1. Dr.S.Preethi
(MD) In Community Medicine

2.  Introduction
 Definition
 12 determinants of health
 Prevention
 Indicators
 References

3. Aesculapius 1200 BC
Daughters
Hygiea Panacea
Department of Hygiene Dept of Medicine
(Public health) ( preventive aspect
curative aspect)

6.  Health is Multifactorial
 Uncontrollable Factors (genetics, gender,
predisposition to a disease)
 Controllable Factors (diet, smoking status, exercise
levels)
 Risk Factor – Determinants which are detrimental to
health (smoking)
 Protective Factors – Promote or enhance health
(exercising)

8.  Physical and mental traits human being determined -
genes -conception.
Testosterone
Male Sex characteristics and sperm
production
Decreases risk of heart disease
Estrogen
Regulates menstrual cycle and
maintain bone density
Menopause inc osteoporosis
regulation of fat distribution – hips
and buttocks

9. Genetics
“ A person may be at increased risk of inheriting a disease
or condition if they have a biological parent who has had
the disease.”
 Ex: If your parent has high cholesterol, you are at a
higher risk of developing high cholesterol.
 Genetic predisposition Alzheimer's disease< 65
 Type 1 diabetes (HLA B8 & 15; DR3 & 4) CVD - High
blood pressure, hypertension
 Certain cancers – (Breast and prostate)

10.  Barker initially reported that in Britain babies born
underweight had an increased incidence of heart attacks,
Diabetes as they grew up.
 This was hypothesized as being due to a smaller size of
pancreatic cells leading to increased prevalence of diabetes,
hypertension and abnormal lipid profile leading to premature
deaths.

11. Body Type
 overweight : CVD, Diabetes, Gall bladder disease,
High blood pressure, osteoarthritis, certain types of
cancer (colon).
 underweight you may be malnourished and develop a
compromised immune function, respiratory disease,
digestive diseases, cancer, osteoporosis, increased risk
of falls and fractures

12. Five leading risk factors identified
1.Childhood underweight,
2.Unsafe sex,
3.Alcohol use,
4.Unsafe water and sanitation,
5.High blood pressure
One quarter of all deaths in the world, and one fifth
of all DALYs.

14.  "The sedentary lifestyle, over stressed life, bad
eating habits and smoking are the other factors which
have made heart disease an modern epidemic in
India,"
 Lifestyle' illnesses, such as CVD have overtaken the
so-called ‘Poverty' diseases of tuberculosis and
Diarrhea as India's biggest killer, reflecting the
country's growing affluence.

16. 1. Personnel hygiene
2. Nutritional and breast feeding habits
3. Weaning and rearing practices
4. Family planning
5. Immunization
6. Seeking early medical care

18.  Ghutti (a mixture of herbs, extracts and flavorings) are given in
Pakistan for the first several days.
 In Ethiopia, infants are initially given boiled water and butter,
thought to protect against infection.
 Chinese babies are given herbal tea for the first two or three days.
 In Mysore, India, babies are bottle-fed sugar water until the
mother's milk comes in. And in India generally, in most cases
infants are given pre-lacteal foods such as water with sugar or
honey.

19.  In peninsular Malaysia a paste of corn flour and water was
given to Malay babies 'in the first few days of life
 In Ethiopia when PPH occurrs, the TBAs commonly allows
the mother to bleed until the unclean blood cleared.
 The dayas probably did not know that such bleeding might
lead to the loss of life of the mother, particularly that of an
anemic mother.

20. SOCIO - CULTURAL PRACTICE
IN ILLNESS

21. It is believed that exposure of a pregnant woman to an
eclipse can cause her infant to have a cleft lip or palate.
 The belief that an infant may have characteristics of an
object that the mother craves during pregnancy if the
craving is not satisfied (e.g., the infant may have
strawberry spots if the mother craves but does not eat
strawberries).

22.  Vegetarian and non-vegetarian
 Hot and cold food
 Garlic and onion
 Beef and pork
 Adulteration of milk
 Fasting
 Alcoholic drinks

23.  Household food security – appropriate food being
available, with adequate access and being affordable
 National food security – able to provide adequate
nutrition within a country without relying heavily on
imported products
 Cold-chain reliability – the safety of transporting
products that deteriorate microbiologically in the heat
 Stein et al reported that poor in utero-foetal growth and
low maternal weight was associated CHD incidence in
a retrospective study from Mysore, Karnataka.

24.  Fisheries – bio-toxins, pollution, chemical use,
wastewater, processing, and occupational health
 Fertiliser use – nitrate levels in food, pollution of
waterways, re-use of agricultural waste.
 Pesticide usage and veterinary drugs– legal
requirements, best practice, consumer issues.

25.  Pettenkoffer stated that agent, host and environmental
factors will act and interact synergistically and act as
joint independent partners in causing the disease.
PETTENKOFFER

26.  Nine environmental and behavioral risks, together with
seven infectious causes, are responsible for 45% of
cancer deaths worldwide

27.  Hippocrates who related disease to environment ( climate, water,
air, etc)
 Centuries later pettenkoffer in Germany revived the concept of
disease- environment association
 Internal “ each and every component part, every tissue, organ-
system and their harmonious functioning within the system
 External- all that which is external to the individual human host-
physical, biological and psychological components, any or all of
which can affect the health of man and his susceptibility to illness.

28.  Poverty is linked to malaria through environmental
degradation.
 About half of India’s land is affected by soil erosion.

30.  7 million deaths caused by air pollution in 2012,
covering both household and ambient air pollution
 4.3 million deaths every year as a result of exposure to
indoor smoke from cooking fuels
 3.7 million deaths every year as a result of exposure to
fine particulate matter
 4,674 deaths Household air pollution attributable
deaths in children under 5 years

31.  The environmental factors range from
housing Industries water supply
sanitation transport

32. Housing
Contribute to ill health
 Overcrowding -mental health ,
unhygienic conditions - infectious parasitic diseases
 Noise and overcrowding -sleeping conditions
 Lack of security – stress and anxious
 Accidents and falls
 Pollutants – Tobacco smoke, Asbestos, Dust pollution
Prevention
 Adequate hot and cold water and washing facilities
 Adequate water supply – safe for drinking Cooking facilities -
conducive to eating a nutritionally sound diet.

33. TRANSPORT
 Accidents
 Pollution from burning fossil fuels (particulates and ozone)
 Noise
 Climate change due to CO2 emission
 Loss of land
 Recreational uses of road spaces
 Improved physical activity from cycling or walking
 Increased access to employment, shops and support services

34.  U- Mask filtering face pieces is suitable for protection
against non- volatile solid/ liquid particles up to 30
times the Threshold Limit Value (TLV).
 The first of millions of Tuk Tuk drivers in Delhi is now
protected and many will follow!

35. Sanitation
 Open field of defecation
 Rural houses and animal keeping
As per 2001 census, 36% of households have toilets , 22%
use toilet in villages
 Total sanitation campaign was a sound beginning
 Nirmal Gram Purushkar – National award under TSC launched on feb
24,2005 by the GOI
 Panchayati Raj Institutions- 50k to 5 lac

36. Waste
 infectious disease from human and animal excreta
 exposure to toxic chemicals
 exposure to radioactive wastes;
 exposure to health-care wastes;
 exposure to solid wastes and involvement in informal waste
recycling; and
 breeding of disease vectors.

37. Industries
 Asbestos and man made fibres
 Cement, glass and ceramics
 Iron and steel
 Manufacture of rubber and plastic products
 Pesticides, paints and pharmaceuticals
 Petroleum products
 Pulp and paper
 Textiles and leather
 Wood and furniture.

38.  50 hours compulsory core module course in
environmental studies six months, UG level in all
streams by various universities -the Hon’ble Supreme
Court of India; with effect from 2004-05.
 The syllabus divided into 8 units covering 50 lectures
including field work activities of 5 lecture hours.

39.  Economic status: The per capita GNP is the most
widely accepted measure of general economic
performance.
 Determines the purchasing power, standard of living,
quality of life, family size and the pattern of disease
and deviant behavior in the community.

41.  Education:education, income has a
‘‘dose-response’’ association with health;
E.g: Kerala IMR 13 compared to 44 for all-India.
 Female literacy rate of 91.8 percent compared
to 65.46 percent for all-India
 Role of education in health outcomes specifically
related to knowledge, cognitive skills and analytical
abilities

42.  Occupation:
The very state of being employed in productive work
promotes health.
Loss of work –loss of income and status- psychological
and social damage.

43. Work and unemployment increase risk of CVD
 Relationships at work – employer, colleagues, public, conflict
 Physical work space – UV exposure, heating and cooling,
seating arrangements, tools and machinery
 Job Stress & Long working hours
 Heavy workload
 Lack of job security
 Harassment & Discrimination
 Depression & Anxiety

44. • Wander et al from rural Punjab also reported a greater
CHD prevalence in skilled workers, priests, teachers
and Retired government service personnel (9.2%, 9.1%,
6.2%, 4.8% respectively) as compared to small time
businessmen (3.4%), housewives (3.1%) and laborers
(1.7%).
 In a case control study, Pais et al reported a greater
CHD prevalence - less educated - poor in Bangalore.

45. Political System:
 WHO has set the target of at least 5 per cent expenditure of
each country’s GNP on health care, however India spends
about 2 percent.
 Economic development + Political commitment= social
development

46.  APL and BPL
 Average income
 Socio Economic Status SES – measure of an adult’s or
family’s economic or social position within society
relative to others
 High SES
 Medium SES
 Low SES

47.  Improve the health status of the population
 Immunization of children can influence incidence/ prevalence of
particular diseases
 Provision of safe water
 Care of pregnant women and children( First Breath Trial)
 Main messages from World health report 2013: Research for universal
health coverage
 Three examples among many in the report to help progress towards
universal health coverage

48.  Bed-nets reduce child deaths
 Cash payments improve child health.
Primary health care
 Appropriateness Completeness
 Availability Comprehensiveness
 Adequacy Continuity
 Accessibility
 Acceptability
 Affordability
 Assessability
 Accountability

49.  By the year 2020, the world will have more than one
billion people aged 60 and over, and more than two-thirds
of them living in developing countries.
 The prevalence of high blood
cholesterol increased with
age to peak for females 65-74
and for males 55-64
 Blood Pressure: The proportion of males and females
with HBP increases markedly with age.

50.  Obesity have increased in all age groups , most marked
increase among 25 – 44 and 75 years and over.
 The burden of disease attributed to CVD increases
markedly with age, particularly 60 years.
 The proportion of people with diagnosed diabetes increased
with age and the highest prevalence rate (age 65 – 74)
 The burden of mental illness for both sexes was greater in
early to middle adulthood than at other ages.

51.  Gender involves “culture-bound conventions, roles and
behaviours” that shape relations between and among women
and men and boys and girls
 In 1993, the Global commission on Women’s Health was
established.
 Formulated an agenda for action on women’s health
covering nutrition, reproductive health, the health
consequences of violence, ageing, lifestyle related
conditions and the occupational environment.

52. Violence against women
Globally 30% of every partnered women have experienced
physical or sexual violence by a partner in their lifetime,
 1000women die every day of the consequences of pregnancy
and child birth
 24more years on average a female can expect to live in a high
income country than a low income country
 1/3 of all female deaths are due to cardiovascular disease and
stroke

53.  Encourage social development by engaging youth in social
activities (communication skills & social roles)
 Lead the youth to experience strong bonds with individuals
outside the family (promoting emotional health)
 Influence other behaviors such as risk-taking behaviors &
substance use (affecting physical health & development)

54.  Promotion of dietary restriction, physically active lifestyle
and avoidance of tobacco use beginning from childhood is
important for primordial prevention.
 All adults should know their blood pressure and blood
cholesterol levels, should not smoke, should monitor their
salt and fat intake and should engage in at least moderate
exercise.
 The mass media should play a major role in health
education programme

55.  Urbanization, Modernization And changes in occupational
behavior , less physical activity
 More Television Viewing
 More Use Of Automobiles
 More Mechanization
 Less Manual Labor

56.  41 out of 134 countries do not have at least one
computer tomography device per million inhabitants
 35 out of 171 countries have a health technology
national policy that is part of the National Health
Program, while 12% have an independent document

57. • Social Cohesion
• Civic Participation
• Perceptions of Discrimination and Equity
Kinds of Justice
◦ Distributive justice
◦ Retributive or corrective justice
◦ Compensatory justice

58. • High School Graduation
• Enrollment in Higher Education
• Language and Literacy
• Early Childhood Education and Development
• The General Comment on the Human Right to Health released in 2000
affirms that the right to health must be interpreted broadly to embrace
key health determinants including
food and nutrition, housing, access to safe and potable water and
adequate sanitation, safe and healthy working conditions, and a
healthy environment

63.  Ambient air pollution attributable deaths
 Household air pollution attributable deaths
 Climate change attributable deaths
 Total density per 1lac population
 Water, sanitation & hygiene attributable death per 1lac
children under 5 years

64.  Health management and support workers density per
1000 population
 Estimate rate of homicides per 1lac population
 Life time prevalence of child sexual abuse, physical
abuse and emotional abuse
 Health management and support workers density per
1000 population

65. 1. Right thinking
2. Right attitude
3. Right speech
4. Right conduct
5. Right livelihood
6. Right effort
7. Right mindfulness
8. Right contemplation

67.  Available from: http://www.who.int/hia/evidence/doh/en/index1.html
[Last Accessed on Jan16th 2015]
 Available from : http://www.who.int/social_determinants/en/ [Last
Accessed on Jan16th 2015]
 Available from : http://apps.who.int/gho/data/node.imr. [Last Accessed
on Jan16th 2015]