BLOCK CBP

SEMESTER I
1. Stadium Generale and Humaniora
2. Medical Communication
3. The Cell as Biochemical Machinery
4. Growth and Development Prenatal and
Postnatal
 SEMESTER II
1. Medical Professionalism
2. Community-Based Practice
3. Health System-Based Practice
4. Evidence-Based Medical Practice
5. Special Topic
6. Elective Study 1
 SEMESTER III
1. The Hematologic System and Disorders
and Clinical Oncology
2. Immune System and Disorders
 SEMESTER IV
1. The Musculoskeletal System and
Connective tissue Disorders
2. Neuroscience and Neurological Disorders
3. Behavior Change and Disorders
4. The Visual System and Disorders
 SEMESTER V
1. The Alimentary and Hepatobiliary System
and Disorders
2. The Endocrine System, Metabolism, and
Disorders
3. Clinical Nutrition and Disorders
4. Special Topic
5. Elective Study 2
 SEMESTER VI
1. The Respiratory System and Disorders
2. The Cardiovascular System and Disorders
3. The Urinary System and Disorders
4. The Reproductive System and Disorders
 SEMESTER VII
1. Medical Emergency
2. Special Topic: Travel Medicine
3. Elective Study 3
Last year there was a debate on one of the National
channel in Indonesia Lawyers Club (ILC) that discuss
about Tobacco restriction law between pro and
anti/contra groups

The perspective/reason of most the participants that

anti/contra was: “Ah, tidak benar merokok ada
kaitannya dengan kanker paru-paru. Buktinya, saya
dan teman-teman saya adalah perokok berat, dan
sudah merokok selama 30 tahun, toh sampai saat ini
tetap sehat-sehat saja”.

“It is not true that smoking causing lung cancer. My

friends and I have been smoking for 30 year and are
heavy smokers, until now still healthy”

Question: as a future doctor  what are your opinion

APPROCHES OF CBP
 Prevention (not curative)
 Community
(not individual)
 Determinants
Genetic Physical
Social, cultural Stage
Environment
Biological, economical of
Behavior dis-
Clinical
Health Services
Presym- stage ability
tomatic
Susceptible stage
(at risk)
Tertiary prev.
Secondary prev. • Disability
Primary prevention
• Early detection limitation
• Health promotion & prompt
• Rehabilitation
• Specific protection treatment
Rules

1. During class 
Switch of (silent) of your
mobile
2. Morning plennary late
> 10 minut es(wall clock on
the classroom) students will
not allow to join the lecture
BLOCK CBP
RULE/REGULATIONS

(Community-based Medical Practice)

1. Switch of mobile during lecture and SGD

2. Bring study guide and all references every
lecture, SGD and individual learning
3. presence and activity during SGD
(5% from final mark)  REMEMBER TO SIGN
4. Your presence on lectures and feedback will be
counted
(if less than 75%)  won’t be allow to sit on the
exam
5. During afternoon plenary  student’s
presentation
6. The presenter must be chosen during SGD and
not in the class room.
7. The presenter must be different for each day

8. At the beginning of afternoon plenary all

presenters sit in the front line

9. Lecture will provide feedback during the

presentations
REFERENCES & MANUAL
• Study Guide & Annexes
• Reference 1-6
• Manual
Please refer to each day
session/module
CURRICULUM  STUDY GUIDE
17 MODULES

DAY 1, 2, 3: MODULE-1

LEARNING MATERIALS:
Reference 1 and 2 ,movie, video clip,
websites (it is advice to download materials from the websites
before the lecture)
Learning Outcomes:
a) Describe several determinants (models)
of diseases and death occurring in the
population
b) Explain the applications of
understanding diseases and death
determinants (models)
c) Identify the strengths and weaknesses of
diseases models
d) Draw figure of the natural history of a
certain disease
e) Explain the applications of the natural
history of a disease for prevention
f) Explain the severity of diseases in a
population and its implication to
prevention
g) Describe the level of disease prevention
based on determinants and natural
history
h) Explain the Ice Berg Phenomenom and
its implication in diseases prevention
LEARNING SCHEDULE
(time table)
• STUDY GUIDE (CLASS B)

• 08.00-09.00: Introductory lecture

• 09.00-11.00: Independent learning
 Reference 1 & 2
 Learning tasks 1, 2 and 3

• 11.00-13.00: SGD
• 14.00-15.00: Student presentation & feedback
LEARNING SCHEDULE
(time table)
• STUDY GUIDE (CLASS A)

• 09.00-10.00: Introductory lecture

• 10.00-12.00: Independent learning
 Reference 1 & 2
 Learning task-1,2 and 3

• 13.00-15.00: SGD
• 15.00-16.00: Student presentation & feedback
APPROCHES OF CBP
 Prevention (not curative)
 Community
(not individual)
“Some of the people need health care
some of the time
BUT
All of the people need public health all
of the time."

C. Everett Koop, MD
former U.S. Surgeon General
MODULE-1
• Determinants of morbidity
and mortality in a population
• Natural history of the
disease
• Diseases prevention
 DAY 1

• Determinants of
morbidity and mortality
in a population
Several models/concept used to
analyzed determinants of morbidity
and mortality in a population
 The Epidemiologic Triad/ Triangle
(Teori Segi Tiga)

 Wheel Model (Teori Roda)

 Web Model (Teori Sarang Laba-laba)

 Model Blum
 Model Mosley
 Model Segitiga (The Epidemiologic Triad/
Triangle)
HOST (intrinsic)
(age, sex, genotype, behaviour, nutritional
status)

AGENT ENVIRONMENT
(biologic, physic, mechanical, (Physical, Biological, Social)
chemical, nutrient)
 HUMAN HOST
AGENT Age, race, sex, habit
Biological, chemical, physical Genetic, personality
Mechanical, Nutrient Defense mechanism

ENVIRONMENT
Biological, chemical, physical
Mechanical, nutrient, social, psychologic
Triad epidemiologik
 Homeostatic Balance
H A
A H

E E
Agent becomes more pathogenic A H The proportion of susceptibles
in population decreases

E
At equilibrium
H Steady rate A
A H
E E
Environmental changes that
Environmental changes that favor the host
favor the agent
Model Roda (Wheel Model)
INTERNAL
(intrinsic)

Social
Biological HOST • politic,
Environ- Genetic • economic
ment • culture

Physical Environment

EXTERNAL (extrinsic)
 Contoh
WEB MODEL Kasus Kematian
(SARANG Ibu
LABA-LABA)

Modifikasi dari: FA Moeloek, 2010

 BLUM MODEL
Genetic

Morbidity and
Behavior Health
mortality in
services
a population

Environmental factors
(biological, physical, social, economical, politic)
CONCEPT (THEORY, MODEL)
INTRODUCED BY
DR. MOSLEY WHICH EXPLAINED
DETERMINANTS OF MORBIDITY AND
MORTALITY OF CHILDREN AGE
UNDER 5 YEARS IN A POPULATION
 Socioeconomic determinants

Maternal Environmental Nutrient

Injury
factors Contamination deficiency

Healthy Sick

Prevention
Treatment
Personal
Illness Growth
control Mortality
faltering
SOCIAL DETERMINANTS OF HEALTH
WHO- CSDH conceptual framework
UNDERSTANDING
CAUSALITY
Four types of Causal relationships
1.Necessary and Sufficient
2.Necessary but not Sufficient
3.Sufficient but not Necessary
4.Neither Sufficient nor Necessary

Necessary = without that factor disease never develops

Sufficient = in the presence of that factor disease always
develops
1. Necessary and Sufficient

Direct:
Factor A Disease

Indirect:
Factor A Step1 Step2 Disease

 rarely happens
A is nesccesary and sufficient in the
development of a disease

Vinil Anggio sarcoma

klorida hepar
2. Necessary but not Sufficient

Factor A
+
Factor B Disease
+
Factor C

Multiple factors required: initiator & promoter

(cancer, TB)
 A,B,C is necessary but not sufficient in
the development of a disease
Infection by
micobacterium

malnutrition
Cellular Clinical
reaction tuberculosis
age

Genetic
factor

Environment
3. Sufficient but not Necessary

Factor A
or
Factor B Disease
or
Factor C

Leukemia = Exposure to radiation OR benzene

 A,B,C are not necessary needed but
sufficient in the development of a disease

smoking

Asbestos Lung Ca
fiber

Radon gas
4. Neither sufficient nor necessary
(contributory causes)

Factor A + Factor B
or
Factor C + Factor D Disease
or
Factor E + Factor F

Most accurately represents causal relationships in most

chronic diseases
END OF DAY 1
 Plenary day 1
• Please refer to the plenary day 1 slides
DAY 2
MODULE-1
• Determinants of morbidity
and mortality in a population
• Natural history of the
disease
• Diseases prevention
 DAY 2

• Natural history of the

disease
• Disease prevention
 Natural History of Disease
• Natural history of disease:
progression of disease in an
individual over time WITHOUT
any intervention.
NATURAL HISTORY OF THE
DISEASE

 Four stages
 Stage of susceptibility (population at risk)
 Stage of pre symptomatic (asymptomatic)
disease
 Stage of clinical (symptomatic) disease
 Stage of disability

 Everydisease has difference natural

history (example: HIV/AIDS, DHF)
 STIMULUS RESPONSE

PROCESS
 

Prepathogenesis period + pathogenesis period

• Agent +,
• Host
• heredity
• predisposition Disease +
• Environment
• physic, economy,
• social, culture

·      
 
Terms in Natural History of Disease

• 1. Disease stimuli is the interaction between host,

agent and environment which trigger the
develompment of disease  disease determinant
model/theory

• 2. Pre-patogenesis period: a period from there is

a disease stimuli to body response
• 3. Patogenesis period: a period from body
response to cure or death
 Stage of susceptibility
(population at risk) =Pre-
pathogenesis
Determinants (risk factors) (+), disease (-)
• Tired
• High cholesterol, high sugar, low fiber
• Smoking
• Multiple partners with unprotected sex
• Sharing needle
• Low physical activity
PATHOGENESIS PERIOD
• From the beginning of disturbance in the body because of
the interaction between disease stimuli to
•Convalescence /cure /recovery
•Death
•Impairment
•Disabled

• Three phase:Periode pathogenesis dapat dibagi menjadi

• subclinical
• clinic
• convalescence  
 Stage of pre symptomatic
(asymptomatic) disease

Disease (+), signs (+/-) symptoms (-)

• Aterosclerotic
• Antibodi (+)
• Pre-cancer lesion
• Lab marker >>>
– Uric acid, fasting glucose, LDL >>, creatinin
>>
 Stage of subclicinical disease
Similar to presymptomatic phase

• The disease not yet develop clinically

signs and symptoms still negatif
there are changes in cell structure and
function

•
“below the level of the clinical horizon”
 
 

Stage of clinical disease)

 The changes that happen in the

body are enough to make disease
develop

 Acute phase and Chronic phase

 Stage of clinical
(symptomatic) disease
Disease (+), signs and symptoms (+)
Anatomical & functional changes (+)
Grouping:
1.Symptoms
2.Functional class
3.Localisation
4. Morfologic/ cell type
5. Theraphy
Ex:
• Cancer stadium
• Hearth disease 
– Functional class
High relationship
– therapy

REASON OF THE GROUPING:

1.Therapeutic reason
2.Epidemiological reason (homogenity,
specific rate)
 Stage of disability

Disease outcome
1.Total recovery (treatment, self limited)
2.Partly recovery
3.Scuele (+); disability
1. Physical (anatomical)
2. Social
3. Phsycological
PREPATOGENESIS PATOGENESIS

Agen Host Fase klinis

Sembuh
Cacat
Lingkungan Fase penyembuhan Mati
Kronis

Fase susceptible Fase subklinis

Perjalanan Alamiah Penyakit 64

 Natural history of disease
TIME
Death

Infection Clinical disease

Susceptible
host Recovery

No infection

Incubation
Latentperiod Infectious Non-infectious

Exposure Onset
NATURAL HISTORY (PERJALANAN
PENYAKIT)
Meninggal
Contoh: Symptomatic
hepatitis stage Khronis

Carrier
Sembuh
Asymptomatic dengan cacat
stage Sembuh
tanpa cacat
 THE NATURAL HISTORY OF A DISEASE
STIMULUS to
HOST REACTION RECOVERY
the HOST
interrelation of
Agent, Host and Latent Period (Pre- Symptoms, with or without Defects,
Environmental symptomatic) Signs(Clinical) Disability
factors

PREPATHOGE
PERIOD OF PATHOGENESIS
NESIS

Health
Promotion Disability Limitation
Early Diagnosis and Prompt
Specific
Treatment,
Protection Rehabilitation

PRIMARY SECONDARY
TREATMENT TERTIARY PREVENTION
PREVENTION PREVENTION

(Leavell's Level of Application of Preventive Medicine)

 Perjalanan infeksi HIV
1000
Viral Load
Jumlah CD4
Jumlah CD4

200
Infeksi Akut Infeksi asimtomatik Simptomatik/AI
Window period DS
Serokonversi
0
Bulan 0 1 2 3 4 Tahun
5 1 2 3 4 5 6 7
Prevention can be done when
determinants and natural history of
the disease are understood
LEVEL OF PREVENTIONS  IN BROAD
CONCEPT
 Primary prevention
 Health promotion
 Behavior change education
 Policy/regulation
 Specific protection
(specific to a certain disease)
 Secondary prevention
 Early detection and
prompt treatment/action

 Tertiary prevention Prolonging

 Disability limitation life/increase
 Rehabilitation quality of life
 Medical
 Psychological
 Social
 Economical
DAY 3
 Using Blum Model/Concept
Genetic Physical
Social, cultural Stage
Environment
Biological, economical of
Behavior dis-
Clinical
Health Services
Presym- stage ability
tomatic
Susceptible stage
(at risk)
Tertiary prev.
Secondary prev. • Disability
Primary prevention
• Early detection limitation
• Health promotion & prompt
• Rehabilitation
• Specific protection treatment
Natural History of Disease and
Level of Prevention
Riwayat Alamiah Penyakit 76
 LIMA TINGKAT PENCEGAHAN
Riwayat Alamiah Setiap Penyakit
Interaksi Agen, Pejamu dan Lingkungan  Reaksi pejamu terhadap RANGSANGAN PENYAKIT ->
Faktor  RANGSANGAN PENYAKIT
Patogenesis  Kerusakan  Penyakit  Konvalesens
awal awal jaringan lanjut
Periode Prepatogenesis Periode Patogenesis

Promosi kesehatan

Pendidikan kesehatan Perlindungan khusus

Gizi yang cukup sesuai dengan
perkembangan
Perumahan, rekreasi dan tempat
kerja
Perkembangan kepribadian
Konseling perkawinan dan
pendidikan seks
Genetika
Pemeriksaan kesehatan secara
berkala
Imunisasi
Kebersihan perorangan
Sanitasi lingkungan
Perlindungan terhadap kecelakaan
akibat kerja
Perlindungan terhadap kecelakaan
Penggunaan gizi tertentu
Perlindungan terhadap zat yang
dapat menyebabkan kanker
Menghindarkan zat-zat allergen
Diagnosis dini dan pengobatan Rehabilitasi
segera
Penemuan kasus, individu dan masal Pembatasan ketidakmampuan Penyediaan fasilitas untuk pelatihan
hingga fungsi tubuh dapat
dimanfaatkan sebaik-baiknya
Skrining Pengobatan yang cukup untuk Pendidikan pada masyarakat dan
menghentikan proses penyakit dan industriawan agar menggunakan
Pemeriksaan khusus mencegah komplikasi mereka yang telah direhabilitasi
Tujuan: Penyediaan fasilitas untuk Penempatan secara selektif
Menyembuhkan dan mencegah membatasi ketidakmampuan dan
penyakit berlanjut mencegah kematian Mempekerjakan sepenuh mungkin
Mencegah penyebaran penyakit Terapi kerja di RS
menular
Penggunaan koloni yang terlindung
Mencegah komplikasi dan akibat
lanjutan

Memperpendek masa ketidakmampuan

Pencegahan primer Pencegahan sekunder Pencegahan tertier
Tingkat Penerapan Upaya Pencegahan
FASE PREPATOGENESIS FASE PATOGENESIS

FASE SUSCEPTIBLE FASE PRESIM- FASE CLINICAL FASE

TOMATIS 1.Early DISABILITY
Masyarakat Umum, Remaja,
ncubation period 2. Late
PUS 1.CRONIC
Virus enter yjr
human body 2.DEATH
HIV AIDS

HEALTH SPECIFIC EARLY DISABILITY

PROMOTION PROTECTION LIMITATION REHABILIT
1.HIV/AIDS DETECTION
EDUCATION 1.ARV ATION
2.DRUGS 1.CONDOM AND PROMT 2 TREATMENT
FOR OI 1.STOP
EDUCATION USE
3. 2.NEEDLE TREATMENT 3. FISIOTHERAPY TRANSMISSION
REPRODUCT PROGRAM 1.KLINIK vct
2.SUPPORT
IVE HEALTH 2.PENGOBATAN GROUP
ARV 3.COUNSELLING
4.Social

PRIMARY PREVENTION SECONDARY TERTIARY PREVENTION

PREVENTION
• ICE-BERG PHENOMENA
• SEVERITY OF DISEASES
 ICE BERG PHENOMENA
(FENOMENA GUNUNG ES)
 TWO CONSEQUENCIES
(DUA KONSKUENSI)
Semakin lebar dasar gunung es:
• Semakin sulit penanggulangan penyakit
(control of the disease)
• Bila memakai data sekunder, data
(statistik penyakit) akan semakin tidak
akurat
CONTOH: DBD dan RABIES
 Epidemiological Iceberg
• Only the tip of the iceberg is
easily observable
• Dog bite example
– 3.73 dog bites annually
– 451,000 medically
treated
– 334,000 emergency
room visits
– 13,360 hospitalizations
– 20 deaths
THE VARIATION OF SYMPTOMATIC
DISEASES SEVERITY
100 CASES

Mild (ringan) Moderate

Severe
Fatal
 DIFFERENCES BETWEEN
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

1. Focus: population 1. Focus: individual

2. Responsibilities: 2. Responsibilities:
all people in certain all people who come
geographical area, health and to the health facilities.
sick, those who come and They usually passive.
those who do not come to
health facilities. They must
actively provide diseases
prevention to all people who
are at risk
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

3. Function: to mobilize all 3. Function:

stakeholders and using to cure and to
management principles to increase the
plan, implement and
patient’s quality
evaluate primary,
secondary, tertiary of life
preventions
4. Place of works: health 4. Place of works:
centre, heath department, private practices,
community clinics, etc hospitals, etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

5. Diagnostic tools: 5. Diagnostic tools:

epidemiology, statistics, stethoscope, ECG, lab
demography examinations kits , CT
Scan, etc
6. Diseases 6. Diseases
measurements in the measurements for
community: individual patient: level
proportion, prevalence, of blood pressure, blood
incidence, ratio sugar, level of
hemoglobin, etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

7. Treatment at the 7. Treatment for

community level individual patient
(prevention): public (diagnosis and
health program such as care):
education program, medical
immunization program, treatments,
nutrition program, surgery,
family planning radiation,
program, etc physiotherapy,
etc
PUBLIC HEALTH DOCTOR CLINICAL DOCTOR

8. Indicators for 8. Indicators for

evaluating community evaluating the result
health program: percent of patient’s
treatments:
decrease of under
decrease of blood
nutrition, percent pressure of the
increase of contraceptive individual patient,
use for family planning, increase of
etc hemoglobin
“FIVE STARS DOCTOR”
(WHO = World Health Organization)
 Care provider (clinical dr)
 Communicator (clinical & PH dr)
 Manager (PH dr)
 Community leader (PH dr)
 Decision maker (clinical & PH dr)
Learning Outcomes:
a) Describe several determinants (models)
of diseases and death occurring in the
population
b) Explain the applications of
understanding diseases and death
determinants (models)
c) Identify the strengths and weaknesses of
diseases models
d) Draw figure of the natural history of a
certain disease
e) Explain the applications of the natural
history of a disease for prevention
f) Explain the severity of diseases in a
population and its implication to
prevention
g) Describe the level of disease prevention
based on determinants and natural
history
h) Explain the Ice Berg Phenomenom and
its implication in diseases prevention
 Model Segitiga (The Epidemiologic Triad/
Triangle)
HOST (intrinsic)
(age, sex, genotype, behaviour, nutritional
status)

AGENT ENVIRONMENT
(biologic, physic, mechanical, (Physical, Biological, Social)
chemical, nutrient)
Model Roda (Wheel Model)
INTERNAL
(intrinsic)

Social
Biological HOST • politic,
Environ- Genetic • economic
ment • culture

Physical Environment

EXTERNAL (extrinsic)
 BLUM MODEL
Genetic

Morbidity and
Behavior Health
mortality in
services
a population

Environmental factors
(biological, physical, social, economical, politic)
 Socioeconomic determinants

Maternal Environmental Nutrient

Injury
factors Contamination deficiency

Healthy Sick

Prevention
Treatment
Personal
Illness Growth
control Mortality
faltering
 SOAL-SOAL
PEMANASAN
SEBELUM UJIAN
As shown in the film ”And The Band Played On”
which was presented to you, there were several
sciences involved in investigation the cause of AIDS.
Those sciences are:

A. Social, economic, politic, epidemiology, statistic,

virology, clinical medicine
B. Social, politic, epidemiology, statistic, virology,
clinical medicine, health education
C. Social, epidemiology, statistic, virology,
clinical medicine, health education
D. Clinical medicine, epidemiology, statistic, social, politic
E. Social science, epidemiology, statistic,
virology, clinical medicine
Dalam film dengan judul ”And The Band Played
On” yang telah Sdr. saksikan pada waktu
pertemuan pertama Blok Community-Based
Practice, ada beberapa metode yang dipergunakan
untuk mengungkapan penyebab AIDS, yaitu:

1. Contact tracing
2. Cohort
3. Case-control
4. Cross-sectional
Bila dilihat dari waktunya, urutan cabang
ilmu yang membantu mengungkapan
penyebab AIDS, yaitu:

A. Paling awal virologi, lalu epidemiologi dan terakhir ilmu klinik

B. Paling awal ilmu klinik, lalu virologi dan terakhir epidemiologi
C. Paling awal ilmu klinik, epidemiologi/statistik/ilmu sosial, lalu
virologi
D. Paling awal virologi, statistik/epidemiologi lalu ilmu klinik
E. Paling awal statistik/epidemiologi, ilmu klinik lalu virologi
Dalam suatu program interaktif yang
membahas topik wabah HIV/AIDS di sebuah
stasiun radio di Bali, banyak pendengar
dengan berapi-api mengatakan melalui
telepon sebagai berikut:

“Lho, kenapa pelacur yang sudah jelas-jelas

dijumpai HIV+ tidak dikarantina. Mereka ..kan
dengan bebas masih menularkan HIV-nya pada
orang lain. Kenapa pada saat terjadi wabah
SARS, yang dicurigai saja sudah langsung
diisolasi?”
Anggota DPRD Provinsi Bali tahun lalu mengatakan
sebagai berikut: “Kami sudah mengalokasikan
dana APBD yang cukup besar untuk
penanggulangan HIV/AIDS di Bali. Kenapa jumlah
orang yang HIV+/AIDS kok terus bertambah
banyak. Harusnya kan berkurang. Kalau begitu
percuma dana yang kami alokasikan tersebut”.

PERTANYAAN: Seandainya Sdr. menjadi petugas

kesehatan, bagaimana Sdr. menjawab pernyataan
anggota DPRD tersebut