The Family As A Unit of Care: 1987 Philippine Constitution
The Family As A Unit of Care: 1987 Philippine Constitution
THE FAMILY AS A
We may become the last of the true family doctors in UNIT OF CARE
the world because the family is strong in
Asia…… in our society, the family of three Zorayda E. Leopando, MD
generations flourishes with the nuclear family which Annabelle Pabilona-Tiu, MD
nevertheless retains close …… ties with parents Angel Erich Sison, M.D.
and grandparents . The family in Asia transmit Arnel V. Herrera, M.D.
ethical and cultural values ; is a reliable source of Joseph A. Jao, M.D.
succor in adversity and provides loving care to their
Philippine Constitution, 1987
Gloria Peret- Clarion, M.D.
disabled and handicapped on the tiniest of Julie Tanchanco- Tiu, M.D.
resources. Ma. Lorena Lorenzo, M.D.
Jena Angela Perano, MD
M. K. Rajakumar,
1993
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BIOSPHERE
SOCIETY
COMMUNITY
Understanding the
FAMILY
family:
PERSON The family and its
functions
Tissue
c
Organ
Human Body
G. Engel, 1979
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FAMILY STRUCTURE
CLASSIFICATION
1.Nuclear Family OF FAMILY
2.Extended Family
ACCORDING TO
3.Single Parent Family
4.Blended Family
HEALTH STATUS
5.Communal/ Corporate Grouping
CLASSIFICATION OF FAMILY
ACCORDING TO HEALTH 1. HEALTHY / WELL FAMILY
STATUS :
CHARACTERISTICS OF A HEALTHY FAMILY :
1. Open to change
1. Healthy Family 2. High self worth
2. Family at Risk 3. Functional defenses
4. Clear rules discussed
3. Family with Problem 5. People take risk to express feelings
6. Can deal with stress
7. Welcomes life stages
8. Clear hierarchy
9. Affect is open
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RISK FACTORS :
RISK FACTORS FOR DISEASE :
A risk factor increases your risk of developing
a disease or health problem
environment
behaviors and lifestyle 1. Environment
Genes
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B. Poor diet
C. Obesity
D. Smoking
Child
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SYSTEM : FAMILIES
FAMILY SYSTEM THEORY :
Are systems of interconnected and
• an entity interdependent individuals, none of
composed of whom can be understood in
discrete parts isolation from the system. CHANGE→
which are • Parts or
connected in such It is the system in which each members • Circularity
a way that a member had a role to play and rules
change in one part to respect. • a change in
results in changes Members of the system are one part • Equilibrium
in all of the other expected to respond to each other results in
parts. in a certain way according to their changes in all
Allan Dionisio, 2013 role, which is determined by parts. • Homeostasis
relationship agreements.
Murray Bowen
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STRUCTURES OF FAMILY
DYNAMICS :
1. Rules of behavior
FAMILY AS A UNIT
2. Boundaries
OF HEALTH CARE
3. Roles played by different members
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FAMILY PARTICIPATION IN
PREVENTION OF DISEASES FAMILY ORIENTED PRIMARY
Primary prevention Secondary prevention Tertiary prevention CARE :
Common lifestyle
diet, non-addictive
Health is shared
responsibility between
Balanced support between
compliance monitoring and 1. Learning to “think family”
behavior, leisure activity, doctor, patient and family. independent activity of 2. The importance of genogram
basic living habits (i.e. monitoring of well- members with chronic
being iillness 3. The family within a larger system – use
an Ecomap
Health maintenance
screening activities and
Encouraging sick member
to seek appropriate help
Adjustment of all members
to changes necessitated by
4.Chronic illness and disability- family
immunization chronic illness in one caregivers
patient 5. Working with family members – the
Family life education Compliance monitoring Coping with crisis created
family conference
sexuality, marriage, regarding management by serious illness or a dying 6. Identifying the family at risk
prenatal care, personal family member
hygiene and sanitation, Graham Bresick, 2006
health risk behavior and
disease prevention, care Hennen et all
of elderly
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FAMILY MEDICINE
• a component of primary care
• specialty of medicine concerned with
providing comprehensive care to individuals
FAMILY MEDICINE and families
AND THE • integrates biomedical, behavioral and social
sciences
FAMILY PHYSICIAN •an academic medical discipline that includes
comprehensive health care services,
research and education
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Teacher/ Teacher/
Educator Educator Counselor
Researcher
Health Care
Provider
……. To patients at various stages of life
….To families at various stages of family life cycle………
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Resolution
References
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REFERENCES
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ANNABELLE PABILONA-TIU, MD
LOURDES CARPENA-MEDALLA, MD At the end of the session, the students should be able to:
MA. TERESITA S. CHUA, MD 1. Discuss family structure, organization and function
JULIE TANCHANCO-TIU, MD 2. Identify unique stresses associated with families of varying
GLORIA T. PERET-CLARION, MD composition
JENA ANGELA PERANO, MD 3. Discuss social changes happening to the Filipino families
FAMILY FAMILY
• Is a group of persons united by ties
• Is a group of people united by a common desire to exist
of marriage, blood or adoption
together, to meet the needs of its members and the
constituting a single household
family unit as a whole
interacting and inter-communicating
with each other in their respective • Is an intimate domestic group made up of people related
social roles of husband and wife, to one another by bonds of blood, sexual mating or legal
father and mother, son and ties
daughter, brother and sister, • Is the smallest and most basic social unit
creating a common culture
• Is the most important primary group in a society
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CHARACTERISTICS OF THE
FAMILY STRUCTURE FAMILY
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1. Husband-Wife Relationship
• Legal, social or formal union A. Conjugal bond- permanency in marriage and intimacy. It is for
recognized between a man and sexual pleasure and protection. It is for procreation.
woman that unites their lives legally, B. Social pressure- the community expects the husband and wife to
economically, and emotionally with be loving and faithful to each other and to have a lasting and
permanent marriage
intimate, mutual long-term
obligations C. Economic cooperation- the husband is the main breadwinner
while the wife takes care primarily of the domestic needs of the
family
1. Loving, caring and protective of their children Rural areas- division of labor based on age and sex provides
each family member a special work- role
2. Work hard and even plunge into debt to provide for their children
3. Train and discipline their children early in life with high hopes for
their bright future • Sons are trained in farm work so that they may take over
the father’s responsibilities someday
4. Aspire to have their children attain a high level of education • Daughters help their mother take care of the home
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4. Siblings Relations
“ NO MATTER WHAT HAPPENS IN LIFE OR THE NEXT, I WILL ALWAYS BE HIS
MOTHER.”
• Mutual love, protection and respect
• Brothers are expected to look after their sisters and protect PARENTING : IS THE PROCESS OF NURTURING, CARING FOR, SOCIALIZING
AND PREPARING ONE’S CHILDREN FOR THEIR EVENTUAL ADULT ROLES
them from harm
• Older siblings are given the responsibility to take care of
1. Parents serve many functions that play a crucial role in the society’s endurance
the younger ones especially when the parents are away and success at many levels
• Younger siblings are in-turn need to obey their elders and 2. Parents function as caregivers to the children in their families
look up to them with respect 3. Parents function as agents of socialization for their children
“PARENTS PROVIDE PRIMARY SOCIALIZATION TO THEIR A network of people who are related by marriage,
CHILDREN. BEGINS AT BIRTH AND MOVE FORWARD UNTIL blood, or social practice or the state of being related
THE BEGINNING OF SCHOOL YEAR” to others culturally learned, not necessarily
determined by biological ties
4. Parents function as teachers
5. Parents function as guardians • Kinship is a means by which societies can
socialize children and transmit culture from one
6. Parents function as mediators generation to the next
• Kinship creates complex social bonds
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• All direct ascendants from great grand parents to all • Union of two consanguineal family
descendants from children to great grandchildren • Balae relationship
• Bilas relationship
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Lee Iacocca
2008 2018
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OBJECTIVES:
World/Universe
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◆In each stage, a family projects various ◆The process which are undertaken
identities and roles, the fulfilment of involves transition, extension, and
which would ensure advancement to overlaps.
the next level.
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Stage IX: Stage IX: Stage III: The Family with Young Children
Aging Family Aging Family
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Challenge
ADOLESCENT :
• 1. Shifting of1. Providing
to parental parent- facilities for
authority MEDICAL:
- Requires increase in the flexibility of (negotiatin
child
relationshi
widely different
g) needs
family boundaries to include children's • "Middle-
essence"
p to
permit the 2. Working out • Drugs /
independence and grandparents weakness meets adolescen money matters in substance abuse
adolescenc t to move the family with • STD
e
• Less time
in and out teenagers • Acne, bad odor
with
of the 3. Sharing task of • Gynecologic
system responsibilities of
extended problem
family family living • Menstrual
2. Refocus
4. Putting marriage
on midlife
relationship into
problem
marital • Allergies / skin
and career focus
issues
disease
• Circumcision
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EMOTIONAL SECOND ORDER FIRST ORDER Changes Or Task PROBLEMS Emotional PROBLEMS
CHANGE Involved SECOND ORDER
PROCESS ENCOUNTERED Process of Changes FIRST ORDER ENCOUNTERED
OF Transition Changes
TRANSITION
PARENTS:
• Continued 1. Keeping the ADOLESCENT : MEDICAL:
mid-life 3. Beginning communication system
challenge shift towards open EMOTIONAL/SOCIAL • Common medical
concern for 2. Maintaining contacts
in problems
older with the worlds as a
marriage generation family and as a person • Sexual • Pre-menopausal
relationsh experimentation symptoms
ip and 7. Growing into the world • Homosexuality • Alcoholism/ vices
with as family and as a • OB-GYN problem
person • Conflict with
extended
family 8. Reworking and parents EMOTIONAL/SOCIAL
maintaining a • Juvenile
philosophy in life
delinquency • Middle life crisis
• Depression due to • Male climacteric
peer pressure • Extra marital affair
• Child prostitution • Insecurities
• Suicidal tendencies secondary to
changing appearance
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6. Re-examine CHILDREN
living Medical:
arrangements • episodic medical -Begins with departure of last child and
problems ,
with parents;
• OB gyne problem
continues through retirement of one or both of the
7. Adjust to reality • menopause problem couple and ends when both are dead
of work
situation; Emotional problems - Coping with physiological decline
8. Assure security • Independence and
for later years; dependency problem; - Accepting the shift in generational roles
9. Participate in juvenile delinquency,
community • peer group pressure
on vices,
activities;
• conflict with parents,
10.Reaffirm values • problems in
in life with real adjustment to married
meaning life
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Family
Role Allocation Accountability
• Assignment of • Make decisions on who will • Refer to a family members • e.g. Parents in healthy families
responsibilities within a be responsible for sense of responsibility for understand that they are
family that enables the completing a certain task or completing the tasks of an responsible for disciplining their
children. When discipline is
family to function properly fulfilling a particular assigned role
needed they do not hesitate
responsibility
5 Essential Roles for Effective Family Functioning 5 Essential Roles for Effective Family Functioning
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• A state of family homeostasis in which member interaction results in • Approach problem in a unified manner as a family.
emotional and physical nurturing, thus promoting growth of family
members and the family unit.
• Have a non-materialistic orientation.
FAMILY HOMEOSTASIS:
• Husband and wife frequently share tasks.
• Ability to maintain a constant state in the midst of a continuous interplay of
internal and external forces. • Perceive the nature of the problem accurately.
DISTURBED BY: • Have a democratic orientation, with diffusion of
- Sudden socio-cultural change leadership regarding problem solving tasks.
- immigration from one culture to another
- unexpected alteration in position on the social ladder
- Role change
LOVE
• Provides an atmosphere of warmth, acceptance and support.
5 BASIC CHARACTERISTICS:
• An attitude of service – looking out for each other
• Clear separation of generation.
• Secure relationship between parents (or other
• Flexibility of family roles. guardian/authority figure)
• Effective and constant communication. • Parents teach and train – encourage each family
member to grow & develop as an individuals
• Tolerance for individuality.
• Attitude of honor: parents lead with love, children respect
and obey
• Have shared experiences/activities on a regular basis
CHARACTERISTICS OF FAMILY WHO • (from “Five Signs of a Functional family” by Gary Chapman)
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• The foundation of a well functioning family is a • Each person tends to select a spouse most likely to provide
balance of love and respect base on a shared set of gratification and best satisfy his needs
values/beliefs
• Harmony and stability within the family system are maintained
• Rules, roles, and relationships work together to if the spouses’ personalities, goals, and expectations are
meet the goals/purpose of the family complimentary
• A healthy family will more easily weather the
storms of life • Relationships needs to be flexible and adjustable over time
• Family members accustomed to helping each other,
self sacrifice • When complimentary function fails, anxiety, conflict, and
• Open to share feelings and fears without being hostility result; equilibrium is disrupted and dysfunction occurs
threatened
• Easier time adjusting to new roles
• More likely to plan ahead and be prepared COMPLIMENTARY NEEDS OF
THE HEALTHY/SUPPORTIVE FAMILY THE FAMILY:
DYSFUNCTIONAL
emotional, physical, &/or sexual abuse.
• Maybe characterized by negative unwritten rules: “Don’t
Talk, Don’t Trust, Don’t Feel.”
• Troubles will be magnified in times of stress
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MARITAL CONFLICTS
• A result of disordered family dynamics.
THE LOST CHILD
• Child feels caught in the middle and forced to take
• Often gets lost in the shuffle. sides with one parent against the other
Adults sometimes can’t
remember the student’s name
because he/she is so quiet and
is seldom a behavior problem.
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• The spouses are not merely unhappy but are openly hostile to • Comes from disordered family relationships
one another, often competing for loyalty of the children
• The mother in a schizophrenic family is typically described as • Families of delinquent children lack a warm,
domineering, over protective and manipulative of both father
and child affectionate relationship between parents and
children
• The father is usually weak, passive, and elusive, having little
interaction with the child
• Parental coalition is absent
• Common among boys who have lost their father or
passed through an important formative years (ages
• Parents are in chronic conflict 4 to 8) without a father figure present or with one
present who serves inadequately in the paternal
• Family members rarely make affirmative statements role.
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TROUBLED FAMILY
5. Internal Catastrophe
TROUBLED FAMILY
Illegitimacy
• Unwilled absence of a
family member.
• Individuals may live together with minimal • Maybe lost to death,
contact and communication and fail to incarceration, or war.
provide for the basic personal and social • Loss of family member
needs of the family member. means that the
relationship between
• Families of professional and managerial remaining members
have to be rewoven to
men seem prone to this type of existence compensate for the lost
individual.
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FAMILY CRISIS
• Chronic disabilities present a
different problem- chronically ill
person must reshape his personal
and social needs so that they are
consistent with his capabilities.
5. INTERNAL CATASTROPHE
• Many crisis are major family disruption • Any event, past or present that changes the
which results from repeated subtle lifestyle or presents a significant strain upon
stresses that have been inadequately family organization.
managed and have weakened family
dynamics until they ultimately CATEGORIES:
culminate in a major threat to family • 1. Normative
stability. • 2. Non-normative
• Examples:
• Example:
• Birth, marriage, moving to a new community
• Infidelity, unplanned pregnancy, sudden fame
NORMATIVE NON-NORMATIVE
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ADDITION
EXTERNAL NON- INTERNAL NON-
NORMATIVE • A crisis identified with short and long
NORMATIVE term addition of one or more to the
• Manmade and • As in marital family structure.
infidelity, criminal • Example:
natural disasters • Adoption, birth, marriage, unplanned
activity pregnancy
• Usually leads to
transient dysfunction • May lead to ABANDONMENT
extended period of
• Rapid pooling of
dysfunction • Associated with the threat of loss or
resources actual departure of a family member
• Example:
• Planned departure, separation, death,
stow away
FAMILY RESPONSES TO
EVALUATING FAMILY CRISIS STRESSFUL LIFE EVENTS:
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Maladaptation
Pathologic defense
DISEQUILIBRIUM RESOURCES
• State of impaired • Assets that serve to
functioning that occurs nurture an individual
when an individuals and those that supply
resources are the means for solving
stressor-induced
inadequate or problems.
unavailable to meet an • Familial, extra-familial,
intense stressor or an social, cultural,
accumulation of religious, economic,
stressor. environmental, and
medical support
systems.
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COPING CRISIS
• Refers to adjustment Example: • State of family
by the family to disequilibrium that
stressors within and • Changes resulting results from the failure
outside the family. of an individual to
from the illness of
identify or use
one of its members resources to resolve a
stressor induced
problem.
PATHOLOGIC TERMINAL
MALADAPTATION DISEQUILIBRIUM DISEQUILIBRIUM
• The use of pathologic ▪ State of impaired ▪ Family function is
defense mechanisms interaction or nurturing continuously
to escape from an within the family that deteriorating because
unresolved crisis, follows the use of of failure to resolve a
resulting in a state of crisis, may eventually
impaired emotional, abnormal defense lead to family
and social functioning. mechanisms to escape dissolution.
from anxiety of
unresolved family
crisis.
DEFENSE
• The greatest problems arise when defense
mechanisms are overused.
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DENIAL DISPLACEMENT
◼ Seeing but refusing ◼ Involves purposeful,
to acknowledge unconscious shifting
what one sees and from one object to
hearing but another the interest of
negating what is solving a conflict.
actually heard
IDENTIFICATION INTROJECTION
◼ Actually plays a crucial ◼ Differs from
role in ego identification in the fact
development, but can that this involves
be used as a defense internalization of the
mechanism when a characteristics of
person unconsciously another person or
incorporates the object, creating a
characteristics and radical shift or
qualities of another alteration in the
person or object into person.
his ego system.
RATIONALIZATION REGRESSION
▪ Individual provides a ◼ Individual retreats to
plausible but an earlier
inaccurate justification developmental stage
for his or her failures. that was more secure
and pleasant and/or
▪ Attributes the use of less mature
achievements to their response in attempting
own qualities and to cope with stress.
skills;
▪ Failures are blamed on
other people or outside
forces
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REPRESSION TRANSFERENCE
◼ Consist of expelling ▪ The redirection of
and withholding from
conscious awareness feelings and desires
of an idea or feeling. and especially of those
unconsciously retained
from childhood toward
a new object.
▪ The inappropriate
repetition in the present
of a relationship that
was important in a
person's childhood.
Defense Mechanisms Defense Mechanisms
INTELLECTUALIZATION PROJECTION
• Taking an objective ▪ Perceiving and reacting
viewpoint. to an unacceptable inner
impulse and their
• Reduces anxiety by derivatives as though
thinking about they were outside the
events in a cold self.
clinical way. ▪ In the family, a child with
a health problem usually
may become the
identified patient onto
whom the unresolved
family problems are
transferred.
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SUBLIMATION
• Often most • “People with more • Redirecting or
constructive and acting out
mature defenses tend to unacceptable
helpful to most adults, be more at peace with impulses or “wrong”
but may require themselves and those urges into socially
practice and effort to around them.” acceptable actions.
put to daily use • Sign of maturity.
• More focus on helping • Example: A person
a person be a more experiencing extreme
anger may take up
constructive boxing/kickboxing as a
component of their means of venting out
environment frustration.
• Reference:
• Zorayda Leopando, Alex Bienvenido Alip, Thelma
Fernandez, Cynthia Hipol, Irene Maglonzo,
Reynaldo Olazo et al (Editors) Textbook of Family
Medicine Principles, Concepts, Practice, Context • Time: An Impatient Young Mother Learns to Treasure
(Volume 1) 2014 Philippine Academy of Family Time with her Son//Viddsee.com
Physicians and C and E Publishing, Quezon City
• PRINCIPLES OF FAMILY PRACTICE by Robert E.
Rakel, M.D.
• Graham Bresik. Family Oriented Primary Care.
Handbook of Family Medicine. Edited by Bob
Mash. Oxford University Press. South Africa,
2006. www.psychologistworld.com
• https://en.m.wikipedia.org
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Tools for
Family Assessment
Arnel V. Herrera, MD
Ronwaldo San Diego, MD
Macario Reandelar Jr., MD
Jena Angela Perano, MD
Zorayda E. Leopando, MD
Ma. Teresita Chua, MD
Marie Ruth Echavez, MD
Desmond Tutu
Objectives:
At the end of the lecture the student should
be able to:
discuss family system approach in clinical
practice
enumerate the various tools for family
assessment and their indications/uses
describe how each tool is made, and FAMILY SYSTEM APPROACH
analyzed
demonstrate how tools are applied
IN CLINICAL PRACTICE
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I. FAMILY TREE
II. FUNCTIONAL CHART
- - Must consist of 3 or more generations, each generation
Gives more dynamic image of the family especially of the
is identified by Roman numerals
relationship of members.
-The family name is placed above each major family unit
Allows one to judge the totality of the unit, its strengths,
- - First born of each generation is farthest to the left, weaknesses and its ability to withstand the future
with the siblings following to the right in the order of stressful situations.
birth
- Given names and ages are placed below each symbol.
- One member of the family with greater medical
significance is known as the INDEX PATIENT and is
identified with an arrow (↗️).
- Members of the family of the Index Patient living in the
house will be enclosed in a circle
- Finally indicate the date when the chart was developed.
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Genogram symbols
III. FAMILY ILLNESS/HISTORY
CERRERA SONIO
I
II MJrC SC
LC VC 48 44
VM LM
II A
PTB HPN
BIENVENIDO CRISTINA 71
73 III LEGEND
Asthma MC 3, RC, MC, KC,
Heart disease 21 19 17 15
Adopted
A Dead
Strong bond
III RICARDO 49 MOISES 44 ERLINDA JOY 20 Smoking
35 Legend Obese Living together
Asthma Informant: SC
Date prepared
Sept 15, 2017
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AFFECTION
How emotional experiences are shared
The member’s satisfaction with the intimacy and
emotional interaction the exists in a family
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A total score of
8-10 = highly functional family
4-7 = moderately functional family
0-3 = severely dysfunctional
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Brother
Family Circle
Nanny ME
A big circle is drawn
The patient is asked to draw smaller circles within the
big circle or outside. Mother
Each circle represents significant people in his/her life.
Distance and size vary according to degree of closeness Sister
and significance to the patient
Father
Assessment is through interpretation by the one who
draws
There are no right or wrong answers
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USEFULNESS OF D.R.A.F.T.
Patients exhibiting evasiveness and guardedness are more Projective drawing like DRAFT has been found to be useful
likely to reveal their underlying traits and psychodynamics and revealing because of the following reasons:
because subjects are more intellectually aware of what - Patients who exhibit evasiveness and guardedness seem
they might expose through verbal communications. more likely to reveal their underlying traits
Drawing can be an expression of the unconscious label - Psychodynamics is more revealed in the drawing
that represents an adulterated basic needs. because through verbal communications subjects are
Drawings are first to show incipient psychopathology and more intellectually aware of what they might expose.
the last to loose signs of illness after patient recovers
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Family mapping
// Dysfunctional or conflict
Functional
Enmeshed or overinvolvement
Clear boundaries
Rigid boundaries
Diffuse boundaries
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SCREEM SCREEM
SCREEM acronym for
RESOURCES PATHOLOGY
Social
SOCIAL + communication, social Social Isolation
Cultural interactions
Religious CULTURAL Pride in ethnicity Feels cultural/ ethnic
Economic inferiority
RELIGIOUS Satisfying spiritual Rigid rituals
Educational experience
Medical ECONOMIC Stable financial status Financial Problems
Helps families assess their resources to meet a crisis.
Lack of resources can cause pathology. EDUCATIONAL Adequate comprehension Handicapped
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FACES FACES
One modality of conceptualizing the family is using the FACES is useful for clinical evaluation, treatment, as well
cohesion, flexibility and communication constructs, as to evaluate the efficacy of marital and family
proposed by Olson as the Family Adaptability and therapeutic intervention (Olson, 1993; Olson, 1996)
Cohesion Evaluation Scale (FACES) It is comprised of 30 items, 16 of which evaluate
cohesion, and 14 of which evaluate adaptability (Olson
1993; Olson 1991; Ravi & Shirali, 1992; Rodick &
Henggeler, 1986)
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PHx:
No medical problems. No regular medications.
Allergies: Penicillin - anaphylaxis
Sexual history:
1 contact in Thailand, female, vaginal no condom.
No other sexual partners for 2 years.
P/SHx
Non smoker. Alcohol at weekends with friends 10 units
Travel history - Thailand on 2 week holiday. Has taken malaria
prophylaxsis.
Was careful about what he was eating and drinking there.
PHYSICAL EXAMINATION:
BP 110/68 RR 18 CR 88 T 36.9 BMI 20
Truncal rash and generalised lymphadenopathy
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IMPACT OF ILLNESS
▪ Training in medical school should focus on treatment of
disease problems and management of illness
problems.
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HOW IS INVESTIGATION
HOW IS INVESTIGATION DONE? DONE?
THE PHYSICIAN:
THE PHYSICIAN:
▪ Investigate the broader set of experiences and
This should be the basis for communication. concerns that patients associate with their illness
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(coping)
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Demos + graphein
ARNEL V. HERRERA, MD
Family Medicine and Community
Health
Census
Community medicine is vitally concerned with
Total process of collecting, compiling and
population as the health of the people publishing demographic, economic and
depends upon: social data pertaining to all persons in a
country at a specified time.
➢ the number of people
➢ the space they occupy Vital registration
➢ the skill that they have acquired Continuous registration of vital events
(births, deaths, marriages)
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Counts
Continuing
population registers Absolute number of a population or any
Continuous recording of demographic event occurring in a specified
information about the population area during specified time period
Ratios
Description by specific A single number that represents the relative
populations size of 2 numbers
Voters registration
Proportion
School enrollment A special type of ratio in which the
Income tax returns numerator is part of the denominator
Social security system
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Population density=
Population density is midyear population
divided by land area in square kilometers.
Midyear population
Land area in sq km
Population is based on the de facto definition
of population, which counts all residents Population is based on the de facto
regardless of legal status or citizenship. definition of population, which counts
all residents regardless of legal status
Land area is a country's total area. or citizenship.
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Age Pyramid
➢ It is a pictorial presentation (double
histogram) of the age-sex composition of
a population
➢ Male & Female are compared for age
➢ Under-developed/developing country: Broad
base & tapering top (pyramid shape)
➢ Developed countries: Bulge in the middle and
has a narrow base (spindle shape)
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1. Age 2. Sex
Males have a higher risk of mortality in
Infancy: high mortality levels
developed and most developing
Childhood: decline countries
Adolescence & early adulthood: Exceptions:
remain at low level ➢ Societies that value survival of male
Adulthood & older ages: increase offspring more than females
The pattern is true for male and Low levels of economic development
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The population grows according to two The growth rate takes into consideration
factors: birth rate and death rate. The birth, death & migration.
difference between these two is called the
rate of natural increase. Growth rate (GR) = RNI + Net migration rate
The rate of natural increase is expressed as a Net migration rate = Immigrants - emigrants
percent.
Rate of natural increase (RNI) =CBR – CDR
10
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Life expectancy
Reasons for increase life expectancy
▪ Expectation of life at a given age is the average number of years
which a person of that age may expect to live, according to the
mortality pattern prevalent at that age
1. Mass control of diseases
▪ Indicator of country development & overall health
▪ Expectation of life at birth – World 2. Advance in medical science
1950 : 46.5 years 3. Better health facility
2002 : 63 years 4. Impact of national programs
2010 : 67 years 5. Improvements in food supply
2018 : 72 years
6. International aid
7. Development of social
▪ Expectation of life at birth – Philippines
consciousness among masses
Year Males Females Ave
1960 51 55 53
2018 67 75 71
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Economic implications
Demographic Implications
Environmental / Ecological Each stage creates
population pyramids
Implications unique to that stage.
Stage 1. Stage 1.
Birth rates are high because: Birth rates are high because:
➢ No birth control or family planning. ➢ No birth control or family planning.
➢ High infant mortality rate so parents
produce more in hope that several will survive.
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Stage 1. Stage 1.
Birth rates are high because: Birth rates are high because:
➢ No birth control or family planning. ➢ No birth control or family planning.
➢ High infant mortality rate so parents ➢ High infant mortality rate so parents
produce more in hope that several will survive. produce more in hope that several will survive.
➢ Many children needed to work in agriculture ➢ Many children needed to work in agriculture
➢ Children expected to support parents in later
life in the absence of pensions.
Stage 1. Stage 1.
Birth rates are high because: Birth rates are high because:
➢ No birth control or family planning. ➢ No birth control or family planning.
➢ High infant mortality rate so parents ➢ High infant mortality rate so parents
produce more in hope that several will survive. produce more in hope that several will survive.
➢ Many children needed to work in agriculture ➢ Many children needed to work in agriculture
➢ Children expected to support parents in later ➢ Children expected to support parents in later
life in the absence of pensions. life in the absence of pensions.
➢ Children regarded as a sign of virility and ➢ Children regarded as a sign of virility and
status in some societies. status in some societies.
➢ Religious beliefs - Roman Catholics, Muslims,
Hindus, encourage large families.
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Stage 1. Stage 1.
Death rates are high because: Death rates are high because:
➢ Lack of access to medical science/supplies - few ➢ Lack of access to medical science/supplies - few
doctors, hospitals, drugs. doctors, hospitals, drugs.
➢ Poor hygiene
Stage 1. Stage 1.
Death rates are high because: Death rates are high because:
➢ Lack of access to medical science/supplies - few ➢ Lack of access to medical science/supplies - few
doctors, hospitals, drugs. doctors, hospitals, drugs.
➢ Poor hygiene ➢ Poor hygiene
➢ Famine, uncertain food supplies, poor diets. ➢ Famine, uncertain food supplies, poor diets.
➢ Disease spread by lack of access to clean water
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Stage 1. Stage 2.
Natural increase (population growth) is low Birth rates remain high because of all
because although there are a lot of births the the same reasons as for Stage 1.
similarly high number of deaths effectively cancels
them out
Stage 2. Stage 2.
Death rates begin to fall because: Death rates begin to fall because:
➢ Improved medical care ➢ Improved medical care
➢ Improved sanitation and water
supply systems reduces disease.
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Stage 2. Stage 2.
Death rates begin to fall because: Death rates begin to fall because:
➢ Improved medical care ➢ Improved medical care
➢ Improved sanitation and water ➢ Improved sanitation and water
supply systems reduces disease. supply systems reduces disease.
➢ Improvements in agricultural ➢ Improvements in agricultural
efficiency efficiency
➢ Improved communications to
transport food, doctors, medicines
etc.
Stage 3.
Stage 2. Birth rates begin to fall
Natural increase (population growth) because:
is high because there is now a large ➢ Lower infant mortality
gap between births and deaths, rate means less pressure to
increasing the population rapidly. have many children.
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Stage 3. Stage 3.
Birth rates begin to fall Birth rates begin to fall
because: because:
➢ Lower infant mortality ➢ Lower infant mortality
rate means less pressure to rate means less pressure to
have many children. have many children.
➢ Widespread availability and ➢ Widespread availability and
knowledge of family planning knowledge of family planning
➢ Change from agrarian to an
industrial society and
mechanisation leads to a
reduction in workforce
requirements.
Stage 3. Stage 3.
Birth rates begin to fall Birth rates begin to fall
because: because:
➢ Lower infant mortality ➢ Emancipation of women
rate means less pressure to and improved educational
have many children. opportunities
➢ Widespread availability and
knowledge of family planning
➢ Change from agrarian to an
industrial society and
mechanisation leads to a
reduction in workforce
requirements.
➢ Welfare systems pensions
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Stage 3. Stage 3.
Birth rates begin to fall Birth rates begin to fall
because: because:
➢ Emancipation of women ➢ Emancipation of women
and improved educational and improved educational
opportunities opportunities
➢ Large families increasingly ➢ Large families increasingly
viewed as an economic and viewed as an economic and
social burden. social burden.
➢ Increased desire to pursue
material lifestyles
Stage 3/4.
Stage 3. Death rates continue to fall
because of ongoing
Natural increase (population growth)
developments in health and
remains high due to the gap between
hygiene already mentioned.
births and deaths but as this stage
progresses the increase gets less as
births and deaths match up again.
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Stage 4.
Birth rates continue to fall for all the same reasons as
Stage 3.
Stage 4.
Natural increase (population growth) is again low
as births and deaths virtually cancel each other
out, but now the population is high..
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General Classification of
Rates General Classification of Rates
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• Proportion
- a part of a whole in which the numerator is part of • Ratio
the denominator - A single number that represents the relative size of two
Form: a numbers
*k a
a+b
Form:
*k
b
where a= count where a=count
b=count b=count
k=factor size k= factor size
• Rates
- Measures the amount of change (no. of new events) in a
given period of time
• Quotient of two numbers without taking a
Form:
particular considerations to time or place *k
t *n
where a= count
• Number of deaths per population N=no. of subjects
t=amount of time
k=factor size
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Rate
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• Incidence Rate
• Refers to newly diagnosed cases of a particular disease
• Designed to provide measures of the rate
• Also known as attack rate, case rate, sickness rate, morbidity rate
at which people without a disease during
• “How frequent do cases of a particular disease occur in a given period specified period of time
of time?”
• Used when dealing with acute conditions and accidents • Provides for statements about probability
No. of cases discovered during a given time period x factor
or risk
• High incidence-→ high risk of disease
Average population of that period
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Crude because:
• Does not take into account the differences in the risk
of dying among different age group
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• Measures the risk of dying during the first year of life • Highest for babies with adolescent mothers and
women in their forties and older
• Good index of the general health condition of a
community
• Decreases with increasing maternal educational
• Used to measure the adequacy of health services as well
levels
as the state of environmental health
• IMR for unmarried mothers is often more than 83%
Total infant deaths in a calendar year x 1, 000
higher than the mortality rate for married mothers
Total Live Births During the Year
• Not a perfect index of the risk of dying, ONLY a • Higher for mothers who smoke than those who do
reasonable approximation not smoke
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• Under-5 mortality rate, is strictly speaking, not a rate • Index of the obstetrical care needed and received by the
(i.e. the number of deaths divided by the number of women in a community
population at risk during a certain period of time) but a
probability of death derived from a life table and • Both sex and cause specific and in a way age specific death
rate
expressed as rate per 1,000 live births.
Deaths among women due to maternal cause x 1000
Live births during the year
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15
Donald E. Stout, Jr 5/12/2021
If you overtake the person in last place, Can you name 3 days in row without using
what place will you be in? the words: Tuesday, Thursday or Saturday?
No one can’t
overtake the
person in last
place!
StatisticsQuality Basics 1
Donald E. Stout, Jr 5/12/2021
A father and his son are involved in a car Measures of Central Tendency
accident, as a result of which the son is Shape of the Distribution
rushed to hospital for emergency Measures of Dispersion
surgery. The surgeon looks at him and Normal Curve
says "I can't operate on him, he's my Measures of Relative Standing
son". Explain.
StatisticsQuality Basics 2
Donald E. Stout, Jr 5/12/2021
Mean = 9
StatisticsQuality Basics 3
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StatisticsQuality Basics 4
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Median Outlier
◆ Find the Median A number that is extremely large or small in
comparison to the rest of the set of data.
4, 5, 6, 6, 7, 8, 9, 10, 12
Ans: 7 Outliers can greatly affect the measures of
◆ Find the Median and Mean central tendency.
5, 6, 6, 7, 8, 9, 10, 100,000
Ans: Median - 7.5
Mean – 12,506
StatisticsQuality Basics 5
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StatisticsQuality Basics 6
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Mode Mode
◆ The mode is not a very useful measure of central
◆ Not Affected by Extreme Values tendency.
◆ Used for Either Numerical or
◆ It is insensitive to large changes in the data set.
Categorical Data ◆ That is, two data sets that are very different from
each other can have the same mode.
7
120
6
100
5
80
4
60
3
40
2
0 1 2 3 4 5 6 1 20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
0 0
Mode = 8 No Mode 1 2 3 4 5 6 7 8 9 10 10 20 30 40 50 60 70 80 90 100
26
Mode
Multimodal Distributions
• A distribution may have more than one mode 6
• For the given example, what are the modes? • If a distribution has
more than 2 “modes,” 5
it is called multimodal 4
Frequency
5
3
4
Frequency
3 2
2 1
1 0
75 80 85 90 95
0
33 34 35 36 37 38 39 40 Score on Exam 1
Score
28
StatisticsQuality Basics 7
Donald E. Stout, Jr 5/12/2021
Questions:
Matching! What is the best measure of central tendency to be
used in the following cases:
Mean Middle 1. Enumerate the top ten cases of morbidity and
mortality in the Phil.
Median Average
2. What is the most sellable brand of rubber shoes in the
dept. store?
3. What is the favorite ice cream flavor of this class?
Mode Most 4. What is the representative wt. and ht. of this class?
5. What is the income of all the hospital personnel in
Fatima University Medical Center?
6. What is the IQ of this class?
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• Answer:
– Mean is the best measure of central Non-symmetric distribution: the patterns from a central
point from the left and right are different.
tendency
Skewed to the left: a tail extends out to the left.
– Most scores “bunched up” in middle
Skewed to the right: a tail extends out to the right.
StatisticsQuality Basics 9
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40
35
30
No. of People
25
20
15
10
5
0
0 20 40 60
mode 80 100 120 140 160 180 200 220 240
Income in 1,000s
mean
4
3 distributions, the mean is
2
greater than the median
1
0
• In negatively skewed
0 20 40 60 80 100
Test score
mean
mode
distributions, the mean is
smaller than the median
40
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Range = 12 - 7 = 5 Range = 12 - 7 = 5
7 8 9 10 11 12 7 8 9 10 11 12
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49
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( X −)
2
◆ The smaller the variance is, the less the i
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StatisticsQuality Basics 16
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=0
=1
frequency
68%
95%
x scale -3 -2 - + +2 +3
99.7%
z scale -3 -2 -1 0 +1 +2 +3
-3 -2 -1 mean +1 +2 +3
Number of standard deviations either side of mean
60 70 80 60 70 80
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50 60 70 80 90 50 60 70 80 90
40 50 60 70 80 90 100 40 50 60 70 80 90 100
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Example: Example:
◆ The distribution of raw scores of second year
Fatima students is approximately normally ◆ Group of boy scouts with a mean weight
distributed with mean of 100 and standard of 30 kg. and SD of 4 kg. Get the
deviation of 10. Get the distribution of score in
68%, 95%, and 99.7%
distribution of weight in 68%, 95%, and
99.7%
◆ Ans: 68% - 26 to 34 kg
95% - 22 to 38 kg
99.7% - 18 to 42 kg
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The Z-Score
What is the
percentile ◆ Each group has a distribution—but in their original
rank for a form, the groups are not comparable
score of 6? ◆ Each original score can be converted to a z-score,
How many which is a standard score that can be compared
scores fall at across groups
or below a z=(x-mean)/s
6? • z=z-score
(9 scores) • x=score
StatisticsQuality Basics 20
Donald E. Stout, Jr 5/12/2021
What is a z-score?
• A measure of an observation’s distance from
the mean. ◆ If a z-score is zero________________
• The distance is measured in standard
deviation units.
• If a z-score is zero, it’s on the mean.
• If a z-score is positive, it’s above the mean.
• If a z-score is negative, it’s below the mean.
• If a z-score is 1, it’s 1 SD above the mean.
• If a z-score is –2, it’s 2 SDs below the mean.
Statistics
◆ If a z-score is negative,_____________
Statistics Statistics
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Donald E. Stout, Jr 5/12/2021
◆ If a z-score is -2,_________________
Statistics Statistics
Characteristics, Continued
◆ Given the standard distribution of scores
within a normal curve, the following
statements are true:
• 84% of the scores fall below z-score of 1
• 16% of the scores fall above z-score of1
◆ The more extreme the z-score, the
farther it is from the mean
Statistics
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Example: Application
For instance, if Steph Curry scored a 70 on ◆ If Step Curry got a z score of 2 on that
a test with a mean of 50 and a standard test, what can we say about his score
deviation of 10, converting the test relative to others who took the exam?
scores to z scores, an X of 70 would be: A. it is above average
Ans: Z = (70 – 50) / 10 = 2 B. it is average
C. it is below average
D. I don’t know
StatisticsQuality Basics 23
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Statistics
StatisticsQuality Basics 24
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Test 3 Z-Score
Peter 57
John 39
Question: Same data above, how many
Paul -1.5 percent would be a score of 52 or less?
Mary 1.3
Statistics Statistics
StatisticsQuality Basics 25
Donald E. Stout, Jr 5/12/2021
Question: Question:
If a distribution is normally distributed, ◆ What percentage of scores falls below
about what percent of the scores fall zero in the standard normal distribution?
below +1 SD? A. zero
A. 15 B. fifty
B. 50 C. seventy five
C. 84 D. one hundred
D. 99
Statistics
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StatisticsQuality Basics 27
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Inferential Statistics
9. Discuss chi-square test as to The process of generalizing and making conclusions
9.1 sampling distribution of proportions and the about a target population based on results from a
sample.
difference between 2 proportions
We rarely observe the general population.
9.2 definition of contingency table, observed and
We only take a sample from that population, collect
expected frequency
data from the sample and make conclusions about
9.3 Assumptions, uses and limitations the target population based on the results from the
9.4 Formula, computation and interpretation of results sample.
Because we only study a sample, we are prone to To understand how we come up with a
making an error. generalization notwithstanding sampling error, we
have to understand sampling distribution of means.
And we call this error, sampling error.
It forms the basis for Inferential Statistics.
The magnitude of the error can be accurately
specified.
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The mean of all sample means will be denoted by The standard deviation of the sampling distribution of
this symbol, means is known as the standard error of means, and
is symbolized by,
X X
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Histogram of the Sampling Distribution of Means of A theoretical distribution, it is, normally distributed,
IQ's of 100 sets of Samples (first property)
12 Thus we can use the z score formula to find the
10 probability of occurrence of any one sample mean
8 under the curve.
6
The standard deviation of the sampling distribution To illustrate, if we know that the population standard
of means, known as the standard error of the mean, deviation (σ) of IQ’s to be 36.7, we can derive the
can be derived by dividing the population standard standard deviation of the sampling distribution of
deviation by the square root of the sample size. means or the standard error, in a sample of 50
students,
X = 𝜎 36.7
n 𝜎 = =
𝑛 50
𝜎 = 5.19
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Interval estimate
Applications of the Sampling Distribution of Means
An estimate of a parameter which is expressed as a
Levels of Confidence Intervals and their corresponding
range of numbers
z-value
Confidence Interval z-value
In an interval estimate the parameter is specified as
being between two values 90% 1.64
95% 1.96
The estimate has an upper limit and a lower limit
defining an interval which is expected to include 99% 2.58
the parameter being estimated according to varying
degrees of confidence
Confidence levels
Purpose of interval estimate
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To illustrate,
PQ
Suppose another researcher is interested in p =
determining the proportion of Medical Technology n
students who are positive for Hepatitis B surface
antigen (HbsAg). p =
0.12 * 0.88
He takes a sample of 50 students and finds 6 50
students to be positive, proportion = 0.12, (6/50). p = 0.0460
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We used the t distribution previously in constructing Thus the 95% confidence interval for the proportion
the confidence interval for the population mean of medical technology students positive for HbsAg is
when the standard deviation was unknown. 95% Confidence Interval = P z (σP)
When dealing with proportions we use the z-test for
constructing confidence intervals for the population 95% Confidence Interval = 0.12 1.96(0.0460)
proportion.
= 0.12 0.09 (margin of error)
= 0.03 to 0.21
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Hypothesis Testing - Null Hypothesis (Ho) Hypothesis Testing – Alternative Hypothesis (Ha)
Any observed difference that may arise between two The alternative hypothesis is the hypothesis that the
independent variables being compared can be researcher hopes to prove.
regarded as a chance occurrence resulting from It states that there exists a difference in the two
sampling error alone. sample means and the difference is not just due to
sampling variability alone.
Therefore, an obtained difference between two
sample means does not represent a true difference There are two ways of stating an alternative
hypothesis: a two-tailed Ha and a one-tailed Ha.
between their population means.
A two-tailed Ha is also known as a non-directional
alternative hypothesis and a one-tailed Ha,
directional alternative hypothesis.
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The level of significance , critical value and the critical The level of significance , critical value and the critical
region region
Region of
rejection
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The level of significance and the critical region The level of significance and the critical region
The level of significance can be set up for any Whenever we decide to reject the null hypothesis at
degree of probability, 0.01, 0.05, 0.10. a certain level of significance, we open ourselves to
The 0.01 level of significance is represented by the the chances of making the wrong decision.
area that lies 2.58 standard deviations in both Rejecting the null hypothesis when we should have
directions from a mean difference of zero. accepted it is known as Type I error.
A more lax alpha can be setup, 0.10 and is A Type I error can only arise when we reject the null
represented by the area that lies 1.64 standard hypothesis, and its probability varies according to the
deviation in both direction from the mean difference level of significance we choose.
of zero.
If we reject the null hypothesis at the 0.05 level of Likewise, if we choose the = 0.01 level of
significance and conclude for example that there is a significance, there is only 1 chance out of 100
difference in IQ between females and males, then (P=0.01) of making the wrong decision regarding the
there are 5 chances out of 100 that we can be difference in IQ between genders.
wrong. Obviously, the more stringent our level of
In other words, P = 0.05 that we can commit Type I significance (the farther out in the tails it lies), the
error, and that there is really no difference in IQ less likely we are to make Type I error.
between females and males.
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Beta Error
Decision
The smaller the level of significance alpha we choose Accept Ho Reject Ho
Reality
however, the greater the risk of making another kind
Type I error
of error known as Type II error. Ho is true Correct Decision
P (Type I error) =
This is the error of accepting the null hypothesis Type II error
when it should be rejected. Ho is false Correct Decision
P (Type II error) =
One method for reducing the risk of committing Type
II error is to increase the sample size.
The probability of Type II error is denoted by
(beta).
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Statistical Test
Test for quantitative data (Parametric data)
The z – test is used for quantitative variables when
the population standard deviation is known. Tests used for hypothesis concerning means
The t – test is used for quantitative variables when
the population standard deviation is unknown. These are tests for the difference between 2
For qualitative variables, chi-square test is used. means
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Statistical significance
Guideline for judging the statistical significance of a
p - value
p – value
If 0.01 < p < 0.05 The difference is significant
The probability of getting a sample statistic or a more Reject the null hypothesis
extreme sample statistic in the direction of the
alternative hypothesis when the null hypothesis is true 0.001 < p < 0.01 The difference is highly significant
Reject the null hypothesis
The probability that the observed result is due to
chance alone p < 0.001 The difference is very highly
significant Reject the null
hypothesis
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0.05 < p < 0.10 The difference is not statistically *These are not hard and fast rules.
significant . Consider the consequences of
type I error before rejecting the null hypothesis
Some researchers do not choose an α but report the p-
value and allow the reader to decide whether the null
p > 0.10 The difference is not significant. hypothesis should be rejected
Do not reject the null hypothesis
Others decide on the α value in advance and use the p-
value to make the decisions
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102−98
𝑧 = = 1.33
3
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We then obtain the standard deviation of the difference Test statistics used here is the t- test with this formula:
(d) for the distribution of before and after measurement
scores:
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In the previous discussion we dealt with Suppose you want to test five levels of treatment
outcomes (dependent variables) that are to 100 patients. You ask a research assistant to
quantitative. make the randomization to the patients.
Thus we compared means. The research assistant hands out to you a
In the following discussion , we deal with frequency distribution of the randomization.
qualitative outcomes.
And we test the association between an
independent variable and a dependent
variable using chi-square (x2).
Treatment Observed Frequency The table shows that 22 of the 100 patients
received Treatment A, 28, Treatment B, and so
A 22 on.
B 28 These are called the observed frequencies (o).
C 18 Observed frequencies refer to the set of
D 15 frequencies obtained in an actual frequency
distribution, that is, when we actually do a
E 17 research or conduct a study.
Total 100
27
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You suspect that the research assistant did not Can you generalize from the distribution he
do the randomization properly. hands to you that he has a preference for one
You think that he probably has a preference for particular treatment level or two?
one or two treatment levels Are the departures from an even distribution of
treatment levels large enough to indicate a real
preference for a particular choice?
28
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Chi-square statistic focuses directly on how close the Notice that if all the observed frequencies were
observed frequencies are to what they are equal to their respective expected frequencies,
expected to be under the null hypothesis. The
formula for chi-square thus is: as the null hypothesis suggests, chi-square value
( o − e) 2 will be equal to zero.
x2 = If all the observed frequencies were close to
e their respective expected frequencies,
consistent with the null hypothesis except for
where o = observed frequency at any level sampling error, chi-square value will be small.
e = expected frequency at any level
29
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The more the set of observed frequencies Just how large the chi-square value is to
deviates from the expected frequencies, reject the null hypothesis?
the larger the chi-square value. The chi-square value must be compared
At some point, the discrepancies of the with a tabular chi-square at certain
observed from the expected frequencies degrees of freedom df and at a
can become larger than can be particular alpha, level of significance.
attributed to sampling error alone. If the chi-square value exceeds the
At that point, chi-square is so large that tabulated value, then we say, the chi-
we are forced to reject the null square value is large enough to reject the
hypothesis and accept the alternative Ho.
hypothesis.
In our example, the computed chi-square value Thus we say that the value is not large enough
= 5.3 so as to reject the Ho.
The tabulated chi-square value at 4 df and at The differences in the observed from the
alpha of 0.05 is = 9.49. expected frequencies are what we might
The computed value is smaller than the attribute to sampling variability or sampling error
tabulated value. alone.
The p-value = 0.258*.
*Note: This value is taken from a computer output.
30
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Fortunately the principles behind one way chi-square For example, suppose we want to find out if
can well be applied to two way chi-square. there is a difference in the proportion of cases
The formula is basically the same. with heart disease (dependent variable) among
The only difference is now we will be dealing with an those with various levels of snoring behavior
independent variable and a dependent variable. (independent variable).
Chi-Square Chi-Square
Relationship between Snoring and Heart Dse
Ho: There is no difference in the proportion of
Heart Snoring Behaviour
cases with heart disease across levels of snoring
behavior. Dse Nver Ocas Freq Alw Total
Ha: There is a difference in the proportion of cases
with heart disease across levels of snoring Yes 4 10 20 24 58
behavior.
No 196 190 180 176 742
31
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Chi-Square Chi-Square
Yes 14.5 14.5 14.5 14.5 58 *Note: Taken from computer output
No 185.5 185.5 185.5 185.5 742
32
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Note the footnote below the table that says 0% When that happens, Fischer’s Exact test will be
of cells have expected count less than 5. used when both the independent and
This is desirable. Because if more than 20% of dependent variables are dichotomous, i.e., a
cells have expected count less than 5, then two by two table.
computation of chi-square value becomes Fischer’s Exact test cannot be used if either one
unstable, making chi-square test not valid. variable has more than two levels, (not
dichotomous).
Chi-Square Exercise #1
In that case, levels may have to be combined You wanted to determine if there was a difference in the
into some meaningful groupings so a two by two fasting blood glucose (FBS) among apparently healthy
adults residing in the urban and in the rural areas. A
table can be constructed.
sample of 50 urban adults and 50 rural adults were
The study on snoring is a 2 by 4 table. Snoring studied and the mean FBS for urban adults was 106 and
has 4 levels. This can be made dichotomous by the rural adults, 102. Supposed that the population
combining never with occasional and frequent standard deviation σ was known to be 15 among urban
adults and 10 among rural adults. Test the hypothesis
with always.
that there existed a difference in the FBS of urban and
rural adults. Use level of significance α = 0.05.
33
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Exercise #1 Exercise #1
Q: What kind of alternative hypothesis was Q: Critical region of rejection is 1.96 and
used? statistical test is calculated to be 1.57. What is
A: Two-tailed alternative hypothesis your decision?
Q: What test statistics do you use? A: Since the calculated statistical test is lower
than the critical region of rejection, we do not
A: Since the Population standard deviation is reject the null hypothesis
known, statistical test to use is z-test.
Exercise #1 Exercise #2
34
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Exercise #2 Exercise #2
Q: What kind of alternative hypothesis was Q: Critical region of rejection is 2.0 and statistical
used? test is calculated to be 0.53. What is your
A: Two-tailed alternative hypothesis decision?
Q: What test statistics do you use? A: Since the calculated statistical test is lower
than the critical region of rejection, we do not
A: Since the Population standard deviation is reject the null hypothesis
unknown, statistical test to use is t-test.
Exercise #2 Exercise #3
Q: What is your conclusion? An oriental form of massage was thought to
Choose the correct answer. decrease the Blood Pressure of patients with Pre-
A. There is no sufficient evidence to say that the hypertension. Blood pressure of 6 patients was
mean grade in Section A differs from that in taken before the massage and another one 5
Section B. minutes after the massage. Test the hypothesis
B. There is no sufficient evidence to say that that the massage decreased the blood pressure
there is a difference in mean grade in the two of these patients. Use alpha=0.05.
sections.
A: B
35
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Exercise #3 Exercise #3
Q: What kind of alternative hypothesis was Q: Critical region of rejection is 2.02 and
used? statistical test is calculated to be 2.19. What is
A: One-tailed alternative hypothesis your decision?
Q: What test statistics do you use? A: Since the calculated statistical test is higher
than the critical region of rejection, we reject
A: Paired t-test. the null hypothesis.
Exercise #3 Exercise #4
Q: What is your conclusion? In a university, 200 staff members who go to
Choose the correct answer. work report the kind of transportation they use
A. There is sufficient evidence to say that as well as whether they are ‘morning people’ or
the massage decreases blood pressure ‘night people’. Table below shows the summary
among patients with pre-hypertension. of results. Test the hypothesis that there is a
B. There is sufficient evidence to say that difference in the mode of transportation
there is a difference in the blood pressure between ‘morning people’ and ‘night people’.
of patients before and after a massage. Use level of significance =0.05.
A: A
36
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Exercise #4 Exercise #4
Bus Carpoo Own Totals Q: What test statistics do you use?
l car
A: Chi-square test.
Mornin 60 30 30 120
g
Night 20 20 40 80
Totals 80 50 70 200
Exercise #4 Exercises #4
Q: Critical region of rejection is 5.99 and Q: What is your conclusion?
statistical test is calculated to be 16.07. What is A. There is sufficient evidence to say that there is
your decision? a difference in the use of the mode of
A: Since the calculated statistical test is higher transportation among morning and evening
than the critical region of rejection, we reject people.
the null hypothesis
37
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GOOD MORNING !
1
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Chain of Infection
2
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OUTBREAK
▪ occurs when there has been no cases of a disease for EPIDEMIC
some time then suddenly a case or a few cases appear.
▪ The occurrence in a community or
region of cases of an illness clearly in
▪ the disease may be absent then suddenly there is a
excess of normal expectancy &
remarkable number of cases seen.
derived from a common or
propagated source.
▪ An epidemic occurs when there are
significantly more cases of the same
disease than past experience would
have predicted for that place at that
time among the population.
Mode of transmission
Epidemiology of Communicable Diseases 6/24/2021 17
3
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4
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Components of investigation
3. Formulate Hypotheses Initial Detection of Epidemics &
Outbreaks
- source of infection
1. Epidemiologic surveillance
- method of contamination & spread systems
- possible control mechanisms - Organizations & structures
4. Test Hypotheses - Surveillance methods
- conduct special epidemiologic,
laboratory & environmental 2. Individuals directly/indirectly
investigations affected by the outbreak
5. Draw conclusions & devise practical
applications
- long-term surveillance
- prevention
Who Investigates ?
1. Local Health Department
- 1st line
2. National/Federal agencies
- Requires further resources
- Attracts substantial public
concern
- Associated w/ a high attack rate
- Serious complications
(hospitalizations/death)
3. Center for Disease Control (CDC)
- Outbreaks of national importance
5
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6
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I. Preliminary Analysis
- check records & seasonal incidence
Steps in Outbreak / Epidemic Investigation
- review routine information & clinical cases
- community information & reports
I. Preliminary Analysis
- surveillance
7
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8
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9
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Identifying the source of the etiologic agent & its mode of transmission
▪ Single exposure
▪ Continued exposure
▪ Person to person spread
▪ Arthropod vector
▪ Animal reservoir
10
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4.3. Person
Steps in Outbreak / Epidemic Investigation 1. Search for additional cases w/c may have been
recognized or reported
I. Preliminary Analysis 2. Determine what additional information is necessary
II. Further Investigation & to answer any question formulated & to test
Analysis tentative hypothesis.
III. Implement Control Plan & conduct a detailed epidemiological
Measures investigation of all cases or a representative
IV. Prepare Report for Epidemic sample of cases using the suitable epidemiological
case form.
Investigation
Arrange for any special investigation needed to
V. Continued Surveillance of establish collateral circumstances using laboratory
the Population facilities, engineering & other expert
consultations.
11
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Considerations:
3. Interrupt transmission
- Hygiene : personal & environmental
- Vector control
12
6/24/2021
Stage 2. Confirmation of AI
Most important control measure –
Infection
▪ Infected Premises – any poultry holding facility in which AI is
confirmed to exist HEALTH INFORMATION
HEALTH EDUCATION
3 km
INFECTED
PREMISES
CONTROL
ZONE
7 km
QUARANTINE
ZONE Level 2
www.birdflufreephilippines.com
Public information and
report@birdflufreephilippines.com
communication
• Pre-pandemic prepared IEC materials
• Communication links at both national and local
level -telephone lines, internet
• Public advisories, IEC materials, press briefing,
hotlines, Designated spokesperson,
• Speakers’ Bureau
• Regular information to doctors at all levels -health
updates
• Linkages with the media at the national and local
level
13
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14
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▪ A public health
manager who was part
of the medical team
was able to obtain the
passenger manifest of
the plane and mapped
out the seating
arrangement of the
quarantined persons.
15
6/24/2021
Case 2 Case 2
University belt dormitory w/ 50 occupants; all students 5 were admitted & the rest were treated &
from the different institutions. subsequently sent home w/ prescriptions.
All took dinner at the dorm cafeteria, owned by a Dx. Acute Food Poisoning
caterer who serves other dorm cafeterias of 5 other Investigation: meal component
dorm building. Squash, embotido, hopia, bottled water, rice
After dinner: some occupants of bldg 1 began to have Labs: culture of food & water samples
abdominal pains, vomiting & LBM.
Self administered questionnaire
20 students were rushed to a secondary hosp;
What is the probable source?
Epidemiology of Communicable Diseases 6/24/2021 97 Epidemiology of Communicable Diseases 6/24/2021 98
16
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Case 2 Case 2
Served Did Did not w/ s/sx w/o s/sx
Served Did Did not w/ s/sx w/o s/sx Attack
Food eat eat Food eat eat Rate
Squash 27 23 18 9 Squash 27 23 18 9 56%
Hopia 22 28 20 2 Hopia 22 28 20 2 91%
Embutido 40 10 35 5 Embutido 40 10 35 5 88%
Rice 30 20 10 20 Rice 30 20 10 20 33%
Bottled 45 5 40 5 Bottled 45 5 40 5 89%
Water Water
Table 1. Number of dorm residents who ate or did not eat food served during dinner and who
Table 1. Number of dorm residents who ate or did not eat food served during dinner and who exhibited signs and symptoms of food poisoning.
exhibited signs and symptoms of food poisoning.
THANK YOU !
17
Epidemiology of Non- Communicable versus
Definition of Epidemiology
Communicable and Communicable Non-communicable diseases
Diseases Epidemiology – science concerned Communicable diseases Non-communicable
JENA ANGELA T. PERANO, MD diseases
with various factors and conditions • Sudden onset • Gradual onset
JULIE TANCHANCO-TIU, MD that influence the occurrence and • Single cause • Multiple causes
GLORIA PERET-CLARION, MD
distribution of health, disease, • Short natural history • Long natural history
JENELL Y. OCZON, MD • Short treatment schedule • Prolonged treatment
defect, disability and death among • Cure is achieved • Care predominates
MACARIO REANDELAR JR., MD
groups of individuals. • Single discipline • Multidisciplinary
ARNEL V. HERRERA, MD • Short follow up • Prolonged follow up
LOURDES C. MEDALLA, MD • Back to normalcy • Quality of life after
treatment
MARIE RUTH ECHAVEZ, MD
Deaths (millions)
40
30
20
10
0
1990 2000 2010 2020
Global Burden of Disease
1
Noncommunicable diseases: Noncommunicable diseases:
DALYs (Globally) Current status and trends in risk Current status and trends in risk
factors factors
1990 2020
Common, preventable risk factors underlie most Several risk factors have the highest
NCDs. These risk factors are a leading cause of the prevalence in high-income countries. These
death and disability burden in nearly all countries, include:
regardless of economic development. 1. physical inactivity among women,
The leading risk factor globally for mortality is: 2. total fat consumption,
1. raised blood pressure (responsible for 13% of
3. raised total cholesterol.
deaths globally),
2. followed by tobacco use (9%),
Some risk factors have become more common
in middle-income countries. These include:
3. raised blood glucose (6%),
1. tobacco use among men,
4. physical inactivity (6%),
Comm. Disease NCDs Injury
5. overweight and obesity (5%). 2. overweight and obesity.
8 9
•SES
•Diseases
•Linear
•Smoking
individual
risk
• Tobacco • Heart disease more non communicable diseases
• Alcohol • Body mass index
•Maternal
nutritional
growth
•Obesity • Physical • Blood pressure •
•
Stroke
Diabetes
• Risk factors have the greatest impact on non
status & Accumulated
Accumulated
risk
inactivity •
•
Blood glucose
Cholesterol • Cancer communicable diseases mortality and
obesity, • Nutrition
•Fetal risk • Respiratory diseases morbidity
growth
• Effective modification of risk factors is
possible through primary prevention
Age
2
Noncommunicable diseases: Communicable Disease
Risk factors under surveillance
Prevention and Control of NCDs
• Tobacco use - is an illness due to a specific
• Alcohol consumption • Millions of deaths can be prevented by stronger infectious (biological) agent or its
• Raised blood pressure implementation of measures that exist today.
▪ Systolic and diastolic • These include policies that promote government-
toxic products that is transmitted
• Obesity wide action against NCDs: to a susceptible host by direct or
▪ Height, weight, body mass index, waist circumference
• Diet
1. stronger anti-tobacco controls indirect contact, through a vehicle
2. promoting healthier diets,
▪ Low fruit, high fat, added salt to served food
3. physical activity,
or vector, or as an airborne
• Physical inactivity infection.
• Diabetes mellitus 4. reducing harmful use of alcohol;
▪ Fasting plasma glucose 5. along with improving people's access to essential
• High serum cholesterol health care.
14
Factors Influencing
Epidemiologic Triad Disease Transmission Chain of Infection
Agent
• Infectivity
Environment A process that begins when an agent
• Weather
Disease is the result of • Pathogenicity • Housing
leaves its reservoir or host through a
• Virulence
forces within a • Immunogenicity
• Geography
• Working condition
dynamic system • Air quality portal of exit, and is transported by
consisting of: • Disaster/War
some mode of transmission, then enters
agent of infection
host
Host • Age through an appropriate portal of entry to
• Sex
environment • Behaviour
infect a susceptible host.
• Nutritional status
• Health status 18
()
3
Chain (Cycle) of Infection
Incubation Period Period of Communicability
Agent
• The period from exposure to infection to the ▪ The time during which an infectious
onset of symptoms or signs of infectious
agent my be transmitted directly or
Susceptible Host Reservoir disease.
IP • The length of incubation period depends on: indirectly from an infected person to a
PC o The portal of entry. susceptible person or animal.
Portal of Entry Portal of Exit o The rate of growth of the organism in the host.
o The dosage of the infectious agent. ▪ Its length varies from one disease to
o The host resistance. another
6/24/2021
Mode of transmission 19 6/24/2021 20 6/24/2021 Epidemiology of Communicable 21
Diseases
4
Virulence: Immunogenicity: 2. Source or Reservoir
It refers to the ability of organisms to produce severe • The reservoir of an agent is the habitat in
pathological reaction.
• Ability of an organism to produce an which an infectious agent normally lives, grows,
immune response that provides and multiplies.
It is the proportion of persons with clinical disease
who become severely ill or die (mortality). protection against re-infection with • “any person, animal, arthropod, plant, soil, or
substance, or a combination of these, in which
Examples: Rabies, Hemorrhagic fevers caused by the same or similar agent. an infectious agent normally lives and
Ebola and Marburg viruses. multiplies, on which it depends primarily for
• Can be life long or for limited periods. survival, and where it reproduces itself in such
Case fatality rate a manner that it can be transmitted to a
susceptible host. It is the natural habitat of the
Total number of deaths from a disease • Important information for infectious agent.”
Case fatality rate = x100
Total number of cases of that disease development of vaccines.
6/24/2021 Epidemiology of Communicable 25 6/24/2021 Epidemiology of Communicable 27
Diseases Diseases
5
Cases Cases Cases
❖ Index – the first case identified
Cases are classified as ❖ Primary – the case that brings the infection into a pop.
❖ Secondary – infected by a primary case
A case is defined as “a person in the • Primary case
• Index case
population or study group identified as • Secondary cases
S
having the particular disease, health According to spectrum of disease: SC
6
Animal reservoirs Zoonoses are Zoonoses
Human Reservoir in non-living things
• Zoonosis is an infection that is transmissible Diseases with
under natural conditions from vertebrate animals Animal
to man. Reservoirs. • Water, Soil and inanimate
• There are over a 100 zoonotic diseases that can matter can also act as reservoir
be conveyed from animal to man.
of infection.
➢ brucellosis (cows and pigs),
➢ anthrax (sheep),
• Pools of water are the primary
reservoir of Legionnaires’
➢ plague (rodents),
bacillus.
➢ rabies (dogs and bats).
6/24/2021 Epidemiology of Communicable 37 6/24/2021 Epidemiology of Communicable 38
Diseases Diseases
7
Modes of Transmission Droplet Transmission Modes of Transmission
Indirect Contact
• Direct Contact (Droplet Transmission) - Vehicle Borne Transmission: vehicle is any
substance that serves as an intermediate
- Large droplets within ~1 meter (3 feet) means to transport and introduce an infectious
transmit infection via: agent into a susceptible portal of entry
▪ Coughing, sneezing, talking - Transmission by an inanimate reservoir
(food, water, soil, fomites)
▪ Medical procedures
8
Airborne Transmission
Vertical Transmission 5. Portal of entry
An agent enters a susceptible host through a portal
1. Transplacental
of entry.
2. During delivery
- The portal of entry must provide access to
tissues in which the agent can multiply or a toxin
can act.
9
General factors which defend against Acquired immunity
infection (Innate Immunity):
Specific (acquired) immune
system
• Skin • 1. Humoral immunity (Antibody- 1. Active
mediated immune system) - B a) Naturally acquired
• Mucous membranes - acquire the disease
cells
• Gastric acidity • 2. Cell mediated immunity – - subclinical immunity
• Cilia in the respiratory tract Cytotoxic T cells b) Artificially acquired
- vaccination
• Cough reflex
6/24/2021 Epidemiology of Communicable 55
Diseases
10
Herd Immunity Preventing Infection
If the herd immunity is sufficiently high, the 1. Decrease host susceptibility
occurrence of an epidemic is highly unlikely a. maintain skin and mucous
High level of immunity (by high vaccination coverage) membrane as first line of defense
------- makes elimination of a diseases possible. b. reinforce or maintain natural
It was crucial in polio and diphtheria protective mechanisms such as
Herd immunity may be determined by serologic
coughing, pH of secretions,
survey.
resident flora
11
Terminology and Methods of Control Prevention of Transmission: Hand-washing
• Sterilization – a process that destroys all viable • HANDWASHING (FOR EVERYONE) -is the • Elements of hand-washing: friction, soap
microbes, including viruses and endospores; single most important procedure for and water – to loosen and flush
microbicidal preventing the transfer of microorganisms & microorganisms
• Disinfection – a process to destroy vegetative therefore preventing the spread of • Medical vs Surgical Hand-washing
pathogens, not endospores; inanimate objects nosocomial infections.
• Antiseptic – disinfectants applied directly to • CDC (Centres for Disease Control and
exposed body surfaces Prevention) recommends at least 20 seconds
• Sanitization – any cleansing technique that hand washing. This will remove most
mechanically removes microbes transient organisms from the skin.
• Degermation – reduces the number of microbes
Sporadic
Pattern of Occurrence and Endemic
Distribution of Diseases • The word sporadic means “scattered
about”. The cases are few and separated • It refers to the constant presence
widely in time and place that they show no
or little connection with each other, nor a of a disease or infectious agent
1. Sporadic recognizable common source of infection. within a given geographic area or
2. Endemic population group. It is the usual or
• However, a sporadic disease could be the
3. Epidemic/Outbreak starting point of an epidemic when the expected frequency of disease
conditions are favorable for its spread.
4. Pandemic within a population.
12
Hyperendemic and Holoendemic Epidemic
Endemic vs Epidemic
• The term “hyperendemic” expresses that the • “The unusual occurrence in a
disease is constantly present at high incidence
community of disease, specific
Number of Cases of a
and/or prevalence rate and affects all age
groups equally. health related behavior, or other
Disease
• The term “holoendemic” expresses a high level
health related events clearly in
of infection beginning early in life and affecting excess of expected occurrence”
most of the child population, leading to a state
of equilibrium such that the adult population • Epidemics can occur upon endemic
shows evidence of the disease much less
commonly than do the children states too.
Endemic Epidemic
Time
13
14
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Objectives
3 4
1
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Fetus
Fetus
• If found to conform to the pattern expected • A Mendelian trait is one that is controlled
for a single major gene: strong evidence of by a single locus in an inheritance pattern.
genetic origin • A mutation in a single gene can cause a
● Failure to conform: suggest environmental disease that is inherited according to
explanation Mendel's principles.
• Dominant diseases manifest in
heterozygous individuals.
• Recessive ones are sometimes inherited
Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
unnoticeably by genetic carriers.
Medical Epidemiology,
114th Edition 12
2
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• The expression of the mutated allele with respect • Each affected person has an affected parent.
to the normal allele can be characterized as • Occurs in every generation.
dominant, co-dominant, or recessive.
• There are five basic modes of inheritance for
single-gene diseases:
• autosomal dominant
• autosomal recessive
• X-linked dominant
• X-linked recessive
• mitochondrial 13 14
15 16
17 18
3
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21 22
4
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Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004). Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
254th Edition Medical Epidemiology,
264th Edition
Monozygotic twins
Monozygotic twins Dizygotic twins • Similarity in disease or trait: evidence of
existence of a genetic component
• Certain characteristics become more alike
as twins age, such as IQ and personality.
• Consistent for a particular disease more
frequently than dizygotic sets
Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
27 Medical Epidemiology,
284th Edition
Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
294th Edition 30
5
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33 34
Greenberg, R.S., Daniels, S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology,
354th Edition 36
6
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MULTIFACTORIAL INHERITANCE
Importance of
Cleft lip and cleft palate
•
• Pyloric stenosis
Screening Measures
• Epilepsy for Evaluation of Diseases
• Mental retardation
• Neural tube defects (spina bifida and
anencephaly)
• Hip dysplasia
39 40
PRENATAL DIAGNOSIS
1. Amniocentesis – between 16 and 18
weeks of gestation
AMNIOCENTESIS
2. Ultrasound
ALPHA FETO PROTEIN TEST
3. Alpha fetoprotein
4. Fetoscopy – a highly invasive procedure
done on pregnant women by using highly
flexible app. to get placental tissues
41 ULTRASOUND 42 FETOSCOPY
7
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CRITERIA FOR EVALUATING SCREENING TOOLS CRITERIA FOR EVALUATING SCREENING TOOLS
CRITERIA FOR EVALUATING SCREENING TOOLS CRITERIA FOR EVALUATING SCREENING TOOLS
• VARIABILITY
• YIELD
▪ Spread of a data set
▪ Amount of screening the test can
▪ Vary from the average value, as well as
accomplish in a time period
the extent to which these data points
▪ How much disease it can detect in the
differ from each other.
screening process
CRITERIA FOR EVALUATING SCREENING TOOLS CRITERIA FOR EVALUATING SCREENING TOOLS
SPECIFICITY
SENSITIVITY • Specificity measures a test’s ability to
• Measures how often a test correctly correctly generate a negative result for
generates a positive result for people who people who don’t have the condition that’s
have the condition that’s being tested for being tested for (the “true negative” rate).
(the “true positive” rate). • A high-specificity test will correctly rule out
• A test that’s highly sensitive will flag almost almost everyone who doesn’t have the
everyone who has the disease and not disease and won’t generate many false-
generate many false-negative results. positive results.
47 48
8
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• PREDICTIVE VALUE
▪ Directly address the estimation of
probability of disease
▪ Positive predictive value
True-positives x 100
True-positives + False-positives
▪ Negative predictive value
True-negatives x 100
True-negatives + False-negatives
Greenberg, R.S., Daniels,
49 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004). 50
Medical Epidemiology, 4th Edition
90 20
CRITERIA FOR EVALUATING SCREENING TOOLS
• SCREENING TEST
▪ Sensitive and specific
Acceptable to the target population
80
▪
10 ▪ Associated with minimal risk
▪ Diagnostic work-up for a positive test
result must have acceptable morbidity,
given the number of false-positive results
51 Greenberg, R.S., Daniels,
52 S.R., Flanders, J.W., Eley, J.W., Boring, J.R. (2004).
Medical Epidemiology, 4th Edition
MEASURES OF PREVENTION OF
OCCURRENCE OF DISEASE
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REFERENCES
EVIDENCE BASED
MEDICINE
• Rosenberg W, Donald A. Evidence based medicine: an approach to
clinical problem-solving. BMJ 1995; 310: 1122–1126.
• Crumley, E, Koufoglannakis, D, Stobart, K. Teaching EBP, part 1. Case
J E N A A N G E L A T. P E R A N O , M D scenarios and the well-built clinical question. Bibliotheca Medica
M A . L O R E N A L O R E N Z O, M D Canadiana 2000: 22(2):80-84.
F R A U L E I N P. TO R M O N , M D
M AC A R I O R E A N D E L A R J R . , M D
RO N WA L D O S A N D I E G O, M D
M A R I E R U T H E C H AV E Z , M D
B I L LY A . G O C O , M D
J E N E L L Y. O C Z O N , M D
• CPGs Patient
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EBM ACQUIRE
• MEDLINE/PubMed
– Full Text online
• There are basically three steps to utilize EBM
as a tool for clinicians in their practice: – Abstracts
– Step One: Search and Acquisition of • EBM at the point-of-care
Evidence – Online availability and accessibility of
– Step Two: Critical Appraisal of the appropriate article that will provide
Evidence timely answer to a clinical dilemma
– Step Three: Application of Evidence
ACQUIRE ACQUIRE
• Boolean Logic - Using the words and, or,
In searching for evidence, consider the following: and not will help refine your search.
• 1) Develop an initial strategy
Connecting your keywords with AND
a) Precise question (use PICOM) AND tells the search tool that all the words
b) Key concepts in the question must be present.
c) Broaden key concept to account for Connecting your keywords with OR tells
differences in terminology the search tool that any of the words can
OR
d) Narrow down yield by using the “intersect” be present.
(use of OR or AND) Using NOT in front of a key word tells
the search tool to exclude any page
NOT contaning that word. Some engines
require you to use AND NOT
ACQUIRE ACQUIRE
•Phrase Searching
–Enclose in quotation marks the
phrase you are searching for
• The quotation marks - the words within
must be exactly as they were typed,
and in the same order.
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ACQUIRE ACQUIRE
ACQUIRE ACQUIRE
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P = PATIENT/POPULATION OF I = INTERVENTION OR
INTEREST EXPOSURE
• Who are the patients of interest? • What therapeutic, diagnostic, preventive or
• Is there a particular age group, gender other health care interventions are you
interested in knowing more about?
or population?
• What health care management strategies are
• What is the health concern?
you interested in comparing?
• Example: For persons entering a health
• Example: For persons entering a health care
care facility…
facility, is hand rubbing with a waterless,
alcohol-based solution…
• Only used if more than one intervention or if • Example: For persons entering a health care
no intervention is a factor. facility, is hand rubbing with a waterless,
alcohol-based solution, as effective as
• Example: For persons entering a health care
standard hand washing with antiseptic soap
facility, is hand rubbing with a waterless,
for reducing hand contamination?
alcohol-based solution, as effective as
standard hand washing with antiseptic soap…
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WHAT TYPE OF QUESTION ARE YOU WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE ASKING AND WHAT WILL THE EVIDENCE
SUPPORT? SUPPORT?
Therapy/Treatment questions:
Evidence supports how to select Diagnosis questions:
treatments to offer your patients Evidence supports how to select
that do more good than harm and and interpret diagnostic tests, in
that are worth the efforts and costs order to confirm or exclude a
of using them. diagnosis, based on considering
their precision, accuracy,
acceptability, expense, safety, etc.
WHAT TYPE OF QUESTION ARE YOU WHAT TYPE OF QUESTION ARE YOU
ASKING AND WHAT WILL THE EVIDENCE ASKING AND WHAT WILL THE EVIDENCE
SUPPORT? SUPPORT?
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• Working on the Developmental Assessment Team for • What is your clinical question in PICO format?
school-aged children of mothers who used cocaine • What type of clinical question is this?
during their pregnancy, you are interested in learning
• What is the best study design to answer this type of
the developmental outcomes for these children as
clinical question?
they begin school compared to children not exposed
to cocaine during pregnancy.
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16.7%(Benefit) 53.3%
Best Scenario
EXERCISE EXERCISE
• If the deaths on treatment were 1/24 and the deaths • Answer: No, the treatment group would have fewer
on placebo were 16/23, would the same drop-out deaths in both the best and worst scenarios.
rates still be worrisome? • Drop-out formula
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• The eight questions on the validity of a study have • If you feel that errors are small or that this is
now been discussed. probably the best study you will find that addresses
• While it is tempting to be strict and insist that all your clinical question, read the results.
eight criteria be satisfied, we must be pragmatic and • If you feel the errors are too great and that there are
remember that we sometimes need to make medical better studies, then don’t waste your time with the
decisions based on less than perfect information. article.
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• These issues usually compel most physicians • For example, venography, the criterion standard
to choose other diagnostic tests as for vein thrombosis, is an invasive procedure
surrogates for their criterion standard test. with significant complications including renal
failure, allergic reaction, and clot formation.
• These risks make venography less desirable than
the alternative diagnostic test—venous duplex
ultrasonography.
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SENSITIVITY AND
SENSITIVITY
SPECIFICITY
a
Disease • Sensitivity = 100
a+c
Test
Yes No
Positive a b
• The ability of the test to detect those who have the
Negative c d disease.
Total a+c b+d • True positive = those persons with the disease and
Disease whose findings are abnormal
Test
Yes No • False negative = Those persons who have the disease but
Positive TP FP whose findings are normal
Negative FN TN
Total
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• This makes a highly sensitive test ideal for a • Predictive value of a Positive test (PVP)
screening examination. • Predictive value of a Negative test (PVN)
• While, highly specific tests are best in a
confirmatory role.
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NOMOGRAM NOMOGRAM
• MIA method
• A 65 year old man complained of
urinary frequency and urgency for
several months. On history taking no
loss of weight nor loss of appetite was
noted. DRE was done which revealed
nodules with asymmetry and difference
in the texture. PSA result was 4.2 ng/ml
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EXAMPLES EXAMPLE
• The standard prostate-specific antigen (PSA)
• DRE and PSA combined Sensitivity and reference range of 0.0-4.0 ng/mL does not account
for age-related volume changes in the prostate that
Specificity is 38% and 87.9% respectively
are related to the development of benign prostatic
• Supposed the index of suspicion of patient hyperplasia (BPH).
having Prostatic CA is 60%. • Oesterling et al proposed that the use of age-related
• What is the probability that the patient have reference ranges would improve cancer detection
rates in younger men and increase the specificity of
Prostatic malignancy after a positive DRE and
PSA testing in older men.
PSA?
• They reported an overall specificity of 95% with the
• MIA method following reference ranges:
EXAMPLE QUESTIONS?
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INFORMATICS
ALGORITHM
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• storage
• retrieval
• optimal use of biomedical
information/data
• knowledge for problem solving and
decision making.
Health Informatics covers the organization and It covers a wide spectrum of applications, from
management of information in the areas of patient computer-based patient records in general
care, research and administration. practices and hospitals to electronic communication
between health care providers, from signal analysis
It focuses on the structuring of health data and and image processing to decision support systems.
knowledge to support data analysis and decision-
making in medicine and health care with the use of Effective delivery of healthcare requires correct
information systems. decision-making based on proper management of
health information.
Work stress can arise from many sources, but the most
commonly reported ones
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APPLICATION APPLICATION
Mrs Smith is a 58 year old teacher was diagnoses with
15 year history of renal impairment caused by childhood
pyelonephritis.
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APPLICATION
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LOST CHART
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INTERNET INTERNET
Ms Amulya Patel is a 48 year old accountant whose mother has recently died of breast
cancer. Ms Patel wonders about her own level of risk, and uses the internet to search for
patient resources
• Be more organized
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ACQUIRE
ACCESS TO MEDICAL LITERATURE
• MEDLINE/PubMed
The New England Journal of Medicine and JAMA are notable in this
regard, although subscriptions are needed to access many of these
–Full Text online
services. –Abstracts
Therefore, they may be available only if accessed by the health • EBM at the point-of-care
professional on the patient’s behalf
–Online availability and accessibility of the
appropriate article that will provide timely
answer to a clinical dilemma
ACQUIRE ACQUIRE
• Boolean Logic - Using the words and, or, and
not will help refine your search.
Connecting your keywords with AND tells
AND the search tool that all the words must be
present.
Connecting your keywords with OR tells
the search tool that any of the words can
OR
be present.
Using NOT in front of a key word tells the
search tool to exclude any page contaning
NOT that word. Some engines require you to use
AND NOT
ACQUIRE ACQUIRE
•Phrase Searching
–Enclose in quotation marks the phrase
you are searching for
• The quotation marks - the words within
must be exactly as they were typed, and in
the same order.
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ACQUIRE ACQUIRE
ACQUIRE
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TELECONSULTATION TELECONSULTATION
APPLICATION
Mr Edward Evans is a 49 year old, recently unemployed,
pharmaceutical company representative who presents with
headaches. He also has symptoms of early morning
wakening and erectile dysfunction
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EXPERIENCED
Experienced doctors use hypothetico-deductive reasoning
methods when assessing patients’ problems.
EXPERIENCED
LESS EXPERIENCED
Less experienced doctors may use a checklist or, when an
unusual presentation occurs, they may return to inductive
reasoning learnt as an undergraduate or trainee.
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APPLICATION APPLICATION
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APPLICATION
The data can improve efficiency when they are entered into
clinical records and made available to other members of
the clinical team.
APPLICATION
CONCLUSION CONCLUSION
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