Concepts of Community

UNIT 1 CONCEPTS OF COMMUNITY HEALTH Health

Structure
1.0 Introduction
1.1 Objectives
1.2 Public Health in India and its Evolution
1.3 Concepts of Health and Illness
1.3.2 Dimensions of Health
1.3.3 Determinants of Health
1.4 Concept of Causation of Disease
1.5 Natural History of Disease
1.6 Levels of Prevention
1.6.1 Primary Prevention
1.6.2 Secondary Prevention
1.6.3 Tertiary Prevention
1.7 Roles and Responsibilities of Mid Level Healthcare Providers (MLHP)
1.8 Let Us Sum up
1.9 Model Answers
1.10 References

1.0 INTRODUCTION
Health is a dynamic concept, which every human being desires to achieve. While
health refers to positive end of spectrum; illness, sickness and disease symbolise
the negative side of the spectrum. In order to protect, promote, and restore the
health of individuals and populations, an integrated discipline of public health or
community health came into existence. Public health has evolved in India since
independence and we have achieved success in terms of improvement of various
morbidity and mortality indicators. However, a lot needs to be achieved and mid
level health care providers (MLHP) can play an important role in this regard. In
this unit we shall discuss about basic concepts of health and disease with brief
description about role of MLHP.

1.1 OBJECTIVES
After completing this unit, you should be able to:
• define health and differentiate between illness, sickness and disease;
• describe various dimensions of health and enumerate determinants of
health;
• draw epidemiological triad with the help of example;
• describe the natural history of disease; and
• enumerate and apply the levels of disease prevention in control of
diseases.
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Introduction to Public Health
and Epidemilogy 1.1 PUBLIC HEALTH IN INDIAAND ITS EVOLUTION
‘Public Health’ is defined as organised community efforts aimed at prevention of
disease and promotion of health. In other words, it is the science and art of
preventing disease, prolonging life and promoting health and efficiency through
organised community efforts. The organised community efforts that promote
health and prolong life are:
• control of communicable infection,
• improved environment– access to safe water and sanitation,
• personal hygiene improvement through education,
• organisation of medical and nursing services for the early diagnosis and
preventive treatment of disease,
• development of the social machinery to ensure everyone a standard of living
adequate for the maintenance of health.
Public health incorporates the inter-disciplinary approaches of epidemiology,
biostatistics and health services. Environmental health, community health,
behavioural health and occupational health are other important subfields.
Public health in India dates back to ancient times. Excavations in the Indus valley
(Harappa culture) show evidence of planned cities, with drainage and practices
of environmental sanitation. Ayurveda and Siddha systems of medicine came
into existence in 1400 B.C. Medical education was introduced in the ancient
universities of Taxila and Nalanda during the post-vedic period. The Greek system
of medicine known as Unani was introduced by Muslims when they entered
India around 1000 A.D. Another phase in evolution of public health came when
British empire conquered India by middle of 18th century. Many legislative
measures for disease control and prevention were taken during this time.
Quarantine act (1825), the Births and Deaths Registration Act (1873), Vaccination
act (1880), Factories act (1881), Local self-government act (1885), Epidemic
disease act (1897), and the Madras Public Health Act (1939) were promulgated
and passed.
Just before independence, Bhore committee was constituted in 1943 to survey
the existing health conditions and organisations. The committee recommended
integration of preventive and curative services at all levels and also emphasised
the social orientation of medical practice. The report formed the basis of health
planning in India. The constitution of India came into force in 1950 and first
five-year plan began with allocated budget for launch of national health
programme. The community development programme was launched in 1952 with
the aim of overall development of rural areas. The National Malaria Control
programme was started in first five-year plan. Important public health institutes
like Central Health Education Bureau (CHEB) in Delhi and the Central Leprosy
Teaching and Training Institute in Chennai were also started during this time.
India has evolved a lot since the time of independence. Over the past six and half
decades public health infrastructure and services have expanded, particularly
after the inception of National Rural Health Mission (NRHM) in 2005. The
progress has been further accelerated with combining of rural and urban
components as National Health Mission in 2013 and launch of RMNCH+A
strategy (Reproductive Maternal Neonatal Child Health plus Adolescence) that
8 stress on provision of continuum of care through every phase of life.
Financial health focuses on one’s attitude toward money and a commitment to Concepts of Community
Health
setting goals for future needs, developing good money habits and effectively
using tools to manage financial resources. In order to be financially healthy, one
does not need to be wealthy; however, one must sensibly manage money. While
financial well-being is not often considered when discussing health, it can be a
significant source of stress which can have major effects on the other dimensions.
Social Health encourages contributing to one’s environment and community. It
emphasises the interdependence between others and nature. It deals with having
a supportive social network, contributing to society, and valuing cultural diversity.
It can also be defined as the “quantity and quality of an individual’s interpersonal
ties and extent of his involvement with the community”. How well a person
mixes and interacts with others in family, society, community and world and
considers him as a part of these, is witnessed as social dimension of his health.
Environmental Health is learning and contributing to the health of the planet and
a sustainable lifestyle. The key to human health largely lies in his external
environment. Much of human being’s ill health can be traced to adverse
environmental factors such as water pollution, soil pollution, air pollution, poor
housing conditions, presence of animal reservoirs and insect vectors of diseases.
Thus, it is pertinent to control all the factors that exert deleterious effect on the
health.

Check Your Progress 1

1. Define Health according to WHO.
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2. Draw the Health Septrum.

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3. Enumerate any 3 dimensions of health.

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1.3.2 Determinants of Health

Health of an individual is a complex subject influenced by a variety of factors
which may lead to either a healthy outcome to promote health or an unhealthy
outcome to have deleterious effects on health. Since these factors are largely
responsible to determine health of a person, they are termed the determinants of
health. The main determinants of health are:
1) Age: There is close relationship of diseased status with age. While some
diseases are common in younger age group, chronic diseases such as
hypertension, diabetes, osteoarthritis are predominant in older age groups.
Age is also an important factor in determining the prognosis of diseases.
11
Introduction to Public Health 2) Gender: Women are considered to be biologically stronger than men.
and Epidemilogy
Consequently, the life expectancy of women is relatively more than men.
Further, some diseases differ according the gender. While oral cancers are
more common among men, breast cancer and cervical cancer affect large
number of women. Similarly, inguinal hernias have gender predisposition
towards males. Due to the gender differences in pattern of a distribution of a
particular disease, you as a Midlevel Health Provider (MLHP) should keep
in mind while dealing with gender.
3) Genetics: The traits transferred from parents during conception as genetic
configuration are permanent and remain unaltered till end of the life. His
physique, intelligence, temperament and response to diseases agents usually
resembles in many respects to either of his parents or grandparents. Many
diseases in humans like chromosomal anomalies, errors of metabolism, mental
retardation, diabetes etc. are known to be of genetic origin.
4) Race, ethnicity: Members of non-white racial and ethnic groups tend to
experience more ill health and disease than their white counterparts.
5) Literacy status: Literacy and education status of the people also have an
indirect impact on health as these are interrelated with occupation, economic
and hygiene standards. People with good educational background have an
understanding to practice better ways and means of living improving their
health standard.
6) Nutrition: Diet has been scientifically and extensively linked to disease.
The relation between high fat diet and coronary heart disease is well
established. Similarly, under-nutrition predisposes the person to multitude
of infections. Thus, the health of a community depends both on the adequate
availability of safe food and the intelligent consumption of it.
7) Environment: A person is fully dependent on external environment for his
body needs in day to day life, but its adverse conditions are responsible for a
very large number of health related problems and diseases. All the diseases
caused by physical and biological agents are the result of adverse conditions
of the external environment. Internal environment of a person is comprised
of his own anatomical body parts and physiological activities which comes
under internal medicine.
8) Socio-economic status: Economic status of the country, community and of
an average individual has an impact on the purchasing power and thus affects
the living standard of a person. Daily needs of nutrition, education, housing,
clothing and standard of life are all dependent on per capita income. Further,
access to health services, are also largely dependent upon the income. Certain
diseases such as lifestyle disorders have been found to be associated among
the group belonging to higher socio-economic status while infectious diseases
such as tuberculosis, leprosy are considered to be diseases of poor.
9) Socio-cultural conditions: Culture is a learned behaviour which has been
socially acquired. A person learns and develops the qualities to interact with
others in the society in his early developmental stage. On interaction with a
person, one can easily think of the culture and a society which he belongs to.
These are all behavioural traits displayed by him during interaction.
Development of such qualities is mostly by learning from prevailing
behavioural and socio-cultural conditions in the society. The health behaviour
12 of person is also influenced by his socio-cultural environment.
10) Health care system/services: Care of people provided through effective Concepts of Community
Health
system of medical and health care services creates a positive influence on
health of the people. Infant mortality rate, maternal mortality rate and
expectation of life at birth are affected by the kind of health services available
in the state or country.
11) Other factors: The development of newer technologies of information and
communication offer tremendous opportunities in providing an easy and
instant access to medical information. Other determinants include adoption
of policies in the economic and social fields that would assist in raising the
standards of living and hence indirectly affecting the health.

Check Your Progress 2

i) List 5 determinants of health.
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ii) What do you understand by socio-economic determinants of health?
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iii) How literacy status affects health?
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1.4 CONCEPT OF CAUSATION OF DISEASE

Let us now read concept of causation of disease.
Since disease has always been a constant accompaniment of human, right from
the pre-historic times onwards, he has been trying to find out the causes of disease.
The various theories prevalent in different civilisations were:
• Supernatural causes like being possessed by evil spirits, wrath of gods,
punishment for evil deeds during previous births etc. cause diseases.
• Contagion theory: Diseases are spread through “bad air” or to various forms
of close contacts with diseased person.
• Germ theory: In 19th century, bacteria was discovered as a cause of human
disease by Robert Koch and Louis Pasteur. It was believed that every human
disease to a specific microbe or “germ”, to the extent that the germ theory of
the human disease emphasised that each and every human disease has to be
caused by a microbe or germ, which is specific for that disease and one must
be able to isolate the microbe from the diseased human being. This was the
central philosophy of the famous Koch’s postulates, formulated by Robert
Koch (now also known as Henle-Koch postulates).
However, with turn of the century, it was being realised that germ theory could
not fully explain the causation of disease. It was being considered that there were
other factors that played the role in accentuation or attenuating the effect of “germ”
or “agent” in causation of disease. This formed the basis for Epidemiological
Triad theory. 13
Introduction to Public Health Epidemiological Triad Theory
and Epidemilogy
Complex interactions among people, their characteristics and the environment
influence health. It, thus, involves a state of interaction between self and
environment. This theory, known as Epidemiological triad theory hypothesizes
that there are 3 important determinants of state of health or disease in human
being namely: agent factors-related to various characteristics of the “agents”
which cause the disease; host factors which relate to various characteristics of
human being like age, gender, ethnicity etc.; environmental factors which describe
the various characteristics of the environment in which human being is living. As
per the theory, as long as a state of fine balance or equilibrium is maintained
between the various agent, host and environmental factors, the person stays in a
state of health. On the other hand, the moment this fine balance is disturbed due
to change in any one or more of the agent, host and environment related factors,
a departure from the state of health occurs as shown in Fig. 1.3 (A.B.C).

AGENT (A)

ENVIRON-
HOST (H)
MENT
(E)
Fig. 1.3(A): Epidemiological Triad

H A

Fig. 1.3(B): Balance

(A)

(H) (E)
Fig. 1.3(C): Disturbed balance

14 Fig. 1.3: (A) (B) (C) Epidemiological Triad

Difficulties come up when an attempt is made to explain the causation of non Concepts of Community
Health
communicable diseases like Ischemic Heart Disease (IHD) or road accidents on
the basis of epidemiological triad. For example, no single agent can be ascribed
for road accidents, there is complex interaction of numerous causative factors
such as lack of driving experience, intake of alcohol while driving, not wearing
of seat belts, poor implementation of legislation. Therefore, for explaining the
causation of non-communicable diseases in particular, theory of web of causation
was postulated. Various factors related the disease, are like an interacting web of
spider. Each factor has its own relative importance in causing the final departure
from the state of health, as well as interacts with others, modifying the effect of
each other.

1.5 NATURAL HISTORY OF DISEASE

Complete course of a disease from the time a human host is exposed to the disease
agent in an environment to its final outcome is termed the natural history of
disease. Let us take an example of a common disease like hepatitis A. After the
infecting organism enters our body by way of food or drinks, there is an incubation
period of about 28 days, after which we have clinical manifestations in the form
of fever, malaise, anorexia, nausea and abdominal discomfort, followed by dark
urine and jaundice. Most of the individuals recover by the third week, though
variable feeling of weakness may persist for a longer time. However, some patients
may develop complications in the third week in the form of relapsing hepatitis,
cholestatic hepatitis and fulminant hepatitis.
It is known that hepatitis A is caused by a virus belonging to picornavirus family.
Some may not be infected due to their immune status (previous exposure to
infection or already received immunisation against hepatitis A). Therefore, another
factor to be considered in development of human diseases is, besides the organism
(agent), the human being himself too. Now, there is yet another factor which
needs to be considered also. There should be water or food which should be
contaminated with the faeces of a patient of hepatitis A. Hence, the third thing,
besides the microbial organism and the human being, which determines the
disease, is the “environment”. Despite the presence of these three factors, some
may get the disease or may not get the disease. We would therefore agree that the
mere presence of agent, host and environment is not enough to cause the disease.
As long as the agent, host and environment are in a state of equilibrium disease
will not be initiated; the process of human disease would be initiated only if
there is an appropriate interaction and a loss in equilibrium, between the agent,
host and environment. For example, if we become malnourished due to an attack
of severe measles or take on to heavy alcoholism, or become poor and hence
forced to consume contaminated food or water, or are exposed to a very heavy
dose of infection (for example, drinking raw water in a flood like situation), we
would become “susceptible” to developing hepatitis. As shown in the Fig. 1.4,
natural history of disease has two phases: pre-pathogenesis (i.e., the process in
the environment) and pathogenesis (i.e., the process in man). The pre-pathogenesis
period refers to period before the onset of disease in man. The causative agent of
disease, has not yet entered man, but the factors (i.e. environmental factors) that
are favourable for its interaction with the human host are already existent in the
environment. However it must be remembered that mere presence of agent, host
and environmental factors in this phase is not sufficient to start the disease. What
is required is an INTERACTION between these factors. (Fig 1.5). 15
Introduction to Public Health
and Epidemilogy

Fig. 1.4: Natural history of disease and level of prevention

Pathogenesis phase: This phase begins with the entry of the disease “agent” in
the susceptible human host. In case of infectious diseases, the disease agent
multiplies and induces physiological changes. The disease progresses through
period of incubation to early and late pathogenesis. The final outcome may vary
between recovery, diability or death depending upon the interventions undertaken.
In chronic diseases, the early pathogenesis phase is referred to as pre-symptomatic
phase as there is no manifestation of disease. The clinical stage begins when
recognisable signs or symptoms appear and by this time, the disease is already
advanced to late pathogenesis phase.

AGENT HOST

ENVIRONMENT

Fig. 1.5: Interaction of Agent, Host and Environment

1.6 LEVELS OF PREVENTION

Prevention and control of diseases is an important concept in preventive medicine.
Knowledge about natural history of a disease helps in applying the preventive
principles in its prevention and control. It further helps in reducing the burden
and morbidity or mortality arising out of the disease occurrence. In general, there
are three major levels of prevention, depending on the phase of the natural history
16
of the disease. Before these three levels of prevention, primodial prevention is Concepts of Community
Health
applied when action is taken to remove even risk factors to develop for example
school children are educated not to smoke as smoking is risk factor for many
disease.

1.6.1 Primary Prevention

All measures of prevention that are undertaken before the onset of the disease, so
that the disease never occurs. Primary prevention involves:
• Health promotion: All steps undertaken to improve the level of general
health and well-being so that conditions for initiation of disease process are
prevented is defined as health promotion. e.g. Cessation of smoking, personal
hygiene, attempts to remove hazards, such as insect-breeding sites or polluted
waters, by environmental control would also promote health.
• Specific protection: These include measures to prevent the initiation of
specific diseases or a group of diseases. e.g. Vaccination, food fortification
(e.g. iodine fortification of salt).

1.6.2 Secondary Prevention

It is defined as “action which halts the progress of a disease at its incipient stage
and prevents complications.”
The specific interventions are: early diagnosis (e.g. screening tests, and case
finding) and adequate treatment.

1.6.3 Tertiary Prevention

It is defined as “all the measures available to reduce or limit impairments and
disabilities, and to promote the patients’ adjustment to irremediable conditions.”
• Disability limitation:The prevention of complications of a disease before
irreversible changes set in would limit disability. For example, careful
attention to skin care daily, particularly of the feet of a diabetic patient, would
prevent the development of ulcers and subsequent gangrene of the feet. Careful
avoidance of injury from cuts, burns, and scalds to the part of the body with
sensory loss, particularly the hands and feet, of leprosy patients could also
avoid the loss of fingers and toes consequent to injury. Disease turns into a
handicap as follows:
• Disease: This is a pathological process and it’s manifestations which
indicate a departure from the state of perfect health.
• Impairment: This is the actual loss or damage of a part of body anatomy
or an aberration of the physiological functions that occurs consequent to
a disease.
• Disability: This is defined as the inability to carry out certain functions
or activities which are otherwise expected for that age / sex, as a result
of the impairment.
• Handicap: This is the final disadvantage in life which occurs consequent
to an impairment or disability, which limits the fulfilment of the role a
person is required to play in life.
• Rehabilitation: When a defect or disability has already occurred, tertiary
prevention can be instituted to restore as much functions as is possible. For 17
Introduction to Public Health example, residual paralysis from poliomyelitis can be overcome by the use
and Epidemilogy
of callipers or other devices. Individuals with mild refractive errors can have
these corrected with lenses, while the partially deaf can be rehabilitated with
hearing aids. Rehabilitation is undertaken at four dimensions:
• Medical rehabilitation: This is done through medical / surgical procedures
to restore the anatomy, anatomical functions and physiological functions
to as near normal as possible.
• Vocational rehabilitation: This includes steps involving training and
education so as to enable the person to earn a livelihood.
• Social rehabilitation: This involves steps for restoration of the family
and social relationships.
• Emotional and Psychological rehabilitation: This involves steps to restore
the confidence and personal dignity.

Check Your Progress 3

1) Explain state of Health.
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2) Explain State of occurance of Disease

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3) Incubations of Hepatitis A is ..................................................................

4) List Clinical manifestations of Hepatitis A.

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1.7 ROLES AND RESPONSIBILITIES OF MID

LEVEL HEALTHCARE PROVIDERS (MLHP)
A mid level healthcare provider is defined as a health provider
a) Who is trained, authorised and regulated to work autonomously
b) Who receives pre-service training at higher education institution for atleast a
total of 2–3 years and
c) Whose scope of practice includes (but is not restricted to) being able to
diagnose, manage and treat illness, disease and impairments (including
perform surgery, where appropriately trained), as well as engage in preventive
and promotive care.
Trained and competent human resources (CHR) are essential for an effective
health care delivery system. There is a pressing need to strengthen health sub
centres to provide Comprehensive Primary Care including for NCDs. Global
18 evidence suggests that suitably trained (3–4 years duration) service providers
can provide considerable primary care. As one of the measures to increase the Concepts of Community
Health
availability of such appropriately qualified HR, especially in rural and remote
areas, on 13th November 2013, the Cabinet approved the introduction of a
3&1/2 year Bachelor of Science in Community Health (BSc CH) Course in
India. However, the uptake for this course has been slow and if some Universities
were to start the course, the first batch of professionals will be available for
recruitment only by the end of the fourth year. On the other hand, qualified
Ayurveda doctors and B.Sc./GNM qualified nurses are available in the system,
who could be trained in public health & primary care through suitably designed
‘Bridge Programmes in Community Health’. Such qualified human resource
may function as Mid Level Health Care Providers and called ‘Community Health
Officers (CHOs)’ and posted at health Sub Centres; which could be developed
as ‘Health & Wellness Centres’.
The BSc (CH) Curriculum is the benchmark for developing this bridge course
and these MLHPs will be primarily deployed at Health & Wellness Centres (or
Sub Centres). You would possess the necessary knowledge and competencies to
deliver comprehensive primary care services and implement public health
programmes.
Job Responsibilities: The trained MLHPs would broadly be expected to carry
out public health functions, ambulatory care, management and leadership at the
Health & Wellness Centres (H&WCs). You would be expected to:
a) Implement National Programmes
b) Administration and management at Health and Wellness Centres (or Sub-
centres)
c) Health education and encourage awareness about Family Planning, Maternal
and Child Health, and Non-Communicable Diseases
d) Preventive, promotive and curative care
e) Identification of Danger Signs and Referral after pre-referral stabilisation
f) Implement Biomedical waste disposal guidelines and Infection Control
policies
g) Supervision of health workers for Maternal and Child Health, Family Planning
and Nutrition related services.
In other words, MLHP are those health cadres often, but not always, linked to
traditional health professions, who have received less training and have a more
restricted scope of practice than professionals. In India, MLHP have been regarded
as “auxillaries” and have been bestowed with following worker’s responsibilities:
1) Health Worker (Female):
a) Maternal and child health: Register and provide care to pregnant women,
ensure that each women comes for at least 4 antenatal visits, get basic
laboratory investigations done for her, refer women with ‘high risk’
pregnancy, make atleast 2 postnatal visits, assess the growth and
development of infant and provide immunisation.
b) Family planning: Maintaining eligible couple register, motivate couples
for family planning services, distribute conventional and oral 19
Introduction to Public Health contraceptives to the couples, motivate couples who have completed
and Epidemilogy
family for permanent methods of sterilisation, organise health education
for the same.
c) Medical termination of pregnancy: Identify women requiring medical
termination of pregnancy and refer them to approved institutions, educate
women about harmful effects of septic abortion and acquaint them about
safe abortion services in the community.
d) Nutrition: Identify cases of malnutrition and refer them to primary care
facility, distribute iron folic acid to women and children, work in
collaboration with anganwadi workers, provide vitamin A
supplementation to all children below 6 years.
e) Immunisation: Immunise pregnant women with tetanus toxoid and
children below 5 years with all vaccines under universal immunisation
programme.
f) Implementation of communicable disease control programme in her
area
g) Recording of vital events
h) Treatment of minor ailments: Treat minor ailments and provide first aid
in case of emergencies and disasters.
i) Maintaining all records of her health facility pertaining to MCH services,
immunisation and family planning.
j) Coordination with other team members like ASHA (Accredited Social
Health Activist) and anganwadi workers, medical officer, etc.
2) Health Worker (Male):
a) Record keeping
b) National health programmes:
i) National vector borne disease control programme: Active
surveillance, collect blood smears, assist in spraying operations, assist
in administration of radical treatment, provide health education.
ii) National leprosy elimination programme: Identify cases and refer to
health facility with doctor, maintain records of patients and ensure
they are taking treatment, health education.
iii) Revised national tuberculosis control programme: : Identify cases
and refer to health facility with doctor, maintain records of patients
and ensure they are taking treatment, health education.
iv) Assisting health worker female (HW-F) in MCH, immunisation and
family planning services.
v) Ensure environmental sanitation.
vi) Rest of the functions same as HW (F).

1.8 LET US SUM UP

In this unit we have discussed various aspects of health.
Health is defined as a state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity.
20
Health is not static. It ranges from complete well-being to uneasiness, disease, Concepts of Community
Health
disability and death.
Pursuit of optimal health includes physical, emotional, intellectual, spiritual,
occupational, financial, social, and environmental dimensions.
Health of an individual is a complex subject influenced by a variety of factors
known as determinants of health.
Disease is the state where a body is not at ease, means it is not comfortable.
Illness refers to the subjective sense of feeling unwell. Sickness refers to socially
and culturally held conceptions of health conditions
Complex interactions among people, their characteristics and the environment
influence health.
Complete course of a disease from the time a human host is exposed to the disease
agent in an environment to its final outcome is termed the natural history of
disease. Concept of interactions between agent, bost and environment is also
death.
We also planned three major levels of prevention, depending on the phase of the
natural history of the disease.

1.9 MODEL ANSWERS

Check Your Progress 1
1) World Health Organization (WHO) defines health as “state of complete
physical, mental and social well-being and not merely an absence of
disease or infirmity”.
2) Refer Fig. 1.1 A, B
3) Three dimension of health are physical, emotional and intellectual.
Check Your Progress 2
i) Genetics, socio-cultural, environment, gender, nutrition
ii) World Health Organization (WHO) describes social determinants of health
as the “the conditions in which people are born, grow, live, work and age”.
iii) Literacy and education status of the people also have an indirect impact
on health as these are interrelated with occupation, economic and hygiene
standards. People with good educational background have an under
standing to practice better ways and means of living improving their health
standard.
Check Your Progress 3
1) As long as agent, host and environment are in a state of balance with each
other the person stays in a state of health.
2) When agent, host and environment are not in fine balance or balance is
disturbed due to change in any one or more of the agent, host and environment
related factors disease occus.
3) Incubation period of Hepatits A is 28 days.
4) Fever, Malaise, anorexia, nausea, abdominal discomfort. 21
Introduction to Public Health
Usual Time
and Epidemilogy of Diagnosis

Pathologic Onset of
Exposure Changes Symptoms

Stage of Stage of Stage of Stage of Recovery,

Susceptibility Subclinical Disease Clinical Disease Disability of Death

Primordial Primary Secondary Tertiary

Prevention Prevention Prevention Prevention

1.10 REFERENCES
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(1920), p. 23.
2) Kishore J. The Dictionary of Public Health. 3rd ed. Century Publications:
New Delhi; 2014.
3) Park K. Park’s Textbook of Preventive and Social Medicine. 23rd ed. Jabalpur.
Bhanot Publishers; 2015.
4) Chapter 1. Public health system in India: An introduction and evolution
[Internet] 2007 [Accessed on 2016, Sept 5]. Available from: http://
shodhganga.inflibnet.ac.in/bitstream/10603/8917/7/07_chapter%201.pdf
5) Roy BN, Saha I. Mahajan & Gupta Textbook of Preventive and Social
Medicine. 4th ed. New Delhi: Jaypee Brothers Medical Publishers; 2013.
6) WHO. The First Ten Years of the World Health Organization. Geneva: WHO,
1968.
7) AFMC Primer on Population Health. Part 1-Theory: Thinking about health.
Chapter 1: Concepts of health and disease [Internet] 2014 [Accessed on 2016,
Sept 5]. Available from: http://phprimer.afmc.ca/Part1-TheoryThinking
AboutHealth/Chapter1ConceptsOfHealthAndIllness/IllnessSickness and
Disease.
8) AJPHNH. A Broadened Spectrum of Health and Illness. Am J Public Health
Nations Health. 1961;51(5):762.
9) WHO. Ottawa Charter for Health Promotion: First International Conference
on Health Promotion. Geneva: WHO;1986.
10) Dimensions of Health. [Internet] 2009 [Accessed on 2014, Mar 30]. Available
from: http://www.buzzle.com/articles/5dimensions-of-health.html
11) Wellness WCSD. 8 Dimensions of Wellness. [Internet] 2012 [Accessed on
2014, Mar 30]. Available from: http://washoecountyschools.org/docs/
wellness/March_2012_ Newsletter.pdf
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