether the difference between
means of paired samples are significant;
2. Whether the difference between
means of independent (unpaired)
samples are significant;
3. the interval a population mean lies on
the basis of a samples characteristics;
and,
4. Whether or not a sample mean differs
significantly from the population mean.

Confidence Limits

We should be able to state with some


degree of confidence where the population
mean falls when all the information we have
is about the sample. Suppose we know
that the average weight of 100 students in
medical school is 70kg with a SD of 11kg
we cannot precisely determine the mean
weight of the general population from this
sample.
What we can do is try and establish a range
where we can state with confidence the
general population average weight will fall.
The degree of confidence is expressed as a
percentage and the higher the percentage
the larger the confidence interval.
SEx = x
nx
= 11

Paired Samples
In a clinic, we can take the blood pressure
of a patient using a digital or a manual BP
machine. Assume ten patients had their
blood pressures taken using both machines.
The results are as shown in table 3.7.

10

= 1.10
The interval extends either side of the
mean. AZ-value of 1.96 is associated with
50

Table 3.7: Blood pressure readings of selected patients


Patient No.

Digital reading

Manual Reading

Difference d

Difference 2 d2

80

85

25

78

80

74

75

73

75

99

100

90

95

25

82

85

81

84

77

80

10

75

78

Total
mean
The standard deviation of the d-values is:
SD =

d2- d 2

28
10

= 63.3

Looking up the t-table at 5% significance


level, the t-value should be equal to or below
2.2662. In our case it is 63.3 therefore the
resultant difference is significant between
using the digital and manual BP machines.

17.6
9
1.956
SD =1.398

Independent Samples
In the above case, the samples were
dependent since we were measuring the
same person in different ways.

the t value is calculated using the


formula:
t

96

1.398

n
n-1

SD = 96 - 28
10
9

28
2.8

1
d

If however we are measuring two samples


that are independent of each other we
may still want to know if there is significant
difference between the two.

SD
n

For example, consider the systolic blood


pressure of a group of men and a group of
women.

In the above case

51

Table 3.8
X
Men

x2
Men
X

Y
Men
x2

y2
women

85
90
100
100
115
115
118
120
122
125
135
22500

7225
8100
10000
10000
13225
13225
13924
14400
14884
15625
18225

1375

161333

1
2
3
4
5
6
7
8
9
10
11
12

100
110
115
120
122
125
135
140
140
145
150

10,000
12,100
13,225
14,400
14,884
15,625
18,225
19,600
19,600
21,025
22,500
150

Total

1402

181,184

Mean

127.45

114.58

SD

15.79

15.53

To get the confidence limit we multiply our


standard error 4.48 by 2.201 = 9.87.
Since this is a two tailed test our population
mean lies between 114.58+and - 9.87.

women
y2

We can compare our sample mean to the


population mean. Suppose from literature
we know that the average female population
diastolic BP is 110. We would like to know
if the average obtained for our sample at
114 is significantly higher. This is a onetailed test.
T = m Y / se
=110 114.58 / 4.48
= 1.02

From the t-table at 11 degrees of freedom


at 95% confidence interval (0.05) the t
value is 2.201. Our result is therefore not
significant.

D
Therefore SD = 17.28

Whenever we use the t-test the standard


deviation for different samples is assumed
to be the same. Remember that the larger
the differences in dispersion between
two samples the less accurate are our
conclusions about differences between
their means.

t = X Y/ sd2 (1/ nx + 1/ ny)


= 127.45 114.58 / 298.75 (1/11 + 1/12)
= 1.78

Using the t-table at 5% level of significance


and 21 degrees of freedom, the score
should be at least 2.0796. Our t is 1.78 and
is therefore not significant.

Because the sample size is small (<30), a


single extreme score can affect our mean
greatly.

Confidence Intervals
The interval in which the population
interval should lie can be calculated using
the following formula. Using the sample of
women blood pressure:
Standard error (SE)

= sd/n
= 15.53 12
= 4.48

At 95% confidence interval and with a


degree of freedom of 11 (12-1) then from
the t-table, the value is 2.201.

52

Questions Section
1.
2.
3.
4.

What is the ideal sample?


Explain the different classes of data and illustrate how they can be presented
Compare and contrast the different measures of location
Describe the characteristics of a normal distribution? Identify examples of
populations that do not have a normal distribution.
5. What are the different types of decision errors and what are the implications of each
decision error?
6. In the literature it is common to come across the following phrases;
We failed to detect any difference...
Our results do not support ...
We found no evidence for ...
Our data did not confirm
When is it appropriate to use each of the phrases?

Further Reading

1. Devane, D., Begley, C. M., & Clarke, M. (2004). How many do I need? Basic
principles of sample size estimation. Journal of Advanced Nursing, 47(3), 297-302.
2. Florey, Charles V. Sample size for beginners. British Medical Journal 306 (1993):
1181-4.
3. Overholser, B. R., Sowinski, K. M., Overholser, B. R., &Sowinski, K. M. (2007).
Biostatistics Primer : Part I. Nutrition In Clinical Practice, 22, 629-635.

53

DEMOGRAPHY

Introduction

Demography can be defined as the study of


the characteristics of human populations,
such as size, growth, density, distribution,
and vital statistics.

the society. At the individual level, everyone


experiences two demographic realities.
We are born and eventually we all die. In
between people have children, migrate
and those who take care of themselves live
happily into old age.

The world population was estimated to be


7 billion people in 2011. In 1950s the world
population was just 2.5 billion. The sheer
number of people increasing at the rate of
250,000 per day and how they compete
for the worlds finite resources is a key
reason to have a grasp of demography and
demographic trends.

World Population Growth


Human beings have been around for tens of
thousands of years, but it is only in the last
250 years that the population has begun to
accelerate. Around the time of the agrarian
revolution, the world population was
estimated at about four million people.

9 billion

Until then, human beings were primarily


hunters and gatherers
and so they
used resources extensively rather than
intensively as we do today.

8 billion
7 billion
6 billion
5 billion
4 billion

Between 8,000 BC and 5,000 BC an


average of just 372 people were added to
the world population each year. By the time
of Christ (1AD), the population growth
rate had increased to 300,000 people per
year and the total world population was
estimated at 200 million people.

2050

2040

2030

2020

2010

2000

1990

1980

1970

3 billion

1960

9
8
7
6
5
4
3
2
1
0

1950

Population (Billions)

10

YEAR
Source: U.S Census Bureau, International Data Base, June 2010 update

Fig. 4.1: World Population : 1950-2050

Whichever sphere of life but particularly


in health, knowledge about how many
people there are, where they live and
work is crucial if we are to make informed
decisions that will improve quality of life in
society.

One theory as to why the industrial


revolution in Europe started around
1750 was that Europe was reaching the
carrying capacity of its agricultural society.
Simultaneously, people migrated looking
for more land and at the same time became
more resourceful in looking for better ways
to utilize the resources they had.

Demography therefore forms part of


the policy decision making process. For
example, in a rapidly growing population,
transitions about family and household
structure, and urban/ rural distributive
changes need to be understood then
planned and managed for the well being of

Prior to this, death rates were very high


and few populations tried to maximize the
number of children born.
54

It is estimated that life expectancy in the


hunter-gatherer years was about 20 years
which means that more than half of all
children born died before reaching 5 years
of age.

same as Europe. But contact with Europe


decimated the population and only in the
latter part of the 20th century did Africa
began to recover its population base. This
is reflected in the population growth rates
for African countries which tend to be
higher than world average,(South Africa is
an exception).

The average woman who survived into


reproductive age had to have 7 children in
order for 2 to survive to adulthood. Only
with the advent of the industrial revolution
has there been a fall in death rates and an
increase in fertility rates to allow more
children to be born and for them to live
longer.

Table 4.1: Population growth rate of select countries

This dramatic increase in world population


is because of exponential growth which
can be described as the power of doubling
as opposed to linear growth where we
add one unit at a time. A common way of
measuring growth potential is to ask how
long it will take the population to double
given the current growth rate. The rule of
70 is the easiest way to calculate this.

Country

Current
Population
2011
(millions)

Current
growth rate

Estimated
population
2025
(millions)

Kenya

41

2.5%

51

Uganda

34

3.6%

56

South Africa 49

-0.4%

48

Italy

58

-0.1%

56

Indonesia

245

1.1%

279

Brazil

203

1.1%

232

Source. Adapted from US Census international data base

The Demographic Equation


Changes in the population occur as a result
of the combination of mortality, fertility
and migration. The interaction of these
demographic variables can be presented in
the form of an equation as shown below.

Exponential growth in mathematics is


expressed by natural logarithms. The
natural logarithm of 2 is 0.70. Multiplying
by 100 to get rid of the decimal point we
get 70. If we then divide 70 by the current
world growth rate of 1.2% we get 58.3
years to double.

PT+ n

= PT + B - D + M

Where;
(Pt + n)
Pt
B
D
M
Population
change

The top five countries by population today


namely, China, India, the United States,
Indonesia and Brazil account for 48% of
the worlds population ironically account
for only 21% of the worlds land surface.
You only have to visit 15 countries to meet
two thirds of the worlds population. The
rest of the population living in over 180
countries occupy 63% of the worlds
land.

= population today
= Population at a presence Pt in time
= Births
= Deaths
= Migrations
=Natural Increase (Birth, deaths) + Migration
(Net)

Age/Sex Structure

In order to observe changes in the


population, we need to look at the age
and sex structure of the population. For
example, changes in fertility will affect the
number of children born and this has an
effect on the number of primary school
places needed in a particular community.

Africa is a recovering continent. In AD1500,


the population was about 100 million, the
55

Changes in the age/sex structure affect


virtually all the social institutions in the
society. Society assigns various roles to
people depending on their age, gender and
sex. It is therefore necessary to have an
understanding of the age/sex structure of
a particular society.

years and over 65 years.

The age/sex structure represents the


number of people of a given age and sex
in society and this is built from the input of
births at age zero, death and migrations at
every age. A population is considered old if
more than 10% of its people are older than
65 years and young if more than 35% of its
population is under 15 years of age. The
age structure can be shown statistically or
represented graphically in three ways:
1. By constructing a population pyramid;
2. Calculating the average age of the
population; and,
3. Calculating the dependency ratio.

The impact of a high dependency ratio can


be felt directly in the health and education
sector. Those with many dependants
save less, and have less money to spend
on housing and food. Note that the ratio
is of potential workers, i.e. those aged
between 14 and 64 years. In reality, not all
in those age groups work thus, the actual
dependency ratio in many developing
countries may be much higher.

Table 4.2: Dependency ratios for select regions


Region

Dependency ratio

Northern America

0.49

South America

0.51

South East Asia

0.49

Eastern Africa

0.88

Below are the age/sex structure for Kenya


and Italy

A population pyramid is a graphical


representation of the distribution of a
population by age and sex. In a developing
country, the broad base is built around
many births tapering to the top where the
numbers of elderly are relatively few with
a high death rate. Developing countries
typically have the classic pyramid.
in developed countries where births are
relatively low and life expectancy is high,
the base is so much narrower that the
pyramid looks more like a barrel.
The average age of a population is usually
calculated using the median. A further
index that is used to measure the economic
and social impact of the age/sex structure
is the dependency ratio. The higher the
dependency ratio, the more people each
worker has to support. The dependant
population is defined as those under 14

Fig. 4.2: Age/sex structure for Kenya and Italy

56

Dynamics of Age/Sex structure


Factors affecting the population structure
affect the sexes in different ways so that
rarely are there the same number of males
and females at each age. At almost every
age, males have a higher mortality rate
compared to females for various reasons.
Fertility too affects the sex structure.
Possibly for biological reasons as well as
social reasons, more boys are born than
girls. Compared to migration and mortality,
fertility has the largest long term impact in
shaping the age pyramid.

improvement from 2003 when it was 115/


1000 live births. Immunization and use of
insecticide treated bed nets are some of
the interventions cited as having helped
reduce these mortality figures.
Demography is essential for planning in
other sectors of the economy. These
include:
1. Food security. The basic resources
required to produce food is land, water
and energy. These are finite resources
and food production needs to be
communserate to the rising
population in a sustainable manner;
2. Energy. Every additional person born
requires energy to produce food,
provide shelter, clothing and for
economic life;
3. Environmental degradation. Increased
population creates greater pressure on
the earth. This has resulted in global
warming, destruction of various
habitats, coral and wildlife;
4. Urban planning
5. International migration
6. Infrastructure such as housing, roads
7. Labour and economic policy.

Role of demography in health


A health worker needs to be aware of
demographic changes both at the local
and national levels. At the local community
level, short term changes can occur due
to in or out migration. Local demographic
measures such as the infant mortality rate
need to be monitored and reduced. As
more people plan their families, the number
of deliveries will drop with consequences
on the number of maternity units needed,
midwives and so on. In the long run, a
community with a high percentage of
elderly people needs to have a different
model of delivering healthcare to a young
community.

Theory of Demographic Change

There are few theories that adequately


explain how populations change over
time. The demographic transition theory
is still used as the underlying basis for
development work around the world. The
demographic transition theory originally
was not a theory but a description by
Warren Thompson of the demographic
changes that had taken place in certain
countries.

At the national level, demography is


crucial to health planning. The provision
of health services is an expensive exercise
and usually long term in nature. A hospital
sited in the wrong area can rarely be
converted into other uses. Understanding
the demographics can help plan what
services are required and at what period
of time. Looking further into the details
of why certain populations have indices
that are high or low can help improve
services. For example, Kenya has an
under five mortality rate of 74/1000 live
births. Although this is high, it reflects an

In 1929, he published data which showed


that countries could be grouped in three
main categories depending on the patterns
of population growth.
57

Group A - Northern Europe and the


United States had moved from high rates of
natural increase to low rates of population
increase.

The term demographic transition then


came to mean the period of rapid growth
when a country moves from high birth and
death rates to low birth and death rates
i.e from high growth potential (Group C)
to incipient decline (Group A). As more
countries were studied they all seemed to
fit somewhere within the model.

Group B - Italy, Spain, and Central Europe


had evidence of a decline in both birth rates
and death rates but Thompson suggested
that the death rate was about to decline
rapidly. The picture was that of group A
countries 50 years earlier.
Group C -The rest of the world had little
evidence of control over wither births
or deaths. Thompson felt that economic
growth and well being would determine
whether such countries were able to move
into group B or A.

From the mid 1940s, rapid population


growth in the developing countries became
a major concern and thus more people
devoted themselves to the demographic
transition
theory.
Their
concerns
were formulated around the theory of
modernization. This theory is based on the
idea that in pre-modern society, people
were governed by tradition.

In 1945, Frank Notestein labelled the


three growth patterns that Thompson
had described. He called Group A pattern
incipient decline, Group B pattern
transitional growth and Group C pattern
high growth potential. In the same year,
Kingsley Davis talked about a population
explosion while referring to Notesteins
transitional growth, in a lead article title
the demographic transition.

In traditional societies, fertility and mortality


rates are high. In modern societies fertility
and mortality rates are low. The advent
of industrialization forced societies, to
change. (the demographic transition).This
change occurred because, as incomes and
health services improved, mortality went
down and people then adjusted accordingly
by having fewer children because they
noticed that they did not all die.

Stage 1

Stage 2

Stage 3

Stage 4

Birth Rate

Level of Technology

Population Growth

Pre-Industrial

Very Slow

Early
Industrial

Mature
Industrial

Rapid

Slowing

Fig. 4.3: The demographic transition

58

Post-Industrial

Very Slow

Because of the enormity of that task and the


ramifications of the information collected,
a census is a very sensitive exercise as the
results are used to allocate resources.

Economic forces moved people from


agriculture where children were an
advantage (extra labour) to urban areas
where they were no longer useful (spend
all their time in school for which the parents
have to pay for).

There are two methods of Data


Collection:
1) De facto method, people are
enumerated people with where you
find them during the defined census
period.
2) De jure method people are counted
with respect to their usually residence
or legal residence.
Both methods have potential to error,
thus in practice, a combination of both
methods is used.
No census can be 100% accurate.

Generally, large families became a


disadvantage thus a decline in fertility rates.
As Teitelbaum (1975) stated, development
is the best contraceptive. There are critics
of the demographic transition theory. They
have pointed out that the theory does not
predict actual levels of mortality or fertility
nor does it tell us when the fertility decline
will occur.
In addition, the countries which are
grouped as in incipient decline never
had the same conditions as the current
developing countries have. Therefore it
may not be a question of following in the
footsteps of developed countries. Current
thinking has looked at the role of education
and economic development as a major
influence on mortality and fertility decline.

Table 4.3 below lists some of the possible


errors.
Table 4.3: Possible errors in a census
Error

Description

Under-enumeration

Some people missed altogether


especially those in crowded urban
slums and remote areas

Double enumeration

Some people are counted twice

The primary source of demographic data


is the census.

Misclassication of
information

For example age can be wrongly


categorized or due to digit
preference. People can avoid
using certain digits e.g. 13 (digit
preference)

Census
This is a complete enumeration of all
persons living in the country at a specified
time called the reference period. The
census is the source of benchmark statistics
on population size and age-sex structure.
Additional data collected include data
on social and economic factors such as
housing, environment, health, income, and
education and disease, such as HIV/AIDS.

Enumerating
non-eligible persons

Counting people in transit,


refugees, deceased

Coverage area

Remote, distant locations and


crowded slums may not be
reached.

Data collection errors

Human, communication barriers,

Political interference

Importance of census for


government resource allocation
can to lead attempts at
manipulation

Obsolete results

Compiling census results can take


such a long time that they are
rendered obsolete

Sources of Demographic Data

Vital registration system


This is a method of collecting data of vital
events such as births, deaths, marriages
and adoptions.

The data is collated to provide information


needed for development planning, policy
decision and research.
59

Demographic variables

For legal purposes, these are registered


on a regular basis. While vital registration
systems are complete and updated in
developed countries most sub-Saharan
countries have inadequate systems.

Demographic valuables include mortality,


fertility , migration and deaths.
Mortality
The ability to control deaths in most parts
of the world today has been one of the
most significant achievements in human
history. However, it has also been the
cause of many problems primarily because
declining death rates has been one of
the major causes of an increased rate of
population growth leading to population
explosion.

The purpose is mainly administrative but


can be used for demographic purposes
especially in updating demographic data.
In countries with small populations, vital
registration can replace a census such as
Denmark.
Sample Survey
This is a method of data collection that
involves looking at a subset of population.
The scope and complexity depends on
the objectives of the investigator. The
demographics and Health survey is an
example of this technique.

In particular, it is the decline in child


mortality that has lead to an increase in
life expectancy. It is important to note
that a number of countries still have a high
mortality rate which means that, as this is
brought under control, they will continue
to exert great pressure on the world
population.

Because surveys are not as complex as a


census, they can be done over a shorter
time. This has certain advantages including
staff retention and use of experimental
techniques in data collection.

The causes of death within a population can


be due to either social or biological factors.
Almost all populations have a universal age
pattern of mortality. The highest death
rates are found among the very young and
the very old.

Table 4.4: Comparisons of census and sample errors


Census

Sample Survey

Expensive and is carried out every


10 years.

Less expensive and


is conducted more
frequently

Main sponsor is the Government

NGOs sponsors

Source of
bench-mark statistics on size, spatial,
spread, density, fertility, mortality,
migration, HIV/AIDS, Orphan load,
therefore Population and Housing
census

For ad hoc purposesdepending on what


sponsor wants to
achieve

Sampling frame-Source of data for


Small areas, villages etc

Sampling population
which should be
representative of the
wider population not
covered. Avoid bias

Rigid and coverage error Delay in


release results

Flexibility
techniques,
questionnaires to
methods used and
Sampling error

Staff recruitment and cost

Staff are retained

Biological factors
The oldest age to which a human being
can live is termed as lifespan. Lifespan is
almost entirely determined biologically
i.e. genetic. The oldest authenticated age
to which anyone ever lived is 122 years,
but the average age to which people live is
about 66 years.
This average is measured by life expectancy
and is greatly influenced by where in the
world we live. Longevity, which is the
ability to remain alive from one year to
60

is to calculate the age/sex specific death


rate (ASDR). For this to be calculated,
a country must have a vital registration
system that reports all deaths by age and
sex in addition to census data that would
give estimates of population by specific age
and sex.

the next, has both biological and social


components.
Our genetic makeup can predispose
to or protect us from certain diseases.
Social factors include lifestyle, how much
control we have over our individual lives
e.g. smoking tobacco, social and economic
infrastructure, how much control we have
over nature, e.g. societal wealth, shelter,
environmental management and available
healthcare.

Number of deaths in a year of people


aged X to X+5
ASDR = Average Number of people in that X 100,000
year aged X to X+5

The most commonly used age specific


death rates are child mortality rate and
maternal mortality rate.

The interaction between our genes and


the various social factors will determine
our longevity. Causes of death can be
grouped under three categories. People
die because they:
catch a disease transmitted from
another person (communicable
diseases);
degenerate (non-communicable/
chronic diseases); and,
are killed by products of the social
and economic environment (e.g. road
traffic crashes).

Child Mortality Rate

Two indicators are used for child mortality


rate, the Infant Mortality Rate (IMR) and
the under five mortality rate. The infant
mortality rate is defined as the number of
deaths during the first year of life per 1,000
live births while the under five mortality
rate is the number of children who die
before the age of five years.
The IMR correlates closely with life
expectancy so that countries with the
highest life expectancies also have the
lowest infant mortality rates. In general,
countries where infant deaths are few,
income and female education levels are
likely to be high. Access to clean water,
good sanitation, adequate nutrition and
quality health care services are key factors
in having a low IMR.

Measures of Mortality
The mortality rate measures the extent
to which people are unable to live to their
full biological potential. The measure most
often used is the crude death rate (CDR).
CDR = total deaths in a year X 1000
mid year population

Because it only requires the total deaths


and total population to calculate, the crude
death rate is relatively easy to determine.
The rate is crude because it does not take
into account the differences in death due
to age or sex.

Maternal Mortality Rate (MMR)

Maternal mortality is defined as the death


of women during pregnancy, childbirth, or
in the 42 days after delivery. It is estimated
that there were 342 900 maternal deaths
worldwide in 2008, down from 526 300 in
1980.

However, country differences in the CDR


can be due to differences in age distribution.
A more detailed way of looking at mortality
61

The global MMR decreased from 422


(358505) in 1980 to 320 (272388) in
1990, and was 251 (221289) per 100 000
live births in 2008.

by the epidemiological transition theory


where changing patterns in health and
disease has resulted in changed mortality
death patterns. Instead of people dying
young of communicable diseases, they
die old mainly from non-communicable
diseases.

Just six countries (India, Nigeria, Pakistan,


Afghanistan, Ethiopia, and the Democratic
Republic of Congo) contribute to more
than 50% of all maternal deaths in 2008.
Maternal mortality is one of the strongest
predictors of the health of a nation and
reflects the disparity between wealthy and
poor nations more than any other measure
of health. The maternal mortality rate is
calculated using the following formula:

The stage at which a country is along


this epidemiological transition can to a
degree explain the mortality rates found
in that country. However there are a
number of other factors that contribute to
differences in mortality. These include level
of urbanization, social status, education,
occupation, gender/sex and fertility levels.

MMR = all maternal deaths in the year X 100,000/ total


population of women of child bearing age (15-49yrs)
in the year

Urbanization
During the time of the industrial revolution,
cities were dangerous places to live.
Overcrowding and poor sanitation meant
that communicable diseases spread easily.
Today, urbanites in developed countries
tend to be better off with better access to
facilities and therefore lower mortality.

Maternal death is the death of a woman while pregnant


or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the
pregnancy or its management but not from accidental
or incidental causes.

Other than these two measures, comparing


age specific mortalities can be a tedious
exercise. A composite measure frequently
used to compare populations is the life
expectancy at birth. This is derived from
life tables and is the average age of death
for a hypothetical group of people born in
a particular year.

However the same relative good health


does not apply in developing countries such
as Kenya. One major reason for this is that
a significant portion of the urban population
in developing countries live in slums and
are poor. This gives rise to a combination
of poor environmental conditions such
as poor sanitation, inadequate housing,
limited access to healthcare and exposure
to occupational hazards. In addition their
lifestyle habits such as as smoking, diet,
alcohol and drug abuse combine to create
an unhealthy lifestyle.

Other than crude death rate or age specific


death rate, a third useful way of looking at
mortality is to look at it by cause. A cause
Specific Death Ratio can be calculated using
the formula shown.
No. of deaths due to a given cause
Specic
X 1000
=
death ratio
All deaths occurring in a given year

They therefore suffer from considerable


morbidity and have high mortality rates
when compared to those living in rural areas
or even their counterparts in developed
countries.

Mortality figures differ across the world.


Over the last 200 years, mortality levels
have fallen greatly. This can be explained
62

Social Status
Income has long been observed to be
a determinant of mortality. In addition,
a persons status in society has a bearing
on mortality such that the higher your
in society the longer you are likely to
live. Marmot studied civil servants in the
United Kingdom and identified the inverse
gradient of health with lower grade of job.

ability to bear a child, termed as fecundity.


Physiologically, a woman is able to get
pregnant after menarche and stops after
menopause.
Boongart (1978) worked out that the
maximum average number of children a
woman can have is 16. Male fecundity starts
in puberty and generally remains even into
old age though at a much lower level.
The nutritional status and disease among
other factors can lower the fecundity in a
population. Within a population, there is a
natural fertility level rather than an absolute
fertility level.

Education
The risk of death declines markedly with
increasing education. A post secondary
education halves the risk of dying when
compared to primary level. Education
gives women the knowledge to demand
and seek proper health care.

The reasons why people have children vary


from one society to the next. Agricultural
societies traditionally favoured having more
children since they were useful additional
labour. In modern society where children
have to go to school and the economic cost
is high, there is greater pressure to have
fewer children. How people control their
fertility depends on the available means
of fertility control and the motivation to
control their fertility.

Occupation
Mortality rates for manual workers tend
to be higher than that of professional
workers. Certain jobs which are inherently
dangerous will have a higher mortality
rate.
Gender
Women generally live longer than men with
an average difference of 2-3 years. This is
important because it has several implications
for women. Married women tend to marry
men older than themselves artificially
increasing the time a woman outlives her
spouse. For individual women, this often
means living alone under poorer economic
conditions with fewer resources.

Fertility control
Fertility control is often thought of as being
synonymous with contraception. This is not
necessarily true. There are three phases to
fertility. namely; intercourse, conception
and gestation. For conception to occur,
fertilization must take place and for a baby
to be born, there must be a successful
gestation.

Fertility
Fertility refers to the number of children
born to women. The fertility rate in a
society is the accumulation of millions of
individual decisions on whether or not to
have children. This decision is influenced
both, biological and societal factors.
Biological factors begin with the physical

Four key proximal determinants of fertility


explain much of the differences in fertility
between populations. These variables are
proportion of single to married, the use
of contraceptives, incidence of abortion
and involuntary fecundity (especially
postpartum breastfeeding).
63

2. Foetal mortality form voluntary causes


(abortions).

Proximate determinants of fertility

Proximate determinants are the factors


affecting exposure to intercourse
(intercourse variables).

Contraception remains one of the key


ways in which fertility is controlled.
One form of contraception or another
has been practiced since ancient times.
Contraceptive methods can be classified
according to whether they are primarily a
female, male or couple method.

They are related to the formation and


dissolution of unions in the reproductive
period and include:
1. Age of entry into sexual unions
(legitimate & illegitimate)
2. Permanent celibacy: proportion of
women never entering sexual unions
3. Amount of reproductive periods spent
after or between unions
When unions are broken down by
divorce, separation or desertion
When unions are broken down
by death of husband.
There are also those factors governing the
exposure to intercourse within unions:
1. Voluntary abstinence such as post
partum breastfeeding
2. Involuntary abstinence (impotence,
illness, unavoidable temporary
separation)
3. Coital frequency (excluding periods of
abstinence).

Table 4.5: Contraceptive methods


Method

Female

Male

Couple

Barrier

Diaphragm
Cervical cap
Vaginal sponge
Female condom
Intra Uterine
Device (IUD)

Male
condom

abstinence

Chemical
(Precoital)
(normal)

Oral
contraceptives
Implants
Injectables

Chemical
(postcoital)
(normal)

Oral
contraceptives
Levonorgesterel
withdrawal

Fertility
awareness
Oral/anal
intercourse

Natural

Surgical

Tubal ligation

vasectomy

Measuring Fertility
In measuring fertility, we are measuring
the number of children that each woman
is capable of producing. The data for this
is usually obtained from a combination of
census, vital statistics sources and sample
surveys.

The third group of factors are those


affecting
exposure
to
conception
(conception variables):
1. Fecundity or infecundity as affected
by involuntary causes but including
breast feeding;
a.) Use or not use of contraception,
b.) By mechanical and chemical means,
2. By other means
3. Fecundity or infecundity as affected by
voluntary causes (sterilization, medical
treatment etc.
The fourth group of factors are those
affecting gestation
and successful
parturition (gestational variables)
1. Foetal mortality from involuntary
causes (miscarriages).

Measures of fertility can be derived from


either period data or cohort data. Period
data provides a cross-sectional view of the
population.
Where as this data is useful, it can be
misleading because it assumes that
women of all ages have the same fertility
characteristics.
64

For example that a 20 year old woman


will behave the same way when she is 30
years old as a woman that age today would
behave.

CWR=

Total births in the year


Total mid year population in the year

Women aged 15-49 yr

X 1000
ASFR =

The crude birth rate relates total number of


births to the total populations but ignores
the age/sex struxture of the population.
For example, a population at war may
have relatively low numbers of young men.
However, just like the crude death rate, it
is easy to calculate crude birth rate because
all you need is the total population and the
total number of births.

Total number of births in year


Mid year population of women aged
15-49 yr

births in a year to women aged x to (x +5)


Total mid-year population of women aged
x to (x+5)

X 1000

Cohort fertility measurements calculate


births to date. Past menopause, we can
calculate the cohort total fertility rate, i.e.
a measure of completed fertility. While it is
useful for historical and planning purposes,
it is better to calculate total fertility using a
synthetic cohort. This can be done through
surveys where women of different ages
are asked how many more children they
intend to have.

General Fertility Rate (GFR) is more


specific as it takes into account the age and
sex structure of the population.
CFR =

X 1000

A more precise way of measuring fertility


is to calculate an age specific fertility rate.
This requires data including births according
to the age of the mother and a population
distribution according to age and sex. The
age specific fertility rate (ASFR) is the
number of births occurring annually per
1,000 women of specific age group usually
given in 5 year age bands.

Cohort data follows a group of women as


they go through their child bearing years.
The crude birth rate (CBR) is an example
of period data as it refers to a particular
calendar year.

CBR =

Total number of children aged 0-4

Fertility control
What motivates people to control their
fertility? One hypothesis is that, if
individuals want to limit their fertility, then
three pre-conditions would have to apply:
I. the acceptance of calculated choice as a
valid element in marital fertility
2. the perception of advantages from
reduced fertility
3. Knowledge and mastery of effective
techniques of control. These factors
can exist even in the absence of a
mortality decline.

X 1000

The GFR tends to be roughly 4.5 times


the CBR. Developing countries have
higher GFR due to less contraceptives
use as compared to developed countries.
Another ratio that is a useful measure of
fertility particularly where good data is
scarce is the child woman ratio (CWR).
This is similar to the general fertility rate
but relies only on census data.

The first pre-condition examines what


peoples beliefs. If having children
65

is something controlled by a higher


supernatural power, then interfering with
fertility can offend the deity. Such people,
even if they have access to fertility control
will not use it. The second pre-condition
assumes that people make rational decisions
and that people do not have children for
the sake of it but have some other reason.

methods has a great influence on whether


people are motivated to control fertility.

Becker, using a demand and supply


framework, assumed that people were
rational and that the desire to have children
could be modelled along the microeconomic theory. Under such theory,
children could be treated as commodities
and the number of children a person would
have was a trade off depending on what
they get out of having children versus the
cost in terms of time and money invested
in the child.

Fertility transition
High fertility in a country is often explained
as a result of high mortality. Couples
have many children because they do not
expect all of them to survive to adulthood.
Children in such societies may be seen as
labour and eventually as old age security.

Women can use different fertility control


methods at different times of their lives.
For example, they can use the pill earlier on
then tubal ligation after they have attained
the desired number of children.

Another reason given for high fertility is


desire to have sons, since it is assumed
that in such a society, sons are more
economically useful compared to daughters.
It is therefore understandable when we
see a family that continues to have children
until a son is born. The problem though for
such societies with high mortality has been
what to do when most of the children born
survive.

In his model, taking into account the fact


that social class determines a persons
taste and lifestyle, the theory states that
those who are well off will have certain
expectations about their children and so
will have fewer children because they will
spend on each child a certain amount of
resources.

The knowledge that child mortality has


declined may not be obvious to a family
as they may assume that the reason their
own children are surviving is due to their
own good fortune. Only years later will
they realize that a mortality decline had
started in the country years earlier. This is
one reason why it is important for health
authorities to communicate mortality
figures. Because most such families are
poor, the high number of children threatens
to drag the family further into poverty.

A poorer person on the other hand has


much less expectation for each child and so
the number of children is not such a crucial
point. Another theory that revolves around
perceived advantages of limiting fertility is
an innovation/ diffusion perspective.
According to this theory, people want to
do what they admire to do. Thus, when
well off people limit the number of children
they have and decide that two is an ideal
number, the rest of the population follows
suit since it is the fashionable thing to do.

In such societies, rather than practice


fertility control, families practiced child
control. Unwanted children were either
killed (Infanticide), given to foster homes,

The availability of suitable fertility control


66

Lack of knowledge about the


safety, effectiveness and availability
of choices
Poor client-provider interaction
Lack of community or spousal
support
Misinformation regarding available
services
Side-effects for some, and
insufficient follow-up to promote
method switching or ensure proper
use and dosage.

(stay with your relative) or placed in


orphanages. These responses though are
becoming harder to carry out as families
become more nuclear in structure.
All the theories above assume that people
will not actively control their fertility until it
is in their interest to do so. Several factors
seem to influence a decline in fertility. In
the modern world, children consume
resources. As such, to acquire wealth
the number of children you have must
be limited since having many children will
keep you relatively poor.

Migration
Globalization, the process by which the
world becomes more integrated in terms of
trade, travel, communication and education,
has led to increased travel and mobility
of the world population. The reasons for
population movement have become more
varied and the demographic make up of
these populations has also become less
homogeneous. The relationship between
health and migration is complex but can be
simplified into two broad processes.

The highest fertility rates are found among


women who do not work while those
who work and are well paid have the
lowest fertility levels. Female education
follows the same pattern with those most
educated having the lowest fertility rates.
Unmet Need
The ability of people to implement their
family size and spacing desires is a matter
of great personal and demographic
importance. In developing countries, total
fertility regularly exceeds what people
report as wanted fertility. Unmet need
refers to women and couples who do
not want another birth within the next
two years, or ever, but are not using a
method of contraception. Unmet need
results from growing demand, service
delivery constraints, lack of support from
communities and spouses, misinformation,
financial
costs
and
transportation
restrictions.
Several
barriers
to
contraceptive use include:
Lack of accessible services, and
shortages of equipment, commodities
and personnel
Lack of method choices appropriate
to the situation of the woman and
her family

The first is the actual process of movement.


This can be divided into three phases. In
the preparation phase, the intended
migrants will have health characteristics
similar to the population surrounding them
taking into account their own personal
lifestyles and genetic characteristics. The
reasons for eventual migration such as the
socio-economic circumstances have an
important role to play in determining the
health status.
The second process is that of living in a new
place. Anyone moving permanently (longer
than 1 year) to another geographic location
within the same country or to another is
described as a migrant; distinctions are
made between internal and international
migration.
67

International migration can be further


classified
into
documented
and
undocumented immigrants, refugees and
asylum seekers. In defining migrants and
immigration, we have to be aware that
there are difficulties in categorizing people
who do not have a permanent home
such as nomads and sojourners who are
international migrants working in certain
countries for a period of time.

total number of migration (total


Total
immigration + total emigration)
=
Migration
total mid year population
Rate (ratio)

This is expressed as a percentage


Total migration rate
Migration =
X 1000
turnover rate Crude net migration rate

Because we rarely have complete data


on migration, it is estimated by deduction
using the demographic equation. That is,
the net change in population is as a result
of addition of births less deaths plus net
migration. This method is known as the
components of change method of
estimating migration.

Measuring migration
A
part from difficulties in defining
migration, further problems arise when
we try to measure migration. Unlike the
other two determinants of population,
there is neither natural limit to migration
nor a pre-determined pattern that people
follow. Many countries keep records of legal
immigrants. Obviously, illegal immigrants
are difficult to measure and countries
rarely have records of emigrants.

Another method of estimating migration is


the forward survival method of migration
estimation. This method combines census
data with life table probabilities of survival.
The difference between the two figures is
assumed to be due to migration.

In measuring migration, we try to measure


out-migration and in-migration rates for a
particular population.
Gross rate
out-migration

(total out-migrants)
Total mid year population

Reasons for migration

Migration is a human response to


local resource pressures generated by
population increase. Where such pressures
exist, people will move to where they
believe there are better opportunities.
The demographic transition described
earlier is linked to economic change and so
is migration. However, who moves, when,
exactly why, and where they go can be
attributed to the following:

X 1000

The difference between the two rates is


the net migration. We can then measure
the crude net migration rate (CNMR) as:
CNMR =

total out-migrants - total in-migrants


Total mid year population

X 1000

X 1000

Push-Pull theory

Just like other crude rates, the CNMR can


be misleading because the denominator
includes people who have no intention of
migrating. However, from the CNMR, we
can calculate the total migration rate which
when compared with the net migration
rate, gives a sense of population turnover.

People move either because they have been


pushed from where they stay or have been
pulled to some place. Push factors include
bad laws, heavy taxation, unattractive
climate and compulsion, e.g. slave trade.
Pull factors are more important in causing
68

migration, that is, people move because


they want a better life for themselves and
not because they had been forced out.

process as having three major stages:


1. The propensity to migrate in general
2. The motivation to migrate to a specific
location
3. The actual decision to migrate.

Various factors may inhibit the desire to


move and not everyone who wants to
migrate does so. Migration is selective
and within a population there is a certain
life stage when people are more likely to
migrate.

In explaining how these factors interact,


the most important seemed to be the
creation of new opportunity structures
for migration, cheaper and quicker
transportation and communication which
together make risk assessment easier
and the risk of migration lower if things
do work out. Differences exist between
internal and international migration.

Young adults are the most likely to migrate.


People who are divorced, separated or
widowed are more likely to migrate.
Table 4.6: Reasons for migration
People more likely to
migrate

People less likely to


migrate

Young people in their 20s

Older people

Divorced separated or
widowed at every age group

Married people

Among young couples those


with young children

Ownership of property

Increased income levels

Personal traits (low risk


taker)

Internal migration is more likely to be


a personal decision while international
migration is influenced more by social
and political climate and the opportunities
available to the migrant. Several theories
attempt to explain international migration.
A neo-classical economics approach states
that migration occurs in response to supply
and demand differences. Countries that
have growing economies and shortages of
labour will have higher wages and therefore
will attract people from countries with
weaker economies.

Increased education levels


In traditional societies men

women

Dejong & Fawcett (1981), devised a model


to explain why those people listed in the
table were more likely to respond to pull
factors compared to other segments of the
population. They described the migration

Fig. 4.4: Motivation for migration

69

different policies that governments pursue.


The HDI is a summary measure of three
dimensions:
1. Life expectancy at birth, a long and
healthy life
2. Education, as measured by the adult
literacy rate (with 2/3 weight) and the
combined primary, secondary, tertiary
gross education enrolment ratio (with
1/3weight)
3. Per capita GDP, decent standard of
living, as measured in (PPP USD).

Modifying
this theory, a household
approach argues that people will make
decisions at the household or family level
so that some members of the family may
migrate and remit some of their money
back home.
The dual labour market theory suggests
that, in developed countries, there are
two kinds of jobs. A primary market that
employs well educated people and pays
them well and a secondary market that
offers lowly jobs that pay poorly. The latter
jobs are unattractive to the locals but will
attract migrants. No single theory explains
migration fully.

For each dimension, an index was created


with minimum and maximum values for
each. Performance in each dimension is
then expressed as a value between 0 and
1. A formula is applied to average the
three dimension indices to determine the
performance of a country.

Migration has certain consequences of


public health importance. Immigrants have
to undergo a process of adaptation and
adjust to a new environment, both socially
and physically. As they settle, the process
moves to acculturation where they adopt
the host culture and diet. This process can
cause a change in epidemiology of disease.

The United Nations Development


Programme has used the HDI since
1990 for its annual Human Development
Reports. Over the years the reports reveal
that countries can improve the quality
of peoples lives using modest resources
provided they are channeled well.
Investment in health and education drives
success in human development.

Human Development Index

Each of the measures used in demography


such as mortality provide one dimension
in characterizing human populations. The
Human Development Index (HDI) is an
attempt to combine various statistics
to rank countries by level of human
development and separate developed
(high development), developing (middle
development), and underdeveloped (low
development) countries.
The HDI is an attempt to assess country
development using criteria other than just
economic development. It is observed that
two countries can have similar levels of
income per person but very different health
or educational standards. This reflects the
70

Questions Section

1. What are the differences between a census and a sample survey. What are the main
errors likely to occur in collecting, analyzing and publishing data from either source.
How can such errors be minimized.
2. What are the advantages of sampling from a population
3. What is the theory of demographic transition.
How valid is the theory in understanding current population dynamics?
4. What are the main sources of demographic data
5. What are the factors that determine family size?
6. List 4 factors that distinguish migration from mortality & fertility.
7. What are the advantages and disadvantages of the defacto and dejure method of
enumeration during census

Further reading

1. Kenya Demographic and Health Survey (1998) Ministry of Planning and Development
2. The Demography of Health and Health Care. By. Louis G. Pol and Richard K.
Thomas. Kluwer. Academic/Plenum Publishers, New York, 2001.
4. UNFPA. The state of world population 2009 Facing a changing world : women,
population and climate. 2009 ;104
5. Sclar ED, Garau P, Carolini G. The 21st century health challenge of slums and cities.
Lancet. 2007 ;365(9462):901-3.1. The Demography of Health and Health Care. By.
Louis G. Pol and Richard K. Thomas. Kluwer. Academic/Plenum Publishers,
New York, 2001.

71

PART II: The individual and public health

Human beings depend on a continuous supply of nutrients to survive. Having these nutrients in
the right quantities and the right balance is a prerequisite for good health. The consequences of
malnutrition in children can be irreversible if the condition begins before the age of two years.
Malnutrition increases vulnerability to disease and can make worse an already existing disease
such as malaria, diarrheoa and pneumonia. Conversely, good nutrition can help sick people
recover from poor health more quickly. Globally, more than one-third of post-neonatal child
deaths are attributable to under-nutrition.
Pregnant and breastfeeding women are especially prone to malnutrition disorders, as their bodies
need extra nutrients. Maternal malnutrition, involving a poor diet leading to anemia and other
micronutrient deficiencies contribute to high maternal and neonatal mortality rates. HIV-infected
mothers risk of dying is ten times higher than that of HIV negative mothers. Poor nutrition is a
major contributing factor.
Over nutrition is one of the contributing risk factors to the emerging epidemic of noncommunicable diseases (NCD). Many governments remain relatively complacent about the
existing levels of NCDs. A greater challenge is the future increases in prevalence of obesity,
diabetes, cardiovascular diseases and other complications that arise from NCDs. Some of these
increases can be attributed to lifestyle choices made by individuals and communities today. The
implications for the health system are huge.
This section will focus on the nutritional needs of vulnerable populations, the various diseases
(communicable and non-communicable), their causal factors, control and preventive interventions.
Thus, the section is divided broadly into nutrition, communicable and non-communicable
diseases. By the end of this section, the reader will be able to:
a) understand the nutritional requirements of vulnerable populations, infants, children,
pregnant women and people with HIV/AIDS
b) promote the role of breast-feeding as part of infant nutrition
c) understand the causes and consequences of malnutrition and be able to take steps to
prevent malnutrition
d) understand the public health management of micro-nutrient deficiencies
e) understand the concept of nutritional surveillance
f) understand the principles of communicable diseases control
g) outline the main measures taken to control an infectious disease
h) discuss the major ways to prevent an outbreak of a communicable disease
i) enumerate the major communicable diseases of public health concern
j) outline the common risk factors for non communicable diseases and
how they interact
k) enumerate the major non-communicable diseases of public health concern
l) understand the concept of risk factor surveillance (WHO Stepwise approach)

72

NUTRITION

Introduction

Nutrition is an input to and the foundation


for health and development. More than
one third of child deaths worldwide are
attributed to undernutrition. Poverty is a
major underlying cause of undernutrition.
The interaction between infection and
malnutrition has been well documented.

behaviour in the broader community.


To the health practitioner, nutrition forms
an integral part of routine patient care. A
good background in public health nutrition
helps establish the linkages between poor
nutrition and ill health and in the prevention
and treatment of diseases.

Better nutrition leads to stronger immune


systems, less illness and better health.
Good nutritional status is especially
vital for children. Healthy children learn
better. Healthy adults are stronger, more
productive and better placed to create
opportunities to break the cycle of poverty
and hunger in a sustainable way.

Attaining maximum functional capacity


depends on the interaction between genetic
potential, environmental interaction and
nutritional status.
Poor eating habits that result in nutritional
deficiencies and excesses, along with
smoking, infections, toxic factors in the
environment, and trauma, are the major
determinants of how closely the functional
capacity, health, and longevity of individuals
match their genetic potential.

Nutrition is the process through which


food is consumed and utilized by a living
organism. Public health nutrition has a
wider definition and focuses on issues
affecting the whole population rather than
the specific dietary needs of an individual.

Damage to genetic potential can begin early


with foetal malnutrition that reflects the
nutritional status and health of the mother.
For example, folic acid supplementation
to pregnant women is known to prevent
neural tube defects in the foetus.

This involves the collection of evidence


regarding the relation of nutritional factors
to health and disease, assessment of
current dietary practices and development
of strategies to modify diets in a manner
deemed to be beneficial in the evaluation
of intervention strategies.

The severe cognitive effects of Marasmus


and Kwashiorkor are known. Poor growth
in the young child occurs while chronically
inadequate diets prevent catch-up growth
following an infectious episode. Most
stunted children become stunted adults
who are physically less productive.

The impact of food production, distribution


and consumption on the nutritional status
and health of particular population groups
is (should be) taken into account, together
with the knowledge, skills, attitudes and

73

Nutritional requirements

Nutritional needs of infants


Children are most vulnerable to nutritional
insult in the first two years of life.The
nutritional needs can be categorized by
dividing them into three age groups;
- Birth to 6 months
- 6 to 12 months
-12 to 24 months

Almost all foods provide both nutrient and


energy. We depend upon a continuous
supply of various nutrients in appropriate
quantities in order to be healthy.
sweets, oils, butter
sugar, crisps
use sparingly
Milk, cheese,
yorghurt
2-3 servings

Meats, poultry,
Fish, dried beans,
eggs, nuts
2-3 servings

Vegetables
3-5 servings

Beyond 24 months of age, studies show that


nutritional interventions especially those
involving food supplementation do not have
a significant effect in reversing deficiencies.
Early breastfeeding within one hour of
birth and exclusive breastfeeding for the
first six months are the key interventions to
reducing child malnutrition and mortality.

Fruits 3-5 servings

Carbohydrates including bread, cereals, rice


(6-10 servings)

The Lancet series (2003) on child and


newborn survival summarized that 13%
to 15% of under-five deaths in resource
poor countries could be prevented
through achievement of 90% coverage
with exclusive breastfeeding alone with
additional 6% deaths prevented by
appropriate complementary feeding.

Fig. 5.1: A food pyramid

Excess or deficient intake of nutrients and


or energy can cause ill health and disease.
The various foods needed can be classified
as per table 5.1 below.
Table 5.1: Food requirements
Nutrient

Notes

Energy

Food energy is obtained from iological


combination of carbohydrates, fats, proteins

Fats

Continuous source of energy and essential


fatty acids act as a solvent for the
absorption of soluble vitamins. Cholesterol
is synthesized in the body fat as forms part
of the cell membranes

Proteins

High intake of products confers no


particular benets.

Fibre

Adds bulk to diet (is non nutrient along with


water

Water

Replaces loss via urine, sweat, faeces and


respiration.

Breastfeeding
For the first six months of an infants life,
breast milk is the perfect and complete food.
Breast milk is easy to digest and protects the
child against infections. Breastfeeding costs
less than artificial feeding. and is the natural
default for feeding infants. Breastfeeding
has several benefits :
It helps a mother bond with the baby.
Breast fed babies are less likely to
cry and more likely to have emotionally
satisfied and affectionate mothers
Breastfeeding for the recommended
six months helps in birth spacing
It reduces the incidence of uterine,
ovarian and breast cancer
Children who have been breast fed
perform better in intelligence tests in

Micronutrients Vitamins and Minerals


Micro-nutrients enhance the nutritional
value of food and have a profound impact
on a childs development and a mothers
health. The major essential micronutrients
of public health importance are iodine,
iron, vitamin A and folate.
74

later childhood and have superior


cognitive development
Breast-feeding protects the infant
against diarrhoea and respiratory
infections by a factor of 6 times in the
first 2 months of life.
Colostrum is the milk produced in the
first few days after birth. It is rich in
growth factors, vitamin A, antibodies and
white blood cells. Colostrum helps the
gastro-intestinal tract to mature faster
and therefore protects against allergy
and infection and helps clear meconium.
Colostrum also helps prevent the
development of jaundice.

Some interventions such as medication


during labour, and separation of mother and
baby may delay initiation of breast-feeding
that may negatively impact lactation. Other
practices such as timed feeding rather than
feeding on demand, use of artificial nipples
and pacifiers can also impact negatively.
Certain interventions have been associated
with maintenance of breastfeeding:
Initiation of breastfeeding within thirty
minutes of delivery
Keeping mother and baby together
after delivery
Avoidance of giving pre lacteal feeds
unless strong indication
Feeding on demand rather than timed
feeding.

Artificial feeding, though convenient for


many, is fraught with danger. Done poorly,
it interferes with the bodys development.
Diseases including respiratory disorders
and malnutrition especially vitamin A
deficiency are more common in artificially
fed babies. Mothers who artificially feed
their babies are more likely to become
pregnant sooner with the increased risks
associated with reduced birth spacing.

A breastfeeding mother needs an additional


500 calories per day as compared to when
she was pregnant. These calories should
come as part of a normal balanced diet
which contains foods rich in iron, calcium
and vitamin A. While an adequate protein
intake is essential, special and expensive
foods are usually unnecessary.

In poor communities without access to


clean water, there is an even higher risk
of the baby having frequent episodes
of diarrhoea. Successful breast-feeding
practice begins early with maternal
education throughout pregnancy so that
breastfeeding can begin immediately after
birth.

However, the mothers dietary intake


generally does not dictate how much
breast milk is produced except in cases of
severe malnutrition of the mother.
Breast-feeding clearly saves lives with
increased risk of infectious disease
mortality among non-breastfed babies.
Infants aged 0 to 5 months who are not
breastfed have seven-fold and five-fold
increased risks of death from diarrhoea
and pneumonia, respectively, compared to
infants who are exclusively breastfed. At
the same age, non-exclusive rather than
exclusive breastfeeding results in more
than two-fold increased risks of dying from
diarrhoea or pneumonia.

Common concerns about breastfeeding


including lack of confidence, fears of
insufficient milk, nipple size and shape and
fear of loss of freedom, embarrassment,
indecent exposure and misinformation from
family and friends need to be countered as
part of the education process. Antenatal
care is therefore a very important process
in ensuring maternal and child well being.
75

Table 5.2: Daily requirements for dietary rehabilitation


Nutrient

Minimum requirement

Calories

120-200 kcal /kg/day

Proteins

2-5-g/-kg body weight /per day

Iron

60mg /day

Folic acids

100 mg /day for 2months

Potassium

1-2 g / day

Magnesium

250 mg 1g daily

Vitamin A

100,000 IU

food when others are eating.


- The process of weaning can commence
with the single introduction of various
foods starting with cereals and adding
vegetables and fruits as the baby grows
older.
Nutrition and HIV/AIDS
HIV/AIDS affects the nutritional status in
a variety of ways. Persons infected with
HIV tend to have a reduction in food
consumption because of poor diet resulting
from singly or a combination of a lack of
food due to poverty, food insecurity, or
from inability to prepare nutritious food
due to being ill or a lack of knowdlege of
nutritional requirements. The condition
is associated with the development of
opportunistic infections which in itself
affects the nutritional status of the
infected.

For HIV-infected mothers, especially in


developing countries, the decision to
breastfeed or to give breast milk substitutes
like infant formula or modified cows milk
provides a dilemma.
While breastfeeding increases the risk
of HIV-transmission to the child with up
to 15%, giving breast milk substitutes
increases the risk due to infectious diseases
like diarrhoea and respiratory infections
about 6 times during the first 2 months.
The World Health Organization and the
government therefore promote exclusive
breastfeeding for the first 6 months as
the ideal policy. Unfortunately, exclusive
breast feeding for 6 months among
mothers continues to be very low and a lot
more needs to be done to encourage and
facilitate mothers to adopt the practice.

Nutrient Malabsorption
Nutrient absorption can be impaired
especially during infection such as diarrhoea.
In almost all stages, malabsorption of fats
and carbohydrates is common. Patients
tend to be vitamin deficient compounding
the problem. There is increased oxidative
stress due to the absence of vitamins A, C,
B and Zinc.

6 12 months
There are several development milestones
to indicate an infant is ready to eat solid
foods. These include:
- The birth weight has doubled
- The baby has good control of head and
neck
- The baby can sit up with some support
- The baby can show fullness by turning
the head away or by not opening the
mouth
- The baby begins showing interest in

Oxidative stress increases HIV replication


and therefore increased viral load. Certain
anti-retroviral drugs are known to affect
fat metabolism often leading to abnormal
fat deposition in the body. The patient
often has increased energy requirements.
A low grade fever with night sweats is a
common complaint. However, because
they are unable to eat properly either
due to lack of appetite or inadequate food
intake, muscles are used for energy leading
to muscle wasting.
76

In addition, the HIV/AIDS pandemic has


brought to the fore the nutritional needs of
all children who are HIV positive or affected
by HIV/AIDS. These include orphans and
those living in households with infected
family members. Many such children are
left to fend for themselves, while others
live with HIV-infected parents who can no
longer provide food for their families.

Dietary management is an integral part


of clinical management of the patient and
should be incorporated into the health
care services of those infected.
Breastfeeding for the HIV-positive
mother
More than 90% of new HIV infections
among children occur during pregnancy,
at the time of delivery, or during breast
feeding. In the absence of any preventive
interventions, infants born to and breastfed
by HIV-infected women have roughly a
one-in-three chance of acquiring infection
themselves.

Nutritional management of HIV/AIDS


Good nutrition is a key component in the
management of HIV/AIDS. Malnutrition
weakens immune systems and increases
vulnerability and opportunistic infections
leading to greater morbidity and reduced
life expectancy. Good dietary management
leads to greater or improved food intake
which compensates for nutritional causes
of disease, helps prevent dehydration
and completes and strengthens medical
treatments.

The risk of mother-to-child-transmission


of HIV is about 15% to 30% if the mother
does not breastfeed the child. With
prolonged breastfeeding, the likelihood
of infection can be as high as 45%. The
risk can be reduced to under 2% by a
combination of antiretroviral prophylaxis
during pregnancy and delivery and to the
neonate with elective caesarean section
and avoidance of breastfeeding.

Below is a summary of common conditions


and strategies. Recommendations should
always consider food habits, taboos,
culture and food security of the population
infected.

The risk of HIV-infection has to be


compared with the risk of morbidity and
mortality due to other causes. Breastfeeding
is protective against death from diarrhoea,
respiratory and other infections, particularly
in the first months of life. Breastfeeding
also provides the necessary nutritional
and related ingredients, as well as the
stimulation necessary proper good psychosocial and neurological development, and
contributes to birth spacing.

Table 5.3 Nutritional management of common conditions in


HIV/AIDS
Condition

Strategy

Anorexia

Encourage eating of small portions of


food frequently and ensure they eat
energy dense food

Constipations

Encourage high bre foods and take


plenty of uids

Bloating and
Heartburn

Encourage eating of small frequent


meals, avoid gas forming foods such as
cabbages, beans and eat long enough
before going to sleep

Diarrhoea

Encourage them to drink plenty of uids


andtake energy and nutrients rich foods
to replace loss.

Anaemia

Encourage iron rich foods especially


animals produce and green leafy
vegetables as well as iron supplements
if necessary.

Nausea

Eat small frequent meals and avoid


lying down immediately after eating.
Take plenty of uids and take soups rich
in energy and nutrients

It is recommended that all HIV infected


mothers should receive counseling and
information about the risks and benefits
of various infant feeding options. If safe
and affordable replacement feeding is
77

Child Malnutrition, Deaths & Disability

Outcome

Inadequate dietary
intake

Insufficient
household
food security

Disease

Inadequate
health services & unhealthy
environment

Inadequate maternal
& child care

Inadequate and /or inappropriate information, education, Communication


& Discriminatory attitudes limit households access to resources

Resources & Control: quantity of actual resources /Human,


economic & organizational

Political, cultural & social structure including


status of women economic structure

Potential Resources: technology,


Environment, People
Adapted from: UNICEF, 1990-1998

Fig. 5.2: Conceptual framework: Causes of malnutrition

78

Immediate

underlying
determinant

not possible, then breastfeeding by HIVpositive mothers is the recommended


choice.

Malnutrition in children
Malnutrition is a major health problem
in developing countries. Out of the 2
million children under 5 years who die
each year in developing countries, 55%
can be attributed directly or indirectly to
malnutrition.

If breastfeeding is the preferred choice,


then the mother needs good breastfeeding
techniques to prevent conditions such as
mastitis and nipple fissure. Breastfeeding
should be discontinued as soon as possible
to reduce the chances of transmission of
HIV. Many mothers in developing countries
cannot afford breast milk substitutes
and lack access to clean water, which is
essential for their safe preparation and use.
Also, in many cultures, women who do not
breastfeed are stigmatised.

Childhood malnutrition can be measured


as the proportion of children who are:
Under weight - low weight for age,
Wasting - Low weight for height,
Stunting - reduced height for age
Assessing the nutritional status of children
in a community is a sensitive way of gauging
the well being of the community.

A mother living with HIV/AIDS therefore


faces many grave difficulties: worries about
her own health and survival, the risk of
infecting her baby through breast milk,
and the danger that her baby will develop
other health problems if she does not
breastfeed.

This is because children have the highest


nutritional needs and therefore they suffer
more when there is lack of adequate
nutrition. While the immediate cause
of malnutrition is inadequate intake,
the factors that lead to this inadequate
intake are multiple and complex in
their interactions. This is outlined in the
framework developed by UNICEF.

Malnutrition

An imbalance in nutrient intake or


absorption leads to malnutrition in which
there is impairment of health. While under
nutrition has been the traditional focus
in developing countries, there is growing
concern about over nutrition leading to
obesity and development of various chronic
diseases.

Disease and a lack of adequate dietary


intake is the first level. The cause of the
disease such as poor hygiene and sanitation
form a secondary level. At the tertiary
level are poor maternal and child care and
insufficient food security.
Consequences of malnutrition
The effects of malnutrition can be analyzed
in terms of macronutrient deficiency and
micronutrient deficiency.

Under-nutrition remains a major problem


in sub-Saharan Africa. The effects of
malnutrition can either be acute or chronic
and can be reversible or irreversible.
Certain groups of people are at a higher risk
of developing malnutrition. These include:
children, the elderly, sick people, pregnant
and lactating women and people living in
emergency situations such as displaced
people and refugees.

Macronutrient deficiency
Protein and energy malnutrition (PEM)
occurs when there is a deficiency in intake
of proteins and energy over a period of
time. Clinically, manifestations reflect a
79

Acute malnutrition in children

Severe
WH < 70% or MUAC < 110 mm

Moderate/ severe
medical conditions

Moderate
WH 70-80% or MUAC 110-125 mm

No/minimal medical
conditions

Bilateral pitting oedema with


any of the following:
oedema +++
severe wasting
high or low body temperature
acute or prolonged respiratory
infection
watery diarhea+ vomiting
poor feeding (poor appetite)
extensive oral thrush
very pale eyes & palms

Bilateral pitting oedema


with any of the following:
Oedema + or ++
Feeding well (good
appetite)
Clinically well or mild
infection

In patient/stabilization care
with F75 & F100

Out patient care with


RUTF

No Oedema
Feeding well (good
appetite
Clinically stable

Supplementary feeding

Fig. 5.3: An algorithm for the diagnosis and management of of acute malnutrition

range of pathological conditions, which


arise from lack of varying proportions of
proteins and calories.

and hair changes, diarrhoea, and oedema.


Kwashiokor
Presence of bilateral
pitting oedemia
Hair changes (brownish,
scanty, straight)
Skin changes (dermatosis)
Alarge, protuberant belly

PEM is composed of a spectrum of


syndromes ranging from simple growth
failure to pure and mixed syndromes of
Kwashiorkor, Marasmus/Kwashiorkor and
Marasmus.

Marasmus
Prominent bones(ribs)
Skinny limbs
Loose skin (on lifting))
Loose skin around the
buttocks (buggy pants)

It occurs more frequently in infants and


young children because of their greater
needs and vulnerability in society and
is commonly associated with infectious
diseases. Protein energy malnutrition
presents with a lower than normal rate
of skeletal growth and weight loss. With
further deterioration, there may be skin

Figure 5.4: Kwashiokor and marasmus

Severe PEM impairs mental and cognitive development. School-age children who suffered from early child-hood
malnutrition have generally been found to have poorer IQ levels,with reduced cognitive function, lower school
achievement and greater behavioural problems than matched controls and to a lesser extent, siblings. (A Review of
Studies of the Effect of Severe Malnutrition On Mental Development, Sally Grantham-McGregor )

80

Classification of PEM
PEM can be classified either by taking into
account only severe forms or by dividing
the cases into mild, moderate and severe.
Using weight for age, Gomez (1965),
classified PEM into three levels as shown
in table 5.4

the child has an emaciated look with loss


of skin turgor due to subcutaneous tissues
loss and muscular atrophy.
A child with Kwashiorkor presents with
a history of lethargy and apathy. There is
inadequate growth and loss of muscular
tissue.

Table 5.4:Gomez classication


Level of Malnutrition

% reference weight for age

Normal

90-110%

First degree
malnutrition

76-90%

Second degree
malnutrition

61-75%

Third degree of
malnutrition

< 61%

Such children have an increased


susceptibility to infections. The hair is thin
with loss of colour and elasticity. The skin
darkens or has a reddish pigmentation.
Oedema is common.
These include dehydration, oedema,
hypothermia and anaemia. The minimum
daily requirement for key macro and
micronutrients are outlined in the table in
table 5.7.

Percent of reference weight for age = ((patient weight) / (weight


of normal child of same age)) * 100

The Waterlow classification improved on


the Gomez classification by using both
weight for age (wasting) and height for age
(stunting).

Table 5.7: Minimum nutrient requirements

Table 5.5: Waterlow classication


Level of
Malnutrition

Weight for Height


(wasting)

Height of age
(stunting)

Normal

>90

>95

Mild

80-90

90-95

Moderate

70-80

85-90

Severe

>70

>85

Oedema absent

80-60%

Kwashiorkor

Under malnourished

<60%

Marasmus

Marasmus

Proteins

2-5-g/-kg/ day

Iron

60mg /day twice daily

Folic acids

100 mg /day for 2months

Potassium

1-2 g / day

Magnesium

250 mg 1g daily

Vitamin

A100,000 IU

Severe Acute Malnutrition in infants and


children is defined as having a weight -forheight below three standard deviations of
the WHO standard.

Table 5.6: Wellcome classication


Oedema
present

120-200 kcal /kg/day

Severe Acute Malnutrition


(SAM)

The Wellcome classification introduces


the presence of clinical signs specifically
oedema together with weight for age.
Weight for
Age (Gomez)

Calories

Dietary Rehabilitation
Prevention and management of malnutrition
is complex. At community and policy level,
focus has been on:
Immunization
Girl child education
Promotion of growth monitoring for
child upto 5years

Marasmus is defined as body weight of less


than 60% of standard. Typically, a marasmic
child presents with a history of failure to
thrive and weight loss. On appearance,
81

Prevention and treatment of diarrhoea


and other infections promptly using
zinc and oral rehydration salts (ORS)
Safe water and sanitation.
Empowering mothers through
nutrition and health education focusing
on:
- importance of breast milk for the
first six months.
- hygienic practices during weaning.

occurring in around 250 million in preschool aged children of whom up to half a


million become blind every year.
These nutritional deficiencies are of
great public health interest in developing
countries because they have a high
prevalence and contribute significant
morbidity and mortality.
The presence of iron and folate deficiency
anaemia significantly increases the risks
that girls and young women face during
pregnancy and childbirth.

Micronutrient deficiency
Micronutrients are essential dietary
elements needed only in small quantities.
They include the trace elements such iron,
copper, zinc, iodine, selenium, magnesium,
cobalt chromium and vitamins. Most
micronutrients are classed as Type I, which
includes iodine, iron, Vitamins A and C.

Sadly, women in developing countries


continue to die despite the availability of
relatively cheap and cost effective health
programs that can prevent such deaths.
Nutritional Anaemia
Anaemia is the condition where there is
a pathological deficiency in the oxygen
carrying capacity of blood. This is usually
the result of reduced unit volume
concentrations of haemoglobin, red blood
cell volume, or red blood cell numbers.

Deficiencies in Type I micronutrients does


not affect growth and therefore deficiency
in Type I micronutrients is not determined
by anthropometric measurement. The
individual may have normal growth with
appropriate weight and still be deficient in
these micronutrients.

Nutritional anaemia is when the cause


of anaemia can be directly attributed
to a nutritional disorder. Iron and folate
deficiency are the two most common types
of nutritional anaemia.

Type II micronutrients, such as magnesium,


essential amino-acids and zinc are essential
for growth and tissue repair. A deficiency in
any of the Type II micronutrients will lead
to growth failure, measured by stunting
and wasting.

Nutritional anaemia is common in:


Premature infant,
Children born of anaemic mothers,
Infants who are over 6 months of age
and are still exclusively breast fed,
Women who are menstruating and
lactating
Persons infested with parasitic
infestation such as hookworms and
malaria

Globally, the three most common forms of


micronutrient malnutrition are iron, iodine
deficiency and vitamin A. Of the three, iron
deficiency is the most prevalent: just over
2 billion people (37% of the total worlds
population) are anaemic. Iodine deficiency
is the next most prevalent, affecting 35%
(1.9 billion) of the worlds population.
In third place is vitamin A deficiency,
82

Prevention and treatment


Prevention
revolves
around
four
strategies:
1. Dietary diversification. Sources of
iron include green leafy vegetables,
starchy roots, fish, fruits, cereals, egg
yolk, liver, and other offal meats.
Ascorbic acid increases iron absorption
while tannins in tea inhibit iron
absorption. Human milk contains 0.2
mg /100mls which is sufficient for the
first six months of life, (Cows milk is
just 0.1mg /100mls).
2. Supplementation of iron for the most
vulnerable. Pregnant women receive
iron and folate during routine antenatal
visits.
3. Public health measures such as:
routine de-worming every six
months of early primary school
going children reduces iron loss due
to worm infestation
Intestinal parasites can be prevented
by good hygiene practices such as
washing hands with soap before
and after toilet use and
before eating. Dishes, kitchen
utensils, vegetables and fruit need
thorough washing. The immediate
household environment should be
free of human and animal waste.
Malaria prevention including use
of insecticide-treated bednets in
endemic areas, prompt treatment
of fever for children under 5 and
prophylaxis for pregnant women.
4. Food fortification. Food fortification is
the public health policy of adding
micronutrients (essential trace
elements and vitamins) to foodstuffs
to ensure that minimum dietary
requirements are met. Iron-fortified
cereal has been demonstrated to be
one of the most effective food vehicles

Iron deficiency anaemia


Iron deficiency anaemia occurs when the
dietary intake or absorption of iron is
inadequate. Iron is needed in the formation
of haemoglobin. At any one time, the body
has about 3g of iron.
Natural iron loss from the body is very low
with less than 1 mg per day lost. The major
cause of iron deficiency anaemia is blood
loss:
during menses in premenopausal
women
due to parasitic infections such as
hookworm, malaria
use of drugs such as non steroidal antiinflammatory drugs (NSAIDS).
In rare cases, lead poisoning has been
reported as causing iron deficiency anaemia
in children.
The symptoms of anaemia develop slowly
as normal stores of body iron are depleted.
Clinical features may include all or some of
the following:
tiredness and apathy
pallor
palpitations
phortness of breath on excretions
lack of concentration
oedema in severe cases.
Treatment requires identification of which
type of deficiency is the cause of anaemia.
For mild to moderate anaemia, daily oral
iron supplements will restore haemoglobin
levels over a period of months . For severely
anaemic patients, a blood transfusion may
be required.
Anaemic
patients
have
increased
susceptibility to infections and low
haemoglobin levels can lead to heart
failure.

83

Clinical examination of the eye may


reveal bitots spots. Other common
manifestations of vitamin A deficiency
include Keratomalacia, conjunctiva and
corneal ulceration.

in combating iron deficiency.


In the United States, the use of ironfortified infant formula and cereal has
significantly reduced iron deficiency
among infants and pre-schoolers

Hyper vitamin A

Vitamin A
Vitamin A is a fat-soluble vitamin found
in meats, livers, dairy products and eggs,
fruit, green leafy vegetables and red palm
oil. Vitamin A has multiple roles within
the body. It is found in rhodopsin within
the retina and is needed for vision. It
also plays a role in foetal development,
hearing, the immune response, growth and
maintainance of healthy epithelial tissues.

Ingested in large quantities, Vitamin A is


toxic. There are three levels of toxicity.
Level
1) Acute

Cause
occurs when there is
ingestion of repeated large
doses (>100,000 IU) very
closely spaced together
2) Chronic
occurs when there is
recurrent ingestion
of excessive doses of
Vitamin A over a period of
several weeks
3)Teratogenic occurs due to excessive
intake of Vitamin A during
pregnancy.

Increasing the vitamin A intake of


populations with vitamin A deficiency
(VAD) can decrease childhood mortality
from such illnesses by nearly a quarter of
childhood deaths. In plant sources, the (carotene must be converted to retinol for
the body to be able to use it. An individuals
vitamin status can be classified into deficient,
marginal, satisfactory, excessive or toxic
depending on the vitamin A levels.

Vitamin A deficiency

Vitamin A deficiency seldom occurs in


isolation. It is usually associated with some
degree of PEM. Inadequate vitamin A
intake can be attributed to:
Seasonal food availability, e.g. reliance
exclusively on fruits and vegetable
which are unavailable for some part of
the year, e.g. mangoes.
Early cessations of breastfeeding and
failure to consume vitamin A rich
foods
Diet that is low in fats which are
necessary for optimal absorption of
vitamin A.
High prevalence of intestinal parasites
and proteins deficiency impairs
absorption from the gastrointestinal
tract.

In the marginal state, the deficiency does


not lead to clinical signs. However, the
individual has inadequate body reserves and
is at a higher risk of developing infections.
This is one cause of children having
repeated infections. Where the individual
has low vitamin A plasma levels (<10ug/
100ml), there is increased morbidity which
can lead to blindness (Xeropthalmia) and
eventually death.
The initial symptoms include night blindness
and photophobia. The patient complains of
dryness of the conjunctiva (Conjunctivitis
xerosis).

84

Absence of iodine leads to impaired


thyroid hormone synthesis and/or thyroid
enlargement (goiter) which in turn leads
to irregular growth resulting in population
effects of severe iodine deficiency, termed
as iodine deficiency disorders (IDDs).

Table 5.8: Risk factors of vitamins A deciency


Category

Reason

Infants

Inadequate breastfeeding

School children

Poor diet

Seasonality

Food supply not constant

Infection

e.g. measles leads to impaired


absorption of nutrients

Poor food security

Inadequate food intake

Iodine is found in vegetables grown on


iodine rich soils. Sea foods such as fish and
seaweed are also rich in iodine. Certain
foods contain compounds (goitrogens) that
inhibit the bodys ability to utilize iodine.

Prevention Strategies
Prevention is through health education.
Women of child bearing age should be
encouraged to eat a diet with plenty of
vitamin A.

Goitrogens suppress the function of


the thyroid gland by interfering with
iodine uptake, which can result in goiter
formation. Certain foods such as brassica
family (cabbage), kale and groundnuts have
been identified as being lightly goitrogenic.

A breastfeeding mother should start infants


off with colostrums which is rich in vitamin
A and continue breastfeeding for at least 2
years.
In some countries certain foods such as
margarine are fortified with vitamin A and
are useful as part of the diet. Porridge
which is primarily cereal should be made
from fortified cereals.

However cooking them inactivates the


goitrogenic effect.
Table 5.9: Recommeded iodine intake
Recommended iodine
intake

Iodine
Twenty-nine percent of the worlds
population, living in approximately 130
countries, is estimated to live in areas
of deficiency. One billion people in the
world suffer from iodine deficiency. Iodine
deficiency occurs primarily in mountainous
regions where iodine has been washed
away through glaciation and flooding and in
lowland regions far from the oceans, such
as Central Africa and Eastern Europe.

Daily requirement

Infants

50g

Children
2-6years-

90g

7-12years

120g

12years

150g

Pregnancy and lactating


women

200g

Iodine Deficiencies Disorder (IDD)

The presence, size and visibility of goitre


within a given population indicates the
presence and severity of iodine deficiency.
If iodine deficiency is suspected, then
assessing the levels of iodine by taking
samples of urine from school children
can help determine the degree of iodine
deficiency in the community. When urinary
secretion per day is <25 / day, then there
is a high probability of cretinism within the
community.

Iodine is a chemical element. It is found in


trace amounts in the human body, in which
its only known function is in the synthesis
of thyroid hormones. Iodine is vital in the
formation of thyroxin, which is an important
factor in-growth and development and the
metabolic regulation of the body.
85

Iodine deficiencies disorder refers to


a spectrum of pathological conditions
resulting from deficiencies of iodine. These
include;
Stillbirths
Low birth weight babies
Intellectual retardation
Cretinism
Goitre
Hypothyroidism
Squint
Deaf-mutism
Dwarfism

compound as domestic animals will also


have iodine deficiency and have higher
rates of miscarriage and lower yields.
Prevention and control

Treatment of individual patients can be by


giving iodized poppy seed oil injections
(475-950mg iodine) to women of child
bearing age, every 3 to 5 years.The optimal
amount of iodine required per person per
day is about 150g. Supplementation is a
useful approach in prevention.
Various countries have put into legislation
requirements to iodize certain foods
especially table salt. This requires
inexpensive technology and is ideal since
iodine is lost in the cooking process. In
other countries, it is added to the water
supply.

The consequences of iodine are worse in


children when compared to adults. In adults
hypothyroidism results in individuals who
feel sleepy, are cold intolerant and have
dry skin and complain of constipation.
Women with goitre have a higher risk of
reproductive failure with higher incidence
of miscarriages and stillbirths. Children
have the same features as adults but have
the risk of mental and physical growth
retardation.

Malnutrition and disease in children


Malnutrition in children often creates a
vicious cycle with malnourished children
having greater vulnerability to disease.This
turn, reduces the childs capacity to absorb
nutrients. It is estimated that malnutrition
still underlies half of the inpatient
admissions morbidity and mortality rates
among children in rural Kenya.

In the newborn, hypothyroidism is tragic


as the physical and mental consequences
are irreversible. Cretins have irreversible
mental retardation, are short in stature,
deaf and mute, and commonly have a squint
as well. Because of lowered immunity, such
children have a higher risk of developing
infections. Communities with high iodine
deficiency are affected socio-economically
because the affected people have lower
mental aptitude, less productive in work
and educationally. The community has
more handicapped individuals who depend
on others for care.

Malnutrition is associated with lowering of


immunity, particularly in PEM and vitamin A
deficiency, which leads to mucosal damage
and lowered resistance to infection. Under
such circumstances, incidence and or
severity of disease may be increased.
Concurrent infection interferes with
nutrition in a number of ways:
Reduction of food intake
Infection may lead to poor appetite
resulting in decreased food intake.
This may be made worse in certain
cultures, illness or infections in children

The dependency ratio in the community


is therefore high and if in such areas, they
are dependant on livestock, then problems
86

the outcome of the pregnancy and these


include:
The gestational stage in which the
mother begins to lack nutrients;
How long the deficiency has been
going on;
Concomitant intake of various
substances such as alcohols, caffeine,
nicotine;
Infections; and,
The physical and emotional state of the
expectant mother.

or adults where certain nutritious


foods are withheld intentionally, for
example, breastfeeding when there is
diarrhoea.
Decreased food utilization
In diarrhoea, rapid transiting of food
through the bowel together with
often-extensive mucosa damage in
children leads to reduced food
absorption and subsequent loss of
water and electrolytes.
Increased nutritional requirement
In almost all illnesses, there is a need
for increased calorie intake, especially
in febrile illnesses and infections
associated with blood loss such as
malaria, shistosomiasis and hookworm
infestation.
Long term, sustainable prevention of
malnutrition and infection involves
health education, immunization
and good environmental sanitation in
addition to tackling poverty at its roots.

During pregnancy, the expectant mother


needs to have adequate nutrition to cater
for the growing foetus. This is reflected in
the weight gain that occurs as the pregnancy
progresses.
In adequate maternal nutrient intake leads
to reduced blood volume with inadequate
increase in cardiac output. The placenta
size is reduced leading to lowered nutrient
al transfer and hence premature birth and
low birth weight babies.

Maternal Nutrition

Malnutrition is an intergenerational
problem. Failure to tackle the problem
of malnutrition in the mother can lead to
not just the mother begin affected but her
children as well.

Obesity

Obesity is the result of caloric imbalance


where less calories are expended for the
amount of calories consumed. It is mediated
by genetic, lifestyle and environmental
factors. Much of the developing world is
undergoing a nutrition transition.

In severe cases, a double tragedy occurs


with the loss of both the mother and the
baby. Malnutrition weakens a womans
ability to survive childbirth. Delivery in
itself is known to be a major mortality risk
factor.

Changes in diet, food availability and lifestyle


mean that often underweight children live
side by side with overweight adults. The
rising levels of obesity is caused by the
availability of cheap energy dense foods
such as those found in fast food restaurants
together with a more urbanized and more
sedentary lifestyle. It is estimated that, the
African continent will be more than 50%
urban by 2025.

A malnourished woman is more likely to


deliver a premature baby with low birth
weight, reducing the chances of the babys
survival. The point at which the mother
lacks nutrients affects the outcome of
the pregnancy. Various factors influence
87

However, the general trend is an increase


in the prevalence of childhood obesity.
Obesity in children has both immediate
and long-term health impacts including
increased risk of:
developing cardiovascular disease. It is
estimated that 70% of obese youth
had at least one risk factor for
cardiovascular disease.
bone and joint problems, sleep apnea,
and social and psychological problems
such as stigmatization and low selfesteem.
becoming overweight or obese adults,
and therefore more at risk for
associated adult health problems,
including heart disease, type 2
diabetes, stroke, several types of
cancer, and osteoarthritis. Prevention
of childhood obesity as outlined below

The presence of under and over nutrition


poses a major dilemma for public health
programs since very often the focus of
nutrition programs is to manage under
nutrition.
Childhood Obesity
Childhood obesity is of growing concern.
In America, an estimated 19.6% of children
aged 6 to 11 years were estimated to be
obese in 2008 up from 6.5% in 1980.
Overweight children are more likely to
become overweight in adulthood than
lean children. Approximately one half of
overweight adolescents and over onethird of overweight children remain obese
as adults. There is still no widely agreed
standard for classifying overweight and
obesity in children and adolescents.

Table 5.10: Stepwise implementation for: prevention of childhood obesity


Strategies/activities/milestones

Steps

Promote and export support six months of exclusive brestfeeding


Create a healthy school enviroment:
Support regular physical activity classes, inclusion of nutrition and physical activity into the curriculum,
healthy food options through school food services ( cafeteria, vending machines etc) and decreased TV
viewing
Involve parents and families
Meet specic needs of school and provide approppriate cultural and local adaptations
Core

Introduce a mass media campaign


Target primarily parents and caregivers and secondary children and adolescents
Support with programmes for new and young parents

Change physical environmnet to support active commuting and space for recreational activity
Ensure walking, cycling and other forms of physical activity are accessible and safe
Improve sports, recreation and leisure facilities (sports for all)
Increase safe spaces for active play

Involve primary health care


Encourage health care facilities to provide range of preventive services and health promoting activities
and monitor childrens growth (including stunting and overweight)
Implementation national dietary and physical activity guidelines
Expanded

Legislation to support healthier composition of foods


Eliminate trans- fatty acids and decrease saturated fats
Fiscal policies to encourage consumption of healthier food products and promote access among poor
communities to recreational physical activity
Support pricing strategies with point-of-decision prompts

Desired

Reduce marketing of food and non-alcohol beverages to children

88

is therefore important in preventing


later life morbidity. Healthy lifestyle
habits, including healthy eating and
physical activity, can lower the risk of
becoming obese and developing
related diseases.

Nutritional Surveillance

Fig. 5.5: Use of MUAC

Nutrition Surveillance involves the


continuous collection and analysis of the
nutritional status of a population.

Mid upper arm circumference (MUAC)


is the circumference of the left upper
arm, measured at the mid-point between
the tip of the shoulder and the tip of the
elbow. MUAC is the circumference of the
left upper arm, measured at the mid-point
between the tip of the shoulder and the tip
of the elbow.

Data collected is used to formulate policy


and make changes to programs that will
lead to improvement in the nutrition
status of the given population. It can also
be employed to give warning of impending
crisis in a vulnerable population. The main
objective is to detect changes in trends in
order to initiate investigative or control
measures.

It is also a very good predictor of the


risk of mortality. It is best used to detect
children in need of treatment rather
than for monitoring population trends.
It is therefore a vital tool in nutritional
surveillance.

Effective surveillance systems should


be able to give timely warning; allowing
adequate time to respond to the situation.
Various indicators are used together to
determine the nutritional status of the
population. Because they are the most
vulnerable segment of the population,
children under 5 years are measured.
Anthropometric measurements that are
used include:
Age.
Height /length
Weight
Presence of oedema

However, there is no agreement for the


measurement and interpretation of MUAC
values in children less than 6 months and
in adults. Such children have a high risk
of death exceeding 9-fold that of children
with a weight-for-height above -1 SD. For
MUAC, the risk of death is increased
below 115 mm. At this level, there is a need
for implementation of intensive nutritional
and medical support.
Nutritional Status Indicators
Once the age, weight, height and MUAC
are known, various indicators of nutritional
status can then be worked out:

Today, all children at birth are provided


with a child card (Fig. 5.6) which has a
growth chart on which nutritional status is
tracked. Especially in the first two years,
any deviation from the trend line should
lead to a corrective response.

Weight for Height (W/H)


This reflects body mass relative to height.
Low (wasting or thinness) indicates in
89

Body Mass Index (BMI) also reflects


body mass relative to height. It is mainly
used for adults and adolescents. High BMI
permits to assess degrees of overweight
and obese people and low BMI to assess
different levels of thinness.

most cases a recent and severe process of


weight loss, which is often associated with
acute starvation and/or severe disease.
However, wasting may also be the result of
a chronic disease condition. Provided there
is no severe food shortage, the prevalence
of wasting is usually below 5 percent, even
in poor countries. A prevalence exceeding
5 percent should be declared a nutritional
emergency as mortality rates soon rise.
High W/H indicates overweight.There is a
strong correlation between high W/H and
obesity as measured by adiposity though
greater lean body mass can also contribute
to high weight-for-height.

Height for Age (H/A) This reflects height


relative to chronological age. Low H/A is
called stunting. Stunted growth reflects
failure to reach linear growth potential
as a result of poor nutritional conditions.
High levels of stunting are associated with
poverty and increased risk of frequent
and early exposure to disease and/or
inappropriate feeding practices.

For population surveillance, high W/H can


be considered as an adequate indicator of
obesity, because the majority of individuals
with high W/H are obese. For individual
measurement however, skinfold thickness
measurement are better for gauging levels
of adipose.

A decrease in the stunting rates is usually


a good indication of socio-economic
improvement within a community. Where
stunting is prevalent, it starts to show
at the age of 3 months and slows down
at around 3 years. Thereafter, a childs

Intrauterine
growth
retriction

Infections

Poverty

Social and
political contexts

Micronutrients
deciences
Disability

Increased
exposure to
infections

Food security

Poor access to
or update of
services

Chronic
undernutrition
(Stunting)
Reduced
energey
intake
Severe acute
malnutrition

Breastfeeding

Death
Infection

Fig. 5.6: Conceptual model of pathways to death and disability from malnutrition

90

Table 5.11: Z - score classication

height is stunted and irreversible though


they continue to grow parallel to growth
reference curve.
Weight for Age(W/A)
This reflects body mass relative to
chronological age. Low W/A is influenced
by both the height of the child (heightfor-age) and his or her weight (weightfor-height). Because of the composite
nature of the indicator, it is often difficult
to interpret.

Nutritional
status

Z score

Wasting

is the percentage of children with a weight


that is more than two Z-scores below the
referenced weight-for-height

Stunting

is the percentage of children with a height


that is more than two Z-scores below the
referenced height-for-age

Underweight

is the percentage of children with a weight


that is more than two Z-scores below the
referenced weight-for-age.

For adults (20-49 years) Body Mass Index


(BMI) is a simple index of weight-forheight that is commonly used to classify
underweight, overweight and obesity
in adults. It is defined as the weight in
kilograms divided by the square of the
height in metres (kg/m2). For example, an
adult who weighs 70kg and whose height
is 1.75m will have a BMI of 22.9. It is useful
as a screening tool. The thresholds are as
outlined in table 5.12.

For example, W/A fails to distinguish


between short children of adequate body
weight and tall, thin children. However,
in the absence of significant wasting in a
community, both W/A and H/A reflect the
long-term health and nutritional experience
of the individual or population.
For nutritional surveillance, the above
indicators are used to assess prevalence
of malnutrition and provide a basis to
determine the types of interventions
needed to correct the identified problems.
For children under five years of age, the Zscore classification system is used.

Table 5.12: BMI classification


Classication

BMI(kg/m2)
Principal cut-off
points

Additional cut-off
points

Underweight

<18.50

Severe thinness

<16.00

<18.50

Moderate thinness

16.00 - 16.99

16.00 - 16.99

For consistency with clinical screening,


prevalence-based data is commonly
reported using cut-off values, usually at
minus two and plus two Z-scores from the
median in the reference population.

Mild thinness

17.00 - 18.49

17.00 - 18.49

Normal range

18.50 - 24.99

18.50 - 22.99
23.00 - 24.99

Overweight

25.00

Pre-obese

25.00 - 29.99

Obese

30.00

This implies that slightly more than 2


percent of the reference population will
be classified as malnourished even if
they are truly healthy individuals with no
growth impairment.

Obese class I

30.00 - 34.99

30.00 - 32.49
32.50 - 34.99

Obese class II

35.00 - 39.99

35.00 - 37.49
37.50 - 39.99

Obese class III

40.00

<16.00

25.00
25.00 - 27.49
27.50 - 29.99
30.00

40.00

Oedema

Oedema is the accumulation of fluid in


the tissues. It is a common complication
of kwashiakor and begins at the feet and

For adults (20-49 years) BMI is used for


screening.

91

include areas that are prone to recurrent


droughts or floods. Farm size, the use of
extension services, local food prices and the
populations response to food shortages
gives an indication of how food secure the
population is. Communities that do not
have permanent sources of water, have
distress sales of livestock and are nomadic
are more likely to be food insecure.

spreads upwards. In severe cases, it can


involve the hands and face.
Socio-economic indicators
Collection of various socio-economic
indicators looks at secondary causes of
under nutrition. These ndicators include:
Quality of housing
Water supply
Sanitation
Diseases and Epidemics
Mortality rates
Literacy levels

Under such circumstances, early warning


systems are needed as part of emergency
planning. As much as possible, nutrition
surveillance systems should be intergrated
with such programs.

Food security

This refers to access to adequate food for


all members of households at all times.
Achieving adequate food security is one of
the key roles of the agriculture sector in
any country. The health sector has a role to
play and therefore effective food security
involves collaboration between the health
and agriculture sectors.

The interactions between the different


determinants of food consumption and
nutritional status are complex and cut across
many sectors. A conceptual framework of
these interactions is provided below and
highlights the difficulty in maintaining food
security in communities where poverty has
not been addressed as a root cause.

Food security indicators


Certain populations suffer from under
nutrition because they subsist in ecologically
fragile zones. Examples of such zones

SOCIO-ECONOMIC
AND POLITICAL
ENVIRONMENT
National Level
Population
Education
Macro economy
Policy environment
Natural resources
Agricultural sector
Market conditions
Sub-national level
House hold
characteristics
Livelihood systems
Social institutions
Cultural attitudes

CARE PRACTICES
Child care
Feeding practices
Nutritional education
Food preparation
Eating habits
Intra-household food
distribution

FOOD
AVAILABILITY
Trends & level)
Production
Imports (net)
Utilization
Stocks

STABILITY OF FOOD
SUPPLIES AND ACCESS
(Variability)
Food production
Incomes
Markets
Social/cultural
ACCESS TO FOOD
(Trends & levels)
Purchasing power
Market integration
Access

FOOD
CONSUMPTION
Energy intake
Nutrient intake
HEALTH &
SANITATION
Health care
practices
Hygiene
Water quality
Sanitation
Food safety &
quality

NUTRITIONAL
STATUS
FOOD
UTILIZATION
BY BODY
Health status

Fig. 5.8: Determinants of food consumption and nutritional status: a conceptual framework

92

Questions Section

1. What are the prevention strategies for PEM


2. What is the role of vitamin A in the body. How can deficiency be prevented?
3. What are the control measures in preventing nutritional anaemia
4. Discuss the value and limitations of breastfeeding for infants

Further reading

1. Caballero B. A nutrition paradox--underweight and obesity in developing countries.


The New England journal of medicine.2005 ;352(15):1514-6.
2. Guerrant, R. L., Ori, R. B., Moore, S. R., Ori, M. O., & Lima, A. A. (2008).
Malnutrition as an enteric infectious disease with long-term effects on
child development. Nutrition Reviews, 66(9), 487-505. doi: 10.1111/j.
1753-4887.2008.00082.x.
3. Weight, Meeting Of Advisory Group Of Maternal Nutrition And Low Birth.
Meeting of Advisory Group of Maternal Nutrition and low birth weight. Nutrition.
Geneva. 2002

93

COMMUNICABLE DISEASES

Introduction

At times, the disease condition arises from


the by-products produced by the agent
organism. The organisms are mainly microorganisms such as bacteria and viruses
though larger parasites such as helminths
are also capable of causing diseases.

Communicable diseases remain a major


cause of mortality and morbidity in
developing countries. In developed
countries, a combination of better
sanitation,
housing,
immunization,
availability of drugs and improved nutrition
has greatly reduced the prevalence and
incidence of communicable diseases.

POPULATION
age
genetic susceptibility
nutritional status
previous exposure
immunisation status
physical condition

While some infectious diseases like


smallpox have been completely eradicated
from the world, new ones like HIV/AIDS
have emerged and old ones like TB have
re-emerged. Rare ones like Ebola have
appeared more frequently as the population
increases.

AGENT
Virulence
Infectious dose
Susceptibility to drugs
mode of transmission
ability to adapt to
change

A communicable disease is one due to a


specific agent or its products and it arises
through the transmission of that agent, its
products or its by-products from a reservoir
to a susceptible host. Transmission can be
either direct (person-to-person) or indirect
through the agency of an intermediate host,
a vector or an inanimate environment.

vector

ENVIRONMENT
Shelter
attitude
Humidity
Sanitation
Food supply
water supply
temperature
overcrowding
essential services

fig.6.1: Equilibrium between the Population, Infectious


Agent, and the environment

Where the agent normally lives and


multiplies is called its reservoir or
definitive host. This can be a human
being, an animal, plant, or even soil. A good
agent normally has some kind of symbiotic
relationship with its reservoir and so does
not kill its reservoir.

Directly transmitted diseases such as


influenza can also be termed contagious
diseases while indirectly transmitted such
as cholera are infectious diseases. Whether
or not there is disease depends upon the
balance between the disease agent, the
population and the environment.

A carrier is an infected person who


harbours the specific agents in the absence
of discernible clinical disease. They are a
potential source of infection for others.

Certain terms are important in order to


understand the underlying concepts used
to prevent and control communicable
diseases. The organism that causes the
disease is known as the agent.

The difficulty is that they are asymptomatic


and therefore are often unaware that they
are a source of disease. A carrier can be
94

diseases, making prompt clinical


diagnosis and early treatment more
difficult.
Increased exposure to disease
vectors.
Changing climatic conditions,
displacement of populations and
population encroachment on previously
unoccupied land can result in greater
exposure to disease-carrying vectors
such as malaria, yellow fever and
arboviruses.
Poor access to health services
Displaced populations can have
increased risk to all of the above
and gender-based violence where
there is civil breakdown can lead to
increased risk of HIV and other
sexually transmitted diseases. A work
environment that prevents families
living together often mimics such
displaced populations such as refugee
camps. In refugee camps, there is
often an increased risk of transmission
of disease such as cholera and measles
due to overcrowding.

acute, chronic, intermittent, or convalescent


(in recovery from the disease).
In order for the agent to infect a victim,
it must escape from the reservoir. In
humans, there are five routes of escape
for a disease agent. The first four involve
normal physiological functions.
1. Respiratory route - escape takes place
through the process of breathing and
coughing. It is naturally difficult to
control and examples include; TB,
Whooping cough, Influenza and other
respiratory diseases.
2. Gastro intestinal route - agent escapes
with faecal matter. Includes viral
disease, poliomyelitis, cholera, typhoid.
3. Genital route - is the route in sexually
transmitted diseases- e.g. Syphilis and
Gonorrhoea
4. Urinary route - through urinary tract
during micturation
5. Abnormal routes - routes that do not
involve normal physiological activities.
Examples include insect bites, e.g.
mosquito and malaria and iatrogenic
routes where infection is introduced
during a medical procedure, e.g.
surgery or injection.

Principles of disease control

Agent Transmission
On escaping from the reservoir, the
agent has to be transmitted to a new
host. Transmission can either be direct
or indirect. For many agents, this period
of transmission is a vulnerable period and
the shorter the period of transmission the
greater the chances of survival.

The following are some of the risk factors


for high burden of communicable disease:
Access to safe water and sanitation
facilities.
Populations that have low levels
of access to safe water and sanitation
facilities have high risks of outbreaks
of waterborne and foodborne diseases.
Malnutrition especially in children
under five.
Malnutrition reduces natural immunity,
leading to more frequent, severe
and prolonged episodes of infections.
Severe malnutrition often masks
symptoms and signs of communicable

Transmission can be accidental, for


example, where a vector such as the
house fly transmits dysentry. Biological
transmission is when the pathogen
undergoes multiplication within the vector.
This is the case in malaria. Various agents
adopt mechanisms to aid survival during
the transmission stage such as bacteria
95

forming spores or protozoa forming into


cysts.

For example, plasmodium requires an


incubation period of 10 to 12 days at
temperatures above 15.60 C to develop
within the mosquito.

In direct transmission, the host or


reservoir has to come into contact with
the victim. This can be through sexual
contact such as a sexually transmitted
disease or aerosol droplet in the case of
a respiratory disease like TB. Conditions
that cause interaction or mixing of people
like overcrowding favour transmission of
disease. Schools, for example, can create
an environment for rapid transmission of
disease such as respiratory tract infection.
Many agents are found in the various
natural secretions such as mucus.

Passive transmission refers to a vehicle


contaminated material or object such as
handkerchief, water, food, milk or clothing
which acts as an intermediate means
oftransport before the agent is introduced
to the victim or next host. There may be
further development or multiplication of
the agent in the vehicle.
Entry into the host is via the same routes
that an agent would escape from the host.
For disease to develop in the host there
has to be an agent-host interaction.

Indirect transmission can be through a


vector or occur passively. In indirect
vector transmission, the vector is usually
an insect. The insect-human contact can
vary considerably in terms of duration and
type of contact. A mosquito settles on
the host for a very short time as it gets its
blood meal.

The type of interaction that occurs depends


on the virulence, dose of the agent and
the hosts immune response to the agent.
The symptoms seen depend mainly on
these interactions and the route of entry.
For example, pulmonary TB is contracted
through the respiratory route.

Others such as ticks may feed on the host


for several days before dropping off. Fleas
spend an even longer period but are not
permanently attached. Ectoparasites such
as body/hair lice are attached to the host
almost permanently.

A common symptom of TB is a chronic


cough. However, there may be other
systemic symptoms such as fever and
weight loss. Such symptoms help guide
us to diagnosis of disease and therefore
possible control of it.

In certain disease processes, the agent


passes through an intermediate host
before it can infect. Transmission by a
vector or intermediate host is termed as
biological transmission when an essential
part of the agents life cycle takes place in
the vector or intermediate host. The host
in which the sexual cycle takes place is
the definitive host while where immature
forms are found is the intermediate host.
Biological transmission can be temperature
dependent and or time dependent.

Control Measures

There are two ways to look at control


measures. The first uses the Agent-hostreservoir model hitherto described. The
other is to look at control in terms of
primary, secondary and tertiary control
(the model more commonly used for noncommunicable diseases).
In the first model, there are several points
at which control measures can be taken.
96

Within the reservoir, at the point of exit


from the reservoir and at the point of entry
into the host.

immunity is achieved.
The herd immunity threshold is the
proportion of a population that must be
immunized in order to cease an epidemic
and impart indirect protection to those
without personal immunity, thereby
preventing the spread of a disease. For
example, measles is highly infectious and so
the level of vaccination required to provide
herd immunity in the population is 95%.

In the reservoir
If the reservoir is non-human, then the
entire reservoir can be destroyed, e.g. rats
in case of plague or wild dogs in the case
of rabies. If the reservoir is human, then
treating the person eliminates the agent
e.g. in TB treatment. In a disease such as
TB the reservoir and the host are one and
the same.

Because a vaccine is given to people


who at the time do not have the disease
to protect against future disease, it is
important to establish the cost benefit
of using a particular vaccine. An effective
vaccine therefore is one that has ceratin
characteristics as shown in table 6.1.

Exit from reservoir


Normal physiological functions are difficult
to control and therefore few measures can
be taken at this level. However, steps can
be taken to reduce the level of person-to person contact, e.g. avoiding overcrowding
or the use of condoms in case of HIV/
AIDS. Where transmission is indirect,
contaminated material can be sterilized,
e.g. milk pasteurization. Understanding the
life cycle of the vector is important reducing
the rate of transmission.

Table 6.1: Characteristics of an effective vaccine

Entry into the host


Barriers can be erected that ensure the
agent cannot enter the host. For example,
use of Mosquito nets or wearing of shoes in
the case of Shistosomiasis can be effective
barriers.

Characteristic

Desired quality

Safety

Vaccine in itself does not cause


disease

Protection

Protection is at population level


and prevents disease when infectious
agent is encountered

Long lasting effects

Should be long lasting

Cost

Inexpensive to produce and deliver


by health worker

Administration

Easy to administer (e.g. single dose)


with minimal side effects

The process of acquiring immunity


through vaccination is known as
Immunoprophylaxis. Drugs can also
be used to prevent the development of
disease, (chemoprophylaxis).

Within the host


How susceptible a host is plays an important
role in determining the access of the agent.
The strength of the host immune system
is dependent on the underlying general
nutritional status and mental well being
of a person. The immune system can be
boosted by the use of vaccines. A vaccine
is a product of a weakened or killed microorganism (bacterium or virus) given for
the prevention or treatment until herd

For example, current treatment guidelines


state that during an influenza outbreak,
it is recommended to give vulnerable
persons such as healthcare workers and
pregnant women chemoprophylaxis with
neuraminidase inhibitors drugs such as
oseltamivir or zanamivir.

97

Primary, secondary and tertiary


control model
Where there is already a disease outbreak
or the disease is endemic then the focus
should be on controlling the more
advances stages of the disease to slow the
progression of disease and prevent further
spread of the disease. These measures can
be grouped as:
Primary Prevention to prevent
the development of biological and
clinical signs of disease by carrying
out immunization of susceptible
people, chlorinating water and
ensuring good sanitation.
Secondary Prevention to prevent
mild illness from becoming more
serious by having good case detection
leading to early diagnosis and
treatment.
Tertiary Prevention to prevent or
minimize disease complications by
early referral and prompt treatment of
disease.

surrounding host population. Because of


this, both relief agencies and local health
authorities need to have an emergency
plan to deal with any displaced populations
within a locality.
While a disease outbreak can occur at any
time among a displaced population, the
occurrence of disease in the population
can be divided into two phases. An acute
emergency and a post emergency phase.

Surveillance of communicable
diseases

Successful control of communicable


diseases needs an effective surveillance
system. It is not enough to achieve a
high coverage of measles immunization,
chlorination of water, and other disease
control measures. The collection and
analysis of health data in a timely fashion
is necessary in order to work out disease
incidence and enables health workers to
detect and report outbreaks especially
where there are large numbers of high risk
populations.

Displaced Populations
Displaced populations often have high
level of risk factors for communicable
diseases. According to the International
Committee of Red Cross between 5195% of deaths in refugee populations can
be attributed to communicable disease.
The displaced population also increase the
risk of communicable disease spread to the

Surveillance can be defined as the


ongoing systematic collection, analysis,
and interpretation of health data, which is
essential to the planning, implementation,
and evaluation of public health programs.
It includes timely dissemination of data to
those who need to know.

Table 6.2: Causes of morbidity and mortality in displaced populations


Emergency Phase

Acute emergency
phase

Post emergency
phase

Predisposing factors

Main causes of morbidity and


mortality
Environment
acute respiratory infections (ARI),
measles, diarrhoeal diseases such
as cholera, typhoid, amoebiasis,
shigellosis, malaria

insufcient shelter,
indoor air pollution
(smoke from cooking
fuel and cigarettes),
overcrowding,
poor access to health care

tuberculosis, meningitis

98

Host
age (<2 years and > 65
years),
low birth weight,
breast-feeding, poor
practices, malnutrition,
vitamin A deciency,
incomplete immunization,
Low maternal education.

A good surveillance system can increase


understanding about the changing disease
patterns and enable effective disease
control measures. Surveillance should be
carried out at both health facilities and
community level.

according to standard case definitions, e.g.,


ARI, TB.
Case definitions may be classified
according to different criteria, including
the following:
Site of clinical disease upper or lower
respiratory infections
Severity of disease uncomplicated or
complicated malaria
Laboratory results suspected or
confirmed meningitis
History of treatment new, relapse,
treatment failure or treatment after
interruption case for tuberculosis

A surveillance system should have a


central registration system for recording
all morbidity and mortality data deaths
occurring at both health facilities and
community levels. Surveillance forms
for morbidity should record only newly
diagnozed cases. The community should
also be sensitized to report any disease
outbreaks. An agreed case definition is
important as it helps to standardize the
criteria used to decide if a person has a
particular disease. Case definitions are
useful in the following ways:

Epidemic thresholds
The importance of having a good
survelliance system is to be able to predict
when an epidemic has began. This can be
done by:
keeping track of weekly incidence rates
and comparing them to those of the
previous month or season may
improve prediction.
Comparing the disease incidence rate
or attack rate (the proportion of
those exposed to an infectious agent
who become clinically ill) to the
epidemic threshold (the minimum
number of cases indicating the
beginning of an outbreak of a
particular disease).

Registration of case
Standard case definitions are used to
diagnose and record common health
problems affecting the population. This
helps to accurately monitor the disease
trends and make better estimates of
required resources. If standard case
definitions are used at several locations
or by different relief agencies, disease
trends among different populations can be
compared.
Notification
Standard case definitions are used to alert
national health authorities about outbreaks
of notifiable diseases (diseases for which
regular, frequent, and timely information
on individual cases is considered necessary
for the prevention and control of the
disease).

Standard epidemic thresholds have


been defined for some diseases, for
example, in measles, a single case may
be enough to signal a possible
outbreak of measles. Any reported
case should be followed by an
immediate investigation of the age and
vaccination status of the suspected
or confirmed case of measles. For
cholera in a non-endemic area an
outbreak of cholera should be

Defining the appropriate treatment


Patient treatment may be prescribed
99

larva. The larval stage is important for


malaria control.

suspected if an adult suddenly


develops severe dehydration or dies
from acute watery diarrhoea or
there is a sudden increase in the daily
number of patients with acute watery
diarrhoea.

Malaria

Description of malaria can be found dating


back thousands of years ago. Hippocrates
in 5 BC described intermittent fevers and
its relationship with marshes. Modern
descriptive history of malaria dates back
to 1880, when Laveran identified the
causative organism.
In 1896, Ross was able to demonstrate
transmission of malaria by the mosquito.
Malaria has been eradicated from Europe,
Australia, Singapore, Japan, North America,
the Caribbean and large parts of North and
South America with no cases of indigenous
transmission reported. However, malaria
but it remains a major killer in sub-Saharan
Africa, South East Asia, the Indian Subcontinent, Central and South America.
More than 250 million people suffer from
malaria and it is responsible for more than
one million deaths per year, most of them
children in sub-Saharan Africa.
`
Reservoir
Humans are the major reservoir for
malaria, with exception of P. malariae, which
also infects chimpanzees (simian). Exit is
via an abnormal route by the bite of the
female mosquito, Anopheles gambiae. Only
the female anopheles mosquito transmits
malaria because a blood meal is required
for the maturation of eggs.
This maturation phase takes between 2 - 3
days and is referred to as the gonotrophic
cycle. Thereafter, the eggs develop into

The adult mosquito emerges from the


larval habitat at dusk. It is during this
swarming that mating takes place. A single
mating is sufficient for the lifetime of a
female mosquito. The agent for malaria is
a protozoan parasite of genus plasmodium
of which four species affect man namely: P.
falciparum, P. Ovale, P. vivax and P. malariae.
The Life cycle consists of alternating
sexual and asexual cycles, which occur
in mosquitoes and humans respectively.
The mosquito is the definitive host while
the human being is the intermediate
host. Transmission is biological with
the plasmodium undergoing sexual
reproduction within the mosquito. This
process is temperature dependent and
does not occur at temperatures 15.60.
The sexual phase ends with the formation
of sporozoites. Once a mosquito bites
a human being, the sporozoites are
introduced into the bloodstream staying
for less than 30 minutes before invading the
liver. Within the human host, they undergo
the asexual phase, dividing into two. In
the liver, they begin the exo-erythrocytic
phase. Over a period of 5 to 15 days, the
Sporozoite transform into schizoid within
which merozoites multiply asexually.
At the end of the first phase, the schizoid
ruptures releasing the merozoites, which
when released into the bloodstream
invade red blood cells (RBC). Within the
red blood cells, the merozoites develop
into trophozoite, which grow feeding
on haemoglobin. They undergo further
asexual multiplication to produce daughter
merozoites, which invade even more
RBC. Possibly, due to immune pressure or

100

Human liver
stages

1 schizont

Mosquito stages
9 Mosquito stages ruptured
Oocyst

10
Mosquito takes a
blood meal (injects
sporozites)

2 Ruptured
schizont

8
Oocyst

7
Mosquito takes a blood
meal
(injects gametocytes)

Human blood
stagses

3
schizont

4
Gamotocytes

Ruptured

schizont

5
Fig. 6.2: Life cycle of the malaria parasite

some metabolic factors, some merozoites


transform into gametocytes. Should the
intermediate host be bitten by a mosquito
then these gametocytes are taken up by
mosquito, to initiate the sexual cycle.
Diagnosis and treatment
The clinical course of uncomplicated
malaria begins with an incubation period
of between 7 to 15 days. Then there
are intermittent repeated cases of fever
alternating with symptom free periods.
These symptoms can persist for as long
as 8 to 10 months. Diagnosis of malaria
is made by eliciting symptoms and signs of
malaria together with peripheral blood film

showing the parasite. Other laboratory


diagnostic methods that can be used
are serological that elicits the presence
of malaria antigen which are useful in
detecting scanty parasiteamia. The use of
rapid diagnostic tests is increasingly being
used and maybe more accurate when
compared to reading blood slides.
Treatment of malaria consists of managing
the symptoms such as fever, headache and
definitive management by targeting the
agent. Drugs that cure malaria can target
the developing merozoites in the liver or
can be gametocytocidal drugs.

More than 250 million people suffer from malaria and it is responsible for more than one million deaths per year, most
of them children in sub-Saharan Africa. A major initiative to eradicate malaria was the launch of the Global Fund to
Fight AIDS, Tuberculosis and Malaria which was created in 2002 following a UN General Assembly Special Session
on AIDS in June 2001. Its mandate is to provide signicant amounts of new resources to allow affected countries to
respond forcefully to the formidable challenge caused by AIDS, TB and Malaria cause six million deaths every year.
From 2002 until 2007 a total of US$ 7.6 billion for 136 countries have been approved to combat the three diseases. In
2011 it had approved funding of US$21.7 billion for more than 600 programs.
Global: www.theglobalfund.org/en/about accessed 15.2.2011.

101

Prevention and Control


At the reservoir level, not much can be done
because, for natural immunity to develop, a
person has to be exposed to all variants of
plasmodium. Chemoprophylaxis is useful,
but interrupts the process of immunity and
therefore makes the person non-immune.
A person on chemoprophylaxis therefore
has to remain on it throughout to avoid
getting severe malaria.

reduces their numbers. Children under five


years and pregnant women generally have
lowered immunity. In addition, pregnant
women have a higher risk of developing
eclampsia if there is malaria infection.
These groups therefore require greater
protections against malaria.
One of the strategies adopted is
intermittent presumptive treatment in
pregnancy and early treatment of fever in
children under five years (within 24hours).
Early diagnosis and treatment also reduces
secondary transmission of malaria. Control
of the vector is a second key platform in
the fight against malaria. The study of
vector bionomics is an important subject.

The use of insecticide-treated bed nets


has been one of the most effective and
successful interventions in the prevention
of malaria. Bed nets on their own provide
a barrier for the mosquito. The insecticide
kills the mosquito on contact and thus

Differential
immunity in
human
population
Climate

Incidence and
parasitemia
in human
population

Regional
climate

% of bites on
% of mosquitoes
infected humans that surviving
infmosquito
sporogony

Local habitat
suitability

Vector control

Human vector
exposure
Vector control
Personal
protection
measures

No. of bites
per human
per day

ma

Housing &
socio-economic
variables

a/g

R0

No. of
human
bites per
mosquito

l/r
Duration of
human infection

Medical systems
and services

Personal
protection
measures

Housing &
socio-economic
variables

% of bites by
infectious mosquitoes Differential
that infect a human
immunity in
human
population
Transmission parameters
Incidence and parasitemia
in the mosquito population

Variables affecting transmission parameters


Fig. 6.3: A summary of factors affecting the prevention and control of malaria

102

Larvicides, both chemical and biological,


have been used to target the larval form.
Chemical larvicides include oils while
biological include larvicidal fish, and
(bacteria) bacillus, thuringensis that feed
on the larva.

Amoebiasis
Entamoeba histolytica, a protozoa, has a
worldwide distribution but is prevalent in
the tropics where there is poor sanitation.
It exists either as a trophozoite or in cyst
form. Its main habitat is the large intestine.

Ensuring proper water flow and draining


stagnant pools of water denies the
mosquito larva its habitat.

When conditions are unfavourable such


as lack of water, it forms into a cyst. Cysts
are the infective forms when ingested
and pass into the caecum where they
form trophozoites. Cysts can be found
in the stool of infected persons who may
not have any diarrhoea. The presence of
trophozoite is pathogenic.

The adult mosquitoes can be targeted


directly by using chemicals pyrethrins
that are used for indoor residual spraying.
DDT was used successfully to eradicate
the mosquito in the 1950s and is not in
current use due to its residual effect in
the food chain. Genetic engineering with
sterile mate release techniques is still in
experimental phase.

Diarrhoeal diseases

Despite the existence of inexpensive and


efficient means of treatment, diarrhoea
kills more children than AIDS, malaria
and measles combined. Most episodes of
diarrhoea are caused by infectious agents.
These can be viral, bacterial, protozoa
or fungal. Examples and how they cause
diarrhoea are outlined in table 6.3.
Table 6.3: Major causes of diarrhoeal diseases
Toxin-mediated

Infective food
poisoning

Protozoa

Clostridia

Rotavirus

Giardiasis

Bacillus cereus

Campylobacter

Amoebiasis

Staphylcoccus

Salmonella

Cryptosporidium

Rotavirus,
Amoebiasis
(Entamaoeba
Histolytica) and typhoid (Salmonella typhi)
are the three major causes of diarrhoeal
disease.

Reservoir
Humans are important reservoirs but
Entamoeba histolytica can also be found in
raw unwashed vegetables and in untreated
water. Transmission can therefore occur in
a number of ways including:
Through cysts which are passed in the
stool of a healthy carrier.
Direct person-to-person
- through contaminated fingers into
contaminated food.
Water borne, through untreated water.
The cysts can survive ordinary chlorination
of water and therefore treatment should
include water filtration.
Pathogenesis
The trophozoites can either be
in
vegetative or invasive forms. The invasive
form invades tissues of the intestines causing
minute ulcerative lesions particularly in the
caecum and ascending colon. Following an
incubation of 8 to 10 days, infection runs a
variable course and may be asymptomatic
or may start with abdominal discomfort,
mild looseness of bowels developing into
severe amoebic dysentery with recurrent
bouts of bloody mucoid stool.
103

Diagnosis and treatment


Diagnosis is by having a high index of
suspicion. The presence of blood mucoid
stool and or trophozoite is confirmatory. It
may be important to distinguish between
carriers and those with the disease through
stool examination.
Table 6.4: Diagnosis of amoebiasis
Stool
Examination

Carriers (no
dysentery)

Dysentery

Trophozoite

Cysts

Drug treatment with the antibiotic


Metronidazole is effective. However,
because amoebiasis is associated with poor
sanitation conditions such as that found in
slums and is easily spread by food handlers
identification of carriers and subsequent
prevention and control of spread of
infection is important.
Prevention and Control
General measures effective for diarrhoeal
diseases are effective for amoebiasis. These
include:
Safe and adequate water supply;
Proper disposal of human waste;
Boiling drinking water is advisable
where water quality is in doubt as cysts
are killed by heating above 50 C;
Cooking kills cysts in foods. For food
that is commonly eaten raw thorough
washing in safe water or soaking in
undiluted vinegar for at least 30minutes
is effective in eliminating the cysts.
Role of flies and cockroaches is not
clear but cysts have been found
vomit and faeces of flies and droppings
of cockroaches.
Proper hygiene in the household
eliminates these insects which are
also associated with other diseases.
Food handlers who potentially can

be cysts passers should be examined


regularly and if found infected be
treated.
Rotavirus
Rotavirus is the leading cause of severe
diarrhoeal disease and dehydration
among infants in the world out of which
though 80% of deaths occur in developing
countries. Rotavirus is a common RNA
virus and it is estimated that by the age of
five years all children have been infected at
least once. Humans are the reservoir for
this.
Pathogenesis
Transmission of the virus is by faecal-oral
route. The incubation period for diarrhoea
cauded by Rotavirus is approximately 2
days. The virus infects and damages the
small intestinal cell wall leading to vomiting
and watery diarrhoea for 3 - 8 days with
fever and abdominal pain.
Immunity after infection is often incomplete
though repeat infections tend to be less
severe than the original infection. In adults,
who are otherwise healthy, a rotavirus
infection may cause at most only mild signs
and symptoms or none.
Diagnosis
The diagnosis can be made clinically and
by rapid detection of rotavirus in stool
specimens. There is no specific treatment
for rotavirus. For people with healthy
immune systems, the gastroenteritis is self
limiting. Treatment therefore is supportive
with oral rehydration.
In a few cases intravenous rehydration and
hospitalization is required, for example,
where there is an underlying condition such
as malnutrition or immunosuppression.

104

Prevention and control


Because the virus is so prevalent, it is
very difficult and at times impossible to
prevent rotavirus infection. Even places
with excellent standards of hygiene and
sanitation can become contaminated.
Vaccination is the most effective preventive
measure. Since 2006, two vaccines against
rotavirus have been licensed and are now
recommended by WHO for global use.
Typhoid Enteric Fever (Salmonella)
Typhoid has a worldwide distribution but
is particularly common wherever sanitary
conditions are poor. It is transmitted by
the through ingestion of food or water
contaminated with the faeces of an infected
person.
Epidemics occur when water supplies in
towns are polluted, for example, when
sewage mixes with fresh water supplies.
Incidence is highest in the dry season when
water supply is inadequate but is also high
during heavy rains when the organism gets
flushed into water sources. The causative
organism is salmonella of which there are
several species and serotypes namely, S.
typhi and S. paratyphoid A,B,C. S. typhi is
the predominant type in Africa.
Reservoir
The human is the reservoir for Salmonella
typhi. Within the body, the bacilli are found
in the bile duct. Infection occurs by coming
into contact with contaminated faeces. A
carrier state exists.
A convalescing patient can excrete typhoid
excrete bacilli in their faeces for up to six
months after an attack. Some can develop
into chronic faecal carries continuing to
pass bacilli intermittently for more than
one year after infection without having
105

symptoms. Women are more likely to be


carriers than men.
Chronic urinary carriers are common where
there is high prevalence of Schistosoma
haematobium because shistosomiasis
shields the bacilli from the bodys immune
system.
Salmonella is a hardy bacillus and can survive
for several weeks in fresh or salty water.
They can also survive in ice and multiply in
milk and milk products. Food handlers are
important potential sources of infection to
the general public. It is therefore mandatory
for food handlers serving the public to be
examined every six months for Salmonella
typhi infection.
The major mode of transmission of
Salmonella typhi is via the gastrointestinal
tract. There are several vehicles of
infections but the major one is via
contaminated water. Food can be infected
by contaminated water used for washing
fresh produce. Infection can also occur if
carriers handle food.
Pathogenesis
Once in the gastro, intestinal tract, the
bacilli attach themselves to the upper
intestinal wall, then pass into the intestinal
lymph glands and into the systemic
circulation. From there they can attack any
organ but commonly the liver, spleen and
gall bladder.
They can also cause a generalized
bacteraemia. Infection causes patchy
hyperplasia of the intestinal wall (Peyers
patches). Eventually, necrosis and
ulcerations of the mucosa occur leading to
symptoms of malaise and anorexia after an
incubation period of 7 - 14 days.

Fig. 6.4: Prevention and control of diarheal diseases

Headache is a common early symptom


followed later by abdominal pain and
abnormal bowel functions with either
diarrhoea or constipation. In any given 20%
of cases, there may be frank diarrhoea. The
stool then has a characteristic pale colour.
Diagnosis
A high index of the suspicion is needed
for diagnosis. Patients are usually sick
looking with symptoms of fever, loose
stool. Salmonella typhi can be isolated from
blood, stool or urine culture. Serological
tests such as Widal tests are not useful for
this diagnosis.
Treatment is through antibiotics such as
ciprofloxacin given for a period of 10 to
14 days. Chloramphenical was the drug
of choice for a long time but there is
now widespread resistance. Symptomatic
treatment as required should also be
given.
Prevention and control
Primary prevention can be achieved by
vaccination. Proper treatment of water

supplies by chlorination kills the Salmonella


organism. Avoiding eating uncooked
vegetables and unpeeled, unwashed fruits
reduces chances of infection. If water is
not chlorinated, then boiling water kills the
organism though this is an expensive way
of prevention.
Health education and proper water and
sanitation are important measures in the
prevention of disease outbreak. Epidemic
forms of the disease do occur. In the event
of a reported outbreak, the first step is to
verify the diagnosis made.
The history of presenting clinical features
should be obtained and specimen collection
undertaken.
An epidemiological investigation into the
environmental factors and who is affected
needs to be done. It is then possible to
hypothesize on the immediate risk factors
and mode of transmission. This is important
in setting out control measures as outlined
earlier.

106

Asymptomatic
phase

Fig. 6.5: Life course of HIV/AIDS infection

Cholera
Cholera is an acute diarrhoeal disease
characterized by painless, effortless
watery diarrhoea and subsequent vomiting
with rapid onset of dehydration. The
agent is Vibrio cholerae and there are
two main biotypes, Classical and El-tor.
They have slightly different epidemiology
presentation with El-tor being responsible
for most current epidemics. They are more
resistance to treatment and therefore have
more carriers.
The seventh pandemic started in 1961
spreading via the Middle East to become
endemic in Africa. It reached South America
in 1990. A new serotype 0139 established
itself in Bangladesh in 1992 thereby possibly
starting a new pandemic.

rate is usually less than one percent, but


where the environment is conducive to the
spread of cholera, the rate can rapidly build
up, e.g., refugees and following disasters
where sanitation and water supply are
disrupted.

Humans are the main reservoir although


shell fish have been known to be a reservoir
as well. Vibrio can survive up to two new
weeks in fresh water and eight weeks in salt
water. In a healthy population, the carrier

Vibrio cholera secrete toxins that interfere


with absorption of sodium chloride leading
to loss of fluids and other electrolytes into
the large intestines. This results in copious
watery diarrhoea.

Cholera occurs in epidemics and


transmission is from human to human via
the faecal oral route.
Under certain circumstances, it can also be
through contaminated water or food.
For infection to occur, a large dose is
required as the vibrio organism is destroyed
by gastric acids. The few that manage to
reach the small intestines multiply rapidly
within the lumen.

107

Diagnosis and treatment


Following an incubation period of 3 - 6 days,
clinical features start with sudden onset
of painless, profuse and watery diarrhoea
often described as rice water stool.
In some cases vomiting may also occur.
Symptoms of dehydration, hyponatraemia
and hypokalemia then ensue. Patients may
rapidly pass into a state of collapse because
of the severe dehydration and electrolyte
depletion. Death can occur within 10-12
hours if there is no treatment.

Helminths

Diagnosis is made following a history of


profuse watery diarrhoea with vomiting
and dehydration. Stool examination shows
gram-negative vibrio under microscopy.
The most important part of treatment is to
first rehydrate and correct the electrolyte
imbalance. The main role of antibiotics is
to eliminate the carrier status.

The major helminths are the roundworm


and the hookworm. One in every four
people is infected worldwide. Both types
are transmitted via soil. The difference
between the two is that hookworms
are found in soil in a larval stage which
penetrates the host while roundworms
survive in soil as eggs which have to be
ingested.

Prevention and control


Cholera is of major public concern during
an epidemic. The main goal of control is to
prevent secondary transmission. This can
be done at an individual level by having good
personal hygiene. Drinking water should
be from a safe water supply or be boiled.
Cholera vaccines exist but the vaccines
protects only about 50% of the population
and only for a period of 6 months. During
an epidemic, it is important to ensure
clean water supply and limit population
movement to reduce transmission. Public
health education is therefore vital. Mass
treatment with tetracycline, disinfection of
soiled clothing and proper hand washing by
all those in contact with patients, especially
health workers can reduce the spread of
cholera.
Long term preventition is achieved through
provision of clean water and adequate
sanitation.

Soil-transmitted helminths are some of the


conditions currently classified as neglected
tropical diseases. The global strategy for
soil-transmitted helminthiasis control
is to treat once or twice per year preschool and school-age children; women
of childbearing age (including pregnant
women in the 2nd and 3rd trimesters and
lactating women) and adults at high risk in
certain occupations (e.g. tea-pickers, and
miners, etc.)

Reservoir
Ascaris lumbricoides (Round worms)
are the most common especially in the
developing countries where sanitation is
poor. Ascaris is a large worm and measures
15 to 35cm in length with the female on
average being larger. It inhabits the small
intestines and eggs are laid and passed out
as immature ova containing un-segmented,
undifferentiated embryo.
Development of the embryo takes places
over a period of three weeks in damp soil
and is temperature dependent. The eggs
do not hatch in soil and human beings are
the sole reservoir, usually children.
Pathogenesis
Infection is via ingestion of eggs from
contaminated soil. Viable eggs have been
found in soil after more than 10 years.
108

Swallowed eggs hatch in the small


intestines releasing hydatiform larvae. The
larvae penetrate the intestinal mucosa,
enter the blood stream and reach the lungs
via the heart where they migrate up the
respiratory tree, then swallowed again into
the small intestines.

Southern Africa, while Ancylostoma


duodenale is predominant in Northern
Africa. Hookworms are major causes of
anaemia in those infested.
The adult worm is found in the small
intestine. It lays eggs that are excreted in
stool where, in damp shaded soil, hatch
after 24 hours into hydatiform larvae. By
the fifth day, the larvae are fully developed
and they then move away from the faeces
into the soil and mould again to form an
infective filariariform larvae that seeks
oxygen and warmth, moving to the soil
surface. On contact with the skin, it
penetrates the intact skin and enters the
circulation reaching the lungs. From there,
it is swallowed into the small intestines
where maturation takes place over a
period of 3-5 weeks. An adult worm can
live up to 9 years and produce as many as
30,000 eggs a day.

Diagnosis and treatment


The larval migration leads to symptoms
similar to asthma with fever like
symptoms, cough and wheezing. Heavy
infections can cause intestinal colic and
obstruction. Chronic infestation is a cause
of malnutrition and may contribute to
vitamin A deficiency.
Diagnosis is done by finding worms or
eggs in the stool. Albendazole is the drug
of choice for treatment and is effective on
the adult worm.
Prevention and control
Key measures for control are personal
and public hygiene. Proper sanitation and
hygienic disposal of faeces especially of
children is recommended. . This requires
health education, particularly as many
people believe that childrens stool is
harmless.

Reservoirs
Humans are the reservoirs and transmission
is normally acquired via the skin from
infective filiariform larvae. In rare cases,
eating uncooked meat containing larvae
can cause infection. Human milk is a very
rare source of infection. This occurs when
migrating larvae are arrested in their
development and migrate to the mammary
glands in a lactating mother.

Mass chemotherapy programs where


young children are de-wormed every term
in school regularly are now being practiced.
This is a cheap and effective strategy
for prevention and leads to enhanced
school performance among children.
Environment control includes prevention
of soil contamination and non-soil base
around the house.

Diagnosis and treatment


Symptoms include itching of the skin at the
site of entry. During the migratory phase,
asthma-like symptoms may occur. Once
an infestation is established, symptoms
of anaemia such as easy fatigability, skin
pallor and signs of heart compensation in
severe cases are the common complaint
due to chronic blood loss. Each hookworm
sucks 0.05 - 0.15ml per day per worm.

Hookworm
Two species with different geographical
spread occur commonly. Necator americanis
predominates in Central, Eastern and
109

The resultant anaemia can be debilitating


especially for school going children.
Diagnosis is from clinical history and by
finding the characteristic eggs in the stool.
An estimate of the number of eggs in the
stool per gram can give an indication of
worm load. Tests for occult blood in stool
are usually positive. Treatment includes
managing the resultant anaemia and deworming with Albendazole given as a single
dose. Anaemia may require treatment with
iron supplements.
Prevention and control
Prevention and control is similar to other
helminths. Regular deworming in schools
is a cost effective way of prevention.
In addition, wearing of shoes prevents
infection of hookworm as this protects g
the skin.

Sexually Transmitted Infections


(STIs)

These are a group of communicable diseases


where the principal mode of transmission
is by sexual activity. STIs can be divided
into two main syndromes where the main
symptom is either discharge or ulcers.
Those where a discharge is the principal
feature can be further divided into STIs
where the feature is most marked in
females (gonorrhoea and non-gonococcal
urethritis) and those where the feature is
more marked in males. The STIs where
ulcers predominate can be further divided
into relatively painless, very painful ulcers,
clean ulcers and dirty ulcers.
Gonorrhoea
Gonorrhoea is an STI caused by a N.
gonococcus. The risk of infection is up to
80% after coitus with an infected partner.
There is an incubation period of 3-7

days. Less than 50% of males show any


symptoms. Where symptoms, occur there
is a thick purulent discharge with urinary
frequency and dysuria. The symptoms are
less dramatic in women compared to men.
Common symptoms are a slight discharge
which, if they coincide with the menstrual
cycle, may not be noticed.
However the complications may be severe
as the condition develops into acute
salphingitis, chronic pelvic inflammatory
disease resulting in infertility. In men,
untreated gonorrhoea can cause urethral
strictures.
Non-gonococcal Urethritis (NGU)
Non-gonococcal urethritis is common
and is co-present in more than 50% of
gonorrhoea cases. The causative organism
is Chlamydia trachomatis and symptoms
are more marked in males than females.
They include a purulent or muco-urulent
urethral discharge usually associated with
dysuria. Diagnosis is made on the basis
of clinical symptoms and by exclusion of
gonococci on urinalysis.
Treatment is through giving antibiotics.
Lack of treatment and repeated episodes
of NGU can lead to pelvic inflammatory
disease and possible infertility.
Pathogenesis
The causative agent is also the cause of
ophtalmia neonatorum. In this condition,
a newborn presents with a purulent eye
discharge a few days after birth. Infection
occurs during delivery as the baby passes
through the infected birth canal. If not
treated blindness can occur. Treatment is
by antibiotic eye drops.
Ulcers, a major cause of clean genital ulcers,
is Treponema pallidum which causes syphilis.

110

The ulcers in syphilis are punched out,


painless genital ulcer with painless swollen
lymph nodes. Syphilis may be latent with
the ulcers healing spontaneously about
two months after the initial infection.
Secondary infection can occur with the
appearance of a generalized body rash.
In a tertiary stage, syphilis presents with
vascular and neuro-pathological features
and death may ensue. Neonatal syphilis
is of major public health concern and is
preventable through mandatory screening
of pregnant women. Early treatment with
penicillin is still effective.
Diagnosis and treatment
Chancroid caused by traemophillus ducryei,
is an example of a dirty ulcer. Infection
is chracterized by dirty, grey ulcers with
runny edges which are very painful. There
is associated lymphadenopathy.

Secondary prevention entails the provision


of treatment and care for infected and
affected persons. The activities should
include:
promotion of health care seeking
behaviour directed not only at those
with symptoms of STIs , but also at
increased risk of acquiring STIs ,
including HIV infection;
provision of clinical services that
are accessible, acceptable and
effective, and which offer diagnosis and
effective treatment for both
symptomatic and asymptomatic
patients with STIs , and their
partners;
support and counselling services for
both STI and HIV patients
include STI prevention and care
services in maternal and child
health, antenatal and family planning
services.

Prevention and control


The main objectives of STIs control are
to:
interrupt the transmission of sexually
acquired infections;
prevent the development of diseases,
complications and sequelae.
reduce the risk of HIV infection.
This can be done through primary
prevention and secondary prevention.
In primary prevention, the aim is to
prevent the acquisition of infection and
disease. This can be done by
promoting:
safer sexual behaviour through
education
the use of condoms for penetrative
sexual acts.
Only primary prevention activities can
have an effect in reducing HIV infection.
111

HIV/AIDS

The human immunodeficiency virus


(HIV) is the causative agent of acquired
immunodeficiency syndrome which was
first identified in 1983 by Robert C. Gallo,
and Luc Montagnier.
Two main viruses are known HIV1 and HIV-2 with the latter causing a
similar illness to the former but it is less
aggressive and restricted mainly to West
Africa. Many different cultural, social a n d
behavioural characteristics determine the
epidemiology of HIV.
Socio-economic
and
demographic
differences help explain some of the
different patterns in disease prevalence
found in developed and less developed
countries.
In Western Europe and the USA, the disease
was in the early years predominantly a
disease of homosexual men.In sub-Saharan
Africa, the dominant mode of transmission
has been heterosexual and mother to
child. In Asia, including China and India,
injection drug users are a significant route
of transmission.
Reservoir
HIV can be found in blood, semen, breast
milk and saliva. Exposure to any of these

body fluids can lead to infection depending


on the:
Integrity of the exposed site
type and volume of body fluids
Viral load
Pathogenesis
The transmission risk depends on the above
factors and the type of body fluid. Today
worldwide heterosexual transmission is
the major route accounting for 70% of
new infections.
Children account for 5 to 10% of new
infections, transmission occurring mainly
during child birth and breastfeeding.
Table 6.5: Risks in HIV/AIDS transmission
Type of body uid

Risk of Transmission

Blood and blood products

>90%

Vertical (Mother to child)

15-40%

Injection drug use

0.5 1%

Genital mucous membrane

0.2 0.5%

Non-genital mucous membrane

<0.1%

HIV is an RNA retrovirus. Following


infection, the virus is transported to lymph
nodes by CD4 cells. Once infection is
established the virus spreads to various
lymph tissues. With time, the CD4 cells are
depleted leading to impaired cell mediated
immunity. This makes the infected person
susceptible to opportunistic infections.

Writing together in the New England Journal of Medicine the two state Many lessons can be drawn from this early
intense period, and most suggest that science requires greater modesty. Our experience with AIDS underscores the
importance of basic research, which gave us the technical and conceptual tools to nd the cause less than three years
after the disease was rst described It has also become clear that nding the cause of an infectious disease is the
alpha but not the omega of its eradication. The identication of HIV has allowed us to eliminate transmission of the
disease through the transfusion of blood and blood products, create rational policies for prevention, and design efcient
antiretroviral therapies. These therapies are not a cure, however, and the epidemic is still growing in many countries for
lack of accessible treatments and preventive vaccines. Moreover, we must recognize that we are still far from having
exhausted the list of potential new pathogens. Finally, one lesson that should be clear is that effective collaboration
among groups of scientists and clinicians is essential and that it is possible to achieve such collaboration without
excluding a certain dose of the competitive spirit as a stimulant .
The Discovery of HIV as the Cause of AIDS, Robert C. Gallo, M.D., and
Luc Montagnier, M.D., N7 Engl J Med 2003; 349:2283-228

112

Diagnosis and treatment


In 70 to 80% of people, 2-4 weeks after
exposure, there are symptoms of primary
infection with fever, a rash and fatigue being
the main symptoms. Thereafter, there is
an asymptomatic period when the infected
person has no obvious symptoms.
Viral replication takes place in the lymph
tissues. Eventually, symptoms like weight
loss, low grade fever and diarrhoea begin
to occur signalling some impairment of the
immune system.
Eventually, the patient develops full blown
disease with symptoms such as herpes
zoster, TB and so on. (see appendix for
AIDS defining conditions). The period
between primary infection and full blown
AIDS can be 7 to 10 years. Diagnosis is
confirmed using an ELISA antibody test.
For vertical transmission, using antibodies
is not useful and PCR tests that measure
the HIV-RNA are needed.
Management of HIV infection involves
treatment of the virus and prevention
of opportunistic infections. The use of
antiretroviral therapy reduces the viral
load leading to improvement of the CD4
count, thus enhancing the bodys immune
system.
The patients quality of life and life expectancy
are enhanced. Current protocols for HIV
management are found the in appendix.
The decision to start a patient on highly
active antiretroviral therapy (HAART) is a
major one as drug side effects can lead to
difficulties in adherence.

In addition to HAART and just as


important is to manage the patients
nutritional status through healthy balanced
diet. Opportunistic infections must be
tackled early. Prophylactic antibiotic
such as combination trimethoprim and
sulfamethoxazole
(septrin)
prevents
common HIV-related illnesses and
opportunistic infections of the chest,
diarrhoea and malaria.
The importance of STIs in the
transmission of HIV
Other STIs increase both HIV infectiousness
and susceptibility. Individuals who are
infected with STIs are more likely than
uninfected individuals to acquire HIV if they
are exposed to the virus through sexual
contact. If an HIV-infected individual is also
infected with another STIs , the person is
more likely to transmit HIV through sexual
contact than other HIV-infected persons.
Certain STIs e.g. syphilis, genital herpes,
chancroid and other infections that cause
genital or rectal ulcers may increase
the risk of HIV transmission per sexual
exposure 10 to 50 times for male-tofemale transmission and 50 to 300 times for
female-to-male exposure. Non-ulcerative
STIs such as Chlamydia and gonorrhea
have also been known to increase the risk
of HIV transmission by a factor of up to 5
times.
Prevention and control
Having a sexually transmitted infection
(STI) indicates risky behaviour which
increases the likelihood of eventually

The world HIV epidemic peaked in 1996. More than 25million people have died of AIDS since 1981.As at 2009,the
number of people living with HIV globally stands at 33.4 million and lthough 2.7 million people became newly infected
with HIV in 2008, this is a decrease by 17% over the last eight years.
Source: UNAIDS 2010

113

Tuberculosis (TB)

becoming infected with HIV. HIV infection


and other STIs are linked not only by
common behaviours, but also by biological
mechanisms.

TB is a chronic disease caused mainly by


the bacteria mycobacterium tuberculosis
and occasionally caused by mycobacterium
bovis and africunum. TB was described by
Hippocrates and signs of TB have been
found in Egyptian mummies. Globally, it is
estimated that there are more than 1.7
million TB related deaths worldwide with
one third of humanity infected. Kenya is
one of the 22 high burdened countries
in the world with reported cases of TB
annually.

The prevention and control of HIV can be


grouped around:
Interrupting transmission
Universal screening of donated blood
for use in hospitals has eliminated
transfusion related HIV transmission.
Among drug injection users, needle
exchange programs have also reduced
infection rates among drug users.
Sexual transmission is much harder to
change.
The use of condoms, abstinence from
sex among youth and health education
to reduce high risk behaviour such as
multiple partners are all aimed at
interrupting the transmission.
Increased awareness
Reduces HIV transmission as people
become more aware of factors that
increase HIV infection. Voluntary
testing and counselling programs are
other measures.
Treatment of HIV infected patients
Already infected patients can
substantially lower their viral loads to
undetectable levels through a
combination of HAART, good nutrition
and use of condoms. Putting
pregnant women on HAART,
follow up through antenatal care and
subsequent delivery at health facility
can ensure that mother-to-child
transmission is reduced to zero.
Integrating HIV and STI prevention
efforts is vital to the success of both
endeavours.

Reservoir
The human body is the reservoir for
mycobacterium tuberculosis while for
mycobacterium bovis it is both human and
cow. The bacilli are transmitted through
air droplets. Infection usually occurs when
people are in close proximity.
Repeated closeness is usually required
for infection to occur, for example, in
overcrowded poor quality housing. The
organisms can remain suspended in air
for several hours and TB therefore usually
spreads among family members, close
friends and work mates.
Transmission in an aeroplane has been
documented but is rare.
Pathogenesis
The probability that tuberculosis will be
transmitted depends on a number of
factors including the:
quantity of bacilli inhaled
Environment in which exposure
occurs;
Duration of exposure; and,
Virulence of the organism.
There are two major patterns of the
disease. In the first degree tuberculosis, the
initial infection is usually seen in children.
114

In many cases, the infection resolves


spontaneously. In a minority of cases, the
infection may spread with bacteraemia and
spread to all parts of the body. Secondary
or reactive TB is present in adults with
immunosuppresion and occurs in reaction
to a variety of factors including co-morbidity
with other conditions such as diabetes and
cancer.
Infection with HIV virus destroys the
immune system. Because the virus
targets lymphocytes which are the bodies
principal defence mechanism against TB,
HIV infections increases the life time risk
of developing tuberculosis from latent
infection by a factor of 10 times the risk of
a non infected person. After inhalation of
the air droplets containing the bacilli, the
first infections that the majority of patients
experience is a cough and low grade fever.
The cough may be dry or scanty sputum
and occasional retrosternal pain. In 5-10 %
first infections will cause clinical pneumonia
in adult patients. Secondary TB disease
is responsible for 90% of the disease in
adults.
Risk factors include disease prolonged
steroids therapy, other
immunosuppressive therapy such as cancer therapy
malnutrition, and most important HIV/
AIDS. TB can affect any organ in the body
but mainly affects the pulmonary system.

Classic presentation in a patient is one with


a chronic cough with haemoptysis, fever,
night sweats and weight loss. There may
be infection in other organs such as the
spine or stomach.
Diagnosis and treatment
Diagnosis is made from a clinical history
of chronic cough of more than three
weeks and other symptoms described
above. A positive sputum examination
under microscope following culture is a
confirmation of the disease. A chest x-ray
can also be used in the diagnosis. Tuberculin
skin test is not very useful where there is
high infection rate. It is only useful in low
prevalence countries. Treatment of TB
involves taking combination of antibiotics
for 6 - 8 months.
The WHO recommends the Direct
Observed Treatment (DOT), where the
drugs are taken under the direct observation
of a health worker to ensure adherence.
This is especially important after the first
month when the patient feels better and
may lapse in completing the long course
of treatment. The treatment regimen
consists of an initial intensive phase of 8
weeks followed by a maintenance phase of
4 to 6 months.
The advent of HIV/AIDS has caused
resurgence in the number of TB cases.
These increased numbers of cases together

UNAIDS and Millennium Villages Project taking steps toeliminate mother-to-child HIV transmission in Africa On
January 11th 2010 Michel Sidib, Executive Director of UNAIDS, and Jeffrey Sachs, Director of the Earth Institute
and Special Advisor to United Nations Secretary-General Ban Ki-moon, visited one of the Millennium Villages in
Sauri (western Kenya) to witness rst-hand efforts to virtually eliminate mother-to-child HIV transmission. UNAIDS
and the Millennium Villages Project joined forces in September 2009 to strengthen prevention of mother-to- child HIV
transmission (PMTCT) services at the village level with the aim of creating MTCT-free zones. In the Millennium
Villages, PMTCT services are integrated within the maternal-child health package and a continuum of care is offered to
the mother from the antenatal period through delivery and the postnatal period. Levels of HIV testing among pregnant
women in the Millennium Village siteshave increased from 10% at baseline to over 60% in three years. The UNAIDSMVP partnership will further improve on these gains by decreasing the incidence of HIV among women, meeting needs
for modern contraceptives and blocking transmission from mothers to their babies.
www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/
2010/january/20100111prunaidsmvp/ accessed 15.2.2011

115

with poor adherence to treatment has


caused the emergence of multi drug
resistance TB (MDR-TB).

be given prophylactic treatment with


isoniazid for six months.

Prevention and control


The principles in the prevention and control
of TB can be summarized as follows:
1. Reduce the incidence of TB through
timely diagnosis of active TB disease,
appropriate treatment and
management of persons with active
disease. Treatment of contacts of
infectious cases
2. Increase public awareness of TB
through health education by engaging
the community opinion leaders,
healthcare providers and community
health workers.
3. Development of new drugs, new
diagnostic methods for the diagnosis,
treatment, and prevention of TB.

Schistosomiasis affects more than 200


million people worldwide. It is the most
deadly of the NTDs, killing an estimated
280,000 people each year. In Kenya, more
than 2 million people are infected. Four
species infect human beings under natural
conditions namely; S.haematobium, S.
mansoni, S. japonicum.

TB maintains itself in the human population


provided one person infects atleast 20
others. Untreated open pulmonary
tuberculosis remains infective for 2 years
on average with one person infecting at
least 10 people each year.
Effective chemotherapy renders an
infectious patient non infectious within
two weeks but cure takes the full 6 to 8
months. Case detection and treatment is
therefore one of the methods used in TB
prevention. The main method of prevention
is through giving the BCG vaccine which is
given to children at birth. People who are
HIV positive require to be tested for TB as
70% of TB cases are now associated with
HIV infection.
Prophylaxis treatment with cotrimoxazole
is given to those found to be TB negative.
Children born to mothers with TB should

Schistosomiasis

Reservoir
S. Haematobium is and S. intercalatim
confined to Africa and Middle East while
S.Mansoni is found in Africa, the Middle
East and South America. S. haematobium
is principally a human parasite while
S. Mansoni is common to humans and
baboons. S. japonicum and S. intercalatim
have a wide range of hosts including
humans and domestic animals.
Pathogenesis
Transmission is by penetration of intact skin
by cercaviae. For transmission to occur
three conditions must be met. First, there
must be contamination of fresh water with
urine or faeces containing schistosomal
eggs. Secondly, the right snail species must
be present in which miracidium are capable
of development. Thirdly, there must be
human contact with the water. The main
forms where humans come into contact
with water where snails are present are in
irrigation schemes and domestic use.
The life cycle consists of two alternating
generations in the host and in fresh water
snails.The adult fluke worm is flat and
leaf-like with an oral sucker with which
it attaches itself to the wall of the vessel
where it lives within the human body. The
male is folded to form a gynaecopheric

116

canal in which the slender female is


enclosed for almost its entire length. Eggs
are passed into fresh water via faeces or
urine. They mature over 6 to 10 days and
hatch into miracidium (1st larval stage). This
must then enter the snail; the intermediate
host where over a period of 4 to 7 weeks
asexual reproduction goes on to form a
large number of sporocysts. These emerge
from the snail as ciraridae which are viable
in water for 48 to 72 hours.
On finding a new host, they penetrate
the skin in few minutes to become
schistosomuts, which enter lymph vessels
then veins, pass through the heart and
eventually the liver. Growth of the adult
fluke takes place in the liver where the
worms pair up.
Thereafter they live in the bladder for an
average of 31/2 years.
Diagnosis and treatment
People of all ages, races and both sexes are
susceptible. The main pathology arises from
the bodys immune response to the eggs.
The adult worm coats itself with antigens
which are similar to the body and so the
immune system is unable to recognize
it as foreign. Eggs laid within the bladder
wall penetrate through and are excreted
through urine.
Within the bladder, eggs penetrate through
the wall and are excreted through urine.
Some eggs are trapped in the bladder wall
and provoke an immune response which
can lead to calcification. If calcification
occurs around the ureter, stenosis may
occur leading to increased pressure in the
kidneys and development of hydroureter
and eventual renal failure.
The same process occurs with S. Mansoni
117

which is found in the mesenteric vessels.


The eggs produced may burrow into
the liver, blocking the hepatic vessels
thereby causing portal hypertension.
Hepatomegaly and splenomegaly may
ensue.
Clinically, three stages can be identified.
1. The stage of invasion is the point
where the cercaviae penetrates intact
skin. At the point of penetration there
may be intense pruritis.
2. In the maturation phase, the
schistosomites migrate through the
lungs. During migration, there is
fever, cough, dysentery and
hepatosplenomegaly.
3. In established infection, the clinical
presentation is varies depending on
the parasite. S. mansoni presents
acutely with dysentery while in late
stages there is development of
oesophageal varices, liver fibrosis,
ascitis, and haematemesis.
S. haematobium acutely presents with
recurrent painless haematuria.
Diagnosis and treatment
The
aim of a schistosomiasis control
program is to reduce morbidity. Individual
diagnosis depends on a high index of
suspicion and the presenting clinical
features. For example, haematuria
in a person coming from an endemic
area for S.haematobium should suggest
schistosomiasis. Diagnosis should also
include examination of urine or stool for
characteristic eggs.
Methods such as Kato concentration
that improves egg recovery can be used
to concentrates the eggs in a patient
specimen. However, methods of diagnosis
that involve egg counts do not measure the

level of infection and do not provide direct


evidence about pathological changes.
The use of ultrasound can help plan
interventions by helping to monitor what
internal organ changes have occurred
and how fast and far healing occurs after
treatment or re-infection. Serological
methods (e.g. ELISA) are useful especially
in mild infections. Finally, a diagnostic rectal
or bladder biopsy can be done looking for
pathogenic sandy patch appearance.
The objective of treatment is to stop the
production of eggs by killing the adult
schistosomiasis. Praziquantel is the drug
of choice and is effective as a single dose.
It produces parasitological cure in 80% of
treated individuals and 90% reduction in
egg counts in the remaining individuals.
Given in early infection, it reverses the
pathologies caused by the infection
such as hepatomegaly and bladder wall
thickening.
Prevention and control
The life cycle of schistosomiasis is broken
if the ova in urine or faeces are not allowed
to contaminate fresh water containing the
snail intermediate host. Therefore, health
education on sanitation, hygiene and the
risks of getting infected by bathing in fresh
water lakes and ponds are of importance.
The provision and use of safe drinking
water and proper sanitation facilities is
necessary. Mass population treatment
while relatively expensive reduces S.
haematobium and S.Mansoni but is not
very useful against S. japonicum because of
its many potential hosts.
Recent efforts have focused on targeted
distribution of Praziquantel in areas of
high disease endemicity. Schistosomiasis

outbreaks can be identified by mapping


the rates of blood in the urine of schoolage children. If the rates are high, the drug
is distributed to the entire community at
risk.
Annual dosing of Praziquantel is sometimes
recommended for areas at high risk for
re-infection with the disease, and has also
been used to help reduce the severity of
symptoms in chronic sufferers.

Infectious diseases associated


with domestic animals

Certain diseases such as anthrax and


brucellosis are spread and closely
associated with domestic animals. Keeping
animals healthy therefore plays a key part
in disease control.
Anthrax
Anthrax is believed to have been the fifth
plague in ancient Egypt. It has worldwide
distribution though; intestinal anthrax is
common in Africa. The agent is Bacillus
anthracis a bacterium. The major reservoir
are herbivores with cattle as an important
reservoir for human intestinal anthrax.
Transmission is by direct contact or
inhalation of spores from infected hides and
skins or by ingestion of B suis South Asia
Pigs associated with spores from infected
meat abscess formation.
Anthrax infection causes a severe disease.
In the cutaneousform following an
incubation period of 1 to 7 days, a small
papule develops at the site of infection.
This develops into a blister within 12 to 48
hours eventually forming a pustule. Fever
and malaise occur simultaneously.
If ntreated, the mortality rate is fairly high
at 10 to 20%. Pulmonary anthrax has an
118

Dissemination via fecal


matter

+
Adult
male/female
schistosomes

Transformation to schistosomula and


shedding of tail in skin

Egg laying

Sexual maturity and pairing


and egg laying

S. japonicum (A)
S. mansoni (B)
S. Haematobium
Skin penetration of
denitive host
(see right panel)

Cercariae
released from
snail

Sporocyst
(replication in
snail)

Migrate against
blood ow to inferior mesentric
veins

Eggs released
in stool

Miracidium

Skin residence
(hours to days)

Penetration of veins

Travel to pulmonary
capillaries (lung stage)
(48-72 hours)

Move into hepatic


portal vein

Reside in liver sinusoids


(2 weeks)

Travel to left ventricle


of heart
Enter systematic arterial
circulation

Fig. 6.6: Life cycle of schistosomiasis

incubation period of 1-5 days after which


there are symptoms of malaise, a non
productive cough, with signs of bronchitis
followed by severe respiratory distress,
stridor, profuse sweating and cyanosis.
The mortality rate is high and death usually
follows within 24 hours of the onset of the
respiratory distress. Intestinal anthrax has
relatively low mortality.
Following an incubation period of 12 to 18
hours after eating the infective meat, there
is nausea, vomiting occasionally with fever,
abdominal pain and diarrhoea, which is
sometimes bloody.
Anthrax produces a toxin that causes
hemorrhagic inflammation leading to tissue
necrosis in the intestines particularly the
ileum and caecum and in various organs
such as the spleen.
A majority of the cases recover but a
few develop septicaemia and sometimes
leading to death.

Diagnosis and treatment


Diagnosis is made first by having a high
index of suspicion. Cutaneous anthrax is an
occupational disease for those associated
cattle. Intestinal anthrax starts from eating
infected meat. The bacilli may be isolated
from the pustule, sputum, blood or stool.
Prevention and control
Animals infected with anthrax should
be immediately buried or incinerated.
Patients suspected of consuming infected
meat should be treated with prophylactic
penicillin given daily for a period of 7 days.
Health education, promoting awareness of
the disease and proper treatments of hides
and skins is important.
Brucellosis
Brucellosis, also called undulant fever,
is an enzootic infection associated with
domesticated animals. Three main species
of Brucella infect man namely, B. abortus, B
melitensis and B Suis.

119

from blood as well as isolation from


urine is diagnostic. Clinical treatment is
administered as tetracycline.

Table 6.6: Species implicated in Brucella infection


Species

Geography

Reservoir

Notes

B. abortus

Africa, Asia,
South America

Cattle

Cause of
spontaneous
abortion
in animals

B.
melitensis

Middle East,
Africa, India,
Central Asia,
South America

Goats and
sheep

Causes
most
severe
disease

B. suis

South Asia

Pigs

Associated
with abscess
formation

Because the spread is via un-pasteurized


milk and milk products, control of the
disease centres around the proper
treatment of raw milk. It is therefore
recommended that milk should be boiled
or pasteurized before use.

Reservoir
In Africa, the first two species are the
principal agents. The disease is zoonosis
from animals with goats (B. melitensis) and
cattle (B. Abortus) as the main reservoirs.
The pregnant animal is the most susceptible
and in cattle, the organism lodges in the
uterus causing abortion hence its name.
Pathogenesis
Transmission to humans is by ingestion of
un-pasteurized milk or via respiratory tract
or ocular route by direct contact. Once in
the body, it localizes in the regional lymph
glands where they proliferate causing
necrosis.
Once in the blood, they are carried into the
liver, spleen and lymph glands. Following
an incubation period of 7 to 21 days, there
are symptoms of weakness, fatigue, fever
and chills. The most characteristic feature
is temperature that rises and falls in a step
like fashion when charted over 7 -10 days.

Viral Hemorrhagic Fevers (VHF)

Viral hemorrhagic fevers are zoonotic


infections. The disease is characterized by
severe multiple organ damage with overall
vascular system impairment leading to
internal bleeding. The disease is caused by
several families of viruses. While some of
the hemorrhagic fevers can be mild, many
cause life threatening infection. There is no
definitive cure for most of the hemorrhagic
fevers.
Reservoir
VHFs are caused by viruses of four distinct
families namely arena viruses, filoviruses,
bunyaviruses, and flaviviruses. All are
RNA viruses whose reservoir is either
an animal or insect host. The viruses are
geographically restricted to the areas
where their host species live.

The fever, may run for several weeks. In


50% of the cases, the disease is self limiting
with spontaneous recovery.

Humans are infected when they come


into contact with infected hosts. However,
it is possible with some viruses that after
the accidental transmission from the host,
humans can transmit the virus to one
another.

Prevention and control


Diagnosis is made by history of symptoms
and after ruling out typhoid fever.
Performing a Brucellin or tuberculin test
is sensitive. Isolation of the organism

Pathogenesis
Ebola and Marburg are considered the
most severe VHFs; with mortality rates
ranging from 25 to 100%. Approximately
1% of individuals exposed to the RVF virus

120

becomes infected, but the mortality rate of


50%.
Ebola first appeared in 1976 in the
equatorial provinces of the Southern Sudan
and Northern Congo, DRC. Since then,
epidemics have occurred and the disease
has spread to Gabon and Uganda.
Lassa fever is a milder infection, with a
fatality rate of 2-15%, and is probably
much more common than is recognized.
Diagnosis and treatment
A high index of suspicion is needed for
diagnosis treatment. Patients withs fever
who have a history of visiting areas where
haemorrhagic fevers occur should be
investigated. The infection rate is high,
particularly for the Zaire subtype of Ebola
virus. Infection occurring during pregnancy
by Ebola virus is universally fatal.
The virus invades all organs producing
necrotic lesions leading to multiple organ
failure with bleeding from all orifices.
Patients develop shock and die. Diagnosis
requires specialized laboratory facilities as
the test presents an extreme biohazard.
The causative virus can be isolated in high
security laboratories the serum and urine.
Hemorrhagic fever viruses are classified

as biosafety level four (BSL-4) pathogens.


Polymerase chain reaction (PCR) tests on
serum during the acute stages of infection
can also be used.
Treatment is supportive with patients
requiring intensive fluid and electrolyte
management. Strict isolation and good
infection control practices are needed to
prevent further transmission. Any person
who has been in contact with a patient or
a patients blood must be put under strict
surveillance and isolation. Health care
workers have frequently been infected
while attending to patients.
Prevention and control
A vaccine is available for Yellow Fever.
For the others, prevention focuses on
avoiding contact with the host species.
However, if that fails and a person does
get infected with the disease, then the
strategy is to prevent further personto-person transmission. Isolation and
strict surveillance is mandatory. Several
hemorrhagic fevers have rodents as hosts.
Control of rodent population including
cleaning up where they nest therefore
mosquito control is another way of
reducing the risk of transmission.
At global level under the WHO there is
a technical collaboration network the

Table 6.7: VHF classifcation by agent


Genus

Example

Area found

Host

Transmission

Arenavirus

e.g. Lassa viruses

West Africa,

Small eld
rodents

Farmers, rural people who eat


such infected rodents

Filoviruses

Ebola, Marburg viruses

Central Africa

Vector unknown

Aerosol transmission suspected in


primate infection.

Bunyaviruses

Rift Valley fever

East Africa,, Middle


East, the Balkans,
Russia, western
China

Mosquito bite

Flaviviruses

Yellow Fever, Kyasanur


Forest disease

Karnataka, India

Kyasanur Forest disease follows


a tick bite in rural areas of the
endemic zone,

121

Global Outbreak Alert and Response


Network (GOARN) that pools human
and technical resources for the rapid
identification, confirmation and response
to outbreaks of international importance.
The network is composed of scientific
institutions in Member States, medical
and surveillance initiatives, regional
technical
networks,
networks
of
laboratories,
UNICEF,
UNHCR,
International Committee of the Red Cross,
(ICRC) and international humanitarian
nongovernmental organizations (e.g.
Mdecins sans Frontires (MSF).

In addition to having a surveillance


framework it is also important to have
clear guidelines to reduce risk when
handling such dangerous pathogens.
Biorisk reduction are strategies that
combines expertise, advice and training on
safe handling and control of these disease
agents that pose significant health risks, with
potential for adverse economic impact and
public concern. In an uncertain world the
emergence of such disease agents can be
natural, accidental or deliberate in origin.
Countries therefore need to be equipped
to handle such eventualities.

122

Questions Section

1. Discuss why communicable diseases remain so important in sub-Saharan Africa?


2. Describe the major communicable diseases of public health importance.
3. Outline the principles of communicable disease prevention and control.
4. What is an epidemic? What are the main measures taken to control an infectious
disease epidemic?
5. Discuss what role the environment plays in the control of communicable diseases.

Further reading

1. Hall A, Horton S. Best practice paper: Deworming. Copenhagen Consensus: 2009.


2. Wardlaw T, Salama P, Brocklehurst C, Chopra M, Mason E. Diarrhoea: why children
are still dying and what can be done. Lancet. 2010 ;375(9718):870-2.
3. Dye C, Lnnroth K, Jaramillo E, Williams B, Raviglione M. Trends in
tuberculosis incidence and their determinants in 134 countries. Bulletin of the
World Health Organization. 2009 ;87(9):683-691.

123

NON-COMMUNICABLE DISEASES

Introduction

The high communicable disease burden in


many developing countries masks a serious
emerging epidemic of non infectious chronic
diseases. The health policy focus in many
developing countries has been the battle
against infectious diseases such as HIV/
AIDS, diarrhoeal and malaria. However,
over the last decade, there has been a rapid
increase in morbidity and mortality rates
arising from heart disease, stroke, cancer,
chronic respiratory diseases, diabetes,
mental disorders, road traffic injuries and
violence.
This twin burden of disease, having both
infectious diseases and non communicable
chronic disease has serious implications on
the provision of how health services are
organized. This new pattern of disease
is occurring because there is still a high
level of poverty mixed with increasing
urbanization and Western lifestyle
exacerbated by population demographics.
A high percentage of young people in
the population mean an increase in social

instability leading to high injury rates and


violence. The global epidemic of chronic
non-communicable diseases continues to
grow.
In sub-Saharan Africa, the situation is
compounded by several factors. Overall,
the burden of disease is extremely high
because of infectious diseases, which
continue to be the leading cause of
morbidity and mortality. However, it has
been observed that the age specific death
rate for non communicable diseases in subSaharan Africa is higher than in established
market economies.
Non communicable diseases are put
together because they share major risk
factors. These include: an unhealthy diet,
physical inactivity, obesity, tobacco use
and alcohol abuse. The risk factors can
be synergistic. According to the WHO
about 80% of premature heart diseases
and stroke, 80% of type 2 diabetes and
40% of cancers are preventable through

Fig. 7.1: Framework: determinants of non-communicable diseases

124

a broad range of existing public-health


interventions that are cost-effective
to implement. While specific causes
of individual chronic diseases are still
unknown, there is some understanding
of the various factors that come into play
and lead to the development of the main
chronic diseases. This is illustrated figure
7.1.
Tobacco use is a risk factor that is both
individual and community influenced.
Public policies such as increased taxation
on tobacco products effectively discourage
tobacco smoking. Broad underlying socioeconomic factors influence peoples
lifestyles. Three major elements contribute
to an unhealthy lifestyle, which in turn
predispose to the development of chronic
diseases. These are:
1. Long-term use of tobacco products,
2. Lack of regular aerobic exercises
during adult life, and,
3. Consumption of an unhealthy diet
over many years.
An unhealthy diet is one that resembles
most developed Westernized countries
and consists of high levels of saturated fat,
particularly of animal origin, and an imbalance
between the different polyunsaturated
fatty acids. This diet is very high in sodium
(salt), sugar, cholesterol, alcohol, sugar and
energy intake, and very low in fibre, vitamin
and trace element intake. The major noncommunicable diseases we are concerned
with are cardiovascular disease, stroke,
cancer, chronic respiratory, diabetes,
mental disorders, road traffic injuries and
violence.
A review of each of the conditions illustrates
the extent of the problems developing
countries are faced when dealing with
non-communicable diseases.

Common Risk factors for NCD

Individual
Background, age, education,sex, genetic
Behavioural, smoking, diet, physical
inactivity
Intermediate, cholesterol, obesity
Community
Socio-economic status (SES) (the poor
dont seek healthcare have poor diet
etc), poverty and unemployment,
Environment includes, climate, air
pollution, heavy metals such as lead in
petrol and paint and water pipes
Culture, practices, norms, values
Urbanization, type of housing, access
to foods/ products
Workforce composition, less women at
home.
The risk factors are interactive, addictive
and synergistic.

Cardiovascular Disease (CVD)

Cardiovascular diseases cover a wide


array of disorders including diseases of the
cardiac muscle and of the vascular system
supplying the heart, brain and other vital
organs. The major cardiovascular diseases
include:
Hypertension (high blood pressure);
Coronary (or ischaemic) heart disease
(heart attack);
Cerebro-vascular disease (stroke);
Heart failure; and,
Rheumatic heart disease.
Burden of disease
CVD affects people in their mid-life years.
Lower socio-economic groups generally
have a greater prevalence risk factors,
diseases and mortality in developed
countries, and a similar pattern is emerging
in developing countries. Because of the
time lag effect of risk factors, the full effect
125

of past exposure to behavioural risk factors,


especially among children is not seen until
many years into the future.
Risk factors
The rise in CVDs can be attributed to
significant lifestyle changes, which are
occurring worldwide. These include
changes in diet habits, physical activity
levels,
and
tobacco
consumption
because of industrialization, urbanization,
economic development and food market
globalization.
Today people are consuming more
energy-dense, nutrient-poor diet and are
less physically active. The result is the
development of biological risk factors such
as hypertension, high blood cholesterol,
overweight and obesity, and diabetes
mellitus. Where more than one risk factor
occurs, there is usually a synergistic effect.
For example, having diabetes more than
doubles the risk of cardiovascular disease.
Hypertension is the main risk factor for the
development of coronary heart disease,
stroke and heart failure.
Aetiology and diagnosis
Most cases of hypertension are classified
as essential hypertension, that is, the cause
is unknown. This is done after ruling out
various causes of hypertension (secondary
hypertension). The commonest causes of
secondary hypertension are:
Diseases of the Kidneys and the urinary
tract;
Coarctation of the aorta
Hormonal disorders including
Pheo-chromocytoma (a tumour that
produces excessive output of
adrenaline; Diabetes Mellitus, Cushings
Syndrome (increased production of
cortisol by the adrenal glands) Conns

Syndrome (increased production


of aldosterone by the adrenal glands
The use of oral contraceptive pill;
Pre-eclamptic toxaemia of
pregnancy.
A stroke can either be ischemic (80%
of stroke) or hemorrhagic (20%). An
ischaemic stroke is caused by an obstruction
in an artery, generally one of the carotid or
coronary arteries and leads to tissue distal
to the obstruction being starved of oxygen.
A hemorrhagic occurs when weakened
blood vessels within the brain or the aorta
rupture and bleed into the surrounding
tissue. The escaped blood can compress
nearby blood vessels, cutting off blood
flow and depriving the surrounding tissue
of oxygen.
Hypertension is usually asymptomatic and
is often diagnosed as an incidental finding
during a routine medical examination.
In a minority of cases symptoms such as
headache, palpitations and dizziness may
occur. Stroke symptoms are typically
unexpected and sudden. One of the most
common symptoms is a sudden weakness
or numbness of one side of the body, face
or limb.
Some stroke sufferers experience a sudden
loss of vision, or loss of speech. These
symptoms may be prefaced by sudden
severe headaches, unexplained dizziness,
unsteadiness, or falls.
Diagnosis is made from history and physical
examination followed by CT scanning or
Magnetic resonance imaging (MRI) and or
Angiography.
Management
As hypertension is the major risk factor in
the development of CVD, management

126

of blood pressure is the key to managing


CVD. Blood pressure above 160/110
mmHg should always be controlled. Blood
pressure is managed through a number of
measures in combination including lifestyle
modification and use of drugs. Lifestyle
modification includes maintaining optimum
weight, reduction in salt and fat intake,
management of cholesterol levels and
increasing aerobic exercise.
Among the major groups of drugs used
in the first line control of blood pressure
are angiotensin receptor antagonists,
thiazide diuretics and blockers. Second line
drugs include long acting calcium channel
antagonists. Many patients need more
than one drug to achieve the necessary
blood pressure reduction. In patients with
diabetes mellitus, the major complication
is cardiovascular.Therefore, prevention
and management of CVD is mandatory in
such patients.
Complications
Complications of hypertension include
an enlarged heart (cardiomegaly),which
leads to heart failure. Renal failure is due
to damage to blood vessels within the
kidneys, aneurysms and stroke. Stroke can
lead to permanent disability and death.
Prevention and control
Effective prevention strategies need to
be focused at the population level rather
than at individual level. This requires policy
change and advocacy. South Korea, for
example, has worked to retain elements
of the traditional diet with civil society and
government led initiatives supporting mass
media campaigns to promote local foods,
traditional cooking methods and the need
to support local farmers.

At individual level, prevention revolves


around lifestyle modification. These
include substituting non-hydrogenated
unsaturated fats (especially polyunsaturated
fat) for saturated and trans-fats; increasing
consumption of omega-3 fatty acids from
fish oil or plant sources, consuming a diet
high in fruits, vegetables, nuts and whole
grains, and low in refined grains, avoiding
excessively salty or sugary foods, at least
30 minutes of regular physical activity daily;
avoiding tobacco smoking and maintaining
a healthy weight
Secondary Prevention
The early identification and prompt
treatment of CVD includes:
Mass screening of high risk individuals
in the community
Correction of high blood cholesterol
Professionally guided weight loss
programs
Close control and monitoring of high
blood pressure among newly diagnosed
patients using lifestyle management and
drug therapy; and,
Stress management.
Tertiary Prevention
Physiotherapy and occupational therapy are
necessary in the rehabilitation needed to
restore lost functions for stroke patients.
Physical therapy helps patients regain the
use of their limbs and the ability to walk, and
helps prevent muscle stiffening in patients
who are paralyzed. Speech therapy can
help patients regain the ability to speak.
Occupational therapy improves patients
hand-eye coordination and helps them
relearn basic activities such as dressing,
cooking, and writing.

127

Where there has been secondary organ


failure such as kidney damage, renal dialysis
may be needed.
Costs - indirect/direct
At present, non communicable diseases
costs are mainly borne by the individual.
Direct costs include costs of medical care
visits, clinician consultation, diagnostics
and hospitalization. Medication remains
very expensive and in most cases must
be taken for the rest of the patients life.
Indirect costs include time lost work and
lost productivity for both the patient and
the care-giver.

Diabetes mellitus

Diabetes mellitus is a group of metabolic


diseases in which blood glucose levels are
above normal (hyperglycemia). Normal
homeostatic mechanisms maintain blood
glucose levels within a narrow range of
3.5-6.5 mmol/l. People develop diabetes
either because the pancreas does not
make enough insulin or because the cells in
the muscles, liver, and fat do not respond
to insulin properly, or both.
As a result, hyperglycemia develops while
conversely the cells are starved of energy.
Over time, hyperglycemia damages
nerves and blood vessels, which can lead
to complications such as heart disease
and stroke, kidney disease and blindness.
Diabetes can be classified into three
types.
Type1diabetes:
This was formerly called juvenile diabetes
and is usually first diagnosed in children or
young adults. In this form of diabetes, the
beta cells of the pancreas no longer make
insulin because the bodys immune system
has attacked and destroyed them.

Type II diabetes:
Formerly called adult-onset diabetes, is the
most common form of diabetes. It usually
develops in middle age and begins with
peripheral tissues like muscle and fat cells
developing insulin resistance. Initially, the
pancreas is able to produce the additional
insulin required but eventually it loses the
ability to keep up and diabetes develops.
Type 3 diabetes:
This develops in some women during
the late stages of pregnancy. Usually, the
diabetes resolves with the birth of the baby.
However, gestational diabetes predispose
to the development of type II diabetes
later in life.
Burden of disease
Diabetes is a major cause of premature
mortality, stroke, cardiovascular disease,
peripheral vascular disease, renal failure
as well as long and short-term disability.
In addition, persons with diabetic
complications have a lower quality of life
compared to persons without diabetes.
World Health Reports put diabetes in fifth
place in terms of cause of death ranking after
communicable diseases, cardiovascular
disease, cancer, and injuries.
Even in the poorest countries, at least
one in twenty adult (3564 years of age)
deaths is diabetes related, and in most
countries, the proportion is substantially
higher. In developing countries, mortality
due to diabetes is dominated by infections
and renal failure rather than the coronary
artery disease and cerebrovascular disease
experienced in developed countries .
Risk factors
The diabetes epidemic closely parallels the
worldwide epidemic of obesity. Numerous
epidemiologic studies have suggested that

128

the combination of a Western diet and


lifestyle is primarily responsible for the
increased risk of diabetes.
People who migrate to Westernized
countries, with their more sedentary
lifestyles and Westernized diets, have
greater risk of developing type II diabetes
than their counterparts, who remain in the
native countries. Even without migration,
in populations where there has been an
increase in Western lifestyle, there has
been a corresponding increase in cases of
diabetes mellitus.
Lifestyle factors contribute significantly to
type II diabetes mellitus. Environmental
and individual factors lead to high fat/
high calorie overeating that, combined
with physical inactivity, leads to obesity.
However, it is important to note that while
most type II patients are obese, only a few
obese people have diabetes.
Retrospective analysis has shown an inverse
relationship between weight at birth and
type II diabetes in late adulthood. It is
suggested that malnutrition in-utero may
damage beta cell development. Ethnicity
and increasing age have independently
been associated with development of type
II diabetes.
Genetic predisposition for type II diabetes is
strong. Concordance rates in monozygotic
twins are almost 100% though the
magnitude of genetic contribution is
unknown and probably involves several
genes.
The thrifty gene hypothesis was first
proposed by Neel in 1962. He proposed
that there was a genetic trait that was
important to survival (ability to go without
food for extended periods).
129

Certain populations (largely indigenous


populations) have developed what is
considered a thrifty gene that allows
them to survive period of famine when
food is in short supply - this thrifty gene
is associated with a metabolic efficiency
that allows storage of calories as fat with
minimal energy expenditure.
However, when food is plentiful, as occurs
in many of these cultures today (the
westernization of diet), the thrifty gene
predisposes to obesity (especially central
obesity) - this may account for the increased
risk for development of diabetes. This trait
may therefore be detrimental where there
is abundant food supplies and reductions in
physical activity.
The development of metabolic syndrome
may contribute to the development
of diabetes. Metabolic syndrome is a
clustering of conditions namely type II
Diabetes, central obesity, hypertension
and dyslipidaemia. Insulin resistance plays
a central role and may be due to defects in
target cells insulin response or abnormality
in insulin molecule. Gestational diabetes
occurs when sensitivity to insulin decreases
during pregnancy.
Aetiology
Type I diabetes mellitus is due to destruction
of pancreatic beta cells by an auto-immune
process. It is assumed to occur following
an environmental trigger in genetically
susceptible individuals and leads to absolute
insulin deficiency.
Clinical onset is generally acute, but
destruction of beta cells may have been
progressive for many years prior to
diagnosis. Type II diabetes mellitus usually
follows progressive development of insulin

resistance which creates a relative insulin


deficiency. Insulin resistance can be due to
a number of reasons. There is consensus
that the aetiology is a multi-factorial
interaction of environmental and genetic
factors. Obesity and overweight is a major
predisposing factor.

The majority of diabetic patients die of


cardiovascular complications. Diabetes is
also the leading cause of blindness, kidney
failure, and non-traumatic amputations,
resulting from micro- vascular complications
with hyperglycemia an independent risk
factor.

Symptoms
Classical symptoms of hyperglycemia polyuria (excessive urination); polydipsia
(thirst); nocturia (nocturnal urination);
lethargy; weight loss. Type I classically
presents in younger age groups with an
acute onset.

Management and treatment


The focus of the management of diabetes
is to reduce the risk of developing these
complications. This means reducing and
controlling:
Smoking
Hypertension
Insulin resistance associated with
obesity
Microalbuminuria
Diabetic nephropathy
(macroalbuminuria)
Poor glycaemic control,
Hyperlipidaemia

Diabetes type II occurs in older age groups


especially obese. 50 % have hypertension
and symptoms of hyperglycemia are long
standing and generally mild. Up to 20%
may have some of the complications of
diabetes present at time of diagnosis.
Diagnosis and Treatment
Confirmation of diabetes is done through
the following tests:
Fasting plasma glucose test
Oral glucose tolerance test,
Random plasma glucose test.
Positive test results should be confirmed
by repeating the fasting plasma glucose
test or the oral glucose tolerance test on
a different day.
Complications
Diabetic patients are at considerable
risk of excessive morbidity and mortality
from cardiovascular, cerebro-vascular,
and peripheral vascular disease leading
to myocardial infarction, strokes, and
amputations. Diabetes is a major risk
factor for coronary heart disease (CHD)
and stroke.

Prevention and control


Primary

Having greater public and professional


awareness of the risk factors and symptoms
of diabetes is one of the major steps in the
primary prevention of the condition. The
goal in primary prevention is to identify and
protects individuals at risk from developing
diabetes.
Primary prevention applies mainly to
type II diabetes, as there is currently no
conclusive evidence to suggest that type I
can be prevented.
Type II diabetes can be prevented largely
through diet and lifestyle modifications.
Excess adiposity is the most important
risk factor for diabetes. Maintaining a
healthy body weight and avoiding weight
gain during adulthood by balancing energy
intake and expenditure, and making healthy

130

food and lifestyle choices are therefore


cornerstones of diabetes prevention at the
individual level.
The benefits of reducing body weight and
increasing physical activity are not confined
to type II diabetes; they also play a role
in preventing other non-communicable
diseases such as reducing heart disease and
high blood pressure.
There is increasing evidence that the
quality of fat and carbohydrate plays a more
important role than does the quantity. This
means that public health strategies should
emphasize replacing saturated and transfats with unsaturated fats and replacing
refined grain products with whole grains in
diets.
Information about the correct lifestyle
choices needs to be communicated to
the public and translated into practice.
The changes required to reduce the
risk of diabetes at the population level
however, unlikely to be achieved without
major environmental changes to facilitate
appropriate choices by individuals.
Secondary

Secondary prevention involves the early


detection and prevention of complications,
therefore reducing the need for
treatment.
Detected early there is increased likelihood
of improved quality of life and can be cost
effective as costs related to hospitalization
are reduced. Consistent control of blood
glucose levels can substantially reduce the
risk and speed of developing complications
of diabetes.
Also vital is the management of high blood
pressure and hyperlipidemia as these are

made worse by diabetes and independently


affect the health of the patient.
Because of weak health systems in
developing countries little prevention is
done at the primary level and secondary
prevention depends on the individual as
rarely is there sufficient resources to fund
diabetes programs.
Patients therefore start secondary
prevention programs late, often when
already complications have set in.
Costs
The costs of diabetes and indeed any other
chronic condition can be direct or indirect.
Direct costs to individuals and their families
include medical care, drugs and other
supplies. Patients may also have to bear
other personal costs, such as increased
payments for health life insurance.
Because of its chronic nature the severity
of its complications and the means required
to control them, diabetes is a costly
disease, not only for the affected individual
and his/her family, but also for the health
authorities.
Studies in India estimate that, for a lowincome Indian family with an adult with
diabetes, as much as 25% of family income
may be devoted to diabetes care. For
families in the USA with a child who has
diabetes, the corresponding figure is 10%.
An analysis of health care expenditure
by the WHO, the Western Pacific region
showed that 16% of hospital expenditure
was on people with diabetes.
Costs range from relatively low-cost items,
such as primary-care consultations and
hospital outpatient episodes, to very high-

131

cost items, such as long hospital inpatient


stays for the treatment of complications.
Overall, direct health care costs of diabetes
range from 2.5% to 15% annual health
care budgets, depending on local diabetes
prevalence and the sophistication of the
treatment available.
For most countries, the largest single
item of diabetes expenditure is hospital
admissions for the treatment of long-term
complications, such as heart disease and
stroke, kidney failure and foot problems.
Most of the complications are potentially
preventable given prompt diagnosis of
diabetes, effective patient and professional
education and comprehensive long term
care. Indirect costs can be intangible costs
such as pain, anxiety, inconvenience and
generally lower quality of life etc.)
Also, a number of diabetes patients may
not be able to continue working or work
as effectively as they could before the
onset of their condition.
Sickness, absence, disability, premature
retirement or premature mortality can
cause loss of productivity. Estimating the
cost to society of this loss of productivity
is not easy. However, in many cases where
estimates have been made, these costs of
lost production may be as great or even
greater than direct health care costs.
Families too, suffer loss of earnings as a
result of diabetes and its consequences.
Pain, anxiety, inconvenience and other
factors which decrease quality of life are
intangible costs, which are just as heavy.
Some activities may have to be foregone
in favour of treatment, discrimination
may be experienced in the workplace,

obtaining jobs may be more difficult, and


professional life may be shortened because
of complications leading to early disability
and even death.
Personal relationships, leisure and mobility
can also be negatively influenced.
Diabetes treatment, particularly insulin
injection and self-monitoring, can be
time-consuming,
inconvenient
and
uncomfortable.

Cancers

Cancer is largely preventable. Many types


of cancer can be detected early in their
development, treated and cured. In late
stages of cancer, the pain can be reduced,
and the progression of the cancer slowed.
Patients and their families can also be
helped to cope with their condition.
More than 70% of all cancer deaths occur
in low and middle-income societies and,
although the risk of developing/ dying from
it is still higher in the developed regions of
the world, the control of communicable
diseases as well as the ageing of the
population in developing countries point to
an increasing burden of cancer worldwide.
The four basic components of cancer
control are:
1. prevention
2. early detection
3. diagnosis and treatment
4. palliative care.
Prevention of cancer is probably the most
cost effective way of controlling cancer
especially if it is integrated with other
prevention programs. Early detection
especially where the cancer is curable in its
early stages, e.g. breast or cervical cancer
offers maximum benefit.

132

Early diagnosis involves creating awareness


in patients so that they seek health care
early enough. Screening of with identified
risk factors can also help identify cancer
cases early. Treatment aims to cure disease,
prolong life, and improve the quality of
remaining life after the diagnosis of cancer.
The most effective and efficient treatment
is linked to early detection programmes
and follows evidence-based standards of
care. Palliative care is necessary to meet
the needs of all patients requiring relief
from symptoms, and psychosocial care of
the patient and their families. This is even
truer in advanced cases where chances of
achieving cure are low.
At this stage, cancer has significant
emotional, spiritual, social and economic
costs and consequences that need to be
addressed to enable the patient to cope
with the disease. Breast cancer illustrates
the principles involved in the management
of various cancers.
Breast Cancer
Breast Cancer is the most common site
specific malignancy affecting women
and the most common cause of cancer
mortality in women worldwide. Across the
world, breast cancer incidence rates are
increasing at an average ranging from 0.5%
to 3% per year. Less than 1% of all breast
cancer patients are male though Uganda
and Zambia report higher annual incidence
rates at 5% and 15%, respectively of all
breast cancer cases .
Burden of Disease
The incidence of breast cancer has been
observed to vary. Incidence rates are higher
in the developed countries than in the
developing countries and Japan. Incidence
rates are also higher in urban areas than

in the rural areas. In Africa, breast cancer


has overtaken cervical cancer as the
commonest malignancy affecting women.
This increase in incidence is attributed
to changes in the demography, socioeconomic parameters, epidemiologic risk
factors, better reporting and awareness of
the disease.
Compounding this increase is the high
mortality rate. While mortality rates are
declining in the developed world because
of early diagnosis, screening, and improved
cancer treatment programs, in developing
countries, health systems are weak and
therefore cancer is often detected late.
Aetiology
Like most other cancers, the precise cause
of breast cancer is unknown. However,
several risk factors have been identified.
Age
The incidence of breast cancer increases
with age and is rare before the age of
20 years. The breast cancer incidence in
Caucasians is highest at age 50-59, after
menopause, dropping after age 70. In
Africa and African-Americans the peak
age incidence is about one decade less,
so that the majority of the patients are
pre- menopausal.The reasons for this age
difference in the different races are not
well understood.
Sex
Breast Cancer is rare in men.
Geographic variation
A wide difference in age adjusted incidence
and mortality for breast cancer exists
between different countries. A possible
explanation is environmental and genetic
factors.

133

Table 7.1: Prevention of breast cancer


Level of resources

Detection method(s)

Evaluation goal

Basic

Breast health awarenes (education -self control)


Clinical breast examination (clinician education)

Baseline assesment and repeated survey

Limited

Targeted/education encouraging CBE for as-risk


groups Diagnostic ultra sound and diagnostic
mammography

Down staging of symptomatic disease

Enhanced

Diagnostic mammography. Opportunistic


mammographic screening

Opportunistic screening of asymptomatic


patients

Maximal

Population-based mammographic screening. Other


imaging technologies as appropriate:high risk
groups targeted

Screening of asymptomatic patients

Hormone/pregnancy related factors


Ostrogen is the primary stimulant for
breast epithelial cell proliferation. As
such, factors that increase exposure to
high or prolonged level of oestrogen are
therefore associated with an increased risk
of developing breast cancer.

A woman is considered to be at increased


risk if the family member is a first degree
relation with early age of onset (< age 50),
if both breasts are involved, or if she has
multiple primary cancers (such as breast
and ovarian cancer). Inheritance of BRCA
gene mutation carries a risk of 50 - 87% of
developing breast cancer.

These include early menarche, late


menopause, use of contraceptives and
exogenous oestrogen, nulliparity and
increased age at first term pregnancy.
Induced abortion and spontaneous abortion
do not increase the risk. Prolonged lactation
and breastfeeding reduce the risk.

However, in native Africans, a wide range


of BRCA-1 and BRCA-2 mutations and
sequence variations have been found to
be unique. This suggests that there may
be significant differences in the genetics of
hereditary breast cancer in Africa.

Previous Breast disease


Individuals who have a prior history of
invasive carcinoma or ductal carcinoma
in Situ have a 0.5%-1% per year risk
of developing a new invasive breast
carcinoma.

Lifestyle risks
Anthropometric measures specifically
height, obesity and high body mass index
are risk factors especially in postmenopausal
women. Alcohol and diets rich in saturated
fat raises the risk while smoking does not
appear to affect the risk.

Radiation exposure
Exposure to ionizing irradiation increases
the risk of developing breast cancer.
Patients receiving radiotherapy and X-ray
technicians have been noted to have a
higher incidence of breast cancer.
Genetics
A family history of breast cancer increases
a womans risk of developing the disease.

Diagnosis and treatment


The primary goal of diagnosis is to accurately
distinguish benign from malignant breast
lesions and invasive from non-invasive
breast lesions. This would allow the
delivery of timely and appropriate care.
Timely diagnosis relies on the population
at risk being sufficiently informed to detect
early symptoms of breast cancer.

134

Breast health awareness is therefore a key


platform in the diagnosis of breast cancer.
However, formal training in breast self
examination has not been shown to reduce
mortality in breast cancer.
Diagnosis is made after clinical breast
examination, imaging and biopsy. Imaging
includes:
Mammography
This is the most useful test to differentiate
between benign and malignant lesions and
is the one that is recommended for breast
cancer screening.
Ultrasonography
This is an important method of resolving
equivocal mammography findings. It can
also be used during needle biopsy. Magnetic
Resonance Imaging is an alternative
imaging method, which is more expensive.
Plain X-rays and Bone Scan are useful in
the detection and diagnosis of metastasis
especially to the bones.
Biopsy
A pathologic diagnosis of a breast lesion
can be achieved after obtaining a biopsy
sample.
Symptoms
Early breast cancer causes no symptoms
and is usually painless. The commonest
symptom is a painless lump in the
breast. Other symptoms include breast
enlargement or asymmetry; nipple changes,
retraction, or discharge, including Pagets
disease; ulceration or erythema of the
skin of the breast including inflammatory
carcinoma; an axillary mass; systemic
symptoms such as fatigue, cough, ascites
or new musculoskeletal discomfort.

The above allows for staging of the cancer.


The staging ranges from stage I & II (early
breast cancer) to stage III and IV. Treatment
and prognosis greatly depends on the stage
of cancer. The median survival of untreated
breast cancer has been estimated to be 2.7
years after initial diagnosis.
Forms of available treatment include
surgery, radiation and chemotherapy. The
first two can be applied locally or regionally.
Treatment usually involves a combination
of the three methods. Chemotherapy
has been shown to substantially improve
the long-term, relapse-free, and overall
survival in both premenopausal and
postmenopausal women up to the age of
70 years.
Prognostic indicators that influence
treatment outcomes include tumour size.
The larger the tumour the low the survival
rate. The histological type and the staging
of the disease also have a bearing.
Prevention and control
Primary Prevention

Annual screening mammography has


been demonstrated to reduce breast
cancer mortality among women older
than 50 years by 20 -39%. The benefit in
younger women is not yet established. For
Caucasian women aged 40-49, the results
of RCTs are consistent in showing no
benefits at 5-7 years after entry, a marginal
benefit at 10-12 years, and unknown
benefit thereafter.
Screening reduces mortality but not
incidence. A better understanding of the
causes of breast cancer could lead to disease
prevention. Currently, strategies revolve
around two areas: chemoprevention and
surgical prophylaxis.

135

Chemoprevention is the use of chemical


agents to reverse or suppress the
progression of a pre-malignant lesion to an
invasive carcinoma. Tamoxifen is currently
the only agent that has been approved
clinically for use in women with high risk of
developing cancer.
Surgical prophylaxis involves either
mastectomy or oophorectomy.
Tertiary Prevention
Palliative care improves by providing
pain and symptom relief, spiritual and
psychosocial support to improve the quality
of life of THE patients and families.
Often in developing countries, most of the
cancer patients are already at an advanced
stage by the time they are first seen by
a doctor. Palliative care is then the only
realistic treatment option.
Costs
The Breast Health Global Initiative (BHGI)
advocates for a tier based approach to
population based management of breast
cancer patients.
The tier levels depend on the resources
available and are based on four observations
namely:
1. Because advanced breast cancer has
the poorest survival and is the most
resource intensive to treat, efforts
aimed at early detection can reduce
the stage at diagnosis; potentially
improving the odds of survival and
cure, and enabling simpler and more
cost-effective treatment. These efforts
are likely to have the greatest overall
benefit in terms of both survival and
costs.
2. There is a need to build programs that
are specific to each countrys unique
situation.

3. The development of cancer centres


can be a cost-effective way to deliver
breast cancer care to some women
when it is not yet possible to deliver
such care to women nationwide.
4. Collecting data on breast cancer is
imperative for deciding how best to
apply resources and for measuring
progress.

Chronic obstructive respiratory


diseases

The most common chronic respiratory


diseases are asthma and chronic
obstructive pulmonary disease (COPD)/
chronic bronchitis. The Global Initiative
for Chronic Obstructive Lung Disease
(GOLD) has defined COPD as a disease
state characterized by airflow limitation
that is not fully reversible. Both typical
symptoms and a history of exposure to
risk factors are required as a basis for
suspecting the presence of the condition,
while spirometry is required to confirm
the diagnosis.
In the British Medical Research Council
definition of chronic bronchitis cough with
phlegm for three successive months for at
least two successive years is commonly
used.
The Global Initiative for Asthma (GINA)
defines asthma as a chronic inflammatory
disorder of the airways in which many
cells and cellular elements play a role.
These episodes are usually associated
with widespread but variable airflow
obstruction that is often reversible either
spontaneously or with treatment.
Burden of disease
Chronic respiratory diseases contribute
to about 4% of the global disease burden.
136

30- year projection from 1990 predicted


a steady rise in the number of COPD
deaths to the third most common cause
worldwide by 2020. WHO predicts that
most of the projected DALY burden will
fall on developing countries.
Asthma is the most common chronic disease
among children occurring in all countries
regardless of level of development.
Risk factors
Identified risk factors for chronic bronchitis
include cigarette smoking, occupational
exposure,
cannabis
smoking,
and
tuberculosis. Poorly ventilated combustion
of biomass fuel is another common cause
prevalent in poor rural areas.
The association between asthma and
passive smoking, particularly maternal
smoking in pregnancy and in the childs
early life, is now well established, although
the mechanism remains elusive.
Other risk factors for childhood asthma
include gender, family history, urban

residence, proximity to sources of


pollution, allergic sensitization, body mass
index (BMI) and passive smoking.
Low socio-economic status for asthmatics
is associated with increased admissions to
intensive care units and mortality.
Aetiology
COPD as understood in developed
countries is primarily caused by tobacco
smoking. By contrast, the causes of asthma
are still poorly understood. Inhaled asthma
triggers such as indoor and outdoor
allergens, tobacco smoke, chemical
irritants and medications such non-steroid
anti-inflammatory drugs and beta blockers,
can cause an asthmatic attack.
Other possible triggers include cold air,
extreme emotional arousal such as anger
or fear, and physical exercise.
Symptoms
The chronic inflammation in asthma causes
an associated increase in airway hyper
responsiveness that leads to recurrent

Table 7.2: Strategies to reduce tobacco use


Interventions

Beneciaries/Target Groups

Process Indicators

Higher taxes on cigarettes and


other tobacco products

Smokers
Potential smokers (especially the
youth)

price of cigarettes (adjust for


ination)
tax as percentage of nal sales price

Bans/restrictions from smoking in


public and work places: schools,
health facilities, public transport, restaurants,
cinemas etc.

Non-smokers protected from


secondhand
smoke

smoke free public spaces and places

Comprehensive bans bans on


advertising and promotion of all tobacco
products, logos and brand names

Smokers and potential smokers


(especially the youth)
societal attitude to smoking

laws, regulations, extent to which


they are respected/enforced

Better consumer information:


counter-advertising, media coverage,
research ndings

Smokers and potential smokers


(especially the youth)
societal attitude to smoking

knowledge of health risks, attitudes


to smoking

Large direct warning labels on


cigarette boxes and other tobacco
products

Smokers

percentage of box surface covered


by label,message, color/front
specicationsa

Quit strategies including increased acces to


Nicotine Replacement (NRT) and
other ocassion therapies

Smokers

number of ex-smokers

137

episodes of wheezing, breathlessness,


chest tightness and coughing, particularly
at night or in the early morning.
Diagnosis and treatment
A suggestive history of risk factor exposure
and symptoms followed by a clinical
examination is the first step in diagnosis.
Spirometry is central to the diagnosis and
management of COPD.
Treatment guidelines are
aimed at
improvement of quality of life of
patients with COPD by prevention of
exacerbations as well as, at smoking
cessation efforts. Drug therapy for relief of
symptoms includes the use of long-acting
beta 2 agonist, anticholinergic drugs and
inhaled corticosteroids in the treatment of
COPD.
Complications
Prevention and Control
Because the aetiology of asthma is poorly
understood, prevention of asthma is
largely directed at secondary prevention
through early diagnosis and appropriate
management of asthma. Prevention and
proper treatment of TB can reduce the
burden of COPD.

Tobacco related diseases

People have used tobacco for centuries,


but cigarettes did not appear in mass
manufactured forms until the Twentieth
Century. Although tobacco is used
throughout the world, social, economic,

and cultural factors determine the nature


and patterns of its use. Tobacco contains
nicotine, an addictive stimulant that
temporarily improves alertness, memory,
and mood, but also forms a strong physical
and psychological chemical dependence
(addiction).
The smoke contains more than 4,000
chemical compounds, including at least 60
cancer causing compounds, e.g. benzene,
ammonia, tar, lead, arsenic etc. WHO
estimates that by 2030 tobacco is expected
to kill more than 9 million people per year
out of which half are aged 35-69 yeras .
The epidemic is increasingly affecting
developing countries, where most of the
worlds smokers (84% or 1 billion) live.
Burden of disease
Smoking contributes 87% of lung cancer
related deaths. The risk of lung cancer
increases directly with the number of
cigarettes smoked. Lung cancer kills more
people than any other type of cancer and
around 90% of these deaths are caused by
smoking.
Statistics show that cigarette smokers
are ten times more likely to develop
emphysema than those who do not
smoke. In high-income countries, smoking
prevalence is on the decline, but in many
middle and low-income countries, smoking
prevalence is rising. In high-income
countries, low socioeconomic status (SES)
is associated with an increased likelihood

The FCTC, WHOs rst international treaty, was adopted by WHO member countries in May 2003. It commit all
countries that ratify it to: eliminate all tobacco advertising, promotion and sponsorship within 5 years (with a narrow
exception for nations whose constitutions prohibit a complete ban); require warning labels occupying at least 30% of
the area of cigarette packs (and suggests 50% or more); prohibit misleading tobacco product descriptors such as light
and mild; and protect nonsmokers from tobacco smoke in public places. The FCTC also urges strict regulation of
tobacco product contents; higher tobacco taxes, global coordination to ght tobacco smuggling, and promotion of
tobacco prevention, cessation and research programs.
WHO framework on Tobacco control. (2005)

138

of being a smoker and with smoking more


cigarettes per day. WHO estimates that
tobacco use causes five million deaths each
year worldwide.
Risk factors
Smoking prevalence tends to be higher
among men with less education and lower
incomes. The harm from second-hand
smoke to others, especially unborn and
young children is established. Smokeless
tobacco use may be a risk factor for
dyslipidemia and hypertension, both of
which are risk factors toward cardiovascular
disease.
Tuberculosis (TB) is responsible for a
huge burden of illness and death in many
countries and several studies have reported
associations between TB and smoking.
Smoking may increase the risk of TB
incidence and mortality. Smoking by
pregnant women is a significant risk factor
for preterm birth, small size for gestational
age, reduced birth weight (e.g., 200 g for
smoking 10 cigarettes daily), and stillbirth.
Aetiology
Lung cancer was the first disease causally
linked to smoking. Over the years, the
list of cancers caused by smoking has
expanded considerably to include cancer
of the oral cavity including the oropharynx,
nasopharynx and larynx, chronic obstructive
pulmonary disease, oesophagus, stomach,
liver, pancreas, urinary bladder, kidney,
uterine cervix and myeloid leukaemia.
In Europe and North America, 90% of
oesophageal cancers are attributable to
tobacco use.
Diagnosis and treatment
Tobacco addiction is more severe than
alcohol and at least as binding as narcotic.
Prevention is therefore key.

Complications
Cardiovascular diseases, including ischemic
heart disease and cerebro-vascular disease,
are leading causes of morbidity and
mortality worldwide. Cigarette smoking is
the leading cause of fatal household fires.
Tobacco agriculture causes substantial
environmental damage from provision
of farmland for growing tobacco and
deforestation for curing the product.
Prevention and control
Efforts to reduce smoking face formidable
obstacles mainly nicotine addiction
combined with social pressures, aggressive
cigarette marketing and promotion. Other
pressing health problems cause affected
individuals and communities to relegate
tobacco related illnesses. Policy makers
overestimate the economic importance of
tobacco.
Many smokers want to quit and while
most quit without help, nicotine addiction
makes quitting very without. Quit rates can
be substantially increased through advice
from health care providers, telephone
quit lines, formal and informal supportgroups, and cessation therapies including
nicotine-replacement (NRT). Over-thecounter(non-prescription) sales improve
access to NRT. In addition, there exists
many potential opportunities for cessation
advice and support within the health
system.
Costs
Tobacco does not serve any basic human
need therefore, the purchase price of
tobacco is an immediate cost to the user
without corresponding benefit. Employers
bear an economic burden from employee
smoking through more employee
absenteeism
decreased
on-the-job
productivity (presenteeism) increased

139

early retirement due to ill health; higher


health-care costs for smokers higher
health, life, and fire insurance premiums;
higher maintenance and cleaning costs and
higher risk of fire damage, explosions, and
other calamities related to smoking.
Although most people in industrialized
countries recognize that smoking can lead
to adverse health consequences, many do
not personalize the risk or understand the
scope and severity of these consequences.
When asked which illnesses are caused
by smoking, lung cancer tends to be the
only illness identified by most smokers,
and smokers generally understand little
about the pain and suffering associated
with smoking-related diseases. Smokers
underestimate their risks of lung cancer
and other diseases relative both to other
smokers and to non-smokers.
Many countries are making cessation
support more available. Training and capacity
building programs, including evidencebased clinical cessation guidelines, have
been developed for health professionals to
use in routine practice.
The U.S. guidelines are built around the 5
As: ask patients about tobacco use at every
clinical encounter, advise to quit, assess
willingness to make a quit attempt, assist
with counselling and pharmacotherapy,
and arrange follow-up.
Injuries/violence and disabilities
Many people consider injuries of various
kinds to be a result of an accident, the
implication being that it is unavoidable.
However, as people better understand the
causes of injuries, it has been realized that
most injuries are a result of non-random
events that can be prevented.

Because of this shift in perception, the


causes of accidents and injuries and their
health consequences now demand the
attention of health practitioners and policy
makers.

Fig. 7.2: Use of seat belt prevents fatalities

The problems of injuries vary depending


on age, sex and socio-economic status.
Injuries result primarily from road traffic
crashes and interpersonal violence.
The WHO defines an injury as physical
damage that results when a human body
is suddenly subjected to energy in amounts
that exceed the threshold of physiological
tolerance, or from a lack of one or more
fatal elements (for example, oxygen). The
energy could be mechanical, thermal,
chemical or radiant. Road traffic crashes
are a major cause of injuries and disabilities
today.

Road traffic crashes

WHOs world report on road traffic injury


prevention defines a road traffic injury
as fatal or non-fatal injuries incurred as a
result of a road traffic crash.
A road traffic crash is defined as a collision
or incident that may or may not lead to
injury, occurring on a public/private road
and involving at least one moving vehicle.
Burden of disease
In 1896, the first person died as a result
of a motor vehicle crash. Today, the annual
death toll worldwide is about 1.2 million

140

a year. An additional 50 million people


are reported as injured in road collisions
each year, many with severe and often
permanently disabling injuries of the brain
and spinal cord. Sub-Saharan Africa has
the worlds highest rate of fatalities per
vehicle.
Risk factors
The risk factors associated with road traffic
crashes can be divided into distal factors
and proximal factors. Distal risk factors
revolve around the socio-economic settings
and policies pursued by government and
societies.
Rapid motorization
The number of motor vehicles per 10, 000
people rises in relation to GDP per capita.
This has a direct link to the total number
of accidents. The growth in the number of
vehicles tends to be faster than the growth
in good road network.
Growth policies
Smart-growth policies, for example, favour
compact, higher density development
with mixed uses so that the places where
people live, work, go to school, shop
and find opportunities for recreation and
entertainment are close together. This
minimizes time spent on roads commuting.
Information communication technolgies
have also led to the emergency of
telecommuting where people work from
their houses.
Use of safer modes of travel
Of the four main modes of travel - road,
rail, air and marine - travel by road puts
people at the greatest risk of injury per
kilometre travelled by far. Globally, road
traffic injuries are a leading cause of death
among young people who drive cars or
ride motorized two-wheelers.

Contributing factors include unfamiliarity


with vehicles, which are often borrowed;
thrill seeking and overconfidence. Young
people are less tolerant of alcohol
compared to older people.
Alcohol is known to increase driver
confidence to the point of over confidence
in their ability to handle motor vehicles.
Regulating motor vehicle use by young
riders and drivers is therefore important
in reducing crashes.
Road design
Roads that are well designed according
to intended function can greatly reduce
road traffic crashes. A key characteristic
of a well-designed road is that it makes
compliance with the intended speed
limit a natural choice for drivers. Nilsson
showed that speed is a major risk factor
for road traffic crashes and that there is an
exponential relationship between higher
speeds and road deaths.
This relationship holds true for pedestrians
as well. Speed and increased speed limits
accounts for much of the increased risks
for road death and injury in high-risk subgroups such as young male drivers, drunk
drivers, fatigued professional drivers,
motorcyclists, and cell-phone users.
The dose-response relationship between
alcohol and crash severity suggests that
alcohols main influence is in changing the
driver behaviour towards accepting higher
risks and choosing higher speeds.
Aetiology
Injuries in road traffic crashes are due to
the basic laws of physics. Research in the
1940s and 1950s by DeHaven and Stapp
proved that kinetic energy of impacts, and
not acceleration or deceleration, was the

141

critical issue in injury mechanics. DeHaven


first documented the effects of free falls
on hard, soft and hollow tissues of human
cadavers.

vehicle safety standards (MVSS). These have


introduced various measures incorporated
into motor vehicles to divert kinetic energy
impacts away from human bodies.

While Stapp carried out a famous


experiment in 1954, in which he emerged
unscathed from a rocket sled into which
he was restrained and which decelerated
from a velocity of 632 mph (1011 kph) in
1.4 seconds.In developing countries, the
state of the roads and the roadworthiness
of vehicles contribute significantly to road
traffic crashes.

The introduction of speed camera network


in various countries for instance in Australia,
United Kingdom(UK), and Norway,
accompanied by slogans such as, Speed
Kills. Kill Speed. has achieved sudden large
and sustained drops in the number of road
deaths. In addition, revenue collected as
fines for exceeding speed limits easily pay
for the maintenance of such networks.

Symptoms and diagnosis


Injuries can affect all the different parts of
the body. Diagnosis depends on recognizing
the different possible types of injuries,
which depend mainly on the cause. The
most common injuries are spinal, head,
and fractures to the bones.

Speed calming

Management and treatment


Treatment begins immediately at the crash
site. Spinal injury patients require careful
immobilization to prevent further injury
to the spinal cord. Broken limbs must be
supported and patients with head injury
need monitoring. All this requires a public
that is aware and a well trained paramedic
system.
Complications
Injuries involving the spine and brain often
result in hemiplegia or paraplegia. Long
hospitalizations result and patients often
succumb to infection and depression. Many
are unable to return to any semblance of a
normal life.

Speed-control policies in the UK and


many European countries have included
restricted zones with special speed limits,
special speed limits for trucks, and, in urban
areas, road bumps, roundabouts, chicanes,
gateways, and other environmental
measures. Speed calming from roundabouts
has produced reductions in deaths and
injures of 37% and 11%, respectively.
In areas where there is mixed road use, i.e.
vehicles and people pedestrian protection
provided by 30-kph speed limits, humps,
bumps, roundabouts, and painted zebrastripes reduces road traffic injuries. Where
vehicle speeds are above 30kph separation
of pedestrians and cyclists from vehicles is
an important safety measure.
Improving the visibility of vehicles and
vulnerable road users also helps.
Public education and information campaigns
have proven to be highly effective when they
accompany laws and law enforcement.
Secondary prevention

Prevention and control


Primary prevention

Stapp and DeHavens experiments were


the forerunner of the U.S. federal, motor

This aims to improve care of the


injuredbefore reaching the hospital A
review of studies in Europe concluded that

142

about 50% of road traffic deaths occur


within few minutes at the scene of the
crash or on the way to a hospital, 15% at
the hospital within 4 hours of the crash and
35% after 4 hours. Many complications
resulting in disability can be prevented prehospital by good paramedic care.
Tertiary prevention

This
includes
physiotherapy
and
occupational therapy. Many victims require
lifelong care to prevent infection and
psychosocial support.
Costs
Nantulya, Muli-Musiime (2001), suggested
that the cost to the economy as a result of
RTAs is approximately 1-2% of countrys
Gross National Product (GNP). Directly,
individuals suffering from injuries and
disabilities will incur costs of medication.
They are not economically productive and
most of the times incapacitated to work.
Indirect costs include those arising from
the resulting disabilities, both physical
and psychosocial which can be a very
high burden to the patient, family and the
community.
In developing countries, the cost of
improving vehicles may be high, relative to
expenditure on health cares, so the effect
of including such activities in the definition
of the health system may be greater.
As mentioned above, unsafe roads also
contribute greatly to the vehicular toll in
poorer countries.
However, the cost of improving roads could
be much larger than the cost of making cars
safer. Behavioural changes such as using
seat belts once installed, and respecting
speed limits, are nearly costless and could
save many lives; they are very likely to

be more cost-effective than treatment of


crash victims.

Mental illness

The WHO definition of health includes


mental health as a component. Mental
health can be defined as the state of well
being in which an individual can cope
with the normal stresses of life, work
productively and is able to contribute to
his/her own community. A mental disorder
then refers to the absence of the above
either in single or in total. The most
common mental disorders are depression,
suicide; schizophrenia, manic-depressive,
alcohol and substance abuse.
Burden of disease
According to the WHO Health Report
(2001), neuropsychiatric disorders account
for 12% of the Global Burden of Disease,
second only to infectious disorders (23%),
and are a bigger burden than AIDS, TB
and malaria combined (10%). In Kenya,
it is estimated that 20% of adults at any
one time have a mental disorder. Mental
disorders are disabling and costly. They
affect the employment and productivity of
the patient and of the family/caregiver.
Mental disorders lead to high health service
utilization, and high rates of utilization of
other formally delivered services including
social services, housing, and education and
in some cases, the criminal justice system.
Risk factors
Risk factors that predispose to mental
illnesses can be divided into individual risk
factors and community/socio-economic
risk factors.
Individual risk factors can be biological,
emotional,
cognitive,
behavioural,
interpersonal or related to the family

143

context. They may have their strongest


impact on mental health at sensitive
periods along the lifespan or even across
generations. Examples include academic
failure, substance abuse including alcohol
and family conflict. Socio-economic and
environmental determinants for mental
health are related to issues such as poverty,
war and inequity. Populations living in
poor socio-economic circumstances are
at increased risk of poor mental health,
depression and lower subjective wellbeing.
Diagnosis and treatment
Diagnosis is often made socially. Depending
on the culture or society the individual
is in certain behaviour can be taken as
manifestations of mental illness. The
clinical diagnosis of mental illness is based
on separation into distinct categories based
on description of symptoms and the cause
of the illness.
The Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) of the USA
is the standard for diagnosis of mental
disorders. It places mental disorders into
16 major diagnostic classes, and within each
class, there is a specific criterion for making
the diagnosis for a particular disorder.
Management and treatment
Treatment and management is multidisciplinary, with a role of medications
and psychosocial treatments. Principles
of treatment include promotion of mental
health, prevention of mental disorders,
medical treatment and rehabilitation into
society. Patients with mental illness often
have stigma, which may prevent the patient
from accessing help.
In addition, patients may exhibit violent
behaviour and even be involved in crime
e.g. sexual assault. People with mental

illness are often discriminated against and


have a high rate of unemployment.
Prevention and control
Primary

Mental illnesses are under-diagnosed and


stigmatized in society. One of the major
dilemmas facing policy-makers and public
health practioners is defining the boundaries
within which public health action should be
taken.
Mental illnesses do not have the clear
definitions that diseases such as malaria
do. Prevention interventions therefore
have to consider a much broader definition
with overlapping boundaries depending on
different cultures and mandate given to
the health care system to tackle mental
conditions.
It is therefore feasible to use a riskbenefit perspective in prevention. Such
an approach defines three categories of
primary prevention namely;
Universal prevention that targets the
general public or entire population
Selective prevention that targets
relatively higher risk individuals or
population subgroups
Indicated prevention that targets
persons at high risk of developing
mental disorders.
Prevention starts with increasing awareness
of what mental health and mental
disorders are, the causes, prevention, and
the availability of effective interventions.
Training primary health workers, teachers,
social workers, and rehabilitation workers
to be able to recognize, manageand
orrefer common mental health problems.
Improving access to education and poverty
alleviation programs can help improve the
ability of individuals to access economic

144

entitlement and so reduce psychosocial


strain. Strengthening community networks,
the development and use of social support
systems can reduce risky behavior in
schools including drug and alcohol abuse.
Control of addictive drugs, alcohol abuse
through increased taxation and better
government controls.
Secondary

Secondary prevention refers to interventions


undertaken to reduce the prevalence
Increased availability and improvement
of mental health services including the
development and implementation of
standards and guidelines for management
of common mental health problems is
the starting point. This eventually leads
to treatment-related strategies of specific
mental health conditions.
Tertiary

The goal is to reduce the effects of


mental illnesses and in so doing allow
the patient to reach the highest feasible
level of functioning. Prevention includes
interventions that reduce disability, all
forms of rehabilitation as well as prevention
of mental illness relapses.
Costs
The mortality from mental illnesses is
relatively low. Costs are related mainly
to morbidity and are mainly indirect
costs related to lost productivity. Those
with mental illnesses miss work, school
or are unemployable. It is estimated that
mental health patients earn up to 40%
less on average because of the chronicity
of mental illnesses and the unpredictability
of when episodes occur. Health schemes
rarely cover mental illnesses fully and so
the burden of financing such conditions is
often left to the patient.

Surveillance of risk factors: The


WHO Stepwise approach

Chronic diseases take decades to become


fully established, having started much earlier.
Management and prevention require a long
term systematic approach. Given the long
duration, there are multiple opportunities
for prevention. Health services must
integrate the response to these diseases
with the response to infectious diseases.
Purpose
The WHO stepwise approach to chronic
disease and risk factors surveillance provide
an entry point for low and middle income
countries to get started on chronic disease
surveillance activities. It is also designed to
help countries build and strengthen their
capacity to conduct surveillance. Objectives
of surveillance include to:
collect consistent data across and
within countries;
develop standardized tools to enable
comparisons over time and across
countries;
prevent chronic disease epidemics;
help health services plan and determine
public health priorities;
predict future caseloads of chronic
diseases; and,
monitor and evaluate population-wide
interventions.
The major (modifiable) behavioural risk
factors identified in the WHO Report
(2002) are:
Tobacco use
Harmful alcohol consumption
Unhealthy diet (low fruit and vegetable
consumption),
Physical inactivity.
The major biological risk factors are:
Overweight and obesity
Raised blood pressure
Raised blood glucose

145

Abnormal blood lipids and its subset


raised total cholesterol.
The rationale for including these eight
core risk factors in STEPS surveillance is
because they have the greatest impact on
chronic disease mortality and morbidity,
modification is possible through effective
prevention, measurement of risk factors

146

has been proven valid and measurements


can be obtained using appropriate ethical
standards.
Using the step instrument for data
collection therefore allows comparisons
over time and across countries because
the tool is standardized.

Questions
1. Describe the major non-communicable diseases of public health importance.
2. Identify the major risk factors that non-communicable diseases have in common.
3. Outline the major public health strategies to control non-communicable disease risk
factors.
4. Discuss why developing countries suffer from a quadruple disease burden.
5. Why is the WHO stepwise methodology ideal for poor resource settings?

Further reading

1. Anderson BO, Yip C, Ramsey SD, Bengoa R, Braun S, Fitch M, et al. Breast cancer
in limited-resource countries: health care systems and public policy. The breast
journal. 2006 ;12 Suppl 1S54-69.
2. Brown ML, Lipscomb J, Snyder C. The burden of illness of cancer: economic cost
and quality of life. Annual review of public health. 2001 ;2291-113.
3. Bleich S, Cutler D, Murray C, Adams A. Why is the developed world obese? Annual
review of public health. 2008 ;29273-95.

147

PART III:

Individual health and the


environment

The environment describes everything that makes up our surroundings both living and nonliving.
Concerns about environmental health date from ancient times. Access to clean water was
evidenced by archaeological remains of water and sewage lines date back more than 4,000 years.
Today we are aware of the continued threat to public health from various environmental hazards.
The impacts of these hazards can be local or global. Climate change, poor sanitation, pollution of
water supplies and food safety are the major areas of concern. Different societies have developed
different ways of adapting environmental impact on health. The most important factors that
determine health are hereditary, environmental, lifestyle and medical care.
The social environment, how society is organized and the social and community networks that an
individual has influence their health status, how, when and what type of healthcare they access.
For example Gender discrimination, low levels of female education, and lack of empowerment
prevent women from seeking care, having the autonomy to make decisions, and accessing the
best choices for themselves and their childrens health, resulting in critical delays and unnecessary
deaths. Educated women are less likely to die in childbirth. Adults will spend a great deal of their
life at the workplace. The work environment therefore needs to be conducive to maintaining
and possibly improving health status. The safety of the workplace is therefore a key concern.
Identifying then understanding the occupational risks and interventions that will reduce these risks
is the major concern of occupational health practioners. Much of the effective work in promoting
worker safety is done through policy and law.
Understanding the linkages between the environment and health and what is needed to predict,
prevent and monitor the environmental hazards is of great importance. By the end of this part
the reader should be able to:
a) list and describe the factors that influence health seeking behaviour
b) describe the characteristics of the sick role
c) discuss the difference between anthropological and biomedical models of health
d) explain the role of culture in health care
e) understand the role of gender in health care
f) appreciate the role of the environment in determining health status.
g) outline the relationship between water and good health
h) understand the concepts in providing proper sanitation
i) outline the principles of food hygiene
j) discuss the growing problem of environmental pollution and how it affects health
k) explain how urbanisation affects health status appreciate the nature and scope of
occupational health.
l) outline the approaches to occupational health
m) list the major occupational risk factors and hazards
n) discuss the challenges in ensuring occupational and health safety standards in a
developing country

148

MEDICAL SOCIOLOGY

Introduction

The World Health Organisation defines


health as the physical, mental, spiritual,
psychological and social well being and not
just the absence of diseases and infirmity.
This internationally accepted definition of
health highlights the role that the social
aspect of life plays in determining health.
We recognize that an individuals health is
partly determined by what happens inside
their body and partly by what is happening
outside their body as well as how they
interact with their environment.
The environment can be thought of in
terms of physical and social dimensions.
The social environment includes the groups
to which we belong, the neighbourhoods
in which we live, the organization of our
workplaces, and the policies we create to
have some order in our lives.
The social environment is associated
with disease and mortality risks, which
are independent of individual risk factors.
Research findings suggest that the social
environment influences disease pathways;
and understanding the role of social
environmental factors, is crucial in the
design of disease prevention and health
promotion programs and for the discovery
of disease aetiology.
Medical sociology and anthropology focus
largely on human organization and practices
and provide an interface between clinical
and the social aspects of human health.
Understanding health in this way allows for

a holistic approach to health, disease and


healthcare seeking.

Culture and health

Various theories or models have been put


forward to explain health seeking behaviour.
These include the health belief model, and
the locus of control model.
The classic model for understanding health
seeking behaviour and how to influence
behaviour change is the health belief model.
It assumes that people act rationally. The
model specifies three factors that influence
behaviour change:
1. The extent to which a person feels
vulnerable to a particular threat;
2. The perceived severity of the threat;
and,
3. The perceived effectiveness of taking
action to prevent or minimize the
problem as compared to barriers
to and cost of taking such an action.
Based on this model, the public health
approach has been to convince people
that the threat is severe and that they are
vulnerable. For example HIV awareness
campaigns have been conducted on this
premise. However, this fear appeal
approach has not necessarily changed
peoples behaviour despite changing their
attitudes external forces have an external
locus of control. Such people can develop
a sense of helplessness that there is nothing
that they can do about the situation they
are in.

149

For example, people who are unable to


control their food intake and become
obese may refuse to take responsibility for
their ill health and blame external forces.
According to this model, people with an
internal locus of control are more likely to
engage in health promotive activities.
The two models focus on internal
motivation to explain health behaviour.
An integrative analytical framework
of health divides factors that influence
health behavious into proximate factors
like
culture, environment, economy,
education; and intermediate factors such as
perception, access, knowledge awareness,
cost of services and outcomes in health.
Culture, health and disease
Key to how health and disease balance
within a community is the cultural
perception and experience of prevailing
conditions. Understanding this complex
interactions requires an understanding of
culture.
What is culture? We use the word culture
to mean two things. It is a way of life and
it also describes the arts and learning the
processes by which people discover, learn
and create new things. There are some
interrelated definitions such as:
- the integrated pattern of human
knowledge, belief, and behavior that
depends upon the capacity for learning
and transmitting knowledge to
succeeding generations
- the customary beliefs, social forms,
and material traits of a racial, religious,
or social group;
- the characteristic features of everyday
existence (as diversions or a way
of life) shared by people in a place or
time.
150

Other definitions include Margaret Meads


Culture is the learned behaviour of a
society or a subgroup and Clifford Geertzs
Culture is simply the ensemble of stories
we tell ourselves about ourselves. There
are different levels of culture, each one
deeper and requiring different tools to be
uncovered.
Table 8.1: Discovering culture
Levels of Culture

Expression

Discovery
methods

Artefacts &
behaviour

expressions of
tradition, clothing,
customs

Observation

Beliefs & values

beliefs about how


the world should
be

Interview &
survey

Assumptions

often unspoken or
unconscious

Inference &
interpretation

Culture is dynamic and not static and is


amenable to change. There are various
determinants
of
culture
including
socialization and - dietary practices.
Factors that lead to cultural change include
interactions with other cultural groups,
religion, economic change, urbanization
and formal education.
Although health and disease are universal
concepts, the way in which we understand
them is rooted in culture. There are two
general explanatory approaches to health
and disease. These are a biomedical and
anthropological models.
Biomedical model
This is the cornerstone of modern Western
medicine based on the developments and
research in natural sciences.
Disease or illness is explained in
interpersonal and systemic terms
(application of the germ theory) its universal
perspective sometimes referred to as the
ethic perspective/approach to health and
disease.

Anthropological
Health and illness are largely previewed
as cultural phenomena, based on cultural
ideas of disease causation that are largely
personas. e.g. attributes of ill-health
to witchcraft, the evil eye, taboos and
transgression (e.g. of child malnutrition
and HIV/AIDS in selected communities and
supernatural falsest (leading to fatalism and
resignation).

care since society in general considers it


a female thing/role. Kleinman, identifies
three overlapping and inter-connected
sectors of health care namely:
The popular sector including lay society
and self medication;
The folk sector including herbal
medicine, homeopathy; and,
The professional sector (western
medicine).

Prevailing cultural ideas influence causes


of ill health. Whether an illness is regarded
as serious or harmless, varies from one
culture to another. Such ideas affect the
patient experiencing the illness episode.

In most societies, Western medicine is


considered as the official medicine and
is elevated above the other forms and is
protected by law.

It is therefore important to understand the


social context within which the community
views health and what their beliefs and
practices are. An important point to note is
that culture plays a role in disease causation
both directly and indirectly through
influencing socio-economic factors such as
peoples living and working conditions.
Cassell uses the word illness to stand for
what the patient feels when he goes to the
doctor and disease as what he has on the
way home from the doctor.
Health System
A societys health care system is embedded
in its socio-cultural, religious, political
and economic organization. The same
assumptions, values and views held for
example, religious would be found in the
health care system.
For example, if in a given society, people
generally do not believe that men should
be involved in birth practices, then the
health system will discourage men from
being present at birth and in antenatal

The popular sector starts at the family level


and this is where illness is first identified
and treated. Depending on the illness and
peoples understanding of the illness, a
patient may do nothing, self treat consult a
folk, healer or a medical practitioner.
Advice or treatment may be sort from a
relative, neighbour, friend, church or even
from someone who has experienced the
particular symptoms or illness and or
someone who has life experience, e.g. an
auntie. In each culture, there is probably
a set of beliefs about health maintenance.
These are a set of guidelines about what
behaviour one should follow in order to
remain healthy, e.g. eat fruits five times a
day.
The folk sector can be secular, religious
or a combination of the two. Such healers
occupy an intermediate position between
the popular and professional sectors. The
range of healers is wide from spiritual
healers, bonesetters and herbalists. People
differentiate which illnesses are best
managed where mental illness and chronic
illnesses such as diabetes, HIV/ AIDS are
often referred to the folk sector. Most folk

151

healers share the same cultural values and


world views of the community they work
and live in and therefore will reason the
same way that the patient does. If ill health
is due to some supernatural cause, then
treatment involves sorting that problem.

structure will reflect that of the wider


society, e.g. the role of women. The larger
and more complex a society is, the wider
the therapeutic choices a person will have
in managing illness. This choice is referred
to as health care pluralism.

A person can become a folk healer in a


number of ways. These include inheritance,
through some sign at birth or a revelation
later on i.e. the person has a gift of healing,
apprenticeship to another healer.

Doctor - Patient interaction

A category that we need to recognize


exists is subordinate workers within the
formal healthy system who then act as
doctors by virtue of being known to work
in the hospital. One advantage of the folk
sector is that the whole family is often
involved unlike the professional sector
where often the doctor sees the patient
in isolation without the benefit of knowing
the community and social circumstances
which the patient originates.
Attempts have been made to incorporate
the folk sector as part of the formal health
system. Traditional birth attendants are one
such example. However, rising maternal
mortality has lead to a reversal of policies
encouraging women to deliver with TBAs.
The professional sector comprises the
organized legally sanctioned professions
including doctors, nurses and other
paramedical professions found within the
sector.
In many societies, the professional sector
provides a relatively small proportion of
healthcare. For example, in Kenya, just
43% of women deliver in health facilities.
While the formal structure of the sector
may be the same worldwide, within each
culture, as mentioned above, the social

The title of doctor in society confers


on the holder great societal respect and
carries with it certain rights and obligations.
Doctors have the authority to heal people.
As a profession across the world, doctors
share certain common values that are
different from those of their patients even
if they come from the same community.

Fig. 8.1: The doctor-patient interaction

Some of those values are espoused in the


Hippocratic Oath and some are gained
through process of enculturation that
occurs in medical school.
This enculturation means that doctors have
their own culture and their own way of
looking at things including how they view
ill health. This view can be different from
the patients view and therefore, there is
potential for miscommunication.
These differences can be identified as the
difference in ill health between disease
and illness. Whereas the patient is ill, the
doctor is looking for a disease.

152

These facts are put together in a logical


casual chain that leads to a diagnosis. Where
a specific cause cannot be identified, they
are often labelled as idiopathic, that is
there is a cause but we do not know what
it is yet. When a patient consults a doctor,
the doctor tries to relate the symptoms to
underlying pathology. Investigations aid the
doctor in uncovering what is really wrong
with the patient. Symptoms achieve their
meaning in relation to physiological states.

Both the meaning given to the symptoms


and their emotional response are influenced
by a persons own background, personality
as well as the cultural, social and economic
context, which they appear.

At that point, if abnormal physiological


parameters are found, then a diagnosis
can be made. Sometimes the diagnosis
made and the treatment prescribed can
be at variance with what the patient is
feeling. At that point, the problem is not
with the disease but with the patient for
not having the correct symptoms for the
disease, which has been identified.
An example of this approach is in the
management of tuberculosis, where we
know that TB is caused by a bacillus.
Therefore, TB is TB no matter the culture
or society it occurs and the treatment
therefore should always be the same.
However, we realize that different
communities will regard TB differently and
these views need to be taken into account
in the management of individuals with TB
from particular communities.
153

LD

The subjective response of the patient and


those around him to being unwell and how
the patient and those around him interpret
the origin and significance of this event
constitute illness. This further includes
how the illness affects his or her behaviour,
his relationship with other people and
the various steps he takes to remedy the
situation.

Modern Scientific medicine views health


from a perspective of scientific rationality.
The emphasis is on measurement of
various physiological and biochemical data.
There is need to establish the cause of a
disease and this must be done in a scientific
manner. That is, it must be possible to test
the hypothesis and assumptions. Only then
do they become facts.

Fig. 8.2: The individual within a complex world

TB, for example, is associated with HIV


and therefore someone who is diagnized
with TB will behave in a different way to
someone diagnosed with chronic bronchitis
even though the symptoms may present in
the same way.
In some societies, a patients view on ill
health is usually part of a much wider
conceptual model sued to explain
misfortune in general; in this model illness
is only one type of adversity and so all
misfortunes can be ascribed to various
causes. In other societies where religion
has reduced influence, people use medical
terms to describe things happening in their
society, e.g. a sick society or a crime
epidemic. Again, within various societies,
certain conditions that other, would
consider ill health are considered normal,

Fig. 8.3:

e.g. a child with a runny nose may not be


considered sick.
Helman, explains that defining oneself
as being ill usually follows a number of
subjective experiences including:
Perceived changes in bodily appearance
such as weight loss, skin colour or
hair falling out;
Changes in regular body functions such
as urinary frequency, irregular heart
beats;
Unusual body emissions such as blood
in urine, sputum or stool;
Changes in function of limbs such as
paralysis;
Changes in five major senses such as
deafness, blindness, lack of smell,
numbness or loss of taste sensation;
Unpleasant physical symptoms such
as pain, headache and fever;
Excessive or unusual emotional states
such as anxiety, depression; and,
Behavioural changes in relation to
others such as marital or work
disharmony.

However, it must be remembered that a


person may have one or more of these
symptoms and still not seek medical care.
Kleinman has suggested the explanatory
model (EM) that can be used to explain
the process by which illness pattern is
interpreted and treated. EM is held by
both patients and doctors to explain
sickness and treatment to guide choices of
available therapies and to provide personal
and social meaning on the experience of
the sickness. They provide explanations to
five aspects of illness:
1. The aetiology of the condition;
2. The timing and mode of onset of
symptoms;
3. The patho physiological processes
involved;
4. The natural history and severity of the
illness; and,
5. The appropriate treatment for the
condition.
The explanatory models are not constant
and are in response to a particular episode

154

of illness. The context of the patient


may be important e.g. socio-economic
class, religion. Because doctors are often
powerful figures, they may be able to
persuade the patient to adopt the doctors
EM of a particular illness.
Lay theories on illness usually place
the cause of ill health in one of the site
illustrated in figure 8.2 above. Even if
from a scientific point of view the person
is wrong, the model often provides an
internally consistent logical approach to
defining and explaining an illness. In the
Western world illness is often ascribed to
a malfunction of the individual e.g. eating
habits leading to obesity.
The natural world, or physical environment
can also cause disease, e.g. very cold nights
can lead to pneumonia. Blaming others for
our own ill health is common in certain
societies. The commonest is the evil eye,
witchcraft and sorcery. Sorcery is the
power to manipulate and later natural
and supernatural events with the proper
magical knowledge.
A sorcerer exerts his power consciously
usually for reasons of envy or malice. This
compares with witchcraft where certain
people possess mystical powers, which
can harm others.
Witches are usually women and are
different from others in their society
by being withered very ugly or very old
or disabled. They tend therefore to be
deviants or outcasts in society with all the
negative and frightening aspects of culture
are projected upon. Anthropologists have
noted that witchcraft accusations are more
common at times of great social change,
uncertainty or social conflict. The evil eye
is common in Africa and in the Middle East

and is simply a look that causes ill health


to the unfortunate person who receives it.
In the supernatural world, illness is due to
the action of gods and spirits. Such illnesses
are usually some kind of punishment for
some behaviour lapse either by omission
or commission. At other times, the spirits
or gods themselves may be malevolent
and therefore cure involves driving out the
spirits.
In almost all cases, the explanations are
multi-casual in that individual, natural,
social and supernatural causes are linked
or interact to cause ill health.
Understanding peoples beliefs about health
can help us to understand three aspects of
the doctor-patient interaction:
1. Why and how do people decide to
consult a doctor when ill?
2. What happens during the consultation;
and,
3. What happens after the consultation?
Why and how do people decide to
consult a doctor when ill?
There are many reasons why an ill person
will not seek medical attention. Barriers
of access such as inability to pay, distance,
scarcity of medical services play a role.
However, even where those barriers
do not exist, only a small percentage of
the population seek care. Very often,
symptoms that are considered normal
in a community do not warrant a visit to
the doctor even if it is a sign of a serious
illness.
Only if there is a further development,
interference with work or nonimprovement (e.g. if I am not better in 2
days time then I will see a doctor) does the
patient seek help.

155

In addition, in some communities, the


decision to seek medical care lies with say
the head of the household or some other
influential person and not the person who
is ill. The patient also has to be convinced
that for this particular illness the doctor
has the solution. For example, a high blood
pressure considered serious by the doctor
may not be considered serious by the
patient (no symptoms) and so efforts at
provide a solution are met by denial
I am not sick!
What happens during the
consultation?
The process of a doctor-patient
consultation involves three steps:
1. The presentation of the illness by the
patient (both verbal and non-verbal);
2. The translation of symptoms and signs
into a pathological disease entity; and,
3. Prescribing treatment that
is acceptable to both the patient and
the doctor.
We have noted that in society, a doctor is
regarded very highly. Therefore, in such
an interaction the patient is less powerful
when compared to the doctor. Yet the
doctor cannot order the patient. There
must be some agreement as to the course
of action, sometimes the agreed treatment
is not necessarily and what the doctor
wants. Problems arise where the patient is
ill but there is no disease identified.
Commonly in Western medicine, the
diagnosis is then made of a psychosomatic
illnesses or a patient is given medicine
anyway which after a day or two they stop
taking because they know that the doctor
did not know and did not treat their illness.
Disease without illness can also lead to
non compliance because the patient is not
convinced that she/he is unwell.

For example, if a patient coming in for a


respiratory infection and the blood pressure
is noted to be high is prescribed antihypertensive, she/ he may refuse to take
them or even to go for further tests arguing
the doctor just wants to make money. The
use of medical terms or not understanding
how certain terms are used in a community
can confuse the consultation.
In Kenya malaria describes symptoms of
the disease ranging from fever to backache
to headache and the disease malaria itself.
Doctors and patients interpret stomach,
heartburn, abdomen in different ways.
Use of mother tongue can breed further
confusing.
For treatment to work for the patient,
it must make sense in terms of their
explanatory models. The patient must
agree in terms of the form and purpose of
the treatment. For example, for cancer, the
medical cure is defined as disease free and
not a guarantee that cancer recurrence will
not occur later. This is important where the
treatment involves unpleasant side effects
either physical or social.
Certain medical procedures may not be
acceptable especially if they make the
patient feel worse than the illness itself.
The elderly often refuse treatment for
chronic condition reasoning that they will
soon die anyway even where the doctor
thinks that the prognosis is good.
The context of the patient-doctor
consultation also has bearing on the
outcome. Each party has their own
expectation based on their own personal
history. As such, each has their prejudices,
cultural assumptions including social,
religion, race and gender factors that they
carry with them.

156

Secondly, where the encounter occurs will


also have a bearing. The wider community
in which it occurs and the immediate
surroundings, (e.g. privacy) will influence
how successful treatment is.
In order to improve on the doctor-patient
interaction therefore, it is necessary to
recognize these potential barriers to an
ideal outcome. Helman suggests five main
strategies:
a) Understanding illness
It is critical that the doctor understands
the clinical disease process. In addition, the
doctor must search for an understanding
of the illness which, as we have discussed
above, is dependant on factors including
the patient and the environment the patient
is coming from:
b) Improving communication
Good treatment is dependant on how well
the doctor is able to decipher the language
of the patient and communicate back to
the patient complex medical terms and
concepts:
c) Increasing reflexivity
Successful communication is only possible if
the doctor has an increased self awareness
of her role, her own social and personal
background and how it can potentially
influence the doctor-patient encounter:
d) Treating illness and disease
Treatment should not only be about
managing the symptoms but should ensure
that the patient is reassured and has an
adequate explanation for why they are
unwell;
e) The potential impact of the context
should always be assessed.

Gender

The human society divides the population


into males and females. This division can be
explained in biological terms for example,
only females can have babies. It can also
be described in terms of how different
societies allocate different attributes and
expected behaviour to male and female
biology. However, there is more than just
biology and the role that either males or
females have in a society, is a result of
an often complex interaction of culture,
environmental, social structure and the
biological nature of humans. Gender
can be divided into various components
including:
Genetic gender-based on their
genotype (XY=male, XX = female)
where there is chromosomal
abnormalities then we have people
who do not fit neatly into the male/
female grouping e.g. Turners
syndrome (XO) or Klinefelters
syndrome (XXY);
Somatic gender-based on physical
appearance and the development
of secondary sexual characteristics e.g.
voice changes, breast development etc;
Psychological gender based on a
persons own self perception and
behaviour; and,
Social gender based on cultural
perceptions as to how people should
think, behave, dress and act depending
on the society they live in.
In many societies, men and women
are expected to have different sexual
behaviour. For example, young men may
be expected to prove their masculinity
while young women are expected to be
chaste. In many African societies, a married
man having extra-marital affairs is accepted
but the same is not true for women.

157

This has implications for the management


of sexually transmitted infections such as
HIV/AIDS.
In certain societies, there may be a rigid
demarcation of how women interact with
non-family members that even health
information assumed to be universally
known does not filter through.
The main basic health care providers and
nutrition in the home are usually women.
As we move into the formal health system,
the lower levels of healthcare are often
excusably staffed by women e.g. female
nurses. A visit to a health centre will
show that most of the clients are female.
Family health is managed by women. Even
traditional medicine at the lower level is
female, e.g. traditional birth attendants.
Yet, as we move higher up the ladder, the
administrators and the medical consultants
and surgeons tend to be male.
These dynamics are reflected in a typical
hospital where the nursing staff which
is predominantly female tend to be the
ones in close contact with the patient. The
doctor, typically male, does a ward round
and leaves.
Once in a hospital, the patient is incapable
of doing anything for themselves and so has
few rights and must obey the doctor who
knows what is right. The nurse, particularly
the senior nurse enforces this.
Conditions that in many societies were
not considered as medical problems
are increasingly being redefined as
such. Menstruation and menopause are
examples of normal physiological events
that are increasingly managed through the
formal health system rather than culturally.
In certain societies, women can manage
the side effects of such events through
medication.

Modern obstetrics have been shown to


reduce birth complications and therefore
reduce infant mortality and maternal
mortality. The current health policy globally
is to encourage delivery by skilled birth
attendants within a health facility. This policy
has redefined pregnancy and birth from a
normal physiological activity to one where
it is a health risk to be managed through
the health system.Medicine has been used
to advance the rights of women.
In addition, medicine continues to play a
role in redefining traditional gender roles.
Family planning is promoted at the national
level as population control but at the
individual level as empowerment of women
to decide when they want to have children.
In traditional settings, when women have
children and the number is large, this is
a family issue. In a marriage where there
are no children, it is the woman who is
often blamed for being infertile even if
biologically she did not have a problem.
In certain societies infertility can be
explained in terms of the persons
behaviour or other peoples ill intentions.
Such a woman may end up ostracized
from society. Snowden et al, divide the
role of the mother into three parts, the
genetic mother, the carrying mother and
the nurturing mother. In traditional society,
these roles are performed by one person.
However, with assisted reproduction
using reproductive techniques such as
in vitro fertilization (IVF) and surrogate
motherhood, this traditional concept of
parenthood and families no longer relevant.
Rather than this being a single person, it is
now possible that three different women
can each take one role. In such a case it may
not be clear who the mother of the child
is? Rather than this being a single person, it

158

is now possible that three different women


can each take one role. Who then is the
mother of the child?

Pain and culture

Pain is the most common complaint that


a patient will clinically present with. In
addition to signalling pathology, pain is found
as part of normal physiological changes such
as menstruation and childbirth. Various
treatments such as injections and surgery
also cause pain. How people respond to
pain depends partly on themselves which
is in turn influenced by their cultural and
social background and partly on the context
in which the pain occurs.
While we can measure pain physiologically,
how the victim communicates the pain
sensation can make objective measurement
difficult. We therefore need to take into
account that diverse social or cultural
groups will respond differently to the same
pain.
Pain behaviour is the reaction to the original
pain sensation. For example, a person
pricked with a needle may howl loudly
and burst into tears. Another person may
just grimace slightly and keep quiet. This
pain behaviour can be expressed publicly
or privately. For example, pain associated
with menstruation is commonly a private
pain to the extent that it is defined as
normal pain.
This contrasts with pain associated with
say a broken leg where the person is
expected to exhibit some kind of public
pain behaviour.
Even then, some cultures expect an
extravagant dramatization of pain while
others will expect people to have a stiff
upper lip. Gender plays a part with women

often regarded as the weaker sex in


some instances while in other instances
they are expected not to complain at all.
Exhibiting pain in public is a form of social
interaction between the sufferer and his/
her audience.
The nature of the relationship determines
whether the pain is revealed in the first
place, how it is revealed and the response
elicited. Sympathy and attention occur if
the pain behaviour matches societys view
of how people in pain should display it.
Chronic pain sufferers have a particular
problem communicating the continuous
pain they suffer.
Because pain behaviour within a culture is
often standardized, someone who wishes
to attract attention to themselves imitate
public pain behaviour. Hypochondriacs and
malingerers are examples. A complication
arises where a person is unable to
adequately describe what they are feeling
and thus resorts to use of pain to elicit
help.
In many African cultures, psychiatric
disorders such as depression and anxiety
are difficult to describe and patients often
start by describing symptoms of pain such
as headache.
If, on further investigation, a pathological
cause such as malaria is not found, the
patient can be dismissed as a malingerer
yet they are genuinely unwell. How pain
is described depends on several factors
including, command of language, past
individual pain experience, familiarity with
medical terms and beliefs and understanding
as to how the body functions. In addition,
the doctors own beliefs influence how the
patients description of pain is interpreted.

159

Some doctors lean towards somatic


interpretation of pain while others may
seek psychosocial interpretations.
The doctors context has an additional
impact. Working in a busy outpatient with
little time and little chance of seeing the
patient again pushes the doctor towards
looking for a disease cause while a doctor
working in a practice with repeat, long term
patients is more likely to understand the
psychosocial dynamics behind a patients
complaint.

Pharmacology and culture

Different people can respond in different


ways to the same medicine or drug. This
drug effect and whether or not a person is
cured by a drug depends on a number of
factors. These include:
1. The pharmacological properties of the
drug itself
2. Other attributes of the drug, e.g. taste,

160

shape, colour, name (branded or not


branded);
3. The attributes of the patient, e.g.
socio-economic background, age, sex,
educational and cultural background
4. The attributes of the prescribers, e.g.
age, sex, personality professional
status
5. The physical setting in which the drug
is prescribed, e.g. a hospital?
These factors can help explain the placebo
effect where the positive drug effect is felt
by the patient but the drug administered
does not have the active substance
present.
Placebos are generally culture specific so
that they have to be administered within
a specific setting and culture for them to
work. In another culture, it may not work
in exactly the same way.

Questions

1. Debate the role of culture in health. What models help explain health seeking
behaviour?
2. Describe the sick role and explain the importance of the concept.
3. Explain the difference between anthropological and biomedical models of health.
4. Summarize the health belief model.
5. Describe the doctor-patient interaction in the context of how it affects patients
wellbeing

Further reading

1. International Centre for Health and Society. DETERMINANTS OF HEALTH: THE


SOLID FACTS. World Health. 2003 ;1-33.
2. Gabrysch, S., Lema, C., Bedriana, E., Bautista, M. A., Campbell, O., Miranda, J. J., et
al. (2009). Cultural adaptation of birthing services in rural Ayacucho , Peru. Bulletin
of the World Health Organization, 87, 1-5. doi: 10.2471/BLT.08.057794.
3. Reeves S, Albert M, Kuper a, Hodges BD. Why use theories in qualitative research?
Bmj. 2008 ;337(aug07 3):a949-a949.

161

Introduction

The environment describes everything


that makes up our surroundings both living
and non- living. The environment can be
divided into biological, physical, social,
political, economic and cultural spheres. All
these spheres individually and collectively
interact to impact on health.
The physical environment consists of air,
water, soil, climate and other physical
conditions. The biological environment
consists of plants, animals and micro
organisms including bacteria and viruses.
Political, social, built and cultural
environments are man made.

Many environmental influences on human


health are human-made. For example,
pesticides, industrial chemicals, and air
pollution. But environmental health also
encompasses broad public health issues
including tobacco use, infectious disease,
indoor air quality and allergies, and
sanitation. In this chapter, we look at how
the physical and biological environments
affect human health.
AL

IC
EMon
H
s
i
C Po ins s
ox rgie
T lle
A

Environmental
health
incorporates
the evaluation and control of those
environmental factors that affect health. It
is aimed at creating healthy surroundings
that prevent disease According to WHO
environmental hazards are responsible
for about a quarter of the total burden of
disease worldwide, and nearly 35% in subSaharan Africa.
As many as 13 million deaths can
be prevented every year by making
our environments healthier. Proper
environmental management is the key
to avoiding the quarter of all preventable
illnesses which are directly caused
by environmental factors. Whereas
environmental science tends to address
how human beings affect the rest of the
biosphere, environmental health focuses
on how the environment affects human
health.

PS
S YCH
B tress OLO
GI
D ored
CA
A iscomom
L
nxi
ety fort

HEALTH

SOCIOLOGY
Overcrowding
Isolation

PHYSICAL
Vibration, Radiation
Noise, Humidity
Thermal
Stress
Illumination

ENVIRONMENTAL HEALTH

BIOLOGICAL
Animal
Insects
Microbiological
Vegetation

Fig. 9.1: Relationship between health and the environment

Concerns about environmental health date


from ancient times. Access to clean water
as evidenced by archaeological remains of
water and sewage lines date back more
than 4,000 years. Food safety has always
been a major issue and some methods of
food preservation date back thousands of
years. In addition, different cultures have
developed certain dietary restrictions
some of which are based on food safety
concerns.

162

The need for properly maintained houses


is even mentioned in the Bible where there
is reference to disease in the house, that
is, mould. The impact of rodents leading to
the epidemics such as the black plague in
the fourteenth century in Europe has been
well documented.
The rapid industrialization that took place
in Europe beginning the 18th century
led to the development of the urban
environment. Sanitation took centre
stage as overcrowding and filthy homes
developed. Poor water supply began to be
directly linked to poor health. Later, people
began to be more concerned with how
human interaction with the environment in
the name of progress was affecting human
health.
Rachel Carson published in 1962 on how
DDT entered into the food chain and
had long term, widespread effects on
the ecosystem. The books publication
is credited with starting the worldwide
environmental movement.
Needleman showed that lead was toxic
to the development of childrens cognitive
behaviour. There is continual work that
links the development of various cancers
to environmental exposure to various
carcinogens, such as asbestos. Frumkin et
al, identifies five trends that will dominate
environmental health in the 21st Century.
1. environmental justice
2. a focus on susceptible groups
3. scientific advances
4. global change and
5. sustainability.
Research generally identifies certain
exposures that disproportionately affect
certain communities more than the general
population. Within health, therefore,

a movement emphasizes human rights


and justice as a right. Certain population
groups are more susceptible to harmful
environmental exposure than others.
Children and
pregnant women are
examples of such groups. Scientific
advances including the use of geographical
information systems are yielding new
insights into the spatial distribution of
environmental exposures and disease.
Global change includes several issues such
as population growth, climate change and
urbanization.
Finally, sustainability has been a buzzword
in the development agenda for the last
30 years. The United Nations in a report
titled our common future defined
sustainable development as development
that meets the needs of the present
without compromising the ability of future
generations to meet their own needs.(UN
1987).
Sustainable development aims to protect
the environmental health of the and future
generations.

The DPSEEA model

A key concept that needs to be understood


in environmental health is that of upstream
thinking. Sometimes the environmental
hazard is far away from the point of
exposure. The sources can be multiple.
For example, in thinking about air pollution
we need to think about factory emission,
car emission, indoor household emissions
which means looking at transport,
industrialization, trade and energy policies,
in managing the environmental health
impact that results.
Trying to analyze all these effects and
decide what kind of development should be

163

allowed and how the effect of development


on the environment affects health can be
quite complex.
Driving Forces
(population & economic
growth, technology e.t.c
Preassures
Production, consumption,
waste release, etc

State
(Natural hazards,
resource, pollution)

Exposure
(External exposure,
absorbed dose)

Action
Economic and
social policies
Clean technologies
Risk management
and communication
Environmental pollution
monitoring and control
Education/ awareness
Treatment/
rehabilitation

Effect
Morbidity, mortality, well being, etc
Fig. 9.2: The DPSEEA model

Policy makers need to not only better data


on the linkages between the complexity
of factors in the environment and
development process affecting human
health, but also enhanced understanding
of such linkages.
The D-P-S-E-E-A Model (driving forces,
pressures, state, exposures, health effects
and actions) offers a framework that can
be used to analyze these multiple forces.
There are various factors which are
responsible for health and environment
problems. These factors may be associated
with such driving forces as population
growth, economic development and
technological change.
Pressures may be exerted on the
environment because development sectors
generate various types of outputs such as
pollutant emissions.

This causes the state or(quality) of the


environment to be degraded through the
dispersal and accumulation of pollutants
in various environmental media, such
as air, soil, water and food. People may
become exposed to potential hazards
in the environment when they come into
direct contact with these media, through
breathing, drinking or eating.
This eventually has health effects ranging
from minor to major of which some may
not manifest for a long time.
Pressures such as increased emissions of
carbon dioxide, which in turn change the
state of the environment. For health to be
affected there must be an exposure and
thereafter we see the health effects. To
control environmental hazards and protect
peoples health, various actions need to be
taken and they can be taken at any of the
mentioned levels.
The most effective actions however are
preventive aimed at reducing or eliminating
the driving forces.

Water and health

Human settlements have always been


around a source of fresh water. For life
to exist we need water. However, water
can also be dangerous for human life. The
danger can be as a result of the physical
attributes of water or source of water or it
can be as a result of water being a vehicle
for disease transmission. In addition, almost
invariably humans pollute water sources
often making it unsuitable for others to use.
Some of the major preventable diseases
are associated with water. The association
with water can be classified as follows:
Water washed
Water borne
Water related
164

Water washed diseases


Water washed diseases are those that are
preventable by washing with clean water.
These diseases are transmitted either
faeco-orally or through poor personal
hygiene. Examples are diarrhoeal disease,
skin diseases and eye diseases such as
trachoma. In sub-saharan Africa, diarrhoeal
disease is a major cause of morbidity and
mortality especially in children under 5
years. The root cause of water washed
diseases is a lack of adequate water. How
far people have to travel to obtain water
therefore has an inverse relationship with
the amount of water washed disease in the
community.
Sources of water
The worlds oceans make up 97% of all
the water available. However, most of
this cannot be used without an expensive
process of desalination. Surface and ground
water are the major sources of fresh water
and need protection.
The minimum average per person per day
is 30 litres. Where water flows more freely
such as in functional cities, the average per
person usage rises to about 120 litres per
day.
Water borne diseases
These diseases are related to the quality
of water used. Examples of water borne
diseases are cholera, typhoid, amoebiasis,
hepatitis and hepatitis A. Each year
worldwide, there are more than 100
million cases of diarrhoea resulting from
water borne disease. The quality of water
can be compromised either naturally or
artificially. Humans pollute water in a
variety of ways.
1) Human excreta, biological including
pathogenic and non-pathogenic
microbes

2) Chemicals or industrials waste, organic


and inorganic include persistence
organic pollutants (POPs) Organics
include, Hg, Lead,
Water quality can also be compromised
naturally. Examples of natural contaminants
are fluoride and radio active materials.
Water with fluoride less than 0-1.2ppm
causes dental caries in children especially 8
to 12. Water with fluoride concentrations
of 1.2 to 1.5, is protective for dental
carries. Beyond this level, there is mottling
of teeth and at high levels (>3ppm) skeletal
fluorosis can develop.
Physical contamination such as silting can
either be natural or artificial.
Protection of water
It is easier to protect water from
contamination than it is to have to remove
the contaminant. Protection of water can
only happen if humans and other reservoirs
of microbes do not come into contact with
the ground above the water supply or the
water itself. Protection can be done:
1. Physically by fencing off the water
source
2. Water purification through the
processes of:
a. Sedimentation

When water is allowed to stand for some


time, many of the pathogens die. In addition,
suspended matter settles to the bottom.
The clean water can then be siphoned off
the top. The three-pot system is a cheap
and effective way of obtaining clean water
in a home. Water is collected in two large
pots that are then allowed to stand for at
least 24 hours.
The clean water from the first pot is then
carefully poured into a smaller second pot.

165

The water in this pot can be used for


drinking. The remainder of the water from
the first pot can then be used for washing
and cleaning the house. The following day
the third pot is then used.
In this way at any one time, there is water
available for use. Keeping tap water in an
opaque container in the fridge achieves the
same effect, in addition, the chilling effect
of the fridge inhibits bacterial growth.
b. Filtration

The process of filtration involves passing


water through various types of filters.In
commercial water treatment plants, large
scale filters are made of different grades of
sand layered with fine sand right at the top
and stone/ pebbles at the bottom with an
intermediate layer of coarse sand.
The filter traps foreign materials.
Periodically, water is pumped in reverse
to clean the filter.
c. Sterilization

In homes, water can be sterilized


by boiling or using available chlorine
preparations. 2% of Iodine can also be
used as a sterilizing agent. While boiling
water has the advantage that it kills almost
all pathogens, the disadvantages are that
oxygen content is reduced thereby making
it less palatable, mineral and chemical
concentration is likely to increase. In urban
water supplies water is chlorinated during
the filtration process.
Testing of water quality
Supplies of water should be regularly
tested for quality. Water quality relates
to its physical, chemical and biological
characteristics. Water quality depends on
the local geology and ecosystem, as well

as human uses such as sewage dispersion,


industrial pollution and use and possible
overuse of the water source, each of key
characteristics must be assessed. This
should be done through bacteriological
and chemical analysis.
For bacteriological analysis, the most
important test is for Escherichia Coli (E.
coli). Samples high in E. coli show that
there is faecal contamination of water and
it is therefore unsafe to drink.
Water related diseases

These are diseases where part of the life


cycle of either the agent or the vector
involves water. Examples are malaria,
Shistosomiasis, trypanosomiasis, and
onchocerciasis.
The vectors (e.g. mosquito, snail) in these
diseases need to breed in or near water.
Another form of water related disease is
water dispersed infection. This is common
where people use air conditioning all the
time.
Sanitation

Proper human excreta disposal is


important in breaking the cycle of infection
for many communicable diseases such
as typhoid, dysentery, cholera, hepatitis
A, Shistosomiasis and intestinal worms.
Infective organism present in faeces and
urine can infect man directly (faeco-oral
transmission) or indirectly. Children are
particularly vulnerable. In rural areas today,
pit latrines are the most important way of
excreta disposal.
The aim of pit latrines is to have a place
where faeces can be deposited without
people and flies coming into contact with
them. A latrine should be at least 30 meters
away from a water source, as deep as

166

possible certainly not less than 3.5 metres


deep, and dug on firm dry ground where
water drains away.
The mouth of the pit should be strong
enough to support cross beams, squatting
plate and an enclosure. A concrete slab
is best as it is easy to clean. A vent pipe
that is covered with wire mesh acts as a fly
trap (both ways) and helps ventilate the pit
latrine. The flush toilet (water closet, WC),
is the most hygienic method of excreta
disposal. The major disadvantage is that
flush toilets require drains and sewage
treatment works, which are extremely
expensive. The lack of a reliable water
supply also makes flush toilets useless and
potentially dangerous to use.
Water borne sewage requires treatment
before disposal. This can be done on a small
scale through a septic tank or on a large
scale through sewage ponds. The principle
is the same in both cases as anaerobic and
aerobic bacteria are utilized to digest the
waste.
In septic tanks, sewage drains into a covered
underground concrete tank where solid
matter settles to the floor. Here, anaerobic
bacteria digest it to produce a relatively
small quantity of sludge and a clear liquid
effluent. The effluent is filtered through
underground drains where aerobic bacteria
can digest any further material leaving water
that is safe for reuse. Sewage farms use the
same steps except that huge open ponds of
various depths are constructed to provide
the environment that allows first anaerobic
then aerobic bacteria to thrive.
Sewage passes through the ponds over a
period of weeks. Towns and cities next to
large lakes and the sea usually discharge
sewage out into the sea or lake. Urban

areas present two challenges in terms of


waste disposal.

Solid waste management

Waste management, is defined as the


generation,
collection,
processing,
transport, and disposal of solid waste.
Solid waste management is becoming a
major public health and environmental
concern in urban areas of many developing
countries. The situation in African coiuntries
, especially in urban areas is severe. The
public sector is unable to deliver services
effectively, regulation of the private sector
is limited and illegal dumping of domestic
and industrial waste is a common practice.
In general, solid waste management is
given a very low priority in these countries.
Local governments already saddled with a
weak local taxation system are unable to
finance local service delivery. As a result,
limited funds are provided for solid waste
management. The levels of service required
for protection of public health and the
environment are not attained.
There are a number of different options
available for the management and treatment
of waste including minimization, recycling,
composting, energy recovery and disposal.
At present, an increasing amount of the
resources contained in waste is recycled,
but a large portion is incinerated or
permanently lost in landfills.
Solid waste can be classified simply as
either organic or inorganic and is generated
by households, commercial institutions
and industry. The waste can be further
classified using terms such as hazardous,
special, toxic, industrial and commercial.
However, the definitions of such terms are
not standard across the world.

167

Improper solid waste management has


significant negative environmental, (air,
soil and water pollution), health (diseases
spread by insects and rodents attracted
by garbage heaps) and safety impact.
Changing lifestyles with the move to a
more consumer society (canned drinks,
disposal diapers) has increased the
challenge of providing effective solid waste
management services.
The net effect is that, an increasing
proportion of urban dwellers in particularly
the urban poor, will continue to lack access
to municipal solid waste management
services and, consequently, suffer from
waste management related environmental
and health problems.
While laws and regulations, what is
generally termed as command and control
instruments (CACs), are the most prevalent
mode of solid waste management, interest
in the use of economic instruments (EIs)
is growing. Whereas CACs prescribe the
standards to be complied by economic
agents and their decisions on what, how,
when, where and how much to produce,
consume, emit and clean up, EIs are much
more flexible and non-prescriptive over
actions required.
This allows economic agents to dynamically
innovate ways of cost-effectively complying
with the minimum standards specified.
In other words, economic agents chose
the level of pollution on the basis of their
marginal cost/marginal benefit equation, by
trading with the level of pollution above or
below the minimum.
Most municipalities are required to have a
landfill where such waste can be disposed
of in a sanitary way. A proper landfill should
be dry and consist of impervious clay soil.

A large hole is dug which is then lined with


plastic. A used quarry can also be used
for the same purpose. Refuse is spread
in thin layers, compacted with bulldozers
and covered with a thin layer of soil. Since
decomposing organic material produces
gases and liquids that are potentially
explosive e.g. methane, there must be
vents and drains for prevention. When the
landfill reaches capacity it is covered with
a layer of soil and the surface can then be
used for a park or some other recreational
facility.
The major drawback to such a system is
the huge amount of land used and possible
contamination of underground water.
Reducing the volume of material requiring
disposal obviously helps to reduce the
time such landfills are exhausted. Hence,
the need to re-use and recycle various
materials. Since not all waste is suitable for
landfills, waste must be segregated. This is
preferably done at the source, either at the
household or factory level.
Other methods that can be used for
waste disposal include composting of
organic material converting to manure.
Incineration with subsequent production
of energy can be a useful way of gaining
from waste material. However emission of
possibly toxic air pollutants means that the
waste material being incinerated must be
careful chosen.
A small percentage of solid waste is
hazardous waste. This includes certain
medical waste. Such waste contains
material that is toxic not only to humans
but also plants and animals. Such waste
disposal tends to be regulated by specific
laws.

168

Food Hygiene (Food Sanitation)

No food remains fresh forever.


Contaminated food can be a source
of disease. Food can be contaminated
by biological, chemical or physical
contaminants. Food can be contaminated:
from the soil or water where it is
grown.
during handling at harvest, processing
or marketing, or storage.
by human or animal sewage from
hands, flies, rats or other pests
polluted air or water
Food hygiene is therefore aimed at
preventing food from going bad or
becoming contaminated in the process
of production, collection, storage, sale,
preparation or consumption. Where food
is preserved it must destroy the destroy
existing pathogens, inhibit growth of
surviving microorganisms and prevent recontamination.
Food quality can deteriorate as a result of
two main factors:
Action of enzymes from within cells as
part of normal life processes.
Fresh vegetables and fruit are still
alive when bought and when eaten

raw. Processes like respiration are


still going on.
Other foods like meat undergo a
gradual process of decomposition
after slaughter (autolysis).
Enzymes can break down fat into
butyric acid which leads to rancid
foods.
Growth of various microbes, usually a
result of surface contamination, also
occurs in food and is especially
important for processed foods as they
can become sealed in packages and
continue growing leading to food
spoilage.
Biological contaminants
The major biological contaminants are
bacteria, parasites, fungi, natural poisons and
others. Insects and rodents can gnaw and
damage food and food packaging exposing
the food to the external elements.
In addition, they can contaminate the food
with fecal matter, urine and body parts.
Fungi such as yeast can cause a change in
taste and visibly colonize food. Moulds give
a moldy taste and can produce micotoxins.
Foods may also contain parasites which

Table 9.1: Types of Indoor pollution


Pollutants

Description

Effects on
health

Radioactive
radon

Odourless, colourless, radioactive


gases, decay periods of radium which occurs
naturally

Responsibilty for 5-12% of all lung cancers may


cause nasal cancers

Formaldehyde

Strong smoking ,colourless, water soluble gas, a


component of glue in making plywood, particle,
strengthen crumbly mineral used in variety of
building materials

Irritation of nose,throat and eyes

Asbestos

Fire proof, strong but crumbly mineral used in


variety of building materials

Lung ailments. fatal in high concentration

Combustion gases
carbon monoxide

Lung damage
Colourless,tasteless gas, formed during combustion
Long exposure lung disease

Nitrogen dioxide

169

can infect humans, e.g. Amoeba histolytica.


Certain plants and animals contain natural
poisons e.g. certain mushrooms.
1) Bacteria
Can be described in several ways according
to whether they cause damage or are useful
to man. Bacteria are further classified as
follows:
1. Beneficial bacteria
2. Benign bacteria
3. Spoilage bacteria
4. Pathogenic bacteria.
a) Beneficial bacteria
These are non harmful bacteria and they are
used in food processing, e.g. lactobacillus
which assists in manufacturing of food
such as cheese, butter milk, curdled milk,
yoghurt and condensed milk.
b) Benign bacteria
These are neither harmful nor beneficial
and the majority of the bacteria belong to
this group.
c) Spoilage bacteria
These are non-pathogenic but lead to food
decomposition. They are the cause of
enormous economic loses.
d) Pathogenic bacteria
Certain food attributes can greatly
influence how rapidly and to what degree
food spoils. The moisture content, pH, fat,
protein and carbohydrate/sugar content
are important factors.
Spoilage bacteria
Spoilage bacteria are in themselves
non-pathogenic but by causing food
decomposition, they cause harm and lead
to enormous economic loses. Within the
temperature range 0-60C, each 10 C

rise in temperature doubles microbial


activity. Above 60C, heat quickly destroys
enzymes and stops living cells from working.
Spoilage bacteria are either thermopilic or
mesophilic.
Three types of spoilage by thermophiles
are recognized:
1. Flat sour - the ends of the can remain
flat and spoilage cannot be detected
unless the can is opened. The spoilage
occurs in low acid foods and is caused
by thermophilic species of Bacillus;
such as B. coagulans and
B. sterothermophilus. These organisms
produce acid without gas
2. Thermophilic acid (TA) spoilage - the
can swells due to production of CO2
and H2 by Clostridium
thermosaccharolyticum. Spoilage
mostly occurs in low and medium acid
foods
3. Sulphide spoilage - is caused by
Clostridium nigrificans in low acid
foods.
Spores of this bacterium are not very
heat resistant and their appearance is
an indication of under processing.
Spoilage is indicated by the presence
of H2 and blackening of the material.
Sources of all these organisms are
generally, the plant equipment, sugar,
starch, and other material or soil.
Spoilage of canned foods by mesophilic
bacteria is indicative of gross under
processing or leakage and is caused by
species of Bacillus, Clostridium, yeast
and fungi.
Clostridium butyricum and C. pasteurianum
produce a butyric acid type of fermentation
in acid or medium acid foods with swelling
of the container by the production of
Co2 and H2, Other species of clostridia

170

may produce H2S and other malodorous


compounds causing the can to swell. Moulds,
yeasts and their spores are destroyed by
pasteurization and temperature changes.
Pathogenic bacteria
Pathogenic bacteria are responsible for
most foodborne illness. Most are mesophilic
bacteria. Unlike spoilage bacteria, they do
not generally affect the taste, smell, or
appearance of food.
Food that is left too long at unsafe
temperatures could be dangerous to eat,
but smells and looks just fine. Campylobacter,
and Salmonella are examples of pathogenic
bacteria.
Pathogenic bacteria produce toxins which
can be either heat stable or heat labile.
Escherichia coli produces heat stable toxins
while Clostridium botilinum toxin is an
example of heat labile toxin producer.

Chemical and physical contaminants


Chemical contaminants include heavy metals
that are usually dissolved by the foods pH,
e.g. lead, mercury, zinc. Certain chemicals
can be accidentally introduced into food
sometimes as part of the packaging, for
example, industrial or cleaning chemicals.
In the same way extraneous material such
as detritus, e.g. a stone that is not part of
the food or a foreign object such as piece of
glass can also be accidentally introduced.
Certain chemical residues can be found in
food after being introduced through the
food chain.
Growth enhancer fed to animals and plants
can persist, e.g. diethyl stilbestrol. Pesticide
residue, insecticide applied inappropriately
may still be present in food. The same
applies to antibiotics used to prevent and
treat disease in animals. Animal feed may
contain recycled animal parts that cause
disease. Mad cow disease is an example.

Table 9.2: Types of Food Spoilage with causative organisms


Food

Types of spoilage

Causative microorganisms

Fresh meat

Putrefaction
Souring

C.perfringens, P. alcaligenes, Proteus spp, Lactobacillus

Fish

Discoloration
Putrefaction

Pseudomonas
Chromobacterium, Halobacterium, Micrococcus

Poultry

Odour, Slime

P. alcaligenes

Eggs

Green rot
Colourless rot
Black rot
Fungal rot

P. uorescens
P. alcaligenes
Pseudomonas
Proteus
Penicillium spp,

Fresh fruits and


vegetables

Bacterial soft rot


Gray mould rot
Rhizopus soft rot
Blue mould rot
Black mould rot
Sliminess or Souring

Pseudomonas spp.
Botryitis cinerea
Rhizopus nigrican
Penicillium spp
Aspergillus niger,
Saprophytic bacteria

Sugar products,
Honey, Syrups

Pink syrup
Green syrup
Mouldy

Aerobacter aerogenes
Saccharomyces, Torula,(yeast)
Pseudomonas uorescens
Aspergillus, Penicillium

Bread

Mouldy (black, green


colour)

Rhizopus stolonifer
Penicillium
Bacillus spp.

171

Table 9.3: Types of chemical contaminants


Group

Example

Potential Health effect

Chlorinated pesticides
Organochlorines
Classied as persistent
organic pollutants

DDT(insecticide)
Endrin (rodent control)
Dieldrine (insecticide)

Dichlorodiphenyltrichloroethane (DDT) is a contact insecticide


that kills by acting as a nerve poison
Persist in environments for long 7-30 years.
DDT banned
Lipophilic nature of chlorinated pesticides, they are bioaccumulative and difcult to excrete from the body.
Carcinogenic,
Reproductive and developmental toxicity,
Neurotoxic
Are banned by UN underStockholm Convention (2001) on
Persistent Organic Pollutants, but still available in a number of
countries

Carbamates
(Household insecticides)

Carbofuran
Aldicarb

Organophosphates are the largest and most versatile class of


insecticides.
In the mid-1930s organophosphorus compounds developed into
nerve gases for war e.g. Sarin, Tabun
Organophosphates and carbamates are structurally distinct but have
similar clinical manifestations and management.
Toxic to bees.

organ phosphorous
Organophosphates
(Agricultural insecticides)

Malathion
Parathion

Organophosphates are the largest and most versatile class of


insecticides.

Fumigants
(Agricultural fumigant
pesticide)

Methyl bromide

Neurotoxic.
Readily absorbed through lungs.
Is a cumulative poison. Because it is an odorless gas victim may
not realize exposure. Under US law Methyl bromide is a Class 1
ozone-depleting substance.

Botanicals
(natural insecticides
produced by chrysanthemum
plant)

Pyrethrines
Pyrethroids (semisynthetic
derivatives)

Relatively safe. Inhaling high levels of pyrethrum may induce


asthmatic breathing, sneezing, headache, nausea, tremors, and
convulsions

Food Preservation

Several methods can be used to preserve


food. The method used depends on the
particular food and how palatable the
resultant preserved food is.
Drying or smoking food removes
moisture, which bacteria need for growth.
e.g. fish, meat.
Low PH is a deterrent for bacteria growth
and therefore substances with low PH like
vinegar can be used as preservatives.
Saturation of foods with salts/sugars
prevents bacterial growth, e.g. jam.
Refrigeration prevents multiplication of
bacteria. However, if the food is kept for
some time at room temperature then it

may be long enough for bacteria to start


growing. Refrigeration does not prevent
spoilage. Heat treatment kills bacteria. If
food is sealed in sterile containers, then
spoilage is prevented. This is the principle
behind canning food. Unfortunately, some
of the methods of preservation have been
shown to have adverse effects.
Smoking foods increases the nitrite
content, which has been implicated in the
development of cancers of the GI tract.
Salt preservation can be a major source of
salt intake, which especially in Africans is
associated with hypertension.

172

In 2008, melamine poisoning was reported to have occurred in China. Six babies died and more than 300,000 children
were affected. China recalled more than 170 tons of milk powder after authorities found some batches of tainted dairy
products ordered to be destroyed in 2008 had instead been redistributed.
Ningxia Tiantian Dairy Co. was shut after a police investigation found it had repackaged and sold more than 164 tons of
milk powder tainted with the chemical melamine, the China Daily newspaper reported, citing the local government.
Melamine is a chemical used in the production of plastics that can also be used to make the protein levels of watereddown milk appear higher.Ningxia Tiantian, based in the northwestern province of Ningxia, was a small company and
couldnt afford to buy a machine needed to test for melamine, the English-language China Daily reported, citing Zhao
Shuming, Secretary-General of the Ningxia Dairy Industry Association.
Dairy companies in the province, which depend on selling their products to other regions, are in panic about how the
recall will affect their businesses, the newspaper cited Zhao as saying
http:// www.businessweek.com/news/2010-02-08/ china-recalls-more-melamine-tainted-milk-in-crackdown- update1.html.Accessed 11.10.2010

Food safety standards

Because of the importance of having safe


food available to the public, various laws
and regulations has been passed at both
international and national level. These
laws and regulations must be monitored
for compliance. The following example
illustrates the importance of having proper
regulation in place together with a robust
compliance monitoring mechanism.
Various international bodies including
the World Trade Organization (WTO)
have policies that govern food standards.
National standards also exist. In Kenya,
there are two acts of laws that regulate food
production, namely the Food, chemicals,
drugs and substances Act (CAP 256) and
the Public health Act (CAP242).
In addition, there are laws that regulate the
food supply chain. This is done through the
relevant ministries of Agriculture, Livestock,
Health and Industry.
Prevention of food borne disease and
outbreaks
In homes, we rely on government regulation
and enforcement of those regulations to
ensure that the food we buy is of appropriate
quality.
Food handled in public institutions and in
hotels and restaurants needs further care.
Certain safety parameters need to be in
173

place to prevent the outbreak of food


borne disease. These include:
1) Education and care of food handlers
and equipments respectively.
Knowledge, attitude, practices
education are very important for food
handlers are required to have good
personal hygiene. Any wounds should
be properly covered. A food handler
should not handle food if they are
unwell, forexample, coughing.
Frequent washing of hands with soap
and water is encouraged. Hands should
be dried with paper towels not electric
blowers where moist conditions can
breed bacteria. Education is necessary.
2) Sanitation should be emphasized from
point of production to point of
consumption.
3) Vigilance and inspection. Must be done
for both local and imported food.
A key principle practiced is whether
food produced can be traced back
to where it was originally grown or
processed/ manufactured.
For example, slaughtered animals are
inspected at the slaughterhouse before
being passed fit for consumption.
At the various ports, imported food is
sampled and inspected to ensure it is
fit for human consumption.
Country of origin labels is an example
of a system to ensure only quality
products are imported and exported.

Fig. 9.3: The steps that food undergoes from production to consumption

Table 9.4: 7 Principles of HACCP

4) The kitchen environment should


be clean. Counters should be sanitized
frequently with disinfectant.
There should be a clear separation
between raw and cooked food. Equipment
used should be of correct standard
with regular cleaning using appropriate
detergents and sanitation agents such
as sodium hypochlorite. Stainless steel
is often used because it is easy to clean
and does not corrode. In large catering
institutions, washing machines are used so
that cleaning of utensils can be done at high
temperatures and drying done without use
of towels that can contaminate equipment
already cleaned.
The HACCP (Hazards, Analysis, Critical
Control Point) is an international food
safety system that ensures food is guarded
from point of production to point of
consumption. It is used as a measure of
quality control.
Food sanitation is increasingly concerned
with the sum of all the above processes
and procedures to prevent contamination
of food by physical, chemical and micro
organisms. The HACCP concept can be
used to identify where in the process,
problems are likely to occur.

1.conduct hazard analysis


i.e. Identify hazards,
evaluate risks and apply
control mechanism

Hazards biological, chemical


or p hysical agent

2.determine critical control


point (ccp)

Applied to control risks


hazards e.g. temperature
,disinfectant

3.establish critical limits


(cls)

Critical which separates


acceptability from
unacceptability e.g. from
reputable source versus nonreputable source table foods

Stainless steel equipments


versus non stainless
4.establish of monitoring
procedures

Monitoring observations,
measurements of control
parameters to assess whether
a ccp is under control

5. Establish collective action

Collective action-action to
be taken when monitoring if
results indicate loss of ccp

6. Establish verication
procedure

Verication-application
methods ,procedure
compliance with HACCP
modication

7.Establish determination
procedures

Codes ,records etc

Housing and health

Proper and adequate housing is important


in promoting good health. Housing built
and maintained to proper standards
protect against communicable disease and
injuries. Social and psychological stress is
reduced where there is less crowding and
family units are intact. WHO recommends
that adequate housing should protect
the inhabitants from cold, sun, dust, rain,
vectors etc. The following standards are
recommended:
1) adequate water both qualitatively and

174

quantitatively to prevent water washed


and water borne disease;
2) adequate disposal of excreta, liquid
and solids waste;
3) located in a safe site away from
possible physical calamity such as
landslides etc;
4) adequate space to prevent
overcrowding; and,
5) shelter should have not have
components that make it a work
place e.g. informal trade.
Certain principles apply when relating
housing to health. This can be looked
at from a number of perspectives. In
our environment, protection against
communicable diseases is a priority.
Housing should have safe water supply
with adequate sanitation and solid waste
management systems. Proper drainage
of surface water is important to prevent
water related disease. There should be
facilities for safe food preparation and
storage.
Protection against injuries, poisoning
and chronic diseases is a second priority.
Adequate ventilation and use of nontoxic material in the construction of
the house and furniture helps prevent
the development of disease. Indoor air
pollution results from use of biomass and
charcoal for cooking and heating and use of
kerosene/paraffin for heating and lighting.
The use of pesticide sprays, burning of
mosquito coils and tobacco smoke can also
contribute significantly to indoor pollution.
Exposure to such has been linked to
development of acute respiratory diseases,
otitis media, chronic obstructive airway
disease, and cancer of the nasopharynx
and lungs. Women who are responsible

Fig. 9.4: Urban housing in the slums

for cooking bear a disproportionate risk


from these sources.
Adequate living space with a reasonable
degree of privacy is important in reducing
psychological and social stress. The
provision of space for social amenities
such as play, sports and recreation with
minimum risks of injury and infection
should be mandatory.
Exposure to noise should be kept to
a minimum. General security and the
availability of health and emergency services
provide a sense of well being essential for
good health. Finally, good housing needs
to protect certain populations that are at
special risks. These include women and
children.

Urbanization

According to the UN by 2030, 61 % of the


worlds population will be living in urban
areas. Rapid urbanization is occurring in
developing countries with growth of mega
cities often unplanned and therefore very
poor infrastructure. Local governments
often do not have the capacity to provide
even basic health services.
Poverty and overcrowding characterizes
developing
country
urban
slums.
175

Health is compromised because of the


physiological and behavioural response
to the environment. Indoor air pollution
results from continual use of biomass and
kerosene. Slums tend to be located next
to the industrial ares that needs cheap
labour.
The industries often pollute the immediate
environment with poor waste disposal
leading to contaminated water that finds
its way into the food chain, e.g. vegetables
grown irrigated by contaminated rivers.
Lack of solid waste disposal systems leads
to increased vectors such as flies and
communicable diseases are therefore
common.
The social environment which lacks the
traditional social support structures found
in rural areas means that cities produce an
environment where sexual promiscuity,
use of drugs including alcohol and violence
is more common.
Land tenure systems do not legally support
slum development. The inhabitants of
slums therefore rarely have title deeds
to the land they live on, sometimes for
generations. The incentive to improve the
environment and benefit economically is
therefore lacking.

Environmental pollution

The continual environmental pollution


leading to degradation of the enrvironment
is becoming a major concern worldwide.
Unprecedented world population growth
has created pressure on environments
that were already fragile. Environmentally
sustainable practices are therefore
necessary if the world is to be able to
support the current large population.

environmental pollution affects everybody


even though it is often casued by a few
individuals. Control of environmental
pollution and maintaining a healthy
environment is therefore one of the
important responsibilities of government.
Developing countries being relatively
poor face the challenge of not having
enough resources to grow economically
while investing to protect their own
environments. They also suffer when
developed countries continue to degrade
the global environment often at the
expense of the poorer countries. People
living in developing countries are more
exposed to the shocks of nature and less
able to mitigate disaster when things go
seriously wrong.
In agriculture there has been a push for
greater use of agrochemicals, fertilizers
and pesticides to improve on farm
productivity. Pesticides are substances
used to prevent, destroy, repel or
otherwise control objectionable insects,
weeds, rodents and any other undesirable
forms of life. Pesticides can be classified as
either biological or chemical.
The biological classification is based on the
target organisms. Therefore, fungicides
target fungi; insecticides target insects and
so on. Chemical classifications are based on
the chemical structure of the pesticides.
The global trend is one of increased
pesticide use due to a growing population
and mass production of synthetic pesticides.
Commercial farming practices have
moved more towards crop monoculture.
This results in increased concentration
of particular pests in an area. Growing
resistance means that more frequent use
176

of pesticides is required to eliminate such


pests.
In tropical countries, disease vectors such
as mosquitoes,tsetse flies are endemic
and therefore, pesticides are required for
public health as well.
Depending on the particular pesticide, the
manufacturing process and its chemical and
physical properties, we need to be aware
of possible sites of exposure. These sites
are outlined in figure 9.5 . Going back from
user to manufacturer. Protection including
the use of protective clothing, masks and
gloves may be required at the various
stages.

177

Fig. 9.5: Safety gear

Questions

1. Illustrate how the DEEPSEA model can be used to analyze an environmental health
problem
2. Outline the relationship between water and health
3. Describe the process of solid waste management in urban and rural areas
4. Explain the principles of food hygiene
5. Discuss the role of housing standards in maintaining good health status
6. Outline the concept of HACCP. Apply the priciples to a common food that you buy

Further Reading

1. UNDP. Human Development Report 2007/2008. United Nations Development


Program . New York,2007 ;1-399.
2. von Schirnding Y. Health in sustainable development planning: the role of
indicators. Chapter 7, World Health Organization,Geneva: 2002. p. 105-120.

178

OCCUPATIONAL HEALTH AND SAFETY

Introduction

It has been known for a long time that


certain occupations carry an increased risk
of developing particular conditions. Unlike
in the general population, a specific work
population can be exposed to risk factors,
either in highly concentrated doses or
over a long period, that predispose to the
development of various medical conditions.
The suffering either in economic terms or
in terms of human life can be tremendous
to the extent of negating economic
development.
Occupational health and safety deals with
the relationship between health and work.
It includes the prevention of occupationally
related illness or injury arising from the
workplace, ensuring that those with preexisting conditions or disabilities are able
to work without increased risk of harming
themselves or others and finally promoting
health and safety in the workplace.
Media attention often focuses on dramatic
health and safety incidences at the
workplace such as a collapsed construction
building or a fire in a factory, but the
overwhelming majority of such incidences
go unnoticed.
Often it is believed that this is the price
to be paid for development as developing
countries cannot afford to pay the same
costs as developed countries. However

the true economic costs resulting from


lost work days, production losses, medical
expenses, retraining, hiring new workers
may mean that the perceived saving by
the business not investing in occupational
health and safety is gained by shifting the
cost to the wider society.
Significant differences exist in the level
of occupational health and safety. These
can be seen at country level, different
economic sectors and at different levels of
business enterprises. Gender, age and other
marginalized segments of the population
may also suffer higher levels of occupational
hazard. Developed countries have lower
incidences of work injury compared to
developing countries. Sectors such as
mining, agriculture, forestry, construction
have high incidences of occupational death
and sometimes occupational disease as
well (e.g. mining).
Small workplaces (defined as less than
50 employees) tend to have a worse
safety record when compared to large
workplaces (more than 200 employees).
Women who tend to occupy a lower status
in many communities may be at risk or have
their specific problems overlooked. Many
work at home or on small farms which
are often not subject to normal safety
and health regulation. Part-time workers
or those on non-permanent terms are

In 1775, Percival Pott of Saint Bartholomews Hospital in London described scrotal cancer as an occupational cancer in chimney
sweeps. At that time chimney sweeps were small boys who could t in the chimneys. The soot to which they were exposed has
similar carcinogens to those found in tobacco smoke. Evidence that radiation exposure causes cancer came from an observed higher
incidence of cancer among radiologists. Certain injuries like repetitive stress injuries are more common among ofce workers sitting
at computers.

179

often not provided with the same level of


protection as permanent employees. The
use of child labour has been outlawed in
many countries but the practice still exists.
The practice being illegal means that such
children often have no protection and
work under terrible conditions.
The result of discoveries such as the risks
faced by radiologists and many other
occupations has lead to the development
of guidelines that identify occupational
environmental hazards and sets standards
that protect human health in the
workplace. Both the The international
labour organisation ILO and WHO have
been instrumental in developing and
assisting member states to develop national
guidelines and structures.
International standards can take the form
of conventions or recommendations.
Conventions are similar to international
treaties and once done are ratified by
individual member states. A government
that ratifies a convention is then expected
to pass laws and create institutions to apply
the ratified convention. Recommendations
are weaker and offer non binding
guidelines that member states may use to
advise national policy and practice. has
adopted over 40 standards that deal with
occupational health and safety.
Policy on occupational health and safety
is contained in international labour
conventions (No. 155, 164, 187), while the
WHO at the 60th world health assembly
adopted a workers health global plan of
action. Such policies inform legislation and
practices at the country level.
There are certain core occupational health
and safety principles. They include the

following:
All workers have rights. Workers as
well as employers have rights that must
be protected. To the worker, these
include the right to work in a safe and
health working environment.
In each workplace occupational health
and safety policies must be established.
Such polices must be communicated to
all parties concerned.
Prevention and protection must
be the aim of occupational health and
safety programs
Compensation, rehabilitation and
curative services must be made
available to workers who suffer
occupational injuries, accidents and
work related disease.
Education and training are vital
components of a safe healthy
working environment
Workers, employers and government
have certain responsibilities, duties
and obligations. For example, workers
should follow established safety
procedures, employers must provide
safe workplaces and government
must communicate and review policy
as appropriate.
Policies must be enforced.
There must be consultation among all
stakeholders

Challenges in occupational
health and safety

These occupational safety and health


standards try to balance the need to
protect human life and health and the
economic benefit derived from the various
activities being undertaken. There cannot
be an absolute standard, otherwise: no
economic activity would take place.
However, in defining what the balance

180

should be, several challenges exist.


Changing technology means that each
year, new chemicals, new techniques of
manufacture and job activities are created.
New standards need to be set for each one
and evaluated.
The influence of globalization means there
are new rules that govern commerce,
changing employment patterns and
working conditions create new stresses
for workers. There has been an increase
in migration of labour, goods and capital
across national boundaries.
Across the world the informal sector has
increased in addition to a shift in industrial
production from developed to developing
countries. This means that a large and
increasing proportion of workers are not
covered by basic occupational safeguards.
Developing and developed countries have
different capacities to enact legislation,
provide necessary education and enforce
the necessary occupational safety standards
needed to protect the health of workers.
Increased inequity and discrimination
among various social groups and absolute
poverty among vulnerable groups such
as women creates further challenges that
need to be addressed. People are also
living and working longer. With chronic
disease prevalence rising there is a need to
focus on the effects of these conditions in
the workplace.
The traditional methods in the prevention
of occupational accidents and work-related
diseases have been through:
1. Promotion, awareness raising and
Advocacy campaigns and,
2. Enactment of various laws, regulations
and their national enforcement through

workplace inspection by labour


officers.
This traditional approach is difficult to follow
in developing countries. Unlike in developed
countries where economic activity is done in
large recognized companies, in developing
countries there has been a proliferation
of small-sized, often informal workplaces.
These are now being further encouraged
through increased acces to micro financing.
Such workplaces can even be in the home
and the entrepreneur, the workers and
family members are exposed to health
hazards.
Since such enterprises are often not in
designated work zones, infrastructure is
poor and they may not even be officially
registered with the government. They
therefore are difficult to reach and police.
A further difficulty relates to the synergistic
effect of different exposures. An example is
tobacco smoke and emissions from factories
and vehicles, which can exacerbate the
development of COPD.

Occupational disease burden

A report done by WHO examined the


disease and injury burden produced by
selected occupational risk factors such
as occupational carcinogens, airborne
particulates noise, ergonomic stressors
and risk factors for injuries. In the report,
the occupational risk factors accounted
for an estimated 37% of back pain, 16%
of hearing loss, 13% of chronic obstructive
pulmonary disease (COPD), 11% of asthma,
8% of injuries, 9% of lung cancer and 2%
of leukaemia. These work-related risks
caused about 775,000 deaths worldwide
in 2000. There were five times as many
deaths in males as in females (647,000 vs.
128,000).

181

PHYSICAL

Vibration
Radiation
Noise
Humidity
Thermal
Stress
Illumination

CHEMICAL

Poison
Toxins
Allergens

Health

Fig. 10.1: A framework for occupational health

The leading occupational cause of death


among the six risk factors was unintentional
injuries (41%) followed by COPD (40%)
and cancer of the trachea and bronchus
or lung (13%). Workers who developed
outcomes related to the occupational risk
factors lost about 22 million years of healthy
life. By far, the main cause of years of healthy
life lost (measured in disability-adjusted
life years [DALYs]), within occupational
diseases, was unintentional injuries with
48% of the burden. This was followed
by hearing loss due to occupational noise
(19%) and COPD due to occupational
agents (17%).
Males experienced almost five times
greater loss of healthy years (DALYs) than
females. Low back pain and hearing loss
have in common the fact that they do not
directly produce premature mortality, but
they cause substantial disability and have
multiple consequences for the individual
and society, particularly for workers
suffering the outcomes at an early age.
Protecting the population at the
workplace can be approached from three
perspectives.
1. Prevention of occupationally related
injury or illness. This involves:
a. hazard identification
b. risk assessment of exposure to

hazard
c. determining the population that is
at risk of the hazard
d. Devising strategies and interventions
to ensure prevention. These include
hazard/risk elimination, substitution
or containment. In addition, the
time that a worker spends exposed
to the risk can be reduced
e. Monitoring and evaluating the
effectiveness of preventive measures
put in place (health surveillance
programs)
2. Protecting workers with disability
or pre-existing illness. This involves:
a. Pre-employment assessment.
Having clear previous medical history
b. Indentifying pertinent risk factors
c. Designing appropriate job
placement and work modifications
e.g. a person with chronic bronchitis
or asthma should not be place in an
environment where attacks will be
triggered.
3. Promoting health in the workplace.
This involves:
a. Specific health promotion related to
that workplace. For example, the
dangers of working in a factory
with machinery that can cause injury
b. General health advice as the
workplace offers a captive audience.
For example bank, workers need

182

physical or chemical stressors in the


environment that worsen the health
outcomes.

advice on non-communicable
diseases as their jobs are relatively
sedentary.

Occupational hazards

An occupational hazard is any condition


in a work place capable of causing
temporary or permanent injury or sickness
to the workers or residence of a given
community.
Occupational hazards can be classified
into:
1. Biological hazards
2. Chemical hazards
3. Accidents.
Biological hazards (Occupational
biohazards)
These are either plants, animals or their
products.
Occupational biohazards include:
Bacterial agents
Chlamydia agents
Viral agents
Fungal agents
Parasitic agents
As mentioned above it is possible that
exposure to biohazards can be coupled
with chemical exposure and concomitant

Chemical hazards
There are thousands of toxic chemicals
associated with work and environments.
These chemicals can exist in either, solid,
working liquid or gas. Exposure can lead
to development of acute or chronic health
conditions. The exposure can be either a
large dose at once or cumulative in small
doses over time.
Exposure to low doses of various toxic
chemicals can lead to accumulation in
various tissues and is associated with
development of chronic conditions. For
example, exposure to dust can lead to
pneumoconiosis.
The response to a chemical hazard can be
either acute or chronic. This depends on a
number of factors such as the:
dose-response relationship
genetic make up
sex
age, children and the elderly tend to
be more affected
chemical substance

Table 10.1: Types of occupational bio hazards


Occupation
Bio-hazards

Biohazards

Health
outcome

Mode
of transmission

Healthcare workers

Blood-borne pathogens
(HIV/AIDS, hepatitis,
Haemarraghic viruses)

Infection

injection

Farmers, slaughterers,
veterinary
workers, sugarcane
plantation
workers

Brucella abortus, maletensis


Bacillus anthracis
Coxiellus rickettsiae
sugar cane dusts

Brucellosis
Anthrax
Byssonosis

Inhalation
skin contact

Miners ,sewer workers,


cane
workers, sh gutters

Leptospira from water


contaminated with urine of
infected animals

Leptospirosis

inhalation contact

183

route of exposure
duration of exposure.

Lead poisoning can occur due to exposure


to small doses over a long period of time.

Lead
Lead has been in use for thousands of
years. However, it is only in the second half
of the 20th Century that there has been
understanding of how little lead is needed
to cause harm. Routes of exposure to lead
include air, water, soil, food, and consumer
products. Lead has many uses in industry. It
is included in the manufacture of batteries,
paint, ceramics and glass. At the beginning
of the 1920s, Lead was added to petrol as
a catalyst to aid combustion.

Over time, Lead poisoning can Lead to


anaemia and chronic nephritis. Control
measures include:
1. Protective clothing e.g. use of
protective personal equipment with
use of a respirator that has a filter
with activated carbon that traps
chemicals.
2. Monitoring of the workers to see level
of exposure to specific chemicals.
3. Adaptive work practices. If we are
unable to reduce chemicals in the
atmosphere, people can work in shifts
that ensure critical exposure levels
are not reached,
4. Substitution of toxic chemicals with
less toxic chemicals.

However, since the 1980s, it has been


banned from such use. Occupational
exposure is therefore a common cause of
lead poisoning in adults. For children one of
the biggest threats is lead paint and water
piping that is used in many old houses.
The recommended maximum blood lead
level is 40ug/ 100mls of blood. If workers
do not wear protective Chemical Routes
of Occupation Health clothing during
the manufacturing processes they can be
exposed to lead via inhalation and possible
ingestion. Lead interferes with vitamin D
pathways and can cross the placenta leading
to foetal damage. It also interferes with the
development of the nervous system and
is therefore particularly toxic to children,
causing potentially permanent learning and
behavior disorders.
While a bit of Lead is excreted via the
kidneys and stool, some find its way into
the tissues primarily red blood cells,
organs such as kidney, liver and bone tissue
including teeth.
Lead replaces calcium in nails and teeth and
shortens the life span of red blood cells.

Accidents
An occupational accident is defined as one
that occurs either at the workplace or on
the way or from the workplace. Accidents
have causes and do not occur naturally. An
accident may occur when work is being
undertaken and a proper risk assessment
has not been done. Accidents are classified
as fatal (leads to death), major, (Worker is
off duty for long and lost some body part
or minor. By law, all fatal or major accidents
should be reported to the authorities. For
example in Kenya to the directorate of
occupational services in the Ministry of
Labour.
Accidents can be caused through
carelessness or due to the inherent
processes being undertaken. There is
an interaction between the individual
and the environment, which includes the
organizational culture. Carelessness can be
due to faulty machines, which are either
not manufactured properly or not serviced

184

according to specifications. Motor vehicle


accidents can often be attributed to the
latter cause or poor driving skills.
Certain
processes
are
inherently
dangerous and there must be a high level
of concentration by the workforce. For
example, processes that involve cutting
machines or other dangerous moving
parts, require extreme care to be taken at
all times, to avoid being entangled within
the machinery.
The work environment is important in
preventing accidents. Poor lighting, the use
of unsuitable clothing, footwear, and the
failure to wear protective clothing such as
gloves where required can have serious
consequences.

Work related ill health

The type of work a person does has a


bearing on the accident rate and how
healthy the person is. Work that imposes
a lot of stress, whether psychological or
physiological can affect the well being and
productivity of the worker. Any stimulus
that disrupts the homeostatic well-being
of the body can have a negative effect.
The stimulus can be heat or cold such as
working in a very hot environment, e.g.
next to a boiler.
Long working hours without a break
or repetitive work can lead to drops in
concentration and lack of motivation.
The organizational structure and how jobs
and tasks are organized can have a large
influence on worker motivation. Lowly
motivated workers are more likely to carry
out their work poorly and so cause more
accidents. Workers who do not participate
in any decision making often have reduced
job satisfaction.
185

Poor supervisor-subordinate relations can


have the same effect. Where workers have
low self esteem and escapist behaviour
such as drug and alcohol abuse, accidents
are more common.
An organization with an uncertain future,
such as when there are redundancies
occurring can make people anxious and
therefore stressed. Role ambiguity, where
people are unclear about exactly what
role they should be performing leads to
uncertainty and stress, as goals are not
clear. Conversely, people who have huge
responsibility over other people also
suffer.
Doctors, pilots and air traffic controllers
have demanding roles that are associated
with increased levels of stress. Job and
task requirements need to be evaluated in
terms of the qualitative workload and the
quantitative workload.
Qualitative work is work that is difficult
to do and requires advanced training or
knowledge to perform.
Quantitative work is low in difficulty but
requires a large amount of time for example;
seeing many patients everyday in a district
hospital may result in job dissatisfaction
and monotony.
A different type of quantitative overload
is among people who hold several jobs or
have multiple and diverse responsibilities
the resultant stress from either workload
can lead to drop in performance and
stressrelated illnesses such as coronary
artery disease and peptic ulcer disease.
Control over ones work, and work spacing,
allows an individual worker to set his or
her own pace. The workplace becomes a
friendlier place when the worker knows

what is expected every day and has a


variety of tasks to perform.
Where people have to perform according
to machine pacing, studies show that there
is a feeling of anonymity.
Such workplaces have frequent sick leave
request and morbidity among workers
in machines paced jobs than those in
self paced jobs. Medical examinations
among machines paced people shows high
incidence of vascular disease and stress
levels.
Stress
The body naturally reacts to stress in a
way originally meant to protect against
perceived threats from predators and
aggressors. The bodys stress response
system is usually self regulating. It decreases
hormone levels and enables the body to
return to normal once a perceived threat
has passed. Highly stressful lifestyles can
trigger a continuous stress response leading
to health problems. There are three main
stages of stress response, namely Alarm,
Resistance and Exhaustion.
The alarm stage is the first and immediate
reaction to perceived stress. It involves the
awareness and recognition of a potential
threat. Symptoms include increased pulse,
increased blood pressure and increased
muscular tension. If the stimulus persists
then the individual enters the resistance
stage. At this stage, the Individual engages
in specific psychological behaviour and
physiological efforts to deal with the
perceived source of stress, e.g. sick offs.
This is often seen in people who have been
in a job a long time and are threatened with
impending retirement.

The third stage is the exhaustion stage


where attempts to cope with the problem
are unsuccessful. Resistance is low and
therefore there is increased vulnerability
to psychological and physical disorders
such as low back pain, high blood pressure
and other chronic diseases. Social
support networks can be an important
way of reducing stress and therefore the
development of health problems.Women
often have much better social networks
than men and therefore have possibly
fewer stress related health problems.
Noise
Noise is defined as sound that is a nuisance
or intolerable. It can also be defined as
sound that has potential for inflicting healing
impairments or other adverse physiological
and psychological changes in the body. In
our daily environment, the main sources
of noise are transport, occupational and
neighbouring noise.
Transport noise emanates from motor
vehicles, trains and aircraft. Occupational
noise comes from industrial machines or
working tools such as printers. Household
equipment such as microwaves, washing
machines, food mixers, vacuum cleaners
also generate noise. Neighbouring noise
comes from the surrounding environment
and can be from bars, or heavy traffic on
roads passing through the estate.
Effects of noise
Exposure to noise can cause damage to
humans. Sound can physically damage the
cochlear and cause noise induced hearing
loss. Such hearing loss can be as a result
of exposure to acute intense sound or
because of the accumulated effects of
long term exposure to high sounds. The
severity of injury is related to the intensity,

186

frequency and duration of noise exposure.


Once there is hearing loss, it is usually
irreversible. Special attention therefore
needs to be paid to protect workers from
excessive noise.
Intense noise of short duration can cause
a temporary threshold shift, which once
the stimulus is removed gradually reduces.
However, if the exposure continues for
a long period of time then permanent
thresholds shifts occurs. Permanent
threshold shifts are associated with damage
to sensory cells in the inner ear.
Sound effects

Db

Effects

150

Ear drum rupture

Jet take off


(161meters away)

120

Human pain
thresholds

Jet take off


(305meters away)

100

Temporary hearing
loss

Vuvuzela

127

associated
with permanent
noise-induced
hearing loss

Vacuum cleaner

70

INTERVENTION

SOURCE

PATHWAY

RECEIVER

Fig. 10.2: Controlling noise

Table 10.2: Effects of the different sounds levels


Jet take of
( 25meters away)

the worker. Measuring the noise levels


can help determine the potential risk, for
an eight hour shift the acceptable noise
level is 85dB. The total sound exposure
can be measured using a dosimeter (not in
decibels (dB). In noisy environments, it is
a requirement that workers have periodic
replacements eudiometry tests.

Prevention
Because hearing loss can be irreversible,
prevention of accidents and ill health in
the workplace requires innovative and
constant health promotion and education.

Medical examinations

Annoying

The degree of hearing loss is age dependent


with older people being less able to recover
from loud sound. Apart from hearing loss,
loud sound has other psychological and
physiological effects. Loud sounds can
cause increased blood pressure and heart
rate. People exposed to continuous loud
sound have been found to have higher rates
of congestive heart failure, hypertension
and digestive problems.
Control of occupational noise
In controlling noise, we can consider the
source of the noise, the path along which
the sound moves and finally the receiver.
Approaches that target the noise source
include isolating the noise source or
inserting a barrier between the noise and
187

Medical examinations are useful both for


the employee and the employer. They can
provide information about the health status
of the individual. Depending on the work
to be performed, some conditions can put
the employee at risk in the workplace.
Some of these conditions include Sound
effects, Epilepsy, Poor vision, Asthma,
Alcoholic or drug users, Jet take-off (25150db) Ear drum rupture heart problems,
and tuberculosis.
Human pain thresholds fit individuals. There
are various types of medical (161meters
away) examinations that can be performed.
Some include the Temporary hearing loss
following: (305meters away)
Pre-employment medical examinations
Return to work medical examinations
resumption of noise-induced hearing
loss work medical examinations,

Regular medical examination.


Pre-employment medical examination are
performed prior to a prospective employee
being accepted as a full time employee.
Certain tests and procedures are typically
performed.

Table 10.4: Indications for medical exams

Table 10.3: Elements in pre-employment medical exams


Element

STIs Test

Full medical history

History of previous illness such as


TB, chronic disease , pregnancy

Family history

chronic disease, genetic disorders,


family history of chronic disease

Social history

Alcohol, dug use/abuse.

Physical examination

All major systems

Respiratory function
tests

CXR

Cardiac Function
tests

ECG

Renal function tests

Urinalysis, Serum Creatinine,

Liver function tests

SGPT, SGOT,

Others

Fasting blood sugar, Serum


cholesterol

The results of a medical examination


belong rightfully to the patient. Therefore,
before performing the examination,
written informed consent is required in
order to release the results thereafter to
the employer or insurance company.
Regular medical examinations are done
periodically, to monitor the health status
of the employees. Where there are known
specific exposures these need to be looked
out for. For example, workers in a battery
factory are exposed to lead and therefore
blood lead levels need to be monitored.
Return to work medical examinations/
resumption of work medical examinations
may be required if one has been sick for a
period of time or has had an occupational
related injury. This examination helps
to establish whether the worker has
recovered the capacity to perform the job
at hand.

Work
involving
risks to
health

Medical
examination
required

Examination
intervals

Indications
for redeployment
and
notication
to the director
OHS

Handling
animals,
animals
products,
eterinary
work

Clinical
examination

Reemployment
and annually

All case of
denite or
suspected
zoonotic
disease

Where
asbestos is
handled

Medical
examination
and clinical
examinations
Lung function
Full sized
chest X-ray
Sputum
cytology

Reemployment
and annually

Progressive
deterioration
in chest x-ray
ndings and
suspected or
diagnosed case
of asbestosis

Handling
fossil fuel

Clinical
examination

Reemployment
and annually

Those with
any abnormal
dermatological
or respiratory
symptoms

Work where
ionizing and
non ionizing
radiation

Clinical
examination

Reemployment
and annually

Arboreal
visual
or clinical
signs

Work
involving
exposure
to lead bits
compounds

Clinical
examinations
Blood lead
level

Reemployment
and annually
Repeat
depending on
the blood
lead
level

Cases of
suspected
lead poisoning
especially with
lead levels
of >70 ug
/ 100 ml for
males and
>50um/100ml
for females

Cases of
suspected
lead
poisoning
especially
with
lead levels
of >70 ug
/ 100 ml for
males and
>50um/
100ml
for females

Audiometric
examinations

Reemployment
and annually

Denition or
suspected
noise induced
deafness and/
or cases with
deterioration
of hearing loss
of 20dbor
more in two
successive
examinations
within two
weeks

Environmental and occupational


diseases

These are diseases or conditions caused


by chemical or physical agents found at the
work place. Occupational lung diseases
are collectively called pneumoconiosis.

188

They are characterized by deposition of


particles in the lungs. The disease condition
is due to the presence of the particles and
the bodys response.The size of particles
has an impact on the bodys response.
Particles larger than 10um in diameter
are trapped in nasal cavities in the throat,
trachea and bronchi. The particles may be
swallowed or expectorated out. Particles
between 0.5um and 5um in diameter can
enter into alveoli of the lungs.
The lungs tend to produce an inflammatory
response that in the long term leads to
scarring of tissue and the development
of ling fibrosis with loss of lung elasticity.
Particles less than 0.5um are easily inhaled
in and exhaled out of the respiratory
system. They can therefore be sources of
infection spread.
Asbestosis
This is an example of on occupational
lung disease. Inhalataion and retention
of asbestos fibers causes a chronic
inflammatory process in the lungs. This
process usually occurs after high intensity
and/or long-term exposure to asbestos for
example persons working in production of
asbestos.
Undamaged, asbestos does not present
a health risk. However, if it becomes
chipped, or broken, asbestos can release
a fine dust made up of the tiny asbestos
fibres. Long-term exposure to asbestos
leads to the development of either lung
cancer or mesothelioma.
In many developed countries including
the European Union (since 2005) but
excluding USA, the use of asbestos in new
construction projects has been banned for
health and safety reasons. In developing
countries including India, China and Russia,
189

there is continued widespread use of


asbestos, most commonly in the form of
corrugated asbestos/cement sheets or A/
C Sheets for roofing and for side walls.
Silicosis
The introduction of the pneumatic hammer
drill (1897) and sandblasting (1904)
increased considerably cases of silicosis. It
is caused by inhalation of crystalline silica
dust specifically silicon dioxide. Those at
risk include workers, in cement plants,
and foundry workers involved in smelting
iron.
Hypersensitive pneumoconiosis can occur
after inhalation of large quantities of dust
that triggers an immune response. Some of
the known allergens are, mould detergents
powder, grain dust and mite dust.
Farmers lung disease is an occupational lung
disease characterized by chronic shortness
of breath. It is caused by an allergic reaction
to fungal spores present in moldy hay dust
that has been inhaled. Such hypersensitivity
can also present as occupational asthma
with similar symptoms of wheezing and
shortness of breath.
Bysinossis
This is an acute and chronic airway disease
caused by exposure to Cotton dust,
Flax, Hemp or Sisal dust. The condition
was more common during the industrial
revolution but is rare today. It occurs in
workers who are employed in yarn and
fabric manufacturing industries.
Occupational skin related conditions
(dermatosis)
Occupational skin related disease can be
classified as either irritant dermatitis (80%)
or allergic dermatitis (20%). Allergic
dermatitis is caused by sensitizers chief

among them are solvents like benzene.


Irritant dermatitis occur when the skin
comes into contact with compounds such
as strong acids, aromatic compounds
(phenols), and quaternary ammonium
compounds.

to diagnose. Often, people have a preexisting skin disease or underlying medical


condition, which may be exacerbated
by occupation. Prevention requires a
combined effort from the management
and workers.

Photosensitivity
This is an abnormal reaction of the skin
to sunlight and it exits in two forms;
photo toxicity and photo allergens. Photo
toxicity can affect anyone but occurs more
frequently in Caucasians. Photo allergens
occur because of an abnormal skin immune
response resulting from exposure to
chemicals.

Environmental control measures start by


storing chemicals where workers are not
exposed to them easily. Providing adequate
ventilation,controlling the humidity levels,
and air conditioning helps to limit exposure
to chemicals. The provisions of showers
can help prevent the accumulation of such
chemicals. Ensuring that factory floors are
cleaned frequently and use of exhauster
systems that extract dust particles from
the work environment are useful. Personal
hygiene is also important.

Dyes, coal tar, and some pharmaceutical


drugs are known to cause such a response.
Occupational acne can occur in workers
who deal with machines and tools that
use insoluble oils. Such oils as crude oil,
tar and halogenated hydrocarbons cause
inflammation, which induces scratching.
Various factors can predispose one to the
development of skin related conditions.
Race
Caucasian skin is more susceptible to
sunlight exposure.
Prevention
Skin conditions are sometimes difficult

Personal protection
The use of Personal protective equipment
(PPE) by workers minimizes occupational
risks or hazards. However, there must be
continual health education and supervision
to ensure that PPEs are used properly at
all times. Workers must understand the
risks involved and this can be done through
provision of material safety data sheets.
These outline how to deal with specific
hazardous materials and what to do in the

Table 10.5: Use of personal protection equipment


Age and
Young inexperienced workers and inadequately trained are more prone to occupational skin disease than
experience
older experienced and well trained staff.
Skin
characteristics
Dry skin

Workers with dry skin are likely to adsorb chemical such as solvents, disinfectants than those with oily skin.

Perspiration

If one sweats a lot, they are more predisposed to skin infection due to breakages in the skin when itching is
most common at armpits and genital areas.

Seasons and
humidity

If temperatures at working areas are high there will be a lot of people with skin disease. Humidity comes
with itching and rashes with cause skin disease.

Poor personal
hygiene

Causes of occupational and non occupational skin disease where humidity is a problem, provided showers
for workers.

Hereditary allergy
(atrophy )

People prone to allergies are more likely to get occupational skin disease.

190

event of excess exposure.

Table 10.6: Use of personal protection equipment


Protected Area

Use

Eye and face

For welding ,use a welding shield

Ear muffs

Airport when noise is above 100 db Ear plugs

Lead rubber shield apron

prevents penetration o f ionizing radiations

Gumboots not good for corrosive materials

Protects feet

Heavy duty work shoes

Protects feet from falling and sharp objects materials

Gloves

Hands to reduce friction


To p rotect hands from irritant substances

Protective creams and lotions

Used t o form a barrier and p rotects


skin from irritant compounds
Should b e washed o ff immediately on leaving work

Respirators are of two


types:
I)air puriers
Ii)air supplies

1. Remove contaminates from the air you inhale


2. Supplies air to worker
e.g. those deep sea diving

191

Discussion questions
1.
2.
3.
4.
5.

Describe the challenges faced by developing countries in implementing


Occupational health and safety standards
Identify and classify the major occupational hazards.
List with examples the occupational health hazards related to industrialization?
Explain how ill health can arise in the workplace.
Discuss the role of medical examinations giving examples of the different types
of medical examinations required

Further Reading

1. Albin, Maria, Karin Broberg, and Kristina Jakobsson. Research challenges


in occupational and environmental medicine until 2030.
Occupational and environmental medicine 66, no. 1 (January 2009): 3-5.
2. Gochfeld M. Chronological history of occupational medicine. Occupational and
environmental medicine 47, no. 2 (2005): 96-114.
3. Guidelines on occupational safety and health managements. International Labour
Organization, Geneva. (2001).
4. World Health Organization. Healthy workplaces : a model for action. World
Health Organization. Geneva, 2010 ;1-32.

192

PART IV: Provision of healthcare

Health is a right. Therefore, the way in which healthcare is provided to everybody in society
is a crucial element in the development process of the country. Healthcare encompasses
both clinical individual care and care at the population level. Provision of healthcare includes
taking care of those who are already ill and preventing those who are healthy from falling ill.
The healthcare provided should be equitable, effective and efficient and this is influenced by
how the health services are financed and structured. Health care services can eliminate risk
factors, reduce disease incidencesprolong life and postpone death, thus leading to improved
quality of life in society. Provision of healthcare encompasses a broad spectrum of issues which
include: mapping and needs assessments to ascertain levels of healthcare needs, development
and implementation of a sustainable health policy that will promote effective management of
health services and facilities in the country. This section is divided into the following chapters
where the main issues of health care provision are discussed in details: health policy, health
economics, management of health services and health promotion. By the end of this section,
the reader should be able to:
a) describe the steps in the health policy process
b) identify and list t he key factors taken into consideration formulating health policy
c) outline a framework for policy analysis
d) describe the components of a health system
e) describe the elements needed to have a responsive health system able to deliver quality
healthcare
f) define the terms demand, supply, market and how they relate to healthcare
g) discuss market failure in healthcare
h) equity in health and how it can be applied in health services
i) list the different methods of health care financing and understand the comparative
advantages of each method
j) enumerate methods of economic evaluation
k) outline the management process and the role of a manager
l) enumerate the steps in the planning cycle
m) apply different decision making models to the management process
n) appreciate the importance of organizational structure in delivering on set goals
o) understand the essentials in human resource management
p) understand the principles of monitoring and evaluation
q) list the different approaches to health promotion
r) outline the different models of health promotion theories
s) discuss the risk approach to health promotion
t) discuss the role of health education in a community
u) outline the role of school health in health improving population health status

193

HEALTH POLICY

Introduction

In a country, three basic health care


resources need to be managed properly
for the better of the society. These are:
1. Health manpower,
2. Health care facilities,
3. Biomedical knowledge.
A good health policy provides for these
resources to be distributed equitably, and
used effectively and efficiently for the health
of all. Poor health systems have been cited
as one of the major factors in the poor
health suffered by developing countries.
It is therefore important not only to have an
understanding of individual components of
the health system but also an understanding
as to how the system is organized and
how policies that govern the system come
into being. With such understanding,
we can then take up the challenge of
thinking of new ways to organize, deliver
and better pay for health services. This
would lead to improved performance in
the effectiveness, efficiency and equity of
the health system ultimately leading to the
control of disease.

What is Policy?

There are several definitions of policy.


Policies are written documents and
regulations within governments, and nongovernment organisations. In society, laws
that govern how society functions are part
of policy.
Policy can also be defined as an expression
of general purpose or a desired state of

affairs or a specific purpose for example,


the millennium development goals.
A less broad approach defines policy as
a series of more or less related activities
and their intended and unintended
consequences for those concerned.
Policy is usually directed towards the
accomplishment of some purpose or goal,
for example, government policy on poverty
eradication or improvement of health.

The policy making process

Government exists primarily to take care


of those issues that we as individuals cannot
take care of on our own. Examples of such
issues include provision of security, building
of roads and provision of public health. In
economics, these are termed as market
failures. Often, where there is market
failure, solutions as to how to correct
things for the advancement of everyone
are not easy or clear-cut.
Policies designed to correct these failures
are therefore often unclear and different
policies within the same government can
even contradict each other.
Understanding the policy process is
therefore important in ensuring that the
results advocated by the specific policy
are achieved. In understanding the policy
process, we want to determine several
variables including, Who did what? When?
Where? Why? How? ( 5 Ws and H). There
is a need to understand how these factors
influence decision making and define
success.

194

These variables come into play at different


times. In the policy, making process, four
stages can be identified.
These are:
1. Problem identification and issue
recognition
How do issues get on to the policy
agenda? Why some issues are not
even
addressed?
2. Policy formulation
Who formulates policy?
How is it formulated?
Where do initiatives come from?
3. Policy implementation is the most
important aspect of policy
What resources are available,
finances, staff?
Who should be involved?
How can implementation be
enforced? Are there alternatives/
options?
4. Policy evaluation
What happens when a policy has
been put in place?
Is it monitored? Who monitors?
Does it achieve its objectives?
Does it produce unintended
objectives/consequences?
Problem
identication

In the decision making process, we want to


know how the alternatives are identified,
how the most effective or best alternative
is chosen and put into practice. Several
models have been proposed that explain
how people arrive at decisions.
The starting point is the classical rational
decision model. Within this model, the
decision maker is assumed to be logical
and rational and the decisions that they
make are made in the best interests of the
population. Several assumptions about the
decision makers are made namely;
1. The problem being addressed can be
defined precisely
2. There is complete information about
the decision situation and possible
alternatives
3. They can effectively eliminate
uncertainly to achieve a decision
condition of certainty
4. They evaluate all aspects of the
decisions situation rationally and
logically.
Clearly, in everyday life, these assumptions
do not hold. With many interested groups
in society, just defining the problem can be
difficult. For example, an irrigation project
can be a health hazard or create economic
opportunities that improve health.

Policy
formulation

Policy
evaluation

the act of choosing one alternative from


among a set of alternatives. Knowing
who makes the decision is not enough.
We are interested in how they make the
decisions.

Policy
implementation
Fig. 11.1:The policy cycle

In reviewing or formulating a health policy,


looking through the lens of each stage
allows us to have a clear idea about what
the policy is about and what the policy will
achieve. Ultimately, policy making is about
making decisions. A decision is defined as
195

Whichever viewpoint one takes depends on


a persons background and the perspective
they bring to the problem. The classical
rational model is therefore a prescriptive
model. It describes what the ideal should

be. Herbert A. Simon, an economist


recognized that people are rarely rational.
In addition, in accumulating information,
choosing alternative policy options, or the
best course of action people are rarely
logical or thorough. People will tend to
accumulate information mainly in areas
that they already have some knowledge
about. In addition, the cost of collecting
and analyzing information can be very high
leading people to naturally limit how much
information they deal with.
The classical rational model is therefore
a prescriptive model. It describes what
the ideal should be. Herbert A. Simon,
an economist recognized that people are
rarely rational. He went on to describe the
administrative model, which explains how
decisions are often made. In the model,
decision makers:
1. Have incomplete and imperfect
information
2. Are constrained by bounded rationality.
Rather than being fully rational,
decision makers are limited by the
values they hold and the skills,
knowledge and habits they possess
3. Tend to satisfy when making
decisions. The concept of satisficing
suggests that rather than conduct
exhaustive researches for every
alternative, decision makers look for
alternatives that meet some minimum
standards of sufficiency.
Apart from individuals being non-rational,
political forces may contribute to the
behaviour of the decision maker. For
example, a coalition, that is an alliance of
individuals or groups formed to achieve a
common goal, can advocate or oppose a
particular policy.

Sometimes to take into account such


groups, policy makers avoid thinking
through their objectives to the end to avoid
conflict. They therefore consider only a
small number of alternatives for dealing with
a problem and choose only options, which
differ marginally with existing policies. For
each option, they only consider the most
important consequences. Under such
circumstances, the best policy is one that
offends the least. This model is sometimes
referred to as the instrumentalist model.
Because of these limitations, the end
decision may or may not be in the best
interest of the population.

Policy Analysis

Policy makers and implementers need to


have a clear understanding of the factors
influencing the effectiveness of policy
change. As discussed health policy is subject
to conflict and uncertainty.
One useful tool that can be used to analyze
policy is the Policy Analysis Triangle (PAT).
This provides a framework that takes into
account the key factors that need to be
considered when looking at a particular
policy. Remember, the main reason why
we need to analyze policy and policy
making is because we want policies that
are successful and that guide us towards
our ultimate goal, which is to improve
health status within the population. The
policy analysis triangle consists of four
main variables that need to be looked at,
namely; content, process, context and the
actors.
CO NTEXT

CO NTENT
Fig. 11.2: Policy analysis triangle.

196

PROCESS

Micro -process

The actors are individuals and interest


groups, usually called stakeholders that
are interested or involved in a particular
policy. Policy making process must take
into account the interests of all the actors.
A stakeholder is a person or organization
who has something to gain or lose through
the outcomes of a particular process.
Depending on the stakes, they can have a
powerful bearing on the outcomes of political
processes. These stakeholders may include
government (local and foreign), individuals
in government, NGOs, media, academic
institutions and community organizations.
The different actors may have different
perspectives on a particular issue and these
views need to be known by policy makers
and policy implementers. Examples of the
different groups of stakeholders are given
in table 11.1 below.
Table 11.1: The different groups of stakeholders in health policy
Public sector
stakeholders

Private sector
stakeholders

Civil society
stakeholders

Bureaucracy
(civil servants
and various
departments)

Companies

Organized
religion /churches

Elected
representatives
(members of
parliament,
senators,
councilors)

Business
associations

Universities/
schools

Political parties

Professional
associations

Trade unions

Local
government

Individuals

International
NGOs

Military

Community
organizations

Judiciary (courts)

Media

extent to which each player can respond


to various incentives is also a necessary
consideration.
The Content describes what the policy
is about. It refers to written laws, policies
and budgets relevant to a specific issue.
In doing so, we need to ask what the
policy objectives are and how they will be
achieved.
Analyzing the nature of the benefits and to
whom the benefits will accrue as a result of
successful policy implementation is the first
step in understanding the policy content.
We then need to understand if any other
options were considered before policy
makers settled on this particular one and
why this particular option has been chosen.
Is the option chosen scientifically sound?
Has it been proven to work elsewhere?
Assessing whether the resources needed
for implementation and the existence or
absence of a well laid out implementation
plan gives clues as to whether the policy
will be successful or not.
The institutions involved in the
implementation should also be considered
as certain institutions command influence
and therefore if they are part of a
particular policy then chances of policy
implementation take off are higher.

Multinational
bodies (world
bank, UN)

In addition to understanding the views


of the various actors, it is important to
gauge how much each actor can influence
policy either individually or in collaboration
with other actors. The capacity and the

The Process describes what is involved in


developing the policy from conceptualisation
up to implementation. It takes into account
how complex the changes are proposed
both at administratively and technically.
The time frame for implementation may
matter. In terms of the policy analysis,
the stage at which the policy is, e.g. draft
or final, may have a bearing on the final

197

outcome if for example; key players have


not been involved.
Using the four stages of the policy making
process together with the policy analysis
triangle, we can begin to understand the
policy process and why certain policies
succeed and others fail at each stage of the
process.
We are interested in knowing who is
involved. If a problem is brought to the
attention of certain important people,
it may lead to the issue entering on the
policy agenda. On the other hand, some
important issues can be left unaddressed
simply because the person pushing for it
is either considered unimportant or is not
part of the system.

The content background has to be taken


into account. The underlying value systems
are important in this respect. Medical
personnel may want to push a certain
policy through but the population may
have certain values that are at odds with
this policy. At times, these values may not
even be overtly known.
For example, in one community in Kenya,
only after some drops of blood of a new
born baby are shed in the house does
that baby legitimately belong to that
homestead.

High
Keep satised

action even though in terms of numbers,


the problem might be small. Thus, getting
members of parliament to enact legislation
to jail rapists might be easier than getting
legislation to ban tobacco smoking. Where
quantitative data is used, the methods used
to collect data and how the data is analysed
needs careful consideration to ensure that
the policy is based on robust information.

Engage closely
and inuence
actively

POWER

Monitor
(minimum effort)

Keep informed

Low
Low

INTEREST

High

Fig. 11.3: A framework for analyzing power and interest

Further to this, it is important to analyze


who the beneficiaries of the intended
policy are. Implementers of the policy can
sometimes be the major beneficiaries.
Who opposes certain policies and why can
have an impact on policy success.
The process of how the issues are identified
includes the data used to present a case
for action should be evaluated critically.
Case studies with a human dimension are
powerful ways of getting people to take

Delivery at home fulfils this cultural


requirement. Such people therefore have
difficulty having deliveries performed at
health facilities. Consequently, child and
maternal morbidity and mortality remain
relatively high in such a community.
However, where such value systems clash
with national or international accepted
norms, pressure may come to bear on
such communities to change. Programs to
end Female Genital Mutilation (FGM) fall
under such a category.
The timing of the policy introduction
depends largely on a number of factors
converging together. The Hall model uses
the concepts of legitimacy, feasibility and
support to suggest that only when an issue
is high in all three factors does it become
an agenda item. In this model, legitimacy

198

refers to those issues that government


feels it should be concerned with. Issues
are therefore high or low in legitimacy.
Feasibility refers to the potential for
implementing the policy. This depends on
technical and financial resources available
in the prevailing circumstances. Support
refers to whether the government has
the people on their side for a particular
policy. It may be that powerful interest
groups will block a particular policy from
taking off. Alternatively, the policy may be
one that is deeply popular with the general
population. Such considerations need to be
taken into account before an issue becomes
established on the policy agenda.
The environment contains contextual
factors that have a bearing on which
and how policies can be affected. Such
influential contextual factors can be

grouped as follows.
SITUATIONAL. The size of the
economy of a country or a particular
region has great influence on health.
How economic incentives are
structured and how much money is
allocated to the health sector;
structural. The political and
economic structure in place who has
the economic power, who controls
the income, the media, etc;
cultural. Denotes the values of
society. Where the society is culturally
heterogeneous, it is often difficult
to have uniform societal values; and,
exogenous. Includes factors such as
international agreements, international
donors that may influence, affect
the power of actors and political and
economic systems to act in certain
ways.

199

Questions

1. Define health policy


2. Describe the policy making process
3. Identify and list the key factors taken into consideration when formulating a health
policy
4. Outline a framework for policy analysis
5. Discuss how health policy affects health service delivery

Further Reading

1. Walt, Gill, Health Policy, An Introduction to Process and Power, fourth Impression
2000,(Johannesburg, Witwatersrand University Press, 2000)
2. Gilson, Lucy, and Nika Raphaely. The terrain of health policy analysis in low
and middle income countries : a review of published literature 1994 2007. Health
Policy and Planning (2008): 294-307.
3. Gwatkin, Davidson R. 10 best resources on . . . health equity. Health policy and
planning 22 (2007): 348-351.
4. Ministry of Public Health and Sanitation. Kenya Health Policy Framework 1994 2010 Analysis of Performance Health Situation trends & distribution : 1994-2010 ,
And Projections for 2011 2030. Nairobi, 2010.
5. World Health Organization. Who pays for health systems? In: World Health Report
2000 chapter 5. Geneva: 2000.

200

HEALTH SYSTEMS MANAGEMENT

Introduction
Health policies are formulated and
implemented to direct the health system
of a country. How good or poor the health
system is defines how successful a country
is in improving the health status of its
citizens. Individual interventions known to
work such as immunization can fail when
the various components of the health
system are not functioning properly. Poor
health systems have been cited as one of
the major factors causing poor health in
developing countries despite considerable
investment in vertical programs such as
HIV/AIDS and malaria.
It is therefore important not only to
have an understanding of individual
components of the health system but also
an understanding as to how the system is
organized and interlinked. Today, there are
growing expectations that every person is
entitled to access to healthcare and that
there should be ways in which the sick and
the very poor are protected against the
financial costs of ill health.
This concept of entitlement to healthcare
and financial protection against ill health is
relatively new and involves a considerable
shift in the economic burden of ill health.
Where a person has no access to healthcare
and has no form of insurance against ill
health, when they fall ill, it is the household
that bears the burden. This burden is both
direct in terms of lost income and indirect
as people have to take care of those family
members who are unwell, sometimes
having to sell family assets. In such a
scenario where it takes time to access care
201

and people are not working the actual cost


of health care may be small compared to
the overall costs incurred.
Where the health system is functional, this
burden is taken up by the system. Peoples
lives are prolonged and are able to be more
productive. For example the introduction
of antiretroviral treatment has lead to
millions of people living longer. The cost
of treatments which includes sensitization
campaigns, laboratory testing, diagnosis,
drugs and follow up is not borne by the
patients directly but is covered by the
health system. Such a system involves many
different professionals each specialized in
their roles not just the traditional doctornurse model.
The health system actually starts from the
household level where much of ill health
is managed without ever approaching the
formal health system and extends to include
the use of drugs whether prescribed or not,
traditional healers and health promotion
activities such as environmental protection
and road safety.
Health systems can therefore be defined
as comprising all the organizations,
institutions and resources that are devoted
to producing health actions. A health
action is defined as any effort, whether in
personal health care, public health services
or through intersectoral initiatives, whose
primary purpose is to improve health.
(WHO 2000).

Objectives of a health system

Stewardship can be defined as the careful


and responsible management of something
entrusted to ones care. The Ministry of
Health provides the overall guidance by
formulating health policies, strategies and
regulation which govern the activities of
the health system which includes both the
private, non profit and public sector.

By meeting these last two objectives, the


health system has a mechanism to improve
on performance in terms of effectiveness,
efficiency and equity while controlling
disease. To meet these objectives, the
health system has three key functions
namely stewardship, financing and health
services provision.

Good policy is needed to be able to


identify between providers (whether
public or private) who are contributing
to health goals, and those who are not.
There needs to be appropriate sanctions
or incentives to bring providers in line with
country health goals. Where practices are
known to course harm, the ministry has
a clear role to take action. For example,
where medicines are sold by unregistered
sellers or antibiotics are given without
prescription, the ministry has to be able to
protect the public.

The primary objective of a health system


is to improve health status of people in the
country. It must however do this while:
providing financial protection against
the cost of ill health
being responsive to expectations of the
people using the service.

Consumers need to be better informed


about what is good and bad for their health,
why not all of their expectations can be
met, and that they have basic rights which
all providers should respect

Fig. 12.1: Objectives of the health systems

Stewardship
People entrust their health and their money
to the health system with little recourse if
service is of poor quality. The level of trust
between the consumer of health services
and the provider therefore needs to be
high. This is why the ultimate responsibility
for health services in a country has to be
with the government.
The care and management of the health
of the population is a core mandate of any
government. The ministry of health must
therefore be the institution responsible
for stewardship of the health system.

Financing
As discussed earlier how the health system
is financed has a significant bearing on
how well the system performs in terms
of its core objectives. Financing has three
aspects to it. The system must be able to
collect the financial resources it needs to
meet its objectives.
On the flip side, it must be able pay the
various providers efficiently and in a manner
that aligns health providers to meet the set
goals and ensures equity for all. Thirdly, it
must be able to protect the health system
users against financial catastrophe arising
from ill health.

202

Pooling of risk and contributions to the


health system is essential to greater
efficiency in health financing. When
consumers pay from their pocket at the
time of service, providers are unsure if
they will recover their costs. Out of pocket
payments are major barriers to access to
care.
Tax financing has been shown to be the
cheapest way of collecting funds for the
health system. However, as discussed
elsewhere it has its own disadvantages.
Insurance schemes, including social health
insurance, have some advantages over
tax financing including the setting aside
of a defined amount for healthcare which
cannot be subverted to non health uses.
The main challenge in revenue collection
is how to expand prepayment. Countries
like Kenya have a relatively small formal
sector, a large informal sector and an even
larger population that is absolutely poor.
Public financing is therefore needed to
supplement mandatory insurance. In this
way, revenue pool created reduces the
financial risk of health-care while ensuring
that everyone participates in the health
system.

finances available. The effects on the health


system are both immediate, e.g. the level
of pay for health workers and long term
e.g. if and when the government decides
to set up a new tertiary referral hospital or
medical school. In addition, through a mix
of regulation and influence, the government
can guide other players in the health system
such as donors and private insurance to
purchase healthcare inputs that improve
equity, the efficiency and effectiveness of
the health system.
The health system differs from other social
systems such as education, and from the
markets for most consumer goods and
services, in two ways which make the goals
of fair financing particularly significant.
The need for individual healthcare is
unpredictable and can lead to financial
ruin, loss of health and dignity. It is vital
for people to be protected against these
disastrous outcomes.
Health services provision
Health services provision can be broken
down into the building blocks as outlined
in the WHO health system framework in
fig. 12.2.

Often, when discussing health financing the


focus is on public financing without factoring
the role of private health financing. With
appropriate stewardship, private health
financing can also serve to improve health
provision for the entire country. Contrary
to what might be expected, the share of
private health financing tends to be larger in
countries where income levels are lower.
However, poorer countries seldom have
clear policies on the role of the private
sector. The direct financial contribution
of the public sector is a major part of the

System building
blocks

Over goals/
outcomes

Health workforce
Improved health
(level and equity

Information
Medical products,
vaccines and
technologies
Financing
Leadership /
governance

Responsiveness
Quality
safety

Improved
efciency

Fig. 12.2: Building blocks of the health systems

203

Health service delivery includes both


curative and promotive (public) health
care. These can be organized in three
different ways :
Hierarchical bureaucracy
Long term contracts
Market based interactions

(2006) suggests a minimum worker density


threshold of 2.3 workers (doctors, nurses
and midwives) per 1000 population if a
country is to achieve the MDGs for health.
In carrying out their work, they must
ensure they treat their clients with dignity
and in an equitable manner.

In a hierarchical bureaucracy, services are


delivered by a system where providers
are directly employed. Under long term
contracts the government agrees with
providers (which can be for profit or not
for profit) to provide certain services.

Training and upgrading of skills of staff has


to be a continuous exercise if the health
system is to keep up with changes in
technology and new knowledge in disease
management. This is especially important
where new knowledge or technology
comes at a greater cost than what it is
replacing.

Insurance contracts between members


and the insurer are another example of
long term contracts. Such contracts ideally
should be the subject of regulation by
government. In market-based interactions,
fees are charged either to the patient
directly or the payer.

Human resources

To carry out these services requires a well


trained, motivated work force. Human
resources are the most important of the
health systems inputs and are usually the
single largest recurrent budgetary line item.
In addition training of health workers is not
cheap. They must be paid properly, have
the right facilities, tools and information to
carry out their work. A lack of tools, drugs
and diagnostic facilities can negatively
impact on staff motivation.
Health systems are labour intensive and
require the right mix of qualified staff with
relevant experience to function well.
There has to be a balance between public
health practioners and clinical staff. In
addition, they must also be appropriately
distributed given the epidemiology of
disease in a country. The WHO report

For example management of chronic


diseases such as HIV/AIDS and diabetes
calls for new strategies not only in following
up patients but greater attention needs to
be paid to compliance for those on drug
treatment and monitoring of side effects
for those on drugs for life. The model
of seeing a patient and discharging from
a clinic after a diagnosis of an episode of
malaria becomes outdated.
New knowledge and skills are not just
for the local level. Purchase of medicines
at global level requires understanding of
complex global trade agreements that
govern patents which in turn lead to high
prices of drugs.
Countries therefore require close
collaboration between the relevant
ministries of health, trade and international
bodies like the WHO, the World Bank and
various trading blocks like COMESA and
EU.

204

Monitoring and evaluation of


health systems

The success of health policies and the


health system itself must be monitored
and evaluated on a regular basis. There
are possibly five areas that need to be
measured.
The overall health status
The distribution of health in the
population
Level of financial contribution to the
health system
Distribution of financial contribution
Quality of health care
The overall health status of the population
must be looked at from a life cycle approach
birth to old age taking into account the
different health needs of the different age
groups and sex. The key indicators that
are used for international comparison are
life expectancy at birth and the under five
mortality rate. Other measures such as
maternal mortality rate are important as
well.
The regional differences in these indicators
show the distribution of health in the
country. Additional input indicators such
as doctor/nurse per population or hospital
bed ratios also show whether a given
population is covered adequately. The
adequate levels of financial contribution are
needed if the health system is to improve
health status.
Monitoring financial inflows can be difficult
where the various players are fragmented
and the ministry of health does not provide
the necessary stewardship to ensure that
information is collected centrally. National
Health Accounts (NHA) provides the
information needed to monitor both capital
and recurrent expenditure in the health

system. The NHA captures domestic,


donor, public and private inputs. Data on
physical assets, the number of hospitals,
the equipment in them and the human
resources running them are all captured.
Such information allows the ministry of
health to formulate evidence-based policy.
The financing of the health system needs to
be equitable so that payment of healthcare
is based on financial ability rather than risk
of ill health. Poverty and poor health status
are intertwined. The health system should
therefore be in a position to help people
escape poverty and make them poorer.
This is a problem not just for out of pocket
expenditure but can apply where taxation is
regressive, that is the poor pay more taxes
as a proportion of their income compared
to those who earn more.
The poor can also be locked out by cost
sharing mechanisms that on the surface
are meant to improve quality of care in
health facilities. On the prevention and
promotion side, poor people often live in
areas that are environmentally unhealthy
with poor sanitation or low standards of
housing. They therefore may need greater
public health investment to improve their
health status.
Quality of care measures are designed to
ensure how the health system responds
not only to the clinical aspects of service
but to the non health aspects such as how
clients are treated when they interact with
the system. Quality of care can be defined
as health care that is safe, effective,
patient-centered, timely, efficient, and
equitable. (Institute of Medicine). A
common complaint in health is how the
private sector is so much better in handling
patients compared to the public sector.

205

Overall however, the health sector is


known for long queues and staff who
are often not moved by the suffering of
their patients. Aspects of care that need
to be monitored include choice of care,
timeliness, appropriateness of treatment,
confidentiality of individual medical data
and the respect with which patients are
treated when they seek care.
A good example of a quality of care standard
in the health system is the ability to refer
complicated cases. Appropriate referral
requires recognition of a complication
beyond the capacity of the initial provider/
facility, a communication system and
proper transport system.
This demonstrates the various components
of a functional health system.
To be efficient, the health system must be
cost-effective in offering quality services.
Various health interventions are known to
be ineffective yet continue to be offered.
The prescription of antibiotics for viral
infections has already been mentioned as
has the marketing of mammography for
breast cancer screening to all women.
Especially in poor countries, the use of

proven cost-effective interventions can


not be over emphasized.
A market approach is not enough where
demand is decided on price. A system
where there is implicit rationing such as
buying only a certain quantity of drugs to
treat cancer also has problems as it leads
to poor quality of service and pushes the
frontline health staff to turn away patients
without proper explanation. This can be
compounded by procurement systems
that are erratic in supply, leading patients
to assume the staff are being dishonest in
managing them. Difficult choices, that is
priority setting, therefore have to be made
explicit.
In an ideal system, it is possible to
differentiate the different roles that people
play in the system.
However, sometimes the various roles are
combined in person and in time such as
when a pregnant woman delivers outside of
a health facility with no assistance. At such a
time, she is the consumer, the patient and
the provider financing her own healthcare.
Definitely, this is a characteristic of a failed
health system.

206

Questions

1. Discuss the major objectives of a health system


2. Describe the elements needed to have a responsive health system able to deliver
quality healthcare
3. Discuss the importance of human resource within a functional health system
4. Specify the major building blocks of a health system required for service provision
5. List and explain areas of a health system that need to be monitored and
evaluated

Further Reading

1. Lee, T. H. Turning Doctors into Leaders. Harvard Business Review, April 2010
2. Managers who lead: a handbook for improving health services.
Management sciences for health 200De Savigny, Don. Systems Thinking for Health
Systems Strengthening. Alliance For Health Policy And Systems Research,
World Health Organization, Geneva, 2009.
3. World Health Organization. HEALTH SYSTEMS AND SERVICES Annual Report
2009. World Health. 2009 ;
4. World Health Organization. The World Health Report 2000 Health systems:
improving performance. World Health. 2000 ;215.
5. Zaleznik A. Managers and leaders. Are they different? Harvard Business Review.
January 2004 ; 74-81.
6. Longest, Beaufort B.,Darr, Kurt, Managing Health Services Organizations and
Systems, 5th Ed., (Health Professions Press, 2000)

207

HEALTH ECONOMICS

Introduction

An unhealthy society cannot be productive.


Once we accept this hypothesis, then we
have to wonder why some societies are
healthier than others. A countrys level
of economic development and health
status are closely related. The empirical
evidence is overwhelming that poverty,
whether measured at the level of societies
or individuals, is causally related to the
poor health of societies and individuals,
respectively.
However, the connection between poverty
and health is multifaceted.
Economics is the study of how society
manages its inevitablly scarce resources.
Not everyone can have everything that
they want. Resources generally have
multiple possible uses. In almost all societies
today, resources are allocated through the
combined actions of millions of households
and individuals rather than through a central
planner. This kind of economy is termed a
market economy.
Poverty is the most important cause of
preventable death, disease, and disability.
Having a grasp of economics therefore,
allows the health worker to have an
understanding of a major cause of ill health
and provides reasons why it is worth
investing in peoples health.

Scarcity of resources

Resources are the basic factors of


production. They range from the time
and abilities of individuals, land and natural

resources such as air, water, minerals and


capital comprising of not just money but also
facilities and equipment. Knowledge, such
as knowledge of production processes and
management is a key resource that is often
underestimated. The law of scarcity is a
principle that most things that people want
is in limited supply. Therefore they must be
rationed in some way either through price
or in some other way.
In developing countries, the issue of scarce
resources is even of greater concern when
compared to developed countries. Most of
the population is poor with low education
levels and have a high disease burden.
Both people and the government have few
resources to prevent or cure diseases. Low
economic productivity is the result which
further hampers mobilization of resources.
The economics problems that societies
face can be summarized as follows.
Unlimited wants. Whereas in theory
we want everything, the reality is that
for every decision we make there is a
trade off for something that we give
up. For example, we have a fixed
amount of time. We can spend it
watching TV or studying. Whichever
choice involves a trade off in terms of
what we gain or lose by carrying out
one activity over the other.
Limited resources. Clearly, the means
(resources) to satisfy all our wants are
limited. Furthermore, these resources
have alternative uses.
Making a choice. Individually, therefore,
we have to make a choice about which

208

want we would like to satisfy using


which resources.
Every economy needs to address 3 basic
questions namely: What goods and services
to produce? How to produce those goods
and services? Whom to produce them
for? Economics studies how these choices
are made. Before moving further, it is
important to define some terms that are
commonly used in economics.
Opportunity cost is whatever we must
give up to obtain some item. Resources
are scarce and there is always something
else that can be done with a particular
resource. Opportunity cost therefore is
the value of the next best use (opportunity)
for an economic good or the value of the
sacrificed alternative.
For example the real cost of an activity
(such as provision of hospital services) is
the other outputs that must be given up
(for example, other health services such as
immunizations, or non-health services or
commodities such as defence or vehicles)
because resources are committed to the
first activity. As a society, the goal should
be to maximize benefits for a given cost.

Market, Supply and Demand

Demand and supply are the forces that


make a market work. They determine the
quantity of each good that is produced and
the price at which that good is sold. The
terms refer to the behaviour of people as
they interact with one another.
This interaction between buyers and sellers
creates a market, which in turn allocates
the economys scarce resources.
In a perfect market, the outcome is efficiency,
that is, maximum consumer satisfaction
at the least cost possible. Conditions for

a perfect market are difficult to achieve.


This is because a perfect market requires
perfect competition. This is where there
many sellers and buyers and the products
offered by sellers are uniform. Under such
circumstances, no single seller or buyer can
affect the market price. Since that is almost
impossible, we need economic policies
aimed at influencing the supply and demand
interaction which in turn influences how
the resources are allocated.
Demand
Is defined as the willingness and ability
to purchase a good or services at a given
price In making a decision to buy a
particular good, certain factors influence
demand. The price of the good in most
cases is inversely related to the quantity
demanded. Generally, the quantity
demanded increases as the price falls and
vice versa. This relationship is called the
law of demand.
Factors affecting demand
A persons income determines demand in
that the lower the income the less you can
spend on a particular good. For example,
the richer you are the more chocolate you
can buy. The price of related goods has a
bearing on how much of a particular good
you will demand.
In the case of chocolate, the availability
of cheaper sweets might influence you to
buy less chocolate. Such a good is termed
as substitute. However, there are times
when the fall in the price of one good
leads to increased demand for a particular
good. This is the case when the goods are
used together. For example at the movie
theatre a combo deal which says buy
a movie ticket on Mondays get popcorn
free leads to increased demand for

209

popcorn. In this case, the two goods are


called complements.
Taste and fashion are the other determinants
of demand. Taste and fashion are based on
a societys culture and history and how an
individual relates within society.

convention, the price is on the vertical yaxis while the quantity is plotted on the
horizontal x-axis.
A demand schedule such as the one above
assumes that all the other factors that
could affect the demand are being held
constant.

A particular car might be deemed the car


and so demand for it and consequently
its price relative to other similar cars will
be high. Cigarette smoking in western
countries peaked in the mid 1960s.
Future Expectations can also influence
demand. If there is a perception that a
particular good might be scarce in the
future, then the price today will reflect that
perception. The price of crude oil is a good
example.
Finally, government polices and regulations
have a significant influence on demand.
Tobacco smoking among the youth is
price sensitive. High government tax on
cigarettes therefore reduces demand
for cigarette smoking and is therefore a
powerful tool in public health prevention.
The law of demand can be illustrated using
a demand schedule. The schedule shows
the quantity of the commodity demanded
at different prices. At a certain high price,
the demand would be zero.
Table 13.1: Demand schedule for chocolate
Price of Chocolate
(shillings)

Bars of Chocolate demanded

20

50

16

100

12

150

200

250

Fig. 13.1: A demand curve

Demand curve shift


The demand curve gives us a relationship
between the price of the goods and the
quantity demanded. Therefore, when there
is a change in the price, there is a change in
quantity. The change can be read along the
curve plotted. The other factors that affect
demand cause a shift in the entire demand
curve either to the left or to the right.
For example, if it is announced that dark
chocolate improves health then demand
for chocolate will increase irrespective of
the price. There would then be a shift in the
curve to the right. A decrease in demand,
perhaps doctors declare that chocolate is
bad for you, would shift the curve to the
left.

If a graph is plotted from the above


schedule, we get a demand curve. By
210

Supply
Supply is the amount of goods that sellers
are willing and able to sell. Just like in
demand, the price is a key determinant of
how much will be supplied.
As the price goes up, the quantity supplied
will increase and as the price falls so will
the quantity supplied. This relationship is
called the law of supply.

between the quantity supplied and price


can be mapped out in a supply schedule.

The major assumption made is that all the


other factors are held constant. The other
factors that can affect the supply include:
Input prices
If the price of inputs used to make a good
increase, then less of the good can be made
for the same cost. Therefore the quantity
of good supplied is inversely related to the
price of inputs used to make the good.
Technology can influence supply
Often, technology greatly reduces the cost
of production and therefore raises the
quantity of goods supplied.
The mechanization of cigarette making
in the early 1900s made the process of
cigarette making cheap; instead of being a
luxury good, cigarettes turned into a mass
market good.
This explains the large incrase in cancer
cases years later and heavy cigarette
smoking has become an issue of great
public health concern.
Expectations can affect supply
If it is expected that the price will be higher
in the future, then some of the current
production will be shelved. This leads to
lower supply today.
Oil is again a good example. The relationship

Fig. 13.2: Market equilibrium

Market equilibrium
When the supply curve and demand curve
are put together, there is a point when
the two curves intersect. This point is the
market equilibrium or market clearingprice. At this point (price), the quantity of
goods that suppliers are willing and able
to sell matches the quantity of goods that
buyers are willing and able to buy.
The interaction of demand and supply
determine the equilibrium prices of goods
and services and by doing so resolve the
three basic questions: what, how and for
whom. The market thus decides on how
much of a commodity is to be produced
by providing or setting the price at which
quantity demanded is equal to quantity
supplied. The market tells us who the
goods are being produced for and who
is willing and able to pay the equilibrium
price. The graph can be used to predict
market prices.

211

The concept of elasticity is important


in healthcare because of how price of
healthcare affects access to healthcare.
User fees are now generally considered to
be a major barrier to access to healthcare
particularly at primary healthcare facilities.
Introducing or increasing even nominal
fees leads to significant segments of the
population being unable to afford care.
This means that, at the lower end
healthcare is price elastic. At the higher
end in the private health sector many
providers continually raise prices so that
medical inflation is always greater than
general inflation.
The assumption then is that private
healthcare demand is price inelastic and
is a necessary good. The reality is that it
may reflect the state of public healthcare
services Compared to luxury goods,
necessities such as basic food tend to
have inelastic demand. People must eat.
However luxury goods are much more
price sensitive and high prices will reduce
demand.
Goods that have close substitutes tend to
have elastic demand. Butter and margarine
are examples. A small increase in butter will
lead to a fall in quantity of butter demanded
because people can switch to margarine,
assuming the price of margarine remains
constant.
Given a long time horizon goods are more
elastic. For example, to counter high price
of petrol, people buy more efficient cars
and so the demand for petrol falls.
Some aspects of health care are relatively
demand inelastic. If you are involved in a
road accident you require care immediately.
However, for cosmetic surgery you can

shop around and decide whether to have it


or not based on your needs and the prices
charged.
Market failure
Adam Smith (1723 -1790) widely regarded
as the father of modern economics coined
the expression the invisible hand of the
market place. He wrote, that every
individual in the pursuit of their own selfish
interests, guided by the invisible hand of
the market place ends up promoting the
general economic well being of everyone.
When the market is in equilibrium of
supply and demand - the consumers and
suppliers needs are maximized. However,
in a perfect market at market equilibrium,
both producers and buyers are left happy.
All suppliers have sold their goods at a
price that covers their cost plus a profit
and all consumers have bought all they
wanted at a price they deem reasonable.
Everyone has gained maximum utility. This
is the ideal sitaution.
Elasticity
This refers to degree to which the quantity
of goods supplied or demanded responds
to one of its determinants such as price
or peoples income. For example, the
price elasticity of demand for a good is the
percentage change in quantity demanded
due to a change in its price. A good is highly
elastic if a small change in price leads to a
large change in quantity demanded. The
demand is inelastic when a change in price
does not lead to a change in the quantity
of goods. The same rule applies to supply.
However, this assumes that the market is
efficient.
Under various circumstances, the market
may not be efficient. This situation is
termed as market failure a situation in

212

which the market, when left on its own,


fails to allocate resources efficiently. Two
major reasons that explain why markets
fail are when there is an externality.When
there is market power.
Externality
An externality is the impact of one persons
activity on the well being of a bystander. The
cost of treatment of TB is expensive. Left
on their own a poor, person with untreated
TB may decide that it is better to buy food
instead of medicine. In the process, they
can infect another person who now suffers
as a result of the action of the first person.
In a case like this, the government has to
intervene to enact regulation, to make
TB treatment mandatory and make its
treatment affordable or free.
The market on its own, relying on peoples
self interests will not lead to people getting
TB treatment in sufficient numbers.
Market power
Another cause of market failure is market
power. This occurs when a single person
or entity has excess influence over market
prices. For example, household water
supply typically comes through one water
pipe a monopoly. If this was owned
by a single individual and there was no
regulation, she/ he could charge as much
as she/he wants. Government intervention
is then required to ensure fair pricing.
Fair pricing entails determining an
economic price that allows profit for future
investment and a return to shareholders at
a cost that those who need the services
can afford.
The market rewards people according to
their ability to produce those things that
the market values. It does not ensure
213

that everyone has what they need in


terms of food, housing health and so on.
A professional football player may be
paid millions compared to a doctor. The
government therefore has to intervene to
improve the distribution of economic well
being. Income tax and various other taxes
is one way of improving equity.

Health economics

Whenever people fall sick or have accidents


they require resources to make them
better. For some conditions, prevention is
better than allowing people to fall ill. Again,
resources are required for prevention
activities and health promotion.
Health economics is defined as the branch
of economics that deals with the provision
of healthcare services, their delivery and
use.
Special attention is paid to quantifying
the demands and measuring outcomes
for such services, the social, financial,
opportunity costs of such services of their
delivery and the benefits obtained. More
emphasis is given to the costs and benefits
of healthcare to a population than to the
individual. Health economics is dynamic
in nature because health issues change
rapidly.
Almost everyone will agree that health
services should be efficient and, effective
and equitable. However,
there are
divergent views about what these terms
mean. Given that a true market condition
cannot apply in healthcare, the goal of
market regulation should be to maximize
benefits for given costs.
The major issue then becomes how
we define benefit and who benefits
from healthcare. It is also important to

understand concepts and tools that can be


used to define benefits and calculate costs.

we can to a certain degree understand the


health of the population.

The use of evidence-based medicine is one


way of ensuring that money is spent only on
health interventions that have been proven
to work. The use of economic evaluation,
such as cost effective analysis (CEA), cost
utility analysis (CUA) and cost benefit
analysis (CBA) can help in determining the
best use of resources.

Demand
Gross (1972), produced a formula that
sort to explain the demand for health.
In the formula he hypothesized various
factors that would influence health care
seeking behaviour and therefore in effect
the demand for health.

Defining health
Health is difficult to define in concrete
universally acceptable terms. The world
health organization, WHO defines
health as: a state of complete physical,
mental, social, economic well being of an
individual and not just absence of disease
of infirmity (WHO 1948). This is a clear
definition but difficult to measure.Different
communities have different perceptions of
what constitutes health. As
discussed earlier the doctor may have a
different view of health from the general
population.
Factors that influence an individuals health
status can be grouped into four.(Lalonde
Report) These are
1. Genetic factors (biology)
2. Lifestyle choices
3. Environment the individual lives in,
4. Consumption of health services &
goods.
Health economics tends to focus on looking
at health services rather than health. This
is partly because it is so difficult to agree
on a measurable definition of health. The
assumption is that, since we each know
about our health, when it is not there
100% then we will seek health services, to
restore us back to full health. By studying
the demand and supply of health services
214

H = f (health care, nutrition, consumption patterns, incomes,


education, occupational hazard)

The formula summarizes these factors and


states that demand for health will depend
on the availability of health services. The
more readily available health care services
are the more people will demand for
them.
Governments seek to improve the health
of the population by targeting certain
services such as antenatal care for pregnant
women. Availability of quality health
facilities increases demand for ANC. On
the negative side, studies have shown that,
where the concentration of obstetricians is
high the rate of caesarean section is also
high.
Nutrition and Consumption patterns
The lifestyle that a person leads for
example, eating certain foods or smoking
tobacco, will influence their demand for
health.
Income and socio-economic status
People of higher socio-economic status
demand more health services.
Education
The more educated a person is the higher
the demand for health care services.

Occupation hazard
Working in an occupation that is high risk
healthwise would lead to an increased
demand for healthcare.
Demand for health services
While the above factors influence how
much health a person demands, there are
barriers that can prevent a person from
accessing healthcare. The most obvious
barrier is the cost of healthcare and in
almost all countries public health systems
are built around the tenet that demand
for health should be based on need, not
on willingness to pay. Demand for health
will then differ in definition from the classic
definition for demand found in classic
economics. The cost of healthcare incurred
by a patient can be divided broadly into
three:
1. The fee charged by the health provider;
2. Costs incurred by the patient in
accessing the care including travel
and time away from work
3. Intangible costs such psychological
costs and pain. These can be quite
difficult to quantify. There are other
barriers to accessing healthcare.
In any structured health system, formal
barriers exist.
Referral policies exist.
Referral policies are necessary in
order to have a planned functional
health system but can have the effect
of denying a patient a particular service
at a particular time.
Principal-agency relationship.
Unlike in classic economics, rarely
do patients access healthcare directly.
Often, the patient is aware of the
symptoms but requires someone else,
the doctor, to interpret the symptoms
and signs.
The type and quantity of healthcare
demanded therefore depends on the

doctor. This relationship between the


patient and the doctor is described as the
principal-agency relationship.
The doctor is the agent of the patient. In
order for the relationship to work to the
best advantage of the patients health,
several things must be in place.
The patient (principal) must be able to
communicate to the doctor the extent
health status.
The doctors incentives must be
aligned with those of the patient.
For example, there is a delay where
the doctor is paid by the number of
procedures performed, she will tend
to steer the patient towards having
more procedures.
The doctor and the patient must be
able to agree on what the patient
really needs.
If the doctor was a perfect agent they
would give the patient all the information
the patient needs in order to make an
informed decision and the doctor would
then implement the patients decision.
The reality may be the other way round
where the patient gives the doctor all
the information he needs in order for the
doctor to make a decision as to what health
services the patient needs.
These barriers to accessing healthcare and
therefore health lead to the conclusion
that, if the principal applied to demand for
health is based on need, then healthcare
should be free or at most a nominal fee
can be charged. Even if health care was
free, we would still have some non-price
barriers. It is clear therefore that the buyer
of health services (patient) is not sovereign.
The patient does not necessarily know
what they want (need), they may not have
choice or the freedom to act as they wish
in pursuit of their own perceived health
needs.

215

Moral hazard
In healthcare systems where the payer for
the health services consumed is someone
other than the patient, there is a problem
of excess demand. Such an instance
arises, for example in an insurance based
scheme and is known as moral hazard.
More healthcare is demanded than would
be the case in a perfect market. This is
because the consumer does not incur any
cost in demanding additional healthcare as
it is covered by insurance. Moral hazard
has two sides to it.
The consumer moral hazard arises because
insurance lowers the cost of being ill thus
the incentive be healthy is reduced.
Additionally at the point of service, care is
free and so expensive health services can
be ordered and the patient is happy with
this. The price of healthcare at this point
has no meaning.
Provider moral hazard occurs when the
provider is paid based on a fee for service.
The more services provided the more
money the provider makes. This holds
where the price of the service is higher
than the competitive price. Where the fee
is below the competitive price there is an
incentive to under provide care.
This means expensive city-based doctors
have a tendency to induce excess demand
for health services among their patients
while poorer rural health service have
a tendency to reduce demand for health
services.
Supply for healthcare
The supply of healthcare is dependant on
how the healthcare system is organized
operationally and how it is financed.
In a classical market, the suppliers and
consumers of goods communicate through

price. The price of the good will determine


how much supply and how much demand
there is in the market. The assumption
made is that the market is one of willing
buyer willing seller. Unfortunately, for
health and healthcare, there are several
factors that interfere with this simple
concept. Most people do not want to
be used to healthcare. Using healthcare
reflects a lack of health and good health is
the preferred state to be in.
Therefore, most people, when demanding
healthcare are not willing buyers. Secondly,
for many health conditions, it is not just
the individual suffering who has a stake in
their own health. When your neighbour
has TB, you have a direct interest that he
gets better quickly before he spreads the
disease to you. The term used to describe
such a situation is externalities.
The third major factor is the doctor-agency
problem described earlier which impacts
in a major way what healthcare is available.
Lastly, is the way in which healthcare is
financed which is discussed below.
Efficiency
As discussed earlier we live in a world of
scarce resources. Therefore minimizing
costs and maximising benefits must be a
key goal. Providing healthcare inefficiently
means that resources are not wasted that
would have saved another life. We can
view efficiency from two perspectives:
Allocative efficiency determines whether
an activity is worth pursuing at all. We
look at the health system as a whole and
determine whether pursuing a certain
policy or programme is worthwhile in the
first place.
Many health interventions look good when
done in small trials for a few patients. A

216

decision needs to be made on whether it


is worth scaling up such an intervention.
For example, mammograms are used
as a screening tool for breast cancer. A
question would arise as to whether the
government should offer mammograms as
part of a national health program. In making
a decision based on efficiency, the question
would be, given this amount of resources,
is this the best way of improving health
status?
In practice, the easiest way is to carry
out a comparison with other possible
interventions and decide which ones
increase health status the most, e.g.
immunization.
Technical or operational efficiency deals
with the question, having agreed that an
activity is worth doing, what is the most
efficient way of carrying out the activity? It
is a question of achieving results using the
least possible resources or carrying out the
maximum activities possible using a fixed
pot of resources.
In health care delivery terms, looking
at efficiency means assessing which
interventions will produce greatest health
gains for a given investment of resources,
focusing on that activity and doing it for the
least cost.
Equity
Equity embodies the concept of fairness.
In all societies, there is concern that there
should be fairness in the distribution of
health services. How equitable health
services are is a key factor taken into
account when judging the success of
policies in the health sector.
There are two scenerios where equity
does not apply. Within society there are

people who are better off, materially and


health wise when compared to others.
Such people are usually concerned that
those less well off should access healthcare
and are willing to pay for these poorer
people. Both sets of people benefit, the
rich, the personal satisfaction that they are
giving back to society and the poor, better
health. However, this is not necessarily
an equitable society because it relies on
the benevolence of the rich rather than a
democratic process where everyone has a
chance to determine what is fair.
Secondly, equity is not the same as equality,
that is, having an equal amount of health
or healthcare. Right from birth, people are
born with different health states depending
on a number of factors mainly influenced
by their genetic make-up.
Society may judge it fair (equitable) to
provide more healthcare to a person born
with a cleft lip than a person born without
any deformity. In such a case, unequal
access to healthcare is deemed fair. We
talk about equity in access to healthcare
rather than equity in health because we
know from the definition of health that it
is difficult to determine exactly what fair
health is.
It is convenient and easier to measure
access to healthcare that access to health. A
good healthcare system therefore pursues
a policy of fair distribution (not equal) of
health services.
In this regard, there are two dimensions
toequity:
Horizontal equity
means equal treatment of equals.
This would require that all those with
similar healthcare needs be given

217

collected from the general population


and put into one pool. A budget process
allocates funds to various government
ministries including health. Taxes can be
progressive or regressive, that is fair to
those less well off in society or take a
disproportionate amount of household
income from poorer households compared
to richer ones. Taxes on food can fall
into this category since the poor spend
a greater percentage of their income on
food compared to the rich.

equal opportunity for treatment.


For example, across the country every
pregnant woman should be treated
the same when it comes to delivery of
her baby.
Vertical equity means unequal
treatment for unequals. It implies
equality in service utilization and
positive discrimination towards those
who are less willing or able to use
health services. Those with greater
needs (more severe illnesses, inability
to pay) would obtain concessional
access. Services targeting low income
groups or gender-based programs are
examples of vertical equity.
Financing health services
Allowing individuals to pay for their
healthcare at the time they need it clearly
leads to problems of inequity. Because of
the market failure, it is unlikely to be an
efficient method of delivering healthcare
The government therefore has to be
involved in financing healthcare. The way
in which health services are financed has a
major impact on delivery. Health services
need to be financed in a way that maximizes
equity and efficiency. This involves looking
at how money is raised to pay for health
services, how suppliers of health services
are paid and how the disadvantaged within
society are able to access health services.
Taxation
General taxation is the method that most
countries use to raise money to pay for
health services. A variety of taxes are

A tax system that makes poor people


poorer is clearly not an equitable one.
Care must therefore be taken to ensure
that taxes do not penalize the poor. If such
taxes are used to purchase healthcare
then we have a situation where the poor
are subsiding the rich. A general taxation
system has several advantages.
The cost of collecting tax is generally low.
Revenue authorities charge an overhead
of 2% or less to collect tax. While
governments retain the right to collect taxes,
the level of taxation is something that the
public has a say in through the democratic
process. However, tax management in
developing countries is often inefficient
with the tax base concentrated on relatively
few people who are easy to collect from.
In almost all developing countries the
government directly provides services
through some kind of national health
service. Such a system should be efficient
due to economy of scale. However it

Inequities are killing people on grand scale, reports


WHOs Commission 28 August 2008 | GENEVA -- A child born in a
Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away. A girl in Lesotho is likely
to live 42 years less than another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in
Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between - and within - countries result
from the social environment where people are born, live, grow, work and age. (The) toxic combination of bad policies, economics,
and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is
biologically possible, the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health.Social injustice is killing people on a grand scale.
Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, WHO 2008

218

is often plagued by same evils such as


corruption, poor management that bedevil
other parts of the public sector. The public
systems in developing countries, therefore,
fail to provide universal healthcare. It is
therefore not surprising that out of pocket
expenditure (OOPs) is highest in the very
poorest countries.
In Kenya, around 56% of total expenditure
in health is private. The government
expenditure is around 44%. (WHO, World
Health report 2005). This out of pocket
spending forms a large part of the income
of the poorest.
Private health insurance
Private health insurance typically augments
a public financing system. Because this is
voluntary, it should in theory be more
efficient as it moves more towards the
classic market structure. However, the
government is still needed to manage
market failures such as adverse selection
and risk management. In addition, private
health insurance is often expensive and
thus the poor cannot afford it.
The fact that private health insurance often
has a profit motive is an ideology that many
people are uncomfortable with. If health
insurance companies make large profits it
means money is being made from a sector
where the function should be restorative
as the health sector does not produce
economic wealth like say the agricultural
sector. However the concept of insurance
is a good one. Insurance aims to protect
individuals against rare and expensive
events.

A debilitating illness can wipe out a family


financially. At individual level, it cannot be
predicted when such an event will occur.
But on a population basis, the number of
such events can be predicted allowing a
premium to be set to cover such events.
However, collecting private health
insurance premiums are often expensive
running up to 50% of the funds collected.
Social health insurance
Social health insurance attempts to address
the problems of exclusivity of private health
insurance, the inefficiency that occurs in a
taxation/public sector finance/provision
model by enrolling the entire population
into a health scheme. This allows pooling
of health risk and pooling of contributions
including government and households.
The issues of adverse and risk selection are
eliminated as contribution is compulsory
and everyone is a member of the scheme.
Social health insurance allows an easier
mechanism to fund private health providers
to mitigate perceived he poor provision
associated with public providers.
Governments are interested in social
health schemes because it allows additional
funding into healthcare. The government
alone is not responsible for financing
healthcare. Because people are paying
directly for their healthcare, they have a
greater say in how the funds are utilized
when compared to public financing.
However, enrolling members is an
expensive exercise and health facilities need
to be at the level expected by members.

As part of structural adjustment programs in the 1980s a number of countries including Kenya introduced cost sharing as a way to help
mitigate falling government nancing. Apart from generating additional revenue the funds would be used by the facility to improve the
quality of care and reduce frivolous demand for healthcare. However over time it has been shown that cost sharing denies access to the
very needy, is inefcient to collect cost of collecting the funds often more than the amount collected and encourages corruption.
(Ref HEALTH POLICY AND PLANNING; 11(1): 52-63 D COLLINS et al).

219

Cost sharing
The theoretical argument for cost sharing
follows from the earlier discussion on
markets and market failure. In a perfect
market, there is no need for insurance
as all the information that is needed by
the consumer is available at the time of
purchase. However, when the consumer
does not pay for healthcare costs, there is a
tendency to consume more than is actually
needed because treatment decisions
are made without regard to the financial
costs.
Care that is high cost and low or no benefit
may be chosen. In a fee for pay system
the care provider may have incentive to
inflate costs and therefore healthcare is
not cost-effective and excessive healthcare
may be provided. However, cost effective
care is only useful if people already use the
service. Where service utilization is low as
in many SSA countries, the major challenge
is to increase utilization.
WHO has recognized this need, and in its
World Health Assembly resolution 2005
WHA 58.33 called on all member states to
plan the transition to universal coverage
of their citizens. The difficulty for policy
makers is how to raise sufficient funds to
pay for the necessary services without
excluding the poor and vulnerable. In
the 1980s, developing countries found
themselves with reduced public sector
budgets due to donor-lead structural
adjustment programs (saps). Following the
publication of an influential World Bank
report by (Akin et al 1987), about financing
of health services, user fees seemed to be
a magic bullet. Introducing user fees would
see three major benefits:
1. Additional revenue would be generated
for the health sector, possibly upto
1520% of operating costs.

2. There would be increased efficiency of


government health services delivery
by reducing frivolous demand and
encouraging use of those with low
charges and costs.
3. Improved access for poor people
because revenues from urban services
could be used to cross-subsidize
disadvantaged people in rural areas.
The overall effect would be that user fees
would be effective (in raising additional
funds), efficient (by encouraging an efficient
use of services), and equitable (in benefiting
poor people disproportionately).
However, over time, it has been shown
that cost sharing denies access to the
very needy, is inefficient to collect - cost
of collecting the funds is often more than
the amount collected and encourages
corruption. UNICEF reported that almost
all studies had a negative effect on equity of
access through reduced access by the poor.
Having realized, this developing countries
are now leading efforts to remove health
user fees.
One way to get the interests of the
consumer and the payer aligned is to get
the consumer to pay part of the cost of
care. This can be done as a:
Cco-payment which is a flat fee paid
for each medical service obtained, for
example a nominal consultation fee.
co-insurance, where the patient pays
a certain percentage of the total bill
e.g. 10% of in-patient care).
deductible or excess payment, where
the patient pays the first part of a bill
then the insurance takes over the rest
of the bill.
Whether cost sharing is effective depends
on a number of factors. In deciding which

220

type of user fees to apply it is important


to take into account the type of medical
service, income levels and the health status
of the patient.
Type of medical service
Cost sharing for preventive services
is associated with lowered levels of
preventive services. It is therefore more
often applied to curative services. Outpatient services such as consultation
fees, drugs, laboratory services are often
targeted for cost sharing.

Income levels
Cost sharing has a disproportionate financial
impact on people with low income.
Health status
Cost sharing may cause those with chronic
conditions requiring repeated visits to cut
back on services. This can impact patients
such as HIV patients on anteretroviral
drugs. Cost sharing done across the board
reduces access to care and affects those
most vulnerable, the chronically ill and
those with low incomes.

221

Questions
1.
2.
3.
4.

Discuss the factors that affect demand and supply for health services
Illustrate with an appropriate health services example, a perfect market
Identify the factors that cause market failure in healthcare
Define the concept of equity as it applies to provision of health care system in a
country
5. List the different methods of financing health care

Further Reading

1. Adam Wagstaff. SOCIAL HEALTH INSURANCE REEXAMINED. Health economics


517, no. April 2009 (2010): 503-517.
2. Alliance for Health Policy and Systems Research. SYSTEMS THINKING for systems
strengthening. World Health Organization,2009 ;1-112.
3. Banta HD, de Wit GA. Public health services and cost-effectiveness analysis. Annual
review of public health. 2008 ;29383-97.
4. McCoy D, Brikci N. Taskforce on Innovative International Financing for Health
Systems: what next? Bulletin of the World Health Organization. 2010 ;88(6):47880.
5. National Health accounts Unit, WHO. Do health expenditures meet health needs?
World Health Organization www.who.int/nha. Geneva: 2009.
6. Remler DK, Greene J. Cost-sharing: a blunt instrument. Annual review of public
health. 2009 ;30293-311.
7. Samuelson Paul A., Nordhous, William D., Economics 18th Ed, (New York,
McGraw-Hill Book Company ,2004)
8. Mankiw, Gregory N., Principles of economics, 5th Ed (Fort Worth, The Dryden Press
,2008)

222

HEALTH SERVICES MANAGEMENT

Introduction

Healthcare services can be defined as the


societal effort focused on delivering health.
Such services are delivered through various
organisations. The type of service being
offered preventive, curative, acute or
chronic care, influences the organizational
set up. We therefore have primary care
organisations, hospitals, clinics, nursing
homes and others. The organization can be
for profit, non-profit or public. In all cases,
these organizations require management if
they are to deliver proper health services.
The organizations themselves can be very
complex. A hospital, for example, offers
hotel services to admitted patients, must
be able to track by name returning patients
to an out-patient diabetes clinic, run an
emergency room and so on. Each service
requires different types of personnel and
resources. The environment is also dynamic
with ever changing medical technology,
new therapy and consumers who expect
higher standards of care.
Under these circumstances, the manager
within the health services at all levels must
have the necessary knowledge and skills
in management and administration to
improve the effectiveness and efficiency of
the health services provided.
Management in health differs from other
sectors in the economy because of the
different and divergent goals that must
be met in delivering service. Businesses
ultimately have a single goal which is to
make profit. The consumer decides what
they would like to buy and the phrase the

customer is always right epitomizes the


power of the buyer. Healthcare starts with
preventative services the aim of which is
to reduce demand for health services.
The elimination of a disease e.g. Small
Pox means that hospitals no longer have
to cater for such patients. Furthermore,
as we saw earlier, suppliers of healthcare
hold considerable power in determining
demand for health services.
The occurrence of monopolies whether
local for example a hospital or more
widespread like the public health system
means that it is almost impossible to use a
business approach to providing healthcare.
Equity remains of paramount importance.
So even though the basic framework of
management, namely planning, organizing,
directing and controlling are used, significant
differences emerge in determining success
in the management of a public health
service.

Defining management

Mary Parker Follett (18681933), writing


in the early
20th Century, defined
management as the art of getting things
done through people. Individual patient
care still relies on the skills and knowledge
of a specific doctor looking after her
or him. However, the doctor needs an
organized system to deliver the necessary
care the patient needs to get well. This
healthcare system is more than just about
curing an individual patients disease. It is
about the provision of health services to
people to prevent illness and treat disease
and conditions of ill health. This involves

223

various cadres of people including doctors


and paramedical people, administrative
support staff from security to accounting.
This institutional arrangement needs
management to hold them together. Peter
Drucker (1909-2005) the guru of modern
management describes management as
being:
About performing tasks
About discipline
About people
Not common sense alone
Both a function and the people who
discharge it.
The management process can therefore
be defined as set of activities including
planning, leading and controlling, directed
at an organizations resources, (human,
financial, physical and information) with
the aim of achieving organizational goals in
an efficient and effective manner.
Planning
& Decision
making

Control

Organizing

Leading

Fig.14.1 : The Management Process

Health sector management challenge


Within the health sector, the role and
importance of management has been slow
to develop. There are still many people
who assume the problems we face are
technical and that the solution lies solely
in having more technical resources. If we
could find the perfect vaccine, then all our

health problems would disappear. While it


is true that breakthroughs such as better
vaccines are important, there is a growing
realization that better management
practices are also essential to delivering
health results.
A good part of management is culture
and therefore it is not enough to import
wholesale, practices that have worked
elsewhere. They may or may not work
within a local context. Thus is because
we are dealing with people in a specific
health environment, that we talk of health
management being a practice and not a
science.
In any developing country the health sector
challenge is immense. These countries
are faced with a quadruple burden of
disease. Communicable diseases are still
prevalent, there is a growing epidemic
of non communicable disease, HIV/AIDS
overshadows much of what is done in
health sector and there is a significant
burden due to injuries associated with
road traffic crashes and the processes of
development.
This scenario is coupled
with very
weak health systems with inadequate
staff numbers, staff with inadequate
management skills, money and other
resources. The management has to be
much better than a resource rich setting to
accomplish the goals of providing quality,
efficient and equitable healthcare.
History of management
The building of the pyramids in Egypt,
apart from being a great engineering feat,
involved considerable management and
organization of thousands of workers
needed to construct them. Ancient Greece
is generally considered to be the foundation
224

of Western civilization and had a powerful


influence on the Roman Empire. After the
collapse of the ancient civilizations and
prior to the Industrial Revolution, most
enterprises were small scale and therefore
issues of management were not necessarily
addressed in a systematic manner.
Only in the late 19th Century did
management as a discipline begin to
take shape with development of various
theories that today are grouped as the
Classical Theories.
Max Weber (18641920), described the
bureaucracy; the structure and set of
regulations in place to control activity, usually
in large organizations and government. A
bureaucracy is characterized by:
1. a well-defined division of administrative
labour among persons and offices,
2. a personnel system with consistent
patterns of recruitment and stable
linear careers,
3. a hierarchy among offices, such
that the authority and status are
differentially distributed among actors,
4. Formal and informal networks that
connect organizational actors to one
another.
Henri Fayol (1841-1925) amended
this definition by adding horizontal
communication and describes the five
elements of a manager as plan, organize,
command, coordinate and control.
In America, Fredrick Taylor (18561915)
performed time and motion studies on
how best to organize people to perform
various tasks.
The phrase time is money is credited to
him and his work led to the development

of assembly line where activities are broken


down into small tasks. While the early
theories focused on how people could
be organized to work, others wondered
what motivated people to work. Elton
Mayo (1880-1949), known as the founder
of the Human Relations Movement, was
a Harvard Psychologist who performed a
famous experiment where he varied the
work environment in a Chicago factory.
He noted that, no matter how the
conditions were adjusted either negatively
or positively, productivity went up. He
established that apart from how work
was organized, work output depended
on group norms and social conditioning.
People needed to feel appreciated in order
to perform well.
Management
Science
incorporating
operation research was first developed
in the 1940s. Mathematical models are
used to determine how best to carry
out management processes. A model is
a simplified representation of a system,
process or relationship.
For example, the queues found in a bank
or the out-patient section can be modelled
using mathematical equations to determine
how best to reduce waiting times.
Today, management is divided into several
branches namely:
1. Human resource management
2. Operations management
3. Strategic management
4. Marketing management
5. Financial management
6. Management information systems
A distinction is also made between
managing a for-profit enterprise and nonprofit and public institution management

225

because of the difference in the overall


institutional goal and objectives.

Table 14.1: Different leadership roles


Role
Interpersonal

The person in management accountable


for the goals of the organization is the
Manager. The manager is in a position
of authority and trust and is very often
the boss as well, charged with making
certain decisions that affect the overall
performance of the organisation.
Thus management or being a manager is
not just about being a supervisor. Being
a manager involves certain key tasks
namely:
Planning (setting objectives)
Organizing (analyze activities and make
decisions that are needed)
Leading (motivate & communicate)
Controlling, measuring (establish
targets and yardsticks).
To be effective, a manager needs to be
good at performing these tasks in order
to ensure organizational goals are met. In
addition to these tasks, a manager must
look to the future and develop both herself
the people around her.
While all these tasks must be performed
on a daily basis, the role that a manager
plays can change depending on the
circumstances.
Henry Mintzberg identified the roles that
a manager can play as being dependent
on whether the manager is providing
information or networking within the
organization.

Informational

Tasks

Figurehead

Attend ceremonies etc

Leader

Encourage employees

Liason

Coordinate between depts

Monitor

Keep abreast of industry


developments

Disseminator

Send memos

Spokesperson

Communicate with
external world

From the different roles, it is evident that


the managerial skills needed include:
Technical skills necessary to
accomplish/understand specific work
being done in a specific organization.
This is why it is better to have a
medical person trained in management
to run a health service than someone
without industry experience.
Interpersonal ability to communicate
with, understand and motivate
individuals and groups
Conceptual skills ability to think in
abstract perspectives
Diagnostic skills ability to visualize
the most appropriate response to a
situation.
Levels of management
Within an organization, there will be
different levels of management. Broadly, we
can divide an organization into three levels
of management, top, middle and lower
levels. At each level, the skills mix required
is different. At lower levels, managers are
more involved operations and therefore
technical skills are needed more.
The Peter Principle states that in a hierarchy, every
employee tends to rise to his level of incompetence; the
cream rises until it sours. People who show competence
are promoted whether or not they are qualied to perform
competently at the next level. Eventually they go beyond
their limits, become incompetent, and stop getting promoted.
The Peter Principle, Laurence J Peter & Raymond Hull,
1969

226

Skills needed

Diagnostic
Middle level

1st line
operation

Finance
Administration

Information ow

Conceptual

Top Strategic

Human Resource
Operational

Other

Technical

Fig. 14.2: Levels of management

At this level, much of the work is


supervisory, while at the highest level a
managers role will be more in strategy
formulation and therefore conceptual
skills are needed more. This involves
the ability to see the big picture, the
external environment and interpret and
communicate what should be.
The strategy that is developed cascades
down into operational goals. At middle
level tactical decisions are made and
executed. To be successful middle
management requires diagnostic skills to
see what is going on at operational level
and determine the immediate best course
of action to achieve goals.

Ethics

Planning is about making choices then


deciding how best to implement the
choices made to achieve the goals set.
Planning begins as an idea or in response
to attention being drawn to a particular
situation which needs changing. What is
to be achieved from a particular situation
becomes the goal. There are many tools
that can be used to guide in decision
making. However, there are few non

religious guidelines for reviewing the ethical


implications of any decision that is made.
Especially in healthcare where decisions
made touch immediately on peoples lives
and health status it is important to have a
clear ethical standpoint when planning.
The problem though is that ethical
dilemmas rarely present clearly and very
often it is hindsight that provides clarity
after the damage is done.
Therefore it is useful to follow principles
of ethics in planning and decision making.
These principles can be grouped in three
categories namely, personal, professional
and international.
Personal ethics includes concern for the
well being of others, respect for other
peoples opinion and rights; preventing
harm, compliance with the law, following
basic laws of justice in being fair, being
honest and doing good (benevolence).
Professional ethics bind an individual
in a professional capacity in addition to
their own moral responsibility. Typically,
professional ethics include being objective,

227

Especially where different professionals


work together as they do in the health
sector, it allows selection of priorities and
provides a foundation for evaluation. The
health of the population and their health
services needs have to be assessed.
1. Assessment
Where are
we now?
What are we
doing?
Why are we
doing it?

In health, unlike in business, whatever goal


is set must take into account the opinion
of the population that is being served by
the health care service. This fundamental
point cannot be overemphasized as it is
probably the major cause of failure in trying
to achieve a health program goal.
Steps in planning
The planning cycle provides a useful outline
of the process of planning. In an existing
organization, the planning process can be
triggered off from any stage. For example,
organizations should continuously be
evaluating themselves in terms of attaining
their goals and objectives.
Situational analysis
The beginning of the planning process
is to identify where the organization is
with regard to its stated objectives and
in relation to the external environment.

5. Measuring

Defining goals and planning how you will


achieve the set goals is one of the critical
functions in management. The goals set
must be measurable so that there is focus
on the most significant things and resources
including time are not wasted on noncritical activities.

6. Evaluation

Planning and decision-making

Are we there
yet?
Is there a better
way to get there?
Do we need to go
further?

How will we
know when we get
there?

2. Objectives

Where do
we want to go
Why do we
want to go
there?

What do
we need to
do to get
there?

Getting there-putting
all the talk into action

3. Actions

The third level is taking into account


international principles of ethics. These
might be subject to interpretation and
are often controversial. However, these
include international justice as reflected by
international law, environmental protection
and respect for society especially those
that are a little different.

A situational analysis provides a common


reference point for the rest of the planning
process.

4. Implementation

maintaining confidentiality, being diligent,


being true to professional responsibilities
and avoiding potential or apparent conflict
of interest.

Fig. 14.3: The planning cycle

Table 14.2 summarizes some of the


information that is useful. What we are
looking for are the determinants of health
and the state of the health services.
A conflict sometimes arises about setting
goals as a result of medical professionals
having certain goals they want to achieve
and what the community desires. For
example, there is a worldwide drive to
eradicate polio. But in certain communities,
individuals are more concerned about
individual risk to their children of adverse

228

effects from polio vaccines. If a situational


assessment found the need for a polio
vaccination program, should giving polio
vaccine be mandatory or optional?
Table 14.2: Data required for Situational Analysis
Category

Key information

Source

Geography

Area
Climatic conditions
Noteworthy? E.g.
mountainous, by the
sea.semi-arid

Routine data

Demography

Population numbers
Age, sex,
Fertility rate, birth/
death rate (IMR,
MMR)

Census,
Demographic
Health Survey
(DHS)

Structure of
the economy,
employment,
income levels and
distribution,

Economic survey

Socioeconomic
situation

Various theoretical decision making models


exist. They range from the theoretical
rational model to a descriptive administrative
model with the mixed scanning model in
between.

Key informat
interviews

Education/ literacy
levels
General
infrastructure

Education/ literacy
levels
Roads, Transport
electricity/water
Communication
schools

Government
reports
survey

Health
infrastructure

facilities, type,
services offered

Health facility
data survey

Health
indicators

Staff(no/type of
nurses, doctors and
other medical )

Routine data,
DHS
MOH reports

The conditions in which the decision making


process is taking place must be taken into
account. These conditions include:
Degree of certainty to what extent
are the consequences of each
alternative known?
Information availability how much
is available and the cost of obtaining
more
The risk is the potential payoff
of each alternative known?

Decision making
The breadth and depth of information
gathered depends on what type of decision
is needed. Decision making is about
choice. First, there must be sufficient
information to define the problem, then
have alternatives to choose from based on
a certain criteria.
Decisions
made can
be either
programmed,
that is fairly structured
and recur regularly e.g. continue treating
pneumonia with antibiotic. Some can be
non-programmed where the decision is
relatively unstructured and occurs less
frequently.

The rational model


Under ideal circumstances, we would want
decisions to be perfect and therefore the
decision maker should also be perfect. This
is called the rational decision making
model. In the rational model, it is assumed
first that the decision maker has clear goals
that do not conflict with each other. They
also have complete information, have
eliminated any uncertainty in terms of risk
and are able to evaluate all aspects of the
decision situation logically and rationally.
The steps in the rational decision making
process are:
1. Recognize and define the situation
2. Identify alternatives
3. Evaluate alternatives
4. Select the best alternative
5. Monitor and evaluate.
Clearly, to identify and evaluate every
possible alternative would consume too
much resources and decisions would never
be made.

229

Administrative (Incremental) model


Rather than being prescriptive, the
administrative model is more descriptive. It
holds that people always have incomplete
and imperfect information with which to
make decisions.
In addition, they are constrained by
bounded rationality, that is, people are
rational only to a degree and tend to satisfy
when making decisions. They make do with
the best decision at the time that makes
some people reasonably happy rather than
the best decision based on the stated goal.
The administrative model takes into
account political forces in decision making.
Often, coalitions (informal alliances formed
to achieve a common goal) form around
certain decisions that need to be made. A
rational process as defined above is then
not possible.
Mixed scanning approach
Thus a mix of the rational and administrative
approach. In a mixed scanning approach, all
opportunities and consequences are looked
into. However, these are then quickly
narrowed down to a set of manageable
options. Incremental decisions are then
made in terms of implementation.
For example, in an outbreak of cholera, a
comprehensive stock take might be done
looking at the determinants of cholera.
But the final action might be to look at
those most at risk first thus a narrow set
of options such as vaccinations and or
purchasing additional quantities of oral
rehydration salts is looked at.
The balance between the rational and
incremental approach is determined by
the availability of resources such as data,

money and time. In a rapidly evolving


situation, there may be no time to conduct
a rational analysis.
Group decision making
Two people using the same information
and using a fairly rational process can come
to two different conclusions as to the way
forward. Who is right? Sometimes decision
making requires consensus of views from
people with different approaches to the
same perceived problem. Consensus can
be obtained through the following:
1. Interacting groups such as committees.
This is the most common approach to
decisions that can bring conflict.
Committees work by having different
people bring their ideas to the table
and then through an agreed
mechanism a decision is made on the
way forward. The mechanism can be
through voting or by consensus.
2. Delphi groups were invented by the
Rand Corporation. Its main use is to
develop consensus among experts
in a particular area. The experts are
gathered together, exchange ideas
and discuss the best way forward
based on the available information.
3. A derivation of the Delphi group is a
nominal group which has the same
experts but they do not meet and
exchange ideas. Each expert is
canvassed as to their opinion and
then the decision maker uses the
collected information from all the
experts to come to a decision.
Group decision making has advantages and
disadvantages over individual decisions
making as shown in table 14.3 on the next
page.

230

Table 14.3 : Group decision- making


Advantages

Disadvantages

Increased information/
knowledge available

Increased costs

More alternatives likely


to be generated

Compromise decisions more


likely

Increased communication
of decision may result

One person may dominate

Increased acceptance of
nal decision

Group think may occur


(desire for consensus more
important than desire for best
decision)

organization should be aligned with the


overall country strategy.

Better decisions generally Politics may dominate


emerge

There are other decision making processes


other than using logic and attempting to be
rational. Gut instinct or Intuition is an innate
belief about something without conscious
consideration. This is seen often in senior
doctors who can make life saving decisions
about a patient seemingly without the need
of many time consuming tests.
Often, the intuition is really an accumulation
of years of experience and practice. A
persons risk propensity plays a role in
the types of decisions made. Even if they
were to use a rational approach, their risk
appetite might dictate making a decision
which is not rational.
Finally and most importantly, for health
ethics must play a big role. Certain decisions
in health cannot be made even if they are
rationalas long as they are perceived be
unethical.

Strategic planning

The overall health sector strategy for a


country is usually outlined in the national
health sector strategy plan. A country plan
such as the Kenya national health strategic
plan follows international goals such as the
millennium development goals and other
priorities set at global level. Strategic goals
for a specific health program or health

The strategic plan is developed at the


top level management. The plan outlines
decisions regarding resource allocation and
priorities. A strategic plan is important to
the health sector because the work load
and health problems can be overwhelming.
It is easy to wake up very day and just work.
However, providing healthcare is complex
and there is probably no more complex an
organization in the world than a hospital. In
order for any organization to remain viable
it must perform its core functions and meet
its objectives. Strategic planning outlines a
s these functions
A strategic plan is best developed by a team
made up of the key managers. Because it
is a function of top management, all those
charged with key responsibilities should
participate in its development not just the
overall manager sitting alone. If possible,
external stakeholders such as suppliers and
partners should be invited to provide input
as they have a view of the organization that
is different from those working inside it.
A common strategic planning tool used is
the SWOT analysis. It uses a framework that
looks at internal strengths and weaknesses
and external opportunities and threats. In
so doing, it provides a simple way to assess
how a strategy can best be implemented. It
assists planners to be realistic about what
they can achieve, and where they should
focus their complete energies.
The first step is a SWOT analysis and this
involves being clear on what the objective
or goal is. Once these are agreed on, the
team can brainstorm. This should involve
an assessment of internal capacity, existing
resources and existing problems that can

231

either be resolved or will require additional


resources to resolve. This gives an idea of
new resources needed.
In reviewing strengths, it is important to
be practical and have real examples of
strengths and not perceived strengths. An
assessment of the external environment
focuses on what is going on outside the
organization. It highlights the areas that
are not yet affecting the strategy, but could
either positively or negatively.
Strengths

Weaknesses

Are your own or your organizational internal strengths and


weaknesses.
People/management expertise
Unique competencies
Facilities/building and equipment
Technology
Reputation/image
Financial resources

Possible social, political and economic


changes
Trends in market
Need for product or service. Likelihood of
change in these needs
External factors that must be noted. A project can fail if
what if is not considered
Opportunities

Threats

Fig. 14.4: SWOT analysis

MDGs are an example of strategic goals


adopted globally.
The MDGs are drawn from the actions and targets contained
in the Millennium Declaration that was adopted by 189
nations-and signed by 147 heads of state and governments
during the UN Millennium Summit in September 2000.
Goal 1: Eradicate extreme poverty and hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and empower
women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and
other diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a Global Partnership
for Development

Goal setting
Because a strategy is a three to five year,
plan those developing a strategic plan need
to think beyond their daily activities and
project their goals imagining success after
the plan is complete.
Having a brainstorming session to set
targets is an ideal way to start. Goals are
critical to organizational effectiveness
because:
They provide guidance and unified
direction
Effective goal setting result in to
good planning
They serve as source of motivation
Useful monitoring and evaluation.
Ideally, goals should be SMART. That is
Specific Measurable Achievable Realistic and
Time bound. Very often, people interpret
achievable or realistic to set low targets.
The impact of the pace of technology is
underestimated when setting goals to be
achieved in say 5 years time.
For example mobile telephony use has
increased exponentially in the last five
years. Having a strategic plan that does not
take into account the potential use of such
a tool is probably a waste of time. Doing
a good analysis helps overcome such
myopia.
Operational Planning involves the
development of a schedule of activities, the
resources required and the time needed.
The format of plan may sometimes vary
according to the organization undertaking
the activity or the organization funding
the activity. A budget is an example of an
operational plan.

232

addressed. On the down side logframe


preparation takes time, skill and training
for it be effective.

Table 14.4: Types of Plans


Strategic

General plan outlining


decisions of
Resource allocation
Priorities
Action plans to meet goals

Tactical Goals

Developed to implement specic


parts of a strategic plan.
Tactics focus mainly on
people & action
- Must specify resources and time
frame
Require use of human resources

Once the logframe has been constructed


there is a danger that it becomes inflexible
and people work to fulfil the objectives
without taking into account changes in the
nature of the project as time passes.

Operational
plans

Are derived from tactical plans


and have narrow focus, short time
horizons typically of one year

Planning health activities

Planning a health program involves the


steps outlined earlier in the planning cycle.

Logical framework (Logframe)


There exist many tools that can be used in
planning. The logframe is one of the more
popular tools used within the health sector.
Its utility lies in the fact that in a systematic
way it helps clarify the objectives of a
project, then the activities giving the
project structure and making monitoring
and evaluation easier.

STEP 1: Assessment of the Health


Situation
In planning a health activity, the first step
is to carry out an assessment of the health
situation. This involves identification of the
health problems. These problems should
ideally be identified from the perspective of
the population rather than the expert.

The process of developing a logframe


allows project team members to focus
on the shared goals and identify what
each members role is. Weaknesses in the
project design can be easily identified and

Key information that is needed for health


planning includes demographic data
like information about the community
-population, births and deaths, age

Table 14.5: Logical framework


Objectives

Measurable Indicators

Means of verication

Important assumptions

GOAL:
Wider problems the project
will help resolve

Quantitative ways of
measuring or qualitative
ways of judging timed
achievement of the goal

Cost effective methods and


sources to quantify of access
indicators

(Goal to super goal)


External factors to sustain
objectives in the long run

PURPOSE:
The immediate impact on the
project area or target group
i.e the change or benet to be
achieved by the project

Quantitative ways of
measuring or qualitative
ways of judging timed
achievement of the purpose

Cost effective methods and


sources to quantify of access
indicators

(Purpose to goal)
External conditions if
achieved project purpose is to
contribute to reaching project
goal

OUTPUTS:
These are specically
deliverable results expected
from the project to attain the
purpose

Quantitative ways of
measuring or qualitative
ways of judging timed
production of outputs

Cost effective methods and


sources to quantify of access
indicators

(Outputs to purpose)
Factors out of project control
which, if present, could
restrict progress from outputs
to achieving project purpose

ACTIVITIES:
These are tasks to be done to
produce the outputs

INPUTS:
This is the summary of the
project budget

Financial outturn report as


agreed in grant agreement

(Activity to output)
Factors out of project
control which, if present,
could restrict progress from
activities to achieving outputs

233

groups, housing, schools, leadership, and


epidemiological information including
health status and health services available.
It is useful to understand where people seek
healthcare, the types of health facilities in
the area concerned what type of medical
personnel equipment and community
resources is available. This process of
gathering information might involve some
data collection.
From the assessment we should be able
to:
have a statement of diseases and health
problems that express their current
magnitude, rank them in priority
and establish a probable future trend
a description of social and economic
conditions that have specifically close
links to the health problem;
a description of the population that
will be covered including the size of
relevant age-groups, the geographical
spread and a projection of future size
STEP 2: Choose most appropriate
interventions
The most appropriate intervention should
then be selected. Rather than jump at the
first or obvious intervention, it is important
to choose the most appropriate.
Appropriateness depends on the situation
at hand, for example, if there is a problem
of malnutrition we need, to decide if the
health campaign should target children
through a school feeding program or
health education of pregnant women. The
first step in this process is to list as many
interventions for the priority problems
that are feasible. Not all interventions in a
health system are health service activities.
Many conditions can be tackled using a
combination of interventions.

Reviewing obstacles and limitations is an


important step. Are there any reasons the
objectives set cannot be achieved? The
obstacles need to be analyzed. Obstacles
and limitations can be categorized under
the following groups:
Obstacles that can be removed that is
a
solution can be found.
Obstacles that can be modified or
reduced.
Obstacles that cannot be removed or
reduced
After an analysis of the obstacles and
limitations, the objectives need reviewing
to adapt or change as necessary.
STEP 3: Monitoring and evaluation
Monitoring and evaluation requires clear
criteria at the beginning that will be used as
a benchmarks to determine if the activities
are on course to achieving the stated
objectives. The criteria may include.
Probable effectiveness
Efficiency
Equity
Efficacy
Acceptability
Timings
Adaptability to available staffing or
premises
Economy
Administrative ease and efficiency
The benchmarks against the preffered
criteria, for example, how long should an
activity take, should be based on evidence
and not arbitrarily chosen.
Organizing
This one of the basic functions of
management together with planning,
directing and controlling. Organizing is
deciding how best to group organizational
elements in order to achieve the goals

234

of the organization. The organizational


elements refer primarily to people and
the resources that they need in order
to accomplish the task given. The basic
elements in organizing can be divided into
six steps. Only a lucky few ever get to
design an organization from scratch.
Usually, there is an existing organizational
structure with job descriptions which may
or may not match the work people actually
carried out. This reality means that, in going
through the steps, there must be sensitivity
to the existing structure. People, jobs and
groupings need to be assessed carefully to
ensure they are aligned to organizational
goals.
Step 1 in organizing Job Design
The primary question is to determine what is
the individual work related responsibilities?
Job design involves determining:
The tasks to be performed
How the job is to be performed, e.g.
machines involved, traveling
Performance standards expected
The starting point is to determine the level
of specialization required. Job specialization
is the degree to which the overall task
of organization is divided into smaller
components.
For example, for someone to maintain
financial records do we need a general
administrative person who has some
knowledge in accounts or do we need a
fully qualified accountant? What tools can
be used that simplify the work for example,
can we use software?
The benefits and disadvantages of job
specialization are summarized in table
14.5.

Table 14.6: Job Specialization


Benets

Disadvantages

More efciency, Performing


small simplied tasks

High specialization can lead


to boredom

Transfer Time taken between


different tasks reduced

Anticipated benets dont


always occur

Increased use of machinery


when task narrowly dened

Repetitive tasks, reduced job


fullment

Easy to train replacement


Reduced costs

Job redundancies

Step 2 in organizing Grouping jobs


What is the most logical structure to group
jobs? In a small organization, this may not
matter. If we have 10 accountants or 30
people carrying out administration within
a hospital, how should they be grouped?
There are four common ways for
departmentalization namely by Function,
Product, Customer and Location.
By function this is the easiest way and has
a number of advantages including having
a group of people with a narrow skill set
which makes supervision easier.
However, disadvantages include slower
decision making, employees having a
narrow focus on departmental goals
rather than broader organizational goals
and therefore potential for conflict
and blame game Accountability and
performance between departments can
be difficult to monitor. Using the other
ways of departmentalization changes these
variables.
Step 3 Establishing reporting
relationships between jobs
In establishing the reporting relationships
between jobs two, principles should be
applied:
1. Chain of command. Each person
should report to one boss only.
This avoids confusion with regard to
responsibility.

235

ultimate authority rests at the top of the


organization.

2. The Scalar principle. There should be


a clear unbroken line of authority from
bottom to top.
Each manager has one or more
subordinates reporting to them. There is
a limit to the number of direct reports that
any one person can handle competently.
This is referred to as the span of reporting
which can either be narrow or wide. With
each subordinate a manager takes care
of three interactions; Direct manager to
subordinate, subordinate to manager and
across the same level from subordinate to
subordinate. The number of interactions
rises exponentially compared to the
number of direct reports.
A wide span works where the subordinates
perform well defined work with limited
responsibility that does not vary daily. The
supervisor therefore has limited activities
to supervise. A narrow span is better where
the subordinate has wider responsibility
and therefore the engagement of the
supervisor has to be more.
In an ideal organization, workers at every
level report to someone whos span of
authority is small enough to enable her
to know those working under her well,
as human beings both personally and
professionally.
Step 4 Distributing authority
among jobs
For each job, it is necessary to know how
much power the person holding the job
has. What are the things that the job holder
has to refer to their supervisor? How is
this done? What happens if a situation
arises that is not covered in the standard
operations? Authority is power legitimized
by the organization. It is assumed that the

Two issues then need to be addressed:


1. How much power to give and how
much responsibility to give.
In delegation, power is given to
perform certain tasks but ultimate
responsibility is retained by the person
delegating the work. For example, at
a bank door at bank closing time the
security guard has delegated power to
deny access because it is closing time,
but can be overruled by the bank
manager taking responsibility to admit
a valued customer after time.
2. With decentralization, both power and
responsibility are ceded.
The person given the job takes
responsibility for their actions and
cannot hide behind their superiors. If a
doctor attending to a patient gives the
wrong treatment she is responsible.
If she feels that the management is
beyond her then she formally hands
over that power to her superior by
referring the patient. Decentralization
is favoured where the environment is
complex and uncertain. (Managing
a single patient in large hospital is a job
given to a specific doctor rather than
the hospital director being directly
responsible). However where the risk
is high then there is more centralization
of power and authority, for example,
in a deadly disease outbreak.
Step 5 Coordinating activity between
jobs
Jobs that have been broken down into
specialized tasks which then have been
grouped together into departments need
coordination to ensure that the different

236

By function

Hospital
Director

Finance
Department

Human Resource
Department

Inpatient
Department

District Medical Ofcer


of Health

By Client/purpose

Director
Child welfare services

Director
Reproductive Services

Director
Water & Sanitation

District Medical Ofcer


of Health

By geography
Medical Ofcer
East division

Medical Ofcer
West division

Medical Ofcer
South division

Fig. 14.5: An organization can be structured by function, geography or client. as shown

jobs and departments work in harmony


towards the stated goals.
This coordination can be done in three
different ways depending on the degree of
interdependence.
1. Pooled nothing really in common
2. Sequential - output of one is input in
another
3. Reciprocal - input of one is output
& vice versa
The creation of a managerial hierarchy is
usually the first step. One manager sits
astride two departments and ensures that
the outputs from the two are integrated
to serve a common purpose. Rules and
procedures also ensure that people within
an organization operate with some degree
of certainty as to output.
Liaison roles which can even develop into
integrating departments can be developed
to ensure that different departments talk

to each other. Ad hoc task forces can be


created to handle a task that does not fall
neatly into any one department. Often, this
is as a result of changing environment that
threatens the organization as a whole.
Step 6 Differentiating between
positions
Differentiating between positions is the last
building block of organizational structure.
People working within an organization
can be divided into two groups. Those
whose output directly contribute to the
organizational goal and those whose
position is advisory. The line positions are
those in the direct chain of command and
work towards organization goal. Their
authority is formal. If they are not at work,
then the organization is not producing.
Within a hospital, nurse doctors attending
to patients are a good example. The staff
position is advisory. They derive their
authority from the advice that they give,

237

(Functional authority). The advice can be


compulsory advice or non compulsory.
For example, the expertise of a lawyer
within a hospital in handling a patient who
needs referral is usually non-compulsory
with the doctor taking ultimate responsibility
for the patient.

Managing the human resource

Up to 70% of health system recurrent


expenditure can be attributed to human
resources in most health systems in low
and middle-income countries. Especially
in sub-Saharan Africa, there is an absolute
shortage of health-care providers and
poor distribution of providers within the
country.
These problems are exacerbated by
deficiencies in skill mixes and poor physical
and managerial infrastructure. Managing
human resources well is therefore a vital
component of health services management.
Human resources management includes
aspects of leadership, motivation,
communication and management of
teams.

Leadership
A successful leader is one who can
understand peoples motivation and enlist
employee participation in accomplishment
of a goal. The ability to influence people
to perform towards a certain goal depends
on the amount of power that the leader
has. There are different sources of power.
table 14.6. In all cases for the power to be
legitimate it must flow from the persons
formal position within the organization.
Responses to use of power
How people respond to the use of power
depends on a number of factors. People
are more likely to follow influential and
strong leaders than weak and isolated
ones. Four organizational factors can affect
a managers power:
1. Rules inherent in the job(less rules
more power)
2. Reward for innovation (more means
more power)
3. External Contact (more means more
power)
4. Senior Contact (More means more
power)

Table 14.7: Response to use of power


Source

Description

Personal

Positional

Reward Power

Ability to reward another


person

Credit for previous or


future favours in day to day
exchanges

Authority to use
organizational resources
including support of seniors

Coercive Power

Ability to obtain compliance


through fear of punishment

Forceful, insistent,
determination

Authority to give instructions


with threat of sanctions
available

Referent Power (charismatic)

Is visible when some


characteristic of the
manager is attractive to the
subordinate. They want to
identify with the person

Individual beliefs, ideas &


personal qualities

Authority to invoke
norms and values of the
organization s culture

Expertise
(technical)

When people acknowledge


someones specialized
knowledge either technical or
administrative

Skill relevant to task

Authority to access expertise/


information & ideas across
the organization

Experience in the business,


knows who to contact to how
to get things done

Authority to use or create


organizational rules and
policies

Expertise

Power

(administrative)

238

These organizational factors interact


with three lines of power, the supply of
resources including money, information
(whats happening where, to who and
how) and the support of senior people
when needed. The more lines of power,
the more powerful the manager. The
outcomes then can be grouped asshown in
table 14.8.
Table 14.8: Outcome to use of power
Outcome

Description

Commentary

Internalization

Target internally
agrees with
decision or request
and makes great
effort to meet it
successfully

Usual most
successful outcome
from point of view of
inuencer, esp. if task
is difcult

Compliance

Target willing
to do task but is
apathetic & make
minimal effort

may be OK for
routine tasks, but for
complicated tasks
may be unsatisfactory

Resistance

Target is opposed
to request &
actively avoids
the task

Target may make


excuses or try to
dissuade inuencer.
May seek higher
authority to
undermine efforts

Leadership is not through power alone. A


leader must be able to influence people
to achieve. An excellent manager evolves
through various stages as outlined below.
Level 1: Highly capable individual Makes
productive contributions through talent,
knowledge, skills, and good work habits.
Level 2: Contributing team member
Contributes to the achievement of group
objectives; works effectively with others in
a group setting.
Level 3: Competent manager
Organizes people and resources toward
the effective and efficient pursuit of
predetermined objectives.
Level 4: Effective leader
Catalyzes commitment to and vigorous
pursuit of a clear and compelling vision;
stimulates the group to high performance
standards.

Level 5: Executive
Builds enduring greatness through a
paradoxical combination of personal
humility and professional will.
Motivation
The purpose of behaviour is to satisfy
needs. A need is anything that is required,
desired, or useful. A need arises when there
is a difference in self-concept (the way I see
myself) and perception (the way I see the
world around me). A want is a conscious
recognition of a need. Motivation is the set
of processes that moves a person toward
a goal. It is important to understand what
motivates people in order to get people
to perform towards the goals set for an
organisation.
There are various factors that affect
motivation at work including:
individual differences - personal needs,
values, attitudes, interests and abilities
job characteristics - the aspects of the
position that determine its limitations
and challenges.
organizational practices-the rules,
human resources policies, managerial
practices, and rewards systems of an
organization
There are two primary approaches to
understanding motivation.
1. A content approach that focuses on
the assumption that individuals are
motivated by the desire to fulfil inner
needs.
2. Process approach that focuses on
external influences or behaviours
that people choose to meet their
needs. The emphasis is how and why
people choose certain behaviours in
order to meet their personal goals. An
example is Vrooms Expectancy Model.
Maslows hierarchy divides needs into

239

five levels. At the bottom are basic needs


that people need to survive such as food
water and shelter. These are the needs
that must be met first when people work
in an organization, otherwise they will not
perform. As needs get met, people move
up the triangle towards self-actualization.
Herzbergs
Dissatisfaction/satisfaction
theory, is based on the work of Maslow. In
this theory the various factors are divided
into motivators and hygiene factors. People
require hygiene factors to be metfirst
before motivating factors. Where hygiene
actors are poor, people might not quit but
at the same time they will not perform
optimally. This explains part of the reason
why poorly paid government officials stay
in a job that clearly does not pay them
enough to live well. As long as the hygiene
factors are lacking any motivating factors
introduced are wasted.
Self
actualization
morality,
creative,
spontaneity,
problem solving,
lack of prejudice,
acceptance of facts
Esteem
Need to feel worthy
and respected
Love/Belonging
Friendship family, sexual
intimacy
Safety
Security of: body,
employment, resources,
morality, the family, health,
property
Physiological
breathing, food , water, sex,
sleep, homeostasis, excretion

Maslows hierarchy
of needs

Motivators
Achievement
Recognition
Work itself
Responsibility
Advancement
Personal growth
Hygiene
(maintenance) factor
Status
security
Relation &
subordinates
Personal life
Relationship with peers
Salary
Work conditions
Relationships with
supervisor
Company policy &
administration
Supervision

Herzbergs motivators
and hygiene factors

Fig. 14.6: A comparison of Herzbergs model and Maslows


hierarchy

The Process approach looks at how people


behave in response to external stimuli
rather than looking internally for the source
of motivation. The way in which people
choose among alternative behaviours
because they anticipate that particular
behaviours will lead to one or more desired
outcomes is termed expectancy. This is the
belief that a particular effort will lead to a
particular outcome directly.
An important notion in the process
approach is the concept of equity, that
is, the perception of fairness involved in
rewards given. A fair or equitable situation
is one in which people with similar inputs
experience similar outcomes. Employees
will compare their rewards with the
rewards received by others for their
efforts.
B.F. Skinner (1904 1990) on the
most influential psychologists of the
20th century proposed the theories of
operant conditioning. He hypothesized
that conditioning involves four types of
consequence:
1. Positive reinforcement creates a
pleasant consequence by using
rewards to increase the likelihood that
behaviour will be repeated.
2. Negative reinforcement occurs when a
person engages in behaviour to avoid
unpleasant consequences or to escape
from existing unpleasant consequences.
3. Punishment is an attempt to discourage
a target behaviour by the application
of negative outcomes whenever it is
possible.
4. Extinction is the absence of any
reinforcement, either positive or
negative, following the occurrence of a
target behaviour.

240

Supervisors
Requests
(Stimulus)

Employees
Dehaviour
(Response)

committed to a common purpose with


collective accountability. Table 14.9 below
illustrates the differences between routine
and complex problems.

Positive
Recognition
(Reward)

Table 14.9 : Routine vs complex problems

Future Positive
Behaviour from
request
(Reinforcement
Fig. 14.7: The Reinforcement Process

Both approaches to determining how


to motivate staff are useful. Employees
study the organization and their seniors
to understand the patterns of reward. Illthought out motivational packages can lead
to quite perverse results. For example,
rewarding clinical staff solely on number of
patients seen can lead to drop in quality of
care. Praising one individual on the basis of
a single act randomly observed can lead to
dissatisfaction among others whose work
does not allow them the lime light.
Teamwork
Everyone talks about teamwork and how
important it is within an organization,
especially in healthcare where there are
many different cadres of workers each
with different skills. This is true, but we
have to differentiate between individuals
with a common reporting arrangement
and a true team.
If the work within the organization is
routine work which can be broken down
into simple tasks and is done all the time,
then it is better to organize the work
around a working group which is led by
a manager in a department. Teams are
best used for projects to tackle complex
challenges or problems.
A team can be defined as a small number
of individuals with complementary skills

Routine Problem

Complex conditions

The problem is well dened


and the solution is known

The situation must be


analysed and the immediate
solution is not known

The problem can be solved


with existing knowledge and
practices

People need to adjust their


values ways of thinking
and practices to address the
condition effectively

A prescribed process can be


implemented to solve the
problem

Implementation requires
learning new approaches and
practices and being exible
as new conditions emerge

The solution can be applied


by a single person or group

Collaborative work by
several stakeholders is
required to achieve the
solution

Harvard business essentials: managers toolkit:the 13 skills


managers need .By Richard Luecke, Harvard Business Press,
2004

By definition, a project has a defined goal


with a clear end date when the project
must be completed. A team is needed for
a project when no single individual has
the combination of necessary skills and
knowledge to complete the project alone.
The individuals working within the project
must be highly interdependent.
Developing a team
Before a team can be assembled, it is
necessary to clearly define what the goal
is. The goal defines what tasks need to
be accomplished in order to for set goal
to be achieved. An effective team will be
one where the competencies necessary to
accomplish the goals are present. An ideal
team is made up of 5 to 8 individuals. The
number of team members depends on
the complexity of the tasks, beyond this
number coordinating members becomes
difficult. Every single member should have
a clear competence that they bring to the
team.

241

A team should never have individuals


who have no specific competence but are
there just because of their position within
the organization or because of work
politics The roles and responsibilities of
each team member must be defined at
the onset, for example, who the team
leader is, what decisions can she/he make,
which decisions are made by all the team
members (unanimous) and which can be
made by the majority rule.
This is important because, in the middle
of the project, there should be no
disagreements about procedure because
members cannot agree.
The goal of the team must be understood
by each member in the team. Each member
then has to commit to ensuring that the
goal(s) are achieved. This commitment is
necessary for the times when the going
gets tough. In order to develop close
interactions it helps if members are in close
physical proximity with each other with an
area designated as the project room.
While every member must contribute
in order for the team to succeed, it is
important for each member to receive
credit for their individual and collective
success. Even though there is a common
goal, each member comes into the team
with their own personal or organisational
goals. These must be recognition and each
member must put in their share of work.
The member who walks into meetings,
voices opinion then waits for the next
meeting is not adding value and slows down
everyone. Even the team leader must work
and take part in the team activities which
might not be pleasant.

A team is more likely to succeed if the


structure is non hierarchical, there is an
appropriate reward structure and the team,
receives support from senior management
in terms of resources. Because each
member is chosen based on the unique
skills and knowledge they bring to the team
they must take responsibility for their own
action. The ability to negotiate with other
team members and being able to say no
when appropriate for the overall goals to
be met is a crucial interpersonal skill.
The team leader is the primary contact
person between the team and the rest of
the organization. She/he is also the person
that acts as the source of motivation for
the team, organises meetings and helps
the team move along whenever the team
gets stuck along the way. It maybe that one
individual is derailing the process or there
is conflict between members or there is a
member who is not carrying their weight in
terms of contribution. It is up to the team
leader to amicably sort out such issues for
the good of the team.
In other words, the role of the team leader
is to get the team members moving and
focused on the goal. Where the team leader
is also the boss, she/ he has to find a balance
between continuing to behave like the
boss, using her vested authority and have
a totally hands off approach thinking that
the team has been empowered. Achieving
this balance can be the difference between
establishing a true team and just duplicating
a traditional department structure.
During and at the end of the project, there
must be evaluation. Achieving the goal is
of course the ultimate measure of success.
Therefore, measuring outputs that link
directly to the goal will ensure that the

242

team is on its way to achieving the goal.


However, how the success is achieved is
an important element of evaluation.
Monitoring the levels of collaboration,
problem solving and conflict resolution
are an important part of the team process.
Often, a successful team is evidenced by
team members who build strong personal
relationships that survive beyond the
specific project.
Steps in setting up a team
1. Define the goal with timelines
2. Establish the need for a team
3. Identify the key competencies that are
needed
4. Identify the individuals needed. Define
their roles including how decisions will
be made
5. Identify the resources needed
6. Implement the project
7. Monitor and evaluate the process and
achievement of defined goals.

2. Storming stage

Team members have different ideas on


how to achieve the goal. Some of these
ideas may be in conflict and team members
may not even agree on leadership or how
to resolve conflict. This stage can be
unpleasant for those who avoid conflict
but is necessary for team members to have
patience and tolerance to succeed.
Many teams fail at this stage and never
progress. However, a team that pulls
through this stage is strong as members
then have an understanding of most issues
and have developed a mechanism for
conflict resolution.
3. Norming stage

Challenges in team formation


Having a functional team is not a simple
matter of identifying individuals and
ordering a team to form. Experience shows
that a vision is powerful when it is shared.
The evolutionary stages through which a
team goes before it is able to produce can
be divided into four.
1. Forming stage

This is when the team meets and learns


about the challenges and opportunities
are. It is at this stage that they agree on
what the goals and key tasks. At this point,
the members are independently motivated
and are at their best behaviour. Team
members are getting to know each other.
At this stage, the group relies heavily on
the team leader to guide them.

Team members adjust their behavior to


each other as they develop work habits
that make teamwork seem more natural
and fluid. The norms of the team are
established and members begin to trust
each other.
The role of the team leader is more
participatory and less directive.
4. Performing stage

This is the point when high performing


teams function as a unit and are able to work
smoothly without the need for external
supervision or constant unresolved conflict.
Team members are motivated and aware
of each others responsibilities. A team may
go through the four stages repeatedly as
the nature of the work changes.

Change management

Providing quality healthcare efficiently


and cost effectively encounter challenges
everyday. Old problems cannot be
addressed the same way in the face of
increasing population, environmental
pressure, new technology and increased
expectation of better service.

243

To make the necessary improvement


requires change. By nature, human beings
tend to resist change. Sometimes, teams
formed to tackle a problem succeed
temporarily because the organizational
structure, system and culture do not
change. Part of management is being able
to lead to create organizational change.
Any change requires a champion to
overcome the obstacles that will be
encountered along the way. Some of the
key factors that need to be taken into
account in leading organizational change
are illustrated in table14.10.
Taking these key factors into account
must be coupled with some knowledge of
peoples response to change.

Fig.14.11: Response to change


Peoples response to
change

How to encourage change

Denial. People block out


signs that change is needed

Provide information so that


they have the evidence they
need to accept change

Resistance. People have


often invested in the status
quo and are scared of losing
out

Outline the benets of


change (pros and cons),
Allow people to express their
fears. Encourage them to
own the vision

Exploration. People need


to be convinced themselves
that the change is good.

Avail opportunities and


resources for people to
discover for themselves

Commitment.

Allow people to embrace


the change. Do not stand in
their way.

The controlling process

Lewis Carroll (1832 1898,) said If you


dont know where you are going, any road
will take you there. A strategy with set
goals should lay out how these goals will
be met. The controlling process is about
checking on how well the strategy is

Table 14.10 : Why change fails


Success factor

Consequences of not taking this step

Communicate
the urgency
by framing the
challenge clearly

Complacency, people will not be mobilized to change if they think that everything is ne the way it is. They
need to understand the challenge they are facing and how it affects their work and their organization

Build the core


team

Going it alone. If there is not a group of early adopters who are committed to change, it will falter in
the face of oppositions. Include key stakeholders and authority gures on the change team in order to get
organizational buy in

Crate a shared
vision

Lack of commitment. If the vision is not created together with all of the stakeholders, there is no clear picture
of the path towards a desired future and energy and commitment will be dispersed. Be inclusive in creating the
vision

Include others in
planning
and
implementation

Lack of involvement. If the vision is not communicated clearly and regularly and used as a guide for shared
planning, it will not have an impact on organization activities. Engage others in creating the implementation
plan.

Overcome
the obstacles
together

Demoralization. When obstacles remain in place and little or no effort is made to remove them, people will not
be able to sustain the energy to continue. Work to identify the root cause of obstacles and overcome them

Focus on results
and crate short
term wins

Lack of sustained effort. When people o no see any positive results in the short term, it is hard to keep them
engaged. Focus on results and how to achieve them.

Maintain
support for
facing ongoing
challenges

Shifts in attention. While the rst positive results may be encouraging, they are not a substitute for lasting
change. The risk of declaring victory too soon is that peoples attention shorts to something else and the effort
to keep the change moving is lost. Continue to frame the new challenges.

244

performing. Monitoring asks, How well


are we progressing? Evaluation asks Did
we achieve our goals? Did we do it in the
best way possible? Within an organization
a written down strategy provides a basis
for control.
Monitoring is the routine tracking of the
key elements of programme performance.
Methods of monitoring include routine
record keeping, reports, surveillance
systems, visits, checklists, meetings and
periodic surveys. We can monitor the
health system at various levels:
a. Inputs,
(i) Availability of personnel, supplies,
equipment
b. Output
(i) Utilization of services, acceptors,
continuation, drop outs
(ii) Quality of care, diagnosis,
education, treatment, counselling
(iii) Contacts, visits, access to services,
high risk visits
(iv) Unit costs
c. Effects
(i) Behaviour
(ii) Knowledge & skills
d. Impacts
(i) Changes in health status
Input level tends to be the easiest to monitor
but the link to change in health status can
be weak depending on the intervention
and how implementation takes place. As
we move down towards impact the effect
becomes greater but it also becomes more
difficult to measure.
Evaluation
Evaluation is the systematic process of
collecting and analyzing data in order to
determine whether and to what degree
objectives have been or are being achieved.

It attempts to link a particular outcome or


impact directly to a particular intervention
after a period of time. It helps determine the
value or worth of a particular programme.
It helps us to have a systematic way of
learning from experience so as to improve
current activities and promote further
learning.
Important factors to consider in evaluation
relate to efficiency and effectiveness.
Efficiency relates to the analysis of costs
expended in comparison to benefits
obtained or effectiveness of program
while effectiveness is measured in terms
of expected change. Impact is long term
change.
There are many reasons to evaluate a
program. It can be part of a program
justification or it may be a part of the
program mandate fro example donor
partner funding often includes an element
of evaluation.
Carrying out an evaluation leads to:
Enhanced understanding of program
goals/objectives by staff and
other stakeholders
Setting of appropriate standards,
indicators and resource allocation
Increased communication with staff
Increased advocacy
Identify new audiences and
opportunities
Types of evaluation
Evaluation can occur either at the beginning
of the program or at the end.
1. Formative Evaluation (needs
assessment), assesses the situation
before a project begins.
2. Project Appraisal, assess plans for a
project. Is the program appropriate for
the assessed needs?

245

3. Summative evaluation. Occurs at the


end or at a defined stage of a project.
Certain assumptions need to be clearly
stated when carrying out an evaluation.
These include:
Structure
- What is the setting under which
activities are taking place. Can we
assume that given a particular proper
setting, good medical care will follow?
Process
- That given proper procedures,
good health outcomes will result.
Outcome
- Considers whether a change in
health status has occurred. How
is the change defined?
Arising from this, we can have evaluation
at different levels within the health system.
The clinical review and the clinical trial are
concerned with the care of the individual
patient. The context within which these
are done have a big influence on the results
and often results cannot be applied widely
outside of context.
Clinical and program trials aim to generate
knowledge that can be applied generally,
especially concerning causal relationships
between care and outcomes. The types of
evaluation therefore differ in the questions
they pose and in the methods used to
answer them. It is important to be clear
which question is being answered when
carrying out an evaluation to avoid resource
wastage.
A Monitoring and evaluation plan
This plan is a document that describes the
context for M & E, defines the indicators and
data collection methods as well as provides
a fully budgeted M & E activity plan. When
defining monitoring and evaluation needs
certain key issues need to be considered:
246

Defining needs for monitoring and


evaluation
Why? Why do you need this
information? What is the
purpose of the information?
Define the use of the information
and who needs it.
What? What should be measured?
What will show that you have
achieved what you wanted to?
Select indicators for monitoring
How? How are you going to track
the indicators? Does a method
exist already? Select method
to collect information
Who? Who will collect the
information? Who should
be involved? Select surveyors
or evaluators, M &E officer for
routine data collection
When? When are you going to collect
the information and how often?
Select periodicity and frequency
Where? Where will information gathering
take place? Select site for example
at the community or health facility
level
How much? How much it will cost?
What resources are needed?
Is there a cheaper option?
Determine budget and identify
sources of funding. Defining the
needs allows identification of the
levels at which evaluation will
take place.
Level 1: Activity- is the planned activity
working?
Level 2: Quality- Standards of quality
Level 3: Efficiency- Cost per unit
Level 4: Effectiveness - Are these the
desired outputs?
Level 5: Outcome validity- Are the
outputs useful?
Level 6: Impact- Long term effectiveness

Other considerations that need to be


taken into account before starting an
evaluation include the prevailing political
and social atmosphere. It has to be clear
who wants the evaluation done? Who
will use the results of the evaluation? To
whom does the evaluator report to? The
person undertaking the evaluation must be
credible with the necessary qualifications
so that the consumers of the report will
have no doubts as to its authority.

Finally,
evaluations have limitations.
Having an evaluation done does not
guarantee change nor does it automatically
lead to wide disclosure of information.
An evaluation can often be a threat to
underperformers and can divert attention
on the necessary changes by focusing on
trivia. Ultimately it is the beneficiary who
can judge success

247

Questions Section
1. Define the key management processes
2. Describe the steps in planning health activities
3. Explain the steps in organizing
4. Interpret the role of power in being a successful leader
5. List the available methods for monitoring and evaluating health service programs
Further reading
1. World Health Report, 2006 WHO,
3. Economics of health care financing, the visible hand, Cam Donaldson and Karen
Gerard 2nd edition, 2005
Cost sharing: a blunt instrument, dahlia K. Remler, Jessica Greene, Annu. Rev.
Public Health 2009. 30:293-311
Private health insurance in developing countries Mark v. Pauly et al, Health Affairs
Vol 25, No 2, 2006
4. World Health Organization. The World Health Report 2000 Health systems:
improving performance. World Health. 2000
5. World Health Organization. HEALTH SYSTEMS AND SERVICES Annual Report
2009.
6. Managers who lead: a handbook for improving health services.
Thinking for Health Systems Strengthening. Alliance For Health Policy And
Systems Research, World Health Organization,
Geneva, 2009.
7. Lee, T. H. Turning Doctors into Leaders. Harvard Business Review, April 2010
8. Zaleznik A. Managers and leaders. Are they different? Harvard Business Review.
January 2004 ; 74-81. World health report, 2010, WHO

248

HEALTH PROMOTION

Health promotion is the process of


enabling people to increase control over
the determinants of health and thereby
improve their health (WHO, 1986).

It recognised that health was a result of


a complex interaction between biology,
environment, lifestyle and the system of
health care.

Introduction

This report was followed by the Ottawa


Charter which identified three approaches
for health promotion. These are:
advocacy for health to create the
essential conditions for health
enabling people to take control of the
eterminants of health in order to
achieve their fullest potential
Mediating between different interests
in society in the pursuit of health

The concept of health promotion today


arose from the public health movements of
the 19th and early 20th Century in Europe
and North America.
Increased knowledge of infectious disease
transmission mechanisms combined with
agitation for social reform led to improved
health regulation and legislation. These
regulations led to better sanitation, food
supply, housing and working condition for
the majority of the population and
consequently a marked improvement in
health. Analyzing these societal actions led
C.E.A. Winslow to describe public health
as the science and art of promoting health,
preventing disease and prolonging life
through the organised efforts of society1
After World War II, the Western world
went through a twenty-year period
when investments were made primarily
in physical health infrastructure such as
hospitals.
The emphasis of public health through
health education of the population was lost
and public health focused on preventive
services such as antenatal care carried out
through the health services. The
publication by the then Minister of Health
Marc Lalonde of the landmark Lalonde
report a new perspective on the health
of Canadians in 1974 marked a turning
point in the history of health promotion.

The charter outlined five areas for health


promotion action under the new public
health, namely:
build healthy public policy;
create supportive environments;
strengthen community action;
develop personal skills; and,
Re-orient health services.
WHO followed up with the health for all
strategy (1978), in which social justice
and equity were recognised as important
parts of health. More recently through
the Bangkok charter (2005), and the
Jakarta declaration on health promotion
into the 21st Century, the WHO
recognizes that new strategies are needed
to fight increasing health inequalities,
environmental degradation, urbanization
and new patterns of consumption.
The rising incidence of non-communicable
diseases in the west and HIV/AIDS in
Sub-Saharan Africa has today brought to
the forefront the limitations of just using

249

preventive services to reduce the disease


burden. Understanding the determinants
of disease, how people behave and
focusing on individual behaviour change is
again becoming an important part of public
health.
Health education is now an important part
of public health strategy. It targets different
population groups including:
Healthy people to modify existing
behaviour to reduce present or future
risk of developing disease or injury (e.g.
wearing seatbelts)
Individual patients to promote optimal
use of health services e.g. early
treatment of malaria.
High risk patients to continue using
health services e.g. mobile phone
sms alerts to remind patients to attend
clinic appointments

Types of health promotion


interventions

Health promotion interventions focus on


preventing or reducing risky behaviour
such as unsafe sex, smoking tobacco or by
promoting health protective behaviour such
as sleeping under a bed net, immunization
and taking exercise. This can be done in
several ways, for example:
Interventions that increase knowledge
and awareness about available services
to prevent risk, e.g. antenatal care;
Interventions that seek to change
attitudes e.g. condom use
Interventions that increase recipients
skills, e.g., assertive skills in negotiating
sex for women;
Interventions that try to change beliefs
and perceptions, e.g.having a pot belly
is a sign of being healthy and affluent
Interventions that influence social
norms for example;

public perception about carrying


condoms.

Models of health promotion

The definition of health promotion


challenges medical services as being the
sole route for the achievement of health. It
stresses the social and economic aspects of
health as being equally important(Downie
et al 1990). There are three models
to improving health based on medical
behavioural change, social, change or
educational change.
The medical model
focuses on disease prevention and is
commonly divided into primary, secondary
and tertiary prevention. The social change
model is based on the view that health is
determined by the social cultural and
physical environment of the individual.
Political solutions such as legislation protect
people from unhealthy environments. The
educational model assumes that people are
rational and that given information people
will modify their lifestyle and behaviour to
achieve health.
These models are simplistic and none
of them on their own describes health
promotion. The Tannahill model combines
the three simpler models. Health
promotion is seen as comprising efforts
to enhance positive health and prevent illhealth, through the overlapping spheres of
health education, prevention, and health
protection. These three overlapping
spheres unite the seven domains that make
up public health namely:
1. preventive services
2. preventive health education
3. preventive health protection
4. health education for preventive health
protection
5. positive health education

250

6. positive health protection


7. Health education aimed at positive
health protection.

Health promotion theories

Health promotion operates at different


levels including, individual, community and
national . A multi-level approach is more
likely to address the whole range of health
determinants and thus have the greatest
effect in promoting good health.
Carrying out a successful health promotion
requires an understanding of health
behaviour at the different levels. There are
many theories that attempt to describe
behaviour. Some of the more established
ones include:
the health belief model;
the stages of change/trans-theoretical
model;
social cognitive theory;
Community organization.
These theories look at a range of factors
influencing behaviour determinants at
individual level, such as thoughts, feelings,
and belief, factors in communities and
government such as regulations, policies,
and laws.
A good theory can help in understanding the
method to use in planning an intervention.
Most health promotion theories or
models originate from the
behavioural and social sciences. These
theories attempt to explain and predict
individual behaviour and social practices.
They should underpin the method through
which change will occur. They can also
help plan the timing and sequencing of the
various interventions.
Depending on the level of intervention
i.e. whether it is individual, community or

national level, different theories will have


grater relevance. It is unlikely that a single
theory will be the perfect fit. Glanz, et al
(2002), offer a simple summary of how
to judge if the theory (theories) being
considered offer a solution to the problem
being addressed. They ask, is it?
Logical?
Consistent with everyday observations?
Similar to those sued in successful
programs?
Supported by past research?

Disease
prevention e.g.
seat belt legislation
for road users

Health
education e.g.
behaviour
Health protection e.g.
legislation

Fig. 15.1: Spheres of health promotion

The health belief model


The health belief model was developed
by researchers at the U.S. Public Health
Service in the 1950s, and was inspired
by a study of why people sought X-ray
examinations for tuberculosis. It attempted
to explain and predict a given health-related
behaviour from certain patterns of belief
about the recommended health behaviour
and the health problems the behaviour was
intended to prevent or control.
The model postulates that the following
four conditions both explain and predict a
health-related behaviour:
1. A person believes that his or her health
is in jeopardy. For the behaviour of

251

seeking a screening test or


examination for an asymptomatic
disease such as tuberculosis,
hypertension, or early cancer, the
person must believe that
he or she can have the disease yet not
feel symptoms. This constellation
of beliefs was later referred to
generally as belief in susceptibility.
2. The person perceives the potential
seriousness of the condition in terms
of pain or discomfort, time lost from
work, economic difficulties or other
outcomes.
3. On assessing the circumstances, the
person believes that benefits stemming
from the recommended behaviour
outweigh the costs and inconvenience
and that they are indeed possible and
within his or her grasp. Note that
this set of beliefs is not equivalent to
actual rewards and barriers
(reinforcing factors). In the health
belief model, these are perceived or
anticipated benefits and costs
(pre-isposing factors).
4. The person receives a cue to action
or a precipitating force that makes the
person feel the need to take action.
The model soon changed shape when
applied to another set of problems
concerning immunization and more
broadly to (the variety of) peoples
different responses to public health
measures and their use of health
services.
The health belief model has been found to
be most useful when applied to behaviour
for which it was originally developed for
such as screening and immunization.

The trans-theoretical model (TTM)


The
trans-theoretical
model
was
developed by James Prochaska and Carlo
Di-Clementes. It explains the different
stages in behaviour change and is based on
the premise that change is a process not an
event and individuals have different levels of
motivation to change. People are thought
to move from a state of no motivation to
one of internalization of new behaviour.
They identify five change stages.
1. Pre-contemplation stage in which
people have no intention to change
their behaviour. In a successful
change process, people make a
transition to;
2. Contemplation stage, in which they are
thinking about changing the behaviour
that leads to the problem. Ideally,
people then move to;
3. Preparation stage in which they are
planning to change this behaviour in
the short term. People who have
recently changed their behaviour are
in the action stage, whereas people
who have performed the behaviour for
a longer time move to the next stage
4. Maintenance stage. This is
sustained and there are predictable
health gains
5. Relapse stage. People may relapse
to an earlier stage thenthe cycle begins..
TTM can be used to describe and to change
behaviour. An important contribution of the
model is the specific tailoring of educational
efforts to include different models and
processes of change for individuals in
different stages of change. For example,
previous smokers of tobacco may need a
different intervention from teenagers who
have never smoked cigarettes.

It is less useful when used to address more


long term, complex and socially determined
behaviour such as alcohol abuse.
252

Relapse

modifies the individuals behaviour


is termed reciprocal determinism.

Contemplation

(returns to previous
Contemplation
pattern of behaviour)

(weighing the pros and cons)

Contemplation

maintenance

Contemplation
(actively maintaining
(weighing the pros and cons)
change)

(weighing the pros and cons)

Preparation
(active changes
putting decision
into practice)

Fig. 15.2: The TTM model

Social cognitive theory


Health promotion interventions often
have poor outcomes because they are
heavy on didactics but poor on personal
motivation. The social cognitive theory
was developed by Albert Bandura. It is
one of the most widely applied theories
because it addresses both the underlying
determinants of health behaviour and
the methods of promoting change.
Bandura recognized that health knowledge
can be conveyed readily, but changes in
values, attitudes, and health habits require
greater effort. Social cognitive theory can
be divided into two parts:
1. It describes the interactions between
individuals and their environment. For
example, in an environment
where most people are non-smokers,
it is easier to modify the behaviour of a
smoker even without formal regulation
as the environment is already less
rewarding to the smoker. The way in
which the individual interacts with the
environment and the environment
provides a feedback which further
253

2. It describes the way in which people


think and are motivated given the
environment described in part one.
Three personal cognitive factors are
important. The first is that people have
the capacity to learn by observing.
For example, girls in school may take
up smoking because they see role
models smoking. The second is
the capacity to anticipate and place
value on the outcome of
different behaviour patterns.
For example, people may believe that
eating eggs makes you fat.
If you want to lose weight then you
would avoid eggs. This emphasizes the
importance of personal beliefs and
motivations that underlie different
behaviour and therefore the need for
short term tangible benefits in trying to
change behaviour. The third cognitive
factor is the importance of belief in
ones own ability - self efficacy.
It is the most important factor for
behaviour change as people have to
believe that they can change
themselves.
Health
promotion
programs
that
encompass the essential elements of the
self-regulatory model achieve greater
success. There are no well established
theories that explain behaviour change at
the community level.
A community is not just a collection of
individuals living in a particular area. It is
a dynamic system and local knowledge
and experience is important in devising
health promotion interventions. Rogers
(2002), developed the theory of innovation
diffusion in which he spelt out five factors

that influence the success with which new


ideas are taken up by a community.
These are:
1. The characteristics of the potential
adopters
2. The rate of adoption
3. The nature of social system
4. The characteristics of the innovation
5. The characteristics of change agents
categorize adopters based on whether
they are innovators, early adopters, early
majority, late majority or laggards who are
very conservative. How compatible is it?
What is the relative advantage? How simple
is the innovation? What are the perceived
risk and reversibility of the innovation?
The social context of behaviour change
should always be taken into account when
carrying out an intervention to change
behaviour. While research has shown that
interventions that are based on a theoretical
model are more effective than those that
are not, problems arise because of the
nature of the models themselves. A model
is usually a simplification of what we find in
the real world.
Unfortunately, when carrying out an
intervention, we have to take into account
the local context and the complexities
therein. This means that, models often
are seen not to work and there is then
a temptation to discard the model as
ineffective. A further problem is the
necessity to modify the model to suit the
factors found locally.
This is the solution to the model
generalization but must be done in a logical
way to retain the scientific basis of the
model and to ensure that results obtained
can be measured. For health promotion

to be acceptable and effective, we have


to take into consideration certain ethical
and political issues that may arise. There
are differences and debate on fundamental
issues such as defining good health.
For example, is an obese person healthy or
unhealthy? What about taking drugs such
as marijuana? These differences also lead
to questions about whose responsibility
it is. At what level does a health problem
become defined as social problem? There
are differences in approach to achieving
health. What happens when one persons
ill health affects another e.g. tuberculosis
or smoking tobacco?. These are some of
the ethical dilemmas.
These questions can be viewed as
philosophical but there are also practical
considerations. Health is affected by socioeconomic factors such as access to health
care, housing, etc.Action to improve health
depends on political will to improve on
these underlying factors.
In carrying out health promotion, four
principles can be outlined to guide us
ethically.
Respect for autonomy. We should
always respect the decisions made by
someone who has the capability to
make a decision, e.g. an adult
Non - maleficence. This means do no
harm
Beneficence. The benefit that accrues
from what is being done should
outweigh the risks
Justice. Benefits, risks and costs should
be distributed fairly.
The starting point for implementing the
principles outlined above is to apply the
principles without knowing the positions in
society of the potential adopters.

254

For example, senior people may create


a rule that favours them when they are in
office but which may not necessarily good
for society as a whole. such people will be
acting for their self interests.
For example, a policy maker who is a smoker
might create rules that favour smokers to
the detriment of the greater public good.
This is not something theoretical but a
practical consideration when carrying out
health promotion especially in the public
domain where an element of coercion
might be necessary.

Still, the risk and the targeting of health


promotion interventions need to take
into account individual determinants of
a disease and determinants of population
incidence. Two strategies which can be
complementary arise. These are the high
risk approach targeting individuals and the
population approach targeting the general
population. Each strategic approach has its
advantages and disadvantages as illustrated
in table 15.2.
Table 15.2:
High Risk
Approach

Risk approach to health promotion


In carrying out any health promotion
intervention, it is necessary to have a
stated goal. Goals, as described earlier
should be clear and well defined. In health
promotion, the setting of goals and targets
is based on risk of a condition or disease to
the population.
In epidemiology, risk is defined in statistical
terms as the probability of an event such
as death occurring. To lay person, such
a definition may not have much meaning.
(What does it mean if I have a risk of
1:100,000 of being knocked down by a
bus?). One way of dealing with this is to
have a common language to risk.

Population
approach

Risk estimate

Example

High

Greater than 1:100

Mother to child
transmission

Moderate

Between 1:100 and


1:1000

Smoking ten
cigarettes per
day

Low

Between 1:1,000 and


1:10,000

Road Accident

Very Low

Between 1:100 and


1:1000

Leukaemia

Minimal

Between 1:100,000
and 1:1,000,000

Vaccination
associated polio

Negligible

Over 1:1,000,000

Hit by lightning

Disadvantages

Intervention
appropriate to
individuals

Difculties and costs


of screening

Subject
motivation
usually high

Does not deal


with the cause
of the problem
Implementation

staff (medical)
motivation
usually high

Limited potential
for population
population health
improvement

Can be a cost
effective use of
resource

Does not address


social norms
that frame health
behaviour

Seeks to remove
the root cause of
the problem

Population
Only a small benet
for most individuals
(prevention paradox)
Poor motivation for
most subjects

Large potential
for population
improvement
Behaviourally
appropriate
as it seeks to
shift population
norms

Table 15.1: Terms describing and quantifying risk


Terms used

Advantages

Poor motivation for


medical staff Benetrisk ratio
may not seem
much to some
individuals

In the population approach, even when


most people change their behaviour the
benefit they get individually is small. This
is the prevention paradox. An example
is the Framingham study which showed
that in a group of 50 men aged up to 55
years, reducing cholesterol level by 10%
would lead to one of them avoiding a heart
attack.
255

However, to avoid this single heart attack


required 49 other men to also change their
eating habits.

radio, billboards and pamphlets where


information about a disease or condition is
outlined.

This illustrates the dilemma with the


population approach where individuals may
be unable to perceive the benefit they will
gain despite the fact that such interventions
are often cost effective ways of improving
population health. Such difficulties as
described above can be avoided by proper
goal setting. Successful goal setting occurs
if the following criteria is met:
Credibility. Targets set should be
realistic
Relevance. Targets should fit into the
overall strategy and tackle clearly
identified health problems
Evidences based. There should be
sufficient scientific evidence
Ownership. All stakeholders should be
involved and consensus should be built
to ensure success
Monitoring and evaluation. Targets
set must have measurable indicators
which can be monitored during and
after the intervention

The key is to ensure that the health


education message is delivered in a way
that is understood by and is credible to
the people being addressed. Evaluation
indicators often include knowledge
and attitude change among recipients.
Ultimately, there should be changes in
morbidity and mortality rates.

Health education

As outlined earlier health education is a


key component of health promotion. With
the ultimate aim of improvement in health
status, health education can be divided into
three phases that build upon each other
to effect the desired improved health
outcome.
Phase 1: Individual behaviour change
This assumes that people are rational
decision makers and that given sufficient
information they will make informed
rational decisions. Examples of suchhealth
education techniques include mass
media awareness campaigns through,

Phase II: Self-empowerment


Information is often not enough to cause
behaviour change. Various underlying
factors may prevent a person from carrying
out a decision they are convinced is right
for them. Such factors include socioeconomic, poverty, gender, cultural and
lifestyle choices.
Self empowerment techniques aim to
improve health by developing peoples
ability to understand and control their health
status within their given environment.
Examples of self empowerment techniques
employed include creation of self help
groups and life skill training such as
business skills which improve the life of the
individual.
Phase III: Collective action
Improvement in health is done by changing
the economic, social and environmental
factors through community involvement.
Examples of collective action include the
creation of advocacy and pressure groups
and administrative change. Similar to
phase one, evaluation measures changes in
knowledge and attitude in the community
and improved morbidity and mortality
rates.

256

Mass media campaigns


Mass media campaigns have become a
major tool to promote healthy behaviour.
Because such campaigns are often
expensive to run, it is important to have a
basic understanding of what makes a good
campaign to avoid wasting resources.
Mass media campaigns aim to change the
normal health habits that the targeted
population have with regard to a particular
disease or condition by influencing their
behaviour.
The influence can be in two forms:
By increasing the amount of available
information about the health problem.
By redefining or framing the issue as
a public health problem to make it
salient, attract the attention of the
target audience, and suggest a solution
to resolve that problem.
Before starting to provide information
about the health problem, the scene
must be set so that people are willing to
receive the information when it is available.
Therefore a mass media campaign must
start by manipulating the environment.
For example, providing information about
jiggers will not lead to a behaviour change
unless people have been sensitized first that
jiggers is a public health problem. If people
become aware that a problem is serious,
then they are more likely take some action
when provided with options.
Because campaigns often have a defined
limited time to run considerable effort must
be placed on getting the right message that
people will respond to.
This requires understanding the:
People who will receive the message in
social, cultural and education terms.
Determinants of health behavior that

could potentially lead to desired health


outcomes.
Finally there must be a mechanism for
monitoring and evaluating the success of
the campaign in terms of the main aim
which is to improve health status. The
use of health promotion theories outlined
above is therefore important as whichever
underlying theory helps explain the
potential impact.

School health

In Kenya, the Government has revised the


curricula of the primary and secondary
schools levels to intergrate life and
emerging health and health related issues.
The additional content has aspects of
hygiene, several health, drug and substance
abuse.
Healthy habits learned at an early age
improve lifestyle later and young people
who understand health risks are less likely
to engage in high risk behaviour that is
detrimental to their health. The major
problem though is that often the topic
of health is approached solely from an
education perspective and not a holistic
health approach.
Individual health topics are taught and
not necessarily related to each other or
integrated fully. For example alcohol can
be taught as a topic but not related to life
skills that enable the individual to manage
situations that might lead to alcohol abuse.

Planning a health promotion


intervention

Just like planning any activity, a health


promotion activity requires a needs
assessment to be done first. This will enable
you to identify the target group clearly and
understand the nature of the problem
within the local context. This means the

257

local environment must be taken into


account. The goal of the intervention can
then be clearly stated and targets that are
SMART set.
Doing a literature search and identifying
past interventions done in similar
circumstances will assist in determining
what model methodology to use in carrying
out the intervention.
The indicators that will be used in monitoring
and evaluation should be identified. The
resources needed and a budget should
be prepared. Implementation of the
interventions should not start until the
above steps have been operationalized.

Evaluating a health promotion


intervention

Evaluation is a critical part of the intervention.


Evaluation is necessary to ensure activities
carried out had the intended effects, are
were effective and were acceptable to the
target population.
Different stakeholders will have differing
perspectives to an evaluation. For the
implementing manager, evaluation is
necessary to get feedback on which
activities contributed to success and which
ones hindered given the local environment
and budget that was in place.
To policy makers, an evaluation enables
them to judge effectiveness but also
whether such an intervention can be
replicated elsewhere and whether it will
be acceptable to various stakeholders

including the general population and


politicians.
To the community, an evaluation provides
a feedback mechanism and gives them an
opportunity to participate in the program
planning and implementation.
Typically, the evaluators come from
academia and their interest is in knowledge
building and understanding the relationships
to develop better models of application.
There are several steps in carrying out an
intervention. Some of these include:
Formative stage. In the early planning
stage, a systematic review of the
effectiveness of the selected
intervention should be carried out
to learn from prior evaluations
done and ways found to address
possible deficiencies.
Pilot stage.Before the full intervention
is carried out, a pilot should be done.
As nuch as possible, the pilot should
match the intended intervention in
terms of target population. This
provides evidence of what can be
achieved within a particular setting
given a certain amount of resources. If
the program is found not to work well
at this stage then the project should
be revised or abandoned.
Implementation stage. During
implementation, there must be a
monitoring system for routine data.
This data would include information on
inputs, outputs, various project
activities, set against predetermined
quality standards. Any deviations

In the mid 1990s WHO launched a global school health initiative, seeking to mobilize and strengthen health promotion and education activities at
the local, national, regional and global levels. The initiative is designed to improve the health of students, school personnel, families and other members
of the community through schools. The goal of the initiative is to increase the number of schools that can truly be called Health-Promoting Schools.
Although denitions vary a Health-Promoting School can be characterized as a school constantly strengthening its capacity as a healthy setting for
living, learning and working.
A global alliance including Education International, Centers for Disease Control and Prevention, Education Development Center, UNESCO, UNAIDS
and NGTZ has been formed to enable teachers representative organizations, worldwide, to improve health through schools.

258

should be attended to immediately.


As the project nears completion
then the outcomes and impact need to
be evaluated.
Dissemination stage. Once the project
is complete, information on
outcome and lessons learnt should
be packaged and disseminated to a
wider audience beyond the
immediate project team.

259

Questions
1.
2.
3.
4.
5.

Describe the different models of health promotion


Specify the different health promotion theories
Outline the different types of health promotion interventions
Describe the health education process
Outline key considerations in the design and implementation of a health
communication campaign.

Further Reading

1. Davis RM, Wakefield M, Amos A, Gupta PC. The Hitchhikers Guide to Tobacco
Control: a global assessment of harms, remedies, and controversies. [Internet].
Annual review of public health. 2007
2. French J, Adams L. From analysis to synthesis: Theories of health education Health
Education Journal. 1986 ;45(2):71-74.
3. U.S. Department of Health and Human Services. Theory at a glance: A guide for
health promotion practice. 2005

260

PART V: Making a community diagnosis

Making a community diagnosis

Planning and implementing cost effective health programs and activities require an accurate
assessment of public health problems and priorities. This requires an in depth knowledge
of the community, that is a community diagnosis. Carrying out a community diagnosis
enables the collection of information that can be used to determine the epidemiology of
disease within the community and list the key factors that influence the identified disease
pattern. The health status of the community is then known allowing targeted health
interventions and the setting up of health services that are responsive to the needs to the
community that they serve.
By the end of this short section the reader will be able to create a community survey plan
be able to conduct a community survey.

261

CONDUCTING A COMMUNITY SURVEY

Introduction

The first thing a doctor has to do on


meeting a patient is to evaluate the health
status of the patient and determine what
the health needs of that particular patient
are. The essence of medical training is
that this evaluation should be done in a
systematic manner before any treatment
is suggested. After a differential diagnosis
is made, the proposed treatment should
be one that is effective in managing the
presenting condition or illness.
The patient presenting at a health facility
may or may not reflect the general health
trends in the wider community where she
or he comes from. For purposes of planning
effective health services it is important
for the health worker to understand the
actual community health needs and not
simply extrapolate it from the patients
presenting at the health facility.
Community members might not use a
health facility for a number of reasons
including:
Lack of information about what the
health facility can and cannot do.
For example, the health facility may
have good quality diagnostic capability
but patients may be unaware and still
travel long distances by passing this
facility. The clinician may assume that
such conditions are rare in
that community.
Privacy and culture. Community
members may not want to be seen at
the local health facility or may use
alternative health services such as

herbal medicine.
Perceived poor or excellent service.
One good clinician may motivate more
patients with a particular condition to
go use the facility. For example, a
diabetic clinic might have large
numbers but that does not mean
the prevalence of diabetes is high.
A neighboring health facility might well
have no patients with diabetes because
the attending clinician has poor public
relations. A health facility holding
a clinic on market days might be
popular as people take the opportunity
to trade and visit the nurse.
Lack of awareness of their health
status.
People in the community might
be unaware that they need
healthcare, for example, patients with
hypertension may present late.
Exclusion of certain segments of the
community. The very poor or
disadvantaged such as orphans and the
elderly may not be able to access the
health facility.
Having a good understanding of
epidemiologic principles is therefore
important. Understanding the health needs
requires a health needs assessment which
can be done at various levels including:
International e.g. by the WHO or
UNICEF
National e.g. to tackle a national
priority such as malaria or mental
health to idenfity gaps in service.

262

Regional level e.g. to identify need for


a regioanl specialist surgical referral
service
Health facility specific e.g. to
identify underserved population wihtin
cathcment area
Focused on specific condition e.g. TB,
diabetes
A community diagnosis identifies the major
health concerns in a specific community
and allows prioritization of interventions to
meet the health needs of the community.
A community survey is defined as a
population based epidemiological study in
which a cross-section of the population is
surveyed. It can be used to identify such
issues and is useful in planning health
services for the community. Such a survey
primarily answers questions about the
magnitude of the problem and identifies
the risk factors that contribute to the
health problem.

Community participation

When the needs of the community are not


taken into account and we rely on patients
attending health facilities to determine
health needs there is a huge risk that
resources will be wasted and community
members suffer while they have a health
facility right at their door step. At the
same time, the health worker wonders
why people are so slow and never come
to the health facility while the community
member wonders why the health workers
are so arrogant and ignore them.
Before conducting a health needs
assessment, it is vital to connect with the
community so that they understand what
you intend to do and what you are able to
do far tahn to set their expectations right.
The community should be sensitized
about the survey and its importance.

Often, health projects begin after a rapid


assessment without fully understanding
what the community needs. Eventually, the
project fails to achieve its stated objectives
because it did not engage the community
fully in its goals.
The participatory appraisal method is one
way of gaining information from and about
the community while at the same time
engaging them to understand what is to
happen next. Such an approach enables
trust to build between the health worker
and the community this is an important step
particularly for marginalized communities.
Understanding why a community is not
part of mainstream development or why
they suffer neglect is the beginning to
solving their health issues. Stereotypes and
assumptions can be dangerous.
While community participation is essential
in every project conducting a community
participatory appraisal can be expensive. It
may require considerable time depending
on the extent of the appraisal. Adequate
resources must be available for proper
training of participants and staff. The data
collected must be analyzed and there must
be proper planning and preparation of
stakeholders, events where the community
meet to discuss possible action plans. It is
therefore not always appropriate for small
projects. It can also raise many conflicting
interests which may be difficult to resolve
within the project period.

Health needs assessment

A health needs assessment differs from


research because here we are trying to
improve health in one community or area.
We are searching for what makes this area
different from the next community so that

263

we can tailor the healthcare services to the


needs of the local population. In research
we are moving in the opposite direction
trying to understand the needs of this
community and hoping thatthe findings
can be replicated in other communities.
A health needs assessment is more like
operational research rather than pure
research.
In carrying out a needs assessment there
must be prioritization. The following
questions can help prioritize.
Is there a realistic chance of achieving
change?
Is the cost of undertaking the work
proportional to the likely benefits?
What are the priorities being suggested
by other organizations?
What can you do about issues that
are not directly under the control of
your organization? Is there a clear
mechanismfor collaboration?
Table 16.1 shows some examples of
prioritization.
Table 16.1 : Example of prioritization
Variable

Data
known
yes/no

What
does the
data say?

What are the


implications?
(So what?)

Priority
Rank

Maternal
deaths
at health
facility

yes

Above
national
average

Need to
identify all
causes

HIV rate
in
community

no

May or
may not
be higher
than
national
average

Assume
national
average and
implement
recommended
strategies

Need, demand and supply of


healthcare services
The interaction between need, demand
and supply of healthcare has to be taken
into account when starting an assessment.
Once a need is identified a suitable health
intervention should be designed to meet

that need which should then lead to an


improvement in health status. It is important
to differentiate demand from need.
The Community
Within the community there are various
determinants of health. These have been
outlined elsewhere. At the community
level we must understand how these
determinants interact with each other to
produce the observed health status. These
include:
Social Structure - what is the power
structure in the community?
Is leadership formal or informal? Are
there clear groupings? What is the role
of women? What is the gender balance?
Family structure - marriage customs,
decision making in household
Economic - what are the main sources
of income in the community? What are
the causes of poverty? What are main
sources of employment?
Infrastructure - Transport, sanitation,
power supply?
Climate - what is the yearly /seasonal
weather pattern? How does the
community manage their affairs in
light of this?
Religion - what is the dominant
religion? What are the implications of
this?
Daily routines - what do people do at
different times of the day?
Obtaining such information allows a
dynamic picture of the community to
build. Gathering the above information is
done first by identifying the local leaders
both formal and informal and getting their
cooperation. Then influential opinion
leaders need to be identified. They can be
interviewed individually or in focus groups.
in most cases the opinion leaders are not in

264

formal positions of power. They are people


who are in tune with public opinion and
often shape it as well. In modern society
opinion leaders are the media (journalists),
politicians, church elders, business people
and other professionals.
Direct observation is useful in mapping
out the infrastructure and key economic
activities to augment the other methods of
gathering information. Conducting a health
needs assessment is a systematic method
of identifying the unmet health needs in the
community. It can be research but often is
not regarded as pure research.
A successful health needs assessment
uses a combination of epidemiological and
qualitative methods to help determine:
the health problems in the population
Identify inequalities in health
health services available and the levels
of access
to them
health priorities given the available
resources
The disease pattern in the community can
be described in terms of person, place and
time.
Table 16.2 : Questions to ask
Location

Question to ask

Person

Who is affected? Who becomes sick?


In terms of age, sex, occupation,
socioeconomic status

Place

Where is the disease more common? How


does the disease vary geographically?

Time

When does the disease occur? Season? Has


there been a change/trend over time?

Disease

What are the most common conditions?


What are the causes?

Time

Who is currently providing care? Where?


When? For what disease conditions? How
effective are they?

Sources of information in the


community
The key to good planning is to have

adequate and timely data. The first step


is to collect relevant data from routine
sources. These include:
Census, Demographic health surveys,
registration of births/deaths
Hospital morbidity/mortality data
Surveillance and monitoring data e.g.
sentinel sites HIV
Previous surveys done
Mass screening exercises
This information collected above is a mix
of national, regional and local data. Such
data needs to be triangulated to be useful.
Gaps in the data can then be identified
and collected through ad-hoc surveys and
interviews. Collecting information around
where the gaps are can be done by asking:
1. Who is not being reached by existing
healthcare? (unmet need)
2. Who is receiving ineffective healthcare?
(resource waste)
3. Who is receiving poor quality
healthcare? (outcomes can be
improved)

Conducting a survey

As a general rule, surveys are an expensive


way of gathering information. Every effort
must be made to get information from
routine sources before deciding that a
survey is necessary. A survey has several
stages: Planning starts with identifying
clear objectives. The objectives of the
survey should be established through
discussion with community and any other
stakeholders.
Proper advance planning ensures that
duplication of effort is avoided and that
resources are utilized well. Most important
we need to ensure that the data collected
is relevant and not just nice to know.
For a thorough health assessment it is
important to have a clear case definition.

265

Cases are those people in the population


who develop a particular disease or those
with a disease who develop a particular
outcome. How the case is defined affects
the reported rates. A complete case
definition gives a case in time, person and
place. How much resource including time
available to conduct the survey should be
confirmed early as it has a bearing on the
kind of study that can be accommodated
within the given resources.
1. Study design
Depending on the objectives the appropriate
study design should be selected. The level
of precision needed should be addressed
at this point depending on what results
are required and how they will be utilised.
A communication strategy as part of the
study design helps think through who
needs what kind of information, in what
form and the best way of disseminating the
information to them.
In such a survey, the community itself will
need feedback on the study findings. What
is the best way of telling them? There may
be certain questions that are important for
them which if you answer will help them
better understand what you are trying to
do. For the scientific community a paper
may have to be established. For a policy
maker a policy brief.
The tools that will be used to collect the
data should be determined. If for example
a questionnaire is to be used the questions
should be designed in such a way that the
information obtained is unbiased. Open
ended questions are easy to formulate but
difficult to process and analyze. With openended questions, the range of answers
may be so varied that any comparisons
will be meaningless. Answers obtained can

be so varied that it is impossible to make


anything out of them. Multiple choice
questions are harder to formulate, much
easier to analyze but bias can easily creep
in. Care must be taken to see that all the
possible response alternatives are included
and that these alternatives do not overlap
sentences with multiple meanings.
The information asked per question
should also not be confusing. This often
happens where too much information is
being asked per question. It is also vital to
know beforehand if the respondents have
satisfactory knowledge about the question
areas. People are often too polite or proud
to acknowledge that they do not know
anything useful about the subject matter
being asked.
Selection of a study population from a
reference population. Careful selection
from a theoretical and practical
perspective is important to ensure that
the data collected is representative of the
population as a whole. There is a need to
first define and select the members of the
population to be surveyed using a predetermined methodology. Where there
is lack of adequate information about the
local population, a simple random sample
can be conducted.
However, this can be costly where the
population is very large.This is why people
often resort to non-probability sampling
such as people exiting a health facility. Valid
generalization can only be made about
the people being interviewed but rarely
about the larger population they come
from. Probability sampling allows the
results obtained to be generalized to the
entire population. In addition the sampling
error and precision of estimates can be
calculated.

266

2. Data collection
Before beginning full scale data collection
it is important to carry out a pilot or pretest using a subset of the population that is
similar but will not be covered in the main
study. The pilot has two main objectives:
a. To discover possible
misunderstanding
and misinterpretation of the
questions being asked.
b. To identify possible problems in the
procedures to be used in data
collection.
Even the most experienced researcher
cannot foresee all the potential problems
that may occur when using new questions
or techniques. Every effort must be made
to ensure those within the sample are
reached.
A low response rate produces more
questionable results than a small sample,
since there is no scientifically valid way to
infer the characteristics of the population
that the non-respondents represent.
Therefore rather than simply ignore the
non-respondents, every attempt should
be made to get them to respond to the
survey.
High response rates are usually obtained by
employing rigorous follow-up procedures
as part of the survey methodology. If further
callbacks do not substantially increase the
response rate, weighting adjustments can
be used to help compensate for potential
non-response bias.
3. Data processing and analysis
The process of data entering, editing, and
analyzing the completed questionnaires
is subject to a great deal of human error.
Maintaining a high level of quality control
during these processes takes time and very

tempting to skip steps that ensure that the


data is reliable. Before the questionnaires
are entered into a database, the returned
questionnaires should be scanned to
determine if respondents are leaving
comments that could indicate that they
misunderstood a question or are answering
a question in an inappropriate manner. If
pre-testing was performed adequately,
there should be very little evidence of
confusion on the questionnaires.
Ideally, all of the questionnaires should
be checked to see if the responses match
what was entered in the computer. Many
professional data entry organizations will
double enter the data to ensure accuracy.
Strange or unintuitive results should be
explored, since these could be caused by
poor data entry, analysis or respondents
who did not understand the questions.
4. Dissemination of results
To be effective in disseminating results that
will result positions change, it is necessary
to have a good understanding of the various
stakeholders and how they influence and
interact with each other.
A communication plan includes:
Who - the target audience
What the key messages articulated
When timing, it will specify the
appropriate time of delivery for
each message
Why the desired outcomes
How - the communication vehicle
(how the message will be delivered)
By whom - the sender (determining
who will deliver the information and
how he or she is chosen)
Where possible, identify people who have
the skill, talent or knowledge to help in

267

promoting the positive ideas. Gladwell


(2002) describes the tipping point as the
moment of critical mass, when certain
phenomena spreads out and is accepted in
an entire community.
For this to happen, the idea, product or
service needs to be promoted by at least
three types of people; connectors, mavens,
and salesmen.
1. Connectors are people with good
social skills and professional experience
in a variety of different fields that make
them unique in connecting many
diverse people whose lives would
not otherwise intersect.
2. Mavens are experts in specific fields or
consumption niches (cars, computers,
etc.) who like to share their knowledge
and to help other people make choices.
3. Salesmen are people with outstanding
personalities and impressive persuasive
powers to influence what others buy
or accept.
An idea or product that receives the
attention of these three types of people is
likely to succeed. Identifying such types of
people in the community is a useful part of
the dissemination plan.

risks
Professionals need to support patients
in making choices by turning raw data
into information that is more helpful to
the discussions than the data
Framing manipulations of
information, such as using information
about relative risk in isolation of base
rates, to achieve professionally
determined goals should be avoided
Decision aids can be useful as they
often include visual presentations of
risk information and relate the
information to more familiar risks just
like any other activity, dissemination of
results requires planning.
Table 16.3 gives a summary communication
plan with key questions that can help
in formulating a dissemination or
communication strategy.
Table 16.3: Communication Plan Summary

Summary points
Patients often desire more information
than is currently provided
Communicating about risks should
be a two way process in which
professionals and patients exchange
information and opinions about those

268

Context

What has happened before?

Content

What are the key messages?

audience

Who are the key audience?


(what does each stakeholder
need to know),what will be
their reaction?

audience
Channels of communications

Personal, mass media,


electronic

Tactics

how will you implement


your strategy, both before,
during and after the main
announcement (assuming
you have one)?
What is the communication
events schedule?

Budget

What are the resources


available?

Evaluation

How will you know that you


have been successful?

Questions

1. List reasons why health facility data may not reflect the health status of the
community
2. Explain the importance of community participation in a community survey
3. Describe the sources of information in the community
4. Outline the steps in conducting a survey
5. Identify methods of disseminating results obtained from a community survey

Further reading

1. Etches, V., Frank, J., Ruggiero, E. D., & Manuel, D. (2006). Measuring Population
Health:
A review of indicators. Annual Review of Public Health, 27, 29-55.
2. Marshall MN. The key informant technique. Family practice. 1996 ;13(1):92-7.
3. Stevens A, Raferty J, eds. Health care needs assessment the epidemiologically based
needs assessment reviews. Oxford: Radcliffe Medical Press , 1994.
4. World Health Organization Outbreak Communication Planning Guide 2008. World
Health, 2008.

269

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Appendix Z - Table
Normal distributions are symmetrical, bell-shaped distributions that are useful in describing real-world data.
The standard normal distribution, represented by the letter Z, is the normal distribution having a mean of
0 and a standard deviation of 1. Since probability tables cannot be printed for every normal distribution,
(there are infinite), it is common practice to convert a normal to a standard normal, and use a Z table to find
probabilities

z 0.00 0.01 0.02


0.0 0.0000 0.0040 0.0080
0.1 0.0398 0.0438 0.0478
0.2 0.0793 0.0832 0.0871
0.3 0.1179 0.1217 0.1255
0.4 0.1554 0.1591 0.1628
0.5 0.1915 0.1950 0.1985
0.6 0.2257 0.2291 0.2324
0.7 0.2580 0.2611 0.2642
0.8 0.2881 0.2910 0.2939
0.9 0.3159 0.3186 0.3212
1.0 0.3413 0.3438 0.3461
1.1 0.3643 0.3665 0.3686
1.2 0.3849 0.3869 0.3888
1.3 0.4032 0.4049 0.4066
1.4 0.4192 0.4207 0.4222
1.5 0.4332 0.4345 0.4357
1.6 0.4452 0.4463 0.4474
1.7 0.4554 0.4564 0.4573
1.8 0.4641 0.4649 0.4656
1.9 0.4713 0.4719 0.4726
2.0 0.4772 0.4778 0.4783
2.1 0.4821 0.4826 0.4830
2.2 0.4861 0.4864 0.4868
2.3 0.4893 0.4896 0.4898
2.4 0.4918 0.4920 0.4922
2.5 0.4938 0.4940 0.4941
2.6 0.4953 0.4955 0.4956
2.7 0.4965 0.4966 0.4967
2.8 0.4974 0.4975 0.4976
2.9 0.4981 0.4982 0.4982
3.0 0.4987 0.4987 0.4987
3.1 0.4990 0.4991 0.4991
3.2 0.4993 0.4993 0.4994
3.3 0.4995 0.4995 0.4995
3.4 0.4997 0.4997 0.4997
3.5 0.4998 0.4998 0.4998
3.6 0.4998 0.4998 0.4999
3.7 0.4999 0.4999 0.4999
3.8 0.4999 0.4999 0.4999

0.03
0.0120
0.0517
0.0910
0.1293
0.1664
0.2019
0.2357
0.2673
0.2967
0.3238
0.3485
0.3708
0.3907
0.4082
0.4236
0.4370
0.4484
0.4582
0.4664
0.4732
0.4788
0.4834
0.4871
0.4901
0.4925
0.4943
0.4957
0.4968
0.4977
0.4983
0.4988
0.4991
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

0.04
0.0160
0.0557
0.0948
0.1331
0.1700
0.2054
0.2389
0.2704
0.2995
0.3264
0.3508
0.3729
0.3925
0.4099
0.4251
0.4382
0.4495
0.4591
0.4671
0.4738
0.4793
0.4838
0.4875
0.4904
0.4927
0.4945
0.4959
0.4969
0.4977
0.4984
0.4988
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

0.05
0.0199
0.0596
0.0987
0.1368
0.1736
0.2088
0.2422
0.2734
0.3023
0.3289
0.3531
0.3749
0.3944
0.4115
0.4265
0.4394
0.4505
0.4599
0.4678
0.4744
0.4798
0.4842
0.4878
0.4906
0.4929
0.4946
0.4960
0.4970
0.4978
0.4984
0.4989
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

0.06
0.0239
0.0636
0.1026
0.1406
0.1772
0.2123
0.2454
0.2764
0.3051
0.3315
0.3554
0.3770
0.3962
0.4131
0.4279
0.4406
0.4515
0.4608
0.4686
0.4750
0.4803
0.4846
0.4881
0.4909
0.4931
0.4948
0.4961
0.4971
0.4979
0.4985
0.4989
0.4992
0.4994
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

276

0.07
0.0279
0.0675
0.1064
0.1443
0.1808
0.2157
0.2486
0.2794
0.3078
0.3304
0.3577
0.3790
0.3980
0.4147
0.4292
0.4418
0.4525
0.4616
0.4693
0.4756
0.4808
0.4850
0.4884
0.4911
0.4932
0.4949
0.4962
0.4972
0.4979
0.4985
0.4989
0.4992
0.4995
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

0.08
0.0319
0.0714
0.1103
0.1480
0.1844
0.2190
0.2517
0.2823
0.3106
0.3365
0.3599
0.3810
0.3997
0.4162
0.4306
0.4429
0.4535
0.4625
0.4699
0.4761
0.4812
0.4854
0.4887
0.4913
0.4934
0.4951
0.4963
0.4973
0.4980
0.4986
0.4990
0.4993
0.4995
0.4996
0.4997
0.4998
0.4999
0.4999
0.4999

0.09
0.0359
0.0753
0.1141
0.1517
0.1879
0.2224
0.2549
0.2852
0.3133
0.3389
0.3621
0.3830
0.4015
0.4177
0.4319
0.4441
0.4545
0.4633
0.4706
0.4767
0.4817
0.4857
0.4890
0.4916
0.4936
0.4952
0.4964
0.4974
0.4981
0.4986
0.4990
0.4993
0.4995
0.4997
0.4998
0.4998
0.4999
0.4999
0.4999

277

278

279

280