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Community Health - Lecture notes
Community Health (HNS 107)
University of Nairobi
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COMMUNITY HEALTH
COMMUNITY HEALTH
Community health is a major field of study within the medical and clinical sciences which focuses on the maintenance, protection and improvement of the health status of population groups and communities as opposed to the health of individual patients. It is a distinct field of study that may be taught within a separate school of public health or environmental health. It is a discipline which concerns itself with the study and improvement of the health characteristics of biological communities. While the term community can be broadly defined, community health tends to focus on geographical areas rather than people with shared characteristics. The health characteristics of a community are often examined using geographic information system (GIS) software and public health datasets. Some projects, such as InfoShare or GEOPROJ combine GIS with existing datasets, allowing the general public to examine the characteristics of any given community in participating countries. Because 'health III' (broadly defined as well-being) is influenced by a wide array of socio- demographic characteristics, relevant variables range from the proportion of residents of a given age group to the overall life expectancy of the neighborhood/community. Medical interventions aimed at improving the health of a community range from improving access to medical care to public health communications campaigns. Recent research efforts have focused on how the built environment and socio-economic status affect health. Community health may be studied within three broad categories: Primary healthcare which refers to interventions that focus on the individual or family such as hand-washing, immunization, circumcision, personal dietary choices, and lifestyle improvement. Secondary healthcare refers to those activities which focus on the environment such as draining puddles of water near the house, clearing bushes, and spraying insecticides to control vectors like mosquitoes. Tertiary healthcare on the other hand refers to those interventions that take place in a hospital setting, such as intravenous rehydration or surgery.
Counseling 31% Mentoring 21% Social support 46% Transportation 36%
Related to work activities, employer-reported duties: Case management 45% Risk identification 41% Patient navigation 18% Direct services 37% Among the many known outcomes of CHWs’ service are the following: Improved access to health care services. Increased health and screening. Better understanding between community members and the health and social service system. Enhanced communication between community members and health providers. Increased use of health care services. Improved adherence to health recommendations. Reduced need for emergency and specialty services. 1
CHWs Take Action to Promote Heart Health in the Community The Initiative’s health education materials are designed to be taught by CHWs, who are trained to use these materials to help community residents improve their quality of life by adopting heart healthy behaviors. With the help of the Initiative, CHWs are able to: Help families understand their risk for developing heart disease. Help community members get appropriate screenings and referrals for health and social services. Track an individual’s progress toward meeting health goals. Hold workshops and group discussions to learn about ways the community can promote heart health.
Teach people how to prepare heart healthy meals, get more physical activity, and stop smoking.
COMMUNITY HEALTH
The term "community health" refers to the health status of a defined group of people, or community, and the actions and conditions that protect and improve the health of the community. Those individuals who make up a community live in a somewhat localized area under the same general regulations, norms, values, and organizations. For example, the health status of the people living in a particular town, and the actions taken to protect and improve the health of these residents, would constitute community health. In the past, most individuals could be identified with a community in either a geographical or an organizational sense. Today, however, with expanding global economies, rapid transportation, and instant communication, communities alone no longer have the resources to control or look after all the needs of their residents or constituents. Thus the term "population health" has emerged. Population health differs from community health only in the scope of people it might address. People who are not organized or have no identity as a group or locality may constitute a population, but not necessarily a community. Women over fifty, adolescents, adults twenty-five to forty-four years of age, seniors living in public housing, prisoners, and blue-collar workers are all examples of populations. As noted in these examples, a population could be a segment of a community, a category of people in several communities of a region, or workers in various industries. The health status of these populations and the actions and conditions needed to protect and improve the health of a population constitute population health. The actions and conditions that protect and improve community or population health can be organized into three areas: health promotion, health protection, and health services. This breakdown emphasizes the collaborative efforts of various public and private sectors in relation to community health. Figure 1 shows the interaction of the various public and private sectors that constitute the practice of community health. Health promotion may be defined as any combination of educational and social efforts designed to help people take greater control of and improve their health. Health protection and health services differ from health promotion in the nature or timing of the actions taken. Health
many miles. Remains of these aqueducts still exist. The Romans did little to advance medical thinking, but the hospital did emerge from their culture. In the Middle Ages (500–1500 c.), health problems were considered to have both spiritual causes and spiritual solutions. The failure to account for the role of physical and biological factors led to epidemics of leprosy, the plague, and other communicable diseases. The worst of these, the plague epidemic of the fourteenth century, also known as the Black Death, killed 25 million people in Europe alone. During the Renaissance (1500–1700 c.), there was a growing belief that diseases were caused by environmental, not spiritual, factors. It was also a time when observations of the sick provided more accurate descriptions of the symptoms and outcomes of diseases. Yet epidemics were still rampant. The eighteenth century was characterized by industrial growth, but workplaces were unsafe and living conditions in general were unhealthful. At the end of the century several important events took place. In 1796 Dr. Edward Jenner successfully demonstrated the process of vaccination for smallpox. And, in 1798, in response to the continuing epidemics and other health problems in the United States, the Marine Hospital Service (the forerunner to the U. Public Health Service) was formed.
The first half of the nineteenth century saw few advances in community health practice. Poor living conditions and epidemics were still concerns, but better agricultural methods led to improved nutrition. The year 1850 marks the beginning of the modern era of public health in the United States. It was that year that Lemuel Shattuck drew up a health report for the Commonwealth of Massachusetts that outlined the public health needs of the state. This came just prior to the work of Dr. John Snow, who removed the handle of the Broad Street pump drinking well in London, England, in 1854, to abate the cholera epidemic. The second half of the nineteenth century also included the proposal of Louis Pasteur of France in 1859 of the germ theory, and German scientist Robert Koch's work in the last quarter of the century showing that a particular microbe, and no other, causes a particular disease. The period from 1875 to 1900 has come to be known as the bacteriological era of public health. The twentieth century can be divided into several different periods. The years between 1900 and 1960 are known as the health resources development era. This period is marked by the growth of health care facilities and providers. The early years of the period saw the birth of the first voluntary health agencies: the National Association for the Study and Prevention of Tuberculosis
(now the American Lung Association) was founded in 1904 and the American Cancer Society in 1913. The government's major involvement in social issues began with the Social Security Act of 1935. The two world wars accelerated medical discoveries, including the development of penicillin. In 1946, Congress passed the National Hospital Survey and Construction Act (Hill- Burton Act) to improve the distribution and enhance the quality of hospitals. The social engineering era (1960–1975) included the passage of amendments to the Social Security Act that set up Medicare (payment of medical bills for the elderly and certain people with disabilities) and Medicaid (payment of medical bills for the poor). The final period of the twentieth century is the health promotion era (1974–1999). During this period it was recognized that the greatest potential for improving the health of communities and populations was not through health care but through health promotion and disease prevention programs. To move in this direction, the U. government created its "blueprint for health" a set of health goals and objectives for the nation. The first set was published in 1980 and titled Promoting Health/Preventing Disease: Objectives for the Nation. Progress toward the objectives has been assessed on a regular basis, and new goals and objectives created in volumes titled Healthy People 2000 , and Healthy People 2010. Other countries, and many states, provinces, and even communities, have developed similar goals and targets to guide community health. Factors that Affect Community and Population Health. There are four categories of factors that affect the health of a community or population. Because these factors will vary in separate communities, the health status of individual communities will be different. The factors that are included in each category, and an example of each factor, are noted here. Figure 2 1. Physical factors—geography (parasitic diseases), environment (availability of natural resources), community size (overcrowding), and industrial development (pollution). 2. Social and cultural factors—beliefs, traditions, and prejudices (smoking in public places, availability of ethnic foods, racial disparities), economy (employee health care benefits), politics (government participation), religion (beliefs about medical treatment), social norms (drinking on a college campus), and socioeconomic status (number of people below poverty level). 3. Community organization—available health agencies (local health department, voluntary health agencies), and the ability to organize to problem solve (lobby city council).
women, infants, and children can enhance health in later years and reduce the necessity to provide more costly medical and/or social assistance later in their life. Maternal health issues include family planning, early and continuous prenatal care, and abortion. Family planning is defined as the process of determining and achieving a preferred number and spacing of children. A major concern is the more than 1 million U. teenagers who become pregnant each year. About 85 percent of these pregnancies are unintended. Also a part of family planning and MIC is appropriate prenatal care, which includes health education, risk assessment, and medical services that begin before the pregnancy and continue through birth. Prenatal care can reduce the chances of a low-birthweight infant, and the poor health outcomes and costs associated with it. A controversial way of dealing with unintended or unwanted pregnancies is with abortion. Abortion has been legal in the United States since 1973 when the Supreme Court ruled in Roe v. Wade that women have a constitutionally protected right to have an abortion in the early stages of pregnancy. According to the Centers for Disease Control and Prevention (CDC), approximately 1 million legal abortions were being performed in the United States each year during the late 1990s.
Infant and child health is the result of parent health behavior during pregnancy, prenatal care, and the care provided after birth. Critical concerns of infant and childhood morbidity and mortality include proper immunization, unintentional injuries, and child abuse and neglect. Though numerous programs in the United States address MIC health concerns, one that has been particularly successful has been the Special Supplemental Food Program for Women, Infants, and Children, known as the WIC program. This program, sponsored by the U. Department of Agriculture, provides food, nutritional counseling, and access to health services for low-income women, infants, and children. Late-twentieth-century figures indicate that the WIC program serves more than seven million mothers and children per month, and saves approximately three dollars for each tax dollar spent. The health of the adolescent and young adult population sets the stage for the rest of adult life. This is a period during which most people complete their physical growth, marry and start families, begin a career, and enjoy increased freedom and decision making. It is also a time in life in which many beliefs, attitudes, and behaviors are adopted and consolidated. Health issues that are particularly associated with this population are unintended injuries; use and abuse of alcohol, tobacco, and drugs; and sexual risk taking. There are no easy, simple, or immediate
solutions to reducing or eliminating these problems. However, in communities where interventions have been successful, they have been comprehensive and communitywide in scope and sustained over long periods of time. The adult population represents about half of the U. population. The health problems associated with this population can often be traced to the consequences of poor socioeconomic conditions and poor health behavior during earlier years. To assist community health workers, this population has been subdivided into two groups: ages twenty-five to forty-four and ages forty-five to sixty-four. For the younger of these two subgroups, unintentional injuries, HIV (human immunodeficiency virus) infection, and cancer are the leading causes of death. For the older group, noncommunicable health problems dominate the list of killers, headed by cancer and heart disease, which account for almost two-thirds of all deaths. For most individuals, however, these years of life are the healthiest. The key to community health interventions for this population has been to stress the quality of life gained by good health, rather than merely the added years of life. The senior population of the United States has grown steadily over the years, and will continue to grow well into the twenty-first century. In 1900 only one in twenty-five Americans was over the age of sixty-five, in 1995 it was one in seven, and by 2030 it is expected to be one in five. Such growth in this population will create new economic, social, and health concerns, especially as the baby boomers (those born between 1946 and 1964) reach their senior years. From a community and population health perspective, greater attention will need to be placed on the increased demands for affordable housing, accessible transportation, personal care created by functional limitations, and all segments of health care including adult day care and respite care. Though many communities have suitable interventions in place to deal with the issues of seniors (including meal services like congregate meals at senior centers, and Meals-on-Wheels), the demands will increase in all communities.
HEALTH PROMOTION
The three strategies by which community health practice is carried out are health promotion, health protection, and the provision of health services and other resources. Figure 3 presents a representation of these strategies, their processes, their objectives, and anticipated benefits for a community or population.
supported by schools, workplaces, public and private recreation and fitness organizations, commercial and semipublic recreation, and commercial entertainment. As with all health- promotion programming, appropriate evaluation helps to monitor progress, appropriate implementation of plans, and outcomes achieved.
HEALTH PROTECTION
Community and population health protection revolve around environmental health and safety. Community health personnel work to identify environmental risks and problems so they can take the necessary actions to protect the community or population. Such protective measures include the control of unintentional and intentional injuries; the control of vectors; the assurance that the air, water, and food are safe to consume; the proper disposal of wastes; and the safety of residential, occupational, and other environments. These protective measures are often the result of educational programs, including self-defense classes; policy development, such as the Safe Drinking Water Act or the Clean Air Act; environmental changes, Figure 3 such as restricting access to dangerous areas; and community planning, as in the case of preparing for natural disasters or upgrading water purification systems.
HEALTH SERVICES AND OTHER RESOURCES
The organization and deployment of the services and resources necessary to plan, implement, and evaluate community and population health strategies constitutes the third general strategy in community and population health. Today's communities differ from those of the past in several ways. Even though community members are better educated, more mobile, and more independent than in the past, communities are less autonomous and more dependent on those outside the community for support. The organizations that can assist communities and populations are classified into governmental, quasi-governmental, and nongovernmental groups. Such organizations can also be classified by the different levels (world, national, state/province, and local) at which they operate. Governmental health agencies are funded primarily by tax dollars, managed by government officials, and have specific responsibilities that are outlined by the governmental bodies that oversee them. Governmental health agencies include: the World Health Organization (WHO), the
U. Department of Health and Human Services, the various state health departments, and the over three thousand local health departments throughout the country. It is at the local level that direct health services and resources reach people. Quasi-governmental health organizations have some official responsibilities, but they also operate in part like voluntary health organizations. They may receive some government funding, yet they operate independently of government supervision. An example of such a community health organization is the American Red Cross (ARC). The ARC has certain official responsibilities placed on it by the federal government, but is funded by voluntary contributions. The official duties of the ARC include acting as the official representative of the U. government during natural disasters and serving as the liaison between members of the armed forces and their families during emergencies. In addition to these official responsibilities, the ARC engages in many nongovernmental services such as blood drives and safety services classes like first aid and water safety instruction. Nongovernmental health agencies are funded primarily by private donations or, in some cases, by membership dues. The thousands of these organizations all have one thing in common: They Figure 4 arose because there was an unmet need for them. Included in this group are voluntary health agencies; professional health organizations and associations; philanthropic foundations; and service, social, and religious organizations.
Voluntary health organizations are usually founded by one or more concerned citizens who felt that a specific health need was not being met by existing government agencies. Examples include the American Cancer Society, Mothers Against Drunk Driving (MADD), and the March of Dimes. Voluntary health agencies share three basic objectives: to raise money from various sources for research, to provide education, and to provide services to afflicted individuals and families. Professional health organizations and associations are comprised of health professionals. Their mission is to promote high standards of professional practice, thereby improving the health of the community. These organizations are funded primarily by membership dues. Examples include the American Public Health Association, the British Medical Association, the Canadian Nurses Association, and the Society for Public Health Education.
equity-producing social policy. Primary health-care (PHC) has basic essential elements and objectives that help to attain better health services for all.
Primary health care elements Essential Elements of Primary Health Care (PHC): There are 8 elements of primary-health care (PHC). That listed below- 1. E – Education concerning prevailing health problems and the methods of identifying, preventing and controlling them. 2. L – Locally endemic disease prevention and control. 3. E – Expandedprogramme of immunization against major infectious diseases. 4. M – Maternal and child health care including family planning. 5. E – Essential drugs arrangement. 6. N – Nutritional food supplement, an adequate supply of safe and basic nutrition.
T – Treatment of communicable and non-communicable disease and promotion of mental health.
S – Safe water and sanitation. Extended Elements in 21st Century:
Expended options of immunizations.
Reproductive health needs.
Provision of essential technologies for health.
Health promotion.
Prevention and control of non-communicable diseases.
Food safety and provision of selected food supplements. Principles of Primary Health Care (PHC): Behind these elements lies a series of basic objectives that should be formulated in national policies in order to launch and sustain primary health-care (PHC) as part of a comprehensive health system and coordination with other sectors.
Improvement in the level of health care of the community.
Favorable population growth structure.
Reduction in the prevalence of preventable, communicable and other disease.
Reduction in morbidity and mortality rates especially among infants and children.
Extension of essential health services with priority given to the undeserved sectors.
Improvement in basic sanitation.
Development of the capability of the community aimed at self-reliance.
Maximizing the contribution of the other sectors for the social and economic development of the community.
Equitable distribution of health care – according to this principle, primary care and other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, and caste, urban/rural and social class. 10 participation-comprehensive healthcare relies on adequate number and distribution of trained physicians, nurses, allied health professions, community health workers and others working as a health team and supported at the local and referral levels.
2. Registration of Vital Events. Definition (UN): ‘legal registration, statistical recording and reporting of the occurrence of and the collection, compilation, presentation, analysis and distribution of statistics pertaining to vital events’ Vital events include: a. Live births b. Deaths c. Fetal deaths d. Marriage e. Divorce f. Adoptions g. Legitimations h. Recognitions i. Annulments and j. Legal separations 3. Sample Registration System (SRS) The civil registration system has a lot to be improved and would require a huge effort and time. A need for having an alternate source of such information was felt. SRS aims to provide reliable estimates of birth and death rates for the States and also at All India level. Following features of SRS ensure the completeness of vital events reporting:
- A representative sample of the population is covered and NOT the WHOLE population
- It is based on Dual – record system: a. First a baseline survey of sampled units is done b. This is followed by continuous enumeration of vital events of the areas by an enumerator (who is a volunteer from the community) c. Independent retrospective 6-monthly surveys are done for recording births and deaths which occurred in the preceding 6 months and the number is matched with the one reported by the enumerator Not only the numbers of vital events should match, it is also verified if the births and deaths reported by the enumerator are the same ones which the survey has found out. This is called as ‘Matching of events’ by the observer. At present, the Sample Registration System (SRS) provides
reliable annual data on fertility and mortality at the state and national levels for rural and urban areas separately. In this survey, the sample units, villages in rural areas and urban blocks in urban areas are replaced once in ten years 4. Notification of Diseases Disease notification is a practice of reporting the occurrence of a specific disease or health- related condition to the appropriate and designated authority. A notifiable disease is any disease that is required by law to be reported to government authorities. Effective notification allows the authorities to monitor the disease, and provides early warning of possible outbreaks A notifiable disease is one for which regular and timely information regarding individual cases is considered necessary for the prevention and control of the disease. Reasons for Declaring a Disease as Notifiable may be: a. It is of interest to national or international regulations or control programs b. Its National/ State/ District incidence c. Its severity (potential for rapid mortality) d. Its communicability/ Its potential to cause outbreaks e. Significant risk of international spread f. The socio-economic costs of its cases g. Its preventability h. Evidence that its pattern is changing In other words, diseases which are considered to be serious menaces to public health are included in the list of notifiable diseases. 5. Disease Registers A registry is basically a list of all the patients in the defined population who have a particular condition. It is different from ‘notification’ where the case is reported and is counted once. A register requires that a permanent record be established that the cases be followed up and that basis statistical tabulation be prepared both on frequency and on survival. Hence mostly for chronic conditions addition the patients on a register are frequently be the subjects of special studies
- Morbidity registers are a valuable source of information such as the
- duration of illness, case fatality and survival
- Natural history of disease especially chronic diseases
Community Health - Lecture notes
Course: Community Health (HNS 107)
University: University of Nairobi
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