Questions Social Medicine 11/2021

MCQ QUESTIONS
Age specific fertility means
o the average number of children a woman would need to have to reproduce herself
✓ annual number of births per woman in a particular group expressed per 1000
o total fertility levels above 2,1 children per woman

All are true about direct standardization except:

✓ Age-specific death rates are not needed
o Populations should be comparable
o number of death peop20le to calculate death rate per same year should be available

All are true about cohort study except

✓ reserved for testing precisely formulates hypothesis
o suitable for rare diseases
o can yield information about more than one outcome
o involves large number of subjects

All are true for randomized controlled trial except

o bias may arise during evaluation
o the groups should be representative of the population
o both study and control group should be comparable
✓ used only for testing new drugs on human animal subjects

An ideal health indicator should be

o sensitive
o specific
o relevant
✓ all of the above

An expert in the field of public health is required to estimate the magnitude of a health problem.
What will he use?
o incidence
✓ prevalence
o case fatality
o cause specific mortality

Below-replacement fertility is
✓ total fertility levels below 2,1 children per woman
o total fertility levels above 1,3 children per woman
o total fertility levels above 5 children per woman

DALY is:
o a complex measure of mortality
o a complex measure of disability
✓ a complex measure of the burden of disease

Disability Adjusted Life Years (DALY) is:

o A measure of mortality
✓ A complex measure of the burden of disease
o A measure of disability

1
Demographers
o are interested in the distribution of population and in movements of people.
o assess the impact of such things as life expectancy and the marriage rate.
o count people and calculate the growth rate of a population.
✓ all are true

Disability adjusted life years

✓ A complex measure of the burden od disease
o A measure of disability
o A measure of morality

Establishment of universal testing system for hepatitis C virus in high risk groups is example for:
✓ Primary prevention
o Tertiary prevention
o Secondary prevention

Fertility rate is
✓ number of live births/year by the number of woman aged 15-49
o the level of the population without the contraception and induced abortion use
o optimal planning of pregnancies and births

For international comparisons of reproduction we prefer the indicator

o birth rate
✓ total fertility rate
o age specific fertility rate
o general fertility rate

Gross reproduction rate is an indicator of

✓ reproduction
o fertility
o age specific fertility

Holistic model of health

o Focuses on conditions outside the individual that affects his or her health, such as quality of
air and water living conditions exposure to harmful substances, SES, social relationships and
the available health care system
o Relies almost exclusively on biological explanations of disease and illness and on interpreting
them in term of malfunctions
✓ Encompasses the physiological, mental, emotional, social, spiritual and environmental
aspects of individuals and communities

Holistic model of health

o focuses on conditions outside the individual that affect his or her health
o relies almost exclusively on biological explanations of disease and illness
✓ emphasizes that each person has the capability and responsibility for optimal health

Ideally suited measure for comparing health status of the population is

✓ standardized mortality rate
o Crude mortality rate
o Specific death rate

2
If the number of deaths from tuberculosis is expressing in relation to the total mid-year population
it is:
o case fatality rate
o age specific death rate
o crude death rate
✓ cause specific mortality rate

Incidence is:
✓ The number of new cases of the disease that develop in a population at risk over a specified
period of time.
o The proportion of people in a population who have a condition / attribute at a specified time

International comparison of mortality is most adequate when applying

o crude death rates
o cause specific death rates
o gender specific death rates
✓ age specific mortality rates

International comparison of mortality is most adequate when applying:

o crude death rates
o cause-specific mortality rates
o gender-specific mortality rates
✓ age-standardized mortality rates

In 1993 Burkina Faso had Gross reproductive rate of 3.5 while United Kingdom was only 0.86 that
means that if 1993 Fertility levels were to continue, which one of the following options will be
correct:
o The net Reproductive Rate of Burkina Faso would definitely be more than 3.5
o In United Kingdom, a woman would produce more than one daughter on average during her
life time
✓ In Burkina Faso, a woman would produce 3.5 daughters on average through her life time
o The Net Reproductive Rate of UK will be more than one

In 2017 Burkina Faso had Gross reproductive rate of 3.5 while United Kingdom was only 0 .1.81
that means if 2017 Fertility levels were to continue, which one of the following options will be
correct:
o The Net Reproductive Rate of Burkina Faso would definitely be more than 3.5
o In United Kingdom, a woman would produce more than one daughter on average during her
life time.
✓ In Burkina Faso, a woman would produce 3.5 daughters on average through her life time
o The Net Reproductive Rate of UK will be more than one

In a community, an increase in new cases of a particular disease is due to:

✓ increase in incidence rate
o increase in prevalence rate
o increase in mortality rate

In a community, an increase in new cases of a particular disease is due to:

✓ Increase in incidence rate
o Increase in prevalence rate
o Both of the above
o None of the above

3
Less economically developed populations compared to developed ones, tend to have
o lower age specific mortality
✓ Higher general fertility rate
o Ageing population structure

Maternal mortality is the ratio of the number of women who died in connection with pregnancy,
childbirth and the postpartum period for a given period and territory to:
✓ The number of live births for the same period and territory
o The average annual population for the same period and territory
o The total number of deaths for the same period and territory

Old-age dependency ratio is:

o Ratio of the economically dependent population (under 15 and 65 and over) to the
o economically independent population (15-64)
o Ratio of the population under 15 to population 15 to 64
✓ Ratio of the population 65 and older to population 15 to 64

Phase one of the demographic transition theory is characterized with

✓ Population size with high birth rates and high mortality rates
o Increasing population size with high mortality and decreasing birth rate
o Population size with high birth rates and high mortality rates

Phase three of the demographic transition theory is characterized with

✓ increasing size of the population, decreasing mortality and decreasing birth rate but with a
lower speed than mortality
o big population size with low mortality and birth rates
o small population size with high mortality and high birth rate
o decreasing population size with increasing mortality and decreasing birth rate

Phase four of the demographic transition theory is characterized with

✓ big population size with low mortality and low birth rate
o small population size with high mortality and birth rates
o increasing population size with decreasing mortality and birth rates
o decreasing population size with increasing mortality and decreasing birth rate

Population age composition is described by

✓ ratios between economically active non-active populations
o number of people aged 0-14
o number of people aged 65 and over

Population age pyramid:

o Represents the age groups and number of population
✓ Is a graphical representation of the age and sex composition of the population
o Provides a quick overall comprehension of age structure

Population growth slows down only when

o birth rates are low
o death rates are high
✓ both birth rates and death rates are low
o both birth rates and death rates are high

4
Primary prevention
✓ seeks to prevent the onset of specific diseases via risk reduction
o includes procedures that detect and treat pre-clinical pathological changed and thereby
control disease progression
o seeks to soften the impact caused by the disease on patient’s function longevity and quality
of life

Replacement-level fertility means

✓ the average number of children a woman would need to have to reproduce herself by
bearing a daughter who survives to childbearing
o annual number of births per woman in a particular age group expressed per 1000 women in
that age group
o total fertility levels above 1,3 children per woman

Specificity of a test means all except

o identifies those without disease
✓ identifies true positives
o identifies true negative
o an ideal screening test should have 100% specificity

To compare the death rate of Nepal with the death rate of Pakistan the most appropriate measure
is a comparison between
o Age specific mortality rates
o Crude death rates
o Maternal mortality rates
o Life expectancy
✓ Standardized mortality rates

Total fertility rate is an indicator of

o fertility
✓ reproduction
o infant mortality

The leading causes of death in a developed country are

✓ Cardio-vascular diseases
o Tuberculosis
o HIV
o Suicides

The leading causes of death in a developed country are:

✓ Cardio-vascular diseases and cancers
o Cardio-vascular diseases and infectious diseases
o Caridio-vascular diseases and accidents

The case fatality rate for lung cancer is:

✓ The ratio of the number of deaths from lung cancer to the number of registered patients
with lung cancer in percent (%) (?denke ich)
o The ratio of the number of deaths from lung cancer to the number of deaths from all causes
in percent (%)
o Number of lung cancer deaths per 1,000 population in a given year and territory

5
The estimate of the average number of additional years a person could expect to live if the age
specific death rates for a given year prevail for the rest of his life is best explained as
o survival index
✓ life expectancy
o crude death rate
o age specific death rate

The net reproduction rate is:

o Average number of live births that a woman would give birth to during her entire fertile
period while maintaining the established age-related fertility
o Average number of girls that a woman would give birth to during her entire fertile period
while maintaining the established age-related fertility
✓ Average number of girls who would give birth to a woman during her entire fertile period
while maintaining the established age-related fertility and mortality

The population pyramid of a country has a broad base and a tapering apex. Which of the
following characterize population growth in this country?
o Low fertility and low childhood mortality
o Low fertility and high childhood mortality
✓ High fertility rates and high mortality rates in younger age groups ?
o High fertility and low childhood mortality
o None of the above

“The population (country) has high fertility rates and lower than average life expectancies”
represent description of:
✓ Expansive population pyramid ?
o High mortality rates
o Effective healthcare system
o High fertility rate

The prevalence of disease is decreased by:

o Longer duration of the disease
o Increase in new cases (increase in incidence)
o In-migration of new cases
o Out-migration of healthy people
✓ Rapid recovery or death ?

What is the theoretical minimum to ensure simple reproduction of the population (replacement
level fertility)?
o 2.0 live births per woman of childbearing age
✓ 2.1 live births per woman of childberaing age
o 3.0 live births per woman of childberaing age

Which of the following dimensions is not included in the WHO definition of health?
o Physical well being
✓ Occupation well being
o Mental well being
o Social well being

6
What indicates the kinks of a pyramid?
o Life expectancy
✓ Dramatic reductions in birth rate
o Birth rate
o Death rate

Which are the four major groups of health determinants?

✓ social, health care system and policy, environmental, genetic
o social, health care system and policy, environmental, physical
o social, health care system and policy, nutritional, genetic

Which population piramyd represents high birth rate, high death rate, short life expectancy with
low elderly dependancy ratio?
✓ stationary type
✓ expansive type
✓ constrictive type

Which prototypical pyramid structure is “constrictive”:

o A pyramid with greater numbers of people in the younger age categories.
o A pyramid, which shows roughly equal numbers of people in all age categories, trend
towards increase in the older age categories.
✓ A pyramid, which is with greater numbers of people in the older age categories

Which of the listed determinants best describes the medical model of health: ???
o healthcare systems
o quality of medical care
o disease prevalence and incidence

Years of life lost to premature death and years lived with disability adjusted for the severity of the
disability is known as:
o QALY
✓ DALY
o Human Development index
o Global Burden of Disease

True/False Questions
Cardiovascular disease mortality rate for the Netherlands for 2014 = total number of
cardiovascular deaths in the Netherlands 2014 / Mid-year population of the Netherlands 2014 x
1000
✓ true
o false

Cervical cancer mortality in Varna, 2020 = Total number of cervical cancer deaths in Varna 2020
/ Mid-year female population of Varna, 2020 * 100000
o True
o False

Crude birth rate is more appropriate for population comparisons than total fertility rate
o true
✓ false

7
Crude death rate = total number of deaths in a specific population in a specific year/midyear-
population in specific year
✓ true
o false

Early neonatal mortality 201 Bulgaria = total number of infant deaths 0 to 6 day 2010 Bulgaria /
total number of live births 2010 Bulgaria x 1000
✓ true
o false

Fetal mortality = total number of still births/total number of births x 1000

✓ true
o false

Fertility of women 20-24 years in Germany, 2018 = Total number of live births in 2018/Total
number of women 15-49 years, Germany, 2018 * 100000
o true
✓ false

Fertility rate of women 19-24 years of age in Germany, for 2019 = Total number of live births to
women at the age of 19-24 years in Germany for 2019 / Total number of women 19-24 years,
Germany, for 2019 * 100000
o True
✓ False ?

Female mortality in Bulgaria 2011= total number of women deaths in Bulgaria 2011/ Mid-year
female population in Bulgaria 2011 x 1000
✓ true
o false

General fertility rate in Berlin: 2014 = total number of live births in Berlin in 2014/total number of
women 15-49 years in Berlin 2014 x 1000
✓ true
o false

High fertility is associated with increased risk of maternal morbidity and mortality
✓ true
o false

High fertility is when total fertility levels are below 2,1 children per woman
o true
✓ false

Infant mortality = total number of deaths of children 0 to 1 year in a given population and
year/total number of deaths in the same population and year
o true
✓ false

Late neonatal mortality is the total number of infant deaths 7-28 day/total number of life births x
1000
✓ true
o false

8
Low fertility is when total fertility levels are below 1,3 children per woman
✓ true
o false

Life expectancy is the potential life span of the average member of any given population.
✓ true
o false

Lung cancer mortality in Varna: 2014=total number of lung cancer deaths in Varna 2014/Mid-year
population of Varna 2014 x 1000
✓ true
o false

Lung cancer mortality in Varna, 2020 = Total number of lung cancer deaths in Varna 2020 /
Mid-year population of Varna, 2020 * 100 000
✓ True
o False

Maternal mortality ratio is the total number of women deaths while pregnant of within 42 days of
termination of pregnancy, irrespective of the duration and site of pregnancy/livebirths x 1000
✓ true
o false

Male Mortality rate is a crude rate

o true
✓ false

Neonatal mortality rate 2014 UK = total number of deaths from 0 to 1 year 2014 UK / total number
of infant deaths 2014 UK x 1000
o true
✓ false

Neonatal mortality rate = Total number of deaths from 29 day up to 1 year / total number of live
births up to first 28 days of life per 1000:
o True
✓ False

Population growth rates are highest in western nations and lower in developing nations
o true
✓ false

Perinatal mortality is the stillbirths + infants deaths from 0 to 6/total number of births x 1000
✓ true
o false

People living in developed countries live longer but die from infectious diseases.
o true
✓ false

9
Postneonatal mortality = total number of infant deaths from 29 day up to 1 yeaar / total number
of infant deaths x 1000
o true
✓ false

Total fertility rate is more appropriate for population comparisons than crude birth rate
✓ true
o false

The general fertility rate for 2010 in Frankfurt is the average number of children a woman in
Frankfurt is expected to have through her childbearing age if age specific fertility rates are stable
for the year of estimation
o true
✓ false

The proportion of cancer deaths in Germany for 2014 = total number of cancer deaths in Germany
2014 / … bild abgeschnitten
o true
✓ false

Under 5 child mortality = Number of deaths of children up to 5 years / total number of children up
to 5 years x 1000
o true
✓ false

Calculation Questions
Breast cancer incidence for 2015 is

o 20
✓ 33
o 54

Crude death rate for all years is:

o 22.1
✓ 13.6
o 10.3

𝑇𝑜𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠
𝑥 1000
𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛

10
Birth rate for 2015 is:
𝑁𝑢𝑚𝑏𝑒𝑟 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛
𝑥 1000
𝑀𝑖𝑑 − 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛

2000
𝑥 1000 = 𝟏𝟔𝟔
12000

Birth rate for 2010 is : 90

Breast cancer prevalence for 2015 is:

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑙𝑙 𝑐𝑎𝑠𝑒𝑠

𝑥 1000
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎 𝑟𝑖𝑠𝑘

A study was conducted on the year 2006 to measure the period prevalence of smokers among 105
students. Out of them 5 were already smokers and 15 started during 2006, period prevalence of
2006 is:

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑙𝑙 𝑐𝑎𝑠𝑒𝑠

𝑥 100
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘

20
𝑥 100 = 19%
105

Write the formula for age-specific death rate among women aged (20-40) in Varna, Bulgaria, if
the following data is available:
o Mid-year population of women aged 20-40 in Bulgaria, for 2018
o Mid-year population of women aged 20-40 in Varna, Bulgaria for 2018 (Denominator)
o Number of women died in Varna, Bulgaria for 2018
o Number of people who died in Bulgaria, for 2018
o Number of women (aged 20-40) died in Vanra, Bulgaria, for 2018 (Numerator)

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑚𝑎𝑛 (𝑎𝑔𝑒𝑛𝑑 20 − 40)𝑑𝑖𝑒𝑑 𝑖𝑛 𝑉𝑎𝑟𝑛𝑎 𝐵𝑢𝑙𝑔𝑎𝑟𝑖𝑎 2018

𝑀𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑎𝑔𝑒𝑑 20 − 40 𝑖𝑛 𝑉𝑎𝑟𝑛𝑎 𝐵𝑢𝑙𝑔𝑎𝑟𝑖𝑎 2018

11
 Open Questions
Define different types of disease frequency (e.g., expected level, sporadic, endemic,
epidemic, pandemic).
Sporadic
➢ Occasional cases occurring at irregular intervals and usually without geographic
concentration
➢ Examples of sporadic diseases: tetanus , rabies cancer

Endemic
➢ Diseases, established within a population that remain at a fairly stable prevalence . They are
constantly present (often at a low level) in a population within a particular geographic region
➢ Example: malaria is endemic in many African countries ; goiter in some mountain areas

Epidemic
➢ Diseases for which a larger than expected number of cases occurs in a short time within a
geographic region
➢ High incidence of a disease in a population for a short time
➢ Example: Influenza in winter time

Pandemic
➢ Widespread, universal disease penetration over a wide geographic area
➢ Widely geographically distributed epidemic
➢ Example:
o Obesity
o COVID 19

Define the difference between incidence rate and prevalence rate.

Incidence rate
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑃𝑒𝑟𝑠𝑜𝑛 𝑦𝑒𝑎𝑟𝑠 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑

➢ Measure of the frequency with which a disease or other incident occurs over a specified time
period
➢ the rate of new cases of a disease occurring in a specific population over a particular period
of time

Prevalence rate
➢ Number of existing cases divided by total population
➢ the number of cases of a disease in a specific population at a particular timepoint or over a
specified period of time

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑜𝑛𝑒 𝑡𝑖𝑚𝑒

𝑇𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒

Incidence conveys information about the risk of contracting the disease, whereas prevalence
indicates how widespread the disease is.
Prevalence is the proportion of the total number of cases to the total population and is more a
measure of the burden of the disease on society with no regard to time at risk or when subjects may
have been exposed to a possible risk factor.

12
List the most common causes of death among developed and undeveloped countries

Developed countries Undeveloped countries

1. Ischaemic heart disease 1. Lower respiratory infections
2. Stroke 2. HIV/AIDS
3. Trachea, bronchus lung cancer 3. Diarrhoeal diseases
4. Alzheimes disease 4. Stroke
5. COPD 5. Ischaemic heart disease

Define HALE
HALE is an abbreviation for health-adjusted life expectancy, and is often referred to as healthy life
expectancy. Unlike life expectancy, HALE takes into account mortality and nonfatal outcomes. HALE
does this by summarizing years lived in less than ideal health (YLDs) and years lost due to premature
mortality (YLLs) in a single measure of average population health for individual countries.

HALE → Health – adjusted life expectancy ( AKA healthy life expectancy)

a. Unlike life expectancy
b. HALE considers mortality and non- fatal outcomes
c. Does this by summarizing
i. years lived in less than ideal health (YLDs) and
ii. years lost due to premature mortality (YLLs) in a single measure of
average population health for individual countries.

List and describe population pyramid types.

Population Pyramid = graphic presentation of the age and sex distribution of the human population
of a particular region
Expansive shape
➢ is typical for fast-growing populations where each birth rate is larger than the previous one
➢ High younger population = wide base
➢ Small older population = narrow top
Constrictive shape
➢ displays lower percentages of younger population due to declining fertility rate
➢ Less younger population = narrow base
➢ Higher older population = wider base
➢ (all developed countries).
Stationary shape
➢ present similar percentages or numbers for almost all age groups
➢ (some developing countries).

List the four determinants of health, and the percent impact they have on an individual.
Lifestyle factors: 49-53%
➢ Smoking, alcohol and drug abuse, low physical activity, unhealthy diet, psychosocial stress
o Coronary heart disease, stroke, most neoplasms, diabetes, chronic respiratory
disease, injuries, obesity…

Genetic and biological factors: 18-22%

➢ The individual predisposition to hereditary and degenerative diseases
o Chromosome diseases, diabetes, ischemic heart disease, some neoplasms

Environmental factors: 17-20%

➢ Illness can be caused by unfavorable factors of the environment – air, drinking water, soil
pollution

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 ➢ Other physical and chemical factors of the environment, risk factors from the working
environment
➢ Socio-economic factors
o income, social status, unemployment, education, housing and living conditions,
social support or exclusion (homeless, unemployed, refugees, immigrants in general
have poor health…)

Healthcare services: 8-10%

➢ Quality, accessibility and timeliness of health care
➢ Effectiveness of preventive interventions, Effectiveness of screening programmes
➢ immunization programmes
➢ family planning programmes, contraceptive use, health services for pregnant woman
➢ Organization and efficiency of health services for pregnant, woman and children, for
chronically ill patients, for elderly

Case Questions
Description: Quthing region is one of the most populated regions in in Lesotho, (South Africa) with 1
900 000 residents. In general, Quthing region has 86% of poverty, 60% illiteracy and over 40% of
women have been victims of gender-based violence. It is also a region with cultural practices of FGM
(female genital mutilations) and high prevalence of HIV. Life expectancy is 49 years and most
common diseases leading to death are HIV/AIDS, cardiovascular disease and diarrheal diseases.
Lesotho is a country with the highest HIV death rates in the world.

Every women gives on average birth to 2,6 children. There were 190 000 babies born in 2018. The
total number of people who died in 2018 is 28 700, and the HIV deaths were 9697. The region has
high infant mortality as well. The number of children that died within the first month after their birth
was 7800, whereas for the whole year the number of children that died during their first year was
13800.

What is the infant mortality rate in Quthing region?

o a.72,6 ‰
o b.41.5‰
o c.15,1‰
o d.73,6 ‰

What is the neonatal infant mortality rate in Quthing region?

o a.72,6 ‰
o b.41.5‰
o c.15,1‰
o d.73,6 ‰

The crude death rate in Quthing region and Varna are approximately 14,9‰. Can we conclude that
both countries have the same death rates?
o absolutely not, because both countries have different socioeconomic level of development
and thus, different healthcare needs and healthcare problems.
o yes, because they have been calculated as people dying per 1000 in a population
o no, because we have not considered the differences in disease prelance in both regions
o absolutely not, because age and population structures are not adjusted in the crude deah
rate.

14
Which are the listed determinants with the highest impact on health in the Quthing region?
o poverty
o gender-based violence
o HIV, diarhreal disease, cardiovascular disease

What is the crude death rate in Quthing region?

o 72,6 ‰
o 41.5‰
o 15,1‰
o 73,6 ‰

In 2018 Quthing women had on average 2.6 children. This is a measure of:
o total fertility rate
o net reproductive rate
o gross reproductive rate

HIV mortality in Quthing 2018 =Total number of HIV deaths in 2018 in Quthing/Total number of
HIV deaths in 2018*1000
o true
o false

What is the HIV death rate in Quithing?

o 72,6 ‰
o 41.5‰
o 33,7‰
o 11,4%

15
 Social Medicine Midterm - IIIrd Semester

1. A study was conducted in the year 2006 to measure the period prevalence of smokers
among 105 students. Out of them 5 were already smokers and 15 started during 2006,
period prevalence of 2006 is:

- 19%

2. Lung cancer mortality in Varna 2014 = Total number of cancer deaths in 2014 in
Varna/Total number ... in Varna in 2014*100

- False

3. Fertility is:

- Number of live births/year by the number of women aged 15-49

4. Neonatal mortality rate, 2014, UK = total number of deaths 0-28 day, 2014, UK/total
number of live births *1000

- True

5. General fertility rate is an indicator of:

- Fertility of the population

6. Age-specific fertility means:

- Annual number of births per woman in a particular age group expressed per 1000 women
in that age group

7. Birth rate for 2015 is:

- 166 (?)

8. If the number of deaths from tuberculosis is expressed in relation to the total mid year
population...?

- Cause specific mortality rate

9. Gross reproduction rate is an indicator of:

- Reproduction

10. All are true about direct standardization except:

- Age-specific death rates are not needed

1
11. Early neonatal mortality, 2010, Bulgaria = total number of infant deaths 0 to 6 day,
2010, Bulgaria / number of live births, 2010, Bulgaria *1000

- True

12. Cardiovascular disease mortality rate for the Netherlands for 2014 = Total number of
cardiovascular deaths in the Netherlands, 2014/Midyear population of the Netherlands,
2014*100,000

- True

13. Below-replacement fertility is:

- Total fertility levels below 2.1 children per woman

14. The leading causes of death in a developed country are:

- Cardio-vascular diseases

15. Holistic model of health:

- "Emphasizes that each person has the capability and..."

(Emphasizes that each person has the capability and the responsibility for optimizing his or
her sense of wellbeing. Emphasizes that each person has the capability and the responsibility
for optimizing his or her sense of wellbeing.)

16. Which of the following dimensions is not included in the WHO definition of health?

- Occupational wellbeing

17. Neonatal mortality rate, 2014, UK = Total number of deaths from 0 to 1 year, 2014,
UK...

- False

18. An expert in the field of public health is required to estimate the magnitude of a health
problem. Which rate would he calculate for this?

- Prevalence

19. Birth rate for 2010 is:

- 90 (?)

20. Years of life lost to premature death and years lives with disability adjusted for the
severity of the disability...

- DALY

2
21. Age-specific fertility means:

- Annual number of births per woman in a particular age group expressed per 1000 women
in the age group

22. High fertility is associated with increased risk of maternal morbidity and mortality

- True

23. Phase FOUR of the demographic transition theory is characterized with:

- Stable big population size with low mortality and low birth rate

24. Expanding health insurance coverage and access to medical care is unlikely to reverse
the (health?) caused by the social determinants of health.

- True

25. Post-neonatal mortality = total number of deaths from 29 day up to 1 year / total
number of live births *1000

- True

26. Holistic model of health:

- Encompasses the physiological, mental, emotional, social, spiritual, and environmental

aspects of individuals and communities.

27. High fertility is when total fertility levels are below 2.1 children per woman

- False

28. Perinatal mortality = Stillbirths + infant deaths from 0 to 6 day / total number of births
*1000

- True

29. International comparison of mortality is most adequate when applying:

- Age standardized mortality rates

30. Infant mortality rate = Total number of deaths of children from 0 to 1 year, in a given
population...

- False

3
31. Fetal mortality = Total number of still births / Total number of births * 1000

- True

32. Crude death rate is a good indicator for international comparisons

- False

33. Total fertility rate is an indicator of

- Reproduction

34. Crude death rate = Total number of deaths in a specific population in a specific year /
Midyear population * 1000

- True

35. Ideally suited measure for comparing health status of the population is:

- Standardized mortality rate

36. Demographers

- all are true (are interested in the distribution of population and in movements of people;
count people and calculate the growth rate of a population; assess the impact of such things
as life expectancy and the marriage rate)

37. Population age composition is described by:

- Ratios between economically active and not active populations

38. Total fertility rate is more appropriate for population comparisons than crude birth
rate

- True

39. Population growth slows down only when:

- Both birth rates and death rates are low

40. Phase THREE of the Demographic theory is characterized with:

- Increasing size of the population, decreasing mortality and decreasing birth rate but with a
lower speed than mortality

4
41. To compare the death rate of Nepal with the death rate of Pakistan, the most
appropriate measure is:

- Standardized mortality rates

42. The proportion of cancer deaths in Germany for 2014 = Total number of cancer deaths
in Germany 2014...

- False

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social medicine

Social Medicine (Medical University-Varna)

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1. For interna,onal comparison of reproduc,on, we prefer the indicator: Age speci;c fer,lity rate
2. Primary Preven,on: Seeks to prevent the onset of speci;c diseases via risk reduc,ons
3. Holis,c model of health – encompasses the physiological, mental, emo,onal, social and environmental
aspects…
4. Speci;city of a test means all except: iden,;es true posi,ves
5. All true about cohort studies except: suitable for rare diseases. Its IneKcient for rare diseases or diseases
with long latency.
6. Infant mortality = total number of deaths of children 0 to 1 year in a given pop/total: true
7. All true for randomized controlled trial except: used only for tes,ng new drugs on human animal subjects
8. Establishment of a universal tes,ng system for hepa,,s C virus in high-risk groups example for: Primary
preven,on
9. In a cohort study which of the following is incorrect: Proceeds from eXect to cause
10. Which of the following dimensions is not included in the WHO de;ni,on of health? Occupa,onal well being
11. Community level weight loss and exercise programs to control metabolic syndrome is an example of: ter,ary
preven,on
12. Disability adjusted life years is: a complex measure of the burden of disease
13. Cardiac rehabilita,on following myocardial infarc,on, seeking to alter behaviours to reduce the likelihood of
reinfarc,on is an example of: ter,ary preven,on
14. The well-known Framingham heart study is an example of: cohort study
15. Replacement Fer,lity means: the average number of children a woman would need to have to reproduce
herself by bearing a daughter who survives childbearing age
16. Late neonatal Mortality – total no. of infant deaths 7-28 days/total number…*1000: false
17. A group of people who share a common characteris,c or experience within a de;ned ,me period is known
as: cohort
18. Screening of hepa,,s C virus infec,on of pa,ents with a history of injec,on drug use refers to: individual
level of secondary preven,on
19. In case control study of smoking and lung cancer, which of the following can be possible conclusion: Lung
cancer is common in smokers than non-smokers
20. To enhance quality of life: ter,ary preven,on
21. Lung Cancer mortality in varna 2014 = total number of cancer deaths in 2014/ total number of… *1000: false
22. Fer,lity is: Number of live births/years by the number of women aged 15-49
23. Neonatal mortality rate = total no. of deaths 0-28days/ total number of live births * 1000: true
24. All are true about direct standardiza,on except: Age speci;c death rates are not needed
25. Early neonatal mortality = total number of ID 0-6 days/total number of live births * 1000: true
26. Cardiovascular disease mortality = total number of CVD deaths/midyear popula,on *1000: true
27. A study was conducted to measure the period of prevalence of smokers among 105 students. Out of them 5
were already smokers and 15 started smoking. Period prevalence is: exis,ng cases/total popula,on = 19%

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28. Below replacement fer,lity is: Total fer,lity level below 2.1 children per woman
29. The leading causes of death in a developed country is: cardiovascular diseases
30. Popula,on growth slows down only when: both birth rates and death rates are low
31. Phase three of demographic transi,on theory is characterised with: increasing size of the popula,on,
decreasing mortality and decreasing birth rate but with a lower speed than mortality
32. High fer,lity is when total fer,lity levels are below 2.1 children per women: false
33. Perinatal Mortality – s,ll births and ID from 0-6days/total number of births *1000: true
34. Expanding health insurance coverage and access to medical care is unlikely caused by social determinants of
health: true
35. Post neonatal Mortality = Total no. of deaths from 29days to 1yr/total no. of live births* 1000: true
36. General Fer,lity rate is an indicator of: fer,lity of the popula,on
37. Age speci;c fer,lity means: annual number of births per woman in a par,cular age group expressed per
1000 women in that age group
38. High fer,lity is associated with increased risk of maternal morbidity and mortality: true
39. Phase four of the demographic transi,on theory is characterised with: stable big popula,on size with low
mortality and low birth rate
40. Interna,onal comparison of mortality is most adequate when applying: Age standardised mortality rates
41. An expert in the ;eld of public health is required to es,mate he magnitude of health problems. Which rate
would he calculated for this? Prevalence

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Social Medicine - Exam June 2020

Social Medicine (Medical University-Varna)

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Exam Social Medicine - MCQ

Female Mortality in Bulgaria, for 2019 = [Total number of women deaths in
Bulgaria, 2019] / [Mid-year female population in Bulgaria, 2019] * 1 000.
True
False

Please, indicate the correct way to evaluate Infant Mortality Rate (IMR):

Cardiovascular diseases mortality rate for the Netherlands for 2017 = [Total
number of cardiovascular deaths in the Netherlands, 2017] / [Mid-year
population of the Netherlands, 2017] * 100 000.
True
False

Fertility rate of women 20-24 years of age in Germany, for 2017 = [Total
number of live births in 2017] / [Total number of women
15-49 years, Germany, 2018] * 100 000.
True
False

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Crude Birth Rate for 2015 is (please, use the data from the table).

Ye a M i d - Num Wom Num Numb Num Numb Total

r y e a r b e r en in ber of er of b e r er of num
populat live fertil men wome o f n e w b e r
ion births e age w h o n who death breast o f
died died s cance breas
from durin r t
prostat
g and cases canc
e
cancer after e r
birth cases
2000 10000 1000 3000 160 25 100 20 100
2010 11000 1000 3500 200 10 200 60 200
2015 12000 2000 4000 100 15 150 40 100
О б 33000 4000 10500 460 50 450 120 400
що
166
‰
91 ‰
86 ‰

Age-specific fertility rate, for women between the age of 15-19 in France
for 2018 = [Total number of live births from mothers at the age of 15-19,
France, 2018] / [Total number of women 15-19 years, France, 2018] * 100 000.
True
False

Old-age-dependency ratio is the ratio between the number of persons aged

65 and over (age when they are generally economically inactive) and the
number of persons aged between 15 and 64. The value is expressed per
100 persons of working age (15-64).
True
False

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All are true about direct standardization except:

Two populations are compared;

A standard population is needed;
Age-specific death rates are not
needed;
Populations should be comparable;

Crude death rate for all years from all causes is (please, use the data from the
table below):

Year Mid- Numb Wome Numb Number Numb Numbe Total

year er of n in er of of er of r of numbe
populati live fertile men women deaths new r of
on birth age who who breast breast
childr died died cancer cancer
en from during cases cases
prostat and
e after
cancer birth
2000 10000 1000 3000 160 25 100 20 100
2010 11000 1000 3500 200 10 200 60 200
2015 12000 2000 4000 100 15 150 40 100
To t 33000 4000 10500 460 50 450 120 400
al
10.3
‰
13.6
‰
22.1
‰

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Which are the four major groups of health determinants?

"social, health care system and policy, environmental, physical";

"social, health care system and policy, environmental, genetic";
"social and environmental; health care system and
policy; behavioural; genetic";

Which prototypical pyramid structure is “constrictive"?

A pyramid, which shows roughly equal numbers of people in all age

categories, trend towards increase in the older age categories.
A pyramid with greater numbers of people in the younger age
categories.
A pyramid, which is with greater numbers of people in the older
age categories.

Neonatal mortality = [Total number of deaths from 29-th day up to 1 year] /

[Total number of life births up to first 28 days of life] per 1 000.
True
False

Disability adjusted life years (DALY) is:

A complex measure of the burden of

disease;
A measure of disability;
A measure of mortality;

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QALY is used to:

Assess both the quality and the quantity of life lived. It is used in
economic evaluation to assess the value for money of medical and
public health interventions.
Estimate the total number of years lost due to specific causes and risk
factors at the country, regional, and global levels.
None of the above

Population age pyramid:

Is a graphical presentation of the age and sex composition

of the population.
Represents the age groups and number of population.
Provides a quick overall comprehension of age structure.

Calculate the Crude Death Rate of cancers in 2015 in Bulgaria if the following
data is available: Number of deaths for 2015 is 110 117, number of people
who died from cancers in 2015 is 18 020, mid-year population for 2015 is
7 153 784.

2.5
‰
25 ‰
4.3
‰

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POSTNEONATAL MORTALITY RATE is the number of resident newborns dying

in a specified geographic area divided by the number of resident live births
for the same geographic area for a specified time period and multiplied by
1 000 within the following period:

between the first day to the 6-th day after birth

between the first day to the 28-th day after birth
between 28-th day and 364 days after birth

Age-specific fertility rates (ASFRs) are more appropriate for population

comparisons than crude birth rate:
True
False

Medical demographers are:

Interested in the distribution of population and in the movements of

people and their health impacts.
Counting people and calculate the growth rate of the population in
relation to health.
Assess the impact of such events as life expectancy, size and
structure of population, etc. related to health.
All are true.

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The leading causes of death in a developed country are:

Cardio-vascular diseases and cancers;

Cardio-vascular diseases and infectious
diseases;
Cardio-vascular diseases and accidents

Lung cancer mortality in Varna, 2017 = [Total number of lung cancer deaths in
Varna, 2017] / [Mid-year population of Varna, 2017] * 100 000.
True
False

Years of life lost due to premature death and years lived with disability
adjusted for the severity of the disability is known as:

Global Burden of Disease

QALY
DALY
Human Development
Index

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Social medicine: MCQs | Questions & answers

Social Medicine (Medical University-Varna)

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Social medicine: MCQs

1. infant mortality = total number of deaths of children 0 to 1 in a given population
and year / total number
True
False

2. all the true for randomised controlled trial except:

Bias may arise during evaluation
The group should be representative of the population
Both study and control group should be comparable
Used only for testing new drugs on human animal subjects

3. establishment of a universal testing system for hepatitis C virus in high risk

groups is example for:
Primary prevention
Tertiary prevention
Secondary prevention

4. “in a cohort study, which of the following is incorrect?”

“Proceeds from” “effect to cause”
Starts with people exposed to risk factor or suspected cause
Yields incidence rates and a relative risk
Time-consuming and expensive

5. which of the following dimensions is not included in the WHO definition of

health?
Physical well-being
Occupational well-being
Mental well-being
Social well-being

6. Community level weight loss and exercise programs to control metabolic

syndrome is an example of:
Primary prevention
Secondary prevention
Tertiary prevention

7. For international comparisons of reproduction we prefer the indicator:

Birth rate
Total fertility rate
Age-specific fertility rate
General fertility rate

8. Primary prevention:
seeks to prevent the onset of specific diseases via risk reduction
Includes procedures that detect and treat preclinical pathological changes and
thereby control disease progression
“seeks to soften the impact caused by the disease on patient's function, longevity,
and quality-of-life”

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9. Holistic model of health:

Focuses on conditions outside of the individual that affect his or her Health, such as
quality of air and water, living conditions
Relies almost exclusively on biological explanations and disease and illness and on
interpreting them in terms of malfunction
Encompasses the physiological, mental, emotional, social, spiritual, and
environmental aspects of individuals and community

10. “specificity” of a test means all except:

Identifies those without disease
Identifies True positives
Identifies True negatives
An ideal screening tests should have 100% specificity

11. All are true about cohort study except:

Reserved for testing precisely formulates hypothesis
Suitable for rare diseases
Can yield information about more than one outcome
Involves a large number of subjects

12. Screening for hepatitis C virus infection of patients with a history of injection
drug use refers to:
Individual level of secondary prevention
Individual level of primary prevention
Population level of primary prevention
Population level of secondary prevention

13. Cardiovascular disease mortality rate for the Netherlands for 2014 = total
number of cardiovascular disease:
True
False

14. Counselling on safe drug use and safe sex to prevent hepatitis C virus
transmission refers to:
Individual level of secondary prevention
Individual level of primary prevention
Population level of primary prevention
Population level of secondary prevention

15. “in a case-control study of smoking and lung cancer, which of the following can
be possible conclusions”:
Smoking is a cause of lung cancer
Lung cancer is common in smokers than non-smokers
“if smoking is stopped, the number of cases of lung cancer will decrease”
Smoking is associated with lung cancer

16. To enhance quality of life is the goal of:

Primary prevention
Tertiary prevention
Secondary prevention

17. Disability adjusted life years is:

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A measure of mortality
A measure of disability
A complex measure of The burden of disease

18. Cardiac rehabilitation following a myocardial infarction, seeking to alter behaviours to

reduce the likelihood of a reinfarction is and exact:
Primary prevention
Tertiary prevention
Secondary prevention

19. The well-known “Framingham heart study” is an example of:

Case-control study
Randomised controlled study
Cohort study

20. Replacement level fertility means:

The average number of children a woman would need to have to reproduce
herself by bearing a daughter who survives to childbearing age
Annual number births per woman in a particular age group expressed per 1000
women in that age-group
Total fertility levels above 1.3 children per Woman

21. Total neonatal mortality = total number of infant deaths 7-28 days / total number
of live births * 1000
True
False

22. A group of people who share common characteristic or experience within a

defined time period is known as:
Cases
Controls
Cohort

23. What are the main differences between “incidence” and “prevalence” as measures of
frequency of disease?

24. Which are the 4 major groups of health determinants? Which group has the
greatest impact on health?
Environment
Health care services
Lifestyle 49 - 53%
Genetics and biological factors

25. What data is necessary for the estimation of the crude birthrate of a defined
population?

26. What date is necessary for the estimation of cause specific infant mortality rate for
congenital anomalies in Japan for 2007?

28. Which are the leading causes of death in developed countries?

29. Which are the leading causes of infant mortality in the developing world?

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30. What is the difference between “crude birth rate” and “general fertility rate” as
demographic indicators?

31. Describe the “secondary” level prevention and give an example.

32. A good indicator of the availability, utilisation and effectiveness of healthcare

services in a country is:
Maternal mortality rate
Hospital bed occupancy rate
Infant mortality rate
Disability adjusted life years (DALYs)

33. “ courses of a disease process without any intervention” is the definition of:
Spectrum disease
Epidemiology of disease
Natural history of disease
Iceberg phenomenon

34. Which level of prevention is applicable for implementation in a population

without any risk factors:
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention

35. False statement about the Disease prevalence include all:

Prevalence is the a portion of people in a given population who currently have the
disease
Prevalence can be estimated from the results of a cross-sectional study
Prevalence is approximately equal to the product of incidence of disease and its
duration
Prevalence is the measure of existing cases of the disease at a particular
point in time (or over a specified period of time), rather than proportion of new
cases that develop during a specified period of time
Prevalence will decrease if a new drug reduces mortality associated with the
disease, even if it does not result in a cure

36. Prevalence is:

Rate
Ratio
Mode
Proportion
None of the above

37. Which definitions do not describe “modern epidemiology”?

A study of the distribution and determinants of health related states or events
in specified populations, and the application of this study to control of health
problems;
A study of the distribution of diseases of epidemic frequencies
A science for the distribution of infectious diseases
Immune-prophylaxis

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38. At the end of the year 2010, the population of a tribal district was 200,000 and
number of cases of tuberculosis were 900. At the end of the year 2001, the
population was 210,000 and 230 new cases were detected and 12 cases had died.
Based on this data, all of the following rates can be calculated except:
Prevalence
Incidence
Crude mortality
Case fatality

39. Which of the following is the most useful study design in a hospital setting?
Case-control study
Prospective cohort study
Randomised controlled clinical trial
Longitudinal

40. Which of the following is a case-control study?

All the controls should be healthy
The attributive risk of breast cancer resulting from the pill may be directly measured
Study of the incidence of cancer in men who have quit smoking
Study the prevalence of smoking men and women in varna

41. In a cohort study, which of the following is incorrect?

Proceeds form “effect to cause”
Starts with people exposed to risk factor or suspected cause
Yields incidence rates and relative risk
Time consuming and expensive

42. Incidence of diarrhoea is a community can be calculated by:

Case-control study
Case series study
Cross-sectional study
Cohort study
Clinical trial

43. A advantage(s) of the cross-sectional studies is that they :

Allow the formulation of epidemiology hypothesis
Are effective
Are easy to interpret temporarily between exposure and outcome

44. Choose the true answer(s) about experimental studies:

The effects of an intervention are measured by comparing the outcome in the
experimental group with that in a control group
Investigator exercises control over allocation of exposure
For ethical reasons the possibilities of conducting experiments in humans is limited
Treatment and exposure occur in a “uncontrolled” environment
Involve an active attempt to change a decrease determinant, such as an exposure
or a behaviour, or the progress of disease through treatment

45. All are true about direct standardisation except:

2 populations are compared
Populations should be comparable

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A standard population is needed

Age-specific mortality rate

46. Advantage(s) of the high-risk individual strategy of primary prevention is/ are:
Provides large benefit to the whole population
Involves high subject and physician motivation
Is behaviourally appropriate
Has radical and permanent effect

47. The negative predictive value of a screening test is:

A function of only the sensitivity and specificity
The probability that an individual with a negative test result does not have the
disease
The probability of disease given a negative test result
The probability that a disease-free individual will have a negative test result

48. Incidence risk, incidence rate. Prevalence

Cohort study, CHD. 1000 people are recruited for a study. 850 agree to participate. 50
have coronary heart disease upon examination. Over the next 10 years, 100 develop
coronary heart disease.
What is the 10 year incidence proportion (average risk) of coronary heart disease in
this cohort?
What is the prevalence of the disease at the beginning of the study?

49. What are the four major groups of health determinants? Which group has the greatest
impact on health?

50. What data is necessary for the estimation of stroke prevalence in Varna for 2007?

51. What data is necessary for the estimation of the general fertility rate of a defined
population?

52. What data is necessary for the estimation of the cause-specific death rate for
tuberculosis in South Africa for 2008?

53. Which are the leading causes of death in developing countries?

54. Which are the leading causes of infant mortality in the developed world?

55. Enumerate the age-specific infant mortality indicators:

56. Describe the “primary” level prevention and given example.

57. All of the following statements about crude birthrate are true EXCEPT:
Is calculated as the number of Live births per 1000 population in a given year
Needs a complete and accurate vital registration system
Not good for comparing fertility across populations with variations in age distribution
Relates births to the age sex group at risk of giving births (usually defined as
the women ages 15 - 49 years)

58. Standardised mortality rates are mostly used for:

Calculating Life expectancy at birth

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Calculating demographic replacement ratio

comparing mortality rates of populations having different age distribution
Calculating the death of infants during the first year of life

59. All the following statements about disease incidence are true EXCEPT:
Incidence will decrease if the new drug is effective in reducing deaths from the
disease
Incidence measures of the absolute risk of developing the disease
Incidence is the probability that a healthy individual will develop the disease during
a specified time period
Incidents will decrease if particular prevention programme is effective

60. Odds ratio (OR) measures which of the following?

The probability that person who was exposed to a certain risk factor will develop the
disease in question
How much more likely it is that a patient who has the disease has been exposed to
a particular risk factor compared to healthy individual
The incidence of the disease
The magnitude of the association between a disease (all other health related
outcome) and a suspected risk factor
B and the D

61. Which study design you would use to identify possible causes of rare disease?
Case-control study
Cross-sectional study
Prospective cohort study
Community trial

62. A case study is characterised by all of the following EXCEPT:

It is relatively inexpensive compared with most other epidemiologic Study designs
Cases with the disease are compared to controls without the disease
Incidence rates may be computed directly
They are useful for studying rare diseases
Not useful for studying rare exposure to risk factors

63. The observational study designs do not involve:

Descriptive Studies
Field trials
Ecological studies
Cross-sectional studies

64. Which of the following statements about the double blinded placebo-controlled
clinical trials is true?
Both the experimental and the control group are contained of blind people
Study participants and the investigators are kept blinded about treatment
assignment
In The experiment involves only the application of placebo effect tablets

65. Which epidemiological studies are most powerful for testing etiological
hypotheses:
Ecological Studies
Cross-sectional studies

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Randomised controlled clinical trials

Cohort studies
Case-control studies

66. A prospective cohort study employs:

Subject known at the onset to have the disease in question
Subjects known at the onset to be disease-free
Subjects whose exposure to suspected risk factor is comparable to that of
the control group at the onset of the study
Comparison groups of equal size

67. The rehabilitation of an ill person refers to:

Secondary level prevention
Primary level prevention
Tertiary level prevention

68. A main disadvantage of the population strategy for primary prevention is that it:
Is behaviourally inappropriate
Provide small benefit to the individual
Provides small potential for the whole population
Has a limited and temporary effect

69. The sensitivity of the screening test is:

Related to the reliability of the test
The probability of disease given a positive test result
The probability for a positive test in a diseased individual
The probability that a disease free individual will have a negative test result

70. All of the following statements about secondary prevention are true EXCEPT:
It is directed at the period between the onset of disease and the normal time of
diagnosis
It aims to reduce the prevalence of disease
Is aimed at reducing the progress or complications of established disease
Can be applied only to diseases in which the natural history includes an early period
when it is easily identified and treated

71. Phase 4 of the demographic transition theory is characterised with:

Big population size with low mortality and low birth rate
Small population size with high mortality and birth rates
Increasing population size with decreasing mortality and birth rates
Decreasing population size with increasing mortality and decreasing birthrates

72. Male mortality rate is a crude rate:

True
False

73. Gross reproduction rate is an indicator of:

Reproduction
Fertility
Age-specific fertility

74. holistic model of health:

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Focuses on conditions outside of the individual that affect his or her Health, such as
quality of air and water, living conditions
Relies almost exclusively on biological explanations and disease and illness and on
interpreting them in terms of malfunction
Emphasises that that each person has the capability And the responsibility
for optimising his or her self-healing, and creating feelings and conditions that help
prevent disease and promote…

75. On expert in the field of public health is required to estimate the magnitude of a
health problem:
Prevalence
Incidence
Case fatality
Cause specific mortality

76. Perinatal mortality = stillbirths + infant deaths from 0 and 6 day / total number of
births * 1000
True
False

77. Population growth rates are highest in Western nations and lower in developing
nations:
True
False

78. Demographers:
Are interested in the distribution of population and in movements of people
Count people and calculate the growth rate of a population
Assess the impact of such things as life expectancy and marriage rate
All are true

79. Cardiovascular disease mortality rate for the Netherlands for 2014 = total
number of cardiovascular disease: 2014/midyear population of the Netherlands,
2004 * 100,000
True
False

80. General fertility rate is an indicator of:

Reproduction of the population
Fertility of the population
Birth rate

81. Population age composition is described by:

Ratios between economically active and non-active populations
Number of people aged 0 to 14
Number of people aged 65 and over

82. Crude death rate = total number of deaths in a specific population in a specific
year/ midyear population
True
False

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83. In a community an increase in new cases of a particular disease due to:

Increase in incidence rate
Increase in prevalence rate
Both of the above

84. Less economically developed populations compared to develop ones tend to

have:
Higher general fertility rate
Lower age specific mortality
Ageing population structure

86. If the number of deaths from tuberculosis is expressed in relation to the total
mid year population:
Cause specific mortality rate
Case fatality rate
Age-specific death rate
Crude death rate

87. For international comparisons of reproduction we prefer the indicator:

Birth rate
Total fertility rate
Age-specific fertility rate
General fertility rate

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Social Medicine Midterm - IIIrd Semester | Questions &

answers
Social Medicine (Medical University-Varna)

StuDocu is not sponsored or endorsed by any college or university

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Social Medicine Midterm - IIIrd Semester

1. A study was conducted in the year 2006 to measure the period prevalence of smokers
among 105 students. Out of them 5 were already smokers and 15 started during 2006,
period prevalence of 2006 is:

- 19%

2. Lung cancer mortality in Varna 2014 = Total number of cancer deaths in 2014 in
Varna/Total number ... in Varna in 2014*100

- False

3. Fertility is:

- Number of live births/year by the number of women aged 15-49

4. Neonatal mortality rate, 2014, UK = total number of deaths 0-28 day, 2014, UK/total
number of live births *1000

- True

5. General fertility rate is an indicator of:

- Fertility of the population

6. Age-specific fertility means:

- Annual number of births per woman in a particular age group expressed per 1000 women
in that age group

7. Birth rate for 2015 is:

- 166 (?)

8. If the number of deaths from tuberculosis is expressed in relation to the total mid year
population...?

- Cause specific mortality rate

9. Gross reproduction rate is an indicator of:

- Reproduction

10. All are true about direct standardization except:

- Age-specific death rates are not needed

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11. Early neonatal mortality, 2010, Bulgaria = total number of infant deaths 0 to 6 day,
2010, Bulgaria / number of live births, 2010, Bulgaria *1000

- True

12. Cardiovascular disease mortality rate for the Netherlands for 2014 = Total number of
cardiovascular deaths in the Netherlands, 2014/Midyear population of the Netherlands,
2014*100,000

- True

13. Below-replacement fertility is:

- Total fertility levels below 2.1 children per woman

14. The leading causes of death in a developed country are:

- Cardio-vascular diseases

15. Holistic model of health:

- "Emphasizes that each person has the capability and..."

(Emphasizes that each person has the capability and the responsibility for optimizing his or
her sense of wellbeing. Emphasizes that each person has the capability and the responsibility
for optimizing his or her sense of wellbeing.)

16. Which of the following dimensions is not included in the WHO definition of health?

- Occupational wellbeing

17. Neonatal mortality rate, 2014, UK = Total number of deaths from 0 to 1 year, 2014,
UK...

- False

18. An expert in the field of public health is required to estimate the magnitude of a health
problem. Which rate would he calculate for this?

- Prevalence

19. Birth rate for 2010 is:

- 90 (?)

20. Years of life lost to premature death and years lives with disability adjusted for the
severity of the disability...

- DALY

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21. Age-specific fertility means:

- Annual number of births per woman in a particular age group expressed per 1000 women
in the age group

22. High fertility is associated with increased risk of maternal morbidity and mortality

- True

23. Phase FOUR of the demographic transition theory is characterized with:

- Stable big population size with low mortality and low birth rate

24. Expanding health insurance coverage and access to medical care is unlikely to reverse
the (health?) caused by the social determinants of health.

- True

25. Post-neonatal mortality = total number of deaths from 29 day up to 1 year / total
number of live births *1000

- True

26. Holistic model of health:

- Encompasses the physiological, mental, emotional, social, spiritual, and environmental

aspects of individuals and communities.

27. High fertility is when total fertility levels are below 2.1 children per woman

- False

28. Perinatal mortality = Stillbirths + infant deaths from 0 to 6 day / total number of births
*1000

- True

29. International comparison of mortality is most adequate when applying:

- Age standardized mortality rates

30. Infant mortality rate = Total number of deaths of children from 0 to 1 year, in a given
population...

- False

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31. Fetal mortality = Total number of still births / Total number of births * 1000

- True

32. Crude death rate is a good indicator for international comparisons

- False

33. Total fertility rate is an indicator of

- Reproduction

34. Crude death rate = Total number of deaths in a specific population in a specific year /
Midyear population * 1000

- True

35. Ideally suited measure for comparing health status of the population is:

- Standardized mortality rate

36. Demographers

- all are true (are interested in the distribution of population and in movements of people;
count people and calculate the growth rate of a population; assess the impact of such things
as life expectancy and the marriage rate)

37. Population age composition is described by:

- Ratios between economically active and not active populations

38. Total fertility rate is more appropriate for population comparisons than crude birth
rate

- True

39. Population growth slows down only when:

- Both birth rates and death rates are low

40. Phase THREE of the Demographic theory is characterized with:

- Increasing size of the population, decreasing mortality and decreasing birth rate but with a
lower speed than mortality

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41. To compare the death rate of Nepal with the death rate of Pakistan, the most
appropriate measure is:

- Standardized mortality rates

42. The proportion of cancer deaths in Germany for 2014 = Total number of cancer deaths
in Germany 2014...

- False

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Social medicine exam essays

Social Medicine (Medical University-Varna)

StuDocu is not sponsored or endorsed by any college or university

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Soci
almedi
cineexam essays

1. Heal
thanddi
[Link]
ti
onsofheal
[Link]
sof
heal
th.
“… astat
eofequil
ibr
ium oftheper
sonwiththebiol
ogic
al,physi
cal
,andsoc
ial
envi
ronment
,withtheobjectofmaximum f
unct
ionalcapabil
it
y

Thestat
eofbeinghale,sound,orwhole,i
nbody,mi
nd,orsoul
;espec
ial
ly,t
hest
ate
ofbei
ngfreef
rom physicaldi
seaseorpain.

“
Heal
thisast
ateofcompl
etephysi
cal
,ment
alandsoc
ialwel
l-
bei
ngandnotmer
ely
t
heabsenc
eofdi
seaseori
nfir
mity.
”

Goodheal t
hi mpli
est heac hievementofdynami cbalancebet weenindividualor
groupsandt heirenvironment .Tot heindivi
dual,goodheal thmeansi mpr ovedqual i
ty
ofli
fe,l
esssicknessanddi sabil
it
y,ahappi erpersonal,familyandsoc ialexistence,
andt heopportunitytomakec hoi
cesinwor [Link] ty,good
healthmeansahi gherst andar dofli
ving,great
erpartici
pat i
oninmaki ngand
implementi
ngc ommuni tyheal t
hpol i
cies,andreducedheal thcarecosts.

"Theextenttowhichani ndividualorgroupi sabletoreali

zeaspi
rati
onsandsati
sfy
needs,andt ochangeorc opewi t
ht heenvironment. Healthisaresour
cefor
everydaylif
e,nottheobjecti
veofliving;i
tisaposi t
iveconcept
,emphasizi
ngsoc
ial
andper sonalr
esources,aswel lasphysicalc apaci
ti
es."

Dimensi
onsofHealt
h:adaptedbyAggl
eton& Homans(1987)andEwles& Si
mnet
t
(
1992)provi
deareali
sti
capproac
handincl
udethef
oll
owingaspect
s:

Physi
cal-mec
hani
sti
cfunc
tionofbody

Ment
al-abi
li
tyt
othi
nkandmakej
udgement
s

Soc
ial-t
heabi
li
tyt
omakeandmai
ntai
nrel
ati
onshi
pswi
thot
her
s

Emot
ional-r
ecogni
seemot
ionssuc
hasf
ear
,joy,gr
iefandanger

Spir
itual-abi
li
tyt
oputi
ntopr
act
icemor
al,r
eli
giousorbel
ief
stoac
hievepeac
eof
mind

Sexual-ac
cept
anc
eandabi
li
tyt
oac
hieveasat
isf
act
oryexpr
essi
onofone'
ssexual
it
y

Soci
etal-t
hebasici
nfrast
ruct
urenecessar
yforheal
th,e.
[Link]
ter
,peac
e,f
ood,
i
ncome,ac er
tai
ndegreeofint
egrat
ionordivi
sionwi
thinsoc
iet
y

Envi
ronmental-physi
calenvi
ronmentinc
ludeshousi
ng,t
ranspor
t,sani
tat
ion,
avai
labi
li
tyofcleanwater,pol
lut
ioncont
rol

Model
sofHeal
th—Medi
calModel
06/01/18

•Heal
thistheabsenceofoneormor
eoft
he“
fiveDs”
—deat
h,di
sease,di
scomf
ort
,
di
sabi
li
ty,anddissat
isf
act
ion.

•Rel
iesalmostexc
lusi
vel
yonbiol
ogi
calexpl
anat
ionsofdi
seaseandi
ll
nessandon
i
nter
pret
ingthem i
ntermsofmalf
unct
ion.

Ash Thomas
1

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Model
sofHeal
th—Envi
ronment
alModel

•Basedonanal
ysesofecosyst
emsandenvironment
alri
skstoheal
th,suchas
soc
ioec
onomi
cst
atus(SES),l
evelofeduc
ati
on,andvari
ousenvi
ronmentalf
act
ors.

•Healt
hisdefinedinter
msoft
hequal
it
yofaper
son’
sadapt
ati
ont
otheenvi
ronment
ascondit
ionschange.

•Focusesonc ondi
tionsoutsidetheindivi
dualt hataffec
thisorherhealt
h,suc
has
quali
tyofairandwat er
,li
vingcondit
ions,exposuretohar mfulsubst
anc
es,SES,
soci
alrel
ati
onships,andt heavailabl
eheal t
hc aresystem.

Model
sofHeal
th—Hol
ist
icModel

•Encompassest
hephysiologi
cal,ment
al,emoti
onal
,social
,spi
ri
tual
,and
envi
ronment
alaspec
tsofindivi
dualsandc ommunit
ies.

•Emphasizesthateachpersonhasthec apabi
li
tyandt heresponsi
bil
it
yfor
opt
imizi
nghisorhersenseofwell-
being,pract
icingsel
f-
heali
ng,andc r
eat
ingf
eel
ings
andcondit
ionsthathel
ppreventdi
seaseandpr omoteandmai ntai
nhealt
h.

06/01/18

Ash Thomas
2

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2. Det
ermi
nant
sofheal
th.
Manyf actor
sc ombinedt
ogethertoaffec
tthehealt
hofi ndi
vidualsandcommuni
ti
es.
Determinantsofhealthi
ncludetherangeofpersonal,soci
al,ec
onomicand
envir
onment alfac
torswhic
hdet er
minet heheal
thstatusofindivi
dual
sor
populat
ions.

TheRepor tofMarkLaLonde(Mini
sterofHeal
th,Canada,1974)i
simportantforthe
i
dentific
ationoft
hefourgener
algr
oupsofhealthdeter
minantsandthei
rc ont
ributi
on
toi
llhealth:

 Genet
icandbi
ologi
calf
act
ors(
18-
22%)

 Li
fest
ylef
act
ors(
49-
53%)

 Envi
ronment
alf
act
ors(
inc
[Link]
io-
economi
c)(
17-
20%)

 Heal
thc
areser
vic
es(
8-10%)

Genet
icandBi
ologi
calFact
ors

 Det
ermi
net
hei
ndi
vidualpr
edi
sposi
ti
ont
oher
edi
tar
yanddegener
ati
vedi
seases;

 Relatedto:chromosomediseases;mentalret
ardat
ion;di
abetes;at
heroscl
erosi
s;
bloodhypertension;i
schemi
cheartdisease;someneoplasms(breastcancer
,
color
ect
alcanc er
);mentaldi
sorder
s,etc.

Li
fest
yleFact
ors

 Smoking,alcoholanddr
ugabuse;l
ow physi
calac
tivi
ty;poorunheal
thydi
et;
psyc
hosocialst
ress;etc
.

 Det
ermi
ne49-53% ofal
lheal
thi
mpai
rment
s;

 Rel
atedt o:cor
onar
yhear tdisease(CHD) ,st
roke;mostneoplasms;diabetes;
c
hroni
cr espir
atorydi
sease;inj
uries;obesi
ty;chroni
cli
verdiseases,c
irr
hosis,etc.

 70-80% ofalldeat
hsinthedevel
opedand40% ofalldeat
hsinthedevel
opi
ng
countri
esar er
elat
edtol
if
estyl
efact
orst
hatar
epotenti
allymanageabl
eand
avoidable.

Envi
ronment
alFact
ors

 Unfavourabl
efac
torsoftheenvi
ronment-ai
r,dri
nki
ngwat
erandsoilpoll
uti
on;
otherphysi
calandchemicalf
actor
softheenvi
ronment
;ri
skf
act
orsf
rom theworki
ng
envir
onment;

 Socio-economicfact
ors-i
nc ome,soc
ialstat
us;unemployment;educ at
ion;
expenditure;housi
ngandl i
vingcondit
ions;soci
alsupportorexcl
usion(homeless,
unempl oyed,ref
ugees,immigrant
singeneralhavepoorheal t
h,etc.
);
06/01/18

 Det
ermi
neabout17–20% onheal
thi
mpai
rment
s.

 Unsafedri
nki
ngwater
 Poorhousi
ngandshel
ter

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3

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Heal
thcar
eServi
ces

 Qual
it
y,ac
cessi
bil
it
yandt
imel
inessofheal
thc
are;

 Effec t
ivenessofpreventi
veinter venti
ons;coveragewi t
himmuni zationprogrammes;
coveragewi thfamil
ypl anningpr ogrammes,c ontr
ac ept
iveuse;effec t
ivenessofthe
screeningpr ogr
ammes;or ganisationandefficiencyofheal t
hservic esforpregnant
,
womenandc hi
ldr
en,forchronicallyillpat
ients,f
orelderl
y,etc
.

 Det
ermi
net
hel
eastpr
opor
tionofi
llheal
th–onl
y8–10% ofheal
thi
mpai
rment
s.

06/01/18

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3. Indi
vidualandpopulat
ionallevelofheal
th.
Indi
cator
s/paramet
ersforstudyingpopulat
ional
heal
th.
Goodheal
thimpl
iest
heachievementofdynami
cbal
anc
ebet
weeni
ndi
vidualor
gr
oupsandthei
renvi
ronment.

•Totheindivi
dual
,goodheal
thmeansimpr
ovedqualit
yofl i
fe,l
esssi
cknessand
di
sabil
it
y,ahappierper
sonal
,famil
yandsoci
alexi
stence,andtheopportuni
tyt
o
makechoicesinworkandrec
reat
ion.

•Tothec ommuni t
y,goodhealt
hmeansahi gherst
andardofli
ving,great
er
part
ici
pationinmakingandi mplement
ingc
ommuni tyheal
thpoli
cies,andreduc
ed
heal
thc arecost
s.

"Theextenttowhi chanindividualorgroupisabl etoreal

izeaspi
rati
onsandsatisf
y
needs,andt oc hangeorcopewi t
ht heenvir
onment .Healt
hi saresourc
eforever
yday
l
ife,nott
heobj ecti
veofli
ving;iti
saposi t
iveconcept,emphasizi
ngsoc i
aland
personalresources,aswellasphysi c
alcapacit
ies."

I
ndi
cat
orsandpar
amet
ersf
orst
udyi
ngpopul
ati
onalheal
th

HALEi sanabbrevi
ationforheal
th-
adjust
edlif
eexpect
ancy,andisof
tenref
err
edt
o
ashealthyl
if
[Link]
keli
feexpect
ancy,HALEconsider
smortal
it
yand
nonf
atalout
comes.

HALEdoest hi
sbysummar i
zingyearslivedi
nlesst
hanidealheal
th(
YLDs)and
yearslostduetoprematuremortal
it
y( YLLs)i
nasinglemeasur
eofaverage
populati
onhealthf
orindivi
dualcountri
es.

NEW I
NDI
CATORSFORLI
FELONGEVI
TY-YLDS

YLD isanabbr eviationforyear sl

ivedwi thdisabil
it
y,whi chcanalsobedesc r
ibedas
yearsli
vedi nlesst hanidealheal t
[Link] sincl
udesc ondi
tionssuchasi nfluenza,
whichmayl astforonl yaf ew days,orepilepsy,whi c
hcanl astalif
eti
me.I ti
s
measuredbyt akingt heprevalenceofthec onditi
onmul t
ipli
edbyt hedisabi li
tyweight
fort
hatcondi t
[Link] sabi
li
tywei ghtsreflec
tthesever i
tyofdiffer
entconditionsand
aredevelopedt hroughsur veysofthegener alpublic.

NEW I
NDI
CATORSFORLI
FELONGEVI
TY-YLLS

Yearsofli
felost(YLLs)areyearslostduetoprematuremortal
it
[Link] al
culated
bysubtracti
ngt heageatdeat hfr
om thelongestpossi
blel
if
eexpectancyforaper son
[Link] e,i
fthelongestli
feexpect
ancyformeninagi vencountryis
75,butamandi esofcancerat65,thiswouldbe10year soflif
elostduetocancer.

NEW I
NDI
CATORSFORLI
FELONGEVI
TY-DALY
06/01/18

DALYi sanabbr evi

ationf
ordisabi
li
ty-
adj
ust
edli
feyear
.Itisauniver
salmet
rict
hat
all
owsr esearchersandpol i
cymakerstoc
ompar
everydiffer
entpopul
ati
onsand
healt
hc ondit
ionsac rosst
ime.

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DALYsequalt
hesum ofyearsofli
felost(YLLs)andyear
sli
vedwi
thdi
sabi
li
ty(
YLDs)
.
OneDALYequalsonelostyearofhealthyli
fe.

DALYsall
ow ustoest
imatethetotalnumberofyearslostduet
ospec
ificc
ausesand
ri
skfac
torsatt
hecountr
y,regional,andgl
oballevel
s

NEW I
NDI
CATORSFORLI
FELONGEVI
TY-QALY

Thequali
ty-
adjustedli
feyearorqual i
ty-adj
ustedlif
e-year(
QALY)isageneric
measureofdiseaseburden,incl
udingbot hthequalit
yandt hequant
ityofli
feli
ved.I
t
i
susedi neconomicevaluat
ion(cost
-util
it
yanal ysi
s)toassesst
hevalueformoneyof
medic
alandpubl icheal
thinter
ventions.

OneQALYequat
est
ooneyeari
nper
fec
theal
th.

Par
amet
ersofr
epr
oduc
tionofpopul
ati
on

 Bi
rthr
ate

•Deat
hrat
e

•I
ndexofnat
urali
ncr
ease

MEASURESOFMORBI
DITY

 Inci
dencerate
 Preval
encerate

I
NCI
DENCE RATE

No . of new cases∈¿ time period

Incidence Rate= × 1,000
population at risk
PREVALENCE RATE

No . of people with a disease

Prevalance Rate ×1,000
people at risk

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4. Demographicindicat
orsformeasur i
ngpublicheal
th.
Sizeandstructur
eoft hepopulati
[Link]
ernati
onal
tr
[Link] at
[Link]
chealth
i
mpl i
cat
[Link]
ionalpyramids.
Demogr
aphy–Thest
udyofapopul
ati
oni
nit
sst
ati
canddynami
caspec
ts[
cit
e..
]

Demos(
Greek)–popul
ati
on,gr
oupofpeopl
eandGr
aphos(
Greek)–wr
ite,desc
ribe

Stati
caspectsincl
udechar
act
eri
sti
csatapoi
nti
nti
mesuch as
composit
ionby:

–Age

–Sex

–Rac
e

–Mar
italst
atus

-Pl
aceofl
ivi
ng

-Ec
onomi
cchar
act
eri
sti
cs

Dynami
caspect
sincl
ude:

–Fer
til
it
y(bi
rths)

-
Mor
bidi
ty(
sic
kness)

–Mor
tal
it
y(deat
hs)

–Mi
grat
ion(
popul
ati
onmovement
s)

–Gr
owt
h

-Ot
here.
[Link]
tionr
ates,di
vor
cer
ateset
c

 Popul
ati
oni
saffec
tedbyf
ert
il
it
y,mor
tal
it
yandmi
grat
ionr
ates

Fi
nalpopul
ati
on=I
nit
ialpopul
ati
on+(
Bir
ths–Deat
hs)+(
Immi
grat
ion–Emi
grat
ion)

Sourcesofdemogr
aphi
cdat
a:popul
ati
onc
ensus,vi
tal(
civi
l)r
egi
str
ati
onsyst
em,
surveys

Census-Thet ot
alprocessofc
oll
ecti
ng,compil
ing,analyzi
ng,andpublishingor
otherwisedi
ssemi nati
ngdemographic,ec
onomic,andsoc i
aldatapert
ainingtoall
personsinac ountryorinawell-
deli
neatedpartofac ountryataspeci
fiedtime
(Source:Uni
tedNat i
ons)
06/01/18

Composi
ti
onoft
hepopul
ati
on

Sever
alchar
act
eri
sti
csar
ecommonl
yusedbydemogr
apher
stodesc
ribeorc
ompar
e
popul
ati
ons:

 sex
 age

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 race/ethnicgroup/national
it
y
 rel
igi
on/mot herlanguage
 mar i
talstat
us
 education/lit
eracy
 economi cpart
ici
pati
on/employed–noti
nlaborf
orc
e/

Populati
onagepyr ami
di sagraphicpresentat
ionoftheageandsexc omposi
tionof
[Link]
onsistsofbar sr
epresenti
ngagegr oupsinascendingorderfrom
lowesttohighestpyrami dedononeanot her
.Barsareusuallypresent
edbysi ngleor
5-yearagegr [Link] amidpr
ovidesaqui ckoveral
lcompr
ehensionofageand
sexstructur
eofapopul ation.

AGE-
SEXCOMPOSI
TIONOFAPOPULATI
ON

Depi
ctedbyt
hePopul
ati
onPyr
ami
d

“
Young”popul
ati
on:pyr
ami
dist
riangul
ar

“
Agei
ng”popul
ati
on:pyr
ami
dbec
omesmor
eandmor
erec
tangul
ar.

“
YOUNG”POPULATI
ON

 % oft
otalpopul
ati
onunderage15i
shi
gh
 Medianageasl ow as15or16
 Duetohighfert
il
it
y

“
AGEI
NG”POPULATI
ON

 Elderl
yr isesfr
om 5% t omor ethan20% oft ot
alpopul
ati
on
 Duemai nlytolow ferti
li
[Link],Singapore
 “Young-old”versus“ old-ol
d”
 Moreandmor eelderlywomen
 Morec hronic& degener ati
vedi seases
 Multi
pleheal t
hpr oblemsar ec ommoni nelderl
ypeopl
e.

Changingshapeovert
imereflect
sthechangingcomposi
ti
onofthepopul
ati
on,
assoc
iatedwit
hchangesi
nf erti
li
tyandmor t
ali
tyateachage.

 Threeprotot
ypicalpyramidstr
uc turesarerecogni
zed:constr
icti
ve,expansive,and
stati
onary.
 A constrict
ivepyr amidwi t
hf ewerpeopl eintheyoungeragec at
egori
es.
 Anexpansi vepyr amidwithgr eaternumber sofpeopl
eint heyoungerage
categor
ies.
 A stati
onarypyr amidshowsr oughlyequalnumber sofpeoplei nallage
categor
ies,wit
hat aperi
ngtowar dstheolderagec at
egori
es.(Figure1)
06/01/18

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Agei
ngoft
hewor
ldpopul
ati
onr
elat
edt
oheal
th

 Proportionoft heelderlyrisesmor et han20% oft otalpopulat

ion;
 Moreandmor eelderl
ywomen;
 Morec hr onic& degener ati
vedi seases–thesoc allednonc ommuni c
abledi seases
(
NCDs) ;
 Multipleheal thproblemsar ec ommoni nelderl
ypeopl e…..
 Globally,Thec ohortofover-60popul ati
onisexpec t
edt or
eac h2bill
ionbymi d-
century( thesilvercentury);
 Europei s“ greying”.Huger egionalvar i
ati
onsbutonedomi nati
ngdemogr aphi c
tr
end–agei [Link] yisgrowing–t il
l2025above25% ofpopul ationwil
l
beabove65.
 Conc eptofac tiveageing–pr eventi
on–bet terhealth-r
elat
edqual i
tyofli
fe.

MORBI
DITYAND MORTALI
TY

TheEpi
demi
ologi
calTr
ansi
ti
on

 Thi
sr ef
erstothechangeindiseasepat t
ernsfr
om mostl
yinfec
tiousdi
seasesto
mostl
yc hroni
canddegener at
ivediseases
 Cancer,heartdi
sease,st
roke,inj
uri
es,diabet
es,ar
thr
iti
setcversusHIV/AIDS,
SARSet c

MEASURESOFMORTALI
TY

 Inf
antmor t
alit
yrate(deathsofbabiesunder1yearol
d)
 Neonatalmortali
tyrat
e(<28daysaf t
erbi
rth)
 Postneonatalmortal
it
yr ate(
between28daysand1yearol
d)
06/01/18

Deaths of babies under 1 year

IMR= ×1,000
Total live births
MEASURESOFMORTALI
TY

I
MR=Neonat
alMor
tal
it
yRat
e+Post
neonat
alMor
tal
it
yRat
e

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 Low Bi
rthWei
ght(
<2.
5kgatbi
rth)gr
eat
lyi
ncr
easest
her
iskofi
nfantmor
tal
it
y

OTHERMEASURESOFMORTALI
TY

 Under5mor tali
tyrate
 Li
feexpec tanc yatbirt
h
 Age-
spec i
ficmor t
ali
tyrat
es
 Cause-spec i
ficmor t
ali
tyrat
es
 Maternalmor tal
ityrat
e

MEASURESOFMORBI
DITY

 Inci
dencerate
 Preval
encerate

I
NCI
DENCERATE

No . of new cases∈¿ time period

Incidence Rate= × 1,000
population at risk
PREVALENCERATE

No . of people with a disease

Prevalance Rate ×1,000
people at risk
Migr
ationGeogr aphi
corspatialmobili
tyinvolvi
ngar elat
ivel
ypermanentchangein
usualresidenc
ebet weencl
ear l
ydefinedpolit
icalorstati
sti
caluni
ts.I
thas
dimensionsoftimeandspac [Link]
ernationalandinternalarethetwobroadtypesof
migrat
ion

 I
n-migrant—Aper sonwhomovesi napolit
icalareawithi
nt hesamec ountr
y
 I
mmi grant—Ani nternationalmigrantwhoent erstheareafrom aplac
eout si
dethe
countr
y
 Out-migr
ant—Aper sonwhomovesoutofapol i
ticalar
eawi thi
nthesamec ountr
y
 Emigrant—Ani nternationalmigrantdeparti
ngt oanothercountrybycrossi
ngthe
i
nternati
onalboundar y
 NetMigrati
on—I n-migrant s-
Out-migrant
s
 NetImmi gr
ati
on—I mmi gr ant
s-Emi gr
ants

Note:Netmi
grat
ionf
oranar
eaof
teni
ncl
udesbot
hint
ernat
ionalandi
nter
nal
migrat
ion

Crudenetmi
grat
ionrate(
CNMR)Differ
enc
ebet weent
henumberofi
n-mi
grant
sand
t
henumberofout-mi
grant
sper1,
000popul at
ion

Geogr
[Link]
einconcludedthatmigr
ati
onwasgovernedbya"push-
pul
l"
pr
ocess.I
nthe1880shedevel opedaser i
esofmigr
ati
on'
l
aws'thatfor
mthebasisf
or
modernmigrat
iont
[Link] i
nci
plesst
ate:
06/01/18

•Mostmi
grant
str
avelonl
yashor
tdi
stanc
e.

•Mi
grant
str
avel
ingl
ongdi
stanc
esusual
lyset
tl
einur
banar
eas.

•Mostmi
grat
ionoc
cur
sinst
eps.

•Mostmi
grat
ioni
srur
alt
our
ban.

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•Eac
hmi
grat
ionflow pr
oduc
esamovementi
ntheopposi
tedi
rec
tion(
"count
erflow"
).

•Mostmi
grant
sar
eadul
ts.

•Mosti
nter
nat
ionalmi
grant
sar
eyoungmal
es,whi
lemor
eint
ernalmi
grant
sar
e
f
emale.

DEMOGRAPHI
CTRANSI
TION

Deat
hratesdr
opbef
orebi
rthrates:t
her ef
ore,ther
eisaper
iodofr
api
dpopul
ati
on
gr
[Link]
sendswhenbirt
hr atesfinall
ydr op.

 Fal
li
ngdeathratesareduetobet
ternut
rit
ionandhigherst
andar
dsofl
ivi
ng
 Fal
li
ngbi
rthratesareduetosoci
alandeconomicc
hanges:

1)Womens
tayi
nsc
hooll
onger

2)Mor
ewomenwor
kout
sidet
hehome

3)Womenmar
ryl
ater

4)Womenpost
ponec
hil
dbear
ing

5)Peopl
echooset
ohavef
ewerki
ds

06/01/18

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5. Birt
hr at
e;Gener
alFer
til
it
y;Tot
al
f
ert
il
it
[Link]
Par
amet
ersofr
epr
oduc
tionofpopul
ati
on

 Bir
thrate
 Deathrat
e
 I
ndexofnatur
ali
ncr
ease

 Fer
til
it
yandBirt
hratearethemajorcomponent
sof
nat
uralmovementofthepopul
ati
on.
 Fer
til
it
yist
hechil
d-beari
ngperf
ormanceofindi
vidual
s,c
oupl
esorpopul
ati
ons.

FERTI
LITYAND HEALTH

 Highf erti
li
tyc ani ncr
easemat ernalandc hil
dmor tali
ty
 Continuousc hil
d-bear i
ngc anhaveanegat iveimpac tonmater
nalhealt
h
 Closely-spacedbi rths(<18mont hsapar t)& low bi
r t
hweightbabies(
<2,500g)at
higherr i
sk
 Il
legalabor ti
onsandmat ernalmor t
ality
 “Femal egenitalmut i
lati
on”& mat ernalmor tal
it
y
 Sex-selecti
veabor t
ioninChi naandI ndi a
 Problem ofteenagepr egnanc i
esi nUSA
 STDssuc hasgonor r
heac anl eadt oinfertil
ityinwomen
 Useofc ondomsr educ etr
ansmi ssionofSTDSe. [Link] V/AI
DS
 Monogamouswomenatr iskofbei ngi nfectedwi t
hHI Vbyhusbandsand
boyfriends

•CrudeBi rt h Rate(CBR)isthenumberofl i
vebir
thsforaspeci
fiedgeogr
aphicarea
(
nation,st
ate,county,etc
.)duri
ngaspec ifiedper
iod(usual
lyacalendaryear)di
vided
bythetotalpopulati
on(usuall
ymi d-year)fort
hatareaandmul t
ipli
edby1000.
St
ronglyinfluencedbyagest r
uctureofthepopulati
on.

 Bi
rthr
atesr
angingfr
om 10-20bi
rthsper1000areconsi
der
edl
ow;
 Bi
rthr
atesf
rom 40-
50birt
hsper1000ar econsi
der
edhigh.

number of lives-births per year

crude birth rate= ×1000
total number of midyear population
for the same territory
 Generalferti
lit
yr ate–wec anlookatt
hisi
ndicat
orasanagestandar
dized
measureoffer
til
it
[Link]
nfluenc
edbyagestruc
tureandthuspr
efer
redfor
compari
sons.
06/01/18

number of lives-births per year

GFR= ×1000
44
total number of women 15- of age (for same year)
49years
 Agespeci ficfert
ilityr
ate–i sthenumberofresi
dentli
vebirt
hst owomeni
na
spec
ificagegroupf oraspec
ifiedgeogr
aphi
carea(count
ry,st
ate,c
ounty)
….

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number of lives-births from women aged X

ASFR= ×1000
total number of women aged X
 Teenbi rt
hr ate-i
sthenumberofresi
dentl
ivebir
thst
omot
her
saged15-
19i
na
spec
ifiedgeogr
aphi
carea(c
ount
ry,stat
e,c
ounty)
….

number of live births to mothers ages 15-19

TBR= ×1000
number of women aged 15-19
Abortionrati
oandr at
e
 Abort
ionrat
ioist
henumberofabortionsper1000l
ivebi
rths
!!!
 Abort
ionrat
eisthenumberofabor
tionsper1000women15- 44year
sofage.

DEMOGRAPHI
CTRENDS

Recent
lywasdet
ec t
edasignific
antdec
reaseofbi
rthr
atel
evel
sinal
lec
onomi
cal
ly
advancedc
ount
ries-undesi
rable

FERTI
LITY

Fer
til
it
yrat
esc
anbeaffec
tedby:

 Publicpolic
ye. [Link] nment spressurecouplest
ohavefewerkids,ot
her
government senc our
aget hem tohavemor e!
 [Link]
gionandc ontracepti
on
 Economi [Link] ngki dsinindustri
alver
susagric
ult
uralsoci
eti
es
 Technologye. [Link]
tivecontracept
ivemethodsavailabl
e?

c
onsequenc
es:

 i
ncreaseofdefic
ienc
yofawor kingpower;
 decreasei
nrateofpopulat
iongrowth;
 changeofit
sagest r
uct
ure(populat
ionagei
ngandr educ
tionofashar
eoff
ert
il
e
agewomen) ;
 i
ncreasethenumberofthesingle-
chil
dfamil
ies,et
c.

06/01/18

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5. Deat
hrate;Tot
alMor
tal
it
y;Spec
ifici
ndi
cat
orsf
or
mort
ali
ty.
 Popul
ati
ondynami
cs-mor
tal
it
y-amaj
ordemogr
aphi
ceventandr
elat
edi
ndexes.

 Crudedeat hrate( CDR)isthet

otalnumberofdeathstoresi
dentsina
geogr
aphicarea(countr
y,stat
e,c
ount y,et
c)di
videdbythetot
alpopulat
ionfort
he
samegeographicarea(foraspec
ifiedtimeper
iod,usual
lyacalendaryear)
multi
pli
edby100, 000

Total resident deaths

CDR= ×100,000
Total population
 Agespeci ficdeathr ate(
ASDR)i sthetotalnumberofdeathstopopulat
ionofa
speci
fiedageoragegr oupspec ifiedinageogr aphi
carea(countr
y,st
ate,c
ounty,
etc
)dividedbyt hetot
alpopul at
ionf ort
hesameageoragegr oupint
hesame
geogr
aphi carea(f
oraspecifiedt imeperiod,usuall
yac al
endaryear)multi
pli
ed
by100, 000
Total resident deaths age 65-70
ASDR (65-70) ×100,000
No of population age 65-70
 Causespeci ficdeat hr at e(CSDR)isthenumberofdeat hsfrom aspecified
causeper100, 000per sonyear [Link] at
oristypi
call
yrestr
ictedt o
resi
dentdeathsi naspec ificgeogr
aphicar ea.
Causespecificdeathratesmaybeadj ustedfortheageandsexc omposit
ion,or
otherc
haracterist
icsofthepopul ati
[Link] hatisdone,fori
nstance,i
nt hec ase
ofageadjustment ,iti
sc alledanage-adjustedrate.
Total resident deaths from a disease, same year
CSDR (from a disease) ×100,000
No of population of the territory, same year

CRUDEDEATH RATE& AGE- ADJUSTED DEATH RATE

 TheCDRi saver ygener alindicator/indexoft heheal t
hst atusofageogr aphi c
areaorpopul [Link] r
uder atei snotappr opr i
ateforc omparisonofdi fferent
popul ationsorar easduet othesi gnific
anti mpac tofagei nmor tali
tydataand
differentage-distri
but i
onsi ndifferentpopul ations.
 Age- adjusteddeat hr atesshouldbeusedf orc ompar ati
ve
anal ysis.
 AGE- ADJUSTED DEATH RATE i sadeat hr atet hatcontrolsfortheeffectsof
differencesinpopul ati
onagedi st r
ibut i
ons.
 Age- adjustmenti susual lydonet hr ougheitherdi rec
tadjust mentori ndir
ec t
adj ustment .
AGE- ADJUSTED DEATH RATE-DI RECT AGE- ADJUSTMENT
Direc tage-adjustment( oragest andar dization)i sthesameasc alculat
inga
wei ghtedaver [Link] ghtstheage- speci
ficr atesobser vedinapopul ationof
06/01/18

i
nt erestbyt hepr oportionofeachagegr oupi nast andardpopul ation.
INDI RECT AGE- ADJUSTMENT
Indi r
ectageadj ust mentaver agest hespec ificratesi nthest andardpopul at i
on,
wei ghtedbyt hedist r
ibuti
onoft hest udypopul ati
on.

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Indir
ectadjust
menti susedl essfr
equentl
yt handi r
ectadj ustment
,buti suseful
whenage- speci
ficnumber sofdeathsinthest udypopul ationareeit
her
unavailabl
eorsmal linnumber
STANDARDI ZED MORTALI TYRATI O(abbreviatedSMR)i sthenumberof
observeddeathsi nthestudypopul at
iondividedbyt henumberofexpec ted
deaths(calc
ulatedf r
om indirectadj
ustment)andmul ti
pliedby100( Lil
ienfel
d&
Stoll
ey,1994;Last ,2001).TheSMRi sthemostc ommonwayofpr esentingthe
result
sofindir
ec tage-adjustmentofadeat hr at
e.

PREMATURE DEATH RATE ( PDR)i sthenumberofdeathsunderage75fora

speci
ficpopul
ati
on(dur
ingaspec i
ficti
meper i
od)
,age-
adjusted(
usi
ngthedirec
t
method)toastandardpopul
ationdistr
ibut
ionandexpressedasarateper
100,000.

THEDEMOGRAPHI CTRANSI TI
ON
Falli
ngdeat
hratesar
eduet opubl
icheal
thac
hievement
s,bet
ternut
rit
ionand
higherst
andar
dsofli
ving.

 Rat
eofnat
urali
ncr
easet
rends–f
rom posi
ti
vet
onegat
ive

RATE OFNATURALI NCREASE (RNI

)OR DECREASE isthedifferenc
ebetween
thenumberofli
vebirt
hsandt henumberofdeat
hsduri
ngtheyear .Thenatural
i
nc r
ease(
ornaturaldecr
ease)i
snegat
ivewhenthenumberofdeat hsexceedsthe
numberofbir
ths.

06/01/18

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6. Inf
antmor tali
[Link] i
ficindi
cator
sforinfant
mortali
ty.Under5c hil
dmor t
ali
[Link]
tal
it
y.
[Link]
cators.
I
nfantmor
tal
it
yref
erst
othedeat
hofani
nfantdur
ingt
hefir
styearofl
if
e

Cal
cul
atedas:

 Numberofdeat
hsamongi
nfant
sunderoneyearol
dper1,
000l
ivebi
rthsi
na
gi
venyearandter
rit
ory.

I
NFANTMORTALI
TYI
MPORTANCE

 Levelofpubl i
chealt
hdevelopmentandt hesoc
ioeconomi
cdevelopmentofa
count r
y;
 Sensi t
ivetothesoci
o-ec
onomicchangesinasoc i
ety;
 Reflectsthequali
tyofhealt
hcareservi
ces;
 Influencesthemostli
feexpect
ancy;
 Eval uatest
hedeathint hemostvulner
ableperi
odofhumansl i
fe.

Medi
co-
Soc
ialAspec
ts

 Oneoft hemosti nf
ormativepubl ichealthindicators;
 Agoodi ndicatoroftheover al
lheal thstatusofapopul ation;
 Muc hhigherthant hemor tali
tyr atesinthef ol
lowi ngagegr oups( beyond1yearof
age) ;
 Amaj ordetermi nantoflif
eexpec tancyatbi rth
 Tremendousgai nsinlif
eexpec tanc yinthefirst70year soft he20th c
enturywere
almostexc lusivelytheresultofadec l
ini
ngi nfantandc hildhoodmor t
ali
ty.
 InfantMor tali
tyi sverysensiti
vet olevelsandc hangesi nsoc io-
economic
condi t
ionsofapopul ati
on;oneoft hebestindi catorstorevealsoc i
alinequali
ti
esi
n
heal t
h;
 Influencedbymanyf actors(healthcareplayingmaj orrole).

I
nfantMor
tal
it
y:Det
ermi
nant
s

 Low bi rthwei ghtandpr ematurebirth–mai nreasonf orneonataldeat

h;
 Unf avour ablesocio-economicconditions;
 Low c ultureandeduc ati
onofpar ents;
 Medi calsur veil
lanceofpr egnantwomenandi nfants;
 Midwi feryandc hildbirt
hhealthcareandser vicesavailabi
li
ty;
 Sur vei
llanc eofhighr iskpregnanc i
esandf amilies
 mot hersyoungert han19orol derthan35year sofage;
 shor ti
nt ervalbetweensubsequentbi rt
hs;
 Incompl iancewi tht hechildnurturer ul
esandr ecommendat ions;
06/01/18

 Influenceofenvi r
onment alfact
ors( poll
uti
on,disaster
s,etc
.)

Bi
rthwei
ghti
sapower
fulpr
edi
ctorofi
nfantmor
tal
it
y;

 Low bir
thweightinfant
sare20% mor
eli
kelytodi
ewit
hinthefir
stf
ew year
s.
 Ver
yl ow wei
ghtinfantsar
e100% morel
ikel
ytodi
ethannormalinf
ant
s.

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I
nfantMor
tal
it
yandMot
her
’sEduc
ati
on

 Consi
stentr
elat
ionshi
pbetweenhi
ghermat
ernaleducat
ionandl
owerl
evel
sof
mort
ali
tyamongc hil
drenunder1andunder5yearsofage.

 Thi
shasbeenobser
vedi
ncount
riesi
nAf
ric
a,Asi
aandLat
inAmer
ica.

Inf
antmortali
tyvar i
eslar
gel
yac r
ossthewor
ld(over50ti
mesdi fferenc
ebetweenthe
countr
iesi
ndi ffer
entpart
softheworl
d)andisverymuc hinfluenc edbythesoci
o-
economicdevelopment–averysensit
ivei
ndi
cat
orf ort
hesocialinequal i
ti
esinheal
th.

INFANT MORTALI TYRATE (IMR)isthenumberofnewbor nsinaspecified

geogr
aphicar
ea( c
ountr
y,st
ate,count
y,etc.
)dyingunderoneyearofagedi videdby
thenumberofresi
dentli
vebirt
hsforthesamegeographicarea(
foraspec ifiedti
me
peri
od,usual
lyac al
endaryear)andmulti
pliedby1,000.

No of newborns in a specified area dying under 1 year of age

IMR= ×1000
No of newborns for the same territory and year
IMRisaprimaryandimpor
tantindi
cat
oroft
heover
allheal
thst
atusorqual
it
yofl
if
e
ofageogr
aphicar
ea’
spopulat
ion.

Dec
linedi
nal
lregi
onsoft
hewor
ldbutwi
dedi
ffer
enc
esbet
weenandwi
thi
ncount
ries

Causes:pr
emat
uri
ty,pneumoni
aanddehydr
ati
onf
rom di
arr
hoea

NEONATALMORTALI TYRATE ( NMR)isthenumberofnewbornsinaspeci

fied
geographi
careadyingatlessthan28daysofagedi vi
dedbythenumberofl
ive
bir
thsforthesamegeographicarea(
foraspeci
fiedt
imeperi
od,usual
lyacal
endar
year)andmultipl
iedby1,000.

No of newborns in a specified area dying under 28 days of age

NMR= ×1000
No of newborns for the same territory and year
POSTNEONATALMORTALI TYRATE (PostNMR)ist henumberofr esi
dentnewbor ns
dyingbetween28and364daysofagei naspec i
fiedgeographicarea(countr
y,st
ate,
county,et
c.)di
videdbyt henumberofr
esidentl
ivebi r
thsforthesamegeogr aphi
c
area(foraspecifiedper
iod,usual
lyac
alendaryear )andmul ti
pli
edby1, 000.

No of newborns in a specified area dying

between 28 days and 364 days of age
postNMR= ×1000
No of newborns for the same territory and year
PERINATALMORTALI TYRATE ( PNMR)i sthesum oft henumberoff oet
aldeat
hsof
28ormor eweeksgestationplusthenumberofr esidentnewbornsdyi ngunder7
daysofageinaspec i
fiedgeographicarea(country,st
ate,c
ounty,etc.
)divi
dedbyt he
sum ofthenumberofresidentli
vebirthsplusthenumberofr esidentfoet
aldeat
hsof
06/01/18

28ormor eweeksgestationfort
hesamegeogr aphicarea(f
oraspec i
fiedti
meperiod,
usuall
yac al
endaryear )andmul t
ipl
iedby1, 000.

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17

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No of foetal deaths of 28 or more G.W. +No of newborns in a specified area

dying under 7 days of age
PNMR= ×1000
No of live births+No of 28 or more G.W.
for the same territory and year
FETALMORTALITYRATE (FMR)isthenumberoff oet
aldeathsinaspeci
fied
geogr
aphi
car
eadivi
dedbythenumberofli
vebirt
hspl usfoet
aldeat
hsforthesame
geogr
aphi
car
ea(f
oraspeci
fiedt
imeperi
od,usuall
yac al
endaryear
)andmul ti
pli
ed
by1,000.

N of foetal deaths in a specified area

FMR= ×1000
No of live births+ No of foetal deaths for the same territory and year
Under -fivemort al
ityrat eremainshighinlessdevelopedr egi
onsandpar t
icul
arlyi
n
theleastdevel opedc ountri
[Link]-
fivemortal
it
yinAf ric
ai smorestr
onglyaffect
ed
byHI V/AI DSt hani sinfantmortal
it
y,becausemostc hildrenbornwit
ht hedisease
survivet hei
rfirstbi
rthdaybutdi ebeforeage5.

MATERNALMORTALI TYRATE ( MMR)i st henumberofr esi

dentmat er
naldeaths
within42daysofpr egnanc yterminati
onduet ocompli
cat
ionsofpregnancy,
chil
dbirt
h,andt hepuer perium inaspec i
fiedgeographi
car ea(c
ountry,st
ate,c
ount y,
etc
.)divi
dedbyt otalresidentlivebir
thsfort hesamegeographicareaforaspecified
ti
meper iod,usual
lyac alendaryear,multipliedby100,000.

No of mternal deaths within 42 days

of pregnancy termination due to compl. in a specified area
MMR= × 100,000
No of total live births for the same territory and year
Amat ernaldeathisdefinedbytheWor ldHealt
hOr ganizat
ionas:Thedeat hofa
womanwhi lepregnantorwithi
n42daysoft er
minationofpregnancy,i
rrespect
iveof
thedurationandt hesit
eofthepregnancy,fr
om anyc auserelat
edtooraggr avated
bythepr egnanc
yori tsmanagement ,butnotfr
om accident
alorinci
dentalcauses

Appr
oxi
mat
ely540000womendi
efr
om pr
egnanc
y-r
elat
edc
ausesannual
ly;

 Everyminuteawomandi esdur i
ngl aborordel
iver
y;
 Almostall(
99%)oft
hesemat er
naldeat hsoccurindevel
opi
ngnations.
 Manydevelopi
ngnationslackadequat eheal
thcareandfamil
yplanning,and
pregnantwomenhavemi nimalaccesstoskil
ledlaborandemergencycare.

Barri ersf ordecreasi ngInfantMort ali

tyRat es:
 Low c overagewi t
hrout i
neimmuni zations;
 Childrenandmot hersmal nutrit
ion(povert
y);
 Insuffici
entpregnanciessurveill
anceandl ow coveragewi
thbasi
cmat
erni
tyc
are;
 Low literacyratesandeduc ationalstatusofwomen;
 Poorandi nadequatelivingconditi
ons.
06/01/18

Themai
ncausesofmat
ernaldeat
hsar
e:

 Postpart
um hemor rhage(24%);
 Indi
rectcauses:anemi a,malar
ia,hear
tdi
sease(
20%)
;
 Inf
ecti
on( 15%);
 Unsafeabor t
ion(13%);

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18

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 Ecl
ampsi a(12%)
;
 Obstr
uctedlabor(8%);
 Ect
opicpregnancy,embol
ism,andanest
hesi
acompl
icat
ions(
8%)

06/01/18

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7. Li
feexpec
tancy–defini
ti
[Link]
endsandfac
tor
s.
Complexi
ndic
ator
sformeasuringbur
denofdi
sease.
Anest
imat
eoft
heaver
agenumberofaddi
ti
onalyear
saper
sonc
oul
dexpec
ttol
ive-

i
ftheage-
spec
ificdeat
hrat
esf
oragi
venyearpr
evai
ledf
ort
her
estofhi
s/herl
if
e.

 Ahypot
het
ical(
condi
ti
onal
)indi
cat
or.

Li
feexpec
tancyc anbemeasur edatage0(atbir
th)-Li
feExpec
tancyatBi
rth,orany
ot
herspeci
ficage,repr
esent
ingexpect
edsurvi
valti
meonceaper sonhasr
eachedthat
age;

Att
hegl
obalwor
ldl
evel
,Li
feexpec
tanc
yatbi
rthhasi
ncr
easedmar
kedl
ysi
nce1950:

 1950–47year
s

 2015-71.
4year
s

Duet
othegr
eatdr
opi
nmor
tal
it
yrat
es(
1900-1940)

Most
lyduet
opubl
icheal
thmeasur
es

Tr
endsi
ndevel
opedcount
ries

Fir
sthalfofthe20thcent
ury-dramati
cinc
reasei
nLif
eExpec t
anc
y,reflec
tingmainly
thereduct
ionininf
ect
iousdi
seasesandadversec
ondi
tionsofmat
ernit
yandi nf
ancy.

 Secondhal fofthe20thcentury-anincreaseandthenadec r
easein
c
ardiovasculardiseasesasac auseofmortali
tyandani nc
reaseincancerand
t
rauma- rel
ateddeaths,sothatli
feexpec
tancyincr
eased,butatalowerratethani
n
t
heear l
ierperiod.

1950s-rapi
ddec
linei
nmor
tal
it
y(expandeduseofant
ibi
oti
cs,vac
cinesand
i
nsect
ici
des)
;

 Consequenti
ncr
easei
nli
feexpec
tanc
yatbi
rth

 From 41year
sin1950-
1955
 To65yearsin2005-
2010.

 Nar
rowedgapi
nli
feexpec
tanc
ybet
weent
hedevel
opedandt
hedevel
opi
ngwor
ld

 From 25year
sin1950-
1955
 To12yearsin2005-
2010.

Li
feExpect
ancyatBi
rth:Tr
endsi
nLeastDevel
opedCount
ries

 Ther
educt
ionofmor
tal
it
yinthel
eastdevel
opedregi
onshasnotkeptpac
ewi
tht
he
c
hangesoc
curri
ngel
sewherei
nthedevel
opingworl
d.
06/01/18

 Li
feexpec
tanc
yinc
reased:

 From 36year
sin1950-
1955
 To53yearsin2005-
2010.

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20

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 Thedifferenceinli
feexpec
tanc
ybet
weenl
eastdevel
opedr
egi
onsandl
ess
devel
opedr egionsinc
reased:

 From 5year
sintheearl
y1950s
 To12years2005-2010.

 Themaincauseforsuchdiver
genc
eisthat31oft
he50l
eastdevel
opedc
ount
ries
ar
ehighl
yaffec
tedbyt heHIV/AIDSepi
demic.

SummaryI
ntr
ends

Therearemaj
ordi
ffer
enc
esi
nli
feexpec
tanc
ybet
weendevel
opedanddevel
opi
ng
countr
ies.

 Theaver
agedi
ffer
enc
ebet
weendevel
opedanddevel
opi
ngc
ount
riesi
s10year
s(8
year
sformenand12yearsf
orwomen);

 Indevel opedcountriesasawhol e,li

feexpectancyaver
ages77year s,
comparedt o67yearsindevelopi
ngc ount r
ies.
 Inthel eastdevelopedcount ri
es,l i
feexpectancyremai
nslow (56yearson
average)
,lowesti
nSubSahar anAf ric
a-52year s–(theHIV/AIDSepidemic
).
 Lif
eexpec t
ancyatbirt
h-verymuc hinfluencedbymassepi demic
sof
communi cabl
eandnonc ommuni c
abl ediseases

Bigdiffer
enc
einLi
feExpec
tanc
yinmenandwomen,espec
ial
lyi
nmor
edevel
oped
regi
ons:

 Innear
lyal
lcount
ries,womenhaveahi gherl
if
eexpect
ancyatbi
rtht
hanmen,
andatthegl
oball
evel,femal
eli
feexpec
tancyexceedst
hatofmal
esby4.5year
s.

06/01/18

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21

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8. Moder
nepi
demi
[Link]
ti
on,t
erms.
EPIDEMIOLOGYisthestudyofthedist
ribut
ionanddeterminant
sofheal
th-
rel
ated
st
atesorevent
sinspec
ifiedpopul
ati
ons,andt heappl
icat
ionoft
hisst
udytocontr
olof
healt
hprobl
ems.

EPIDEMI OLOGYc anbedescribedasabasi cscienceofpubl

ichealt
handc l
ini
cal
medicine,thatst
udiestheocc ur
renceofhealt
hphenomena( well
-bei
ng,heal
th
complains,disor
ders,handicaps,compli
cat
ions,death,et
c.i
nhumanpopul ati
ons,
oft
eninr el
ationtootherphenomena.

POPULATION-gr oupofpeople,shari
ngcommonchar
act
eri
sti
cs-i
ndust
rywor
ker
s,
hospi
talpat
ient
s,mili
tar
yr ec
r ui
tsforagi
venyear

POPULATI
ONATRI SK-thatpartofapopul
ati
onwhi
chi
ssusc
ept
ibl
etodi
seaseand
fr
om whi
chthenew c
asescoul
dar i
se.

RISKFACTOR-per sonalandlif
estyl
echar
act
eri
sti
cs,envi
ronmentalf
actor
s,genet
ic
orcongeni
talc
har
ac t
eri
sti
cs,t
hatincr
easet
heprobabil
it
yofdiseaseoccurr
enceand
thathavetobepr
evented.

EXPOSURE-specificf
act
orthatc
anbemeasur
edquant
it
ati
vel
ybyl
evelanddose
/of
tenusedassynonym forri
skfac
tor
/

 EXPOSED GROUP-gr oupofpersonsexposedt

otheinfluenc
eoft hefac
tor/wit
ha
negat
iveorposi
ti
veeffec
t/understudy;
 NONEXPOSED GROUP-t hegr
oupt hati
snotexposedtotheinfluenc
eofthefact
or
understudy.

PREVALENCE

Measur
est
hef
requenc
yofexi
sti
ngc
asesi
nadefinedpopul
ati
on:

•Atagi
venpoi
nti
nti
mewhi
chi
sPr
eval
enc
eorPoi
ntPr
eval
enc
e;

•Dur
ingaspec
ifiedper
iodoft
imewhi
chi
sPer
iodpr
eval
enc
e.

ThenumberofcasesofadiseaseEXISTI
NG i
nadefinedpopul
ati
onatonepoi
nti
n
ti
me;•Moresui
tedtochroni
cdiseases

POINT PREVALENCEMeasur
est
hef
requenc
yofexi
sti
ngc
asesatonemoment
,in
cr
oss-
secti
onalst
udi
es.

Of
tenusedt
odesc
ribet
hepopul
ati
onheal
th.

Number of existing cases at a given point in time

× 10n
population at risk at the same moment
PERIOD PREVALENCE•Measuresthenumberofcasesatt
hebeginni
ngoft
he
06/01/18

per
iodplust
henewlydevel
opedcases,devi
dedbyt
hepopulat
ionatri
skdur
ingt
hat
per
iod.

 Descr
ibest
heheal
th-
rel
atedprobl
em i
nt hepopul
ati
on.
 Usef
ulmeasur
einplanninganddist
ributi
ngheal
thresour
ses.

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22

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Number of registered cases/ old and new/ during a given period

× 10n
population at risk at the same period
Pr
eval
encei
sincr
easedby:

 longerdur ationofthedisease;
 lowerc ase-fatal
it
y;
 medi caltechnology,improvi
ngsur vi
valofpati
ent
s;
 increaseinnew c asesduetoc hangesinriskf
act
orsori
mpr
oveddi
sease
diagnostic.
 in-migrati
onofc ases.
 out-migrati
onofheal t
hypeople.

I
NCI
DENCE RATE

Measur
esthenumberofnew c
asesofdi
seaset
hatdevel
opi
napopul
ati
onatr
isk
dur
ingaspeci
fiedt
imeperi
od.

Number of new cases of a disease during a period n

Incidence Rate= × 10
Sum of the individual time at risk for
each person in the population at risk
I
nci
denceisc
onsi
deredtobeameasur
eoft
hei
nst
ant
aneousr
ateofdevel
opmentof
adi
seasei
napopulat
ion.

ChangesintheInc
idenceofadiseasereflec
tthechangesinthefr
equencyort
hedose
oft
her i
skfact
orandindic
atet
hel evelofsuccessofc
ontr
oll
ingpubli
chealt
h
measures.

ThenumberofNEW c asesofadiseaseARISING dur

ingagi
venti
meperiodi na
spec
ifiedpopul
ati
on–moresuit
edt oacut
edisease(i
ncl
udi
nginf
ecti
ousdiseases)
.

06/01/18

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10. Mor
bidi
tyi
ndi
cat
ors:pr
eval
enc
eandi
nci
denc
e
PREVALENCE (
bur
denofdi
sease)

Measur
est
hef
requenc
yofexi
sti
ngc
asesi
nadefinedpopul
ati
on:

•Atagi
venpoi
nti
nti
mewhi
chi
sPr
eval
enc
eorPoi
ntPr
eval
enc
e;

•Dur
ingaspec
ifiedper
iodoft
imewhi
chi
sPer
iodpr
eval
enc
e.

ThenumberofcasesofadiseaseEXISTI
NG i
nadefinedpopul
ati
onatonepoi
nti
n
ti
me;•Moresui
tedtochroni
cdiseases

POINT PREVALENCEMeasur
est
hef
requenc
yofexi
sti
ngc
asesatonemoment
,in
cr
oss-
secti
onalst
udi
es.

Of
tenusedt
odesc
ribet
hepopul
ati
onheal
th.

Number of existing cases at a given point in time n

× 10
population at risk at the same moment
PERIOD PREVALENCE•Measuresthenumberofcasesatt
hebegi
nningoft
he
per
iodplust
henewlydevel
opedcases,di
videdbyt
hepopul
ati
onatri
skduri
ngthat
per
iod.

 Descr
ibest
heheal
th-
rel
atedprobl
em i
nt hepopul
ati
on.
 Usef
ulmeasur
einplanninganddist
ributi
ngheal
thresour
ces.

Number of registered cases/ old and new/ during a given period

× 10n
population at risk at the same period
Pr
eval
encei
sincr
easedby:

 longerdur ationofthedisease;
 lowerc ase-fatal
it
y;
 medi caltechnology,improvi
ngsur vi
valofpati
ent
s;
 increaseinnew c asesduetoc hangesinriskf
act
orsori
mpr
oveddi
sease
diagnostic.
 in-migrati
onofc ases.
 out-migrati
onofheal t
hypeople.

I
NCI
DENCE RATE

Measur
esthenumberofnew c
asesofdi
seaset
hatdevel
opi
napopul
ati
onatr
isk
dur
ingaspeci
fiedt
imeperi
od.

Number of new cases of a disease during a period n

Incidence Rate= × 10
Sum of the individual time at risk for
06/01/18

each person in the population at risk

I
nci
denceisc
onsi
deredtobeameasur
eoft
hei
nst
ant
aneousr
ateofdevel
opmentof
adi
seasei
napopulat
ion.

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ChangesintheInc
idenceofadiseasereflec
tthechangesinthefr
equencyort
hedose
oft
her i
skfact
orandindic
atet
hel evelofsuccessofc
ontr
oll
ingpubli
chealt
h
measures.

ThenumberofNEW c asesofadiseaseARISING dur

ingagi
venti
meperiodi na
spec
ifiedpopul
ati
on–moresuit
edt oacut
edisease(i
ncl
udi
nginf
ecti
ousdiseases)
.

CUMULATI
VE I
NCI
DENCE

•Quanti
fiest
hef
requenc
yofnewl
ydevel
opedc
asesi
nac
losedc
ohor
toveraper
iod
oft
ime

•Iti
sameasur eoft
her
iskofi
ndi
vidual
sint
hepopul
ati
onget
ti
ngt
hedi
seasedur
ing
t
hespec
ifiedperi
od

Number of new cases of a disease during a period n

Cumulative incidence= ×10
Population at risk at the beginning of the period

06/01/18

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[Link]
demi
ologi
calst
udydesi
gns
Epidemiologic
alstudyisasc i
ent
ifici
nvesti
gat
iont
orevealt
hef r
equenc
yandthe
di
stri
but i
onofdi seasei
nhumanpopul at
ionsandtherel
ati
onshipofdi
seaset
o
di
fferentpotenti
alriskf
act
ors.

•Defini
ti
onoft
her
esear
chquest
ion.

•For
mul
ati
onofhypot
hesi
s.

•Test
ingt
hehypot
hesi
sinanappr
opr
iat
est
udydesi
gn.

Sci
enti
ficstudi
esoft
hedist
ribut
ionofdi
seaseorotherheal
th-
relat
edst at
esorevent
s
i
nspec i
fiedhumanpopul
ationsaswellasthei
rpresumabledeterminants–ri
sk
f
actor
sorc auses.

Scient
ificstudi
esonhumanpopul at
ions,whic
hat t
empttoli
nkhumanheal
theffec
ts
(
[Link] er
)toacause(
[Link]
et oaspeci
ficchemi
cal
).

Epi
demi
ologi
calst
udi
esar
ecl
assi
fiedi
ntot
womaj
ort
ypes:

 Obser
vati
onal
 Exper
imental

TYPES OFEPI
DEMI
OLOGI
CALSTUDI
[Link]
[Link]
MENTAL
STUDIES

Observationalstudies-all
ow natur
etot
akeitscour
se:theinvest
igat
ormeasures
andanalysebutdoesnoti nt
erveneanddoesnothavecontr
olovertheexposur
eor
theprogr
essofdisease.(
Descri
pti
veandAnalyt
ic)

Experiment alstudies-theinvesti
gat
orac ti
vel
yi nt
ervenestoc hangeadi sease
det
ermi nant/exposur
eorbehaviour/ort heprogressofadi seasethroughthe
i
nterventi
[Link]
gatori
sc ont
rol
li
ngt heexperimentalsituat
ion.(
randomizati
on)

EPI
DEMI
OLOGI
CALRESEARCH DESI
GNS

Accor
dingtoessenti
aldiffer
enc esintiming,di
recti
on,andt ypeofcommuni
ti
es
sampled-ei
theropen(dynami cpopulati
on)orclosed(fixedpopul
ati
on,c
ohort
)–
sever
aldesignsforepi
demi ologic
alresearchcanbedi st i
ngui
shed:

 Cr oss-sec ti
onalst udies( compar ablewi thsurveyr esear chinsoc ialsci
enc es)–non-
exper iment alorobser vational( PREVALENCE–snapshot–1poi nti nti
me)
 Case- controlstudies( c aser eferentstudies)
-non- exper i
ment alorobser vational;
longi t
udi nal–mor et han1poi ntintime
 Cohor tstudies:Pr ospec ti
ve( concurrent)cohortstudies-non- exper i
ment alor
obser vat i
onal ;longitudi nal( exposure Di sease)
 Ret rospec ti
ve( non-conc urrent)cohortstudies-non- experiment alorobser vational
;
06/01/18

longi t
udi nal( Disease Exposur e/Riskf ac t
or)
 Ec ologicalst udydesi gns-usi nggroupofpeopl erathert hani ndividual
s
(compar ingc ount r
ies,GP- prac t
icesetc.
)
o Caseser ies–anal ysisbasedonaser iesofcompar ablec asesofdi sease;
o Caser epor t–ananal ysisbasedonasi nglecase.

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 RandomisedControl
ledTr
ial
s(RCT,aspec
ialc
aseofc
ohor
ttypeofst
udy)
exper
imental
;longi
tudi
nal

06/01/18

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[Link]
vat
ionalst
udi
es
Theinvest
igat
orj
ustobser
vesocc
urrenc
eofcondit
ions,event
s,di
seases(
and
measuresandmakest heanal
ysi
s)-butdoesnotinter
vene;

Tr
eat
mentandexposur
esoc
curi
na“
nonc
ont
rol
led”envi
ronment
;

Indi
vidual
si ncl
udedintheepidemiol
ogic
alstudy(st
udypar
tic
ipant
s)c
anbe
observedprospect
ivel
y,r
etr
ospect
ivel
y,orconcur
rent
ly.

TwoBr
oadTypesofObservat
ionalSt
udi
es

 DESCRI
PTI
VEobser
vat
ionalst
udi
es

 Desc
ribethedistri
buti
onofdi
seaseinapopul
ati
onorsubgroupsac
cor
dingt
o
per
son’
sc har
act
er i
sti
cs,t
imeandplace;(
why,what,when,where)

 Exampl
e:Desc
ribet
hedi
ffer
entdi
str
ibut
ionofdepr
essi
onorsui
cidalat
tempt
sby
gender
;

 Ecological(
Correlati
onal
,Popul
ation-
based)
 CaseRepor t
s
 CaseSer i
es
 Сross-secti
onal(Preval
encest
udies)

 ANALYTI
CALobser
vat
ionalst
udi
es

 Det
ectassoc
iati
onbetweenexposureandout
comebyt
est
inghypot
hesest
hatar
e
f
ormul
atedbyt hedesc
ript
ivest
udies.

 Exampl
e:I
dent
if
yfac
tor
sthatexpl
ain

 CaseCont
rol(CHD andsmoki
ngbetweenCHD andnoCHD -c
ont
rol
)
 Cohor
t(Br
iti
shdoct
orstudy–lungc
ancerandsmoki
ng)

DESCRI
PTI
VESTUDI
ES

Descr
ibeandcomparet
hepatter
nsofdiseaseoc
cur
renc
einandbet
weent
he
popul
ati
onsinrel
ati
ont
operson,pl
aceandt i
me.

Descript
ive-theyarel
imi
tedtoadescr
ipt
ionoft
heocc
urrenc
eofdiseaseordisease-
rel
atedphenomenainapopulat
ionac
cor ngt
di obasicgroupcharacteri
stics,
geographiclocati
onandt i
me.

Theyanswert
hef
oll
owi
ngquest
ions:

[Link]
ngt
hedi
sease?/Whatar
ethebasi
cchar
act
eri
sti
csofpeopl
ewhohave
thedi
sease?

[Link]
ethedi
seaseoc
cur
s?/Whati
sthegeogr
aphi
caldi
str
ibut
ionoft
hedi
sease?
06/01/18

[Link]
hedi
seaseoc
cur
s?/Whati
sthepat
ter
nofdi
seaseoc
cur
renc
eint
ime?

Desc
ript
ionofdi
seasepat
ter
ninr
elat
iont
oper
son:

[Link]
aphi
cchar
act
eri
sti
cs-age,sex,r
ace,mar
italst
atus

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28

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[Link]
io-
economi
cchar
act
eri
sti
cs-educ
ati
on,oc
cupat
ion,i
ncome,r
eli
gion

[Link]
sonalhabi
ts-smoki
ng,di
et

[Link]
ologi
calc
har
act
eri
sti
cs-Hb,Er
,Leuc

[Link]
icc
har
act
eri
sti
cs-bl
oodgr
oup,HLA-syst
em

Advant
agesofDescri
pti
veSt
udi
es

 Pr
ovideinfor
mat i
onaboutthemaincharacteri
sti
csofthepeopl ewhohavet he
hi
ghestprobabil
it
yofdevel
opingadisease,pointthepl
ac eswi t
hthehighest
pr
obabil
it
yofdi seaseoc
curr
ence,aswellasthet imeofdi seaseocc
urr
enc e.

 Mayexaminepatt
ernsofdi
seaseordeathbyage,sex,et
hni
cit
y,soci
oec
onomi
cor
ot
herc
haract
eri
sti
csduri
ngspeci
fiedper
iodoft
imeorc er
tai
nregi
ons.

 Descri
bethehealt
hst
atusofapopulat
ionandthusassi
stheal
thaut
hor
iti
esi
n
r
esourc
eal l
ocat
ionandpl
anningofpr
eventi
vepr
ogrammes.

 Suggestt
heprobabl
ec ausesorriskfact
orsfort
hedi seaseandareusedt
o
gener
atehypot
hesisontherelat
ionshipbetweenaf ac
torandadi sease.

 Basedon:

 routi
nel
yavai l
abledat afrom di
ffer
entsour ces
 census,vit
alstati
sti
cs,datafrom medi calrecords
 occupati
onalscreening,hospi
talrecords,registr
ies,et
[Link]
consumptionandser vi
cesandmedi c
ineut il
izati
on,etc.
,)
;orspec
ialsur
veysdat
a.

 Usual
lyar
echeaperandf
ast(
nott
imec
onsumi
ng)

 Of
tenar
ethefir
stst
epi
nanepi
demi
ologi
cali
nvest
igat
ion;

Di
sadvant
agesofDescri
pti
veSt
udi
es

 Cannotanalyse(cannott
estahypot
hesi
sfor
)ar
elat
ionshi
pbet
weenexposur
eand
heal
theffec
t(di
sease);

Analyt
ical-t
heyanal
yset
herelat
ionshi
psbetweenheal
thst
atusandot
her
var
iabl
esandexpl
aint
heobser
vedpat t
ernofocc
urr
enceofdi
sease:

 c
ohor
tstudies–indi
viduals
 c
ase-
contr
olstudi
es–i ndi
vidual
s

ECOLOGI
CAL/CORRELATI
ONAL/EPI
DEMI
OLOGI
CALSTUDI
ES

Observat
ionalst
udi esinwhichtheuni
tsofst
udyandanalysi
sarepopul at
ionsor
gr
[Link] isonsofdiseaseocc
urr
encearemadebetweenpopulati
onsin
di
ffer
entcountri
esatt hesamet i
meorinthesamepopul
ati
onatdiffer
entti
mes.
06/01/18

Rel
yondat aavai
labl
efr
om r
out
inenat
ionalst
ati
sti
cs;c
anbedonequi
ckl
yand
i
nexpensi
vel
y

Ash Thomas
29

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[Link]
oss–sec
tionalst
udydesi
gn
CROSS-
SECTI
ONAL/PREVALENCE/EPI
DEMI
OLOGI
CALSTUDI
ES(
Anal
yti
c)

Measurethepreval
enceofdiseaseatapart
icularmomentandt
hedat
aar
ecol
lec
ted
di
rect
lyfr
om thestudysubject
sinashortperiodoft
ime.

Dataarecoll
ect
edondi st
ribut
ionofr
iskf
act
ors,heal
thser
vic
esut
il
izat
ion,heal
th
needs,sel
f-
perc
eivedhealt
hstatusandot
hervariabl
es.

Usedt
opr
ovi
deasnapshotofapopul
ati
onatapoi
nti
nti
me.

 Exposur
estat
usanddiseasest
atusoftheindivi
dual
sinadefinedsampl
ear
e
measuredatonepoi
nti
ntime(si
multaneousl
y).
-concur
rent

 Preval
enc
erat
esamongthosewi
thandwi
thoutt
heexposur
eanddi
seasear
e
det
erminedandcompar
ed.

 Of
tenbasedonasampl
eoft
hegener
alpopul
ati
on–ac
ross-
sec
tion.

 Hi
ghl
ygener
ali
zabl
e.

Advant
agesofCr
oss-
sect
ionalSt
udi
es

 Rel
ativel
yeasyandec onomical(mi ni
malc ost
s).
 Carri
edoutoverashor tt
imeper iod.
 All
ow measur ementof:
06/01/18

 Thepr evalenceofdisease;(frequencyofexi
sti
ngdisease)
 Thepr evalenceofar i
skfac torinapopulati
on
 Heal t
hc ar
eneedsandat t
itudesofpopulati
on.
 Majoradvantage-t heyareoftenbasedonasampl eoft
hegeneralpopul
ati
on–
t
husgener al
izable;

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30

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 Manyc ount
riesconduc
tregularcr
oss-sec
tionalsurveysonr epr
esent
ati
vesamples
ofthei
rpopulati
ons–NationalHealt
hSur veys.
 Focusonpersonalanddemogr aphi
cc haract
eri
sti
cs,ill
nessesandhealt
hrelat
ed
behavi
ours.

Di
sadvant
agesofCr
oss-
Sect
ionalSt
udi
es

 Timef rameofc auseandeffec tcannotal waysbedet er

mi ned;
 Notusef ulf ordet ermi ningc ausaleffec tsofr iskfactorschangi ngovertime,not
possiblet odet ermi newhet herthef actorpr ecededt hedi seaseoroc c
urredaf ter
thedi seaseappear anc e.
 Notappr opr i
ateforst udyi ngr ar
edi seasesordi seaseswi thshortduration;
 Cannotmeasur et hei ncidenc eofdi sease;Cr oss-sec t
ionalStudiesareappr opri
ate
for
:
 I nvestigatingexposur est hatar efixedc haracteristi
csofi ndi
viduals(ethnicit
y,
socioec onomi cst atus,bl oodgr oup,r ace,etc.)
;
 Li mitedt ost udi esofc ausest hatar er easonabl yper manentc haract
er i
stic
sof
theindi vidualsot hatc auseandeffec tarepr esentatt hesamet ime.

Exampl
es:

 St
omac
hul
cerandbl
oodgr
oupr
elat
ionshi
p

 Br
eastc
anc
erandr
acer
elat
ionshi
p.

 ButnotoverweightandDi abet
esmel l
it
us2(bodywei
ghti
schangeabl
eandnot
fixedi
nti
mec haracter
ist
icoftheindi
vidual)
.

06/01/18

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[Link]–c
ont
rolst
udy
Agroupofpeopl
ewi t
hadi seaseorotherout
comevar i
ableofi
nterest(
CASES)anda
suit
abl
econtr
olgroupofpeopleunaffec
tedbythediseaseoroutcomevari
able
(CONTROLS)arecomparedforprevi
ousexposuret
oapossi bl
ecause( f
act
or)
.

Anobser
vat
ional
,anal
yti
cst
udydesi
gn;

 Descri
besassoc i
ationbet weenexposureandout come;
 Sel
ectssubjectsont hebasisofdiseasestatus;
 Compar espastexposur etosuspect
edc ausalfact
or si
ndiseasedcasesandi
n
heal
thyc ontr
olsfr
om t hesamepopul ati
on;
 Dataconc er
ningmor et hanonepointintimeiscollect
ed–longit
udinal
;
 Exposuredat aiscoll
ectedretr
ospect
ivel
y;

[Link]
ectpopulation;
[Link]
ectcasest hatmeetthediseasecasedefini
ti
on;
[Link]
ectnon-diseasedindivi
dualsfr
om thepopulati
ontoactascont
rol
s;
[Link]
ousexposur e/ri
skfact
orhist
ori
esfrom bot
hgroupsandcompar
e.

 Manyoutbreakinvest
igat
ionsuset
hisst
udydesign;
 Mostf
easibledesi
gnforstudyi
ngraredi
seases.

Wheni sacase- controlst udycarri ed

06/01/18

 Ac ase-
c ontrolst
udyi susual lyconductedbe foreac ohortoranexperi
ment alst
udy
toi
dent ifythepossi bl
eaetiology(setofc auses)ofthedisease;
 Itc
ostsr elati
velylessandc anbec onduc tedinashor terti
me;
 Foragi vendi sease,ac ase-contr
olstudyc aninvest
igatemulti
pleexposures;
 Ac ase-
c ontrolst
udyi spreferredwhent hedi seaseisrarebecauseinvest
igator
s
canintent i
onallysearchforthec ases;

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Sour cesofCases/TypesofCases
Representativenessofcasesisveryimportant!
 Hospital
-basedc ases
 I
dent i
fyc aseswher eyouc anfindthem e.
g.,hospit
als;
 Mostc ommonl yused( dependsont hestudieddisease)
 But……t heissueofr epr
esentat
ivenessi
sapr obl
em?

 Popul
ati
on-basedcases
 Random sampleofthegeneralpopulat
ion,ther
efor
ehi
ghl
yrepr
esent
ati
ve;
 Veryt
imec onsumi
ngandl abourintensive.

 Othersourc
esofc ases
 Cancerregi
str
ies,ambulat
oryc
aref
aci
li
ti
es,medi
cali
nsur
anc
ecompani
es,
ret
ir
ementgroups,etc…

SourcesofCont rols/TypesofCont rols

 Hospital
-basedCont r
ols
 Indi
vidualsseekingmedicalcareatt
hesamehospi t
alasthecases-fora
condi
tionbelievedtobeunrel
atedtothediseasebei
ngstudi
ed;
 Thehospi t
alpopulati
onmaybever ydiffer
entfr
om t
hegeneralpopul
ation,t
hus
l
essgener ali
zabil
it
yofresul
ts.

 Nei
ghbourhoodControls
 Usuall
yofsimil
arsocioeconomi
cst
atus
 Si
milarenvi
ronment.

 Popul at
ion-basedCont r
ols
 Cont r
olssel ec tedfrom ar andom sampl eofthegener alpopul
ati
on,e.
[Link]
arandom
digitdiall
ing
 Provideshi ghl yrepr esentativec ontrol
s
 Cost l
ymet hod,r efusalr ates,lackofphonec overage.
 OtherCont rols
 Friends,relat ives,spouses,c oll
eagues,c o-
wor kers;
 Easi l
yident ifiableandusual lyc ooperat
ive.

Matching-Thepr oc
essofsel
ect
ingcontrol
sinacasecont
rolstudysot hatt
he
cont
rolsaresi
mil
artothecaseswit
hr egardtoc
ert
ainkeycharacter
ist
ics-suchas
age,sex,andrac
e;

Advant
agesofCase-
Cont
rolSt
udi
es

 Si
mpl
etoc
onduc
t;
06/01/18

 Rel
ati
vel
yqui
ckandi
nexpensi
vec
ompar
edt
oot
heranal
yti
cdesi
gns;

 Effic
ientf
orst
udyi
ngr
aredi
seasesanddi
seasewi
thl
ongl
atenc
y;

 Caneasi
lyst
udymul
ti
pleexposur
esf
orasi
ngl
edi
sease;

 Caseseasi
lyavai
labl
e;

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 Numberofsubj
ect
sneededi
ssmal
l.

Li
mit
ati
onsofCase-
Cont
rolSt
udi
es

 Notappr
opr
iat
eforst
udyi
ngr
areexposur
es;

 Notwel
lsui
tedt
ost
udymul
ti
pleout
comes;

 Unabl
et opr
ovi
dedat
aoni
nci
denc
erat
es(
absol
uter
isk)andt
hec
alc
ulat
ionof
r
elat
iver
isk.

 Bec
ausedonotf
oll
ow adi
sease-
freepopul
ati
onovert
ime.

 Thest
rengt
hoft
heassoc
iat
ionbet
weenexposur
eanddi
seasei
smeasur
edbyOR
(
oddsrat
io)

ORgr
eat
ert
han1=

ORl
esst
han1=

OR=0=

 Ti
mesequenc
eofexposur
eandout
comec
anbeunc
lear
;

 Manypot
ent
ialsour
cesofbi
asander
ror
;

 Rel
yonr
ecal
lorexi
sti
ngr
ecor
dsaboutpastexposur
e

I nfor
mationonpotenti
alri
skfact
orsmaynotbeavai
labl
efr
om r
ecor
dsorst
udy
subject
s’memory;(
whi c
hc ancausebias)

 Casesmaysearchforacausefortheirdiseaseandbemorel i
kelyt
orecal
lan
exposur
ethancont
rol
s(aform ofr
ecallbias)e.
[Link]
sassessingapotent
ial
exposur
eduri
ngpregnancy

I denti
fyi
ngandassembl
ingac
asegr
oupr
epr
esent
ati
veofal
lcasesmaybe
di
ffic
ult
;

I
dent
if
yingandassembl
inganappr
opr
iat
econt
rolgr
oupmaybedi
ffic
ult
.

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[Link]
tSt
udy
Studythoseexposedandnotexposedt
oac
auset
oseet
heeffec
tsoft
hatc
ausei
n
thefut
ure.

 Beginwi thgr oupofpeopl ef

reeofdisease,whoar ecl
assifiedintosubgr
oups
accordingt oexposuretopotenti
alcauseofdi sease.
 Cohor tisfoll
owedupf ormonths,years,evendec adestoassesshow subsequent
developmentofnew c asesofthediseasedi ffersbetweent hegr oupswit
hand
withoutexposur e.
 Longitudinal–pr ospecti
veorretr
ospecti
ve(hi stor
ical
)cohor tst
udi es

Advant
agesofCohortSt
udi
es

 Wel lsuit
edt ostudyr ar
eexposur es;
 Candemonst r
ateat empor alrelat i
onshipbet weenexposur eanddi sease;
 Allow directmeasur ementofi ncidenc eofdi seaseintheexposedandnon- exposed
popul ati
onandadi rectmeasur eofr iskforout c
omeamongexposedand
unexposedper sons;
 Allow directmeasur ementoft hest r
engthoft heassoc i
ationbetweenexposureand
outcomet hrought heRel ativeRi sk( RR);
 Sinc ecohortst udiest akeheal thypeopl easst arti
ngpoint–t heycanassess
mul ti
pleout comes( effects)ofasi ngleexposur e(Case-contr
olstudi
esexami nea
si
ngl eend- point–r etrospec t
ivet herefor
ei denti
fiesexposurefrom case)
.

 Exampl
e:

 TheFr amingham St
udy-begani n1948,hasi nvesti
gat
edriskfactor
sassoc i
ated
notonlyforcardi
ovasc
ulardi
seases,butalsoforawi derangeofotherdiseases,such
06/01/18

asrespir
ator
y,musc ul
ar-
skel
etaldi
sorder
s,etc
.

Di
sadvant
agesofCohortSt
udi
es

 Expensiveandtimeconsumi
ng( I
fpr
ospect
ive):
 Mayr equi
relongper
iodsoff
oll
ow upsinc
edi seasemayoc
cural
ongt
imeaf
ter
exposure;

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 Inefficientforraredi seasesordi seaseswi thlongl atency.

 Notwel lsui
tedt ostudymul ti
pleexposur es.
 Validityoft her esultcanbeaffec tedbyl osst ofol
low- upandt r
acki
ngst udy
subj ects.
 Ifretrospec ti
ve,requirestheavai labil
it
yofexi sti
ngr ecor
ds.
 Themai nli
mitati
onoft heprospec t
ivecohor tdesi
gni sthetimeandc ostinvol
ved
espec ial l
ywhenst udyingc hronicdiseasest hatmayonl ybecomeappar entyear
s
aftert heexposur eofi nterestormayr equireyearsofexposur eto“c
ause”t he
outcome.

 Exampl
e:

 Toi nvest
igatetheri
skofc oloncancer(annuali
ncidence=100- 300/100,000
persons)woul drequi
reac ohortofthousandshealt
hyi ndi
vidualstobefol
lowedfor
10-15year sinordertoidentif
yasufficientnumberofoutcomes( newl
yoccurr
ed
casesofc ol
onc ancer
)forar el
iabl
eestimationoft
heassoc i
ation

TypesofCohortSt
udi
es

Pr
ospec
tive(
thet
ypi
calone)

 Thoset
hatf
oll
ow agr
oupi
ntot
hef
utur
e.

Exposureandnon-exposurestat
usar easc
ertainedast
heyoccuri
nthest
udy;gr
oups
arefol
lowed-
upforseveralyearsint
othefutureandinc
idenc
eismeasur
ed.

Pr
ospec
tiveCohor
tSt
udy

 Investi
gatori
denti
fiesori
ginals
tudypopulati
onatthebegi
nningofthestudy.
 Thei ndivi
dualsar
ef ol
lowedprospec
tivel
ythrought
imeunti
ldiseasedevel
opsor
doesnotdevelop.

 Di
sadvant
ages:

 Requi
reslongfol
low-
upt
ime(
year
s)
 Veryexpensi
ve

Ret
rospec
tive

 Thosethatlookbackinti
metor econstr
uc texposuresandhealthoutcomes.
 Exposureisascer
tai
nedfrom pastrecords,andout come(devel
opmentorno
devel
opmentofdisease)i
sasc er
tainedfrom exist
ingrecor
dsatt hebeginni
ngof
thestudy.

Ret
rospec
tive(
Hist
ori
cal
)Cohor
t

 Anal t
er nati
vest rategyfortheprospecti
vestudydesi gninordertoreduc et
ime
andc osts.
 Thisdesi gnr equir
esi dentif
yingadefinedcohortfrom sometimei nthepast.
06/01/18

Thefollow-upper iodisthet i
met hatel
apsedsinceexposur estatuswas
deter
mi nedunt i
lthepr esent.
 Parti
cularlyusef ulwhent heexposureunderinvestigati
onis“unique”insome
way-oc curredonl yint hepast,occurr
[Link]
ore,
thi
sdesi gnisof tenappl iedtothestudyofac ut
eenvi ronmentalexposures.

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Example:Thyr
oidc
anc
err
iskamongpeopl
eexposedt
otheCher
nobylnuc
lear
-reac
tor
acci
dent.

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[Link]
zedc
lini
calt
rial
.
Randomizedc
ont
rol
ledtr
ial
s-anepi
demiol
ogi
calexper
imentt
ost
udyanew
pr
event
iveort
her
apeuti
cregi
meningr
oupsofpati
ents;

Obser
vat
ional

 Desc
ript
ive
 Anal
ytic

Exper
iment
al

 RandomizedContr
oll
edCl
ini
calTr
ial
s
 Fi
eldtr
ials
 Communi t
ytr
ial
s

 Begi nswithadefinedpopul at
ionthatisrandomizedi ntotwogroups:new
tr
eat ment(exper i
mentalgroup)andc urr
enttradi
ti
onalt reat
mentorplacebo
(
c ont r
olgr
oup);
 Followssubjec tsineachgroup( exper
imentalandc ontrolgr
oup)toseeand
compar et
her esult
sinbothgr oups;
 Somet i
mes,thenew t r
eatmentmaybec ompar edwi t
hnoac ti
vetr
eatment,but
plac ebo(j
ustpsyc hol
ogic
aleffect)
.

Gol
dSt
andar
dofSt
udyDesi
gns

 Randomizedtr
ial
saregol
dstandar
dofstudydesi
gnsbec
auset
hepot
ent
ialf
or
bi
as(sel
ect
ionint
otreat
mentgr
oups)i
savoi
ded

Randomi
zedCl
ini
calTr
ialDesi
gn

[Link]
ect
ionoft
hest
udypopul
ati
on

[Link]
loc
ati
onoft
het
reat
mentr
egi
mens

[Link]
ntenanc
eandassessmentofpar
tic
ipant
s’c
ompl
ianc
e

[Link]
comes

 Suffici
entfoll
ow- upperiodofexperi
mentaltr
eatment
 Assessingt heeffectoft
heexper i
mentalt
reatmentbycompar
ingt
heout
comei
n
thet wogroups( experi
mentalandc ont
rol
).

TypesofRCT

 Par
all
elt
reat
mentorsi
mpl
e,non-
crossoverTr
ial

 Cr
ossoverTr
ial

 Fact
ori
alTr
ial-Thi
sdesignal
lowst
hei
nvest
igat
orst
ocompar
e2exper
iment
al
06/01/18

i
nter
venti
onswitht
hecont
rol

Ar
easofAppl
icat
ion

 Usedformanypurposes:
 Eval
uatenew dr
ugsandot hert
reat
ment
sofdi
sease;

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 Assessnew progr
amsf orscreeni
ngandear l
ydetect
ion–new met
hodsof
prevent
ion;
 New medi c
al/healt
hc aretechnol
ogyassessment;
 Assessnew waysofor gani
zinganddeliver
inghealt
hservi
ces;
 New healthcar
epoli
ciesassessment,et
c.

Advant
agesofRCTs

 NB!The“
gol
dst andard”ofresear
chdesi
gns;
 Pr
ovi
demostconvinc
ingevidenceofr
elat
ionshi
pbet
weenexposur
eandeffec
t;

Di
sadvant
agesofRCTs

 Ver yexpensi ve–Cost !

 Notappr opriat
etoanswerc ert
aintypesofquest i
ons–Et hi
calconsider
ati
ons!
 Pr act
icesorsubst ancesknownt obehar mf
ulshoul dnotbeal l
ocatedbyany
investigator;
 Ther apiesknownt obebenefic i
al,suc
hasmedi caltr
eatmentofhyper t
ensi
on,
shoul dnotbewi t
hheldf rom anyaffect
edindividual
.
 Pat i
entsf rom t
hec ontr
olgroupwhoneedt reatment–c annotbeleftwit
hout
treatment( j
ustonapl aceboeffect)
.

06/01/18

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[Link]
herexper
iment
alst
udydesi
gns
Obser
vat
ional

 Desc
ript
ive
 Anal
ytic

Exper
iment
al

 RandomizedContr
oll
edCl
ini
calTr
ial
s
 Fi
eldtr
ials
 Communi t
ytr
ial
s

Fiel
dtri
als-anexperi
mentthati
nvol
vedi
sease-
freepeopl
econsi
der
edt
obeatr
isk
andthei
nter
vent
ioni
sappli
edtoeachper
sonindi
viduall
y;

Inc ont
rastt
ocl
ini
calt
rial
s,i
nvol
vepeopl
ewhoar
edi
seasef
reebutpr
esumedt
obe
atr
isk.

 Datacol
lec
tiont
akesplacei
nt hefiel
d(noti
nthehospit
alandcl
ini
calenvi
ronment
),
usual
lyamongnon-inst
it
uti
onal
isedpeopleinthegener
alpopul
ati
on.

I
nvol
vegr
eatnumberofpar
tic
ipant
sandsubst
ant
ialfinanc
ialr
esour
ces.

Communitytri
als-anexperi
mentinwhi
cht
hei
nter
vent
ioni
sappl
iedt
o
communi
ti
esr
athert
hanindivi
dual
s;

 Unitofintervent
ion,observati
onandanal ysisarecommuni
tiesrathert
han
i
ndividuals;
 Appropriateforhighl
ypr eval
entdiseasesthathavethei
ror
iginsinsoci
al
condit
ionsandbehavi our alf
actor
s;

Examples:Car
diovascul
ardi
seasei
sagoodexampl
e;Nor
thKar
eli
aInt
ervent
ion
Proj
ectandCINDIProgrammeCommuni
tyTri
al

06/01/18

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Advant
agesofCommuni
tyTri
als

 Coul
dinfluenc
ebehavi
our
alandot
herl
if
est
ylef
act
ors;

 Coul
dreal
izesubst
ant
ialandc
ompl
exeffec
tont
heheal
thoft
heent
ir
ecommuni
ty;

 Theout
comesof
tenbec
omeasc
ient
ificbasi
sforpubl
icheal
thpol
icy.

Li
mit
ati
onsofCommuni
tyTri
als

 Ver
yexpensi
ve;

 Onl
yasmal
lnumberofc
ommuni
ti
esc
anbei
ncl
uded;

 Random al
loc
ati
onofc
ommuni
ti
esi
snotpr
act
icabl
e;

 Diffic
ultt
oisolat
ethec
ommunit
ieswher
eint
ervent
ioni
staki
ngpl
acef
rom gener
al
soc
ialc hangesthatmaybeoc
cur
ring;

 Mayunder
est
imat
eeffec
tofi
nter
vent
ion.

 Loseexper
iment
alc
ont
rol
.

06/01/18

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[Link] i
[Link]
uteandr
elat
iver
[Link]
e
ofi
nter
vent
ionali
mpac t
.
Inf
ormat
ionaboutt
heRI
SKofc
ont
rac
tingadi
seasei
sofgr
eatval
uei
nMedi
cineand
Publi
cheal
th.

Theknowl
edget
hatsomef
act
ori
sar
iskf
act
orf
oradi
seasec
anhel
pfor
:

 Preventi
ngthedisease;
 Predict
ingit
sfutureinci
denc
eandpr eval
ence;
 Diagnosingthedisease;
 Establi
shingthecauseofadi seaseofunknownaet
iol
ogy.

TheCumulat
iveInc
idenc
eofadi
seasei
napopul
ati
oni
ster
medt
heABSOLUTERI
SK
ofc
ontr
act
ingit
.

Absoluteri
skcani ndi
catethemagnitudeoftheri
skinagr oupofpeoplewit
ha
cer
tainexposure,butbecauseitdoesnottakeint
oconsiderat
iont
heriskofdiseasei
n
non-exposedi
ndi vi
duals,i
tdoesnotindi
catewhethertheexposur
eisassociatedwit
h
aninc r
easedri
skoft hedisease.

Twomaj
ort
ypesofr
isk(
frequenc
iesc
ompar
isons)
:

 ABSOLUTE COMPARI SON -indicatesonanabsol

utescal
ehow muchgr eat
erthe
fr
equenc
yofdiseaseisintheexposedgr oupcomparedwit
hthenon-exposed.
 RELATIVE COMPARI SON -indicateshow muchmoreli
kel
yexposedgroupi st
o
devel
opadiseasethanthenon- exposed.

Rel
ati
vec
ompar
ison

 Rel
ati
veri
sk–incohortst
udies
 Oddsrat
io–i
nc ase-
contr
olstudi
es

Absol
utec
ompar
isons

 Att
ribut
abler
isk(Riskdiffer
ence)
 Att
ribut
abler
iskfract
ioni nexposed
 Populat
ionat
tri
butableriskandf rac
tion

I
nter
pret
ingMeasur
esofAssoc
iat
ion

 RR(
OR)>1-posi
ti
veassoc
iat
ion

(
ani
ncr
easedr
iskamongt
heexposed)

 RR(
OR)=1-noassoc
iat
ion

(
theoc
cur
renc
eofdi
seasei
ntheexposedandunexposedgr
oupsar
eident
ical
)
06/01/18

 RR(
OR)<1-negat
iveassoc
iat
ion

(
adec
reasedr
iskamongt
heexposedgr
oup–t
heexposur
ehasapr
otec
tiveeffec
t)

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Rel
ati
veCompar
ison

Rel
ati
veRi
sk(
RR)

 How manyt
imesexposur
etot
her
iskf
act
ori
ncr
easest
her
iskf
orc
ont
rac
tingt
he
di
sease;

 Therat
iooft
heinci
denceofdiseaseamongexposedper
sonst
othei
nci
denc
eoft
he
di
seaseamongunexposedpersons.

 RR-anindi
cat
oroft
hest
rengt
hofanassoc
iat
ionbet
weenanexposur
eanda
di
sease:

Risk ∈theexposed
RR=
Risk ∈theunexposed
RR=I
nci
denc
einexposed+I
nci
denc
einunexposed-

Measur
esofAssoc
iat
ioni
nCaseCont
rolSt
udi
es:OddsRat
io(
OR)

I
nac
ohor
tst
udy,t
heRRc
anbec
alc
ulat
eddi
rec
tly.

I nacase-
contr
olstudy,theRRcannotbecal
cul
ateddirect
lybecausewedonot
know t
hepopulat
ionatriskandcannotdet
ermi
neIncidenceortheAbsol
uter
iskof
cont
rac
tingt
hedisease.

Inac ase-
cont
rolst
udy,theORi
susedasanest
imat
eoft
heassoc
iat
ionbet
ween
t
heexposureandthedisease.

 OddsRati
o(OR)istherati
ooft
heoddsofexposur
eamongt
hec
asest
otheoddsof
exposur
eamongthecontr
ols.

Rel
ati
veandAt
tri
but
abl
[Link]
sksDi
sti
nct
ions

Rel
ati
ver
isk:RR(
OR)

 I
sthereanassoci
ationbetweenexposure& di
sease?
 Measureoft
hestrengt
hoft heassoci
ati
on
 I
mportanti
nestabli
shingetiol
ogi
crel
ati
onshi
ps.

At
tri
but
abl
eri
sks:AR,ARF,PAR

 How muchofthediseasethatoc c
urscanbeatt
ribut
edtoac
ert
ainexposur
e(c
an
wehopetopreventifwear eabletoeli
minat
eexposure)
?
 Est
imat
ingthepotenti
alforpreventi
on.

Absol
uteCompari
[Link]
tri
but
abl
eRi
sk (
Exposed)

At
tri
but
abl
eRi
sk(
RiskDi
ffer
enc
e)(
RD)

 Theaddit
ionali
nci
denceofadi seaset
hatisattr
ibutabl
etoexposur
e;
06/01/18

 Equalt
otheinci
denceofthediseaseinexposedpersonsminustheinc
idenc
eof
thedi
seaseinunexposedper
sons:

RD =I
e–I
o

 Theaddi
tionalnumberofc
asesoft
hedi
seaset
hatt
heexposedpopul
ati
onhasi
n
rel
ati
ont
oi t
sexposur
e.

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19. Pr
event
ion–sc
opeandl
evel
sofpr
event
ion
Preventi
onis“t
hec ombinat
ionofmedicalandnon-medi
calmeasur
esthatt
hesoci
ety
undertakestoreducet
her i
skofdisease,pr
ematur
edeath,i
ll
nessordi
sabi
li
tyorany
ot
herundesirableheal
thevent”
.

I
naddr
essi
ngar
iskbehavi
our
,ri
skf
act
orordi
seasec
ondi
ti
on,

pr
event
iveac
tionai
mst
o

•er
adi
cat
eit
,e.
[Link]
lpox

•r
educ
ether
iskofdevel
opi
ngi
t,e.
[Link]
ngandl
ungdi
sease

•l
imi
tit
simpac
tshoul
ditoc
cure.
[Link]
cisei
ndi
abet
ics

Level
sofPr
event
ion

 Fourlevel
sofpreventioncanbei
dent
ified,c
orr
espondi
ngt
odi
ffer
entphasesoft
he
developmentofdisease:
 Pri
mor di
al
 Pri
mar y
 Secondary
 Tert
iary

 Primordialprevent ionai mst omi nimi zefuturehazar dst ohealth,inhibitthe

establi
shmentoff ac tor sknownt oinc reaserisk(envir onmental,economi c,soci
al,
behavioural,cultural )
.
 Primarypr eventionai msatl ower i
ngt heoccurrenceofdi sease( i
.[Link]
casesofdi sease,e. g.i mmuni sat
ion)
 Secondar yprevent i
onai msatear lydi agnosisandt r eatmentini t
sear lystages
06/01/18

beforeitresult
si nmor bidity(e.
[Link] reening,medi cati
onf orosteoporosis),orto
preventrecurrenc e( e.g.t r
eatmentt or educer i
skofr ec urr
enceofahear tat t
ack)
 Terti
arypr eventionai mst oreduc ethenegat i
veimpac tofexist
ingdi seaseand
reducec omplications( [Link]
ndnessf rom diabetes,rehabili
tati
onaf terspinal
inj
uryoramput ation

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[Link]
mar yprevent
ion–i ndi
vidualandpopul
ati
onal
st
rat
egyforpri
mar ypreventi
on
PRI
MARYPREVENTI
ONSTRATEGI
ES

St
rat
egi
esmayi
nvol
ve:

 heal
thsector(
immunisation)
 ot
hersectors(
waterfluor
idationtor
educ
edent
alc
ari
es)
 bemulti
sector
al(
roadac cidents)

St
rat
egi
esc
anaddr
ess

 wholepopul
ati
onorthoseathi
ghr i
sk(e.
g.i
nover
wei
ghtt
opr
eventdi
abet
es)
 Bot
h( c
omplement
arytooneanother)

RATI
ONALEPRI
MARYPREVENTI
ON

•Reduc i
ngrisk,event
osmal lext
ent
,int
hemajori
tyoft
hepopul
ati
onwi
llmake
gr
eatestimpactonpopulat
ionburdenofdi
sease

•Eac
hindi
vidualbenefitt
osmal
lext
entbutaddst
olar
gebenefitf
ort
hepopul
ati
on

•Anal
ogyofl
argerpr
ofit
sinhight ur
nover,f
astf
oodrest
aur [Link]
ve
r
est
aurant–l
att
erhaslargerprofit/c ust
omerbutf
ewerc l
ients,solowertot
alpr
ofit
.

Di
rec
tedat
:thei
nter
act
ionbet
weent
her
iskf
act
orandt
hesusc
ept
ibl
eindi
vidual
;

Ai
m:

 Topreventtheonsetofadiseaseei
therthrought
hec omplet
eabolishmentoft
he
r
iskfact
ororthroughthereduct
ionofi
tslevelinadefinedpopulat
ion;ort
hroughthe
i
ncreaseoftheresi
stanceoft
hepeopleinrisk;
06/01/18

 Tol
imi
tthei
nci
denc
eofdi
seasebyc
ont
rol
li
ngc
ausesandr
iskf
act
ors.

 Phaseofdi
sease:bef
oret
heonsetofdi
sease;spec
ificc
ausalandr
iskf
act
ors;

 Tar
get
:tot
alpopul
ati
onorsel
ect
edgr
oupsorheal
thyi
ndi
vidual
s;

Exampl
e

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 Eliminat i
onofhazar dsorr educt
ionofexposur et olevelsthatdonotc auseill
-
healt
h;
 Useofcondomsi npreventi
onofHI Vi nfect
ionorSTD;
 Developmentofneedl eexchangesyst emsf orintravenousdr uguserstoprevent
thespreadofhepat i
ti
sBandHI Vinfecti
on;
 Employmentofsyst emat i
ci mmuni zationt opr eventc ommuni cabl
ediseases;
 Int
roducingobligat
orycarseat -bel
tuset opr eventdeat hinr oadaccidents;
 Useofi odi zedsaltfori
odinedeficiencydiseasespr evention.
 Fluoridationofpubl icwat ersuppl iesforc ariesprotection.

St
rat
egi
esofPr
imar
yPr
event
ion

Pr
imar
ypr
event
ioni
nvol
vest
wost
rat
egi
est
hatar
eof
tenc
ompl
ement
ary:

 Popul
ati
onst
rat
egy

 Suit
ableforappli
catoni
i npopul at
ionswi t
h high preval
enceoftherisk
fact
or;
 Aim:Tofoc usonthewhol epopulationaimingtor educetheaveragerisk(
to
movetheent ir
edist
ribut
ionoft
heriskfac
torinadefinedpopul
ati
ontothel
ower
l
evelsofrisk)
;

 Hi
gh-
riski
ndi
vidualst
rat
egy

 Aim:Toi denti
fyandpr
otectt
hesuscept
ibl
eindi
vidual
satgr
eat
estri
skofa
spec
ificdisease.

Popul
ati
onSt
rat
egyf
orpr
imar
yPr
event
ion

Advant
ages:

 Radical–tri
estoel
iminatet
hecausefort
hehi
ghi
nci
denc
eoft
hedi
sease;
 Largepotenti
alf
orthewholepopul
ati
on;
 Behavioural
lyappr
opriat
e.

Di
sadvant
ages:

 Smallbenefittothei
ndivi
dual(
Roseprevent
ionpar
adox)
 Poormot i
vati
onofsubject
s;
 Poormot i
vati
onofphysici
ansandotherheal
thprof
essi
onal
s;
 Benefit
-t
o-ri
skr at
iomaybelow.

Hi
gh-
riskI
ndi
vidualSt
rat
egyf
orPr
imar
yPr
event
ion

Advant
ages:

 Inter
venti
onsareappr opriatetothepar
tic
ularhi
gh-
riski
ndi
vidual
sadvi
sedt
o
takethem;
 Subject
sar ehi
ghlymot ivated;
06/01/18

 Physici
ansarehighl ymot i
vated;
 Favourablebenefit
-t
o-r
iskr ati
o.

Di
sadvant
ages:

 Di
ffic
ult
iesi
nident
if
yinghi
gh-
riski
ndi
vidual
s;

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 Li
mitedandtempor
ar yeffect;
 Behavi
oural
lyi
nappropri
at e.

Acombinat
ionisusuall
yneededbet
weent
hepopul
ati
onandt
hehi
gh-
riski
ndi
vidual
st
rat
egyofpri
marypr event
ion.

 Thepr
opor
tionofpeopl
eathi
ghr
iski
napopul
ati
oni
snotl
arge.

 Lar
genumberofpeopl
eatsmallri
skmaycont
ribut
emor ecasesofapar
ticul
ar
c
ondit
iont
hanasmal l
ernumberofpeopl
ewhoareindivi
dual
lyatgreat
err
isk.

06/01/18

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[Link]
ondar
ypr
event
ion–sc
reeni
ng
Di
rec
tedat
:theear
ly–pr
e-sympt
omat
icst
ageofdi
sease;

 Aim:Ear lydet ecti

onofdi seasebef oret heappear anceofc lini
calsympt omsand
throughear l
y,pr omptandeffec ti
vei nter vention-t oimpr ovethepr ognosis(
tocure
orr educ ethemor eser i
ousc onsequenc esofdi sease);
 Ifdi seasei si dent i
fiedear l
y-t heni nter ventionmeasur eswi l
lbemor eeffect
ive…
lessc ostly… l essinvasi ve…
 Target :Pat i
ent si nanear l
ypr e- sympt omat icstageofdi sease;
 Maj ori nstrument–Sc reening;
 Exampl es:Br eastc ancersc reeni ng;c ervi c
alc anc erscreening;occultbloodinstool
forc olonc anc ersc reening;sc reeni ngf orhyper tension,sc r
eeningfordiabetes
mel lit
us;sc reeni ngofnewbor nsf orphenyl ketonur i
aandc ongeni
tal
hypot hyr oidism

Screeningisthepr ocessofusi ngtestsonal argesc aletoident i

fythepr esenc eof
diseasei napparentlyheal t
hypeopl [Link]
eeningt estsdonotusual lyestablisha
diagnosis,butratherthepr esenceorabsenc eofani dentifiedr iskfactor
,andt hus
requir
ei ndi
vidualfoll
ow- upandt [Link] her eci
pient sofsc reeningareusual l
y
peoplewhohavenoi llnessitisimportantthatthesc reeningt estit
selfisveryunl ikel
y
tocausehar [Link] reeningc analsobeusedt oident i
fyhighexposur etor i
skf actor
s.
Forinstance,chil
dren`sbl oodsampl escanbesc r
eenedf orl eadi nareasofhi ghuse
ofledinpai nt.

Screeni
ngistesti
ngagr oupofpeopl einthepopul at
ionforsi
gnsofadiseasewhen
tr
eatmentissti
llpossibl
[Link]
sai mtofinddiseaseintheear
lystages,
beforei
tcausessympt [Link] ncreased
ri
skofapar ti
culardiseasebec auseoftheirage,genderorotherf
act
ors

•Twoassumpt
ions:

[Link]
seasec
anbedet
ect
edbef
oresympt
omsoc
cur

2.I
fdet
ect
ed,ear
li
ert
reat
mentl
eadst
oabet
terout
come

“
Screeningi
stheprocessbywhichunrec
ognizeddi
seasesordef
ect
sar
eident
ifiedby
t
estthatcanbeappli
edr api
dlyandonal ar
gescal
e”.

 Sc r
eeni
ngtestsarenotdi
agnost
ici
nthemsel
ves;t
heyusual
lysi
mplyi
dent
ifysmall
groupswithhighri
skofthecondi
ti
onwhothengoont ohavef
urt
hert
est
stoconfir
m
thediagnosi
s.

Pur
poseofSc
reeni
ng:Pr
event
ion

 Pr
eventi
ngser
iousoutcomesofexist
ingdi
seaseatit
searl
ystage-ear
ly
pr
esymptomat
icdiagnosi
sandtreatment–improvedpr
ognosi
s.
06/01/18

 Exampl
es:

 Scr
eeningf
orbreastcancer
,cer
vic
alc ancer;
 Scr
eeningf
orarteri
alhypert
ensi
on,di abet
es;
 Scr
eeningf
ormet abol
ici
nborndefec
ts–phenyl ket
onur
iaandc
ongeni
tal
hypot
hyroi
dism.

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 Pr
event
ingt
heoc
cur
renc
eofdi
seasebysc
reeni
ngf
orr
iskf
act
ors:

 Exampl
es:

 Scr
eeningf
orhighchol
est
erolc
onc entr
ati
ons–asar
iskf
act
orf
orCHD;
 Pr
enatalsc
reeni
ng;Genet
icscreening.

Thet i
melyandearl
ydetec
tionofsomedi seasesbyusingpopul at
ionbasedscreeni
ng
programmeshasledtoimprovedprognosis,hi
ghersurvi
valratesanddecreased
mor t
ali
tyinmanyNort
hernandWest er
nEur opeancountr
ies.

TypesofScr
eeni
ng

 Massscr
eeni
ng

 I
nvol
vest
hesc
reeni
ngofawhol
epopul
ati
on

 Example:Checki
ngalli
nfant
sforhear
ingpr
obl
emsorphenyl
ket
onur
iaor
c
ongenit
alhypothyr
oidi
sm.

 Mul
tipl
eormul
tiphasescr
eeni
ng

 Theuseofavar
iet
y(asequenc
e)ofsc
reeni
ngt
est
sont
hesameoc
casi
on.

 Exampl
e:Sc
reeningforbreastc
ancer–star
tingwi
thphysi
calexaminat
ion,
f
oll
owedbyanultrasoundtest,mammographyandfinal
ly–biopsy.

 i
.[Link]
ingwit
htheleasti
nvasi
vebutal
soleastpr
eci
seandconti
nui
ng(i
f
necessary)wi
thmoreinvasi
vebutmoreacc
urateandprec
iset
est
sfordet
ermi
ning
thepresenceofdi
sease.

 Tar
get
edscr
eeni
ngofgr
oupswi
th speci
ficexposur
es

 Oft
enusedi
noc c
upati
onalorenvi
ronmentalheal
thamongspec
ificpopul
ati
on
gr
oupsathi
gherriskf
ort
hediseaseofint
erest
.

 Exampl
e:HI
Vtest
sinpr
ost
it
utesordr
ugaddi
cts

 Oppor
tuni
sti
cscr
eeni
ng(
orcase-
findi
ng)

 Rest
ric
tedt
opat
ient
swhoc
onsul
taheal
thpr
act
it
ionerf
orsomeot
herpur
pose.

 The4l
ogi
calpossi
bil
iti
es(
findi
ngs)i
nascr
eeni
ngt
est
:

 TP(t
rue-posit
ive)-aposi
tivetestresultisobtainedi napersonwhohast he
di
sease;
 FP(f
al seposi
tive)–apositi
vetestresultisobtainedi napersonwhodoesnot
havethedisease;
 FN(falsenegative)–anegativetestresultisobtainedinaper sonwhohasthe
di
sease;
 TN(truenegative)–anegativetestresultisobtainedinaper sonwhodoesnot
06/01/18

havethedisease;

Sensi
tivi
ty-
Speci
fici
tyCompr
omi
se

 Incl
ini
calpr
act
ice,sensi
ti
vit
yandspec
ific
ityar
einver
sel
yrel
ated:ani
ncr
easei
n
onecausesadecreaseintheot
her
.

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 Thisisbecausegr oupsofpatient
swi t
ht hediseaseandgr oupswhoar edi
sease
fr
eelieonac ontinuum,overlappi
ngeac hother,ratherthanf ormingtwotot
all
y
discr
etegroups.
 Tomakeadi agnosticdeci
sion–a“ cut
-offpoi
nt”needst obesel ect
ed.
 Highlysensit
ivetestsareli
kelytohavelow specifici
tyandhi ghl
yspeci
fict
est
sare
l
ikel
yt ohavel ow sensi
ti
vit
y.

Thepr obl
em oftrade-offbetweensensi
tivit
yandspec ific
itydependsonthe
consequencesoffalseposi t
ivedi
agnosis(innotspec
ifictests)orthec
onsequenc
esof
f
alsenegat i
veresults(missedcases)i
nt estswit
hlow sensi ti
vit
y.

Becauseoft heinverserel
ationshipbet
weensensi t
ivi
tyandspeci
fic
ity,andser ious
consequencesofbothl ow sensit
ivi
ty(f
alsenegat
iveresul
ts)andl
ow spec i
fic
ity( f
alse
posit
ivediagnosis)–insomesi tuati
ons–bothhighsensiti
vit
yandhi ghspec i
fic
ityare
requi
red.

 Bestt
ouseac
ombi
nat
ionoft
est
s.

 Ahi ghlysensiti
ve( andusual
lyrelat
ivel
ycheap)testshouldbeusedfirst
,al
most
guaranteeingthedet ect
ionofal
lcasesofthedisease(albei
tattheexpenseofbei
ng
notspecificandincludingasubstanti
alnumberoff al
sepositi
veresul
ts)
.

 Thisshoul
dbefoll
owedbyahi ghl
yspec
ific(
andusual
lymor
eexpensi
ve)t
estt
o
el
iminat
ethefal
se-
posit
iver
esul
ts.

 Verysensi
ti
vetest
sareusedforr
uli
[Link]
heresultofhighly
sensi
ti
vetesti
snegat
ive,i
tal
lowsthedi
seasetober uledoutwithconfidence.

Sensi
ti
vit
y:RememberSNOUT

Ver
ySensi
ti
vet
estwi
thaNegat
iver
esul
t

r
ulesOUTt
hedi
sease.

 Veryspec
ifictestsareappropr
iat
eforconfir
mingorr ul
inginthedisease.I
fthe
resul
tofahi ghlyspeci
fict
esti
sposit
ive,t
hedi seaseisalmostcer
tainl
ypresent
.

Spec
ific
ity:RememberSPI
N

Ver
ySpec
ifict
estwi
thaPosi
ti
ver
esul
t

r
ulesI
Nthedi
sease.
06/01/18

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06/01/18

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[Link]
thcaresyst
ems(
Bever
idge,Bi
smar
ck
andpri
vateheal
thcar
e)
Aheal t
hsystem,al
sosometimesrefer
redtoasheal thcaresystem orashealt
hcare
system,istheor
ganizat
ionofpeopl
e,inst
ituti
ons,andresourcesthatdel
iverheal
th
careservi
cestomeetthehealt
hneedsoft argetpopul
ati
ons.

•Healt
hc ar
esystem i
st he“thecombi
nati
onofresourc
es,organi
zat
ion,financi
ngand
managementthatculminateinthedel
iver
yofhealthservi
cestot
hepopul ati
on.
”(t
he
cl
assi
calbookonhealthc ar
esystems-Roemer
,1991)

•TheWor ldHealt
hOr ganizat
ionintheWor l
dHeal t
hRepor t
,2000r edefinedthemai n
purposei nthedefini
tionofaheal thsyst
em as“allact
ivi
ti
eswhosepr imar ypurpose
i
st opromot e,r
est
ore,andmai ntainheal
th.
”Inrecentyears,thedefini
ti
onof
“purpose”hasbeenf urtherextendedtoinc
ludethepreventionofhousehol dpovert
y
duet oil
lness.

THEBEVERI
DGEMODEL

NamedafterWi
ll
iam Beveri
dge–i
nspi
redBri
tain’
sNHS;Gr
eatBr
itai
n,I
tal
y,Spai
n,
Cuba,andtheU.
[Link] t
mentofVet
eranAffai
rs

Charac
teri
sti
cs:Heal
thcar
eispr
ovidedandfinancedbyt
hegover
nment
,thr
ought
ax
payments(l
ikethepol
icef
orc
eorthepubli
cli
brary).

 Therearenomedi calbil
ls
 Medicaltr
eatmentisapubl i
cservi
ce
 Provi
derscanbegover nmentemployees
 Lowsc ost
sb/ct hegovernmentcontr
olscost
sast
hesolepayer
 Thisisprobabl
ywhatAmer icanshaveinmindwhentheythi
nkof“
soc
ial
ized
medicine”

Mosthospit
alsandc li
nic
sareownedbythegover
nment,somedoctor
sare
gover
nmentempl oyees,butt
her
eareal
sopri
vatedoc
tor
swhoc oll
ectthei
rfeesf
rom
thegover
nment.

THEBI
SMARCKMODEL

Namedf
orPr
ussi
anc
hanc
ell
orOt
tovonBi
smar
ck,i
nvent
oroft
hewel
far
est
ate.

Ger
many,Japan,Fr
anc
e,Bel
gium,Swi
tzer
land,Japan,andLat
inAmer
ica

Char
act
eri
sti
cs:

 Pr ovidersandpayer sar epr i

vat e
 Pr ivateinsuranc eplans–financ edjointl
ybyempl oyersandempl oyeesthr
ough
payr ol
ldeduc tion
06/01/18

 Thepl ansc overever yoneanddonotmakeapr ofit

 Ti ghtregulationofmedi c
alser vicesandf ees(costcontr
ol)
 Itusesani nsur anc esystem -theinsur ancear ecall
ed“ si
cknessfunds”–usually
financ edjointl
ybyempl oyersandempl oyeest hr
oughpayr ol
ldeducti
on.
 Thi st ypeofheal thinsurancepl anhast oc overever ybody,andtheydon` tmakea
pr ofit
.

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 Doc
tor
sandhospi
tal
stendt
obepr
ivat
e.

TheNat
ionalHeal
thI
nsur
anc
emodel

 Thissyst em hasel ement sofbot hBeveridgeandBi smarck.

 Itusespr i
vat e-
sectorpr ovi
der s,butpaymentc omesf rom agover
nment-r
un
i
nsur anc epr ogram t hateveryc it
izenpaysinto.
 Theuni versalinsur ancepr ogramst endtobec heaperandmuc hsimpl
er
admi nistrati
velythanAmer i
can-styl
efor–profitinsur
ance.
 Thesi nglepayert endst ohavec onsider
ablemar ketpowertonegot
iat
eforlower
pric
es.
 Count ri
eswi thNat ionalHeal thInsurancesystem –Canada,Tai wan,SouthKorea.

TheOut
-of
-Poc
ketmodel

 Onlytherichgetmedicalc
are;thepoorst
aysi c
kordie
 Mostmedi c
alcareispaidforbythepati
ent,out-
of-
poc
ket
 Noinsuranceorgovernmentplan
 Countri
es:rur
alregi
onsofAf r
ica,Chi
naandSout hAmeric
a

06/01/18

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Whati
saDALY?

DALYi sanabbr eviati

onf ordisabi l
it
y-adjustedli
feyear.I
tisauni versalmet ri
c
thatall
owsr esearchersandpol icymaker stocompareverydi ffer
entpopul ations
andheal t
hc ondit
ionsac rosst i
[Link] hesum ofyear sofli
f el
ost( YLLs)
andyear sli
vedwi thdi sabili
ty(YLDs) .OneDALYequal sonel ostyearofheal t
hy
l
[Link] ust oestimatet hetotalnumberofyear slostduet ospecific
causesandr iskfactorsatt hec ountry,regi
onal,andgloballevels.

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saYLL?

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felost( YLLs)areyearslostduetoprematuremor t
ali
[Link]
cal
culatedbysubt racti
ngtheageatdeat hfr
om thelongestpossi
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yis75,butamandi esofcancerat65,t hi
swouldbe10
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.

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ibed
asyear sli
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i
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l
if
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ionsandar edevelopedt hroughsur veysoft hegener alpubli
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henumberofyear
saper
sonc
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sHALE?

HALEi sanabbr eviati

onf orheal
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kelif
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dualcount r
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06/01/18

Ash Thomas
56

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Social Medicine notes

Social Medicine (Medical University-Varna)

StuDocu is not sponsored or endorsed by any college or university

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Dental Medicine - 2nd year; summer semester

Social Medicine.
Examination Synopsis

SOCIAL MEDICINE
1. Social Medicine – as a scientific discipline: subject, fields and methods of study; development and
significance.

2. Health and disease as fundamental categories in medicine. Models, dimensions and definitions of health.

3. Determinants of health. Main groups and impact. Social determinants of health. Inequalities in health.

4. Medical demography – essence, terminology and indicators. Measuring population change. Sources of
demographic data. Demographic transition.

5. Population size and growth. World trends and projections. Population distribution by major characteristics
– health aspects and application. Types of age/gender population composition. Population pyramids.

6. Population ageing – measurement, impacts and trends. International comparison.

7. Migration. Types and modern trends of migration flows. Health impacts of migration.

8. Natural flow of the population. Fertility and reproduction – measurement, characteristics, trends and
medico-social aspects. International comparison. Birth registration.

9. Mortality - measurement, characteristic, trends and medico-social aspects. International comparison.

Death registration, death certificate.

[Link] and maternal mortality - measurement, characteristic, trends and medico-social aspects.
International comparison.
Life expectancy at birth. Indicators, data and trends. International comparisons. Complex indicators for
measuring population health and global burden of disease.

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1. Social Medicine – as a scientific discipline: subject, fields and

methods of study; development and significance.

2. Health and disease as fundamental categories in medicine.

Models, dimensions and definitions of health.

Health: Definition
State of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO
- 1948)

Disease: Definition
Disorder of the body or mind, which destroys good health
✦ Can have a single or multiple causes
✦ Has characteristics symptoms, may be physical or mental, both
✦ Can be classified as acute (sudden onset with rapid change, lasts short time) or chronic (may continue for
months or years)
✦ Categories: non-communicable and communicable
‣ Non-communicable → Responsible for 70% of deaths worldwide
‣ Communicable → Spread from person to person through different ways (blood, bites, air)

Health Models
๏ Medical model

• Health is the absence of the 5 Ds: death, disease, discomfort, disability, dissatisfaction

๏ Environmental model

• Based on analysis of ecosystem and environmental risks of health e.g. socioeconomic status, education level,
variable environmental factors
• Includes quality of air and water, living conditions, exposure to harmful substances, …

๏ Hollistic model

• Encompasses the physiological, mental, emotional, social and environmental aspects of individuals and
communities
• Each person has the capability and the responsibility for optimizing his/her sense of wellbeing

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3. Determinants of health. Main groups and impact. Social

determinants of health. Inequalities in health.
4 general groups of health determinants:

1. Lifestyle factors 49-53%

2. Genetic and biological factors 18-22%
3. Environmental factors 17-20%
4. Healthcare services 8-10%

๏ Lifestyle factors

• Smoking, alcohol and drug abuse; low physical activity; unhealthy diet; psychosocial stress; etc.
• Coronary heart disease (CHD), stroke; most neoplasms; diabetes; chronic respiratory disease; injuries; obesity;
chronic liver diseases, cirrhosis, …
• Determine 49-53% of all health impairments

๏ Genetic and biological factors

• The individual susceptibility to hereditary and degenerative diseases

• Chromosome diseases; diabetes; ischemic heart disease; some neoplasms (breast cancer, colorectal cancer); …
• Determine 18-22% of all health impairments

๏ Environmental factors

• Unfavourable factors of the environment - air, drinking water and soil pollution; other physical and chemical factors
of the environment; risk factors from the working environment;
• Socio-economic factors - income, social status; unemployment; education; expenditure; housing and living
conditions; social support or exclusion (homeless, unemployed, refugees, immigrants in general have poor health,
etc.)
• Determine 17–20% of all health impairments

๏ Healthcare services

• Quality, accessibility and timeliness of health care

• immunization programmes; family planning programmes, contraceptive use; screening programmes; health
services for pregnant, women, etc.
• Determine 8–10% of all health impairments

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4. Medical demography – essence, terminology and indicators.

Measuring population change. Sources of demographic data.
Demographic transition.

Measuring population health

๏ Sources of data

• Surveys
• Censuses
• Registration (birth/death)
• Civil registration
• Records

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5. Population size and growth. World trends and projections.

Population distribution by major characteristics – health aspects
and application. Types of age/gender population composition.
Population pyramids.

Population Growth:
✦ Population growth: the change in population over a unit time period, often expressed as a percentage of the
number of individuals in the population at the beginning of that period
✦ Positive growth rate: indicates that the population is increasing
✦ Negative growth rate: indicates that the population is decreasing.
✦ Growth ratio of zero: indicates that there were the same number of individuals at the beginning and end of the
period

Population Growth: Trends

• More developed countries (MDC) → lower rates of population growth

• Less developed countries (LDC) → higher rates of population growth

• Least developed countries as a group are experiencing most rapid population growth

Population Composition:
✦ Population composition: Describes how a total given population is constituted by demographic, social or economic
variables at a fixed moment in time; in %
✦ Population Age Composition: Described by the proportion of population over 60 or over 65 years of age (in %)

๏ Total Dependency Ratio

• The ratio of populations who are economically not active (0-14 )+(>65) to those who are economically active
(15–64)
Populat ion below 15 + populat ion 65 a n d a bove
• Total Depen denc y Rat io = Populat ion 15 − 64 years
* 100

๏ Demographic Replacement Ratio

• The ratio of people aged 15-19 (entering working age) to people aged 60-65 (going out of working age)

๏ Population Sex Composition

• % of men and women or number of women to 100 or 1000 men

๏ Population Composition by Urban/Rural Residence

• Level of urbanization is lower in less developed countries → more people live in rural regions

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6. Population ageing – measurement, impacts and trends.

International comparison.

Total age dependency ratio

• Ratio of population who are economically not active
• Small age dependency ratio: higher working population
• Higher age dependency ratio: higher pressure on economically active part of population

Population ageing: Trends

• Worldwide tendency of population aging
• Developing countries:
➡ Less advanced population aging → relatively young
➡ Faster aging rate due to rapid fertility reduction
• Developed countries:
➡ Advanced population aging
➡ Number of old persons surpassed number of children

Population ageing: Impacts

• More chronic & degenerative diseases
• More health problems
• Greater health care expenditures
• Economic impacts:
✦ Less labor forces
✦ Less economic growth
✦ Higher pressure on young people to support older generations

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8. Natural flow of the population. Fertility and reproduction –

measurement, characteristics, trends and medico-social aspects.
International comparison. Birth registration.

Determinants of fertility
• Biological determinants → Age in the reproduction period, spontaneous abortions / miscarriages, Infertility, …

• Behavioural determinants → Employment of women, education of women, culture and traditions, birth control
methods, Induced abortions

Fertility indicators
๏ Crude Birth Rate

• Number of live births per 1000 population in a given year

• Only a crude estimate of fertility
• Not good for comparing fertility across populations, as variations in age distribution of the populations being
compared will affect the birth rate
num ber of live bir th s per year
• CBR = * 1000
total mid − year populat ion

๏ General Fertility Rate

• Average number of children that would be borne by a woman if she would conform to age specific fertility
rates of given year
• Relates births to the age-sex group at risk of giving births (women in reproductive age -usually defined as
15-49 years)
• More refined measure than Crude birth rate to compare fertility across populations – less influenced by the age
distribution of the population
num ber of live bir th s per year
• GFR = Num ber of wom en ages 15 to 49 * 1000

๏ Age Specific Fertility Rate (ASFR)

• Number of live births per year per 1000 women of a specific age (group) → 15 to 19; 19 to 24; 25 to 29; …
• Relates births to the age-sex group at risk of giving births (women in reproductive age -usually defined as
15-49 years)
Num ber of live bir th s to wom en age 20 − 25
• ASFR wom en ages 20 to 25 = Num ber of wom en age 20 to 25 years
* 1000

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Reproduction indicators
๏ Total Fertility Rate (TFR)

• Average number of children that would be born by a woman by the time she ended childbearing if she were to
pass through all her childbearing years
• Hypothetical measure & independent of age structure of population
• Best single measure to compare fertility across populations

๏ Gross Reproduction Rate (GRR)

• Average number of daughters that would be born to a woman during her lifetime
• Counts only daughters and literally measures “reproduction” – a woman reproducing herself in the next
generation by having a daughter

๏ Net Reproduction Rate (NRR)

• The average number of daughters that would be born to a woman if she passed through her life-time from
birth to the end of her reproductive years conforming to the age-specific fertility and mortality rates of a given
year
• Always lower than Gross Reproduction Rate, because it takes into account the fact that some women will die
before entering and completing their child- bearing years

๏ Replacement Level Fertility

• Reached when Total Fertility Rate (TFR) = 2.1 → roughly 2 children per couple

Birth registration
The United Nations recommends that the following be collected for live birth registration:
• Data on event:
✦ Date of occurrence;
✦ Date of registration;
✦ Place of occurrence;
✦ Type of birth/delivery;
✦ Attendance at birth.
• Data on infant:
✦ Sex;
✦ Legitimacy status;
✦ Length and Weight at birth
• Data on mother:
✦ Age or date of birth;
✦ Number of previous children born alive;
✦ Date of marriage or duration of marriage;
✦ Place of usual residence.

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9. Mortality - measurement, characteristic, trends and medico-

social aspects. International comparison. Death registration,
death certificate.

Mortality determinants
• Biological → age, gender, race, diseases
• Behavioural → diet, hygiene, drugs, alcohol & tobacco
• Environmental → exposure to infections/ chemical/physical agents, occupational hazards
• Socio- economic → residence, wealth, education
• Health-care system → immunization, preventive programs

Measures of mortality: Mortality Indicators

• Crude Death Rates
• Specific Death Rates
✦ Age-Specific Death Rates
✦ Cause-Specific Death Rates
• Standardized Mortality Rates
• Special Indicators
✦ Infant mortality rates
✦ Under 5 mortality rates
✦ Maternal mortality rates
• Life Table Estimates
✦ Life expectancy
✦ Survivorship (by age)

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๏ Crude Death Rate

- Generalized indicator of a population’s health

- Dependent on population age structure
- It is not appropriate for comparison of different populations due to the significant impact of age in mortality data
and different age- distribution in different populations
num ber of death s
- CDR = * 1000
total populat ion

๏ Age specific death rate (ASDR)

- Number of deaths per year in a specific age (group) per 1000 persons in this age group
num ber of death s for a speci f ic age group
- ASDR = populat ion for th at age group
* 1000

๏ Gender specific death rate

- Number of deaths per year in men or women per 1000 men or women, usually higher for men

๏ Cause specific death rate (CSDR)

- Number of deaths attributable to a particular cause in a calendar year divided by the mid-year population at risk
- Dependent on population age structure
- Cause specific death rates may be adjusted for the age and sex composition
num ber of death s at tr ibuted to a par t icular cause
- CSDR = mid − year populat ion at r isk
* 100.000

๏ Standardized Mortality Rates)

- Used to compare crude mortality rates of populations having different age distribution
- Hypothetical indicators: mortality rate if population would not differ in age distribution

Death Registration: Content of Death Certificate

mandatory in most countries and must be signed by a licensed physician
• Data on event: Date of occurrence; Date of registration; Place of occurrence; Cause of death; Certifier
• Data on deceased: Age or date of birth; Sex; Marital status; Occupation; Place of usual residence

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10. Infant and maternal mortality - measurement, characteristic,

trends and medico-social aspects. International comparison. Life
expectancy at birth. Indicators, data and trends. International
comparisons. Complex indicators for measuring population
health and global burden of disease.

Infant mortality:
✦ Infant mortality refers to the death of an infant during the first year of life
num ber of death s a m ong in fa nts un der one year old
✦ in fa nt m or talit y =
1,000 live bir th s in a given year a n d ter r itor y
✦ Good indicator of the overall health status of a population
✦ Much higher than the mortality rates in the following age groups (beyond 1 year of age)

๏ Infant mortality: Determinants

• Low birth weight & premature birth

• Unfavourable socio-economic conditions;
• Low culture and education of parents;
• Medical surveillance of pregnant women and infants;
• Midwifery and childbirth healthcare and services availability;
• Surveillance of high risk pregnancies and families
• Incompliance with the child nurture rules and recommendations;
• Influence of environmental factors (pollution, disasters, …)

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๏ Infant mortality indicators: Infant mortality rate (IMR)

num ber of death s a m ong in fa nts un der one year old
• IMR = total live bir th s in th at year
* 1000

๏ Infant mortality indicators: Perinatal Mortality

• Perinatal period: 28th week of gestation → 7th day after birth

num ber of st ill bir th s + live bir th s died dur ing the f irst 7 d a ys of li fe
• Per in atal Mor talit y = total num ber of bir th s (st ill a n d live bir th s)
* 1000

๏ Infant mortality indicators: Neonatal Mortality

• Neonatal period: birth → 28 days after birth

num ber of live bir th s died dur ing the f irst 28 d a ys of li fe
• Neon atal Mor talit y = total num ber of live bir th s
* 1000

๏ Infant mortality indicators: Early Neonatal Mortality

• Early neonatal period: first 7 days of life

num ber of live bir th s died dur ing the f irst 7 d a ys of li fe
• Early Neon atal Mor talit y = total num ber of live bir th s
* 1000

๏ Infant mortality indicators: Late Neonatal Mortality

• Late neonatal period: between 7th and 28th days of life

Num ber of in fa nts died bet ween the 7th a n d 28th d a y a f ter bir th
• L ate Neon atal Mor talit y = Num ber of live bir th s h aving sur vived the f irst 6 d a ys of li fe
* 1000

๏ Infant mortality indicators: Postneonatal Mortality

• Postneonatal period: 29th day after birth → 1 year old

Num ber of in fa nts died bet ween the 29th d a y of li fe a n d the en d of the 1st year
• Post neon atal Mor talit y = Num ber of live bir th s h aving sur vived the f irst 28 d a ys of li fe
* 1000

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Maternal mortality:
✦ Maternal death: Death of a woman from any cause related to pregnancy or its management (+ abortion)
✦ Indicator for women’s wealth and maternity care
✦ 94% of maternal deaths in developing countries (no adequate health care, family planning, skilled labor, emergency
care)
✦ Maternal Mortality Rate: per 100,000 women of childbearing age
✦ Maternal Mortality Ratio: per 100,000 live births (or per 1000 live births)

๏ Maternal Mortality Rate

Num ber of m ater n al death s
• Mater n al Mor talit y = Num ber of wom en ages 15 − 49 * 100.000

๏ Maternal mortality: Causes

• Postpartum hemorrhage
• Indirect causes (anemia, malaria)
• Infection
• Unsafe abortion
• Obstructed labor

Life expectancy:
✦ An estimate of the average number of additional years a person could expect to live if the age-specific death rates
for a given year prevailed for the rest of his/her life
✦ Can be measured at age 0 (at birth) - Life Expectancy at Birth, or any other specific age

๏ Life expectancy: Trends

• Globally life expectancy at birth has increased → drop in mortality rate

• Developing countries:
➡ Rapid decline in mortality (antibiotics, vaccines, insecticides)
➡ Consent increase in life expectancy at birth
• Developed countries:
➡ First dramatic increase in life expectancy (reduction infectious disease and conditions of maternity and
infancy)
➡ Later decrease in cardiovascular disease, increase in cancer + trauma-related deaths
➡ Increase of life expectancy but in lower rate

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Social medicine summary

Social Medicine (Medical University-Varna)

StuDocu is not sponsored or endorsed by any college or university

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Nikhila Issac
15E

17. Modern concepts of health – definitions, models and dimensions

Health = state of equilibrium of the person with the biological, physical and social environment,
with the object of maximum funcAonal capability - > not merely the absence of disease or
inDrmity

Good health = implies the achievement of dynamic balance between individual or groups and
their environment

Public health = All organized measures (whether public or private) to prevent disease, promote
health and prolong life among the populaAon as a whole

 There is a very strong correlaAon between socio-economic status and health

 People from lower social classes experience more sickness and ill health
 Poverty reduces people’s choice of a healthy lifestyle
o Lower income > greater risk of premature illness + death
 Work is an important social determinant of health
o Unemployed = higher rate of mental ill health
 Depression
 Anxiety
 Sleep disturbances
 Suicide rate
 Marriage or stable con=nuous partnership = Good health

Dimensions of Health:
1. Physical - mechanisAc funcAon of body
2. Mental – ability to think and make judgments
3. Emo=onal – Recognize emoAons (fear, joy, grief, anger)
4. Environmental – physical environment including housing, transport, sanitaAon, clean
water, polluAon
5. Social – ability to make and maintain relaAonship with others
6. Spiritual - ability to put into pracAce moral, religious or beliefs to achieve peace of mind
7. Sexual - acceptance and ability to achieve a saAsfactory expression of oneʼs sexuality
8. Societal - the basic infrastructure necessary for health (shelter, peace, food, income,
certain degree of integraAon or division within society)

Models:

1. Environmental Model:
a. Based on the analysis of ecosystems and environmental risks to health
i. such as :

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Nikhila Issac
15E

 Socio –economic risks to health

 Level of educaAon
 Various environmental factors
b. Includes quality of air and water, living condiAons, exposure to harmful
substances, social relaAonships.
2. Holis=c Model:
a. Encompasses the physiological, mental, emoAonal, social, spiritual and
environmental aspects of individuals and communiAes
b. Each person has the capability and the responsibility for opAmizing his/her sense
of well- being, pracAcing self-healing, craAng feelings and condiAons that help
prevent diseases and promote health.
3. Medical Model:
a. Health is the absence of one or more of the “Dve Ds”—death, disease,
discomfort, disability, and dissaAsfacAon.
b. Relies almost exclusively on biological explanaAons of disease and illness and on
interpreAng them in terms of malfuncAon.

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Nikhila Issac
15E

18. Determinants of health and disease – classification and mechanism of influence.

Inequalities in health.

4 Major groups of health determinants and their contribuAon to ill health:

- GeneAc and biological factors = (18 -22%)
- Lifestyle factors = (49- 53%)
- Environmental factors (incl. socio-economic) = (17- 20%)
- Healthcare service = (8 -10%)

1. Gene=c & Biological factors:

a. Determine the individual predisposiAon to hereditary and degeneraAve diseases;
b. Related to:
i. chromosome diseases;
ii. mental retardaAon;
iii. diabetes;
iv. atherosclerosis;
v. blood hypertension
2. Lifestyle Factors:
a. Smoking, alcohol and drug abuse = low physical acAvity> unhealthy diet so can
lead to psychosocial stress; etc.
b. Related to:
i. coronary heart disease (CHD),
ii. stroke;
iii. most neoplasms;
iv. diabetes;
v. chronic respiratory disease;
vi. chronic liver diseases,
vii. cirrhosis, etc
70-80% of all deaths in the developed and 40% of all deaths in the developing countries
are related to lifestyle factors that are potenAally manageable and avoidable.

3. Environmental Factors:
a. Illnesses can be caused by unfavourable factors of the environment - air, drinking
water and soil polluAon;
b. other physical and chemical factors of the environment; risk factors from the
working environment
c. Socio-economic factors - income, social status; unemployment; educaAon;
expenditure; housing and living condiAons; social support or exclusion
(homeless, unemployed, refugees, immigrants in general have poor health, etc.)
4. Healthcare service:
a. Quality, accessibility and Ameliness of health care
b. EjecAveness of prevenAve intervenAons;

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Nikhila Issac
15E

c. coverage with immunizaAon programmes;

d. coverage with family planning programmes,
e. contracepAve use;
f. ejecAveness of the screening programmes;
g. organisaAon and ekciency of health services for pregnant, women and children,
for chronically ill paAents, for elderly, etc.

Inequali=es:
It is one of the greatest of contemporary social injus=ces that people who live in the most
disadvantaged circumstances have more illnesses, more disability and shorter lives than those
who are more aUuent.

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Nikhila Issac
15E

19. Measuring population health – main groups and categories of indicators. Sources of
data. Public health impact.

There are diWerent indicators to measure popula=on health:

1. HALE  Health – adjusted life expectancy ( AKA healthy life expectancy)

a. Unlike life expectancy
b. HALE considers mortality and non- fatal outcomes
c. Does this by summarizing
i. years lived in less than ideal health (YLDs) and
ii. years lost due to premature mortality (YLLs) in a single measure of
average populaAon health for individual countries.

2. YLDs  years lived with disability (AKA years lived in less than ideal health)
a. This includes condiAons such as inmuenza, which may last for only a few days, or
epilepsy, which can last a lifeAme.
b. Measured: Prevalence of the condiAon X disability weight for that condiAon.
c. Disability weights remect the severity of dijerent condiAons and are developed
through surveys of the general public.

[Link]  Years of life lost (YLLs) are years lost due to premature mortality.
a. YLLs are calculated by subtracAng the age at death from the longest possible life
expectancy for a person at that age.
b. For example, if the longest life expectancy for men in a given country is 75, but a
man dies of cancer at 65, this would be 10 years of life lost due to cancer.

4. DALY  disability-adjusted life year.

a. DALYs equal the sum of years of life lost (YLLs) and years lived with disability
(YLDs).
b. 1 DALY= 1 lost year of healthy life.
c. DALYs allow us to esAmate the total number of years lost due to speciDc causes
and risk factors at the country, regional, and global levels

5. QALY  quality-adjusted life year or

a. is a generic measure of disease burden,including both the quality and the quanAty
of life lived.
b. It is used in economic evaluaAon (cost-uAlity analysis) to assess the value for
money of medical and public health intervenAons.
c. One QALY equates to one year in perfect health.

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Nikhila Issac
15E

Parameters of reproducAon of populaAon

 Birth rate
• Death rate
• Index of natural increase

MEASURES OF MORBIDITY
 Incidence rate
 Prevalence rate
INCIDENCE RATE
No . of new cases∈¿ time period
Incidence Rate= × 1,000
population at risk
PREVALENCE RATE
No . of people wit h a disease
Prevalance Rate ×1,000
people at risk

Sources of data
- Surveys  representaAve sample of populaAon
- Censuses
- RegistraAon (birth/death)
- Civil registraAon
- Records

less developed countries more developed countries

- High ferAlity - Low ferAlity
- High infant mortality - Older women having babies
- Younger populaAon - Older populaAon
- High emigraAon - High immigraAon

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20. Population size and growth – measurement, global trends and projections.

Popula=on density :
(number of persons per square kilometer) – varies largely across the world

Popula=on size and growth es=ma=on by: -

- populaAon number at a Dxed moment of Ame
- average annual growth rate
- period, required to gain each addiAonal billion or to double the populaAon in size

Facts:
 European city-state of Monaco is the most densely populated country
 Mongolia is least densely populated country
 China (1.4 billion) and India (1.3 billion) remain the two most populous countries

 By 2030 India's populaAon (1.7 billion) is expected to surpass China's, to become the
largest country in the world.

 Nigeria is growing the most rapidly. populaAon of Nigeria, currently the world’s 7th
largest, will surpass that of the United States and become the third largest country in the
world shortly before 2050

 Countries like Belarus, Bulgaria and Ukraine’s populaAon growth is expected to decline
between 2010 and 2050 along with other 47 countries

Popula=on increases by:

1. Natural Increase Rate = (Crude Birth rate – Crude Death rate) x 1000
2. Crude Net migra=on = (In-migrants – Out-migrants)/ P x 1000

Popula=on size
Ca. 1800 – 1 billion
Ca. 1960 – 3 billion
Ca. 2000 – 6 billion
Ca. 2020 – 7.7 billion
Ca. 2037 – 9 billion
Ca. 2057 - 10 billion

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Ca. 2100 – 11 billion

Popula=on growth
- Over most human history, world populaAon grew very slowly
- growth accelerates and reaches peak from 1965- 1970 (2%)
- Since then speed of populaAon growth decelerates due to lower ferAlity rates
- Currently popula=on growth rate of around 1.09% per year
- And is projected to Decline to 0.4 % per year (2050)
Decline to 0.06% per year (2100)

 More developed countries (MDC) – lower rates of populaAon growth (even

nega=ve populaAon growth).
 Less developed countries (LDC) - higher rates of populaAon growth;
 Least developed countries as a group are experiencing most rapid popula=on
growth.

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21. Population distribution by major characteristics – health aspects and application.

Types of population age structure. Population pyramids.

What is demography?
Popula=on Composi=on:
 Describes how a given populaAon is consAtuted by demographic, social or economic
variables at a Dxed moment in Ame;
 Expressed in %;

Popula=on Composi=on by Age:

 Popula=on composi=on by age is determined by:
o proporAon of the people over 60 and over 65 years of age;
o raAos between people of economically acAve and not-acAve age (dependency
raAo)
o Total-age Dependency Ra=o
PopulaAon below 15 + populaAon 65 & above X 100
PopulaAon 15–64 years
o Demographic Replacement Ra=o:
 The raAo of people aged 15-19 (entering working age) to people aged 60-
65 (going out of working age)

Popula=on Composi=on by Age-Sex:

 Popula=on composi=on by age- sex is determined by:
o Popula=on pyramid - very popular graphic presentaAon of the age and sex
distribuAon of the human populaAon of a parAcular region

3 main popula=on pyramid types:

1. Expansive shape
a. is typical for fast-growing populaAons where each birth rate is larger than the
previous one
b. High younger populaAon = wide base
c. Small older populaAon = narrow top
2. Constric:ve shape
a. displays lower percentages of younger populaAon due to declining ferAlity
rate

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b. Less younger populaAon = narrow base

c. Higher older populaAon = wider base
d. (all developed countries).
3. Sta:onary shape
a. present somehow similar percentages for almost all age groups
b. (some developing countries).

Popula=on Composi=on by Sex:

 Expressed as:
 % of men and women or
 number of women to 100 or 1000 men;
 Almost in all countries in the world, the proporAon of women is higher than the
proporAon of men due to the higher mortality rates in men

Popula=on Composi=on by Residence (Urban/Rural):

 Expressed as the proporAon of the urban and the proporAon of the rural populaAon –
(in %)
 In 2008, the number of urban inhabitants surpass the number of rural inhabitants for
the Drst Ame in world history.
 By 2050, over 70% of the world populaAon will be urban.

Popula=on Composi=on by Ethnicity:

 The world is made up of thousands of ethnic groups
 The single largest ethnic group on the world is Han Chinese, which represents about 20%
of the global populaAon

Bulgarians: - 84.8%
2. Turkish: - 8.8%
3. Roma: - 4.9%
4. Other and unspeciDed - 1.5%

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22. Aging of the population. Indicators for assessment. Trends and impacts.

Impacts on Health:
 More chronic & degeneraAve diseases
 Greater healthcare expenditures
 More staj

Impacts on Economy:
 Worsening potenAal for economic growth.
 Increased burden on younger and producAve generaAons to support the older
generaAons
 Challenge the Dnancial sustainability of pension systems and of health-care systems

Indicators:
 ProporAon of the populaAon over 65 years of age
 PopulaAon Median Age
 Elderly support ra=o - the number of working-age populaAon aged 15 to 64 divided to
the number of persons 65 or older.

o Total-age Dependency Ra=o
PopulaAon below 15 + populaAon 65 & above X 100
PopulaAon 15–64 years
 Old-age dependency ra=o
PopulaAon 65 & above years of age X 100
PopulaAon 15–64 years

Developed country Developing country

Advanced populaAon ageing Less advanced ageing populaAon - SAll
relaAvely young
2018  60+ = 22% 2018  9%
2050  33% 2050  20%

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23. Fertility and reproduction –measurement, characteristics, influencing factors.

International comparison, trends and [Link] registration

 Normal birth weight  Birth weights greater than or equal to 2500 grams
 Low birth weight (LBW)  Birth weights less than 2500 grams
 Very low birth weight (VLBW)  Birth weights less than 1500 grams
 Extremely low birth weight (ELBW)  Birth weights less than 1000 grams

Fer=lity Determinants:

 Social determinants: educaAon, income, work, social status of women;

 Cultural determinants: marriage pracAces, post-partum absAnence, religious beliefs
about contracepAon;
 Health determinants: prevalence of STDs, HIV;
 Poli=cal determinants: government policies regarding family planning, female
educaAon;
 Pro-natalist (sAmulaAng) or restricAve policies
 Programme determinants: availability of contracepAve informaAon and services

Crude Birth Rate:

 Number of live births per 1000 populaAon in a given year
 Number of live births / year x 1000
Total mid-year populaAon

General Fer=lity Rate:

 Number of live births per 1000 women aged 15-49 in a given year.
 Number of live births / year x 1000
Number of women aged 15 to 49

Total Fer=lity Rate:

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 The average number of children that would be born by a woman by the Ame she
ended childbearing

Gross Reproduc=on Rate:

 Average number of daughters that would be born to a woman during her lifeAme
 Exactly like TFR but only counts daughters

Net Reproduc=on Rate: (NRR)

 Average number of daughters that would be born to a woman during her lifeAme
 Net ReproducAon Rate is always lower than Gross ReproducAon Rate,
 because it takes into account the fact that some women will die before entering or
compleAng their child-bearing years
 Globally, the net reproducAon rate is 1.1 surviving daughters per woman.
 Europe = 0.8 , Africa = 1.9

Replacement Level Fer=lity:

 Roughly, this is when a couple have an average of two children.
 is said to have been reached when Total FerAlity Rate (TFR) is = 2.1

Number of Abortions for specified

location per year х 1000
Abortion
Number of women aged 15 to 49 for the
rate = same location & year

Fer=lity Measurement:
 Censuses
 Vital registra=on systems (birth cer=kcates)
 NaAonally representaAve sample surveys
 World FerAlity Surveys (WFS)
 Demographic and Health Surveys (DHS), etc.

Birth Registra=on:
 Medical cer:@cate for birth

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o Collect minimum of:

 Data on event
 Data on infant
 Data on mother

Fer=lity Trends:

 World average Crude Birth Rate - about 20%о;

 More developed countries - CBR – about 12%о;
 Less developed countries – CBR – about 22%о;
 Least developed countries – CBR – about 35%о.

 Highest Fer=lity levels:

 CBR in Africa (around 37%о), followed by Asia (19%о) and South America (17%о);
 Lowest Fer=lity levels:
 Europe (CBR) - 9.9%о, and North America (13%o

Projec=ons:
 Birth rates are expected
o to drop further in less developed countries,
o whereas in more developed countries, they are expected to remain fairly
constant

Impacts:
 Low economy growth
 Less people in work
 Less people to support elderly

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24. Mortality - measurement, characteristics, influencing factors. International

comparison, trends and impacts. Death registration

Mortality Determinants:
 Biological (Age; Gender; Race; Ethnicity; Disease/Cause of death)
 Behavioural –
o Risky or health-promoAve behaviours (i.e. diet, hygiene, alcohol and
tobacco use, sexual behavior, etc.)
 Environmental exposures and intervenAons –
o Ecological sewng,
o exposure to infecAous or chemical or physical agents,
o occupaAonal hazards,
 Socio-economic condiAons; -
o residence,
o Household wealth;
o Community development;
o EducaAon, Employment; (women’s educaAon and employment),
 Health-care system –
o Public health intervenAons (immunizaAons, prevenAve programmes,
screening);
o Accessibility to health care;
o EjecAveness of diagnosAcs and treatment,
o Development of medicine, science and technologies, etc
Measurements:
 Na=onal vital registra=on systems - a major source in developed countries;
o Universal coverage of the populaAon
o ConAnuous operaAon
 Sample registra=on systems
o (e.g., in China and India);
 Household surveys
o (e.g. - to esAmate infant and child mortality);

Death Cer=kcate:
 mandatory reporAng of all deaths - okcial noADcaAon that a death has occurred;

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 SecAons:
o Cause of Death
o Other condiAons contribuAng to death
o Date/Time/Place of injury
o Date/Time/Place of death
o Signed by a licensed physician
Indicators:
 Crude Death Rate CDR


 Gender Specikc Death rate:

o Number of deaths per year in men or women per 1000 men or women;

 Age Specikc Death Rate ASDR

o Number of deaths per year in a speciDc age (group) per 1000 persons in this age
group;

 Cause Specikc Death:

o Number of deaths axributable to a parAcular cause in a calendar year divided by
the mid-year populaAon at risk; per 100, 000 populaAon
o
Mortality Trends:
 Crude Death Rate (2010) –
o Worldwide – CDR - 8.5 %o .
o - More developed regions - CDR - 10.1%o
o - Less developed regions - CDR - 8.1%o
o - Least developed regions – CDR – 11.4 %o (Sub-Saharan Africa – 11.4 %o )
o - High CDR in the world – Sierra Leone – 17.1%o;
o - Low CDR in the world – United Arab Emirates – 1.1 %o.
Countries with highest mortality rates in Europe: Ukraine (16.0%о), Russia, Belarus, - Countries
with lowest mortality rates in Europe: Ireland – 6.4%о; Cyprus - 6.4‰;

Standardized Mortality Rates –

 When comparing crude mortality rates by regions – the standardized mortality indicators
are recommended (removing the dijerences in populaAons’ age distribuAon
 higher in the developing and least developed countries;

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25. Infant and maternal mortality - measurement, characteristic, trends and medico-
social aspects. Weight of babies limits

Infant Mortality:
 Number of deaths among infants under one year old per 1,000 live births in a
given year and territory.

Medico – Social Aspects:

 One of the most informaAve public health indicators;
 A good indicator of the overall health status of a populaAon;
 Much higher than the mortality rates in the following age groups (beyond 1 year
of age);
 A major determinant of life expectancy at birth
o Tremendous gains in life expectancy in the Drst 70 years of the 20th
century were almost exclusively the result of a declining infant and
childhood mortality.
 Infant Mortality is very sensiAve to levels and changes in socio-economic
condiAons of a populaAon;
o one of the best indicators to reveal social inequaliAes in health;
 Inmuenced by many factors (healthcare playing major role).

Determinants:
1. Low birth weight and premature birth – main reason for neonatal death
2. Unfavourable socio-economic condiAons;
3. Low culture and educaAon of parents;
4. Medical surveillance of pregnant women and infants;
5. Midwifery and childbirth healthcare and services availability;
6. Surveillance of high risk pregnancies and families
a. mothers younger than 19 or older than 35 years of age;
b. short interval between subsequent births;
7. Incompliance with the child nurture rules and recommendaAons;
8. Inmuence of environmental factors (polluAon, disasters, etc.

Birth weight is a powerful predictor of infant mortality;

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 Low birth weight infants  20 Ames more likely to die within the Drst year of life than
normal weighted infants
 Very low birth weight infants  80 Ames more likely to die than normal-weight infants.

Indicators:

 Infant Mortality Rate IMR:

 Age specikc Infant Mortality

Number of stillbirths + live births

Perinatal
= died during the first 7 days of life х
Mortality
Total number of births (still-and live 1000
Number of livebirths)
births died during
Neonatal
= the first 28th days of life х
Mortality
Number of live births 1000
Number of live births died during
Early
= the first 7th days of life х
Neonatal
Number of live births 1000
Mortality
Number of infants died between the
Late
= 7th and the 28th day after birth х
Neonatal
Number of live births having survived 1000
Mortality
Numberthe first 6 days
of infants died of life
between the
Postneonat
= 29 day of life and the end of the 1
th st
al Mortality х
year having survived
Number of live births 1000
 Cause Specikc Infant Mortality:the first 28 days of life

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o Measures the frequency of infant deaths from a parAcular cause / per 100,000
live births
o

Infant Mortality Trends:

 World average – high Infant Mortality Rate - 47 %o –
 More Developed Regions – 6 %o –
 Less Developed Regions – 52 %o –
 Least Developed Regions – 82 %o

Under 5 mortality rates –

number of deaths among children under 5 years per 1000 live births in a year

Maternal Mortality Rate:

 Number of women who die as a result of complicaAons of pregnancy or childbearing

(puerperal causes) in a given year per 100,000 live births in the populaAon.

Characteris=cs:
i. One of the most informaAve public health indicators;
ii. Important indicator for the assessment of women’s health, the quality of ante-natal,
obstetric and maternity care;

MMR Trends:
 World – 400 %ооо –
 More Developed Countries - 11 %ооо (Europe) –
 Less Developed Countries – 450 %ооо –
 Least Developed countries – 870 %ооо ,

MMR Causes:
 Postpartum hemorrhage
 Unsafe aborAon
 Anesthesia ComplicaAons
 Indirect cause  Anemia, Heart disease, Malaria

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28. Definition and scope of Epidemiology. Historical development and basic concepts.
Application of epidemiology in preventive medicine, clinical practice and public
health.

Dekni=on:
 Study of “distribu=on and determinants of health-related condi=ons or events in
popula=ons” and the applica>on of this study to control health problems

Scope:
Epidemiology is applied to the whole spectrum of health-related states or events: -
 InfecAous diseases ,
 Chronic diseases, Environmental problems ,
 Behavioural problems , Injuries ,
 Causes of death, ReacAons to prevenAve regimens , Provision and use of health services

History:

John Graunt 1629 – 1674:

 Father of demography & vital sta=s=cs
 First to quan=fy paperns of birth, death and disease occurrence;

Bernardino Ramazzini (1633-1714):

 Occupa=onal medicine & Industrial Hygiene
 Preven=ve measures in occupa=onal environment
 E.g.
o blindness in cesspool workers
o mercury poisoning in mirror makers
o kidney damages in couriers and those who rode for long distances

 1774, Pop – prostate cancer in chimney cleaners;

 19th century – cervical cancer – lacking in nuns. (later this statement is ques=oned and
reviewed)

Edward Jenner (1749-1823):

 Developed a vaccine against smallpox using cow pox (160 years before the virus
was iden=ked);

 Dr John Snow (1813-1858)

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Described the associa=on between dirty contaminated water and cholera (44
years before vibrio was iden=ked);

 Ignaz Semmelweis (1818-1865)

 Described the associa=on between puerperal fever and physician’s unclean
hands (32 years before causal agent was discovered).

Basic Concepts:
 “Popula=on” –
o Can be deDned through geographic or other characterisAcs; -
o PopulaAon of a country, of a speciDc territory at a parAcular Ame,
o a group of workers, a group of hospitalized paAents.
 “Risk” –
o The probability that an event will occur –
o It is assessed as low, medium or high (in %).
 “Popula=on at risk” –
o That part of a populaAon which is suscepAble to a disease –
o Can be deDned for any concrete disease or event on the basis of demographic
or environmental factors.
 “Risk group” –
o SpeciDc group of the populaAon with higher than the average risk for
developing the disease
 “Risk Factors” or “Causal Agents” related to disease: -
o Biological agents – bacteria, viruses, insects; -
o NutriAonal agents – diet (fats, carbohydrates, food nutrients); -
o Chemical agents – gases, toxic agents; -
o Physical agents – climate, vegetaAon, chemical pollutants (air, water, food); -
o Social agents – occupaAon, stress, social class, lifestyle, residence, health
services
 “Exposure” –
o A level and duraAon of inmuence on the individual or a group of a type of
harmful or health protecAng factor (example: physical acAvity, healthy
eaAng); -
o Exposure may be short-term (acute) or long-term (chronic).

 “Exposed person” –
 An individual who is exposed to a supposed cause of a disease or a
health event of interest or possess a characterisAc that is a
determinant of the health outcome of interest;

In Preven=on:

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 To idenAfy subgroups in the populaAon who are at high risk for disease (risk groups
idenADcaAon);
 To idenAfy speciDc factor or characterisAcs that puts them at high risk (risk factors
idenADcaAon);
 To direct prevenAve ejorts for early disease detecAon;
 To assess the ejecAveness of the prevenAve measures.

Clinical Medicine:
 Clinical decision-making should be based on sound scienADc evidences. This requires
relevant research with a strong scienADc basis (epidemiological studies)
 The Central Concerns of Clinical Epidemiology are: -
o DeDniAons of normality and abnormality,
o Accuracy of diagnosAc tests,
o Natural history and prognosis of disease,
o EjecAveness of treatment,
o PrevenAon in clinical pracAce

Public Health:
 Causa=on
o What cause the disease:
o Risk factors
 Describe health status of popula=on groups or the community:
o E.g. prevalence
o Change over =me
 Natural History:
o Study the natural history (course, outcome) and prognosis of disease

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29. Types of epidemiological studies – classification, general characteristics. Descriptive

epidemiological studies – design, advantages, limitations and application

Classikca=on:
1. Observa=onal
a. The invesAgator just observes occurrence of condiAons, events, diseases
b. Measures and makes analysis
c. But does not intervene
d. E.g. treatment and exposure in a “non – controlled” environment
2. Experimental
a. Involve an acAve axempt to change a disease determinant, such as an exposure
or a behaviour,
b. Or
c. the progress of a disease through treatment
d. the invesAgator intervenes
e. E.g. Treatment or exposure occur in a “controlled / experimental” environment
i. Clinical trials are the most well-known experimental designs

Observa=onal  Descrip=ve  Ecological & Individual

Observa=onal  Analy=cal  Case control & Cohort

Descrip=ve Studies:
 Study of the occurrence and distribuAon of disease
 in terms of:
o Ame
o place
o person
Design:
 Whether the personal characteris>cs of the people having a disease diGer from
those who do not have it? WHO
 Whether a certain geographic loca>on has higher or lower prevalence of a
disease? WHERE
Advantages:
• Provides main characterisAcs, places and Ame at which developing the disease is at
highest probability
• ExaminaAon of paxerns of disease or death by age, ethnicity, socioeconomic during
speciDed period of Ame or region can be made.
• Cheaper and Fast

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• Based on rouAnely available data from dijerent sources increasing the reliability
Disadvantages of Descrip=ve Studies:
 • Cannot analyse a relaAonship between exposure and disease.

30. Analytic epidemiological studies - case-control and cohort studies. Study design,
advantages, limitations and application.

Analytical Studies:
 Examine the relationship between exposure (risk factor) and outcome (disease) by testing
the hypotheses generated by the descriptive studies.
 “Are exposure and disease linked?” - answers questions like this

Analytical  Case- control studies & Cohort studies

Case Control Studies: A group of people with a disease (cases) and a suitable control group of
people unajected by the disease (controls) are compared for previous exposure to a possible
cause(factor).
Advantages of Case-Control Studies:
o • Simple to conduct
o • RelaAvely quick and inexpensive compared to other analyAcal designs
o • Ekcient for studying rare diseases and disease with long latency
o • Can easily study mulAple exposures for a single disease
o • Cases are easily available
o • Number of subjects required is small
Disadvantages of Case-Control Studies:
o • Not appropriate for studying rare exposures
o • Not well to study mulAple outcomes
o • Unable to provide data on incidence rates and relaAve risk
o • Time sequence of exposure and outcome can be unclear
o • PotenAal sources of bias and error

Cohort Study: – Study those exposed and not exposed to a cause to see the effects of the cause
in the future.
The group free of disease, who are classified into subgroups according to exposure to potential
cause of disease. Cohort is then flowed in due time

 Types of Cohort Studies:

o • ProspecAve - Follow a group into the future for several years and incidence is
measured.
o • RetrospecAve – Look back in Ame to reconstruct exposures and health
outcomes. Exposure is obtained from past records.
 Advantages of Cohort Studies:
o • Well suited to study rare exposures

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o • Demonstrate temporal relaAonship between exposure and disease

o • It can assess mulAple outcomes of a single exposure
o • Allow direct measurement of incidence of disease and risk of outcome among
exposed and unexposed person
 Disadvantages of Cohort Studies:
o • Expensive and Ame consuming
o • Inekcient for rare diseases or diseases with long latency
o • Not suited to study mulAple exposure

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31. Experimental epidemiological studies – randomized clinical trial, field trial and
community based interventions. Study design, advantages, limitations and
application.

Exper
iment
al
 RandomizedCont
rol
ledCl
ini
calTr
ial
s
 Fi
eldt
rial
s
 Communi
tyt
rial
s
RCT:

DeDned populaAon that is randomized into two groups

o New treatment (experimental group)
o Current TradiAonal treatment (placebo) (control group
) • Follow subjects in groups, See and compare results in both groups

Design:
1. Selec>on of the study popula>on
2. Alloca>on of the treatment regimens
3. Maintenance and assessment of par>cipants’compliance
4. Assessment of outcomes

Areas of Applica>on
 Used for many purposes:
 Evaluate new drugs and other treatments of disease;
 Assess new programs for screening and earlydetec>on – new methods of preven>on;
 New medical / health care technology assessment;
 Assess new ways of organizing and delivering healthservices;
 New health care policies assessment, etc.
Advantages of RCTs
 NB! The “gold standard” of research designs;

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 Provide most convincing evidence of rela>onship between exposure and eGect;

Disadvantages of RCTs
 Very expensive – Cost!
 Not appropriate to answer certain types ofques>ons – Ethical considera>ons!
 Prac>ces or substances known to be harmful shouldnot be allocated by any inves>gator;
 Therapies known to be bene_cial, such as medicaltreatment of hypertension, should not be
withheld fromany aGected individual.
 Pa>ents from the control group who need treatment –cannot be le` without treatment (just
on a placeboeGect).

Field trials - an experiment that involve disease-freepeople considered to be at risk and the
interven>on isapplied to each person individually;

Data collec>on takes place in the _eld (not in the hospital and clinical environment), usually
among non-ins>tu>onalised people in the general popula>on.
 Involve great number of par>cipants and substan>al _nancial resources.

Community trials - an experiment in which the interven>on is applied to communi>es rather

than individuals;
 Appropriate for highly prevalent diseases that have their origins in social condi>ons and
behavioural factors;
Examples: Cardiovascular disease is a good example

Advantages of Community Trials

 Could infuence behavioural and other lifestyle factors;
 Could realize substan>al and complex eGecton the health of the en>re community;
 The outcomes o`en become a scien>_c basis for public health policy.

Limita:ons of Community Trials

 Very expensive;
 Only a small number of communi>es can be included;
 Random alloca>on of communi>es is not prac>cable;

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 Difcult to isolate the communi>es where interven>on is taking place from general social
changes that may be occurring;
 May underes>mate eGect of interven>on.
 Lose experimental control.

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32. Comparing disease occurrence and measurement of risk. Typesofrisk. Risk factors,
risk groups.

RelaAve risk
- Assess presence of associaAon between exposure and disease
- Measure strength of associaAon

Rela=ve risk – cohort studies

- how many Ames exposure to risk factor increases risk for disease
- raAo of incidence among exposed persons to unexposed persons
 indicates strength of relaAon between exposure and disease

risk∈ exposed
RR=
risk ∈unexposed
Odds ra=on – case-control studies
- esAmaAon of relaAon between exposure and disease

ratio of the odds of exposure among cases

¿=
ratio of the odds of exposure a mong controls

RR (OR) > 1  posiAve associaAon  increased risk among exposed

RR (OR) = 1  no associaAon  same risk among exposed + unexposed
RR (OR) < 1  negaAve associaAon  decreased risk among exposed

Absolute risk
= cumulaAve incidence of a disease in a populaAon
- Indicates magnitude of risk in a group with certain exposure
- Does not indicate associaAon between exposure and increased risk of disease

Apributable risk AR
= risk dijerence RD
AddiAonal incidence of a disease due to axributable exposure

AR=I e −I 0

Apributable risk frac=on (exposed)

= proporAon of diseased in exposed populaAon that can berelated to their exposure

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AR
ARF = x 100
Ie

Popula=on apributable risk/frac=on

= proporAon of disease incidences in total populaAon that can be related to exposure

I total population −I 0
PAR= x 100
I total population

33. Prevention – scope and levels. Strategies for primary prevention.

Preven=on - combinaAon of medical and non medical measures that the society undertakes to
reduce the risk of disease, premature death, illness or disability or any other undesirable health
event.

4 Stages of Preven=on:
1. Primordial
2. Primary
3. Secondary
4. TerAary

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Primary:

 Directed at  interacAon between the risk factor and the suscepAble individual
 Aim 
o Prevent onset of disease either through complete abolishment of the risk factor
or through the reducAon of its level in a deDned populaAon or through the
increase of the resistance of the people in the risk
o Limit incidence of disease by controlling causes and risk factors
 Phase of disease  before onset of disease – speciDc casual and risk factors
 Target  Total populaAon or selected groups or healthy individuals
 Strategies:
o PopulaAon Strategy:
 Suitable for applicaAon in populaAons with high prevalence of the risk
factor;
 Aim 
 To focus on the whole populaAon aiming to reduce the average
risk
 (to move the enAre distribuAon of the risk factor in a deDned
populaAon to the lower levels of risk);
 -
 Advantages:
 Radical–tries to eliminate the cause for the high incidence of the
disease; •
 Large potenAal for the whole populaAon;
 Behaviourally appropriate

o High Risk Individual Strategy:

 Aim  To idenAfy and protect the suscepAble individuals at greatest risk
of a speciDc disease.

 Advantages:
 IntervenAons are appropriate to the parAcular high-risk
individuals advised to take them;
 Subjects are highly moAvated;
 Physicians are highly moAvated;
 Favorable beneDt-to-risk raAo.

 Disadvantages:
 DikculAes in idenAfying high-risk individuals;
 Limited and temporary eject;
 Behaviorally inappropriate

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Secondary:
- At early, pre-symptomaAc stage of disease
- Major instrument: screening
- Early detecAon of disease  early + ejecAve intervenAon  improve prognosis
 If disease is idenADed early -then intervenAon measures will be more ejecAve … less
costly … less invasive
 Examples breast cancer screening, cervical cancer screening, hypertension screening.

Ter=ary preven=on
- At late stage disease,
- Treatment + rehabilitaAon  reduce complicaAons + sujering, prevent recurrence +
premature death
 prevenAon leads to decreasing incidence, prevalence and mortality rates

34. Screening. Criteria for instituting population-based screening programmes.

Characteristics of screening test.

Dekni=on:
“Screening is the process by which unrecognized diseases or defects are idenADed by test that
can be applied rapidly and on a large scale”

Purpose of Screening:
- At early, pre-symptomaAc stage of disease
- Major instrument: screening
- Early detecAon of disease  early + ejecAve intervenAon  improve prognosis
 If disease is idenADed early -then intervenAon measures will be more ejecAve … less
costly … less invasive

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Types:
1. Mass screening
o Involves the screening of a whole populaAon
o Example: Checking all infants for hearing problems or phenylketonuria or
congenital hypothyroidism
2. MulAple or mulAphase screening •
o The use of a variety (a sequence) of screening testson the same occasion.
o Example: Screening for breast cancer –starAng with physical examinaAon,
followed by an ultrasound test, mamographyand Dnally –biopsy.
3. Targeted screening of groups with speciDc exposures
o O|en used in occupaAonal or environmental health among speciDc populaAon
groups at higher risk for the disease of interest
4. OpportunisAc screening (or case-Dnding
o Restricted to paAents consulAng a health pracAAoner for some other purpose
Criteria
Validity (accuracy):
- SensiAvity, speciDcity
- PredicAve Values
o PosiAve predicAve value –
o NegaAve predicAve value
Reliability:
- Repeatability  same results
- Consistent, stable

intrasubject varia=on – variaAon within species (condiAons)

interobserver varia=on – variaAon between observers

Increase reliability:
- Training staj
- Detailed protocol
- CalibraAng instruments
- StandardizaAon of instruments
- CalculaAon of mean value of several measurements

SensiAvity
Ability to detect true posiAve results (TP)  right result in diseased person

number TP
sensitivity= x 100
total number of diseased person tested

100% sensiAve  no missed diseased cases

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SpeciDcity
Ability to detect true negaAve results (TN)  right result in healthy person

number TN
specificity= x 100
total number of healthy person tested

100% speciDc  no false posiAve cases

 combinaAon: Drst sensiAve test (cheaper) followed by speciDc test (to eliminate FP)

PredicAve value
Posi=ve PV – likelihood that diseased person has posiAve test

TP
PPV = x 100
TP+FP

Nega=ve PV – likelihood that healthy person has negaAve test

TN
NPV = x 100
TN +FN
High prevalence  high PPV (low NPV)

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Social Zusammenfassung

Social Medicine (Medical University-Varna)

StuDocu is not sponsored or endorsed by any college or university

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Social Medicine
Zusammenfassung

Ivo

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Health Models

 Medical model: health is the absence of the 5 Ds: death, disease, discomfort, disability,
dissatisfaction
 Environmental model: based on analysis of ecosystem and environmental risks of health e.g.
socioeconomic status, education level, variable environmental factors
o Health, quality of a person’s adaption to the environment as conditions change
o Conditions affecting the health of individuals: air quality, living conditions, water
quality
 Hollistic model: encompasses the physiological, mental, emotional, social and environmental
aspects of individuals and communities
o Emphasizes each one has own responsibility for optimizing well being
 Self healing
 Prevention

Disease

 Definition: disorder of the body or mind, which destroys good health

o Can have a single or multiple causes
o Has characteristics symptoms, may be physical or mental, both
o Can be classified as acute (sudden onset with rapid change, lasts short time) or
chronic (may continue for months or years)
 Categories: non-communicable and communicable
o Non-communicable
 Responsible for 70% of deaths worldwide
o Communicable
 Spread from person to person through different ways (blood, bites, air)

Health Determinants

 Genetic and biological factors

o Determine the individual predisposition to hereditary and degenerative diseases
o Determine 18 - 22% of all health impairments
 Lifestyle factors
o smoking, alcohol and drug abuse; low physical activity; poor unhealthy diet;
psychosocial stress; etc.
o Determine 49 - 53% of all health impairments
 Environmental factors (incl. socio-economic)
o Unfavourable factors of the environment - air, drinking water and soil pollution;
other physical and chemical factors of the environment; risk factors from the
working environment;
o Socio-economic factors - income, social status; unemployment; education;
expenditure; housing and living conditions; social support or exclusion
(homeless, unemployed, refugees, immigrants in general have poor health, etc.)
Determine about 17–20% оf health impairments

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 Healthcare services
o Quality, accessibility and timeliness of health care, prevention, immunization,
screening, family planning
o Determine the least proportion of ill health – only 8 –10% of health impairments
 Social class, income, employment status and health are linked (i.e. higher class/income,
better job  healthier life)
 Gender
o “Women get sick and men die”
o Women: higher recorded morbidity but lower mortality compared to men
o Men: riskier behavior, go less to doctor, less screening/prevention
o Suicide: women try more often, men succeed more often; men use more “effective”
ways than women
 Place of Residence: urban vs rural
 Religion – affects some health related behaviours such as eating habits, smoking, alcohol
consumption, sexual behaviour, contraceptive use, healthcare utilization, etc
 Education: higher education  better health
 Marital Status: marriage is good for health
 Race

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Population Size and Growth

 More developed countries (MDC) – lower rates of population growth

 Less developed countries (LDC) - higher rates of population growth
 Least developed countries as a group are experiencing most rapid population growth
 population growth rate refers to the change in population over a unit time period, often
expressed as a percentage of the number of individuals in the population at the beginning of
that period
 A positive growth rate indicates that the population is increasing, while a negative growth
rate indicates that the population is decreasing. A growth ratio of zero indicates that there
were the same number of individuals at the beginning and end of the period

Population Composition

 Describes how a total given population is constituted by demographic, social or economic

variables at a fixed moment in time; in %
 Population Age Composition: Described by the proportion of population over 60 or over 65
years of age (in %)
Population below 15 + population 65 & above
 Total Dependency Ratio: Population 15−64 years
∗ 100

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o The ratio of populations who are economically not active (0-14 )+(>65) to those who
are economically active (15–64)
 Aged dependency ratio: same only for people >65 or for people <15
 Demographic Replacement Ratio: The ratio of people aged 15-19 (entering working age) to
people aged 60-65 (going out of working age)
 Population Pyramid – very popular graphic presentation of the age and sex distribution of
the human population of a particular region

o
o Developing countries: Have much younger populations; The population below the
age of 15 comprises 33%
o Least developed countries: Youngest populations, Children under 15 constitute 40%
of their population
o Developed countries: Have much older populations; The population below the age
of 15 comprises only 17 %
 Population Sex Composition: % of men and women or number of women to 100 or 1000
men
 Population Composition by Urban/Rural Residence: Expressed as the proportion of the
urban and the proportion of the rural population – (in %), The level of urbanization is lower
in the less developed regions (43%) than in the more developed regions (74%)
 Population Composition by Ethnicity, Religion, mother tongue
 The Oldest Old Population: The oldest old (aged 80 or over) constitute the fastest growing
segment of the population, The number of centenarians (persons aged 100 years or over) is
growing even faster than the oldest old
 Median Age: As an Indicator of Population Aging

Fertility and Reproduction

Number of live births per year
 Crude Birth Rate: Total mid−year population
* 1000
o Only a crude estimate of fertility
o Not good for comparing fertility across populations, as variations in age
distribution of the populations being compared will affect the birth rate
Number of live births per year
 General Fertility Rate: Number of women ages 15 to 49 * 1000
o Relates births to the age-sex group at risk of giving births (women in
reproductive age -usually defined as 15-49 years)
o More refined measure than Crude birth rate to compare fertility across
populations – less influenced by the age distribution of the population
 Age Specific Fertility Rate: Number of live births per year per 1000 women of a specific
age (group)

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 Total Fertility Rate: average number of children that would be born by a woman by the
time she ended childbearing if she were to pass through all her childbearing years
conforming to the age-specific fertility rates of a given year
o hypothetical measure of fertility that is independent of age structure of a
population
o Best single measure to compare fertility across populations
 Gross Reproduction Rate: Average number of daughters that would be born to a woman
during her lifetime
o Counts only daughters and literally measures “reproduction”– a woman
reproducing herself in the next generation by having a daughter
 Net Reproduction Rate: The average number of daughters that would be born to a
woman if she passed through her life-time from birth to the end of her reproductive
years conforming to the age-specific fertility and mortality rates of a given year
o always lower than Gross Reproduction Rate, because it takes into account the
fact that some women will die before entering and completing their child-
bearing years
 Replacement Level Fertility: said to have been reached when Total Fertility Rate (TFR) =
2.1  roughly 2 children per couple

MORTALITY

 Determinants: Biological, Behavioural, Environmental exposures and interventions, Social-

economic, Health-care system
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑝𝑒𝑟 𝑦𝑒𝑎𝑟
 Crude Death Rate: 𝑀𝑖𝑑−𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
∗ 1000
o generalized indicator of a population’s health
 Gender Specific Death Rates: Number of deaths per year in men or women per 1000 men or
women, usually higher for men
 Age Specific Death Rates: Number of deaths per year in a specific age (group) per 1000
persons in this age group
 Standardized Mortality Rates: Used to compare crude mortality rates of populations having
different age distribution
 Cause Specific Death Rates: Number of deaths attributable to a particular cause in a calendar
year divided by the mid-year population at risk
 Proportions: All deaths that occurred in a given population over a specific time period (e.g. a
calendar year) are taken as 100% and their structural distribution can be calculated for
different variables (age, sex, residence, ethnicity, cause of death, etc.) in %

Infant and Maternal Mortality. Life Expectancy

 Infant mortality refers to the death of an infant during the first year of life
o Number of deaths among infants under one year old per 1,000 live births in a given
year and territory
 Periodization of the 1st year of child’s life
o Perinatal period: 28th week of gestation to 7th day after birth

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o Neonatal: begins at birth and ends at 28 completed days after birth

 Early neonatal – occurring during the first 7 days of life
 Late neonatal - occurring after the 7th day but before the 28th completed
days of life
o Postneonatal: begins with the 29th day after birth and ends up with completion of
1st year of age
 Age Specific Infant Mortality Indicators:

o
 Cause Specific Infant Mortality Rate: Measures the frequency of infant deaths from a
particular cause / per 100,000 live births
 Under 5 Mortality Rates: Number of deaths among children under 5 years old per 1000 live
births in a given year and territory (in ‰ Promille)
o U5MR Assessment Scale
o Low - under 30 ‰
o Medium - 30 - 94 ‰
o High - 95 - 170 ‰
o Very high - over 170 ‰
 Maternal Mortality
o Maternal death: the death of a woman from any cause related to or aggravated by
pregnancy or its management (regardless of duration or site of pregnancy), but not
from accidental or incidental causes.
o Maternal Mortality Rate: per 100,000 women of childbearing age
o Maternal Mortality Ratio: per 100,000 live births (or per 1000 live births)
 Life Expectancy
o An estimate of the average number of additional years a person could expect to live
if the age-specific death rates for a given year prevailed for the rest of his/her life
o can be measured at age 0 (at birth) - Life Expectancy at Birth, or any other specific
age

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Epidemiology

 Study of “distribution and determinants of health-related conditions or events in

populations”
o Study: principles of statistics and research methodologies
o Distribution: descriptive, Characterizes health events by: time, place and person
o Determinants: causes or factors
 deals with populations or groups of people rather than with individual patients
 main concepts
o population: defined through geographic or other characteristics
o risk: probability that an event will occur, e.g., that an individual will become ill or die
within a stated period of time or by a certain age
o Population at risk: part of a population which is susceptible to a disease
o Risk group: Specific group of the population with higher than the average risk for
developing the disease
o Exposure: level and duration of influence on the individual or a group of a toxic,
carcinogenic, microbiological, physical or other type of harmful or health protecting
factor; can be short or long term
o Exposed person: An individual who is exposed to a supposed cause of a disease or a
health event of interest or possess a characteristic that is a determinant of the
health outcome of interest
 Incidence: Measure of new cases of disease (or other events of interest) that develop in a
population during a specified period of time
 Prevalence: Number of existing cases of disease or other condition in a population at a
specific point of time


 Level of Disease - amount of a particular disease that is usually present in a community
o Sporadic: Irregular pattern of occurrence, with occasional cases occurring at
irregular intervals

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o Epidemic: Significant increase in the number of persons affected by a disease - in

excess of the expected level for a given time period; The first occurrence of a new
disease
o Endemic: A disease that is established within a population that remain at a fairly
stable prevalence
o Pandemic: Widespread, universal disease penetration over a wide geographic area

 In all epidemiological studies it is essential to have two things:

o A clear definition of a case of the disease (based on symptoms, signs, lab data, etc.)
o A clear definition of an exposed person (based on characteristics that identify a
person as being exposed to the factor under study)
o Disease status is usually determined by a questionnaire, physical exam, lab tests or
other methods; Diagnostic criteria should be established in advance, divide cases
into definite (confirmed case), probable, and possible (suspected case) disease
categories
o Assessment of Exposure: interviews, records, measurements; quantification of
exposure: information on the amount, duration and frequency of exposure
 Observational studies
o investigator just observes occurrence of conditions, events, diseases (and measures
and makes the analysis) - but does not intervene
o Treatment and exposures occur in a “non-controlled” environment
o can be observed prospectively, retrospectively, or concurrently
o two broad types: descriptive and analytical
 DESCRIPTIVE: Describe the distribution of disease in a population or
subgroups according to person’s characteristics, time and place
 Advantages: information about the main characteristics of the
people, places and the time of disease occurrence; examine patterns
of disease or death; Describe the health status of a population; used
to generate hypothesis on the relationship between a factor and a
disease
 Based on: routinely available data from different sources or special
surveys  Usually are cheaper and fast often first step
 Disadvantages: Cannot analyze (cannot test a hypothesis for) a
relationship between exposure and health effect (disease)
 ANALYTICAL: Detect association between exposure and outcome by testing
hypotheses that are formulated by the descriptive studies
o Types of descriptive studies:
 Ecological Studies (Correlational / Population-based)
 Frequently initiate the research process
 Data on exposure and health outcome is population-based (not
individual based)
 Advantages: fast, easy, relatively cheap
 Disadvantages: data on different exposures may not be available;
Individual link between exposure and effect cannot be made;
Associations observed between variables at population (group) level
may prove to be invalid at individual level

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 Case Reports
 Detailed presentation of a single case
 Generally report a new, unique or unusual finding in a single case
 Case series
 Experience of a group of patients with a similar diagnosis
 Generally report on new / unique / unusual condition in a series of
cases
 May be the only realistic design for rare disorders
 Advantages: Useful for hypothesis generation, Informative for very
rare disease with few established risk factors
 Disadvantages: Cannot study cause and effect relationships, Cannot
assess disease frequency
 Cross-sectional (Prevalence) Studies
 provide a snapshot of a population at a point in time
 Exposure status and disease status of the individuals in a defined
sample are measured at one point in time (simultaneously)
 Prevalence rates among those with and without the exposure and
disease are determined and compared
 Often based on a sample of the general population – a cross-section
 Highly generalizable (e.g. National Health Surveys)
 Advantages: Relatively easy and economical, short time period,
Allow measurement of:The prevalence of disease; The prevalence of
a risk factor in a population, Health care needs and attitudes of
population
 Disadvantages: Time frame of cause and effect cannot always be
determined; Not useful for determining causal effects of risk factors
changing over time; Not appropriate for studying rare diseases or
diseases with short duration; Cannot measure the incidence of
disease
 Appropriate for: exposures that are fixed characteristics, causes that
are reasonably permanent characteristics
o Types of analytic studies:
 Case-Control Studies
 A group of people with a disease or other outcome variable of
interest (CASES) and a suitable control group of people unaffected
by the disease or outcome variable (CONTROLS) are compared for
previous exposure to a possible cause (factor)
 Describes association between exposure and outcome
 How do diseased cases differ from non-diseased controls with
respect to prior exposure history?
 Most feasible design for studying rare diseases
 conducted before a cohort or an experimental study, costs relatively
less, takes short time, can investigate multiple exposures
 source of cases: Hospital-based, Population-based, other
 matching: controls are similar to the cases with regard to certain key
characteristics - such as age, sex, and race; can be performed at an
individual or group level

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 advantages: simple, quick and inexpensive, Efficient for studying

rare diseases and disease with long latency, Can easily study
multiple exposures for a single disease, Cases easily available;
Number of subjects needed is small
 limitations: Not appropriate for studying rare exposures, Not well
suited to study multiple outcomes, Unable to provide data on
incidence rates, Time sequence of exposure and outcome can be
unclear, Many potential sources of bias and error, Rely on recall or
existing records about past exposure , Identifying and assembling a
case group representative of all cases may be difficult, Identifying
and assembling an appropriate control group may be difficult
o Recall bias occurs when the recall is better among cases
than controls because of the presence of the disease.
Consequently, a false association may be found between
exposure and disease
o COHORT STUDIES
 Study those exposed and not exposed to a cause to see the effects of that
cause in the future
 Begin with group of people free of disease, who are classified into subgroups
according to exposure to potential cause of disease.
 Cohort is followed up for months, years, even decades to assess how
subsequent development of new cases of the disease differs between the
groups with and without exposure
 Longitudinal – prospective or retrospective (historical) cohort studies
 Advantages: Well suited to study rare exposures, Can demonstrate a
temporal relationship between exposure and disease, Allow direct
measurement of incidence of disease in the exposed and non-exposed
population and a direct measure of risk for outcome among exposed and
unexposed persons, Allow direct measurement of the strength of the
association between exposure and outcome, can assess multiple outcomes
(effects) of a single exposure
 Disadvantages: Expensive and time consuming, Inefficient for rare diseases
or diseases with long latency, Not well suited to study multiple exposures,
Validity of the result can be affected by loss to follow-up and tracking study
subjects, If retrospective, requires the availability of existing records
 Prospective (the typical one)
 Those that follow a group into the future.
 Exposure and non-exposure status are ascertained as they occur in
the study; groups are followed-up for several years into the future
and incidence is measured
 Retrospective
 Those that look back in time to reconstruct exposures and health
outcomes.
 Exposure is ascertained from past records, and outcome
(development or no development of disease) is ascertained from
existing records at the beginning of the study.

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 Experimental Studies
o Involve an active attempt of the investigator to change a disease determinant, such
as a risk factor, an exposure or a behaviour, or to change the progress of a disease
through treatment – i.e. the investigator intervenes Treatment or exposure occur
in a “controlled” (experimental) environment
o The best (most powerful) epidemiologic design to test etiological hypotheses for a
relationship between an exposure and a disease and to prove causal relationship
o The effects of an intervention are measured by comparing the outcome in the
experimental group with that in a control group
o For ethical reasons, the possibilities for conducting experiments in humans are
limited
o Types:
 Randomized Controlled Clinical Trials
 Begins with a defined population that is randomized into two
groups: new treatment (experimental group) and current traditional
treatment or placebo (control group)
 Follows subjects in each group (experimental and control group) to
see and compare the results in both groups
 Randomized: Patients are randomly put into treatment or control
group
 Single blind: patients don’t know which group they belong to
 Double blind: patients and doctors don’t know
 removes bias, gold standard for trials; Provide most convincing
evidence of relationship between exposure and effect
 Types:

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o
o Factorial: 2 or more interventions are evaluated separately,
but also in combination and against a control (e.g. drug A,
drug B, drug A+B, control)
 Disadvantages: costs, ethical considerations (benefits costs analysis)
 Meta-analysis: methodology with a purpose to combine studies,
especially clinical trials, to increase the power by more precise
overall assessment of results

 Field trials
 involve people who are disease free but presumed to be at risk
 Data collection takes place in the field, among non-institutionalised
people in the general population
 Involve great number of participants and substantial financial
resources
 Community trials
 Unit of intervention, observation and analysis are communities
rather than individuals
 Appropriate for highly prevalent diseases that have their origins in
social conditions and behavioural factors
 Advantages: Could influence behavioural and other lifestyle factors;
Could realize substantial and complex effect on the health of the

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entire community; The outcomes often become a scientific basis for

public health policy
 Disadvantages: expensive; Only a small number of communities can
be included; Random allocation of communities is not practicable;
May underestimate effect of intervention; Lose experimental
control

RISK

 Information about the RISK of contracting a disease is of great value in Medicine and Public
health
 The Cumulative Incidence of a disease in a population is termed the ABSOLUTE RISK of
contracting it, does not indicate whether the exposure is associated with an increased risk of
the disease
 Comparing Disease Frequencies: Estimating Risk
o Is there an association between exposure and disease?
 answered by comparing frequencies of diseases (Incidence rates) in exposed
populations with non-exposed populations i.e. by Controlled randomized
experiment or prospective cohort study
o Absolute comparisons  made by subtraction (x is more than y)
o Attributable Risk (Risk Difference) (RD): The additional incidence of a disease that is
attributable to exposure
 Equal to the incidence of the disease in exposed persons minus the
incidence of the disease in unexposed persons RD = Ie – Io
 If we subtract the rate of disease in a population that does not have a risk
factor from the rate of disease in a population that DOES have a risk factor,
we get the Attributable Risk
o Attributable Risk Fraction (Exposed): proportion of the diseased in exposed
Ie−Io
population that can be related to their exposure 𝐴𝑅𝐹 = Ie
∗ 100
o Population Attributable Risk / Fraction (PAR): What proportion of the disease
incidence in a total population – both exposed and unexposed can be attributed to a
specific exposure?
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 – 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑖𝑛 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑔𝑟𝑜𝑢𝑝
 𝑃𝐴𝑅 = Incidence in total population
∗ 100
o
o Relative comparisons  made by division (x is twice as much as y)
 Relative Risk (RR): an indicator of the strength of an association between an
exposure and a disease
 RR = Risk in the exposed/Risk in the unexposed
 RR = Incidence in exposed/Incidence in unexposed
 Odds Ratio (OR): is the ratio of the odds of exposure among the cases to the
odds of exposure among the controls; used as an estimate of the association
between the exposure and the disease
o RR (OR) > 1 - positive association (an increased risk among the exposed)
o RR (OR) = 1 - no association (the occurrence of disease in the exposed and
unexposed groups are identical)

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o RR (OR) < 1 - negative association (a decreased risk among the exposed group – the
exposure has a protective effect)

PREVENTION

 the combination of medical and non medical measures that the society undertakes to reduce
the risk of disease, premature death, illness or disability or any other undesirable health
event
 Identification of risk factors and causes of diseases and death ( especially factors that may be
modifiable)
 Identification of population groups or subgroups that are at high risk for disease
 Setting priorities in prevention (based on the data of population risk assessment)
 Development of preventive strategies and programmes
 Assessment of effectiveness of preventive interventions
 4 levels of prevention: Primordial, Primary, Secondary, Tertiary
o Primary Prevention
 Directed at: the interaction between the risk factor and the susceptible
individual
 Aim: To prevent the onset of a disease; To limit the incidence of disease by
controlling causes and risk factors
 Phase of disease : before the onset of disease; specific causal and risk
factors
 Target: total population or selected groups or healthy individuals
 Population strategy: in populations with high prevalence of the risk factor;
focus on the whole population aiming to reduce the average risk
 Advantages: Radical – tries to eliminate the cause for the high
incidence of the disease; Large potential for the whole population;
Behaviourally appropriate
 Disadvantages: Small benefit to the individual (Rose prevention
paradox); Poor motivation of subjects; Poor motivation of physicians
and other health professionals; Benefit-to-risk ratio may be low
 “Preventive Paradox” of Rose: “A preventive measure that brings
large benefits to the community – offers little immediate benefits to
each participating individual”
 High-risk individual strategy: identify and protect the susceptible individuals
at greatest risk of a specific disease
 Advantages: Interventions are appropriate to the particular high-risk
individuals advised to take them; Subjects are highly motivated;
Physicians are highly motivated; Favourable benefit-to-risk ratio
 Disadvantages: Difficulties in identifying high-risk individuals;
Limited and temporary effect; Behaviourally inappropriate.
 A combination is usually needed between the population and the high-
risk individual strategy of primary prevention
 The proportion of people at high risk in a population is not large
 Large number of people at small risk may contribute more cases of a
particular condition than a smaller number of people who are
individually at greater risk

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o Secondary Prevention
 Directed at: the early – pre-symptomatic stage of disease
 Aim: Early detection of disease before the appearance of clinical symptoms
and through early, prompt and effective intervention - to improve the
prognosis
 Target: Patients in an early pre-symptomatic stage of disease
 Major instrument – Screening
o Tertiary Prevention
 Directed at: the late stage of clinically established disease: Treatment,
rehabilitation
 Aim: To reduce the progress or complications of established disease
 For many diseases – the application of integrated approach for prevention and control has
proved to be effective, leading to decreasing the incidence, the prevalence of disease and
the mortality rates
o It involves a combination of: all levels of prevention (primary, secondary and
tertiary) as well as interventions directed at the entire population and the
individuals at greatest risk.

Screening

 Screening is the process by which unrecognized diseases or defects are identified by test that
can be applied rapidly and on a large scale
 Screening tests are not diagnostic in themselves; they usually simply identify small groups
with high risk of the condition who then go on to have further tests to confirm the diagnosis
 Purpose of Screening:
o Preventing serious outcomes of existing disease at its early stage - early
presymptomatic diagnosis and treatment – improved prognosis
o Preventing the occurrence of disease by screening for risk factors e.g. population
based screening programmes
 Types:
o Mass screening: Involves the screening of a whole population
o Multiple or multiphase screening: The use of a variety (a sequence) of screening
tests on the same occasion
o Targeted screening of groups with specific exposures: Often used in occupational or
environmental health among specific population groups at higher risk for the disease
of interest
o Opportunistic screening (or case-finding): Restricted to patients who consult a
health practitioner for some other purpose

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 Criteria for Population based Screening Program

o Criteria for the Disease
 Important and serious public health problem
 High prevalence of disease
 Long lead time and known natural history of disease (not rapidly progressing
disease)
 Disease has a recognizable latent or early symptomatic stage (detected by a
screening test)
o Diagnosis and Treatment
 Facilities are adequate – follow-up diagnostic tests and treatments should
be readily available
 Effective, acceptable and safe treatment available
o Cost Considerations: cost-effectiveness of screening programs is very important to
consider
 Criteria for the Screening Test
o Safe, minimal risk
o Simple and easy to apply, minimal discomfort
o Acceptable to the public and med. professionals
o Low cost
o Reliable: repeatability, consistency and reproducibility
 Intrasubject variation (variation within individual subjects)
 Interobserver variation (variation between those reading the test results)
o Valid: Sensitivity and Specificity, Predictive Values (Positive/ Negative predictive
value)

o
𝑁𝑢𝑚𝑏𝑒𝑟 𝑡𝑒𝑠𝑡𝑖𝑛𝑔 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒 𝑤ℎ𝑜 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑇𝑃)
o 𝑆𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑡𝑒𝑠𝑡𝑒𝑑 𝑤ℎ𝑜 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑇𝑃 + 𝐹𝑁) ∗ 100
  very highly sensitive test (~100% sensitivity) would have no missed cases
(no false negatives)
𝑁𝑢𝑚𝑏𝑒𝑟 𝑡𝑒𝑠𝑡𝑖𝑛𝑔 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒 𝑤ℎ𝑜 𝑑𝑜 𝑛𝑜𝑡 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑇𝑁)
o 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐𝑖𝑡𝑦 = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑡𝑒𝑠𝑡𝑒𝑑 𝑤ℎ𝑜 𝑑𝑜 𝑛𝑜𝑡 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝐹𝑃 + 𝑇𝑁)
∗ 100
 test of high specificity (~100%) would have no false positives (no people
wrongly labeled as diseased)
o Sensitivity-Specificity Compromise
 sensitivity and specificity are inversely related: an increase in one causes a
decrease in the other
 To make a diagnostic decision – a “cut-off point” needs to be selected
 Highly sensitive tests are likely to have low specificity and highly specific
tests are likely to have low sensitivity

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 problem of trade-off between sensitivity and specificity depends on

the consequences of false positive diagnosis (in not specific tests) or
the consequences of false negative results (missed cases) in tests
with low sensitivity
 Best to use a combination of tests: first high sensitive, then highly specific
 SNOUT and SPIN


o Positive predictive value (PPV) is the likelihood that a person with a positive test
result truly has the disease
𝑁𝑢𝑚𝑏𝑒𝑟 𝑤ℎ𝑜 𝑡𝑒𝑠𝑡 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒 𝑎𝑛𝑑 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑇𝑃)
 𝑃𝑃𝑉 = 𝑇 𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑤ℎ𝑜 𝑡𝑒𝑠𝑡 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒 (𝑇𝑃 + 𝐹𝑃)
∗ 100
o Negative predictive value (NPV) is the likelihood that a person with a negative result
truly does not have the disease
𝑁𝑢𝑚𝑏𝑒𝑟 𝑤ℎ𝑜 𝑡𝑒𝑠𝑡 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒 𝑎𝑛𝑑 𝑑𝑜 𝑛𝑜𝑡 ℎ𝑎𝑣𝑒 𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 (𝑇𝑁)
 𝑁𝑃𝑉 = 𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑤ℎ𝑜 𝑡𝑒𝑠𝑡 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒 (𝑇𝑁 + 𝐹𝑁)
∗ 100
o Sensitivity and Specificity: Are unaffected by prevalence of disease; Depend only on
the characteristics of the test.
o Predictive Values: Are affected by prevalence of the disease
  higher the prevalence of a disease in a population, the higher the PPV
and the lower the NPV of a test for it
 screening program is most productive and efficient if it is directed to a high-
risk target population
 If a disease is rare, even a very specific test may have a low PPV because it
produces a large number of false-positive results

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Types of health care systems

 Health systems: all the institutions, people and actions whose primary purpose is to improve
health
 OBJECTIVES:
o Improving people’s health and well being
o Responding to people’s expectations
o Providing protection against the costs of ill-health
 Health Services are the set of institutions and programs that provide: Direct care to health
and disease needs of individuals; Public Health Services for the protection of collective
health, (i.e. the health of communities)
 4 basic systems: Beveridge, Bismarck, National Health Insurance and Out-of-Pocket Model
 Beveridge Model (UK, Scandinavia, Spain, NZ)
o Health care is provided and financed by the government through tax payments
o Many, but not all, hospitals and clinics are owned by the government; some doctors
are government employees, but there are also private doctors who collect their fees
from the government
o tend to have low costs per capita, because the government, as the sole payer,
controls what doctors can do and what they can charge
 Bismarck Model (Germany, France, Benelux, Switzerland)
o uses an insurance system – the insurers are called “sickness funds” – usually
financed jointly by employers and employees through payroll deduction
o health insurance plans have to cover everybody, and they don’t make a profit
o Doctors and hospitals tend to be private
o multi-payer model (a lot of different funds)
o Tight regulation gives government much of the cost-control clout that the single-
payer Beveridge Model provides
 National Health Insurance Model (Canada, Taiwan, South Korea)
o has elements of both Beveridge and Bismarck
o uses private-sector providers, but payment comes from a government-run insurance
program that every citizen pays into
o universal insurance programs tend to be cheaper and much simpler administratively
than American-style for-profit insurance
o The single payer tends to have considerable market power to negotiate for lower
prices
o also control costs by limiting the medical services they will pay for, or by making
patients wait to be treated
 Out-of-Pocket Model (rural regions Africa, India, China, South America)
o the rich get medical care; the poor stay sick or die in nations which are are too
poor and too disorganized to provide any kind of mass medical care
o no or sporadic access to professional healthcare, usage of local healers

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