SYLLABUS FOR THEORETICAL STATE EXAM IN SOCIAL MEDICINE

1. Social medicine as a science. Public Health.

● Study of how social and environmental factors impact health and disease
● Health= state of complete, physical, mental and emotional well-being and the ability to
lead an socially and economically productive life
● Diseases→ impairment → disability → handicap
● Impairment: any loss of psychological/ physiological / anatomical structure / function
● Disability: restriction/lack of ability to perform an activity in what's considered the
normal range for humans
● Handicap: a disadvantage resulting from impairment / disability that limits the fulfilment
of a role that is normal for that individual
● Interviews (personal form of research)- individual / group / telephone /structure
(standardised)/ unstructured (based on interviewee’s intelligence, understanding,
belief)
● Observation (sociological observation)- according to observer (self or external) /
conditions (natural or controlled) / level of anonymity (overt or covert)
● Historical method: social history of patient for diagnosis and prophylaxis→ personality/
environment/ social history of patient based on genetic history
● Statistical method: demographic trends of diseases for vaccinations and disease
control
● Epidemiological method: incidence, distribution and control of disease (+ other factors
relating to health) → causes + natural history of disease → risk factors and provide
data for prevention, control and treatment of disease

2. Social factors of health and disease. Socio-medical approach to health and disease.
● Negative definition of health- patient is confident in their health and doesnt strive for
better
● Positive definition- proactive approach to achieving optimal health
● Factors contributing to good health: genetics, age, gender, absence of disease + social
factors
● Social factors: social and economic background (wage gap) + education +
environment (air, water, housing, roads, working conditions) + healthcare
(vaccinations and treatment) + social support
● Classification: social factors that act on a population level (general regulations+laws)
OR social factors that act on an individual level (socioeconomic background)
●
● Sociomedical approach: the more complete the social history, the higher degree the
physician is able to identify the socio-medical needs of the patient and make a
management plan
● Information is gathered from medical interviews (patient/relatives), observations,
physical exams, document analysis, medical tests
Information:
1. somatic status - age, gender, height, weight, body language, smoker, drinker
2. Objective status- complaints, symptoms (SOCRATES), genetic predispositions,
diagnosis, history of illness
3. Personal characteristics: education, religion, lifestyle
4. Occupation (details)
5. Family - members, housing, relationship, social class, health problems
 6. public environment: relationships
7. Healthcare: visits + attitude
8. Medico-social conclusions + needs
9. Plans for future

3. Sociological methods in Medicine and health care.

● Sociology: social interrelations among people
● Medical sociology: studying health, health behaviour and health institutions
● Sociological methods- research by doctors to study behaviour + background of patient
● Application of medical sociology: public health, clinical medicine, epidemiology
(incidence, distribution, control)
Sociological methods:
1. direct inquiry OR indirect enquiry
2. Interview: individual / group / telephone / structured / unstructured / semi-structured
3. Observation: objective (self/external) / dependent upon conditions (lab/natural) / covert
/ overt
4. Documentary method: written / pictures / films / clothes
● Requirements of questionnaires in medical sociology: objective, name, purpose,
positive statements, grammatically correct, simple, structure
● Types of questions: open-ended, closed-ended, filtered (subsequent questions if
applicable
● Advantages vs disadvantages: direct inquiry / indirect inquiry / interview / observation

4. Measuring disease frequency. Comparison of risks.

● Principle of epidemiology is to measure disease occurrence and make comparisons
between population groups to understand distribution of disease
● Health outcomes that are measured: morbidity, mortality, infectious disease incidence,
birth defects, disability, injury, vaccine efficacy, utilization of hospital services
● Disease frequency= how common an illness is with reference to size of population
● → prevalence; measures existing cases (a proportion of cases/population at a given
time)
● → incidence; measures new cases (person-time units) → incidence RISK % (new
cases/disease-free people at the beginning of study) → Incidence RATE % (new
cases/total person-time at risk at follow up)
● P = ID (P = Prevalence, I = Incidence Rate, D = Average duration of the disease)
1. Risk difference (RD)= the absolute distinction between the incidence among the
exposed and non exposed groups
● le + Cle = incidence among exposed
● lo + Clo = incidence among non-exposed
2. Etiological fraction of exposed (EF) = the share of diseases among exposed that is
due to considered risk factor
3. Population Attributive Risk (PAR) = share of diseases among whole population that is
due to considered risk factor
4. Measures of relative risk (RR) = ratio of incidence in exposed and non-exposed
people
● RR=1.0 means that incidence of disease in exposed and unexposed groups are equal
(no association between disease and risk factor)
● RR>1.0 means that incidence of disease is higher in those exposed to the risk factor
(e.g. 1.3 = 30% rise)
5. Analytical epidemiological studies.
● Analytical studies researches the relationship between an exposure and the risk of
developing disease. (cohort or case-control)

Case control study: comparison of the characteristics of cases in a population with those
people at risk from illness within the same population
ADVANTAGES DISADVANTAGES ​
Study rare health outcomes ​ Not suitable to study rare theories
​
Quick, cheap and easy to conduct Greater potential for bias

Study more than one risk factor at same time ​ Cannot measure incidence rates ​

Suitable for diseases with long latent period Cannot measure absolute or relative risks

​
● Data analysis: statistical tables + odds ratio calculation
● Odds ratio <1 = incidence in exposed person is < than incidence in non-exposed
● Odds ratio=1 = no link
● Odds ratio >1 = association with risk factor and disease

Cohort study: observational- follows a group of healthy people with different levels of
exposure and assesses what happens to their health over time → allows for direct
estimation of risk of developing disease + how it varies with time since exposure
Advantages:
→ studies the full range of effects of suspected etiological factor
→ directly measures incidence rates within exposed/non-exposed
→ provide direct estimates of risk of disease for each exposed group
→ allows for studying rare factors
→ less biased (exposure is evaluated before health status is known)
Dissadvantages:
→ time consuming + expensive
→ not suitable for studying rare diseases
→ requires standardised diagnostic methods
→ some participants may exit study leading to analytical problems

6. Experimental epidemiological studies. Evidence based Medicine.

● Experimental studies ^^^^
● Evidence based medicine (EBM) = approach to medical practice intended to optimize
decision-making by emphasising the use of evidence from well-designed and well-
conducted research
7. Disease prevention. Screening.
Disease prevention focuses of prevention strategies to reduce risk of developing chronic
diseases and other morbidities
Types:
1. primary prevention- preventing exposures to hazards, altering unsafe behaviours and
increasing resistance
2. Secondary prevention- reduce impact of disease/injury that has already occurred by
detection and treatment ASAP. Prevent re-injury/recurrence + programs via regular
exams/screening tests, diet, exercise, low-dose aspirins, modify environment/
occupational factors
3. Tertiary prevention- soften the impact of chronic illnesses/ permanent impairments to
improve ability to function, quality of life and life expectancy
Screening: Mass screening (whole population / sub-group) OR high-risk/selective screening
OR multiphasic screening (2 or more screening tests to large populations

8. Health promotion.
● Ottawa charter for health promotion- process of enabling people to increase control
over their health and its determinants, thereby improving health
● Factors: income, housing, food, security, clean water, stable exosystem, peace,m
employment, quality of working conditions
● Should be a joint coordination of government, health services, community, social and
professional groups, managers, non-governmental organisations and political groups
to encourage political, cultural, economic, social and environmental health.
● Principle: public health policy, living environments, health activity promotion, education,
skills, abilities
● High-risk VS population-based (more efficient) health promotion

9. Health culture and health education.

Health culture: a system of thoughts and behaviours shared by a group of people that may
influence health
→ health motivation
→ health knowledge + skills: education, income and occupation, religion, political affiliation,
geographical region
Health education: learning and experiences within individuals and communities
→ early diagnosis + management
→ health promotion + disease prevention
→ utilization of available health services
● Phases of health education: unawareness → awareness → interest → evaluation →
trial → adoption
● Models of health education: traditional / shared / promoting
● Methods of health education: classical (verbal / printed / visual / mixed) OR modern
(social / diffusion of innovations / social immunization / mass media strategies)

10. Demographic approach to population health. Demographic statics. Migration and health.
Demography= science of population dynamics by investigating 2 main demographic
processes (birth, migration, aging) which contribute to changes in populations and how
these populations inhabit earth, form nations and develop culture.
Demographic processes are dynamic and are interrelated
Status = number + condition of population
Dynamics = mechanical + natural movement of population
Composition of population:
Past 300-400= substantial increase in population of most european countries → this has
stabilised recently → >7 billion people will double in the next 40 years
past 400 years= Large emigration to americas, australias, africa
Natural movement of population: vital processes including birth and death (relies on
accurate documentation)
Birth rate is the dominant factor in determining rate of population growth (depends on level
of fertility and age structure of population) → decline in birth rates due to social trends
(decreased marriage rates, economic forces, growing number of women in labor force,
urbanization, emergence of social insurance, use of contraception, adoption schemes,
government policies)
Death rate accurately indicates current mortality impact on population
Growth of a population + age structure is related to birth rate + death rate + changes in life
expectancy
​ ​ ​ ​

​ ​

Mechanical movement of population

Internal migration: Urbanization (end of 20th century) - migration into towns and cities with
advantages (better living conditions, electricity, trade, healthcare, education, connections)
and disadvantages (pollution, traffic, psychic disorders, non-social activities)
Dislocation= disturbance from an original/usual place or state
External migration:
1. immigration - international movement of people into a destination country of which
they are not natives/citizens in order to reside there/take up employment.
Economically, migration is beneficial for the receiving and sending counties. 2000-
2015 Asia added 26 million international migrants and Europe added 20 million.
2. Emigration- act of leaving one's resident country with the intent to settle elsewhere
Influence of migration:
- high/low skilled workers increase income per person and living standards of new home
countries.
- high skilled migrants bring diverse talent and expertise
- low skilled migrants fill essential occupations for which natives are in short supply
- Asylum seekers / refugees → overcrowding, imprisonment, socio-economic hardship,
language barriers, lack of knowledge of new residing country, health services, loss of
social status, discrimination, marginalisation, psycho-social issues related to lower
social/unemployment positions
- skilled migrants may leave their origin countries with depleted local infrastructure

11. Population dynamics. Fertility and mortality.

Reproduction of population: changing of generations measured by gross reproduction rates
that indicate the ratio between the sizes of the daughters and mothers generations.
Net reproduction rate <1 = decreasing generation size
3 basic population pyramid shapes:
1. Progressive pyramid = high birth rate and high death rate (growing younger
generation in developing countries with high fertility rates and lower than average life
expectancy)
2. Stationary pyramid = unchanging pattern of fertility and mortality (population size
remains constant)
3. regressive pyramid = Declining birth rate and low mortality rate (declining birth rate
and low mortality rate)

Fertility rate = the number of live births / 1000 women of childbearing age (15-49) in the
population in a given year
Total Fertility Rate: The number of children that would be born per woman if she were to live
to the end of her child-bearing years and bear children at each age in accordance with
prevailing age-specific fertility rates.
Birth rates of developed countries < underdeveloped countries
factors related to increased fertility = religion, intent, maternal support
factors related to decreased fertility = wealth, education, female labour participation, urban
residence, intelligence, ^female age, ^ male age

Mortality:
perinatal mortality rate
infant deaths (<1yr)
neonatal death (<28 days)
early neonatal death (<7 days)
Late neonatal death (7-28 days)
post neonatal death (1 month - 1yr)
Stillbirth (fetus >24weeks gestation)
^^^^ ALL mortality rates = per 1000 live births per annum
Main causes of neonatal deaths: preterm, severe infection, asphyxia, congenital anomalies,
neonatal tetanus, diarrhoeal diseases
Life expectancy at birth = one of the most frequently used health status indicators (can be
increased by improving living standards, improving lifestyle, quality healthcare and better
education)

12. Infant mortality, Under-5 mortality and Life expectancy.

^^^^^

13. Morbidity as a measure of population health.

Morbidity= condition of being diseased measured as morbidity rate, duration and severity
Incidence= number of new cases occurring per unit of population per unit time
Incidence rate= (total number of new cases of a given disease during a given period of time /
total population at risk during the time period) x 1000
Prevalence= all the current and existing cases in a given population
period prevalence= the number of people with a disease in a defined population over a
period of time
prevalence rate= (all new and pre existing cases of a specific disease during a given time
period / total population during the same time period) x 1000
Iceberg phenomenon of morbidity = actual known morbidity is >50% of total occurence of
disease in a population due to patient-led barriers (lack of information) or profession-led
barriers (false reassurance/incorrect diagnosis)

​
Concept of double burden of disease= coexistence of old communicable diseases (infectious
diseases) along with modern non-communicable diseases (obesity) within a population
International classification of disease (ICD)- international standard diagnostic tool for
epidemiology, health management and clinical purposes with easy storage, retrieval and
analysis of health info for evidenced-based decision making. Allows for sharing and
comparing health info between hospitals, regions and countries. Used in 117 countries and
is coded by GP’s in 17 languages.

14. Major diseases. DALYs. Major risk factors for chronic non-communicable diseases.
Dramatic increase in life expectancy + changes in lifestyle = global epidemic of chronic
diseases (contributes to half of deaths)
Concept of double burden of disease= coexistence of old communicable diseases (infectious
diseases) along with modern non-communicable diseases (obesity) within a population
disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the
number of years lost due to ill-health, disability or early death.
2020:
Ischemic heart disease → cerebrovascular disease → chronic obstructive pulmonary
disease → lower respiratory infections → cancer
developed countries (dramatic decrease in infectious diseases) - obesity, diabetes,
cardiovascular disorders, liver damage (drinking), obstructive lung problems (smoking)
Developing countries (low/middle level of health development index) - infectious diseases
(TB + malaria) due to poor sanitation, diet, unsatisfactory healthcare system
Risk factors for health:
Primary- inactivity, obesity, high bp, high levels of cholesterol, stress, tension, smoking
Secondary- fatigue, injury, overweight, pain, bowel/bladder problems
individual health: state of health / fitness, lifestyle, posture, exercise habits
public health: unsafe sex, unsafe water, sanitation hygiene
Lifestyle + health (define):
Health behaviour
preventative health behaviour
illness behaviour
Diet + nutrition
physical activity
tobacco use + smoking
alcohol
heredity contributes directly and indirectly to pathogenesis of disease- Cancer, CVD,
diabetes
Environmental risk factors: air pollution, passive smoking, radon, unsanitary conditions,
unclean water
Healthcare system
Risk contingents from the population:
- women- breast, cervical cancer. Anxiety + postpartum depression for pregnant women.
- New-borns: prematurity, jaundice, pink eye, hep A, chickenpox, skin rash allergies,
diarrhea
- old people- dementia, parkinson's disease, poor vision, hearing loss
- disabled people- musculoskeletal problems (arthritis, heart disease, stroke)
- mentally ill: depression, schizophrenia, lack of motivation
- lower socioeconomic background: malnourishment, isolation, parasitic diseases
- Programs for prevention and promotion: WHO programs for cities, schools and
workplaces.

15. International health cooperation. International organizations, strategies and programs in

the field of health.Globalisation: worldwide movement towards economic, financial, trade and
communication integration
Global health situation:
→ population: global population is expected to reach 8 billion by 2025
→ life expectancy: 1955 (48yrs) → 1995 (65 yrs) → 2025 (73yrs and all countries > 50yrs)
International health cooperation: develops standards, mechanisms and procedures to
provide services related to mobilisation, coordination, management and assessment of
externally supported health projects and initiatives.
WHO headquarter: Geneva, switzerland
Goal: the attainment by all peoples of the highest level of health so that they can lead a
socially and economically productive life.
Principles:
- International health activities coordination
- providing help for governments in developing their health systems
- preparing an international standards for food, biological and pharmaceutical products
- providing information and advice concerning the management and organization of the
public health
responsibilities concerning these areas: prevention + control of specific diseases,
development of comprehensive health services, family health, environmental health, health
statistics, bio-medical research, health literature and information, cooperation with other
organizations
WHO consists of 3 principal organs:
1. The world health assembly- health parliament of nations and supreme governing body
of organization → meets annualy (May)
2. The executive board- originally 18 members with member state which meets twice a
year → gives effect to the decisions and policies of the assembly and can take action
in emergencies
3. The secretariat- director general who is chief technical administrative officer of the
organization
Strategic objectives of health 2020: alma-ata conference 1978 provided WHO and UNICEF
with a common charter for health → health promotion → global strategy for health for all
(21st century)
EU: Health21 policy framework to achieve full health potential for all people in the region→
to promote and protect people's health throughout their lives and to reduce incidence of the
main diseases and injuries (and alleviating the suffering they cause)
​
​ ​
16. Health as a social system. Health services.

17. Health legislation. Basic Health Laws - Health Act, Health Insurance Act, Health Care
Facilities Act.
Tasks of health policy: defines a vision for the future, outlines priorities and extended roles of
different groups and builds consensus and informs people
role of health policy: organisation, financing and delivery of healthcare services → training of
health professionals, overseeing safety of drugs and medical devices, administrating public
programs, regulating public and private health insurance
modern technologies used in health policy: Health2020 is the new european health policy
which aims to “significantly improve the health and well-being of populations, reduce health
inequalities, strengthen public health and ensure people-centred health systems that are
universal, equitable, sustainable and of high quality”.

Health system: organization of people, institutions and resources that deliver healthcare
services to meet the health needs of a target population ​
4 basic activities of management: planning, organizing, communicating, monitoring
Management techniques are based on principles of behavioral sciences as quantitative
methods developed to achieve goals efficiently
Health policy: Life-course approach and empowering people by tackling regions major health
​
challenges so communicable/non-communicable diseases. Strengthening people-centred
health systems, public health capacity and emergency preparedness, surveillance and
response. Creating resilient communicating and supportive environments 3. Political Action
Plan of the World Health Organisation – Health 2020 sets out the strategic directions and
priority policy action areas for Member States and the WHO Regional Office for Europe. The
Health 2020 policy framework has been developed through a fully participatory process with
Member States and a wide variety of other interested parties across the European Region.
EU health policy- The aim of EU policies and actions in public health is to improve and
protect human health, and to support the modernisation of Europe's health systems, thereby
contributing to the Commission's 2014-2019 priority on growth and jobs. In line with the
principles of proportionality and subsidiarity, the Commission's role is mainly to support the
EU Member States' efforts to protect and improve the health of their citizens and to ensure
the accessibility, effectiveness and resilience of their health systems.
18. Main types of healthcare systems.
4 types of healthcare systems
1. The Beveridge model (UK)- National single-payer healthcare system where the
majority of physicians and doctors work for the government, although private ones
exist. Payment is via taxes and the government controls which pharmaceutical
companies and doctors can charge. Some may argue that this model compromises
quality of care.
2. The Bismarck model (Germany)- National single-payer healthcare system where
health care is provided through insurance companies who are paid by employer and
employee payroll deductions. Everyone is covered and no-one is left with no access
to care. In addition, hospitals and doctors may not operate for profit, so overall costs
are again much more affordable than they are under our current US model.
3. The national health insurance model (Asia): National single-payer healthcare system
which combines aspects of beveridge and bismarck models. Health care is paid
through higher taxation; however, patients are free to choose any doctor or hospital
they wish. And, again, as with Beveridge and Bismarck, there is no profit incentive,
so prices tend to stay lower. They tend to have better health outcomes (Japans
preventative approach)
4. The private insurance system (US)- individuals are either covered by their employers,
covered by a private policy the policyholder purchases themselves or they go without
coverage at all. An uninsured person in the US who suffers an accident or illness
may find themselves bankrupted by the experience. The private insurance health
care system also means that more Americans put off needed preventative care that
can keep illnesses from becoming devastating down the road.

19. Health policy. Priorities of health policy in developed countries.

Q17

20. Organization, current status and trends of primary health care.

Primary health care is essential health care made universally accessible to individuals &
acceptable to them, through their participation and at a cost the community and country can
afford
Primary health care – family medicine, specialised outpatient care, dispensary, emergency
Levels of health care
Health care services are usually described at three levels – primary, secondary and tertiary
care levels. ​
o Primary level: it is the first level of contact for the patient with the health system. It deals
with the most common health problems ​
o Secondary level: at this level more complex problems are dealt with.
o Tertiary care level: this is the most specialized level. It requires highly specialized health
workers and facilities
Services delivered by primary healthcare providers include:
● diagnosis, treatment and care of people with health problems
● promoting good health
● preventing health problems
● early intervention
● managing ongoing and long-term conditions.
Healthcare services play an important role in advising and helping you to prevent illness and
maintain good health. Important areas that you should seek advice on include:
● managing and stopping smoking
● hazardous drinking
● stress and depression
● poor diet and
● physical inactivity.
Primary health organisations (PHOs) ensure the provision of essential primary health care
services, mostly through general practices, to people who are enrolled with the PHO. PHOs
are funded by district health boards (DHBs), who focus on the health of their population.
21. Organization, current status and trends of hospital care.
​
1. A hospital is an institution providing medical and surgical treatment and nursing care
for sick or injured people.
​
2. Types of hospitals: ​
● According to function:
(1) Hospitals for active treatment - for patients with acute diseases, traumas,
aggravated chronic diseases, conditions requiring operative treatment in hospital
conditions as well as natal care and medical cosmetic services.
(2) Hospitals for long term treatment- this type of hospital admits persons needing
long recovery of health and persons with chronic diseases requiring long-term care.
(3) Hospitals for rehabilitation- for persons in need of physical therapy, motor & psychic
rehabilitation, balneological, climatological and thalassotherapy.
● According to the specialization:
(1) Multi-profile hospitals- which have departments or clinics on different medical
specialities.
(2) Specialised hospitals-in which there are departments or clinics corresponding to
one basic medical speciality.
● According to the profit:
​
(1) Non-profit hospitals
(2) Private for-profit hospitals
​
3. Basic hospital activities:
● Diagnostics & treatment of diseases when the purpose of the treatment cannot be
 achieved in the conditions of outpatient care
● Natal care
● Rehabilitation
● Diagnostics & consultations requested by a doctor, or a dental doctor or by other
medical establishments
● Transplantation of organs, tissues & cells
● Medical cosmetic services
● Clinical tests of medicines & medical equipment
● Educational & scientific activity
​
4. Hospital structure
A Hospital consists of:
​● Clinics or departments with beds
​● Medical diagnostic and medical technical laboratories
​● Departments without beds
​● Hospital pharmacy
​● Consulting rooms
​● Units for administrative economic & servicing activities
5. Financing of the Hospital Sources of financing of a hospital can be:
​● Public health insurance funds
​● Republican and municipal budgets
​● Private health insurance funds
​● Local & foreign corporate bodies & individuals
6. Indicators for assessing Hospital care Quantitative indicators:
​● Hospital beds per 1000
​● Average length of stay
​● Utilization of beds
​● Turnover of beds
​
Qualitative indicators:
​● Surgical wound infection rate in % from all operations
​● Hospital mortality
​● Match of clinical diagnosis with the pathology diagnosis
​
​ ​
​
22. Organization, current state and trends of emergency care.
1. Emergency medical services (EMS) systems form an integral part of any public health
 care system: their primary function is to deliver emergency medical care in all
emergencies, including disasters.
​
2. Emergency medical condition means a medical condition manifesting itself by acute
symptoms of severity (including severe pain) such that a prudent lay person, who
possesses an average knowledge of health & medicine, could reasonably expect the
absence of immediate medical attention to result in:
(1) Placing the health of the individual in serious jeopardy
(2) Serious impairment of bodily functions
(3) Serious dysfunction of any bodily organ or part.
Emergency Services: Those services provided after the sudden onset of a medical
condition manifested by symptoms of sufficient severity, including severe pain, so
that the absence of immediate medical attention could reasonably be expected to
result in placing the patients’ health in serious jeopardy, serious impairment to bodily
functions, or serious dysfunction of any bodily organ or part.
​
3. Basic Life Support (BLS)- The constellation of emergency procedures needed to
ensure a person’s immediate survival, including Cardio- Pulmonary Resuscitation
(CPR), control of bleeding, treatment of shock & poisoning, stabilization of injuries
and/or wounds, and basic first aid.
​
4. Out-of-hospital emergency medical services (O-H-EMS), also known as pre-hospital
EMS, typically refer to the delivery of medical care at the site of the adverse medical
event ​
(1) Dispatch centers receive the initial request for ambulance services and organize
the appropriate response, the organization & management of ambulance services
that deliver on-site medical care & provide rapid transportation to health facilaties.
Both services are usually provided or at least coordinated and supervised by local,
regional or national government and can be accessed through a national (or
regional) public telephone number.
​
The emergency call number for the most of the European countries is 112, and in
some of them there is a national number as well (e.g. in Bulgaria 150)
DC is to get the right resources to the right patients in the appropriate amount of
time.
4 (2) Ambulance services.Ambulance-vehicle or craft intended to be crewed by a
minimum of two appropriately trained staff for the provision of care and
transport of at least one stretched patient. According to the latest EU
standards, road ambulances can be categorized into 3
types: ​
● Type A- patient transport ambulance ​
● Type B- emergency ambulance
● Type C- mobile intensive care unit (ICU)
In-Hospital EMS ​
● The Emergency department (ED), sometimes called emergency room, emergency ward,
accident & emergency department or casualty department is a hospital department that
provides initial treatment to patients.
5. Legislation & Financing
The legislative framework in the majority of EU Member States implies secured funding
mechanisms for EMS. Similarly, more than two thirds of countries specify, within the legal
framework, standards of care, equipment & professional qualification in EMS.
In reality, some countries or regions or even individual hospitals invoice patients for
emergency care. This usually effects non- EU residents and, occasionally, persons from a
‘socially marginalized group’. However, co-payment for emergency care is waived in the
event of (life threatening) conditions.
In most countries, EMS are purchased by the state or through a national health insurance
scheme according to the number & type of services delivered. Payment systems rely mainly
on classification of services e.g. diagnosis-related groups.

23. Health and health care for mothers and children. National programs for maternal and
child health.
Improving the well-being of mothers, infants, and children is an important public health goal
worldwide. Their well-being determines the health of the next generation and can help
predict future public health challenges for families, communities, and the health care system.
The objectives of the Maternal, Infant, and Child Health topic area address a wide range of
conditions, health behaviors, and health systems indicators that affect the health, wellness,
and quality of life of women, children, and families.
Pregnancy can provide an opportunity to identify existing health risks in women and to
prevent future health problems for women and their children. These health risks may
include:
● Hypertension and heart disease
● Diabetes
● Depression
● Intimate partner violence
● Genetic conditions
● Sexually transmitted diseases (STDs)
● Tobacco, alcohol, and substance use
● Inadequate nutrition
● Unhealthy weight
The risk of maternal and infant mortality and pregnancy-related complications can be
reduced by increasing access to quality preconception (before pregnancy), prenatal (during
pregnancy), and interconception (between pregnancies) care.1 Moreover, healthy birth
outcomes and early identification and treatment of developmental delays and disabilities and
other health conditions among infants can prevent death or disability and enable children to
reach their full potential.
Many factors can affect pregnancy and childbirth, including:
● Preconception health status
● Age
● Access to appropriate preconception, prenatal, and interconception health care
● Poverty
Infant and child health are similarly influenced by sociodemographic and behavioral factors,
such as education, family income, and breastfeeding, but are also linked to the physical and
mental health of parents and caregivers.
There are racial and ethnic disparities in mortality and morbidity for mothers and children; in
particular, maternal and infant mortality and morbidity are highest for African Americans.
Maternal and child health (MCH) programs focus on health issues concerning women,
children and families, such as access to recommended prenatal and well-child care, infant
and maternal mortality prevention, maternal and child mental health, newborn screening,
child immunizations, child nutrition and services for children with special health care needs.
States invest in healthy children and families to strengthen communities and avoid
unnecessary health care costs.
Both federal and state funds contribute to MCH-related programs.
States also pass a broad range of policies to improve health for children and families,
including policies related to health insurance coverage, perinatal care, maternal and infant
mortality, child nutrition, mental health and substance use disorders. NCSL tracks enacted
MCH legislation on topics such as maternal and infant mortality, childhood nutrition,
children’s mental health, and others, in NCSL’s Maternal and Child Health Database.

24. Health and health care for the elderly.

1 1) Classification of age:
▪ Classification according to WHO:
● The period that has elapsed since birth.
● The number of people reaching age 65 couples with their increased life
expectancy , has expanded the classification of those age 65 years and older to
include three sub-populations commonly referred to as:
1) The “young old” 65 to 74
2) The “old “74-84
3) The “oldest- old” 85+
▪ Classification for the purposes of education and health:
● Individuals are educated about: physical health, social health, emotional health
intellectual health and spiritual health.
2) Elderly as a specific heterogeneous group:
▪ With an active career
▪ Seniors in good health
▪ Sick and dependent people
▪ Identifying needs and potential interventions
3) Characteristics of health in older people:
● Multiple pathology
● Many different medications.
● Interaction between drugs.
● Not known bad side effects.
4) Particularities of the disease in the elderly:
● There are several distinct mechanism leading to unrecognised diseases:
1) Failure to report symptoms
2) Denial of symptoms
3) Under investigation by doctors
4) Poor diagnosis by doctors
▪ Older people as risk group :
● Injury- falls and injuries increase the burden of disease and disability. Requiring
hospitalisation as well as expensive interventions.
​● Risk factors of non communicable diseases- harmful behaviour which has been
early established in life , can reduce the quality of life and even premature- death.
​
● Poverty- Many older patients cannot afford to pay for health costs and treatment further
worsening their condition.
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● Social isolation and exclusion, mental health disorder- affect all aspects of health and
wellbeing including mental health, dehydration or malnutrition.
5) Priority issues in the third adult
● Difficulty in health and problems in managing the disabled adults expenses
​
6) WHO: investing in “healthy aging”- Strategy and action plan for healthy aging in Europe.
2012-2016:
▪ Ensuring access to prevention
​▪ The quality of healthcare
​▪ Long-term care
​▪ Protective from abuse
​
7) Health strategy “Europe 2020”:
​▪ Promotion of good health in an aging Europe
​▪ Innovations related to healthy and active aging
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25. Medical expertise of working ability.
Preserved and impaired ability to work: ​
-Preserved ability to work: this is the healthy state of a person where the person is prevented
from any disease which can in one way or the other cause a person to be in an impaired
state of health preventing him to work. ​
-The medical expertise of ability to work is organized and directed by the Ministry of health.
-Impaired ability to work: also can be classed as having a disability, which makes a person
unable to work and dependent. ​
Temporary inability to work:It is temporary absence of legal capability to perform an act. It’s
curable impairment of mental or physical state that may prevent the affected person from
functioning normally only as far as he/she is under treatment
​
-Hospital list for temporary disability: It’s the source of studying morbidity with temporary
disability. They are issued only of health provided and working
people. ​
Sick leave is calculated in calendar days and not working
days. ​
-Types of Hospital list: ​
1) Primary Hospital list: issued for every new illness with temporary disability. ​
2) Extension of Hospital list: issued for repeated visit to the doctor on the occasion of the
same illness. ​
-Reasons for temporary inability to work can be: injuries, surgery, short-term medical
conditions such as broken limb or injured hand, looking after a healthy child, because of a
quarantine in the kindergarten, urgent accompany of a sick family member for a medical
examination and looking after a diseased family
member. ​
Expertise of temporary inability for work- who is taking part, number of days of the issued
hospital lists.
The number of days of the issued hospital list depends on the incubation period of the
temporary ill (such as infections) and the infectivity. ​
Temporary: ​
-The role of treating physicians in the expertise of temporary disability: the treating physician
can issue a hospital list for temporary disability for 14 consecutive days and for no more than
40 non-consecutive days in a calendar.
-The role of LKK (physician Consulting Commission) in the expertise of temporary inability
for work: LKK can issue a hospital list for temporary disability for 30 calendar days without
interpretation and for no more than 6 months in one calendar
year. ​
Permanent:
-The role of TELK (Territorial expert physician Commission) in the expertise of temporary
inability of work: allow sick leave because temporary disability over 6 months.it takes part in
expertise of disability but doesn’t issue hospital list.
-The role of NELK (National expert physician Commission) in the expertise of temporary
inability of work: Decides over controversial points of the expertise of inability to
work. ​
Permanent inability to work: (invalidity)
This is the condition of being invalid to perform any task. It is a form of dependency where
an individual is unable to work. This is defined as a percentage lost ability for work
compared to the abilities of the healthy person. ​
Expertise of permanent disability to work:
1) Extent of the permanent disability in percentage compared to healthy person 2) The need
for somebody else’s assistance
3) The initial date of becoming disabled
4) The duration of permanent inability to work and final date of it
5) The contra-indicated work conditions and the necessity for a transfer to a more
appropriate job. The expertise of permanent disability to work is carried by TELK and NELK
Types of Invalidity (as a percentage of loss of ability to work):
1) First group permanent disability- over 90% lost of ability to work (with/without right to
somebody else’s assistance)
2) Second group permanent disability- from 71% to 90% lost of ability to work
3) Third group permanent disability- from 50 to 70% lost ability to work
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