HEALTH CHALLENGES TODAY

OBJECTIVES - Complex health problems

Discuss the features of collaborative practice - Limited resources
Analyze the key elements of collaboration - Fragmented health system
Discuss the interactional, organizational and - Health inequities
systemic determinants of collaboration
COLLABORATIVE PRACTICE
COLLABORATIVE PRACTICE WHY do we need to have practice collaboration?
WHAT do we mean when we say collaboration?
WHO should we involved in this kind of practice?
WHEN should it be done?
HOW would it be done?

WHY
INTERPROFESSIONAL COLLABORATION results to
- Optimal use of health human resources
- Better access to and coordination of health services
- Reduced cost of healthcare
- Improved treatment outcomes including patient
UK Center for Advancement of Interprofessional safety
Education, 2002 - Holistic patient care
When multiple health workers from different backgrounds - Improved over-all health
provide comprehensive services by working together with
patients, families, carers, and communities to deliver the - World Health Organization 2010
highest quality of care across settings.
There is really no negative outcome in interprofessional
Primary Health Care USSR- ALMA ATA 1978 collaboration. However, it is very challenges. Pushing the
resources to the limit. It is a challenge to make this into reality.
“…the attainment of the highest possible level of
health…requires the action of many social and economic WHAT
sectors in addition to the health sector.”

“Relies…on health workers, including physicians, nurses,

midwives, auxiliaries and community workers…traditional
practitioners as needed, suitably trained – socially and
technically – to work as a health team.”

Holistic and comprehensive care will be provided for those

who are needing health care especially at the community
level.

Charles Boelen, 2000

Call for a new professionalism
“The ideal health professional would possess a balance of
content expertise (mastery of methodologies and tools in a
given technical area) and linkage expertise (capacity to
interact with practitioners of other technical areas in the wider
Notice the difference in the type of communication and the
domain of health and development).
dynamics between the relationship among the key members.
And the attribute in terms of leadership.
WHO, 2010
“The WHO and its partners recognize interprofessional
COLLABORATION
collaboration in education and practice as an innovative
strategy that will play an important role in mitigating the global - Type of relations/interactions occurring among co-
health workforce crisis.” workers
- A dynamic process that focuses on the following
Realities of Collaborative Work in Healthcare Practice related key elements:
A. Sharing
B. Partnership
C. Interdependency
D. Power

A. SHARING
- shared responsibilities, health care philosophy,
values, planning and interventions, professional
perspectives
- Sharing doesn’t mean that one profession would
follow the other profession. But you actually respect
and value for the things that you share among each

1
other. There is awareness of what to other members identified and this will guide who will be part of the
has to offer. team to take care of the patient.
B. PARTNERSHIP 3. Who must be involved so that my patient’s needs will
- two or more people join together in a collegial, be well addressed?
authentic and productive relationship, - Neurologist, Endocrinologist, Rehabilitation
characterized by open and honest sspecialist. And depending on the case of the
communication, mutual trust and respect. patient, may also need social worker, nurse who can
- Each partner must value the work and do home visit, and members of the support group.
perspectives of the other professionals and work 4. How can I make them involved?
toward a common goal or goals and specific a. Sharing
outcomes. b. Partnership
- Talks more about the interaction between the c. Power
different key members. d. Interdependency
5. How can I support their involvement?
C. POWER 6. How can I promote future collaboration?
- is shared among team members; empowerment is
accorded to all participants; based on knowledge WHEN
and experience, rather than on functions or titles.
- Leader can change depending on the issue or the
client that you are working with.

D. INTERDEPENDENCY
- common desire to fulfill the patient’s needs,
- Interdependence rather than autonomous
- because of this the output of the whole is much larger
than the sum of the individuals involved
- leads to collective action

INTERPROFESSIONAL RELATIONSHIP
“In general, harmonization of a wide range of activities of
different professional groups, even when genuinely moved by
the same will to serve people’s health needs, does not
happen easily or naturally. It must be organized.”
- Charles Boelen, 2000

5 STAGES OF GROUP DEVELOPMENT (BRUCE

TUCKMANN) TASK INTERDEPENDENCY: How a certain responsibility
would require the efforts of the different members of the health
team.

HOW
DETERMINANTS OF COLLABORATION

Every member of a group must go through and must

overcome the challenges of each stage of development.
Unfortunately, some group are not able to overcome some
stages.
How these four different elements (Sharing, Partnership,
Power and Interdependency) go hand in hand so that you will
experience true collaboration

WHO
- When multiple health workers from different
backgrounds provide comprehensive services by
working together with patients, families, careers and
communities to deliver the highest quality of care
across settings.
- Collaboration in healthcare teams is the process by “In view of… changing trends, corresponding changes must
which interdependent professionals are structuring a be made in the way health care providers are educated and
collective action towards patients’ care needs trained. If health care providers are expected to work together
- This process is built on a voluntary basis and and share expertise in a team environment, it makes sense
necessarily that their education and training should prepare them for
- implies negotiation this type of working environment.”
- Building on Values, The Future of Health Care in
GUIDE QUESTIONS FOR COLLABORATIVE CARE Canada by Roy J. Romanow, Q.C.
1. Will my patient benefit from collaborative care?
2. What are my patient’s needs? INTERPROFESSIONAL EDUCATION
- Example: Px is a diabetic who had a stroke, “Occasions when members or students of two or more
experiencing body weakness. Needs must be professions learn from, with and about each other to
2
improve collaboration and the quality of care and services Health Professions Network Nursing and
for patients, families and communities. Midwifery Human Resources for Health (2010).
- CAIPE, 2016

There should be changes in the educational curriculum so Over the years, resolutions on nursing and midwifery
that professors/teachers can teach us how to collaborate. adopted by the WHO World Health Assembly have helped to
There are a lot of systemic determinants that affects on provide a strong foundation for strengthening nursing and
how you work with others. But nevertheless, organizational
determinants are something that can be worked on. midwifery services. The most recent resolution, WHA 64.7,
gives WHO the mandate to develop and strengthen strategies
COLLABORATIVE COMPETENCIES such as: capacity of nursing and midwifery workforce through
1. Describe one’s roles and responsibilities clearly to other the provision of support to Member States on developing
professionals.
o What is a doctor? What is the role of the doctor? targets, action plans and forging strong interdisciplinary health
You will be able to explain this clearly to other persons. teams as well as strengthening the dataset on nursing and
2. Recognize and observe the constraints of one’s role, midwifery. The mandates have been operationalized through
responsibilities, and competence, yet perceive needs of
patients, clients in a wider framework the various strategic directions of strengthening nursing and
o Know your own weakness and strength. midwifery. The Global strategic directions for strengthening
3. Recognize and respect the roles, responsibilities, and nursing and midwifery 2016–2020, being the third in the series
competence of other professions in relation to one’s own.
follows the versions of 2002–2008 and 2011–2015.
o Partnership, there is valuing and respecting the
roles of other. Together with the Global Strategy on Human
4. Work with other professions to effect change and resolve Resources for Health: Workforce 2030, the Global strategic
conflict in the provision of care and treatment? directions for strengthening nursing and midwifery 2016–2020
5. Work with others to assess, plan, provide and review care
for individual patients provides a robust WHO strategic response to develop nursing
o Sharing interventions and treatment plans. and midwifery as it outlines critical objectives. Collaboration
6. Tolerate differences, misunderstandings and shortcoming with key stakeholders will help deliver the overall vision of
in other professions
7. Facilitate interprofessional case conferences achieving universal health coverage and the Sustainable
o Interprofessional communication. Able to agree, Development Goals. The Global strategic directions are
talk, discuss on how you can operationalize your organized according to the following four thematic areas:
differences of opinion and at the same time you are
able to complement each other
Ensuring an educated, competent and motivated
8. Enter into interdependent relationship with other
professional nursing and midwifery workforce within effective and
o Looking at the overall goal rather than your own responsive health systems at all levels and in
discipline’s target different settings;
- Barr, 1998 Optimizing policy development, effective leadership,
management and governance;
Reflect on yourself. How are you in terms of having these Working together to maximize the capacities and
competencies already? Are there other competencies that you potentials of nurses and midwives through intra and
need to develop? How can you develop these competencies? interprofessional collaborative partnerships,
education and continuing professional development;
*Review Guide Questions for Collaborative Care*
and
SOURCE: Mobilizing political will to invest in building effective
- evidence-based nursing and midwifery workforce
development.

Through a set of guiding principles, strategic interventions

NOTE! REQUIRED READINGS! under the different thematic areas mentioned above are
- Health Professions Network Nursing and Midwifery outlined for implementation at country, regional and global
Human Resources for Health (2010). Framework for levels
Action on Interprofessional Education and
Collaborative Practice World Health Organization,
Geneza, Switzerland.
- L. San Martin- Rodriguez, M. Beaulier, D. D’Amour
and M. Ferrada-Videla (2005). The determinants of
successful collaboration: A review of theoretical and
empirical studies. Journal of Interprofessional Care,
Supplement 1:132-147.

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FEU – NICANOR REYES MEDICAL FOUNDATION
PREVENTIVE MEDICINE 1.5 LONG TERM, PALLIATIVE & HOSPICE CARE
BARBARA AMITY FLORES, MD, FPAFP, FPSHPM
OBJECTIVES SITUATIONAL FACTORS
• Identify patients needs • Language issues
• Identify different types of patients • Literacy Issues
• Enumerate the components of difficult encounters • Diverse cultures
• Identify the difficult patient • Religious issues
• Apply the HEAT Method in dealing with difficult patients • Gender issues
“culturally competent” à “culturally sensitive”
Type of Patient Needs o Different beliefs may lead to misunderstanding or
Personal Need Practical need miscommunication.
• To be recognized • Specialized knowledge
• To be treated with and medical expertise Multiple People in the Exam Room
respect • Patient companion/clinic staff during consults
• Made to feel important o needed / wanted by the patient
o Limit staff to those with important roles
Types of Patients o Identify: Important people involved in care of the
Patients patient
• Satisfied patients • Honor what is in the best interest of the patient given the
• Lets you know it situation
• Most rewarding
• They make you feel that you made a difference Breaking Bad News
• Causing distress in another person causes distress in ourselves
Patrons • Remember your SPIKES!
• Satisfied but
• Rarely open about it Environmental Issues
• Most satisfying • Noisy, chaotic
• Even if they don’t say anything, you will feel that they appreciate • Does no afford appropriate privacy
you o patients, providers and staff are all more likely to be
• Giving gifts, refer family member and friends to you to show their unhappy or unpleasant.
appreciation • Having a comfortable environment will help diffuse any difficult
encounter
Talkers
• NOT satisfied Not all difficult encounters can be blamed on Situational factors nor
• Will tell you about it just to patient factors
• Gives greatest opportunity to exceed expectation
• Because you know what’s going on and what’s wrong, you will be PHYSICAN FACTOR
able to make it up for them • Situations that make us more likely to react negatively to
patients...
Walkers
• NOT satisfied Fatigued or Harassed Physician
• Don’t tell you about it • Overworked
• Walks away • Sleep-deprived
• Biggest challenge • Generally busier than one needs to be
• Because you don’t know what went wrong → you can’t make it • Over-committed
up to them • High achieving professional

As much as 15% of patient- physician encounters are labeled as Angry or Defensive Physician
“difficult” by the physicians • Burned out
- How to Manage Difficult Patient Encounters. Family Practice • Stressed
Management [Link]/fpm | June 2007 • Frustrated
COMPONENTS OF A DIFFICULT ENCOUNTER
Situational issues Physician characteristics Sources of Stress
• Language and • Angry or defensive H - Hungry
literacy issues physicians A - Angry
• Multiple people in the • Fatigued of harried L – Late/ Lonely
exam room physicians T – tired
• Breaking bad news • Dogmatic or arrogant S - Scared
• Environmental issues physicians
Table 1. Physician Factors That Can Lead to Difficult Clinical
Encounters
Attitudes Conditions Knowledge
• Emotional • Anxiety / depression • Inadequate training in
burnout • Exhaustion / psychosocial medicine
• Insecurity overworked • Limited knowledge of the
• Intolerance of • Personal health issues patient’s health condition
diagnostic • Situational stressors
uncertainty • Sleep deprivation Skills
Patient characteristics • Negative bias • Difficulty expressing
toward specific empathy
• Angry, defensive, frightened
health • Easily frustrated
of resistant patients conditions • Poor communication
• Manipulative patients • Perceived time skills
• Somatizing patients pressure
• Grieving patients
• “Frequent fliers” 1⏐3
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Dogmatic or Arrogant Physician •
PREVENTIVE MEDICINE
Compare what they have to a friend’s
• Overemphasized personal beliefs, values and emotion or relative’s experience
o Imposed on patients
o Hinders assessment without bias
o May disempower patients and prevent them from
sharing information about their care

stress, fatigue, burnout, personal and work-related issues,

dogmatic/arrogant attitude
Lack skills Somatizing Patient/The Seeker
Lack empathy • Doctor shoppers. Undergone many tests and subspecialist but
Inadequate knowledge nobody can pinpoint what is actually happening to the patient
Poor attitude • Most somatizing have underlying psychosocial problems: victims
inhibit communication and spark difficult encounters of abuse, dysfunctional families.
• Present with chronic, multiple vague or exaggerated symptoms
Breakdown in communication between physician and patients lead to • Often doctor-shops
patient anger, dissatisfaction and possible litigation.” • Has had numerous tests and has seen numerous subspecialists
- Service Plus • May also suffer from anxiety, depression or PD
PATIENT CHARACTERISTICS
Patient Factors That Can Lead to Difficult Clinical Encounters Anxious Patient
A. Behavioral Issues B. Conditions • Upset, nervous, distracted, and uncomfortable.
• Angry/argumentative/rude • Addiction to alcohol or drugs • Provoked by:
• Demanding/entitled • Belief systems foreign to o Chronic illness
• Drug-seeking behavior physician’s frame of o Life-threatening
• Highly anxious reference o Prolonged symptoms
• Hypervigilance to body • Chronic pain syndromes o Uncontrolled symptoms
sensations • Conflict between patient’s o Past experience (Own experience, family, friends)
• Manipulative and physician’s goals for the
• Manner in which patient visit The Non-compliant patient
seeks medical care • Financial constraints causing
• Does not take a prescribed medication or follow a prescribed
• Nonadherence to treatment difficulty with therapy
course of treatment
for chronic medical adherence
• Continuously fail to follow up as required or miss scheduled
conditions • Functional somatic disorders
appointments
• Not in control of negative • Low literacy
A considerable number of patients who are labelled difficult may meet
emotions • Multiple (more than four)
the Diagnostic and Statistic Manual of Mental Disorders (DSM) criteria
• Reluctance to take medical issues per visit
for:
responsibility for his or her • Physical, emotional, or
• Mood disorder
health mental abuse
• Anxiety disorder
• - Self-saboteur
• Borderline Personality Disorders
American Family Physician Volume 87, Number 6, March 2013
MANAGEMENT OF DIFFICULT PATIENTS
How do you see them? Varieties of patient anger:
• CEA
• The Angry patient • Frustrated
o Active listening skills
• The bully • Irritable o Find/ Know the Emotionally Critical Misperception
• The internet expert • Demanding behind the difficult encounter.
• The Silent Type • Defensive
• The Seeker of Truth • Frightened • Prompt assessment (DSM criteria) and referral
• The Anxious Patient • Resistant o Assess for and identify psychiatric symptoms
• The Non-compliant Patient • Anxious
DEALING WITH THE DIFFICULT PATIENT: HEAT METHOD
Angry/Argumentative: H– Hear them out
• Clenched fists E– Empathize
• Furrowed brows A– Apologize (acknowledge)
• Wringing of the hands T– Take responsibility for your action
• Restricted breathing patterns
• Warnings from office staff that something is wrong CLARIFY THE SITUATION
• “You sound / look really upset, can you tell me what is wrong?
The BULLY • You seem to be cross about something.”
• Manipulative/Demanding/Entitled • “Tell me about it...”
• Wants something and wants it now • “You were very angry with the nurse, why was that?
o Demand investigation, treatment or referral • “Can you describe the situation in more detail?”
o Play on the guilt of other
o Threaten with rage, legal action or suicide Know what is going on – tell me more about what is happening...
o Exhibit impulsive behavior directed at obtaining what • Leading skills
they want • Probe Active Listening Skills
• Differential Diagnosis: Borderline Personality Disorder • Reflect
o Content (Paraphrase / Perception Check)
The Internet Expert o Feelings
• Present with print-outs of either complex and/or marginal o Experience
information about their problem from a web site • Bracketing
• Demands unnecessary medical tests or treatments based on the • Summarize / Check understanding
net
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Hear Them Out
PREVENTIVE MEDICINE
Different version of HEAT…
• Allow the person to ventilate without interruption Six steps: UNIVERSAL UPSET PATIENT PROTOCOL
• Encourage them to speak up 1. You look really upset Clarify the situation
o Active Listening Skills 2. Tell me about it Hear them out
o Identify ECMS 3. I’m so sorry this is happening to you Empathize
Apologize/Acknowledge
Empathize 4. What would you like me to do to help Take Responsibility
• “It must be frustrating/upsetting to ...” you?
• “I can see/ understand why you feel that way... I see what you 5. Here’s what I’d like to do next
mean...” 6. Thank you so much for sharing your Confirm satisfaction
• “It sounds like you’re upset/angry about ...” feelings with me, it’s really important
• “I think I can see where you are coming from. “Let me see if I got that we understand each other
this straight... (summarize) completely, thank you.

Validate the experience and the negative feelings. Source:

• Based on your explanation of what happened, it seems that.. Dealing With the Difficult Patient: Dr. Barbara Amity Flores’ PPT and lecture
... your feelings of anger is reasonable
• ... your anxiety may have some bearing
• ... I would feel sad as well

Empathizing is not the same as agreeing.

Apologize (Acknowledge)
• “I’m sorry you we’re inconvenienced”
• “I apologize for the situation.”
• “I’m sorry it didn’t meet your expectation.”
• “I am sorry you feel this way...”
• “I am sorry you are having this problem...”

Avoid defensive explanations or responses

• Give information that patients desire
o Based on the issues/concerns raised
o Based on rules/ protocols

Take Responsibility
• “I’d like to take care of this right away.”
• “Let’s talk about how we can correct the situation.”
• “I’ll do what I can to remedy the situation.”
• Take opportunities to exceed expectations, when possible.

MEET or EXCEED the NEED

• Routine situation → act promptly and courteously
• Not routine situation → agree on a clear course of action
• Take opportunities to exceed expectations, when possible
§ “What would you like me to do to help you?”
§ “I’ll take care of this right away.”
§ “What I’ll do is ______. Is that okay?”
§ “Another thing we can do is ______”
§ “This is what we can do, would this be ok or do you have other
suggestions?

CONFIRM SATISFACTION
• Ask questions to confirm satisfaction
o “Is there anything else I can do?”
o “Is that satisfactory?”
o “Does that take care of everything?”
o “If you have any other questions, feel free to call me.”
• Commit to follow- through if appropriate.
• Thank the patient.

Aimlessly defending yourself (or the person who upset them) will just add
fuel into the fire...

You end up with hurt feelings and longer delays in the conversation.

3⏐3
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PREVENTIVE MEDICINE / SEPTEMBER 2019 • Infants less than 6 months have humoral immunity from their
DR. POLICARPIO JOVES JR. mother transplacentally, which is why they are usually
INTRODUCTION TO EPIDEMIOLOGY protected against measles and chicken pox
Sources: Lecture Recording, Class Notes, Dr Joves Trans, • Immunity from mother wanes at 6 months, that is when
Epidemiology Workbook of BS Health Sciences vaccinations are usually done since the humoral immunity of
the child is developed
Note: Tried to make it as clear as possible, but Doc Joves jumps
• BCG can be given at birth since cellular immunity acts on it
from one topic to the next so it is kind of hard, so please double
• Immunizations are usually humoral immunity, hence, you
check also!!
can’t give it at birth, it won’t work anyways since they do not
have humoral immunity yet
EPIDEMIOLOGY
• Epidemiology is the study of the distribution of the disease ENVIRONMENTAL RISK FACTOR
in human population and factors (determinants) affecting
Climate change is an important environmental risk factor, since
the distribution of the disease
this change in environment can cause differences in the life
• Three components stages of certain agents of disease.
o Disease distribution – time and place Examples:
o Human population – characterize who are the people
• Flooding – can relocate eggs, larvae, etc. of disease-causing
affected (ex. young/old, female/male, rich/poor, race, etc.)
pathogens causing a non-endemic area to turn into an
o Factors affecting
endemic area
• The disease must be characterized as person, place, and
• Ice caps melting – re-emergence of already dormant diseases
time to be able to identify the factors and determinants of
Social interactions also pose as a risk since whomever the
the disease (look at the disease distribution and human
patient interacts with can be part of the disease causation
population to identify the factor causing the disease)
Example:
• To determine the determinants of a disease it is very important
• Patient is living with father with tuberculosis – might have
that in the disease causation that you don’t just think of
tuberculosis too
biological agents because there are other factors that affect it
Polical unrest/Wartorn areas – high prevalence of disease
• If you know the factors affecting the distribution, you would because focus is towards the war instead of health; resources
know what the epidemiology is about – epidemiology aims to are scarce (example in Mindanao: there is a disparity in the
prevent the disease and to maintain one’s health. socio-economic status – a lot are undernourished)
Agents of disease:
EPIDEMIOLOGY AT WORK
Biologic Bacteria, virus, protozoan, etc.
Chemical Chemical characteristics of the pathogen (Air Malaria in a certain tribe that believes that mosquitoes are
pollution, different strands of viruses) sacred. Dr. Juan Flavier then devised a strategy to lower the
prevalence rate of malaria in the area. He told the tribesmen
Physical Cold, heat, noise, atmospheric pressure,
that bad spirits can go inside the mosquito and they shouldn’t
vibration, radiation
let the mosquitoes bite them. Resulted to lowered prevalence
of malaria in the area, and the emergence of protective clothing
Factors of a disease:
and other strategies against malaria.
Environmental Social, climate change, political, socie-
economic
Flavier used epidemiology to solve his problem. He found a
Host Factors Habits, customs, traditions, recreational disease (malaria) that was distributed in a certain area (tribes
activities, sexual behavior people), he identified the specific factor affecting the distribution
(mosquitoes are sacred), and he was able to prevent the
DEFINITIONS: disease (by changing the tribe’s behavior towards mosquito
• Incidence – new cases of a disease bites) and treat the people themselves (wearing of protective
• Prevalence – existing cases of a disease (old + new cases) clothing).
• Epidemic – increase in the number of cases in excess of what
is considered as normal (Example: polio case in the PH: • We should strive for equity in healthcare à no one should be
normal for us is zero percent, so just one polio case means
deprived of healthcare access (Luzon = Visayas = Mindanao)
an epidemic already)
• Universal Health Care – equal first contact care; primary care
• Infectivity – ability of an agent of disease to lodge and
multiply in the host
• Pathogenic – once agent of disease creates a disease (not EPIDEMIOLOGIC MODELS
all agents of disease are pathogenic, it can lodge and not 1. Wheel – genetic core, some people are more predisposed to
create a disease) diseases
• Pathogenicity – ability of an agent to cause a disease
• Immunogenicity – ability of the agent to produce an immune
response (measles and chicken pox, you only get it once
because there is immune response)
• Toxigenic – ability of an agent to produce toxins
• Virulence – ability of agents to produce virulent disease
(Ebola, rabies, SARS) virulent means severe or harmful
• Invasive – ability of an agent to invade the body (parasites)

IMMUNITY
• Sometimes, agent of disease is not virulent, but host is
immune-deficient, so easier to have disease.
• Those with chronic diseases are immunocompromised, so
they need to be healthy at all times
• Only cellular immunity is developed at birth, humoral immunity
needs time for it to develop
to
Human as
gentil are
-

1 of 2
2. Lever – environment as the fulcrum EPIDEMIOLOGIC CHAIN

Prevention
• When you are trying to prevent the illness, behavior should be
elicited in the pre-pathogenic phase. Host factors should be
elicited in pre-pathogenic stage.
• Even when disease has already occurred, prevention should
still be applied since prevention is continuous
3. Triangle – there should balance, or else, disease will ensue • Patients should be diagnosed early, so we can treat them
early

Stages of Prevention
• Primordial Prevention – intervention is done pre-
pathogenic, lifestyle of the patient is considered, done for
chronic diseases (ex. eating habit, exercise)
• Primary Prevention – done in pre-pathogenic phase as well,
focuses on health-promotion or specific protection
o Health Promotion – not targeting a specific disease (ex.
nutrition counselling)
o Specific Protection – when targeting a specific disease
(ex. immunization to specific diseases)
• Secondary Prevention – during pathogenic, for early
diagnosis and treatment such as screening and diagnostic
tests (ex. mammography, papsmear, colonoscopy, sputum
microscopy)
• Tertiary Prevention – severe disease (ex. rehabilitation,
disability limitation, palliative care)

EPIDEMIOLOGIC RESEARCH DESIGNS

Descriptive Case Report – one unusual case
– generate Case Series – several unusual cases
hypothesis; Cross-sectional Descriptive – random
define the sampling; get prevalence
disease
Analytical Observational Case Control – start with
4. Web – disease is caused by a complex genealogy of – test the outcome (odds ratio)
anteceded causes; multiple causation hypothesis Cohort – start with factor
(risk ratio)
Cross-sectional Analytic
– with differential statistics
Experimental
*The greater the RR and OR then the greater the disease
causation
INFERENTIAL STATISTICS:
Quali à Quali Chi Squared
Quali à Quanti T-Score (<30)
Z-Score (>30)
ANOVA (>3 groups)
Quanti à Quali Logistics Analysis
Quanti à Quanti Linear Regression

2 of 2
PREVENTIVE MEDICINE
OUTBREAK, EPIDEMIC, PANDEMIC, AND PUBLIC HEALTH SURVEILLANCE
Dr. Policarpio Joves, Jr.
Sources: Dr. Joves’ PPT (2020), Additional Video Links from PPT, CDC

OUTBREAK, EPIDEMIC, PANDEMIC TYPES OF OUTBREAKS

OUTBREAK
Point Source Outbreak
Sudden rise in cases of a disease in a particular place
An unusual/excess spike in the number people affected by a disease A population/group of people are exposed to a pathogen at a single
o If there are normally 2/20 people affected by a disease in a source at a point in time/for brief period of time
particular place, an outbreak occurs when 4-5/20 people have the o Ex: guests getting food poisoning at the wedding reception
disease Even if people got exposed at the same time, the onset of symptoms may
An increase in cases of a particular disease in a local area not occur at the same time
Ex: Measles outbreak in NCR o Due to variations in:
Extent of exposure
EPIDEMIC Individual susceptibility
An outbreak over a larger geographic area/a vast region The number of cases rises rapidly to a peak, and falls gradually
o Outbreaks that spread throughout a country The majority of cases occur within one incubation period of the disease
The occurrence of illnesses of similar nature in a community or region
Ex: poliomyelitis in Lanao del Sur, Laguna, and NCR

PANDEMIC
An epidemic that spread to multiple countries, continents, and across the
world
Ex: COVID-19, SARS
Current Pandemics (March 2020): HIV/AIDS, COVID-19
Past Pandemics
o 2009: Swine Flu (H1N1) – 150,000 deaths
o 1968: Hong Kong Flu (H3N2) – 10M deaths Common Source/Contiguous Common Source
o 1958: Asian Flu (H2N2) – 10M deaths
Persons are exposed to the same source over a prolonged period of time
o 1918: Spanish Flu (H1N1) – 20M deaths
(days, weeks, or longer)
o Ex: pathogens polluting a common water source
NOTE: The population is exposed for an extended period of time
An epidemiologist studies the effect of diseases in populations
o People continue to get sick until the end of the maximum
How should the spread of a disease be controlled?
incubation period
How could an epidemic impact a city?
o Because the period of time during which the people are exposed is
extended, the point at which people stop getting ill will be the
maximum incubation period from the end of the exposure
EPIDEMIC CURVE
The epi curve rises gradually and might plateau

Propagated Outbreak
Visual representation of the onset of illness among cases in an outbreak An infectious agent spreads from person-to-person
There is no common source
PERIODS OF INFECTION AND INCUBATION The graph will assume the classic epi curve shape of progressively taller
Incubation Period peaks, one incubation period apart
o Time of exposure to the causative agent until the first symptoms
develop
o Characteristic for each disease agent
Minimal Incubation Period
o The period of time during which no one gets ill even after exposure
to an infectious agent
Maximum Incubation Period
o The period of time after which no one gets ill
Infectious Period
o Period of time in which the person can spread the disease
o Does not necessarily have to start after the person becomes
asymptomatic
o A person can be spreading the disease before they become ill
Latent Period
o The period of time between being infected and becoming infectious

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The respective spikes on the epi curve get higher and higher until they TYPES OF SURVEILLANCE
merge together to form a wave, then the epidemic will burn itself out
Passive Surveillance
o Epidemics burn out because the pathogens run out of susceptible
individuals to infect Routine reporting of health data
People in the population will get sick, recover, and become Examples:
immune to the disease o Some diseases/conditions are required to be notified by law
People in the population will get sick and die (notifiable diseases)
As the outbreak unfolds, more and more of the population will o Diseases Registries
get sick/infected, and will no longer be candidates to be Collections of health data like births, deaths, chronic diseases,
infected etc.
Public health control methods may be put in place to control o Hospital data
the onward spread of the disease Number and type of patient that seek treatment
Valuable source of health information
o Generally inexpensive
PUBLIC HEALTH SURVEILLANCE o Can provide baseline data to monitor trends or monitor the impact
SURVEILLANCE of an intervention
Ongoing systematic collection, analysis, interpretation, and dissemination o Data sets can be linked to provide a complete picture of health
of data regarding a health event Limitations
o For use in public health action o Under-reporting
o To reduce morbidity and mortality Mild or asymptomatic illnesses
o To improve health Lack of access to treatment
Can be used to monitor any health-related event Inadequate laboratories
Logistical issues
o Varies from country-to-country
Reflects social, economic, cultural, and epidemiologic factors

Active Surveillance
Health data is actively sought out
Commonly used during outbreaks
o Health teams may visit communities to actively seek out cases that
may not have presented in health centers
Serosurveillance
o Involves testing blood in a selected population for various markers
o Ex: checking for antibodies can be useful to test for active or past
USES OF SURVEILLANCE disease
The eyes and ears of public health Health Surveys
o Can be done on community members, health facilities, or entire
The information gained from surveillance may be used for:
countries
o Characterizing patterns of disease
o Can be done on an as-needed basis or regularly
o Detecting epidemics and outbreaks
Provides more complete and better-quality data
o Suggesting hypotheses for further investigations
More resource intensive
o Identifying cases for further research
o Guiding disease control programs
Sentinel Surveillance
o Setting public health priorities
o Evaluation of health programs Uses selected institutions or groups to provide health data on specific
diseases or conditions
ELEMENTS OF A SURVEILLANCE SYSTEM Useful for monitoring diseases/trends, and detecting outbreaks
Detection and Notification of Health Events Disadvantage
o Usually done by a health service/laboratory o Because it is restricted to a few groups, it cannot detect events that
Data Collection and Storage happen outside these groups
o Needs to be done in a systematic way o Not useful for rare/uncommon conditions
Analysis and Interpretation of Data
Dissemination of Findings Rumor Surveillance
o So appropriate action can be taken Becoming increasingly useful in today’s interconnected world
Relies on unofficial sources of information
o Blogs/discussion sites
o Media
o Hearsay
o Social media
Can alert public health authorities to incidents/events that require
further investigation
Can lead to early detection of disease outbreaks

Syndromic Surveillance
Involves monitoring non-specific syndromes
o Presentations for fever, respiratory/GIT illness
o Purchase of medicine
o Absenteeism from work/school
Aim is early identification of clusters of illnesses before diagnoses are
confirmed and reported to public health agencies
Usually relies on automated/electronic methods for real-time reporting

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Others Verify the diagnosis
ProMED o Necessary to work out what is causing the outbreak and to help
o Website that puts together reports of disease events decide on the best control method
Global Public Health Intelligence Network (GPHIN) o Done by reviewing the clinical and laboratory findings
o Internet-based early warning tool At this stage, there can be immediate action that can be taken to control
o Uses an automated process to monitor online news sources for the outbreak, especially if the source and mode of transmission is known
diseases or significant health events To proceed with the outbreak investigation, an investigation team may
be put together
NOTE: o The size of the team will depend on the nature of the outbreak
An integrative approach using all sources of information
provides the best overall picture of health DESCRIBE
Provides an insight into who is infected, where the illness occurs, and
CHARACTERISTICS OF A GOOD SURVEILLANCE SYSTEM (US CDC) other characteristics of the outbreak
Have clearly defined objectives and have a good system to ensure that Who is going to be considered a case?
these objectives are achieved o Case Definition
Simple Sets the criteria that needs to be met to classify a person as a
o Easy to operate case
o Have straight-forward case definitions that are easy to apply There are generally criteria for time, place, person, clinical and
Flexible laboratory features
o Can accommodate changes in information needs or conditions with Have all the cases been found?
minimal adjustments o Once there is a case definition, the cases are looked for in a
Of quality systematic way, and information about the case is recorded
o Data should be complete and accurate o Usually done using questionnaires
Acceptable How to describe the cases?
o Accepted by people and organizations participating in surveillance o Time
Have a good sensitivity and PPV Tracks the development of the outbreak
o Should pick up most if not all diseases that exist in the population Ex: epi curve
Valid o Place
o It must measure what it intends to measure Provide information about the geographical spread of the
Representative illness
o It must accurately represent the occurrence of the health event in Identifies clusters
the population that it is being studied with regards to time, place, Modern mapping tools and geographical information systems
and person (GIS) technology have become important tools in mapping
Timely outbreaks
o Must detect events in a timely manner so authorities can take o Person
action Describe people affected by the outbreak by age, sex,
Stable occupation, ethnicity, etc.
o The resources (human and material) involved in running the system Provide useful insights into the disease
must be stable and available when needed Allows investigators to figure out who is more at risk
Must be evaluated routinely
o Make sure they are meeting their objectives and that they are DETERMINE CAUSE
serving a useful public health function What is the likely cause?
Investigators may have a hypothesis based on the information from
REMEMBER: previous steps
Surveillance is not just about monitoring health events. It must also If the pathogen that caused the outbreak is known, it can provide
provide useful information for public health action information about the source and mode of transmission of the outbreak
o Ex: in an outbreak of cholera, investigators will look into
contaminated water as the source of the outbreak
OUTBREAK INVESTIGATION If the causative agent is not clear, investigators will have to test the
STEPS hypothesis that was developed
Outbreak investigation goes through a few systematic steps o Usually done with an analytical epidemiological study (cohort and
o The number of steps, order, and content can vary case-control studies)
o Some steps can be done at the same time Studies can determine how likely it is that a factor is the cause
In essence, an outbreak investigation consists of 4 steps: of the outbreak
o An environmental investigation can also confirm the hypothesis
In a food-borne outbreak, the environmental investigation can
Determine identify factors that may have contributed to/caused the
Confirm Describe Control
Cause outbreak (ex: contaminated eggs, improper food storage, poor
hygiene)
o Laboratories are very useful at this stage
CONFIRM Provide microbiological information to confirm the hypothesis
First step
Investigators need to decide: Is there an outbreak? CONTROL
Need the baseline of the disease within the population to determine The primary goal of investigating an outbreak
whether there are more cases of illness than what is expected Can happen at any stage of the outbreak investigation
o Compare the baseline level to the level of illness being observed to Can be targeted at any step of the transmission pathways between the
confirm if there is an increase agent, host, and environment
o NOTE: the rise in cases can be due to other factors Control Measures
Increased testing, lab/diagnostic error, increase in population o Behavioral Interventions (ex: using mosquito repellant)
need to be ruled out o Vaccination
o Medication

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o Environmental (ex: insecticide spraying, improving water quality)
o Infection Control (ex: wearing PPE, disinfection)
o Health Education
Targeted and appropriate
Ensures that those who are sick know how to prevent
spreading the disease and those who are not sick know how
to prevent getting sick
After control measures are implemented, there should be active
surveillance to monitor the outbreak
o Make sure that the control measures are working

COMMUNICATION
Important in managing any outbreak
About making sure that accurate and timely information gets to the right
people at the right time
Communicating to the public is important, especially those who are
affected by the outbreak
o Allows them to adopt protective behaviors
o Helps with disease surveillance
o Reduces anxiety, confusion, and misinformation
The media is a useful partner in outbreak communication
o Shares information about the outbreak via online forums or
scientific journals
o Describe which measures were effective and what lessons were
learned
o Help others manage future outbreaks

OUTBREAK OVER
Once the investigators are satisfied with the control of the outbreak, it
must be declared to be OVER
Ex: generally, for infectious diseases, 2 incubation periods w/o a new
case must have passed before the outbreak can be declared over

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PREVENTIVE MEDICINE
EPIDEMIOLOGIC STUDY DESIGNS
Dr. Polly T. Chua-Chan
Sources: Dr. Chua-Chan’s PPT and Video Lecture (2020)

INTRODUCTION SOME SOURCES* OF DATA FOR DESCRIPTIVE STUDIES

THE EPIDEMIOLOGIC APPROACH Census data
Vital statistical records
Surveys on food consumption, medication use, etc.
Patient records from clinics or hospitals
Employment health examinations
*sources: readily available, less resource-intensive than analytic studies

CLASSIFICATION OF DESCRIPTIVE STUDY DESIGNS

use Descriptive Studies to examine existing facts and generate new hypotheses
test these hypotheses with Analytic Studies draw conclusions related to cause
and effect generate new knowledge cycle continues

EPIDEMIOLOGIC HYPOTHESIS
A testable statement of a putative relationship between exposure/s and
outcome/s CASE REPORT AND CASE SERIES
A possible explanation about the determinants of health and disease Case Report
A detailed account of a patient’s experience and clinical manifestations
Variable X ----------------------- Variable Y
that comprise a novel/atypical health or disease event
Independent Variable Dependent Variable
Importance: to inform the medical community of such a case
Exposure Variable Outcome Variable
Factor Disease Cases Worth Reporting:
o A case which has never been described before
BRANCHES OF EPIDEMIOLOGY o A case of a very rare health disease or condition
o A known disease with new clinical features
Descriptive Analytic o A known disease showing a novel pattern (ex: SARS, COVID-19)
Study the distribution of Study the determinants of Ex: 8 physicians in NYC individually reported that they unexpectedly
health-related states health-related states seen 8 male patients with Kaposi’s sarcoma (KS)
Describes disease occurrence o Determinants:
o KS was very rare in the US and occurred primarily in the lower
as to person, place, and time risk/exposure factors
extremities of older patients
Studies generate hypotheses Examines associations between
variables o These cases were decades younger, had generalized KS, and a much
o Relationship between lower rate of survival
causes and certain o This was before the discovery of HIV or the use of the term “AIDS”
disease outcomes (effect) o This case report was one of the first published items about AIDS
Studies test hypotheses patients

Epidemiologic Variables Case Series

o Person - Who are affected by the problem? A study of several subjects manifesting similar signs and symptoms and
o Time - When is the problem occurring? Is it seasonal? Periodic? linked by a common exposure/experience
o Place - Where is the problem occurring? A collection of individual case reports
o Health-related state (ex: disease) - What is the problem? Historically important in epidemiology
o Often used as an early warning sign of an epidemic
EPIDEMIOLOGIC STUDY DESIGNS Using a case series rather than a single case report can mean
Epidemiologic studies are usually biased towards quantitative study differentiating between formulating a useful hypothesis and merely
designs over qualitative study designs documenting an interesting medical oddity
Descriptive Analytic Ex: Creech and Johnson, 1974
Case Report/Case Series Observational o 3 cases of hepatic angiosarcoma among vinyl chloride workers
Cross-Sectional o Cross-Sectional o Hypothesis: exposure to vinyl chloride leads to liver CA
Ecologic o Case-Control
o Cohort Limitations of Case Reports and Case Series
Experimental/Interventional Cannot be used to test for the presence of a valid statistical association
*experimental study designs must be randomized and have an intervention o Can only generate new hypothesis
o Case Report: based on the experience of ONE person
o Case Series: lack of an appropriate comparison group
DESCRIPTIVE EPIDEMIOLOGY Vinyl chloride workers ↑ Liver angiosarcoma
RATIONALE Non-vinyl chloride workers ? Liver angiosarcoma
Diseases do not occur at random
Diseases patterns
o Can be identified
o May contribute to the predictability of the disease
o Provide clues as to the etiology of the disease

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PREVALENCE SURVEY/CROSS-SECTIONAL STUDY Ecological Fallacy
A study that determines the proportion of individuals with disease (or o Making a causal inference at the individual level from an aggregate-
other health event) in a defined population at a given time point level analysis of data
Provides a “snapshot” of the population’s health experience at a specified To say that there is an association between the factor and the
time outcome at the individual level when such is seen at the
Prevalence Proportion population level
The conclusion about the individuals is drawn from the
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎 observation of the population to which the individuals belong
𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑎𝑡 𝑎 𝑡𝑖𝑚𝑒 𝑝𝑜𝑖𝑛𝑡
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑃𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 = 𝑥𝐹
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑒𝑥𝑎𝑚𝑖𝑛𝑒𝑑 𝑎𝑡 𝑡𝑖𝑚𝑒 𝑝𝑜𝑖𝑛𝑡
E↔D E↔D
Applications of Prevalence Survey Population Level = Individual Level
o Can assess health status and health care needs of the general
population Ex: Emile Durkheim, “Le Suicide” (1897)
Burden of disease o “More generally, whatever the proportional share of these two
Distribution of physiologic or biochemical measurements confessions in the total population, wherever their comparison has
(anthropometrics, blood chemistry) been possible from the point of view of suicide, protestants are
Impact of health interventions (immunization coverage, length found to kill themselves much more often than Catholics”
of hospital stay)
o Can provide information on prevalence of disease or other health
outcomes in special groups
Age, occupation, religion, etc.

ECOLOGIC STUDY
A study that compares frequency of disease (and/or other health
outcomes) among groups
Have been used extensively by social scientists
o Easily and inexpensively conducted
Utilizes aggregate data
Rationale for Using Ecologic Studies
o Summaries (means or proportions) of observations
o Low cost and convenience
o While the aggregate data are derived from individuals in each
o Simplicity of analysis and presentation
group, the researcher of an ecologic study rarely has access to
o Interest in ecologic effects
these individual-level data
Impact of population interventions (policies or programs)
Types
o Limitations of individual-level studies
o (A) Multiple-Group Comparison
Exposure effects that vary minimally from person to person
o (B) Time-Trend/Time Series Design
but significantly between clusters of individuals
o (C) Correlational Study
Ex: environmental epidemiology, social epidemiology
Limitations of Using Ecologic Studies
o Correlational data represent average rather than actual exposure
levels
Any apparent association may be masking a more complicated
relationship between exposure and disease
o Temporal ambiguity
Because the cause and effect are being studied
simultaneously, there is no time factor/temporal sequencing
A B of events
This is also a problem of prevalence studies
o Difficulty in controlling for the effects of potential confounders

ANALYTIC STUDIES
OVERVIEW
In epidemiology, we would like to determine what factors cause
disease/death
o Factors
C Exposure factors, Risk factors
o Outcome
Correlational Analysis Event of interest
Disease/death
o Exposure should precede the outcome
o Need to determine these factors in order to prevent disease/death
Terminologies
o Outcome - health-related event of interest
Ex: death, disease condition
o Exposed – having/being exposed to a potential cause or risk factor
for disease/other outcome
Ex: being a smoker; having sex with someone with an STI
o Unexposed – not having/not being exposed to a potential cause or
risk factor for disease/other outcome
o Cases – individuals that are disease positive
o Controls – individuals that are disease negative

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Analytic Studies Ex: Smoking and Hypertension in a Community
o Always have a comparison o Hypothesis: is smoking related to hypertension?
Main difference between analytic and descriptive studies o Factor/Exposure Factor: smoking
Control vs. Case o Outcome: hypertension
Exposed vs. Unexposed o Are there people who smoke and have hypertension? Are there
With Outcome vs. Without Outcome people who do not smoke and have hypertension? Are there people
o Test the hypothesis of relationship between (at minimum) 2 who smoke but do not have hypertension?
variables
1 independent variable (exposure) COHORT STUDY
1 dependent variable (disease conditions/death) Cohort
o A group whose members share a distinct set of characteristics,
CROSS-SECTIONAL STUDY followed up within a specific period of time
Exposure (E) and Outcome (O) are measured at one point in time o The shared characteristics may be secondary to:
o Observational A common setting (ex: a school cohort)
A common experience (ex: a birth cohort)
Cohort Effect
o Refers to the secular change of disease frequency in a group as
influenced by membership in that particular group
Exposure is measured at the present time, and the participants are
followed up to measure Outcome at a future time
o Longitudinal, prospective, and observational
Uses of a Cross-Sectional Study o ALWAYS start with the exposure and end with the outcome
o Estimate burden of disease (prevalence)
o Establish baseline data
o Determine association between coexisting variables
Analysis
o Measures of Disease Occurrence
Prevalence in population
Prevalence among exposed
Prevalence among unexposed Cohort Study
o Measures of Association/Effect Measure o Aka Follow-up Study, Longitudinal Study, Incidence Study
Makes it an analytic study Types of Cohort Studies
Prevalence Ratio (PR)/Prevalence Odds Ratio o Prospective/Concurrent
𝑝𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 Classical cohort study
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑖𝑜 = Researcher begins at the start of the study, then waits for the
𝑝𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑
outcome among participants
Interpretation of Prevalence Ratio (PR) o Retrospective/Non-Concurrent
o If the numerator is equal to the denominator, the ratio = 1 The researcher begins at the end of the study, and gets data
No relationship retrospectively
1 is a null value o Ambispective
o If the prevalence of the disease is higher among the exposed than The researcher begins in the middle
among the unexposed, the ratio is >1 Gets some data retrospectively, gets other data through
Exposed > Unexposed observation
The exposure variable is a risk factor to the disease Combination of prospective and retrospective
o If the prevalence of the disease is higher among the unexposed
than among the exposed, the ratio is <1 start future
Unexposed > Exposed X (Prospective/Concurrent) ----------------------------------------------
The exposure variable is protective of the disease -------------------------------------- (Retrospective/Non-concurrent) X
--------------------------- X (Ambispective) ---------------------------

*X = researcher

Uses of Cohort Studies

o Calculate risk of developing disease
o Establish the temporal relationship between study variables
Tells the story of the natural course of the disease
o Expedient in examining multiple outcomes
o Practical in studying rare exposures
Issues of Cross-Sectional Studies Analysis
Advantages Disadvantages o Measures of Disease Occurrence
Resource-efficient Difficult to establish causality Incidence Proportions
o Quick; exposure and o Temporal ambiguity Incidence Rates
outcome are done at between exposure and o Measures of Association
once the outcome (which Risk Ratio/Rate Ratio/Relative Risk
Does not suffer from attrition came first?) Incidence Proportion
o No people lost to o No temporal sequencing o Describes the average risk for developing a disease condition
follow-up of events o More useful in determining etiologic/risk factors of diseases than
Generalizable Can only establish TRENDS prevalence proportion
o Often based on a Low level of evidence to 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎
sample of the general establish causality because of 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
population temporal ambiguity 𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑃𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 = 𝑥𝐹
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑜𝑓 𝑑𝑒𝑣𝑒𝑙𝑜𝑝𝑖𝑛𝑔
𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑

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Incidence Rate Outcome is measures at the present time and Exposure of the
o Describes the speed at which new cases occur participants in the past is estimated
o “Time at risk” o Longitudinal, retrospective, observational
Period or duration at which each person is vulnerable (at risk)
of developing the disease
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎
𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑖𝑜 = 𝑥𝐹
𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 𝑡𝑖𝑚𝑒 (𝑃𝑇) 𝑎𝑡 𝑟𝑖𝑠𝑘
Relative Risk (RR)
o Calculated from a cohort study Uses of Case-Control Study
o Incidence of disease in the exposure group over the incidence of o Determine association between variables
disease in the unexposed o Estimate relative risk
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝑅𝑒𝑙𝑎𝑡𝑖𝑣𝑒 𝑅𝑖𝑠𝑘 = o Expedient in examining multiple exposures
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 o Practical in studying rare diseases
o Also known as Analysis
Risk Ratio: if comparing incidence proportions o Measure of Disease Occurrence: NONE
Rate Ratio: if comparing incidence rates o Measure of Exposure Occurrence
o Interpretation Exposure Odds
o Measure of Association
Odds Ratio
Odds
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑎𝑛 𝑒𝑣𝑒𝑛𝑡 ℎ𝑎𝑝𝑝𝑒𝑛𝑖𝑛𝑔
𝑂𝑑𝑑𝑠 =
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑎𝑛 𝑒𝑣𝑒𝑛𝑡 𝑛𝑜𝑡 ℎ𝑎𝑝𝑝𝑒𝑛𝑖𝑛𝑔

Exposure Odds
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒
𝐸𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑂𝑑𝑑𝑠 =
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑛𝑜𝑡 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒
o Exposure Odds Among Cases
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑎𝑠𝑒𝑠
o RR>1 shows association =
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑛𝑜𝑡 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑎𝑠𝑒𝑠
Conclusion: those with the exposure were more likely to
develop disease o Exposure Odds Among Controls
o A more powerful effect measure than OR 𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑜𝑛𝑡𝑟𝑜𝑙𝑠
OR is just an estimation of the RR =
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑛𝑜𝑡 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑜𝑛𝑡𝑟𝑜𝑙𝑠
Issues of a Cohort Study
Advantages Disadvantages Odds Ratio (OR)
More likely to determine Resource-intensive o Calculated from a case-control study
causality compared to a o May need long follow- o The ratio of 2 odds
cross-sectional study up Ratio of the odds of exposure among the cases to the odds of
o Exposure is known to o expensive the exposure among the controls
come before the disease Suffers from attrition 𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑎𝑠𝑒𝑠
o Risk of loss to follow-up 𝑂𝑑𝑑𝑠 𝑅𝑎𝑡𝑖𝑜 =
𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑜𝑛𝑡𝑟𝑜𝑙𝑠
Ex: A study looked at whether exposure to bisphenol A (BPA) early in
life affects obesity levels in children later in life o Interpretation
o Positive associations were found between prenatal BPA
concentrations in urine and increased fat mass index, percent body
fat, and waist circumference at age 7
o Factor: BPA
o Outcome: adiposity
o At the start, those with the outcome of interest should be excluded

CASE-CONTROL STUDY
Type of study that attempts to capture the advantages of both cross-
sectional and cohort studies If OR>1, those with the disease are more likely to have the
Tries to eliminate temporal ambiguity of the cross-sectional study while exposure (harmful)
shortening the duration of the study If OR = 1, the exposure and disease are not associated
Procedure: If OR<1, the exposure has a protective effect against the
o Select the cases from a target population disease
Cases – group of individuals with the outcome or disease o Only an estimate for the RR
o Select another group of individuals without the outcome or disease Cohort studies are more accurate
(Controls) Issues of a Case-Control Study
o Cases and controls should have similar characteristics EXCEPT for Advantages Disadvantages
the outcome of interest Less-resource intensive Likely to suffer from
compared to a cohort study problems with recall (recall
o Go back in time (retrospective) to determine exposure in the cases
No attrition bias)
and in the control
o No loss to follow-up o Participants may not
o Compare the exposure status among the cases and among controls because it is recall their exposure
Aka “Trohoc study” retrospective Information Bias
o Old name of case-control studies o The information from
o Case-Control starts from the outcome, looks for the exposure the participant may be
(reverse of cohort studies) affected by the bias of
o “Trohoc” is “cohort” spelled backwards the interviewer

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Case-Control vs. Retrospective Cohort o Risk Ratio
o Both are retrospective The ratio of the risk of the disease in the experimental group
o Dependent on the temporal relationship between the initiation of (EER) and the risk in the control group (CER)
the study and the occurrence of the outcome 𝐸𝐸𝑅
𝑅𝑖𝑠𝑘 𝑅𝑎𝑡𝑖𝑜 =
Case-Control Retrospective Cohort 𝐶𝐸𝑅
E -------------- O E -------------- O o Absolute Risk Reduction (ARR)
Starts with outcome Starts with exposure Aka Risk Difference
Gets information from Gets information from databases Difference in the event rates for the EER and CER
participant interviews (less recall bias)
𝐴𝑅𝑅 = 𝐶𝐸𝑅 − 𝐸𝐸𝑅

EXPERIMENTAL STUDY o Relative Risk Reduction (RRR)

A cohort study, only with: Aka efficacy
o Assignment/manipulation of exposure (intentional) Relative decrease in the risk of an adverse effect in the
o Randomization/random allocation exposed group compared to the unexposed group
Best study design for controlling confounders 𝐶𝐸𝑅 − 𝐸𝐸𝑅 𝐴𝑅𝑅
𝑅𝑅𝑅 = =
Provides the strongest causal inference 𝐶𝐸𝑅 𝐶𝐸𝑅
Longitudinal, prospective, experimental o Numbers Needed to Treat (NNT)
The number of patients who would have to receive the
treatment for one of them to benefit
1
𝑁𝑁𝑇 =
𝐴𝑅𝑅
Classification
Clinical Trial Community Trial
Intervention is allocated to Intervention is allocated to an
RA = random allocation/randomization individuals entire community
Manipulation Therapeutic Trial Prophylactic Trial
o One group is not given the intervention (control) Intervention is a treatment Intervention is a preventive
The control should be the standard treatment agent agent
In the absence of a standard treatment, use a placebo Parallel Design Crossover Design
o One group is given the intervention (experimental) Aka “between subjects” Aka “within subjects” design
design
Randomization/Random Allocation
o Randomize into Test (Experimental) group and Control group Issues of an Experimental Study
o Process of assigning each participant into a group (experimental or o Ethical Considerations
control) by chance Potential threat to experimental group
o Ensures that both groups’ characteristics will become homogenous Loss of potential benefit to control group
(the same), EXCEPT for the treatment o Resource-Intensive
The only difference observed is the effect of the treatment May need long follow-up (can suffer attrition/loss to follow-
o A defining feature of a modern trial design up)
Types Expensive
o True Experiments: randomization in the allocation of treatment o If it is unethical to do an experimental study, the 2nd best study
o Quasi Experiments: no randomization is done design is a cohort study
Analysis Follows the same rules, except for the randomization
o Measures of Disease Occurrence Ex: the effect of adding pilates to a treatment regiment of NSAID use
Incidence Proportions for individuals with chronic low back pain
Incidence Rates o Individuals who included pilates method in their therapy took fewer
o Measures of Association NSAIDs and experienced statistically significant improvements in
Risk Ratio pain, function, and quality of life
Rate Ratio o Control Group: participants who took NSAIDs only
Treatment Effect o Experimental Group: participants who took NSAIDs and did pilates
o The proportion of cases of disease that were prevented by the
intervention under study among those who received it
𝐼 −𝐼 NEW STUDY DESIGNS
𝑇𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 𝐸𝑓𝑓𝑒𝑐𝑡 =
𝐼 SYSTEMATIC REVIEW
A comprehensive review of all relevant studies on a particular clinical or
o May also be given by: health-related topic/question
𝑇𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 𝐸𝑓𝑓𝑒𝑐𝑡 = 1 − 𝑅𝑅 Created after reviewing and combining all the information from
published and unpublished studies then summarizing the findings
Clinical Trials
o Focusing on clinical trials of similar treatments
o Experimental Event Rate (EER)
Advantages
The number of events or disease (risk) in the experimental
o Exhaustive review of the current literature and other sources
group
𝑎 (unpublished studies, ongoing research)
𝐸𝐸𝑅 =
𝑎+𝑏 o Less costly to review prior studies than to create a new study
o Control Event Rate (CER) o Less time required than conducting a new study
Number of events or disease (risk) in the control group o Results can be generalized and extrapolated into the general
𝑐 population more broadly than individual studies
𝐶𝐸𝑅 =
𝑐+𝑑 o More reliable and accurate than individual studies
*a = exposed w/ outcome; b = exposed w/o outcome; o Considered an evidence-based resource
c = unexposed w/ outcome; d = unexposed w/o outcome Disadvantages
o Very time-consuming
o May not be easy to combine studies

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Design Pitfalls to Look Out For Application of Real-World Data
o Studies included in systematic review may be of varying study o Provide insights into drug safety, in health and financial terms, and
designs, but should collectively be studying the same outcome its long-term effects
o Is each study included in the review studying the same variables? o Can improve decision-making, pre-authorization, and
o Some reviews may group and analyze studies by variables such as reimbursement of new drugs and treatments
age and gender; factors that were not allocated to participants o Can benefit medical research and patient outcomes
o Do the analyses in the systematic review fit the variables being studied in
the original studies?
VALIDITY OF EPIDEMIOLOGIC STUDIES
META-ANALYSIS
A subset of systematic reviews
A method for systematically combining pertinent qualitative and
quantitative study data from several selected studies to develop a single
conclusion that has a greater statistical power
o This conclusion is statistically stronger than the analysis of any
single study due to:
Increased number of subjects
Greater diversity among subjects
Accumulated effects and results
Uses
o To establish statistical significance with studies that have
conflicting results
o To develop a more correct estimate of effect magnitude
o To provide a more complex analysis of harms, safety data, and INTRODUCTION
benefits Epidemiologic studies try to provide accurate answers to questions
o To examine subgroups with individual numbers that are not o Ex: “What is the prevalence of smoking in QC?”
statistically significant “What is the additional risk of liver cancer due to previous
Advantages hepatitis B infection?”
o Greater statistical power o Estimates ≠ Real Prevalence or Real Risk Error
o Confirmatory data analysis Epidemiologic research involves generating and testing hypothesis about
o Greater ability to extrapolate the general population affected factors that cause or prevent disease
o Considered an evidence-based resource o The major objective of every investigator who tests an etiologic
Disadvantages hypothesis is to eliminate alternative explanations for his/her
o Difficult and time consuming to identify appropriate studies findings
o Not all studies provide adequate data for inclusion and analysis A valid study is one in which the observed association is NOT due to
o Requires advanced statistical techniques various sources of error (systematic or random errors)
o Heterogeneity of study populations
Design Pitfalls to Look Out For BIAS
o The studies pooled for review should be similar in type A systematic error that results in an invalid or incorrect estimate of the
Ex: all randomized controlled trials (RCTs) measure of association
Are the studies being reviews all the same type of study or are they o Systematic Error
a mixture of types? From the poor design and/or poor conduct of the study
o The analysis should include published and unpublished results to Ex: Non-comparability of groups, measurement flaws
avoid publication bias o Incorrect Estimates
o Does the meta-analysis include any appropriate relevant studies that may Can either underestimate or overestimate the true measure of
have had negative outcomes? association

REAL-WORLD DATA SELECTION BIAS

Randomized Control Trials (RCTs) Results form procedures used to select subjects and factors that
o Gold standard for demonstrating causality between the use of a influence participation in the study
specific medicine and intended/unintended effects under ideal Major Principle in the Selection of Study Groups:
conditions o Groups being compared should be AS SIMILAR AS POSSIBLE with
o The highly selective populations examined within the setting of respect to all other factors that may be related to the disease,
RCTs are often not comparable with the more heterogenous EXCEPT the determinant under investigation
populations in clinical practice If there really is no association between the exposure and the
Heterogenous population in the real-world setting disease, the disease rates in the populations being compared
o Patients with varying genetic make-ups, who present with different will be essentially the same
comorbidities, or already receive different medications for other Sampling Bias
morbidities o Systematically excluding or over-representing certain groups
“Efficacy-Effectiveness Gap” (Eichleretal) o Example: A study to estimate the prevalence of smoking in a
o Disparity of findings on the therapeutic efficacy of medicines from population, choosing a city center as the location of the study
tightly controlled RCT settings and the effectiveness of medicines If interviews are only conducted on weekdays, the study is
in the real world likely to under-represent people who are in full-time
Various Sources employment, and to include a higher proportion of
o Patient Registries unemployed/off-work/mothers with children
o Administrative Claims
o Social Media Channels

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Allocation Bias CONFOUNDING
o Systematic differences in the way in which subjects are recruited The mixing of effects between exposure, the disease, and the third
into different groups for a study variable (confounder)
o Example: A study may fail to do random sampling
First 20 patients who arrived at the clinic are allocated to a
new treatment
The next 20 patients are allocated to an existing treatment
However, the patients who arrived early may be fitter or
wealthier OR the doctor may have asked to see the most
seriously ill patient first The “third variable problem”
Responder Bias o When present, the association between exposure and disease is
o Missed responders or non-responders distorted
o Example: A study may send questionnaires to members of the Occurs when a separate factor (or factors) influences the risk of
control group. developing a disease, other than the risk being studied
If these subjects are from a different social class to the cases, Confounders
there may be differences in the proportion of responses that o Have to be related to the exposure
are received o Have to be independent risk factors for the disease being studied
Controls who are non-cases may also see little point in Examples of Confounders
responding o Age and sex
Common causes of confounding
INFORMATION BIAS o Ethnicity, smoking
Systematic differences in data collection, measurement, or classification o Mortality is higher in older people
Aka measurement error, misclassification bias, observation bias o Men tend to die earlier than women
A flaw in measuring exposure or outcome variables that result in o African-Caribbean people are at increased risk for hypertension
incorrect information between comparison groups o Smoker > smokers are more likely to develop lung cancer and
Recall Bias coronary heart disease
o People suffering from a disease may have spent more time thinking Confounding = Spuriousness
of possible links between their past behavior and their disease than o Scenario
non-sufferers Acne breakouts are common among high school freshmen
o Cases may report more exposure to possible hazards Therefore, entering high school causes acne
Social Acceptability Bias To prevent acne, one must not go to high school
o Some subjects may exaggerate or understate their responses, or
deny that they engage in embarrassing or undesirable activities
Recording Bias
o Medical records may contain more information on patients who are
“cases”
Interviewer Bias
o Interviewers may phrase questions differently for different
subjects, or write down their own interpretations of what the MINIMIZING ERRORS
subjects said No study is perfectly valid
Follow-Up Bias o At best, all known sources of errors are addressed and minimized
o In studies that follow up at intervals, people from certain groups Eliminate Effect of Confounding in Studies
may tend to be lost to follow-up, or a disproportionate number of o Randomization
exposed subjects may be lost to follow-up compared with non- Ensure samples are randomly selected
exposed subjects o Matching
Misclassification Bias In case-control studies, controls are matched to cases at the
o Patients may be systematically misclassified as either having disease start of the study according to particular characteristics which
or exposure are known to be present in cases (age, sex, ethnicity, smoker,
Some groups may give different responses etc.)
o Ex: Older people of lower social class may be less likely to express o Stratified Analysis
dissatisfaction with a health-related service Divide subjects into groups at the analysis stage and analyze
Investigators may look more closely at exposed patients to try to find the on this basis
presence of a disease, OR they may be more attentive to certain types of Ex: by age, sex, smoker/non-smoker
subjects

littlemarmaid 7
SUMMARY PAGE

Study Designs

Legend:
P = population S = sample size E = exposure O = outcome X = Researcher
+ = present - = absent = time progression RA = Random Allocation

True Experimental Quasi Experimental

Longitudinal Longitudinal
Prospective Prospective
Experimental Experimental

Prospective Cohort Retrospective Cohort

Longitudinal Longitudinal
Prospective Retrospective
Observational Observational

Case-Control Cross-Sectional

Longitudinal
Retrospective Observational
Observational

Equations and Measures

Prevalence Proportion Prevalence Ratio (PR)

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎
𝑐𝑒𝑟𝑡𝑎𝑖𝑛 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑎𝑡 𝑎 𝑡𝑖𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑝𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑
𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑃𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 = 𝑥𝐹 𝑃𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑖𝑜 =
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑒𝑥𝑎𝑚𝑖𝑛𝑒𝑑 𝑎𝑡 𝑡𝑖𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑝𝑟𝑒𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑

Incidence Proportion Incidence Rate

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎
𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑃𝑟𝑜𝑝𝑜𝑟𝑡𝑖𝑜𝑛 = 𝑥𝐹
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑜𝑓 𝑑𝑒𝑣𝑒𝑙𝑜𝑝𝑖𝑛𝑔 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑖𝑜 = 𝑥𝐹
𝑡ℎ𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 𝑡𝑖𝑚𝑒 (𝑃𝑇) 𝑎𝑡 𝑟𝑖𝑠𝑘

Relative Risk (RR) Odds

𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑎𝑛 𝑒𝑣𝑒𝑛𝑡 ℎ𝑎𝑝𝑝𝑒𝑛𝑖𝑛𝑔
𝑅𝑒𝑙𝑎𝑡𝑖𝑣𝑒 𝑅𝑖𝑠𝑘 = 𝑂𝑑𝑑𝑠 =
𝑖𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑎𝑚𝑜𝑛𝑔 𝑢𝑛𝑒𝑥𝑝𝑜𝑠𝑒𝑑 𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑎𝑛 𝑒𝑣𝑒𝑛𝑡 𝑛𝑜𝑡 ℎ𝑎𝑝𝑝𝑒𝑛𝑖𝑛𝑔

Exposure Odds Odds Ratio (OR)

𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑎𝑠𝑒𝑠

𝐸𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑂𝑑𝑑𝑠 = 𝑂𝑑𝑑𝑠 𝑅𝑎𝑡𝑖𝑜 =
𝑝𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑛𝑜𝑡 ℎ𝑎𝑣𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑂𝑑𝑑𝑠 𝑜𝑓 𝑒𝑥𝑝𝑜𝑠𝑢𝑟𝑒 𝑎𝑚𝑜𝑛𝑔 𝑐𝑜𝑛𝑡𝑟𝑜𝑙𝑠

Treatment Effect Experimental Event Rate (EER)

𝐼 −𝐼 𝑎
𝑇𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 𝐸𝑓𝑓𝑒𝑐𝑡 = 𝐸𝐸𝑅 =
𝐼 𝑎+𝑏
Control Event Rate (CER)
𝑐
𝐶𝐸𝑅 =
𝑇𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡 𝐸𝑓𝑓𝑒𝑐𝑡 = 1 − 𝑅𝑅 𝑐+𝑑

a = exposed w/ outcome; b = exposed w/o outcome;

c = unexposed w/ outcome; d = unexposed w/o outcome
Risk Ratio Absolute Risk Reduction (ARR)
𝐸𝐸𝑅
𝑅𝑖𝑠𝑘 𝑅𝑎𝑡𝑖𝑜 =
𝐶𝐸𝑅 𝐴𝑅𝑅 = 𝐶𝐸𝑅 − 𝐸𝐸𝑅

Relative Risk Reduction (RRR) Numbers Needed to Treat

𝐶𝐸𝑅 − 𝐸𝐸𝑅 𝐴𝑅𝑅 1
𝑅𝑅𝑅 = = 𝑁𝑁𝑇 =
𝐶𝐸𝑅 𝐶𝐸𝑅 𝐴𝑅𝑅

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PREVENTIVE MEDICINE
DEMOGRAPHY
Dr. Polly Chua-Chan
Sources: Dr. Polly’s PPT and Lecture (2020)

INTRODUCTION SOURCES OF DEMOGRAPHIC DATA

DEMOGRAPHY Census
The empirical, statistical, and mathematical study of human population o The total process of collecting, compiling, and publishing
The scientific study of human populations with respect to size, structure, demographic, economic, and social data pertaining to all persons in
and development the country at a specific time
The mathematical and statistical study of o Census Allocation
o The size, composition, and spatial distribution of human populations There are 2 ways of allocating people during census-taking
o Changes over time in these aspects through the operation of five
Assigns individuals to the place of their usual
processes of: De Jure
residence regardless of where they were
Fertility Method
actually enumerated during the census
Marriage People are allocated to the areas where they
Mortality De Facto were physically present at the census date
Migration Method regardless of where they usually live
Social Mobility Events are registered where they happened
o No morbidity because illness does not change the number of
o All vital events are recorded in the De Facto method
people in the population
Implication: NCR (a referral area) may have higher mortality rates
because of more complicated/high-risk patients, not because
THREE FOCI/AREAS OF STUDY
doctors are not good at their job
Population Size
Sampling Surveys
Composition of the Population
o Where demographic information is obtained based on a sample of
Distribution of the Population
the population
**also concerned with reasons for changes and Vital Registration Systems
the implications of these changes** o Continuously recorded vital events
Ex: births, adoptions, deaths, marriages, and annulments
USES OF DEMOGRAPHY Continuing Population Registers
Determines the number and distribution of a population in a certain area o Continuously updated on particular events that occur to each
o For planning, priority setting, and fund allocation individual and selected characteristics of this individual
Determines growth (or decline) and dispersal of population in the past o Not available in the PH
Establishes a “causal relationship” between population trends and various Other Sources
aspects of social organization o Voter’s Registration, School Enrollment, Income Tax Returns
Predicts future developments and their possible consequences
Serves as denominators for health indicators
CENSUS
TOOLS OF DEMOGRAPHY FEATURES OF A NATIONAL CENSUS
Counts Sponsorship
o Absolute numbers of a population or any demographic event o Usually a government agency
occurring over a specified period, area, and time Definite Coverage
o Ex: population size, number of males in the PH o Definite areas
Ratio Universality
o A single number that represents the relative size of 2 numbers o All members of the population should be counted without
o Used to describe the relationship between 2 numerical quantities or omissions or duplications
measures of events WITHOUT taking particular considerations to Simultaneity
the time or place o With only one reference date
Quantities do not necessarily represent the same entities, but With provisions for compilation and publication
the unit of measure for both the numerate and denominator
should be the SAME INFORMATION OBTAINED IN A CENSUS
Proportion Geographic
o Special type of ratio o Region, province, municipality/city, barangay (village)
o Numerator is part of the denominator Household or Family Information
o Percentage: a proportion where the factor is 100 o No. of Households, No. of Household Members
Rates Personal Characteristics
o Has a time factor o Sex, Age, Marital Status, Place of Birth, Citizenship
o Measures the amount of change (no. of new events) in a given
period of time
POPULATION SIZE AND COMPOSITION
POPULATION SIZE
Pertains to
o Actual population size
o In Vital Statistics, a rate shows the relationship between a vital o Changes or trends in population size
event and those persons exposed to the occurrence of said event, Absolute Changes
within a given area and during a specific unit of time Rates of Changes
The persons experiencing the event (numerator) must come Trends
from the total population exposed to the risk of the same Affected by natality, mortality, and migration
event (denominator)

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POPULATION COMPOSITION AGE AND SEX COMPOSITION
Pertains to measurable characteristics of the population Population Pyramid
o Age o A graphical representation of the age and sex composition of the
o Sex population
o Marital Status o Enables one to explain and describe the demographic trends of the
o Occupation population in the past
o Religion

DISTRIBUTION OF THE POPULATION

Refers to the location of the population in geographic subdivisions of a
given area
o Continents, countries, states
o Urban, rural, “rurban” (combination of urban and rural)

DESCRIBING THE POPULATION COMPOSITION

SEX COMPOSITION
Sex Ratio
o Compares the number of males to the number of females
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑚𝑎𝑙𝑒𝑠
𝑆𝑒𝑥 𝑅𝑎𝑡𝑖𝑜 = 𝑥 100
𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒𝑠
o For every 100 females, how many females are there?
o Ex: In the certain locality, there were 30,745,341 males and Interpretation
30,115,929 females enumerated o Developing countries have a more wide-based pyramid
30,745,341 More dependent people, less economically productive people
𝑆𝑒𝑥 𝑅𝑎𝑡𝑖𝑜 = 𝑥 100 = 102.8 ≈ 102 to support them
30,115,929
o Slow Growth and Negative Growth are ideal
There were 102 males for every 100 females
There are a lot of economically productive people to support
Sex Structure
few dependent people
o Compares the sex ratios across different categories/levels of
Seen in developed countries
another characteristic
o The population pyramid is change with each generation
o Example:
The wide-based pyramids are best reserve for human
Sex Ratios:
resources later on
At Birth: 1.05 male(s)/female
Population control and family planning should not be so strict
Under 15 years: 1.04 male(s)/female
because you never know what the future generations will look
15-64 years: 0.99 male(s)/female
like
65+ years: 0.77 males(s)/female
Constructing a Population Pyramid
At birth, there are more males than females, but because of longevity, the o Compute the percentage of the population falling in each age-sex
sex ratio is lower in older age groups. Males are more prone to certain group
diseases, and tend to take higher-risk jobs Use the total population as the denominator
o Let each age group be represented by a horizontal bar
AGE COMPOSITION The first bar, which represents the youngest age group, is
Median Age drawn at the base of the pyramid
o The value which cuts-off the upper 50% and lower 50% of the ages The bars for the males are drawn on the left side of the
of the population central vertical axis
o Indicates whether the population is young or old The bars for females are drawn on the right side
o Ex: Median Age (2020 est.) = 25.7 years o The length of each bar corresponds to the percent (%) of the
population falling in the specific age-sex group being plotted
Age-Dependency Ratio
Ex: Philippines 2019
o Provides an index of age-induced economic drain of manpower
resources
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 0 𝑡𝑜 14𝑦𝑟𝑠 + 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 ≥ 60𝑦𝑟𝑠
𝐴𝑔𝑒 𝐷𝑒𝑝. 𝑅𝑎𝑡𝑖𝑜 = 𝑥 100
𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 15 𝑡𝑜 59 𝑦𝑒𝑎𝑟𝑠

o Assumes that people 0-14 and ≥60 years are economically

unproductive and that people 15-58 years are economically
productive
The best formula would be the number of dependents divided
by the number of economically productive people
Interpret with caution
Factors Affective Age Composition
o Fertility
Higher fertility younger population
o Urban-Rural Differences
Urban are generally older than rural
People in urban areas usually have less children Determinants of the Sex Composition of a Population
o Peace and Order Situation o Sex ratio at birth
There are less babies born in times of war o Differences between sexes in death rates
o Cultural Practices o Geographic, economic conditions
Age at marriage o Occupation
Age pattern of childbearing o Differences between sexes in net migration rates

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Some Generalization of the Sex Composition of a Population Relative Increase
o Sex ratio at birth o The actual difference (absolute increase) between 2 census counts
o Age-specific mortality rates are usually greater among males expressed in percent of the initial population size
The sex ratio decreases with age, eventually falling below 100 𝑃𝑡 − 𝑃𝑜
o Sex ratio is generally higher in rural than in urban areas 𝑅𝑒𝑙𝑎𝑡𝑖𝑣𝑒 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 (%) =
𝑃𝑜
o Frontier communities and colonies generally have a higher sex ratio o Example: Town X
Consequences of Age and Sex Structure Census Date Population Size
o Consumption Patterns May 1, 2010 7,948,392
Young Population food and education Sept. 1, 2015 9,454,040
Old Population medical care and social services
o Death Rate 9,545,040 − 7,948,392
Young Population lower crude death rate 𝑅𝑒𝑙𝑎𝑡𝑖𝑣𝑒 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 (%) = 𝑥 100 = 18.9%
7,498,392
o Rates and Patterns of Migration
Young adults are more mobile than middle-aged and elderly Interpretation: The population increased by 19%
persons Annual Rate of Growth (r)
o Probability of Marriage for Men and Women o Also utilized results of 2 census counts to quantify the amount of
o Power Structure change in a population size during a specific time period
Old Population more conservative o Assumes that the population is increasing at a constant rate per
year
o Formula for computing r depends on whether the population is
POPULATION ESTIMATION considered to be increasing geometrically or exponentially
LIFE EXPECTANCY AT BIRTH o Example:
The average number of years a newly born infant is expected to live Population 2000: 48,316,503
under the mortality conditions for a given year Population 2010: 62,049,229
Derived from life tables Relative Increase:
, , , ,
= 28.4%
Calculated separately for males and females , ,

Ex: Life Expectancy (2020 est.) = 71.28 years 62,048,229 − 48,316,503

𝐴𝑣𝑒. 𝐴𝑏𝑠𝑜𝑙𝑢𝑡𝑒 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 𝑃𝑒𝑟 𝑌𝑒𝑎𝑟 = = 1,373,273
o Male = 68.7 years 10 𝑦𝑟𝑠
o Female = 74.7 years
PURPOSES FOR ESTIMATION
TOOLS FOR MEASURING CHANGES IN POPULATION SIZE For analysis of various trends
Natural Increase For measuring shifts in population
o The difference between the number of births and the number of For determining allocation of public funds or political representation in
deaths which occurred the government
𝑁𝑎𝑡𝑢𝑟𝑎𝑙 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 = 𝑛𝑜. 𝑜𝑓 𝑏𝑖𝑟𝑡ℎ𝑠 − 𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 For planning

o Ex: Natural Increase (Phil year x) TYPES OF ESTIMATION AND PROJECTION

no. of births – no. of deaths According to Detail Desired
1,631,069 – 313,890 = 1,317,179 persons o Total Population vs. Subgroups
Rate of Natural Increase (RNI) o Population by selected characteristics (ex: age, sex)
o The difference between the crude birth rate (CBR) and the crude According to Time Reference
death rate (CDR) of a specific population within a specified time o Intercensal Estimates
period, usually a year Refer to population estimates made on any date intermediate
to 2 censuses
𝑅𝑁𝐼 = 𝐶𝐵𝑅 − 𝐶𝐷𝑅
Take the results of these censuses into account
o Example:
o Post-censal Estimates
𝑅𝑁𝐼 𝑦𝑟 𝑥 = 𝐶𝐵𝑅 𝑦𝑟 𝑥 − 𝐶𝐷𝑅 𝑦𝑟 𝑥
Estimates of population size on any date in the past or during
26.3/1000 – 5.1/1000 = 21.2/1000 population
a current date following a census
Absolute Increase Per Year (b) Use the results of the most recent census and possibly earlier
o Measures the average number of people added to the population censuses, but NOT later censuses
each year o Projections
𝑃𝑡 − 𝑃𝑜 Populations estimates made on any date following the last
𝐴𝑏𝑠𝑜𝑙𝑢𝑡𝑒 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 𝑃𝑒𝑟 𝑌𝑒𝑎𝑟 (𝑏) =
𝑡 census for which no current reports are available
Where: Po = population size at initial time, 0 According to Method (or Assumption) Used
Pt = population size at latter time, t o Component Method/Inflow-Outflow Method
Also known as the balancing equation
o Numerator is equal to the absolute increase
o Denominator is the interval between time 0 and time t Pt = Po + (B – D) + (I – O)
o Example: Town X natural net
Census Date Population Size increase migration
May 1, 2010 7,948,392 o Arithmetic Method
Sept. 1, 2015 9,454,040 Assumes an equal amount of increase every year

t = 5.33 years (5 years and 4 months) Pt = Po + bt

9,454,040 − 7,948,392 where b = absolute increase in population per year
𝑏= = 282,486 𝑝𝑒𝑟𝑠𝑜𝑛𝑠
5.33 o Geometric Method
Assumes that the population increases (or decreases) at the
same rate over each unit of time (ex: each year)
Pt = Po (1 + r)t
Where r = rate of growth between 0 and time t

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o Exponential Method
Assumes a constant rate of increase (or decrease) and that the
population is increasing continuously
A constant rate of change is applied at every infinitesimal
amount of time
Pt = Po (ert)
Where e = constant equivalent to 2.7183;
r = rate of growth between 0 and time, t

TYPES OF PROJECTION/ESTIMATION PROBLEMS

Estimation of an Earlier Population (Po)
Estimation of Future Population (Pt)
Estimation of The Absolute Increase/Decrease Per Year (b) or Constant
Rate of Growth/Decline (r)
Estimation of the amount of time (t) it takes for a population to reach a
certain number (Pt)
Estimation of Doubling Time (t*)
o Doubling Time: the number of years it will take to double the
population

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PREVENTIVE MEDICINE
HEALTH INDICES: RATES AND RATIOS
Dr. Polly Chua-Chan
Sources: Dr. Polly’s PPT and Lecture (2020)

INTRODUCTION GENERAL FERTILITY RATE (GFR)

A more appropriate measure of fertility
o Males are included in the denominator of crude birth rate
Relates the number of births to the segment of the population who is
actually at risk of giving birth (the number of women in the reproductive
age group)

𝑛𝑜. 𝑜𝑓 𝑟𝑒𝑝𝑜𝑟𝑡𝑒𝑑 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠

𝐺𝐹𝑅 = 𝑥 1000
𝑛𝑜. 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒𝑠 𝑜𝑓 𝑟𝑒𝑝𝑟𝑜𝑑𝑢𝑐𝑡𝑖𝑣𝑒 𝑎𝑔𝑒

o The denominator represents the midyear population of women in

the reproductive years (between 15-44 or 15-49 yrs old)

OTHERS (not usually used)

Age-Specific Birth Rate

𝑏𝑖𝑟𝑡ℎ𝑠 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑦𝑒𝑎𝑟

𝑡𝑜 𝑤𝑜𝑚𝑒𝑛 𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑎𝑔𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
𝐴𝑔𝑒 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐵𝑖𝑟𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝑥 1000
Health Status Indicators (Rates and Ratios) 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛
𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑎𝑔𝑒 𝑔𝑟𝑜𝑢𝑝

Child-Women Ratio

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛
< 5 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑
𝐶ℎ𝑖𝑙𝑑 𝑊𝑜𝑚𝑒𝑛 𝑅𝑎𝑡𝑖𝑜 = 𝑥 1000
𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓
𝑤𝑜𝑚𝑒𝑛 15 − 44 𝑦/𝑜

In the community level, we deal with several people and collective statistics. To
diagnose whether a community is healthy or not, we use health status indicators
(mortality, morbidity rates). If there are a lot of morbidities or mortalities, the MORBIDITY RATES
community is not healthy. Morbidity = presence of sickness/disease/illness
All measures of morbidity fall under 2 basic types
TYPES OF RATES o Measures of Incidence
Crude Rate (General Rate) o Measures of Prevalence
o If the actual number of events is related to the WHOLE population
Specific Rate INCIDENCE
o If the events are related to specific SUBGROUPS of the population Measures the number of new cases developing during a period of time
Adjusted Rate (Standardized Rate) o Implies that the new cases come from a population which is
o Not a true rate disease-free at the beginning of an observation period
o Fictitious summary rates constructed to permit fair comparison o Develop the disease over the course of the observation period
between population groups differing in some important o This disease-free population is the population at risk
characteristics
Ex: cannot fairly compare a rich community vs a poor Cumulative Incidence (CI)
community, so you have to adjust the rates to put them on A measure of the average risk or the average probability of developing an
equal footing illness in a disease-free individual
o There are 2 methods to compute for the Adjusted Rate
𝑛𝑜. 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝐶𝐼 = 𝑥𝐹
FERTILITY RATES 𝑛𝑜. 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑓𝑟𝑒𝑒 𝑖𝑛𝑑𝑖𝑣𝑖𝑑𝑢𝑎𝑙𝑠
CRUIDE BIRTH RATE (CBR) CRUDE BIRTH RATE 𝑎𝑡 𝑡ℎ𝑒 𝑏𝑒𝑔𝑖𝑛𝑛𝑖𝑛𝑔 𝑜𝑓 𝑡ℎ𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
Measures how fast the population increases through the process of o The numerator generally refers to first occurrence of the illness
natality (birth) o The period of observation should be explicitly stated
A measure of one characteristic of the natural growth or increase of a The participants of the study should be observed for the
population whole period
Related the number of live births that occurred in a specific population The number of the participants at the start of the observation
during a specific time interval to the whole population period should be the same as the number of participants at
the end
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑟𝑒𝑔𝑖𝑠𝑡𝑒𝑟𝑒𝑑 𝑖𝑛 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑦𝑒𝑎𝑟
𝐶𝐵𝑅 = 𝑥 1000 The longer the observation period, the higher the CI will be
𝑎𝑣𝑒𝑟𝑎𝑔𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑠𝑖𝑧𝑒 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟 Attack Rate
o Special kind of CI where the period of observation is limited
o Since the population size changes during the year, the midyear Ex: the incubation period in an epidemic
population is used as the denominator (estimated population as of o Requires that all non-cases be followed up for the entire duration of
July 1) the follow-up period
Midyear population is also referred to as the average o Conditional on not dying first of other diseases during the
population size during the year observation period

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Incidence Density (ID) or Incidence Rate (IR) Period Prevalence (PP)
An estimate of the average rate of disease occurrence in a population Period: covering a segment or period of time
Aka force of morbidity or hazard rate Combines the prevalence at the beginning of a period and all the cases
that will develop during that period
𝑛𝑜. 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑎 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 o Point prevalence + cumulative incidence during the period
𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑝𝑒𝑟𝑖𝑜𝑑
𝐼𝐷 = 𝑥𝐹
𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 𝑡𝑖𝑚𝑒 𝑜𝑓 𝑜𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛 𝑛𝑜. 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑜𝑐𝑐𝑢𝑟𝑖𝑛𝑔 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎
𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑃𝑃 = 𝑥𝐹
The period of observation for the entire group may not be explicit BUT 𝑎𝑣𝑒𝑟𝑎𝑔𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
the time of follow-up for each individual is taken into consideration in the
denominator (person-time) point prevalence new cases
o Unlike CI, each person need not be followed-up for the same ↑ ↓↓↓
duration of time -----------------------------------------------------------------------------------
Considers that some patients will be lost to follow-up in a period of interest (ex: 1 year)
cohort-study
Very rarely used in a cross-sectional study
Person-Time (PT)
o The sum of the period of observation for each individual in the RELATIONSHIP BETWEEN INCIDENCE AND PREVALENCE
cohort
All illnesses start as incidence, then become prevalence (if chronic illness)
o The time after the disease occurs in a participant is NOT included in
o Ex: A patient with TB is an incidence on the day of exposure, but
the computation
becomes a prevalent case as time progresses
Example:
o Ex: A patient develops a cold today (incidence). 3 months later, he
develops a cold again (still an incidence because there is no
chronicity)
Acute illnesses will never become a prevalent case

Steady State
If a population is stable in its size and structure, and if both the
prevalence and incidence rates remain constant
Prevalence of a disease varies directly with the incidence rate and the
mean duration of the disease
𝑃≈𝐼𝑥𝐷
Example
= case of disease
Average annual incidence of lung cancer = 45.9/100,000
1 case of the disease
Average prevalence = 23/100,000
Total PT = 2 + 1.5 + 3* + 4 + 5 = 15.5 person-years
What is the average duration?
*Subject C only contributed 3 person-years 𝑃 23/100,000
because they got sick at Year 4 𝐷= = = 0.5 𝑦𝑒𝑎𝑟𝑠
𝐼 45.9/100,000

1
𝐼𝐷 = 𝑥 1000 = 64.5/1000 𝑝𝑒𝑟𝑠𝑜𝑛 𝑦𝑒𝑎𝑟𝑠
15.5 𝑝𝑒𝑟𝑠𝑜𝑛 𝑦𝑒𝑎𝑟𝑠 MORTALITY RATES
CRUDE DEATH RATE
In studies with a lot of participants, it may be tedious to compute for the
person-time, so the average time of observation may be used as the 𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑎𝑙𝑙 𝑐𝑎𝑢𝑠𝑒𝑠
denominator instead 𝐶𝐷𝑅 = 𝑥 1000
𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑠𝑖𝑧𝑒

PREVALENCE Measures the decrease in population size due to death

Measures the number of existing cases (old and new cases) at a point in Measures the force of mortality or estimates the probability of dying
time relative to a population at that time Summarizes age-specific death rates
Usually computed annually for a particular population
Point Prevalence (P)/Prevalence Proportion
The probability of an individual being a case at a point in time CAUSE OF DEATH RATE/CAUSE-SPECIFIC DEATH RATE
o NOT of developing the disease Numerator: number of deaths due to a particular disease
Generally used in health planning to quantify needs or demands for Denominator: total population (for most computations)
services o EXCEPTIONS:
Infant Mortality Rate (IMR)
𝑛𝑜. 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 𝑎𝑡 𝑎 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒 Some Age-Sex Specific Rates
𝑃= 𝑥𝐹
𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑡ℎ𝑎𝑡 𝑝𝑜𝑖𝑛𝑡 𝑖𝑛 𝑡𝑖𝑚𝑒 General Formula
Generally meant to by the term “prevalence” 𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑡𝑜 𝑎 𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑑𝑖𝑠𝑒𝑎𝑠𝑒
𝐶𝑎𝑢𝑠𝑒 𝑜𝑓 𝐷𝑒𝑎𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝑥𝐹
May refer to a population at a specific calendar time or to a population of 𝑚𝑖𝑑𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑠𝑖𝑧𝑒
a specific group
Measures the residuals of illnesses Used as the basis for determining the ten leading causes of deaths in a
o Prevalence is used for chronic diseases specific population
o Examples: o The cause of death in the death certificate is reflected in the cause
If a person is diagnosed with diabetes, they will forever be of death rate
diagnosed with diabetes o If the doctor fills out the wrong diagnosis/wrong cause of death, it
If a person is diagnosed with cancer, they will forever be will affect the statistics of the 10 leading causes of death
diagnosed with cancer

littlemarmaid 2
SPECIFIC DEATH RATES MATERNAL MORTALITY RATE (MMR)
Counts only deaths that occurred among a particular subset of the Measures the risk of dying from causes associated with childbirth
population (pregnancy, labor, and puerperium)
Examples: o Puerperium: period after birth (6 weeks)
o Among females only (Sex-Specific Death Rate) o DO NOT count deaths of pregnant women due to other causes
o Among children between 1-4 years old (Age-Specific Death Rate) Ex: a pregnant woman dies after being involved in a car crash
o Among farmers aged 18-24 years old (Age-Occupation Specific (not included because the cause of death is the crash, not her
Death Rate) pregnancy)
General Formula Formula
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑤𝑜𝑚𝑒𝑛 𝐷𝐼𝑅𝐸𝐶𝑇𝐿𝑌
𝑠𝑢𝑏𝑔𝑟𝑜𝑢𝑝 𝑤 𝑎𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑒 𝑜𝑓 𝑖𝑛𝑡𝑒𝑟𝑒𝑠𝑡 𝑑𝑢𝑒 𝑡𝑜 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑐𝑦, 𝑙𝑎𝑏𝑜𝑟, 𝑎𝑛𝑑 𝑝𝑢𝑒𝑟𝑝𝑒𝑟𝑖𝑢𝑚
𝑉𝑎𝑟𝑖𝑎𝑏𝑙𝑒 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐷𝑒𝑎𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝑥𝐹 𝑀𝑀𝑅 = 𝑥𝐹
𝑠𝑖𝑧𝑒 𝑜𝑓 𝑡ℎ𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑎𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑒
The number of live births is used in the denominator does NOT represent
the entire population-at-risk of dying
PROPORTIONATE MORTALITY RATE/RATIO (PMR) o The real population-at-risk of dying from maternal causes is the
Proportion: numerator is part of the denominator population of pregnant women/the number of pregnancies
May be computed by cause, age, sex, occupation, etc. o Since that number is usually unknown, the number of live births has
Formula (Ex: TB) been conventionally used as the surrogate denominator for
practical measures
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑑𝑢𝑒 𝑇𝐵, 𝑎𝑙𝑙 𝑎𝑔𝑒𝑠
𝑃𝑀𝑅, 𝑇𝐵 = 𝑥 100
𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠, 𝑎𝑙𝑙 𝑎𝑔𝑒𝑠 INFANT MORTALITY RATE (IMR)
Disadvantage 𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 < 1 𝑦𝑒𝑎𝑟 𝑜𝑙𝑑
o When an epidemic of a single disease occurs, the total number of 𝐼𝑀𝑅 = 𝑥 1000
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
deaths is increased with a corresponding decrease in the PMR from
other causes even if there may not have been any absolute One of the most sensitive indices of the health conditions of the general
decrease in the number of deaths from these other causes population
Relatively easy to obtain o Low Infant Mortality Rate is good
o Population data is not required in the computation o More sensitive compared to Swaroop’s index
o Usually no problems of age classification, except at age 50+ Interpretation of low IMR:
o Generally stable and not disturbed even by poor quality of From a Health From a Sanitarian’s From a Social
registration and age classification Officer’s POV POV Worker’s POV
o Records (data sources of PMR) are usually available from a large Adequate Good Illegitimates are
number of countries immunization environmental not neglected
Swaroop’s Index program sanitation Female babies
o An example of age PMR Sound infant and Good water are equally
maternal supply welcome as male
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 50 𝑦𝑒𝑎𝑟𝑠 𝑜𝑙𝑑 𝑎𝑛𝑑 𝑎𝑏𝑜𝑣𝑒
𝑆𝐼 = 𝑥 100 nutrition program Adequate insect babies
𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 Satisfactory ante- and vermin High standard of
o One of the sensitive indices of the health condition of the and post-natal control living
population services Good housing
Good disease facilities, etc.
High Swaroop’s Index is good (population lives longer)
control program
Low Swaroop’s Index is bad (population dies young)
Strict laws
governing the
CASE FATALITY RATE (CFR) administration of
Ideal: health programs
o Identify the cases of a particular disease, then set a length of
observation or follow-up period during which the cause of death in
the cases is observed The ideal denominator of IMR is the population of infants, but the
o The duration of the follow-up period is usually the duration of the number of live births is used as a substitute
clinical course of the disease during which the patient may die o Relatively good data on the number of live births is a lot easier to
In practice, CFR is computed by: obtain than good data on the population of infants
o Difference in the way live birth is defined may cause errors in the
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑎 𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 computation of IMR
𝐶𝐹𝑅 = 𝑥𝐹
𝑛𝑜. 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑜𝑓 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 o Campaigning for birth registration may lower IMR without really
reducing the number of infant deaths
Directly measures the “killing power” of the disease Bloats the denominator
o The more fatal course of the disease, the higher the CFR
CFR is modified/affected by One variation of IMR is Infant Death Rate (IDR)
o Completeness of reporting cases and deaths o Very similar to IMR
In the PH, the reporting of deaths is relatively complete o Same numerator, different denominators
because the cause of death needs to be determined before a IDR uses the number of children under 1 year
person is buried IMR uses the total reported live births
o Treatment and other procedures that can extend the lives of those o Accurate data on the number of infants is difficult to obtain, so IMR
affected is more commonly used than IDR
Example:
CFR, Rabies = 99%
CFR, SARS-COV = 5%
Comparing the two case fatality rates, it is apparent
that rabies is more fatal than SARS-COV

littlemarmaid 3
OTHER IMR-RELATED MORTALITY INDICATORS Category I Category II
Neonatal Mortality Rate (<28 Days or <1 month) Immediately Notifiable Diseases/ Weekly Notifiable
Syndromes/Events and Conditions Diseases/Syndromes
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑖𝑛𝑓𝑎𝑛𝑡𝑠
Acute Flaccid Paralysis Acute Bloody Diarrhea
< 28 𝑑𝑎𝑦𝑠 𝑜𝑙𝑑
𝑁𝑒𝑜𝑛𝑎𝑡𝑎𝑙 𝑀𝑜𝑟𝑡𝑎𝑙𝑖𝑡𝑦 𝑅𝑎𝑡𝑒 = 𝑥𝐹 Adverse Event Following Acute Encephalitis Syndrome
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 Immunization Acute Hemorrhagic Fever
Deaths in the neonatal period are mostly due to prenatal causes Anthrax Syndrome
o More difficult to reduce than the post-natal period Human Avian Influenza Acute Viral Hepatitis
Measles Bacterial Meningitis
o Need to take care of the mother to lower the Neonatal Mortality
Meningococcal Disease Cholera
Rate
Neonatal Tetanus Dengue
Neonatal deaths are more common in the PH Paralytic Shellfish Poisoning Diphtheria
Rabies Influenza-Like Illness
Post-Neonatal Death Rate/Late Infant Mortality Rate Severe Acute Respiratory Leptospirosis
Syndrome (SARS) Malaria
𝑛𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑎𝑚𝑜𝑛𝑔 𝑖𝑛𝑓𝑎𝑛𝑡𝑠
Outbreaks Non-Neonatal Tetanus
28 𝑑𝑎𝑦𝑠 𝑡𝑜 < 1 𝑦𝑒𝑎𝑟 𝑜𝑙𝑑
𝑃𝑜𝑠𝑡 𝑁𝑒𝑜𝑛𝑎𝑡𝑎𝑙 𝐷𝑒𝑎𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝑥𝐹 Clusters of diseases Pertussis
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 Unusual diseases or threats Typhoid and Paratyphoid Fever
Death rate of infants from 28 days to under 1 year old (COVID)
Due to environmental causes Non-Communicable Diseases
o More preventable o Integrated Chronic Non-Communicable Diseases Registry System
Stroke
Cancer
NOTE: Diabetes
IMR = Neonatal Mortality Rate + Post-Neonatal Mortality Rate o Fireworks Injury Surveillance (in December and January)

FILLING OUT THE DEATH CERTIFICATE

Only physicians are allowed to fill out a death certificate
Still Birth Rate/Fetal Death Ratio o In the absence of an attending physician, a municipal health officer
𝑓𝑒𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠 28 𝑤𝑒𝑒𝑘𝑠 𝑎𝑛𝑑 𝑜𝑣𝑒𝑟 𝐴𝑂𝐺 (MHO) can certify the death of the individual
𝑆𝑡𝑖𝑙𝑙𝑏𝑖𝑟𝑡ℎ 𝑅𝑎𝑡𝑒 = 𝑥𝐹 No MHO mayor; no mayor next of kin
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
o Unlicensed physicians (PGIs) are NOT allowed to sign the death
certificate
28 weeks = cut-off week for the fetus to survive
Deaths are color PINK (baby), BLUE (older patients)
In the computation of fetal deaths, the appropriate denominator is the
number of conceptions and pregnancies
o Indirectly obtained by adding all fetal deaths and live births
o Since fetal deaths (esp. early fetal deaths) are seldom reported,
WHO recommends the use of live births only in the denominator of
the rate

Perinatal Mortality Rate

𝑓𝑒𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ𝑠 28 𝑤𝑒𝑒𝑘𝑠 𝑎𝑛𝑑 𝑜𝑣𝑒𝑟 𝐴𝑂𝐺
+ 𝑖𝑛𝑓𝑎𝑛𝑡 𝑑𝑒𝑎𝑡ℎ𝑠 𝑏𝑒𝑙𝑜𝑤 7 𝑑𝑎𝑦𝑠
𝑃𝑒𝑟𝑖𝑛𝑎𝑡𝑎𝑙 𝑀𝑜𝑟𝑡𝑎𝑙𝑖𝑡𝑦 𝑅𝑎𝑡𝑒 = 𝑥𝐹
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
Cause of Death
Encroaches fetal deaths and neonatal deaths
I. Immediate Cause _________________________
Perinatologist: OB, expertise is the events surrounding birth until Antecedent Cause ________________________
puerperium Underlying Cause _________________________

II. Other Significant Conditions Contributing to Death

IN THE PHILIPPINES
HEALTH INDICATORS Underlying Cause of Death
Crude Birth Rate o Must be correct (recorded in statistics)
Crude Death Rate o If there is nothing indicated in the underlying cause, the antecedent
Maternal Mortality Rate cause is used (if no antecedent, immediate cause is used)
Infant Mortality Rate Examples
Leading Causes of: o A driver fell from the ravine. He sustained multiple fractures due to the
o Morbidity, Mortality, Maternal Mortality, Infant Mortality fall. He was brought to the ER, and noted to have palpable blood pressure
Need to know the leading causes to curb the problems of morbidity and He must have hypovolemic shock. Cardio-Pulmonary arrest*.
mortality Eventually pronounced dead.

REPORTING DISEASES Cause of Death

Births need to be registered within the prescriptive period of 30 days I. Immediate Cause: Hypovolemic Shock
Deaths need to be registered within 48 hours Antecedent Cause: Multiple Fracture
Underlying Cause: Fall
Communicable Diseases
o AO 2008-2009 Republic Act 3573 (Law of Reporting II. Other Significant Conditions Contributing to Death
Communicable Diseases)
*CP arrest is NEVER indicated as the immediate cause. All deaths will
end in cardio-pulmonary arrest.

littlemarmaid 4
o A child with a long history of thalassemia. 2 weeks PTC, he had severe
anemia due to the condition, and developed high output cardiac failure.
Later, he developed difficulty of breathing due to pneumonia.
Eventually succumbed.

Cause of Death
I. Immediate Cause: High Cardiac Output Failure
Antecedent Cause: Severe Anemia
Underlying Cause: Pneumonia
II. Other Significant Conditions Contributing to Death: Thalassemia

littlemarmaid 5
PRËVËÑTÏVË MËDÏÇÏÑË
FAMILY CEA & BREAKING THE BAD NEWS - Marital & sexual difficulties
Dr. Nunez Involves husband and wife, no need to call the other
family members
OBJECTIVES:
To discuss: FAMILY CONFERENCE
Why family meetings are important Hospitalization
Critical care issues
family meetings
What is done during family meetings
End of Life Care
How family meetings are conducted Institutionalization
To apply active listening skills and CEA in convening the Family conflict or dysfunction that interferes with patient care
family
WHO?
FAMILY: All emotionally significant people bound together by
Using Active Listening Skills in Conducting Family Meetings enduring ties
WHY?
Family influence on health Family intervention involves at least 2 members.
o Values, beliefs and attitudes are imbibed and behaviors
are learned in the context of family MEDICAL ROLES IN THE FAMILY
o Resource / therapeutic ally vs. obstacle to health care -
Indecision / poor illness understanding / - The nurse/first assist
misperceptions (ECMS), etc. -
Family interventions are more effective than individual - The medical board of directors
approach. **
o Because in the Philippines we have strong family ties
WHO DOES WHAT AND WHEN?
WHEN? - WHEN SOMEONE GETS SICK IN YOUR FAMILY,
When is it imperative / essential to convene the family? WHO DOES HE GO TO FIRST?
- WHO ASSISTS THAT PERSON?
Majority of patients can be handled individually but there will be -
times when the physician will be more effective if the family is - WHO DECIDES WHEN ADMISSION IS NECESSARY?
convened. - WHO WILL PAY FOR THIS ADMISSION?
- WHO WILL STAY WITH THE PATIENT?
LEVELS OF PHYSICIAN INVOLVEMENT WITH FAMILIES
LEVEL 1 Minimal involvement of the family (focus on the **Make sure you are speaking with the correct family members
individual)
**easily treatable diseases WHAT?
LEVEL 2 Focus is on health education of patient and family Educate
**ex. If child has asthma, health education is given o Illness understanding and management
to parents o Assistance with problem solving / decision making
LEVEL 3 HEALTH EDUCATION + IMPACT OF ILLNESS Provide psychological support
PROVISION OF EMOTIONAL SUPPORT o Empathy, opportunity to share feelings, assistance in
**all doctors should be here atleast. coping
LEVEL 4 Assessment of family dynamics & how it affects the Tasks to accomplish during FAMILY MEETINGS
illness; (Intervention restructuring)
HOW?
LEVEL 5 Family therapy C CATHARSIS
Doherty and Baird. Family Centered Medical Care
E EDUCATION
ROUTINELY CONVENE THE FAMILY: A ACTION
- Obstetrical & well-child care
OB: husband must be there as well 4-STEP CATHARSIS
Child care: needs parents or guardian 1. When you heard the
- Diagnosis of an infectious or a serious chronic illness diagnosis/experienced the
Management requires family support symptoms, what thoughts
This is also for them to understand what is happening came to your mind?
to the patient. 2. What did you feel when
these thoughts entered your mind?
COMMON SCENARIOS AND TASKS THAT WOULD REQUIRE FAMILY o Ano ang naging damdamin mo?
SUPPORT 3. Probe the feeling.
Giving diagnosis especially poor prognosis or bad news o What is it about these thoughts that makes you feel
Communicating prognosis / eliciting understanding and that
expectations 4. Summarize the thoughts and feelings.
Explaining complex medical information
Clarifying goals and management plans CATHARSIS
Determining options and preferences Explore the
Discussing advance directives, negotiating code status Identify ECMs (Emotional Critical Misperceptions) that cause:
o greatest emotional upset
CONSIDER CONVENING THE FAMILY:
o greatest obstacle to treatment
- Compliance problem
Leading Skills / Probing / Reflecting Skills
Need guide for the patient to comply.
- Poor control of a chronic illness
CATHARSIS (patient and family)
- High utilization of medical services
What do you call the illness / disability?
- Anxiety, depression
What do you understand about the illness?
- Substance abuse
What do you think has caused the illness?

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PRËVËÑTÏVË MËDÏÇÏÑË
CATHARSIS (patient)
What does your sickness do to you? IMPORTANT POINTS:
What can you no longer do that you would like to do? Make sure you have the correct family members
How do you feel about your sickness? attending the meeting
How does your family react to you because of your illness? Remain neutral
How do you feel about their reaction?
Give equal time / equal chance to speak
CATHARSIS Use proper active listening skills
o Reflect: Paraphrase / perception check
Family Both
o Summarize
How does his / her What do you think will
o Empathize (validate emotions)
sickness affect you? happen to the illness in
Switch from directive facilitator (biomedical physician) to
How do you feel about the future?
non-directive listener
his / her illness? What do you fear most
Always make a clear connection between the data you
about the illness?
are giving and the ECM.
What is the worst thing
If there are a lot of family members, you can group them.
that could happen?

EDUCATION
*Once misperceptions are identified
Objectives
IDENTIFY & CORRECT MISPERCEPTIONS At the end of the session you should be able to:
Share your findings with the patient and family Understand the principles in communicating bad news
Address the ECMs Learn the process involved in communicating bad news
Provide other information that the patient and family needs Perform proper disclosure of bad news using SPIKES.

VALIDATE APPROPRIATE PERCEPTIONS & EMOTIONS

Any news
of his or her future
Each family members have different emotions not all have
Any news that results in a cognitive, behavioral, or emotional
same levels of anxiety.
deficit in the person receiving the news
o may persist for sometime time even after the news is
ACTION/TREATMENT
received
1.
o Explain the recommended treatment and elicit their Bad news
perceptions and feelings about it -
o Address ECMs about treatment perceptions
Patient Both
BREAKING BAD NEWS
How do you feel about What might make the
the treatment plan that I treatment difficult for you
o Fear of how the patient might react
have just explained to to follow?
o Patients differ in what information they want and how
you? What would you like your
they want to receive it
What important results do doctor to do for you?
o Feeling of failure or inadequacy
you expect from this
treatment?
No formal preparation
*Lead, probe, reflect, summarize, address ECMs
Lack of communication skills and technique
2. INVOLVE THE PATIENT AND FAMILY IN THE MANAGEMENT PLAN
o Explicitly state what each needs from one another Brings sense of unpleasantness
o Agree about the things that they will do for each other May lead physicians to emotionally disengage from their
patients
o
o Breaking bad news is seldom a question of whether tell or not to
o you state what you are willing to do more a matter of
for each other in response to the needs expressed?
As a doctor, this our obligation, to tell or break the bad news.
Include tasks of the patient and family members and set a
HOW DO YOU BREAK BAD NEWS?
*Table is in the last page
(What are each family member willing to do for the other?)
SPIKES (6-STEP PROTOCOL)
CLOSING AND FOLLOW UP University of Texas MD Anderson Cancer Center

- Do a feelings check S etting

- Set specific date and time for follow-up P erception
o Sometimes, need immediate follow-up. I nvitation
K nowledge
HOW? E mpathize (address E motions)
Establish the need and get the necessary permission S trategize and S ummarize
o MDTC (services on board)
o Patient
o Family
SETTING
Arrange privacy
o Non-distracting environment
o Quiet place

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PRËVËÑTÏVË
o Curtains
MËDÏÇÏÑË
**But sometimes this is not followed already
Involve significant others
o Is there anyone else you want to be here with
you?
Make time, cellphone off, call a friend
Gather needed medical information
o Relevant data - imaging, test results, etc
o Options for treatment & care plans
Multi-disciplinary team (MDT) meeting
o Discuss with other consultants involved in the

o Ensure that the patient receives consistent

information.
Attending skills (Active listening skills)
- Lean forward EXPRESS EMPATHY
- Open posture o
- Verbal/voice of compassion o
- Eye contact o
- Relaxed o
- Seating arrangement
**Although now (COVID times) less eye contact or seating arrangement
is changed. But voice of compassion should still be there
PERCEPTION STRATEGY AND SUMMARY
Active listening skills
Ask the patient if he/she is ready to discuss prognosis and
are on the same page. What is management
your understanding of your Check in before you turn to giving a plan or discussing the

you

yesterday; what did the doctors Discuss plans and goals (what comes next?)
o important because it makes the future less scary
Do not make assumptions and more predictable

Emotionally Critical Misperceptions ECMs Explain and collaborate with the patient (and family)
- CEA (Catharsis, Education,
Action)
Offer realistic hope based on the
INVITATION
How much do they want to know?
prepare for the
Ensure that the patient is prepared to receive the news
Ask permission to give the bad news
Summarize main ideas
Assess understanding (address ECMs)
- have been
Set up succeeding appointments
thinking and feeling about your illness, I have something
else / there are some other things that I want / I need you

-
-
KNOWLEDGE
Before you give the information warn the patient that you
are proceeding with the bad news
Impart the message
o Avoid medical jargon
o Give information in small pieces
o Avoid excessive bluntness

DISCLOSE the information

EMPATHIZE, ADDRESS EMOTIONS

Allow the patient to experience the feeling and respond
empathetically.
Use silence to allow processing of information
Attend to emotions as they arise
Encourage and validate emotions
o Observe for emotions
o Identify the emotion
o Identify the reason behind the emotion

~end

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PRËVËÑTÏVË MËDÏÇÏÑË

DISCLAIMER: This is based on what I understood in the lecture. Sorry if

there are mistakes.
REFERENCE: Dr. Flores PPT and Lecture

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``
CFM: LECTURE 1 PRELIMS
INTRODUCTION TO CFM/ COMMUNICATION SKILLS
Dr. Jenell Y. Oczon | 11 JAN 2021
INSTITUTE OF MEDICINE 2024E

OUTLINE Intended message – verbal and non-verbal

I. Introduction B. Bio-psychosocial Unintended message – given off beyond
A. Communication approach awareness
II. Attitude and Active C. Active Listening 3. Channel of transmission – way of sending the message to
Listening Skills Skills one or more senses
A. Communication D. Attitudes written, oral, non-verbal
Process III. References 4. Receiver – perceives the sender’s message
5. Feedback – allows evaluation of the interpretation of the
message
important book previous trans
Forms of Communication
OBJECTIVES - all three can occur simultaneously (Linguistic, Para-linguistic,
At the end of the session, the students must be able to: Non-linguistic)
Define key terms
Identify the forms of communication 1) Linguistic Communication
Describe the attitudes in communication Messages that conveyed through words which may
Describe the opening and closing skills relate to ideas or to describe feelings or behaviors
Demonstrate the attitudes and the active listening Guide to honest labeling:
skills Rapport is already established
Person is ready
I. INTRODUCTION Choose words that shed light and not to
The heart of day to day activity of a practicing physician contribute to misinterpretation
is an effective doctor-patient relationship Speaking honestly does not mean speaking
The doctor-patient relationship can make or break the brutally
outcome of interaction Painful or unwelcome interpretation should
Communication is a complex aspect of the relationship be shared with compassion and sensitivity
Each participant sends and receives messages at multiple to the effect such news may have to the
levels and through multiple modalities simultaneously receiver
A competent physician must accurately receive and Interviewers exhibit four types of verbal responses:
interpret patient messages and ensures that the patient
accurately receives and interprets the physician’s a) Exploratory
message - open-ended responses that
The use of effective communication can assist physicians encourage a person to continue
to provide better care of their patients. talking
- Direct and Indirect leads and probes
b) Clarifying
A. COMMUNICATION
- ensures that the message was indeed
received and allows a person to correct
Functions of communication or check interpretation
Establish relationship between the persons involved - Paraphrase, perception check, and
Impart new information summary
Reinforce knowledge c) Affective
Direct the receiver in some ways as to: - attends to feelings, attitudes and
Change behavior values, and fosters self-awareness
Stimulate thoughts d) Honest Labeling
Provoke questions - speaks directly and honestly about the
Reinforce attitude issues

Elements of communication Word choice – words have varying degree of

1. Sender – source / initiates communication precision and conscious awareness
2. Message – subject matter which needs to be presented
and how it is being communicated
MORDEN, L. 1 of 6
CFM L1 PL MENDOZA, C.
The meaning of a particular word is intended to convey, It is essential in family practice
the meaning attached to the word by the hearer and the It can be used in the day to day family practice
interpretation given to the entire communication may be very
different for each of the two parties in an interchange.
Denotation- dictionary definition
Connotation- meanings, images or feelings that
come to mind when a word is used but that strictly
speaking are not part of its formal definition
Words that are best to avoid:
Slang words
Euphemisms can carry out many
connotations
Medical jargons convey concepts that may
be misunderstood Figure 1. Bio-psychosocial Approach Model
2. Paralinguistic Communication
Non-word messages conveyed through speech A bio-psychosocially oriented Physician is concerned with:
Vocal messages affected by intonation, pacing, sighs, Diseased organ
grunts and pauses. Patient’s feelings and perceptions of his illness
A person who has stopped speaking because of Manner in which these feelings and perceptions and the
overwhelming feelings must be allowed a few disease itself interact with the larger family, community
moments of silence. and cultural systems to which the patient belongs
3. Non-linguistic Communication
a) FACIAL EXPRESSION - associated with strong Family Medicine’s PFC Matrix
conflicting feelings that are not generally in the 1. PATIENT-CENTERED – utilizes understanding of the
conscious awareness of the person emitting them interplay of biomedical psychosocial factors disease in
frequent affective and clarifying responses are order to implement management that is tailor-fitted to the
used to bring non-word messages into the needs and values of the patient
verbal arena in order to understand them more
correctly and completely 2. FAMILY-FOCUSED – utilizes family assessment to generate
assumptions on how the family dynamics affect or facilitate
b) BODY PLACEMENT- tells much about their feelings and the prescribed management of the patient’s disease
the nature of their relationship to those around them
Personal space - 3ft front, 1ft behind 3. COMMUNITY-ORIENTED – enables the family physician to
Body position - inclined slightly forward use social determinants of health and health systems as
Sitting position - same eye level lens to understand how larger systems support or hinder
Parallel movement -mirror image the provision of care
Complementary movement - conveys
understanding and challenge 4. PATIENT-CENTERED FAMILY FOCUSED COMMUNITY
ORIENTED
c) USE OF TOUCH - handshake, gentle touch the family physician is able to manage the patient in a
holistic manner by recognizing patient needs, creating
d) PHYSICAL ARRANGEMENT – cleanliness and sanitation, an enabling family support environment and helping the
dividers and curtains, temperature of the room, patient and family navigate various community
lightings, noise control, scent and odors, table and resources
chairs, gadgets, and others this results not only in optimal health for the patient but
impacts to create a more responsive health system
II. ATTITUDE AND ACTIVE LISTENING SKILLS the use of the PFC matrix particularly in primary care in
the light of universal health care will impact on
A. COMMUNICATION PROCESS outcomes and will connect patients and families at the
has two components; cognitive and affective or correct tiers of the health system
emotional tone
COGNITIVE – dictionary definition of the words that C. ACTIVE LISTENING SKILLS
make up conversation Directs the physician to focus and give attention to
AFFECTIVE – emotional tone of the communication listening
We need to understand that we do not see or hear
[Link]-PSYCHOSOCIAL APPROACH those which we are not trained to see or hear.
Dr. George Engel – introduced the bio-psychosocial Therefore, WE NEED TO LISTEN MORE
approach model, 1970s
CFM L1 PL Introduction to CFM/ Communication Skills 2 of 6
It is important to hear both cognitive and affective b) Direct Lead
components and respond to each of them - the MD chooses the direction where the
It is important to understand the concept of hearing conversation should go.
and listening: - oftentimes it is based on the disease entity
HEARING – physiological sensory process by which that the MD is considering
auditory sensations are received by ears and - it is also worthwhile to choose basing it on
transmitted to the brain what is most emotionally disturbing for the
LISTENING – involves interpreting and understanding patient
the significance of the sensory experience - e.g. “Tell me more about…”
“Let’s talk about…”
Opening Skills 4.) FOCUSING
First half of the patient-doctor encounter the MD: – Patients in emotional pain sometimes brings up a lot of
Brings out the patient’s perceptions and frame of things one after the other
reference – in such cases, ask the patient to do the choosing of
Sees the situation from the patient’s perspectives rather what is most important to him
than from his own
Helps the patient become aware of his perception 5.) PROBING
Helps the patient to understand how such a perspective – questions that the MD asks in order to find more about
results in the symptoms, feelings and behaviors which how the patient is reacting to the illness
the patient experiences – ask open-ended questions not answerable by yes or no
The opening skills bring out perceptions vs. reality – between probing an event and probing a feeling, it is
Very often the patient’s point of view is not enough; his better to probe the feeling
perceptions and perspectives may in – avoid “WHY” questions
some ways be distorted and unproductive – use “HOW” , “WHAT” , “could you please explain”
It is the role of the MD to challenge the distortion and
incongruence with reality 6.) ATTENTIVE SILENCE
– one of the hardest skills to master, as people often feel
1.) ATTENDING SKILLS uncomfortable with silence and feel the compulsion to
– involves the listener giving his/her physical attention to jump in and fill in the silence
the speaker – there are times when silence is the most appropriate
– it includes: response, as when:
attentive, open, posture he speaker is searching for a response
appropriate body movement the speakers is emotionally distressed,
appropriate eye contact with speaker silence allows the person to experience distress, regains
open and receptive facial expression composure and continue the communication
establishing a non-distracting environment
7.) REFLECTING SKILLS
2.) BRACKETING – facilitates the attempt of the listener to communicate
– form of psychological attending that s/he understands the perspective of the speaker
– it is a mental skill involving suspending own judgment
and feelings and then setting them aside for a while in CASE: EXAMPLE
order to listen more fully to the patient
Post MI husband “I really love my wife. She does many things
3.) LEADING SKILLS for me constantly. She reminds me of my medicines, she sees
a) Indirect Lead to it that I get to sleep early, she fusses about my food, she
- open invitation by the MD to the patient to talk keeps track of where I am all the time because she said that
about whatever concerns him she is worried about me. Sometimes though, I can’t breathe
- includes verbal and non-verbal encouragers because of all these things.”
which are used to show that the listener is
listening and following what the speaker is a) REFLECTING CONTENT
saying 1) Paraphrasing - listen for the basic message of
- encourages the speaker to continue talking the patient; restate to the patient a concise
- e.g. “What can I do for you?” and simple summary of the basic message;
“What would you like to talk about?” don’t add anything which the patient did not
- verbal: “yes”, “go on”, “and then”, “I see” mention
“Uhmmm” e.g. “You appreciate all these things that
- non-verbal: nodding, smiling, eye contact your wife is doing for you, but it kind of
suffocates you.”

CFM L1 PL Introduction to CFM/ Communication Skills 3 of 6

mother. I feel so ashamed.”
2) Perception Checking - paraphrase what you Paraphrase: “You drank to the point where tears
think you heard; ask for confirmation directly came freely. You’re ashamed now as you talk about it.”
from the patient about the accuracy of your
perception; allow the patient to correct your Perception Check: “You feel very badly about what
perception if inaccurate happened last night.”
e.g. “You appreciate all these things that Informative Statement: “You feel badly that you lost control
your wife is doing for you, but it kind of of yourself last night.”
suffocates you. Is that right?” Alternative Interpretation: “You drank until you lost control
of your feelings. As you look back on the evening now you
b) REFLECTING FEELING want to punish yourself acting in that childish way.”
- empathic responses facilitate and deepen
communication by focusing on the speaker’s 2. Interpretative question – question form; implies a more
feelings rather than content details tentative quality than declarative statements and makes
- involves expressing in fresh words the patient’s interpreting less risky
essential feelings, stated or strongly implied
e.g. “You appreciate your wife’s EXAMPLE:
attentiveness, but it somehow irritates Doctor: “When are you going to be concerned about
you, doesn’t it?” yourself too?”
“it sounds as if you felt…” Patient: “That is a selfish attitude.”
“As I understand it, you seem to be Doctor: “So, what’s wrong with that?”
feeling…” Patient: “I don’t like selfish people.”
Doctor: “Because…?”
c) REFLECTING EXPERIENCE
- oftentimes, the patient has a lot of non-verbal Patient: “Selfish people aren’t so popular.”
or gestures which reflect some emotional state Doctor: (Interpretative Question) “So, popularity is
but the feeling is not articulated important to you; and if you are self-centered, people
- the MD can mirror the non-verbal behavior won’t like you. Is that getting close to where you are
back to the patient and ask for clarification as now?”
to what the behavior means
e.g. “While you were talking about your 3. Fantasy or Metaphor - interpretation is put into the form
wife, I noticed that you were clenching of a fantasy (daydream), or by using the picture language of a
and unclenching your fist. What do you metaphor
think that could mean?”
EXAMPLE
Closing Skills
Fantasy: “I have a fantasy about what you said. I
align perceptions to reality
picture you walking down a path of woods, coming to a
latter half of the consultation process :
MD helped the patient to see the situation fork in the path, and being undecided which one to
from a more realistic point of view choose. You unconcernedly flip a coin and run joyfully
MD helped the patient to set reasonable down the path chosen by the coin. How does this fit?”
goals toward the resolution of his problem Metaphor: “Most of the time I perceive you as a great
big soft teddy bear who stays in any position he is
1.) INTERPRETATION placed.”
– involves sharing your “hunches” with the patient as to
what is behind the experiences, behaviors, and feelings GUIDELINES FOR INTERPRETATION:
– the goal of all interpretative effort is increasing self- 1. Look at the basic message(s) of the patient
interpretation by the patient 2. Paraphrase
– the more the patient knows about him/herself. The 3. Add your understanding of what the messages mean to
more he will be able to change his behavior him in terms of your theory
4. Keep the language simple and close to the patient’s
FORMS OF INTERPRETATION: messages
1. Interpretative statement - declarative statement about 5. Avoid wild speculations
your hunches 6. Offer tentative ideas on what their words and behaviors
EXAMPLE: mean
Patient: “I was at the party last night where I 7. Solicit patient’s reactions to your interpretation. 8. Teach
drank too much. I broke into tears and cried and the patient to do his own interpreting
cried. I acted like a child who wants to go home to
CFM L1 PL Introduction to CFM/ Communication Skills 4 of 6
2.) CONFRONTATION Example: “We have been talking about your problems in
– enables the MD to challenge the discrepancies, getting along with people. You may be interested to
distortions, smoke screens and games that the patient know that I have been increasingly irritated with
is using, knowingly or unknowingly, to keep himself your persistent quibbling almost everything I say. I
and others from seeing his problems clearly, thus
sometimes feel that I don’t want to listen to you
getting in the way of problem-managing actions
– an invitation to examine behaviors that may be self- anymore. Do you think my reaction to you is typical of
defeating or harmful to self or others other people you know?”
– an invitation to change behavior
4. Give feedback in small amounts so that the patient can
Be mindful that the CONFRONTATION skill may be experience its full impact
perceived as offensive and may lead to defensive behavior,
non-compliance, loss of the patient, loss of practice Example: “I don’t like the way you constantly
interrupt me,” is better than “I don’t like you
FORMS OF CONFRONTATION:
because you constantly interrupt me.”
1. Challenging discrepancies
between what the patient thinks or feels and what
he says 5. Feedback should be a prompt response to current or to
between what he says and what he does specific behavior, not unfinished emotional business from the
between what he is and what he wishes to be past
between his expressed values and his actual 6. Give feedback on the things the patient can change
behavior 7. Give positive feedbacks
8. Ask for reactions to your feedback
EXAMPLE:
“You say you have been dieting, but so far you Example: “You have shown a firm awareness of your own
have failed to show any weight loss. Perhaps we feelings, though they have changed. This helps me
need to examine your daily eating record.” believe that, given time, you can find a way though these
“You say health is important to you, but you struggles.”
have not been in for a check-up in five years.
3.) SUMMARIZING
Let’s talk about it…”
– involves tying together into one statement several
ideas and feelings at the end of a discussion or
2. Challenging distortions interview
some patients cannot face the situation as it is so
that they distort it in various way
EXAMPLE:
EXAMPLE: After a patient has talked about situations about
Nancy sees herself as a sexual victim, but this is his life experiences and the vague feelings of
only partially true because she flirts and seduces. inadequacy running through all of them.
Challenge: “Nancy, I realized that the sexual Summary: From your talk about your family,
demands made on you by your boss have had a school, and now your new job of selling, you
profound impact on you, but you’re continuing appear to have experienced feelings of personal
to put most of the responsibility for your sexual failure in all of them.
problems on others seems to be self-defeating. It
also seems to be convenient.” – broader than paraphrase
– gives focus or direction to counseling process
– help clients view their situation in a more focused way,
3. Feedback and opinion
clarify and begin to set goals
MD’s reaction to the therapeutic interchange, his
own perception of the problem.
GUIDE FOR SUMMARIZING:
GUIDELINES IN GIVING FEEDBACK: 1. Attend to the various themes and emotional overtones as
1. Patient must be ready the patient speaks
2. Describe the behavior before giving your reaction to it, 2. Put together key ideas and feelings into broad statements
which may be thru sharing your feeling of their basic meanings
3. Give feedback about the behavior rather than judgment 3. Do not add new ideas in the summary
about the person 4. Decide if it would be more helpful to let the patient
summarize for you

CFM L1 PL Introduction to CFM/ Communication Skills 5 of 6

4.) GOAL SETTING D. ATTITUDES
– most important part of the session since it ties all the
processes together 1. GENUINESS
– being honest and open about feelings, needs and ideas
CHARACTERISTICS OF GOAL SETTING: – a genuine person can be himself with another so they know
1. specific and measurable him as he truly is
2. realistic – a genuine person is aware of his innermost thoughts and
3. hierarchical feelings, accepts them and whenever appropriate, shares
4. desired by the person them responsibly
5. tailored to him – 3 ingredients: self-awareness, self acceptance and self-
6. frequently evaluated expression
STEPS FOR GOAL SETTING: 2. UNCONDITIONAL POSITIVE REGARD
1. Identify and affirm strengths – choose to believe that there is something good in a person
2. Discuss resources regardless of the external qualities
3. Identify the needs/wants in terms of behavior one would – involves accepting, respecting and supporting another
like for himself or from others person
4. Help patient decide which alternatives he would like to try. – non-possessive love, willed love

GOAL SETTING: ON GIVING ADVICE AND SHARING 3. EMPATHY

PERSONAL EXPERIENCES – ability to put oneself in the shoes of the other
- The content comes not from the client but from – to be with, feel with and think with the other
the doctor-counselor – ability to really see and hear another person and
- “client-centered” understand him from his perspective

INFORMATION GIVING – enables the doctor-counselor to COMPETENCE – knowledge + attitude + skills

help the patients acquire the kind of information that enables Communication flows out of basic attitudes as well as
them to see their problem situation in a new light; helpful through specific methods and skills
during goal setting The person who has mastered the skills but lacks
genuineness, love and empathy will find his expertise
TWO WAYS OF GIVING INFORMATION: irrelevant
1) Advising – based on experience
- appropriate in crisis situations
- inappropriate for dealing with major individual
III. REFERENCES
choices
Dr. Oczon, J. (2021). Communication Skills Concept.
2) Informing – based on expertise and evidences (Powerpoint Presentation). FEU-NRMF.
- involves both giving information and correcting Previous Trans. Bautista, A. MD2023
misinformation on the part of the counselee

DOCTORS DO NOT PRETEND TO KNOW EVERYTHING!

GUIDELINES:
1) Clear and relevant
2) Do not overwhelm patients
3) Do not push your own values
4) Be informed
5) Phrase advise in the form of tentative
suggestions

HELPER SELF-SHARING – doctor reveals something about his

personal life (Self-disclosure)
GUIDELINES:
1) Selective and focused
2) Not a burden to the patient
3) Done sparingly

CFM L1 PL Introduction to CFM/ Communication Skills 6 of 6