30.4 Community Medicine: Principles of Public Health Administration and Program Planning, Vital Health Indices (Infant and Maternal Mortality), the Ecologic Concept of Health, Lifestyle and Non-Communicable Diseases, Health-Seeking Behavior and Traditional Medicine

Why this area matters

The TOS community medicine competencies are to:

• classify the health problems of a community;
• describe available health programs;
• plan, organize, implement, evaluate and monitor community programs;
• compare lifestyle diseases and NCDs;
• educate families and communities and formulate wellness programs.

Questions often ask for the right indicator, the correct order of program planning steps, or the cultural factor behind a delay in seeking care.

Principles of public health administration

• Public health administration applies management to population health. Its functions are often summarized by POSDCORB:
  • Planning;
  • Organizing;
  • Staffing;
  • Directing;
  • Coordinating;
  • Reporting;
  • Budgeting.
• The program planning cycle:
  1. Situational analysis and community diagnosis: health statistics, surveys, key informants, prioritization by magnitude, severity, feasibility and community concern.
  2. Setting goals and SMART objectives: specific, measurable, attainable, relevant and time-bound.
  3. Choosing strategies and planning activities, resources and timelines (for example, a Gantt chart or logical framework).
  4. Implementation, with supervision and coordination.
  5. Monitoring (tracking inputs, activities and outputs during implementation).
  6. Evaluation (assessing outcomes and impact against objectives).
• Indicators:
  • input: staff, drugs, money;
  • process: activities done;
  • output: services delivered, such as children immunized;
  • outcome: coverage and behavior change;
  • impact: long-term change in morbidity and mortality.
• Leadership and coordination:
  • the municipal health officer heads the rural health unit team;
  • the Local Health Board advises the local chief executive;
  • intersectoral and inter-local health zone arrangements link barangays, municipalities and hospitals.

Vital health indices and infant mortality

• Causes of infant death:
  • neonatal deaths come mainly from prematurity, birth asphyxia, congenital anomalies and sepsis;
  • later infant deaths come mainly from pneumonia and diarrhea, worsened by malnutrition.
• Reducing infant mortality relies on EINC, breastfeeding, immunization, IMCI and safe water.

The ecologic concept of health and disease

• Health (WHO) is a state of complete physical, mental and social well-being, not merely the absence of disease.
• The ecologic view: health results from the balance between people and their physical, biological and social environment. Disease follows when this balance is upset by agents, host factors or environmental change, such as floods spreading leptospirosis, urbanization spreading dengue, or deforestation and climate change shifting vectors.
• The health-illness continuum runs from optimal wellness to death. Wellness and health maintenance keep people at the healthy end through lifestyle, screening, immunization and a supportive environment.

Lifestyle and non-communicable diseases

• Burden: NCDs (cardiovascular disease, cancers, diabetes, chronic respiratory disease) now cause most deaths in the Philippines. Many of these deaths occur before age 70.
• The four main modifiable risk factors:
  • tobacco use;
  • harmful use of alcohol;
  • unhealthy diet (salt, sugar, trans fats, low fruit and vegetable intake);
  • physical inactivity.
  • These drive the metabolic risks of hypertension, obesity, diabetes and dyslipidemia.
• PhilPEN (Philippine Package of Essential NCD Interventions):
  • primary care screening of adults with risk assessment (BP, BMI and waist, smoking, alcohol, diet, activity, glucose and lipids where available);
  • total cardiovascular risk estimation;
  • lifestyle counseling and treatment by protocol;
  • referral.
• Policy measures (primordial and primary prevention):
  • tobacco control: the Tobacco Regulation Act (RA 9211), graphic health warnings (RA 10643), sin taxes, a nationwide smoke-free environment order (EO 26, 2017) and regulation of vapes;
  • salt and sugar reduction and taxes on sweetened beverages;
  • promotion of physical activity.
• Lifestyle diseases compared with communicable diseases:
  • lifestyle diseases have multiple causes, long latency and chronic courses, and are controlled by risk-factor modification and long-term care;
  • communicable diseases have specific agents and are controlled by breaking transmission.

Health-seeking behavior, socio-cultural factors and traditional medicine

• Health-seeking behavior depends on:
  • perceived severity;
  • cost and distance;
  • trust in providers;
  • previous experiences;
  • gender roles;
  • beliefs about cause.
• Common patterns in the Philippines:
  • self-medication with over-the-counter drugs;
  • consulting traditional healers (hilot for massage and bone-setting and traditional birth care, albularyo for herbal and spiritual healing, manghihilot, mananambal);
  • delays until illness is severe, sometimes linked to hiya or to fear of costs.
• Socio-cultural beliefs about illness:
  • pasma (imbalance of hot and cold);
  • usog (illness caused by a greeting from a stranger);
  • kulam (sorcery);
  • illness as fate or punishment.
  • Physicians respect these beliefs while explaining care, and work with traditional healers to encourage early referral.
• Traditional and alternative medicine:
  • the Traditional and Alternative Medicine Act (RA 8423, 1997) created the Philippine Institute of Traditional and Alternative Health Care (PITAHC) to develop and regulate traditional medicine;
  • the DOH has promoted 10 herbal medicines: