1.

Counts – absolute numbers of a

CPH LECTURE population or any demographic variable
occurring over a specified period of time
MODULE 2: DEMOGRAPHY AND
HEALTH INDICATORS Example: population size, number of
Lesson 1: Demography males

Demography refers to empirical, statistical 2. 2. Ratio – a single number that

and mathematical study of human represents the relative size of 2 numbers
populations. It is the science of population, the
study of human populations with respect to Example: sex ratio, which describes the
size, structure and development. The reason number of males relative to the number of
why we study demography is to find out females
reasons for changes in the populations and its
implications. 3. Proportion – special type of ratio, in
which the numerator is part of the
Demography is characterized in terms denominator
of: population size, population
composition, and population distribution Example: prevalence proportion,
describing the total number of those who are
These 3 are used to describe a certain sick among all those examined in the
population, such as how large or small population
population is (size), what comprise the
population in terms of age or sex 4. Rates – measures the amount of
(composition), and how or where the change (number of new events) in a given
population is located (distribution). Each of period of time
these characteristic has different ways to be
measured. Example: mortality rates, describing the
number of deaths in a given year
A dynamic, living population is characterized
by its size, structure, and distribution that Most Common Sources of Demographic
changes over time and space through death, Data
migration, and birth.
1. Census
Uses of Demography
“Total process of collecting, compiling and
By describing the demography or studying a publishing demographic, economic, social
certain population, the information collected data pertaining at specified time or times, to
can be used in many ways, especially in public ALL persons in a country or delimited territory”
health, such as:
• Most nations: once every 5 to 10 years
Can be used for planning and priority setting • Including military installations,
of resource allocation through the: hospitals, prisons, college dormitories
• Make a record of where each person is
• Determination of the population living
distribution per area
• Determination of growth (or decline) in There are 2 ways of allocating people
the size of population enumerated in census:
• Prediction population size in the future
• Establishment of the relationship/trend a) De jure method – assigns
between population characteristics individuals to the place of their usual
residence regardless of where they
Tools of Demography were actually enumerated during the
census
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 b) De facto method – allocate resources to include in the information
individuals to the areas where they being collected)
were physically present at the census
date regardless of where they usually Disadvantage:
live
a) Subject to sampling error (because a
Advantages of Census: sample is obtained, errors may be
committed in the measurements if the
a) Good geographical coverage (due to sample covered does not represent well
total enumeration, it covers everyone) the population)

b) Not subject to sampling error 3. Vital Registration systems

(because it includes ALL, no need to
get a sample that can cause error) Continuous recording systems of vital events
such as births, deaths, marriage, divorces,
c) Wide range of socioeconomic annulments, and adoptions as they occur in
variables covered population

Disadvantages of census: Advantage:

a) Infrequent – because it is costly and a) Frequent updating of indicators

tedious possible – because it is a maintained
continuous system, it is more frequent
b) Limited range and depth of topics – to be updated
because it covers the entire population,
it will take more time to have in-depth Disadvantages:
interviews,
a) Subject to response errors since it
c) Completeness of coverage suffers in rely heavily on the informant – the
highly mobile population information is registered by a related
person and the accuracy relies on that
person who reported the information

b) Incompleteness due to reporting

problems – aside from accuracy of the
2. Sample surveys information, the completeness may
also be compromised depending on the
Due to tedious and costly nature of census, informant
some resort to doing surveys in order to collect
information from households. In this source of
data, only a subset of population is studied, to
obtain information, representing the whole
population What are the information obtained from all of
these sources?
Examples are National Demographic and
Health Survey and National Nutrition Survey a) Geographic – region, province,
municipality, barangay
Advantages:
b) Household or family information – no. of
a) Less time consuming, easier households, no. of HH members (size)

b) Wider range of socioeconomic c) Personal characteristics – sex, age,

variables covered (more time and marital status, place of birth, citizenship

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Population: Size, Composition, a. Natural increase = number of births –
Distribution number of deaths (same year or same period
of time)
The next part will discuss the different
measures of population size, composition and b. Rate of natural increase = Crude birth rate
distribution and how the are obtained. – crude death rate

3.1. 1.1 Population Size • CBR and CDR are number of births
and deaths per midyear/average
POPULATION SIZE population size

Population size refer to the frequency or Examples:

count of members in a population, such as
number of male or number of female in a • Natural increase = 1,684,395 -
specific population. 319,579 ****= 1,364,816 persons

This is affected by natality (birth), mortality It means that 1,364,816 persons were added
(death) and migration. It means that the size of to the population in that year through natural
the population changes as there are births, means.
deaths or people transferring from one place
to another. • Rate of natural increase = 25.8/1000
– 4.9/1000 = 20.9/1000
Changes can be described using:
About 21 persons per 1000 population were
a) Absolute changes (by how many) added to the population through natural
means.
b) Rate of changes (how fast the change is)
Another ways of measuring changes in the
c) Trends (patterns of change) population are absolute
increase and relative increase.
Changes in the population can measures in
various ways. Absolute increase and relative increase are
measures that do not only rely on the numbers
The first 2 ways are determining the natural of births and deaths but makes use of
increase and rate of natural increase. population counts obtained during 2 censuses
which take into account also those people who
Natural increase and rate of natural migrate places.
increase both deal with the excess of births
over deaths. Absolute increase per year measures the
average number of people added to the
• Natural increase is the difference population per year.
between the number of births and
number of deaths which occurred in In the formula used to obtain absolute
specific population within a specified increase, the numerator is the difference
period of time (usually in one year) between two population counts and
• When natural increase is expressed the denominator is the time interval. For
relative to a population size, it is example, to determine the absolute increase
referred to as the rate of natural from 1980 to 1990, the numerator is the
increase. It is the difference between difference between the population counts of
crude death rate and crude birth rate of 1980 and 1990, and the denominator is the
a specific population within a specified interval between the 2 years which is 10 years.
period of time.

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 Estimating and Projecting
Populations

3 methods:
where: • Arithmetic method
• Geometric method
P = population count at the latter
t
• Exponential method
time/year t = number of years between the
two periods Arithmetic method assumes that an equal
amount of absolute change occurs in the
P = population count at the initial year
0
population every year
Example: Geometric method and exponential
method assume that a constant rate of
Given: increase or decrease occurs in the population.
They differ in regards to time interval during
1980 population count: 771,320 which population growth is assumed to occur.
Both should be very close each other.
1990 population count: 1,150,458
Geometric method – assumes that a
constant rate of increase and decrease occurs
over each unit of time (year)

During the 10-year period, 37,914 persons Exponential method – assumes that
were added to the population each year population size is changing continuously;
additions and subtractions to population occur
Relative increase refers to the actual at every infinitesimal or very small amounts of
difference between the two census counts time.
expressed in percent relative to the population
size during the earlier census. These 3 methods are used in estimation of:

• Population size for any future date (Pt)

• Population count for any date in the
past (P0(
• Annual rate of growth (r) or absolute
increase per year (b)
• Length of time it takes for population to
Example:
reach a certain number
• Length of time it would take for a
1980 population count: 771,320
population to double its size
1990 population count: 1,150,458

The increase in the population between 1980

and 1990 is 49.2% of its original population
(1980 population).

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 time interval (t)between the two dates is 5.17
years.

Now, the necessary values are complete and

can already be used and substituted in the
formulas to estimate the future population of
the country by July 1, 1995..

P = 60, 559, 116 (May 1, 1990 population)

0

b = 1,000,000 r = 2.33%

t = 5.17 years

• Arithmetic method

1. Estimating population size for any future

date (P )t

Unknown: Pt

Given (example):
P = 60, 559, 116 + (1,000,000)(5.17)
t
P0 = 60, 559, 116 (May 1, 1990 population)
= 60, 559, 116 + 5,170,000
b = 1,000,000
= 65, 729, 116
r = 2.33%
Therefore, the midyear (or average)
Assuming that the population increases by
population of the country by the year 1995
1,000,000 per year on the average, how large
is 65, 729, 116
will be the population on July 1, 1995?

To get the value of t for this example**,** write

the dates in Year/Months/Day format
• Geometric Method
and subtract the 2 dates from each other
(later date - initial date) starting from the right
Using the same given population, rate of
to left (like a usual method of subtraction)
increase and time interval, we will use the
geomteric method to predict future population.
year mo day
Substitute the values in the formula below (r
July 1, 1995 --> 1995 7 1 should be converted into decimal before using
in the formula).
May 1, 1990 --> 1990 5 1

5 2 0

Based on the computation, t is equal to 5

years and 2 months. However, it is
necessary to transform the months into a unit
of year. This is done by dividing 2 by 12
(because there are 12 months in 1 year) and Pt = 60, 559, 116 (1+0.0233)5.17
add the resulting value to 5. Therefore, the
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= 60, 559, 116 (1.0233)5.17 Again, find the value of t by subtracting the
dates (year/month/day) Subtraction should be
= 60, 559, 116 (1.123646) done from right to left (starting on the day).

Pt = 68, 217, 422 is the estimated midyear

population by July 1995

• Exponential Method
As observed, the example is not a
straightforward subtraction, because some
values in the minuend (where you subtract
from) are smaller than the subtrahend values
(such as 1 being smaller than 31, therefore,
you cannot subtract directly 31 from 1)

Therefore, we will be using the “borrowing”

method in subtraction.

In the above example, 31 cannot be

subtracted from 1, therefore, the “days”
column should borrow from the “month”
column. One month (which is equivalent to 30
days) is added to 1 in the day column making
where e is a mathematical constant equivalent
it 31. Therefore, the month will be diminished
to 2.71
from 5 to 4. Now, you can subtract the days
column (31 minus 31).
2. Estimation of a Past Population Next is the month column wherein 12 cannot
(P )0
be subtracted from 4. Therefore, it would
borrow 1 year from the “year” column beside
To solve problems that ask to estimate a it, making the year diminished from 1990 into
population on a previous date, values of 1989 (less 1 year) and the borrowed year will
population on a later date Pt , time interval and be transferred to the months column adding 12
the constant rate of growth(r) or absolute months to 4 months, making it 16 months.
increase (b) are needed. Now, you can already subtract 12 from 16
months.
Example: How large was the population of
the country last Dec 31, 1987 (P ) 0
The resulting value is 2 years and 4 months.
Convert the 4 months into a fraction/decimal of
To solve this, any available population count of 1 year. This results to t = 2.33 years.
a country during a year later than 1987 should
be used as P , then get the time interval
t
Unknown: P December 30, 1987
0
between these 2 dates for the value of t.
Pt = 60, 559, 116 b = 1,000,000 r=
For this example, we will use the population of 2.33% t = 2.33
May 1, 1990 (60, 559, 116) in the first example
since 1990 is a later year than 1987. We will
also use the rate of increase which is 2.33% or • Arithmetic Method
b which is 1,000,000 (depending on the
method and formula to be used).

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 These estimation problems need data on
population counts for 2 separate years to
determine the growth or increase of the
population from 1 later year to another year.

Examples:

Given the populations of 60,559,116 on

Substitute the values into the formula May 1, 1990 and 48,098,460 on May 1, 1980,
determine the absolute increase or rate if
P = P – bt
0 t
increase from May 1, 1980 to May 1, 1990.

= 60, 559, 116 – (1,000,000)(2.33) Given:

= 60, 559, 116 – 2,330,000 P = 48,098,460

0

P0= 58,229,116 is the average population P= 60,559,116

size last December 30, 1987.
t = 10 years

• Geometric method

• Arithmetic Method

Average number of persons added per

year to the population between May 1,1980
and May 1,1990 is 1,246,066.
57,396,565 is the average population size
last December 30, 1987, using the
geometric method.
• Geometric Method

• Exponential Method

r is commonly expressed as percentage,

therefore 0.0233 must be multiplied by 100.

This population’s annual rate of growth is

2.33% during the1980 to 1990 period.
57,358,511 is the average population size
last December 30, 1987, using the
exponential method.
• Exponential Method
3. Estimation of the Annual rate of growth
(r) or absolute increase per year (b)

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 Interpretation: 50% or half of the population
is 18 years old or below and the other half is
over 18 years old

b. Age dependency ratio - relates the size of

the dependent segment of the population to
3.2. 1.2 Population Composition and the economically productive age-group of the
Distribution population. It indicates the number of
dependents that need to be supported by
POPULATION COMPOSITION every 100 persons in the economically active
age groups. ADR is used as an index of age-
This measures the characteristics of induced economic drain on manpower
the members of population such as the age, resources.
sex, marital status, occupation. Most common
measures are for sex and age characteristics. - Numerator: dependents of the
population
Sex Composition – measured by sex ratio - Denominator: economically productive
and sex structure segment of population

a. Sex ratio – compares the number of males

to the number of females

Ex. ADR = 69.04

Interpretation: In the year 2000, every 100

persons in the economically productive age
groups has to support 69 dependents.

Factors Affecting Age Composition

Interpretation: In 2000, there were 102 males There are factors affecting the age
for every 100 females in the Philippines. composition of the population. These factors
may increase or decrease a certain age group
b. Sex structure – compares the sex ratio in the population. There are populations who
across different categories of another are considered young when the fertility level is
characteristics high. It means that the population is mostly
composed of young members.
Examples: There is a higher sex ratio in the
younger age groups and a lower sex ration at - Fertility level
the older age groups - Peace and order situation – “baby
boom”
Age Composition – measured by median - Urban-rural difference in fertility level
age or age dependency ratio - Cultural practices

a. Median age - the middle most age in a a. Age And Sex Composition – showed
population arranged from youngest to oldest. in population pyramid
It indicates whether the population is young or
old. Population pyramid - graphical
representation of the age and sex composition
Example: median age = 18 of the population at the same time

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 4th pyramid: low birth and death rate

Consequences of Age and Sex structure

Differences in the age and structure can

help in determining the programs and services
that are needed by the population. If the
population is young, food and education
should have more allocations in terms of
resources and services. If it is old, then the
government can prioritize the medical services
- Each age group is represented by a to cater to the needs of the older population.
horizontal bar (youngest at the base)
- Bars of males at the left side, females at
the right side Consumption patterns
- Vertical axis – age groups (usually with - Young – food and education should be
interval of 5 years) prioritized
- Horizontal axis - % of population (but - Old – medical care and social services
some pyramids also make use of counts should be empowered
instead of %)
Death rate
Population pyramids can appear in - Young population – lower crude death
various ways such as below. rate is expected, because the chances of
dying are higher among older population (due
The width/length of the bases, middle and to sicknesses and age) However, this cannot
the peak differ in each pyramid types. be true to all nations depending on the living
conditions in a country
These show the growth of population
(through births and deaths) and composition Rates and patterns of migration
based on the age groups. - Young adults are more mobile than
middle aged and elderly persons
- If there are higher rates of migration, the
segment of the population constituted by
young people are more vulnerable to changes,
because they tend to transfer to places due to
work, education, family settling, etc.

3. POPULATION DISTRIBUTION – location

of the population in geographic subdivisions of
a given area
1st pyramid: broader base,sides bow more
sharply, marked reduction in infant and child Example: Urban/rural, among regions
mortality, rapidly increasing population with
increasing median age, high birth rate, short - Urban-rural distribution - by residence
life expectancy - Population density – Average number of
persons per unit area or space. The higher the
2nd pyramid: broad base, gently sloping population density, it means there is high
sides, high rates of birth and death, low concentration of people dwelling in a certain
median age, high dependency ratio, slightly place.
loner life expectancy, more people living in - Crowding index – This is more specific
middle age measure of density, measured by total number
of persons in the household divided by the
3rd pyramid: declining birth and death rate, number of rooms in the house. A household
more people living in old age resided by more members of a family (or
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extended family) will have higher value of Example: In 2018, a total of 1,668,120
crowding index. live births were registered, which is equivalent
to a crude birth rate (CBR) of 15.8 or 16 births
Lesson 2: Health Indicators per thousand population.

HEALTH INDICATORS are quantitative b. General fertility rate is a more

measures that describe and summarize specific measure than CBR since birth are
aspects of health status of the population, related to segment of the population deemed
such as birth, deaths and illnesses. capable of giving birth (as seen on the
denominator, only women are accounted in
These are usually expressed as ratios, GFR. It is the average number of children that
proportions and rates would be born per woman if all women lived to
the end of their childbearing years
- Proportion (between 0 and 1, %, per 1,000
or per 10,000)
- Rate – crude rates, specific rates,
adjusted/standardized rates
- Crude rates – denominator: total
population (such as crude birth rate,
crude death rate)
- Specific rates = denominator: 2. Mortality indicators – indicators that
population subgroups (such as specific measure death in a given population
mortality rates)
a. Crude death rate measures how fast
Note: midyear population is the population mortality occurs in a given population
count by July 1 (middle of the year) of a
specified year. It refers to the average
population of that year.

1. Fertility indicators – indicators that

measures birth in the population Same as CBR, this is also affected by
age-sex composition, adverse environmental
a. Crude birth rate measures how fast and occupational conditions, peace and order
people are added to population through births conditions. More older people in the population
may increase number of deaths. Adverse
It is affected by fertility, marriage environmental and occupational conditions
patterns, age-sex composition, and accuracy causes more risk to people’s health and lives,
of registration. Why? If there is an increased which can affect CDR.
fertility (increased ability to conceive children,
CBR can increase. Same thing also goes with Example: Reported deaths in 2017 reached
having more married couples in the 579,237, a decrease of 0.5 percent than the
population, or more people who are on the age previous year’s 582,183 deaths. This is
of being able to conceive children. Accuracy of equivalent to a crude death rate (CDR) of 5.5,
registration of births will cause increase in or about six (6) persons per thousand
births because births are being accounted to, population (Philippine Statistics Authority,
while if there is poor system of birth 2019).
registration, some children goes unregistered,
causing lower CBR. b. Specific mortality rate refer to rate which
measure the force of mortality in specific
subgroups of the population (not the total
population, as compared to crude rates, refer
to the denominator of the formula).

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 d. Infant mortality rate (IMR) is a useful
indicator of a country’s level of health and
development.

- SMR can be age-specific, sex-specific,

age-sex specific, occupation specific, etc. This
means that SMR measures how fast deaths
happen in a certain subgroup of a population,
such as a specific age group, specific sex or - High IMR means low health standards
specific occupation. This is considered more that can be due to poor maternal and child
valid than CDR when comparing mortality care, malnutrition, poor environmental
among different groups. sanitation or deficient health service delivery.
- Looking at the formula below, for Can be artificially lowered by improving
example SMR is to be computed for the age registration of births.
above 60 years. The number of deaths among
those people whose age is above 60 is May be subdivided into:
counted (numerator) and divided by the
number of the population of all people aged 60 - Neonatal mortality ratio – include
years and above (denominator). deaths in the first 28 days of life
- Post-neonatal mortality ratio –
*F can be 100, 1000 or 10, 000 include deaths after 28 days of life but before
1 year
c. Cause of death rate is the mortality rate - These 2 are separated due to different
from specific diseases or conditions and is factors that affect neonatal deaths (prenatal
used in determining the leading causes of and genetic factors) and post-neonatal deaths
mortality. It relates the deaths from a specific (genetic, nutrition or environmental factors)
cause to the midyear population.
Example: There was a daily average of
60 infant deaths and was equivalent to an
Infant Mortality Rate (IMR) of 12.5 deaths per
thousand live births in 2013. (Department of
Health, 2013)
- This is a type of crude rate (the
denominator is the midyear population, as e. Maternal mortality ratio (MMR) measures
compared to SMR). This is also affected by the occurrence of maternal deaths and is
completeness of registration of deaths, affected by maternal health practices,
composition. completeness of registration of births and
diagnostic ascertainment.

- Reflects the level of obstetric risk in a

population

Maternal death (WHO) – death of a

woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and the site of the pregnancy, from
Source: Department of Health, 2013 any cause-related to or aggravated by the
pregnancy or its management but not from
accidental or incidental causes.

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f. Proportional mortality ratio measures the disease. It is more useful in describing chronic
proportion of total deaths occurring in a conditions (no clear onset)
particular population group or from a particular
group from a particular cause. This can be
higher during epidemics

b. Incidence rate measures the development

of a disease in a group exposed to the risk of
- Denominator: total number of the disease in period of time. It gives
deaths not the population size information on the speed of development of a
disease condition.
g. Swaroop’s index – special kind of PMR,
also sensitive indicator of health
care standards

- This is more appropriately used to

describe acute conditions and a measure of
choice in determining etiologic factors
h. Case fatality rate measures how much
afflicted die from the disease. This can be SUMMARY
affected by the nature of the disease,
diagnostic ascertainment and level of Health indicators: fertility, mortality and
reporting in the population morbidity

HIGH CFR INDICATES THAT THE DISEASE Fertility indicators - births

IS FATAL
1. Crude birth rate
2. General fertility rate

Mortality Indicators - deaths

i. Under-five mortality rate - Shows

probability of a child born in a specific year or 1. Crude death rate
period dying before reaching the age of five, if 2. Specific mortality rate
subject to age-specific mortality rates of that 3. Cause of death rate
period 4. Infant mortality rate
5. Maternal mortality ratio
6. Proportional mortality ratio
7. Swaroop's index
8. Case fatality rate
9. Under-five mortality rate
Example: Morbidity indicators - illness
In 2018, the under-five mortality rate is 28.4
per 1,000 live births in the country. 1. Prevalence proportion
2. Incidence rate
3. Morbidity indicators – measures
occurrence of illness in a community

a. Prevalence proportion measures the

proportion of existing (old and new) cases of a
disease in the population. It reflects both
incidence and probability of surviving with
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CPH LECTURE: MODULE 3 – environment, including seasonal variation in
EPIDEMIOLOGY illness.

Lesson 1: Introduction to Epidemiology John Graunt (1662) - First to employ

quantitative methods in describing population
EPIDEMIOLOGY is the study of vital statistics
the distribution and determinants of health
-related states or events in specified John Snow - formulated natural
populations, and the application of this epidemiological experiment to test the
study to the control of health problems hypothesis that cholera was transmitted by
contaminated water.
Epi “upon”, Demos “people”, Logos “study”
Epidemic of cholera struck the Golden Square
Underlined keywords: study, distribution, of London
determinants, health-related states or events
in specified populations, application to 1. He began his investigation by determining
prevention and control where in this area persons with cholera
lived and worked, as well as the location of
• Study = epidemiology is a form of study. the water pumps (marked them x in a spot
Surveillance, observation, hypothesis map)
testing, analytic research and experiments 2. Through the spot map, he observed the
are methods of studying the population in clusters of cases and found out that they
order to determine the distribution and were around a certain water pump (Broad
determinants of the existing health Street pump).
problems in the population
• Distribution = Main goal of epidemiology
is to determine how a health-related event
is distributed or spread out in a particular
setting or place, time or class of people
affected
• Determinants = Aside from the
distribution, the determinants or the factors
that influence health (biological, chemical,
physical, social, cultural, economic,
genetic and behavioral) are also
determined in epidemiological
investigation
• Health-related states and events =
Epidemiology investigates not only
diseases but also other events that are
related to health such as cause of death,
behaviors, positive health status, response
to preventive regimes and provision of use
of health services
3. He further questioned the residents’
• Specified populations = Epidemiology
source of water, why they prefer a certain
studies population with identified
water pump than the other as sources of water
characteristics
supply. He collected more data about the
• Application to prevention and control =
cases and non-cases around the water
The distribution and determinants of
pumps, and determined the common factors of
diseases that were studied from the
them.
epidemiological investigation are used to
4. He, later on, established that the Broad
aid in prevention and control of diseases.
Street pump was the source of epidemic. The
History of Epidemiology handle of the pump was removed when Snow
presented his findings to the government
Hippocrates (400 BC) - hypothesized that officials. This ended the cholera outbreak.
disease might be associated with the physical
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 5. He also investigated about the water increase or decrease the risk of getting the
companies supplying the water to the disease
pump, and plotted them against the cholera • Public health perspective: This
cases and deaths. This identification of perspective focuses on coming up with the
source helped in controlling the cholera right solution depending on the needs of
outbreak. the population, by setting health goals,
priorities, allocations of resources,
Doll & Hill - used a case-control design to assessment and evaluation of the impact of
describe and test association between health services, for better public health
smoking and lung cancer services.
Dawber et al - used cohort design to study risk
factors for cardiovascular disease in the Descriptive and Analytical Epidemiology
Framingham Heart Study. Epidemiology is subdivided into 2 areas to be
Objectives of Epidemiology able to carry out its objectives.

Epidemiology aims to quantify the extent of 1. Descriptive epidemiology – From the

disease or any health-related event in a word “descriptive”, it describes the
specified population and also to investigate the amounts and distributions (time, person,
sources, how they are transmitted in the and place) of health-related conditions,
population, in order to formulate appropriate behaviors, and factors identified in a
disease prevention and control efforts. specified population.
Specifically, epidemiology aims to:
• Investigate etiology of disease and modes It determines the extent of the health-related
of transmission event in a population by answering:
• Determine the extent of disease problems • Person: WHO are affected by the
in the community disease? What are the common
• Study the natural history and prognosis of characteristics of these affected
disease people? Are they mostly young or old?
• Evaluate both existing and new preventive Are they males or females?
and therapeutic measures and modes of • Place: WHERE are these people
health care delivery affected by the disease? What are
• Provide foundation for developing public these places? What setting or place is
policy and regulatory decisions the disease present? What are the
In epidemiology, the assumption is that common characteristics of this place?
diseases DO NOT OCCUR RANDOMLY but • Time: WHEN do the disease
follow predictable patterns that can be studied commonly occur? Is there a pattern of
and expressed in terms of what (disease and time that a disease occur in the
determinants) , where (distribution), when environment?
(distribution), who (distribution), why 2. Analytical epidemiology – This
(causal association between disease and branch of epidemiology “connects the dots”
determinants) and what's next (prevention that were investigated in descriptive
and control application). epidemiology. It studies the factors that are
mostly causing the occurrence of the
Epidemiology has 2 perspectives or disease. It aims to establish or investigate
approach, biomedical and public health. the causal (etiological) relationships
Effective epidemiology utilizes both between recognized causative factors and
perspectives. the health conditions of the population.
• Biomedical perspective of Deaths from Cholera by Company
epidemiology: This perspective focuses Supplying Water to Household
on describing the disease, its
manifestations, etiology, course or natural
history, transmission and factors that

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 Cause refers to an event, condition,
characteristic or combination of these factors
which plays an important role in producing the
disease (brings about an effect or result)
Causal association is the association
In the table above, it is shown how between categories of events or
cholera cases were being related to the source characteristics in which an alteration in the
of water being used by the households, since frequency and quality of one category is
cholera is a waterborne illness. The most followed by a change in the other.
number of cases were found out common
Multiple causation of disease recognizes
among the group of households being
the role of environment in the occurrence of
supplied by one specific water company
disease, disease cannot be attributed to a
(Sothwark and Vauxhall Company). The data
single factor
gathered and tabulated (descriptive
epidemiology) helped in further studying the Types of cause:
relationships of poor quality of water supply
and the cholera cases (analytic epidemiology). • Direct cause: factor that causes the
With this, the source of the disease or health problem without any intermediate steps
problem is traced and the appropriate • Indirect cause: factor that may cause a
measures to prevent further cases were problem, but with intermediate factor or
executed. In this case, the water supply step
company was notified to correct their actions. The following are disease causation models
Epidemiologic Data depicting the factors affecting the disease
1. Disease status or health-related conditions occurrence in a population.
2. Determinants of health and disease a. Epidemiologic triad: Agent, Host and
Sources of Epidemiologic Data: Environment
1. Data on vital events
2. Disease statistics Epidemiologic Triad - model for transmission
3. Data on physiologic and/or pathologic of infectious disease that links the factors of
conditions agent, host and environment that are
4. Statistics on health resources and services responsible for this transmission
5. Statistics on environment
6. Socio-cultural (knowledge, attitudes,
practices)
Types of Data:
1. primary - firsthand information, collected by
the researcher through observation, queries
(interviews and surveys) and used for their
specific objectives
2. Secondary - routinely collected statistics,
patient records, disease registries, reportable
disease statistics, vital events registration
(these are already available when used by Agent - biological instruments, chemical
other researchers) factors that can lead to disease or a health
condition
Lesson 2: Disease Causation Models
• Can be biological, chemical, physical,
What causes diseases among humans? nutritive, mechanical agents
How do humans get sick with different • Agent Factors – characteristics of these
diseases, of different characteristics and causative agents
sources?
In the context of disease causation,

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 have poor water supply (in terms of quality)
may be more at risk of these diseases. Also,
housing conditions have role in disease
transmission. Poor housing conditions mean
smaller and crowded spaces that will allow
faster transmission of disease among
household or community members.

Host - the organism that is affected by the

agent (or can also be a reservoir of the
agent). In epidemiology, it is the human beings
Host Factors - characteristics of the hosts that Sources of food can affect the nutrition status
can be a risk factor for certain diseases of the people. Lack of access to healthy and
clean food (plants or animals) can result to
various diseases. Disruption due to wars affect
the food and water supply to communities.
Also, wars or disasters lead to displacement of
people. These people are evacuated to a
place where overcrowding is possible, poor
water and food supply, resulting to certain
diseases to spread among families.
All of these factors are interlinked with each
other as seen in the epidemiologic triad. The
triad shows that the factors of host, agent and
For example, age. There are diseases that environment contribute to disease causation.
mostly affects those who are in their childhood
age such as measles. Therefore, it can be b. Epidemiologic Lever - Another disease
expected that measles have higher cases causation model showing
among children than among adults. Also, there that environment can enhance or diminish
are diseases that are most common to people survival of agent
at their older age (osteoporosis). All factors
above can affect the distribution of diseases in
the population.
Environment - The surrounding conditions of
agent and host, not just the air, water, and the
physical milieu, but also involves the social
and economic conditions in which people live
• Environmental Factors

Water supply quality can have a role in

spreading of waterborne illnesses. Places who Instead of being a simple triad, the lever shows
how environment is important in the disease.
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Environment brings agent and host into individual (using devices), results of laboratory
contact. The lever must be at equilibrium for tests and autopsy findings
the disease not to occur. An increase in the
susceptibility of host or increase in the SCREENING
infectivity of agent may result to the infection. Screening test is a presumptive identification
Also, a disruption/disturbance in the of unrecognized disease or defect through the
environmental condition that can increase the application of tests, examinations, or other
host susceptibility or agent’s infectivity may procedures. These can be applied rapidly to
also result to disease. sort out apparently well persons who probably
c. Wheel of Causation – Instead of triad or have the disease from those who probably do
lever, it de-emphasizes agent as sole cause not.
of disease as it highlights the interplay of Screening is usually undertaken as part of an
physical, biological and social environment, epidemiologic survey to determine frequency
and the genetic core of the host. (incidence and/or prevalence) or to describe
the natural history of a condition. Also, it aims
to prevent contagion and protect public’s
health by having detection of disease or
precursors of disease to guide the medical
care of individuals
Screening tests are used as secondary
prevention effort (subclinical disease) to
reduce the complications and improve the
survival of the individual.

d. Web of Causation
– Shows Interconnections of possible causes
and no single risk factor. It is usually used to
address chronic diseases/lifestyle
diseases/NCDs but it can also be used for
communicable diseases

Types of Screening
Screening varies depending on the health
conditions, administration process and
purpose. A screening is called a multiphasic
screening if there is administration of multiple
tests or procedures to several pathologic
conditions during the dame screening
visits. Mass or population screening is
organized application of early diagnosis and
treatment activities in large group. Selective
Lesson 3: Screening Tests or targeted screening is the application of
In epidemiology, in order to determine screening activities targeting the high-risk
distribution and determinants of diseases, groups.
measurements are done especially to detect Advantages
or identify presence of diseases or risk factors.
1. Improved prognosis for some cases
Most commonly used methods to detect detected by screening
presence or absence of 2. Reassurance for those with negative test
disease/exposure/risk factors are clinical results
diagnosis by physicians based on signs and
symptoms, use of interviews or Disadvantages
questionnaires, physical examinations of
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1. False reassurance for those with false characteristics, observer
negative results variation
2. Anxiety and morbidity for those with false
positive 3. Yield – Amount of previously
3. Unnecessary medical intervention for false unrecognized disease that is diagnosed
positive and brought to treatment as a result of
4. Hazard of screening tests screening. This is influenced by sensitivity,
5. Resource costs prevalence of unrecognized disease,
testing format (single or multiphasic)
Examples of Screening programs (these frequency of screening, extent of
screening procedures aims to detect those participation in screening program
persons who have higher risk of developing
the disease because of the present risk Measures of validity:
factors) are screening tests for hypertension, 1. Sensitivity – probability of testing positive
hypercholesterolemia, breast cancer if the disease is truly present
screening, cervical cancer screening, and
genetic screening/ newborn screening. Some It computes the percentage of people with the
of these diseases are usually chronic or do not disease who are detected by the test.
manifest early symptoms, having the need for As sensitivity increases, false-negatives
screening for those who are at risk of getting decrease. It means that as the test becomes
sick. more SENSITIVE, it detects more true
Important characteristics positives and less false negatives.

The following measures are important FORMULA: % sensitivity = (TP/TP+FN) x 100

characteristics of a screening test. 2. Specificity – probability of testing
1. Validity (sensitivity, specificity) negative if the disease is truly absent. It
2. Reliability determines the percentage of people
3. Yield without the disease who are correctly
4. Predictive value labeled by the test as not diseased. As
1. Validity – Validity of a test measures the specificity increases, false-positives
extent to which the test measures what is decrease
supposed to measure (being near the true FORMULA: % specificity = (TN/FP+TN) x
value). A test with high validity should have 100
a good preliminary indication of whether an
individual has a disease or not. Valid DISEASE DISEASE
TEST or EXAM TOTAL
tests should have good sensitivity and PRESENT ABSENT
specificity. Sensitivity and specificity will be Positive (indicating True False
explained further in the next chapter of the TP +
disease is probably Positive Positive
FP
lesson. present) (TP) (FP)
2. Reliability – Means reproducibility,
Negative(indicating False True
repeatability, stability, consistency of disease is probably Negative Negative
FN +
information TN
absent) (FN) (TN)
Reliability is the extent to which TP +
similar information is supplied FN
when measurements are TOTAL TP + FN FP + TN
FP +
performed more than once. It is TN
the ability of test to give
consistent results (values are % false negative – percentage of people with
near to each other) when test is the disease BUT who are not detected by the
performed more than once in test (they appeared negative in the test, but
same individual or conditions. actually positive for the disease)
Variation can be due to method,
%false positive – percentage of people
fluctuation of biological
without the disease BUT who are incorrectly
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labeled by the test as having disease (they are when succeeding diagnostic evaluations of
detected as positive but they actually do not positive screening tests of minimal cost and
have the disease) risk. Being detected as positive will not cost
too much risks and price of the succeeding
procedures to be done to a patient.
Specificity is more valuable than
sensitivity when costs/risks associated with
further diagnostic techniques are significant.
The test must be specific enough to detect the
true cases so that unnecessary costs and risks
Example: will not be incurred.
TEST or DISEASE DISEASE Lesson 4: Outbreak Investigation
TOTAL
EXAM PRESENT ABSENT
Concepts and Definitions
Positive 142 0 142
Outbreak or epidemic – occurrence of a
Negative 3 313 316
health-related event clearly in excess of the
TOTAL 145 313 458 normal expectancy, in defined community,
geographical area or season.
The table above shows the screening test
results and the presence/absence of the • It may occur in a restricted geographical
disease (based on a gold standard test). A area or may extend over several countries
gold standard test has the highest validity to (pandemic), may last for few hours, few
detect the disease precursors, reflecting the weeks, several years
most accurate results. • It can be a single case of a communicable
disease long absent from a population or
Interpretation of the table: a single case caused by an agent not
There are a total of 458 patients who previously recognized in that community or
underwent the test. Out of 458, 145 actually area, or most of the time emergence of a
has the disease, while the remaining 313 do previously unknown disease.
not have the disease. Only 142 of these 145 To differentiate outbreak from epidemic,
were detected and correctly labelled by the outbreak is an epidemic limited to localized
test as POSITIVE. The remaining 3 patients increase in incidence.
were labelled as NEGATIVE by the test. All of
the 313 who do not have disease were More Terms:
detected, and correctly labeled as NEGATIVE • Cluster - an aggregation of cases in a
by the test. given area over a particular period without
Proportion of diseased individuals regard to whether the number of cases is
= (145/458) x 100 = 31.66% more than expected.
• Endemic – constant presence of a
% sensitivity = (142/145) x 100 = 97.9% disease or infectious agent within a given
% specificity = (313/313) x 100 = 100% geographic area
• Hyperendemic – constant presence at a
% FN = (3/145) x 100 = 2.1% high level of incidence
• Holoendemic – high level of prevalence
% FP = 0 since all non-diseased individuals
with infectious beginning early in life and
were detected as NEGATIVE
affecting most of the population
Sensitivity is more important than
Epidemics occur due to various reasons
Specificity when the penalty or risks
associated with missing a case is HIGH (when 1. When susceptible individuals travel into an
the disease is serious and a definitive endemic area where the infectious disease
treatment exists). It means that the disease is exists
too serious therefore it is important not to miss
a case. Also, sensitivity is more important
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2. When a new infectious disease is 3. Verify the diagnosis
introduced by humans or animals traveling 4. Define and identify cases
from an endemic area into a susceptible 5. Describe and orient data based on time,
human population in whom the disease is place and time – descriptive epidemiology
not endemic or when contamination of 6. Develop hypothesis
food, water or other vehicles takes place by 7. Evaluate hypothesis
an agent not normally present 8. Refine hypothesis
3. When a preexisting infection occurs in an 9. Implement control measures
area of low endemicity and reaches 10. Communicate findings
susceptible persons as a result of new or
unusual social, behavioral, sexual or 1. PREPARE FOR FIELD WORK
cultural practices
4. When host susceptibility and response are Preparation for field work means assembly of
modified by natural or drug induced the investigation team and other resources
immunosuppression (cancer treatment), Team is composed of epidemiologist,
malnutrition or diseases such as AIDS laboratory and other medical specialists,
computer specialist, local health officials
Goals of Outbreak Detection
Team members:
1. To assess the range and extent of the
outbreak a. Epidemiologist – develop study
2. To reduce the number of cases associated design and survey questionnaires create
with the outbreak databases and conduct data analysis
3. To prevent future occurrence by identifying b. Microbiologist – verify diagnosis,
and eliminating the source of the problem subtype pathogen to help refine case
4. To identify new disease syndromes definition
5. To assess the efficacy of currently c. Environmental health
employed prevention strategies specialist – collect food and
6. To address liability concerns environmental samples, provide guidance
7. To train epidemiologists on food safety regulations
8. To provide for good public relations and d. Interviewers – collect data in person or
educate the public by telephone
e. Clinicians – administer vaccines,
Common Interventions to Control an prophylaxis, collect clinical specimens
Epidemic f. Regulators – facilitate identification of
source of outbreak and develop prevention
1. Control the source of the pathogen strategies
• remove the source of contamination
g. Media spokesperson
• remove persons from exposure
• inactivate or neutralize pathogen
2. ESTABLISH THE EXISTENCE OF AN
• treat infected persons
OUTBREAK – To confirm that the reported
2. Interrupt the transmission cases represent a true outbreak with a
• sterilize or disinfect environmental common cause.
sources of transmission
• control mosquito or vector transmission Some clusters turn out to be true outbreaks
using skin repellants with a common cause, some are sporadic and
• improve personal sanitation unrelated cases of the same disease, and
3. Control or modify host response others are unrelated cases of similar but
• immunize the susceptible hosts unrelated diseases. In this step, all possible
(prophylactic chemotherapy) reliable data sources must be maximized for
• modify behavior or use a barrier (wearing utilization.
protective clothing)
Data sources:
Steps of an Outbreak Investigation • Surveillance records (for notifiable
diseases) and local records
1. Prepare for field work • if local data are not available, estimates on
2. Establish the existence of an outbreak data from neighboring cities, provinces or
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 national data, survey data of local hospitals Example: Meningococcal Disease – Pan
or physicians to determine whether they American Health Organization Case
have seen more cases of the disease than Definition
usual or survey of people in the community
to establish the background level of Clinical case definition: An illness with
disease sudden onset of fever (>38.5C rectal or
>38.0C axillary) and one or more of the
In some situations, number of cases may not following: neck stiffness, altered
be always the basis. There can be observed consciousness, other meningeal sign or
clustering of cases. It means that there petechial or puerperal rash
is aggregation of cases in a given area over a
particular period without regard to whether the Laboratory criteria for diagnosis: Positive
number of cases is more than expected. This cerebrospinal fluid (CSF) antigen detection or
may not be an outbreak. positive culture

Observed cases should exceed the expected Case classification

occurrence from a comparable period • Suspected: a case that meets the clinical
It also depends on: severity of illness, case definition
• Probable: a suspected case as defined
potential for spread, availability of control
measures, political considerations, public above and turbid CSF (with or without
relations, and available resources. positive Gram stain) or ongoing epidemic
and epidemiological link to a confirmed
3. VERIFY THE DIAGNOSIS case
• Confirmed: A suspected or probable case
To ensure that disease has been properly with laboratory confirmation
identified, medical records, laboratory report,
conduct of clinical testing must be obtained. 5. CASE FINDING (FIND CASES
Additional verification can be done by visiting SYSTEMATICALLY AND RECORD
several cases for better understanding of the INFORMATION)
cause, exposure, and spread of the disease.
Search for previously identified cases using
4. CONSTRUCT A WORKING CASE health care facilities – physician’s offices,
DEFINITION clinics, hospitals, laboratories, media support,
or conduct survey using questionnaire or
There must be a case definition to standardize laboratory diagnosis in restricted areas like
the reporting of cases. schools and offices for sources of more
Clinical case definition – standard set of information.
criteria for deciding whether an individual will
be classified as having the disease. It includes The information to be collected are:
the clinical criteria – nature of disease, time,
place of occurrence, person affected and a. Identifying information – name,
the laboratory criteria. Case definition should address, contact numbers
be sensitive and specific. b. Demographic information – age, sex,
race, occupation
Case classification: c. Clinical information – symptoms
a. Suspected (possible) – some clinical (type, duration), onset dates and/or time
feature, symptoms reported but not d. Risk factor/ exposure information –
confirmed, no lab or epidemiologic link food and water sources, etc.
b. Probable – clinical features confirmed, e. Reporter/source information
no lab or epidemiologic link Line listing – this important tool provides
c. Confirmed – clinical + laboratory organized information about the cases in an
confirmation + epidemiologic link outbreak; this enables the investigator to
Start with high sensitivity with loose quickly summarize, visualize and analyze the
definition à tighten the criteria to drop key components of the outbreak.
suspected cases (high specificity)
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Line listing provide information about person, This helps in determining the extent of the
place, and time that is obtained from case cases, and the clustering or patterns of these
finding efforts, and can be quickly reviewed cases that can be observed from a spot map.
and updated. The figure below is a portion of a
line listing table. c. TIME – When did the outbreak
start? Through the use of epidemic curve,
the outbreak’s pattern of spread,
magnitude, incubation period, point source
or propagating outbreak can be illustrated
clearly.
Epidemic curve – a graphical depiction of the
number of cases of illness by the date of
illness onset (shape can reveal the pattern or
type of outbreak). It shows the magnitude,
time trend and outliers, where y axis contains
Source: Centers for Disease Control (CDC) the number of incident cases while x
In a line listing table, each row represents a axis indicates time line, must begin before
case and each column represents variable of outbreak and extend after outbreak (time scale
interest. Always include components of case used should be 1/8 or 1/3 the average
definition, case name or identifying number, incubation period)
date of symptom onset (or specimen collection
date) Epidemic curve types:

It can generate frequency distributions of 1. common source – exposure to an agent

demographics from the information about from a single source over a brief time,
exposure and/or risk of disease, or frequency point source, people are
distributions of potential exposures – exposed continuously or intermittently to a
information about source or route transmission harmful source; period of exposure may be
or Spot maps from information about brief or long, sudden rise and rapid fall
exposure patterns. curves
a. Point source – sharp upward
6. PERFORM DESCRIPTIVE slope and a gradual downward slope, all
EPIDEMIOLOGY (person, place, time) cases occur within one incubation period
Information are already available in the
previous step. Next is to determine the
common characteristics of these tabulated
cases. Therefore, a descriptive epidemiology
is performed. The cases are characterized in
terms of person’s characteristic, places
involved, and the patterns and magnitude of
spread.
a. PERSON
• Host characteristics – age, race, sex
Who are mostly the cases? What is their
age range? Are they mostly men or
women? Are they working population?
•Possible exposures – occupation, b. Continuous exposure will often cause
leisure activities, behavior, use of cases to rise gradually (possibly
medications, tobacco and drugs to plateau, rather than to peak)
b. PLACE – WHERE are the cases? Through
the use of spot map: residence, office,
geographic area.

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c. Intermittent exposure often results in an
epi curve with irregular peaks that reflect
timing and the extent of exposure

2. Propagated – can last longer than

common source outbreaks, person to person
propagation
• may have multiple waves
• spread from person to person
• progressively taller peaks, an incubation
7. DEVELOP HYPOTHESES
period apart
• shows plateau or continued rise Answering the question: “What is
the possible source of infection and
what the patterns of transmission are?
Knowledge and understanding on the agent’s
usual reservoir, how it is usually transmitted,
the vehicles that are commonly implicated and
the known risk factors will help in generating
hypothesis. Also, interview with patients (for
the causes, exposures, etc.) and the
information provided by the descriptive
epidemiology will provide clues.
Other epidemic curves:
8. EVALUATE HYPOTHESES
EPIDEMIOLOGICALLY - relative risk and
odds ratio are computed. Observe for:
• A high attack rate among exposed and low
attack rate among non-
exposed à suspected source of outbreak
• A high difference or ratio between attack
rates for the 2 exposure groups

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The following tables are lifted from the Centers 10. IMPLEMENT CONTROL AND
for Disease Control website, to be used in this PREVENTION MEASURES
module for example.
The objective of this step is to bring
current epidemic to a termination and
prevent future occurrences
In implementing control and prevention
measures, weakest link in the
transmission must be targeted. These
weakest link are usually those who are
most modifiable or most susceptible to
intervention (agent, source, reservoir,
mode of transmission)
Initiate or maintain surveillance – to decide
if outbreak is over or has spread to other
areas, to document effectiveness of control
measures
Scan the column of attack rates among Reasons why some outbreaks end
those who ate the specified items to
answer the following questions: 1. No more susceptible individuals,
everybody who was susceptible got the
• Which item shows the highest attack disease
rate? Answer: beef 2. No more exposure to the source. the
• Is the attack rate low among persons not individuals move away from the source of
exposed to that item? Yes (lowest) infection
• Were most of the 57 case-patients 3. No more source of contamination. the
exposed to that food item? (53 out of 57) source of contamination ends/consumed
4. Individuals decrease their susceptibility –
got immunized or used preventive
measures
5. Pathogen becomes less pathogenic/less
capable of producing disease due to some
mutations
11. COMMUNICATE FINDINGS
Risk ratio is calculated as the ratio of the attack It is important that the findings of the
rates or risks. (Attack rate of exposed investigations is documented and
group/attack rate of unexposed group). communicated to the public. This can be done
Exposure is the consumption of beef. In the through oral briefing and written report.
example, when 65.4% (exposed) divided by
11.4 % (unexposed), the resulting risk ratio is Oral briefing – attended by local health
5.7. This risk ratio indicates that persons who authorities and people responsible for
ate the beef were 5.7 times more likely to implementing control and prevention
become ill than those who did not eat the beef. measures, to disseminate information,
beginning and end of outbreak or as needed
9. AS NECESSARY, RECONSIDER, REFINE
AND REEVALUATE Written report – follows usual scientific
HYPOTHESES – additional epidemiologic format, to document investigation, at the end
studies are done, if hypotheses were not of outbreak
confirmed. New modes of transmission are
investigated. Laboratory and/or environmental
studies through isolation of organism and
special laboratory tests are reviewed,
confirmed and compared.
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MODULE 4: PUBLIC HEALTH • Sick role behavior - any activity
PROMOTION AND EDUCATION undertaken by an individual who
considered himself to be ill for the purpose
Lesson 1: Health Education and Health of getting well. Includes receiving
Promotion treatment from medical providers.
Scope of health education
What is health education?
Health education covers health
Health education is any combination of promotion, specific health protection, early
learning experiences designed to facilitate diagnosis and treatment, disability limitation to
voluntary adaptations of behavior conducive to rehabilitation
health. (Green et al 1980)
Dissemination of health information,
• It is leading what people already know and communication, social marketing, motivation
believe and do about their health, programs, behavior modification, health
modifying those that are undesirable and counselling
developing desirable behaviors that are
conducive to health. Can take place in various settings:
• The process of assisting individuals, acting
• Health care settings - health centers,
separately and collectively, to make
clinics, hospitals, health maintenance
informed decisions about matters affecting
organizations
the personal health and that of others.
• Schools -> desirable health behaviour ,
These are the keywords in the first definition: supportive hygienic school environment,
school health services, training of health
• Process – series of learning experiences professionals
• Combination – no single best method, • Communities
combination is desirable • Worksite – industries, offices, food
• Designed – planned, not hit or miss establishments, entertainment
• Facilitates – educator-learner relationship establishments, hotels, etc
• Voluntary adaptations – not manipulated
or coerced
• Behavior – target outcomes Health promotion
Health behavior is the target outcome for “Health promotion works through concrete and
health education. This is often mentioned in effective community action in setting priorities,
the previous definitions. making decisions, planning strategies and
implementing them to achieve better health.”
Health behavior - this can be categorized (Ottawa Charter)
into 3
Principles of health promotion
• Preventive health behavior – any activity
undertaken by an individual who believes 1. Health promotion involves the population
himself to be healthy for the purpose of as a whole in the context of their everyday
preventing or detecting illness in an life, rather than focusing on people at risk
asymptomatic state from specific diseases.
• Illness behavior – any activity undertaken 2. Health promotion is directed
by an individual who perceives himself to towards action on the determinants or
be ill; to define the state of his health and cause of health. This requires a close
to discover suitable remedy cooperation between sectors beyond
health care reflecting the diversity of
5 stages: symptom experience, conditions which influence health.
assumption of sick role, medical care 3. Health promotion combines diverse but
contact, dependent patient, recovery and complementary methods or approaches
rehabilitation. including communication, education,
legislation, fiscal measures, organizational
change, community development and

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 spontaneous local activities against health • Feedback – reversal of the process,
hazards. provides the reaction to the message sent
4. Health promotion aims particularly by the sender
at effective and concrete public
participation. Principles:
5. Health promotion is primarily a societal 1. People select what they see or hear.
and political venture and not a medical 2. Interpret selectively what they see or hear.
service. 3. Choose what they want to remember and
In health education and promotion, there are 3 what they want to forget.
basic processes: learning process, 4. Words do not have meanings, meanings
communication process and change process. are in people, contexts and in relationships.

Learning Process Barriers

Learning is shown by a change of behaviour • Environmental barriers – noise,
as a result of experience. competition for attention and time
It can be acquisition of new behaviour • Terminology and complexity of the
patterns, confirmation or invalidation of message
existing patterns of behaviour which lead to • Personal barriers
strengthening or weaking of old behaviour
patterns. Change Process

Elements of learning: It was mentioned that in the learning

process, learning is shown through
• Goal behavior change. Behavior change is the
• Readiness target outcomes of health education and
• Situation promotion.
• Interpretation
• Response • Cognition change – change in knowledge
• Consequence and/or perception
• Reaction to thwarting • Attitude change – change in individual’s
beliefs, predispositions, intentions, and
Communication Process tendencies
A process by which people attempt to share • Behavior change – alteration in an
meaning via the transmission of symbolic individual/groups knowledge, attitude and
messages practices
Communication involves people and shared • Social change – departure from existing
meaning. It is also symbolic because of the ways and means of doing things which
words, letters, numbers, gestures, sounds, results in a change in of relationship in the
etc. system

Elements: source or sender, message, Change may occur at various levels:

channel, receiver, feedback individual, group, social level

• Source/sender – individual/organization How do change happens? What are the

who has a purpose, information and/or components of the change process?
need to communicate with one or more Elements of Change
people, initiates the communication
process. • Innovation – idea, set of behaviour, new
• Message – physical form into which the technology, project, program
sender encodes the information/idea that • Targets of change – individual, group of
he/she wants to communicate or to share, people, segment of the community or the
can be in any form. entire community itself
• Channel – mode of transmission, • Change agent – person or group of people
important for the message to be effective introducing the innovation
• Strategies of Change – deliberate
actions, set of activities, approaches,
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 tactics or processes designed to effect • Public policy factors, including local,
change state, and federal policies and laws that
regulate or support health actions and
Characteristics of Innovations: practices for disease prevention including
1. Relative advantage early detection, control, and management.
2. Impact on social relations
3. Divisibility and reversibility
4. Complexity
5. Compatibility
6. Communicability
7. Time
Barriers to Change
• Tradition Ecological models are believed to provide
• Fatalism comprehensive frameworks for understanding
• Cultural ethnocentrism the multiple and interacting determinants of
• Pride and dignity health behaviors. More importantly, ecological
• Norms of Modesty models can be used to develop
• Unforeseen consequences of planned comprehensive intervention approaches that
change systematically target mechanisms of change
• Relative value at each level of influence.
Lesson 2: Theories and Models in
Health Education and Promotion HEALTH BELIEF MODEL
Lesson 1: THEORIES AND MODELS IN
HEALTH PROMOTION AND EDUCATION
1. Ecological Model
2. Health belief model
3. Transtheoretical model
4. Social cognitive theory
ECOLOGICAL MODEL
The core concept of an ecological model is
that behavior has multiple levels of
influences.
These are composed of:
One of the first theories developed to explain
• Intrapersonal/individual factors, which and predict health related behaviors. This
influence behaviour such as knowledge, model helps explain why some community
attitudes, beliefs, and personality members participated in public health
• Interpersonal factors, such as services. The model is composed of blocks or
interactions with other people, which can components.
provide social support or create barriers to
interpersonal growth that promotes healthy
behavior.
• Institutional and organizational Health belief model Building blocks
factors, including the rules, regulations,
policies, and informal structures that 1. Perceived susceptibility - Individual’s
constrain or promote healthy behaviors. belief that he or she will develop a disease
• Community factors, such as formal or or experience harmful consequences of a
informal social norms that exist among disease, if he or she either engaged or
individuals, groups, or organizations, can does not engage in a particular behavior
limit or enhance healthy behavior
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2. Perceived severity- An individual’s belief time), progress is not linear because it
in the seriousness of, or the extent of harm tends to cycle or recycle through stages
that could result from, the consequences of
the disease or harmful condition STAGES OF CHANGE
3. Perceived benefits - An individual’s belief 1. Precontemplation
that there are advantages in taking action In this stage, there is no intention of
to reduce disease risk over continuing changing health behavior in the distant
actions that may increase risk for disease future (1-6 months) due to any of the
4. Perceived barriers - Impediments an following scenarios:
individual faces when adopting a certain Scenarios:
behavior
5. Cues to Action - Environmental or internal • The person might be unaware that
triggers that increase or decrease the a problem exists
likelihood of an individual engaging in a • The person may be in denial that
behavior they are at risk for any health
6. Self-efficacy - An individual’s belief, or problems/ there are any reasons to
confidence, in his or her ability to engage change
in a specified behavior, or to overcome a • The person have tried to change in
barrier, in order to engage in a specified the past but failed, no longer
behavior attempting to change
2. Contemplation
Study findings showed that: In this stage, the individual is changing in the
Perceived barriers and perceived distant future (next 1-6 months), because
benefits – strongest predictors of health he/she is recognizing the need to change but
behaviors are not ready to fully engage in the behavior

Perceived severity – weak but significant Individuals can get stuck in chronic
predictor contemplation (contemplation for a longer
period of time but never progresses)
Perceived susceptibility – largely not
related, may not vary among individuals who 3. Preparation
are already diagnosed with a health condition In this stage, individual is planning to make
or disease, may be influenced by other “meaningful” behavior change but has not yet
variable such as self-efficacy and perceived made the change.
severity Examples: reduce smoking behavior from a
Transtheoretical model (TTM) pack/day to half pack/day, physically active for
25 mins on most days of the week, consume
A model conceptualized by James Prochaska three servings of fruits and vegetables per day,
(1970s) explaining what to change, when and read literature on other options for quitting
how to help people change health-related smoking, getting behavioral counselling, and
behaviour. join gym
The model’s building blocks are: 4. Action
In this stage, an individual make a meaningful
a. stages of changes (when) behavior change. This action should persist for
b. processes of change (how) at least one to six months.
c. levels of change (what)
5. Maintenance
Stages of change An individual is in a maintenance stage of
This block is unique to the transtheoretical change when behavior change is maintained
model. It represents a number of interrelated for at least 6 months.
concepts (attitudes, intentions, and behaviors)
that indicate an individual’s readiness to 6. Termination
change. A stage wherein the behavior progresses and
individuals reach a point when there is no
It also highlights that time is an important possibility the unhealthy behavior will resume.
concept (not as an event but as a period of
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TTM: Processes of Change Individuals experience positive and negative
• This building block of TTM highlights the reinforcements for engaging in certain
intentional or unintentional activities that behaviors
change individuals’ emotions, knowledge,
skills or behaviors in ways that help them 9. Helping relationships
progress and move through the stages of Involves having connections, or interactions
change. Knowledge on these processes of with people who will facilitate the attainment of
change can be beneficial to health program a goal
planners. 10. Social liberation
1. Consciousness raising Increasing social opportunities to promote
Process of increasing insight or awareness healthier behaviors
about a problematic Levels of Change
behavior/disease/condition Single, well-defined behavioral problems or
Awareness can be related to the causes of the psychological problems that can influence the
problem, consequences of the problem, and processes or stages of change.
potential treatments for the problem [WATCH VID]
2. Dramatic relief SOCIAL COGNITIVE THEORY
Emotional catharsis (liberation)
Expressing of deep emotions resulting from
the problematic behavior and subsequently
feeling relief when the behavior is modified
3. Self-reevaluation
In this process, individuals evaluate their self-
concept and imagine their lives with or without
their problematic behavior
"if I continue doing this behavior, I will end up
being ”
“if I change my behavior, I will become ” • By Albert Bandura and Richard Walters
4. Environmental reevaluation • People are not driven by internal forces or
In this process, individuals evaluate the way environmental stimuli alone; rather; human
their behaviors are affecting their social functioning is the result of a triadic
environment such as their relationship to other relationship among 1) behaviors, 2)
people. Is smoking affecting his relationship cognitive and personal factors, and 3
with his family? environmental cues or events
• Triadic relationship – reciprocal
determinism

5. Self-liberation SCT Building blocks

Individuals develop the sense that they have
the choice to change their behavior and that
they can make a commitment to changing
6. Counterconditioning
Individuals substitute a new healthy behavior
for an old, unhealthy behaviour
7. Stimulus control
Individuals avoid old cues that trigger
unhealthy behaviors and gain new cues that
trigger healthy behaviors
8. Contingency management
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1. Knowledge – awareness that engaging or • It complements or supplements mass
not engaging in a behavior may lead to media approach
some risk or to some benefit (precondition
for change) Advantages: highly interactive, can fit to
2. Perceived self-efficacy – individual’s the individual needs, allows for immediate
belief or confidence in his or her ability to feedback, allows for in-depth discussion of
engage in a specified behavior a topic, high capability to select particular
audience
This is the most important building
block, cornerstone of SCT. Disadvantages: limited reach in terms of
number of people
3. Perceived facilitators and
impediments – actual and perceived Examples:
environmental factors that promote, enable, or Individual: counselling, individual instruction,
reinforce behavior or become hindrance to home visits, referrals, risk assessment, patient
behavior education
4. Outcome expectation – the expected Group: lecture, small group discussions,
outcomes an individual perceives to be forum, seminars
associated with engaging in a certain behavior
5. Goal setting – setting short-term Mass Media – channels through which
(proximal) goals and long term (distal) goals large numbers if people are addressed
• The target group makes little or no effort to
• Proximal goals – making concrete plans, receive a message
monitoring oneself during the plan, rewarding • More inclusive because these are based
oneself for success, adjusting one’s behavior on the programs/services to the entire
when faced with failure population/community
• Dissemination of messages is from a single
Lesson 3: Health education and health source and reach a large number of people
promotion methods and places.
In the selection of strategy/method to
utilize for specific health promotion Different formats: documentaries, news,
programs, the following factors have to be plugs, drama, talk shows, short feature,
considered: educational program, forum, jingle, posters,
leaflets, brochures, newsletters.
• Objective of the intervention
• Characteristics and need of target Strength: ability to reach very large audiences
group Weaknesses:
• Resources to include human, financial
and time • diverse and largely undifferentiated
audience reached (therefore, there
The different methods can be applied to are messages that should be developed
different settings (community, health care for particular audience)
institutions, schools, worksite) • little control over the audience’s exposure
Health education strategies can be according to message (repetition of message in
to focus: individual, groups or whole different formats will help increase
populations exposure of audience to the message)
• inability to obtain immediate feedback most
There are 2 main categories of health of the time (feedback mechanisms should
education and promotion methods: be developed)
• interpersonal communication Roles of mass media:
• mass media
• Informing or education people
How do these 2 differ? • Reminding people on what they are
Interpersonal communication – direct, face already aware of
to face encounter between 2 persons or • Increase people’s motivations
groups • Providing self-help
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• Providing context within which regulatory 3. Develop a tentative outline of the
change can be introduced material
4. Gather information for reference
Type Characteristic 5. Develop prototype of material
6. Pre-test materials
LIMITED REACH MEDIA 7. Revise based on results of pretest
Information transmission Pretesting the material – process for
Pamphlets
(cognition>emotion) determining a target group’s reaction to and
understanding of health messages or
Information Quick convenient behaviour change information before
sheets information materials are produced in final form
Agenda setting function, What to check in the pretesting
Posters visual message, creative process? Understandable, culturally
input required appropriate, believable and realistic,
acceptable to the audience, visually
Emotive, personal, useful for appealing, informative,
T-shirts cementing commitment to motivationalPretesting methods: individual
program/idea interviews, focus group discussions,
Short messages to readability testing, expert review
identify/motivate the user
Stickers
and cement commitment, Below are examples of these health education
cheap, persuasive and promotion materials in different forms.
Instructional, motivational,
Videos
useful for personal viewing

MASS REACH MEDIA

Awareness, modelling and

Television image creation role, useful in
information,

Informative, cost-effective,
Radio
useful in creating awareness
Long and short copy of
Newspapers information
Magazines Wide readership and
influence

Communication materials:
• Print - Posters, flyers, comics,
brochures, news ads
• Audio – radio spots, radio drama, jingle
• Audio-visual materials – television ads,
slide presentation, video tapes,
documentary
General steps in producing mass media
materials
1. Determine communication objectives
2. Decide on target audience
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 MODULE 5: COMMUNITY ORGANIZING
AND PUBLIC HEALTH PROGRAM
PLANNING
Lesson 1: Community Organizing
Concepts and Principles
Definitions
Community - geographic area with
boundaries, based on the traditional dictionary
definition. However, there is a wider definition
of community. Community is defined as
“Collective body of individuals identified by
common characteristics such as geography,
interests, experiences, concerns or values.”
Community organizing – process by which
community groups are helped to identify
common problems or goals, mobilize
resources, and develop and implement
strategies for reaching the goals they have
collectively set
Bottom-up or grassroots approach - People
relevant to the program at this early stage are
actively working together
Community building – process by which
individuals create and enhance their
communities in order to identify common
problems and goals, mobilize resources, and
develop and implement strategies for teaching
the goals they collectively have set

Basic Principles of Community Organizing

• Principle of Needs/Problems and Issues
• Principle of Leadership
• Principle of Participation
• Principle of Communication
• Principle of Structure
• Principles of Evaluation

5 STAGES OF COMMUNITY ORGANIZING

STAGE 1
COMMUNITY ANALYSIS – process of
assessing, defining needs, opportunities and
resources involved in initiating community
health action program (community diagnosis)
The community diagnosis consists of
collecting data and assessment of the
following:

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 • Demographic, social and economic as well as the line and span of authority.
profile of community Necessary trainings can be provided that will
• Health risk profile (social, behavioral, help in the actual implementation.
and environmental risks)
• Behavioral – dietary habits, lifestyle STAGE 3
concenrs IMPLEMENTATION
• Social – long term unemployment, low
education, isolation In the implementation, broad citizen
• Health/wellness outcomes profile – participation is generate to mobilize the entire
morbidity and mortality data community. Comprehensive and integrated
• Survey of current health promotion strategies are implemented into the particular
programs program.
• Studies conducted in certain target It is important that community value is
groups integrated into the programs, materials and
Community Analysis is done by first, defining messages to ensure wide community
the community using the above indicators. participation. It is best that the community
Data are collected and factors that affect people understands and approves the
implementation of programs and services in programs and they are in line with their values
the community. These factors are community in life.
capacity, community barriers and readiness STAGE 4
for change.
PROGRAM MAINTENANCE–
Community capacity – refers to participation, CONSOLIDATION
leaders and other resources
In program maintenance, an ongoing
Community people’s capacity to participate to recruitment plan is established It means that in
programs and services, having leaders and order to sustain the program and the
resources to implement community programs community participation to it, there should be
As opposed to community a plan of recruiting participants.
capacity, community barriers are gaps in the Also, part of program maintenance is the
community that hinder the participation and establishment of positive organizational
support of the people to programs and culture and community networks. Community
activities. These can refer to lack of networks will help in the delivery of
information, misinformation, poor leadership, intervention activities to reach every person in
and many more. the community.
Community readiness – willingness to STAGE 5
implement programs or interventions, enact
policies or laws or build environmental DISSEMINATION – REASSESSMENT
structures
In the last stage, there is a reassessment of
Lastly, all the collected data are synthesized in the community after the implementation to
order to set priorities. update community analysis.
STAGE 2 This will determine the effectiveness of
interventions/programs, identify gaps and
DESIGN AND INITIATION barriers, and future directories and
In this stage, the community capacity and modifications will be plotted. Results will be
barriers are already identified. Core planning summarized and disseminated accordingly.
groups are established. These groups are the
people who will plan and lead the community
organizing.
Local organizers are selected and an
organizational structure is constructed. This
will help on clarifying roles and responsibilities,
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 A decision/prioritization matrix is a
table containing a set of criteria that will guide
in deciding the priority problem. Each problem
is rated/graded based on the given criteria.
Examples of criteria are magnitude, feasibility,
urgency, and sustainability. It depends on the
program planner on what set of criteria to use.
These criteria must have standard
Problem Identification in Program definitions. For example, magnitude is
Planning defined by the planner as the severity of the
Community Planning problem in terms of its prevalence/incidence in
the community. Feasibility is defined as the
It has 3 core elements – planning, capability of being implemented within 1 month
implementation, and evaluation given the community’s resources. These are
just examples and the definitions may vary
Generalized Model
depending on the program planners. These
1. Preplanning definitions will help the group of program
2. Step 1: Assessing Needs planners to rate each problem more accurately
3. Step 2: Setting Goals and Objectives because they are based on a standard
4. Step 3: Developing interventions definition of the criterion.
5. Step 4: Implementing interventions
Aside from the criterion, the rating
6. Step 5: Evaluating results
scales must be also properly defined. In a
PLANNING rating scale of 1 to 5, which is the lowest and
which is the highest? Is 1 the lowest score?
In planning for programs, the first step is to
have a situational analysis. If 1 is the lowest score, then a problem
which is perceived to be with the least
Situational analysis is similar to the community prevalence will be given a score/rating of 1
analysis done in community organizing. under the criterion of magnitude. A problem
It is a comprehensive description of a that is perceived to be the least feasible at the
community and its situation in various aspects time will be rated as 1 under the criterion of
such as the geography, politics, economy feasibility. All scores in all criteria will be
(livelihood, source of income), summed up to obtain a total score for each
sociodemographic and cultural structure, problem. The problem with the highest score
stakeholders of the community, population will be the priority health problem to be solved
size, composition and distribution, in the community.
environmental indices (water supply, waste In the table below, each criterion has a
management, food establishments), social % weight where the rating/grade is multiplied
indices (transportation, communication, by. Therefore, each rating is weighted based
electricity source, education, housing), health on the %. The weight of each criterion is
indicators (births, morbidity, mortality), health variable and dependent on the program
resources and programs. planner’s judgment. If a program planner
1. After the situational analysis, health wanted to give importance on the magnitude
problems from the overall health situation of a problem, then a higher % can be given.
of the community are identified such as high The weight (%) makes the decision method
prevalence of hypertension, high incidence more accurate.
rates of dengue, etc. All prevailing health
problems are identified first before choosing Example (Decision Matrix)
one to address through a health program.
List of Magnitu Urgenc Feasibili Tot
2. In order to identify the priority problem
Problems de (50%) y (25%) ty (25%) al
of the community, a decision matrix is used.

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Hypertensi 3 (x0.50) 1(x0.25) 2(x0.25) To create a problem tree,
2.25
on = 1.5 = 0.25 = 0.5

2
3(x0.25) 3(x0.25)
Dengue (x0.50)= 2.50
= 0.75 = 0.75
1

Waterborn 1 (x0.50) 2(x0.25) 1(x0.25)=

1.25
e diseases = 0.50 = 0.50 0.25

1. Identify the issue or core problem to be

analyzed (trunk)
2. Identify the causes of the problem (root)
Problem Analysis 3. Identify the consequences/effects of the
Therefore, in this lesson, problem problem (branches)
identification will be discussed further using a 4. A problem tree can be later on
method called problem tree analysis. transformed into an objective tree, with
each part of the tree being turned into a
The prioritized problem in the decision positive statement.
matrix is the problem to be analysed. In
analysis of the problem, problem tree analysis Example of a problem tree:
can be used. A problem tree analysis helps
to find solutions by mapping out the anatomy
of cause and effect around an issue. This
enables a clearer prioritization of factors and
helps focus objectives.
To construct a problem tree:
• The identified core problem to be analysed
must be put in the middle (trunk)
• Identify the causes of the problem (roots of
the tree) A problem tree can be further transformed into
• Identify the consequences/effects of the an objective tree, where each statement in the
problem (branches of the tree) problem is turned into a positive statement.
In this method, the problem will be
"dissected" to create a map of the anatomy of Example of an Objective Tree
cause and effects of a particular problem. This
approach is not only used in public health but
also in other fields that involves program
management.
It is important that in order to provide the
correct solutions, the real problems and their
causes and effects will be identified and
therefore addressed.
The problem will be broken down into
chunks by identifying its root and Alternative tree is the same as the objective
intermediate (or secondary) causes. This will tree but in the alternative tree, the specific
help in better understanding of the problem means (roots of the tree) in the objective tree
and the situation. that are planned to be addressed by the
program are specified or highlighted.

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 Outcome: Increased knowledge of
Planning the Interventions community members on the prevention and
control of leptospirosis by 50%
Next is the development of logframe matrix
(also called as Logical framework Analysis or Outputs: Increased dissemination/reach (%)
LFA). In this approach, a comprehensive of health education activities about
overview of the intervention logic of a project leptospirosis prevention and control in each
is presented in a table. The logframe matrix is barangay
a table that also depicts the causal links Activities: Conduct of seminars/lectures 2x a
between the intervention and the expected week in every barangay, production and
results. house-to-house dissemination of IEC
materials

Indicators (objectively verifiable) and

means of verifications are used to measure the
progress and success of the project. Means of
verifications are the tangible materials used to
verify the indicators such as records,
attendance sheets, materials produced, etc.
There are indicators for the three levels
of results (outputs, outcomes, impact) and the
related means of verification. These indicators
are the measuring stick for a reliable
assessment.
Impacts have long term changes in the In planning programs, possible risks are
society. They are usually attained in the long identified and recognized. Risks are external
run of a program. factors that could have a negative influence on
Outcome statements describe the direct and the project. They are called assumptions when
often immediate effects as well as the converted into positive statements.
intermediate effects, which the project’s 1. The logframe matrix is a guide in
outputs are expected to have on the implementing and monitoring the progress of a
beneficiaries and target system. They are program.
verified by means of measurable indicators.
Lesson 3: Health Programs in the
Activities and outputs define the expected
Philippines
outputs and the activities of the project
Health Programs in the Philippines
Outputs consist of services and goods such as
training events, manuals (operational Promotion of Breast-feeding program/
guidelines), new technologies or methods, Mother and Baby Friendly Hospital
better or new infrastructure for organisations
such as equipment, buildings, etc. Outputs
may also be public infrastructure such as
health facilities. Activities are needed to
produce the outputs.

EXAMPLE
Impact: Reduced prevalence of leptospirosis
by 50%

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Initiative (MBFHI) - This is a nationwide, continuous and
concerted effort to eliminate the breeding
places of Aedes aegypti.
- Other initiatives are dissemination of IEC
materials and tri-media coverage

Expanded program on Immunization

- Main strategy to transform all hospitals with

maternity and new born services into facilities
which fully protect, promote, support breast
feeding and rooming-in practices - The expanded program on immunization is
one of the DOH programs that has already
- To sustain this initiative, the field health been institutionalized and adopted by all LGUs
personnel has to provide antenatal assistance in the region.
and breastfeeding counseling to pregnant and
lactating mothers as well as to the - Its objective is to reduce infant mortality and
breastfeeding support groups in the morbidity through decreasing the prevalence
community; there should also be continuous of six (6) immunizable diseases (TB,
orientation and re-orientation/updates to newly diphtheria, pertussis, tetanus, polio and
hired and old personnel, respectively, in measles.
support of this initiative.

Family Planning Program

Dengue Control Program

- The thrust of the Dengue Control Program is
directed towards community-based prevention
and control in endemic areas
- The program is anchored on the following
- Major strategy is advocacy and promotion,
basic principles
particularly the Four O’clock Habit which was
adopted by most LGUs.
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1. Responsible Parenthood which means that
each family has the right and duty to
determine the desired number of children
they might have and when they might have
them
2. Respect for life
3. Birth spacing refers to interval between
pregnancies (which is ideally 3 years)

National TB Control Program

- WHO introduced the Directly Observed
Treatment Short Course (DOTS) to ensure
completion of treatment
- The DOTS strategy depends on five
elements for its success:
- Microscope, Medicines, Monitoring, DOT
and Political Commitment
- If any of these elements are missing, our
ability to consistency cure TB patients slips
through our fingers.

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