NJALA UNIVERSITY
LECTURE NOTES
On
Introduction to Public Health (1)
Compiled and presented
by:
MR. Alfred Y. Kargbou
Public Health Epidemiologist (MSc,MPH)
2024/2025 Academic Year
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Introduction To Public Health
Public health is “the science and art of preventing disease, prolonging life, and promoting
health through the organized efforts and informed choices of society, organizations, public
and private communities, and individuals.” — CEA Winslow
The Mission of Public Health
“Fulfilling society’s interest in assuring conditions in which people can be healthy.” (Institute
of Medicine).
The Institute of Medicine states that the mission of public health is fulfilling society’s interest
in assuring conditions in which people can be healthy.
“Public health aims to provide maximum benefit for the largest number of people.” (WHO)
Similarly, the World Health Organization stresses that public health aims to provide
maximum benefit for the largest number of people.
Public health focuses on groups of people, rather than just an individual. At the core of public
health lies the principle of social justice, providing people the right to be healthy and to live
in conditions that will support their health.
Public Health Key Terms
clinical care: prevention, treatment, and management of illness and the preservation of
mental and physical well-being through the services offered by medical and allied health
professions; also known as health care.
determinant: factor that contributes to the generation of a trait.
epidemic or outbreak: occurrence in a community or region of cases of an illness, specific
health-related behavior, or other health-related event clearly in excess of normal expectancy.
Both terms are used interchangeably; however, epidemic usually refers to a larger geographic
distribution of illness or health-related events
health outcome: result of a medical condition that directly affects the length or quality of a
person’s life.
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The History of Public Health
• Around 500 BCE, the ancient Greeks and Romans actively practiced community sanitation
measures.
• Approximately 2 millennia later, the Public Health Act of 1848 was established. It provided a
central board of health and placed responsibilities for sanitation in the hands of boroughs.
• In 1970, the Nixon Administration established the Environmental Protection Agency, which
protects human health by safeguarding air, water, and land.
• Pandemics are epidemics or outbreaks of disease that spread far and wide, affecting the
populations of multiple continents.
- Influenza, or the flu, has caused pandemics many times during both the distant past and
recent history. Almost a century ago, the Spanish flu infected 500 million people across the
world, including remote Pacific islands and the Arctic, killing 20 to 50 million persons. More
recently, the influenza pandemic in 2009 infected persons in 214 countries, causing almost
19,000 confirmed deaths. Preparing for and controlling the effects of influenza will likely
remain top priorities for public health.
- Historically, polio was a common and highly feared disease that caused severe illness,
including paralysis, and death among thousands of people each year. Thousands of people
lined up to receive the polio vaccine after it was introduced in 1955. An initiative to eradicate
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polio was launched in 1988 because of outbreaks in more than 125 countries. Today, polio
exists in only a few countries.
- During the 1980s, human immunodeficiency virus, or HIV, emerged and spread rapidly
across the globe. Public health has responded to this pandemic by developing new ways to
diagnose and treat those who are infected. New infections of HIV are down 20% over the
past 10 years, which is a sign that public health interventions are successful.
Public health’s role in preparedness and disaster response, both for natural disasters
and human-made threats.
- The use of biological warfare to infect people and animals goes back centuries. During the
Siege of Kaffa in the 14th century AD, the attacking Tartar forces used plague as a weapon of
war by hurling plague-infected corpses into the enemy’s city. Their actions started the first
stage of the Black Death (or plague) among Europeans.
- In the immediate wake of the terrorist attacks on September 11, 2001, public health workers
were on the ground at the World Trade Center and the Pentagon, conducting surveillance to
identify outbreaks of diseases or other possible health conditions resulting from the attacks.
Public health workers closely monitored the health of first responders, city residents, and
environmental conditions to detect health threats during the cleanup after the attack.
- After Hurricane Katrina in 2005, public health workers and other disaster-relief agencies
tirelessly provided emergency services. Teams were dispatched to conduct surveillance for
illness and injury among people who evacuated to shelters and other places of refuge after the
storm.
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Public health problems are diverse and can include infectious diseases, chronic diseases,
emergencies, injuries, environmental health problems, as well as other health threats.
Regardless of the topic, we take the same approach to a public health problem by following
four general steps.
First, we ask “What is the problem?”
In public health, we identify the problem by using surveillance systems to monitor health
events and behaviors occurring among a population.
After we’ve identified the problem, the next question is, “What is the cause of the problem?”
For example, are there factors that might make certain populations more susceptible to
disease, such as something in the environment or certain behaviors that people are practicing?
Once we’ve identified the risk factors related to the problem, we ask, “What intervention
works to address the problem?”
We look at what has worked in the past in addressing this same problem and if a proposed
intervention makes sense with our affected population.
In the last step, we ask, “How can we implement the intervention? Given the resources we
have and what we know about the affected population, will this work?”
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Public Health Core Sciences
To implement the public health approach, practitioners use and apply scientific methods.
These methods come from a series of core sciences that provide the foundation.
These sciences include Public Health Surveillance, which we use to monitor a public health
situation.
Epidemiology enables us to determine where diseases originate, how or why they move
through populations, and how we can prevent them.
Public Health Laboratories support public health by performing tests to confirm disease
diagnoses. Laboratories also support public health by conducting research and training.
As we continue to move from the use of paper documents to electronic health records, Public
Health Informatics continues to increase in importance. Informatics deals with the methods
for collecting, compiling, and presenting health information. It enables us to use electronic
data effectively when addressing a public health situation.
Prevention Effectiveness is closely linked to public health policy. Prevention effectiveness
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studies provide important economic information for decision makers to help them choose the
best option available.
Together, these five core sciences can help us protect and promote the public’s health by
giving public health practitioners the answers they need. Public health is better able to
respond to the situation by using contributions from each of these sciences. One science alone
cannot answer the questions and provide a solution; it is the application of these core sciences
together.
For example, let’s look at the public health problem of influenza. Public health surveillance
can monitor when and where cases of influenza occur each year. Professionals can use the
science of epidemiology to understand why different populations choose to get vaccinated
against influenza. They can use the science of informatics to receive and analyze electronic
information from health care institutions (e.g., doctors’ offices and hospitals) to determine
whether persons who get influenza go to see a doctor and whether they get well or die. Public
health practitioners can use laboratory science to determine whether persons with fever and
cough have influenza or a different infection, and they can use prevention effectiveness to
show that influenza vaccination campaigns that might cost $200,000 can prevent $1 million
in medical costs, lost wages, and other costs.
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Ten essential public health services are grouped under the three core functions. These
services are not a prescription for what public health agencies should be doing. Instead, they
are intended to serve as a descriptive tool to capture the field of public health and to
communicate what public health provides.
Possible answers are listed with each function.
1. Assessment
• Monitor health status: Monitor smoking use among segments of the population, such as
youth.
• Diagnose and investigate health problems: Investigate risk factors associated with tobacco
use.
2. Policy Development
• Inform, educate, and empower people about health concerns: Place public service
announcements on television regarding the dangers of smoking.
• Mobilize community partnerships: Work with advocacy groups to develop antismoking
interventions that will work in a specific community.
• Develop policies and plans: Passage of Proposition 99 (the cigarette tax to fund antismoking
campaigns); smoke-free workplaces, apartment complexes, and other shared spaces.
3. Assurance
• Enforce laws and regulations: Enforcement of policies and laws, such as placement of
cigarette vending machines.
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• Link people to needed personal health services: Address potential barriers related to
culture and the language of materials, or staff serving special population groups. In
California, ads in the tobacco control media campaign were broadcast in Spanish and
Mandarin as well as English.
• Assure a competent public health and personal health care workforce: Ensure a
knowledgeable workforce is in place to develop and implement the antismoking campaign.
• Evaluate effectiveness: Ongoing evaluation of the campaign to ensure it works as desired;
determining how it might be improved.
• Research for new innovative solutions to health programs: Take insights gained from the
field on what works and confirm them through collaborative study with health researchers.
HEALTH AND SOCIAL DETERMINANTS:
WHAT IS HEALTH?
One of the most fundamental conditions in life and core to everyday life
“A state of complete physical, mental and social wellbeing and not merely the absence of
disease or inrmity” (WHO, 1946)
• Dimensions of health
• Physical
• Social
• Mental
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• Spiritual
• Environmental
Health promotion approach to health: process of enabling people to increase control over and
to improve their health
Public health approach: refers to all organised measures to protect health among populations,
and to prevent disease, promote health and prolong life among the population as a whole
SOCIAL GRADIENT (WILKINSON AND MARMOT 1998,2003):
Lower socio-economic conditions result in a shorter life expectancy than for those higher
up on the socio-economic ladder
PUBLIC HEALTH FUNCTIONS
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OLD PUBLIC HEALTH: A social movement of the 19th century that worked to improve
living conditions through the development of physical infrastructure, including water,
sanitation and housing, as well as policy and legislation to support and drive change
NEW PUBLIC HEALTH: An explicitly social and political approach to health development
that emphasises knowledge to action on the social determinants of health, intersectoral action
to support health, health public policy, environments for health, sustainable development and
equity in health
HEALTH PROMOTION: “the process of enabling people to increase control over the
determinants of healthy and thereby improve their health” WHO 1986
HEALTH PROMOTION:
WHO led initiative
Landmark document laying out a clear statement of action that continues to provide
framework for health workers around the world
Health promotion action must occur on 5 fronts:
1. Build health public policy
2. Create supportive environments
3. Strengthen community action
4. Develop personal skills
5. Reorient health services
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LEVELS OF PREVENTION:
3 basic strategies for health promotion- enable, mediate and advocate
• Primary- prevention of disease in individuals
• Secondary
• Tertiary
The three levels of prevention—primary, secondary, and tertiary—are aimed at preventing
disease and promoting health at different stages:
1. Primary Prevention:
o Goal: Prevent the onset of disease or injury before it occurs.
o Approach: Focuses on reducing risk factors or increasing resistance to
diseases through proactive measures.
o Examples: Vaccination, promoting healthy lifestyle habits (e.g., proper
nutrition, regular physical activity), smoking cessation campaigns, and
ensuring clean water and sanitation.
2. Secondary Prevention:
o Goal: Detect disease early in its development to halt or slow its progression.
o Approach: Involves screening and early diagnosis to allow for timely
intervention before the disease becomes symptomatic or causes serious
damage.
o Examples: Regular health check-ups, screening tests (e.g., mammograms for
breast cancer, blood pressure monitoring), and early treatment to prevent
complications.
3. Tertiary Prevention:
o Goal: Reduce the impact of an already established disease by preventing
further deterioration, improving quality of life, and minimizing complications
or disability.
o Approach: Focuses on rehabilitation, disease management, and providing
support to help individuals manage long-term health issues.
o Examples: Physical therapy for stroke patients, cardiac rehabilitation
programs, managing diabetes with medication and lifestyle changes, and long-
term care for chronic diseases.
These prevention strategies work together to address health at different stages of illness, from
preventing the disease entirely to managing its effects after it has occurred
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GLOBAL HEALTH:
WHAT IS GLOBAL HEALTH?
Strategies developed and implemented for health improvement across national boundaries
• A term used to describe the impacts on health that result from globalisation
WHO: Created in 1948 as a specialised agency of the UN
• Its fundamental goal ‘the attainment by all peoples of the highest possible level of
health’.
TRANSNATIONAL: Issues that direct health across countries and continents such as
climate change and urbanisation
MILLENIUM DEVELOPMENR GOALS
The eight-millennium development goals focus on poverty, hunger, education, gender
equality, child mortality, maternal mortality, HIV/AIDS and water and sanitation.
HUMAN RIGHTS:
➢ The work of human rights is about inscribing certain moral principles into laws of
countries
➢ and is led by international law
➢ The Universal Declaration of Human Rights 1948 set out principles saying:
➢ Human rights apply equally to all humans
➢ All people are equal in dignity
➢ Human rights are about freedom from discrimination, slavery, torture and arbitrary
detention
➢ Human rights are about freedom of movement, expression and religion, and about
➢ the right to life, liberty and security of the person and privacy
➢ All people have the right to work, to health, to an adequate standard of education
➢ and housing
• The Peoples Health Movement. A political and social movement as well as a health
movement and is concerned with health as a human right as well as civil and political right.
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Its processes, activities and aspirations aim to change both the way power is distributed and
the way it is used
ECOLOGICAL HEALTH:
WHAT IS CLIMATE CHANGE?
• A change in global or regional climate patterns in particular a change apparent from the
mid to late 20th century onwards and attributed largely to the increased levels of
atmospheric carbon dioxide produced by the use of fossil fuels
• Climate and health co-benefits:
o Many of the drivers of climate change (eg. Fossil fuel burning, overconsumption of meat,
poorly designed cities and overdependence on motorised transport) also contribute to many
health problems (obesity, diabetes, respiratory and heart disease and road deaths)
o Health gains can be achieved through interventions such as switching to cleaner, low
carbon energy sources, urban planning that promotes active transport and reducing red meat
and dairy consumption
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This figure takes an ecological view of health which situates the individual and their personal
characteristics within their living and working conditions, the social and economic resources
and opportunities available and importantly the built and natural environment
ECOLOGICAL PUBLIC HEALTH:
• The outcome of complex interrelationships and interdependencies between human beings,
the determinants of health and the broader environment in which they exist
• The Earth Charter articulates four principles (help to describe relationship between the
theoretical perspectives of ecology and public health practice)
1) Respect and care for the community of life
2) Ecological integrity
3) Social and economic justice
4) Democracy, nonviolence and peace
WHAT IS ENVIRONMENTAL HEALTH?
• It is 'concerned with creating and maintaining environments which promote good public
health'
• basic requirements for a healthy environment: clean air; safe and sufficient water; adequate
and safe food; safe and peaceful settlements; safe workplaces; and a stable global
environment
NON COMMUNICABLE DISEASE AND INJURY:
➢ Non communicable diseases account for 60% of global mortality
➢ The other 40% are due to communicable diseases, maternal and child illnesses and
violence and injuries
➢ 80% of NCDs are in low-middle income countries and 26% are premature deaths
➢ Major NCDs are cardiovascular disease, cancer, diabetes and chronic respiratory
disease which share common risk factors; tobacco, unhealthy diet, physical inactivity
and harmful use of alcohol
➢ For prevention of NCDs people need to employ health living choices
➢ Tobacco control policies
➢ If all countries implement and enforce 6 tobacco control policies, populations
worldwide could be protected from morbidity and premature death caused by tobacco
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➢ The WHO framework convention on tobacco control represents a regulatory strategy
to address factors that drive the global tobacco epidemic, these factors include; global
marketing, transnational tobacco advertising, trade liberalisation and direct foreign
investment and the international movement of contraband and counterfeit tobacco
products. It also addresses the importance of reduction strategies as well as supply
issues
➢ Nutrition policy
➢ Strong link between intake of trans fat, excessive salt consumption, low consumption
of fruits and vegetables, high consumptions of sat fat and sugars and NCDs
➢ The three major processes of globalisation are driving up these intakes; foreign direct
investment in food processing and retailing, global food advertising and promotion,
production and trade of agricultural goods
➢ At an individual level health education is key
➢ Transnational corporations are major drivers of non-communicable disease epidemics
and protection from increased consumption of tobacco, alcohol and ultra processed
food and drink
➢ Alcohol and ultra processed food and drink industries use similar strategies as the
tobacco industry to undermine effective public policy and programmes
➢ Unhealthy commodity industries should have no role in the formation of national or
➢ international policy for non-communicable disease policy
➢ Despite the common reliance on industry self-regulation and public private
partnerships to improve public health there is no evidence to support their e:ectiveness
or safety
➢ In view of the present and predicted scale of non communicable disease epidemics the
only evidence based mechanisms that can prevent harm caused by unhealthy
commodity industries are public regulation and market intervention
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COMMUNICABLE DISEASE
Capable of being transmitted from one person to another eg.
➢ Blood borne diseases (hepatitis)
➢ Gastrointestinal diseases (salmonellosis, typhoid)
➢ Bacterial infections (tuberculosis)
➢ Sexually Transmitted diseases (syphilis)
The emergence and re-emergence of communicable disease threats to human health has been
exacerbated in recent times by
➢ Climate change and changing land use patterns
➢ Globalisation
➢ Population mobility
➢ Decreased vaccination rates
➢ Accidental and malicious release of dangerous pathogens
➢ STIS
• Globally communicable diseases account for 50% of years life lost
➢ 8% in high income countries
➢ 68% in lowincome countries
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PREVENTING INFECTIOUS DISEASE
➢ Effective hand hygiene
➢ Safe sex
➢ Safe travel
➢ Vaccination
WHAT IS HEALTH PROMOTION PLANNING?
Based on good evidence and community consultation
• Has clear and achievable goals and objectives
• Allows for good evaluation at all stages of the cycle
CHANGING BEHAVIOUR K+A+S+E=B:
• K=what do people need to KNOW?
• A=what ATTITUDES will be helpful?
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• S= what SKILLS are required?
• E= what ENVIORNMENT will support the behaviour
• =B what BEHAVIOUR are we wanting to change or promote?
BEHAVIOUR CHANGE:
• Individual level
• Group/community level
• Population level
WHAT IS A PROGRAM PLAN?
• A plan designed to create elective and sustainable change by taking a structured approach to
the logic of goals, objectives, strategies and outcomes
Program logic= when program plans ensure that all conceptual and technical elements of the
program are linked through logical connection
TYPES OF PUBLIC HEALTH RESEARCH
• Descriptive: describing the problem
• Analytic: identifying the causes and consequences of the problem
• Evaluation: collecting data to judge whether interventions were successful and what did or
did not
UPSTREAM PUBLIC HEALTH INTERVENTIONS
• Those at the macro level including government policies, global trade agreements and
investment in population health research
DOWNSTREAM PUBLIC HEALTH INTERVENTION
• Those at the micro level including treatment systems, disease management and investment
in clinical research
INTEGRATED HEALTH PROMOTION
A program design that uses a mix of health promotion interventions across the upstream-
downstream continuum and capacity building strategies to address priority health and well-
being issues
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MULTI LEVEL HEALTH PROMOTION
• A program design that simultaneously addresses two or more outcome levels such as
individual, family, or group, community, organisational or societal
TWO TIER HEALTH PROMOTION PLAN
TIER ONE:
• Evidence of the problem
• Determinants of the problem
• Population of interest
• Settings
• Outcome levels
TIER TWO:
• Partnership development and rationale
• Vision setting
• Goals and objectives
• Action mapping and strategy selection
• Implementation
• Evaluation and dissemination
HEALTH EDUCATION FOR EMPOWERMENT
WHAT IS HEALTH LITERACY?
• Involves the cognitive and social skills which determine the motivation and ability of
individuals to gain access to, understand and use information in ways that promote and
maintain good health
• Literacy levels are strongly correlated with health outcomes
• It informs peoples’ capacity to maintain good health, prevent and manage communicable
and non-communicable diseases
HEALTH EDUCATION
• Aims to encourage and motivate individuals to adopt health promoting behaviours and to
help individuals make decisions about their health and acquire the necessary confidence and
skills to put their decisions into practice
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• Aims to advocate for changes in environment and health policy
• Influence policy makers to implement changes
WHAT IS HEALTH EDUCATION?
o Communication of knowledge and the provision of experiences to help individuals develop
attitudes and skills which will assist their adopting behaviour to improve and maintain health
for themselves and others
o About making informed decisions regarding health
FOUR MODELS OF HEALTH EDUCATION
• Traditional medical model-works through professional patient interaction, concerned with
compliance and raising awareness of health risk and encouraging behaviour change
• Client-cantered model-seeks to strengthen patient autonomy and encourages their active
participation in treatment and disease management
• Behaviour change model-designed to encourage healthy choices and for people to take
personal responsibility for their health decisions
• Empowerment model – a process that also facilitates or enables people to gain control over
the determinants of their health in order to improve their quality of life
HEALTH PROMOTION
• Combination of educational, organisational, economic, social and political actions designed
with meaningful participation to enable individuals, groups and communities to increase
control over and to improve their health through attitudinal, behavioural, social and
environmental changes
MOST COMMON BEHAVIOURAL RISK FACTORS
• Smoking
• Physical inactivity
• Poor nutrition
• Harmful use of alcohol
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POOR NUTRITION
• Important factor in obesity prevention
• 91% of people aged 15 and over do not consume sufficient serve of vegetables
• 50% do not consume sufficient serves of fruit
PHYSICAL INACTIVITY AND SEDENTARY BEHAVIOUR:
• Over 60% of people are not active enough to gain any health benefits
• Physical in activity guidelines for different age groups
• Sedentary behaviour guidelines: minimise the amount of time spent in prolonged sitting,
break up long periods
HARMFUL USE OF ALCOHOL
• Harmful levels are associated with increased risk of
o Chronic disease
o Cancer
o Injury
o Premature death
HEALTH POLICY:
• A formal statement or procedure within institutions that defines priorities and the
parameters for action in response to health needs, available resources and other political
pressures
PUBLIC POLICY
Actions developed by governments and public authorities to address a given problem or
an interrelated set of problems
• Has a social purpose it is developed from a recognition that for people to lead healthy
productive lives there must be an appropriate structural, environmental and social supports in
place
• Values framework
o Justice and fairness
o Basic living standards for all people with a decent minimum income
o Redistributive taxation and welfare support when people need it
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ORGANISATIONAL POLICIES
• Organisational policies are developed by organisations to govern matters such as
o Equal opportunity, staffing policies, diversity, anti-discrimination, bullying and harassment
o Guidelines for practice, such as health promotion or counselling services
POLICY FOR ADVOCACY
• Policies developed by interest groups and NGOs as position papers and/or lobbying tools
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