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CURRICULUM FOR THE

FEMALE HEALTH SUPERVISORY

IN SERVICE TRAINING

DIRECTORATE OF HEALTH SERVICES THIRUVANANTHAPURAM KERALA 2005

Supported by European Commission Sector Investment Programme

1 A SECTROR INVESTMENT PROGRAMME SUPPORTED BY EUROPEAN COMMISSION

PREPARED BY Dr. J. VIJAYA BHANU PRINCIPAL PUBLIC HEALTH TRAINING SCHOOL THIRUVANANTHAPURAM KERALA, INDIA

2 Trivandrum 08-09-2005

Dear Friends,

Government of Kerala have entrusted Dr. J.Vihayabhanu, Principal, Public Health Training School, Thiruvananthapuram, to develop the curriculum for the Health workers according to the changing needs of People. We are extremely happy to see that he has included almost all health issues existing today and their solution also. Most striking thing is that he has given more emphasis on Non communicable diseases (N.C.D) which will be a major Problem in the coming years. This book can be used for all states of India also for the developing countries. We are thankful to the sector investment and the European Commission for supporting the Project.

Sri.C. Ramachandran Dr.B.Mahilamani Addl. Chief Secretary, H & F.W Director of Health Services Kerala Kerala

3 Sri. K.K. RAMACHANDRAN MASTER MINISTER FOR HEALTH

08.09.2005

MESSAGE I am extremely happy to see that the syllabus of the Health Workers’ Course has been prepared in such a comprehensive way that the trained personnel will be able to deal with almost all the Health problem, that are likely to be faced by the common man. I take this opportunity to congratulate all those who have contributed to bring out this useful book.

(K.K. RAMACHANDRAN MASTER)

4 FOREWORD

Considering the advancements made in the field of science and technology and in all disciplines of medicine it is imperative to update the knowledge and managerial skills of health functionaries engaged in the delivery of health care. It is an accepted fact that technical competence of the of the supervisor leads to success. Moreover it is an important principle that supervision should be a teaching learning process. The contents of this module would considerably facilitate the trainees in improving their managerial skills. This will also help the course facilitators while organizing the training programme. I hope the health administrators and institutions engaged in organising the training course for the Female Health Supervisors will appreciate the efforts behind the preparation of these module and utilize the same effectively. I am appreciating Dr. Vijayabhanu Principal, Public Health Training School Thiruvananthapuram for taking this challenge.

Dr.B.MAHILAMANI (Director of Health Service)

5 PREFACE

Supervision is an art or a process by which designated individual or a group of individuals oversee the work of others and establish control to improve the work as well as the worker. The modern concept of supervision is to guide and help and subordinates in their work by way of training, demonstration, checking, individual counseling and guidance. The effectiveness of workers depend largely on the supervision they receive. In other words quality of work is directly related to the degree of supervision. These modules are prepared after an analysis of the job description, while modifying the curriculum for the female health Supervisory Course in view of the specific objectives, principles and functions of supervision and the qualities of a good supervisor. I am grateful to the Sector Reform Cell of European commission for technical guidance and financial assistance for the valuable endeavour.

Dr. T.K.KUTTAMANI (Addl. Director of Health Services (FW) Kerala)

6 7 INTRODUCTION Training is a conscious effort to fill the gap between the existing and expected levels of knowledge, attitude and practices. Any organized training requires to be done with proper planning with regard to what is to be taught, how it is to be taught and by whom. All this will depend on the training needs. It is therefore, a common practice in all training centres, institutions and university etc. to prepare what is known as curriculum. Curriculum is a design for enabling the learning in a training situation. It is detailed out line plan of the entire training course with a systematic, sequential arrangements of the objectives, the content i.e. The subject or the topics to be taught, the time to be apportioned to different topics, the indication of methods of instructions, and the scheme of examination or evaluation. Curriculum development entails certain specific steps like (1) Job analysis and the study of the job specification. This is done to know the training needs. (2) Setting up of objectives in view of the job description or expectation. (3) Listing of subjects, topics or areas that are essential, sequential arrangement, ranking and prioritization of subjects or topics. (4) The method of instruction of each area or unit to be discussed, evolved and time allotment shall be made with regard to each method of instruction (Theory, discussion practical etc). (5) A scheme of evaluation of trainees and trainers as well. It is needless to say that in any job oriented training the emphasis should be more on the skill development and therefore it should provide adequate opportunity for practical exercises demonstration etc. etc.

8 A study of the job responsibility of LHI reveals that the same vide G.O. (p) 225/83/H&FWD dated 8-8-1983 were redefined vide G.O (p) 254/2003/H&FWD dated Thiruvananthapuram, 9th Dec. 2003, on the basis of the changes in the national Health Programme, changes in the strategies/approaches in health care delivery system by the personnel in the PHC and others institutions. Proper training is inevitable for the supervisory personnel to fill the gap between the existing and expected levels of knowledge, attitude and practices on the basis of a modified curriculum since the same followed for the Female Health Supervisors is about 20 years old. Accordingly I am entrusted with the activities for modifying the same through a series of discussion with Dr. Rajan Gobragale Addl. Secretary (H & FW) to Government, Kerala, the Director of H.S., Addl. DHS, in charge of Sector Reform Cell, Addl. D.H.S. (Planning) District Medical Officer of Health, Trivandrum, a panel of experts in the subjects, programmes & projects members of a faculty of Public Health Training School, Representatives of concerned associations and Union, representatives of Junior PHN’s etc etc with the objective of assessing the details of curriculum modification. Workshops were conducted involving the above personnel. Finally modules of 6 months Female health Supervisory training were prepared with the assistance of panel of experts as resource persons. The Valuable contribution of Sri. Rajan Babu, Jr. Accounts officer, Public health Training School, Thiruvananthapuram for the development of the curriculum is duly acknowledged. The field experience and rich contribution by the trainees of 39th batch of female Health Supervisory training programme is well appreciated.

Dr. J.VIJAYABHANU

9 (Principal, Public Health Training School, Tvm)

ADVISORY BOARD 1. C. Ramachandran .I.A.S, Addl. Chief secretary 2. Dr. Vishwas Metha. I.A.S, Secretary Health H & F.W 3. Dr. Rajan Khobragade. I.A.S, Addl. Secretary H & F.W 4. Dr.B.Mahilamani Director of Health Services 5. Dr.T.K.Kuttamany Additional Director of Health Services (Planning) 6. Dr.Hema Additional Director of Health Services (F.W) 7. Dr.K.R.Thankappan, Addl. Professor and H.O.D Achutha Menon Centre for Health Science Studies, Trivandrum 8. Dr.E.K.Madhavan, D.M.O. of Health, Thiruvananthapuram. 9. Dr.A.P.Sasikumar, State Programme Officer, R.C.H, D.H.S Office, Thiruvananthapuram. 10. Dr.Sandeep.K, Technical Secretary European Commission-S.R.C 11. Sri.K. Rajeevakshan, Registrar, Kerala Medical Council

10 PANEL OF RESOURCE PERSONS 1. Dr.B.Mahilamani, Director of health services Kerala. 2. Dr.T.K.Kuttamani, Addl. Director of Health Services (F.W) Kerala. 3. Dr.K.Raghavan, Addl. Director of health services (planning) Kerala. 4. Dr.E.K.Madhavan, District Medical Officer of Health, Thiruvananthapuram. 5. Dr.K.R.Thankappan Addl. Professor & Head of the Department, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram. 6. Dr.J.Vijayabhanu Principal, public Health Training School, Thiruvananthapuram 7. Dr.J.Padmalatha Epidemologist, Public Health Training School, Thiruvananthapuram 8. Dr. R.C. Nair, Auchutha Menon centre for Health Science Studies, Thiruvananthapuram. 9. Dr. Manju R. Nair., Scientist C (Medical), Achutha Menon Centre for Health Science Studies, Thiruvananthapuram 10. Dr.Biju Soman, Asst. Professor, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram. 11. Dr. Sandeep.K, Technical Secretary European Commission, Sector Reform Cell, D.H.S office 12. Dr.A.P.Sasi Kumar State programme Officer, R.C.H., D.H.S Office, Thiruvananthapuram.

11 13. Dr.V.Mohanan Nair Principal, State institute of H & FW Training centre, Trivandrum 14. Dr. Gigi Asst. Professor, Regional Cancer centre Thiruvananthapuram 15. Dr. Jaya Krishnan, Infertility clinic, K.J.K. Hospital, Trivandrum 16. Dr. Churchin Ben.S.G, Addl. Director of Health Services (Rtd), PM&R)

17. Dr. Suprakasan, Associate professor, Skin & VD, Medical College, Trivandrum 18. Dr. Sunil Kumar.M, T.B.Cell, Trivandrum 19. Mr.Januaries.M, (Rtd), State Training Co-Ordinator Directorate of Health Service & Guest Lecture, FHS, Training Schools, TVM & CLT 20. Mr. T.Selvadas (Rtd), Social Science Instructor, H&FWTC Kozhikkode & Guest Lecturer, F.H.S. Training School, TVM & Calicut. 21. Smt. Sobha Ganesh, Communication officer, P.H.T.S, TVM. 22. Mr. Baijukumar.P, Tutor, P.H.T.S, TVM 23. Smt. T.K.Ammini, P.H.N Tutor, P.H.T.S, TVM 24. Smt. C.K.Krishnamma, P.H.N. Tutor, P.H.T.S, TVM 25. Mr. T.D.Chacko, Technical Officer, D.H.S. Office, Trivandrum 26. Mr. G.Lawrence, Technical Assistant P.F.A, D.H.S Office 27. Mr. Dileep, Biologist, Directorate of Health Services 28. Smt. M. Rosamma, State Secretary, K.G.P.H.N and Supervisors Association 29. Smt. N. Vijayamma, General Secretary, K.G.P.H.N and Supervisors Association 30. Smt. Indiramma, General Scretary, K.G.J.P.H.N and Supervisors Union 31. Smt.Aleyamma Varkey, State Scretary, K.G.J.P.H.N andSupervisors Union

12 CONTENTS

Chapter Topic Page

1 ORDER OF JOB RESPONSIBILITIES 2-63 1.1 Job Responsibilities of Junior Public Health Nurse 1.2 Job Responsibilities of Lady Health Inspector 1.3 Job Responsibilities of Lady Health Supervisor

2. TRAINING 64-69

3. SUPERVISION 70-101

3.1 Supervision 3.2 Supervisory Check-list 3.3 Evaluation and Monitoring 3.4 Team Work 3.5 Leadership

4. MANAGEMENT 102-130 4.1 Management 4.2 Personnel Management 4.3 Management of Conflicts 4.4 Material Management 4.5 Time Management

5. REPRODUCTIVE AND CHILD HEALTH [R.C.H] 131-216

13 5.1 Community Need Assessment and Sub-Centre Planning (C.N.A) 5.2 Universal Immunization Programme (U.I.P) 2.3 Oral Rehydration Theraphy (ORT) 5.4 Acute Respiratory Infection control – Programme 5.5 Vitamin A – Prophylaxis and Control 5.6 Anaemia Control and Prophylaxis 5.7 Essential Care During Pregnancy 5.8 Essential New Born Care 5.9 Baby Friendly Hospital Initiative (B.F.H.I) 5.10 Birth Spacing, Birth Limiting & Birth Timing 5.11 Infertility 5.12 Safe Abortion 5.13 Prevention and Management of Reproductive Tract infections [R.T.I] & Sexually Transmitted Infections [S.T.I] 5.14 First Referral Unit [F.R.U]

6. ELEMENTARY SOCIOLOGY 217-226

7. PSYCHOLOGY AND MENTAL HEALTH 227-259

8. HEALTH EDUCATION AND COMMUNICATION 260-281

9. SCHOOL HEALTH PROGRAMME 282-285

10. ADOLESCENT HEALTH 286-304

11. NUTRITION AND HEALTH 305-356

12. PREVENTION OF FOOD ADULTERATION ACT & P.H ACT 357-360

13. ENVIRONMENTAL SANITATION 361-382

14. ANATOMY AND PHYSIOLOGY 383-408

15. EPIDEMIOLOGY 409-410

16. CERTAIN COMMUNICABLE DISEASES 411-419

17. REVISED NATIONAL TUBER CULOSIS CONTROL PROGRAMME [RNTCP] 420-429

18. NATIONAL LEPROSY ERADICATION PROGRAMME [NLEP] 430-433

19. HIV/AIDS 434-472

20. NON COMMUNICABLE DISEASES [N.C.D] 473-484

21. CANCER-PREVENTION DETECTION CONTROL 485-494

14 22. COMMON SKIN DESEASES 495-501

23. DENTAL CARE AND ORAL HYGIENE 502-503

24. DISABILITY DETECTION & MANAGEMENT & EARLY REFERAL 504-506

25. GERIATRIC HEALTH 507-511

26. GENDER ISSUES 512-520

27. BIO MEDICAL WASTE MANAGEMENT SYSTEM 521-530

28. DISASTER MANAGEMENT 531-544

29. NATIONAL RURAL HEALTH MISSION 545-551

30. PANCHAYAT RAJ 552-554

31. ETHICAL ISSUES RELATED TO ACTIVITIES OF SUPERVISION AND WORKFORCE MANAGEMENT 555-558

32. VITAL STATISTICS 559-565

33. FERTILITY –RELATED STATISTICS 566-568

34. HEALTH INDICATORS OF KERALA 569-570

35. MAINTENANCE OF RECORDS, REPORTS AND REGISTERS 571-599

36. PROJECT WORK 600

37. SOME IMPORTANT DAYS RELEVANT TO HEALTH 601

38. EXPANSION OF CERTAIN ABBREVIATIONS 602-605

15 GOVERNMENT OF KERALA Abstract EUROPEAN COMMISSION SUPPORTED SECTOR INVESTMENT PROGRAMME DEFTNE/REDEFINE THE JOB RESPONSIBILITIES OF MULTI PURPOSE HEALTH WORKERS AND MEDICAL OFFICERS IN PRIMARY HEALTH CARE INSTITUTIONS IN THE KERALA HEALI-H SERVICES'7--APPROVED-ORDERS ISSUED

HEALTH & FAMLY WELFARE (FW) DEPARTMENT

G.O.(P) No. 254/2003/H&FWD Dated, Thiruvananthapuram, 9th December, 2003 Read:--G. 0. (P) 225/83/H&FWD dated 8-8-1983").

ORDER As envisaged in the European Commission-Sector Investment Programme Project Document and in suppression of the Government Order read above, Government are pleased to approve the "Define/Redefine the Job Responsibilities. of Multi Purpose Health Workers and Medical Officers in Primary Health Care Institutions in the Kerala Health Services" appended to this order.

By order of the Governor,

E. K. BHARAT BHUSHAN,

Secretary to Government To Shri S. C. Srivastava, Director (DC), Government of India, Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi (with covering letter). Mr. Indrajit Pal, Programme Advisor, ECTA Office, D-127, Panch Shed Enclave, New Delhi-110 017. (with covering letter) The Director of Health Services/Additional Director of Health Services (FW), Thiruvananthapuram. The Technical Secretary (SRC). All District Medical Officers. All Medical Officers in Public Health Centres. Stock File/Office Copy.

1 GCPT. 3/146/2004/DTP.

Chapter-1 ORDER OF JOB RESPONSIBILITIES 1.1 JOB RESPONSIBILITIES OF JUNIOR PUBLIC HEALTH NURSES (Jr. PHNs) The Female Health Workers or Junior Public Health Nurses (JPHNs) as they are known in Kerala, are expected to provide comprehensive primary health care to the community. The gamut of services they are expected to provide under Multi purpose Health Worker (MPW) scheme is very wide -and encompasses promotive, preventive and curative services. They are neither trained nor intended to work as full time curative service providers. They are basically trained as field oriented functionaries. A JPHN can work attached to a Primary Health Care institution and be involved in field activities. They can be deployed for in-patient and out patient services only if such services are integral components of primary health care activities or those under National Health Programmes like contraception, immunization etc. JPHNs have both institutional and field responsibilities. Their institutional responsibilities include activities in subcentres from where they operate. Their field level activities are related to specified population or geographic areas as-signed from, "time to time. Normally they will be assigned 3,000 to 8,000 population depending on the density of population of the area and its geographic terrain. The area assigned jointly to a 'male and female worker constitutes a "subcentre area". Both workers will be operating from a subcentre situated in the service delivery area. A committee viz. "Subcentre Committee" should be constituted to help, guide and monitor the functioning of the subcentre, which the local Grama Panchayat ward members as Chair person and JPHN as convener. The members of the committee should be as per the guidelines issued from -time to time. The committee should meet at least once in two months. It will support the subcentre in its smooth and effective functioning. The committee should support the subcentre in activities like C.N.A selection and

2 motivation of beneficiaries and in the implementation of health programmes and other activities. The JPHN should maintain written minutes suggested action taken in the meetings of such committee.

Field Level Activities

For the ease of discharging duties, area assigned to the grass root level workers viz. the male and female workers may be divided in to 40 "Day Blocks". A "Day Block" is the field area to be covered by, a health worker in a day's fieldwork. Earlier the service area of a subcentre used to be divided in 20 "day blocks". Taking in to consideration the demographic changes that have occurred over the past two decades, the area to be covered in day's fieldwork may be reduced to half of its previous dimension and hence the earlier 20 day blocks to be re-organized in to 40. A worker should cover 20 such day blocks in a month so that the whole area may be covered in 2 months. Field visits should be planned in such a way that her male counter part (JHI) is involved in field activities in the other half of the area. Thus if a JPHN is involved in the field activities in-a-day blocks 1-20 during a month, the concerned JHI from the subcentre is expected to cover the day blocks from 21 to 40. This should be reversed during the succeeding month so that each household in the area is visited by a health worker (either male or female) every month and each worker visits all the households in their area in two months time. 1. FIELD VISIT 1.1 Area- Designated area under a subcentre. This may be redefined and as when necessary. The whole population under the designated area may be considered as her beneficiaries; Irrespective of the residential status whole population in the area should be provided services. Any individual who is a normal resident in the area for more than six months will be considered a "regular beneficiary", for her service provision. This definition of "regular beneficiary" need not deter her from providing services to others who don't qualify to be regular beneficiaries". They should also be provided services and reported accordingly. Whoever is provided service, irrespective of their beneficiary status; should be reported and accounted for.

3 1.2 Visit- At least one visit, once in two months to each household, in the area allotted. 1.3 Reporting- To the concerned medical officer through their Multi purpose supervisors. In the case of Block Primary Health Centres and Community Health Centres the reports should be routed through the Health Supervisors or Lady Health Supervisors. 1.4 Supervision- Being multipurpose health workers, JPHNs should be supervised by female multipurpose supervisors viz. Lady Health Inspectors and Lady Health Supervisors. 2. MAINTENANCE OF RECORDS AND REGISTERS 2.1 Family and Village Survey-Comprehensive survey of all households in the subcentre areas should be conducted during specified period. Such data should be updated from time to time. Periodicity of such updating will be specified from time to time by authorities. -The responsibility of survey should be shared by male and female workers and a single updated database on the area should be maintained in the subcentre, which may be used by both the workers. All households that qualify to be "beneficiary households" are to be separately registered. The subcentre should also collect details. about migrant or nomadic population present in the area, houseless dwellers and individuals on visit to the area. These groups . should be constantly followed up. Once they exceed their stay in the area for more than six months they should also be considered regular eligible beneficiaries. 2.2 Family and Village Records-A copy of the family and village record should be maintained in the subcentre and utilized by both the male and female workers for planning activities. This may be prepared and updated through joint effort. 3. REPRODUCTIVE AND CHILD HEALTH (RCH) SERVICES RCH programme envisages "client centred, quality oriented, demand driven services provided with full community participation and based on "life cycle approach". Subcentre is the key institution in provision of such services. The programme implementation plan of RCH project clearly defines the services to be made available through the subcentres. Here also subcentre is considered as a unit having two grass root

4 level workers- one male and one female. Essential services to be provided at the subcentre and community levels under-this programme are as follows:

ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SEREVICES AT

COMMUNITY AND SUBCENTRE LEVELS Health Intervations Community Level Subcentre level Preventation and 1. Sexuality and gender 1. Sexuality and gender information management of information, education and education and counseling unwanted pregnancy counselling. 2. Providing Oral Contraceptives (OCS) and 2. Community mobilization and condoms education for adolescents, newly 3. Providing IUD after screening for contra- married youth, men and women. spective-indications 3. Community based 4. Counseling and early referral for medical contraceptive distribution termination of pregnancy ( through Panchayaths Village 5. Counseling/ management /referral for side health Guidance, Mahila Swastiya effects, methods-related problems. Change of Sangham, etc, with follow up) method where indicated 4. Motivating referral for 6. Add other methods to expand choice sterilization 7. Providing treatment for minor ailments 5. Social marketing of condoms and referral for problems and oral pills through Community sources and G.P. (oral [pills to be distributed through health personnel including Gps to starting pills for the first time) 6. Free supply of condoms st the community level. Through depot Maternity Care holders etc. 1. Awareness raising for importance of appropriate care during pregnancy & 1. Awareness raising for identification of danger signs Importance of appropriate care 2. To mobilize community support for during pregnancy & identification transport, referral and blood donation of danger signs 3. Counselling/ education for breast-feeding, 2. To mobilize community nutrition, family planning, rest, exercise & support for transport, referral and personal hygiene etc. Early detection and

5 blood donation referral of high risk pregnancies 3. Counseling/ education for 4. Three Antenatal contacts with women breast-feeding, nutrition, family either at the Subcentre or at the outreach planning, rest, exercise and village sites during immunization/MCH personal hygiene etc. sessions. 4. Early detection and referral of 5. Early detection of High risk factors & high risk pregnancies maternal complication and prompt referral. Delivery planning 6. Refferal of high-risk woman for * The need for IEC support and Institutional Delivery. establishment of first referral 7. Treatment of Malaria (facilities including facilities. Drugs to be made available at centre.) Prenatal Care 1. Early recognition of Pregnancy and it’s 1. Early recognition of danger signal (rupture of membranes of more Pregnancy and its danger signals than 12 hours duration. Prolapse of the cord, (rupture of membranes of more hemorrhage) than 12 hours duration. Prolapse 2. Conducting clean deliveries with delivery of the cord, hemorrhage) kits by trained personnel 2. Conducting clean deliveries 3. Detection of complicated referral for with delivery kits by trained hospital delivery personnel. 4. Providing transport for referral 3. Detection of complicated 5. Supervising Home Delivery referral for hospital delivery. 6. Prophylaxis & Treatment for Infection 4. Providing transport for (Except sepsis) Delivery services referral. 7. Routine Prophylaxis gonococcal eye infection

1. Breast Feeding Support 2. Family Planning Counseling 1. Breast-Feeding Support 3. Nutrition Counseling 2. Family Planning Counseling 4. Resucitation for asphyxia of the New Postpartum services 3. Nutrition counseling Born 4. Resucitation for asphyxia of 5. management of Neonatal Hypothermia the New Born 6. Early recognition of post partum sepsis 5. management of Neonatal and referral hypothermia 7. Referral for Complications Giving Inj Early recognition of post partum Ergometrine after delivery of placenta. sepsis and referral

6 JPHNs are excepted to assign more importance to service and children. For this purpose should provide some specific service and maintain specific records and registers. 3. REGISTRATION

3.1.1 Register (a) Women in the reproductive age group(15 to 45 years of age) (b) All pregnant women in her area as early as possible during pregnancy (c) All. Post menopausal women in the area (d) All Infants and children through home visits and clinics. Separate list of children of age less than one year and less than 5 years may be maintained. (e) All adolescents, sex -wise in the area. 3.1.2 Maintain a. Eligible Couple Register (Common for both the workers) b. Mother and Child Register c. Register of Contraceptive acceptors- by methods 3.1.3 Categorize the Eligible Couple according to the number of children and age of mothers. 3.2 Field level services JPHN should render the following services. 3.2.1 Render care to pregnant women through out -the period of pregnancy (vide guidelines). 3.2.2 Give advice on nutrition to expectant and nursing mothers. 3.2.3 Distribute Iron and Folic acid tablets to eligible beneficiaries. 3.2.4 Distribute Vit. A drops or syrup. 3.2.5 Immunize pregnant women with Tetanus Toxoid. 3.2.6 Test urine for albumin and sugar and estimate Hemoglobin percentage 3.2.7 Identify high-risk cases and refer them early. 3.2.8 Attend to deliveries in-the area, if so requested. Prefer institutional delivery and refer accordingly. 3.2.9 Supervise deliveries conducted by dais when called in. 3.2.10 Refer cases of difficult labour to institutions and render follow up care. 3.2.11 Refer newborns with abnormalities to .institutions and follow them up.

7 3.2.12 Provide at least three post delivery visits to each mother and render necessary advice (vide RCH guidelines). 3.2.13 Contact eligible couples, educate and motivative them for accepting family welfare methods 3.2.14 Distribute conventional contraceptives. 3.2.15 Provide follow-up service to acceptors and identify complications and failures and provide service or advice. 3.2.16 Assess growth and development of infants and take necessary actions. 3.2.17 Provide advise to- peri -menopausal and post menopausal women. Sensitize them regarding common malignancies among women and motivate them for periodic check up and screening for these conditions. 3.2.18 Provide counseling services to the adolescents. Monitor the girl children for anaemia. malnutrition and take corrective steps. Arrange sessions to provide sex education and family education to this group of beneficiaries Care at the Clinic. JPHN should render the following services 3.2.19 Arrange and assist the Medical officer in various RCH clinics 3.2.20 Conduct Antenatal and immunisation clinics in the subcentre on a regular basis. Routine examination, weight recording, checking the blood pressure, urine examination, haemoglobin estimation and per abdominal examination may be done in all pregnant women attending these clinics. SERUM VDRL and, HBs Ag testing may be done in all pregnant women. Periodicity of such examination may be decided as per the guidelines issued in the RCH programme or as modified from', time to time. Details of such examinations may always be documented. Proper entries to be made in the "Mother and Child register" and the beneficiary to be provided a copy of such examination findings and details of services provided. 3.2.21 Educate mothers individually and in groups regarding family health, M.C.H., family planning, nutrition, immunization, personal hygiene etc. 3.2.22 Conduct adolescent counseling sessions, distribute Iron and folic acid tablets.

8 3-3 Care in the community JPHN should render the following services at community level. 3.3.1 Spread the message of small family concept and of family welfare to the community and motivate the eligible couples to adopt the small family norm. 3.3.2 Identify local leaders and educate them and utilize their services for implementing RCH programme. 3.3.3 Distribute contraceptives and setup depot holders for contraceptive distribution. 3.3.4 Participate in Mahila Samajam meetings and utilize the occasion for educating women. 3.3.5 Render necessary assistance to voluntary workers and organizations involved in health and family welfare activities. 3.3.6 Organize and conduct meetings of Mahila Swasthya Sanghs (MSS) and provide guidance and supervision to these voluntary workers in health activities. 3.3.7 Utilize satisfied customers and village leaders for promoting family welfare methods. 3.3.8 Provide regular follow up services to contraceptive acceptors for early detection of complications. 3.3.9 Provide prompt services to any complication following contraception. Make timely referral under report to the medical officer through supervisors 3.3.10 Participate in training of Dais when required. 3.3.11 Impart training to voluntary workers, MS.S workers and Anganwadi Workers when required 4. NUTRITIONAL SERVICES 4.1 Identify cases of malnutrition among children and refer them to feeding centres or P.H. Centres for nutrient supplement or treatment. 4.2 Distribute iron and folic acid tablets to eligible beneficiaries. 4.3 Administer Vit.A drops or syrup to children. 4.4 Visit Balavadis, Anganwadis under the ICDS programme and other feeding centres under other departments and provide support and supervision. 4.5 Educate families about nutritious diets and method of preparing food without loss of nutritive value.

9 4-6 Conduct nutrition education sessions, orientation sessions to women and adolescents and help other departments in arranging camps and nutrition education sessions. 5. IMMUNISATION 5.1 JPHNs should be responsible for maintenance of cold chain at all levels of service provision. They may discharge duties as per the instructions of Lady Health Inspectors and Lady Health Supervisors and other superiors in maintenance of cold chain, upkeep of vaccines and other related activities. 5.2 JPHN attached to the main centre should do the temperature recording of ILR and all other activities related to vaccine storage. She may help the LHI in maintaining stock and distribution of vaccines. She may also render support in maintenance and utilization of ice-packs, vaccine carries, day carriers and any other accessory for vaccine storage and distribution. 5.3 Administer vaccines against Vaccine Preventable Diseases (VPDs), as and when supplied with instructions. 5.4 Assist in organizing immunisation camps and in school immunisation. 5.5 Conduct immunisation clinics in the subcentre or at fixed places in subcentre area. At least monthly sessions may be arranged in such manner. It is preferred to have fixed day “out reach sessions". 5.6 Educate the community about the importance and procedures of immunisation and encourage community participation in immunization programmes. 5.7 Organize and conduct special immunisation sessions as and when necessary. This will include sessions like National Immunisation Days -(NIDs) as in "Pulse Polio" immunisation, "Mop up rounds" etc 5.8 Help to arrange immunisation sessions for other vaccine preventable diseases that are not currently included in the government immunisation schedule. Examples are vaccination against Hepatitis-B, Meningitis etc. 5.9 Keep abreast with the latest developments in immunisation and spread the message. Render support to individuals and organisations coming forward for immunisation against any VPDS. 6. IMPLEMENTATION OF HEALTH PROGRAMMES

10 JPHN should be responsible for the following services. 6.1 Take blood smear of any fever case that she comes across during house visits and give presumptive treatment. The blood smears may be handed over to the male Health worker. 6.2 Enquire about persons with chest symptoms, particularly cough of more than two weeks duration and direct them to the nearest sputum examination centres. 6.3 Administer DOTS and arrange for DOTS providers for TB patients RNTCP. Ensure follow up of patients enrolled for treatment. Help to trace defaulters of treatment and bring them back to medical treatment. 6.4 Provide health education about prevention, detection and treatment of Tuberculosis with emphasis on DOTS. 6.5 Identify persons having suspicious patches or anaesthetic patches and direct them to S.E.T. Centres, medical officers or to visiting medical team during "Pulse circuit". 6.6 Assist to collect or collect cervical smears for cancer detection when instructed. 6.7 Sensitize females about the common forms of cancers among them and educate them on early detection and timely care seeking. 6.8 Any other duties or functions in respect of implementation of any other health programmes as arid when instructed by authorities. 7. HEALTH AND FAMILY WELFARE EDUCATION

7-1 Educate community about health and diseases personal hygiene, prevention of diseases and promotion of health.

Conduct health and Family Welfare education through personal interviews, group discussions. 7-2 Assist in conducting film shows and health and family welfare education activities. 7-4 Assist in special programmes of education for specified purposes. 8 CONTROL OF COMMUNICABLE DISEASES 8-1 Notify notifiable diseases and other diseases of public health importance. 8-2 Assist in carrying out control measures like anti-cholera inoculation, chlorination,

11 distribution of ORS, DDT spraying, mass survey etc. 8-3 Exchange information about communicable diseases with the male Health Worker. 9. PROVISION OF CURATIVE SERVICES 9.1 Render services in the management of sick persons including treatment of minor ailments and render first aid to the extent to which she is trained and permitted. 10. NATIONAL DISEASE SURVEILLANCE PROGRAMME 10.1 Assist in the implementation of National Diseases Surveillance programme as per guidelines issued. 11. VITAL EVENTS 11.1 Enquire and record births and deaths and give. information about deaths to the Health Worker or Health Inspector. 11.2 Provide information about births/deliveries to the Registrar of Births and Deaths. 11.3 Educate community about the importance of registration of births and deaths, and about procedure for Registration 12 SCHOOL HEALTH 1.2.1 Assist in organizing and conducting Medical Examination of School children. 1.2.2 Assist in organizing and conducting School immunization sessions. 1.2.3 Conduct health education talks to pupils of the schools of the area. 13. ENVIRONMENTAL SANITATION 13.1 Render and co-operation for implementation of environmental sanitation pogrammes. 13.2 Educate community about the importance and significance of environmental sanitation. 14. MEDICAL TERMINATION OF PREGNANCY 14.1 Render assistance and guidance of those requiring Medical Termination of Pregnancy (vide services under RCH programme) & Act 14.2 Educate women on the availability of services for medical termination of pregnancy. 15. OTHER RESPONSIBILITIES

12 15.1 Identify the elderly in the area and keep a list of all persons above 65 years of age Collect details about the common ailments among them and provide services to the extent possible. 15.2 Identify cases of Hypertension and Diabetes mellitus in the community. Provide health education about prevention, detection, timely and proper management and complications of such diseases. 15.3 Help in the implementation of mental health prograrmne and provide health education on early detection and treatment of such problems. Assist in follow up and community rehabilitation of the mentally ill.' 15.4 Provide health education about other life style related diseases. 15.5 Provide health education about- Reproductive Tract Infections, Sexually Transmitted Infections, HIV and AIDS. (Vide RCH guidelines). Help in early detection of such diseases and fetch the victims counseling and medical support, 15.6 Detect cases of Cataract and other causes of blindness and fetch them medical help. Provide health education regarding care of eyes, causes of blindness and other services available wider the National Programme for control of blindness. Provide sufficient information and support to those willing for "Eye Donation.. 15.7 Maintain a list of all the physically challenged persons in the area. Provide them with support on-rehabilitation. 15.8 Any other duty authorities by authorities from time to time. 16. STAFF MEETINGS AND CONFERENCES 16.1 Attend staff meetings and conferences at PHCS, Block Offices or Panchayat Offices or at any other places or occasions as and when required or instructed. 16.2 Attend the sectoral and project level meetings of the ICDS. Render continuing education sessions to the Anganwadi workers in the sectoral meetings. Collect and consolidate the Monthly Monitoring Reports of the Anganwadi Workers of their field area and pass it on -to the primary health centre through their superiors. 16.3 Hold regular meetings of the MSS and other voluntary workers and enhance their participation in health care activities. 17. REGISTERS AND RECORDS The JPHNs should- maintain the following registers

13 1. General Information Register 2. Family Health Survey and follow up register with an index. 3. Community Education Register. These three registers are common to both the male and female health workers 4. Mother and Child Register. 5. Contraceptive Acceptance and follow up register. 6. Stock Register. 7. Issue register of contraceptives to individual couples. 8. Daily case register for clinics and treatment of minor ailments. 9. Daily abstract of activities, area maps, progress charts. 10. Field Dairy. 11. Instruction Book. 12. Inspection Book Any other register required by specific programmes

18. ON CALL SERVICES Should be available as 24 hour on call duty during medical or public health emergencies or if requested by higher authorities 19. ANY OTHER DUTY ASSIGNED BY AUTHORITIES FROM TIME TO TIME JOB RESPONSIBILITIES OF MULTI PURPOSE HEALTH WORKER (MALE) JUNIOR HEALTH INSPECTORS (JHIS) Multipurpose Health Worker- Male (Junior Health Inspector in Kerala) is one of the two staff members of a subcentre - the grass foot level facility to provide comprehensive primary health care to the community. This level of institutions and these two grass root level workers are the first level of contact of community with the formal health care delivery system of the State. The gamut of services a male health 'worker is expected to provide under the Multi purpose Health worker scheme is very wide; and

14 encompasses promotive, preventive and curative services. They have public health responsibilities also. Male Health Workers have both institutional and field responsibilities. Their Institutional responsibilities include activities in the subcentre from where they operate and field activities are related to specified population of geographic areas assigned from time to time. Normally they will be assigned 3,000 to 8,000 populations depending on the density of population of the area and geographic terrain of the area. 1. Area, Periodicity of visit and Reporting 1-1 Area- Area and population to be covered may be specified from time to time 1-2 Visit- At least one visit in two months to each household in the area allotted 1-3 Reporting - To the concerned medical officer through his supervisors. 2. Maintenance of Family and Village records 2.1 Family and Village Survey-Survey all families in the allotted area and collect generalinformation about each family, village and locality of the area:. This should be completed by joint effort of both the JHI and JPHN. 2.2 Family and Village Records- Along with the JPHN, prepare and maintain and utilize family records and village registers containing particulars about Family Planning Immunisation, Vital events, Environmental Sanitation, local health problems Educational activities, services rendered, achievement etc. 3. Implementation of National Health Programmes 3.1 National Malaria Programme 3-1-1 May identify Fever cases 3.1.2 Make thick and thin smears of blood from patients 3.1.3 May give presumptive treatment 3.1.4 Despatch blood smears to the laboratory twice a week by post or personally. 3.1.5 Record results of examination of blood smears. 3.1.6 Should collect contact smears and mass survey smears when positive case is detected. 3.1.7 Arrange in focal spraying. 3.1.8 Assist or arrange for radical treatment of diagnosed Malaria cases. 3.1.9 Collect follow-up Smears.

15 3.1.10 Educate community on the importance of blood smear examination of fever cases, insecticidal spraying and treatment of malaria cases 3.2 Revised National Tuberculosis Control Programme 3-2-1 Enquire about persons with chest symptoms particularly cough lasting for, more than two weeks duration and direct them to PH centre. 3.2.2 Create awareness regarding the importance of sputum examination and direct the symptomatic patients to microscopy centres. 3.2.2.1 Help in the provision of Directly Observed Treatment Short Course (DOTS) and in arranging DOTS providers.. 3.2.3 Help those under treatment to continue and complete treatment. 3.2.4 Follow up the cases on direction from the by the Medical Officer-Help to trace defaulters of treatment and bring them back for treatment. 3.2.5 Conduct -BCG vaccination when required. 3.2.6 Any other responsibility regarding TB Control as and when instructed. 3.2.7 Educate public about prevention, detection and treatment of Tuberculosis with emphasis on DOTS. 3-3 National Leprosy Control Programme. 3-3-1 Identify persons having suspicious patches or anaesthetic patches and direct S.E.T.Centre, Control Unit, medical officer or to "Pulse circuits". 3-3-2 Help those under treatment to continue and complete treatment. 3 -3-3 Follow up reported cases. 3-3-4 Educate the community about leprosy, its causation, ways of detection, treatment and try to dispel the stigma attached to the disease. 3-4 Other health programmes and activities 3.4.1 Identify elderly in the area and keep a list of all persons above 65 years of age. Collect details about common ailments among them and provide services to the extent possible. 3.4.2 Identify cases of Hypertension and Diabetes mellitus in the community. Provide Health education about prevention, detection, timely and proper management and complications of such diseases.

16 3.4.3 Help in the implementation of mental health programme and provide health education on early detection and treatment of such problems. Assist in follow up and community rehabilitation of the mentally ill. 3.4.4 Provide health education about other life style related diseases 3.4.5 Provide health education about Reproductive Tract Infections, Sexually Transmitted Infections, HIV and AIDS. (Vide RCH guidelines). Help in early detection of such diseases and fetch the victims counseling and, medical. support. 3.4.6 Detect cases of Cataract and other causes of blindness and fetch them medical help. Provide health education regarding care of eyes, causes of blindness and other services available under the National Programme for control of blindness. Provide sufficient information and support to those willing for "Eye Donation". 3.4.7 Maintain a list of all the physically challenged persons in the area. Provide them with support on rehabilitation. 3.5 Implement any other national health programme or activities as per the instructions issued from time to time. Any other duties like mass surveying, mass vaccination etc., of the area of the PHC for which the worker is deputed or allotted in connection with the implementation of programmes. 4. Reproductive and Child Health Programme (vide. Essential RCH service rendederd through the subcentres Job responsibilities of JPHNS) 4.1 Detect antenatal cases and furnish information to Lady health worker and refer them to P.H.Centre or subcentre. 4.2 List Eligible Couples and contact them, . educate them, motivate them for accepting suitable contraceptive methods. 4.3 Spread the message of small family concept and of family planning to the community and motivate the eligible couples to adopt the small family norm. 4.4 Distribute conventional contraceptives. 4.5 Provide follow up service to acceptors of family planning. Identify complications and failures and provide service or necessary advice. 4.6 Establish Depot holders and provide necessary information and replenishment of stocks 4.7 Render assistance to family planning promoters.

17 4.8 Utilize satisfied customers, village -teachers and others for promoting family planning programme. 4.9 Identify local leaders and with their help educate and involve the community in health and family planning programmes. 4.10 Assist in subcentre clinics 4.11 Get acquainted with the services to be provided at the community and subcentre level under the RCH programme (included in the job responsibilities of the female health workers) and render all support and service in accomplishing them. 4.12 Ensure male participation in the RCH programme 4.13 Provide advise to peri-menopausal and post menopausal women. Sensitize the regarding common malignancies among women and motivate them for periodic check and screening for these conditions. 4.14 Provide counseling services to the adolescents. Monitor the girt children for anemia malnutrition and take corrective steps. Arrange sessions to provide sex education family education to this group of beneficiaries 5. Environmental Sanitation. 5.1 Give advice for construction and maintenance of sanitary wells. 5.2 Educate community about the advantages of protected and purified water. 5.3 Chlorinate public water sources during routine visits. 5.4 Educate the community on: (a) methods of disposal of liquid wastes and help in construction of soakage pits kitchen garden etc. (b) methods of disposal of solid wastes (including excretal and help to provide manure pits, compost pits etc. (c) home sanitation, advantages and uses of sanitary types of latrines provide them information on construction and maintenance of such latrines. 5.5 Provide advice about cattle sheds and stables to prevent nuisance and hazards due to dang and other wastes. 6 Control of Communicable diseases 6.1 Identify notifiable diseases like Cholera, Chickenpox, Smallpox, Plague, Poliomyelitis Hepatitis, Measles, Mumps, Whooping Cough, Meningitis,

18 intermittent fever and other communicable diseases like diarrhea, gastroenteritis, etc. and notify to P.H.Centre. 6.2 Carry out control measures and other supports including distribution of ORS. 6.3 Educate community about the importance of control and preventive measures against such diseases. 6.4 Render assistance in the implementation of National Diseases Surveillance programme. 6.5 Report to the authorities about stray dogs. 7. Health and Family Education 7.1 Educate community about health and diseases,, personal hygiene, environment sanitation, prevention of diseases and promotion of health as and when occasions are during routine visits or during special campaigns 7.2 Conduct Health and Family Education through personal interviews, group discussions other IEC methods. 7.3 Assist in arranging film shows and health education activities. 7.4 Conduct specific education for specific programmes 8. Nutritional Services 8.1 Identify cases of malnutrition among children and refer them to P.H.Centres for nutrient supplement or treatment. 8.2 Distribute iron and folic acid tablets to eligible beneficiaries. 8.3 Administer Vit. A drops or syrup to children as per instruction 8.4 Educate families about nutritious diets for mothers and children. 9. Immunisation JHI should take part in the following. 9.1 Help in the administration of Vaccines against. Vaccine Preventable Diseases (VPDS) as and when instructed by higher authorities. 9.2 Help in the maintenance of "cold chain' and improper storage and distribution of vaccines. Render support for maintenance of cold chain as per the instructions of Lady Health Inspectors and other supervisors 9.3 Assist other staff in immunisation camps and in school immunisation programmes 9.4 Assist in conducting immunisation clinics in the area. 9.5 Educate community about the importance and procedures of immunisation and encourage community participation in immunisation programmes.

19 10. Curative Services Provide source to the sick persons including treatment of minor ailments and rendering first aid, to the extent to which a Health Worker is trained and rendering first aid, to the extend to which a Health Worker is trained and, permitted. (Supervisory Officers may provide separate guidelines to the Workers on this.) 11 Collection of details of vital events. 9.6 Enquire and record births and deaths and give information about births to the Female Health Worker/Lady Health Inspector and regarding death to the Health Inspector/Health Supervisor. 9.7 Educate the community about the importance of registration of births and deaths about procedures for registration of such events. 12 School Health 12.1 Assist in Medical Examination of School children when instructed. 12.2 Assist in organizing and conducting immunization camps in schools. 12.1 Conduct health education talks to pupils of schools in the area. 12.2 Conduct Sanitation inspection of schools and assist teachers for maintenance of healthy environment of schools. 13. Medical Termination of Pregnancy. 13.1 Render assistance and guidance to those requiring Medical Termination of Pregnancy. 13.2 Educate women on the availability of services for medical termination of pregnancy and about the of hazards of "unsafe abortion".

14 Public Health Responsibilities 14.1 Conduct inspection of places where. dangerous and offensive trades are occurring, including eating and drinking laces, places where food items are prepared (eg. Bakery)and also places or activities causing nuisance. Suggest corrective measures if necessary. In cases where action under Public Health Act or any other statute is required, the matter shall be reported to the concerned health authority, through superiors.

20 14.2 Assist the supervisors and medical officers in preparing technical reports related to public health activities. 14.3 Any other duty assigned by higher authorities, related to Public Health. 15. Environmental Sanitation 15.1 Give help and co-operation for implementation of environmental sanitation programme. 15.2 Educate community about the importance and significance of environmental sanitation 16. Staff meetings and Conferences. 16.1 Attend staff meetings and conferences at PHCS, Block Offices or Panchayat Offices or at any other places as and when required or instructed. 16.2 Attend the sectoral and project level meetings of the ICDS. Render continuing education sessions to the Anganwadi workers in the sectoral meetings. Help the female worker to collect and consolidate Monthly Monitoring Reports of the Anganwadi Workers of their field area. 16.3 Render help to female health worker in organizing and conducting meetings for Mss workers and other voluntary agencies. 17 Services to the Elderly "Challenged" and "Mentally ill" 17.1. Maintain an updated register of the elderly (above 65 years of age) and provided them services. Detect Hypertension and Diabetes among the elderly and motivate them to avail treatment. Provide follow up services for already detected cases 17.2. Provide health education to prevent life style diseases and sensitize the community about prevention of such diseases and on promotion of positive health. 17.3. Keep an updated list of the "Physically challenged" persons in the area and render support in fetching them help and rehabilitation support wherever necessary. 17.4. Render support in the implementation of Mental health programmes and help the community in early detection of mental disorders and getting treatment. 18 Services for prevention of RTI/STI and HIV/AIDS 18-1 Provide health education and arrange IEC activities to prevent the spread of RTI/ST-Is. Spread the message of prevention of spread of HIV/AIDS infection.

21 18.2 Target the "Special High risk groups" and come but, with interventions as specified in the National HIV/AIDS control programme. 19. Services under other National health programmes Provide services under other national health progranunes, as per the -guidelines of such programmes, as and when directed to do so. 20. Maintenance of Registers and Records. JHI should maintain the following registers. 1. General Information Register 2. Family Health Survey and follow up register with an index. 3. Community Education Register. These three registers are common. to both male and female workers. 4. Stock Register. 5. Issue Register of contraceptives to individual couples. 6. Daily case register for clinics and treatment of minor ailments. 7. Daily abstract of activities, area maps, progress charts. 8. Field Diary. 9. Instruction Book. 10. Individual Registers for National health programmes like National Ant malaria programme, National Leprosy Eradication programme etc. 11. Registers of any other health activities or programmes as and when required. 21. On call Services Should be available as 24 hour on call duty during medical or public health emergencies or if requested by higher authorities 22. Any other duties or responsibilities assigned by authorities.

1.2 JOB RESPONSIBILITIES OF LADY HEALTH INSPECTORS (LHIS) I. General Lady Health Inspectors (LHIS) are the first level of multipurpose female supervisory personnel. These officials assume great importance in current context where she may be the only female supervisor in a mini Primary Health Centre.

22 Lady Health Inspectors' job functions are mainly related to Supervision, General administration of field staff under them, Co-ordination of primary health care activities in their service area, coordination of activities with the Local Self Government Institutions, maintaining public relations and supporting their superiors in day today activities of institutions to which they are posted. II. Area and Jurisdiction There should be one Lady Health Inspector (LHI) for every 25-30,000 population. This corresponds to the service areas of about 5-6 grass root level workers. This would also be the area and population covered by a mini Primary Health Centre. Each mini Primary Health Centres may have a Lady Health Inspector. Lady Health Inspectors need be present in block Primary Health Centres only if the centres are directly providing services to any field areas. In some block Primary Health Centres whole field area had been –transferred to mini Primary Health Centres and such block Primary Health Centres need not have Lady Health Inspectors. Health Supervisor and Lady Health Supervisor, who are the designated supervisors for whole block areas, may accomplish the overall supervisory work in those centres. A Mini primary health centre catering to a population of 25000 to 40000 may ideally have a Health Inspector and a Lady Health inspector and a total of about 10 to 16 grass root level workers. III Supervisory Responsibilities: III. I Concurrent supervision of Health Workers. Concurrent supervision is crucial in assuring quality of services. It gives opportunity to observe workers in their duty and chances to guide, correct and follow them up. The basic philosophy of National Health Programmes like Reproductive and. Child Health (RCH) and Revised National Tuberculosis Control Programmes (RNTCP is quality oriented services. In this context, concurrent supervision assumes very great significance. A Lady Health Inspector should make not less than six concurrent supervisions in a calendar month. Schedule of concurrent supervision should be clearly made out in advance tour programmes and may be strictly adhered to. These supervisory sessions may be changed only under extreme emergency situations and that also with the concurrence and ratification of superiors. Lady Health Inspectors, through their

23 immediate superiors, should submit reports of these supervise visits to the medial officers in charge. They in turn may consolidate all such visits and send their reports to the District Medical Officer of Health. III.2 Consecutive Supervision of grass root level workers. Only consecutive supervisory visits can assess the quantum of work done by grass root level workers. They will also provide necessary information about the periodicity of visit of the health worker to the area, their punctuality and the profile of beneficiaries who are being served by the workers. It would also provide information about the lapses and gaps in service provision and would provide opportunities to fill those gaps and rectify lapses. A Lady Health Inspector should make at least 5 consecutive supervisory visits every month. All these supervisory visits should be of nature and need be disclosed only to the Medical Officer in charge of the institution. The detailed reports of such visits should be furnished to the medial officer in charge through proper, channel. These visits are to be followed and reports of such follow-ups should also be furnished that least every two months till all the corrective steps mentioned by the LHI had been fully implemented. The LHIs should report on concurrent and consecutive supervision of the health workers in monthly review meeting of the Primary Health -Centre. Reports should be furnished in formats for conducting supervision of subcentres. Follow up action should be discussed in general so that all workers can derive benefit. III.3 Routine supervisory responsibilities The Lady Health Inspector in addition to the mandatory concurrent and consecutive supervisory, responsibilities should also discharge routine supervisory responsibilities. They should guide and supervise the health workers in their routine activities, special clinics and outreach sessions. They may also help workers in organ in clinics, antenatal clinics, contraceptive camps, school health programmes, adolescent counseling sessions, STI/RTI counseling sessions, National Imununization Days (NIDS) and such similar activities.

III 4. Supervision/Reporting and record keeping

24 They should help and the health workers to prepare proper reports and scrutinize the records maintained by them provide guidance to them in proper record keeping and maintenance of registers. Ill. 5 Training and guidance of health workers Lady Health Inspectors may impart training as and when necessary to the health workers' under them. Workers joining the service or transferred in to an institution should be provided training by the LHI to "induct" them to work and to the new worksite. Imparting such induction training to the health workers may be jointly organized by the Health Inspector and Lady Health Inspector with help and guidance from all their superiors. The LHIs should keep copies of the "Job responsibilities of all cadres under their control" and should provide them with sufficient information on their job responsibilities. Whenever new programme get added, Lady health inspector and the health inspector should provide guidelines to health workers under them. LHIS and Hls should take initiatives to discuss the job responsibilities of subordinates frequently in monthly review meetings so that all workers get chance to update their knowledge. IV. Organizing and conducting meetings IV.I Meetings in primary health centres Lady Health Inspectors along with Health Inspectors may be jointly responsible organizing and conducting meetings at the Primary Health Centre. IV.1.1 HALF day and full day zonal meetings They should be responsible for organizing and conducting Half Day Zonal and Full Day Zonal meetings. in mini Primary Health Centres LHIs and Hls may take responsibility by turn in organizing these meetings. Medical officers need not participate in these meetings and reports of such meetings should be furnished to the medical officer, on the succeeding day of meeting. The periodicity of such meetings should be informed from time to time. Both Half Day Zonal and Full Day Zonal meetings may be conducted in the periphery in Subcentres, the location being fixed on a rotational basis and announced during the monthly review meeting at the Primary Health Centre. They should also help to organize and conduct the at the Primary Health Centre level.

25 IV.2 ICDS meetings

LHIs along with Hls and health workers should attend sectoral meetings of Anganwadi workers in their area. Service area of a LHI would almost correspond to a sector of ICDS project and a LHI need attend -only one such sectoral meeting. In rare instances the service area of LH1 may be in more than one sector of an ICDS project. In such cases the project officers should be consulted and sectoral meetings arranged in such a manner that-the LHI can attend all of them. An alternate strategy in such areas should be that either Health Inspector or Lady Health Inspector should attend each meeting and take turns subsequently so that both the officials get chance to interact with the Anganwadi Workers (AWW) of both the sectors. This is possible only when both HI and LHI are available in a centre. In ICDS sectoral meetings LHIs with the help of Hls- may collect and consolidate all "Monthly Monitoring -Reports (MMRs)" of the Anganwadi workers (AWWs). With the help of health workers and HIs, they may arrange "continuing education sessions" for the AWWs on topics of current interest. Lady Health Inspectors and Health Inspectors may jointly ensure attendance of all health workers in the area for such meetings. They may initiate necessary actions against defaulters and follow up such actions. IV.3 Meetings with the Local Self Government Institutions (LSGIS) LHIs are to attend meetings organized by, LSGIs, if they are directed to do so. Such directions to the LHIs should be routed-through their superiors and medical officers. They should report to their medical officers through proper channel on all such meetings. All communications to and from the Lady Health Inspectors involving the LSGIs may be routed through proper channel through the medical officers in charge only. IV.4 Other official meetings LHI is should attend any other meetings as and when directed to do so. They should organize beneficiary meetings, meetings of community leaders and opinion leaders in matters related to health and health care activities. They should supervise meetings of MSS workers and other voluntary agencies organised by health workers.

V Activities related to National health Programmes

V.1 Reproductive and Child health Programme V.I.I Help health workers in arranging all the programme activities

26 V.I.2 Render help in conducting antenatal, -immunization and contraception camps V.I.3. Lady Health inspector should be responsible for all "Cold Chain" related activities in mini Primary Health Centres and should help the LHS in such activities in higher level institutions. They should maintain stock of vaccines, ice packs, vaccine carriers, day carriers and other ancillary equipment related to cold chain. They should avail the services of JPHNs or any other functionaries in the institutions, for maintaining cold chain under orders of the medical officer in charge. V.I.4. Supervise contraceptive service provision and ensure proper follow up, of contraceptive acceptance. Contraception failure or complication may be followed up meticulously under. report to the medical officer and utmost quality of care ensured. Keep abreast with the services to be provided through the Subcentres as per the RCH (See the job responsibilities of Female health worker- JPHN) and provide supervision. Lady Health Inspectors are to refer to Reproductive and Child Health Programme for Health Assistants (Female) - LHV - Integrated Skill development training" published by the National Institute of Health and Family Welfare New Delhi to get full information regarding their responsibilities under this programme. The module is available with the officers in charge of training at the district level and also at the State Institute of Health and Family Welfare, Thiruvananthapuram.. V.2 National Antimalaria programme Encourage the health workers (both male and female) in Antimalaria activities. Supervise active and passive blood smear collection. Follow up positive cases and enhance other Antimalaria activities like contact smear collection, DDT spraying and other activities. Organize and execute mass surveys, DDT spraying campaigns and antimalaria activities in areas from where cases had been detected. In the wake of slightest suspicion of any complications cases may be referred and transferred to primary health centres. Depending on the gravity of the situation arrange for medical consultation and help to the patient. Keep track of the positive malaria cases (through the health workers) and ensure treatment compliance. V.3 Revised National Tuberculosis Control Programme (RNTCP) RNTCP is fully integrated with the general health services and is being implemented through it. LHIs along with Hls may ensure compliance of their workers with the guidelines issued under this programme. DOTS provision by health workers and

27 other "providers" is should be closely monitored and reported to the treatment centres through the medical officers. They should help in tracing and bringing back to treatment all "defaulters" and should also render support in fetching medical help to patients who develop complications or adverse reactions. Lady Health Inspectors should take active role in IEC activities of the programme and also impart health education regarding prevention, early detection, treatment and follow up of Tuberculosis. V.4 National Leprosy Eradication programme Supervise the health workers in their activities and help the control units in organizing the "Pulse Circuits" for provision of drugs. Help the workers in case detection, bringing them for treatment follows up and combating adverse drug reaction and other reactions in Leprosy. Provide health education, supervise IEC activities and organize mass camps, special camps etc. for case detection. V.5. National Programme for control of Blindness Help and supervise the workers in their programme activities. Help in organizing cataract detection and cataract surgery camps, health education and sensitization camps, school camps and camps organized by voluntary organizations and NGOs towards blindness control activities. V.6 Other National Health Programmes V.6.1 Supervise health education and IEC activities aimed at prevention of sexually transmitted infections. Help in early detection of sexually transmitted infections and Reproductive tract infections, with the help of health workers ensure treatment of victims. V.6.2 Arrange counseling sessions and health education sessions with the aim of bringing down the prevalence of RTI/STIs and HIV/AIDS infection and disease. V.6.3 Render help and supervision in activities aimed at prevention and early detection of different types of cancers. Help in fetching treatment to cancer victims. V.6.4 Organize and supervise service provision to cancer patients who are terminally ill. Arrange for provision of pain relief and palliative care services through grass root level health workers. Collect, consolidate and maintain a register of such patients in the service area.

28 V.6.5. Render support in detection and management of life style diseases like Hypertension and Diabetes Mellitus. Encourage heath workers to spread the message of prevention of such diseases, early detection and treatment compliance. Help to spread the message of healthy lifestyles, importance of exercise, food habits and avoidance of smoking and alcohol. V.6.6 Support the health workers in the implementation of National Disease Surveillance activities. V.6.7 Provide support in implementing mental health programmes. Support the community rehabilitation of the mentally ill. Spread the message of the importance of prevention, early detection and proper treatment of mental -disorders. Sensitize the community about the problems related to "Substance Abuse" and arrange help for the treatment and rehabilitation of substance abuse victims. V.6.8 Render help and guidance to the health workers in other national health programmes as per the guidelines issued on each from time to time. V.7 Services to the elderly As a result of the demographic transition occurring in the state, elderly people are emerging as a major chunk of population and need special attention. Because of their physical incapability they may find it difficult to access health care facilities. Health workers should be motivated to render services at the doorsteps of the elderly. Try to understand the disease profile among the elderly in the service area and device interventions to address them with the help of superiors and the medical officers. Implement them with the help of health workers and provide help, guidance and supervision in these activities. V.8. Services to the -Physically challenged Render support and guidance to the health workers in keeping a list of all the challenged individuals in the service area provide them necessary support. Help in their rehabilitative measures. VI. Record keeping and reporting VI. 1. Area map and baseline details

29 Keep an updated map of the area being served. This may show, in detail, the area assigned to individual health workers (both male and females) in addition to the usual landmarks. Lady Health Inspectors should have the demographic details of their service area.

VI.2. Advance Programme and Diary Submit advance programme duly countersigned by the immediate superior to the medical officer before the first working day of every month. Get it approved in the monthly review meeting. The. programme should be planned in such a way that all the Subcentres/sections are covered and all -health workers are being supervised. Maintain an updated -diary containing all the details of field visit. Separate sections should be allotted in the diary for each Subcentre area so that all the areas are evenly covered. Priority visits and 'surprise supervisory visits' may be made as separate entries in the diary VI.3 Reports and Registers HI should maintain the following registers 1. Base line details about the area - common to both HI and LHI 2. Consolidation register 3. Minutes of meetings - joint responsibility of Hls and LHIs 4. Stock register 5. Contraception failure and complications - follow up register- joint responsibility of Health Inspectors and Lady Health Inspectors.. 6. Birth and death Registers 7. Family Registers 8. Consolidate immunization Registers 9. Consolidation Registers of MSS activities in the area 10. Consolidation Register of ICDS activities in the area including details of consolidated monthly monitoring reports of AWWs and Sectoral meetings 11. Registers of special activities like National Immunization Days (NIDs-Eg. Pulse Polio Immunization)

30 12. Other registers as required for national health programmes and special activities. They should furnish periodic reports duly countersigned by the superiors to the medical officer in charge. Furnish reports of RCH and RNTC Programmes in prescribed formats. In the case of other activities reports may be furnished as directed from time to time.

VII Other responsibilities VII.I School health activities Organize school Health programmes with the help of Health Inspector and the health workers VII.2. IEC activities Assist the Health Inspectors in organizing and, conducting various IEC activities related to national health programmes and health education activities.- VII.3 Health activities by voluntary agencies, non-governmental organizations (NGOS) etc. Co-ordinate the activities of various agencies involved in health care activities in the area and co-ordinate the activities of health workers with these agencies. VII.4 Camps and campaigns Participate various camps and campaigns in relation to the health care activities VII.6 Local Self Government Institutions Work with the LSGIs in matters related to health care activities and involve in the planning and implementation of various health activities, projects and programmes of the LSGIS. VII.7 On call Services Should be available as 24 hour on call duty during medical or public health emergencies or if requested by higher authorities. VII.8 Any other duties ordered by higher authorities.

31 JOB RESPONSIBILITIES OF HEALTH INSPECTORS (HI) 1. General Health Inspectors (HI) are the first level of multipurpose male supervisory personnel. These officials assume great importance in current context where he may be the only male supervisor in a mini Primary Health Centre. Health Inspectors’ job functions are mainly related to Supervision, General administration of the field staff under them, Co-ordination of primary health care activities in their service area, coordination of activities with the Local Self Government Institutions, maintaining public relations, actively involving in public health related activities and supporting their superiors in day today activities of the institutions in which they are posted. II. Area and Jurisdiction There is one Health Inspector (HI) for every 25-30,000 population. This corresponds to the service areas of about 10-12 grass root level workers. This would also be the area and population covered by a mini Primary Health Centre. Mini Primary Health Centres only if the centres are directly providing services to any field areas. In some block Primary Health Centres whole field area had been transferred to mini Primary Health Centres and such block Primary Health Centres need not have Health Inspectors. Health Supervisor and Lady Health overall supervisory work in those centres. A Mini primary health centre catering to a population of 25000 to 40000 may ideally have a Health Inspector and a Lady Health inspector and a total of about 10 to 16 grass root level workers. III. Supervisory Responsibilities: III.1 Concurrent supervision Concurrent supervision is crucial in assuring quality of services. It gives opportunity to observe workers in their duty and chances to guide, correct and follow them up. The basic philosophy of National Health Programmes like Reproductive and. Child Health (RCH) and Revised National Tuberculosis Control Programmes (RNTCP is quality oriented services concurrent supervision assumes very great importance.

32 A Health Inspector should make not less than six concurrent supervisions in a calendar month. Schedule of concurrent supervision should be clearly made out in advance tour programmes and may be strictly adhered to. These supervisory sessions may be changed only under extreme emergency situations and that also with the concurrence and ratification of superiors. Health Inspectors, through their immediate superiors, should submit reports of these supervisory visits to the medical officers in charge. They in turn may consolidate all such visits and send their reports to the District Medical Officer of Health, reports may be finished in prescribed format.

III.2 Consecutive Supervision Only consecutive supervisory visits can assess the quantum of work done by grass root' level workers. They will also provide necessary information about the periodicity of visit of the health worker to the area, their punctuality and the profile of beneficiaries who are being served by the workers. It would also provide information about the lapses and gaps in service provision and would provide opportunities to fill those gaps and rectify lapses. A Health Inspector should make at least 5 consecutive supervisory visits every month. All these supervisory visits should be of “Surprise visit” nature and need be disclosed only to the Medical officer in charge of the institution. The detailed reports of such visits should be furnished to the medial officer in charge through proper, channel. These visits are to be followed and reports of such follow-ups should also be furnished at least every two months The HI may report on concurrent and consecutive supervision of the workers in monthly review meetings. The follow up action should be discussed in general so that all workers can derive benefit. III.3 Routine supervisory responsibilities The Health Inspector in addition to the mandatory concurrent and consecutive supervisory responsibilities also discharge routine supervisory responsibilities. They should guide and supervise health workers in the routine activities, special clinics and outreach sessions. They help workers in organizing and conducting immunization clinics, antenatal clinics, contraceptive camps, school health programmes, adolescent counseling

33 sessions, STI/RTI counseling sessions, National Immunization Days (NIDs) and similar activities. 4. Supervision of reporting and record keeping Help and guide the health workers to prepare proper reports and scrutinize the records maintained by them. Provide guidance to them in proper record keeping and maintenance of registers. 5 Training and guidance Health Inspectors may impart-t training as and when necessary to the health workers' under them. Workers joining the service or transferred in to an institution should be provided training by the HI to "induct" them to work and to the new worksite. Such health workers are to be on objected to ore numbers of concurrent supervisory visits during the initial months till they get used to the area and also with their job responsibilities. His should keep with them copies of “Job responsibilities” of all cadres under their control and should provide them with sufficient information on their job responsibilities. Whenever new programmes are added, detailed guidelines about them should be provided by HIs to their to their subordinates. HIs may take initiative to discuss the job responsibilities of subordinates. Frequently in monthly review meeting so that all the workers get chance to update their knowledge. In all these matters Health Inspectors and Lady health Inspectors may be jointly held responsible. IV. Organizing and conducting meetings IV.1 Meetings in primary health centres Health Inspectors along with Health Inspectors may be jointly organizing and conducting meetings at the Primary Health Centre. They should be responsible for organizing and conducting Half Day Zonal and Full Day Zonal meetings. In these two types of meeting s at the mini Primary Health Centres LHIs and Hls may take responsibility in turn during every month. In these meetings Medical officers need not participate and hence the reports of these meetings should be furnished to the medical officer on the succeeding day of such meetings. The periodicity of such meetings will be informed from time to time. Both the half Day Zonal and full Day Zonal meetings should be conducted in periphery in subcentres, the location being fixed on rotational basis and announced during the monthly review meetings at the Primary Health Centre.

34 IV.2. ICDS meetings HIs along with LHls and health workers should attend sectoral meetings of Anganwadi workers in their area. Usually the service area of a LHI would almost correspond to a sector of ICDS project and a HI need attend only one such sectoral meeting. In rare instances the service area of H1 may be in more than one sector of an ICDS project. In such cases the project officers may be consulted and spectral meetings arranged in such a manner that-the HI can attend all of them. An alternate strategy in such areas should be that either Health Inspector or Lady Health Inspector should attend each meeting and take turns subsequently so that both the officials get chance to interact with the Anganwadi Workers (AWW) of both the sectors. In ICDS sectoral meetings HIs to collect and consolidate all “monthly monitoring reports” from the Anganwadi workers (AWWs). They should also help LHIS to arrange “continuing education sessions” for the AWWa on topics of current interest. Health Inspectors or the health workers can also conduct classes on subjects of public health interest or of concern to the primary health care field. Health Inspectors and Lady Health Inspectors should jointly ensure attendance of all health workers such meetings. They should initiate necessary actions against defaulters and should follow up such actions. IV.3 Meetings with the Local Self Government Institutions (LSGIs) HIs are to attend meetings organized by LSGIs, if they are directed to do so. Such directions to the HIs should be routed-through their superiors and medical officers. They should report to their medical officers through proper channel on all such meetings. All communications to and from the Health Inspectors involving the LSGIs may be routed through proper channel through the medical officers in charge . IV.4 Other official meetings HIs should attend any other meetings as and when directed to do so. They should organize beneficiary meetings, meetings of community leaders and opinion leaders in matters related to health and health care activities. V Activities related to National health Programmes V.1 Reproductive and Child health Programme VI. .I Help health workers in arranging all the programme activities.

35 VI. 2. Render help in conducting antenatal, immunization and contraception camps VI. 3 Render help and support to the LHI in maintaining “Cold chain” in vaccine storage, distribution and administration to the beneficiaries. Supervise the health workers in maintenance of cold chain and immunization activities. V1.4 Supervise contraceptive service provision and ensure proper follow up, of contraceptive acceptance VI.5. Contraception failure or complication may be followed up meticulously and report to the medical officer and utmost quality of care should be ensured. VI.6. Keep abreast with the services to be provided through the Subcentres as per the RCH programmes (See the job responsibilities of Female health worker- JPHN) and provide supervision. Health Inspectors have to refer to Reproductive and Child Health Programme for Health Assistants (Female) - LHV - Integrated Skill development training" published by the National Institute of Health and Family Welfare New Delhi to get full information regarding their responsibilities under this programme. The module is available with the officers in charge of training at the district level and also at the State Institute of Health and Family Welfare, Thiruvananthapuram V.2 National Antimalaria programme Encourage the health workers (both male and female) in Antimalaria activities. Supervise active and passive blood smear collection. Follow up positive cases and enhance other Antimalaria activities like contact smear collection, DDT spraying and other activities. Organize and execute mass surveys, DDT spraying campaigns and antimalaria activities in areas from where cases had been detected. In the wake of slightest suspicion of any complications cases may be referred and transferred to primary health centres. Depending on the gravity of the situation arrange for medical consultation and help to the patient. Keep track of the positive malaria cases (through the health workers) and ensure treatment compliance. V.3 Revised National Tuberculosis Control Programme (RNTCP) RNTCP is fully integrated with the general health services and is being implemented through it. HIs along with LHls may ensure compliance of their workers with the guidelines issued under this programme. DOTS provision by health workers and other "providers" should be closely monitored and reported to the treatment centres

36 through the medical officers. They should help in tracing and bringing back to treatment all "defaulters" and should also render support in fetching medical help to patients who develop complications or adverse reactions. Health Inspectors should take active role in IEC activities of the programme and also impart health education regarding prevention,. early detection, treatment and follow up of Tuberculosis. V.4 National Leprosy Eradication programme Supervise the health workers in their activities and help the control units in organizing the "Pulse Circuits" for provision of drugs. Help the workers in case detection, bringing them for treatment, follows up and combating adverse drug reaction and other reactions in Leprosy. Provide health education, supervise IEC activities and organize mass camps, special camps etc. for case detection. V.5 National Programme for control of Blindness Help and supervise the workers the workers in their programme activities. Help in organizing cataract detection and cataract surgery camps, health education and sensitization camps, school camps and organizesd by voluntary organizations and towards blindness control activities. Educate the public about “eye donation’ and provide guidance and support to the willing persons for “eye donation”. V.6. Other national health programmes V.6.1 Supervise health education and IEC activities aimed at prevention of sexually transmitted infections. Help in early detection of Sexually transmitted infections and Reproductive tract infections. With the help of health workers ensure treatment of victims. V.6.2. Arrange counseling and health education sessions with the aim of bringing down the prevalence of RTI/STIs and HIV/AID infection and disease. V.6.3. Render help and supervision in activities aimed at prevention and early detection of different types of cancers. Help in providing treatment to cancer victims. V.6.4. Organize and supervise service provision to cancer patients who are terminally ill. Arrange for provision of pain relief and palliative care service through grass root level health workers. Collect, consolidate and maintain a register of such patients in the service area.

37 V.6.5. Render support in detection and management of life style disease like hypertension and Diabetes mellitus. Encourages the health workers to spread the message of prevention of such disease, early detection and treatment compliance. Help to spread the message of healthy lifestyles, importance V.6.7 Provide support in implementing mental health programmes. Support community rehabilitation of the mentally ill. Spread the message of the importance of prevention, early detection and proper treatment of mental -disorders. Sensitize the community about the problems related to "Substance Abuse" and arrange help for the treatment and rehabilitation of substance abuse victims. V.6.8 Render help and guidance to the health workers in other national health programmes as per the guidelines issued on each from time to time. V.7 Services to the elderly Considering the demographic transition in the state, elderly people who are emerging as a major chunk of population need attention. Because of their physical incapability this group of beneficiaries very often find it difficult to access the health care facilities. The health workers should be motivated to render services at the doorsteps of the elderly. Try to understand the disease profile among the elderly in the service area and device interventions to address them with the help of superiors and the medical officers. Implement them with the help of health workers and provide help, guidance and supervision in these activities. V.8. Services to the Physically challenged Render support and guidance to the health workers in keeping a list of all the challenged individuals in the service area provide them necessary support. Help in their rehabilitative measures. VI. Record keeping and reporting VI. 1. Area map and baseline details Keep an updated map of the area being served. This may show, in detail, the area assigned to individual health workers (both male and females) in addition to the usual landmarks. Lady Health Inspectors should have the demographic details of their service area. VI.2. Advance Programme and Diary

38 Submit advance programme duly countersigned by the immediate superior to the medical officer before the first working day of every month. Get it approved in the monthly review meeting. The. programme should be planned in such a way that all the Subcentres/sections are covered and all -health workers are being supervised. Maintain an updated -diary containing all the details of field visit. Separate sections should be allotted in the diary for each Subcentre area so that all the areas are evenly covered. Priority visits and surprise supervisory visits' may be made as separate entries in the diary VI.3 Reports and Registers HI should maintain the following registers i. Base line details about the area - common to both HI and LHI ii. Consolidation register iii. Minutes of meetings - joint responsibility of Hls and LHIs iv. Stock register v. Contraception failure and complications - follow up register- joint responsibility of Health Inspectors and Lady Health Inspectors.. vi. Register of Malaria cases with details of follow up vii. List of institution of public health importance in the area. viii. Register of public health activities ix Birth and death registers x Family registers xi. Other registers as required for national health programmes and special activities They should furnished periodic reports duly countersigned by superiors to the medical officer in charge. Help the Lady Health Inspector in furnishing reports of RCH and RNTC Programmes in prescribed formats. In the case of other activities reports are to be furnished as directed from time to time. VII Other responsibilities VII.1. School health Organize School Health programmes with the help of Health Inspector and the health workers VII.2. Public health Activities

39 VII.2.1Conduct inspection of places of public health like eating and drinking places, places where food items are being prepared for sale and implement corrective and remedial measures for any defects detected. VII.2.3 Conduct inspections of place of dangerous offensive trades and also place or activities causing public nuisance and implement corrective and remedial measures. VII.2.2 Advise the LSGIs through the Medical Officers regarding issuing license to establishments mentioned in VII2.1 and VII 2.2. VII.2.3 Visits areas of disputed regarding public health like construction of latrines, wells and drinking water sources, poultry farms etc. under intimation to the medical officers and furnish first impression report to the medical officer in preparing\technical reports related to public health activities. VII.2.4 Render support to the Supervisors and Medical Officers in preparing technical reports related to public health activities.

VII.2.5 Give advice and guidance to the public health activities VII.3 IEC activities Assist in organizing and conducting various IEC activities related health programmes and health education activities. VII.4 Health activities by voluntary agencies, non-governmental organizations (NGOS) etc. Co-ordinate the activities of various agencies involved in health care activities in the area and co-ordinate the activities of health workers with these agencies. VII.5 Camps and campaigns Participate in various camps and campaigns organized in relation to health care activities VII.6 Local Self Government Institutions Work with the LSGIs in matters related to health care activities and involve in the planning and implementation of various health activities, projects and programmes of the LSGIS.

40 VII.8 On call Services Should be available as 24 hour on call duty during medical or public health emergencies or if requested by higher authorities. VII.9 Any other duties ordered by higher authorities 1.3 JOB RESPONSIBILITIES OF LADY HEALTH SUPERVISOR (LHSS) Lady Health Supervisors (LHS) belong to the second level of supervisory officials lock Primary Health Centres and Community Health Centres (CHCs).They cater to 'Population of about 10,0000 to 15,0000 and may have -about 40 to 60 grass root level workers and their first level supervisors under them. The officials operate from block primary-health centres or CHCs and have jurisdiction over the mini primary health centres and their field staff placed under the block Primary Health Centre/CHCS. Their job responsibilities are related to supervision of lower levels of employees and helping the medical officers in the smooth running of primary health care institutions. They also play key roles in the public health related activities of the area. 1. Jurisdiction Jurisdiction of a Lady Health Supervisor is the whole area of Primary Health Centre/CHC to which they are attached, the field staffs in the mini Primary Health Centres under the concerned block. Primary Health Centre and CHC also come under the control of Lady Health Supervisor. II. Administrative responsibilities II.1 Lady Health Supervisor and Health Supervisor occupy the highest level among the cadres of field staff in the primary health care institutions. Since the posts of Block Extension Educators are nonexistent in Kerala, the Health Supervisors and Lady Health Supervisors have responsibilities in IEC activities also. II.2 Assist the Medical Officer in organising and implementing various health and family welfare programmes including mass camps and mass campaigns. II.3 Collect reports from all Health Inspectors A Lady Health Inspectors as the case may be.

41 II.4 Lady Health Supervisor and Health Supervisor may jointly consolidate reports with the help of computer clerk. II.5 Maintain a consolidation Register and record all information regarding activities. II.6 Reporting to the charge Medical Officer. All reports from the field staff in block Primary Health Centres and community Health Centres to the medical officer are to be routed through the LHS/HS. Reports from mini Primary Health Centres also may be consolidated by the LHS/HS. II.7 She should keep with her copies of the, job responsibilities of all categories of employees in Primary Health Care Institutions. II.8 LHS and HS may jointly arrange INDUCTION- Training Session to ail fresh recruits. III.1 Supervisory Responsibilities Lady Health Supervisor is expected to play a crucial-role in the supervision of all levels of field staff in primary health care institutions. She should supervise the first level. of supervisors viz. the Lady Health Inspectors as well as the grass root level female health workers under her control. III.1 Approving and forwarding the advance programme of all health workers. HS/LHS -should approve and forward the tour programme Of HI/LHI. The advance tour programmes of all- the health workers- (JPHNs and JHls) may be countersigned by the LHIs/Hls and submitted to the LHS/HS for scrutiny. Only after such scrutiny the advance programme of health workers may be finalized. In mini Primary Health Centres the HI/LHI may approve the advance programme of the health workers, to be subsequently scrutinized and approved by the LHS/HS. III.2 Concurrent Supervision LHSs should conduct at least 6 concurrent supervisory sessions every month. Categories of field staff viz. JPHNs and LHIs may be subjected to concurrent supervisions. To cover all the institutions and staff under her, the visits may be planned in such a way that all cadres and all employees are being supervised by rotation on an evenly fashion. The schedule of such visits ay be approved in the monthly conferences. She may make at least two concurrent supervisory sessions without prior notice (surprise sessions) every month.

42 The reports of all such supervisory visits may be forwarded within two working days of completing such sessions to the medical officer. The medical officer may consolidate all such reports and forward them to the District Medical Officers of Health. III.3 Consecutive supervision Lady Health Supervisors should conduct at least three consecutive supervisory sessions on her subordinates every month All these visits may be of surprise nature and reports are to be forwarded to the medical officers within two days-of such visit. III.4 Routine Supervisory responsibilities Should give necessary guidance and assistance to Health Workers and their first level supervisors for arranging group talks or discussions for health and family welfare -education, school health education and in all their routine activities. III.5 Organize special strategies for education purpose in respect of specific and special programmes. III Responsibilities under National Health Programmes III.1 Reproductive and Child health Programme III.1.1 Help the health workers and their supervisors in arranging all the programme activities. III.1.2 Lady Health Supervisor may be responsible for the maintenance of cold chain and proper upkeep an delivery of all vaccines. She may supervise the upkeep of cold chain and assign clear-out responsibilities to her subordinates to ensure that cold chain is being maintained in tact. III.1.3 Render help in conducting antenatal, immunization and contraception camps III 1.4 Supervise service provision under the programme and ensure proper follow up of contraceptive acceptance. Contraception failure/ complications are to be followed up meticulously under report to the medical officer and utmost quality of care ensured. I.1.5 Keep abreast of the services to be provided through the Subcentres as per the RCH programme (See the job responsibilities of Female health worker- JPHN) and provide support and supervision. Lady Health Supervisors should refer to Reproductive and Child Health Programme Module for Health Supervisor (Female)- Integrated Skill

43 development training" published by the National Institute of Health and Family Welfare, New Delhi to get full information regarding their responsibilities under this programme. The module is available with the officers in charge of training at the district level and also at the state Institute of Health and Family Welfare, Thiruvananthapuram III 1.6. Lady Health Supervisors should consolidates the reports , with the help of Health Supervisors, of all activities related to the programme and submit to the medical officers in charge.

III.2. National Antimalaria programme III.2.1 Encourage health workers in antimalaria activities. Supervise active and passive blood smear collection. III.2.2 Follow up positive cases and enhance other anti malarial activities like contact smear collection, DDT spraying and other activities., III.2.3 Help the Health Supervisor to organize and execute mass surveys, DDT spraying campaigns and antimalaria activities in areas from where cases had been detected. III.2.4 Cases of complication should be referred and transferred to primary health centres. Depending on the gravity of the situation may arrange for medical consultation and help to the patient. III.2.5. Keep tract of the positive malaria cases (through the health workers) and ensure treatment compliance.

III.3 Revised National Tuberculosis Control Programme III.3.1 RNTCP is fully integrated with the general health services and is being implemented through it. Lady Health Supervisors may supervise the JPHNs and LHIs in their programming activities. III.3.2 They should ensure compliance of the staff under them with the guidelines issued under this programme. III.3.3 Reports from the first level supervisors on DOTS provision by health workers and other "providers" may be closely monitored and reported to the medical officers.

44 III.3.4 They should help in tracing and bringing back to treatment all the defaulters and may render support in fetching medical help for patients developing complications or adverse reactions. III.3.5 Lady Health Supervisors should take active role in the IEC activities of the programme and also in imparting health education regarding prevention, early detection, treatment and follow up of Tuberculosis.

III. 4 National Leprosy Eradication programme III.4.1 Supervise the health workers and their supervisors in their activities and help the control units in organizing the "Pulse Circuits" for provision of drugs. III.4.2 Help the workers and their supervisors in case detection treatment, follow up and combating adverse drug reaction and other reaction in Leprosy- III.4.3 Jointly with the Health Supervisor provide health education, arrange IEC activities and organize mass camps, special camps etc . for case detection.

III.5 National Programme for control of Blindness III.5.I Help and supervise the workers and their supervisors in their programme activities. III.5.2 Jointly with the Health Supervisor, she may organize cataract detection and cataract surgery camps, health education, and sensitization camps, school camps. III.5.3 Render support and supervision for camps and activities organized by voluntary organizations and NGOs for control of blindness. III.5.4 Spread, through the health workers, the message of injury prevention to eyes. Sensitize the community about early detection of visual problems and timely correction. III.5.5 Sensitize the community, about the importance of "Eye donation" and motivate and render support in eye donation activities. III.5.6 Organize eye camps in schools. Help to detect visual problem's in school children and in correction. III.6. Other national health programmes III.6.1 Jointly with the Health Supervisors she should arrange-health education and IEC activities aimed at prevention of sexually transmitted infections. Help in early detection of Sexually transmitted diseases and Reproductive tract infections. With the help of health workers ensure treatment of victims.

45 III.6.2 Arrange counseling sessions and health education sessions with the aim of bringing down the prevalence of RTI/STIs and HIV/AIDS infection and disease. III.6.3 Render help and supervision in activities aimed at prevention and Early detection of different type of cancers. Help in fetching treatment to cancer victims. III.6.4 Organise and superviser service provision to cancer patients who are terminally ill. Arrange for provision of pain and palliative care services through grass root level health workers. Jointly with the Health Supervisor collect, consolidate and maintain a register of such patients in the service area. III 6.5 Jointly with the Health Supervisors, she should organize programme for detection and management of life style disease like Hypertension and Diabetes mellitus. Encourage the health workers to spread the message of preventation of such diseases, early detection and treatment compliance. Help to spread the message of healthy lifestyles, importance of exercise, importance of food habits and avoidance of smoking and alcohol. III.6.6 Support and supervise the health workers in the implementation of National Disease Survellance activities. III. 6.7 Provide support in implementing Mental health programmes. Supervise the health workers in their activities related to the programme. Impress upon them the importance of preventation, early detection and timely management of such diseases. Help in the community based management and rehabilitation of the mentally ill. Sensitize the community about the diseases to dispel attached stigma. Educate the community about the harms of “Substance Abuse” and fetch medical help to the victims of substance abuse.

III.6.8. Render help and guidance to the health workers in other national health programmes as per the guidelines issued from them time to time.

IV Service to the elderly In the wake of the demographic transition occurring in the state, elderly people are emerging as a major chunk of population and they need special attention. Because of their physical incapability they often find it difficult to access the health care facilities.

46 IV. I Motivate the health workers to render services at the doorsteps of this vulnerable section of the community. IV.2 Jointly with the Health Supervisor, she should collect a clear profile of the disease Pattern of elderly in the area and devise interventions to address them with the help of all the staff in Primary Health Centre/CHC IV.3 Provide help, guidance and supervision to health workers in all their services to the elderly.

V. Services to the physically challenged V.1 Jointly with the Health Supervisor maintain an updated list of all the physically challenged individuals in the service area V.2 Jointly with the Health Supervisor she should organize programmes and activities aimed at the well being of physically challenged and guide and supervise the heath workers in their activities in this direction. V.3 Arrange progmmmes and activities aimed at the retaliation of the physically challenged.

VI. Health Education and IEC activities VI. I Render necessary assistance to District Mass Media Wings and the IEC team for various education Programmes in Health and Family Welfare VI.2 Maintain good public relationship, with the staff and with the public and act as a Liaison Officer among the staff.

VI.3. Render necessary assistance to other staff to maintain good public relationship will people.

VI. Administrative Responsibilities in the institution VI.1 Render necessary administrative assistance to the Medical Officers. VI.2 Assist the Medical Officer in preparing technical reports and reports related to various national health programmes and activities.

VI.3 Help the medical officer and the Health Supervisor to investigate outbreaks of communicable diseases. VI.4 Jointly with the Health, Supervisor she should prepare indent for (through the medical officer) procure and supply in time Registers and Materials required by

47 the Health workers and their supervisors and maintain a stock register for such items.

VI.5 Jointly with the Health Supervisor arrange the monthly staff conferences at Primary Health Centre/CHC and render all help to the medical officer in conducting the conference. Minutes of such meetings, prepared by the computer- clerk should be scrutinized jointly by the LH and the Health Supervisor. LHS/ HS may present the minutes of such meetings in subsequent sessions for approval. She should attend any other meetings arranged in PHC/CHC, at the District Offices, arranged by LSGIs etc. As and when instructed she should also attend training session as per instructions. VII. Registers and records VII.1 Common to Health Supervisor and Lady Health Supervisor 1. General Information Register 2. Community Education Register 3. Stock register 4. Field Diaries 5. Area maps, Charts etc.

VII.2 Specific to Lady health supervisor 6. Separate consolidation Register for recording details of Immunization, School health and special MCH Programme. 7. Stock and Issue register of Vaccines and sub-centre medicines. 8. Any other register of specific programmes or activities as and required.

VIII. On call services Should be available as 24 hour on call duty during medical or public health emergencies or if requested by higher authorities VIV. Any other duties assigned routinely or specially. 6. JOB RESRONSIBILITIES OF HEALTH SUPERVISORS (HSS)

48 Health Supervisors (HS) are the second level supervisory officials in Block Primary Health Centres and community Health Centres (CHCs). They cater to a population of about 1,00,000 to 1,50,000 and may have about 40 to 60 grass root level workers and their first level supervisors under them. The officials operate from block primary health centers or CHCs and have jurisdiction over the mini primary health centers and their field staff placed under the block Primary Health center or CHCs. Their job responsibilities are related to supervision of primary health care institutions. They also play key roles in the public health related activities of the area. 1. Jurisdiction Jurisdiction of a Health Supervisor is the whole area of Primary Health Centre/CHC to which they are attached. The field staffs in the mini Primary Health Centres under the concerned block Primary Health Centre or CHC also come under the control of Health Supervisor. II Administrative responsibilities II.1 Health Supervisor occupy the highest level among -the cadres of field staff in the primary health care institutions. Since the posts of Block Extension Educators are nonexistent in Kerala, the Health Supervisors have responsibilities in IEC activities in the Primary Health Centres/CHCs they are attached to. II.2 Assist the Medical Officer in organizing and implementing various health and family welfare programmes including mass camps and mass campaigns. II.3 Collect reports from all Health Inspectors /Lady Health Inspectors as the case may be. II.4 Health Supervisor and Lady Health Supervisor should jointly consolidate reports with the help of computer clerk. II.5 Maintain a consolidation Register and record all information regarding activities. II.6 Reporting to the charge Medical Officer. All reports from the field staff in block Primary Health Centres and Community Health Centres should be routed through the HS/ LHS to the medical officer. Reports from mini Primary Health Centres may be consolidated by the HS/LHS. II.7 HS should keep copies of the job responsibilities of all categories of staff in Primary Health Care institutions.

49 II.8 HS and LHS may jointly arrange INDUCTION training for fresh recruiters. II.9 HS should attend all meetings arranged by PRIS, District Medical Officer of Health & Other departments as and when directed to do. II.10 HS should co-ordinate the activities in the area with all other government departments. However, all communication to other departments of Government may be forwarded through the medical officer only. III Supervisory Responsibilities Health Supervisor should play crucial role in the supervision of all staff in primary health care, institutions. They may supervise the first level of supervisors viz. the Health Inspectors and the Lady Health Inspectors. as well as the grass root level male and female health workers under their control. III.1 Approving and forwarding the advance programme of all health workers HS/LHS should approve and forward the tour programme of HI/LHI. The advance tour programmes of all the health workers (JPHNs and JHIs) may be countersigned by the Lhis/His and submitted to the HS/LHS for scrutiny. Only after such scrutiny the advance programme of health workers may be finalized. In min Primary Health Centres the HI/LHI approve the advance programme of their health workers, to be subsequently scrutinized and approved by the HS/LHS. III.2 Concurrent Supervision HSs should conduct at least 6 concurrent sessions every month. Categories of field staff viz. JHIs, and HIS should be subjected to concurrent supervisions. To cover all the institutions and staff under them, the visit may be planned in such a way that all cardes and all employees are being supervised by rotation on an evenly fashion. The schedule of such visits may be approved in the monthly conference of the institution and known prior notice (surprise sessions) every month. The reports of all such supervisory visits should be forwarded within two working days of conduction such sessions to the medical officer. The medical officer should consolidate all such reports and forward them to the District Medical Officers of Health. They should use prescribed format for Supervisor visits.

III.3 Consecutive supervision

50 Health Supervisors should conduct at least three consecutive supervisors sessions every month on, their subordinates. All these visits should be of surprise nature and reports are to be forwarded to the medical officers within two days of such visit. III.4 Routine Supervisory responsibilities Give necessary guidance and assistance to Health Workers and their first level supervisors for arranging group talks or discussions for -health and family welfare education, school health education and in all their routine activities. III.5 Organize special strategies for education purpose in respect of specific and special programmes. III. Responsibilities under National Health Programmes III.1.Reproductive and Child health Programme III.1.1Help the health workers and their super all the programme activities. III. 1.2 Help the Lady Health Supervisor in the maintenance of cold chain and proper -upkeep and delivery of all vaccines. III.1.3 Render help in conducting antenatal, immunization and contraception camps III. 1.4 Supervise service provision under the programme and ensure proper follow up of contraceptive acceptance. Contraception failure/ complications are may to be followed up meticulously under report to the medical officer and utmost quality of care ensured. III.1.5. Keep abreast of the services to be provided through the subcentres as per- the RCH programme (See the job responsibilities of Female health worker- JPHN) and provide support and supervision. Health Supervisors may to refer to " Reproductive and Child Health Programme Module for Health Supervisor (Male) - Integrated Skill development training" published by the National Institution of Health and Family Welfare, New Delhi to get full information regarding their responsibilities under this programme. The module is available with the officers in charge of training at the district level and also at the State Institute of Health- and Family Welfare, Thiruvananthapuram. III.1.6 Help the Lady Health Supervisor to consolidate the reports of all activities related to RCH programme.

III.2. National Antimalaria programme

51 III.2.1 Encourage health workers (both male and female) in antimalaria activities. Should supervise active and passive blood smear collection. III.2.2 Follow up positive, cases and enhance other antimalaria activities like contact smear collection, DDTs praying and other activities. III.2.3. Organize and execute mass surveys, DDT, spraying campaigns and antimalaria activities in areas from where cases had been detected. III.2.4 Cases of complication should be referred and transferred to primary health centres. Depending on the gravity of the situation arrange for medical consultation and help to the patient. III.2.5. Keep track of the positive malaria cases'(through the health workers) and ensure treatment compliance. III.3 Revised National Tuberculosis Control Programme III.3.1 RNTCP is fully integrated with the general health services and is being implemented through it. Health Supervisors should supervise the His and JHIs in their programme activities. III.3.2 They should ensure compliance of the staff under them with the guidelines issued under this programme. III.3.3 Reports from the first level supervisors on DOTS provision by health workers and other "providers" may -be closely monitored and reported to the medical officers. III.3.4 They should help in tracing and bringing back to treatment all the defaulters and may. render support in providing medical help for patients developing complications or adverse reactions III.3.5 Health Supervisors should take active role in the IEC activities of the programme and also in -imparting health education regarding prevention, early detection treatment and follow up of Tuberculosis. III.4 National Leprosy Eradication programme III.4.1 Supervise the health workers and their supervisors in their activities and help the control units in organizing the "Pulse Circuits" for provision of drugs III.4.2 Help the workers and their supervisors in case detection, treatment, follow up and combating address drug reaction another reactions in Leprosy III.4.3 Jointly with the Lady Health Supervisor provide health education,. arrange IEC activities and organize mass camps special camp etc. for case detection.

52 III.5 National Programme for Control of Blindness III.5.1 Help and-supervise the workers and their supervisors in their programme activities. III.5.2 Jointly with the Lady Health Supervisor, HS should organize cataract detection and cataract surgery camps, health education and sensitization camps, and, school camps. III.5.3 Render support and supervision for camps and activities organized by voluntary organizations and NGOs for control of blindness. III.5.4 Spread, through the health workers, the message of injury prevention to eyes. Sensitize the community about early detection of visual problems and timely correction. III.5.5 Sensitize the community about the importance of "Eye donation" and motivate and render support in eye donation activities. III.5.6 Organize eye camps in schools. Help to detect visual problems in school children and in correction. III.6 Other National Health programmes III.6.1 Jointly with the Lady Health Supervisors arrange health education and IEC activities aimed at prevention of sexually transmitted infections and Reproductive Tract Infections. With the help of health workers ensure treatment of victims. III.6.2 Arrange counseling sessions and health education sessions with the aim of bringing down the prevalence of RTI/STIs and HIV/AIDS infection and disease. III.6.3 Render help and supervision in activities aimed at prevention and early detection of different types of cancers. Help in fetching treatment to cancer victims. III.6.4 Organize and supervise service provision to cancer patients who are terminally ill. Arrange for provision of pain and palliative care services through grass root level health workers. Jointly with the Lady Health Supervisor collect, consolidate and maintain a register of such patients in the service area. III.6.5 Jointly with the Lady Health Supervisors organize programmes for detection and management of life style diseases like Hypertension and Diabetes mellitus. Encourage the, heath workers to spread the message of prevention of such diseases, early detection and treatment compliance. Help to spread the message of

53 healthy lifestyles, importance of exercise, importance of food habits and avoidance of smoking and alcohol. III.6.6 Support and supervise the health workers in the implementation of National Disease Surveillance activities. III.6.7 Provide support in implementing Mental health programmes, Supervise the health workers in their activities related to the programme. Impress upon their the importance of prevention, early detection and timely management of such diseases. Help in the community based management and rehabilitation of the mentally ill. Sensitize the community about the diseases to dispel attached stigma. Educate the community about the harms of "Substance Abuse" and provide medical help to the victims of substance abuse. III.6.8 Render help and guidance to the health workers in other national health programmes as per the guidelines issued from them from time to time. IV. Services to the elderly In wake of the demographic transition occurring in the State elderly people are emerging as a major chunk of population. They need special attention. Because of their physical incapability this group of beneficiaries very often find it difficult to access -the health care facilities. IV. I -Motivate the health workers to render services at the doorsteps of this vulnerable section of the community. IV.2. Jointly with the lady Health Supervisor, Health Supervisor should collect a clear profile of the disease pattern of elderly in the area and devise interventions to address them with the help of all the staff in Primary Health Centre/CHC. IV.3 Provide help, guidance and supervision to health workers in all their services to the elderly. V. Services to the "Physically challenged" V.I. Jointly with the lady Health Supervisor maintain 'an updated list of all the physically challenged individuals in the service area V.2 Jointly with the Lady Health Supervisor and HS should organize programmes and activities aimed at the well being of physically challenged and guide and supervise the health workers in their activities in this direction.

54 V.3 Arrange programmes and activities aimed at the rehabilitation of the physically challenged

VI. Health Education and IEC activities VI.1 Render necessary assistance to District Mass Media Wing and the IEC team for various education programmes in Health and Family Welfare. VI.2 Maintain good public relationship, with the staff and with the public and act as a Liaison Officer among the staff. VI.3 Render necessary assistance to other staff maintain good relationship with the people.

VII. Administrative Responsibilities in the institution VI.1 Render necessary administrative assistance to the Medical Officers. VI.2 Assist the Medical Officer in preparing technical reports and reports related to various national health programmes and activities. VI.3 Assist the Medical Officer in preparing technical reports related implementing the provisions of Public Health Act. VI.4 Investigative outbreaks of communicable diseases and furnish the report to the concerned Medical Officer, when there is need for special investigation. Vl.-5 Jointly with the Lady Health Supervisor prepare indent for (through the medical officer), procure and Supply in the Register and Materials required by the Health workers and their supervisors and maintain a stock register t6r such items. VI.6 Jointly with the Lady Health supervisor arrange the monthly staff conferences at Primary Health Centre/CHC and render all help to the medical officer in conducting the conference. Minutes of such meetings prepared by the computer-clerk may be scrutinized jointly by the LHS and the Health Supervisor. LHS/ HS can present the minutes of such meetings in subsequent sessions for approval.

VII. Registers and Records A Common to Health Supervisor and Lady Health Supervisor 1. .General Information Register 2. Community Education Register 3. Stock Register

55 4. Field Diaries 5. Area maps, Charts, etc. B. Specific to Health Supervisor a. Consolidation Register of activities of all workers (Male & Female) and Health Inspectors (Male &Female) and Register for Communicable Diseases. b. Register for recording the various educational-activities in the PHC area. c. Minutes for staff meetings. d. Stock & Issue Register of Education Materials. e. Any other registers for programmes or activities, as may be instructor from time to time. IX. On call Services Should be available as 24 hour on cull duty during medical or public health emergencies or if requested by higher authorities X. Any other duties assigned routinely or specially. 7. Job Responsibilities of Medical officers in primary health care institution In Kerala, the primary health care institutions fall mainly under three categories. They are: 1. Mini Primary Health Centres 2. Block Primary Health Centres and 3. Community Health Centres In addition to the above, some of the Referral Units (FRUS) and their Post Partum Units (PP Units) also have field staff under the supervision of Medical Officers. Medical Officers -working in the above institutions differ from their counterparts in secondary and tertiary level curative institutions in that they have field responsibilities in addition to curative services. Thus Medical Officers working in primary health care institutions have different job responsibilities from their counterparts in secondary, and tertiary level curative institutions. In all these -institutions Medical Officers are holding the administrative responsibility and job responsibilities of the medical officer in charge would vary- from

56 those of other Medical Officers. Thus the "Medical Officers in charge" are to be considered as a separate entity for describing the job functions. -In addition to all the responsibilities that any Medical Officer in primary health care institutions would have, the Medical Officers in charge have some -specific responsibilities by virtue of his being the administrative head of the institution. Generally, mini Primary Health Centres have only one Medical Officer who may also hold charge of the institution. In cases where there is more than one, medical Officer the senior among them may be in charge of the. institution. In block Primary Health Centres and Community Health Centres, where there are more than one Doctor, the senior most among them may be in charge of the institution. A junior may hold charge of all institution in the presence of a senior only under specific orders from authorities. Charge Medical Officer a directly -report to the District Medical Officer of Health in matters of administration such as transfer leave sanction etc., and to the concerned Deputy District Medical Officer of Health or District Medical, Officer of Health as the case may be in matters relating to finance, professional matters, supervision, coordination and control. He can collect and forward, his comments the recommendations, all reports, submissions and communications from other Medical Officers to District Medical Officer of Health or Deputy District Medical Officer of Health as the case may be. 1. Medical Officer in charge 1.1 The Medical Officer in charge should have overall charge and is responsible for implementing all activities grouped under health and family welfare in the institution area. 1.2 They should have overall supervisory responsibility of all the staff and should assign responsibilities to Dictionaries under them for proper functioning of the institution. 1.3 M.O in charge should be responsible for organizing dispensary, out patient clinic and assigning responsibilities and duties to the auxiliary staff. He should organize the laboratory in the institution and within the scope of such laboratory would help in diagnosis in doubtful cases. 1.4 M.O in charge should be responsible for the overall supervision of other Medical Officers and all the field staff in their field activities.

57 I.5 M.O in charge should be responsible for all financial transactions in the institution subject to the provisions under delegation of financial powers. 1.6 M.O in charge should have administrative, financial and disciplinary: functions as per delegation of powers and can exercise overall control over the staff and activities in the institution. These responsibilities would be guided by the service rules and orders of the government. 1.7 Conduct monthly staff meeting at the institution and attend all the, meetings at the district level 1.8 Exercise powers and render duties as, "village health authority" and other powers and duties as per any statute existing. 1.9 Conduct concurrent and consecutive supervision of all Medical Officers under him including Medical Officers in mini primary Health Centres. 1.10 Organize and conduct "Performance Audit” of institutions (Subcentres and Mini Primary Health Centres) with the help of audit team constituted for this purpose-. (Instructions on this regard may be issued separately.) 1.11.1 Attend sectoral and project level meeting of ICDS projects. Review the health, care related works of AWWS. Render continue education sessions to AWWs in sectoral and Project level meetings 1.12 Organize and conduct induction training for field staff or other categories of employees at the institution level with in reasonable period of their joining service. Over and above the responsibilities mentioned above M.0 in charge would have responsibilities common to all Medical Officers, unless specified otherwise. M.0 in charge should have to undertake and implement any other tasks or programmes the authorities may assign from time to time. II Responsibilities common to all Medical Officers Medical Officers in Primary Health Care institutions have the following responsibilities: (i) Administrative and Financial (ii) Professional - Provision of curative services (iii) Professional -Field Responsibilities (iv) Supervision, Co-ordination and control. I. Administrative and financial responsibilities

58 1.1 Medical Officers who are not in charge may have administrative and financial functions as per delegation of powers made by authority. 1.2 Reporting Medical Officers other than charge Medical Officer are to report to charge

Medical Officer in all matters. All communications to higher levels are to be routed through the medical officer in charge only. II. Professional responsibilities - Provision of curative services. III.1 Out patient services All Medical Officers in primary health care institutions have responsibilities related to provision of curative services They are to be available for routine out patient services in the institution during prescribed time for out patient clinics to screen, example diagnose, prescribe, investigate, treat and follow-up sick individuals, examine. III.2 In patient service In patient services are usually provided in institution having two or more Medical Officers. Since there is no “unit system” in these institutions all the Medical Officers may have responsibility in service provision to the in-patients. After the routine out-patient hours all call from the inpatients should be attended by the Medical Officer “On call duty”. Medical officers in charge is in on call charge of inpatients. If there are at least two more Medical Officers available for taking call duty, the charge medical officer may be exempted from “call duty”. Medical Officers should attend call duty on rotational basis and such duty assignment should be made by medical officer in charge and approved in the monthly conference of the institution. The name of Medical Officers on “call duty” should be displayed for the knowledge of staff and public. The Medical officer on call duty should attend all calls from the inpatients. Such calls should be made, by the staff on duty in the institution. Calls can be sent by any mode i.e. over telephone, through a staff member or a messenger. In the latter cases calls may be sent in writing under the signature of the staff on duty sending the call. 111.4 Medico -legal cases and emergencies All Medical Officers including the medical officer in -charge are to-attend medico legal cases and emergencies. All Medical Officers have equal responsibility in attending

59 such cases during routine working hours. After routine OPD hours, staff on duty should report such cases to the Medical Officer on "call duty". However, the -medical officer in charge should, ensure that such cases are not denied services. Duty staff in the institution should send "call" to the. duty doctor on such emergencies and medico legal cases as and when such cases report to the institution.

IV. Professional responsibilities related to the field activities. IV. 1. All Medical Officers in primary health care institutions should have field responsibilities. Medical officer in charge would be in overall charge of all the field activities. All field staff would be-reporting to the officer in charge through proper channel. IV 2 Whole area under a mini Primary Health Centre would usually be under the single Medical Officer available. If there is more than one Medical Officer, the area will be assigned in such a way that all of them are having equal areas to serve. IV.3 Block Primary Health Centres and CHCS should have only one panchayat area under their direct service, provision. They may, also have varying members of mini Primary Health Centres under them, In such cases Medical Officers. in the block Primary Health Centres may be assigned field responsibilities over mini Primary Health Centre areas. For this purpose the whole field area under any bockPrimary Health Centre or CHC may be considered as a single unit and may be divided and assigned to all Medical Officers in block Primary Health Centre or CHC. These Medical Officers, should be directed to coordinate the field activities in the field area of the mini Primary Health Centre with the help and support of the medical officer of the institution and should be held as the "responsible officer at the head quarters" for such mini Primary Health Centre areas. Since vehicles are being provided to the mini Primary Health Centres from the block Primary Health Centre/CHC for field activities, Doctors, Medical Officers can easily proceed to the mini Primary Health Centres for such field activities. IV.4 Concurrent Supervision All Medical Officers in primary health care institutions should engage is concurrent Supervision of their field staff. Each Medical Officer should perform concurrent supervision of at least two JPHNs, two JHIs and two supervisors (LHI, HI,

60 HS, LHS as the case may be) during any calendar month and should report to the medical officer in charge. Details of such concurrent supervision should be discussed in monthly review meetings. Compliance with remedial/corrective measures proposed during such visits should be followed up meticulously. IV.5 Consecutive Supervision All the Medical Officers in primary healthcare institutions should do consecutive supervision of their field staff. Each Medical Officer should. perform consecutive supervision of at least one JPHN, one JHI and one supervisor (LHI, ]RI, HS, LHS as the case may be), during any calendar month and should report to the medical officer in charge. Details of such consecutive supervision should be discussed in monthly review meetings and subsequently followed up. IV.6 All Medical Officers may be involved in "performance audit" of staff as per. the guidelines of "Performance Audit" to be issued separately. IV.7 Implementation of National Health programmes IV.7.1 Reproductive and child health programme All Medical Officers 'in primary health care institutions, have responsibilities under this programme. All field activities should be consolidated and reported through the medical officers in charge. Individual job responsibilities of medical officers could be understood from the programme implementation plan and Medical Officers can use the publication "Reproductive and Child health Programme- Module for Primary Health Centre medical Officers- integrated skill development training” published by the National Institute of health and Family Welfare, New Delhi as a reference material. The publication is available for reference with district training officials and at the State Institute of Health and Family Welfare, Thiruvananthapuram. IV.7.2. National Anti-malaria programme 7.2.1 All Medical Officer should actively involve in both active and passive surveillance. 7..2.2 They should guide health workers, and their supervisors in preventive strategies, case detection and treatment. 7.2.3 They should guide them on correct dosage in radical treatment and may render medical support in cases of adverse drug reactions and other complications.

61 7.2.4 All cases of Malaria in the area should have to be investigated by one of the Medical Officers to the satisfaction of medical officer 'in charge, who should be ultimately responsible for such activities 7.2..5 Medical officer in charge or one of the Medical Officers delegated should be responsible for coordinating the work with the Laboratory technician, supervising him and for sending sufficient number of slides for cross checking as laid down in the programme plan. 7.2.6 Medical Officers during their supervisory should ensure compliance of workers and their supervisors with guidelines of the programme.

IV.7.3 National Leprosy Eradication Programme 7.3.1. Help in detection and management of cases of Leprosy. 7.3.2. Give guidance to health workers and their supervisors on programme activities. 7.3.3. Render support in treating reactions of Leprosy and adverse drug reactions. 7.3.4 Render support in health education activities and IEC activities. 7.3.5 Coordinate of NGOs and voluntary agencies involved in leprosy Elimination Activities IV.7.4. STD/AIDS Control programme 7.4.1 Help in early detection of STI/RTI cases and provide treatment (guidelines issued under Syndromic management of RTI/STIs may be followed) 7.4.2 Provide health education and arrange IEC activities to prevent spread of RTI/STIs. 7.4.3. Arrange health education sessions aimed at prevention of RTI/STI infections and HIV/AIDS. 7.4.3 Target the. "Special High risk groups" and, come out with interventions as specified in the National HIV/AIDS control programme. IV.7.5. Revised National Tuberculosis Control programme 7.5.1 Impress upon the health workers and their supervisors that RNTCP -is a programme implemented through general health services. Enlighten them on the importance of case detection and prompt treatment with DOTS. 7.5.2 One of the Medical Officer should be assigned the specific responsibility of coordinating all the programme, activities in the centre.

62 7.5.3 Render support in medical management (DOTS)'of cases. Fetch timely medical support for patients who develop adverse drug reactions. Manage them at the institution and refer them if necessary to higher centres. 7.5.4 Encourage health workers on case detection, examination and referral of patients to microscopy centres. IV.7.6 National programme for control of blindness 7.6.1 Coordinate blindness control activities in the assigned area. 7.6.2 Help in detection of cataract cases and them for surgery. 7.6.3 Detect and treat ailments of the eye and refer to specialists as and when necessary 7.6.4 Detect cases of visual defects in children and refer them for expert treatment and connection of visual impairment. 7.6.7 Organize eye check up camps in schools with the help of refractionists and refer children with visual problems for specialist, care. 7.6.8 Help to organize and conduct special camps for detection of cases of blindness, especially due to cataract and motivate them for surgery. 7.6.9 Arrange special camps for surgery of cataract cases and render all support in mobilizing patients, conducting surgeries and following them up. 7.6.10 Spread the message of "eye donation" and render support and guidance to individuals willing to donate their eyes. 7.6.11 Arrange for removal of eyes from willing individuals without delay. 7.6.11 Enlighten the community about eye care, importance of Vit. A supplementation, dietary habits and prevention -of injuries to eyes. IV.7.7. School Health Programme 7.8.1 Conduct medical examination of school children and provide services accordingly 7.8.2 Arrange health education sessions in schools and spread the message of healthy lifestyles, national health programmes and topics of importance from health care point of view. 7.8.3 Supervise health workers and Supervisors in their school health activities IV.7.9 National Mental Health Programme 7.9.1 Render support to detect cases of mental illnesses and provide medical treatment. 7.9.2 Provide referral support to patients with mental illnesses

63 7.9.3 Encourage community based management and rehabilitation of chronically mentally ill. 7.9.4 Detect and arrange for treatment of diseases related to mental stress 7.9.5 Spread the message of healthy lifestyles, 'avoidance of habit forming substances, problems of. "substance abuse" and other psychosocial problems. Render support in early detection of such problems and management. IV.7.10 Services to Adolescents 7.10.1 Arrange health education/counseling sessions for adolescents with the help of field staff. 7.10.2 Arrange Adolescent Clinics and provide special services to the adolescents Refer programme guidelines of Reproductive and Child Health Programme for information) IV.7.11. Service to the “Elderly” 7.11.1 Motivate the health workers to render services at, the doorsteps of the elderly 7.11.2 With the help of field staff, collect a clear profile of the disease-pattern of elderly in the area and devise interventions to address them. 7.11.3 Provide medical help and rehabilitative support to elderly. IV.7-12. Services to the "Physically challenged 7.12.1 Arrange programmes and activities aimed at the rehabilitation of the physically challenged. 7.12.2 Render medical help, support and suitable referral services to physically challenged as and when required. IV.7.13. Other-national health programme 7.13.1 Actively participate in implementation of other health programmes. Take steps to implement the programmes as per individual programme, implementation guidelines. Provide guidance, support and supervision to health workers, supervisors and other paramedical staff in their programme activities. 7.13.2 Actively involve in organisation of special programmes like National Immunization Days (NIDS: eg. Pulse Polio), Special camps and similar activities IV.7.14 Health Education and IEC-activities

64 7.14-l Refer necessary assistance to District Mass Media Officers/Health Education Officers and the IEC team for various education programmes in Health and Family Welfare. 7.14.2 Take necessary steps for control of comnumicable diseases such as chicken pox Cholera gastroenteritis, dysentery, typhoid, UlP target diseases etc. 7.14.3 Conduct out break investigations,, as and when directed and report to the medical officer in charge. Help the medical officer in charge in preparing technical reports, containment and preventive measures and other activities in times of outbreaks/epidemics of communicable diseases 7.14.4 Give necessary directions and guidance to all subordinates especially Health Supervisors and Lady health supervisors for Health, Family Welfare and Nutrition Education. 7.14.5 Arrange, supervise and co-ordinate programmes for Environmental Sanitation. 7.14.6 Detect, treat and prevent malnutrition especially-among children and mothers and render necessary nutrition services and conduct nutrition education. V Other Responsibilities V. 1. Attend conference at various levels when required including monthly staff meeting at PHC. V.2 Attend sectoral and project level meetings of ICDS, projects. Review the health care related works of AWWS. Render continuing education sessions to AWWs in sectoral and Project level meetings V.3 Attend meetings of MSS workers, voluntary health workers and meetings of similar groups on request from the organizing health worker and provide training and education sessions V.4 Render support to the supervisors in organizing- and conducting “induction training" of field staff at the institution level. V.5 Attend in-service , trainings and other training's related to national health Programmes or special activities as and when directed to do so. V.6. Issue certificates, in the capacity of medical officer, to beneficiaries of various social security and benefit schemes as and when Tested.

65 V.7 Issue medical certificates and fitness. Certificates and certificates of Physical fitness (to join employment etc) in the Capacity of medical officer and may charge the prescribed fee. V.8. Attend to emergency cases at the residence of the patients and give necessary emergency, treatment and advice. V.9 Attend special duties related to fairs and festivals, natural calamities, visits by VIPs, special campaigns and camps as and when directed by authority. V.10. Any other duties which a Medical Officer of a PHC is expected to perform in view of his position and any other duties which will be assigned as and when required.

Chapter – 2 T R A I N I N G Learning Objectives 1. By the end of this session the participant trainee should be able to understand the importance and gain sufficient knowledge and develop positive attitude in the various aspects with regard to training. 2. To develop skill, in managing the different training programmes in a PHC and thus become able to assist the MO in the same. Duration : 2 Hrs Methodology : Lecture Cum Discussion The dictionary meaning of “to train” is to educate to rear and instruct to discipline, to break or reduce to docility, to teach, to perform certain tricks etc. etc. Training is therefore, the process of education in which both the mind and body are brought under exercise and discipline. Definition Training is a conscious effort to fill the gap between the existing and expected levels of knowledge, attitude and practice. Objectives of Training

66 In public service the following are the objectives of training 1) Efficiency 2) Economy in learning time 3) Elimination of faults 4) Morale building 5) Career development 6) Improvement of administration Types of Training There are different types of training depending on the situation and purpose. In the case of technical personnel there are three blocks of training phases-Pre-services training, orientation and in service training. The pre-service training takes care of the preparation in general of any individual (trainee) for qualifying for a certain set of professional or specific job oriented roles. The orientation training is given to the persons who have been recruited for a particular job. This is to orient them towards their job responsibilities. This is therefore of short duration than the pre service training. In orientation training they learn their responsibilities and get aquatinted with the responsibilities of the others with whom they work in the organization. Orientation also gives a deeper insight about the methodology of the day to day activities and the overall goal and objective of the organization or department. Sometimes orientation training is required from time to time when new responsibilities are given to the workers. Either they may have changed or new set of roles to play or may have some additional role to play besides what they were doing already. In short orientation training is a preparation for the specific job to be performed in a particular position. Pre-service training is pre recruitment whereas orientation training is in the form of new recruitment or apprentice training. The other types of training commonly given to the people in service are in service and refresher courses. Such training is given with a view to updating knowledge and skills of the workers in any department or organization. Training Process Training in any situation is split into three parts or phases. The pre-training phase, training phase and the post training phase.

67 In the pre-training phase the training needs according to the job description are identified. The employer in need of trained personnel has to be consulted with regard to the job specification, description etc and the course is planned for its curriculum content, duration etc. During this phase other preparations are also to be made for getting ready to conduct the course. The necessary staff, and their orientation, physical facilities, proper selection of candidates, etc, fall in this first phase of preparation. In the actual training phase the training curriculum is to be followed and necessary arrangements have to be made for concurrent monitoring and evaluation. The training curriculum is to be modified now and then by making mid course evaluation and changes to suit the objective and needs. The training phase must have the opportunities for learning by doing and also creating necessary environment in which learning can take place effectively. The post training phase refers to the follow up of the trainees in their new positions to ascertain how much they have absorbed from the training and how much is put in to practice. This kind of post training evaluation is a very difficult task because the training organization must have necessary facilities for this work and the department concerned must also permit this mechanisms to be applied for unbiased evaluation. Such evaluation of course, will help for remodelling the training curriculum The basic training in any technical job is an intensified, structured course of training and its focus is on the technical subjects and their practical to provide opportunities for the trainees to acquire the necessary knowledge and information and practical skills in relation to the functions. The in service training is organized by the organization which employs people, whereas the basic trainings usually under taken by the appropriate training centres which have to satisfy the required norms and standards for ensuring a proper quality of training. For an effective training process the following components are essential. The attitude of the department has to be sympathetic and frank. They should be able to express and demand from the training centre, whether basic or in service, what exactly the trainees have to learn in order to be able to function effectively and fulfill the tasks given. The trainee must have proper aptitude for learning and working with sincerely.

68 A very high sense of commitment and sincerity will be required from the trainees because it is in shown that a huge responsibility lies in shaping and moulding the behaviour of the trainees to understand their future responsibilities without any lack of understanding or pit-fall. The training aspect which embraces the training institution and its personnel and paraphernalia and the methodologies of training will be the most important intervening variable. It is on the quality and quantity of the training that the behaviour and the performance of the Trainee in future occasion depends. Therefore the performance of the trainee and in turn the efficiency and effectiveness of the programmes are the dependent variables. In the post training phase when trainee is put in the job he should have a high motivation and enthusiasm to apply what he has learnt meaningfully. To sustain his interest and effort he must have proper organizational support, by way of able direction, guidance, supervision, incentive, rewards, etc. Strategy of Training Though training in general means the education of people to equip them for their own work, it must be understood that different categories of people will require different types of training depending on their levels of comprehension, previous back ground, maturity, commitments and so on. The industry of training and the balance between theoretical and practical training will also change from category to category. Curriculum Planning Any organized training requires to be done with proper planning, with regard to, what is to be taught and how it is to be taught and by whom. All this will depend on the training needs. Unless everything is specifically planned in advance and kept ready it may become difficult to follow a systematic course of event after the training has been commenced. It is, therefore, a common practice in all training centres and institution to prepare what is known as curriculum. Curriculum is a design for enabling the learning in a training situation. It is a systematic sequential arrangement of the objectives, the content, the methods of instructions to be adopted and the materials to be used in support of educational methods.

69 Curriculum development or curriculum planning entails the following steps. 1. Job analysis and study of the job specification. This is done to know the training needs, while the job analysis will give a comprehensive picture of the training needs it is always better and necessary to know from the administrator or employer, any other specific needs that may be in their minds. 2. The objectives should be framed in keeping with the job description or expectation. 3. Listing of subjects, topics or area that are essential. After preliminary agreement on the different objectives to be taught, sequence should be worked out to enable the learner to learn his job step by step, ranking and prioritization should be done with regard to the subjects or topics 4. The method of instruction for each area or unit should be discussed and evolved and time allotment shall be made with regard to the method of instruction (theory demonstration practical, etc) 5. A scheme of evaluation should be worked out to monitor the levels of comprehension and change of attitude and behavior among the trainees, during the training and at the end of it. A well developed curriculum may require modification from time to time depending on the changing training needs for the job and also the feed back of the evaluation. A curriculum is of great help in organizing training course because it is a carefully planned document. It is needless to say that in any job oriented training the emphasis should be more on the skill development and therefore, it should provide adequate practical exercise and demonstrations. Lesson Plan It is a statement of the aims and objectives of a particular session and the specific methodology and means of instruction and learning. Lesson plan is the guide for the teachers because it helps to cover the topics and without missing anything. The following steps may be followed while preparing a useful lesson plan 1) Setting preliminary information with regard to the date, place and topic of the lesson and the background of the trainees

70 2) Framing the objective or intended outline of the lesson plan 3) Giving a synoptic outline of the content ensuring that all the salient points are included. This outline has to be used as a guide at the time of conducting the session and the teacher must make sure that no point is missed. 4) Deciding the method of instruction and the aids to be used 5) Provision for concurrent evaluation during the session and time for review or essional evaluation. A format for the lesson plan 1) Category of trainees 2) Topic 3) Time 4) Objectives 5) Content (introduction, content summary) 6) Method 7) Aid 8) Evaluation 9) Reference Training Evaluation It is a process of determining the degree or amount of services with pre determined objective. Evaluations is an attempt to learn what changes have taken place during and after specific programme and what part of these changes can be attributed to the programme and how much of the objective has been achieved. Therefore evaluation can be qualitative and quantitative - qualitative in the sense that a desired change has taken place or has not taken place; quantitative in the sense of measuring how much the change has been taken place. The objectives of training are change and increase in knowledge, attitude and skills. Impact of any training programme depends upon the trainer and trainee. The ultimate purpose of training evaluation is to provide information with which the training programme can further be improved. Evaluation should be made side by side with the training process. The terminal evaluation will help in knowing the sum total of the change of knowledge, attitude and behaviour.

71 Areas Of Evaluation Of Training 1. Trainee 2. Trainer 3. Training Content Steps In Evaluating Training Programme 1. Assertain the objectives 2. Decide on the criteria for evaluation as against the objectives qualitative and quantitative. 3. Develop indicators or indices for measurement. 4. Decide the design of evaluation 5. Data to be collected 6. Analysis and interpretation.

Chapter – 3 S U P E R V I S I O N 3.1. SUPERVISION Learning objectives 1. By the end of the session the participant should be able to gain adequate knowledge with regard to the meaning concepts, definition objectives principles, functions and qualities of supervision. 2. To enable the participant to develop proper skill in effective and supportive supervision Duration : 12 hours for theory 3 days for observation, Role play & practice Methods : 1 Lecture cum discussion

72 2 Brain storming 3 Observation 4 Role play 5 Practice Introduction Supervision is overseeing the work of other/others to ensure that a job is done properly. Therefore a supervisor is always dependent on others for his/her own success. As a lady Healthy Inspector, your primary responsibility is to supervise, and above all to assist the Jr.P.H.N. Supervision is essentially an educational process in which you take the responsibility for helping your subordinates to develop themselves and become more competent in their job. Concepts Supervision is earlier conceived as inspecting and finding fault with subordinates. The modern concept of supervision is to guide and help the subordinates in their work by way of training, demonstration, checking, individual counselling and guidance.

Why Supervision Is Important The effectiveness of workers depends largely on the supervision they receive. In other words, quality of work is directly related to the degree of supervision. High degree of supervision improves the quality of work. Poor supervision leads to poor work. So good supervision is very important for health workers. Even well trained and highly motivated health workers eventually become discouraged when supervision is lacking. Objectives of Supervision 1) To help subordinates to do their job skillfully/effectively 2) To develop subordinates capacity to the fullest extent 3) To guide/assist in meeting pre – determined work objectives. 4) To promote effectiveness of subordinates. 5) To motivate subordinates and maintain high morale. 6) To promote team work. Methods Of Supervision 1) Staff meatings

73 2) Informal discussion of observations 3) Training sessions 4) Review of records, and reports. 5) Formal evaluations perhaps using check list) On the job supervision is the best because supervisor can identify shortcomings and immediately give guidance Definition Of Supervision It may be defined as an art or a process by which designated individual or a group of individuals oversee the work of others and establish control to improve the work as well as the worker Functions Of Supervision A supervisor is often called an educator, a research person, a group member, observer, a learner and an administration. The major supervisory function are 1) Orientation of newly posted staff. 2) Assessment of the work loads of individuals and groups. 3) Arranging for the flow of materials. 4) Encouraging community participation. 5) co-ordination of the efforts 6) promotion of effectiveness of workers 7) Promotion of social contacts with in the work team. 8) Helping individuals to cope with their personal problems 9) Facilitating the flow of communication 10) Raising the level of motivation 11) Establishment of controls 12) Development of confidence 13) Record keeping. Principles Of Supervision (Principle can be defined as a fundamental statement of truth which serve as a guide to thought and action. A principle enables a man to approach his problem systematically in a methodological and scientific way.) 1) Supervisors should not overburden any individual or group

74 2) Causing un reasonable pressure for achievement results in low performance and low confidence in the supervisor 3) Supervision should be general and not too close. 4) Supervision calls for good planning and organization. 5) Encourage worker participation in decision making. 6) Effective supervisors are good communicators 7) Capacity to influence downwards depends in capacity to influence upwards. 8) Supervisors need to understand the problem and the situation. 9) Supervision is a process of co operation and co ordination. 10) Creat suitable climate for productive work. 11) Give autonomy to workers depending upon personality, competence and characteristics 12) Technical competence of supervisor contributes to success. 13) Supervision should be a teaching learning process. 14) Make considerable efforts to train subordinates. 15) Supervision should focus on low performing staff and guide them properly

16) Supervisors are responsible for checking and guidance. 17) Good leadership is part of good supervision. Qualities of a supervisor 1) Forcefulness, integrity and firmness. 2) Full awareness of the job and the rules and regulations. 3) Full awareness of the existing situation. 4) Intelligence and willingness to Grow 5) Good judgment, impartial, understanding of others emotions, attitude and feeling and quickness in recognizing achievement of subordinates 6) Ability to delegate duties and responsibilities, to the right ones to the right persons. 7) Non interference, unless necessary 8) Continuous guidance, cooperation and co ordination

75 9) Sympathetic attitude and good listening. 10) Willingness to adopt new policies and accept changes if necessary. 11) Ability of communicate information skillfully and tactfully. 12) Good health, self confidence, enthusiasm for work. 13) Ability to work with others, ability to inspire, and take immediate action. 14) Knowledge of activities, techniques and procedures. 15) Objectivity, impartiality and fairness in dealing. Types Of Supervision Effective Supervision Supervision that brings about improvement in the skills of the health worker, improvement, in the utilization of the available health services by the people and positive changes in the health behaviour of the people is said to be effective supervision. A Lady Health inspector requires certain skills to be an effective supervisor. They are: 1. Inter Personal Communication Skills (IPC) She should use effective IPC skills. This consists of effective speaking, active listening and movable skills. Deal with the Jr PMNs in a friendly and Diplomatic way. Only at times, when need comes and LHI has to be firm. The above skills will motivate or impress her health worker and health workers will be motivated.

2. Technical knowledge She possess should technical knowledge of the programme activities and the various other activities, she is supposed to do. She may have to demonstrate, how each activity is performed. 3. Leadership qualities: A good supervisor is a good leader. It depends upon the ability to handle various situations. . Ability to handle various situations. . Ability to take responsible decisions . Capacity to understand the feelings and problems of the subordinates. . Objectivity in approaching a problem.

76 . Willingness to sacrifice personal one to assist the subordinates . Avoiding personal bias and prejudice in making decisions Remain committed: Any activity undertaken, must show that she is committed. It helps others to take up the activities with the same real.

PATH TO GOOD SUPERVISION Observe . To what extent health worker uses communication the delivering services . Does the interpersonal communication input help client to better understand the problem . What is lacking in IPC of health worker?

77 DECIDE . The gaps observed by the L.H.I in use of communication skills by the health worker . The extent to which communication needs of the people by health worker has been recognized . Whether outcome of communication efforts has been effective

ACT . Give specific training on the gaps identified during observation . Give, on the job training, on communication skills. . Organise work shops for the health workers at different points in time, on regular intervals. . Help the health workers to fulfill the communication needs of the people to be listened to and provide in formation with empathy and winning the confidence of people.

Direct Supervision

This is the best method of supervision. Generally it is difficult to evaluate the work especially of communication activities like counseling or the sessions conducted during MSS meetings. It is better if you can observe the entire range of communication activities undertaken by the health worker directly and get immediate feedback. Following is a list of things that you can directly and get immediate feedback. Following is a list of things that you can directly observe by paying visits to the community to the sub-centre conferences and training sessions.

78  The IPC skills of health workers and the way she interacts with clients, village panchayat members, school teachers, adolescents opinion leaders etc.  The counseling skills of the health workers.  The interviewing skills.  The ability to motivate the community members and form effective partnerships.

Indirect Supervision

Supervision can also be done by indirect observation of records, reports and various data from the field. However, in indirect observation you are not in a position to give immediate feedback to the health workers. In direct supervision can be done during the monthly review meetings in the PHC. This only helps you to assess the performance such as the number of meetings held, number of posters distributed, etc. But it does not provide you what was discussed and what emerged out of such efforts. For this direct supervision is very effective tool.

Situations for Supervision

A checklist is a tool, which will help you to systematically monitor the quality of services that are being provided by your health workers. The check list contains a list of programme activities as well as performance standards that are expected from the health personnel. The items in a checklist must be grouped and arranged logically and should not be too long or too short.

Following is sample checklist, with will help you to monitor the communication process followed by the health worker while delivering the RCH services. If you wish you can add a few more column to suit your needs. Date Services Location Audience Average Communicat Follow up Results Remark profile number of ion method activities s people to be used. attending Promotion of Community Eligible 15 Focus Group Counselling for the contraceptive Hall couple Discussion adoption of usage appropriate method at the sub-centre Motivate for Village School Mahila 20 Group Meeting of the MTP Mandal meeting acceptors to be Laparoscopy, Anganwa conducted by MO

79 Mini di at the Sub-centre Laproctomy Workers, TBAs Education on Youth club High risk 8 IPC Referral medical RTI/STI group men check ups at the and PHC women

Supportive supervision Supportive supervision means to support and supervise. In order to perform supportive health worker but you yourself will be able to perform such activities. This will help you to support the health workers in their activities and also teach them on the job. Supportive supervision is very useful as it help to raise the confidence of the health workers. It is like an umbrella which provide relief in the scorching sun. To understand supportive supervision, you can consider a situation where a health worker is finding it hard to counsel a couple who has come to the sub-centre to learn about various contraceptive methods. You can then help her to counsel the couple by actually taking the counseling session yourself. The health worker observes you, way of counseling the couple, and learns the techniques of managing clients. Review with health worker on areas which really helped couple decide. Supportive supervision can be done to help the health worker in:  Conducting interviews.  Counselling clients.  Managing rumours and misconceptions.  Using IPC skills like verbal, non – verbal and listening skills effectively.

Supervising the making of community partners The purpose of the new RCH Programme is to bring in a behaviour change in people. This task is enormous and cannot be done by a few people. Here, you will understand that to bring about a wide change in the behaviour of the people, we need to seek the help of key persons of the community by making them partner.

80 As an L.H.I, you should help the health worker assess the need of a particular programme or activity. For e.g., the success of the immunization programme may require that partnerships be formed with school teachers, NGOs, village panchayats and parents. The next stage is to help the health workers from partnership with the key persons on whom the decision has been taken. You should ensure that the health workers approach these partners with care. They should be able to convince them to be partners so that all come forward to help her willingly. You should also ensure that the partnership are formed willingly and no force is applied.

Forming Partnerships

The partners can also be:  Organised or  Unorganised The organized groups are village, Panchayats, women collectives, youth groups etc. The unorganized groups are housewives, mothers-in-law, husbands etc

Methods To Involve Community Partners

After having formed the community partners, it is important to identify the problems and the needs of the community, jointly. There are many Participatory Learning for Action (PARTCIPATORY LEARNING APPROACH) methods of interacting with the community. These are:  Chapatti Diagrams: These can be used to indicate the relationships of various institutions, organization, programmes or individuals with each other, and within the village.  Relative Ranking: This method can be used to determine the priorities and preferences in the way people and the community perceive them. Partners can be asked to do a relative ranking of the health priorities of the communities they belong to.  Village Walk: Village walks are used to locate areas in a village which are not utilizing the services offered by the sub-centre or which require special attention. For a health worker, going for a village walk with her partners is an effective

81 PARTCIPATORY LEARNING APPROACH method of collecting first hand information of the community.

Skills For Developing Good Partnerships

Certain skills are important for developing good partnerships. You should ensure that your health workers possess the following essential skills:  Coordination skills  Good IPC Skills  Interviewing skills  Following is a checklist that will be helpful to you to supervise community participation for the pulse polio immunization programme.  If there is participation and support of Panchayat leaders.  Meeting religious leaders and getting their support.  If request of public announcements from religious places that has to be made..  Concentrating on communities resisting polio drops or are uncooperative  Informing people about the location of the booth/post.  Performing wall writing at place frequented by people  Making public announcements using public address systems in market places, streets, festivals, melas, weekly gathering etc.  Organise drum beating at important place in the community.  Enlisting the volunteers for booth/post.

Key Points

 Supervision is the main activity of an L.H.I.  Supervision needed for handling complicated situations.  Components of effective supervision: IPC Skills, Technical Knowledge, Leader ship Qualities  Direct and Indirect method of supervision  Direct method is most effective  Support and supervise gives supportive supervision  Supervise for making community partners

82  Participatory Learning Approach methods to involve community partners.

Test Questions

* Define supervision.

* Why should you supervise ?

* What are the skills of effective supervision ?

* Why is direct eye contact with your clients essential ?

* What are the two methods of conducting supervision ?

* Define supportive supervision ?

* Explain supportive supervision with an example.

* How can you supervise the making of partners ?

* What are PLA methods ?

Supervisory roles

 AS A PLANNER the supervisor should be able to set largest and tasks among subordinates and enable them to prepare work plans and schedules jointly.

 AS A FACILITATOR provides resources and necessary support to the staff.

 AS A COMMUNICATOR helps by communicating and classifying duties and responsibilities and instruction and operational administrative guidelines.

 AS AN ADMINISTRATOR ensures achievements of programme targets, ensures discipline in work situation and whenever necessary initiates disciplinary procedures.

 AS A SUPERVISOR guide, assist, check number and evaluate the activities of her subordinates.

 AS A GUIDE AND FRIEND many of the personal problems may badly or adversely affect the officials duties of subordinates. In such situation a supervisor should be a good guide and friend for solving such problems as to improve the worker as well as the work.

83  AS A LEADER she has to build up team spirit among her subordinates and influence and motivate them to achieve goals as a group. She has to take initiative for different activities.

 AS A TRAINER she has to provide training whenever and wherever necessary

 AS A CO-ORDINATOR success of any group activity is largely dependent upon the quality of co-ordination of the different activities of the same programme. Hence as a supervisor has a very important role as Co-ordinator.

3.2 SUPERVISORY CHECK LIST

The goal of a Lady Health Inspector is to ensure that Health Workers provide the health care success to the community in the highest possible standard. To achieve this goal it is necessary to monitor systematically and regularly the activities of the health workers. A check list is a tool to help supervisors systematically monitor the health services being provided by health workers. This is done to ensure that health workers are providing high quality services. The activities and data on the checklist are determined by the types of services being provided and by the skills being performed by the health workers. The items on the check list are usually grouped and arranged in a logical order to make it easier for the supervisor are the check list. Some supervisors use a standardized check list, but since some may organic that work in different ways and in such cases check list may be framed accordingly. One can make the check list as a guide. The supervisors have to take it with them. When they make their visits to the subcentres. After checking an item, on the list make brief notes of your observation, assessment, recommendations or action taken. Record these notes before leaving the centre, or else you may forget to record important information. A checklist should be neither too long nor short. A long checklist will not serve the purpose effectively. If it is too short, it will not give you enough guidance, when you are visiting a sub centre. When you develop your own check list, include enough details to serve as a guide.

84 Format For Checklist

One of the sample formats is given below. Activities and skills to be monitored are listed in the left hand column. The supervisor writes her notes on her observation, assessment recommendation, action taken etc in the right hand column. Each entry should be dated. Activities and skills to be Notes Date of visit monitored 1 2 3 4 5 6

This is only one sample format. You may have a format that suits you better. If so, use your format when you develop your supervisory check list. One very important point is that supervisory check-lists are not survey forms. Participants will have had experience doing community surveys, where the objective is to collect a large amount of information. Community survey forms are often around 10 pages and are used to describe the social structure of a community and identify community leaders, desirable health conditions, and identify health problems. Supervisory checklists have a much more limited objective Checklists focus on the worker being supervised the knowledge, skills, major activities, plans, performance etc, of the worker. The checklist is a reminder to the supervisor of areas that should be covered. A useful check list is usually not more than 4 -5 pages (maximum). A number of checklists are appended herewith. The students may be

divided in to groups and opportunities may be arranged for them to test the

efficiency of there checklists. The trainees are to submit a report of their

experience of the same.

Supervisory Checklist

85 You have to supervise the ANM when she is giving ante – natal care. While supervising you must ensure that she: Tick if applicable A. Preliminaries and X if not 1. .Makes home visits whenever required. 2. Calculates the no. of pregnant women in the community 3. Conveys the importance of early registration pregnancy 4. Ensures cleanliness at place of work 5. Ensures adequate light at place of work. B. History taking 1. Greets the patient 2. Obtains information like a. Name and address b. Age of the patient c. Marital status d. Order of pregnancy e. Interval from last pregnancy f. Date of last menstrual period g. Menstrual history h. Calculates the EDD i.. Calculates period of gestation 3. Obtains obstetric history - a.. No. of times she has conceived b.. No. of living children. c. H/ o abortions d. H/O still births 4. Asks for history of any systemic illness 5. Asks for any surgery done 6. Asks for complaints if any such as: a. Breathlessness, b. Excessive tiredness c Prolonged nausea and vomiting d. Palpitation e. Puffiness of face f. Tightening of bangles or rings g. Headache or blurring of vision h. Bleeding or leaking, per vaginum j. Pain in abdomen at any stage of pregnancy Fever k.Vaginal itching or unusual discharge

86 Tick if applicable C. General Examination and X if not 1.1. Observes built and nutrition 1.2. Measures height as follows a. ensures patient has taken off shoes b. makes patient stand against wall/firm surface, and c. uses a scale/firm object to mark the height from the top of the patient's head. 3. Take weight as follows a. Checks zero error on the weighing machine before taking patient's weight. b. Ensures patient takes off slippers, and c. Compares the weight with previous weight if known. 4 Inspects for pallor on nails, conjuctiva and tongue in good light. 5. Inspects for jaundice in good light 6. Records pulse for one minute. 7. Records BP a. makes patient sit comfortably/lie down. b.checks zero error on the dial. c. ties the cuff properly over the arm. d.places the stethoscope over the front of the elbow. e. records BP correctly. 8. Tells all the procedures, of examinations to the patient. 9. Examines breasts for the presence of pregnancy changes and nipple and areola condition

87 D. Abdominal Examination 1. Inspects the abdomen for scars, size, contour and pigmentation 2. With tape or hand, measures fundal height a. ensures privacy at place of examination. b. makes patient lie down with extended legs. c. stands on side of the patient while performing the examination. d. uses ulnar border of the hand to palpate fundal height. 3. Palpates the abdomen for foetal lie and presentation. 4. Palpates for fetal movement. 5. Palpates for contractility. 6. Auscultates the foetal heart rate. 7. Recognizes abnormalities like twins, abnormal lie. F. Follow-up visits 1. Greets the patient 2. Takes the history 3. Asks for any complaints 2. Calculates period of gestation 5. Takes weight and watches for weight gain 6. Takes pulse, BP 7. Looks for pallor 8. Looks for oedema of feet 9. Takes fundal height 10. Palpates abdomen. for fetal lie, presentation contractility and fetal movement 11. Auscultates fetal heart rate 12 Advises regarding next visit and management

88 G. Ante-natal advice 1. Can do Hb estimation 2. Can test urine for albumin and sugar 3. Counsels about adequate diet 4. Explains about adequate rest 5. a. explains about increased requirements of iron b. explains the dangers from anaemia c. gives Iron-Folic acid tablets to the patient d advises patient to take tablet daily 6. a. explains about TT immunization b. gives immunization in the correct dose c. ensures a gap of at least one month between 2 doses H. Counselling 1. Counsels about importance of adequate diet and rest. 2. Counsels about what and how much to eat according to local food habits. 3. Counsels regarding - expected changes during pregnancy. 1. Counsels regarding regular ante-natal check-up. 2. Counsels for breast care and exclusive breast feeding of neonate. 3. Counsels regarding hygiene. 4. Counsels about where, when , whom to approach in case of emergency. 5. Counsels regarding preparation for delivery a. by trained person b. for clean delivery c. availability of disposable, delivery kit d. referral to nearest hospital 'in an emergency e. for arrangement for transport f. to arrange for financial aid if required in emergency 9. Counsels regarding minor ailments during pregnancy

89 Supervisory check list

You have to supervise the ANM when she is giving intra – natal care. While supervising you must ensure that she:

Tick if A. Preliminaries applicable and 1. Ensures to check-up her delivery kit. X if not 2. Ensures availability of adequate light 3. Identifies most appropriate place for safe delivery 4. Ensures cleanliness at the place of delivery. 5. Ensures soap, water, clean towel, BP apparatus , fetoscope and weighing scale and watch. 6. Reviews the patients ante-partum record for the following 7. Checks age parity, weeks of gestation normal progress of pregnancy problems/complications 8. Washes hands with soap and water.

Tick if B. History taking applicable and X 1. Greets the patient. if not 2. Enquiries about time of onset of contractions 3. Enquiries about about frequency, duration and intensity of contractions 4. Asks for blood stained discharge. 5. Asks for leaking PV and if yes since when and colour 6. Enquiries about foetal movements 7. Enquiries about the when she had anything taken orally

90 Tick if C. First stage of labour applicable and X 1. Encourages frequent emptying of bladder. if not 2. Recognizes !st stage of labour 3. Differentiates true and false labour pains 4. Gives soft diet and liquids to the patient during 1 st stage of labour frequently in small amounts Monitors matemal vital signs. 6. Monitors progress of labour. 7. Monitors foetal condition. 8. Encourages ambulation till bag of waters is ruptured. 9. Counsels to reduce the anxiety of patient. 10. Detects during labour any risk factor early. 11. Arranges for early referral 12 Reassures the patient and tells her NOT to bear down in 1st stage of labour

Tick if D. 2nd Stage of Labour applicable 1. Practices asepsis during delivery and X if 2. Recognises onset of 2nd stage of labour. not 3 Encourages her to 'push' only during good contraction. 4. Tells her to relax and take deep breaths between pains. 5. Provides support to perenium with a pad when crowning of head takes place. 6. Conducts normal vaginal delivery safely and efficiently. 7. Prevents injury to maternal tissues and fetus. 8. Ties arid cuts the cord aseptically leaving behind adequate stump. 9. Wipes the baby clean and wraps it. 10. Does suction through mucus extractor if so needed

E. 3rd Stage of Labour

91 1 Recognizes the onset of 3" stage of labour. 2. Delivers the placenta and membranes properly. 3. Inspects the placenta and membranes for its completeness. 4. Gives inj. Methyl ergometrine (0.2 mg) IM after delivery of placenta. 5. Performs immediate maternal physical examination. 6. Identifies complicated case and arranges for referral. 7. Observes the patient for 1 hour after delivery of placenta for signs of PPH.

You have to supervise the record maintenance done by ANM and ensure timely vital registration. Self-assessment questions:

List the signs of onset of labour. Which pregnant woman can be delivered at home? What are signs of separation, of placenta ? Tick if A Immediate Post-natal Care applicable 1 Records the details of the birth for registration etc and X if 2 Monitors maternal vital signs and baby’s condition. not 3 Watches for bleeding PV 4 Weighs the newborn and records it 5 Gives the baby to the mother to breast feed 6 Explains the mother how to care for herself and her baby by regular check-up, nutrition, immunization and family planning

Tick if B Follow up[ visits at home a clear room with a right to privacy applicable 1 Elicit proper history about general health, diet bowel, bladder and X if movements, bleeding PV not 2 · Notes temperature • Notes B. P • Notes pulse • Examine breast • Palpates abdomen for height and consistency of uterus. • Does perineal inspection examination and observes the colour of vaginal discharge. • Looks for the swelling over legs, redness and asks for pain in legs if any.

3 Inspects lochia

4 Enquiries about any post partum complications

92 5 Looks for signs of sepsis and if so, refers the patient. 6 Assesses newborn (See..for fontanelle, eyes, colour of skin, hydration umbilical cord, sucking, passing urine and stool and gives the- first immunization),

7 Advises for atleast 3 post-natal-follow-up visits 8 Explains the advantages of breast feeding correct technique. 9 Explains about weaning and its benefits. 10 Explains all the queries that the woman attendants have in an encouraging manner.

Tick if C Family planning Advice applicable and X 1 Explains importance of birth spacing if not 2 Informs about different methods of contraception 3 Explain about relative benefits and side effects of each method 4 Helps her to choose the right contraceptive measure 5 Guides her for its utilization and follow up 6 Explains about best choice of IUD insertion as post natal contraceptive measures 7 Teaches correct use of barrier method if opted

Supervisory Check-list: You have to supervise the ANM when she is giving health education and counselling on MTP services under the RCH programme. While supervising you must ensure that she

Tick if A. preliminaries applicable and X if not 1. Can calculate period of gestation before referring for MTP. 2. Can guide to the centre where MTP can be done. B. Post MTP follow- 1. Ask or history of bleeding PN or discharge pervaginum. 2. Ask for history fevers, pain, abdomen to excludes complications of MTP. 3. Advises about contraception. 4. Advises about next follow-up visit.

93 You have to supervise the ANM when she is giving ante natal care while supervising you have to ensure that she

Tick if applicable 1. Detects the early signs and symptoms of RTI/STI and X if 2. Traces partnep and refers the contact for treatment. not 3. Performs speculum examination in a case of viginal discharge 4. Performs bimanual examination in a suspected case 5. Takes adequate precautions to avoid contamination and to protect self and others 6. Counsels regarding prevention of RTI/STI 7. Explains the importance of the use of condoms to prevent RTI/STI. 8. Explains about sexual hygiene 9. Explains about monogamous relationship 10 Refers the client to MO PHC.

94 You have to supervise the ANM when she is giving Health education / counselling on RTI/STI while supervising you have to ensure that she

Tick if 1. Can use methods of preventation of infections applicable 2. Can enumerate the fundamental principles of infection and X if prevention. not 3. Can discuss the correct method of hand washing and wearing gloves. 4. Takes necessary precautions while examining, performing procedures on clients. 5. Can use the antiseptics and disinfectants appropriately. 6. Can make the household bleach, sodium hypochlorite and calcium hypochlorite solution. 7. Decontaminates everything immediately after use and before clearing. 8. Can do disposal of the waste in the correct way 9. Sterilises gloves. 10. Sterilises and store gauze pieces. 11. Sterilises instruments. 12. Disinfects labour room and labour table. 13. Disinfects blood soaked clothes. 14. Dispose off the placenta and blood soaked pads.

Supervisory check-list:

You have to check-up the following in context of newborn care while you are supervising the work of ANM. Mark tick () cross (X) against each item on appreciation/otherwise respectively. 1 Ensure five cleans before receiving the newborn. 2. Observe six steps of hand washing. 3. Drying the baby and maintenance of temperature. 4. Cutting and tying of umbilical stump. 5. Weighing the baby. 6. Initiation of breast-feeding. 7 Use of mucus sucker. 8. Giving mouth to mouth breathing. 9. Identification of congenital abnormality. 10 Identification of high-risk newborn. 11 Advise appropriate referral.

95 Supervisory check list: You have to check-up the following in context of immunization while you are supervising the work of ANM. Mark tick () cross (X) against each item on appreciation/otherwise respectively. 1 Sterlization of immunization equipments. The use of a) Autoclave b) Steam sterilizer. c) Other method: boiling 2) Use of vaccine carrier. 3) Use of refrigerator i.e. which vaccine to be kept where ? a) Intramuscular b) Subcutaneous c) Intradermal d) Oral 5) Identification of adverse reactions following immunization and their remedies. Supervisory check list: You have to check-up the following in context of nutrition while you are supervising the work of ANM. Mark tick () cross (X) against each item on appreciation/otherwise respectively. 1. Correct maintenance and interpretation of "Road to health" card. 2. Correct positioning of baby during breast-feeding. 3. Identify: (a)Pallor (b)Oedema (c)Bitot spots (d)Xerosis (e)Marasmus (f) Kwashiorkor. 4. To develop linkage with ANMs for supplementary feeding for under weight children.

96 Group discussion – talk about prevention of diarrhea Supervisory check-list: You have to check-up the following in context of diarrhea while you are supervising the work of ANM. Mark tick if cross (X) against each item on appreciation/ otherwise respectively. 1. Identification of signs of dehydration correctly. 2. Preparation and administration of home available fluids (HAFs). 3. Preparation and administration of ORS solution. 4. Identification of danger signs in diarrhoea. 5. Counseling for home care and nutrition in diarrhoea. Supervisory check-list: You have to check-up the following in context of fever while you are supervising the work of ANM. Mark tick (/cross (X) against each item on appreciation/otherwise respectively. 1. History taking in fever. 2. Signs and symptoms of malaria. 3. Technique of taking thick and thin blood smears. 4. Identification of cerebral malaria. 5. Identification of complications of malaria. 6. Administration of anti-malaria drugs in correct doses in presumptive treatment of malaria. 7. Counseling for prevention of malaria.

3.3 EVALUATION AND MONITORING

Learning objectives By the end of the session the Jr.P.H.N (trainee) should be able to

97 1 Acquire sufficient knowledge with regard to the various aspects of monitoring and evaluation 2. Evaluate and monitor various activities under different health programmes as a supervisor.

Method 1. Lecture cum discussion 2. Practice of monitoring and evaluation Duration 1. 1 Hour for theory 2. ½ day for practice When plans are under implementation, they need to be monitored regularly and systematically and based on the feed back information that monitoring provides, corrective or control measures have to be taken to ensure that work proceeds again according to plan. Measurement is an important step in monitoring and control. Measurement is greatly facilitated, if at the time of setting objectives, care is taken to specify broadly what you would consider as satisfactory result is stipulated in terms of quality, quantity, time and where applicable, cost effective It is easy to develop the PHC staff to monitor and control their own work at the time of allocation of task to them, they are also told how to measure progress of their own work and when they show report for assistance and help. Monitoring and evaluation are two important management functions. Monitoring is done frequently (daily) during the implementation of the plan, and is one of the managers day to day responsibilities. It may be done by direct observation, discussions, and reviewing statistics and reports. Evaluation is the comulative result of monitoring over a period of time. Evaluation is an assessment of the quality and quantity of work turned out by an individual or an organization. Monitoring and evaluation are closely linked to constitute a manager’s control function.

98 Evaluation is just like salt. Nearly all foods taste better with salt. Some food need more salt than others, but too much salt spoil the meals.  Difference between monitoring and evaluation The process of monitoring consists of collecting and analyzing information of actual operations so that deviations from the plan are detected. Evaluation is also used to assess the accomplishment of objectives as attained in a plan. But the difference between monitoring and evaluation can be seen in their respective scope. While monitoring is confined to oversee on going operations evaluation is mostly concerned with the final outcome and with factors associated with it.  Why evaluate? The purpose of evaluation is to know whether or not the programme has achieved it goals. It aims at finding out the strength and weakness of the programme so that attempts can be made to remove the weaknesses and strengthen the points inorder to make the programme more effective.  When to evaluate? Evaluation is a continuous process and needs to be done before the actual programme begins, during the programme and after the programme has been completed.  What to evaluate? If it is a training course evaluation of the trainees, evaluation of trainers and evaluation of the course effectiveness The supervisor has to assist the M.O. in evaluation. How to evaluate? (Techniques) 1. Observation and feed back 2. Question answer or discussion 3. Assignments 4. Review of reports and statistics 5. Tests and examinations 6. Other methods- eg. Quiz competition 7. Demonstration of certain items The success of monitoring and evaluation depends upon quantitative indicators. Quantitative indicators are needed at the input, activity and output levels. In most cases indicators for output are given as targets. While developing these indicators it should be

99 kept in mind what information is readily available at the primary health centres. The indicators for monitoring should rely on readily available information. The indicators should also be comprehensive, reliable valid and simple.

3.4 TEAM WORK

Learning objectives With the help of this knowledge the participant (trainee) should he able to:  Explain What is team work  Supervise constitution of working team at village level  Maintain support with the team members and make the team effective.  Ensure that the worker (female) organizes meeting with the team members. Introduction “A team of people is greater than the sum of its parts” a fact that is recognized in organizations across the world. However, effective team working does not just happen or its own individual have to work together and motivated to achieve results. What is a team? A team is a group of two or more people who work together for a common objective. A team works as one unit to achieve a common objective. What is a health team? A health team is a group of people who work together to promote better health in a community Health teams follow rules. These rules are governed by health and family welfare policies. The rules describe the type of health services that the team should provides and the procedures it should follow. Each member of the team knows the job he/ she is going to do in to operations with each other. Health teams have leaders to help co ordinate their work. Definition:

100 A team is a group of two or more persons with different levels of knowledge, abilities and personalities who must complement each other and who share a common unifying goal. The definition of the team given above presents several features of a team and the way in which it functions Viz: 1. A team consists of a group of persons 2. All persons in the team comes from different disciplines and have different personalities and different levels of knowledge and abilities so that they are able to compliment each other. 3. All of them have learned to communicate effectively with each other. 4. All of them share a common unifying goal. 5. They have developed faith in each other. 6. They have learned to put aside certain of their individual difference to achieve a common objectives. Every team must have a team leader who should be able to: 1. Stimulate each of the individuals in the team to make their own contribution and bring out their potentialities and activity. 2. Realise that each member of the team has something individually to contribute. 3. Accept the fact that he must work as much as or more than, any other member of the team. 4. Behave in a democratic manner with the team members 5. Demonstrate to them that he has the overall vision, experience and knowledge which gives him the capacity to make final decisions after consultation with the group. 6. Instill in each member a team sprint i.e. a sense of loyalty to the group and a feeling of pride in belonging to the team. 7. Lead the team members in group activity which is more productive than individual efforts. 8. Refrain from using the team for his own selfish motives or for purposes other than its primary goals.

101 9. Maintain harmony among the team members and prevent jealousy among them by behaving impartially towards the members. 10. Help the group to develop joint accountability and to take responsibility not only for successes but also for failures, if occur. 11. Distribute responsibilities and tasks so that the team can function in then most efficient way. 12. Coordinate the union activities of the team. Benefits and advantages of team work 1. Economy in time 2. Economy in energy 3. Gives opportunity to all for work (Utilises individual skills) 4. Builds up “We Feeling” or team spirit and avoids conflicts 5. Each aspect of the programme gets maximum care and attain perfection 6. Avoids burden of overwork, hatred, absentism or escapism etc.

3.5 LEADERSHIP

Learning objectives: By the end of the session the participant is able to 1. Adopt the suitable style of leadership among the subordinates and be able to lead them effectively to achieve the goals of the group. Method: 1 Role play 2 Lecturer cum Discussion Duration 4 hours  Introduction Leadership is the sum total of everything a supervisor does in the work environment. Leadership influences the reactions of the members of the work group. It affects the productivity of the supervisor and the group. A number of factors are involved in the ability to lead including the following: a. Insight in to human behaviour

102 b. Decision making ability on a practical basis c. Ability to plan, organize and direct efforts of others. d. Ability to relate to others on a face to face basis whenever a group is faced with a problem or an emergency, the group seeks to have a leader. Leadership is a group process and a leader is the representative of a group for the accomplishment of certain tasks which the members of a group feel necessary to be achieved for the stability of the group. Man is a social being and he loves to move and work in groups. Many things we can do through groups rather than as individuals. Eg: Union/ Association. Leaders are the right channels of communication through which we can convey our message to the group. They are the decision makers, in the group.

 Definition: Leader is an agent who helps the group to achieve its goals. Leaders are those who influence the activities of other members of the group. Leadership is a group process in which an agent influence the activities of the members of the group and achieve the goals of the groups.  Styles/ types of leadership 1. Participative or Democratic The leader of this type wants his staff participate in setting objectives for their work. He uses them for decision making, team planning and secure cooperation in getting work done. Consequently the staff takes responsibility for the work and are committed to the work. The participative leader trusts his staff’s ability, he listens to their opinions and encourages them to contribute their ideas on how to provide better health services. He always helps them improve their skills. He gives them more responsibilities as their skills improve. He spends much of his time with his staff. He works with them to solve problem at the PHC and in the community. To the outsider, especially one who favors authoritarian style the participatory leader looks as though he is not doing any job. He always consult with his staff and encourages them in their work But he does not do the work by himself. He does not use

103 firm control and authority to lead his staff. He encourages them to speak up and to give their opinions. The participative style has three advantages. 1. The staff will feel that they belong to a team and therefore will work harder. 2. The staff will be more motivated. They will accept decisions and will carry out work with more commitment and enthusiasm 3. The quality of decisions will be improved because the ideas and experiences of the entire staff rather than just that of the supervisor will go in to making decisions. 2 Authoritarian or autocratic An authoritarian leader focuses only on the work done. He must plan the work and watch his staff closely while they are doing the work. He sets the objective for the staff and then he pushes them to get their work done. The authoritarian leader assumes that he should give orders and the staff should obey them. He takes his decisions as the best one. He assumes most workers dislike work and must told what to do. He feels that he must plan their work in detail and tell them when to do it. He believes his own procedures and work methods are the best and his staff should follow his example. 3 Laissez Faire Leader is not really a leader at all. He has no interest in how the work is done. He leaves it to his subordinates to plan and organize their work as they like. The laissez faire leader does not show any interest in subordinates and his only wish is that subordinates do not bother him with their question or problems. A laissez faire leader will often announce targets & objectives, but he does not plan how to achieve their targets or objectives, nor does he evaluate to see if the targets are being achieved. A laissez faire leader is a person who is reluctant to play the role of a leader or who altogether refuses to play that role. One important point about leadership styles is that supervisors tend to copy the leadership style of their supervisors. Decisions are taken at state and district levels and PHCS are district to follow the rules and regulation. Naturally the Medical offices also follow the same authoritarian style and in turn the LHS may use the same style i.e. Medical officers at PHCS tend to copy this authoritarian style, often, unconsciously, when dealing with their staff. Therefore, make a conscious effort to use a participative

104 style, even though your own superiors may continue to use an authoritarian’s style with you.

Qualities Of Leaders

The Traits commonly observed in leaders are 1 Intelligence 2 Self confidence 3 Formal education 4 Adaptability 5 Emotional stability 6 Enthusiasm and Initiative 7 Ability to express ideas clearly (skills in communications) 8 Human relation skill Chapter - 4 M A N A G E M E N T 4.1 MANAGEMENT Learning objectives The Jr. P.H.N should be able to 1. understand the meaning, concept, principles, functions etc 2. Identify the management functions as an LHI 3. Assist the MO in managing the health system effectively. Methods 1. Lecture cum discussion 2. Brain Storming 3. Assignments Duration 6 hours for theory 2 hours for assignment Almost everyone has some concept of the word 'Management' and is conscious, that management requires certain abilities which are distinct from those required to do the work. Thus a man may be a first-class doctor but may be unable to manage a large

105 hospital successfully. This is common knowledge, and most people have seen or read about cases in which a business failed, not because its owner did not know his field, but because he ' was a poor manager. To cite one well known example, Thomas Edison was a superb inventor, but the company he established to manufacture electric light bulbs failed because Edison was a poor manager. When a person becomes a manager, he may continue to do part of his former work, but more importantly he takes on new duties that are entirely managerial in character. He must lay out the work for others, decide which part of the total job each of the groups or individuals under him should do, establish priorities, induce subordinates to put forth their best efforts, and check on their progress. Knowledge of the work will help a manager, but he will need something more. Even when he knows exactly how he would do the job himself, he may be unable to explain to others how it should be done or to decide how to divide the job in parts when several people are to do the job. But if a manager needs more than knowledge of the work itself, what exactly does he need to know? Or is management an art that can be practiced effectively only by those with a special natural talent for it? There is general agreement that management is partly an art. No foolproof rules exist that do away with the need for judgment and common sense. Management and administration anyone may learn. And regardless of a ' person's natural talent for management, or lack of it, he will be a better manager because he has acquired this knowledge. Definition In order to determine what a manager should know, it is necessary to define management. Management is the purposeful and efficient use of resources.- Management comprises of one of the important elements of manpower, resources, which requires proper management. In the process of managing personnel the manager must not only understand how to get people to do what he wants them to do; he must also know what they should be doing, what results should be achieved, what each person or group should contribute to the common effort, and be achieved without duplication of work or wastage or resources. The essentially resource management, planning, coordination, evaluation and supervision.

106 Again, management involves decision-making and it is quite true that many of the most important actions managers take are simple decisions. And the manager has to get things done through other people. Then, the manager must decide first of all what he wants the people to do; then he must decide who can best do each part of the job and how he can ensure that each person does a good job. If the study of management is to foster better decision-making, the management job must be broken down into functional areas that will make it possible to clearly see what knowledge and skills the modern manager needs. Six of these functional areas are described below: Management Functions Planning: The manager first outlines the job he wants to be done. He must set short and long objectives for the Organisation and decide on the means that will be used to achieve them. For this it is necessary for him to forecast as much as he visible, the economic, social and political environment in which his Organisation will be operating, and the resources it will have for the programmes example, some plans may be feasible only in times of prosperity and may be utterly impractical in a period of resource constraints. Organising: The manager must carry out the plan by organising resources - personnel supplies, transport, finances, etc. He must establish operating procedures and reporting relationships. The work done by subordinates will necessarily be interrelated; hence, some means of coordinating their efforts must be provided. Coordination is, in fact, an essential part of organising. Staffing: Having known the work to be done, he must find the right person for each job. An established health service, of course, already has people filling the staff positions. However, staffing obviously cannot be done once and for all, since people are resigning being promoted, and retiring. Furthermore, worker's skills change with acquiring more experience, or getting additional training. So a management must make periodical assessment of his staff and attempt to plan each person into the position where he can do the best job. Direction: Since problems and opportunities in the day-to-day work cannot be anticipated beforehand, job descriptions must be stated in general terms. The manager, while providing day-today direction to his subordinates, must make sure that they know the results he expects in each situation, help them to improve their skills, and, in some

107 cases, tell exactly how and when to perform certain tasks. A good manager makes his subordinates feel that they want to do best possible job, not merely work well enough to get by. Coordination: The manager has to inter-relate the various activities contributing to the achievement of an objective. This is an important function of management to blend all the activities into a unified action. Reporting: The manager has to report the progress to his superiors regularly. The progress needs to be assessed from records and reports, which will also be useful for monitoring and evaluation. Budgeting: The manager has to prepare a budget, and monitor expenditure. At the end of the year he has to assess the financial performance. Control: A control mechanism helps the manager to determine how well the jobs have been done and what progress is being made towards the goals. He must therefore know what is happening so that he can step in and make changes, if the Organisation is deviating from the path he has set for it. A mechanisms of control is for systematically judging progress towards goals. Innovation: A good manager is always an innovator. Peter Drucker, an important pioneer in modern management, has said, 'Managing a business cannot be a bureaucratic and administrative job... must be a creative task. A manager may innovate in several ways, for example, he may develop new ideas himself, combine old ideas into new ones, pick up ideas from other fields and adapt them to his own use, or merely act as a catalyst and stimulate others to develop and carry out innovations. Principles Of Management

1. Division of work – delegation 2. Authority and responsibility 3. Discipline 4. Unity of command 5. Subordination of individual interest to common goals 6. Proper remuneration 7. Centralization of power 8. Order

108 9. Equity 10. Stability of tenure 11. Initiative 12. “Esprit de corps”

4.2 PERSONNEL MANAGEMENT

Method Lecture cum discussion Duration 45 minutes Definition Personnel management is the planning, organizing, directing and controlling of the Procurement, development, compensation, integration and maintenance of people for the purpose of contributing to organizational individual and solietal goals” Functions of Personnel Management. Functions broadly divided in to two categories 1) Managerial 2) Operative

1. Management Functions 1 Planning 2 Organizing 3 Controlling 4 Directing 2 Operative functions 1) Procurement 2) Training & Development 3) Proper Compensation 4) Integration 5) Maintenance 6) Motivation

4.3 MANAGEMENT OF CONFLICTS

109 Learning objectives By the end of the session the Jr.P.H.N should be able to 1. understand the conflict tactics, its causes 2. understand the guide lines for resolving conflicts 3. know how to prevent conflicts at a PHC. Methods 1. Lecture cum discussion 2. Brain storming Duration 2 hours. Managing Conflict Conflict occurs in all human interactions. Each person has different needs and values. These differences become evident and produce conflict when the persons undertake group activity. The conflict may be positive in some cases and negative in others. But without conflict, no growth takes place either in individuals, teams, or society as a whole. Productive conflict arises out of concern for the group and the individuals in it. Because members are concerned, they are willing, if necessary, to risk a conflict in order to help to improve a situation. There is a human trait which encourages us to suppress feelings associated with conflict. We tend to avoid conflict by denying it. A more serious mistake is to pretend outward friendliness to hide bad feelings. In working with teams, we may keep the following suggestions in mind as guidelines for dealing with conflict:  Accept conflict as natural. When a team struggles to accomplish a goal-to face problems and resolve them-you can expect here will be some conflict. Different personalities, different feelings, different values and different ideas are bound to collide.  Each person involved in the conflict must accept the others' right to their own values and ideas. Above all, each person must be allowed to retain his dignity, regardless of his behaviour or point of view.  There must be trust in the group if the conflict ultimately is to be resolved.  We must not evade the source of the conflict, although it may take courage to face it.

110  The persons in conflict must be flexible and prepare compromise inorder to resolve the conflict. Conflict is negative when it results from a desire to destroy. Conflict is positive when it results from a desire to unite and improve. Positive conflict is a sign of a healthy group. Conflict Tactics 1. Fighting or arguing in front of others. 2. Criticizing the other person, either directly or to a third person. 3. Blaming each other for problems. 4. Lecturing each other. 5. Questioning or challenging each others' judgment 6. Attributing negative qualities to the other person, but positive qualities to oneself. Causes of Conflicts at a PHC 1. Exploitation. If a staff member feels he/she is being treated unjustly or exploited, by the supervisor, it will cause conflict. 2. Lack of recognition leads to conflict. PHC staff perform a difficult and demanding job. They want to know that their work is appreciated. They want recognition for the job they are doing. If they do not get this recognition, conflicts may arise. 3. Lack of involvement leads to conflict. PHC staff want to know what is going on. They want to be prepared for changes, and they want to know why the changes are necessary. They want to be asked for their suggestions and ideas. If staff do not feel involved, they may oppose changes, which lead to conflict. 4. A lack of training leads to conflict especially a lack of continuing education to maintain and improve skills. PHC staff who know their jobs well are confident and usually satisfied with their work. However, if staff do not receive adequate training and continuing education they will not be competent to do their jobs. They will make many mistakes which will lead to conflicts with supervisors and fellow staff. 5. Personal problems or deficiencies lead to conflict. For example, some staff members may lack motivation or they may be undependable. Others have no sense of responsibility toward patients or other staff members. Such personal problems may cause conflicts.

111 6. Inadequate and inappropriate supervision is a common cause of conflicts Supervisors sometimes make mistakes. They give incorrect instructions or apply a policy incorrectly. They may, fail to visit sub-centres regularly, leaving health workers isolated. Supervisors may not provide equal guidance and support to all PH, C staff members. How to Prevent Conflicts at a PHC Some conflict is natural and unavoidable but too much conflict distract staff from their best work. Here are a few simple preventive measures to help you minimize conflicts at the PHC. 1 . Get to know the PHC staff: Establish a personal relationship with your staff Show them that you are interested in them as individuals as well as in their work. Get to know the needs and concerns of each staff member so that you can anticipate conflicts that may occur. Also pay close attention to areas that have caused conflicts in the past. 2. Know the personnel policies and apply them consistently and fairly: The second preventive measure is to know the State/ organisational personnel policies and apply them consistently and fairly. You need to know the rationale for these policies as well as the policies themselves. PHC staff members will have fewer conflicts, if you explain the policies clearly and apply them consistently. 3. Use a participative style that encourages involvement: Praise your staff whenever they deserve it, and give recognition for the job they are doing. 4. Provide continuing education: A well-organized programme of continuing education is one of the best preventive measures for reducing conflicts. 5. Recognise conflicts early and resolve them: Resolve small conflicts before they grow into large ones. A certain amount of conflict within a group is natural. However, you should resolve conflicts before they lower morale and lead to disciplinary problems. 6. Support and guide PHC staff: Demonstrate by your attitude and your behaviour that you are interested in your staff. If you make a mistake, and admit it, your staff respects a supervisor who admits his mistakes and then correct it. Be, especially supportive to your staff positively. Avoid criticizing them in front of patients or

112 members of the community. These simple measures can prevent many conflicts and give yourself and your Staff time for other more constructive activities. Guidelines for Resolving Conflicts at a PHC 1. Get all the facts about the conflict before taking action. 2. Act early; do not let small conflicts grow. 3. Be fair and consistent in your handling of the conflict situation. 4. Do not try to resolve conflicts when persons are involved. Wait until they are quiet and calm. 5. Give each person an opportunity to explain how he sees the conflict before attempting to resolve it. 6. Encourage the persons in conflict to suggest solutions rather than imposing your

own solution. 7. Follow the situation Carefully to see that the conflict has been resolved, or at least contained.

4.4 MATERIAL MANAGMENT (MANAGEMENT OF DRUGS, VACCINES AND OTHER SUPPLIES) Learning Objectives With the help of this unit, you should be able to: o Guide the Female Health Worker to estimate quantity of drugs and vaccines required at sub-centre level based on action plan. o Ensure procurement of drugs and vaccines in right quantity and at right time. o Ensure storage of drugs, vaccines and other materials properly till their utilization. o Supervise maintenance of equipments supplied to sub-centre level. o Oversee maintenance of stock register for all items issued to sub-centre by PHC. Contents: o Estimation of requirements of vaccines. o Estimation of requirements of ORS and other drugs. o Procurement of drugs and vaccines from PHC. o Storage of drugs and other materials.

113 o Maintenance of all requirements made available to sub-centre. o Maintenance of stock register. Introduction Since there are no fixed targets imposed from the higher levels, you are expected to estimate service needs of the RCH programme for the community residing in the sub- centre areas of your supervision. Also, the emphasis should be on quality of services. You need to prepare indent for drugs, vaccines and other materials that would be required towards the provision of estimated services. Estimation of drugs etc. followed by indenting of right quantity of each drug, vaccine and other materials is absolutely essential to ensure continued availability of such items at sub-centre level for providing services to assigned community members on regular basis. You must ensure that there is no surpluses and wastage of the same. Once the annual requirement of the items mentioned earlier, are estimated and submitted to the controlling PHC, the mechanism of ensuring timely supply of needed items and materials should be worked out based upon the prevalent procedures and practices of supply under RCH programme (once or twice every year). The demand made should match with the sub-centre action plan under your supervision. However, replenishment should be arranged as and when needed. It may be even earlier than scheduled time in case of exhausted stock or stock out situation. This module will help you to prepare estimation of material resources needed in right quantity, procure the same at right time and store them properly before being put to use. Maintenance of other equipments provided at sub-centre also needs your attention so as to ensure their prolonged use. You must ensure that Health Worker (Female) . Maintains a stock-register for all the drugs, vaccines and material received and used at sub-centre level. The correct demand estimation, procurement, timely replenishment, storage and maintenance of supplies and their related records are essential aspects of material management. Management of Drugs and Vaccines at Sub-centre level Includes:  Estimation of required quality of the drugs and vaccines needed for provision of services.  Procurement of drugs and vaccines in right quantity and at right time.  Proper storage and judicious use of drugs and vaccines.

114 Even though you are still getting readymade packet of drugs, materials and vaccines as per estimated requirement for each immunization session, and you should be able to calculate the requirement as per your number of beneficiaries by you while preparing Action Plan through CNA process.

Estimation of vaccine requirement: While overseeing calculation of the requirement of vaccines you should consider the factors mentioned below:  Number of beneficiaries  Number of doses of each vaccine  Wastage and multiplication factor  Number of sessions The estimated requirements of various types of vaccines as worked out by you can be further verified with the calculations arrived at by using demongraphic rates.

The correctness of estimates of vaccines worked out by you should be discussed with MO of the PHC. These estimates are to be finalised after the MO is satisfied keeping in view the total requirement of area, past performance and local situation.

For example: As per the model used earlier for Action Plan. Sub-centre population = 5000, Birth rate = 30/1000

Vaccines:

Number of pregnant mothers =165

(2 doses of Tetanus Toxoid for each pregnant mother) =330 (Approx.)

Suppose the Infant Mortality Rate (IMR) in your district is 75/1000 live births.

(If the total number of live births are 150 then out of 150 live biths. The No. of infants who would probably die before one year of age

=150x75/1000=11(approx.)

115 Hence, no. of infants alive at 1 year of age = 150-11=139

OPV and DPT doses to be administered 139 x 4 =556

(4 doses for each child, 3 doses and 1 dose at 16-24 months)

OPV/DPT doses required -556 x 1.33 = 740 (Approximate)

(Wastage and multiplication factor = 1.33)

BCG/Measles doses to be administered =139

(BCG/Measles doses required 139 x 2) =27

(Wastage multiplication factor =2)

(The vaccines are supplied in 5, 10 or 20 dose vials or ampules. To calculate the number of vials required, number of doses are divided by 5, 10 or 20 and rounded off to the next 5, 10 or 20 as per the number of doses per vial. The quantities thus calculated would be for the whole year).

The calculation for vaccine requirement will have to be done on the basis of number of sessions planned for each month. With more number of sessions, additional vaccines would be required as for each session a new vial is required to be used.

Requirement of Vit A Concentrated Solution:

All children below 1 year of age will require 1 dose of 1 lakh unit

All children between 1-3 years of age will require 4 doses each of 2 lakh unit.

Therefore, the total requirement of doses will be - 139 doses of 1 lakh units and 1044 doses of 2 lakh units.

(If number of children below 1 year of age= 139 and between 1 to 3 years of age=261).

However, requirement of vaccine for conducting an immunization session is given in Child Health Block, which you can refer for organizing each immunization session.

Iron and Folic Acid Tablets:

For pregnant mothers:

116 Number of pregnant mothers registered – 165

100 tablets for each mother – 16500 tablets 50 per cent of the mothers expected to be anaemic and would need double the dose i.e 100 additional for each.

That is 165/2 x 100 = 8250 Hence, the total requirement of iron and folic acid tablets would be: 16,500 + 8,250 = 24,750 tablets. Iron and Folic Acid (Small) for Children: IFA small tablets are meant for children between the age of 1 to 5 years, who show visible signs of anaemia. Each child is to be given 1 tablet/day for 100 days.

a. If the number of children (1.5 years) is 500 (approx.) b. Number expected to show visible signs of anaemia (50%) – 250 c. Requirement of IFA (small) is (250 x 100) =25,000. ORS Packets: A child under 5 years of age suffers on an average 3 episodes of diarrhea every year. Thus, there will be 650 x 3 = 1950 episodes of dirrhoea every year in a sub-centre area. [If number of children below 5 years of age = 650]. One packet of ORS is required for these episode. That means 1950 packets will be required for these children. However 10% of these episodes are with dehydration which would require an additional packet of ORS. That means 195 episodes (10 % of 1950 episodes) will require 195 more ORS packets. Thus, the total requirement of ORS packets in every year will be: 1950 + 195 = 2145 packets.

However, all the children may not report for each episode. In view of the past performance, MOHFW supplies a certain quantity. In case you fall short, you can always ask for more packets from PHC. Sudden increase in reporting and consumption of ORS packets is an alarming sign to you for anticipating epidemics of diarrhoeal diseases.

Cotrimoxazole Tablets (Paediatric): The total episodes of Acute Respiratory Infection (ARI) at the rate of 3 episodes per child under 5 years in a year would be equal to diarrhoeal episodes of 1950 cases as calculated above. It had been worked out that only 10 per cent of the episodes of ARI are

117 pneumonia requiring antibiotic therapy. Thus, 195 episodes of pheumonia will on an average need 20 tablets of cotrimoxazole (paediatric) each. Hence, the total annual requirement of contrimoxazole would be 195 x 20 = 3900 tablets. It would be desirable to compare all these estimates with the estimates and actual use of the last year and verify whether the same has increased by 5 to 25 per cent or not.

Procurement: Having prepared estimates, the next step is to fill the Action Plan Form along with the form on ‘Inventory of Vaccines and Drugs and submit the same by 10th of March every year (Along with the Action Plan to the PHC). Comparison between the assessment and actual quantity received and requirement for current year would be visible in the form. There is also a column in the form for listine surpluses or shortages of the last year. Usually, the drugs and materials would be supplied on quarterly basis and replenished it needed. Stock out must be avoided in all possible manners. You must ensure that there is always stock for one or two months at sub-centre. Larger quantity of stock would indicate either over-indenting or non-performance or under-utilization of services.

The supply of vaccine to sub-centre is not done on monthly/quarterly basis. The vaccines are to be procured in the ‘vaccine carrier’ only on the day of immunization session. The required action to procure additional drugs/vaccines both should be taken well in time and a list of ‘Inventory for Drugs and Vaccines’ (See Annexure 1.1 at the end of this unit).

Storage: Vaccines: You have to ensure that vaccines are not stored at the sub-centre level in any case. These must be supplied from the PHC on the day of use only. The precautions to be observed to keep vaccines safe and potent are as follows:

 Only required quantities for day’s consumption during immunization session be procured.  The vaccine carrier must have frozen ice-packs.

118  Immunization must be carried out in the shade and OPV and Measles vaccines must be kept in an ice-pack or in a cup of ice during the session.  Only one vial of each vaccine should be taken out of the carrier at a time.  Unused vials must be returned to PHC on the same day. Other drugs: You as the Health Assistant (Female ) must ensure that:  All drugs being supplied, in general, should be kept in a cool dry place protected from direct sunlight, air and moisture.  The drugs must be stored in respective containers with proper labels.  The drugs supplied in strips and the ORS packets should be stored in a container/cardboard box. Arrange drugs in bottles/strips in such a way that one with earlier expiry date are in front, so that these can be used first. The recent supplies received should be placed behind. The principle of first-in-first-out (FIFO) must be followed in true spirit.  Do not use expired drugs if they have changed colour or there is a change in consistency. Check drugs from time to time.  Always check the expiry date before use. Maintain a stock register: You must check during supervisory visit to a sub-centre that the Health Worker (Female) maintains a stock register by making entries with date of supply to quantity received from the PHC. The entries with regard to quantity used daily must be made in column 6 of stock register. At the end of each month, check the balance by way of physical verification. With the information in column 7, you would get to know the items, which are not consumed and thus would required physical verification.

119 Information to be filled in Stock Register: Name of the drug: Date Previous Quantity Quantity Balance Expiry Remark balance received used in hand date

Maintenance of equipments at sub-centre level: The maintenance of equipments at sub-centre level is done to ensure quality and effectiveness of services provided and satisfaction of the beneficiaries.

Vaccines Carriers: You have to make sure that the Health Worker (Female) uses ‘vaccine carriers’ for procuring and carrying small quantity of vaccines (i.e.16-20 vials) to sub-centre area and its villages. The vaccine carrier is made of insulated material. It should not be cracked or broken. You must ensure that the ice packs for lining the sides of carrier are fully frozen and the lid of carrier is closed tightly. The vials of DPT, DT and TT vaccines should come in direct contact with the frozen ice packs.

You have to ensure that the Health Worker (Female) observes the following precautions before using or packing the vaccines in the vaccine carrier:

- Takes out vaccine carrier and confirm that there are no cracks in its body. - Takes out the required number of ice packs and wipes them dry. Checks each pack. - Places fully frozen ice packs in and closes the lid of the carrier and waits for few minutes for temperature to fall to less than 8 degree Celsius. - Puts vaccine vials and ampules in a polythene bag and close it.

120 - Place some packing material between DPT vaccine and the ice to prevent them from touching the ice packs. - Stocks vaccines and diluent in the carrier. - Close the lid tightly. The following points would help you guide the Female Health Worker in ensuring that she keeps the vaccine carriers in good condition when not in use. The Health Worker (Female) must:

- Clean and dry inner side of carrier after each use. - Examine the carrier both from inside and outside after each use for any crack. - Keep the carrier away from direct sunlight and other sources of sunlight, as this may cause the plastic to crack. - Does not place anything heavy on vaccine carrier. - The carriers with four ice packs can keep the vaccines cold for 2 days provided the ice packs used are fully frozen and the lid of carrier is closed tightly. Blood Pressure Apparatus: A sphygmomanometer or an aneroid B.P. instrument has been provided to all sub- centres. You must make sure that the Health Worker (Female) uses it for measuring B.P. during ante-natal check-up in clinics. You must also make sure that when the aneroid B.P. instrument is taken out of the case the dial should be held properly otherwise it may fall and break.

The sphygmomanometer along with the stethoscope (if available) should be kept in the cupboard free from dust and sunlight. While packing you should take care that the cuff is properly deflated and then folded and the rubber tube is not kinked. When not used for a long time, the rubber tube and the cuff may start softening, particularly in summer and start leaking. You must check this frequently so as to keep the instrument worthy of use.

Weighing Scale: A weighing scale for adult and a spring/pan balance for babies are provided to all sub-centres. As an in-charge of sub-centre you should ensure that these equipments are

121 maintained properly. The weighing scales must be kept in the cupboard. You must periodically check the same for zero error by weighing a known weight (measure). Take adequate precautions to ensure that the spring balance does not get rusted.

KEY POINTS  Ensure correct estimation of the requirement of drugs and vaccines based on estimated quantity of services to be provided/rendered.  Make sure that no vaccine is stored at sub-centre level. These should be procured on the same day of immunization clinic/session in a vaccine carrier.  Ensure that other drugs are stored in a container with proper labels in cool and dry place.  Make sure that the Health Worker (Female) does not use any drugs if there is charge in colour or change in consistency.  Ensure that the Health Worker (Female) maintains a stock register for accounting of used and balance of supplies received.

122 INVENTORY OF VACCINES AND DRUGS

Sr Item Unit Requireme Actual Surplus Requirement No. nt assessed quantit or for current last year y shortage year received last year last year 1 ORS Packets 2 Metronidazole Tablets 3 Cotrimoxazol e 4 Paracetamol 5 Chloroquine 6 Antiseptic solution 7 Uristix 8 DD kits (Disposable Delivery Kits) 9 Thermometer 10 Gloves 11 IFA large tablets 12 IFA small tablets 13 Vit-A solution 14 Condom 15 Oral pills 16 IUDS 17 Syringe and Needles

Source: Manual on Community Need Assessment in Family Welfare Programme, Department of Family Welfare, MOHFW, New Delhi.

123 4.5 TIME MANAGEMENT

Objectives To emphasize the importance of time To provide basic aspects of time management to keep the participants achieve mastery over time management

Methods Brain storming Lecture cum discussion Duration : 2 hours Time is irretrievable If cannot be preserved It Cannot be purchased Dost thou love life ? Then do not squander time, For that’s the staff life is made of Sir Walter Scott Importance of time A Successful person is one who understands the importance of time and uses it wisely. Time is man’s, precious asset, in a scarce resource: yet it is available equally to all. The concept of time varie from person to person. Time is neglected by all. We take time for granted and pay little importance to its effectiveness. It is important to know that time once lost is lost for ever.” It is a universal truth that all work consumers time . Time is an asset and not enemy to be afraid. In many ways time management in very important; but that does not make it simple. One of the serious misconception about time is making up of time. Technically time once spent is irretrievable. Another misconception of time is that time will take care of everything. This is wrong because time is not an omniscient healer. Frame is to be effectively used. It is aimed at achieving important things. It is an important part of the management process. In fact time management is an important part

124 of life management. Effective time management can help individual become masters of their destiny and time is one of the tools they can use to achieve their goals and objectives. Time management is a skill, which one ought to learn, in order to develop habits of work which are of great value and which will help achieve success. What is time management : It is a unique resource : It can not be saved or stored : It can not be bent or borrowed : It is irreversible As your awareness of your roles increase in each of their above dimension you will be in a much better position to make choices about how you want in use your time and where you need to strengthen your skills.

: Yesterday is a cancelled cheque, : Tomorrow is a promissory note : Today is ready cash, use it. Psychology of time Time has it own psychology. Twice is an opportunity the key to time management is to work smarter and not Harder. In every phase of one life, each of us, regardless of our function, can control time. Why Time Management Needed It is interesting to analyze certain statements, misconceptions, beliefs, superstition, practices, after effects connected with mismanagement of time while trying to understand the need for time management. 1. No time 2. Bad time 3. Misfortune 4. Rahu 5. Late attendance 6. Absenteeism 7. Procrastination

125 8. Indifferent 9. Evading 10. Pending work 11. Tension 12. Less hours for sleep and sleep lesseness 13. Late awakening 14. Forgetting to do things 15. Missing busses 16. Over work 17. Fatigue 18. Complaints of children’s and spouse 19. Disorder 20. Setting time in Watches/clocks in advance of actual Time analysis is a pre requisite to time management. Before we plan to manage our time effectively we need to know how we are using it and why do we procrastinate. Why do we Procrastinate.  Because the task at hand is not urgent  Because we are afraid of failure  Because the task is too demanding  Because we do not understand our requirements  Because the task is boring or un interesting  Because we need more time  Because the job needs a lot of inputs  Because the job is not well defined  Because the requirements are too complex The best way is to analyse your reason and find a solution. Procrastination will only make the job more difficult Principles Of Time Management The following principles of time management will help individuals achieve mastery over the time they process and become masters of change and not victims of change.

126 (1) Principle of brevity (2) Principle of habit (3) Principle of proper planning (4) Principle of prioritization (5) Principle of Effectiveness (6) Principle of Equal Distribution (7) Principle of time estimates (8) Principle of delegation of Authority (9) Principle of Analysis (10) Principle of Management of exception (11) Principle of interruption and control (12) Principle of implementation (13) Principle of follow up (14) Time is Irreplaceable and Irretrievable. The principles of time management once followed would help in making proper use of time. Besides, it facilitates clean thinking and problem solving. Goal Setting Towards Effective Time Management The purpose of goal setting is draw our attention to them. We will not reach towards achieving a goal until we have certain clean objectives in mind. The magic begins when we set goals. It is them that the switch is tuned on and the current begins to flow and the power to accomplish become a reality. “There is no achievement without goals” Robert J Mekain Techniques for managing time more effectively  List goals and set priorities  Make a daily To Do list and priorities of activities  Ask yourself the question, “What is the best use of my time right now?” as needed and get on track  Do it now TAKE TIME TO MANAGE * Take time to THINK It is the way to know what is possible

127 * Take time to PLAN. It is important for effectiveness * Take time to BUILD It leads to improved ideas. * Take time to DELEGATE It develops others and saves time * Take time to say NO It saves time spent on calls * Take time to RELAX It reduces stress * Take time to PLAY It helps you to be more creative * Take time to READ It keeps you up date * Take time to TRAIN It allows you to delegate. * Take time to TRUST It builds good relation * Take time to ENCOURAGE If increase morale * Take time to give RECOGNITION It is the greatest motivation Techniques to conquer procrastination It seems to be basic to our human nature to procrastinate. We tend to prefer doing tasks that are pleasant, familiar and reinforcing and put off tasks that are not so pleasant. All effective workers have found ways to complete tasks they would prefer to avoid. These might range from calling for meetings with the perceived enemy, writing a difficult report or telephoning someone who talks too much. Discussed below are some hints on techniques for conquering procrastinations. 1. Determine the cause

128 The first step in conquering procrastination is to identify its root. The four primary reason for procrastination are: Fear, awe, dislike, and boredom. Understanding the root of the procrastination can help you determine how and when to apply the following techniques. 2. Identifying your fear: We are convinced that the number one cause for avoiding unpleasant work is fear. Most of the time this fear is irrational. Assess the nature of the fear preventing you from doing the task. Are you afraid of doing a poor job, being judged unfairly, making a fool of yourself, or not being able to handle the results of your actions? How rational are these fears? Once you can identify what you are afraid of, talking the job becomes much easier and the fears may simply melt away.

3. Task analysis Tasks become easier to approach once the extent of work involved is comprehensible and orderly. If you are avoiding a major project because it seems too awesome to even decide where to begin, try minute sub components that are quick and simple to accomplish. You don’t have to do them in order. If you are bogged down with one task, turn to another on the list. As you begin to complete each “Simple task” you”ll be amazed at how your once impossible project becomes both manageable and even enjoyable. 4. Weigh the consequences: Ask yourself, “What is the worst and best thing that could happen if I don’t do this task?” Try making a written list of these consequences and compare them with that list which enumerates the road blocks which are preventing you from doing the task. Have this in writing hence point out how irrational your fears and excuses are for not doing the task, and can motivate you to get started. 5. Do anything Relating to completing this task. Sharpen a pencil, dial the first digit, write Dear sir, etc,. do any subtasks that force you to focus on completing some part of the total task.

129 Once you have begun, your momentum will be build up an you will very likely want to continue working. 6. Do nothing Push you chair away from your desk and sit with your hands folded on your lap for five minutes. As you sit ask yourself a series of questions about what you are procrastinating on and what techniques you can try to being this task. When you return to your desk you will very likely begin the item you wee putting off. This technique works extremely well because it creates a radial change from your typical compulsive work habits. In this case you confront your procrastination heads on and behaviorally manipulate yourself into positive action. 7. Create a deadline No task has a sense of urgency to it without a deadline. Too often, we put off items we really should be doing for lack of a firm deadline. We find many rationalizations to procrastinate. Put the deadline in writing and force yourself into accountability for coupling this with public commitment.

8. Make a public commitment To complete the task. Let others know you are taking responsibility for completing the task. Identify a group of people who you would be embarrassed to ‘let down’ by not following through on this commitment. This way you foce yourself into being accountable and carry through the task. 9. Do the task early in the day Some people make a habit of doing what they consider the day’s most noxious task first. Once it’s completed and out of the way the sense of exhilaration and accomplishment they feel helps make the rest of the day a breeze. The trick is to make this a daily habit. As a new behaviour you’ll need to force yourself into it at first. The rewards will be so immediately apparent, however, that it won’ 10. Slow down your arm As you see yourself once again, placing that item on to the pending shelf,’ physically slow your movement down and catch yourself in the process of procrastination. You will often find that this helps you to bring the item back into your

130 focus of attention. As with “do nothing” technique it works because it’s a unique behavioural manipulation from your old pattern of action. 11. Create a game Out of tasks that are usually boring. If it’s a repetitive task you’r tired of doing, try challenging yourself with breaking a speed record or focus on a constant improvement of the quality of the product. 12. Write the institutions For someone else a to do the project. Make them very detailed and see if you can allow them and proceed to execute the instructions. By spelling it out in fine detail you can become both intrigued by the project and very familiar with its ingredients. Following your instruction becomes the next logical step. 13. Reward yourself Do something to make yourself feel good after completing an unpleasant task. Take a coffee break, take yourself out to dinner, or leave work early. Having an immediate reward in mind can be an additional motivation for completing an unpleasant taken.

Strategies To Handle Interruptions And Crises  Keep interruptions short - Set a time limit - Look at the stage - Keep pencil in hand - Stay standing - Meet in the other person’s office - It takes two to small talk * Most interruptions are caused by people. Rule: Be ruthless with time, gracious with people. - Try not to feel annoyed - We waste time when we are angry. The brain shuts off. - Ask “What is your main problem with this?’

131 - Say no when they ask for too much. * Get back on track after interruptions - Don’t use this as an excuse for procrastinating * how to control crisis DON’T - become emotional immediately - blame other for the crisis - worry about what others may think - throw away good (time) management techniques. - do the first thing that comes to mind - do the things that won’t change the situation DO - Concentrate on the problem - take a thinking break * Turn crises into an opportunity - put into play some creative alternatives - view it as a opportunity to glow - try new ideas - try new short cuts - It will be noticed if your fly off the handle - Show you boss that you can handle situations * Prevent interruptions - Reorganize work area - Don’t keep too many chairs - Have an easily visible. Clock - Eliminate distractions - Turn down the volume of the telephone - have someone take your call, it possible - Use ‘Do not /disturb’ sign - Remove yourself from the interruptions; go somewhere else to work. - Close your door if you have one

132 Tips On What To Do About Common Time Wasters The following are some practical tips for identifying and overcoming time wasters. Internal time wasters Possible tips A Poor communication 1 Verbal Communication -Be brief and clear - Give only relevant data - Develop the art of listening - Give the other person a chance to speak 2 Written Communication

Cause of poor communication Sender’s Viewpoint Receiver’s Viewpoint  Lack of clear objective  The message does not for the message receive full attention  Lack of full attention  Prejudge the objective of the message  Message badly  constructed  Failure to assess  Failure to check capability of receiver to understand understanding with the sender  Use of wrong medium  Takes action before verifying his version  Choose an inappropriate  Misinterprets message time to communicate a message

133  Speaks indistinctly

- Delegate responsibility in answering letters - Give clear and concise instructions - Examine the necessity of putting it in writing - Consider telephone B. Procrastination - Use alternative means - Find the cause - Monitor your progress - Learn from experience - Set deadlines - Set priorities - Avoid taking too much work at a time C. Inability to say ‘No’ - Start with inconsequential matters - Be assertive - Stick to your decisions - Examine and recognize the need to avoid unpleasantness - Say no firmly and politely without offending. D. Taking on more than what Can be - Reorganize and control desire to be liked Managed and appear cooperative - Schedule for the unforeseen - Differentiate between ‘urgent’ and ‘Important’ E Inadequate Planning - Develop the knack of saying ‘no’ - Plan your work and work your plan - Stress on results - Develop priorities and deadlines - Schedule a block of time to plan - Maintain a time log - Schedule for flexibility in your plan F Failure to Delegate - Develop alternative plans - Learn to manage by exception - Ensure that delegation is result oriented. - Ensure that your subordinates actively participate in deciding the tasks to be

134 delegated. - Delegate as much as you can - Allow the subordinates the right to be wrong - Overcome the need to do everything yourself - Have confidence and trust in your staff - Delegate, do not abdicate. G. The Disorganized Personality - Set daily targets - Maintain a time log - Avoid attempting too much at once

Chapter – 5 REPRODUCTIVE AND CHILD HEALTH (R.C.H)

5.1 COMMUNITY NEED ASSESSMENT AND

SUB-CENTRE PLANNING (C.N.A)

Learning objectives:  With the help of this unit, you should be able to:  Explain the concept and purpose of CNA approach.  Explain the community need assessment process.  Demonstrate how to carry out the consultative process for CNA in the community.  Explain what is sub-centre planning for health and family welfare services, CONTENTS:

 Concept and purpose of CNA (What is CNA and Why it is needed) Consultative process for CNA in the community (How CNA can be conducted)  Sub-Centre Planning 1.1 Introduction Under the National Family Welfare Programme, targets for each service were fixed at higher level and passed on to the health functionaries at different levels. There were also cash incentives for the health functionaries as well as the client for each case.

135 This resulted in inflation and manipulation of performance, which deteriorated the quality of services. In order to overcome this, the Government of India and all the State Governments together decided to stop fixing targets at higher level and passing these to lower level. Instead, the Health Workers would assess the community felt needs and estimate workload at their own level, through consultation with the community people. With this approach, it is expected that client-centered and demandbased services can be provided at sub-centre level. This approach was initially -referred to as Target Free Approach, but this was not understood correctly by most of the health functionaries. Therefore, it was later renamed as “Community Need Assessment” approach. Since, this process is to be initiated at the sub-centre level; the entire work plan for providing relevant services adequately, depends on the effectiveness on this CNA process. It is for this reason that the female health workers must understand it very clearly so that they are able to assess the community needs and then estimate service requirement for the people in her area and is able to provide these services effectively. This unit will help you in this direction. 1.2 Concept and Purpose of CNA: 1.2.1 What is CNA? The overall objective of the family welfare programme has been to stabilise the population of the country. It has been realised that this can be achieved by providing quality of health and family welfare services and promoting use of birth spacing methods based on actual needs of the people and not on the needs as estimated by the top level health personnel. Thus, the approach under RCH has been changed to planning for each health care services as per actual needs assessed by the service providers at their own level instead of achieving the set targets passed on to them. This approach for need assessment and planning for services to be provided is referred to as "Community Need Assessment" (CNA) approach. 1.2.2 Purpose of CNA: Through CNA approach services will be provided to the people in the community-based on their actual needs. These needs will be assessed systematically and therefore these would be relevant to local situations. Thus, it would help you in:  Setting priorities.

136  Identifying target as well as high-risk groups.  Realistic estimation of services and matching of resource needed for the same.  Developing a realistic action plan/work plan for you. 1.3 CNA Process: In this approach, the process suggested for assessment of community needs is by conducting household survey and consultation with representatives of the community and other functionaries working in the same community. Hence, the CNA approach is:  Based on felt needs of the community.  Not to give uniform target to all sub-centre, as was done in earlier approach but to develop realistic workload based on the actual needs of the people for different services.,  Also based on actual capacity of the service provider.  Based on people's involvement and consultations with them for their coordination, cooperation and for better utilisation of the services. 1.3.1 Steps for CNA Process: At village level, the Female Health Worker should develop a team under your supervision consisting of the following members: Anganwadi Workers (AWWS) Traditional Birth Attendants/Dais Mahila Swasthy Sangh or equivalent women's group members i.e., (DWACRA etc.) Development of women and children of Rural Area Village link persons (if any) Leaders of youth organisations These members can directly help the Health Workers under your supervision in conducting the household survey, collection of other relevant information and reporting of the major events like birth, death, marriage, epidemic etc. You must also involve the Male Health Worker and share the responsibilities between the Female Health Worker and him and divide the sub-centre area for the survey amongst them. The other members who could be included in the group during CNA for consultative process are: Sarpanch, Pradhans, village panchayat members etc. School teachers. Religious leaders/priests.

137 Opinion leaders. Members of NGOS. Members of informal organisations in the villages. Medical practitioners of any system of medicine. As a supervisor of the team you should ensure that the Female Health Worker organises meetings regularly with the consultative members and other team members and involve them in planning and providing services. For organising meeting with the consultative group you must take help from the Sarpanch for conducting the meeting. This will ensure attendance of all these members. These members can help you in correct assessment of the community needs and follow-up of various services provided by you. 1.4 Sub-Centre Planning: In earlier approach, as the targets were fixed for the health workers and a fixed amount of material/equipment was supplied to each sub-centre, there was no need for you to work out any plan for the service needs to be provided. But in the present set-up, you have to assess the needs of the people in the community and estimate service requirement for meeting these needs. Hence, you should plan for providing these services and estimate the material/equipment required. Based on this estimation of services and: resource (material/equipment) requirement, supply will be made from PHC level to facilitate you to provide these services. This is referred to as sub-centre planning. You are expected to prepare an annual action plan and submit it to MO (PHC) by 10th March every year. Planning at sub-centre level is crucial as all the sub-centre plans are compiled at PHC level for preparation of action plan for each PHC. All the PHC medical 'officers submit these PHC plans to the district, which along with other services provided at district level form the Annual District Plan. All the district plans are put together to prepare annual plan for the State. Thus, the planning for all the service components of RCH Programme starts from the most peripheral level and goes upto higher level. Hence, it is critically important for you to follow the steps and make sure that these are carried out properly. REPRODUCTIVE AND CHILD HEALTH 5.2 UNIVERSAL IMMUNIZATION PROGRAMME [U.I.P]

138 This programme was introduced during the year 1985. Before that E.P.I (Expanded Programme on Immunisation) was there since 1978 after the ALMA ATTA Declaration to give “Health For all by 2000 – AD” Objectives of U.I.P 1) To Protect all Pregnant mothers against “Tetanus” by giving T.T. (Tetanus Toxoid) during Pregnancy. 2) To Protect all Infants against 6 major killer diseases of their childhood. T.T. Immunisation during Pregnancy Ist Pregnancy 2 doses of T.T. Ist dose – 3 months to 4 months 2nd dose 4 months to 5 months. If the second pregnancy falls with in the fist 3 years after taking Ist dose of T.T, We need to give only one dose of T.T, That is also given between 3 to 4 months of pregnancy,. If the second pregnancy falls after 3 years of taking T.T. we have to given 2 doses of T.T. just like the first pregnancy Should not give T.T. during the first trimester of Pregnancy due to the fear of damage to the foeus. If the patient is brought with abortion please give ready made ANTIBODY That is TETGLOBE. Major Killer Diseases of Childhood Days 1. Tuberculosis of childhood days BC.G is given at birth, that is with in the first 2 days of life. 2) Diphtherias D 3) Pertussis P is given 4) Tetanus T DPT is also known as triple vaccine 1st dose of DPT 1 ½ months 2nd dose 2 ½ months 3rd dose 3 ½ months Booster dose 1 ½ years of age

139 By giving 4 doses of DPT, We can make sure that the child is fully protected against diphtheria and pertussis. But to get 100% protection against TETANUS we should give T.T at age of 10 years and T.T. at the age of 16 years. 5) Polio (poliomyelitis) Kerala is on the way to eradicate polio. If there is no Polio Cases, which is scientifically proved, through surveillance, for the last 3 years we can declare that, the disease is eradicated. Every child should get a maximum of 5 doses of oral Polio vaccine (OPV) before 1 ½ years. Zero does – at birth along with BCG 1 ½ months 2 ½ months Along with DPT 3 ½ months

Booster dose 1 ½ years For the eradication two extra doses every year at the time of pulse polio immunisation (PPI) A child can have even 18 doses before reaching 5 years Measles Measles vaccine should be given between the age of 9 months (completed) and 12 months (before the first happy birthday) Criterias for a Successful Vaccination 1) Potency of the vaccine 2) Age of the child as mentioned 3) Correct dose 4) Correct technique 5) Correct site. Potency of the vaccine Vaccine must be kept between 20-80C, from the manufacturer site till it reaches the site of vaccination. The is known as the COLD CHAIN SYSTEM. The Equipments used and persons involved are part of the cold chain system.

140 Correct Technique B.C.G. intra dermally in the deltoid region, upper outer quadrant. DPT -Deep intra muscular in the Thigh Measles – subcutaneously, Preferably in the Thigh Reverse Cold Chain It is procedure of testing the potency of the vaccine. The vaccine is collected from the institutions and it is send to the testing laboratory in ideal cold chain system, between 20-80C Vaccine is collected from govt. as well as private institutions Balance vaccine of used vials are also taken. OPV is usually taken, because OPV is more sensitive. As far as Kerala is concerned Pasteur Institute of India coonoor is the nearest testing laboratory and every month the reverse cold chain system is done.

Cold Chain System From the manufacturer site, till the vaccine reaches the site of immunization the vaccine must be kept in an ideal temperature, between 20-80C. The equipments used and men involved are part of the system Usually the Vaccine is air lifted and the ideal temperature is 20 - 80. From the air port, the vaccine is collected in a refrigerated van and stored in regional store Kerala has 3 regional stores -Trivandrum , Ernakulam and Calicut. The regional stores are, called walk in cooler (W.I.C) where the temperature is ideal. From the WIC, in the refrigerated van, the vaccine is supplied to other districts. All the districts are having W.I.C. (Small) For the field immunization vaccine is taken in vaccine carrier. 5.3 ORAL REHYDRATION THERAPHY (ORT) Oral Relydration Therapy for the Control of Diarrhoeal Diseases. The Principle of ORT

141 Since, 60-80% of the diarrhoea is due to ROTA virus, which is self limiting and can survive in human body only for a period of 2-3 days. After 3 days all the virus will be totally destroyed by itself. But the problem is the child may go in for DEHYDRATION and if it is severe, death can occure. To Prevent all these things what we should educate all people is 1) To give Home Available fluids (HAF) 2) To give normal diet Because the loss is Fluid, Electrolytes and Nutrients mainly HAF (Home Available Fluids) 1) Salted Kanji Water 2) Black coffee 3) Tea, coffee 4) If the child is breast fed – continue giving breast feeding 5) Tender coconut water 6) Butter milk 7) Lemon juice Normal Diet During diarrhoea the child can take any normal diet, provided, it should be given in a hygienic way. 1) Salted kanji 2) Cooked rice 3) Clean fruits 4) Pappad Encourage giving IDDLY and DOSA because it contains black gram, which is a rich source of protein As mentioned early the main losses are 1) Fluids can be regained by giving HAF 2) Electrolyte - sodium - Potassium - Bicarbonate and chloride

142 By adding common salt the child is getting sodium and choloride Pappad is a rich source of bicarbonate All fruits are having potassium Also tender coconut water is a rich source of Potassium By giving HAF and normal diet, the child will NEVER go in for any DEHYDRATION But, if due to some reason if the child is not getting the above things in time, may go in for dehydration Dehydration 1) Some dehydration 2) Severe dehydration Features of Some Dehydration 1. Condition - irritable 2) EYES - sunken 3) Tears - Absent 4) Mouth, Lips, tounge – Dry 5) Thirst - Increased 6) Urine out put - Low, High coloured In this some Dehydration, apart from the HAF and normal diet we should give ORS (ORAL Rehydration Salt ) ORS Contains 1) Glucose - 20 gms 2) Sodium chloride - 3.5ms 3) sodium citrate - 2.9gms 4) Potassium chloride - 1.5 gms 27.9 gms It should be dissolved in one litre of boiled and cooled water. It is easy to educative the common people , how to take one litre of boiled and cooled water. 5 glass of water (STANDARD Glass). The standard Glass is being used in our house, is having 200 ml capacity. We must demonstrate. Give the ORS solution, according to the need of the child because excess quantity may produce vomiting and also dehydration.

143 - one litre of water - one packet of ORS Other wise the variations can be dangers for the child. If the child is not given ORS in some dehydration the child may go in for SEVERE DEHYDRATION SEVERE DEHYDRATION 1) Condition- Lethargic, floppy, some times unconscious 2) Eyes - Very sunken 3) Tears Absent 4) Mouth, lips and tongue – very dry 5) Urine – very low out put and high coloured If the child is conscious give ORAL Fluids Preferably O.R.S. Solutions, then Hopitalise. If unconscious Hospitalize RINGER LACTATE SOLUTION is given as intra – venus fluid 5% Dextrose should not be given Dextrose saline should not be given. If ringer lactate solution is not available give normal saline and when the child regains consciousness give O.R.S. solution. 20-40% of the diarrloea is due to some other reasons which requires treatment 1) Cholera 2) Dysentry - Blood in stool 3) Food Allergy 4) Food Poisoning 5) Certain intestinal cancer 5.4 ACUTE RESPIRATORY INFECTION CONTROL - PROGRAMME (ARI Programme) One of the major causes of death among children below the age of 5 years is due to pneumonia. Pneumonia can be detected early and can be treated by the health worker. The health worker can detect pneumonia even without a stethoscope or X ray, by simply counting the respiratory rate they can detect pneumonia. If the pneumonia is not complicated the health workers can treat pneumonia, by administering co-trimoxazole tablets. Classification of ARI 1. Common cold (No Pneumonia)

144 The child may have fever. That can be correct by giving Paracetamol. There is no need of any antibiotics. Sometimes, the un-necessary use of antibiotics may be harmful to the baby. The health worker should give advice to the parents about the followings things. 1) Give paracetamol when required 2) Protect the child from loosing warmth by proper clothing 3) Normal diet can be given 4) Continue giving breast feeding 5) Home made fluids like Jaggery water with thulasi ginger and pepper can be added. 6) If there is nasal block don’t use any nasal drops. If at all saline nasal drops 2. Pneumonia (Simple Pneumonia) Pneumonia can be detected by simply counting the respiratory rate. The respiratory rate is counted by looking in to the movements of the abdomen, in a lying child = Zero age to 2 months – if the respiratory rate is 60 or above it is suggestive of pneumonia - 2 months to 1 year 50 or more - 1 year to 5 years 40 or more

Simple pneumonia can be treated by a health worker by giving co trimoxazole tablets as follows = 0-2 months 1-0-1x 5 days = 2-12 months – 2-0-2 x5 days = 1 year – 5 years – 3-0 3x 5 days But for young infants (0-2 months) the Health workers are expected to give the first dose of the tablets and then to refer to FRU, because, young infants can go for complication at any time. But for other category the health workers are requested to give the tablets for 2 days only for the first time. Then, go for a review check up, if the child is better, give, the

145 rest of the tablets for 5 to 7 days. More than 90% of the cases will respond, 4-5% may not show any change Another 4-5% may go in for severe pneumonia. For these children give the first dose of tablet and then refer the case to the nearest FRU 3. Severe Pneumonia fast Breathing rate + Chest – in drawing The health workers are expected to give first dose of antibiotic and the refer the case to the nearest FRU 4 Very Serve Disease The health workers cannot diagnosis the disease. The features of the severe diseage are a) Unconscious child b) Abnormally sleepy c) Difficulty even to drink fluids d) Convulsions e) STRIDOR in a calm child Give first dose of antibiotic if the child is conscious and then refer the child to the nearest FRU

5.5 VIT-A -PROPHYLAXIS AND CONTROL Vit -A is highly essential for the health of eyes to get good vision. We are getting Vit – A through our diet especially from 1) Green leafy Vegitables 2) Yellow fruits 3) Milk etc, etc. But in the changing world, especially when the urbanization is shooting up like any thing the intake of VIT A is gradually coming down and our children are prone to get VIT – A deficiency diseases.

146 To prevent this govt. have introduced the VIT – A supplementary programme as a prophylaxis. Through this programme, every child must get 5 doses of VIT A before they reach 3 years 1st dose - 9 months – 1 year (1ml) (One Lakh of international unit) 2nd dose - 1 ½ years (2ml) (2 lakhs of international unit) 3rd dose - 2 years (2ml) 4th dose - 2 ½ years (2ml) 5th dose - 3 years (2ml) Along with the VIT A supplementation we must encourage Parents to give green leafy vegetables, yellow fruits etc. If the VIT – A is not gettings in the required quantity – the child may go in for VIT –A deficiency diseases To start with - Night Blindness. 2ml of VIT – A on the 1st day followed by 2 ml after one month will correct the problem. Encourage the diet also. - Bitot’s spots. If the VIT – A is not given in time child may go in for Bitot’s spot Raised triangular cheesy materials can be seen the sclera, close to the cornea. This can also be corrected by giving VIT-A 2ml on the first day and one month after 2ml 3. Xerophthalmia. If VIT-A is not given, child may get Xerophthalmia. The cornea and conjunctive may become dry Inject able VIT – A is given. 4. Keratomalacia : If xerophthalmia is not treated properly keratomalacia will develop that is melting of cornea and conjunctive 5. Corneal nlcer: Keratomalacia will lead to corneal nlcer 6. Corneal Scar: Corneal ulcer will lead to corneal scar. If the entire cornea is affected total blindness of that eye. Only corneal transplantation can correct the Problem. 5.6 ANAEMIA CONTROL AND PROPHYLAXIS

147 DURING PREGNANCY AND FOR CHILDREN If the pregnant lady is not anaemic she should take 100 IFA tablet during the pregnancy time, one daily, after food, as a prophylaxis. ( 60mg elemental Iron) If she is anaemic she should be given 200 IF`A tablet, as control, two tablets daily for 100 days. Apart from the IFA tablet, health education should be given regarding the diet. Deworming after the 1st trimester For children For children below the age of 5 years should be given small IFA tablet 100 as prophlaxis, that is one daily after food. If the child is anaemic 200 small IFA tablet should be given two tablets daily for 100 days after food. Deworming is a must. Dietary advice should be given. 5.7 ESSENTIAL CARE DURING PREGNANCY Learning Objective At the end of this sub-unit, you should be able to:  Clinically diagnose pregnancy.  Elicit proper history, do clinical examination and routine investigation in ante- natal period.  Assess the risk factors and do the appropriate referral.  Give T.T. immunization and distribute iron and folic acid tablets depending on haemoglobin estimation  List and understand implications of danger signals.  Manage minor ailments. Contents Introduction Aims and importance of ante-natal care Provision of ante-natal care  Diagnosis of pregnancy  Clinical assessment (History taking, physical examination and routine investigations)  Assessment of risk factors

148  Tetanus Toxoid immunization  Identification and preparation for institutional/home delivery Common complications of pregnancy and their management  Diagnosis of anaemia and its management  Pregnancy induced hypertension and management (P.I.H)  Bleeding during pregnancy  Early recognition of complications and urgency in referral  Health education and counselling  Management of minor ailments  Record maintenance  Collaboration with Dais, Anganwadi Workers and Community leaders  Supervisory checklist  Self-assessment questions Introduction: Effective ante-natal care to a pregnant woman can improve the health of the mother and also improve the chance of giving birth to a healthy baby. Regular monitoring during pregnancies can help to ensure that complications are detected early and treated before they become life-threatening emergencies. However, pregnancy is an ongoing risk process and even with the most effective screening tool currently available one cannot predict which individual will develop complications. Hence every mother needs special care and education on when and where to go if complications arise. Aims and importance of ante-natal care As you know, the aims and importance of ante-natal care are:  To promote and maintain good physical and mental health during pregnancy.  To monitor progress of pregnancy.  To detect early and treat appropriately medical and obstetrical conditions that would endanger the life or impair the health of pregnant woman or baby.  To ensure a mature live and healthy infant.  To prepare the woman for delivery, breast-feeding and subsequent care of her child.

149  To encourage the concept of having regular ante-natal check-up and proper care of the pregnant woman even in an apparently normal pregnancy.  To prevent maternal as well as neonatal tetanus.  To facilitate health education regarding diet, exercise, rest and avoidance of unnecessary travel, during pregnancy and preparations for delivery. You have to estimate number of pregnant women in your area and ensure early registration of all pregnant women. The number of women registered should be checked with estimated number of pregnant women so that one can know whether women are receiving the essential care. If the number of women coming to you is less than expected then you have to approach to the community to ensure that more pregnant women are coming for ANC. By estimating the expected number of pregnant woman you can calculate the requirement of vaccine., IFA tablets and DDK. (Disposible Delivery kit) You may wonder why women need -early registration during first 12 weeks of pregnancy. This is to:  Assess the health status of mother and to obtain baseline information on B.P., Hb, weight etc.  Screen for risk factors early and manage appropriately by referring to PHC/CHC or district hospital.  Recall easily the last menstrual period.  Get MTP done in unwanted pregnancy if required (it can be done safely between 6 to 10 weeks).  Build up good rapport between you and the pregnant woman. Some pregnant women will come themselves to the antenatal/MCH clinic at sub- centre or villages. Many may not come to the clinic/village MCH session and you have to find them. Whenever you go on home visits you should be always alert to identify those who are pregnant. Relatives, Dais, AWWS, depot holders, school teachers, as well as friends and neighbours can help to give you information about pregnant women in the community. Register the woman after confirmation of pregnancy and prepare the mother and infant immunization card.

150 The duration of a normal pregnancy is 280 days from first day of the last menstrual. period (LMP) or 40 weeks or 9 calendar months plus 7 days.- Pregnancy is divided into three trimesters. 1. The first trimester is from the first day of the last menstrual period (LMP) to 12 weeks. (First 3 months) 2. Second trimester is from 13 weeks to 28 weeks. (Second 3 months) 3. Third trimester is from 29 weeks to 40 weeks. (Last 3 months) At least 5 check-ups are advised after confirmation of pregnancy and registration. Optimal number of check-ups are between 9 to 10. You must ensure that every pregnant woman must get at least 5 check-ups during pregnancy other than registration The first check-up after registration is in the second trimester at 16 to 20 weeks and next in the third trimester at 32 weeks and 36 weeks. During last month every week, if possible. The activities of five check ups after registration are as follows: 1st Check-up: end of 4th month (16-20 weeks)  Screen for risk factors and medical conditions  Record BP, weight and height  Screen for anaemia  Give tetanus toxoid  Provide education for nutrition  Develop individualized birth plan 2nd Check-up: 28 to 32 weeks  Record BP and weight  Abdominal examination to assess for intrauterine growth retardation (IUGR), twins etc.  2nd dose of tetanus toxoid  Anaemia prophylaxis/treatment  Develop individualized birth plan  Health education

151 Further Check-up: 36 weeks onwards:  Record BP and weight.  Detect-Pregnancy induced hypertension.  Abdominal examination to identify foetal lie/presentation to detect IUGR.  To rule out if head is bigger than pelvis in primi-gravida after 37 weeks.  Update individualized birth plan with the trained birth attendant and family.  But in Kerala situation minimum 5 antenatal check ups.  Health education: Diet, rest, IFA tab consumption, danger signs and where to go when any complications arise. You should encourage her to visit more often, especially in the third trimester of pregnancy. Provision of ante-natal care Diagnosis of pregnancy: Signs and symptoms of pregnancy: (upto 20 weeks) You can diagnose pregnancy in the first half when there is history of:  Missed menstrual period.  Nausea and vomiting.  Frequent passing of urine due to pressure of growing uterus on the bladder.  Increase In size of breasts.  Darkening of nipples and sometimes painful when touched. Signs and symptoms of pregnancy: (Between 20-36 weeks) You can diagnose pregnancy in the second half when:  There is enlargement of abdomen due to increase in the size of uterus.  Parts of baby (foetal parts) can be felt.  There are painless contractions of uterus.  Mother feels movements of baby. (Foetal movement Reported by the mother) Clinical Assessment: (History taking, physical examination and investigations) During the ante-natal check-up you must:

152 a. Take a careful history by interviewing the woman. b. Do physical examination and conduct routine investigations to determine the presence of any risk factors and to check whether the pregnancy is progressing normally. (A) History - You must elicit the following information about the mother while taking history before examining the woman. (i) Date of last menstrual period You should ask the woman for the date of first day of last menstrual period and based on this calculate the expected date of delivery (EDD). You should estimate period of gestation at each visit. For calculating expected date of delivery add to the first day (date) of last menstrual period, 9 calendar months + 7 days. You should ask the history of quickening around 16-20 weeks (First movement of the foetus felt by the mother) this will help you to confirm EDD and to confirm that there is a live foetus. (ii) Age Those who are less than 18 years or more than 35 years of age are at a higher risk of complications. (iii) Duration of marriage If there is a long period before conception the pregnancy becomes precious (without use of any contraception). (iv) The order of pregnancy Primigravida and those who have had 4 or more deliveries (grand multipara) are at higher risk of developing complication both during pregnancy and labour. (v) Number of living children If the family is complete (2 to 3 children) then you should advise the couple to limit the family. (vi) Date of last child- birth/Last abortion Interval less than two years from last pregnancy or 3 months from last abortion is a risk factor for developing anaemia. (vii) History of previous pregnancy/delivery, Enquire if the woman had experienced any of the following:  Still birth or neonatal death

153  Abortions or premature births if any  Eclampsia-pre-eciampsia  Ante-partum haembrrhage (APH)  Malaria, anaemia, urinary tract infection  Complicated delivery such as prolonged labour, PROM( Premature rupture of membranes).  Post partum haemorrhage (PPH), retained placenta  Puerperal sepsis  Operation - especially LSCS or abdominal surgery (for ectopic/perforation during MTP) etc.  Induced labour  Baby's weight at birth, sex and its current health status  Difficult labour/surgical intervention/neonatal outcome Any of the above problems in a previous pregnancy makes the woman high-risk in this pregnancy, which need referral as indicated in the AN card (if available). (viii) History of any Systemic Illness (both present and past) You must take history of systemic illness e.g.:  Heart disease  Diabetes  Tuberculosis  Hypertension  Urinary tract infection  Malaria  Thyroid or any disease for which she has been advised to take medication  Syphilis Presence of any systemic illness is a high-risk factor needing referral as indicated in the AN card. (ix) Family History Ask about the family history of:  delivery of twins

154  delivery of congenitally malformed baby  diabetes

(x) Complaints during present pregnancy: (To be asked during each visit). During each visit you should ask whether she has any of the following complaints:  Breathlessness  Excessive tiredness  Palpitation  Puffiness of face  Tightening of bangles or rings  Headache or blurring of vision  Bleeding or leaking per vaginum  Pain abdomen at any stage of pregnancy  Fever After 4-5 months of pregnancy, ask at every visit whether she is feeling foetal movements well or not. Presence of - any complaints could need action depending on their severity as indicated in the AN card (if available). Key questions: (in History Taking)  The date of last menstrual period  The age  The order of pregnancy  No of living children  Date of last delivery/abortion  Any problem during the previous pregnancy/delivery  History of any systemic illness, significant family history.  Complication in the current pregnancy

155 (B) Physical Examination: 1. General Examination: It includes checking for gait, height, weight, BP, pallor and oedema.  Gait You must observe the gait of the woman as she walks into the room. The woman with abnormalities of the spine, hip joint and lower limbs e.g. in poliomyelitis may not deliver vaginally, hence you must refer her to MO (PHC).  Height A short woman with height less than 145 cms may have a small pelvis, hence may have problems during delivery. Such woman should be referred to MOPHC. While measuring height the pregnant woman should stand against the scale with her feet touching the wall/scale and head held straight (She may also need caesarian).  Weight (kg) Adult women wearing light, clothing are requested to stand erect in such a way that the weight is distributed evenly on the platform of the balance, before taking weight. Weight measurement is done to the nearest. l00 gms. Weight must be recorded at every ante-natal visit. Weight gain during the first trimester is minimal. However: the expected weight gain during pregnancy is around 10 kgs,. After first trimester women gain around 2 kgs every month or 0.5 kg/week. The weight she should have gained since her last visit should be estimated using the calculation of 0.5 kg/week for the number of weeks since her last visit and compared against actual weight gain observed. An excessive weight gain (more than 3 kgs in a month) should arouse a suspicion of pre- eclampsia/twins. You must refer woman with excessive weight gain to MOPHC. Under- weight women and women gaining less than 2 kgs should also be referred to AWW for food supplementation. In follow-up visits it must be checked that she is gaining adequate weight. In spite of supplementary feeding, if weight gain is poor she must be referred to M.O. PHC  Blood Pressure Recording You must record the BP of pregnant woman correctly at every visit.

156 a. The systolic blood pressure is defined as the BP at which the sounds first appear and diastolic blood pressure as the BP at which the sounds tend to get muffled. In pregnancy often the disappearance of the sounds occur when the BP reading is very low. (Note the diastolic pressure if stethoscope is available). The BP is recorded as follows b. Ask the patient to sit or lie down comfortably and relax. c. Ensure pointer on the dial is at zero by adjusting with the knob attached to the dial. d. Fix arm cuff on the upper part of either arm. e. All clothing should be removed from the arm. The cuff should be applied closely to the upper arm, with the lower border not less than 2.5 cms from the cubital fossa (elbow). f. Feel the pulse at the wrist by either arm. g. Tighten the knob above the rubber bulb and inflate the cuff with your right hand. h. The manometer is placed so as to be at the same level as the observer's eye. i. Needle of the dial will show deflection as the pressure increases within cuff. j. Keep on inflating the pressure by pressing bulb with fingers on pulse. When pressure in cuff increases more than the blood pressure, you will not feel the pulse. Measuring Blood Pressure k. Note the reading on the dial just at the point above which the pulse is not palpable and below which the pulse is palpable. This is the systolic blood pressure of the woman. For example if the reading on the dial shows 120 at which you stop feeling the pulse and if the dial moves below 120, you can feel the pulse, then the systolic BP of the women is 120 mm Hg. l. Deflate the cuff by loosening the screw above the bulb. m. The blood pressure reading is normally less than 140 mm Hg. n. If it is more than 140 mm Hg, take blood pressure again, make sure the expectant mother is, calm and not anxious. o. If stethoscope is available the radial pulse is palpated while the cuff is inflated to a pressure of 30 mm Hg above the level at which radial pulsation can no longer be felt. p. The stethoscope is then placed lightly on the cubital fossa. q. The pressure in the cuff is lowered, 5,mm Hg at a time, until the first sound is heard, which is the s systolic pressure.

157 r. Continue to lower the pressure in the .,cuff until the sound becomes suddenly faint or muffled. This is the diastolic pressure. The BP is expressed as systolic/diastolic(s/d). s. Blood pressure must be recorded at every ante-natal visit. Abnormal blood pressure is a pressure of 140 mm Hg systolic or more which is sustained (two consecutive readings at least 6 hours apart after rest). When it develops after 20 weeks of pre- eclampsia. Women with blood gestation it is suggestive of pressure 140/90 or above but less than 160/110 mm Hg should be referred to PHC. Blood pressure of 160/.110 mm Hg is a danger signal and the women must be referred to CHC/FRU immediately. If BP is 140/90 with proteinuria (presence of protein in urine) she should be referred to FRU.

 Pallor You must examine pregnant woman for pallor on the nails, conjunctiva, tongue and palate. If the pallor is present it indicates anaemia. To look for pallor, pull down the lower lid of the eye with a gentle but firm pressure with your index finger and look at the colour of the inside of the lid (palpebral conjunctiva) and palate which may be pale pink. In addition look at the tongue - to see if it is white, and smooth. Looking for Pallor at the Palpebral Conjunctiva and Tongue The nails will also look white instead of pale pink. Koilonychia also occurs in iron deficiency anaemia i.e. the nails are soft, thin and brittle and the normal convexity is lost and replaced by a concavity. In our country the practice of putting kajal/kohl in the eye, chewing betelnut, putting nail polish, may mask the signs of anaemia.  Oedema: It can be diagnosed by looking for the following: - Puffiness of- face - Swollen fingers - Swelling over abdominal wall (Foetoscope will make an impression on the abdomen). - Presence of oedema feet - Apply for firm pressure over the anklebone for about 10-15 seconds and see if a pit it formed. This is significant pitting oedema. - Oedema may be associated with PIH. 2. Breast Examination:

158 While examining breasts the following findings are looked for:  The breasts are to: be palpated for any lumps or tenderness. On palpation if there are lumps present, refer her to the MO (Please don’t squece the nipple for fear of abortion). 3. Abdominal Examination: Abdominal examination is done to monitor progress of pregnancy and foetal growth and to determine foetal lie and presentation as well as to auscultate foetal heart sounds. The woman may be asked to lie on her back with the hips and knees partially flexed having previously emptied her bladder. It is essential that bladder is completely emptied just prior to measurement of fundal height since even a half full bladder might result in increase in fundal height by 1 cm or more. You must stand on her right side and examine the abdomen gently in a systematic manner. The attention of the woman may be diverted by conversation. Your hand must be warm and the hand should be allowed to rest for a moment on the surface of the abdomen till the uterus is relaxed before palpation is actually begun. Poking with the fingertips should be avoided at all costs. During abdominal palpation the following need to be done:  Measure height of the fundus. (This indicates progress of pregnancy and foetal growth).  Determine foetal lie (whether longitudinal, transverse or oblique) and presenting part of foetus (vertex or breech or shoulder). • Fundal Height Measurement The uterus becomes an abdominal organ after 14 weeks. Gestational period (in. weeks) can be estimated from the fundal height after 14 weeks of gestation . Correct dextro-rotation (uterus is more towards the right side) by pushing the uterus towards midline from right side using back of fingers of right hand. Simultaneously begin the palpation from near the xiphisternum using the ulnar border of the left hand. Keep palpating until the fundus is reached. Mark the top of the fundus. Ask the woman to stretch her legs fully. The upper border of the symphysis pubis is palpated and marked. The distance between the two markings is measured to the nearest mm. by placing the

159 tape along the curvature of the anterior abdominal wall. The height in cms. corresponds to period of gestation in weeks after 24 weeks of pregnancy. If there is any disparity I.e. it is either more or less than period of gestation, then you must refer her to PHC. Fundal Height at different period of pregnancy 14 weeks Just above symphysis. 16 weeks mid-way between symphysis pubis and umbilicus. 24 weeks at the level of umbilicus (the distance between the umbilicus and the xiphisternum is divided into three equal parts). 28 weeks at the junction of lower third and upper two-third of the distance between umbilicus and xiphisternum. 32 weeks junction of upper and, middle third between umbilicus and xiphisternum 36 weeks just below the xiphisternum. 40 weeks fundal height comes down but flanks are full. If the height of uterus is more or less than expected - Refer toM.0 (PHC). For examination to determine the lie of the foetus you may practice the following: (i) First Manoeuvre, Fundal Grip Palpate the uterine fundus gently between the two hands in an attempt to determine which pole of the fetus (the breech or the head) is occupying the fundal area. (ii) Second Manoeuvre, Lateral Grip Now slip the hands along the side of the uterus. Palpate on either side of the uterus. By this means, the back of the foetus is identified as a continuous flat surfaces n one side of the midline, and the limbs as small irregular knobs. Often you will feel the fetus move under your hands. (iii) The Third Manoeuvre (Superficial pelvic grip) The third manoeuvre is not always necessary and, unless you perform it gently. It may be painful. Spread your right hand widely on the pubic symphysis. When the fingers and the thumb are approximated the presenting part can be felt between them and its mobility above the pelvic brim can be determined. Although palpation is usually easy, occasionally the woman may be tense and the uterus contracted. In such cases it is better to wait for a while till uterus is relaxed rather than to persist with palpation.

160 (iv) Fourth Manoeuvre (Deep pelvic grip) You must face the foot end of the mother and with the hands on the lower part of the uterus, keep palpating downwards medially attempting to recognize the presenting part. Usually it is the head, which is firm, large and rounded and unless fixed in the pelvis, is ballotable from side to side between the fingers. If the presenting part cannot be readily identified because it is fixed in the pelvis, the fingers are slipped further downwards and inwards until they dip into the pelvic brim. If the woman cannot relax her muscles, she should flex her legs slightly and be told to breathe deeply', Palpate in between deep breathing. After palpating note down the lie. Longitudinal Lie, Horizontal/Transverse Lie Auscultation You should auscultate for the foetal heart rate. This can be done with the foetoscope. Normal foetal heart rate is 120-160 per minute. Heart rate more than 160 or less than 120/minute indicates foetal abnormality. Foetal heart is heard against the back of the baby. All the clinical findings and the following routine test results are recorded in ante-natal card if available. (C) Routine Investigations In routine investigations hemoglobin is estimated, urine is examined for albumin and sugar. I Hemoglobin Estimation Materials  Sahli's haemoglobin meter  Graduated tube  Sahli's pipette marked to 0.02 ml.  Filter paper  Dropper  Glass rod  N/1 0 hydrochloric acid  Sterile lancet

161 Materials for haemoglobin estimation by Sahli’s method Why and when you should do Hb estimation:  Estimation of haemoglobin is done to check if the pregnant woman is suffering from anaemia. It is important as many women suffer from anaemia and its complications, which can even cause, death.  Hb estimation is done during pregnancy at the first visit and at 32 weeks routinely.  If anaemia is present then estimation is repeated 4 weeks after iron-folic acid therapy. If no improvement is seen after 4 weeks refer the case to M.O. Method of Haemoglobin Estimation Hb estimation is done by Sahli's method by using haemoglobinometer.

Blood collection by capillary method The steps to be followed by in haemoglobin estimation by Sahli's method are given below:  Blood is collected from the side of the ring the finger prick.  For this clean the site with spirit swab.  Prick the finger firmly and rapidly.  Wipe away the first drop of blood with cotton, wool (don't squeeze the finger for blood drop to appear as the tissue fluid may be squeezed and may give wrong results).  Wait for another drop of blood to appear.  Draw the blood in the pipette upto 0.02 mark; do not allow air bubbles to enter.  Keep the graduated tube ready upto 20 mark with N/10 hydrochloric acid.  Draw the blood as mentioned above  Wipe the extra blood from the outside of the pipette.  Slowly blow out the blood into the acid in the graduated tube. Rinse the pipette by drawing and blowing out the acid solution 3 times.  Allow standing for 5 minutes.  Place the graduated tube in the haemoglobinometer.  Compare the colour of diluted blood in the tube with the reference tube.

162  If the colour is same or lighter, then the hemoglobin value is less than 4 gms %.  If the colour is darker than the reference tubes, continue to dilute by adding N/10 HCL drop by drop.  Water can also be used at this stage to dilute.  Stir with the glass rod after adding each drop.  Remove the rod and compare the colours of the two, tubes.  Stop when the colours match. Note the mark reached. II. Urine Test for Albumin and Sugar Test for presence of albumin and sugar in urine during every ante-natal visit. Use uristix method for estimation of albumin and sugar in urine.

1.2.3.3. Assessment of risk factors: As you already know that all pregnant women are at risk of complications. There are some conditions the presence of which make the pregnant woman exposed to a higher risk of complications and threat to life of mother and baby. These risk factors are identified during ante-natal check-up, timely action can be taken to save life of mother and baby. Women at risk in pregnancy or delivery are those with: a) Weight less than .38 kgs at first trimester. b) Short stature (less than 145 cms or 4 feet and 10 inches). c) Age less than 18 years or more than 35 years. d) Problems in previous pregnancy.  Operative delivery.  Still birth/neonatal death in previous pregnancy.  Complicated delivery such as prolonged labour, retained placenta, ante-partum and postpartum haemorrhage and sepsis  History of more than four deliveries.  History of repeated abortions. e) History of illness such as heart disease, diabetes, T.B., malaria, anaemia and other medical problems. f) Problems in present pregnancy like:

163  Bleeding anytime during pregnancy  Abnormal presentation  Pregnancy induced hypertension  Severe anaemia  Twins, over-distended uterus  Floating head in a primigravida at 38 th week or later  Very big or very small baby  Pre-term labour (earlier than, 37 weeks) For the following risk factors refer to PH, C: If the ANM detects the following risk factors during ante-natal check-up, you may tell her to refer the woman to PHC:  Short statured women  Age less than 18 years  History of any medical problem  Height of uterus not corresponding to period of gestation  Sluggish/loss of foetal movement.  Hb <10 gms.  Fever more than 3 days. For the following risk factors refer to FRU: If you detect the following risk factors during ante-natal checkup you may refer the woman to FRU:  Bad obstetric history i.e. previous still born  Bleeding during pregnancy (more than 12 weeks.  Pregnancy induced hypertension with proteinuria (preeclampsia)  Abnormal presentation  Multiple pregnancy/over distended uterus  Grande multipara i.e. four or more deliveries in the past  Previous history of operative delivery e.g. Caesarean section  Age more than 35 years  Floating head in a primigravida at 38 weeks or later

164  Pre-term labour  Premature rupture of membranes (if labour pain does not start within 6-8 hours of rupture of membranes)  Very big/very small baby For the following danger signs refer to FRU: Presence of the following signs makes pregnant woman at risk to life threatening conditions. Hence you should refer them to FRU as soon as possible:  Bleeding  Breathlessness (severe anaemia)  Convulsion, severe headache  Swelling of face and hands  High grade fever  Labour pains for more than 12 hours TT immunization Explain to the pregnant woman that TT immunization protects her and her newborn baby against tetanus, which is a serious disease with a high mortality. TT immunization must be given to all pregnant women and there are no contraindications. It is given as intramuscular injection of 0.5 ml. - The first injection is given at the time of the first contact with the pregnant woman, between 3-4 months. - The second injection is given after one month. If the woman had received tetanus toxoid during a pervious pregnancy less than 3 years ago, only one injection is sufficient. However, in. case of doubt give 2 injections. - You must ensure that the injections must be completed at least one month before delivery. There may be slight pain at the injection site for a day or two. Tetanus toxoid must be administered under proper aseptic precautions. Giving Injection Tetanus Toxoid  It is given at the outer aspect of upper one-third of the upper arm. Clean the part with cotton and spirit.  Allow it to dry.

165  Stretch the part of the skin between the thumb and finger by holding the arm from beneath the axilla.  Prick the prepared part and withdraw the Piston to see whether there is blood coming or not. If no blood is coming then give the injection. If blood is seen coming into the syringe then with draw the needle and repeat the procedure at different site. The tetanus spores are widespread in the environment, especially in the rural areas where there are a large number of animals living in close proximity. It is therefore important that high T.T. immunization coverage levels are sustained and clean delivery practices continued even if there are no cases of neonatal tetanus.

Iron folic acid distribution Prophylactic iron tablets should be given to all pregnant women after 16 weeks of gestation till three months after delivery. The government distributes 100 tablets (each containing 100 mg of elemental iron) of IFA to all pregnant women. Identification and preparations for institutional/home delivery: At every ante-natal visit, individualized birth plan is discussed with the family. You must encourage them to have delivery at an institution. The woman who insists on home delivery should be told that complications can occur anytime and the family should be ready to take the woman to the nearest FRU/PHC immediately when complications arise. However, if the woman or the family insists on home delivery then home delivery may be advised to only those women who have had one or two previous deliveries with live children and have had regular ante.-natal care with no problem during the current pregnancy. Common complications of pregnancy and their management Diagnosis of anaemia and management: Most of the women in India suffer from anaemia. Pregnancy aggravates anaemia. Many of the complications like congestive heart failure, pre-term labour, infections in pregnancy are due to anaemia or aggravated by anaemia.  Signs and symptoms

166 a. Tired and breathless after doing normal days work. b. History of malaria and worms like roundworm and hookworm. c. Woman looks pale (conjunctiva, nails and tongue). d. In severe anaemia, generalised oedema, breathlessness may be present.  Investigation Confirm the diagnosis by estimating haemoglobin by Sahli's method. If haemoglobin is less than 7 gms it is severe anaemia.  Management - In severe anaemia (Hb less than 7 gm/di) Refer to FRU (whatever period of pregn ancy)

 In mild anaemia (Hb more than 7gm/dl) up to 32 weeks a. Treat with oral IFA - 2 tabs of IFA large daily till six weeks postpartum. b. Ensure compliance by counselling c. Diet - advise to take green leafy vegetables, soyabean, jaggery, whole pulse, milk and locally available food. d. If patient is not responding to IFA after one month refer to PHC.

In mild anaemia (Hb more than 7 gms/di) after 32 weeks. Refer to PHC Diagnosis of pregnancy induced hypertension and its management: (P.I.H) This is development of hypertension with or without proteinuria with oedema or both induced by pregnancy after 20th week of pregnancy and regresses after pregnancy. PIH has serious consequences for both mother and foetus like eclampsia in mother and foetal asphyxia in foetus.  Symptoms and Signs: - Usually, the woman has no complaints until the condition becomes very severe. However she may complain of swelling over hands, feet and face.

167 - Excessive weight gain. - Oedema. - A raised blood pressure during pregnancy leads to serious consequences for mother and child. Hence at every visit check the BP of the woman.  Investigation: - Test urine for protein like albumin. (if protein like albumin is present in urine this is known as proteinuria.) - Any BP> 140/90 must be monitored by repeating after 6 hrs. Women with blood pressure 140/90 or above but less than 160/1 1 0 mm Hg should be referred to PHC. Blood pressure of 160/110 mm Hg is a danger signal and the woman must be referred to CHC/FRU immediately. If BP is 140/90 with proteinuria you should refer her to FRU. If the family does not agree to referral explain to the relatives about the risk to the life of the mother and the child and persuade them to go to PHC/FRU as the case may be. If they still do not agree then advise: a. Family members about the signs of imminent eclampsia and the need for immediate referral to FRU if symptoms appear. b. To take bed rest. C. To take normal diet and fluid intake. d. To keep record of baby movement count after eighth month of pregnancy (less than 10 kicks in 12 hours period persisting for 3 days or more needs immediate referral to a FRU). You must monitor BP daily and test urine for albumin Threatening (imminent) eclampsia. The presence of following symptoms and signs indicate threatening (imminent) eclampsia: a) Severe headache and dizziness, b) Generalized edema of hands and or face c) Blurring of vision or double vision d) Nausea, vomiting and/or epigastric pain e) Proteinuria

168 f) Decreased urine output (Oliguria) If the patient has imminent eclampsia a. Ask her relatives to arrange transport to the FRU and explain seriousness of condition. b. You must accompany the woman to hospital c. Keep a mouth gag ready. Eclampsia This is a very serious condition that can lead to death of the mother and baby. Eclampsia is preventable in most of the cases. Early identification and prompt management of pregnancy induced hypertension can help you to avoid the serious consequence of eclampsia. Any patient with a BP of 140/90 or more can develop convulsions. In eclampsia patient gets convulsions. If the patient has fit i.e eclampsia:  Keep the airway open by ensuring that the woman is on her side with head slightly extended.  Put a soft gag made of cloth between teeth so that she does not bite her tongue in case she has convulsions on the way to the hospital.  You must accompany the woman to the hospital. Bleeding during pregnancy This could be due to abortion or ante- partum, haemorrhage. Abortion: In the first 20 weeks of pregnancy hemorrhage is due to abortion which may be spontaneous or induced. In case of induced abortion you will get the history of intervention.  If spontaneous abortion is less than 8 weeks of gestation refer to MO (PHC).  If spontaneous abortion is more than 8 weeks or there is history of interference (induced abortion) refer to FRU.  For induced abortion refer to Unit 11 of this module. Ante-partum Haemorrhage

169 After 20 weeks of pregnancy all cases of bleeding PV are to be treated as ante- partum haemorrhage. This is a condition that can be fatal and women with antepartum haemorrhage should deliver in a hospital. You should not do vaginal examination in a woman with antepartum hemorrhage. Refer the patient to FRU with family members and friends who can donate blood. During transportation:  She should lie in the left lateral position.  She should be kept covered and warm. Early recognition of complications and urgency in referral: All pregnant women are at risk of complications and in some women these complications can occur without any warning. Therefore the community, family members of pregnant women and pregnant women themselves must be educated about the danger signals. It is also important that all pregnant women and their families are aware of the nearest hospital,, how to reach it, to make advance arrangements for transport in anticipation of the emergency. They should keep sufficient money for such an emergency. Some complications require immediate response as the time between onset and death in a woman can be very short. Delivery of 'high-risk' women in the hospitals will reduce the number of avoidable serious life-threatening complications such as rupture uterus, septicemia and haemorrhage and reduce maternal and peri-natal mortality and morbidity due to these complications. You must teach the pregnant women, her family as well as the community about the need to identify the danger signals and seek immediate medical help at CHC/FRU. Danger signals are:  Vaginal bleeding or spotting.  Pallor with breathlessness or marked palpitations.  Dizziness, blurring of vision, headache or vomiting.  Fits/convulsions.

170  Marked reduction in urinary output.  Severe abdominal pain.  Pre- term labour before 37 weeks and premature rupture of membranes before 37 weeks. Premature rupture of membranes and no labour pains within 10 -12 hours. Leaking before 37 weeks must be referred to PHC. Fever during ante-natal period for more than 3 days. 1.2.5. Health Education and Counselling: You should educate the woman about the following: (1) Drugs Drugs are not to be used in the first trimester unless required for a life-threatening emergency. The pregnant woman should be advised to consult a doctor if there is any such problem. (2) Bath The woman should have daily bath and keep her body clean and wear clean loose clothes. She must keep vulval region clean to prevent infection. (3) Rest The mother needs to rest on her side for about two hours in the afternoon and get at least 8 hours of sleep at night. Rest improves the circulation to the foetus. Short periods of rest in between ordinary day-to-day activities should also be taken. Ordinary day-to-day routine activities should be continued in normal pregnancy. However heavy manual work is not advisable. It is important to advise the woman and other family members that the woman gets adequate rest so that family responsibilities are shared and pregnant woman gets the rest she needs. Rest and: Nutrition (4) Food and Nutrition Pregnant women from poorer socio-economic groups need to take an extra meal of the family food everyday. Pregnant women should preferably take local seasonal foods which are rich In iron (Example:- green leafy vegetables, spinach, cabbage and of her available green vegetables). You are already aware that under-nourished women are

171 likely to suffer from anaemia, give birth to low birth weight babies and both mother and baby are susceptible to illness. (5) Preparing for Delivery You should discuss with the woman and family members about the need for institutional delivery. The community, family members of the pregnant women and the woman herself must be told that even in low risk cases sometimes complications develop suddenly with serious consequences to mother and child. So it is better for the woman to have an institutional delivery by trained personnel. In case they are not willing for institutional delivery, they should be provided with DDK. In case the DDK is not available they should be advised to buy a new blade and thread and keep them handy. The thread should be boiled for 20 minutes and sun dried before use. You should also ask the woman and family to keep old clean cotton cloth for mother and for the newborn. It is important that these are clean to prevent infection. Clothes should be washed with soap and sun dried. They should be kept away from dust. It is very important that all women who are pregnant, their family members and the community must be informed regarding the nearest hospital so that they can be taken there immediately if there is an emergency. They must also make some arrangements in advance, for transportation so that no time is lost if the woman has to be rushed to a hospital. Blood transfusion is often required for obstetric emergencies and family members and friends must accompany the woman to donate blood.

(6) Education for Breast-Feeding and Breast Examination All pregnant women must be advised on early and exclusive breast-feeding and care of the newborn. Care of the breasts should start during pregnancy. Breast feeding should be given with in half an hour after delivery. Everyday while having a bath, the mother should wash the breasts well. You should give advice regarding other aspects: a. Intercourse is best avoided after 36th week of pregnancy and for six weeks after delivery.

172 b. Long travel by bus or bullock cart should be avoided in the first three month or after twenty-eight weeks of pregnancy. c. Teeth must be cleaned daily and dental caries must be treated. d. The pregnant woman should not smoke as it affects the growth of the baby. e. Bowels should be regulated, as constipation can be troublesome. This can be avoided by advising her to drink plenty of fluid especially warm water on getting up in the morning. Fruits and green vegetables in the food will all help to keep the bowels regular. Strong purgatives are to be avoided. For details of counselling refer to communication block Management of minor ailments: You may be consulted for minor problems related to pregnancy. The minor problems, which are related to pregnancy can cause a lot of discomfort and may interfere with nutrition of the pregnant women. Such women would require help and advice and you must be able to help them. (1) Morning sickness Advice her to eat some solid food on getting up in the morning before tea or coffee. They can be taken 10 to 15 minutes later. She has to take small frequent meals and she should drink plenty of fluids. The food should be tasty with lot of green vegetables. In case the woman is not able to retain food or fluids and urine becomes scanty and dark, with signs of dehydration, refer her to PHC for treatment. (2) Heartburn and nausea Advise her to avoid eating fried, spicy or rich food. She may take sips of milk and should avoid lying down immediately after eating. If the symptoms persist or become worse, refer her to PHC.

(3) Backache Advise her to increase the period of rest, if the pain is severe and persistent, advise her to go to PHC. (4) Constipation Advise her to drink plenty of fluids; eat well-washed raw fruit and vegetables, coarsely ground cereals and green leafy vegetables. If inspite of following this advice, the constipation continues, a doctor should see the woman.

173 Record maintenance: Entry should be made as' early as possible in the appropriate register/forms.

Collaboration with Dai/Anganwadi Workers and community leaders: Some pregnant women will come themselves to the antenatal/MCH clinic at sub- centre or the village. Many will not come to the clinic/village. MCH session and you may have to find them. When you go on home visits you should be always alert to identify those who are pregnant. Relatives, Dais, AWW,s depot holders, school teachers, as well as friends and neighbours can help to give you information about pregnant women in the community. In addition the members of the community should also be made aware:  When to go to referral centre by informing them about danger signals of pregnancy (refer to danger signals).  Where to go for care by explaining location of institutions (should know where the FRU/nursing home is).  How to go - providing information about the transport and approximate cost. Key points of Ante Natal Care  Early registration of pregnant women.  Providing essential ante-natal care (at least 3 visits).  Essential care includes detailed history taking, general and obstetrical examination and routine investigations.  Detection and treatment of anaemic women.  Follow-up of ante-natal woman at specified intervals.  Management/referral of high-risk pregnant women.  Management of minor ailments during pregnancy. When to refer to FRU?

D. 2nd Stage of Labour

174 Tick if 1. Practices asepsis during delivery applicable 2. Recognises onset of 2nd stage of labour. and X if not 3 Encourages her to'push' only during good contraction. 4. Tells her to relax and take deep breaths between pains. 5. Provides support to perenium with a pad when crowning of head takes place. 6. Conducts normal vaginal delivery safely and efficiently. 7. Prevents injury to maternal tissues and fetus. 8. Ties arid cuts the cord aseptically leaving behind adequate stump. 9. Wipes the baby clean and wraps it. 10. Does suction through mucus extractor if so needed

E. 3rd Stage of Labour 1 . Recognizes the onset of 3" stage of labour. 2. Delivers the placenta and membranes properly. 3. Inspects the placenta and membranes for its completeness. 4. Gives inj. Methyl ergometrine (0.2 mg) IM after delivery of placenta. 5. Performs immediate maternal physical examination. 6. Identifies complicated case and arranges for referral. 7. Observes the patient for 1 hour after delivery of placenta for signs of PPH.

You have to supervise the record maintenance done by Jr.P.H.L and ensure timely vital registration. 1.3.12. Self-assessment questions: 5. List the signs of onset of labour. 6. Which pregnant woman can be delivered at home? 7. What are signs of separation, of placenta ?

175 Tick if A Immediate Post-natal Care applicable 1 Records the details of the birth for registration etc and X if not 2 Monitors maternal vital signs and baby’s condition. 3 Watches for bleeding PV 4 Weighs the newborn and records it 5 Gives the baby to the mother to breast feed 6 Explains the mother how to care for herself and her baby by regular check-up, nutrition, immunization and family planning

Tick if B Follow up visits at home a clear room with a right to privacy applicable 1 Elicit proper history about general health, diet bowel, bladder movements, and X if not bleeding PV 2 · Notes temperature • Notes B. P • Notes pulse • Examine breast • Palpates abdomen for height and consistency of uterus. • Does perineal inspection examination and observes the colour of vaginal discharge. • Looks for the swelling over legs, redness and asks for pain in legs if any. 3 Inspects lochia 4 Enquiries about any post partum complications 5 Looks for signs of sepsis and if so, refers the patient. 6 Assesses newborn (See..for fontanelle, eyes, colour of skin, hydration umbilical cord, sucking, passing urine and stool and gives the- first immunization), 7 Advises for atleast 3 post-natal-follow-up visits 8 Explains the advantages of breast feeding correct technique. 9 Explains about weaning and its benefits. 10 Explains all the queries that the woman attendants have in an encouraging manner.

Tick if C Family planning Advice applicable 1 Explains importance of birth spacing and X if not 2 Informs about different methods of contraception 3 Explain about relative benefits and side effects of each method 4 Helps her to choose the right contraceptive measure 5 Guides her for its utilization and follow up 6 Explains about best choice of IUD insertion as post natal contraceptive measures 7 Teaches correct use of barrier method if opted

176 Supervisory Check-list: You have to supervise the ANM when she is giving health education and counselling on MTP services under the RCH programme. While supervising you must ensure that she' Tick if A. preliminaries applicable and X if not 1. Can calculate period of gestation before referring for MTP. 2. Can guide to the centre where MTP can be done.

B. Post MTP follow- 1. Ask or history of bleeding PN or discharge pervaginum. 2. Ask for history fevers, pain, abdomen to excludes complications of MTP. 3. Advises about contraception. 4. Advises about next follow-up visit.

EXAMPLE Check-list for Selection of Acceptors of Oral Pills Fill the following check-list before selecting an acceptor for oral pill. If any of them is positive, then she should be referred to medical officer. 1. Age above 40 years. 2. Smoker aged above 35 years 3. Using oral pills continuously for more than 5 years. 4. Pregnancy. 5. Lactating less than 6 months. 6. Complaint of prolonged/frequent headache. 7. Visual disturbances. 8. Breathlessness on exertion. 9. Fits. 10. Persistent/frequent attacks of pain in abdomen. 11. Irregular vaginal bleeding. 12. History of taking drugs., 13. Repeated skin rashes. 14. Gross malnutrition. 15. Gross obesity. 16. Yellow skin and conjunctiva (jaundice). 17. Pulse rate above 120/min. 18. Oedema of extremities. 19. Lump in breast.

177 20. Sugar in urine - Diabetes. 21. Albumin in urine. Tick if 1. Detects the early signs and symptoms of RTI/STI applicable 2. Traces partner and refers the contact for treatment. and X if 3. Performs speculum examination in a case of viginal discharge not 4. Performs bimanual examination in a suspected case 5. Takes adequate precautions to avoid contamination and to protect self and others 6. Counsels regarding prevention of RTI/STI 7. Explains the importance of the use of condoms to prevent RTI/STI. 8. Explains about sexual hygiene 9. Explains about monogamous relationship 10 Refers the client to MO PHC. Tick if 1. Can use methods of preventation of infections applicable 2. Can enumerate the fundamental principles of infection prevention. and X if 3. Can discuss the correct method of hand washing and wearing not gloves. 4. Takes necessary precautions while examining, performing procedures on clients. 5. Can use the antiseptics and disinfectants appropriately. 6. Can make the household bleach, sodium hypochlorite and calcium hypochlorite solution. 7. Decontaminates everything immediately after use and before clearing. 8. Can do disposal of the waste in the correct way 9. Sterilises gloves. 10. Sterilises and store gauze pieces. 11. Sterilises instruments. 12. Disinfects labour room and labour table. 13. Disinfects blood soaked clothes. 14. Dispose off the placenta and blood soaked pads.

178 Supervisory check-list: 1. Ensure five cleans before receiving the newborn. 2. Observe six steps of hand washing. 3. Drying the baby and maintenance of temperature. 4. Cutting and tying of umbilical stump. 5. Weighing the baby. 6. Initiation of breast-feeding. 7 Use of mucus sucker. 8. Giving mouth to mouth breathing. 9. Identification of congenital abnormality. 10 Identification of high-risk newborn. 11. Advise appropriate referral. Supervisory check-list: You have to check-up the following in context of newborn care while You are supervising the work of ANM. Mark tick if cross (X) against each item on appreciation/ otherwise respectively. 1. Identification of signs of dehydration correctly. 2. Preparation and administration of home available fluids (HAFs). 3. Preparation and administration of ORS solution. 4. Identification of danger signs in diarrhoea. 5. Counseling for home care and nutrition in diarrhoea. 5.8 ESSENTIAL CARE OF NEW BORN Care should start from the womb itself Proper antenatal checkup not less than 3; in our setup -5 checkup are advised with proper antenatal care and immunization for a better outcome. Stress should be given for high risk pregnancies and concentrate on preventive neonatology. Don't encourage any domiciliary delivery. As we are concerned, the medical facilities are in our doorsteps. So we can give better care from the labor rooms. It is a sad fact most of the delivery rooms in our country are not adequately equipped for resuscitation of an asphyxiated new born. Each delivery room must have a well lighted warm micro environment to receive the newly born infant. The resuscitation

179 kit must be checked by every staff nurse of every duty shift and rechecked by physician before each very. The pencil handle laryngoscope with infant (0,1) straight blade is preferred. The light source and battery are in working condition. Gamma irradiated disposable endotracheal tube of internal diameter 2.5, 3, 3.5, 4 mm should be available. Either electrical or De-Lee mucous trap must be available to meet the emergency. Oxygen cylinder, Ambu bag with mask and oxygen reservoir will provide 90% oxygen. The kit should contain disposable sterile endotracheal tube, suction catheter, plastic oral airway, syringe and needle, 7.5% sodium bicarbonate, .1:10000 epinephrine, Naloxone, Physiological saline dextrose etc. Sterile neonatal deliygiy pack containing bowl, scissors, cotton swabs and umbilical ties should be needed, The-hassinet on which the baby is to be received should be kept warm. Baby should be received in warm towels. The resuscitation of a new born is not cost effective but it is highly slul Plea of a baby at birth I have come from an extremely warm, clean, quiet and comfortable abode Protect me at birth from microbes and cold. I am wet, naked- dry me, cover me and place me under a heater. I don't know how to smile, let me announce my arrival by a cry. Don't hurt me but gently clean my wind pipe to let me cry. Don't give me injections but give me a breath to save my life. I have been swimming all through the womb. Don't be in a hurry to bath me in the labor room. The following condition demandiniz resuscitation alert Placental insufficiency  Toxemia  Hypertension  Diabetes mellitus  Post maturity  Mal-presentation or abnormal lie  Multi fetal presentation  Poor fetal growth  Rhesus iso-immunization

180  Bad obstetrical history  Bleeding in 2nd and 3d trimester  Matemal systemic diseases  Poly or oligo-hydranmios  Drugs like Rowrpino Lithiujrn carbonate Magnesium sulphate Adrenergic blocking agents Intra partum factors Evidence of fetal distress Premature labor Ante-parturn hemorrhage Placenta previa Abruptio placenta Cord prolapse Meconium stained liquor Premature rupture of lpembrane(> 1 2 hrs.) Prolonged labor (>24 hrs.) Prolonged second stage of labor (>2 hrs.) Use of general anesthesia and narcotics. APGAR Score Signs 0 1 2 Heart rate Absent <100/min >100/min Respiration Absent Low/Irregular Good, Crying Muscle tone Limp Some flexion Active motion Reflex Irritability No response, Grimace Cough/Sneeze (Catheter in nares) Color Blue/Pale Blue extremities Complete pink

181 In view of the inherent limitation of APGAR scoring system, it is no longer used to make decisions for neonatal resuscitation. So it is suggested an action assessment and resuscitation i.e. New NALS [Neonatal Advanced Life Support] Establishment of spontaneous breathing and maintenance of body temperature should receive top priority in the care of newborn baby at birth. Most babies have smooth transition from fetal to neonatal life and establish spontaneous breathing with out any assistance. About 3.5 - 7.5% of babies have difficulty in initiating spontaneous breathing at birth and need active assistance. For intact survival these infants demands vigilant observation and prompt intervention by skilled and experienced personnel. Effective resuscitation demands presence of at least one physician and an assistant or a nurse.

Assessment and support Temperature [Warm and dry] Airway [Position and suction] Breathing [Stimulate and dry] Circulation [Heart rate and color] Five question clearly differentiate the baby is in need of assistance or baby who can receive routine care. Ensure "5 cleans" in the labor room.  Is anmiotic fluid clear of meconium?  Is the baby breathing or crying?  Is there good muscle tone?  Is the baby color pink?  Is the baby term?

If all the answers are "yes" the baby can provide routine care. Receive the baby in a clean pre-waited towel. Dry and cover with another pre- warmed towel. Wipe the babies mouth and nose. If needed suck the babies mouth first and then the nose. [N comes after M] Cut the umbilical cord 2 cm away from the base and tie with a clean thread. Don't apply any medication. Early bedding in and breast feeding. This will prevent hypothennia and hypoglycemia.

182 If any of the answers is no, without meconium aspiration- Apply routine care and evaluate respiration and heart rate. Stimulate the respiration by tactile stimulus on feet or back of abdomen. Only gentle stimulus is necessary. If the respiration is good and the heart rate above 100/min and with out cyanosis-observe the child. In meconium stained liquor- intrapartum auctioning from mouth pharynx and nose when head is delivered. If the baby after delivery does not have a strong respiratory effort as evidenced by good cry, good muscle tone or heart rate >I 00/niin then the newborn requires tracheal auctioning. If you don't get any meconium, stop the procedure and assess. If gasp present tracheal stimulation intermittent positive pressure ventilation [IPPV] for 30 sec. and assess heart rate. If heart rate is picking up continue the procedure. After IPPV and bag and mask for 30 sec. still HR <60 endo-tracheal intubation, IPPV and start cardiac compression in the ratio 3:1 for 30/sec [90:30]Still heart rate not picking up administer medications i.e. Epinephrine (1:10000) solution through umbilical vein. Continue resuscitation and cardiac massage. Review every 30/sec. Usually the child improve. When the HR >60/min stop massaging. Continue IPPV. Good respiration and HR.> 100/min can stop the IPPV and evaluate every 30sec till the child achieves active tone, color and respiration. Always needed Dry, Warrn, Position Suction, Stimulate Oxygen Establish effective ventilation Bag and mask Endotracheal suction Infrequently needed Chest compression Medication Inverted pyramid reflecting frequencies of neonatal resuscitation effort for the newborry who does not have meconium stained amniotic fluid. Note that a majority of newborn responds to simple measures. When to do or stop CPR at birth Can be abandoned when it is considered futile in terms of survival or survival is likely to cause gross neuromuscular disability with extreme or quality of life. Can be

183 abandoned in fresh still born babies if there is no signs of life at 10 min or if spontaneous breathing is not established by 30 min.

What are the don'ts in resuscitation. Don't give heavy sedation to the mother. Don’t keep the head too low for top long. Don't give vigorous and continuous suction. Don't allow the baby to become hypotherinic. Don't delay endo-tracheal incubation in an apnoeic baby. Don't continue with tactile stimulation if baby does not respond to 3 to4 flicks. Don't blow your lungs into babies mouth while resuscitation with mouth to mouth breathing. Don't use full palmar grasp for giving bag and mask ventilation. Don't give Sodium bicarbonate till ventilation is established. Don't give respiratory stimulants. So prevention of hypothermia, hypoxia and hypoglycemia are the fundamental aims of new born care. 5.9 BABY FRIENDLY HOSPITAL INITIATIVE (B.F.H.I) Baby Friendly Hospital Initiative Every child should get exclusive breast feeding up to the age of 4-6 months. 4 months are applicable to twins or triplets. For single baby exclusive breast feeding up to 6 months Continue giving breast feeding up to 3 years. But give weaning food after the exclusive breast feeding time. There is no place for any traditional practices like 1) Giving honey soon after birth (infection) 2) Sugar water -(Infection)

184 3) No place for cows milk because, the milk is species specific. Cows milk is for calf. Human milk is for our babies. But after 6 months cows milk can be given as a supplementary food. 4) No place for any tin food for fear of adulteration and chances of getting newer life style diseases in a letter stage.

Every baby should get COLOSTRUMS the fist milk, which is yellowish in colour. Colostrums is a rich source of antibodies and all the nutrients are of high quality. Sometimes the mothers may complain that they are not having adequate milk for the exclusive breast feeding. This is because of the unscientific way of sucking the breast. The proper way is as follows. If the baby is sucking from the left breast : The head of the baby should rest in the left hand of mother : The cheeck of the baby should touch the breast : Chest of the baby should touch the chest of the mother : Abdomen of baby to abdomen of mother Then the mother is holding the entire nipple and areola with the right middle and index finger and pushing the entire areola and nipple in to the mouth of the baby. Then the baby starts sucking. This is the proper sucking and a suckling reflux is produced. This reflux reaches the brain hypothalamus and produces a hormone Prolactin which is acting on the breast the lactiferous duct and again milk is produced. It means that proper sucking is required for the milk production. 5.10 BIRTH SPACING BIRTH LIMITING & BIRTH TIMING Learning objectives At the end of the training the trainee should be able to  Explain the various contraceptive methods and list the benefits, side effects and contra indications of each method and appropriate referral.  Provide health education/counsel the women family and community Methodology : Exam discussion Duration : 6 HRS

185 Contraception includes all methods used to prevent conception and thus regulate fertility. Each method prevents pregnancy in a different way. The contraceptive method may be: Temporary (spacing) for delaying first pregnancy or spacing the child births Permanent (Sterilization) for Limiting the family after achieving the described family size.

SPACING OF CHILDREN  Ensure health of the mother,  Enable her to care and front feed her child and  Prevent low birth weight of the next infant

Birth Timing The right period for child bearing considered to be 20-30 years. Observing this living ensure  Health of the mother  Opportunities for employment for mother  Health of the child  Economic security of the family  Happiness in the family

BIRTH SPACING Condoms Barrier methods of contraception especially condoms and also spermicide help preventing pregnancy. Condom is put on the hard erect penis immediately before intercourse. It collects the semen and prevents the sperm from entering the women's vagina. About lcm. of condom is left loose to hold the semen (condom with a teat). After ejaculation, as penis

186 is withdrawn, the condom is held at the base of the penis to prevent it from slipping off and spilling the semen. A new condom must be used during each act of intercourse. Use of barrier methods', of contraception or condoms also help in preventing HIV transmission. Barrier contraceptives cause virtually no health problems, yet provide protection against STD and AIDS. “They also protect against some of the consequences of STDs including infertility, ectopic pregnancy and cervical cancer.."

Mechanism of action: It prevents deposition of sperm in the vagina.

Advantages: • Easily available. • Easy to carry. • Cheap • Protects against STDs and AIDS. • Ensures male participation. • No prescription is needed. • No systemic side-effects. • Help men with premature ejaculation. • Effective when used with a spermicide. • Help in prevention of cancer cervix in female partner. Disadvantages: • Interrupts sexual intercourse as condom has to be put on an erect penis. • Penile sensitivity sometime decreases. • It may tear off or slip off during intercourse and can fall if not removed correctly. • Condom may deteriorate in too much heat or light or if stored for more than 3 years Selection of condom:

187 Condoms are available in large variety of sizes, thickness, colours, textures as well -as in lubricated or nonlubricated forms. Warning sign that a user should know that if he is allergic to latex or lubricaor lubricants, local irritation could occur. Condom is best indicated under the following conditions: • Best for partners at risk of exposure to STDs and AIDS. • As a back-up method, when pills are forgotten for more than 2 days. Disadvantages: • Effective for a short period-1 hour only. • Must be used before each act of sexual intercoruse. • May interrupt sexual intercourse and needs privacy as it is to be inserted 10 mins. before the act. • Some woman may be sensitive to the spermicide and develop irritation. Contraindications: • Woman or partner allergic to Nonoxynol-9. Instructions to clients: • It should be inserted just before intercourse. • If more than one hour passes the second one will be needed. Oral Contraceptive Pill: You should have the necessary knowledge to provide Oral Contraceptive Pill Services including counselling, appropriate screening and selection of clients, management of side-effects and offer follow-up services. There are different .types of oral pills. The common ones in use under family planning welfare programme in the country is Mala-N./Mala-D. What is (Mala-N/Mala-D) Oral Pill ? Mala --N/ Mala D is a contraceptive pill. • When other effective methods are contraindicated for women e.g. heart disease, liver disease, or the woman Is unwilling to use other effective methods. • Women who are breast-feeding and need contraceptive. Spermicides:

188 Spermicides are available in the form of creams and foaming tablets or suppositories. "Delfen" - a cream and "Today" - a foaming tablet are available. They contain Nonoxynol-9. They can be used with condoms to increase effectiveness. Mechanism of action: Spermicides inactivate the sperms. The protection begins 10 to'15 mins. after insertion and they remain effective for about one hour. Indications: You can advise this to the women who are: • Breast-feeding, • Using barrier methods like condoms, • At risk of exposure to STDs including AIDS, and • Unwilling to use or -have contraindications to other methods. Advantages: • Easy to use • Reversible • No medical intervention or prescription required • Helps protection against STDs • No systemic effects It is an effective, safe and reversible contraceptive for women desiring to delay their first pregnancy or space the next child. Mala D/Mala-N is available in packages containing supply for one cycle. Each packet has 28 tablets; first 21 of which are white hormonal tablets and remaining are coloured iron tablets for maintaining the continuity. Mala-N is available free of cost under National Family Welfare Programme and Mala D under the Social Marketing Programme. Mechanism of action The pills act by suppressing release of the ovum (the egg cell) from ovaries. Where to get the pill ? The pills are available free of charge as Mala N at all the Health and Family Welfare Centres and government hospitals. They are also sold in chemist shops and social marketing outlets under the name of Mala -D at subsidized cost. Advantages: • Safe

189 • Reversible • Decision with woman herself • Non-invasive • Privacy not required • Other health benefits are: - Reduces menstrual blood ['loss, thus reduces chances of anemia. - Relief from pain during menstruation. - Relief from premenstrual symptoms. - Regulates menstrual cycles if they are irregular. - Reduces chances of ectopic pregnancy. - Provides some protection against pelvic infection. - Protects against benign tumours of breast and ovarian cysts. - Reduces chances of developing cancer of uterus and ovary.

Disadvantages: • Need to take daily. • No protection from STDs/AIDS. Selection of acceptors: Any woman in the reproductive age group who wishes to delay the first pregnancy or wants to postpone the next' pregnancy can use oral pills provided she does not have any contraindications for its use. It is necessary to screen the acceptor for finding out her suitability for use of pills. You should fill the check-list given below: I. Ask menstrual history: -Date of last menstrual period (to exclude pregnancy). -Number of days she bleeds during period. -Interval between two periods. II Ask obstetric history: Number of children Age of last child

190 Whether the child is breast-fed (OC should not be given for the six months after delivery). III Ask the questions serially from the check-list. -Look for gross malnutrition or obesity -Examine eyes for jaundice -Look for oedema over legs and face -Count pulse rate -Palpate breasts for lump -Perform urine analysis for sugar and albumin

Check-list for Selection of Acceptors of Oral Pills

Fill the following check-list before selecting an acceptor for oral pill. If any of them is positive, then she should be referred to medical officer. 1. Age above 40 years. 2. Smoker aged above 35 years 3. Using oral pills continuously for more than 5 years. 4. Pregnancy. 5. Lactating less than 6 months. 6. Complaint of prolonged/frequent headache. 7. Visual disturbances. 8. Breathlessness on exertion. 9. Fits. 10. Persistent/frequent attacks of pain in abdomen. 11 Irregular vaginal bleeding. 12. History of taking drugs. 13. Repeated skin rashes. 14. Gross malnutrition. 15. Gross obesity. 16. Yellow skin and conjunctiva (jaundice). 17. Pulse rate above 120/min. 18. Oedema of extremities.

191 19. Lump in breast. 20. Sugar in urine -Diabetes. 21. Albumin in urine. The woman with history of toxaemia of pregnancy should not be put on oral pill After filling up the check-list, if answer to all the points are 'No', then she can be selected for oral contraceptives. If any of the answer is 'Yes', then she should be referred to medical officer. Side-Effects: Oral contraceptives produce some metabolic, biochemical and functional changes which are responsible for a few minor side-effects and adverse effects. Minor Side-Effects: Women on oral contraceptive pills experience some minor side effects like: 1. Nausea vomiting. 2. Breast tenderness. 3. Headache. 4. Depression. 5. Breakthrough bleeding. 6. Mild elevation of blood pressure (which usually disappears on discontinuation of, pills). 7. Weight gain. 8. Return of Menstruation and Fertility: The incidence of post oral contraceptive pill amenorrhoea is low and there is no evidence of decreased fertility in oral contraceptive users. 9. Pregnancy Outcome: There is no evidence to indicate .increased incidence of spontaneous abortion or foetal abnormalities in oral contraceptive users including in those who conceive soon after discontinuing oral contraceptives. Where pregnancy has occurred during oral contraceptive use and the woman has inadvertently continued pills after missing the period', no increased risk of foetal abnormality has been demonstrated. However, pills should be discontinued in the event of suspicion of pregnancy. Many of these symptoms disappear on continued use of pills hence you need to assure the user for the first three cycles.

192 Instructions for use of 28 pill pack: • When to start pills ? Start the Pill I. Day 5 of menstruation II. Day 1 of MTP/spontaneous abortion III. After delivery - -Nursing mother: after 6 months -Non-lactating: after 6 weeks • How to take the pill ? i. Before starting the pills, tell the client to read the instruction leaflet carefully if she is literate. ii. The first course should be started on the fifth day of the menstrual cycle (counting first day of bleeding as day number one, by taking the pill from the pack marked as START. iii. For subsequent days, one pill, a day should be taken from the pack in the order indicated by the arrows; till all the pills in that pack are over. iv. The pill should be taken. everyday at a fixed time, preferably while retiring to bed. v. The next pack should be started the very next day by taking the first pill from the pack marked as START. vi. Consult a doctor within three months after starting the pill. vii. Keep the pills away from children. • If a Pill is Missed If a woman misses a pill on a particular night, the missed pill should be taken the next day as soon as she remembers. She should take another pill at night as usual. In other words, on the day following a missed pill day, she has to take two pills. If she misses 2-3 pills, she should continue taking pills regularly but in addition she should also use another contraceptive method like condoms till the next cycle starts. • Duration of Use In India continuous use of oral contraceptive pills over 5 years is not recommended. However, in women who are otherwise. well, low dose oral contraceptives may be continued for several years under medical supervision and there is

193 no need for periodic discontinuation. For women, over 40 years of age, oral contraceptives may be prescribed with caution. Oral contraceptives to be stopped two -months prior to planning of pregnancy. • Danger Signs Ask the oral contractive users to report immediately if they have: - Abdominal pain (severe). - Chest pain, shortness of breath. - Headache - severe throbbing unilateral. - Eye problems (visual loss, double vision, blurring of vision). - Severe leg pains or swelling. Refer such women to MO(PHC). Follow-up Services: You should provide follow-up services during your routine home visits. Initially a woman can be given one packet of oral contraceptive pills. Later when the pills are found to be suitable for her, she can be given a supply for three months. She must return regularly to the clinic/service centres for getting the required supply and for necessary check-up at regular intervals. Arrange follow-up services/visits to the acceptors of oral pills as per the following schedule: First Visit You must visit her within 2 weeks after she has been put on pills: • enquire as to how she is feeling. • treat any minor ailments and reassure her. • check the pill count from the packet. • stress the need to take the pill regularly and to return for more pills before the packet is over. Second Visit: One month after she has beeh7' put on oral pills you should visit her again to: 1. Find out whether she is taking pills regularly; if not enquire as to why she has discontinued the pills. 2. Ask if she has any complaints; if none give her three packets. Stress the need to take pills regularly and to return for more pills before the third packet is over.

194 3. Reassure the beneficiary in case of any complaints and persuade her to continue the pills Subsequent Visits: Your subsequent visit should be monthly-until the side-effects cease and the woman is well adjusted to the pills regularly. Next visit should be after six months and then annually. During routine visits to that area, visit the user and carry out the following: • Ascertain that she is taking the pills regularly. • Reassure her as needed. • Treat or refer her for side-effects. • Give her supplies of pills. • Enquire about the date of LMP and for any irregularity in periods. If there are major problems (as per check-list) or any danger sign refer to the doctor. Medical check-up for Oral Contraceptives Users Arrange for a medical check-up for your client by the medical officer. First : Before starting the pills or with in three months of starting the pills subsequent: 6 months and 12 months, after starting the pill then yearly. Anytime, if any danger sign appears. When to stop pills ? She should be advised to stop pills after 5 years of continuous use. If she desires pregnancy stop 2 months before planning pregnancy. If she misses menstrual period for 2 months continuously. If she develops or experiences: • Discomfort in chest • Any disturbances in vision • Pain and swelling in legs • Continuous headache • Jaundice When to refer to MO (PHC You should refer her to MOPHC within 3 months of starting pills

195 • after one year of continuous use • every year subsequently • if any danger sign appears • no menstrual period of 2 months Messages to be given to community: 1. Pills are to be used regularly for avoiding pregnancy. 2. It is the optimum method to postpone first pregnancy. Pills can be used for spacing the next pregnancy especially if the woman cannot use IUD. 3 Pills can be used continuously for. 5 -years safely. 4. Mala-N or Mala-D tablets contain ver low doses of hormones; hence these pills are safe.' 5. For appropriately selected acceptors. pills are safe. 6. Pills do not lead to cancer. 7. Pills have many other health benefits in addition to contraception. Clearing myths about pills: To promote pill acceptance, the prevailing myths should be removed and the facts should be explained. Copper T: Copper T (CuT) is an intrauterine contraceptive device. Cu T 200 B is a ‘T’ shaped plastic device made of polyethylene and impregnated with Barium Sulphate to make it radio-opaque. It is 3.6 cms in length and 3.2 cms in width. Copper is wound round its vertical stem. Its surface area is 200 mm and the thread is attached to the lower end of the vertical stem. Figure 3.3 shows Cu T 200 B. It is a safe and reliable method of contraception and it offers several Advantages, namely – • One time insertion procedure. • It is readily reversible. • It is coitus independent. • Effective for 3 years. • It is cost effective. Despite all these, it is disappointing to note that the continuation rate of less than 30% at the end of one year has not improved over the years. This may be due to

196 improper selection of cases who may develop side-effects and demand its removal. It may also be due to poor counselling and motivation by the medical and paramedical staff. In view of this and the above mentioned advantages it is necessary to increase the acceptability and continuation rates of this method especially for spacing of children. Counselling: The client should be counselled in a simple language which she understands and following information should be provided to her: I. It is one of the most effective and reversible methods for family planning. II. It is ideal for spacing of children, as it does not affect the quality of milk in lactating mothers. Spacing is important for health of the mother and children. III It can be easily removed when desired. IV It provides continuous protection for 3 years. V Its insertion is a simple procedure and the optimal time of insertion is during the last two days of the menstrual period and immediately following MTP. It can be inserted within seven to ten days after last menstrual period. VI. It does not affect sexual pleasure, performance nor hurt the husband. VII. IUD does not affect a women's chance of becoming pregnant after its removal. VIII. IUD does not cause cancer. IX. It has 1-3 % chance of failure. (For details of counselling technique refer to Block on Communication)

Selection of cases for IUD: • Any woman in the reproductive age group who wants to space or avoid pregnancy • It should be promoted in couples having two children when the age of the younger child is less than five years. • Woman who has borne at least one child. • Woman who has no history of pelvic diseases. • Woman who has normal menstrual periods. • Woman who is willing to check the IUD tall. • Woman who has access to follow-up and treatment of potential problems. • Woman who is in a monogamous relationship

197 To summarize most of the woman can be advised IUD safely after their first delivery. You should rule out pregnancy, abdominal pain with heavy irregular or prolonged bleeding or purulent discharge. Contradictions: • Absolute IUD should not be inserted in the following conditions: - Pregnancy; - Anaemia with haemoglobin less -than 8 gms; - Excessive or irregular menstrual bleeding; - Active genital tract infection e.g. vaginitis, cervicitis, pelvic inflammatory disease, septic abortion, cervical erosion; - Enlarged uterus; and - Previous history of ectopic pregnancy. • Relative -Previous history of Caesarean section; -Medical disorders like heart diseases diabetes, etc. In both these conditions refer to specialists. Timing of insertion: - The safest and optimum time for insertion is the last two days of the menstruation but can be inserted within 7-10 days of the LMP. - Immediately after MTP is performed. - After the first period following spontaneous abortion. The most suitable time for CuT insertion is during menstruation or within 10 days of the beginning of menstrual period. Venue of insertion: IUD insertion should be conducted only at the sub-centre, primary health centre, community health centre or Hospital. Privacy is a must. IUD must not be inserted at residence of the woman centre or hospital. Sterilisation of equipment: CuT is available in a pre-sterilised pack.

198 You must ensure that all instruments/gloves are preferably autoclaved. In case autoclaving is not possible you must see that the instruments are fully immersed in water and boil for at least 20 minutes. In order to prevent any infection it is essential that instruments are autoclaved or fully immersed in water and boiled for at least 20 minutes after the water starts boiling. Examination of client: 1. History Taking You must take history very carefully and should include age of the client, medical, surgical I and gynecological history. Last menstrual period must invariably be noted. Menstrual and obstetric history. needs to be carefully taken - Periods - regular or irregular, flow excessive or normal. - Date of last menstrual period. - No. of deliveries and abortions/MTP, previous history of caesarian section/ectopic pregnancy. - Recent history of post-partum/post abortal infection. 1. General Examination Particular attention has to be paid to detect whether the client has severe anaemia, diabetes or heart disease. Details of procedures for IUD insertion will be provided to you during your specialized skill training in hospitals. Post insertion advice The IUD wearer should be given the following instructions: i. She should regularly check the threads or tail to be sure that the IUD is in the uterus; if she falls to locate the threads, she must consult the MO(PHC). ii. She should visit the clinic whenever she experiences any side-effect such as fever, pelvic pain and bleed' iii. If she misses a period, she must consult the doctor. As there will be more loss of blood during menstruation, the client is advised to take IFA tablets. iv. There may be slight pain and or bleeding for few days or the IUD may be expelled spontaneously.

199 Removal of IUDS: i. Client is positioned as for the insertion of IUD. ii. Wear sterile gloves. iii. Clean the vulva and vagina with antispectic solution (Savion 1%). iv. Put the sterile speculum into the vagina, locate the thread; grasp the thread close to the cervix with the sponge holding forceps and pull it out by steady gentle traction. v. Show the IUD to the client and discard it. vi. If the thread is not seen, refer the client for special attention. If the removal requires more than a gentle traction, do not try to remove it but refer her to the specialist. Failure rate: Pregnancy may occur in 3-5 per 100 IUD users per year. If the woman becomes pregnant with the IUD, she should be advised that only 25 0/0 of pregnancies would have a successful outcome if the IUD were left in place. Remember: The side-effects of IUD and oral pill are few and do not occur in all individuals. Follow-up schedule: The under mentioned follow-up schedule is proposed: • First Visit: immediately after the first menstrual period following/insertion. • Second Visit: after one year. • During your routine visits you should advise your client to come for follow-up. Side-effects and complications after IUD insertion and their management: i. Bleeding The most common and important side-effect of IUD insertion is bleeding per vagina: • Spotting in few cases. • In case of bleeding, do a PV examination to ascertain the cause which may be - Infection - Treat the infection refer to MO (PHC). - Displacement of Copper T - removes the IUD and call for reinsertion during the next period. In case no cause is found, reassure the client and prescribe haematinics. ii. Pain

200 - In case of cramps in lower abdomen/low backache give tablet paracetamol. - In case of severe pain - remove the IUD Immediately. iii. Infection In case of vaginal discharge, pain and fever; give a course of antibiotics. Refer to MO(PHC). If there is no relief - remove the IUD. iv Perforation This is rare following CuT insertion and is likely in the post-abortive/post-partum uteri. , CU-T should not be inserted if the uterine size measures less than 6 cms. When string is not seen and Cu-T not f6it ' o n' uterine sounding, perforation of uterus and intraperitoneal migration of IUD should be suspected. The client should be referred to a specialist at the earliest. Refer to PHC/FRU. Pregnancy It is a rare occurrence, in case the client becomes pregnant with Cu T in situ, she may be offered MTP if so desired. In case she wants to continue pregnancy there is no need to remove copper T. Refer to PHC. Expulsion This occurs mostly if the Cu T is inserted in the immediate postpartum period and soon after spontaneous abortion. Avoid inserting IUD at this time. Expulsion occurs mostly in the first year of use (6%) but the incidence decreases to 2 % in the subsequent years. Missing IUD String When the thread can't be felt by the client and cannot be visualized by you further investigation is necessary and the client should be referred to PHC. Ectopic Pregnancy Ectopic pregnancy is rare and if suspected the client should be referred to the FRU

BIRTH LIMITING You must counsel the clients for permanent methods of sterilization and refer those who opt for permanent methods of sterilization to M.O. PHC. To-the female client you can tell about tubectomy by minilap or laparoscopy. To the male client you can tell

201 about vasectomy. By non-scalpel method or conventional. To ensure male participation, LHI has to guide the Jr. PHN for promoting 50% Vasectomy among the eligible couple Health Education/Counselling Follow the steps explained below, during the client's first family planning visit or any time the client wishes to change her contraceptive methods. The important steps to follow are summarized below: • Greet the client, offer her a seat, make her comfortable, tell your name and ask for her name. • Establish rapport, show concern, respect privacy and confidentiality. • Let her get the feeling that you are there to help her. • Ask what will happen from beginning to the end of the visit. • Discuss all available methods so the client can make an informed choice. • Follow procedures for the specific method chosen. Subsequent steps, once the client has chosen any one of the method be as follows: Step I Discuss the client's past experience with the method. If she has no past experience with the method, discuss and clarify any rumours or mistaken ideas the client may have about the method. Step II Explain in details what the method is and how it works. If appropriate, a sample can be provided. She may examine it and handle it. Encourage her to ask questions or any clarification about any information you have provided. Step III Describe the advantages and disadvantages of the method both contraceptive and noncontraceptive. Step IV Explain the appropriateness of the method for the client through history and physical examination. After history and examination, if the method is not appropriate, inform her why the method is not appropriate for her. Help the client make an informed choice of another appropriate method. Step V Explain the instructions to the client for use of the method. Encourage to -repeat the instructions in their own words. If she has misunderstood or omitted any instruction, go over the information again with her.

202 Step VI Plan for the return visit. Explain and schedule the next visit. Remind client about warning signals and tell them to return sooner than planned in case of presence of warning signals. Step VII Follow procedures for the return visit. For details of counselling technique refer to Block on Communication. Ask during the follow-up visit, whether they are happy with their chosen method. For satisfied clients, ensure that the instructions are followed correctly for the use of the method  Remind warning signals again.  Dispense supplies where appropriate.  Plan for next return visit. For dissatisfied clients, manage the side-effects as necessary or remove the method and help the client to make an informed choice of another method. Monitoring/Reporting as per Format: To be done for oral pills, Cu-T, and sterilization as per formats. Refer to Block on Management. For satisfied clients, ensure that the instructions are followed correctly for the use of the method.] Remind warning signals again. Dispense supplies where appropriate. V/ Plan for next return visit. For dissatisfied clients, manage the side-effects as necessary or remove the method and help the client to make an informed choice of another method Monitoring/Reporting as per Format: To be done for oral pills, Cu-T, and sterilization as per formats. Refer to Block on Management. Key points (Contraception): • Planning requirement for contraception based on birth rate, parity and number of previous users (condom, OCP). • Too early, too late, too many pregnancies are cause of high maternal and neonatal morbidity and mortality rates.

203 • Counselling for appropriate contraceptive method is crucial for success of the programme. • Benefits and risks of each contraceptive method should be explained to the client. • Management of logistics and supplies for family planning. Danger signals to be explained to the client. • Follow-up of the family planning acceptors is necessary. • Reporting services provided accuracy and completeness as per the formats. Supervisory check- list You have to supervise the ANM when she is counselling on contraception.' While supervising you must ensure that she: Tick if applicable A Natural Methods and X if not 1. Estimates the number of eligible couples. 2. Is aware of natural methods of contraception. 3. Is aware of exclusive breast-feeding. 4. Can calculate the safe period. B Barrier Methods 1. Can store condorhs. 2. Knows the advantages of condoms. 3. Is aware of spermicides. C Oral Contraceptive Pills 1. Fills the check-list prior to preserving oral pills 2. Can instruct the client how to start the pills. 3. Can do the regular follow-up of women on OCs 4. Can enumerate the contraindications of OCs. 5. Knows how to manage the minor side-effects. 6. Knows how to procure the pill and store them. D IUDs 1. Can follow-up the patient. 2. Is aware of the complications of IUDs and their management. 3. Knows the indications for removal. 4. Can remove IUD.

Self-assessment Questions: 13. What are the advantages of Condoms? 14. What are the advantages of Oral-pills? 15. What are contraindications of IUCD ?

5.11 INFERTILITY

204 Although It’s natural to feel discouraged and confused about fertility problems, there are good reasons to be optimistic. In most case, your doctor can help you find the source of these problems and explore all possible solutions. It is essential you talk with your doctor. Feel free to ask questions. This booklet guides you in understanding your situation and reaching solutions. The path to Pregnancy: The process of conceiving is no less than a miracle. An intricate sequence of events must be carefully orchestrated by chemical messengers (hormones). In both the man and woman, the follicle stimulating hormone (FSH) and the luteinizing hormone (LH) prepare sperm and egg for their union.

Sperm Development In Man

Beginning in puberty, a man’s body produces millions of sperms everyday of his life. FSH and LH are released by the pituitary gland at the base of the brain, FSH activates sperm production, LH stimulates production of TESTOSTERONE, which also contributes to the development of nature sperm.

An Egg Develops In The Woman

By the time she’s born. A woman already has her entire supply of eggs about two million. The immature eggs, which are stored in the ovaries, decrease in number and quality as a woman ages. Beginning in puberty, pituitary (FSH & LH) and ovarian hormones (OESTROGEN & PROGESTERONE) are released which initiate ovulation and menstruation How sperm and egg meet: For fertilization to occur, sperm must reach the egg within hours of ovulation. To do so they need a clear passageway and “Sperm-friendly cervical mucus.

Fertilization

The egg is fertilized when one of the sperm manages to tunnel its way through the egg’s protective covering. Inside the fallopian tube , the fertilized egg (now called an embryo) prepares it self for implantation in the uterus. The embryo imbeds itself in the uterine lining (endometrium) few days after arriving in the uterus. The pregnancy

205 hormone human chorionic gonadotropin (HCG) is now secreted by the cells around the embryo .This hormone helps keep up production of oestrogen & progesterone from the ovary, which helps maintain pregnancy. What if infertility ? Infertility is the inability to become pregnant after one year of having regular, unprotected sexual intercourses. This called primary infertility If you are able to get pregnant but you have recurrent miscarriage, you have Secondary Infertility. It can be defined as the inability to conceive after one or more successful pregnancies. Which partner is responsible for infertility ? 40% are related to the women 40% are related to the man 10% are due to couple problems 10% have unknown causes How does infertility occur.? Female Infertility: The most common reason for female infertility is failure to release an egg (ovulate). Failure to ovulate may be caused by:  Hormone imbalance (FSH & LH)  Obseity and weight gain  Prolonged excessive stress  Tumour or cyst on the ovary and other ovarian disorders.  Irregular cycle that is for brief.  Weight loss for various reason , including eating disorders such as anorexia.  Various medications. Another common reason for infertility is damage to the fallopian tube or uterus due to

 Previous infection, such as pelvic inflammatory diseases or sexually transmitted diseases.  Birth defect.

206  Previous surgery to remove a tubal pregnancy.  Other conditions such as endometriosis, fibroids or an abnormally shaped uterus.

Other causes of infertility

 Genetic problems  Natural decline in fertility due to ageing . This decline occurs more quickly after the age of 30 years  Psychological- Fear, nervous tension Male Infertility:

The common reasons for male Infertility are: Low sperm count, immature or abnormally shaped sperm, a problem with its delivery to the female genital tract. This may be caused due to :  Psychological : Nervous tension, psychiatric illness.  Endocrine factors : Hypothyroidism  High fever, hot environments excess weight, may raise testicular temperature & decrease fertility.  Systemic factors : Ageing over 45 years, severe diabetes mellitus, fatigue, heavy smoking, alcoholism.  Certain types of medications. How is the problem diagnosed ? The doctor will give you and your partner thorough physical examination to help investigate and find a treatment for infertility. You may have to give the doctor more information to help determine why pregnancy doesn’t occur. The doctor will ask both you and your partner questions during joint and separate interviews. Some of the commonly asked questions are : medical conditions such as illnesses and infections, use of drugs and alcohol, sexual intercourse practices, detailed sexual history (including previous pregnancy, miscarriage, abortion), genital surgery, circumcision and normal genital development. Which are the tests commonly carried out during diagnosis ?

207 In addition to a complete physical an gynaecological exam, the doctor may want to do the following tests : Your Evaluation  Basal Body Temperature Chart : The doctor may also instruct you on how to take and chart your body temperature each morning. There is a natural rise in body temperature after ovulation. By looking at your temperature chart, the doctor may determine if and when ovulation is occurring.  Urine and blood tests to check for infections and hormone balance. Blood tests may help determine if you are ovulating normally or reveal antibodies that may be attacking the sperms. This also includes measurement of serum prolactin and thyroid stimulating hormone. Higher levels of serum prolactin leads to infertility in both males & females.  Post Coital Test : Tests on a sample of cervical mucus to determine if ovulation is occurring & to evaluate the interaction between sperm and cervical secretions. This test is usually done one or two days before ovulation, when the cervical mucus is the most favourable to sperm. Your evaluation : Various diagnostic procedures : A doctor may do the following procedures to check if a blockage in the fallopian tubes or uterus is causing the infertility : Endometrial Biopsy : The uterine lining (endometrium) is examined to see how it responds to hormones. This is usually done tow to four days before menstruation. Hysterosalpingography : Screening procedure to view the uterine cavity and detect tubal blockade. This test is usually done after menstruation and before ovulation. A laparoscopy : A laparoscope is inserted into your abdomen so the doctor may view the organs to reveal any scar tissue or abnormal growths on the outer surfaces of your reproductive organs.

Ultrasound :

208 Uses high frequency sound waves to produce images of internal organs. It can also reveal cysts, fibroids, and thickness of the uterine lining. Your partner’s evaluation : Semen analysis : A count of your partner’s sperm to see if the cause of infertility is due to few sperms (Oligozoospermia) or immature sperms. Antibody testing : Determines whether the man or woman produces antibodies to sperm. Appearing in blood, cervical mucus or seminal vesicles the antibodies may react to sperm and destroy or immobilize them. Vasogram : an X-ray that uses a dye to outline ducts to reveal any obstruction. How is infertility treated ? Your treatment : If the doctor discovers you have a disorder that is causing the infertility , he or she will recommend treating this problem to try to restore your fertility. Treatment may include medication (usually hormones or antibiotics) or surgery. Sometimes a combination of treatments is necessary to correct the problem. Your age, health and medical history will be considered before hormones are prescribed.

To restore fertility the doctor may suggest the following :

209 Improving ovulation : Some of the common hormonal medications used in the treatment of infertility are : Clomiphene Increases production of hormones that stimulate egg Citrate production. Bromocriptine Reduces production of the hormone prolactin. Used in infertility due to hyperprolactinemia. Human Provides extra supply of FSH & LH, helping to stimulate Menopausal development of eggs. Gonadotrophins (HMG) Folicle Stimulating Provides extra supply of FSH to stimulate development of Hormone (FSH) eggs.

Human Triggers ovulation Chorionic Gonadotrophins Gonadotrophin (GnRH analogues-goserelin) : Adjunctive thereapy to Releasing controlled ovarian stimulation –significantly improves the rate Hormone of assisted reproduction techniques Analogues  Keep a record of your daily temperature to track ovulation. This will help predict when you are most fertile or if the drugs you are taking stimulate egg production.  Improving passage of the sperm : Through the cervix – sperm may not move through the cervix due to infections (antibiotic treatment ), too little cervical mucus (oestrogen pills or intrauernie insemination ) or antibody production which immobilizes sperms (in-vitro fertilization) 1. Through the fallopian tubes : Various factors (adhesion, mucus plug or tubal sterilization ) can damage fallopian tubes, preventing sperm from traveling through them. This is often treated with surgery to remove blockage (mucus plug) or scar tissue from the fallopian tubes or uterus  Improving implanation : In the uterus : An egg may not implant in the uterus due to problem such as scarring (can be treated by hesteroscopic surgery) or fibroids ( can be treated by hysteroscopic or abdominal surgery)  Treating endometriosis : Endometriosis occurs when tissue form the internal lining of the uterus (endometrium) grows in or other parts of the reproductive system. Laparoscopic

210 surgery, Hormone therapy (danazol, medroxyprogesterone acetate) or both may be used to treat this condition. Your partner’s treatment : Improving sperm production : 1. Treating infection : Treatment of infections of reproductive tract ( urinary tract, prostate) with antibiotics. 2. Improving sperm concentration. Immature sperms – Clomiphene Citrate. Hyperprolactnemia related oligozoospermina – bromocriptine 3. Treating sperm antibodies : Some men form antibodies that attack their own sperms, interfering with fertilization. In-vitro fertilization is often the only way to avoid sperm antibody problems. 4. Correcting hormone problems : Hormone therapy may boost hormone levels which may increase sperm production. Other treatments include reversing vasectomy, clearing ductal obstruction, treating ejaculation problems. What is assisted reproduction ? Artificial insemination : If you cannot become pregnant because your partner’s sperm motility/count is low, artificial insemination is an option. The sperm is collected and then placed in the uterus using a thin catheter inserted through the cervix during the most fertile time in your menstrual cycle. This has varying success. If your partner’s sperm count is still insufficient, you may become pregnant using sperm donated from another man at Sperm Banks. In-vitro fertilization : In this procedure, the egg is fertilized with the sperm in the laboratory and implanted into the woman’s uterus. This procedure is an option if the man’s sperm count is low, sperm antibodies are present or if your fallopian tubes are blocked or damaged and cannot be corrected with surgery. 5. 12 SAFE ABORTION Learning Objectives: At the end of this unit, you should be able to:

211 • identify women who may need safe abortion services and refer them. • explain the dangers of unsafe abortion and period of pregnancy when safe abortion is possible. • identification of women with complication of abortion. counsel and educate the individual, family and community about safe abortion services. CONTENTS: 1. Introduction 2. Identification of women who need safe abortion services 3. Dangers of unsafe abortion 4 Indications for MTP and the period upto which MTP is done legally under MTP act of 1971 which was implemented in 1972 5 Complications of abortion 6 Health education/counselling 7 Record maintenance 8 Supervisory check-list8 9 Self-assessment questions Introduction: Approximately 11% maternal deaths are due to unsafe and septic abortions. Medical Termination of Pregnancy (M.T.P) was legalized in 1971 in -India. You have 'to play a vital role by informing women, family and community about the provisions under MTP act, where services are available to ensure safe abortion and follow-up care. During MTP the product of conception is removed from the uterus, under safe clean conditions by a qualified person, after assessing the woman's health condition provided the case fulfils the criteria (indication) for performing MTP. MTP is done in a hospital or health care centre, which has been approved by government and has the required facilities and manpower. 2. Identification of Women Who Need Safe Abortion Services: • A woman who already has child/children and became pregnant because of not using any contraceptive method before 3 years after the last delivery (will know from eligible couple and child register).

212 • Woman who became pregnant due to failure of contraceptive method. (will know from woman). • Unmarried woman/widow or victims of rape who becomes pregnant (will know from Dai, Anganwadi Worker or any community member). You should know the centres with facility for providing MTP services and refer the woman to these centers (PHC/CHC/FRU/Nursing homes). 3 Dangers of Unsafe Abortion: • Infections (sepsis) resulting in various life-threatening situations like peritonitis, septicemia, renal failure and death. • Excessive vaginal bleeding resulting in shock, and death. • May result in injury to urinary bladder and rectum. 4. lndications: for MTP and the Period upto which Abortion is done Under the MTP Act: • If the continuation of pregnancy will endanger the life of the woman and cause grave injury to her physical and mental health. • If there is danger of the child being born with handicaps or there is risk of child having physical and mental abnormalities. • If the pregnancy had been caused by rape. • If the pregnancy is due to failure of contraceptive methods by MTP can be done upto 20 weeks but the best period for safe abortion is between 6-10 weeks of gestation. 5. Complications of Abortion: Some of the common complications of abortion are 1 Incomplete evacuation 2 Continuation of pregnancy 3. Infection 4. Perforation of uterus 5. Chronic pelvic pain 6. Secondary amenorrhoea 1 Incomplete evacuation- It, is the commonest complication. Patient presents with excessive of prolonged bleeding per-vaginum, fever or painof abdomen. When you suspect incomplete abortion refer to MOPHC.

213 2. Continuation of pregnancy: Sometimes there may be failure to terminate pregnancy. Hence if the symptoms of pregnancy persist think of continuation of pregnancy and refer to MO (PHC). 3. Infection: The patient may present with fever, abdominal pain and bleeding pervaginum and foul smelling discharge after MTP. Refer to FRU. 4. Perforation of uterus: Patients may present with fever, abdominal pain, swelling over abdomen, vomiting and discharge pervaginum. Patient looks very sick and pale. These symptoms could be due to perforation of uterus. Refer to FRU. 5. Chronic pelvic pain: Chronic pelvic inflammation following MTP may result in secondary infertility, ectopic pregnancy and menstrual disorders. Refer to MOPHC. 6. Secondary amenorrhoea: It may occur due to vigorous curattage leading to secondary amenorrhoea and infertility. Refer to FRU. 2.6. Health Education/Counselling: • You should make the woman, family and community aware that use of contraceptive is better than going for MTP as the complications are more in MTP. • Abortions are to be done in recognized centres by trained personnel between 6-10 weeks to minimize the complications. • Abortion performed after 10 weeks gestation is associated with more complication even if done by trained personnel in F.R.U • Abortion by untrained personnel can result in life threatening situation. It can also lead to infertility, ectopic pregnancy, fistula and chronic pelvic inflammatory disease. • It is advisable to use contraceptives after abortion instead of repeated MTPS. You should counsel the woman about M.T.P procedure 7. Record Maintenance: You must maintain records as per format. Key points : (Safe Abortion) . • Identification of women likely to require safe abortion services. • Knowledge of nearest centres with facilities for performing MTPS. • Knowledge of period when MTP is safe. • Counselling regarding safe abortion and need for appropriate contraception. • Follow-up of women who had MTP.

214 • Early detection of complication after MTP and appropriate referral. 8 Supervisory Check-list: You have to supervise the Jr.P.H.N when she is giving health education and counselling on MTP services under the RCH programme. While supervising you must ensure that she: Tick if A. Preliminaries 1 .Can calculate period of gestation before referring for applicable and MTP. X if not 2 Can guide to the centre where MTP can be done. B. Post MTP follow-up 1 . Ask for history of bleeding P.V or discharge pervaginum. Ask for history fevers, pain, abdomen to exclude complications of MTP. 3. Advises about contraception 4. Advises about next follow-up 'Visit.

You must ensure that she maintains records as per format. Refer to Block on Management.

9. Self-assessment Questions: 10. What are the dangers of unsafe abortion? II. Which period of pregnancy is best for safe abortion/ MTP? 5.13 PREVENTION AND MANAGEMENT, OF REPRODUCTIVE TRACT INFECTIONS [R.T.I] & SEXUALLY TRANSMITTED INFECTIONS [S.T.I] Learning Objectives: At the end of this unit, you should be able to: • identify the individual with symptoms of RTI/STI. • elicit and record relevant history in symptomatic individual and do appropriate referral. • explain the importance of partner identification.

215 • provide counselling/health education to the individual, family and the community to prevent RTI/STI including HIV/AIDS. • practise methods of infection control to prevent spread of infection amongst the health personnel. CONTENTS: 4.1. Introduction 4.2. Identification of the individual with symptoms of RTI/STI 4.3. History taking 4.4. Importance of partner identification and prompt referral 4.5. Facts and misconception regarding HIV/AIDS 4.6. Health education/counselling to prevent RTI/STI including HIV/AIDS 4.7. Methods of infection control for prevention of infection amongst health personnel and patients 4.8 Recording and reporting 4.9 Supervisory check-list 4.10 Self-assessment questions 1. Introduction: Reproductive Tract Infection (RTI) is an infection of the genital tract. The infection can affect vulva, vagina, cervix, uterus, tubes and ovaries in the woman. Infection of uterus and the tubes is known as Pelvic Inflammatory Disease (PID). It can occur even without producing symptoms. In addition to the personal discomfort 'in it may also result in infertility. In severe cases of PID I infection can spread to abdominal cavity leading even to death of the woman, due to Peritonitis. Sexually Transmitted Infections (STI) occur following sexual intercourse with the infected person, which results In genital ulcers and discharges. If untreated they can be a cause for spread of HIV/AIDS in the community. Presence of RTI/STI in any person may result in flare-up of infection following insertion of IUCD. Therefore insertion of IUCD in such patient is contraindicated. In pregnancy the foetus may be affected by these infections. They may also be a cause for development of cervical cancer. You should know about RTI/STI since you are expected to identify the woman who have these problems and to advise/counsel them and appropriately refer them to MO (PHC).

216 2. Identification of the Individual, with Symptoms of RTIs/STis: RTI/STI is suspected in a woman who seeks health care for: • Vaginal discharge with or without itching • Genital ulcers • Lower abdominal pain • Backache Woman whose husband/sexual partner has problem of urethral discharge with burning during urination or ulcers of genitals, scrotal swelling or enlarged inguinal lymphnodes, Suspect R.T.I/S.T.I. Vaginal discharge is a common complaint in women. It may be caused by any of the following conditions: Physiological - During ovulation, just before menstruation or during pregnancy. At these times the discharge is mucoid, not blood stained, or foul smelling and not associated with itching of the vulva. Candidial infection (thrush): It is a fungal infection that appears as curd like, white patches on the vaginal mucosa accompanied by thick, curdy white discharge and itching at the vulva. This infection occurs commonly during pregnancy. Parasitic infestation (trichomonal vaginitis): This may be transmitted during sexual intercourse or by contact with contaminated articles. It is characterized by greenish, yellow, frothy, foul smelling discharge accompanied by itching and redness of the genital area. Gonorrhoea: This is a sexually transmitted disease. In women it is characterized at times by purulent discharge from the cervix and urethra but this may be mild and'. may pass unnoticed. These women may develop salphingitis it is at a later stage and may complain of pain in the lower abdomen and fever. Untreated gonorrhoea may result in infertility in women. Puerperal/Post-abortal sepsis: This is. an "infection of the genital tract, which occurs following delivery or after an abortion. Taking proper aseptic precautions during delivery/abortidn can prevent it. Puerperal sepsis is characterized by high fever, headache, low abdominal pain and foul smelling, purulent vaginal discharge. Following IUD insertion: This may be found quite often. This discharge is profuse and watery and usually subsides after the first menstrual period following insertion.

217 Cancer cervix: This generally occurs in older women. In the early stages, it is characterized by watery discharge, which later becomes bloodstained and foul smelling. The woman usually complains of irregular vaginal bleeding in between periods or vaginal bleeding following sexual intercourse. History Taking: If a woman complains of vaginal discharge, proceed as follows to ask: 1. When did the discharge start? 2. Does her sexual partner have any sore on the genital organ or urethral discharge? 3. What is the nature of discharge i.e. (a) whether watery, (b) sticky and clear, (c) purulent, (d) curd-like, (e) yellow, (f) greenish and frothy, (g) bloodstained or foul smelling, and (h) whether it, is scanty or profuse? 4. Is the woman pregnant or whether she has recently delivered or had an abortion? 5 ls the woman using Copper-“T” 6. Whether she has burning sensation while passing urine or itching in the vulva? 7. Does she have pain in lower labdomen, which increases during menstrual period? 8. Does she have any ulcer in the genital region 4. Importance of Partner Identification and Prompt Referral: All the STIs are transmitted from an infected partner. The treatment of the individual is not sufficient unless and until her partner is treated simultaneously. Many a time their male sexual partner may not be having any manifest symptoms like ulcers or uretheral discharges or any other complaints. It is important that the affected sexual partner gets properly diagnosed and treated by referring him to M.O. PHC. This will prevent continuance and spread of infection in the sexual partners. 5. Facts and Misconceptions Regarding HIV/AIDS: HIV/AIDS Problem in India

218 The growing evidence available from all over the world undoubtedly indicates that the incidence of HIV infection is higher in conditions related to STDS. India has a high incidence of STDS. 5% of all infections are due to STDS. STDs particularly those characterized by genital ulcers increase the chance of HIV infection. Therefore a person already having STD, has a greater risk of acquiring HIV from sexual intercourse if, he/she comes in contact with an infected partner. Among the probable source of HIV transmission in our country heterosexual promiscuity constitutes the major route as almost 75 % of HIV infection occur due to unprotected and multipartner sexual contacts. It can be prevented by consistent use of good quality condoms. Probable source of infection Heterosexuals 74.15% Others 10.92% Injectable drug users 7.3cyo Homosexuals 0.58% Recipients of blood 7.05% (Source NACO, Country Scenario 1998-99, India) There are three modes of HIV transmission: 1. Sexual transmission. 2. Blood transmission (Blood, blood products, infected needles or instruments). 3. Vertical transmission (Placental i.e., maternal to foetal). You have to dispel the following misconceptions regarding mode of transmission of HIV.-  Mosquito bites  Any other insect bite  Casual contact with infected persons  Within households  Sharing same food, water, clothes , toilets  Professional contact (health personnel) 6 Health Education/Counselling to Prevent RTI/STI Including HIV/AIDS:

219 Counselling means providing the individual with information with regard to their ailment and empowering her to make her own decisions. You should communicate to the individual the information on one to one basis, maintaining the confidentiality of the information received Health education is providing general information to the individual, family or community at large with regard to RTI/STI including HIV/AIDS. Counselling of the individual is important in the context of preventing the spread of RTIs/STIs. , HIV and AIDS. Health education/counselling on RTI/STI including HIV should be providing information with regard to protective measures like: • single mutually faithful sexual partnership. • avoiding sexual contact if any of the sexual partners is having RTI/STI. • correct condom usage. • ensuring complete treatment of self and sexual partners. • maintaining proper menstrual hygiene by use of clean pads/cloth, frequent change of the cloth. • observing aseptic precautions during delivery/abortions and utilizing the available ante-natal and intra-natal and M.T.P. services. • protecting your baby against the effect of RTI/STI by attending ante-natal clinic regularly. All cases of RTI/STI to be referred promptly to medical officer for diagnosis and treatment. Methods of Infection Control for Prevention of Infection Amongst Health Personnel: If proper methods of control of infection are not practised by you while examining client and partner RTI/STI the infection can spread to you as well as other women examined by you. To avoid this, the following practices should be adopted:  Hand washing with soap under running water for 10-15 seconds.  Wear gloves in both hands, wash hands after removing gloves.  Proper decontamination and disinfecting of the instruments, gloves and linen. All the things can be decontaminated by dipping in bleaching

220 powder solution (1 Tablespoonful - 15 gms in 1 litre of water ) for 10 minutes.  Sterilization of the instruments by autoclaving or boiling for 20 minutes.  Wipe all the contaminated surfaces with 1.5 % bleaching solution.  Disposal of waste material: Waste should be buried or burnt. It should never be left outside or left open in pits. 8. Recording and Reporting: To be done for RTI/STI as per format KEY POINTS: (RTI/STI)  Identify the women with RTI/STI.  Refer the women for examination and treatment to MO PHC promptly.  Identify sexual partners and ensure their treatment.  Provide counseling/health education to individuals, sexual contacts, family and community  Observe infection prevention measures to prevent infection amongst the health personnel. 9. Supervisory check-list: You have to supervise the ANM when she is giving ante-natal care. While supervising you must ensure that she the following things are done

Tick if 1. Detects the early signs and symptoms of RTI/STI. applicable and 2. Traces partner and refers the contact for treatment X if not 3. Performs speculum examination in a case of vaginal discharge 4. Performs bimanual examination in a suspected case. 5. Takes adequate precautions to avoid contamination and to protect self and others. 6. Counsels regarding prevention of RTI/STI. 7. Explains the importance of the use of condoms to prevent RTI/STI. 8. Explains about sexual hygiene. 9. Explains about monogamous relationship

221 1 0. Refers the client to MO PHC. 10. Self-assessment Questions: 16. What are the common symptoms in women infected with RTI/STI? 17. What are the important messages to be communicated to the individual for prevention of RTI,/STI? 18. What is physiological discharge.?

5.14 FIRST REFERAL UNITS (F.R.U)

Learning Objectives : (1) To remind the participants regarding the objectives of FRU (2) To enable the community to utilise, the facilities and thus contribute to achieve the national goals connected with the functioning of F.R.U. Method : Group discussion group exercise & Visit to F.R.U Duration : I Hour (for discussion and exercise) Objectives of F.R.U To reduce Infant Mortality Rate and Material Mortality Rate Bulk death occurs under IMR (50%) within the first 28th days due to low Birth Weight of babies, Infections, Hypothermia etc. To improve this condition and to materialize the above concept, all instruments and facilities to manage essential new born care and also emergency obstetric care are provided under this scheme. Women and children Hospitals and Taluk Head Quarters Hospitals are provided with FRUs. The requirement under this scheme are: 1) Gynaecologist 2) Surgeon 3) Anaesthesiologist 4) Equipments for anaesthesia 5) Paediatrician 6) Physician

222 7) Blood Bank 8) Lab Technician 9) Ambulance 10) Operation Theater

223 Chapter - 6 ELEMENTARY SOCIOLOGY

I. Sociology II. Social and Behavioural sciences. Ill. Concepts in Sociology. IV. Social Organizations. V. Social Classifications. VI The Family. VII. The Family in Health and Disease, VIII. Hospital Sociology. IX. Medical Social work. X. The Art of Interviewing. XI. The Cultural Factors in Health and Disease. 1. Sociology:- Sociology is of recent origin. It is of more recent origin than psychology. Sociology is the study of society and is the science of human society. It is also the scientific study of the social aspect of human life. It is the study of the relation ship between human beings. It is also the study of individual as well as groups in society that is the study of social interaction. It may be said that sociology is the study of the behaviour of the people in groups and of the influence of the groups on people. 1. Meaning and Origin: The French Philosopher August Committee (1 798-1857) is supposed to be the father of modern sociology. He coined the word using the Greek word "Soclus" and the Latin word "Logos". "Soclus" means " Society" and " Logos" means "Science". Thus "Sociology" means "Science of Society" or " Science about society". Sociology can be viewed from Two angles. a). It can be seen as the study of relationships between human beings. b). Sociology is concerned with the study of human behaviour 2. Definitions :- "Sociology is the science of society or of social phenomena" by Word.

224 "Sociology is the science of collective behaviour" by Park & Burgess. "Sociology deals with the behaviour of men in groups" by Kimball & Young. "Sociology is the study of human inter-actions and inter-relations, their conditions and consequences" by Gins Burg. 3. Sociology and Health:- Medicine is both an art and science. In premitive societies the practice of medicine was associated with religion, magic and astrology. It is recognised that successful application of medicine to individuals and groups does involve more than mere scientific or biological knowledge, it involves an understanding of the behaviour of individuals and groups who lives together. Man is not only a biological animal, but also a social animal. Man is controlled by habits, customs, beliefs, norms, values, superstitions etc reacting upon his body and mind. The social scientists were pre- occupied with studies of human society.. 4. Fields of Specializtion. a). Medical Sociology. b). Urban Sociology. c). Rural Sociology. d). Industrial Sociology. e). Sociology of Religion. f) Sociology of education. g). Criminalogy. h). Hospital Sociology. i). Demography. 5. Areas of Health: Specialists in community health, clinical medicine, epidemiology are all seeking the co-operation and help of social scientists in understanding problem such as the social components of health and disease. a) Community Health : The terms public health, preventive medicine and social medicine which have been used to describe the traditional and important responsibilities are now included in the concept of community health. Modem community, health seeks to bring together all the available health services that is medical care, M.C.H. and F.W. Services, environmental sanitation, Laboratory services, Disease control programmes, health education with in the reach of the people and also prepare the people who need these services receptive to those services

225 Community health services postulates a unified and balanced integration of entire preventive and promotional health services. Specialists in community health are trained in epidemiology, statistics, medical sociology, operational research, medical care administration and modem management studies. Community health includes. The state of health of the members of the community, the problem affecting their health and the health care provided for the community. b) Clinical Medicines: The present medical services (eg Anatomy, Physiology, Microbiology, Pathology) are insufficient to train the physician to cope with the socio-cultural aspects of medicine. It is recognized that the physician needs two kinds of knowledge, medical knowledge and social knowledge so that he could more effectively save the patient and the community. c) Epidemiology: Epidemiology is the science of epidemics. It is the study of the distribution and determinants of disease frequency in man. Epidemiologists have a close alliance with social scientists in testing the distribution of health and disease in human population and factors that cause the distribution. Disease is studied in relation to such factors as social status, income, occupation, housing, overcrowding, social customs, habits, behaviour etc. II. Social and behavioural Sciences. The Social science is applied to those disciplins committed to the scientific examination of human behaviour. These are economics, political science, sociology, social psychology and social anthropology. The term behavioural science is applied to sociology, social psychology and social anthropology because they deal directly with human behaviour. a) Economics: The field of economics has a very close relationship with sociology. Economics deals with human relationships in the specific context of production, distribution, consumption and ownership of searce resources, goods and services. Sociology and economics overlap in many sense : both are concerned with inter- dependence in human relations b) Political Science: Historically economics and political science tended to be a single discipline. As a separate discipline political science is concerned with the study of the system of laws and institutions which constitute govt. of whole societies.

226 c) Social psychology: This discipline come from psychology. It is concerned with the psychology of individuals living in human society or groups it deals with the effect of social environment on persons, their attitudes and motivations. d) Anthropology: It is the study of the physical, social and cultural history of man. Of all the sciences, which study various aspects of man, anthropology is one which comes nearest to bring a total study of man. e) Medical Sociology: Medical Sociology is a specialization with in the field of sociology. Its main interest is in the study of health, health behaviour and medical institutions. Broadly speaking medical sociology includes studies of other medical profession, social factors in the etiology, prevalence, incidence and interpretation of disease. III. Concepts in sociology: Such terms as society, social institutions, socialization, social control, Social problems, social pathology, social services etc are frequently used by all sociologists IV. Social Organization: Society is a group of individuals drawn together by a common bond of nearness and who act together in general for the achievement of certain common goals. Different groups are needed for different purposes: these 1. Family 2. Religion and caste 3. Groups: Primary group, Secondary group, in group, out group etc. 4. Community: Rural Community, Urban community- Rural & urban problems, the administrative patterns, The health facilities available in community - Primary level, Intermediate level, Central level.-Public sector Private sector-Indigenous systems of medicines and Voluntary Health Agencies.

V. Social Classifications

People in a community are differentiated by certain characteristics which they have These may be 1. Personal characteristics such as age, sex, marital status, place of birth and citizenship. 2. Economic characteristics such as occupation, type of activity. 3. Cultural characteristics such as language, religion and caste.

227 4. Educational characteristics such as literacy and level of education. Social scientists have used occupation as a means of determining the level of social standing of an individual in a community, because occupation has an enormous importance in all societies for understanding human behaviour. Occupation is a major determinant of a). Economic rewards. b). Extent of authority. c). Extent of obligations. d). Degree of status and f). Values and life styles. i) Occupational classification ii) Limitations of occupational classification iii) Other measures of social differentiation iv) Factors involved in social class: differences in health disease.

VI. The Family

The Family is the basic unit in all societies. It is the most powerful example of social cohesion. It is a group of biologically related individuals living together and eating from a common kitchen. The family members share a pool of genes: as a social unit they share a common physical and social environment. As a cultural unit the family reflects the culture of the coider society. The classification of family based on the nature of residence is Patriarchal family and Matriarchal family. Family is again classified according to marriage. Monogamy- the condition of one wife or husband at a time, Polygamy - the condition of more than one wife at a time and Polyandry-the practice of families having more husbands than one at the same time. Famlies are not constant, they are ever changing. Four stages are descrided in the life cycle of an elementary family. They are 1. Stage of formation which begins with marriage. 2. Stage of growth: The children are born and the family size increases.3. Stage of retraction: The children grow up and leave their family of origin and form their own families and the parents are left alone. 4. Stage of disintegration: The parent family may cease to exist because of the death eventually of one or both the parents. a) Types of family: 1. The Nuclear family. 2. The Joint family 3. The Three Generation family

228 b) Functions of the family: 1. Residence 2. Division of labour 3. Reproduction and bringing up of children. 4. Socialization 5. Economic Functions 6. Social care

VII. The Family in Health and Disease:

Family performs many functions. There are certain functions which are relevant to health and health behaviour and are important from the medical sociology point of view. They are 1. The child rearing 2. socialization 3. Personality formation 4. Care of dependent adults i) care of sick and injured ii) care of women during pregnancy iii) care of the aged and handicapped 5. Stebilization of adult personality 6. Familial susceptibility to disease 7. Broaken Family 8. Problem Family

VIII. Hospital Sociology:

Hospitals are among the most complex organisations in modem society. The modern hospital is a social universe with a multiplicity of goals. The patient is the hospital's client. The complex character of the hospital has facinated the social scientists for the study of human behaviour. Hospitals are teaching either medical or nursing personnel and research designed to increase medical knowledge.

229 The import area of medical sociology is doctor - patient relationship in which complex social factors are implicated. The Doctor must know how to communicate with his patients. The Doctor bound to give maximum psychological satisfaction to his patients. The medical scientists and para-medicals are studying sociology because human behaviour is determined not clearly biological and physiological environment but also by social factors. Illness is not a medical problem but also a psychological and social problem. The problems presented by patients are not always purely medical but also psychosocial. So medical personnels are turning their attention to the study of social behavioural factors of illness.

IX. Medical Social Work:

Medicine is not only the concern of physician. Medicine is the concern of the nurse, the pharmacist, the social worker, the biological physical, behavioral and communication scientists, the engineer, a host of administrators, technicians and other auxiliaries ofassociats and assistants. Medicine is caring for patients, preventing disease and protecting health. Medicine can be said to be the meeting ground of all sciences and all the arts. Medicine adds to and takes from all areas of human endeavour. 1. Social Work : Social Work is a professional service to people for the purpose of assisting them, as individuals or in groups to attain satisfying relationship and standards of life in accordance with their, Aishes and capacities and in harmony with those of the community. 2. Medical Social Work: A Medical social worker is a paramedical worker who has been trained in social case work and in the art of interviewing people. He is a kind, warm, generous, helpful person who makes it possible for people to live richer, more satisfying lives. There are many situation, in medical and public health organizations where medical social workers are being employed eg. hospitals T.B. Clinics, F.W. Clinics, Cancer control centres, mental hospitals etc. The medical social worker forms a link between the institution where he is employed. The principal work of the medical social worker is to visit the family and probe into the personal, economic and social causes of illness and

230 collect social history of the patient. The medical social worker helps in the rehabilitation of the patient. He is now recognised as an essential professional college of the doctor in the analysis and correction of the social and emotional factors and is increasingly relied upon for supplying information that is of fundamental importance in formulating the complete diagnosis and in directing the treatment of many patients

X. The art of Interviewing:

Interview is the principal instrument used to obtain information about individuals. It is a device for investigation and an instrument of research. The social scientist uses the interview technique in his investigations. a). Aims of Interview: One of the aims of interview is to find out facts, to study health conditions, to find out what people know about health and to get to know people and to let them know about yourself It also enable to remove the blocks to communication made, by fear, mistrust, misunderstanding etc and to get to do something about health problems and to help people, to solve their problems b. Kinds of Interview: 1. Direct or Structural Interview 2. Non-directive or unstructured Interview 3. Focussed Interview 4. Repetitive Interview 5. Systematic Interview 6. Un-systematic Interview etc. c) Techniques of Interview: a). Establishing contact f) Encouragement b) Starting the Interview i) Recording the Interview c) Securing Rapport j) Closing the Interview d) Recall k) Report e) Probe questions h) Guiding Interview

231 XI. The Cultural Factors in Health and Disease

All people, whether rural or urban have their own believes and practices about health and disease. Cultural factors are deeply involved in all the affairs of man including health and disease. Not all the customs are bad. Some of the cultural factors have stood in the way of implementing health programs. Information about these factors that is customs, habits, believes, superstitions relating to health and disease is necessary for implementing the 1. Concept of Etiology and Cure: The course of disease fall into two groups a) Super natural Causes i. Wrath of Gods and Goddesses ii. Breach of Taboo iii. Past sins iv. Evil eve v. Spirit or ghost intrusion b) Physical Causes i. Effect of weather ii. Water iii. Impure Blood 2. Environmental Sanitation: a) Disposal of Human excreta b) Disposal of wastes c) Water supply d) Housing 3. Food Habits: Food habits have deep psychological roots. Diet of the people is influenced by local conditions, religious customs and belief. Food habits have a religious sanction from early days. Vegetarianism is given a place of honour in Hindu society. Muslims abhor pork and Hindus beef The concept of hot and cold foods is widely prevalent in the country. Foods such as meat, fish, eggs and jiggery are considered to generate heat in the body, foods such as curd, milk, vegetables and lemon are considered to cool the body.

232 Adulteration of food and food articles is a common practice. Muslims observe fasts during Rumzan and Hindus on several occasions. Alcoholic drinks are tabooed by Muslims and high-caste Hindus. Ganj a, Bhang Charos, Alcohol etc are frequently consumed by the younger generation. Hindu women often take food left over by their husband. In some societies men eat first, then children and women last. Some people do not eat unless they have taken bath. Thus food is a subject of widespread customs, habits, beliefs etc, which vary from country to country and from one religion to another.

4. Mother and Child Health: Mother and child health is surrounded by wide range of customs and beliefs. Marriage is universal in Indian society and the family is incomplete without the birth of a male child. The various customs in the field of mother and child health have been classified as good, bad, unimportant and uncertain a) Good: Prolonged breast feeding, oil bath massage and exposure to sun. b) Bad: Some foods-eggs, meats, fish, milk, leafy vegetables-are forbidden during pregnancy in some parts of the country. Most deliveries are conducted by the traditional untrained die or birth attendant. The child is not put to the breast during the first tree days of birth because of the belief that colostrum might be harmful. c) Unimportant: Punching of ear and nose, application of oil or a paste of turmeric etc. d) Uncertain: The practice of applying kajal or black mixed with oil is applied to the eyelids partly for beautification and partly for warding off the effects of evil eye. This custom have been blamed for transmitting trachoma and other eye infections. g offthe effects of 'evil eye'. This custom have been blamed for trans- 5. Personal Hygiene: a)Oral Hygiene, b) Bathing, c) Shaving, d) Smoking, e) Purdah, f) Sleep, g)Wearing shoes, etc 6. Sex and Marriage: Sex is what man and woman do together. Every human being from the moment he is born until the instant of his death is ruled by two irresistible compulsions, the quest for food and sex. Sex is the deepest, most eloquent expression of love that men and

233 women can exchange. Without love there can be no really satisfying sex. Without sex no real love. Sexual customs vary among different social, religious and ethnic groups. For certain religious groups menstruation is a time of "uncleanness. Muslim women are forbidden to pray or have intercourse during menses: orthodox Jews are forbidden to have intercourse for seven days after the menstruation ceases. Marriage is a sacred institution. The mean age at marriage in India is 20 years in the case of boys and in the case of girls.18 years Monogamy is the most universal form of marriage. Polygamy and Polyandry are also prelevent in India.

Chapter - 7 PSYCHOLOGY AND MENTAL HEALTH

Psychology is defined as "the study of human behaviour - of how people behave and why they behave in just the way they do". A knowledge of psychology is essential to know others better; to differentiate between the normal and abnormal; and to help promote mental health in individuals and families. Scope of Psychology Psychology is vast in its scope, as indicated by the numerous branches of psychology, e.g., normal psychology, abnormal psychology, educational psychology, social psychology, child psychology, applied psychology, psychoanalysis, etc. Medical psychology deals with patients suffering from disorders of the mind. Persons trained in medicine and psychology are called psychiatrists. Thus psychology includes every aspect of human life and every type of human relation.

234 Behaviour The theme common to community medicine and psychology is human behaviour. The main concern of psychology is to study human behaviour. Human behaviour is the result of physical and mental factors (body and mind) interacting in complicated ways. The broad categories of factors that may influence individual and community health behaviour include : knowledge, beliefs, values, attitudes, skills, finance, materials, time, and the influence of family members, friends, co-workers, opinion leaders, and even health workers themselves. Serious consideration must also be given to the community or social context in which a given type of behaviour occurs. Cultural and social factors provide a setting for individuals. However, behavioural decisions may also be made that are other than those predicted on the basis of these factors. Psychological factors relating to public health programmes may be considered under the heading of health, illness and treatment behaviours.

Health behaviour: Health behaviour refers to those activities people undertake to avoid disease and to detect asymptomatic infections through appropriate screening tests. For instance, sexually transmitted diseases can be prevented by avoiding sexual exposure with infectious sexual partners. Other health behaviours that might reduce the risks of infection include the use of condoms. Illness behaviour Illness behaviour refers to how people react to symptoms. Generally, people who detect symptoms will wait to see if the symptoms persist or worsen. If the symptoms continue, 'the affected person may ask a friend or acquaintance for advice, before seeking medical help. Treatment behaviour: Treatment behaviour refers to those activities used to cure diseases and restore health. It is important for patients to take medication as directed, return for tests for cure, and cooperate in efforts to identify untreated cases. All forms of behaviour are responses to stimuli. For example, a child sees a dog rushing towards him, and starts running away. The sight of a dog rushing towards him is

235 the stimulus and running away is the response. To understand behaviour, we must, find out the cause for stimulus. The goal of psychology is to find relations that exist between stimuli and responses. Responses The various responses may be classified as follows i) Physical responses habits, skills ii) Organic responses emotions, feelings, tension iii) Intellectual responses : perceptions, thinking, reasoning Causes All behaviour is caused, and the causes are very complex. They include: i) Environmental stimuli The environmental stimuli (e.g., sight, smell, touch, etc.) reach the cerebral cortex through nerve impulses. The information received is assembled and evaluated. By another set of impulses, the cerebral cortex "orders" the behaviour of the individual. This is known as conscious behaviour. It is the behaviour determined by the standards or expectations of the society, e.g., professional behaviour of doctors with patients. This accounts for the variation in a person's behaviour in different situations. ii) Emotions and feelings Behaviour is also dependent on our feelings and emotions. These stimuli arise from within the body. When we say a person is blind with rage or paralysed with fear, we mean that he is a victim or captive to his own emotions. Emotions thus affect our behaviour. The seat of primary emotions (e.g., anger, joy, hunger) is the thalamus in the brain. It is under the control of cerebral cortex. When the influence of cerebral cortex is removed, as for example, when an injury to cerebral cortex occurs, the person's behaviour may be affected. iii) Needs An individual's behaviour is also influenced by his needs. The terms-needs, wants, desires and urges are used synonymously. iv) Motivation

236 Motivation is an inner force which drives an individual to a certain action. It also determines human behaviour. Without motivation, behavioural changes cannot take place. v) Intellectual perception A person's intellectual perception, thinking and reasoning can influence his behaviour in a given situation. That is why each individual behaves in ways which make sense to him. Making adjustments Behaviour is also described as an adjustment to meet the needs of a given situation. For example, when a person does not succeed in something there are several ways he or she can react:  losing temper and complaining to every one  isolating oneself or simply avoiding facing others  making excuses for the failure  accepting failure with good grace and making amends by changing his behaviour or otherwise. This adjustment is both active and passive. That is why some people blow hot and cold to suit their physical and social environment. Unconscious behaviour There is also behaviour of which the individual is not conscious. For example, if ten people witness an accident we get ten conflicting reports of the accident. This is because Of -certain forces (e.g., perceptions, prejudices, and notions) which colour the incident, over which the individual has no control. Another example is that some people forget important things because they are unpleasant and remain happily unconscious about them. Emotions An emotion is a strong feeling of the whole organism. Emotions motivate human behaviour. An emotional experience is characterised by both external and internal changes in the human being. The external changes are those which are apparent and easily seen by others such as changes in facial expression, changes in posture. By studying the facial expression we can find out if a person is angry, happy, depressed or elevated. The internal changes brought about by emotions are psychological such as

237 rapid pulse, respiration, increased blood pressure, tension and pain. Usually these changes are temporary, and subside when the individual returns to the "normal". Some of the major emotions are Fear Jealousy Sympathy Anger Moodiness Pity Love Joy Lust Hate Sorrow Grief Scientists have proved that emotions can be a major barrier to communication. Man is indeed a slave to his emotions. The doctor should be able to understand the emotions 'of the patient. Once the emotional barriers are broken down, a mutual trust between the patient and the doctor develops, and the patient will begin to talk more freely about himself. This is the basis of doctor-patient relationship. The desirable qualities in a doctor are cheerfulness and an even temperament. Moodiness, emotional instability and getting easily upset are undesirable qualities. Some Specific Emotions (1) FEAR: Fear is the most common emotion of man. It may produce excitement or depression; flight or fight. Some of the common fears of man are - fear of the dark, fear of dogs, fear of snakes, fear of ghosts, fear of sickness, fear of death, etc, When the fear becomes exaggerated or unnecessary, it is called phobia. Such fears are common in patients with mental disorders. (2) ANGER : Anger or rage is another basic emotion of man. It is a reaction of the offensive type. Anger is a destructive force. If it is not controlled, it may impel a person even to commit murder. (3) ANXIETY : Anxiety may manifest in such symptoms as rapid pulse and breathing, flushing, tremors, sweating, dry mouth, nausea, diarrhoea, raised blood pressure, etc. Patients admitted to hospitals are anxious. Anxiety leads to tension, and tension to pain. The doctor must understand the patient's anxiety and give him reassurance. A kind word from the doctor or nurse works like a magic and gives the patient considerable relief from mental anxiety. (4) LOVE : Love is a feeling of attachment to some person. It is a basic emotion of man. Role of emotions in health and disease Emotional states determine human behaviour. Anger can cause a person to be rude and sarcastic. Disorders of emotion interfere with human efficiency - lack of concentration, lack of appetite, increased risk of accidents, lack of sleep, palpitation, etc.

238 Emotional disorders in children may appear in the form of temper, abdominal pain, spasms, tics, and anti -social behaviour such as aggressiveness. Psychosocial illness : There are a group of diseases known as "psychosocial diseases" (mind acting on body), e.g., essential hypertension, peptic ulcer, asthma, ulcerative colitis which are attributed to disturbed emotional states. Control of emotions A well-adjusted and mentally healthy person is one who is able to keep his emotions under control. One should not be carried away by one's emotions. Children should be shown love and appreciation so that they may grow into emotional maturity. For adults, a happy family life is basic for emotional adjustment. Patients who are anxious need reassurance and their fears must be allayed. The following tips may be useful in controlling one's emotions : (i) cultivate hobbies, good habits of reading and recreation (ii) adopt a philosophy of life to enable you to avoid mental conflicts (iii) try to understand your own limitations, and (iv) develop a sense of humour. A study of psychology helps us to understand the basis of emotions and the need to keep emotions under control. Motivation Motivation is a key word in psychology, It is an inner force which drives an individual to a certain action. It also is called attention – determines human behaviour. Motivation may be positive (the carrot) or negative (the stick): Without motivation, behavioural changes cannot be expected to take place. Positive motivation is often more successful than negative motivation. Motivation is not manipulation. A motivated person acts willingly and knowingly. The terms motives, needs, wants, desires and urges are all used synonymously; these terms are interrelated and interdependent. Kinds of needs and urges: It is difficult to define human needs. There are many kinds of needs and urges (a) Biologic needs : These are survival needs. A hungry man needs food, a thirsty man water, a sick man medicine. There are other needs such as sleep, rest, recreation and fresh air. The doctor should be aware of these needs in the day -to -day care of the patients. (b) Social needs : The need for company, the need for love and affection, the need for recognition, the need for education are all social needs. Some of these needs are met by the family, and some by the community. (c) Economic needs : Economic

239 security, that is security from want, is one which everyone desires. (d) Ego-integrative needs : The desire for prestige, power and self-respect come in this category. Motivation is contagious; it spreads from one motivated person to another. We make use of motives and incentives in community health work. Motivation of eligible couples for a small family norm is an important activity in the National Family Welfare Programme. Motivation is required to enlist people's participation in community health work. Incentives Incentives are among the factors that stimulate motivation and encourage specific behaviours. Incentives can be either intrinsic or extrinsic, material or psychological, self determined or selected by others. An intrinsic incentive is the benefit that comes from solving one's own problems. Extrinsic incentives are rewards that do not relate directly to the goal towards which the desired behaviour is aimed, for example, financial compensation of individuals undergoing sterilization operation for family planning. Material incentives are tangible goods or services; psychological incentives include the satisfaction, self -esteem, or enhanced capabilities gained through a proposed course of action. Legislation Legislation can serve as an important tool to support, promote and sustain activities at the community level. Laws should satisfy requirements and, at the same time be compatible with the political, cultural, social, and economic situation of the country. Observation Treatment involves lot of correct observation of the patient's condition. Observation involves two mental activities perception and attention. Hippocrates, the Father of Medicine, laid the foundation of modern medicine by accurate observation of signs and symptoms. By observing an apple fall, Newton formulated the theory of gravitation. By observation, penicillin was discovered. Observation is a psychological skill. It consists of the noting of the phenomena of life as they occur. It requires correct use of the senses of seeing, hearing, touch, smell, movements etc. A doctor should cultivate the habit of correct observation. Correct observation leads to correct thinking, reasoning and learning.

240 Observation promotes attention. To observe more carefully is called attention. Among the object attracts more attention than a static object, a large object attracts more attention than small object, an uncommon object attracts more attention than a common one, a bright colour attracts more attention than dull colour. In attention, certain adjustments of sense organs are involved such as turning the head, converging the eyes, other words, attention means closer observation. Attention is not a fixed state or power of the mind. We constantly change our attention from one object to another according to the demands of the situation. Concentration, i.e., the focusing o consciousness on a particular object to the exclusion of all of the objects has been defined as sustained attention Errors in perception The word perception implies observation, recognition and discrimination. Perception takes place with the help of sensory organs. Thus we have visual perception, auditory perception, olfactory perception, and muscular perception. The disorders of perception are : (1) Imperception : That is, inability to recognise. This may be due to damage to the sense organs, e.g., anaesthesia, (2) Illusion : An illusion is a false perception. Mistaking a rope for a snake, a tree for an animal are called illusions. Illusions occur in mental diseases. Illusions may be auditory or visual. (3) Hallucination : Hallucination is an imaginary perception. It is a gross error of perception. Seeing objects that do not exist, hearing sounds that are false, seeing objects moving in a room are called hallucinations. Hallucinations occur in mental disorders. Attitudes Attitudes are acquired characteristics of an individual. They are more or less permanent ways of behaving. An attitude includes three components : (a) a cognitive or knowledge element (b) an affective or feeling element, and (c) a tendency to action. An attitude has been defined as a relatively enduring organization of beliefs around an object, subject or concept which pre-disposes one to respond in some preferential manner. Attitudes are not learnt from text books, they are acquired by social interaction, e.g., attitude towards persons, things, situations and issues (e.g.. government policies, programmes and administrative measures). It has been truly said that attitudes, are caught, and not taught. Once formed, attitudes are difficult to change. The responsibility to develop healthy attitudes devolves upon parents, teachers, religious leaders and elders.

241 Our success or failure in life depends upon our attitudes. 'Social psychology is largely a study of attitudes. In recent years, attitude surveys and attitude measurements have been widely used by psychologists and health professionals. Opinions and Beliefs Opinions are views held by people on a point of dispute. They are, based on evidence available at the time. Opinions by definition are temporary, provisional. They can be looked on as beliefs for the time being. Beliefs, on the other hand are permanent, stable, almost unchanging. It is thus easier to give up one's opinions when faced with the facts; attitudes and beliefs do not succumb so easily. Interests Numerous interests come into play in a communication situation. Most significant are our own interests - of security, pleasure, and self-esteem. Then come the interests of the various groups we are associated with - primary and secondary, as well as the reference groups whose values and norms we aspire to promote. Our communities, castes, language groups, peer groups, and other religious, social, political and professional groups so dear to us are vital to our interests. One must not overlook the social, regional and national interests that shape our selection of communications, and also the way we perceive them. Learning Learning is any relative permanent change in behaviour that occurs as a result of practice or experience. It means acquiring something new - knowledge, new techniques, new skills, new fears and new experiences. Learning is necessary for man's survival and for human progress. It includes not only acquiring knowledge but also skills and formation of habits, and development of perception. Learning depends largely upon intelligence. Learning also depends upon motivation, and motivation depends on the need students feel to learn. Learning is a continuous process. It is both conscious and unconscious. Conditions affecting learning (1) Intelligence : Learning depends upon the intelligence or mental status of an individual. It involves the activity of sensory adjustment and motor mechanisms of the body. The mental faculty is related to heredity, nutrition and IQ. Children with low IQ are poor learners; they may not learn at all. (2) Age: The curve of learning reaches its

242 peak between 22 and 25 years of age. After the age of 30, there is a sharp decline. It has been appropriately said : You cannot teach an old dog a new trick . (3) Learning situation : Physical facilities for learning, viz, institutions, teachers, textbooks, audio-visual aids promote learning. (4) Motivation : In order to learn effectively, there must be adequate motivation. The powerful motives are encouragement, praise, reward and success. These stimulate learning. (5) Physical health : A Physically handicapped person, e.g. deaf, dumb, chronically sick cannot learn. (6) Mental health : Worries, anxieties, and fears interfere with learning. Types of learning There are 3 types of learning (1) Cognitive learning (knowledge) (2) Affective learning (attitudes) (3) Psychomotor learning (skills) Habits Habit is an accustomed way of doing things, Habits are said to have 3 characteristics: (a) they are acquired through repetition (b) they are automatic, and (c) they can be performed only under similar circumstances. Habits accumulated through generations emerge as customs, and customs in turn create habits. Habits once formed persist and influence human behaviour. Habit formation Habits are formed. They are of many kinds, e.g., habits relating to food, sleep, work, smoking, intake of drugs and alcohol, etc. There are both good and bad habits. Good habits promote health; bad habits (e.g., drug dependence) may ruin health. Therefore, cultivation of good habits is desirable. The (1) Habit formation should begin early in childhood, when the child has not yet formed any habits, and is receptive to all influences; (2) Habits are formed by frequent repetition; (3) It takes time to form habits; they cannot be formed overnight; (4) There should be a strong emotional stimulus to form habits (e.g., taking a vow, reward, recognition, etc.) Good habits kill bad habits. The best way to break bad habits is to cultivate good habits.

243 (5) Habits build up human personality. Man should not become a slave to his habits, he should remain a master. It is the job of the psychologist to find out how good habits can be developed, and bad ones eliminated. Frustrations and Conflicts  Frustrations All peoples have needs - biological, social, economic, which they try to satisfy. When they are unable to meet their needs and desires, they feel frustrated. The sources of frustration may be external - e.g., unemployment, failures and defects, or, internal - e.g., lack of health, lack of intellectual ability, etc. Sometimes, frustration may rouse the individual to higher and bigger effort to overcome failures. The individual may bypass the frustration conditions by changing his goals in life. Frustration, if it is allowed to continue, may damage one's personality. It may generate feelings of anger, dejection, hostility, withdrawal or even attempts at suicide. That is why some people take to drugs and alcohol to escape frustration.  Conflicts A conflict is like a tug of war between two or more courses of action or between opposing ideas. The person is required to act one way or the other, often generating painful emotions as for example in choosing a life partner or a job. He has to weigh principles involved in habit formation are the pros and cons of the situation to be able to make a correct decision. It is essential for a person's mental health that conflicts should be resolved as quickly as possible, within a reasonable period of time, before emotional disturbances occur. Defense Mechanisms When an individual is faced with problems, difficulties or failures, he employs certain ways or devices to achieve health. happiness or success. These are called ‘Defence mechanisms' Psychologists have identified a number of such defence mechanisms, which include the following:

1. Rationalization

244 Instead of accepting failure and correcting himself, the individual tries to make excuses and justifies his behaviour. It is like the proverbial fox declaring that the grapes were sour, when it could not reach them. This is called rationalization. It is a face-saving device. 2. Projection Sometimes the individual blames others for his mistakes or failures. It is-just like the student saying that he could not score good marks in the examination because, his teacher did not like him. 3. Compensation Many people make use of compensation to enhance, their self-esteem and prestige. The familiar example is that-, the student who is not good in his studies may distinguish himself in sports or dramatics, music or other activities. 4. Escape mechanism Some individuals adopt what is known as an "escape mechanism" to overcome failure to defeat. Some students pretend illness and do not appear for examinations. This is an escape phenomenon. Then there are others who take to alcohol or drugs trying to solve their problems. This is also an escape phenomenon. 5. Displacement An office clerk badly snubbed by his superior takes it out on his wife and children on reaching home. This is like a rebound phenomenon. It is trying to escape from one situation and fixing blame on another situation 6. Regression Some people resort to childhood practices (e.g., weeping when something goes wrong) as a mode of adjustment. The above list of "defence mechanisms" serves to illustrate the various modes of adjustments the individual adopts to escape from realities. A mentally healthy person will not use defence mechanisms for achieving success or happiness. Personality The term 'personality" is a key word in psychology. It implies certain physical and mental traits which are characteristic of a given individual: these traits determine to some extent, the individual's behaviour or adjustments to his surroundings. The terms personality and human behaviour are inter-related. Psychology, in its broader concept,

245 implies study of human personality. It is important to bear in mind that the personality of the doctor affects very much the well-being of the patient. Components of personality There are at least 4 components of human personality (1)Physical : These are the physical traits or features of an individual namely height, weight, colour, facial expression, physical health, etc. To the layman, a good personality means an impressive, symmetrical and healthy body. (2) Emotional: A person's emotions also go into the make up of his personality. Emotions are the feelings we have fear, anger, love, jealousy, guilt, worries. These feelings affect an individual's personality. (3) Intelligence : Personality also implies intellectual ability. An intelligent person will have a forceful personality. A person with sub-normal intelligence is described as a "dull" person. (4) Behaviour : Behaviour is a reflection of one's personality. It is partly dependent upon our feelings and partly on the expectations of the society. Behaviour is described in such terms as gentle, kind, affectionate, balanced, submissive and aggressive. When we assess human personality, all these components must be taken into consideration. Personality traits A trait is described as tendency to behave in a consistent manner in variable situations. Human personality is a bundle of traits. The basic personality traits are established by the age of 6 years. Some traits, we cultivate (e.g., good manners); some, we may conceal (e.g., kindliness), and some, we modify depending upon the society in which we are placed (e.g., sense of humour). The following are some of the personality traits

Cheerfulness Loyalty Good manners Reliability Sportsmanship Sense of humour Honesty Tactfulness Kindliness Willing to help others. The personality traits we look for in a doctor are kindliness, honesty, patience. tolerance, perseverance, consciousness, thoroughness and initiative. It is possible to cultivate these traits.

246 Development of personality Human life consists of definite stages of growth, and each stage is marked by distinctive psychology. (1) Infancy: The first one year of life is called infancy. The infant is hardly a social creature. There is rapid physical and mental growth. The infant is totally dependent on the mother. By the end of first year, the infant is able to stand up for a short while and tries to walk with a little support. He enjoys simple tricks and games. (2) Pre-School Child: This stage is marked by considerable growth of brain. The child feeds himself, speaks, loves his home, fears dark, loves stories and wants to assume responsibility. He begins to mix with other small children. (3) School Age: The school -age period ranges from 5 to 15 years. The school going child is active all the time. By the age of 8, the mental powers are fully developed. The brain of the child at the age of 8 years is almost of the same size as an adult. The child begins to reason. There is a gradual detachment from the family, and greater attachment to his playmates and friends. He begins to form groups. The period of childhood terminates with the onset of puberty, which is about 11 years in the case of girls and 13 in the case of boys. (4) Adolescence : Adolescence or "teenage" is a turbulent Period in one's life. This is a period of rosy dreams, adventure, and romance. The teenager strives for independence. He is likes parental authority. He becomes fully aware of social values and norms. There is rapid physical growth. 5) ADULTS : The person is mature and more balanced. The physical and mental characteristics are fully developed. It is difficult to draw a line when adolescence ceases, and adulthood begins. (6) OLD AGE: It is difficult to say when old age begins. It is a gradual process marked by decline in physical powers and acuity of sense organs. Old age is marked certain psychological changes such as impaired memory, rigidity of outlook, irritability, bitterness, inner withdrawal and social maladjustment. Character and will The concept of personality also involves assumptions about character and will of the person. Will indicates determination and character implies moral worth. Personality and character are not identical; both are different. Man's character may be good at one time and bad at another time, though his Personality remains the same. There is no acceptable definition character.

247 Thinking Man is called a thinking animal. Thinking includes perception, memory, imagination and reasoning. It is an active mentalists. Imaginative thinking is a mental process, it involves thinking in the absence of original sensory stimuli. Day-reaming and thinking about our future plans are examples of imaginative thinking. The highest form of thinking is said to be creative thinking , e.g., an artist painting a picture. Creative thinking is said to be responsible for new inventions, new views –of life and new discoveries. In fact, the purpose of education is to teach ,people to think, and not merely to memorise facts and figures. Problem solving An aspect of thinking is, problem solving. It is regarded as highest stage in human learning. Some problems in life are actively simple; there are others which are more difficult and complex calling for thinking and reasoning. REASONING require intelligence. There are several steps in the reasoning -access - collection of information on the subject, the arrangement of data carefully, observation of the implications etc.. Intelligence Intelligence is an important aspect of personality. It has not satisfactorily defined as yet. The widely accepted, function is that it is the ability to see meaningful relationships ,wean things. It includes perceiving, knowing, reasoning and numbering. Psychologists believe that intelligence results an interplay between hereditary and environmental. Some psychologists emphasize genetic factors as riving major significance while others emphasize environmental factors. There is considerable relationship between a person's degree of intelligence and range of activities, the level of achievement and the depth of understanding possible to him. Psychologists observed the differences between animals and human beings, and the differences between organisms of the species, they were impressed by the fact that there are creations in the case and adequacy with which adjustments to situations occur. It was out of such observations that the concept of intelligence arose. Mental Age The first tests of intelligence were devised by Binet and Simon (1896). They developed the concept of mental age. That is, a child who could do the five-year tests but who could not go on to the six-year level, was credited with mental age of five years.

248 The concept of mental age indicated the level of intelligence achieved, but it gave no indication of the brightness or dullness of the individual concerned. Intelligence Quotient This is an improvement over the concept of mental age. It is obtained by dividing the mental age by chronological age, and multiplying by 100. IQ = Mental age x 100 Chronological age When the mental age is the same as chronological age, the IQ is 100. The higher the IQ, the more brilliant the child. 80 per cent of people have an IQ of or near 100. On the other hand, say for example, if a child is 10 years of age and his mental age level is that of 5 years, the IQ is 50. Levels of Intelligence IQ Range Idiot 0-24 Imbecile 25-49 Moron 50-69 Border Line 70-79 Low normal 80-89 Normal 90-109 Superior 110 119 Very Superior 120-139 Near Genius 140 and over

The current interpretation is that the IQ is the measurement of the quality and potential of intelligence. The higher the IQ the more "brilliant' the child is and is more capable of higher performance at school -age. Adult Intelligence The components of, adult intelligence have been analysed by many specialists. Thurstone, for instance, defines them as : (1) space : the ability to perceive objects (2) number: familiarity with elementary arithmetic (3) verbal comprehension the ability to reason from verbal concepts (4) facility of expression the ability to employ the appropriate words

249 (5) memory : the ability to retain words and ideas (6) induction : the ability to discover principles (7) deduction : the ability to use those principles to solve concrete problems (8) flexibility and quickness of thought. Intelligence tests Intelligence tests can be classified under the categories of group tests and individual tests. These two kinds of tests have been constructed mostly to meet practical necessities. Naturally, if large numbers of subjects are to be tested, it would be more convenient to test them in large group to save time. But under particular situations, such as in a guidance clinic, each individual could be tested separately and would need to be tested separately. To suit these different requirements, we now have both group tests and individual tests. In a group test, all the subjects must start at one time and finish at the same time just as in an examination. Here, the time factor is constant. One's intelligence is measured in terms of the amount of work successfully completed within the given time. Individual tests on the other hand need not necessarily depend on a constant time factor. Time tests can also be used for individuals. Strictly speaking, all tests of intelligence are measures of performance. However, the term performance is customarily applied to tests which call for a minimal understanding and use of language. These tests provide a measure of fundamental psychological process, such as reasoning and seeing relationship, without at the same time depending upon particular cultural or educational opportunities. They enable us to measure the intelligence of individuals - (1) who are too young to have learned a language, who are illiterate through lack of educational opportunity or feeblemindedness, and (3) who speak only a foreign tongue. As the child grows older, his intelligence undergoes a gradual increase. There is an improvement with age in his versatility of adjustment - in the readiness with which he gathers information and acquires new skills which enable him to adjust to the changing circumstances of his environment. When a normally healthy school child, whose educational opportunities have been average, is tested year after year, his I.Q. remains fairly constant. Changes in educational opportunities lead to fluctuations in I.Q. There are cases on record, too, where the I.Q. rose considerably after glandular therapy. The chief values of discovering a child's I.Q. are that (1) those of low I.Q. can be taken aside for special education in line with their capacity to acquire intelligent

250 behaviour; (2) those of very high capacity can be selected for education in keeping with their capacity; (3) intelligence tests as an aid in the determination of the right time to enter school; (4) the use of intelligence test in maintaining the adjustment of a pupil to his work; (5) the selection of applicants for college and professional school; (6) the use of intelligence test in educational guidance; and (7) the use of intelligence test to the therapist . Measurement of disability There have been many attempts to measure or record in standardized form the aspects of behaviour, psychological functions and social performance. One of the most important is Wing's comprehensive Handicaps, Behaviour and Skills Schedule (HBS) which has been used in epidemiological studies to assess the total child population in terms of detailed scales of specific abilities and disabilities. Results from these surveys have raised important questions about ethnic differences in disability profiles, individual programme planning, defining new syndromes of disability and the possibilities of new parameters for classification. The HBS is essentially a research tool, but Wing has developed from it a small practical schedule for use in service contexts using that had emerged as the most important aspect of mobility, communication and social interaction. The resulting Disability Assessment Schedule (DAS) is being used in several communities as a source of high quality routine data for total population. Social Psychology Social psychology is an important branch of psychology. It is defined as the science of behaviour of the individual in society. That is, it studies the behaviour of the individual in group, crowd, mob, audience and other social situations. It also studies the attitudes of the individuals towards cultural and social values. Group behaviour Man is a social being. From birth till death, he is associated with people. He is born in particular culture which is made up of customs, laws, ideals, art, literature, crafts, science, technology and institutions. All these act on the individual and influence his social behaviour. Group behaviour is also known as social behaviour. Social Interaction (a)Inter-personal relationships : The individual learns many things from his parents, teachers and friends. This is known as person -to -person interaction.

251 (b)Inter-group relationships : The individual is a member of a group, of a family and of a community. He has to follow the traditions of the group. For example, in many communities in India the person is not permitted to marry outside his caste. This is the result of person -to -group interaction. The individual, through social interaction and social learning acquires patterns of behaviour prevalent in his society, and is accepted as a member of that community. This process of adaptation is known as socialization. Social interaction converts the biological organism into human, social and moral. As a result of social interaction, the individual acquires attitudes towards persons, things, situations and issues. Social attitudes are shared by others in the community, e.g., attitude to prohibition, family planning, child marriage, etc. In any democratic society, people's attitudes are a matter of vital importance to the State. Group morale Every group has leaders. They are responsible for the solidarity of the group behaviour and the morale of the people in the group. Groups work together. They have definite programmes and objectives. Often their members think, feel and act together. Many community problems can be solved by group effort. We can approach the group through group discussions. The problem is one of how to make these group activities happy and satisfying experiences for those who participate in them. MENTAL HEALTH Objectives: At the end of the training, the trainee should be able to  Have an idea with regard to the different aspects of mental diamention of the concept of health.  Perform their duties in a better way in the implementation of the National Mental Health Programme. Mental health is not mere absence of mental illness. Good mental health is the ability to respond to the many varied experiences of life with flexibility and a sense of purpose. More recently mental health has been defined as “a state of balance between the individual and the surrounding world, a state of harmony between oneself and

252 others, a co- existence between the realities of the self and that of other people and that of the environment”. A few short decades ago, the mind and body were considered independent entities. Recently, however, researchers have discovered that psychological factors can induce all kinds of illness not simply mental ones. They include conditions such as essential hypertension, peptic ulcer and bronchial asthma. Some major mental illnesses such as depression and schizophrenia have a biological component. The underlying inference is that there is a behavioral, psychological or biological dysfunction and that gives disturbance in the mental equilibrium is not merely in the relationship between the individual and society. Even though mental health is an essential component of health, the scientific foundations of mental health are not yet clear. Therefore, we do not have precise tools to assess the state of mental health unlike physical health. Psychologists have mentioned the following characteristics as attributes of a mentally healthy person. a. a mentally healthy person is free from internal conflicts, he is not at “war” with himself. b. He is well adjusted, i.e., he is able to get along well with others. He accepts criticism and is not easily upset. c. He searches for identity d. He has a strong sense of self esteem e. He knows himself his needs, problems and goals (this is known as self actualization) f. He has a good self control balances rationally and emotionality g. He faces problems and tries to solve them intelligently, i.e., coping with stress and activity. Assessment of mental health at the population level may be made by administering mental status questionnaires by trained interviewers. The most commonly used questionnaires seek to determine the presence and extent of organic disease and of symptoms that could indicate psychotic disorder; some personal assessment of mental well being is also made. The most basic decision to be made in assessing mental health is whether to assess mental functioning i.e., the extent to which cognitive or affective

253 impairments impede role performance and subjective life quality, or psychiatric diagnosis. One of the keys to good health is a positive mental health. Unfortunately our knowledge about mental health is far from complete. Types of mental illness … “A mentally healthy person feels right towards others” Health is defined as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. A sound mind in a sound body has been recognizes as a social ideal for many centuries. The Indian sages and seers had paid particular attention to the unconscious, wherein lay the suppressed unfulfilled desires and compulsions of several kinds which led the individual astray; by mastering their mind, they attained the highest level of emotional equilibrium. Mental health is thus the balanced development of the individual’s personality and emotional attitudes which enable him to live harmoniously with his fellow men. Mental health is not exclusively a matter of relation between persons; it is also a matter of relation of the individual towards the community he lives in, towards the society of which the community is a part and towards the social institutions which for a large part guide his life,. Determine his way of living, working, leisure, and the way he earns and spends his money, the way he sees happiness, stability and security In 1950, a WHO Expert Committee on mental health reviewed the various definitions of mental health and observed “Mental health, as the Committee understands it is influenced by both biological and social factors. It is not a static condition but subjects to variations and fluctuations of degree; the Committee’s conception implies the capacity in an individual to form harmonious relations with others and to participate in or contribute constructively to changes in his social and physical environment. It implies also his ability to achieve a harmonious and balanced satisfaction of his own potentially conflicting instinctive drives in that it reaches an integrated synthesis rather than the denial of satisfaction to certain instinctive tendencies as a means of avoiding the thwarting of others. History For long the mentally ill were considered to be possessed by devils. Patients were locked up in tall jail like buildings far removed from the centres of population, alienated

254 from the rest of society. During the 20th Century psychiatry began to make scientific advance. The late 1930’s and early 1940’s saw the introduction of two empirical treatments insulin coma therapy and electric shock treatment. Then came the tranquillizers they made it possible to admit and treat all types of mental illness in the general hospital. The idea that the mental patients can be admitted and treated in a general hospital developed. The current trend is complete integration of the mentally ill patient into the normal pattern of medical care with continuity of care from his family doctor, utilization of the general hospital and community resources. Problem statement WORLD About 500 million people are believed to suffer from neurotic stress related and somatoform (psychological problems which present themselves as physical complaints). A further 200 million suffer from mood disorders such as chronic and manic depression. Mental retardation affects about 83 million people, epilepsy 30 million dementia 22 million and schizophrenia 16 million. INDIA Surveys of mental morbidity carried out in various parts of the country suggest a morbidity rate of not less than 18-20 per 1,000 and the types of illness and their prevalence are very much the same as in other parts of the world. The number of mental hospital beds in the country as per a 1991 survey is 21147 while on the basis of surveys carried out the number of people needing psychiatric treatment will not be less than 11,000,000. The number of qualified psychiatrists in the country is also far below the requirement. Characteristics of a mentally healthy person Mental Health is not mere absence of metal illness. A mentally healthy person has three main characteristics: 1. He feels comfortable about himself that is he feels reasonably secure and adequate. He neither underestimates nor overestimates his own ability. He accepts his shortcomings. He has self respect. 2. The mentally healthy person feels right towards others. This means that he is able to be interested in others and to love them. He has friendships that are satisfying and lasting. He is able to feel a part of a group without being submerged by it. He is able to like and trust others. He takes responsibility for his neighbours and his fellow men.

255 3. The mentally healthy person is able to meet the demands of life. He does something about the problems as they arise. He is able to think for himself and to take his own decisions. He sets reasonable goals for himself. He shoulders his daily responsibilities. He is not bowled over by his own emotions of fear, anger, love or guilt Warning Signals of Poor Mental Health William C. Menninger, President of the Menninger Foundation, Topeka, Kansas, United States of America drew up the following questions to aid in taking one’s own mental health pulse: 1. Are you always worrying? 2. Are you unable to concentrate because of unrecognized reasons? 3. Are you continually unhappy without justified cause? 4. Do you lose your temper easily and often? 5. Are you troubled by regular insomnia? 6. Do you have wide fluctuations in your moods from depression to elation, back to depression, which incapacitate you? 7. Do you continually dislike to be with people? 8. Are you upset if the routine of your life is disturbed? 9. Do your children consistently get on your nerves? 10. Are you “browned off” and constantly bitter? 11. Are you afraid without real cause? 12. Are you always right and the other person always wrong? 13. Do you have numerous aches and pains for which no doctor can find a physical cause? The conditions chartered in these questions are the major warning signals of poor mental health in one degree or another. According to Dr. Menninger, help is necessary if the answer to any these questions is definitely “yes”.

Types of mental illness Mental illness is a vast subject, broad in its limits and difficult to define precisely. There are major and minor illnesses. The major illnesses are called psychosis. Here, the person is "insane" and out of touch with reality. There are three major illnesses: (1)

256 Schizophrenia (split personality) in which the patient lives in a dream world of his own. (2) Manic depressive psychosis in which the symptoms vary from heights of excitement to depths of depression and (3) Paranoid which is associated with undue and extreme suspicion and a progressive tendency to regard the whole world in a framework of delusions. The minor illnesses are of two groups: (a) Neurosis or Psychoneurosis: In this the patient is unable to react normally to life situations. He is not considered "insane" by his associates, but nevertheless exhibits certain peculiar symptoms such as morbid fears, compulsions and obsessions, (b) Personality and Character Disorders: This group of disorders are the largely due to unfortunate childhood experiences and perceptions. Causes of mental ill health Mental illness like physical illness is due to multiple causes. There are many known factors of agent, host and environment in the natural histories of mental disorders. Among the known factors are the following: (1) Organic Conditions: Mental illnesses may have their origin in organic conditions such as cerebral arteriosclerosis, neoplasms, metabolic diseases, neurological diseases, endocrine diseases and chronic diseases such as tuberculosis, leprosy, epilepsy, etc. (2) Heredity. Heredity may be an important factor in some cases. For example, the child of two schizophrenic parents is 40 times more likely to develop schizophrenia than is the child of healthy parents. (3) Social Pathological Causes: To produce any disease, there must be a combination of genetic and environmental factors. The social and environmental factors associated with mental ill health comprise : worries, anxieties, emotional stress, tension, frustration, unhappy marriages, broken homes, poverty, industrialisation, urbanisation, changing family structure, population mobility, economic insecurity, cruelty, rejection, neglect etc. The social environment not only determines the individual’s attitudes but also provides the "framework" within which mental health is formulated. Environmental factors other than psychosocial ones capable of producing abnormal human behaviour are: (1) Toxic substances - carbon disulfide, mercury, manganese, tin, lead compounds, etc. (2) Psychotropic drugs - barbiturates, alcohol, griseofulvin. (3) Nutritional factors - deficiency of thiamine, pyridoxine. (4) Minerals - deficiency of iodine. (5) infective agents- infectious disease (e.g., measles, rubella) during the prenatal, natal and post-natal periods of life may have adverse effects on the brain's development and the integration of mental functions. (6) Traumatic factors - road and

257 occupational accidents and (7) Radiation - nervous system is most sensitive to radiation during the period of neural development.

Crucial points in the life cycle of human beings There are certain key points in the development of the, human being which are important from the point of view of mental health. These are : (1) Prenatal period : Pregnancy is a stressful period for some women. They need help not only for their physical but also emotional needs. (2) First 5 years of life: The roots of mental health are in early childhood. The infant and young child should experience a warm, intimate and continuous relationship with his mother and father. It is in this relationship where underlies the development of mental health. It follows that broken homes are likely to produce behaviour disorders in children and this has been confirmed by several studies. (3) School child : Everything that happens in the school affects the mental health of the child. The programmes and practices of the school may satisfy or frustrate the emotional needs of the child. Children who have emotional problems may need child guidance clinic or psychiatric services. From the standpoint of the child's mental health and his effectiveness in learning, proper teacher-pupil relationship and climate of the class room are very important. (4) Adolescence : The transition from adolescence to manhood is often a stormy one and fraught with dangers to mental health, manifested in the form of mental ill health among the young, and juvenile delinquents in particular. (5) Old age : The mental health problems of the aged have received considerable attention in recent times in the developed countries. The causes of mental illness in the aged are organic conditions of the brain, economic insecurity, lack of a home, poor status and insecurity. Thus throughout his life, the needs of man remain the same (1) the need for affection, (2) the need for belonging, (3) the need for independence, (4) the need for achievement, (5) the need for recognition or approval. (6) the need for a sense of personal worth and (7) the need for self-actualization. These needs only differ in degree and qualitative importance at various ages. Preventive aspects Three levels of prevention have been described (5). (1) Primary: Primary prevention operates on a community basis. This consists of "improving the social environment", and promotion of the social, emotional and physical

258 well-being of all people. It includes working for better living conditions and improved health and welfare resources in the community. (2) Secondary: This consists of early diagnosis of mental illness and of social and emotional disturbances through screening programmes in schools, universities, industry, recreation centres, etc., and provision of treatment facilities and effective community resources. In this regard, "family based" health services have much role to play. The family service agencies identify emotional problems and early symptoms of mental illness, help family members to cope with overwhelming stress, treat problems of individual and social maladjustment when required and prepare individual family members for psychiatric care. "Counselling" is the method most commonly employed by the family service agencies. The agencies, main responsibility is to provide a counselling service and help to families with marital conflict, disturbed parent-child relationships and strained interpersonal relationships. Family counselling is one method of treatment intervention for helping the mentally ill. Family counsellors (3) Tertiary: Tertiary prevention seeks to reduce the duration of mental illness and thus reduce the stresses they create for the family and the community. In short, the goal at this level is to prevent further break-down and disruption. Mental health services Mental health services in a community are concerned not only with early diagnosis and treatment, but also with the preservation and promotion of good mental health and prevention of mental illness. The mental health services comprise: (1) Early diagnosis and treatment (2) Rehabilitation (3) Group and individual psychotherapy (4) Mental health education (5) Use of modern psychoactive drugs (6) After-care services Comprehensive mental health programme Since 95 per cent of psychiatric cases can be treated with or without hospitalization close to their homes, the current trend is full integration of psychiatric services with other health services. The Community Mental Health Programme includes all community facilities pertinent in any way to prevention, treatment and rehabilitation. The philosophy of Community Mental Health Programme consists of the following essential elements: (1) Inpatient services (2) Out-patient services (3) Partial hospitalization (4) Emergency services (5) Diagnostic services (6) Pre-care and aftercare

259 services including foster home placement and home visiting (7) Education services (8) Training and (9) Research and evaluation.

Alchaholism And Drug Dependence Definition The word "drug" is defined as "any substance that, when taken into the living organism, may modify one or more of its functions" (WHO). "Drug abuse" is defined as self administration of a drug for non-medical reasons, in quantities and frequencies which may impair an individual's ability to function effectively, and which may result in social, physical, or emotional harm. "Drug dependence" is described as "a state, psychic and sometimes also physical, resulting from. the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. A person may be dependent upon more than one drug. The Problem The use of alcohol and other psychoactive drugs has become a matter of serious concern in many countries. While alcohol abuse is a more or less universal problem, the incidence of drug abuse varies from place to place. Agent factors Dependence-producing drug A dependence-producing drug is one that has the capacity to produce dependence, as described above. The specific characteristics of dependence varies with the type of drug involved. The following psychoactive drugs, or drug classes, the self administration of which may produce mental and behavioural disorders, including dependence 1. Alcohol 2. Opioids 3. Cannabinoids 4. Sedatives or hypnotics 5. Cocain 6. Other stimulants including caffeine

260 7. Hallucinogens 8. Tobacco 9. Volatile solvents 10. Other psychoactive Substances, and drugs from different classes used in combination (1) Amphetamines and Cocaine: Amphetamines are synthetic drugs, structurally similar to adrenaline. In medical practice, they are used to treat obesity, mild depression, narcolepsy and 'Certain behaviour disorders in children, the ordinary therapeutic dose is 10-30 mg a day. There are various brands of amphetamines: the common names are Benzedrine, Dexedrine, Methedrine, etc. These drugs act on the central nervous system. They produce mood elevation, a feeling of well-being and increased alertness and a sense of heightened awareness. Because they give a tremendous boost to self-confidence and energy, while increasing endurance, they are called "superman" drugs. The use of these drugs results in psychic dependence. With large doses, such dependence is often rapid and strong. (2) Cocaine is derived from the leaves of the coca plant. It was formerly used in medical practice as a potent local anaesthetic. cocaine is a central nervous stimulant. It produces a sense of excitement, heightened and distorted awareness and hallucinations. Unlike amphetamines, it produces no tolerance. (2) Barbiturates: If amphetamines stimulate, barbiturates sedate. They are a major ingredient in sleeping pills. The drug-users generally prefer short-acting barbiturates such as pentobarbital and secobarbital to long acting ones. The addiction to barbiturates is one of the worst forms of suffering. It leads to craving, or both physical and psychic dependence. (3) Cannabis: Perhaps, the most widely used drug today is Cannabis, which is a very ancient drug obtained from the hemp plants. (4) Heroin: Heroin, morphine, codein, morphine, pethidine are narcotic analgesics. Addiction to heroin is perhaps the worst type of addiction because it produces craving. With narcotics generally psychic dependence is strong and tends to develop early. Tolerance to narcotics also occurs rapidly, making it necessary to take increasing doses of the drug to achieve the same effect.

261 (5) LSD: Lysergic acid diethylamide (LSD) was synthesized in 1938 by Hoffmann in the Sandoz Laboratories in Switzerland. Its psychic properties were noticed much later in 1943, when he accidentally sniffed a few micrograms of it. LSD is a potent psychotogenic agent. Oral doses in the range of 100-250mg are usually required to effect intense depersonalization. The lethal dose in man is not known. LSD alters the normal structuring of perception. The individual perceives the world in a different manner. There is intensification of colour perception and auditory acuity; body image distortions, visual illusions, fantasies pseudo hallucinations are common. Colours are heard and music becomes palpable. Subjective time is deranged so that seconds seem to be minutes and minutes pass as slowly as hours. (6) Alcohol: By pharmacological definition, alcohol is a drug and may be classified as a sedative, tranquillizer. hypnotic or anaesthetic, depending upon the quantity consumed. Of all the drugs, alcohol is the only drug whose self-induced intoxication is socially acceptable. (7) Alcohol is rapidly absorbed from the stomach and small intestine. Within 2-3 minutes of consumption, it can be detected in the blood-the maximum concentration is usually reached about one hour after consumption. The presence of food in the stomach inhibits the absorption of alcohol . Over the past 30-40 years, increasing percentages of you, people have started to drink alcoholic beverages, their alcohol, consumption has increased in quantity and frequency, and the age at which drinking starts has declined . This situation is disturbing because the young people concerned may run a greater risk of alcoholic problems in later life and also, in the short term, because of increased rates of drunkenness and involvement in road accidents. Alcohol has a marked effect on the central nervous system. It is not a "stimulant" as long believed, but a primary and continuous depressant. Alcohol produces psychic dependence of varying degrees from mild to strong. Physical dependence develops slowly. According to current concepts, alcoholism is considered a disease and alcohol a "disease agent" which causes acute and chronic intoxication, cirrhosis of the liver, toxic psychosis, gastritis, pancreatitis, cardiomyopathy and peripheral neuropathy. Also, evidence is mounting that it is related to cancer of the mouth, pharynx, larynx and

262 oesophagus. Further, alcohol is an important aetiologic factor in suicide, automobile and other accidents, and injuries and deaths due to violence. The health problems for which alcohol is responsible are only part of the total social damage which includes family disorganization, crime and loss of productivity. (7) Tobacco : Tobacco is in legal use everywhere in the world, yet it causes far more deaths than all other psychoactive substances combined. About 3 million premature deaths have (6 per cent of the world total) already attributed to tobacco smoking. Tobacco is responsible for about 30 per cent of all cancer deaths in developed countries. More people die from tobacco related diseases other than cancer such as stroke, myocardial infarction, aortic aneurysm and peptic ulcer. Young people who take up smoking have been shown to experience an early onset of cough, and shortness of breath on exertion. There is evidence that the earlier a person begins to smoke, the greater is the risk of life-threatening diseases such as chronic bronchitis, emphysema, cardiovascular disease, and lung cancer. Experimentation with smoking as a symbol of "adult" behaviour is common in adolescence. If a child's older sibling and both parents smoke, the child, is four times as likely to smoke as one with no smoking model in 'the family . Smoking also harms the health of others. Among nonsmokers, exposure to environmental tobacco smoke increases the risk of lung cancer. The babies of the mothers who smoke weigh, on an average, 200 grams less at birth, than those of nonsmokers. (8) Volatile Solvents: In a number of countries, the sniffing of substances such as glue, petrol, diethyl ether, chloroform, nitrous oxide, paint thinner, cleaning fluids, typewriter correction fluid etc., is causing increasing concern, as it can result in death, even on the first occasion. (9) Caffeine: Caffeine is one of the most commonly used drug worldwide. About 10 billion pounds of coffee are consumed yearly throughout the world. Tea, cocoa, and cola drinks also contribute to an intake of caffeine that is often very high in a large number of people. The approximate content of caffeine in a cup (180 ml) of beverage is as follows : brewed coffee 80-140 mg; instant coffee 60-100 mg; decaffeinated coffee 1-6 mg; black leaf tea 30-80 mg; tea bags 25-75 mg; instant tea 30-60 mg; cocoa 10-50 mg; and 12 oz cola drinks 30-65 mg. Symptoms of caffeinism (usually associated with ingestion of over 500 mg/day) include anxiety, agitation, restlessness, insomnia and somatic symptoms

263 referable to the heart and gastrointestinal tract. Withdrawal from caffeine can produce headache, irritability, lethargy, and occasional nausea. Host factors The average age of drug users has decreased considerably in recent years. Multiple drug-use has also become more common. Concern over drug-use by teenagers increased in the late 1960s, particularly in the developed countries. In countries with long experience of heavy drug use, there is a tendency to prefer a single drug, perhaps because a continuous supply is less problematic. Multiple drug use may be more common where drug abuse is a relatively recent occurrence. Symptoms of drug addiction 1. Loss of interest in daily routine 2. Loss of appetite and body weight ; 3. Unsteady gait, clumpsy movements, tremors 4. Reddening and puffiness of eyes, unclear vision 5. Slurring of speech 6. Fresh, numerous injection marks on body and blood stains on cloths 7. Nausea, vomiting and body pain; 8. Drowsiness or sleeplessness, lethargy and passivity 9. Acute anxiety, depression, profuse sweating 10. Changing mood, temper, 11. Depersonalisation and emotional detachment 12. Impaired memory and concentration; Environmental factors Among the environmental factors attributed to drug dependence are rapid technological developments with associated need for extended periods of education, along with the in-applicability of old solutions to novel problems. Television, world travel, affluence, freedom to speculate and experiment have encouraged youngsters to question and often reject the values and goals of their parents. Established social values are perceived as irrelevant, all to be stripped away, partly through the use of drugs in order to reveal the real person, the real humanity, and the real goals of mankind. Studies confirm that those who take drugs usually form part of a small antisocial and often criminal subculture.

264 Factors associated with a high risk for drug abuse  unemployment  migration to cities  alienation from family  leaving school early Prevention Approaches to prevention of drug dependence should have realistic aims. Over- ambitious hopes of eradicating a drug problem in a short time are likely to lead to policies that are unrealistic and self-discrediting. Changes in culture attitudes and alteration in relevant aspects of the environment can be brought about only slowly. Legal Approach : The legal control on the distribution of drugs, when effectively applied has been and remains an important approach in the prevention of drug abuse. Legislation restricting or prohibiting advertisements that directly or indirectly promote use of tobacco and alcohol has been increasingly common in recent years. The antismoking measures suggested are : (a) prohibition of the sale of tobacco products to minors; (b) restriction on the sale of cigarettes from automatic vending machines; (c) prohibition of smoking in schools and other places frequented by young people; (d) prohibition of smoking in public; (e) prohibition of cigarette advertising at times, and in places and ways, calculated to ensure its maximum impact on adolescents; (f) establishment of mandatory public health education on health consequences of smoking; (g) insisting on the placing of mandatory health warning on cigarette packets. Educational approach : Educational approaches to the prevention of drug use and drug- related problems have been used in many countries. Common approaches have included educational programmes for school children and public information campaigns on electronic media. General principles of communication can be applied to increase the effectiveness of educational approach. The message should be clear to the intended audience, and come from credible source of information. The message should also provide specific advice, rather than general, and as far as possible the information should be new to the audience and should be capable of provoking discussion or action. Community approach : The non-medical use of the drugs individually as well as in its mass appearance involves a complex interaction of drug, man, and his environment, including social, economic, cultural, political and other elements of varying character and

265 strength. The rapid changes taking place at the present time in relations between individuals, groups and nations are also reflected in a rapidly changing pattern of drug abuse in many parts of the world. There should be a strong emphasis on action at the community level to prevent drug abuse. Treatment Treatment cannot take place unless the individual attends for treatment. He must come to terms with the possibility of a life without drug taking. Unfortunately, drug takers, as a rule, have little or no motivation to undergo treatment. Alcoholics tend to deny that their consumption is abnormal; others openly defend their habits. Long term treatment is not only a medical problem, but needs the cooperation of psychologists and sociologists. There is a high relapse rate with all treatment methods . Though drug addiction may be considered as a social problem, the first step in its management is medical care, which includes :  identification of drug addicts and motivation for detoxication  detoxication (requires hospitalization)  post-detoxication counselling and follow-up (based on clinic and home visits), and  rehabilitation. Simultaneously with medical treatment, changes in environment (home, school, college, social circles) are important. The patient must effect a complete break with his group, otherwise the chances of relapse are 100 per cent. Psychotherapy has a valuable place in the management of the addict. Rehabilitation The rehabilitation of former drug user, regardless of age, is in most cases a long and difficult process. Relapses are very frequent. Success of the treatment necessitates the adoption of mature and realistic attitude by the local community and the avoidance of panic, moral condemnation and discrimination. Facilities for vocational training and sometimes the provision of sheltered work opportunities are useful in rehabilitation and help to prevent relapse. Generally speaking, facilities for the registration, diagnosis, treatment, after-care, etc., of drug dependent individuals and groups should be regarded as indispensable integrated parts of the health and social services structure of any community in which drug-dependence exists.

266 National Mental Health Programme Mental illness is widely prevalent in India. About 15-20%.of all patients visiting general health services, esp. O.P. departments do so because of emotional and psychology problems. Govt. of India appointed a committee (1982): the NMHP. They pointed out that (1) Majority of the mental illness do not reach the existing psychiatric services. (2) Majorities of cases in the community are ambulatory or self limited and- managable -at the peripheral medical institutions (3) Proper orientation and know-how at the peripheral level can ensure proper care of those patients.

Objectives of NMHP (NATIONAL MENTAL HEALTH PROGRAMME) (i) To ensure availability and accessibility of Minimum mental health care for all. (ii) Creation of awareness of mental-health knowledge in general public. Strategy (i) Diffusion of Mental-Health treatment skills to the periphery of the health system. (ii) Integration of basic mental health care within general health services (iii) To deliver the service through the existing infrastructure By (a) training MOs & Paramedical staff (b) Supply of essential drugs (c) I.E.C for popularising Mental Health Care. Achievements 1. Increased the awareness of the public 2. District Mental Health Programme, Trivandrum (5 year project) aim at improving  Training  I.E.C  Supply of essential drugs Constraints 1. The social stigma 2. Patients are reluctant to-approach local-doctors 3. Myths

267 4. Low standards of service from peripheral centres Medical officers Duty with help of health workers (i) To see patient as an individual -'Whole Man' (ii) Treat all minor cases (iii) Counselling (iv) Prompt referral of major oases (v) Follow up of cases which are referred (vi) Try to overcome the social stigma

Chapter - 8 HEALTH EDUCATION AND COMMUNICATION

I. What is Health Education II. Aims and Objectives of Health Education. III. Approaches to Public Health. IV. Adoption of New Ideas and Practices. V. Educational Diagnosis VI. Health Education vize Propaganda. VII. Content of Health Education VIII. Principles of Health Education. IX. Communication in Health Education. X. Audio - Visual Aids in Health Education. XI. Practice of Health Education

268 XII. School Health Services. XIII. Planning and evaluation. XIV. Administration and Organization. XV. Audio - Visual Aids - Practice.

1. What is Health Education?

"Health education is a process that informs, motivates and helps people to adopt and maintain healthy practices and lifestyles, advocates environmental changes as needed to facilitate this goal and conducts professional Training and research to the same end." This is the definition adopted by the National Conference of Preventive Medicine in U.S.A.. Health education is an abstract term means different things to different people. To some it is a matter of public relations aimed at publicizing the activities of health departments and winning public goodwill. Some consider it synonymous with propaganda, that is spreading particular systemized doctrines about health. Many equate it with transmission of information about health and disease from the expert professional to the lay client. For others, there is no difference between health education and mass carnpaigns. These different perceptions are attributed both to the historical development of Health Education and our under standing of the learning process. Whatever these perceptions may be, the present guide is based on the following understanding of the meaning of the term health education. The sum and substance of health education is to effect the behaviour change to the positive direction. Its aim is not merely to improve the quality of life, but to achieve a higher and better standard in his quality. Hence the behaviour change has to be in time with the latest findings of science regarding factors like prevention and treatment of disease. Health education attempts to close the gap between what is known about optimum health practices and what is actually practiced. Health education is concerned not only with individuals and their families, but also with the institutions and the social conditions that impede or facilitate individuals towards achieving optimum health.

269 Health education aims at developing in people a sense of responsibility for their own better and that of the community. Health education is as wide as community health and it is a process which affects changes in the health practices of people and in the knowledge and attitudes related to such changes. It includes imparting knowledge about health, removing superstitions and beliefs, building favourable health habits and attitudes and effecting the necessary changes in the health practices. Health education is only a tool - an essential tool, to be used to make sound health decisions and undertake sound health behaviour. The most important aspect is whether, when and how well people utilise such knowledge in their daily contact. As health education being an essential tool of community health, health education occupies an important position in the health services. It is concerned with the behavioural aspects of the people to accept the health programmes launched in the community. Health education is a complex activity in which different organisations play an important part. 1. Definitions "Health Education is a process which affects changes in the health practices of the people and in the knowledge and attitudes related to such changes' "Health education like general education is concerned with the changes in knowledge, feelings and behaviour of people and concentrates on developing such health practices as are believed to bring about the best possible state of well-being" In other words health education is defined as the "translation of what is known about health into desirable individual family and community behaviour patterns through educational means." Both the definitions underline the importance of guiding or leading the people to a behaviour pattern based on up-to-date scientific knowledge on matters relating to health. These two definitions imply that Health Education has knowledge, attitude and behaviour components and that health education aims at individual, family and community behaviour and their to interaction patterns.

II. Aims and objectives of Health Education.

1. Aims (a). to assume that health is valued as an asset in the community (b) to equip the people with skills, knowledge and attitudes to enable them to solve their health problems by their own action and effects.

270 (c) to promote the development and proper use of health services. 2. Objectives: The principal Objective of health education is to help people to achieve health by their own actions and effects. Health education begins, there fore, with the interest of people in improving their own conditions and aims at developing a sense of responsibility. The three main objectives of health education are 1. Informing people: The first directive of health education is to inform people or disseminate scientific knowledge about prevention of disease and promotion of health, exposure to knowledge which melt away the barriers of ignorance, prejudice and misconceptions about health and disease. This creates an awareness of health needs and problems and also of responsibilities on the part of people 2. Motivating people: People must be motivated to change their habits and ways of living since many present day problems of community health behaviour or changes in the health practices which are detrimental to health viz pollution of water, out door defecation, indulgence of alcohol, cigarette smoking, drug addiction etc. Health education must provide learning experiences which favourably influence habits, attitudes and knowledge relating to individual, family and community health. 3. Guiding in to action: People need help to adopt and maintain healthy practices and lifestyles which may be totally new to them. Govt. have a major responsibility to provide the necessary infrastructure of health services. People need to be encouraged to use health services available to them.

III Approaches to Public Health.

There are three well known approaches to public health. 1. Regulatory Approach : The regulatory or legal approach seeks to protect the health of people through the enforcement of laws and regulations eg: Epidemic Diseases s Act, Prevention of Food Adulteration Act etc. 2. Service Approach: The service or administrative approach aims at providing all the health facilities needed by the community in the hope that people would use them to improve their own health eg: Health Services, ESP slabs on subsidised rate etc.

271 3. Educational Approach: The educational approach is a major means today for achieving change in health practices and the recognition of health needs. It involves motivation, communication and decision making eg: Health educations, motivation, communications etc. The educational approaches may be classified as (a) Individual and Family Approach. (b) Small group Approach (c) Mass Approach Since individuals vary so much to their socioeconomic conditions, traditions, attitudes, beliefs and level of knowledge, a single educational approach may not be, suitable. Mixtures of approach must be evolved depending upon local circumstances

IV. Adoption of new Ideas and Practices

People appear to pass through a series of distinguishable stages before they adopt a new practice. They are (a) Awareness (b) Interest (c) Evaluation (d) Trial (e) Adoption

V. Educational Diagnosis

Educational Diagnosis consists of studies of the level of knowledge and under standing, attitudes and beliefs.

VI. Health Education Viz Propaganda

Health education is not health propaganda. Both are diametrically opposed. Techniques of propaganda discourages thinking by substituting ready made slogans, while education teaches people to think for themselves.

272 Propaganda appeals to the emotion. But education recognizing these emotions, play an important role in our lives, appeals chiefly to man's reasons. Knowledge through propaganda is spoon-fed and is passively received while knowledge through education is acquired through self reliant activity. Instructive and impulsive action is promoted by propaganda - benefit accures to the propagandist, while benefits derived from education accure to the educated and not to the educator

VII. Content of Health Education

The content of health education may be divided in to eight main divisions 1. Human Biology 2. Nutrition 3. Hygiene 4. Family Health Care 5. Control of Communicable and Non - Communicable Diseases 6. Mental Health 7. Prevention of Accidents 8. Use of Health Services

VIII. Principles of Health Education

1. Interest 2. Participation 3. Known to Unknown 4. Comprehension 5. Acceptance 6. Re inforcement 7. Motivation 8. Learning By Doing 9. Soil, Seed, and Sower 10. Communication 11. Good Human Relations 12. Leaders

273 IX. Communication in Health Education

Communication has come from the Latin word “Conimunis-meaning” –“commonness”. The health educator must know how to communicate with his audience Communication is a process by which an idea is transferred from a source to a 'receiver, with an intension to change his behaviour. Communication is carrying of an idea, information, thoughts or feelings from one person to another or to number of persons The key elements in the communication process are 1. The communicator 2. Message 3. Audience. 4. Channels - Individual - Group - Mass 5. Treatment 6. Audience (Feed back) The Barriers of communication The Barriers of communication are vastness of the country, diversity of languages, illiteracy, lack of communication channels, disturbance in the channels, distribution in communications, anxiety, fear, distance, low voice, lack of rapport, lack of perceptions, lack of understanding, lack of patience etc. 1. Principles of communication It should be two way process Make use of all available resources while communicating Your action should support your communication Be meaningful while you communicate Environment created by communicator influence the communication. Communicate all the more effective of its related to the needs or evaluate of the audience. Short messages are more acceptable than lengthy messages. Community participation is essential in any communication. Be careful about your tone while you communicate. It should be well planned

274 A 2-way communication is more likely to influence behaviour than one way communication Wherever possible, communication should be adjusted to the local cultural patterns (Folk media) of the people 2. Motivation: Motivation is defined as mobilising the energy towards some imagined or known goal object or goal situation. "Motivation is any thing that causes a person to act, to change behaviour" Factors that tend to motivate 1. Good working conditions 2. Good salary 3. Job security 4. Job satisfaction 5. Decent boss, Real Leaders 6. Recreational facilities 7. Fringe Benefits 8. Savings, Insurance etc. 3. Ways to motivate the sub-ordinates in Health Services - Role of Lady Health Inspectors to motivate subordinate a) Set a good example b) Develop and maintain good personal relations c) Place sub-ordinates where they can work better d) Use a participatory style - Participation and involvement.- e) Guide, encourage and support subordinates f) Reward good work g) Build Team spirit h) Provide continuing education to subordinates

X Audio Visual Aids

Communication is facilitated and strengthened or reinforced by the use of suitable audiovisual aids. Aids are facilitators of communication both for the senator and for the

275 receiver. It is common knowledge that any communication has to pass through one or more elements of communication and it becomes a stimulus received by the receiver or the audience An audio visual aid is a device which can be seen and heard by the audience and helps the teacher inputting across an idea. The purpose of audiovisual aid is to provide a basic understanding and utilization of audiovisual materials in communication process. Communicational aid means to exchange idea and experience through a medium of device. It is facilitating to learn thoroughly, by picture-and text. These aids are popularly known as communication aids or audio visual aids eg: Films, Filmstrips, slides, Posters, Chart, Maps illustrations, models, television, programmed instruction etc etc. There are numerous types of audiovisual aids. They can be broadly catagorised in three headings. 1. Audio, 2. Visual, 3. Audio-visual Learning takes place through the help of sense receptors. If one can use more than one sense the learning takes place more. Studies have shown that through sight, people learn 80% and through hearing 40 %. Similarly we retain 50 % what we see and hear and only 20% what we hear alone. The eye and ear are providing to listening and seeing to understand the facts and perfects. Eye and ear are the important biological chambers for learning. The visual image and sound impulses are transmitting to brain for re-organising the facts for the stimuli for learning. The picture and sketches are primary elements for concrete learning. Picture is the perfect basic universal language and it is the crystallized medium for learning. Ear is one of the bio-counter for receiving the message from the external source. The message passes through ear chamber to brain. Ear is stimulating agent to brain. Audible sound and voice is converting to understand or response. Audio learning is less advantage comparatively to visual learning. Audio experience will not stand in mind for a long, because it is invisible and un imaged aid. Daily we are getting much experiences in the external world and stocking into mind one or the other. After some months back, we could not recollect any specific situation and fact. So that storing cell or memory department had biologically erasing-- forgetting-- it is naturally changing the process in the sense. In order to be a good device and audio- visual aid must be simple, legible, appropriate reasoned, planned, accurate, realistic, colourful, manageable and meaningful. Audio-visual aids are effective in teaching and

276 learning situations, because they bring into the learning process the sense of sight as well as hearing. Therefore when we use audio-visual aids in a teaching and learning process the following results can be expected 1. Arouse interest 2. Increase retention 3. Intensified group impression 4. Save time 5. Simplified handling of ideas 6. Maintained and directed attention 7. Broadened experience. Audio-visal aids don't eliminate the need for a competent teacher. What a teacher has to say is still the most important phase of any programme. The teacher see the following things during the presentation of his aid provide maximum utilization. 1. Introduction of material to be covered before presentation 2. Explanation of the key points during presentation 3. Repetition of the key points after the presentation( If necessary summarise the whole presentation) Do not show the aids, try to, use the, aids as far as possible. If you want to use the aids one must know the content of the aids, smooth handling and its sequence. Also the teacher should ask him self/ herself what, where, when, whom, why and how he / she wants to use aids. For attracting and arouse interest one have to use combination of art principles and colours. Above all choose and use right type of aids to the right place of audience, with thorough preparation.

XI. Practice of Health Education

Health Education is practiced in every context with a purpose of ensuring a health related behaviour necessary for preservation and maintenance of health. Every one in the health and allied departments and personnel rendering health services have responsibility for providing health education. Throughout their work doctors, nurses, health workers, in different programmes have to deal with people. They should get into the habit of providing health information and utilize every opportunity for health education. Each health worker makes a positive approach for health education connected with any health programme. Health Education is carried out at three main levels: 1. Individual and family health education

277 2. Group health education. 3. Education of the general public.

1. Individual and family health education: There are plenty of opportunities for individual health education in personal interviews in the consultation room of the doctor or in the health centre or in the houses during house visits. There is opportunity in educating the patients as well as bystanders on matters of interest- diet, cause and nature of illness and its prevention, personal hygiene etc. 2. Group health education: Group health education is an effective way of educating the community. The choice of the subject in group health education is very important. It must directly related to the interest of the group. 3. Education of the general public. (Mass): For the individual approach and group approach in health education, the communication is usually face - to - face with or with out the aid of visual aids and audio aids. But when the entire community has to be contacted one has to resort to mass media. The communication, that is aimed to reach the general public or the people at large is called mass communication. In sociology mass communication refers to any communication that is given in the community where the collection of people does not come under a group. In other words, all sections of community irrespective of social economic strata are reached by mass communication. It is obvious that because of the large number of people in the community, communication can not be achieved quickly by face-to face communication. The media that are generally used for mass communication go by the name of mass media. In the present day the commonly used mass media are microphones or public address system, radio, cinema, television, news print, posters, health exhibition, health magazines, health museums etc. Health education provides opportunity for people to learn practice and experience health related behaviour. It has a large element of education of individuals and groups to acquire information to identify problems and to accept new behaviour and to realize better ways of living and so on. For any change behaviour to be sustained and purposeful, there is a need for proper : internalisation of ideas and formation of favourable attitude.

278 Education is a process of change within a person himself in his knowledge, his belief and his action. We have the formal and informal or non-formal education. Health education is concerned with both formal and informal educational methods. The formal methods refer particularly to class room situation and to the different methods in which there is a systematic way of changing for teaching -learning process for groups. Formal education is scheduled and structured so as to be followed strictly. In the non -formal education it is more an opportunity given to people to learn according to their own needs. The health educator is concerned both with the formal and in formal educational methods because in the community he has to employ both methods. When he has to impart training to medical and paramedical workers or other personnel he has to use different educational methods. 1. Formal Presentation of Methods a. Lecture or speech b. Dialogue c Symposium d. Pannel Discussion e. Colloquy f. Forum 2. Group Discussion a. Buzz group or Buzz session b. Workshop c. Conference / Seminar d. Brain Storming e. Role Playing f Demonstration: i) Method Demonstration, ii) Result Demonstration, iii) Method of "Learning by doing"

XII. Planning and Evaluation

1. Planning: Planning is essential for effective health education. Planning is part of everyday life. It is deciding what to be done and how and when it will be down, planning is for tomorrow. The purpose of planning is to match the limited resources with many

279 problems, to eliminate wasteful expenditure and to develop the best course of action to accomplish a defined objective. The planning is a matter of team work and consultation. The planning team consists of not only specialists within the field, but also specialists in other fields eg: Economics, Sociology, Anthropology, Statistics etc. A 'Plan' is a statement of future activities. The logistics for planning are: 1. Establishment of Objectives 2. Collection of information about the problem 3. Collection of information about the community. 4. Development and implementation of the plan.' 5. Evaluation. Planning may be a long- term underling involving implementation of a number of activities such as trial, studies, feasibility surveys over several years. The duration of planning may vary depending upon its size and complexity and the availability of the information required. The planning process consists of : a). Defining community problems b). Establishing objectives and goals c). Fixing priorities. d). Setting up targets e). Surveying the existing resources in terms of money, material and man power. Drawing up the plan. g). Execution h). Evaluation There are definite guidelines for planning which must be adopted to the local situation. The feasibility survey is a preliminary study for collecting and analising the background information. On the basis of the feasibility survey an assessment is made whether a plan programme could be implemented or not within resources. The components of a feasibility survey are a). Technical feasibility b) Operational feasibility

280 c) Administrative feasibility and d) Socio-economic feasibility 2. Health Planning: Health planning is a concept of recent origin. It has been defined by W.H.0 as the careful, intelligent interpretation and orderly development of health services in accordance with modem knowledge and experience to meet the health needs of a nation within its resources. The purpose of health planning is to improve the health services. For proper health planning certain basic data are essential. These comprise: a). Age, sex and occupation b). Data on the health problems c). Data on the medical care facilities and health personnel already available. The driving force behind the recent health planning is the commitment of the nation. to achieve the goal of " Health for all by 2000AD". The health plan is implemented at various level...... national, state, district, block and village. 3. Evaluation of Health Services: Evaluation is the most difficult task in the whole area of health services. The following are the main features of components of the evaluation process: a). Relevance or requisiteness : This is the appropriateness of the service, whether it is needed. If there is no need, the service can be of any use. b). Accessibility : There are variations in the distribution of health services between rural and urban and also allocation of resources to different groups c). Acceptability : The service may be acceptable to all. d). Effectiveness: It is the extent to which the underlying problem is prevented. e). Efficiency: It is a measure of the cost that is in achieving results. f). Utilization and coverage: That is what proportion of the people who can or utilizing it. g). Medical Audit: It is an objective and systematic way of evaluating the physician - performance, the quality of medical care provided by the physician. h). Satisfaction: This is an assessment of the satisfaction or dissatisfaction expressed by the community concerned regarding the effects of the programme, service or institution.

XIII. Administration and Organization

As health education, being an essential tool of community health and about 80% of our population are living in the rural areas of the country, it becomes a responsibility

281 of the government for assisting and guiding the health education of the general public. Hence in 1956, in the Central Ministry of Health, a Health Education Bureau was established with the assistance of the Technical Co-operation Mission of the United States of America. In Kerala the organising the existing health education facilities, the State Health Education Bureau was introduced in 1960. By about 1971 District Health Education Bureau were established by winding up the Regional Health Education Unit in all the districts. The Central Health Education Bureau consists of training, media, research and evaluation divisions in addition to an administrative section. India became independent in 1947 and the Ministries of Health were established at centre and states. India is a union of states. The Constituent Assembly adopted the Constitution of India on 26 November 1949. Article 246 of the Constitution of India covers all the health subjects, these have been ingenerated in the seventh schedule under three lists Union lists, Concurrent lists and State lists. Under the Constitution of India, the state largely independent in matters relating to the delivery of health care to the people'. Each state, therefore has developed its own system of health care delivery independent of the Central Government. The Central responsibility consists mainly of policy making, planning, guiding, assisting, evaluating and coordinating the work of the state. The health system of India has three main links : Central, State and Local or peripheral. Just as there is a Central as well as State Government, we have central administration and state administration of health services. Also, within each state, the government health services are organised at the District, Taluk, and Village levels. Health Services at Central Level : The official 'organ' of the health system at the national level consists 1. The Ministry of Health and Family Welfare 2. The Directorate General of Health Services 3. The Central Council of Health and Family Welfare. Organization: The Union Ministry of Health and Family Welfare is headed by a Minister for Health and Family Welfare. Currently the Union Health Minister has the following departments.

282 1. Department of the Health headed by a Secretary to Govt. of India as its executive head assisted by Joint - Secretaries and a large Administrative staff. 2. Department of family Welfare was created in 1966 within the Ministry of Health and Family Welfare. The Secretary to Govt. of India in the Minister of Health and Family Welfare is the overall charge of the Department of Family Welfare. He is assisted by an Additional Secretary and Commissioner (F. W) and one Joint Secretary assisted by Deputy Secretaries and a large administrate staff. The State Ministry of Health : Under the Constitution of India the states are largely independent in matters relating to the delivery of health care to the people. Each state therefore, has developed its own systems of health care delivery: independent of the Central Govt. The Central Govt. responsibility consists mainly of policy making, planning, guiding, assisting, evaluating and coordinating the work of State Health Ministers, so that health services, cover every part of the country and no state lags behind for want of these services. Every state in India has both a Ministry of Health and a Directorate of Health Services. The State of Health Ministry is headed by the Minister of Health and Family Welfare who is elected by the people. The Health Secretariat is the official organ of the State Ministry of Health and is headed by a Principal Secretary who is assisted by Additional Secretaries, Under Secretaries and a large administrative staff. The Principal Health Secretary is a Senior I.A. S. officer. The Health Ministry deals mainly with administration, policy decision, approval of plans, finance and budgets. State Health Directorate The Health Directorate is headed by the Director of Health Services who is the chief technical advisor to State Govt. on all health matters. The Director of Health Services have so many additional Directors assisted by Deputy Directors, Assistant Directors and a large administrative staff. The Director of Health Services is ex-officio Secretary of Govt. (Health) also District Health Services: At present there is one Dist. Medical Officer of Health being the head of the Dist. Under him there are two Deputy Dist Medical Officers of Health and the Dist. is equally divided into two and the Dy. D.M.O.H is in charge of half of the Dist. To help him the following officers are there in a Dist. viz R.C.H. Officer, D.E.M.0,

283 M.C.H. Officers, T. A. Grade 1 & 2, Dist. Health Education officer, D.N.0, D.P.H.N, Store Officer, Dist. Store Verification Officer, Administrative Officer, other office staffs etc, etc. Primary Health centres: The first level point of contact between individuals and the health systems, where Primary health care is delivered is primary Health centres. P.H.Cs occupy a key position in the nation’s Health Care System. It is the nucleolus round which rural health services have been built. Hospitals: Apart from the P.H.C.s the present organization of health services by Govt. sector consists of rural hospitals, Taluk hospitals, Dist. hospitals, specialist hospitals and teaching institutions. Urban Health Centres : Health Services in urban areas are provided by Corporations and Municipalities. A Corporation headed by an elected Mayor has a Health officer and assistants. Service include sanitation and public health, M.C.H, Food sanitation and collection of vital statistics. Municipalities are headed by elected Chairman. They provide sanitation and public health services and family welfare services. Voluntary Health Agencies: The voluntary health agencies occupy an important role in the total health services in India. XV. Audio -Visual Aids Practice Graphic or picturesque Aids: All visual aids are graphic aids. These aids essentially consist of drawings sketches, cartoons, pictures and also graphs, charts, tables etc. They are shown or displayed as such and do not necessary depend on any projected equipment. The commonly used and known picturesque aids are briefly described below 1. Picture The pictupis drawn or painted and is the expression of ideas and feelings. A pictures drawn according to the perception of the mind. 2. Photograph: A photograph is the actual image of any object or person, taken by the application of the principle of light devised in a photographic camera. The photograph is the actual image of the objects whereas the picture is drawn according to mental

284 perception. The picture and photograph of the same object will therefore have some difference. Pictures drawn by experts will be self explanatory. Photographs are the actual image and therefore have a greater impact on the mind of the audience than the drawn pictures. 3. Poster : Poster is a pictorial bold design with message or caption or slogan written not only to explain but to catch the attention of the passersby. Occasionally posters may have mere written matter and no picture or drawing. The posters are widely used in public places to catch and fix the attention of the public. They are cheap and can be taken to distant places 4. Cartoon: Cartoon is the metaphorical representation of a situation or person or fact. It is the fact content and easily effectively convey the message to the readers, horror, fiction, fidelity, sincere, serious etc can be convey smoothly, forcefully, and effectively to the readers. Cartoons are generally made in newspapers or magazines to give satirical or jocular commentary on any event. Cartoon films are used for educational purpose or entertainment. 5. Flash Cards : Flash card or lecture card is the pictorial preparation of visual aid. It is made by cardboard of compact size. A set of flash cards explaining a story. It is consisting 15 to 30 cards, each one is telling a simple fact. The contrast colours and counter illustrations are effectively flash into audience. The cards are arranged in proper sequence so as to send out the message to the audience. The cards can be used by any educator and shown to the audience with necessary verbal explanation. In the preparation of flash cards the theme just decided upon and the message in each card is also planned. The size of the card is some what important. For about 30 persons in a group the flash card size should be at least 20"x 22". The cards are taken out one by one by the educator and flashed one after the other in sequence. 6. Charts and Graphs: A theme of information represent in a single paper with all other attractive details, that is called chart. A theme of information have written or drawn more than two papers (the top side should be tricked together and hanging rope should be provided),that is called flipchart. Charts are classified into chart, flip chart, flow chart,

285 disc and manipulation charts etc. Chart is used to present numerical data as well as materials in abstract form. Graph is a chart form that is used to present statistical data and resent relationship between variables. The statistical representation of a quantitative data convert into simplified sign and symbols which are : Bar graph, Pie graph, Line graph, Pictorial graph etc Charts and graphs are useful to summarize, explain and interpret numerical facts by means of points, lines, areas, geometric forms and to facilitate comparison of values, trends and relationships. 7. Map : Map is an accurate representation of earth's surface or a part of it, its physical, political, socio economical and cultural facts etc. It can be prepared scale and un scale measured.

8. Printed Materials (or duplicated Materials) a) Books: Books present knowledge and experience systematically and thoroughly which is available at all times and places and at the convenience of the reader. b) Pamphlets, booklets, folders, leaflets and brochures: Provide knowledge and experience in special areas - inexpensive. A pamphlet is also called a brochure or booklet. Single sheet with one or more folds are often spoken of as pamphlets. They are folders of leaf lets. An unfolded sheet is a leaf let file or handbill. A pamphlet must be as brief as possible. There is no specification about the number of pages. However, it is better to keep it to the minimum. 1. Picture The pectoris drawn or painted and is the expression of ideas and feelings. A pictures drawn according to the perception of the mind. 2. Photograph: A photograph is the actual image of any object or person, taken by the application of the principle of light devised in a photographic camera. The photograph is the actual image of the objects whereas the picture is drawn according to mental perception. The picture and photograph of the same object will therefore have some difference. Pictures drawn by experts will be self explanatory. Photographs are the actual image and therefore have a greater impact on the mind of the audience than the drawn pictures. 3.

286 Poster : Poster is a pictorial bold design with message or caption or slogan written not only to explain but to catch the attention of the passersby. Occasionally posters may have mere written matter and no picture or drawing. The posters are widely used in public places to catch and fix the attention of the public. They are cheap and can be taken to distant places 4. Cartoon: Cartoon is the metaphorical representation of a situation or person or fact. It is the fact content and easily effectively convey the message to the readers, humor, fiction, fidelity, sincere, serious etc can be convey smoothly, forcefully, and effectively to the readers. Cartoons are generally made in newspapers or magazines to give satirical or j ocular commentary on any event. Cartoon films are used for educational purpose or entertainment. 5. Flash Cards : Flash card or lecture card is the pictorial preparation of visual aid. It is made by carboard of compact size. A set of flash cards explaining a story. It is consisting 15 to 30 cards, each one is telling a simple fact. The contrast colours and counter illustrations are effectively flash into audience. The cards are arranged in proper sequence so as to send out the message to the audience. The cards can be used by any educator and shown to the audience with necessary verbal explanation. In the preparation of flash cards the theme first decided upon and the message in each card is also planned. The size of the card is some what important. For about 30 persons in a group the flash card size should be at least 20"x 22". The cards are taken out one by one by the educator and flashed one after the other in sequence. 6. Charts and Graphs: A theme of information represent in a single paper with all other attractive details, that is called chart. A theme of information have written or drawn more than two papers (the top side should be trenched together and hanging rope should be provided),that is called flipchart Charts are classified into chart, flip chart, flow chart, disc and manipulation charts etc. Chart is used to present numerical data as well as materials in abstract form. Graph is a chart form that is used to present statistical data and present relationship between variables. The statistical representation of a quantitative data convert into simplified sign and simbals which are : Bar graph, Pie graph, Line graph, Pictorial graph etc.

287 Charts and graphs are useful to summarize, explain and interpret numerical facts by means of points, lines, areas, geometric forms and to facilitate comparison of values, trends and relationships. 7. Map: Map is an accurate representation of earth's surface or a part of it, its physical, political, socio-economical and cultural facts etc. It can be prepared scale and unscale measured. 8. Printed Materials (or duplicated Materials) a) Books: Books present knowledge and experience systematically and thoroughly which is available at all times and places and at the convenience of the reader. b) Pamphlets, booklets, folders, leaflets and brochures: Provide knowledge and experience in special areas - inexpensive. A pamphlet is also called a brochure or booklet. Single sheet with one or more folds are often spoken of as pamphlets. They are folders of leaf lets. An unfolded sheet is a leaf let file or handbill. A pamphlet must be as brief as possible. There is no specification about the number of pages. However, it is better to keep it to the minimum. Booklet is the graphical representation of visual aid. A theme of information is briefly printed in compact size book form. Normally, visible and legible, text, and pictorial contents are more attractive to read a booklet is consisting 1 0 to 20 pages. Folder is the graphical representation of visual aid. It is made by thin or thick paper, with clourful details and folded in to handy size. The legible look and readable letters are effectively attracting the readers eye. 9. Display Boards: A. Flannel board: This teaching tool is called by different names such as flannel graph, khaddargraph, gospelo graph, visual board, strick board, slap board, felt board, chorograph and video graph. It is a graphical representation of visual aid. It is made by card board or printed pictures or other visual aids. One side message and behind the same pasted with sand paper is in every pieces. Flannel graph consists of two parts 1. The board 2. Cut -out 1. The board : The board size will depend upon the needs of the situation. The average sizes for effective display are 5'x4'or 4'x3'. The board may be made out of wood, plywood, hard- board or heavy cardboard. The board is covered is with fibrour, fezzy

288 and rough cloth like flannel, khadi, felt, velvet or any other such material. Almost any colour can be used but dark green, black and grey afford excellent contrast for other colours. This covering material is fixed tightly over the board with the help of stapler, thumb tacks or drawing pins. Care has to be taken so that the covering material does not sag or present loose folds. 2. The cut- outs : Making cut- outs is important and it takes a lot of time in proper selection of illustrations and symbols. The cut-out should be the prepared subject -wise and arranged sequentially and kept in a separate file for ready use. Colour adds to the effectiveness of the medium, strits of sand paper should be pasted on the back of the cut- outs. When the rough surface of the cut-out is presented on the flannel board, it adheres to the fuzzy surface. B. Bulletin Board: Bulletin board, as the name implies, is a place for bulletins, news items, announcements, multifarious items and visual displays. It Functions as a notice board also. It provides the cheapest and multipurpose nucleus for visual education. In the corridors of common meeting halls and places bulletin boards provide motivating exhibits. It can be used to display. 1. Personal news and announcements 2. Book lets. 3. Photos, Drawing illustrations. 4. charts, maps, graphs, posters 5. News paper and magazine cuttings 6. Models and specimens 7. Progress records. Bulletin boards can be made from materials like khadi jute, coconut and bamboo mats and sugar can stalk. These panels can be fronted and built on bamboo or wooden stands or can be fixed direly on the wall. Bulletin boards should be placed at least three feet above the floor in an area that is well lighted at all times. 10. Folder: It is simple and compact size of visual aid. The pictorial or textural message, colourful details, are more attraction to the reader's interest. 11. Illustration: Pictoral elucidation of any subject or a theme of informations or pictorially complete by it self

289 12. Sketch: To give essential facts or points of with out going into details by picture. 13. Diagram: A picture composed of liner, serving to illustrate or an illustrate figure giving an out line on general scheme of an object and its various parts. 14. Journal: Journal is a printed visual aid. A journal is giving research articles, references and other notified facture like institutional information’s to the potential readers. It is non-commercial fortnightly/ monthly/ quarterly or yearly publication 15. Magazine: Magazine is the printed visual aid. It is giving the dynamic news to the readers. A Magazine contains long stories, short stories, fiction, comic, cartoon, advertisement, socio cultural, political and economic factors. Magazine is a commercial publication. It is publishing fortnightly/monthly/quarterly and regularly. 16. Comic: Comic is the series of a cartoon pictures. 17. Painting: The representation of message printed realistically defect, selection and representation of colours is depends up on with effective skills of painter. 18. News Paper: News Paper is the information given to the public. A good news paper is giving International, National, Regional, Native and spot daily news 19. Banners: Banner is the visual aid, display in a public place. The bold design, brief and simple picture, attractive colours are attract the public. It can be prepared, cloth, rexin, plastic or any synthetic material. It may be flexible and portable. 20. Story cards: Story cards is the graphical representation of visual aid. A theme of information is picture is in sequence order. It is mini size as flash card. It is a best device for individual contact. 21. Stickres : Sticker is the best adhesive visual aid. Key words, important headlines, or pictorial details are printed in the plastic or metalic sheets or rexin. or any other synthetic materials colourful presentation, attractive lay out easily attract the looker. Now a days it is best out door advertising media.

290 Chapter - 9 SCHOOL HEALTH PROGRAMME

Objectives : The partiapant (trainee) should be able to assist the MO (PHC) in the following activities of the school health Programme. 1. Regular medical check up and follow up of children who require treatment. 2. Protection against preventable diseases by immunisation. 3. Training of teachers for involvement in the school health programme 4. Health and population education programme for children, teachers and parents. 5. Healthful school environment 6. Nutrition programmes, if any 7. Maintenance and use of school health cards. Method i. Lecture cum discussion on the subject by MO (P.H.C)

291 ii Practice of assisting in school health Programme.

Duration 2 Hours for Lecture cum discussion 2 Hours for observation and assistance to MO School health is an important branch of community health. It is an economical and powerful means of raising community health in future generations. It is therefore important that the physical and mental health of this segment of the population should be the concern of all those responsible for ensuring the health of the people Healthful habbits as regards personal hygiene, clean surroundings, nutritious diet, exercise, rest and recreation if formed at an early stage will remain with a person through out the life and will help to develop healthy citizens in the full and positive sense of the term viz persons who are in a state of complete physical, mental and social well being. School Health programme has the following broad objectives (a) To prepare the younger generations to adopt measures to become healthy so as to help them to make the best of educational facilities, to utilise the leisure time in a productive and constructive manner, to enjoy recreation and to develop concern for others. (b) To help the younger generation to become healthy and useful individuals who will be able to performs their role effectively for the welfare of themselves, their families, the community at large and the community as a whole. The programme has certain specific objectives as follows Objectives 1) Promotion of positive health 2) Prevention of diseases 3) Early diagnosis, treatment and follow up of defects. 4) Awakening health consciousness in children 5) Provision of healthful environment To achieve objectives the programme should involve the following Components (aspects) I Regular medical Checkup of school children Enabling early detection of defects and disease and prompt referral for treatment.

292 This will be carried out at least twice during the school year i.e. (a) at the time of first admission to school (b) when at class IV for each child a cumulative health record will be maintained which will cover a)history b) medical examination carried out c) Immunisation given Parents will be requested to be present at the time of medical examination of their children Teachers will assist the staff of PHC in filling up history part of the cumulative health record in bringing to the notice of the PHC staff any defect or ailment which they have reheart in the child, screening children for height, weight, vision etc. Examination of each child will include the following (a) Eyes: Vision Examination for defects eg: signal examination for diseases eg: Vitamin – “A” deficiency, trachoma, conjectitivities etc. (b) Teeth: Look for caris, bleeding, pyorrhea etc (c) Throat Look for enlarged, in flamed inside (d) Ears Test for hearing , Note for ear discharge (e) Chest Auscultate heart and hungs (f) Abdomen palpate for enlargement of liver or spleen Look for presence of lump or tenderness (g) Limb & spine Test for residual paralysis Look for defects Look for signs of rickets (h) Skin and hair: Look for red or hypopegmented area If the child has minor ailment advise the teacher or parent what treatment is to be given. If the child needs further investigation or has an ailment which is beyond competence of school give the teacher or parent a referral slip and advise them where to take the child. Prepare a summary report of each school examined, high lighting the number of children examined, no of cases detected of various aliments, number of children refered. II Immunisation

293 With the help of class teacher prepare a class wise list of children who have received the various immunisation under the national immunization schedule. Arrange for carrying the necessary immunanisation for the un protected children III Teachers training Plan with the head master and teachers for the organization of a teacher training programme on a one time or continuing basis. Take the help of M.O PHC/ providing health education materials and in conducting sessions for the teachers. IV Health & Population education Classes are to be organized and conducted involving the children, parents and teachers in the school using various methods and media. Health parades, inter-class competition, exhibition, film shows can be conducted. Necessary aids and equipments needed for the above are also to be arranged. Some of the topics which could be covered are as follows.  Personal hygiene  Safe drinking water  Clean surroundings  Nutritious food, especially vegetable food. Avoid fast food.  Prevention of communicable diseases growing up  Tomorrows parents  Prevention of accidents  First aid  Your primary health centre V Healthful school environment Observe whether the school environment is healthy, That is a) Enough provisions for safe drinking water b) Sufficient sanitary toilets and they are maintained properly c) Facilities for hand washing d) Facilities for disposal of refuse e) Proper ventilation and light for the class rooms

294 f) Proper seating arrangements for the children g) Any accident hazards in the school premises like, unprotected wells, ponds, defective electrical using, defective building, fire hazards etc. h) Any provision/precaution against accidents like buckets of sand and water, properly stocked first aid kit etc. i) Space for play, during breaks j) Suitable place for taking mid day meals VI Nutrition Programme If there is a feeding programme in the school observe the following a) Nutritional supplements or meals provided b) Storage, handling and preparation c) Food distribution and serving d) Personal hygiene of food handlers and children Role of LHI/LHS From the above activities the lady health inspector will have the following roles (L.H.I) 1) As organizer 2) As educator 3) As Counselor 4) As Interpreter 5) As Laison officer

Chapter - 10 ADOLESCENT HEALTH Learning Objectives A the end of the session the trainee should be able to  Describe the physical and physiological changes during adolescence  Explain the physiological and behavioural changes during adolescence.  Discuss the importance of nutrition during the period of adolescence.

295  Describe the importance of personal hygiene.  Discuss major reproductive health problems among adolescents.  Explain the role of the trainee in educating adolescents Methodology : 1) Lecture cum Discussion 2) Brain storming Duration : 6 Hrs Introduction Adolescence is a period of transition from child hood to adulthood. It is the period of life between age of 10-19 years. Among the adolescents teen ages alone constitute around 25% of population. This period is very crucial since these are formative years in the life of an individual when major physical, psychological and behavioural changes take place. This is a period of preparation for undertaking greater responsibilities including healthy responsible parent hood. They from a valuable human resources of our country and hence future of our society depends on adolescents. Characteristics of health problems of adolescents reveals in that they are different from those of younger children and older adults. Due to lack of accurate information, adolescents are prone to various behavioural and reproductive health problems. The period of transition from childhood to adulthood is important for the adolescent health because they develop behavoural problems with absence of proper guidance and counseling. An LHI/LHS can play very important role in preventing these problems.

General characteristics of puberty It is difficult to determine precisely when puberty begins for boys may be the first nocturnal emission, for girls it may begin with the first menstruation. Other physical and physiological changes that begin at puberty and continue through adolescence including changes in physical growth and general body contours, breast development in girls and voice change in boys. The rate and sequence of growth and maturation of these various characteristics of adolescence development vary from person to person.

296 Growth Pattern Height At birth for the boy is slightly higher than the girl. When 10 years old, the boys loses his height advantage for several years. During the middle teenage he regains the advantage, which he continue to maintain. The girls who reach menarche earliest also attain their maximum height earliest, girls who reach their menarche later attain their maximum height later, yet they often become taller than the girls who begin to menstruate at an earlier date. For boys greater growth increase occurs during the middle or slightly after the middle of the pubertal period. There are significant differences in height growth among boys or girls of the same age. Weight:- Growth in height alone does not give an accurate picture of the story of growth during adolescence. Before puberty usually girls are having less weight than boys. But after puberty girls gains more weight. Once boys become heavier and taken than girls they maintain this advantage through out the remainder of their lives. Changes in skeletal structure and body proportion changes take place in the skeletal structure during adolescence and by adulthood the number of bones are 206. The process of hardening of the bones and development takes place continuously from infancy to adolescence. The boy’s form usually characterized by straight leg lines, slender hips and broad shoulders. A girl’s leg lines usually becomes curved and her hips are widened although her shoulders remain narrow. The girls can well compete with boys in running upto about 9 years of age, but with the broadening of the hips in girls in adolescence they are unable to attain the same speed in running as boys of the same age. Physiological changes during adolescence-Growth of heart-By the time an individual is 12 years old his heart can be expected to weigh about seven times as much as it did at birth. When compared to size at birth the heart appears to double in size between the ages of 12 and 17. From about puberty onward, boys, tend to have higher blood pressure than girls. During adolescence the pulse rate of girls is from 2 to 6 beats per. minute more than that of the boys. Muscular strength and co-ordination Muscular strength increases during adolescence. The girls have less muscular strength than boys.

297 Effects of Physical status upon adolescent adjustment-Adolescent boys and girls are greatly disturbed by differences in physical features. Among the features that disturb adolescent boys are smaller than average stature, extreme stoutness, facial blemishes of any kind, small and rounded shoulders, small genitals and poor physique in general. Girls are disturbed by such physical features as extreme tallness or shortness, excessive stoutness or thinness, under and over developed breasts, acne and any features in which a girl believes she is different from other girls of her age. Physical features exert a powerful influence on. adolescent attitudes and behaviour. Boys desire to be strong and well built. Adolescents continually want their peer associates and their elders to admire their physical appearance. Mental development-The ability to concentrate-The child's attention span is short and it increases with age. An individual develops greater power to return to the original attention-demanding situation from which he was momentarily distracted. Environmental conditions and moodiness caused by anxiety regarding bodily changes may interfere with concentration. Fundamentally, however, successful concentration is linked with adolescent interests. The ability to memorise - Pleasant experiences, are remembered longer than distressing ones. Memory can be classified as rote (verbatim reproduction of memorized material) or logical (recall of meaningful ideas presented in one's own words)., Children are willing to memorize by rote certain materials such as poems or process passages but adolescents find it monotonous. They are interested in ideas more than in the words themselves. They are more willing and able than children to master the contents logically. The ability to think logically-There are several important characteristics of our adolescent's -thinking that differentiate him from the elementary school age child. first, the adolescent is capable of considering all the possible ways a particular problem might be solved. The second characteristic of adolescent's thinking is that it is deductive and resembles the thought of a scientist. The adolescent is capable of accepting imaginary hypothesis and attempting to reason out the answer.

298 A third characteristic of adolescent's thought is that of - using abstract rules to solve a whole class of problems. This is what enables him to solve abstract problems in algebra and geometry. Specific adolescent interests Boys and girls in this stage indicate a strong desire to be self directing, to establish and work for worthwhile goals and to be productive. We can lassify their interests in terms of three categories. They are personal, social and vocational. Personal interests-All young adolescent boys and girls develop great interest in their physical appearance. (i) Grooming: Good grooming becomes increasingly important to the adolescent boy. He exhibits an increasing interest in cleanliness. He experiments with various styles of hair cuts. Girls like themselves to spend more time. Making attractive. (ii) Voice: Voice tone and quality becomes exceedingly important to adolescents. The free shouting and laughter of childhood days give, way to greater control of the voice. The boy is interested in developing a deep, manly voice. The girls strive to achieve feminine modulation of tone and dignified smiling instead of loud speech and uncontrolled laughter. (iii) Dress: Adolescents usually are extremely interested in clothes. They like bright colours, unusual combinations and modem fashionable clothes. (iv) Conversation: Adolescent boys enjoy telling stories and sometimes questionable jokes and engage in more or less good-natured banter. Girl's conversation includes the discussion of topics such as clothes, books, motion pictures, other girls, school activities, parties, family affairs and personal interests. (v) Writing: During early adolescence both boys and girls show interest in the writing of, autobiographies, which may or may not be completely truthful accounts of their experiences. (vi) Study: An adolescent's urge for independence, his growing awareness of himself as a person and the increase in the number and intensity of his interests expert powerful effect upon his attitude towards study and work. (vii) work: Adolescents like to work if the work is of their own choosing and represent their felt interest.

299 (viii) Recreational interests: Both boys and girls engage in team activities interest in radio, television and motion pictures. Girls tend to continue their interest in, romantic themes, but they want the programmers to be, realistic. Boys prefer mystery stories to the wild shows that, thrilled them as children. Interest in reading for enjoyment is strong - in both sexes. Crime news and advertisements have some appeal for both. In general, adolescent boys prefer magazines that deal With science and mechanics, adventure and the. lives of, heroic men. The girls continue throughout adolescence to prefer magazines containing romantic stories and in some cases, home interest magazines. Girls give evidence of greater interest in the reading of poetry than do boys. During this age-period, girls show interest in long stories, while boys prefer shorter articles or stories. There are some boys, however, who are intensely interested in long adventure stories or biographies. Personal Social Interests (i) The Development of Positive Peer Relations: The normal adolescent is interested in any kind of activity he can engage in with his peers. Interaction with peers is important during adolescence for many reasons. A young boy or girl who has not learnt to get along with his/her -peers during adolescence, is likely to have problems- of social adjustment during adulthood. - As an' adolescent becomes more independent from his parents, it is with the peer group that he can share his confusing emotions, his doubts and his dreams., The peer group, also - helps the adolescent to find at least a partial answer to his questions "who-am I", "what is the meaning of my life", We are often under the impression that the values of the parents and the peer group conflict with each other. This is not necessarily so. Because of the similarity in the background from which they come, the peer group does share the basic moral and social values of the parents. Differences arise only in areas like choice of clothing, hair style, music, entertainment, language and the likes. Learning to be an acceptable, member of the peer group is an important developmental goal of adolescence. (ii) The Development of Adolescent Independence: The development of independence is another important developmental goal during adolescence. Establishing true independence from parents is seldom a simple-matter. The adolescent may be reluctant in one way to give up the rewards and security of dependence and accept the responsibilities of independence along-with its

300 privileges. The difficulties adolescents face in achieving independence and the extent to which they will succeed depends upon (1) the society’s expectations and (2) the child- rearing practices and models provided by parents. (iii) The Development of Sense of Identity: Sometimes- during adolescence every young boy or girl needs to develop a sense of identity; that is a definition of oneself as a person the adolescent is in search of an answer to the question "who arm I". The most important factor is a rewarding, warm relationship with his parents, and motivation. (iv)Moral Development and Values: Another characteristic of adolescence is the increasing interest in moral values and beliefs. A Young child's mobility is based more on avoidance of Punishment, the need to be called as a good boy or a good girl. The adolescent begins to think in terms of moral principles and conscience. Vocational Interests: The choice of a vocation during adolescence may be influenced by the occupational activities of the members of the family or older friends who have achieved success in their field. The adolescent's career choice may also be affected by his school environment, by his teachers and by his peers. The child’s interest in a glamorous or adventurous vocation may Persist with modification well into adolescence. However, the adolescent becomes increasingly more realistic and is now likely to refer to occupations which are considered Prestigious and have a high social status. The adolescents need some vocational guidance to help them make a proper choice. Emotional problems of adolescents and how to adjust with them Adolescence is a time when boys and girls are painfully sensitive and this leads to emotional problems. We shall discuss some of the major causes of emotional Problems during adolescence and how best to adjust with them. On the one hand there is the fear that the changes may not occur, and on the other hand there is the fear that the changes may be too obvious. What makes it worse is that one is not very clear about the end pic- ture that is what exactly one will grow up to be like. Physical appearance is a matter of real concern to most adolescents perhaps no exception to this rule. A teenager is likely to look into a mirror and wish for something different from what he sees. Applying tape measures to breast, waist and- hips, the girl sadly notes the differences between her and Miss. India.

301 Encourage eating the right kinds of food in right time and take enough rest. Exercise and sports will add a sparkle to his eyes and skin and a sense of well being and this will surely make good and more confident. The bodily changes that accompany sexual maturing may also prove to be a source of pride as well as embarrassment for the adolescent. How comfortable he feels about his sexual maturity depends to a large extent upon the attitudes towards; sexual development, conveyed by his parents and the school. Parental attitudes of secrecy and taboo concerning the sexual functions lead to unnecessary worry and anxiety among adolescents. Teenagers should be neither be surprised nor ashamed, if their attraction to someone of the other sex. These new feelings usually appear during adolescence along with the body changes which make a boy or girl sexually mature. Some adolescents may not know how to manage the new urges since sexual feelings may be quite strong before a young man or woman is ready to marry. A few facts and suggestions may be helpful. Day dreams, combined with the physical urges of sex, cause most boys and girls, at sometime during their teens, to handle their external sex organs so as to cause an intense sensation. Young people often worry, because they have heared that masturbation causes insanity, feeble mindedness, pimples or other physical ailments. Physician believe today that masturbation, does not cause any of these things. However, indulging in masturbation is likely to cause guilty feelings that may be very disturbing. Some of the other factors which lead to emotional problems in adolescence are: concern regarding early or late maturation, Human beings must constantly reassure themselves of their worth. The indirect way of trying to fill life with good friendship, good fun, and interesting, worthwhile activities is probably of the best way to avoid many emotional problems, real or imaginary. How Mature An Adolescent GROWING mature is a life long process. At no point of time can anyone stand up and say that he has matured fully. Maturity is indicative of one's readiness to share adult experiences, privileges and responsibilities celebration of birthdays in a way marks a step towards maturity but it does, not mean that he is really mature.

302 There are different aspects of maturity. 1. Chronological (number of birthdays he has celebrated. 2. Physical (proper growth of body). 3. Intellectual (how nature his thinking is 4 Emotional (feelings and how they are expressed) 5. Social (relationships with other people). 6. Philosophical (beliefs, ideals, purposes, morality and values). Chronological Maturity He can tell exactly how old he is in years, months and days. Next year he will be one year older than what he is now. The chronological age cannot hurry it up or slow it down. Chronological maturity is important in some. respects e.g. getting the right to vote, inheriting property, obtaining driving license, getting married, opening a savings account in the post office or a bank. Physical Maturity One gains physical maturity when one has obtained his full height, weight and strength. There, are higher expectations from physically: well-developed boys and girls than their smaller and lesser developed counterparts. Sports, games, outings, jobs and even relationships within the family and outside depend to a certain extent on how physically when developed looks If physical development is left to nature, it normally takes care of. Proper nutrition is very important. Exercise can help but cannot altogether change the pattern of physical growth. There are -other phases of maturity which are equally important and he can do something to improve them. Intellectual maturity It is difficult to measure- intellectual maturity as there is no common agreement as to what it involves. However it can be thought of in the following manner

1. Intellectual maturity means they can handle and understand the language of words, figures and signs or symbols in accordance with culture.

303 2. An intellectually mature person takes his own decisions and does not wait for advice or prompting from others. The more independently he takes decisions the more mature intellectually he is supposed to grow. 3. He can be considered intellectually mature if he can look at his, problems impartially and objectively 5. If he make hasty judgements he is like the child who makes quick moves without weighing pros and cons. An adult always feels that judgments cannot be made hastily. It involves a mental exercise in weighing all the relevant facts before making any final choice of action. 6. One intellectually mature if can reserve judgments considered the pros and cons and what is actually involved and what needs to, be done. Intellectual growth varies from person to person and also depends on situations in which one lives. Emotional Maturity He often loses his temper and feels very-much annoyed when things don't go the way desires This may be due to lack of emotional maturity. Children of such parents who do not get easily disturbed and upset, tend to grow emotionally mature. An emotionally mature person will restrain himself and will not be easily disturbed by his immediate impulses. Social Maturity Social maturity is his ability to get along with people. As he grows up from a baby to a child, then to an adolescent and to an adult spheres of his social relationship and activity keeps on enlarging. As he grows up, he needs more and more people of various kinds in his life and he needs different things from them. Social maturity is gradually learned as he learns to live in a world full of people. He must have by now scored his social maturity. It is not the same all the time. His success, popularity and satisfaction to a great extent depends upon how he gets along with the people around him. Philosophical maturity Every human being has a philosophy of life which includes having long term values, having goals worth striving for, making true friends and having a dedication and a mission in life.

304 His philosophy of life depends upon the customs and values of the people in his family, his religion, his community, etc. The teachings of his religion has already set a goal before him. The great thoughts noble ideas and the lives of great men have always moulded the philosophy of life of many. The people whom he over and admire also helps in building philosophy of life. It is important to maintain good physical, mental, emotional and social health. Psychological and behavioural changes During this transition phase from child hood to adult hood due to rapid physical and sexual changes in the body, the adolescent develops anxiety and apprehension. Adolescence is a time for exploration adventure and discovery of one's own body and one's capability and potential. Sometimes this can lead to confusion and to experimentation with harmful substances like drugs, alcohol etc. and risky behaviour. Sometimes expression of sexual urge by adolescents may lead to anger among adults while among adolescents this may lead to feeling of fear, guilt and shame. Often adolescents hesitate to make communication about sexual development and other related matters with elders. In case they are not given appropriate information and education on these normal physical, sexual and psychological changes they are prone to health risk behaviour such as sex experiments and drug abuse leading to teenage pregnancy, contracting RTI/ STI, HIV/AIDS, injuries, accidents, violence, rape, homicides, suicides etc. Nutrition and health needs in adolescence The nutritional requirement of adolescents is more due to rapid growth spurt and increase in physical activity. You have to ensure that during this Period, the adolescents are encouraged to develop healthy eating habits and life style. Good nutrition is equally important for proper growth of both male and female adolescents. Adolescents need more of all nutrients particularly calcium, iodine and iron. The need for more iron in adolescents is due to growth spurt and the onset of menstruation. Inadequate iron stored during adolescence before conception is a major cause of iron deficiency anaemia during pregnancy, which aggravates the risks during pregnancy. In endemic areas incidence of Iodine deficiency disorders is high resulting in retardation of growth, mental retardation etc. They should take calcium rich food like milk and milk

305 products, consume iodized salt and iron-rich food such as green leafy vegetables, whole pulses, jaggery, meat, poultry, fish etc. Stunted and under-nourished girls are more likely to have complications during pregnancy and give birth to low birth-weight babies. You should educate the community and family members about the importance of healthy eating habits and nutritious foods. Personal hygiene It is the one of the basic components for protection of health. Adolescents should take care of personal hygiene such as:  Clean hands thoroughly before and after taking food and after going to toilet.  Clean teeth and tongue twice daily once in the morning after leaving bed and at the time before going to bed at night.  Must take bath daily, twice  Boys should give attention to clean "Smegma" i.e. (a thick secretion collected under the fore-skin' of, the penis) during bathing and after urination.  Boys and girls should keep the groin clean and dry otherwise fungal infection, leading to itching etc. will develop.  Girls should use clean clothes, pads or sanitary napkins during periods. It should be changed frequently and the part should be kept clean and dry. Adolescent girl may have itching around genitalia and groin after menstruation for which one should not be worried.  Sometimes girls may have vaginal discharge which may be smelling/ stains clothes. In such case she should contact a doctor with whom she has confidence.  Close to the urethral opening are the vaginal opening and anus. So always wash after passing urine. Washing after passing stool and urine must be from front to back and not reverse, as there is chance of urinary infection. Health problems in adolescence Some health problems among adolescents are consequence of certain child hood infections like repeated diarrhoeal and respiratory infections, or other factors affecting health status like malnutrition etc. Irregular Menstrual cycle

306 Irregular bleeding is sometimes seen after menarche. You should reassure the girl and her parents and advise her to take nutritious diet. In most of the cases the periods get regular within about 2 years of menarche. If they do not get regular menstrual bleeding, then you should refer her to MO (PHC). Under-nutrition Under-nutrition among adolescent girls is major public health problem in India. Under-nutrition during childhood and adolescence leads to impaired growth, anaemia, iodine deficiency etc. Some other problems originating during adolescence may have life long consequences like use of tobacco, alcohol, drugs, etc. Unprotected sex and unwanted/ unplanned pregnancy Since adolescent sexuality remains taboo in many societies, there is widespread ignorance among adolescents about risks associated with unprotected sexual activity. Unprotected sex may lead to unwanted/unplanned pregnancy which in turn may lead to increased demand for induced abortion. Pregnancy among unmarried adolescent girls may lead them to seek abortion services from untrained practitioners and quacks and become victims of the consequent complications. Termination of unwanted pregnancy through Induced abortion among a adolescent girls cause greater risk to life than in adult women. Even if pregnancy continues, tendency to hide the same and to avoid proper antenatal care among adolescents may lead to serious complications of pregnancy and child birth. Risk of pregnancy in adolescence Health of adolescent girls is at high risk if they are married at very young age which leads to consequent early child bearing. The chance of anaemia, retarded foetal growth, premature birth and complications during labour are significantly higher for adolescent mothers and may even lead to death. Unprotected sex and sexually transmitted diseases. A major consequence of unprotected sex among adolescents is the chances of infection from STDs which include syphilis, gonorrhea and HIV/AIDS. Young adolescents of both sexes who engage in unprotected sexual activities are highly vulnerable to STDS.

307 Acquiring STDs during adolescence often results in serious consequences -in future like infertility, pelvic inflammatory disease, ectopic pregnancy etc. How to prevent adolescent pregnancy and STDs. Adolescent pregnancies are at high risk, pregnancies. Hence for delaying pregnancies there is need to delay age at marriage. This can be achieved through advocacy, counselling and social as well as legal actions. Counselling of adolescents can enable them to take proper decisions to prevent pregnancies by adopting abstinence or use of contraceptives. Counselling can also help them to take decision for adopting safe abortion services in case of unplanned/unwanted pregnancy. Use of condom not only provides protection against unwanted pregnancies but also against STD and HIV/AIDS. Counselling and education may be provided to the adolescents regarding need for practice of safe sex not only to avoid pregnancy but also for protection against STDs including HIV/AIDS. Remember that adolescents have a right to get complete, correct and detailed knowledge and information relating to their development; physical and psychological changes that take place during adolescence, sexuality in human beings and its implications on their health as well as means to protect themselves from reproductive health related problems. Crucial role of family and community in adolescent health Family has a crucial role in shaping the adolescents behaviour. Parents and adults in the family must ensure a safe and secure and supportive environment for the adolescents during their formative years of growth and development. Family members need to be informed and educated in this regard. A positive and encouraging attitude among parents and family members to interact with adolescents and to give clarifications and correct information on their doubts will facilitate better relationship of trust and confidence. Your role to educate the community to help adolescents Adolescents confront a number of "problems because of the lack of authentic knowledge regarding their process of growing up, particularly, the issues relating to reproductive health.

308 They need accurate information and do not often know from where to obtain this. Therefore you are expected to educate the community members as well as adolescents about the normal physiological changes with special reference to nutrition and health needs of adolescents. You should educate the adolescents about healthy life style and behaviours among them. Key points 1. Adolescents need extra food as. they are growing very fast. 2. Adolescents are more likely to become anaemic due to rapid growth in muscle mass (and menstruation in girls) Give them more iron rich foods like whole pulses, green vegetables, jaggery, meat, poultry, fish etc. and treat with IFA tablet, if they are anaemic 3. Adolescents are under psychological stress very often, as they are becoming more independent and assertive as part of their growing up. Hence they should be dealt in a more sympathetic and understanding manner by family members, teachers and other adults in the community Friendly approach. 4. Adolescents are undergoing sexual development and they are curious to know about it. They should be encouraged to ask and know about this from parents, health workers and others who can give them correct information. They should be told about the risk of unprotected sexual behavior i.e. disease like STDs and AIDS. 5. Adolescents may not have adequate information about dangers of experimenting with unprotected sex, use of dangerous drugs and alcohol, risky driving, smoking etc. 6. Adolescents have the right to have the information and knowledge about their development, healthy behaviour, sensitive sexual issues, their own health needs etc. 7. Unprotected sexual relations increases the risk of unwanted pregnancy, induced abortion and sexually Transmitted Infections. 8. A pregnant adolescent below the age of 18 years is 2-5 times is at risk and more likely to die than a pregnant woman between 18-25 years. 9. STDs are major cause of reproductive health complications and their sequel including infertility.

309 10. Lack of knowledge, lack of access to contraception and hesitation in seeking information from adults puts the adolescents at high risk of unwanted pregnancy and STDS. 5. LIFE SKILLS Life Skill Education Existence of a society is dependent upon the healthy development of its individuals. Growth of an individual is only possible when he/she is aware of oneself and the responsibilities of normal living. Gaining adequate knowledge and developing skills that are required to cope in the present day society is the task ahead. And as we know, it is the present day adolescents and youths - the trendsetters, who can revolutionize life. Life skill can be defined as the abilities for adaptive and positive behavior that empower us in making Informed, choices in the face of complex life situation. The proper use of life skill gives a person -'psychological competence'. It helps in the development of healthy Interaction and behaviour, which enhances the future of, so called problem adolescents. Life skills identified by WHO (1994) for promotion of health and well being of children and adolescents are:  Listening skills  Basics of friendship  Communication Skills  Learning to say  Building self-confidence and positive thinking  Self awareness  Coping with emotions  Coping with stress  Resolving conflicts  Decision Making: When confronted with a problem we go through two different stages of thinking. First we think about the options/choices available. regarding the particular problem and then about the consequences the different decisions may have. And one needs to develop these skills to lead a constructive life.

310 The desirable steps are 1. Define the problem: state exactly what the problem is or the situation around which a decision needs to be made. 2. Consider the consequences of each: list all the possible outcomes - both positive and negative for each alternative source of action that may be taken. 3. Consider family and personal values: these values include beliefs about how one should act and behave, the personal and family rules one lives by.

6 COUNSELLING Counselling is both a humane and professional service, which helps a persons to work for the right solutions for his problems.

 It is simply a process or helping people to learn about them selves, learn to understand the problems, the situation, environment or surroundings and ways to resolve the them.  It is helping people make choices and act on those choices  It is a growth and hearing process where one is helped to express oneself, overcome fears, learn coping skills.  It is a process of making people self-aware and develop their personality according to their roles.  It is a search for true Identity and achieve goals important to them.  It is making a change for the better. ADOLESCENT COUNSELLING Adolescence brings In Its wake a host of problems that need to be met and resolved with understanding. Therefore, guidance of the pupil at this stage is of great importance. There are two factors that need to be considered. a. At the secondary school stage the pupils have to make academic choice that ultimately determines their vocational future. b. The pupils becoming sexually mature. During adolescent period, all children pass through phases of temporary maladjustment. The period of adolescence becomes difficult whenever the individuals

311 are expected to make a number of adjustments to various changes and expectations. It is believed that emotional differences may clear up with adequate support system. Lack of sufficient, Insight and support from the part of parents, teachers or responsible others, may be decisive factors in, whether or not an adolescent Is able to cope with stressful situations. Some of the commonly reported adolescent adjustment problems are: • Adjusting with physiological changes, • Dealing with one's own attitudinal changes • Responding to the expectations of parents and responsible others • Peer group adjustment • Academic achievement and career related Issues • Problems In the family (financial, Illness, broken family, death, quarrel, alcoholism/ drug abuse, factors related to living environment etc.) • Adjusting with teachers, school and syllabus • Lack of proper and effective communication and interaction with parents Create discussion on the following statements. Discussions can be held with the whole class or In small groups. 1. Girls are more social than boys 2. Boys have higher self-esteem than girls 3. Girls are better than boys at simple repetitive tasks 4. Boys have greater mathematical and visual spatial abilities than girls 5. Boys are more analytical than girls 6. Girls have greater verbal ability than boys 7. Boys have a stronger motivation to achieve 8. Girls are less aggressive than boys 9. Girls are time alert to auditory stimulation; boys are more alert to visual stimulation. 10. Girls are always dependent on boys This gives an opportunity for the boys and girls to understand each other which is an essential pre-requisite for understanding the adolescent-problems. Conduct mock counseling sessions among the participants. Skit : Introducing Inferiority Complex

312 What all areas 1. Physical Defects, deformities - Others notice it and make you feel bad. Defects, deformities - Others are sympathetic but the person still feel bad Personal worries and distractions due to various factors, e.g. Body Image  Issues In friendship with opposite sex  Other Issues due to lack of self confidence, self respect, Inferiority feeling, unhealthy comparisons, Identity crisis, lack of motivation etc.  Adjustment problems as part of normal development and due to various other environmental factors can be reduced by providing proper counselling to the adolescent. Through counselling, the adolescents can be equipped with self-help skills. Counselling is required for. Those who have various adjustment difficulties.  Those with scholastic difficulties  Those with character and personality disorders  Those with specific behavioural problems  No-assertive adolescent  Attitudes and Interests During adolescence and later, there are changes in the mental and social characteristics leading to different attitudes towards parents, school, teachers, peers and authorities. Interests change rapidly and sometimes are not easy to understand. It is the responsibility of the school to help the young grow into disciplined, mature adults and exhibit a conduct that is approved by society at large. From the School or College 1. Choose the curriculum which suits his/her abilities Interests and aspirations or goals optimally 2. Acquire efficient study habits and practices which would enable him/her to achieve the desirable levels of academic success 3. Develop social Interests and talents outside the academic field since the demands of life are myriad and confusing,

313 4. Enjoy his/her life at school through happy and rewarding Interpersonal relationships with teachers and other pupils. Parents - counsellors / preachers Problems In the family may affect the adolescent in a serious manner. Often this can present themselves as serious health problems in the adolescent - psychosomatic disorder. Teachers are the ones who deal with the adolescents closely and hence should be able to identify those with the problems early. Parents Instead of becoming all time preachers can try and become supportive of them at moments of crisis. They should try to be reasonable persons who are willing to understand, communicate effectively and solve problems amicably.

Pre-marital sex: Sexual relation is a very intimate and private aspect of marital life and hence something which has to be taken seriously. Although it may not be any more fashionable to say so, premarital sex has to be avoided, as after marriage it is your partner and children who suffer for your irresponsible premarital sexual life. Message:- Children do not pick up bad habits just by knowing the truth, intact knowledge empowers them to protect themselves.

314 Chapter-11 NUTRITION AND HEALTH

Nutrition may be defined as the science of food and its relationship to health. It is concerned primarily with the part played by nutrients in body growth, development and maintenance (1). The word Nutrient or "food factor" is used for specific dietary constituents such as proteins, vitamins and minerals. Dietetics is the practical application of the principles of nutrition,--it includes the planning of meals for the well and the sick. Good nutrition means "maintaining a nutritional status that enables us to grow well and enjoy good health" (2). The subject of nutrition is very extensive. Since our concern is with community aspects of nutrition, CLASSIFICATION OF FOODS There are many ways of classifying foods: 1. Classification by origin 1) Foods of animal origin 2) Foods of vegetable origin 2. Classification by chemical composition

315 1) Proteins 2) Fats 3) Carbohydrates 4) Vitamins 5) Minerals 3. Classification by predominant function 1) Body-building foods, e.g., milk, meat, poultry, fish, eggs, pulses, groundnuts, etc. 2) Energy-giving foods, e.g., cereals, sugars, roots and tubers, fats and oils. 3) Protective foods, e.g., vegetables, fruits, milk 4. Classification by nutritive value 1) Cereals and millets 2) Pulses (legumes) 3) Vegetables 4) Nuts and oilseeds 5) Fruits 6) Animal foods 7) Fats and oils 8) Sugar and jaggery 9) Condiments and spices 10) Miscellaneous foods

NUTRIENTS Nutrients are organic and inorganic complexes contained in food. There are about 50 different nutrients which are normally supplied through the foods we eat. Each nutrient has specific functions in the body. Most natural foods contain more than one nutrient. These may be divided into : (i) Macronutrients : These are proteins, fats and carbohydrates which are often called "proximate principles" because they form the main bulk of food. In the Indian dietary, they contribute to the total energy intake in the following proportions. Proteins 7 to 15 per cent Fats 10 to 30 per cent Carbohydrates 65 to 80 per cent

316 (ii) Micronutrients : These are vitamins and minerals . They are called micronutrients because they are required in small amounts which may vary from a fraction of a milligram to several grams. A short review of basic facts about these nutrients is given below. PROTEINS Proteins are complex organic nitrogenous compounds. They are composed of carbon, hydrogen, oxygen, nitrogen and sulphur in varying amounts. Some proteins also contain phosphorus and iron and occasionally other elements. Proteins differ from carbohydrates and fats in that they contain nitrogen, this usually amounting to about 16 per cent. Proteins constitute about 20 per cent of the body weight in an adult.

Essential amino acids Proteins are made up of smaller units, called amino acids. Some 24 amino acids are stated to be needed by the human body, of which 9 are called "essential" because the body cannot synthesize them in amounts corresponding to its needs, and therefore, they must be obtained from dietary proteins. They are : leucine, isoleucine,

lysine, methionine, phenylalanine, threonine, valine, tryptophan and histidine. Evidence is now accumulating that histidine is essential even for adults Non-essential amino acids include arginine,asparaginic acid, serine, glutamic acid, proline and glycine. Both essential and non-essential amino acids are needed for synthesis of tissue proteins, the former must be supplied through diet, whereas the latter can be synthesized by the body provided other building blocks are present. Some of the essential amino acids have important biological functions, e.g., formation of niacin from tryptophan; the action of methionine as a donor of methyl groups for the synthesis of choline, folates and nucleic acids. There is evidence that cystine and tyrosine are essential for premature babies . New tissues cannot be formed unless all the essential amino acids (EAA) are present in the diet. A protein is said to be "biologically complete" if it contains all the EAA in amounts corresponding to human needs. When one or more of the EAA are lacking, the

317 protein is said to be "biologically incomplete". The quality of dietary protein is closely related to its pattern of amino acids. From the nutritional standpoint, animal proteins are rated superior to vegetable proteins because they are "biologically complete". For example milk and egg proteins have a pattern of amino acids considered most suitable for humans.

Functions Proteins are needed by the body for (a) body building, this component is small compared with the maintenance component, except in the very young child and infant; repair and maintenance of body tissues; (c) maintenance of osmotic pressure; and (d) synthesis of certain substances like antibodies, plasma proteins, haemoglobin, enzymes, hormones and coagulation factors. Proteins are connected with the immune mechanism of the body. The cell mediated immune response and the bactericidal activity of leucocytes have been found to be lowered in severe forms of protein energy malnutrition. Proteins can also supply energy (4 kcal per one gram) when the calorie intake is inadequate, but this is not their primary function. It is considered wasteful if proteins were used for such a purpose.

Sources Humans obtain protein from two main dietary sources; (a) ANIMAL SOURCES: Proteins of animal origin are found in milk, meat, eggs, cheese, fish etc. These proteins contain all the essential amino acids (EAA) in adequate amounts. Egg proteins are considered to be the best among food proteins because, of their high biological value and digestibility. They are used in nutrition studies as a "reference protein". (b) VEGETABLE SOURCES : Vegetable proteins are found in pulses (legumes), cereals, beans, nuts, oil-seed cakes, etc. They are poor in EAA. In developing countries such as India, cereals and pulses are the main sources of dietary protein because they are cheap, easily available and consumed in bulk.

Supplementary action of proteins When two or more of vegetarian foods are eaten together (as for example, rice- dhal combination in India) their proteins supplement one another and provide a protein

318 comparable to animal protein in respect of EAA. Thus with proper planning, it is possible for a vegetarian to obtain a high grade protein, at low cost, from mixed diets of cereals, pulses and vegetables. This is known as supplementary action of proteins, and is the basis of counselling people to eat mixed diets.

Protein metabolism There are three features of protein metabolism : (a) since proteins are not stored in human body in the way that energy is stored in adipose tissue, they have to be replaced every day; (b) the body proteins are constantly being broken down into their constituent amino acids and then reused for protein synthesis.

Assessment of protein nutrition status A battery of tests have been suggested to assess the state of protein nutrition. These include : arm muscle circumference, the creatinine - height index, serum albumin and transferrin, total body nitrogen, etc. At the present time the best measure of the state of protein nutrition is probably serum albumin concentration. It should be more than 3.5 g/dl, a level of 3.5 g/dl is considered mild degree of malnutrition; a level of 3.0 g/dl severe

malnutrition. Serum albumin and transferrin assess the ability of the liver to synthesize proteins.

Protein requirements

It is customary to express protein requirements in terms of body weight. The Indian Council of Medical Research in 1989 recommended 1.0 g protein/kg body weight for an Indian adult, assuming a NPU of 65 for the dietary proteins. FATS Fats are solid at 20 deg. C; They are called "oils" if they are liquid at that temperature. Fats and oils are concentrated sources of energy. They are classified as: (a) Simple lipids, e.g., triglycerides (b) Compound lipids, e.g., phospholipids

319 (c) Derived lipids, e.g., cholesterol The human body can synthesize triglycerides and cholesterol endogenously. Most of the body fat (99 per cent) in the adipose tissue is in the form of triglycerides. In normal human subjects, adipose tissue constitutes between 10 to 15 per cent of body weight. The accumulation of one kilogram of adipose tissue corresponds to 7700 kcal of energy

Fatty acids Fats yield fatty acids and glycerol on hydrolysis. Fatty acids are divided into saturated fatty acids such as lauric, palmitic and stearic acids, and unsaturated fatty acids which are further divided into monounsaturated (MUFA) (e.g., oleic acid) and polyunsaturated fatty acids (PUFA) (e.g.,linolenic acid and (x-linolenic acid). The polyunsaturated fatty acids are mostly found in vegetable oils, and the saturated fatty acids mainly in animal fats. However, there are exceptions, as for example, coconut and palm oils, although vegetable oils, have an extremely -high percentage of saturated fatty acids. On the other hand, fish oils, although they are not vegetable oils, contain poly and mono -unsaturated fatty acids.

TABLE I Fatty acid content of different fats(per cent) Fats Saturated Mono- Polyunsaturated Fatty acids Unsaturated fatty acids Fatty acids (PUFA) (MUFA) Coconut oil 92 6 2 Palm oil 46 44 10 Cotton seed oil 25 50 Groundnut oil 25 50 31 Safflower oil 19 15 75 Sunflower seed oil 10 27 65 Corn oil 8 27 65

320 Soya bean oil 8 24 62 Butter 14 37 3 Margarine 60 25 50 25

Essential fatty acids Essential fatty acids are those that cannot be synthesized by humans. They canbe derived only from food. The most important essential fatty acid (EFA) is linoleic acid, which serves as a basis for the production of other essential fatty acids (e.g., linolenic and arachidonic acids). Not all polyunsaturated fatty acids are essential fatty acids. Linoleic acid is abundantly found in vegetable oils. The dietary sources of EFA are as shown in Table 2.

TABLE 2 Dietary sources of EFA Essential Dietary source Per cent Fatty acids Content Linoleic acid Sunflower oil 73 Corn oil 57 Sunflower oil 56 Soyabean oil 51 Sesame oil 40 Groundnut oil 39 Mustard oil 15

321 Palm oil 9 Coconut oil 2 Arachidonic acid Meat, eggs 0.5-0.3 Milk (fat) 0.4-0.6 Linolenic acid Soyabean oil 7 Leafy greens varied Eichosapentaenoic acid Fish oil 10

Sources

The dietary sources of fats may be classified as: (a) ANIMAL FATS : The major sources of animal fats are ghee, butter, milk, cheese, eggs, and fat of meat and fish. Animal fats with few exceptions like cod liver oil and sardine oil are mostly saturated fats. (b)VEGETABLE FATS: Some plants store fat in their seeds, e.g., groundnut, mustard, sesame, coconut, etc. They are sources of vegetable oils. (c)OTHER SOURCES: Small quantities of fat (invisible fat) are found in most other foods such as cereals, pulses, nuts and vegetables. For example, rice carries 3 per cent of fat, wheat 3 per cent, jowar 4 per cent and bajra 6.5 per cent. Large cereal consumption, as in India, provides considerable amounts of "invisible fat". Moreover, the body can convert carbohydrate into fat.

Functions Fats have always been equated with calories. They are high energy foods, providing as much as 9 kcal for every gram. By supplying energy, fats spare proteins from being used for energy. Besides providing energy, fats serve as vehicles for fat- soluble vitamins. Fats in the body support viscera such as heart, kidney and intestine; and fat beneath the skin provides insulation against cold. Without fat, food is limited in palatability. Vegetable fats are rich sources of essential fatty acids which are needed by the body for growth, for structural integrity of the cell membrane and decreased platelet adhesiveness. Diets rich in EFA have been reported to reduce serum cholesterol and low-

322 density lipoproteins . Polyunsaturated fatty acids are precursors of Prostaglandins - a group of compounds, now recognised as "local hormones"; they play a major role in controlling many of the physiological functions of the body such as vascular homeostasis, kidney function, acid secretion in stomach, gastrointestinal motility, lung physiology and reproduction. Cholesterol is essential as a component of membranes and nervous tissue and is a precursor for the synthesis of steroid hormones and bile acids. Thus fats and oils are useful to the body in several ways.

Visible and invisible fats "Visible" fats are those that are separated from their natural source, e.g., ghee (butter) from milk, cooking oils from oilbearing seeds and nuts. It is easy to estimate their intake in the daily diet. "Invisible" fats are those which are not visible to the naked eye. They are present in almost every article of food, e.g., cereals, pulses, nuts, milk, eggs, etc. It is difficult to estimate their intake. In fact, the major contribution to total fat intake is from invisible sources rather than visible sources (Table 3).

TABLE 3 Energy contribution from visible and invisible fats Calorie Fat intake(grams)

State Intake Invisible Visible Total Per cent As energy Kerala 2140 50.52 3 53.52 22.3 Tamil Nadu 1871 25.96 10 35.96 14.7 Andra 2340 24.22 17 35.96 15.5 Pradesh

323 Gujat 2375 32.29 19 41.22 19.8 Orissa 2468 20.73 6 26.73 9.8 U.P. 2115 21.03 4 25.03 10.7 25.03

Hydrogenation When vegetable oils are hydrogenated under conditions of optimum temperature and pressure in the presence of a catalyst, the liquid oils are converted into semi-solid and solid fat. The resulting hydrogenated fat is known as "vanaspati" or vegetable ghee, which is a popular cooking medium in India. During the process of hydrogenation, unsaturated fatty acids are converted into saturated acids and the EFA content is drastically reduced. The main advantage of vanaspati is its ghee-like consistency and its keeping quality even in hot humid climates. Since vanaspati is lacking in fat-soluble vitamins, it is fortified with vitamins A and D by government regulation to the extent of 2500 IU of vitamin A and 175 IU of vitamin D per 100 grams.

Refined oils Refining is usually done by treatment with steam, alkali, etc. Refining and deodorization of raw oils is done mainly to remove the free fatty acids and rancid materials which may be present in them. Refining does not bring about any change in the unsaturated fatty acid content of the oil. It only improves the quality and taste of oils.

Fats and disease (a)OBESITY: A diet, rich in fat, can pose a threat to human health by encouraging obesity. In fat people, adipose tissue may increase up to 30 per cent. (b) PHRENODERMA : Deficiency of essential fatty acids in the diet is associated with rough and dry skin, a condition known as phrenoderma or "toad skin". This condition is reported in Kerala. It is characterised by horny popular eruptions on the posterior and lateral aspects of limbs and on the back and buttocks. Phrenoderma can be cured rapidly by the administration of linseed or sun flower oil Which are rich in EFA, along with vitamins of the B -complex group. (c) CORONARY HEART DISEASE : High fat intake

324 (i.e., dietary fat representing 40 per cent or over of the energy supply and containing a high proportion of saturated fats) has been identified as a major risk factor for CHD. Epidemiological studies indicate that LDL and VLDL fractions are atherogenic and HDL exerts a protective effect against the development of atherosclerosis. There is evidence indicating an inverse relationship between EFA intake and CHD mortality. (d) CANCER : In recent years, there has been some evidence that diets high in fat increase the risk of colon cancer OTHERS : The skin lesions of kwashiorkor, and those induced by EFA deficiency are similar, The 'possible association between the skin lesions of kwashiorkor and EFA deficiency has attracted attention

Fat requirements In developed countries, dietary fats provide 30 to 40 per cent of total energy intake. The WHO Expert committee on Prevention of Coronary Heart Disease has recommended only 20 to 30 per cent of total dietary energy to be provided by fats. At least 50 per cent of fat intake should consist of vegetable oils rich in essential fatty acids. The Indian Council of Medical Research (1989) has recommended a daily intake of not more than 20 per cent of total energy intake through fats. C CARBOHYDRATE The third major component of food is carbohydrate, which is the main source of energy, providing 4 kcals per gram. Carbohydrate is also essential for the oxidation of fats and for the synthesis of certain non-essential amino acids. There are three main sources of carbohydrate, viz., starches, sugar and cellulose. Starch is

basic to the human diet. It is found in abundance in cereals, roots and tubers. Sugars comprise monosaccharides (glucose, fructose and galactose) and disaccharides (sucrose, lactose and maltose). These free sugars are highly water soluble and easily assimilated. Free sugars along with starches constitute a key source of energy.. The carbohydrate reserve (glycogen) of a human adult is about 500 g. This reserve is rapidly exhausted when a man is fasting.

325 Dietary fibre Dietary fibre which is mainly non-starch polysaccharide is a physiologically important component of the diet. It is found in vegetables, fruits and grains, It may be divided broadly into cellulose and non-cellulose polysaccharides which include hemi- cellulose pectin, storage polysaccharides like inulin, and the plant gums and mucilages. These are all degraded to a greater or lesser extent by the microflora in the human colon. In the last few years, the role of dietary fibre has attracted considerable attention. The fibre absorbs water, and this increases the bulk of the stool and helps reduce the tendency to constipation by encouraging bowel movements. Fibre may also have a role in weight reduction. However, its relation to gallstones, diabetes, coronary heart disease, hypertension and bowel disease, including cancer, is not well-established VITAMINS Vitamins are a class of organic compounds categorized as essential nutrients. They are required by the body in very small amounts. They fall in the category of micronutrients. Vitamins do not yield energy but enable the body to use other nutrients. Since the body is generally unable to synthesize them (at least in sufficient amounts) they must be provided by food. A well balanced diet supplies in most instances the vitamin needs of a healthy person. Vitamins are divided into two groups : (a) fat soluble vitamins, viz., vitamins A, D, E and K; and (b) water soluble vitamins, viz., vitamins of the B-group and vitamin C. Each vitamin has a specific function to perform and deficiency of any particular vitamin may lead to specific deficiency diseases.

VITAMIN A "Vitamin A” covers both a pre -formed vitamin, retinol, and a pro-vitamin, beta carotene, some of which is converted to retinol in the intestinal mucosa

326 Functions Vitamin A participates in many bodily functions (a) it is indispensable for normal vision. It contributes to the production of retinal pigments which are needed for vision in dim light. (b) it is necessary for maintaining the integrity and the normal functioning of glandular and epithelial tissue which lines intestinal, respiratory and urinary tracts as well as the skin and eyes (c) it supports growth especially skeletal growth (d) it is anti- infective; there is increased susceptibility to infection and lowered immune response in vitamin A deficiency, and (e) it may protect against some epithelial cancers such as bronchial cancers, but the data are not fully consistent Sources Vitamin A is widely distributed in animal and plant foods in animal foods as preformed vitamin A (retinol), and in plant foods as provitamins (carotenes). (a) ANIMAL FOODS : Foods rich in retinol are liver, eggs, butter, cheese, whole milk, fish and meat. Fish liver oils are the richest natural sources of retinol (Table 4), but they are generally used as nutritional supplements rather than as food sources. (b) PLANT FOODS : The cheapest source of vitamin A is green leafy vegetables such as spinach and amaranth which are found in great abundance in nature throughout the year. The darker the green leaves, the higher its carotene content. Vitamin A also occurs in most green and yellow fruits and vegetables (e.g., papaya, mango, pumpkin) and in some roots (e.g., carrots). The most important carotenoid is beta-carotene which has the highest vitamin A activity. Carotenes are converted to vitamin A in the small intestine. (c) FORTIFIED FOODS: Foods fortified with vitamin A (e.g,,vanspati, margarine, milk) can be an important source. Vitamin A content of selected foods is given in Table 4.

TABLE 4

327 Retinol content of selected foods Retinol equivalents (RE) (mcg/100g) Halibut liver oil 900,000 Carrot 1167 Cod liver oil 18,000 Spinach 607 Liver, Ox 16,500 Amaranth 515 Butter 825 Green leaves 300 Margarine 900 Mango, ripe 313 Cheese 350 Papaya 118 Egg 140 Orange 25 Milk, Cow 38 Tomato 84 Fish 40

The liver has an enormous capacity for storing vitamin A, mostly in the form of retinol palmitate. Under normal conditions, a well-fed person has sufficient vitamin A reserves to meet his needs for 6 to 9 months or more. Free retinol is highly active but toxic and is therefore transported in the blood stream in combination with retinol-binding protein, which is produced by the liver

Deficiency The signs of vitamin A deficiency are predominantly ocular. They include nightblindness, conjunctival xerosis, Bitot's spots, corneal xerosis and keratomalacia. The term "xerophthalmia" (dry eye) comprises all the ocular manifestations of vitamin A deficiency ranging from nightblindness to keratomalacia,. (a) Nightblindness Lack of vitamin A, first causes nightblindness or inability to see in dim light. (b) Conjunctival xerosis This is the first clinical sign of vitamin A deficiency. The conjuctiva becomes dry and non- wettable. (c) Bitot's spots Bitot's spots are triangular, pearly-white or yellowish,foamy spots on the bulbar conjunctiva on either side of the cornea. They are frequently bilateral. (d) Corneal xerosis (xeroph thalmia)

328 This stage is particularly serious. The cornea appears dull, dry and non-wettable and eventually opaque. It does not have a moist appearance (e) Keratomalacia Keratomalacia or liquefaction of the cornea is a grave medical emergency. ( f) Corneal ulcer. (g) Blindness due to sear EXTRA-OCULAR MANIFESTAT!ONS These comprise follicular hyperkeratosis, anorexia and growth retardation which have long been recognised. They are non-specific and difficult to quantify. Recent studies seem to indicate that even mild vitamin A deficiency causes an increase in morbidity and mortality due to respiratory and intestinal infection. Deficiency of vitamin A has recently been linked to child mortality. Treatment Vitamin A deficiency should be treated urgently. Nearly all of the early stages of xerophthalmia can be reversed by administration of a massive dose (200,000 IU or 110 mg of retinol palmitate) orally on two successive days . All children with corneal ulcers should receive vitamin A whether or not a deficiency is suspected. Prevention Prevention and/or control takes two forms (a) improvement of people's diet so as to ensure a regular and adequate intake of foods rich in vitamin A, and (b) reducing the frequency and severity of contributory factors, e.g., PEM, respiratory tract infections, diarrhoea and measles. Both are long term measures involving intensive nutrition education of the public and community participation. Recommended allowances The recommended daily intake of vitamin A is 600 micrograms for adults. The detailed recommendations are given in Table 7.

TABLE 7

329 Daily intake of vitamin A recommened by ICMR (1989) Group Retinolor B-carotene (mcg) (mcg) Adults Man 600 2400 Woman 600 2400 Pregnancy 600 2400 Lactation 950 3800 Infants 0 to 12 months 350 1200 Children 1 to 6 years 400 1600 7 to 12 years 600 2400 Adolescents 13 to 19 years 600 2400

Vitamin A Supplementation 9-12 months-1ml 1 ½ years 2 years 2ml 1 ml is equal to one lakh International unit 2 ½ years 3 years 2ml as Prophylaxis Toxicity An excess intake of retinol causes nausea, vomiting, anorexia and sleep disorders followed by skin desquamation. High intakes of carotene may colour plasma and skin, but do not appear to be dangerous. The teratogenic effects of massive doses of vitamin A is the most recent focus of interest . VITAMIN D The nutritionally important forms of Vitamin D in man are Calceferol (Vitamin D,) and Cholecalciferol (Vitamin D 3).Vitamin D is found in animal fats and fish liver oils. It is also derived from exposure to UV rays of the sunlight which convert the cholesterol in the skin to vitamin D. Vitamin D is stored largely in the fat depots.

330 Vitamin D: Kidney hormone Major advances have been made in recent years in our understanding of the metabolism of vitamin D in the body . It is now known that vitamin D, by itself, is metabolically inactive unless it undergoes endogenous transformation into Several active metabolites first in the liver and later in the kidney. These metabolites are bound to specific transport proteins and are carried to the target tissues - bone and intestine. It has been proposed that vitamin D should be regarded as a kidney hormone

Functions The functions of vitamin D are as summarised in Table 8. TABLE 8 Functions of vitamin D and its metabolites Intestine: Promotes intestinal absorption of calcium and phosphorus Bone: Stimulates normal mineralization,enhances bone resorption, affects collgen maturation. Kidney: Increases tubular reabsorption of phosphate, Variable effect on reabsorption of calcium Other: Permits normal growth

Sources Vitamin D is unique because it is derived both from sunlight and foods. Sunlight: Vitamin D is synthesized by the body by the action of UV rays of sunlight TABLE 9 Dietary sources of vitamin D g/per 100g g/per 100g Butter 0.5-1.5 Shark liver oil 30-100 Eggs 1.25-1.5 Cod liver oil 200-750 Milk,Whole 0.1 Halibut liver oil 500-10,000 Fish fat 5-30

Deficiency (1) Rickets vitamin D deficiency leads to rickets, which is usually observed in young children between the age of six months and two years. There is reduced

331 calcification of growing bones. The disease is characterized by growth failure,bone deformity, muscular hypotonia, tetany and convulsions due to hypo-calcemia.

Prevention Prevention measures include (a) educating parents to expose their children regularly to sunshine; (b) periodic dosing (prophylaxis)-of young children with vitamin D; and (c) vitamin D fortification of foods, especially milk. Some industrialised countries still carry out the last measure. Periodic dosing and education appear to be the most practical approaches in developing countries.

Daily requirements The daily requirements of vitamin D are Adults 2.5mcg (100 IU) Infants and children 5.0 mcg (200 IU) Pregnancy and lactation 10.0 mcg (400 IU) (One international unit (IU) of vitamin D = 0.025g of calciferrol –) VITAMIN E (Tocopherol) Vitamin E is the generic name for a group of closely related and naturally occurring fat soluble compounds, the tocopherols. Of these alpha –tocopherol is biologically the most potent. Vitamin E is widely distributed in foods. By far the richest sources are vegetable oils, cotton-seed, sunflower seed, egg yolk and butter. Foods rich in polyunsaturated fatty acids are also rich in vitamin E. The usual plasma level of vitamin E in adults is between 0.8 and 1.4 mg per 100 ml . Wile there is no doubt that man requires tocopherol in his diet, there is no clear indication of dietary deficiency. The role of vitamin E at the molecular level is little understood. The current estimate of vitamin E requirement is about 0.8 mg/g of essential fatty acids.

VITAMIN K Vitamin K occurs in at least two major forms - vitamin K and vitamin K 2' Vitamin K is found mainly in fresh green vegetables particularly dark green ones, and in some fruits. Cow's milk is a richer source (60 mcg/L) of vitamin K than human milk (15

332 mcg/L). Vitamin K2 is synthesized by the intestinal bacteria, which usually provide an adequate supply in man. Long-term administration of antibiotic doses for more than a week may temporarily suppress the normal intestinal flora, (a source of vitamin K,) and may cause a deficiency of vitamin K. Vitamin K is stored in the liver. The role of vitamin K is to stimulate the production and/or the release of certain coagulation factors. In vitamin K deficiency, the prothrombin content of blood is markedly decreased and the blood clotting time is considerably prolonged.

THIAMINE Thiamine (vitamin Bl) is a water-soluble vitamin. It is essential for the utilization of carbohydrates. In thiamine deficiency, -there .is accumulation of pyruvic and lactic acids in the tissues and body fluids.

Sources The main source of thiamine in the diet of India people is cereals (rice and wheat) which contribute from 60-85 pr cent of the total supply. The thiamine content of selected food stuff is given in table 10. TABLE 10 Dietry sources of thiamine Foods of Mg/100g Foods of animal Mg/100 g Vegetable origin Origin Wheat whole 0.45 Milk, cow’s 0.05 Rice, raw home 0.21 Egg.hen’s 0.10 pounded Rice, milled 0.06 Mutton 0.18 Bengal gram dhal 0.48 Liver, sheep 0.36 Almounds 0.24 Gingelly seeds 1.01 Groundnut 0.90

Deficiency

The two principal deficiency diseases are beriberi and Wernick’s encephalopathy. Beriberi may occur in three main forms: (a) the dry form characterized by nerve involvement (peripheral neuritis); (b) the wet fom charactrisd by heart involvement (cardiac beriberi); and (c) infantile briberi, seen in infants between 2 and

333 4months of age. The affected baby is usually breast-fed by a thiamine-deficient mother who commonly shows signs of peripheral neuropathy. Wernick’s encephalopathy, (seen often in alcoholics) is characterized by ophthalmoplegia, polyneuritis, ataxia and mental deterioration. It occurs occasionally in people who fast.

Prevention

Beriberi can be eliminated by educating people to eat wellbalanced, mixed diets containing thiamine-rich foods (e.g., parboiled and undermilled rice) and to stop alcahol. Recommended allowances Daily requirement of thiamine is 0.5 mg per 1000 kcals of energy intake RIBOFLAVIN Riboflavin (Vitamin B2) is a member of the B -group vitamins. It has a fundamental role in cellular oxidation. It is a co-factor in a number of enzymes involved with energy metabolism. Sources Its richest natural sources are milk, eggs, liver, kidney and green leafy vegetables. Meat and fish contain small amounts. TABLE 11 Dietary sources of riboflavin Foods of animal Mg/100g Foods of vegetable Mg/100g origin Origin Liver, sheep 1.70 Wholecereals 0.10-0.16 Milk, cow’s 0.19 Milled cereals 0.03-0.08 Egg, hen 0.40 Pulses 0.21-0.32 Meat 0.14 Leafy veg. 0.15-0.30

Deficiency Deficiency of riboflavin. or ariboflavinosis is widespread in India particularly in population where rice is the staple. The most common lesion associated with riboflavin deficiency is angular stomatitis, cheilosis, glossing nasolated dyssebacia.

334 Requirement There are no real body stores of riboflavin. Daily requirement is 0.6 mg per 1000 kcal of energy intake.

NIACIN Niacin or nicotinic acid is essential for the metabolism of carbohydrate, fat and protein. It is also essential for the normal functioning of the skin, intestinal and nervous systems. This vitamin differs from the other vitamins of the B -complex group in that an essential amino acid, tryptophan serves as its precursor. Another characteristic of niacin is that it is not excreted in urine as such, but is metabolised

Sources Foods rich in, niacin and or tryptophan are liver, kidney meat, poultry, fish, legumes and groundnut.

Deficiency Niacin deficiency results in pellagra. The disease is characterised by three D's diarrhoea. dermatitis and dementia. In addition glossitis and stomatitis usually occur. The dermatitis is bilaterally symmetrical and is found only on those surfaces of the body exposed to sunlight, such as back of the hands, lower legs, face and neck. Mental changes may also occur which include depression, irritability and delirium.

Prevention Pellagra is a preventable disease. A good mixed diet containing milk and/or meat is universally regarded as an essential part of prevention and treatment. Avoidance of total dependence on maize or sorghum is an important preventive measure. Pellagra is a disease of poverty. Given modern knowledge and opportunities for economic, agricultural and social development, there is every reason to hope that this disease could be eliminated.

Requirement The recommended daily allowance is 6.6 mg/1000 kcal of energy intake.

VITAMIN B6

335 Pyridoxine (vitamin B 6) exists in three forms: pyridoxine, pyridoxal and pyridoxamine. It plays an important role in the metabolism of amino acids, fats and carbohydrate. It is widely distributed in foods, e.g., milk, liver, meat, egg yolk, fish, whole grain cereals, legumes and vegetables. Pyridoxine deficiency is associated with peripheral neuritis The requirements of adults vary directly with protein intake. Adults may need 2 mg/day; during pregnancy and lactation, 2.5 mg/day. Balanced diets usually contain pyridoxine, therefore deficiency is rare. PANTOTHENIC ACID There is a long standing evidence for a relation between pantothenic acid and adrenal cortical function. Recent work indicates a more specific role for pantothenic acid in the biosynthesis of corticosteroids. Human blood normally contains 18 to 35mg of pantothenic acid per 100 ml, mostly present in the cells as coenzyme A. The daily requirement is set at 10 mg. All foods contribute to dietary intake. About 3 mg are excreted daily in urine.

FOLATE The recommended name is folate, alternative name is folacin and the usual pharmaceutical preparation is folic acid. Folic acid occurs in food in two forms : free folates and bound folates. The total folates represent both the groups. In man, free folate is rapidly absorbed, primarily from the proximal part of small intestine. The availability . of bound folate is uncertain. Folic acid plays a role in the synthesis of the nucleic acids (which constitute the chromosomes). It is also needed for the normal development of blood cells in the marrow.

Sources The name comes form the latin folia (= leaf) but foods such as liver, meat, dairy products, eggs, milk, fruits and cereals are as good dietary sources as leafy vegetables.

336 Deficiency Folate deficiency may occur simply from a poor diet. It is commonly found in pregnancy and lactation where requirements are increased. It results in megaloblastic anaemia, glossitis, cheilosis and gastrointestinal disturbances such as diarrhoea, distension and flatulence. Severe folate deficiency may cause infertility or even sterility. There is also evidence that the administration of folic acid antagonists (e.g., alcohol. pyrimethamine, and cotrimoxazole) in early pregnancy may produce abortions or congenital malformations.

Requirement Body stores of folate are not large, about 5-10 mg, and therefore, folate deficiency can develop quickly. Folic acid requirements are greatest in conditions where there is rapid cell multiplication, such as during growth in young children and during pregnancy . Folic acid supplementation during pregnancy has been found to increase the birth weight of infants and decrease the incidence of low birth weight babies. Intake values recommended by ICMR (1989) are given below Per day a) Healthy adults 100 mcg b) Pregnancy 400 mcg c) Lactation 150 mcg d) Children 100 mcg

VITAMIN B12 Vitamin B12 is complex organo -metallic compound with a cobalt atom. The preparation which is therapeutically used is cyanocobalamine, which is relatively cheap.

Vitamin B12 cooperates With folate in the synthesis of DNA, so deficiency of either leads to megaloblastosis.

Sources Good sources are liver. kidney, meat, fish, eggs, milk and cheese. Vitamin B is not found in foods of vegetable origin. It is also synthesized by bacteria in colon. Unlike

337 folic acid, vitamin B 12 is relatively heat stable. Liver is the main storage site of vitamin

B12.

Deficiency

Vitamin B12 deficiency is associated with megaloblastic anaemia (pernicious anaemia), demyelinating neurological lesions in the spinal cord and infertility (in animal species).Dietary deficiency of B12 may arise in subjects who are strict vegetarians and eat no animal products. Requirement Intake values recommended by ICMR (1981) are as below : Per day a) Normal adults 1 mcg b) Pregnancy 1.5 mcg c) Lactation 1.5 mcg d) Infants & children 0.2 mcg VITAMIN C Vitamin C (ascorbic acid) is a water-soluble vitamin. It is the most sensitive of all vitamins to heat. Functions Vitamin C has an important role to play in tissue oxidation. It is needed for the formation of collagen, which accounts for 25 per cent of total body protein. Collagen provides a supporting matrix for the blood vessels and connective tissue, and for bones and cartilage. That explains why in vitamin C deficiency this support fails, with the result that local haemorrhages occur and the bones fracture easily. Vitamin C, by reducing ferric iron to ferrous iron, facilitates the absorption of iron from vegetable foods. It inhibits nitrosamine formation by the intestinal mucosa. Other claims such as prevention of common cold and protection against infections are not substantiated.

Sources

338 The main dietary sources of vitamin C are fresh fruits and green leafy vegetables. Traces of vitamin C occur in fresh meat. and fish but scarcely in cereals. Germinating pulses contain good amounts. Roots and tubers contain small amounts. Amla or the Indian gooseberry is one of the richest sources of ‘C’ both in the fresh as well as in the dry condition. Guavas are another richest source of this vitamin. The dietary sources of vitamin C are given in Table 12. TABLE 12 Dietary sources of vitamin C Mg Per 100 g Fruits: Vegetables: Amla :: 600 Amaranth :: 99 Guava :: 212 Cabbage :: 124 Lime :: 63 Spinach :: 28 Orange :: 30 Brinjal :: 12 Tomato :: 27 Cauliflower :: 56 Germinated Potatoes :: 17 Pulses Bengal gram :: 16 Radish :: 15

Deficiency Deficiency of vitamin C results in scurvy, the signs of which are swollen and bleeding gums, subcutaneous bruising or bleeding into the skin or joints, delayed wound healing, anaemia and weakness. Scurvy which was once an important deficiency disease is no longer a disease of world importance .

Requirement The estimated requirement for vitamin C has recently been raised from 40 to 60 mg with much larger doses advocated by some. The normal body when fully saturated contains about 5 g of vitamin C

Minerals

339 More than 50 chemical elements are found in the human body, which are required for growth, repair and regulation of vital body functions. These can be divided into three major groups : (a) MAJOR MINERALS : These include calcium, phosphorus, sodium, potassium and magnesium (b) TRACE ELEMENTS : These are elements required by the body in quantities of less than a few milligrams per day, e.g. iron, iodine, fluorine, zinc, copper cobalt, chromium, manganese, molybdenum, selenium, nickel, tin, silicon and vanadium (51). Many more have been added to the list in the last few years. (c) TRACE CONTAMINANTS WITH NO KNOWN FUNCTION: These include lead, mercury, barium, boron, and aluminium. Calcium Calcium is a major mineral element of the body. It constitutes 1.5-2 per cent of the body weight of an adult human being. An average adult body contains about 1200 g of calcium of which over 98 per cent is found in the bones. The amount of calcium in the blood is usually about 10 mg/dl. The developing foetus requires about 30 g of calcium. There is a dynamic equilibrium between the calcium in the blood and that in the skeleton; this equilibrium is maintained by the interaction of vitamin D, parathyroid hormone, and probably calcitonin. Functions Ionized calcium in the plasma has many vital functions including formation of bones and teeth, coagulation of blood, contraction of muscles, cardiac action, milk production, relay of electrical and chemical messages that arrive at a cell's surface membrane to the biochemical machinery within the cell, keeping the membranes of cells intact and in the metabolism of enzymes and hormones. It also plays a crucial role in the transformation of light to electrical impulses in the retina. In short, the calcium ion controls many life processes ranging from muscle contraction to cell division.

Sources Calcium is readily available from many sources. By far the best natural sources are milk and milk products, (e.g., cheese, curd, skimmed milk and butter milk), eggs and fish.

340 Deficiency No clear-cut disease due to calcium deficiency has ever been observed, even under conditions of low intake. it has been established that if the intake of vitamin D is adequate, the problems of rickets and osteomalacia do not arise even with low calcium intake. On the other hand, no deleterious effects have been observed in man as a result of prolonged intakes of large amounts of dietary calcium, neither have any benefits been demonstrated.

Requirements A daily intake of 400 to 500 mg of calcium has been suggested for adults. The physiological requirements are higher in children, expectant and nursing mothers.

PHOSPHORUS Phosphorus is essential for the formation of bones and teeth. It plays an important part in all metabolisms. An adult human body contains about 400-700 g of phosphorus as phosphates, most of this occurs in bones and teeth. Phosphorus is widely distributed in foodstuffs; its deficiency rarely occurs. A large part of phosphorus present in vegetable foods occurs in combination with phytin and is available to the body only to the extent of 40-60 per cent.

SODIUM Sodium is found in all body fluids. The adult human body contains about 100 g of sodium ion. Sodium occurs in many foods, and is also added to food during cooking in the form of sodium chloride. Sodium is lost from the body through urine and sweat; that which is passed out in urine is regulated by the kidney, but that which is lost by sweating is not controlled. Depletion of sodium chloride causes muscular cramps. The requirement of sodium chloride depends upon climate, occupation and physical activity. Adult requirement is about 10 to 15 g. People engaged in hard work will need more.

341 POTASSIUM The adult human body contains about 250 g of potassium, Pottassium occurs a widely in foodstuffs, so there is little likelihood of its deficieny. The daily requirement of potassium has not been determined accurately.

MAGNESIUM Magnesium is a constituent of bones, and is present in all body cells. Human adult body contains about 25 g of magnesium of which about half is found in the skeleton. It appears that magnesium is essential for the normal metabolism of calcium and potassium. The principal clinical features attributed to magnesium deficiency are irritability, tetany, hyperreflexia and occasionally hypoerflexia. Requirements are estimated to be about 200 -300 mg/day for adults

IRON Iron is of great importance in human nutrition. The adult human body contains between 3-4 g of iron, of which a bout 60-70 per cent is present in the blood (Hb iron) as circulating iron, and the rest (1 to 1.5 g) as storage iron. Each gram of haemoglobin contains about 3.34 mg of iron.

Functions Iron is necessary for many functions in the body including formation of haemoglobin, brain development and function, regulation of body temperature, muscle activity, and catecholamine metabolism. Lack of iron directly affects the immune system; it diminishes the number of T-cells and the production of antibodies. Besides haemoglobin, iron is a component of myoglobin, the cytochromes, catalase and certain enzyme systems. Iron is essential for binding oxygen to the blood cells. The central function of iron is "oxygen transport", and cell respiration.

342 Sources There are two forms of iron, haem-iron and non-haem iron. Haem iron is better absorbed than non -haem iron. Foods rich, in haem-iron are liver, meat, poultry and fish. They are not only important sources of readily available iron but they also promote the absorption of non--haem iron in plant foods Iron content of breast milk averages less than, 0.2 mg/dl, and it is well utilized. Foods containing non-haem iron are those of vegetable origin, e.g., cereals, green leafy vegetables, legumes, nuts, oilseeds, jaggery and dried fruits. They are important sources of iron in the diets of a large majority of Indian people. Absorption Iron is mostly absorbed from duodenum and upper small intestine in the ferrous state, according to body needs. The absorbed iron is transported as plasma ferritin and stored in liver, spleen, bone marrow and kidney. When red cells are broken down, the liberated iron is reutilized in the formation of new red cells. Iron losses The total daily iron loss of an adult is probably I mg, and about 2 mg in menstruating women. Major routes of iron loss are : (a) through haemorrhage, that is, wherever blood is lost, iron is lost, the causes of which may be physiological (e.g., menstruation, childbirth) or pathological (e.g., hookworms, malaria, haemorrhoids, peptic ulcer); (b) basal losses, such as excretion through urine, sweat and bile, and desquamated surface cells. The recent widespread use of IUDs in the family planning programme is an additional cause of iron loss. IUDs have been shown to increase the average monthly blood loss by between 35 and 146 per cent depending upon the type of the device Iron deficiency The end result of iron deficiency is nutritional anaemia which is not a disease entity. It is rather a syndrome cause by malnutrition in its widest sense Besides anaemia, there may be other functional disturbance such as impaired cell mediated immunity,

343 reduced resistance to infection, increased morbidity and mortality and diminished work performance.

Diagnosis of anaemia A WHO Expert Group proposed that "anaemia or deficiency should be considered to exist" when haemoglobin is below the following levels.

Adult males Adult females, non-

pregnant Children, 6 months to 6

years Children , 6 to 14 years

Evaluation of iron status is based on the following parameters :

(a) Haemoglobin concentration :

(b) Serum iron concentration : This is a more useful index about haemoglobin concentration. The normal range is 0.80 to1.80 mg/L; values below 0.50 mg/L indicate probable iron deficiency

(c) Serum ferritin :

(d) Serum transferring saturation

Iron requirements Because of the recycling of iron, only a small amount of iron is need by the body. In general, iron requirements are greater when there is rapid expansion of tissue and red cell mass, as for example during pregnancy, childhood & adolescence. Table 14 shows the recommended daily intakes.

344 TABLE 14 Requirements of iron for different age groups Age Group Iron in mg that should Infants (5-12 months) 0.7 Children (1-12 years) 1.0 Adolescents (13-16 years) 1.8 (males) 2.4(females) Adults, males 0.9 Adults, females: Menstruation 2.8 Pregnancy(first half) 0.8 (Second half) 3.5 Lactation 2.4 Post-menopause 0.7

IOINE Iodine is a essential micronutrient. It is required for the synthesis of the thyroid hormones, thyroxine (T4)and triliodothyronine (T3) containing respectively 4 and 3 atoms of iodine. Iodine is essential in minute amounts for the normal growth and development and well being of all humans. The adult human body contains about 50 mg of iodine, and the blood level is about 8-12 micrograms/dl.

Sources The best sources of iodine are sea foods (e.g., sea fish, sea salt) and cod liver oil. Smaller amounts occur in other foods, e.g., milk, meat vegetables, cereals,etc. The iodine content of fresh water is small and very variable, about 1-50 micrograms/L. About 90 per cent of iodine comes from foods eaten; the remainder from drinking water. The iodine content of the soil determines its presence in both water and locally grown foods. The deficiency is geochemical in nature.

Goitrogens

345 “Goitrogens", are chemical substances leading to the development of goitre. They interfere with iodine utilization by the thyroid gland. They may occur in food and water. The brassic group of vegetables (e.g., cabbage, cauliflower) may contain goitrogens. Most important among the dietary goitrogens are probably cyanoglycosides and the thiocyanates.

Deficiency

The most obvious consequence of iodine deficiency is goitre but recent studies have indicated that there is a much wider spectrum of disorders, some of them so severe as to be disabling. They include : (a) hypothyroidism (b) retarded physical development and impaired mental function (c) increased rate of spontaneous abortion and stillbirth (d) neurological cretinism, including deaf-mutism; and (e) myxedematous cretinism, including dwarfism and severe mental retardation. To express this state of affairs more accurately, the term "endemic goitre", is now replaced by the term Iodine Deficiency Disorders (IDD) to refer to all the effects of iodine deficiency on human growth and development which can be prevented by correction of iodine deficiency . The spectrum of IDD is as shown in Table 15.

346 TABLE 15

The spectrum of iodine deficiency disorders in approximate order of increasing severity

Disorders Levels of severity Goitre -GradeI -GradeII -GradeIII HYPOTHYROIDISM -Varying combinations of clinical signs (depending on age of onset, duration and severity) Subnormal intelligence Delayed motor Milestones Mental deficiency Variable severity Hearing defects Speech defects -Unilateral Strabismus (squint) - Bilatreral

Nystagmus -Bilateral

Spasticity (extrapyramida) Neuromuscular weakness -Muscle weakness in legs arms Trunk -Spastic diplegia -Spastic quadriplegia Endemic cretinism -Hypothyroid cretinism -Neurological cretinism Intrauterine death (spontaneous abortion, miscarriage)

Adequate technology exists for the successful prevention of iodine deficiency disorders.

347 REQUIREMENT

The daily requirement of iodine for adults is placed at 150 micrograms per day. This amount is normally supplied by well balanced diets and drinking water except in regions where food and water are deficient in iodine.

Epidemiological assessment of iodine deficiency

This is necessary before initiating an iodization programme, and for surveillance of goitre control programmes. The following indicators are useful in this regard  prevalence of goiter  prevalence of cretinism  urinary iodine excretion  measurement of thyroid function by determination of serum levels of

thyroxine(T4)and pituitary thyrotropic hormone (TSH), and  prevalence of neonatal hypothyroidism

Since the objective of goitre control programme is to increase iodine intake, indices of urinary excretion are particularly recommended for use in surveillance. Neonatal hypothyroidism has been found to be a sensitive indicator of environmental iodine deficiency. Serum T 4 level is a more sensitive indicator of thyroid insufficiency

than T3' FLUORINE Fluorine is the most abundant element in nature. Being so highly reactive, it is never found in its elemental gaseous form, but only in combined form. About 96 per cent of the fluoride in the body is found in bones and teeth. Fluorine is essential for the normal mineralization of bones and formation of dental enamel.

Sources (a) Drinking water : Foods : Fluorides occur in traces in many foods, but some foods such as sea fish, cheese and tea are reported to be rich in fluorides.

348 Deficiency/Excess Fluorine is often called a two-edged sword. Prolonged ingestion of fluorides through drinking water in excess of the daily requirement is associated with dental and skeletal flurosis; and inadequate intake with dental caries. The use of fluoride is recognized as the most effective means available for the prevention of dental caries. OTHER TRACE ELEMENTS Zinc Zinc is a component of many enzymes. It is active in the metabolism of glucides and proteins, and is required for the synthesis of insulin by the pancreas and for the immunity development Zinc deficiency has been reported to result in growth failure and sexual infantilism in adolescents, and in loss of taste and delayed wound healing. There are also reports of low circulating zinc levels in clinical disorders such as liver disease, pernicious anaemia, thalassaemia and myocardial infarction. Copper The amount of copper in an adult body is estimated to be between 100-150 mg. Copper is widely distributed in nature. Even poor diets provide enough copper for human needs. Hypocupremia occurs in patients with nephrosis, Wilson's disease and protein energy malnutrition and in infants fed for long periods exclusively on cow's milk. Neutropenia is the best documented abnormality of copper deficiency. Estimated copper requirement for adults is about 2.2 Rg per day. Cobalt The only established function of cobalt in the human is as a part of the vitamin B 12 molecule, which must be ingested preformed. There is no evidence as yet of cobalt deficiency in man . Recently cobalt deficiency and cobalt iodine ratio in the soil have shown to produce goitre in humans. It. is suggested that cobalt may be necessary for the first stage of hormone production. i.e., capture of iodine by the gland . Cobalt may interact with iodine and affect its utilization .

349 Chromium Total body content of chromium is small, less then 6 mg. Current interest in chromium is based on the occurrence of unusual glucose tolerance curves that are responsive to chromium. Thus there is suggestive evidence that chromium plays a role in relation to carbohydrate and insulin function . Selenium Until recently, little attention had been given to selenium in human nutrition. The first report that selenium deficiency may occur in man appeared in 1961, and a similar report in 1967. Selenium administration to children with kwashiorkor resulted in significant weight increase. Studies indicate that human selenium deficiency may occur in protein-energy malnutrition . Selenium deficiency especially when combined with vitamin E deficiency, reduces antibody production . NUTRITIONAL PROFILES OF PRINCIPAL FOODS When planning balanced diets, it is important to know what foods are available according to origin, approximate chemical composition, predominant function and how to combine them to increase nutritive value. Since each food has a different Nutritional profile, an intake of different types of foods is desired to achieve optimum health. 1. Cereals and millets CEREALS Cereals (e.g., rice, wheat) constitute the bulk of the daily diet. Rice is the staple food of more than half the human race. Next to rice, wheat is the most important cereal. Maize ranks next to rice and wheat in world consumption. Maize is also used as food for cattle and poultry because it is rich in fat, besides being cheaper than rice or wheat.

350 TABLE 16 Nutritive value of some common cereals Rice: parboiling presents the nutrive value Raw Rice Wheat Maize dry Milled Whole Protein(g) 6.8 11.81 11.1 Fat (g) 0.5 1.5 3.6 Carbohydrate (g) 78.2 71.2 66.2 Thiamine (mg) 0.06 0.45 0.42 Niacin (mg) 1.9 5.0 1.8 Riboflabin (mg) 0.06 0.17 0.1 Minerals (g) 0.6 1.5 1.5 Energy(kcal) 345 346 342

351 Parboiling

Parboiling (partial cooking in steam) is ancient Indian technique of preserving the nutritive quality of rice. There are many techniques of parboiling. The technique recommended by the Central Food Technological Research Institute, Mysore is known as the hot soaking process.

The process starts with soaking the paddy (unhusked rice) in hot water at 65 to 70 deg. C for 3 to 4 hours, which swells the grain. This is followed by draining of water and steaming the soaked paddy in the same container for 5 to 10 minutes. The paddy is then dried and later homepounded or milled.

During the steaming process, a greater part of the vitamins and minerals present in the outer aleurone layer of the rice grain are driven into the inner endosperm. With subsequent milling, even to a high degree, the nutrients are not removed. During the drying process, the germ gets attached more firmly to the grain. In addition, the heat used in drying hardens the rice grain. It results in the grain becoming more resistant to insect invasion and more suitable for storage than raw rice. The starch also gets gelatinized which improves the keeping quality of rice. The serious disadvantage of parboiling is the development of a peculiar smell or "off flavour" which some consumers do not relish. Modern methods of parboiling rice have been developed by which the finished product does not give any bad odour. Wheat Next to rice, wheat is the most important cereal. Maize Maize (Corn, bhutta) ranks next to rice and wheat in world consumption, and in certain areas it is the principal source of proteins and energy both. MILLETS The term "millet" is used for smaller grains which are ground and eaten without having the outer layer removed; they are jowar (sorghum), bajra (pearl millet), ragi, kodo

352 and a few others known as "minor millets" or pseudocereals The nutritive value of millets is as shown in Table 18. TABLE 18 Nutritive value of millets (values per 100 g) Jowar Bajra Ragi Protein (g) 10.4 11.6 7.3 Fat (g) 1.9 5.0 1.3 Carbohydrate (g) 72.6 67.5 72.0 Minerals (g) 1.6 2.3 2.7 Calcium (mg) 25.0 42.0 344.0 Iron (mg) 4.1 8 3.9 Thiamine (mg) 0.3 0.3 0.2 Riboflavin (mg) 1.3 0.25 0.18 Niacin (mg) 3.1 2.3 2.3 Energy (mg) 349 361 328

Jowar (sorghum) Jowar is also known as kaffir corn or Milo. It is a major crop grown in India next only to wheat and rice. For several population groups, it is a staple diet. The protein content of jowar varies from 9 to 14 per cent, and the proteins are limiting in lysine and threonine.

Ragi Ragi is a popular millet in Andhra and Karnataka. It is the cheapest among millets. Ragi flour is cooked and eaten as porridge. Ragi is rich in calcium . 2. Pulses (legumes) Pulses comprise a variety of grams, also known as dhals. Most commonly eaten pulses are bengal gram (chana), red gram (tuvor or arhar), green gram (mung) and black gram (urd). Others include lentils (masur), peas and beans including soya-bean. Khesari dhal (lathyrus sativus), is consumed in parts of Madhya Pradesh, Uttar Pradesh and Bihar, excessive consumption of which is associated with lathyrism.

353 Pulses contain 20 to 25 per cent of proteins, which is double that found in wheat and three times that found in rice. In fact, pulses contain more protein than eggs, fish or flesh foods. But in regard to quality, pulse proteins are inferior to animal proteins. Pulse proteins are poor in methionine and to a lesser extent in cystein. On the other hand they are rich in lysine. Soya bean is exceptionally rich in protein, containing up to 40 per cent. In addition, pulses are rich in minerals and B-group vitamins such as riboflavin and thiamine. In the dry state, pulses do not contain vitamin C. Germinating pulses, however, contain higher concentration of vitamins, especially vitamin C and B vitamins. Fermentation also modifies the nutritive value of pulses in that the vitamin content particularly that of riboflavin, thiamine and niacin is enhanced. Although pulses are called "poor man's meat" they are eaten by the rich and poor alike in India. They give'variety to the diet and make the food more palatable. Table 19 gives the nutritive value of some common pulses. TABLE 19 Nutritive value of pulses (values per 100 g) Energy Proteins Fat Calcium Iron Thiamine Riboflavin Niacin Vit (kcal) (g) (g) (mg) (mg) (mg) (mg) (mg) C Bengal Gram 360 17.1 5.3 202 4.6 0.30 0.15 2.9 3 Black Gram 347 24.0 1.4 154 3.8 0.42 0.20 2.0 0 Red Gram 335 22.3 1.7 73 2.7 0.45 0.19 2.9 0 Soya Gram 432 43.2 19.5 240 10.4 0.73 0.39 3.2 0

3. Vegetables

Vegetables are classed as "protective foods"; their value resides in their high vitamin and mineral content. Some vegetables (e.g., green peas, beans) are also good sources o protein. Vegetables usually have a large water content, energy and protein content and varying amounts of "dietar fibre". Vegetables are divided into three groups green leaves" "roots and tubers", and "others".

a. Green leaves

The term "green leaves" designates a number of indigenous leafy vegetables consumed by the people. They include pala (spinach), amaranth, cabbage, fenugreek (methi) etc.

354 The darker the green leaves, the greater their nutritive value. With the possible exception of vitamin B 12, green leaves are rich sources of carotenes, calcium, iron and vitamin C. They are also fairly good sources of riboflavin, folic acid and many other micronutrients. In addition, leaf proteins (2 to 4 per cent) are good sources of lysine, although deficient in sulphurcontaining amino acids. The bio-availability of calcium and iron from greens is rather poor because of the presence of high amounts of oxalates. Leafy vegetables are high in water content and dietary fibre. Because of their low caloric value (25 to 50 kcal per 100 g) and large bulk, they have an important place in the dietaries of obese people who wish to cut down their calorie intake. The recommended daily intake of green leafy vegetables is about 40 g for an adult.

Roots and tubers

Included in this group are potato, sweet potato, tapioca, yam, carrots, onion, radish and colocasia. They vary widely in composition, some are good sources of carbohydrates such as potatoes and tapioca. In general roots and tubers are poor in protein, minerals and vitamins. Some vegetables like cluster beans, drumsticks and green mango contain fair amounts of iron. Carrots are exceptionally high in betacarotene. In times of cereal shortage, potatoes, sweet potatoes, and tapioca can serve as subsidiary foods for limited periods. But bulk and low protein make them unsuitable as staple foods for longer periods, unless supplemented by foods richer in protein. The recommended daily intake of roots and tubers is 50 to 60 g for an adult.

b. Other vegetables

There is a wide range of "other" vegetables such as brinjal, tomatoes, cauliflower, etc. They bring variety to the diet. Many of them are fairly good sources of minerals and vitamins. The daily recommended intake is 60 to 70 grams,

4. Nuts and oilseeds

355 Included in this group are groundnut (Peanut), cashew nut, coconut, walnut, almonds, pistachio, mustard seeds, sesame seeds, cotton seeds, sunflower seeds, maize germ and many others from which cooking oils are extracted.

Nuts and oilseeds contain good amount of fat and good quality protein in a relatively small bulk.

5. Fruits

Fruits are protective foods. They are invaluable in human nutrition because they are good sources of vitamins and minerals. One special feature which distinguishes fruits from other foods is that they can be eaten raw and fresh. This makes the vitamins and minerals present in fruit easily available.

Nutritive Value (1) Vitamins : Fruits are prized for their vitamins. (2) Minerals : Fruits are good sources of minerals especially sodium and potassium. (3) Carbohydrate : Fruits in general have a low energy value but some fruits like banana and mango contain good amounts of carbohydrate and can act as good source of energy. Pectin, a kind of sugar, present in fruits like guavas is helpful in the preparation of fruit jellies. The fruit sugars are easily digestible and completely absorbed. The more ripe a fruit is, the higher its sugar content. (4) Cellulose : Fruits contain cellulose which assists in normal bowel movements.

Name Calories Calcium Iron Carotene Vit.C (mg) (mg) (mg) (mg) Fresh Fruits:

356 Banana 104 10 0.5 124 7 Grapes 71 20 1.5 0 1 Guava 51 10 0.27 0 212 Mango 74 14 1.3 2210 16 Orange 48 26 0.32 2240 68 Papaya 32 17 0.5 2740 57 Sitaphal 104 17 4.31 0 37 Amla 58 50 1.2 9 600 Dry fruits Dates 317 120 7.3 44 3 Raisins 308 87 7.7 2.4 1

6. Animal foods

Foods of animal origin include meat, poultry, fish, eggs, milk and dairy products. They provide high quality protein (containing all the essential amino acids) and good amounts of fat, besides some vitamins and minerals. Vitamin B 12 is one of the . rare nutrients found only in animal foods. Since they are expensive, animal foods are consumed in small amounts in most developing countries. Even small amounts of animal foods add considerably to the nutritive value of the diet. Among animal foods, cow's milk and hen's egg are perhaps nature's two most nearly perfect foods.

Milk Milk is the best and most complete of all foods.

TABLE 20 Nutritive value of milks compared (Value per 100 grams)

357 Buffalo Cow Goat Human Fat (g) 6.5 4.1 4.5 3.4 Protein (g) 4.3 3.2 3.3 1.1 Lactose (g) 5.1 4.4 4.6 7.4 Calcium (mg) 210 120 170 28 Iron (mg) 0.2 0.2 0.3 - Vitamine C (mg) 1 2 1 3 Minerals (g) 0.8 0.8 0.8 0.1 Water (g) 81.0 87 86.8 88 Energy (kcal) 117 67 72 65 Egg Egg contains all the nutrients except carbohydrate and vitamin C. Fish Fish is nutritious food rich in proteins (15 to 25 per cent) with a good biological value and a satisfactory amino acid balance. The fat of fish is rich in unsaturated fatty acids and A and D vitamins. Fish liver oils are the richest source of vitamins A and D. Fish bones when eaten are an excellent source of calcium, phosphorus and fluorides. Meat The term "meat" is applied to the flesh of cattle, sheep and goats. Meats contain 15 to 20 per cent of protein, which is less than that found in pulses, but meat proteins are a good source of essential amino acids. Iron contained in meat (2 to 4 mg per 100 g) is more easily absorbed than iron in plants and this is another major quality of meat. In addition, meat contains varying amounts of fat, which is composed of non-essential saturated fat. The energy provided by meat depends upon its fat content. Besides iron, meat provides minerals such as zinc and B-vitamins. It is poor in calcium (10 to 25 mg per 100 g) but rich in phosphorus. Liver is extremely rich in many nutrients.

TABLE 21 Nutritive value of meat, fish and eggs Nutritive Value of Meat. Fish and Eggs (g/100 g) Proteins Fat Minerals

358 Meat, Goat 21.4 3.6 1.1 Fish 19.5 2.4 1.5 Egg. Hen 13.3 13.3 1.0 Liver goat 20.0 3.0 1.3 Two large eggs without shell weigh about 100 g.

7. Fats and oils Good cooking demands liberal use of oils and fats. Fats which are liquid at room temperature are called oils. Fats and oils are good sources of energy and fat-soluble vitamins. Fats of animal origin are poor sources of essential fatty acids. Those of vegetable origin are rich in poly-unsaturated fatty acids, excepting coconut and palm oils. The vegetable oils contain no vitamin A and D, except for red palm oil which is extremely rich in carotene. During the past 25 years, there has been a great increase in manufacture of vanaspati (hydrogenated fat) under various trade names. Margarine is made from vegetable oils and is fortified with vitamin A and D. 8. Sugar and jaggery These are carbohydrate foods. Sugar is produced from sugarcane in India, and from sugar beet elsewhere. Refined sugar is pure sucrose and contains no other nutrients. Jaggery is prepared from sugarcane in India. Honey consists of about 75 per cent sugars, mostly fructose and glucose. Condiments and spices These include as afoetida, cardamom, chillies, garlic, cloves, ginger, mustard, pepper, tamarind, turmeric, etc. They are mainly used, to enhance the palatability of foods and stimulate appetite. The essential oils present in them have carminative properties and may aid in digestion.

TABLE 22 The chemical composition of coffee, tea and cocoa (Values per cup of 150 tnl) Coffee Tea Cocoa Protein (g) 1.8 0.9 7.2

359 Fat (g) 2.2 1.1 8.8 Carbohydrate (g) 17.8 16.4 26.2 Kcal 98.0 79.0 213.0

Soft drinks NUTRITIONAL REQUIREMENTS Basic concepts The science of human nutrition is mainly concerned with defining the nutritional requirements for the promotion, protection and maintenance of health in all groups of the population. Such knowledge is necessary in order to assess the nutritional adequacy of diets for growth of infants, children and adolescents, and for maintenance of health in adults of both sexes and during pregnancy and lactation in women. In this context, a variety of terms have been used to define the amount of nutrients needed by the body such as : optimum requirements, minimum requirements, recommended intakes or allowances, and safe level of intake. Of these, the term "recommended daily intake" or allowance (RDA) has been widely accepted . Recommended daily allowance (RDA) The term "recommended daily intake "is defined as the amounts of nutrient sufficient for the maintenance of health in nearly all people ENERGY Energy is a prime requisite for body function and growth. When a child's intake of food falls below a standard reference, growth slows, and if low levels of intake persist, adult stature will be reduced. Similarly, if adults fail to meet their food requirements they lose weight.

If an adequate energy supply is not provided, some protein will be burnt to provide energy. This is considered wasteful, as they are no longer available for their essential body building function. TABLE 23 Recommended daily intake for energy Group Body weight Kcals Energy allowance perday MJ

360 Infancy 0-6 months 118 7-12 months 108 kcal/kg/day Children 1-3 years 12.03 1240 5.1 4-6 years 18.87 1690 7.0 7-9 years 26.37 1950 8.1 Adolescents 10-12 years (males) 35.4 2190 9.1 (Females) 31.5 1970 8.2 13-15years (males) 47.8 2450 10.2 (Females) 46.7 2060 8.6 16-18 years (males) 57.1 2640 11.0 (Females) 49.9 2060 8.6 Adults Ref Males (light work) 60 2425 10.1 (Moderate work) 2875 12.0 (heavy work) 3800 15.8 Ref Females(light work) 50 1875 7.8 (Moderate work) 2225 9.3 (heavy work) 2925 12.2

Pregnancy +300 +1.25 Lactation (First 6 months) +500 +2.3 (6-12 months) +400 +1.63

TABLE 24 Daily intake of energy Age Body weight kg kcal.kg.24hrs (approximate) -1year (average 112 1to 3 years 12.0 100

361 4 to 6 years 18.8 90 7 to 9 years 26.3 80 Reference man 60 45 Reference woman 50 40

PROTEIN Protein requirements vary from individual to individual. Apart from age, sex and other physiological variables, factors like infection, worm infestation, emotional disturbances and stress situations can affect a person's protein requirement. Assessment of protein (a) Protein Quality The quality of a protein is assessed by comparison to the reference protein" which is usually egg protein. (b) Protein Quantity The protein content of many Indian foods has been determined and published in food composition tables. One way of evaluating foods as source of protein is to determine what per cent of their energy value is supplied by their protein content. This is known as Protein-Energy Ratio (PE ratio or percentage). Energy from protein x 100 PE per cent = Total energy in diet

This concept is useful because in many population groups adequate diet is not consumed to meet energy needs, resulting in energy deficits.

TABLE 25 Nutrients per 100g Energy from proteins Food Kcal Protein Actual PE% (g) (kcal) Fish 100 20.0 80 80 Milk(cow) 67 3.2 13 20 Dhal 350 21.0 84 24

362 Rice 350 7.0 28 8 Potato 100 1.6 6 6 Banana 100 1.0 4 4 Tapioca 160 0.7 3 2

If the PE is less than 4 per cent, the subject will be unable to eat enough to satisfy protein requirements. It is recommended that protein should account for approximately 15 to 20 per cent of the total daily energy intake Carbohydrate The recommended intake of carbohydrate in balanced diets is placed so as to contribute between 50 to 70 per cent of total energy intake. Most Indian diets contain amounts more than this, providing as much as 90 per cent of total energy intake in some cases, which makes the diet imbalanced. This needs to be corrected through nutrition education. BALANCED DIET A diet may be defined as the kinds of food on which a person or group lives. A balanced diet is defined as one which contains a variety of foods in such quantities and proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrate and other nutrients is adequately met for maintaining health, vitality and general well- being acid also makes a small provision for extra nutrients to withstand short duration of leanness . A balanced diet has become an accepted means to safeguard a population from nutritional deficiencies. In constructing balanced diet, the following principles should be borne in mind : (a) First and foremost, the daily requirement of protein should be met. This amounts to 15-20 per cent of the daily energy intake. (b) Next comes the fat requirement, which should be limited to 20-30 per cent of the daily energy intake (c) Carbohydrates rich in natural fibre should constitute the remaining food energy. The requirements of micronutrients should be met. The dietary pattern varies widely in different parts of the world. It is generally developed around the kinds of food produced (or imported) depending upon the climatic conditions of the region, economic capacity, religion, customs, taboos, tastes and habits of the people.

363 DIETARY GOALS All countries should develop a national nutrition and food policy setting out "dietary goals" for achievement NUTRITIONAL PROBLEMS IN PUBLIC HEALTH

There are many nutritional problems which affect vast segments of our population. The major ones which deserve special mention are highlighted

1 Low birth weight Low birth weight (i.e., birth weight less than 2500 g) is a major public health problem in many developing countries. About 30 per cent of babies born in India are LBW . In countries where the proportion of LBW is high, the majority are suffering from foetal growth retardation. In countries where the proportion of LBW infants is low, most of them are pre-term . Although we do not know all the causes of LBW, maternal malnutrition and anaemia appear to be significant risk factors in its occurrence. Among the other causes of LBW are hard physical labour during pregnancy, and illnesses especially infections. Short maternal stature, very young age, high parity, smoking, close birth intervals are all associated factors. All these factors are interrelated.

Since the problem is multifactor, there is no universal solution. Interventions have to be cause -specific.

The proportion of infants born with LBW has been selected as one of the nutritional indicators for monitoring progress towards Health for All by the year 2000. The goal of the National Health Policy is to reduce the incidence of LBW infants to about 10 per cent by the year 2000.

2. Protein energy malnutrition

Protein energy malnutrition (PEM) has been identified as a major health and nutrition problem in India. It occurs particularly in children in the first years of life. I is not only an important cause of childhood morbidity and mortality, but leads also to

364 permanent impairment of physical and possibly, of mental growth of those who survive . The current concept of PEM is that its clinical forms - kwashiorkor and marasmus - are two different clinical pictures at opposite poles of a single continuum.

The incidence of PEM in India in preschool age children is 1-2 per cent . The great majority of cases of PEM, nearly 80 per cent, are the "intermediate" ones, that is the mild and moderate cases which frequently go unrecognized. The problem exists in all the States and that nutritional marasmus is more frequent than kwashiorkor. In the 1970s, it was widely held that PEM was due to protein deficiency. Over the years, the concept of "protein gap" has given place to the concept of "food gap". That is, PEM is primarily due to (a) an inadequate intake of food (food gap) both in quantity and quality, and (b) infections, notably diarrhoea, respiratory infections, measles and intestinal worms which increase requirements for calories, protein and other nutrients, while decreasing their absorption and utilization. It is a viscious circle - infection contributing to malnutrition and malnutrition contributing to infection, both acting synergistically .

365 Inadequate deitary intake

Appetites loss, Nutrients loss, malabsorption Altered Weight loss Growth metabolism faltering immunity lowered Mucosal damage

Disease: Incidence, duration severity

There are numerous other contributory factors in the web of causation, viz. poor environmental conditions, large family size, poor maternal health, failure of lactation, premature termination of breast feeding, and adverse cultural practices relating to child rearing and weaning such as the use of over diluted cow's milk and discarding cooking water from cereals and delayed supplementary feeding .

Malnutrition is self-perpetuating. A child's nutritional status at any point of time depends on his or her past nutritional history, which may particularly account for the present status. To some extent, this nutritional history is linked to the mother's health and nutritional status. This in turn has been influenced by her living conditions and nutritional history during her own childhood (Fig. 2).

366 Nutritional woman of child- bearing age

Nutritional status at puberty Nutritional status of pregnant woman

Girl,s nutritional status

Neonatal and infant nutritional status

Nutritional status of lactating women

Fig.2 Influence of each generation’s nutritional status on the following generation. Early Detection of PEM The first indicator of PEM is under-weight for age. The most practical method to detect this, which can be employed even by field health workers, is to maintain growth charts. These charts indicate at a glance whether the child is gaining or losing weight.

Nutritional anemia In India: Iron deficiency anemia is a nutritional problem in India and many other developing countries. The incidence of anemia is highest among women and young children, varying between 60 to 70 per cent. Detrimential effects

The detrimential effects of anemia can be seen in three important areas.(a) Pregnancy: Anaemia increases the risk of maternal and foetal mortality and morbidity. In India, 20 to 40 per cent increases the risk of maternal deaths were found to be due to anaemia Conditions such as abortions, premature births, postpartum

367 haemorrhage and low birth weight were especially associated with low haemoglobin levels in pregnancy. (b) Infection: Anaemia can be caused or aggravated by parasitic disease. Further iron deficiency may impair cellular response and immune functions and increases susceptibility to infection (c) work capacity: Anaemia (even when mild) causes a significant impairment of maximal work capacity. The more severe the anaemia, the greater the reduction in work performance, and thereby productivity. This has great significance on the economy of the country.

Interventions

Iron and folic acid supplementation

Dosage: (a) Mothers: One tablet of iron and folic acid containing 60 mg elemental iron(180 mg of ferrous sulphates) and 0.5 mg of folic acid should be given daily. Administration should be continued until the haemoglobin level has returned to normal so that iron stores are replenished. It is necessary that estimation of haemoglobin is repeated at 3-4 month intervals. The exact period of supplementation will depend upon the progress of the beneficiary (b) Children: If anaemia is suspected – Deworming is done first. Followed by I.F.A tablet (Small) is given twice daily for 100 days.

368 Chapter - 12

PREVENTION OF FOOD ADULTERATION ACT AND PH-ACT

IMPLEMENTATION OF PREVENTION OF FOOD ADULTERATION ACT IN KERALA The prevention of food adulteration Act 1954 is a Central act which is being enforced in the Kerala State by the Department of Health Services. The Supervisory of implementing the Act and its working has been vasted with the Director of Health Services, being the State Food (Health) Authority.

There is a Food Administration Wing with Deputy director of Health Services (PFA) as the State programme officer. One Law Officer (PFA) and Technical Assistant (PFA) working in the Directorate, assist Dy. DHS (PFA) for effective implementation of the ACT.

The three machineries functioning for the implementation of prevention of food Adulteration Act are as follows:-

i. The Enforcement Machinery

ii. The Laboratory Services.

iii. Prosecution of the prevention of Food Adulteration cases

I The enforcement Machinery

The food inspectors are appointed and notified for the purpose of periodical inspection and collection of food samples for analyses as per the provision of the Act and Rules from the local area assigned to him.

There are 60 circle Food Inspectors in the Health Services Department for implementing the Act in the Rural area. Each Food Inspectors having about 11 to 15 panchayats under his jurisdiction. For guidance and supervision of the statutory work of the Food inspectors, A supervision of the statutory work of the food Inspectors, a supervisory cadre of District Food Inspector’s place were created and they are notified as the Local (Health) Authority

369 by Government notification. At present three are 14 district Food Inspectors one for each District.

There are three Mobile Vigilance squad comprising of three notified Food Inspector each having jurisdiction on a regional basis including Municipal and corporation areas, with Head Quarters at Thiruvanathapuram, Ernakulam and Kozhikode, the Chief Food Inspector being the head of the wing in each squad. The M.V.squad makers surprise inspection, investigate complaints received from consumers, volantry organization and also pays more attention to control adulteration in manufacture level. In the case of Urban areas consisting of Corporation and Municipalities the Food inspectors are appointed by Local Authorities. Out of 32, 19 post of Food Inspectors are filled up by deputation from Health Services and others are promoted from Municipal Common Service. II Laboratory Services: Till 1975, the Government Analyst Laboratory at Thiruvananthapuram was the only Laboratory for the statutory analysis of food samples. On account of better implementation of PFA Act in all panchayat area and Urban areas the number of samples increased considerably and Government decided to start two Regional Analystical Laboratories at Ernakulam and Kozhikode and they started functioning in 1975. Government also provided additional staff for these Laboratories. The food samples collected by the Food Inspectors under the PFA Act are analysed in these Laboratories and the analytical reports are to be issued within a time limit of 40 days. The Chief Government Analyst is the controlling officer of these three analytical Laboratories who is also notified as Public Analyst. Besides the statutory analysis of food articles, these Laboratories under take the analysts of Hospital diet articles supplied to Government Hospitals, water for drinking purposes and Industrial purposes and effluent water samples. Facilities are also available in these Laboratories for private parties to get good and water samples analysed by paying fees. III Prosecution of Cases

370 All the Food Inspectors notified under section 9 of PFA Act authorized to Institute prosecutions under the Act within the local area assigned to them Prosecutions are lauched in all cases where the food articles are reported to be

adulterated by the public Analyst. The chief government analyst, Government Analyst and the Deputy Government Analysts are notified as Public Analysts under the Act. The analytical report signed by the Public Analyst is used as evidence of facts started therein for any proceeding under the Act. When a case ends in acquitted, the judgement is examined by the State Food (Health) Authority with (Legal) to see whether there is any scope for appeal and accordingly appeals are filed. If the office is proved the concerned vender is convicted, the minimum punishment being 6 months imprisonment with a fine of Rs.1000/- PUBLIC HEALTH ACT IN KERALA Public Health is defined as the art and science of maintaining protection and improving the health of people through organized community efforts. The three approaches for the promotion of public health is education, service and legislation Promotion of the Public Health one of the legitimate and most important functions of Civil Government. Health is not only the right but the duty of the state or local body to pass such laws as may be necessary for the preservation of health of the public. Public health law and legislation have expanded to provide authorization, direction and regulation of many fields of environment and personal health services. In Kerala there are two Public Health act in the Travancore – Cochin area follows; the Travancore – Cochin Public Health Act 1955(Act XVI of 1955) and in the Malabar area follows the Madras Public Health Act 1939(Act published in St.George Gazette dated 7-3-1939) The structure of enforcement wing of Public Health Act is as follows. Director of Health Services shall be the Ultimate Health Authority of the state, District Medical officer shall be the Ultimate Health Authority of the district, Deputy District Medical Officer/Medical Officer in charge of primary health centre/,Medical officer possessing post graduation in community health for corporation/municipality and township areas and Health supervisor/health inspectoras health officers. As per public health officers are the

371 implementing/detecting officers of this Act. The power of health officer may be delegated to any public health staff (section 9 of T.C. PH Act and section II of Madras P.H. Act)

Extracts from Travancore- Cochin Public Health Act and Madras Public Health Act

Section 2 class (14) of T.C. PH Act Section 3 class (12) of Madras PH Act “Food” includes every articles consumed or used by man for food, drug, drink or chewing and all materials used or admixed in the composition or preparation of such articles and shall also include the flavoring and colouring matter and condiments.

Section 2 class (27) of TC PH Act Section 3 class (25) of Madras PH Act nuisance includes any act, omission, place or thing which causes or is likely to cause injury, danger, annoyance or offence to the sense of sight, smell or hearing or disturbance to rest, sleep or which is or may be dangerous to life or injurious to the health or property of the public or the people in general who dwell or occupy property in the vicinity or persons who may have occasion to use any public right. Section 32 of TC PH Act salvage or sewage not to be let out streets ------Section 40 of Madras PH Act

Section 39 of TC PH Act Section 41 of Madras P.H.Act Certain things to be nuisance without Prejudice to generality of the definition of the expression ‘nuisance’ contained in class 27 of section 2 (class 1) of section) the following shall be deemed specially to be nuisances for the purpose- The Kerala Municipal Act 1994 and Kerala Panchayat Act 1994 also have the similar provition for promoting Health of Public. Also the Criminal Procedure Code also have a provition to abaite the nuisance.

372 Chapter - 13 ENVIRONMENTAL SANITATION

The word sanitation is derived from the Latin word Sanitas which means a state of health. The W.H.O. defines environmental sanitation as “the control of all those factors in man’s physical environment which exercise or may exercise a deleterious effect on the physical development, health and survival.” UNIT I HOUSING The house is the centre of family life. The kinds of houses in which people live affect their health. Good house protect health. Bad house may damage health. The community health worker should know how housing affects health and should be able to advise people on how to improve their houses in order to have a healthier environment and better health. In judging how good a house is, consider five important points  the site of the house  the amount of space, the layout and the ventilation  protection against rain and wind, heat and cold, insects and animals  materials used in constructing the house  how people maintain and use their house Learning Objectives

373 1. Give advise on where to site a house 2. Give advise on space layout and the ventilation of a house 3. Explain to the people what is needed for a house to give the necessary protection 4. Explain how floors and walls may be made safe. 5. Explain the need to clean and maintain the house and warn against over crowding A HEALTHY HOUSE A healthy house need not to a big house made of modern material. Traditional house often suit peoples needs and activities and the local climate better

than modern houses. Often traditional houses can be made more healthy if attention is paid to clean liness and simple improvements that do not cost much. THE SITE OF THE HOUSE The site of the house is important for health. For example, a house should not be sited close to a place where people dump waste. This is because there will be many flies other insects and rats near the waste dump and these animals spread disease. If rain water floods the site, or if ground water seeps into the walls, the house will damp and unhealthy. The exposure of the site to the sun should be considered in a cool or cold climate the sun can heat the walls, in a hot climate the site should be shaded from the sun as much as possible, for example by choosing a site which is surrounded by trees. In general a healthy house is  Close to a reliable supply of safe water  More than 100 metres away from a place where people dump waste.  Close to a sanitary means of disposal of excreta  In a place from which rain water and waste water drain away Space When a house is very crowded disease spread more easily from person to person. More space is better for health.

374 LAYOUT Waste water and waste are full of germs that may cause disease. There must be a way of draining away waste water or of using it to water a garden. Solid waste should be disposed of safely because waste attracts flies and other insects and animals which may spread diseases. Domestic animals should be kept is a separate area so as to avoid bringing dirt in to the house where people live. A fence should keep out hens, goats and other animals. Every house should have a latrine of its own. The house should be safe for young children. Anything that might harm them, such as fire, knives, medicines or chemical used in the garden should be kept out of their reach. Small children should not be allowed in the cooking area.

VENTILATION It is important to have fresh air blowing freely through the house so that smoke and stale air clear quickly. This can be done by positioning doors and windows in such a way that air can pass freely through the rooms of the house. If the windows have to be kept shut in the cold season, then the house should have a chimney or a hole in the roof to let out the smoke from the fire. In general a healthy house has  Enough space so that people are not crowded together especially when sleeping, barriers to keep animals out and a fenced off area, at least 10m from the house and from outdoor living areas, for goats, sheep, pigs, cows, or other domestic animals.  Separate place for bathing ad washing household utensils and cloths, with drainage of waste water for plants in the garden.  A place to store food and water, which can be reached easily but can also be kept very clean and safe from rats, other animals and insets.  A place for a fire or cooking stove (under a chimney or an opening in the roof to let out the smoke) which is protected to minimize danger of burns and scalds especially to little children.

375  Windows that permit cross-currents of air so that fresh air may enter and stale or smoky air may be drawn or blown out  Protected place to store dangerous substances and objects out of the reach of children. A HOUSE SHOULD PROVIDE THE NECESSARY PROTECTION A healthy house is neither too warm nor too cold, people should feel comfortable in it. There should be a door to keep animals out. Food in the house should be stored in such a way that rats and mice cannot reach it. If possible doors and windows should have net screens to keep flies and mosquito out. Mosquito nets can also be used over beds while people are sleeping. In warm climates the walls should be protected from the sun by for example, sunshades or a simple veranda, around the house. Rain water should flow from the roof into a gutter that leads into a drain or container, this keeps the walls and the ground around the house dry. In general a healthy house has  a good roof to keep out the rain  good walls and doors to protect against bad weather, and to keep out animals  Screens of netting wire at the windows and doors to keep out insets, especially mosquito  Sun shades all around to protect the walls from direct sunlight in hot weather. FLOORS AND WALLS SHOULD BE MADE SAFE Always remember that local materials and local construction can often by very good and healthy. Bricks, cement and corrugated iron sheets are not necessarily better than traditional materials which have always served their purpose well. The so called modern way whenever possible building materials that do not burn easily should be changed instead of materials that catch fire easily In general a healthy house has

376  A floor of wood stamped clay, bamboo, concrete, tiles or similar materials, so that people do not have to work on the bare earth and so that the floor can be easily cleaned.  Walls with a smooth hard surface so that they can easily be cleaned and with no holes or cracks, in which insects, rodents or other carriers of disease can live A house should be clean, well maintained and not over crowded. The way people use their house earn effect their health. Every house, no matter how small or what material it is made of can be made more healthy by regular cleaning, removal of refuse, time repairs and construction use of latrines when two many people live in one house it makes cleaning and maintenance difficult, causes tension among the occupants, and may result in respiratory infection.

Water Supply Much sickness is cause by dirty or unsafe water. To be healthy, people need clean water for

 Drinking  Preparing and cooking food  Washing the body  Washing clothes

A clean water supply is essential for community health. Clean water comes from a protected tap, spring, well, or borehole. Water for drinking from any other source should first be treated to make it safe. When it cannot be boiled it should be cleaned by filtration. The vessels and other containers used for storing or carrying water must be kept clean. The whole community should always be concerned with improving and maintaining the quality of the water supply.

377 Learning objectives After studying this section you should be able to: 1. Find out whether the water from the water source in your community is safe for drinking and cooking or bathing and other uses. 2. Discuss with the people the danger of drinking dirty water. 3. Discuss with the people how they can protect their sources of water. 4. Show the people how they can clean water by filtering, boiling or disinfecting it. 5. Discuss with the people why they should keep clean and cover carefully the vessels and tanks in which they store water.

Dirty water causes diarrhoea If people often get diarrhoea in your community you should check where people get their water from and how they use it. The use of unclean water is often a main cause of diarrhea.

Visit the places where the people get their water from and decide what is wrong and what action should be taken to improve the situation. The people usually get water from:  A pond  A river  A spring  A well or a borehole  A tank (rainwater). The people may be drawing the water directly from the source of the water may be coming through pipes to a common village tap or stand-pipe or to separate house connections. Watch how they draw their drinking water from the source and how they carry and store it. Visit houses to find out what they do to keep their drinking water clean. Water from a pond

378 If there is no other place from which to get water tell the people to boil the water, filter it, or disinfect it with chemicals before drinking and store it in a clean container. They should avoid bathing in the pond. Discuss with the village chief how to find some other way of getting clean water such as from a river or a spring. If there is another place (river, spring or well) from which to get water First make sure the other sources are clean and not too far away. Then advise the people not to use water from the pond for drinking. The pond can then be used for other purposes such as watering the cattle, or watering gardens, but not for drinking or cooking. Water from a river If there is no other place to get water from The people should draw water from the river before it reaches the village and boil, filter, or disinfect the water before drinking it. They should bathe and wash clothes only where the river leaves the village, and only let the animals drink the water further down the river. If there is a well or a spring Advise the people that it is safer to get drinking water from a well or spring if the water from these sources is known to be clean. See the next two sections on wells and springs. Water from a spring Spring water is usually clean but only if the spring is well protected. A spring is properly protected when  There is a fence all the way around it and there is a gate that is kept closed and is opened only when someone wants to get water.  There is a cemented stone wall half a metre high round the spring.  There is a pipe coming out of this wall and the water is taken from this pipe  There is cover over the spring to keep out animals, birds, insects, and dirt. If the spring is not properly protected or is not being used See the village chief and help the village to have it properly protected. See your supervisor if you cannot arrange to get water from the spring or protect it properly. If the people want to bring the water from a spring to the village trough pipes

379 This is usually a very good idea. Consult your supervisor about any help or advice that may be needed. Water from a well Water from a well is usually clean, but only if the well is properly protected. A well is properly protected if:  It is at least 20 metres away and uphill from any latrine or rubbish heap  It is at least 3 metres deep  It is lined inside with stones stuck with mortar  There is a stone wall around it which is at least half a metre high.  It has a removable cover and a hand- pump, if possible or another simple device for drawing water.  There is a ditch for the rainwater to drain away.  People do not let dirt get into it and they do not wash in it  Any water that is spilled can drain away from the well.

If the well is not protected Discuss with the community committee how the well may be protected. Talk with your supervisor about choosing a place for a new well if necessary. If the people want to improve the well (by putting in a pump, for example) or if they are talking about drilling to search for water, ask your supervisor’s advice. Water from a rainwater tank If rainwater is collected in tanks for drinking and cooking, explain to the people how to keep the tank-water clean. The water in the tank will be clean if:  It enters the tank through a screen or a filter to keep out leaves, dirt and insects  The tank is covered to keep out dirt and insects  The tank is emptied and cleaned at the beginning of the rainy season  The water is taken from the tank either through a tap (above-ground tank), or with a hand-pump or a hand-winch (below-ground tank). People carry water from the well or spring in a container and store it at home

380 The water can be kept clean if the container:  is kept clean  is cleaned and rinsed before it is filled  is disinfected with bleaching powder (see Annex 2) or by boiling water in it  is used only for clean water  is kept covered with a clean cloth or lid. Do not put hands or dirty cups or dippers into the water. Use a clean cup with a long handle to take water out. Filtration of water Filtering water does not disinfect it, as boiling does, but it is a simple way of removing some disease-causing germs and eggs of some worms. Filtering will make the water less dangerous. Instructions on how to make a filter are given in Annex 2.

Chlorination of water It is possible to purify water and make it safe for drinking by adding to it a disinfectant such as chlorine. Chlorination of water is a procedure that is best implemented at the community level. Food Safety Food is very precious. People should not let it go bad or be eaten or spoiled by rats and other animals. It should be kept clean at every stage from production until it is eaten. Stale or contaminated food can cause diarrhea and other diseases. Food can also be contaminated by chemicals through:  Careless use of household insecticides  Careless use of pesticides by the farmer  Treatment of seeds with chemicals  Accidental contamination during transport and storage.

381 You should know how to prevent the diseases or sicknesses that people can get from eating stale or contaminated foods. Learning Objectives After studying this unit you should be able to: 1. Find out what the people in your community eat, and how they prepare and store food. 2. Explain to them how food animals should be hygienically slaughtered and offered for sale. 3. Discuss with the community leaders, families and those who handle or sell food the risks to health of eating contaminated food and how to prevent contamination of food. 4. Explain to the people how to store food and how to protect it from rodents, insects, files and dirt. Contaminated food can cause diarrhoea If there are 5 or more new patients with diarrhoea in 1 week, or your supervisor has asked you what you have done since his last visit to have the village protected, or you have noticed that food is stored carelessly or that meat or fish is put on sale from dirty stalls in the market or the pond from which fish come is polluted what are you doing to do? Find out:  What the people eat  How they prepare their food  How they store their food Then decide what action to take What do the people eat Grain (wheat, rice or other) The main problems with grain concern storage. See section on storage on page 51. Vegetables

382 Vegetables that will be eaten raw should not be fertilized with faeces. When faeces have been used as fertilizer, vegetables should always be well washed and properly cooked before they are eaten. Meat Eating raw or underground meat can be very dangerous. Eating infected or contaminated meat can cause severe vomiting and diarrhoea, infestation with worms, and other illnesses that sometimes cause death. Food animals should be slaughtered hygienically and in a way that prevents disease. The food animals should be healthy. They should be hanging during slaughter, and after that they should be fully bled. The slaughter house (abattoir) or the place of slaughtering should be fenced off and kept clean. Diseased parts (e.g., liver with worms) found during removal of the offal and processing of the carcass should be burned or buried and not given to dogs. Meat shops should be kept clean. Meat should be sold separately from other foods in special covered shops. A large cut of meat should be kept hanging before it is sold and it should be protected from insects and animals. The butcher should wash his hands very well before he begins the sale of meat. He should be also wash his hands with soap each time he goes to the lavatory (latrine) and should use a clean cloth to

dry his hands. The butcher should make sure that all cutting instruments and the surfaces on which meat is cut are kept clean. Advise the butcher on how to keep the shop and meat clean. Visit the shop from time to time to make sure he is following your advice. If you find that he is not following your advice, inform community committee and other leaders. Handling meat in the house. Surfaces on which meat is cut and instruments used for cutting raw meat should be very well washed and dried before use. Utensils in which meat is cooked and served should also be cleaned in a similar way. To prevent spoilage, meat may be dried, or salted, or cooked immediately. Properly dried and salted meat will keep for a long time. Cooked meat should be eaten at once or within a very short time of cooking. Fish

383 Fish is a very good food, but it can go bad very quickly in warm climates, sometimes even within a few hours of being caught. Fish and shellfish can spread many diseases caused by germs and poisons, especially if it has been caught in polluted water or if it is eaten raw or undercooked. Fresh fish should always be:  Gutted as soon as possible  Kept away from direct sunlight and dry wind  Kept as cold as possible  Cooked and eaten without delay. If the water (sea, lake, river, pond) in which the fish or shellfish is caught is polluted with sewage, faeces, or animal waste, the fish should not be eaten raw. If the water is polluted with discharge from factories or with oil, the fish will often be dangerous to eat. You should discuss this problem with the community committee and ask your supervisor for help in dealing with it. Milk Milk is a very good food, but it can pass on several diseases from the cow, camel, or goat to the person who drinks it. It can also become contaminated by dirt from the animal and from the hands or throat (through coughing ) of the milk handler, and in that way spread diseases. If milk has to be stored for use during the day, boil it every 4-5 hours. If it has to be left overnight, boil it and keep it in a cool place away from insects, rodents, and cats. Boil the milk again in the morning before use. To avoid diseases spread by milk:  Take the milk only from healthy-looking animals  Wash the animal’s udder before milking; the milker’s hands should also be washed  Boil the milk before drinking it  Store milk in clean vessels in which water has been boiled or which have been rinsed with hot water. Eggs

384 Eggs provide essential body-building food. Hen’s eggs may be eaten raw when fresh. Duck eggs should always be cooked. Fruit Fresh fruit contains vitamins and minerals, which are very good for the body. Fruit should be eaten fresh after being washed or peeled. How to prevent contamination of food People who handle, prepare, and serve food should wash their hands well, with clean water and soap. They should always keep any finger wounds bandaged cleanly. The tables or other surfaces on which food is prepared, and the utensils used, should be kept clean. Show the women who prepare food at home how to wash and dry their hands properly and to clean their nails. Show the people who work in the restaurants and food shops how to wash and dry their hands properly. Ask the village chief to remind the people in the community from time to time to wash their hands before they touch food, especially after they have been the latrine. People should also be reminded regularly to:  Cook food for only one meal at a time, unless they can chill the leftovers  See that the food is eaten soon after it is cooked – food should not be left for long in a warm place.

How should people store their food ? Storing cooked food Put the food in a clean container in which water has just been boiled or which has been rinsed with hot water. Cover the container with a clean cloth. Store it in a cool place which is protected against files, other insects, mice, rats, and other animals. In hot countries, people often store drinking water in a shaded, but breezy, corner of the house. This keeps the water cool. It is a good idea to store cooked food near the drinking water vessel. This will keep the food cool and unspoiled for a few hours. If earthen pots are used to store water, the place around the vessel will be even cooler.

385 Storage of grain The grain store is properly protected against rats if:  It is closed on all sides  It is raised at least 30 cm above the ground  There is no grain (or other food) lying around near it or near the house.  There is a lid to close the container properly  Metallic cones are placed on the poles that support the container to prevent the rats from climbing up. If you see a grain store that is not properly protected against rats, show the head of the household what to do (see page 51). If after a month there are still some rats, consult your supervisor.

Always remember Dirty food brings disease (particularly diarrhoea) to the whole family. To avoid wasting food: . Prevent flies, worms, rats and other animals from reaching the food and eating or contaminating it . Eat the food soon after clean and safe.

To keep the food clean and safe:  Wash your hands before touching or preparing food  Prevent dust from the house and the road, flies, clothes, mice, rats, animals, and children’s or adults hands from touching what is going to be eaten  Cook enough food for one metal only and never keep left over if you cannot chill them  Keep your kitchen utensils clean  Do not leave clean utensils lying on the ground. Getting rid of waste

386 Every household produces waste (or rubbish) from cooking, eating, sweeping, cleaning, and other work. If this rubbish is left lying around the house it becomes dangerous. In hot climates it should be removed daily. To stay, healthy, a household must get rid of its waste safely.

Learning objectives After studying this unit you should be able to: 1. Tell the people which main health problems are caused by unsafe ways of getting rid of waste. 2. find out how families get rid of their household waste. 3. Discuss with them whether what they do is safe and how to make it safer. 4. propose to the village chief or committee what might be done by the whole community and by individual households to get rid of household waste properly. Main health problems caused by waste When waste is left lying around it makes the area look dirty and it produces a bad smell. It also attracts flies and rats and other animals which can carry disease germs to the people. For example, if flies that have been sitting on dirty waste sit on food, the people who eat the food can become ill.

If waste is left to rot near a river, pond, well or spring there is the danger that it will come into contact with the drinking water and make it dirty. When people drink this dirty water they can get diarrhoea and other diseases.

If children get hurt when playing with waste or near it, their wounds can become badly infected. Find out where people throw their waste, discuss with them what they do, and suggest what action to take.

Dumping waste in a common pit In most villages there is a common pit where people throw their waste. This pit should be properly protected from animals and flies in order to prevent diseases in the community. A common pit is properly placed and protected if:

387  It is outside the village and at least 20 metres away from the nearest house.  It is in a hollow and not on a hill  It is at least 100 metres away from any river, well or spring  There is a fence around it  The waste is piled up in a hole and not scattered around.  The waste is kept covered with earth at least 2 or 3 cm deep  Surface water cannot run into it. If the pit is not being properly used, discuss with the chief how the village can have a good common pit. Once proper arrangements are made, see whether it is being properly used by visiting it regularly.

A well-placed common pit: a common pit should be at least 20 metres from the nearest house and 100 metres from any river, well or spring.

When there is no common pit (1) If people throw waste around their house, this can be dangerous. People can get diarrhoea and other diseases if the waste is left rotting around the house. You should discuss this matter with the people and the village chief, and try to get a common pit ready as soon as possible. Make sure that the common pit is safe and well protected (see previous sections on dumping of waste in a common pit). It will be useful to ask your supervisor to come and advise on how to dig a pit or on other ways of disposing of and burning waste.

(2) If people throw waste near a river, well or spring or near a drain that flows into the river, there is a danger that the water may become dirty. If people drink such dirty water they may become ill. Discuss this problem with the village chief and your supervisor. Try to get a common pit drug. Make sure it is used properly.

388 Other suggestions you can make for getting rid of waste (1) Bury the waste in a hole at a safe distance from the houses and from sources of drinking-water. (2) Collect the waste in a container or make a neat heap of it and burn it once a week away from the village to avoid problems of smoke and smell. (3) If the waste that comes from plants(leaves, vegetables, fruit, roots) is put into a separate hole or heap (and if possible mixed with soil), it will soon become compost, which can be used as fertilizer for growing vegetables and other plants. If there is an agricultural extension worker in the community, discuss with him how to make compost and how he can help you in persuading households to make it.

Disposal of excreta: Latrines People who have diarrhoea, choleara, or worms pass there diseases on through their faeces. Like waste, faeces attract flies and animals. Flies that land on faeces that contain germs can carry these germs to food, and people who eat such food may fall ill. Therefore, people should not be careless about where they defecate.

If people defecate near a river or spring there is a danger that the water can become dirty, and that people drinking this water may then fall ill. To prevent the diseases that are spread through faeces, people should not defecate in places where other people, flies, animals and birds can touch the faeces, or where water can be contaminated. Every household should have a latrine of its own. If human excreta is left in a pit for 2-3 months it turns into fertilizer. This can be used in the fields to grow plants. If you want to know more about this, ask your supervisor.

Learning objectives After studying this unit you should be able to: 1. Find out where the village people go to defecate.

389 2. Discuss with the people why it is dangerous to defecate just anywhere, why a household should build a latrine, and how to do so. 3. Help households to build their own latrines and make sure they use and maintain them properly. The Problem Some people in your community defecate carelessly in the open. Others do not keep their latrines clean. Many children and other people are suffering from diseases that are defecate causes diseases to spread. What do you do ?

First find out where the villagers go to defecate, then discuss why it is dangerous to defecate just anywhere. The following actions can be taken depending upon the situation in your community.

When people have no latrines

If people defecate around their houses

There is a danger of diseases from faeces, particularly when people defecate less than 20 metres away from the house or on the paths that lead to the house.

 Advise the head of the household to tell the family to defecate in a latrine or, if they have no latrine, to defecate in the fields away from the house.

 Ask for the help of the village chief. He may speak to the people abut the problem. If he wants the people to build latrines, ask your supervisor for help. Afterwards make sure that the latrines are being used properly.

If people defecate in the river

The river water becomes dirty and dangerous when people defecate in it. Tell the people not to defecate:

 In the river  Within 20 metres of the river

On the path leading to the river

390 If people continue to do so in spite of your telling them not to, ask the village chief to help in persuading the people to build latrines and not to defecate in or around the river. If people defecate in the fields or the forest There is not much danger of disease if people defecate in the fields or the forest, provided that:  People defecate at least 20 metres away from any house, spring, well, river, etc.  People defecate far away from any path or track. In the open, it is better to defecate in sunny places rather than in the shade. The sun can kill the germs in the faeces. People should not defecate in agricultural fields. Remember, it is always best to use a latrine, if possible.

When people have latrines but do not use them properly Advise the head of the household to:  Make sure that no faeces are left on the slab (cover) of the latrines  Have the latrine scrubbed and cleaned regularly with water. Check from time to time to see whether the people are keeping their latrines clean.

When people use latrines properly Even when people are careful and use their latrines properly, their children may suffer from diseases spread by faeces because other people defecate carelessly. People who use latrines properly may be able to help you in showing other people how to make latrines and use them properly. When is a latrine properly built ? A proper latrine has the following features:  It is downhill and more than 20 metres away from the water supply (well river, borehole, spring, pond).  It is at least 20 metres away from the house.  It has a pit at least 1 metre deep.

391  It has a slab (cover) over the pit made of concrete (best) or wood; the slab has a hole through which faeces and urine can drop. The hole should be small enough so that children too can use the latrine; but it should be large enough for faeces and urine to fall through it. The hole should have a cover.  It has walls and a roof made of materials that are easy to get and cheap to buy and repair.  It is kept clean. (A separate broom and water bucket should be kept for cleaning the latrine. Water for washing or leaves or paper for cleaning oneself should also be kept in the latrine). Other types of latrines can also be built, depending on local conditions. You should discuss this with your supervisor. When is a latrine properly used ? A latrine is properly use when:  Everyone in the household uses it  It is kept clean and the floor and the slab are washed often  The pit is kept covered when the latrine is not being used  Materials for personal cleaning are always available (water, leaves, paper)  The pit is emptied or a new one is drug when the pit is full. When a new pit is drug, the latrine is moved to the new site. The earth from the new pit is used to cover, the old one, but the same slab is used to keep the new pit covered.

DISINFECTION The process that eliminates most but not all disease causing micro organisms from inanimate objects such as floor, drains, instruments etc. High level disinfection (HLD) though boiling for 20 minutes or use of the chemicals, eliminates all micro organisms except some of the bacterial endospores like tetanus spores. Disinfectants are not safe to be applied to living tissues. Commonly used disinfectants are Phenol (1% solution) Bleaching powder Potassium permanganate Hydrogen peroxide

392 Soap Chlorine Dettol Glutaraldehyde (Cidex) Formal dyhede Cresol Lime Savalon (Cetrimide) Instruments and equipments which can not be autolaved or boiled can be disinfected using chemical disinfectants. DISINFECTION TYPE OF DISINFECTION 1. Concurrent Disinfection It is carried out during course of patients of patients illness eg: Bioling of utensils used by patients 2. Terminal disinfection Disinfection of infected material after removal of patient to hospital, after recovery or death Eg: Disinfection of beddings and line by steam. Disinfection of rooms by fumigation Sterilization It is the process that eliminates all the micro organics (bacteria, viruses, fungi and parasites) including bacterial endospores Sterilized objects should not be touched with bare hands. Do not use antiseptic solution to sterilize syringes and needles. Methods of sterilization Sterilization is effected by steam and dry heat 1) Sterilization by steam Steam sterilization (autoclaving) is the method of choice for reusable medical instruments including needles, syringes gloves, etc. 2. Sterilization by dry heat:

393 Instrument which can with stand the temperature of 1700 C can be sterilized by dry heat in hot air ovens. Antiseptics. They are chemical agents used on skin and mucous membrane to reduce the number of micro-organisms without causing damage or irritation. They are not meant to be used on inanimate objects. They can safely be applied to living tissues like ulcers, wounds etc. Eg. Softramycin Iodine (Bet adine) Dettol Salicylic acid Boric acid 0.2% Solution of phenol. Savlon Gentian violet Germicide An agent that destroys micro-organisms, particularly those causing disease Deodorant An agent that reduces or removes unpleasant body odours by destroying bacteria that live on the skin. Eg: Hexachlorophene FOOD HYGIENE Food is a potential source of infection and is liable to contamination by micro- organisms, at any point during its journey from the producer to the consumer. Food hygiene implies hygiene in the production, handling, distribution and serving of all types of food. The primary aim of food hygiene is to prevent food poisoning and other food borne illnesses like typhoid fever, paratyphoid fever, salmonellosis, botulism, diarrhoea, shigellosis, brucellosis, viral hepatitis, Amoebiasis, lathyrism, worm infestation etc.

394 Milk Hygiene Milk is an efficient vehicle for a great variety of diseases agents. The sources of infection or contamination of milk may be from (1) the dairy animal (2) human handler or (3) the environment. Eg. Contaminated vessels, polluted water, flies, dust etc. Diseases like TB, Brucellosis, Salmonellosis, Q fever, cow pox, Anthrax, Leptospirosis, Tick – borne encephalitis, Typhoid fever, Para typhoid fever, shigellosis, cholera, Diph theria, Viral Hepatitis, etc. are transmitted through milk.

395 Chapter – 14 ANATOMY AND PHYSIOLOGY

1. CIRCULATORY SYSTEM The circulatory system is the transport system of the body. It suppliers oxygen, food and water to the tissue cells and their waste products are carried away. The part of the circulatory systems are (1) blood (2)the heart, which is the pump, forcing blood into circulation.(3) the blood vessels, in which the blood travels. The blood A total of about 6 liters of blood continually circulates through the heart and blood vessels in all parts of the body in adults Blood is a fluid tissue composed of two parts-fluid portion called plasma which the blood cells are suspended.(About 55% fluid and 45% blood cells) Plasma is a paler yellow fluid consist of Water-90%, Protein-8%(Albumin, globulin, fibrinogen, Prothrombin), Salts( including, Sodium Chloride)-0.9%. The balance is made up of traces of glucose, fats, urea, uric, acid, cholesterol, Cratinia, hormones etc. (Nutrients, Glucose, fats, amino acids, vitamins) Blood cells: are of three main types (1) Red Blood Cells or Erythrocytes (RBC) (2) White blood cells or leukocytes (WBC) (3) platelets or thromobocytes. RBC are small, circular biconcave, discs shaped cells. They have no nucleus. They contain hemoglobin which is made from iron and protein (hemoglobin). Hemoglobin gives red colour to the blood. RBC’s are formed in the bone marrow. Life span of RBC is about 120 day. After that they are destroyed in the spleen and liver. The normal amount of hemoglobin is about 14-15 gms/100ml blood. Decrease in amount of hemoglobin/RBC is called anaemia, Functions.(Normal count-4.5-5millions/per cubic m.m blood. (1) Transport of oxygen from lungs to the tissues and carbon dioxide back. (2) Maintenance of acid-base balance. WBCs. are colourless cells larger than RBC their number is less compared to RBC’s (4000-1100 per cubic blood), WBC’s are classified as- 1. Granulocytes Polymorph, Eosinophils & Basophiles (these WBC have granules in the Cytoplasm. They have a nucleuswhich contains 2 or more lobes

396 2. Agranulocytes-lymphocytes and monocytes. This type of WBC do not have granules. They have a single nucleus which is not lobed. Lymphocytes are produced in lymph glands, spleen and bone marrow. Polymorphs-65-70% total WBC, Eosinophils-2.4% total WBC, Basophil-0.5% total WBC, Lymphocytes-25% total Monocytes –2.4% total WBC Functions, of WBC 1. Protection against infection by granulocytes and monocyte. By phagocytic action. They ingest living bacteria. They have power of amoeboid movement which helps them to surround the microorganisms. They then engulf the bacteria and destroy the bacteria by their enzymes. This is called phagocytosis. Many leukocytes die in the fight and become pus cells 2. To help in the repair of injured tissues 3. To produce immune substances(Lymphocytes produce antibodies which are formed of gamma globulins) Platelets. They are small round/oval cells about 1/3 size of RBC. Normal count is 2- 5lakhas/Cu.mm blood They are formed in the bone narrow Functions (1) clotting of blood (2) Control of bleeding after injury Functions of blood 1. Carries oxygen to the tissues by the red blood cell 2. Carries nutrients to the tissues 3. Transports waste products from the tissue to the excretory organs 4. Carries hormones from the glands to various tissues 5. Contains antibodies and white blood cells which protect the body from diseases. 6. Redistributes water and help to maintain water balance of the body 7. Helps to maintain body temperature

397 CLOTTING OF BLOOD Clotting of blood is defence mechanism of the body. It prevents loss of blood from the site of injury. The average clotting time of blood is about 3-5 minutes. Process of clotting. Prothrobine+Calcium+Thrombokinase Thrombin Thrombin + fibrinogen fibrin Fibrin + blood cells clot Prothrombin and fibrinogen are formed in the liver. The clot formed plugs the site of injury and prevents further loss of blood

HEART The heart is a cone shaped muscular organ about the size of its owners closed fist. It is situated in the chest behind the sternum, between the lungs. The heart never stops beating until the time of death. The beating is due to the alternate contraction( Systole) and relaxation (diastole) of the heart muscle The heat consist of three layers:- 1. The pericardium or outer covering 2. Myocardium- Middle Muscular layer 3. Endocardium-Inner lining The pericardium has two layers with a little serus fluid between them. It permits free action of the heart muscle. Myocardium is the middle muscular coat of the heart. It also forms the heart valves. The inside of the heart has four chambers or cavities. The right atrium left atrium, right ventricle and left ventricle. The right and left sides of the heart is separated by a septum. Normally there is no communication between the two sides after birth. So the right and left sides heart act as a separate pump, but work together. Valves Separate the atria from the ventricles. They can open and close. The valves allow passage of blood in one direction only from atrium to ventricle and prevent the blood

398 flowing backwards from ventricle to atrium. The valve between (Right atrium and Right ventricle is called tricuspid valve and the valve between left atrium and left ventricle is called bicuspid valve. Right side of the heart The superior and inferior vena cava open into the right atrium. They are the largest of the veins and which bring impure blood from various parts of the body to the heart. During diastole the impure blood flows into the right atrium and when it contracts, blood passes to right ventricle through the tricuspid valve. From there to the lungs through the pulmonary artery by the contraction the right ventricle. Left side of the heart After removing carbon dioxide from the blood and replaced by oxygen in the lungs, the pure blood returns to the left atrium of the heart through four pulmaonary veins. It passes through the mitral valve to the left ventricle and through the aorta to all parts of the body. Function of the heart The heart works like a pump to keep the circulation of blood. 1. It draws blood back from the capillarics and veins 2. It sends blood to the lungs for oxygenation 3. It sends pure blood through aorta to all pars of the body. Heart sounds The working of the heart produces certain sounds which can be heared through a stethoscope. Two sounds may be heard during the action of the heart due to closing of the valves Heart rate (Pumping rate of the heart)-Normal heart rate is 72.min(60-80). Normal pulse rate-Adults-60-80/min Newborn-140/min(120-160) First year-120/min Cardiac cycle –The events which take place in the heart, during a single beat. E.S.R( Erthrocyte Sedimentation rate) is the rate at which RBC’s sink to the bottom when placed in a vertical column after adding and anticoagulant. Normal values is 3-5 mm/hr in males 4-7 mm/hr in females.

399 Cardiac Uutput It is defined as the quantity of blood pumped by the heart in one minute; It depends on 1. The amount of blood returned to the heart through veins 2. Peripheral resistance offered by blood vessels Apex of the heart. A point marked on the left side of the chest between 5th &6th ribs 9cm from the lower end of sternun gives the position of the apex of the heart. Electro Cardiogram(ECG)- Recording of the electrical activity of the heart. The instrument used is called electrocardiograph. Blood pressure (B.P) it is defined as the lateral pressure exerted by the blood on blood vessels. Has two phases- Systolic blood pressure-It is the minimum blood pressure. It occurs during the systole of the heart (range 100-120 mm Hg.) Diostolic Blood pressure- It is the minimum pressure, It occurs dutring the diostole of the heart (range 60-80 mmHg) Pulse pressure- Difference between systolic and diastolic blood pressure is nearly 40mm Hg B.P Measured by an instrument called sphygmomanometer Circulation of the blood The heart is the chief organ of the circulation of the blood. The course of the blood from the left ventricle through arteries, arterioles and capillaries returning to the right atrium by veins is called systemic circulation The course from the right ventricle through the lungs to the left atrium is the pulmonary circulation. The circulation involving blood supply to the heart is called coronary circulation and circulation through liver is called portal circulation Blood vessels Arteries and arterioles carry blood away from the heart, always oxygenated blood with the exception of pulmonary arteries which carry venous blood. Arteries are formed of 3 layers outer fibrous coat, called Tunica adventitia, Middle muscular and elastic coat inner endothelial coat consist of a single layer of

400 cells Veins have same 3 layers but middle layers is thinner and less elastic than the arteries. Capillaries-Only one layer of inner endothelial cells. Pressure points:- These are points where an artery lies near the surface and near a bone. (They are useful to stop bleeding from an artery) 1. Carotid-Side of neck,5cm above collar bone against spine 2. Temporal-Infront of ear opening at the side of the face. 3. Brachial-Middle of humerus, with fingers under the arm. 4. Femoral- middle of groin Lymphatic system:- composed of lymph, lymphatic andlymph glands(nodes). Lymph is a fluid like the plasma and the tissue fluid at contains less protein. The Lymph glands add lymphocytes to the lymph. Lymph node (Glands) are small bean shaped structure seenalong the course of lymph vessels. They are found in groups in the neck, axilla, groins and pelvis also abdominal cavities Functions of lymph glands They help to protect the body from infection by 1. Filtering the lymph to prevent germs from getting into the blood. 2. Producing new lymphocytes for the blood. Lymphocytes drain excess fluid and carry waste products from tissue to blood. Spleen:- This is a dark purple organs situated in the left side of the upper abdormen, behind the stomach Functions 1. It produces new lymphocytes 2. Helps to fight infection 3. Destroys old red blood cells 4. Acts as a reservoir for RBC’s which it release in time of need as in sudden hemorrhage. 5. Spleen produces all types of blood cells during foetal life. Blood grouping and cross matching

401 When a blood transfusion is to be given, the blood groups of both the person giving blood (donor) and the person receiving blood (receipient) must be known. The two bloods should be cross matched. If unmatched blood is given, red cells may from clumps and are destroyed. This can cause serious illness or even death.

Blood Grouping Individuals are divided into four groups-A,B.AB and O. Group of blood can match with only that groups, but ‘O’ group can be accepted by all group blood are calls Universal Donors Individuals with blood group AB can receive blood from all groups. So they are called Universal recipients. Rh factor (Rhesus factor) RH+ve individuals have this factor, but Rh-ve individuals do not have this factor Rh factor is important in repeated transfusions in pregnancy where the mother is Rh negative. Cross matching means direct mixing of a little blood from the donor with a sample of the recipient’s blood to make sure matches and is safe. Usually blood of the same group is transferred after cross matching.

2. RESPIRATORY SYSTEM Respiration is defined as the exchange of gases between body tissue and external environment. Supply of oxygen and removal of carbon dioxide occurs through repiration. Parts:- Respiratory system consists of the following structures. Nasal cavity, pharynx, larynx, trachea, bronchi, bronchioles, alveoli Nasal Cavity is divided into right and left portions by the nasal septum. Nasal cavity is lined by mucous membrane, It is a passage for air, also the organ to smell and helps in voice production. Air breathed in by the nose is Moistened by the mucus, warmed by the blood and filtered by fine hairs and cilia. Pharynx (throata) is a muscular tube about 12 cm long. it is situated behind the nose. Mouth and larynx and in front of cervical vertibrae. Function are- It acts as a passage for air and for food, helps in voice production, helps in swallowing.

402 Larynx It is formed by piece of cartilage connected together by ligaments and membrane. The larynx is closed during swallowing by a leaf shaped carriage to the top of the larynx. This is called epiglottis. Larynx also contains the vocal cords. The vibrations of vocal cards due to the air passing through the Larynx, produce the voice. It is formed of elastic tissue stretched across from front to back. They tighten and come close together to produce high sounds, and loosens to produce low sounds of the voice. The space between them is called glottis. The nose, pharynx, and larynx are upper air passages. Trachea (Wind pipe) is a tube about 9 cm long. It is connected to the larynx above and passes down to the front of the neck into the thorax and divides into right and left bronchi. It’s walls are formed by incomplete. ‘C’ shaped eartilage rings connected by fibrous tissue. Trachea acts as a passage for air. Bronchi Trachea ends by dividing into right and left bronchi leading to each lung. Bronchi are short tubes. Similar to trachea, but made of complete rings of cartilage. Right bronchus is shorter and wider than the left. Bronchioles They are formed by the division of bronchi. They do not have cartilage. They lead to minute cavities for air called alveoli. Alveoli (Air sacs) Consist of thin layer of epithelial cells surrounded by capillaries. Exchange of gases takes place here Lungs are the chief organs of respiration. They are two cone shaped spongy organs. They fill; the greater part of the thoracic cavity. The two lungs are separated in the middle by the heart. Lobes

403 Each lung is divide into lobes. The right lung has three lobes and left lung has two lobes. Each lobe is composed of a number of lobules. A small bronchial tube centres each lobule and as it divides, its walls become thinner and thinners and end in air sacs of the lungs. The lungs float in water because of the air contained in it.

The lungs are covered on the outside by pleura. The pleura consist of two layers of membrane. The inner layer covers the lung and the outer layer lines the chest cavity. The pleura prevents friction when the lungs move during respiration. Between the two layers of the pleura there is a small amount of fluid called pleura fluid. Function of the lung is the exchange of the gases between blood and air. There are tow kinds of respiration. Respiration 1. External respiration – takes place in the lungs. Here oxygen is absorbed form the

air breathed in and the Carbon dioxide from the blood passes out and is breathed out. 2. Internal respiration (Cell brething). The tissue cells take oxygen from the blood and the blood receives the waste product carbon dioxide. Capacity of the lungs Total air capacity of the lungs is about 4-5 litres. During normal quiet breathing, about ½ (500 ml) of air is exchanged at every breath. Vital capacity is the volume of air that can be made to Pass in and out of the lungs by forcible inspiration and expiration. Males 4-5 L, Females 3-4 L. Rate of respiration is 12-18/min in adults (16-18) New borns 40/min 1yr 30/min Control of respiration The rate and depth of breathing are controlled by the respiratory centre in the medulla. This centre receives messages about the amount of carbon dioxide in the

404 circulating blood. Increase in the amount of carbon dioxide in the blood, causes the respiratory center to stimulate the muscles of respiration. Mecahnism of Respiraiton Respiration involves two stages. 1) Inspiration 2) Expiration

Inspiration (breathing in) It is an active process. It is pronounced by contraction of diaphragm and intercostal muscles. The chest cavity increases and air flows into the lungs due to expansion of the lungs. Expiration (breathing out) It is a passive process. It is produced by relaxation of diaphram and intercostals muscles and by elastic recoil of the lungs. The size of chest cavity decreases and forces air out of the lungs.

3 DIGESTIVE SYSTEM The digestive system consists of 2 parts – 1. the digestive /Alimentary tract consisting of mouth pharynx, oesophages, stomach smail and large intestines. 2. The digestive glands – salivary glands, pancreas, liver and gall bladder. The mouth or oral cavity is the beginning of the digestive tract. The mouth contains teeth, tongue, and opening of salivary glands. The cheeks from the side walls and ;palate is the roof of the mouth. Palate separates mouth from the nasal cavity. The palate is hard in front and soft behind. The soft palate help in swallowing by closing off the nose. The teeth are very important for chewing of food. Teeth begins form before birth and appear above the gums during the first 2 years of life. Temporary/milk teeth are 20 in number and are found in childhood. They are replaced by permanent teeth. Adult has 32 teeth. Structure of tooth.

405 It is made of enamel, dentine and pulp. Inside each tooth is the ;pulp cavity containing blood vessesls and nerves. It is surrounded by a hard material called dentine. It is covered by enamel which is a very hard substance . Each tooth has 3 parts – The crown, neck and root. The crown is the part seen above the gum, the neck is the part surrounded by gum, and the root is the part buried in the jawbone. The tongue is a muscular organ, tongue is the taste organ, helps in masticatin and help in swallowing. It has taste buds on the surface. Salivary glands are in three pairs and are situed around the mouth. The Parotid glands, are situated below and in front of the ears. Others are present under the lower jaw an under the tongue. The function of these glands is to produce saliva, which passes to the mouth. Saliva is a watery, alkaline fluid containing an enzymecalled ptyalin, which starts digestion of carbohydrates. Saliva helps to keep the mouth moist and clean. Pharynx is a passage for both food and air Oesopagus It is a tube about 25 cm long leading down from the pharynx to the stomach through the diaphragm. The muscles in the wall of the oesophagus contract, pushing the food downwards. This type of muscle action is called peristalsis. Contents of abdomen – Stomach, intestines, liver, spleen, pancreas, kidney, adrenal glands, abdominal aorta, inferior venacava peritoneum and fat. It is separated form the chest cavity by the diaphragm. Stomach It is situated in the upper left part of the abomen below the diaphragm. It is bag shaped with a capacity of about one litre. Parts : It consists of an upper part called fundus, the main body and a lower horizontal part. The pyloric antrum. Struture Stomacnh consists of four coasts – 1) Peritoneal coat – outer protective covering 2) Muscular coat – made of longitudinal, circular and oblique muscle fibers. 3) Subnmucuous coat – made of loose areolae tissue 4) Mucous coat- made of mucous membrane Themucos membrane contain digestive glands which secrete gastric juice. This contains acid & enzymes Food remains in the stomach for 1-5 hours. The food becomes semisolid and partially digests.

406 Secretions:- 1. Hydrochloric acid in the gastric juice neutralize the saliva. It also kills some of the germs. 2. :Pepsin-is an enzyme , which converts proteins to peptones. 3. Renin-It is the enzyme which curdles milk by converting caseinogen to insoluble caesin.

4. Intrinsic factor-Necessary for absorption of Vit. B12 , which is essential for RBC production. Chyme it is the digested food in the stomach. It is in a semi liquid form and is passed on to the duodenum.

Small intestine Consist of 3: parts- duodenum, jejunum and ileum. The duodenum is the first part of small intestine. It is C shaped, part attached to the posterior abdominal wall. The bile duct and pancreatic duct opens to this part. So the food mixes with pancreatic juice, bile and intestinal juice at this part. These juices digest the proteins, carbohydrates and fats in the food changing them to amino acids, glucose and fatty acids. Absorption of food : Absorption of digested food in smell intestine occurs through the villi. Villi are minute projections which are present in the mucous coat of intenstine. Each villus has a central lymph vessels called lacteal, surrouned by a network of capillaries. Digested fat is absorbed into the lacteal and digested carbonydrates and proteins are absorbed into the capillaries. Large intestine extends from lleum upto the rectum parts (1) Ceacum – Dilated (Sac like) first part situated in the right ilac fossa. Vermiform Appendix – Is attached to ceacum at the junction ileum and ceacum, the lumen of appendix communicated with that of ceacum. Appendix is composed of same four coats. The inflammation of appendix is called appendicits. Ascending colon- Ascends upward from ceacum up to the right kidney and truns left to form the transverse colon. It extends from lower surface of spleen to the pelvis.

407 LIVER The liver is the largest gland in the body. It weighs about 1500 gm, soft, reddish brown in colour. It is situated in the right upper ;part of the abdomen. It is made up of special liver cells (paranchymal cells) surrounded by many blood vesels. The liver is divided into 4 lobes. Each lobe is divided into lobules containing liver cells, blood vessels and bile canaliculi. There are minute channels between liver cells and they unite to; form bile ducts.

Function of liver

1. Secretion of bile 2. Synthiesis and storage of glycogen 3. Storage of iron, Vit A, D & B12 4. Destruction of toxic protein 5. Production of plasma protein 6. production of substances need for blood clotting 7. Syntheiss heparin 8. Formation of urea 9. production of heat

Gall Bladder It is a storage sae for bile. It is situated under the liver (right lobe). It is about 8- 10 cm long and capacity of bout 60 ml .The duct of gall bladder is called cystic duct. When fat is present in the duodenum, the gall bladder is stimulated to contract and send bile to help in digestion. Functions: The gall bladder stores and concentrated the bile that is secreted by the liver. Bile: It is an alkanline fluid secreted by the liver and stored in gall bladder. About 500- 1000ml is secreted by liver/day bile contains 86% water rest bile salts, bile pigments etc.

Pancreas

408 It is a long slender gland lying behind the stomach in the curve of duodenum. It is composed of two types of tissues. Function ;production of pancreatic juice – containing enzymes for digestion of carbohydrates, fats and proteins, (2) Production of insulin by tissue called islets of Langerhans. Inasulin is necessary for carbohydrates metabolism.

4 URINARY SYSTEM It is the main excretory system of the body. It consists of 2 kidneys, 2 urters, urinary bladder and urethra. Kidneys. These are two bean –shaped organs , situated at the back of the abdomen on each side of the vertebral column

Structure:- Each kidney is surrounded by a fibrous capsule for protection. The structural and functional unit is called a nephron. It has 2 parts the glomerulas or bowman’s capsule and renal tubules. The glomerular is the upper expanded cup shaped portion in which there are loops of capillaries bringing blood containing water and waste ;products to be excreted. These materials pass form the blood into the nephrons and urine is formed,

Functions of Kidney 1. They excrete excess water 2. They excrete urea, the end ;product of protein metabolism 3. Excretion of harmful substances like drugs toxins 4. Regulations of PH of blood

Formation of urine 1. Glomerular filtration – filtration of waters, salts and other substances 2. Tubular secretion – secretion of abnormal substance or excess of normal substances 3. Tubular re-absorbtion – About 99% filtrate reabsorbed. Urine is the fluid formed the above process. It passes to the collecting duct and then to the pelvis of the kidney. PH –acidic .Volume of urine formed is bout 1.5L/day (1-2) Ureter :- It is the duct which carries urine form kidney to the bladder.

409 Urinary bladder, It is a mascualr sac which acts as a reservoir of urine. It lies in the pelvic cavity behind the symphisis pubiss. Urethra. It is a canal through which urine ;passes from the bladder to outside. Composition of urine .It is acidic . Water 96 % Uric acid and salts -2%. 5 REPRODUCTIVE SYSTEM Male reproductive system The organs of male reproductive system can be classified into – External genital organs and internal genital organs, External gentile organs include penis containing urethra. Internal genital organs include tests, vas deference, seminal vesicle and prostate gland. The tests are the male reproductive organs, which produce spermatozoa. The testes are two oval shaped bodies, lying one on each side in the scrotum,. The scrotum forms a bag for the testes, Testosterone is the male sex hormone secreted by the testis. It is responsible for development of secondary sexual characteristics. Epididymis:- Small organ lying behind the testis. It is formed of very long narrow tubes through which the sperms pass. Vas deferns starts form epididymis an enters the abdominal cavity and pelvis and joins with seminal vesicle. Seminal Vesicle are paired tubular organ. It joins the Vas deferens to form the common ejaculatory duct. The secretion of seminal vesicle is an essential; component of seminal fluid. Prostate gland is below the bladder. It surrounds the first past of urethra. Secretion of prostate gland mixes with the secretion of testes.

FEMALE REPRODUCTIVE SYSTEM

External organs Internal organs External organs together form the vulva. They are Mons Pubis – a pad of fat lying over the; pubis and is covered with hair after puberty. Labia majora – Thick fold which forms the sides of the vulva. Labia minora – Two small folds of skin between the upper parts of labia majora. Clitoris - small erectile body similar to the male penis. It is situated where the labia minora meet.

410 Vestibule - a triangular part between labia minora where the urethral and vaginal opening are present. Internal organs Vagnia ,uterus, fallopian tubes, ovaries Ovaries are 2 in number, found on either side of the uterus below the fallopian tube. They contain a large number of immature ova called ocytes. At each menstrual cycle one of these mature to form a graffian follicle. At about middle of the menstrual cycle ovum is set free by rupture of graffian follicle which later forms an yellow body known as corpus luteum. Fallopian tubes :- They are 2 in no. Starts form the side of the upper part of uterus and ends in finger like processes filled fimbriae. Functions are 1) conveys the ovum form ovary to uterus 2) fertilisaion takes places in it.

Uterus (womb) is a hollow thick walled muscular organ inside pelvis. It is between the urinary bladder in front and rectum behind. It’s macular wall is called myometrium and vascular internal; lining is called endometrium. Uterus has there portions – fundus, body and cervix. Fundus is the broad upper part, body is the narrow middle portion and cervix is the lower narrow; part. Fallopian tubes are attached to the sides of the fundus. Vagina - Vagina is a muscular tube which connects internal and external organs. It extends form cervix above to the vaginal opening below.

Fertilization

Female produces eggs (ova) and male produces sperms. These sex cells unite to form a new individual. When the sperm enters the ovum it is called conception or pregnancy. The fertilized ovum grows rapidly and multiply to form an individual . Duration of pregnancy – 40 weeks. 3-8 weeks – embryo After 8 weeks – foetus After fertilization of ovum. It reaches the uteruses and gets embedded in the endomentum. It is called implantation. It develops to form the foetus which is surrounded by a bag of membranes called amniotic sac. It’s filled with a fluid called amniotic fluid, which protects the foetus and allows free movement of it and uniform growth of foetus.

411 Placentra – the foetus gets nourishment and oxygen from the placenta which is attached to the wall of the uterus. It is rich in blood vessels form both mother and foctus. Umbilical cord – connects foctus with its blood vessels to the placenta. Summary of digestive processes

Organ Digestive Reaction Enzymes Chemical action of enzymes Fluid 1 Mouth Saliva Alkaline Ptyalin(Salivary Converts cooked starch and Amylase) carbohydrates to maltose 2 Stomach Gastric Acid 1. Pepsin Converts proteins topeptones Juice 2. Rennin Converts caseinogen Casein 3 Duodenum Pancreatic Alkaline 1. Trysin Proteins & peptones -> amnoacid Fluid 2. Amylase Sugar -> Maltose 3. Lipase Fats -> Faty acids & Glycerole Bile Alkaline - Helps digestion of fats 4 Small Intestinal Alkaline Sucase All carbohydrates -> Glucose Intestine Juice Maltase Proteins -> Amino acids Lactase Helps in the action of trypsin in Erepsin the pancreatic fluid Enterokinase

6 Ear. Nose. Throat (E.N.T)

412 The common problem related to ear are 1. wax 2. Foreign bodies 3. Infections Wax is formed by sebum, dust particles and desquamated epithelium. It is formed in the external canal of every person and is removed by a natural course. When wax is formed in more amounts and not removed by natural method then it remains in the external canal and becomes hard. In this situation, removal of wax under observation is done. Wax can be removed by using wax hook , by syringing after making the wax soft or by wiping. All procedure should be done in good light. - With sterile materials - In sitting or lying down position with head tilted to one side - In case of child, ask his mother to hold his head and arms close to her. - Hold pinna in correct position to straighten the canal - While cleaning if the patient complains of pain, stop the procedure. In children foreign body removal is always done under general Anaesthesia. 1. Otitis Media means inflammation of the middle ear cleft which includes middle ear, Eustachian tube, mastoid and sometimes the aircells Usually a history of upperresperatory infections will be there. Infection spread through Eustachian tube while coughing, sneezing and also by violent blowing of Nose. Very rarely diseases like measles, influenza etc. cause an otitis media. In children H.influenza is the most common organism Symptom and sign Most important symptom is pain- will be very acute & severe. Fever, loss of appetite, malaise etc will be there. In infants – Baby become restless, crying sleep, will be disturbed, rolls his head, pull the ear on affected side, refuses breast feeding etc. Treatment is rest, antibiotics, nasal decongestants and analgesics. If the middle ear infection is not controlled in the acute stage, the otitis media turn to a (chronic form- chronic suppurative otitics media) and can develop mastoidites. Nose

413 Bleeding from Nose (Epistaxis) Causes – Traumatic - Infection - Neoplastic - Sponaneous from Little area of septum - General Hypertenscon - Rhino Sporidosis Bleeding from Nose. Treatment - Ask the patient to sit with head tilted titled forwards - Ask him to breathe through mouth. - Pinch the nostrils together - Discourage swallowing of blood

- Ask him to spit out any blood in the throat - Place him in a room where he gets fresh air - Apply cold compresses over the Nose. Usually bleeding stops by this procedure When bleeding is stopped ask him not to blow the nose and to take cold semisolid diet. If the bleeding is not stopped and nasal packing becomes essential. 7 CENTRAL NERVOUS SYSTEM AND SPECIAL SENSES Central Nerous System (C.N.S) directs, controls and co-ordinates all physiological activities in our body. This system does the following things- 1. Perception of senses 2. Transmission of impulses 3. Response to Stimuli Nervous System consists of 1. Central Nervous system – Brain and Spinalcord 2. Peripheral Nervous System – Cranial and spinal Nerves 3. Autonomic Nervous System – Sympathetic and parasympathetic Nerve fibre Structural and functional unit of Nervous system is a neuron or Nerve cell.

414 Briefly discuss the parts of Brain and their important functions covering of brain and spinal Cord, Cerebrospinal fluid etc. Reflex action and other functions of spinal cord. Different cranial Nerves and function of important Nerves Importance of Peripheral Nervous System. The Special Semes There are 5 sense organs Organ Special sense 1. Eye - Sight 2. Ear - Hearing 3. Nose - Smell 4. Tongue - Taste 5. Skin - Touch

The eye Eyes are two oval shaped organs which are well protected inside the orbital cavity of skull and lies within the orbital pad of fat. Accessory organ such as eyebrows, eyelids, conjunctiva, tear gland and muscles of eyeball also protect the eye. Eyeball - Oval in shape - Diameter is linch - Transparent in front - Optic Nerve is joined at the back like a stalk There are 3 coats for eyeball 1) Outer fibrous coat - Sclera 2) Middle vascular - Choroid Inner Nervous coat - Retina Briefly discuss about the functions of each layer Parts of eyeball from, front to back 1) Cornea 2) Anterior Chamber 3) Iris

415 4) Pupil. 5) Posterior chamber 6) Lens 7) Vitreous humour.

Mechanism of sight-Most important thing needed for sight is light. The light reflected from an object passes through the transparent cornea aquous humour pupil (size will be adjusted according to the brightness of light) lens (Biconvex) Vitreous humour Stimulate nerve endings in the retina. Stimuli received by the retina is passed along the optictracts to reach the visual area (occipital lobe) of brain where it is interpreted.

The Ear

The ear is the organ of hearing. Nerve supplying this special sense, is the 8 th cranial Nerve (Vestibuto Cochlear nerve). Parts of Ear 1) External Ear - Consists of Pinna external canal Tympanic membrane 2) Middle Ear - Airfilled cavity which is separated from the external canal by Tympanic membrane and contains the three ossicles, malleus incuse and stapes, which from a chain Malleus is attached to the Tympanic membrane and stapes to the oval window of cochlea. 3) Inner Ear - Consists of bony labyrinth and inside this membranous Labyrinth. A fluid called perilymph is seen between the bony labyrinth and the membranous labyrinth. Endo lymph is the fluid seen inside the membaranous Labyrinth.

416 Labyrinth consists of 3 Semicircular canals and a cochlea. Semicircular canals are important for maintaining the balance of our body, and cochlea for hearing. Vibrations of sound from the tympanic membrane passes through the ossicular chain to reach the inner ear and penlymph is stimulated first and then the endolymph. Nerve endings in the endolymph get stimulated and this stimulation is carried through the 8th cranial nerve to the brain center where it is interpreted.

Briefly discuss about the effects of Noise

TASTE SENSATION OF TONGUE

Tongue is mainly concerned with the special sense of Taste. It is a muscular organ and consists of both intrinsic and extrimic muscles.

Mucous membrane covering the tongue is moist and pink in health. On the upper surface the mucous membrane is velvety in appearance due to the presence of papillae.

Three types of papillae are seen 1. Circum vallate papillae. 2. Fungi form papillae 3. Filiform papillae

These papillae contain taste buds (end organs for taste). Sensation of taste are supplied by 5th 7th 9th Cranial Nerves. Muscles of tongue are supplied by hypoglossal Nerve (12th Cranial Nerve).

Smell

Smell is carried to brain by the first Cranial nerve (olfactory Nerve) from the end organs of smell. End organ of smell are situated in the mucus membrane covering the upper 1/3 of nasal septum, root of Nose and lateral wall. This part is known as olfactory epithelium. The sensation from endorgans, pass through the olfactory tract and finally reaches the olfactory centre in the temporal lobe of Brain. Sense of smell is stimulated by gas or smaller particles.

Skin

417 The skin forms the outer protective covering of whole body. Skin is divided into 2 layer.

1) The epidermis 2) The Dermis Horny Zone Epidermis Germinal Zone

Stratum Corneum Horny zone is again divided into Stratum Lucidum Stratum Gramlosum Prickle cell layer Germinal Zone Based cell layer From the cells of this layer new epidermal cells are formed

Epidermis does not contain any blood vessels. Ducts of sweat glands pass through it and it accommodates hair

The dermis

Dermis is made of fibrous and elastic tissue. Surface of dermis is arranged in small papilla Dermis contain Nerve endings, capillaries tactile bodies, sweatglands, sebaceous glands etc.

Hair, Nails are the appendages of skin Functions of the skin 1) Regulation of body temperature 2) Protective function 3) Excretion of waster through sweat. 4) Production of Vitamin D

418 5) Storage - Acts as Storage of water. Adipose tissue beneath the skin is one of the principal fat depots of body.

8 SKELETAL SYSTEM

Skeleton is the Bony frame work of the body. Skeleton is composed of 206 separate bones in the adult. Cartilages and ligaments which help to unite the bones at the joint.  Parts of skeleton  Skull  Vertebral column  Thorax  Upper limbs  Lower limbs Types of bones-Long bones, short bones, flat bones, Irregular bones, seramoid bone. Structure of skeletal tissue 1) Periosteun 2) Compact bone 3) Cancellous bone 4) Bone marrow

Functions of skeleton - supports and give shape to the body - Protect internal organ - Movements with the help of muscles - Blood cell formation The skull consist of two parts The cranium and the bones of face. Cranium consists of 8 bones namely frontal, Parietal, Occipital, Temporal, Sphenoid and Ethmoide. Bones of face are 14 in numbers. The immovable fibrous joints between the bones of skull are called sutures. The important sutures are coronal sutures (between the frontal and Parietal bores). Sagittal surface (between the two Parietal bores) and Lambdoid suture. (Between occipital and parietal bone)

419 The Fontanellae

Bones of the skull of an infant is not fully ossified at birth. There are spaces between the bones. These spacer are filled by a membranes. Spaces at the angle of bones filled by membranese are called fontanellae.

The vertebral column consists of 33 circular bones. They are called vertebrae  Cervical vertebrace 7  Thoracic 12  Lumbar 5  Sacral 5  Coccyx 4 The thorax or chest is formed by the sternum and costal cartilages in front, ribs at the sides and 12- thoracic vertebrae at the back Skeleton of upper limb Shoulder griddle is formed by scapula and collarbone of one side together with those of the other side Bones of upper limb  Humerus (Upper arm)  Radius and ulna – forearm

 Meta carpels 5  Phalanges 14  Carpal 8

Skelton of Lower Limbs

Bones of lower extremity are connected with the trunk by means of pelvic girdle. Girdle is formed by a part of axial Skelton, Sacrum and coccyx wedged in between the two Innominate bones. Innominate bone articulate with its fellow on the opposite side at the symphysis pubis

Innominate bone one on each side join with the scrum to form pubis Functions of pelvis

420 - Protection of pelvic organ - Supports abdomen - Provides deep socket for hip joint Innominate bone is formed by ilium ischium and Pubis. On the outer side of Innominate bone, there are 3 bones meet at a deep socket called acetabulam. true pelvis - lies below the brim Pelvis False pelvis-formed by ileac bone, extending above the brim. Inlet of Pelvis is formed by Sacrum Ileopectineal line on each side Rest of public hones Outlet is bounded by coccyx and ischial tuberosities Joints of Pelvis  Sacro ileae joint  Symphysis pubis  Lower limb bones  Femur  Tibia, fibula  Patella  Tarsal bones 7  Metatarsal bones-5  Phalanges -14 Joints of Skeleton 1) Fibrous Immovable joints-eg sutures 2) Cartilaginous Slightly movable eg: Symphysis pubis 3) synovial freely movable. Different types are there Ball & socket, Pivot, condyloid, saddle, Gliding etc.

421 Chapter - 15 EPIDEMIOLOGY

The study of the distribution and determinants of health related states and events in population and the application of this study to control health problems. This is providing newer opportunities for prevention, Treatment, planning and improving the effectiveness and efficiency of the health services system. = infectius disease epidemiology = Chromic disease epidemiology = clinical epidemiology

422 = Serological epidemiology = Cancer epidemiology = Malaria epidemiology = Neuro epidemiology = Genetic epidemiology = Occupational epidemiology = Psychosocial epidemiology Aims 1) To describe the distribution and volume of disease problems in human population 2) To identity the aetiological factors responsible for the disease 3) To provide the data, for the planning, implementation and evaluation for the preventation, control and Treatment of diseases. Types of Epidemiology = Descriptive = Analytical = experimental (intervention) 1) Descriptive - Time of distribution, climate, year, month - Place of distribution Person Age - Sex Occupation Social status Education 2) Analytical  Case control study (Retrospective ) (eg. Smoking and Lung cancer Thalidomide tragedy  Cohort study (observational) (Prospective) Eg. 1) Vaccine trials 2) Uranium miners and lung Cancer . 3) Experimental epidemiology

423 (Randomized controlled Trials) eg: (1) Animal studies (Drugs) (2) Human studies Iodine deficiency and goiter Uses of Epidemiology (1) To study historically the rise and fall of diseases in the population (2) Community diagnosis (3) Planning and evaluation (4) Evaluation of individuals at risk and cancer (5) Completing natural history of disease (6) Searching for causes and Risk factors Epidemiological Triad Agent

Host Environment

Chapter 16 CERTAIN COMMUNICABLE DISEASES

1. DENGUE SYNDROME Is a viral infection. The vector is Aedes aeygypti. The cycle is Man-mosquito- Man. Incubution pd- 3 to 10 days. The onset is sudden with chills and high fever, very severe head ache, Body pain. The fever may last for 5-7 days. Death is rare Control

424 (1) Mosquito Control (2) Symptomatic treatment 2. JAPANEESE ENCEPHALITIS Viral disease Vector is Mosquito. This virus can infect other animals also (Pig) Infected Culex Mosquito can spread the disease. Rarely anopheles mosquito can also spread. No. man-to-man spread. Incubation period- 5-15 days Clinical features: Fever, Head ache, and features of encephalitis. (altered Sensorium, convulsions and coma) The fatality rate is 20-40% Control 1) Vector control - mosquito control 2) Vaccination - 2 doses (1 ml) S/C at one week interval 3. KFD – KYASANER FOREST DISEASE Is caused by a virus - arbouirus and transmitted to man by the bite of infected ticks. (Ticks lives monkey) Was first detected in 1957 in shimog district of Karnataka State, Kyasaner forest. Agent Arbo virs Host Rat, squirrels are the main reservoirs and monkeys are amplifying hosts.

Vectors Hard Tick, rarely from soft tick. Mode of transmission Mainly monkeys ticks and man Incubation period : 3-8 days. Clinical features Sudden onset of fever head ache, myalgia which last for a 2 weeks followed by bleeding from nose, gums and nose there can be memingo – encephalitis. Controls

425 Control of ticks Vaccination Personal protection 4. PLAGUE Agent Is a zoonotic diseases and primarily a disorder caused by a bacteria – y Pestis. This is primarily infecting rodents . From the infected rodents, the infected fleas spread the disease to man by their bites. Reservoir Rodents, mainly rat. Source Infected rodents, fleas and case of pneumonia plague Host All ages and both sex Environmental Season September to may Types of plague Bubonic (lymphe nodes) Septicaemic plague and Pneumonia Prevention and control 1) Control of case ………….Early 4 diagnosis - Notification -Treatment -Disinfection 2) Control of fleas:-DDT 3. Control of rodents 4) Vaccination One week prior to the out break 2 doses – 0.5 ml 1st doze 1 ml - 2nd does one week after. 5. AMOEBIASIS Agent: E Histolytica, which exist in veg. form and cystic form Man is the only one reservoir

426 Host Any age, Any sex Environment Related to poor sanitation and poor socio economic status Prevention 1) Primary prevention -Better Sanitation -Food hygine -Safe water 1) Secondary prevention Early diagnosis : Treatment 6. HOOK WORM Agent Caused by ancylostoma (necator) Adults women live in small intenstine It produces 30,000 eggs/day. Man is the only reservoir Host All ages and both sex. Malnutrition is the pre disposing factor and may cause malnutrition. Occupation:- more in agriculturist. Environmental : Moist sandy soil is more favorable than clay, rainfall favors : Rainfall favours.

:The Larvae penetrate the skin Effects of HW infestation: Chronic Blood Loss. Chronic blood loss, leading to anemia Prevention : Sanitary disposal of faecal matter : Drugs : Health Education

427 7. ASCARIASIS Caused by Ascariasis Lumbricoids, which lives in the lumon of small intestine. The Female Ley eggs 2,40,000/day, which is excreted. After ingestion by man the embryonated eggs hatches in small intensive. The large penetrate the gut wall and are carried to the liver, then to the lungs via, blood stream. In lungs they break through the alveoli and migrate in to the bronchiole. It is then coughed up through the trachea and then swallowed by the human beings. On reaching the intestine, they become mature in to the adults in 60-80 days. The life span of an adult is 6-12 months. Reservoir Man is the only reservoir Host Mainly children Environment Eggs remain viable in the soil for months to years Mode of transmission By the faeco - oral route Incubation period 2 months Prevention and control Primary Sanitary disposal of human excreta Provision of safe drinking water Food hygine Health education

Secondary

Drugs

Mebendazole 100my bid x 3 days

Pyrantel Pamoate

Single dose of 10 mg/kg body wt.

8. RABIES

428 (Hydrophobia)

Caused by a virus lyssavirus type I . It is a zoonotic disease, spreads form dogs, cat jackals etc, by their bites or licks. The disease is highly fatal

The disease is rare in developed countries and wide spread in developing countries.

Agent

Lyssa virus: is a Nero tropic.

R.N.A. Virus. This virus is exerted through the saliva of infect animals.

Reservoir of infection:

Transfer of infection from wild life to domestic dogs is responsible for 99% cases.

Source of infection

Saliva of infected animals.

Host

All warm blooded animals, including man.

Mode of transmission

Animal bite

Licks

Aerosols (respiratory) rare

Person to person (Rare)

Incubation period

3-8 weeks

(may very from 4 days to years)

depending upon - : Site of bite

429 - Severity of bite

- No. of wounds

- Treatment undertaken.

Clinical features

Head ache, malaise 3 4days. Gradually the patient will become intolerant to noise, bright light. Violent spasms of the pharygeal muscles and neck muscles. The symptoms are progressively aggravated and all attempts for swallowing liquid becomes unsuccessful. With in 5-6 days the patient may die. To-date only three people are on record, who have been stricken with rubies have survived. Vaccines Vaccines are prepared in the tissues of Rabbits, Sheep, Goat Embrayo of duck egg In cell culture Nerrous tissue vaccine (sheep) Cell culture vaccine 1) Human diploid cell HDC 2) Second generation tissue culture Eg: chick Embryo Vaccine Classification of exposure Class – I Licks on healthy unbroken skin Consumption of un boiled milk suspected animal Scratches by the animal

Class II Licks on fresh wound Scratches by the animal Class II Licks on fresh wound

430 Scratches with oozing of blood All bites except those on head neck face, palms. Minor wounds Class III All bites or scratches with oozing blood on head and neck face and palms Lacerated wounds an any part of body Multiple wounds more than 5 Bite from wild animals Dosage (Coonoor vaccine) Adult children duration Class I 2ml 1 ml 7 days Class II 3 ml 3ml 10 days Class III 5 ml 3 ml 10 days Cell culture vaccine 0 3 7 14 and 30 days booster dose by 90th day 9. LEISHMANIASIS Protozoal disease cause by a parasite Leishmania and transmitted to man by the bite of female (phlebotomine) Sandfly Types 1) Kala agar (visceral leishmania) 2) Cutaneous Leishmaniaris 3) Muco- cutaneous Leishmaniaris 4) Zoonotic cutaneous Leishmanesis 5) Post kala Azar dermal leshmaniasis. Visceral leshmaniasis is most common in India especially in Assam, west Bengal, Bihar, UP and Tamil Nadu,.

Agent – Sand fly Leishmania are Intra cellular parasite L Donovani is the causatire agent of Kalazar Reservoir Dogs, fox, jackals, rodents etc. Host:

431 More in males All ages Environmental factors During and immediately after rain. More in rural areas Mode of transmission By the bite of female sand fly Incubation Period Generally 1-4 months but 10 days to 2 years Clinical features Fever accompanised by Splenomegaly Anaemia and weight loss Hepatomegaly Darkening of the skin of face, hands, feet and abdomen is common. That is why the disease is known as Kalaazar (black sickness,) Control Measures 1. Control of reservoir Man is the only reservoir hence active and passive case detection and treatment. Treatment Pentavalent antimony compounds Eg: Sodium stibogluconate Adult 10 age/kg x 20 days 1 Children  10mg//Kgm x 20 days 1/M 2 Sand fly control D.D.T 3. Personal prophylaxes Individual protective measure.

IMMUNITY Active and passive Active 1) Humoral immunity

432 2) Cellular immunity 3) Combined Passive 1) Normal human 1g 2) Specific human 1g 3) Antisera Active The immunity developed as a result of infection or immunization. The immunity produced is specific for the disease Active immunity may be acquired in 3 ways - - Following infection: eg chicken Pox, Measles. - Following sub clinical infection - Following immunization. After the immunization – primary antigenic challenge is taking place, that is education for the RETICULO endothelial system. There is production of Memory cells or primed cells by both B and T lymphocytes. These cells are responsible for the immunological memory, which takes place after the immunization. Humeral immunity: Comes form B lymphocytes (Bone Marrow derived) and the antibodies are specific and react with the same antigen. Cellular immunity It is mediated by T Lymphocytes. On contact with antigens the T cells initiate a chain of responses – eg: Activation of macrophages, release of cyto toxic factors, mononuclear inflammatory reactions secretion of immunological mediators. Passive immunity : By administration of immuno globulin : Trans placental : By transfer of lymphocytes to induce passive cellular immunity.

Chapter - 17 REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME [RNTCP]

433 Definitions Diagnosis – Staining method – Key in the preparation and staining of smeres – Ziehl Necclsen staining. Treatment – expected break up of 135 cases under RNTCP. DOTS and its salient features. Treatment categories and sputum examination schedules Phases and duration of treatment Duration of treatment of speculum smere in positive at 2/3 months Management of patients who interrupt treatment Treatment of Children Possible side effects of anti. Tuberculosis drugs Supervisory visits. Summary of key indicators and possible actions Filling up of treatment card Filling up of referral forms Filling up of PHI forms Filling up of identify cards IEC activities Role of LHI Theory – 3 Hours Visit to DTC, TB Unit, Micro scropic centre, Dots Centre – 2 Hours EXTENT OF THE TUBERCULOSIS PROBLEM

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis and, less commonly, by other organisms of the 'tuberculosis complex'. It is estimated that 3 million people die from tuberculosis each year-the majority of them in developing countries. The annual incidence of New cases of all forms of tuberculosis (pulmonary and extra-pulmonary) worldwide is estimated to be approximately 8 million, of which about 95% occur in developing countries. Many tuberculosis cases in developing countries remain undiscovered. Of the discovered smear-positive cases, less than half, complete treatment. Consequently, the estimated prevalence (the total

434 number of tuberculosis cases at a given time) worldwide is 16 to 20 million, of whom about 8 to 10 million are sputum smear-positive and highly infectious. The number of persons infected with the tuberculosis bacillus is estimated to be 1.7 billion, of which 1.3 billion live in developing countries. In India, more than 40% of adults are infected with TB, and approximately 1.5 million cases are put on treatment every year. An estimated 5 lakh deaths from TB occur every year. The greatest burden of tuberculosis incidence and mortality in developing countries is in adults aged 15 to 60 years. These include the most productive members of society such as parents, workers and community leaders. While there has been a tremendous decrease in tuberculosis cases in developed countries in the last forty years, there has been an increase in the number of tuberculosis cases in developing countries. This is due to failure to cure a high proportion of sputum smear-positive cases. Every year, each smear-positive patient can infect approximately ten to fifteen persons, thereby increasing the pool of infected persons. Many partially treated patients have isolates which are resistant to the drugs they have taken. These patients infect other people, with drug resistant bacilli. Many patients who do not receive directly observed treatment stop taking drugs after 2 months because they 'feel better'. Studies in India and many other countries consistently show that at least one-third of the patients do not take medicines regularly, and it is neither possible to predict who these patients will be, nor to reliably prevent non- compliance by improving patient education. Globally, the HIV epidemic is increasing and the number of tuberculosis cases and accelerating the spread of the disease. During this course, you will learn how to prevent the spread of tuberculosis and the development of drug resistance by improving diagnosis and treatment of patients and enhancing supervision of programme management.

AIM OF THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

435 In developing countries such as India, the fight against tuberculosis can be successfully carried out only within the setting of a National Tuberculosis Programme. This programme is part of the country's general health services. The primary aim of the RNTCP is to achieve a high cure rate of New sputum smear-positive patients thereby interrupting the chain of transmission. The target cure rate is at least 85%. Target: Cure at least 85% of New sputum smear-positive patients. The only effective means by which 85% cure rate has been shown to be achievable on a programme basis is by application of the so-called DOTS (Directly Observed Treatment, Short-course chemotherapy) strategy. DOTS is a systematic strategy which has five components:  Political and administrative commitment: TB is the leading infectious cause of death among adults. It kills more women than all causes associated with childbirth combined and leaves more orphans than any other infectious disease. And, since tuberculosis can be cured and the epidemic reversed, it warrants the topmost priority which it has been accorded by the Government of India. This priority must be continued and expanded at state, district, and local levels.  Good quality diagnosis: Case detection is done primarily by sputum microscopy among symptomatic patients attending health facilities. This policy allows effective diagnosis in the periphery and appropriate prioritization of efforts.  Good quality drugs: An uninterrupted supply of good quality anti-tuberculosis drugs must be available. In the RNTCP, a box of medications for the entire treatment is earmarked for every patient registered, ensuring the availability of the full course of treatment to the patient the moment he is registered for treatment. Hence in DOTS the treatment never fails on account of non-availability of medicines.  Short-course chemotherapy given in a programme of direct observation: RNTCP uses the best anti-tuberculosis medications available.

436 But unless treatment is taken by patients, it will fail. This is why the heart of the DOTS programme is "directly observed treatment" in which a health worker or other trained person who is not a family member watches as the patient swallows the anti-TB medicines in their presence. With short course chemotherapy it is easier to prevent drug resistance by using directly observed treatment, and achieve high cure rates. In addition, because short-course treatment lasts half as long as conventional treatment, at any one point of time only half the number of patients are on treatment, reducing the quantity of work and allowing increased emphasis on quality of services.  Systematic monitoring and accountability: There are two means of monitoring the success of treatment. First ' sputum is examined during the course of treatment to monitor the progress and cure of patients. Second, a revised recording and reporting system rigorously monitors and evaluates the outcome of every patient treated. The cure rate and other key indicators are monitored at every level of the health system, and if any area is not achieving 90% sputum conversion rate at the end of 3 months and 85% cure rate, supervision should be intensified. For effective programme implementation, having well-trained and motivated staff is essential. The RNTCP shifts the responsibility for cure from the patient to the health system. It should be noted that the principles of diagnosis of TB by microscopy, ambulatory treatment, and direct observation of treatment were first established in India at NTI, Bangalore and TRC, Chennai. Another objective of the RNTCP is 70% detection of New sputum smear positive cases. However, the target for case detection should only be attempted if the cure rate of already-detected patients is more than 85%. When cure rates are high, health facilities will attract more patients due to the good results obtained in the cases already treated. As one Programme Manager of a successful RNTCP site in India said, 'Every cured patient is a pamphlet. Remember: Increase the cure-rate before attempting to achieve case detection targets.

437 STRUCTURE OF THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME The RNTCP has a central division, state, district and sub-district levels and health units. As noted above, a major organizational change is the creation of a sub- district level. Creation of a sub-district level allows for the systematic monitoring of the outcome of every patient. An additional structure of the RNTCP is the District Tuberculosis Control Society. This society functions with the District Collector as the Chairman, the District Tuberculosis Officer (DTO) as Member Secretary, and has governmental and non- governmental representatives. It is responsible for monitoring the programme implementation, arranging necessary logistics such as transport and procuring materials such as laboratory consumables. Central TB Division At this level is the Ministry of Health, where the Central TB Division is responsible for tuberculosis control in the whole country. A National Programme Director (Deputy Director General [TB]) is in charge of the tuberculosis programme in the entire country. Main technical responsibilities of the Central TB Division are to:  Plan, supervise, monitor and evaluate anti-tuberculosis activities throughout the country;  coordinate with other sections of the Ministry of Health and other central government agencies;  provide drugs, laboratory equipment and -documents (e.g. manuals and modules) needed in the country; and  train or coordinate the training of the nodal personnel involved in the RNTCP. State level At this level, a State Tuberculosis Officer (STO) is responsible for planning, training, supervising and monitoring the programme in the state. He is responsible,

438 administratively to the State Director of Health Services and technically follows instructions of the Central TB Division. There should be a full-time STO trained in the RNTCP for each state.

Main responsibilities at the state level are to:  work closely with the Central TB Division for performing the duties mentioned above;  plan, supervise, monitor and evaluate anti-tuberculosis activities throughout the state;  ensure adequate supply of drugs, laboratory equipment and documents needed in the state,  organize training programmes in the state in collaboration with the Central TB Division, the State TB Training and Demonstration Centre (STDC) and the District Chief Medical Officers, and to give on-the-job training to the district and peripheral workers;  ensure that the required reports on case-finding, results of treatment and programme management are completed in each district and sent to the Central TB Division in time;  review the reports on case-finding, results of treatment and programme management from the districts and take necessary action for their improvement; and  ensure close cooperation between the staff in case-finding and treatment of tuberculosis and the microscopy services. District level The district is the key level for the management of primary health care. The district level (or municipal corporation level in large metropolitan areas) performs functions similar to those of the state level in its area. The Chief District Health Officer or his equivalent is the principal health functionary in the district and is responsible for all, medical and public health activities including control of TB. The District Tuberculosis Centre (DTC) is the nodal point for TB control activities in the district and also functions

439 as a specialized referral centre. The DTO at the DTC has the overall responsibility of the Programme at the district level and is assisted by an MO, Statistical Assistant and other paramedical staff. For each district, there should be a full-time DTO who is trained in the RNTCP.

In some large metropolitan cities diagnosis is made at specialized TB Dispensaries/Chest Clinics, and microscopy and treatment administration are done by special staff based in a general health facility. Main responsibilities at the district level are to: • implement the RNTCP through the district health staff, • maintain a map of the area detailing all health facilities, government organizations and NGOs which specifically carry out TB activities, including the staff responsible for these activities (name, position and location); • train and re-train the medical and paramedical staff, • maintain a regular supply of drugs, treatment-related materials, sputum containers and slides, laboratory-related materials, forms and registers for the district; • supervise and ensure proper treatment of tuberculosis throughout the district, and particularly ensure that: - the correct treatment is prescribed in all health facilities - patients are receiving the appropriate drugs under direct observation of health workers during the intensive phase of treatment and at least one dose per week in the continuation phase is directly observed - regimens are given for the required period, and cured patients are discharged from treatment - sputum is examined for acid-fast bacilli' (AFB) at the stipulated time intervals - patients are individually advised about their disease - patients are referred or transferred: as appropriate - treatment outcomes of patients are determined and recorded in the Tuberculosis Register; • organize health education and establish liaison with private practitioners and NGOs who provide TB services to promote compliance with national

440 norms and facilitate referral; • assist staff in the diagnosis of TB in all health facilities in the district; • ensure that the sub-district staff visit all microscopy centres for supervision at least once a month;

• make sure, by reviewing quarterly reports and randomly spot-checking, that MOs and health workers properly identify symptomatic patients, collect and transport sputum specimens and refer patients for diagnosis; • visit all sub-district Tuberculosis Units, hospitals, Community Health Centres (CHC) and Block Primary Health Centres (Block PHCS) at least once a quarter; and complete quarterly reports on notified New and retreatment cases of tuberculosis, sputum conversion and on the results of treatment. Sub-district level A team comprising a specifically designated MO-TC, STLS and STS is based in a CHC or Taluk Hospital (TH) or Block PHC. The team constitutes the TU, and the STS and STLS are under the administrative supervision of the DTO. The staff from the DTC (laboratory technician and treatment organizer) will carry out the functions of the sub- district supervisory team in its respective sub-district in addition to their functions as a microscopy and treatment centre. The sub-district covers a population of approximately 5,00,000. The sub-district is reponsible for accurate maintenance of the Tuberculosis Register and timely submission of quarterly reports. Functions of the TU are to:  maintain a map of the area detailing all health facilities, and government organizations and NGOs which specifically carry out TB activities, including the staff responsible for these activities (name, position and location);  maintain a regular supply of drugs and other logistics and ensure their uninterrupted availability in all designated centres in the sub-district. Retrieve unfinished medicine boxes of patients who have defaulted (i.e. stopped treatment for two months or more continuously)

441  establish liaison with private practitioner's and NGOs providing  TB services to promote compliance with national norms, facilitate referral and ensure registration and notification-,  organize sputum smear examination at the microscopy centres of the sub-district;  carry out categorization of treatment services and DOT;  organize regular training and continuing education;

 supervise the microscopy centres and PHCs at least once a month, and form quality control of slides as per the Laboratory Manual;  prepare and distribute reagents, and ensure regular and sufficient supply of reagents and sputum containers in each health facility;  keep the Tuberculosis Register up-to-date and accurate;  prepare quarterly reports on case detection, sputum conversion, treatment outcome and programme management;  make sure that MOs and health workers correctly identify symptomatic patients and refer patients for diagnosis;  diagnose smear-negative patients who require X-ray examination (if facilities exist);  act as a referral point, for example, for patients who: - present diagnostic problems - have drug reactions - refuse to take drugs - are failure cases requiring further investigation - do not convert to smear-negative status at the end of the intensive phase and identify the reasons for the same - require evaluation of treatment outcome, i.e. cured, treatment completed, defaulted, died, transferred out, failure; and  monitor the maintenance of the Laboratory Register and the documentation related to microscopy examinations. Health Units

442 At this level are the rural and other hospitals, health centres, dispensaries and health facilities within a district. Main responsibilities at the health units are to:  send tuberculosis suspects or their sputum specimens to designated microscopy centres for examination;  carry out categorization of treatment services and DOT;  trace patients who do not collect their drugs and bring them back under treatment;

 keep Tuberculosis Treatment Cards and records and make them available for the STLS, STS, MO-TC, DTO and other supervisory staff when they visit the health unit;  facilitate follow-up sputum smear examinations;  trace and investigate contacts; and  discharge patients who have come to the end of their treatment regimen in coordination with the designated MO-TC of the' sub-district or the DTO.

443 Chapter - 18 NLEP : NATIONAL LEPROSY ERADIATION PROGRAME

One of the achievements of NLEP has been considerable fall in case load in India because of the efficient use of MDT by health workers. However, the problem is not yet over. The time has came to involve every health persons so as to reach the ultimate goal of making the world free of leprosy. Basic Facts about Leprosy - Leprosy is a chronic infection caused by M. Leprae. - It affects mainly the periferal nerves and skin - It is one of the oldest diseases known to mankind. - It causes permanent and progressive physical disability. - Its visible disabilities contribute to social discrimination of patients. - Man is the only known for the leprosy. The major sites are the nose and nose appears to be the major site of entry of the bacilli. - The incubation period could be as small as 6 months as long as 30 years. Average of 2-4 years. Cardinals Signs of Leprosy At least one of the cardinal sign must be present to diagnose leprosy. 1. Hypo pigmented or reddish skin with loss of sensation. 2. Involvement of peripheral nerves.

444 3. Demonstration of M. Leprae in the affected area. Clinical Examination Includes careful interview of patient to get detailed history and skin and nerve examination History:- Name, Age, Sex, Address and occupation presenting complaints and their duration. History of recurrence:- A recurrent lesion which comes and goes will not be due to leprosy. Treatment history Any other associated illness Family history. Skin Examination Remember the cardinal sign. Choose a spot where good light is available As far as possible, choose a spot there is privacy. Examine the whole skin from head to toe. Note:- the site of patch Number of patches Colour of patch (Leverin of leprosy are never depigmented) Sensory loss Patch with sensory loss-Refer to medical Officer. Weakness of mussels of hands and feet pain in the nerves and loss of Sensation - Refer to Medical Officer. Nerves normally affected Great auricular Nerve Radial Nerve ulmar nerve Superficial Radial Nerve Posterial tibial Nerve How to test Sensations. Use a ball point pen.

445 Explain to the patient what you are going to do. First touch the normal skin and then over the patch. Ask the patient to touch the point tested. If he cannot touch the point, ask the patient if he has clearly understood the procedure. Then repeat the procedure with his eyes closed Note:- The weight of the pen is sufficient to elicit the remarks. Don’t apply here pressure. Start from normal skin and then on the patch. Test only one point at a time. Give sufficient time for patient to answer. TREATMENT With Multi Drug Therapy, the M.Leprae are destroyed and soon an infections patient because non-infections. The established disabilities cannot be corrected by medicines. Hence it is very important to see that patients are detected early and given treatment, so that disabilities are prevented. For MDT to be effective it is very important to ensure that the patient takes the medicines regularly and for the full duration of treatment. The medicines used in MDT are: 1. Rifampicin 2. Dapsone 3. Clofazimine Classification of the disease P.B (Pauci Bacillary) : 1-5 patches and/or only one nerve affected M.B (Multibacillary) : More than 5 patches 2 and or more nerves affected. Treatment and Duration PB : Rifampicin - Once a month x 6 months Dapsome - Daily

MB : Rifampicin - Once a month Dapsome - Daily x 12 months Clofazimicine - Daily

Ensure that the patient is taking the medicines regularly. Side effects of MDT Side effects are rare.

446 Refer to medical officer if patient develops yellowish discoloration of skin, eyes or urine, or if patient develops severe abdominal pain. What to do to ensure that patient takes full treatment Proper counseling of the patient at the time of treatment. Tell him about the duration and importance of taking full treatment. PB patient should be under surveillance for 2 yrs and MB patient for 5 years after completing the treatment. Disability can develop in hands and feet . Loss of sensation weakness of muscles are the causes for disabilities. Common disabilities are Claw hand : Wrist drop Claw toes : foot drop To Prevent disabilities - Early disabilities before any disability sets in - Proper counseling of the Patient.

How to equip the community for early detection - Increase the awarears of the community about the symptoms - hypopigmented patches on the skin and sensory loss. - leprosy is curable - MDT is free and available in health centres. National leprosy control programme started in 1954-55 MDT started under National Leprosy Eradication, Programme in 1982 MDT started in Kerala in 1987. Records & Registers to be maintained in the P.H.C 1) PHC treatment register 2) Drug stock register 3) Treatment cards 4) Monthly/ Annual Reports

447 Chapter - 19 HIV/AIDS

Session-1

INTRODUCTION TO THE TRAINING PROGRAMME Learning Objectives By the end of this session, all participants will be able to: Describe the general objectives of the training pr0ogramme and the indicators for of these objectives. Time : Thirty Minutes Method : Group Discussion Materials : "General objectives of the training programme" flip chart, writing materials Introduction 1. Display the “General objectives of the training programme” flip chart, ask the participants to read the objectives carefully (5 minutes).

448 2. Ask the participants what they understand by objectives and their indicators. Clarify doubts, if any (10 minutes). 3. Discuss the expectations of participants and see whether they fit or do not fit with the objectives. Describe the difference between making clear what this programme is and what is not? 4. Explore with the participants how the objectives relate to their job responsibilities, to improve their performance. Outcome of the Session Each participant will write the general objectives of the training programme: 1. 2. 3. 4. 5. 6.

Objectives of Training The overall objective of this training programme are to impart knowledge and develop skills in health workers and supervisors in order to prevent the HIV/AIDS epidemic from spreading further and to reduce the impact of the epidemic not only upon the infected persons but also upon the health and socioeconomic status of the general population at all levels. The specific objectives of the training are:  To make the health workers/supervisors capable to promote' better understanding of HIV infection among the people at large, to generate awareness about the nature of its transmission and to adopt safe behavioural practices to prevent the disease from spreading.  To enable them to provide adequate and equitable provision of health care to HIV-infected people and to draw attention to the compelling public health rationale for overcoming stigmatisation and discrimination against them in the society.

449  To enable them to identify community based organisations like Mahila Swasthya Sanghs, Youth Clubs, Panchayats and other partners, and to mobilise their support in prevention of spread of HIV/AIDS in the community.  To enable them to seek community participation in implementing the various components of the National AIDS Control Programme at each level.  To enable them to provide proper health care at homes and support to people living with HIV/ AIDS (PLWA).  To know the common STI prevalence in the community and to understand the relationship between HIV/AIDS and STIs/RTIs and to facilitate early diagnosis and prompt treatment of RTIs/STIs.  To understand the meaning of opportunistic infections and co-infection between H.I.V/AIDS and Mycobacterium tuberculosis.

Session-2 HIV/AIDS, PANDEMIC-CHALLENGES AND RESPONSE, LINK WITH DEVELOPMENT ISSUES Learning Objectives  By the end of this session, all the participants will be able to :  Describe the magnitude of HIV/AIDS problem in our country.  Understand the detrimental effect on child survival and safe motherhood interventions.  Enlist the various socioeconomic depressions related to HIV/AIDS pandemic.  Describe the areas where community response is needed to check the spread of HIV/AIDS infection

450 Time : One hour Method : Small group exercise Materials : Two sets of coloured cards-Challenges (red) and Response (green) cards. About 50 cards of each colour, flip chart and writing material. Introduction Explain what is AIDs and why it has become a number one public health threat to the community. Explain how HIV/AIDS infection may have a determental effect on mother and child health programme and health services in general. Explain what is opportunistic infection and co-infection of HIV and TB. They should be made to understand that HIV and AIDS is deeply related to the development of the country and if not controlled quickly then it may cause severe socioeconomic depressions. In this session, the group will review their existing work activity and will also identify new services and actions to be integrated in their work activity to face the challenge of HIV/AIDS. (10 minutes). Procedure 1. Divide the group into two groups randomly. Ask the participants to discuss and write on separate cards [Red] various challenges and threats due to HIV/AIDS infection. In one red card only one threat and challenge

should be written. Simultaneously they should also write the action [response] to be taken against each threat/challenge identified by them. Fix all the red cards on one side of flip chart and corresponding green cards [response/action] against each red card. [25 minutes]. 2. Bring the two groups together and discuss the various threats and actions identified by them and enlist priorities for action.[15 minutes]. Outcome At the end of the discussion, consensus on threats and actions should be identified by the group. Introduction to H.I.V/AIDs: AIDs is the name of that life threatening condition. Till today, there is neither any vaccine to protect the community from this dreadful virus, nor drug to cure if infection occurs. HIV IS AN ACQUIRED INFECTION

451 As is evident from its name, the disease is transmitted to the individual due to some activity which he performs, like that of sexual contact with an infected partner, transfusion of HIV infected blood and blood products, HIV contaminated syringes, needles, and other body piercing instruments, in case they are not properly sterilized and shared by others and prenatal transmission of HIV from an infected mother to foetus. Once the individual is infected, the virus starts depleting his immune system and he loses body defence. There are so many organisms in the body and environment who do not cause any harm to the body because of the normal defense mechanism of the body, but in case of HIV infected person/AIDS these opportunistic infections may take the advantage of the depleting defence system of the body and may manifest in the form of various symptoms and signs i.e. Acquired Immuno-Deficiency Syndrome. RAPID SPREAD OF VIRUS In India the HIV/AIDS epidemic is now more than a decade old. Within

this short period it has emerged as one of the most serious public problems in the country. The initial cases of HIV/AIDS were reported among commercial sex workers in Mumbai and Chennai and injecting drug users in the north-eastern State

of Manipur. The disease spread rapidly in the area adjoining these, epicenters and by

1996 Maharashtra, Tamil Nadu and Manipur together accounted for 77% of the total

AIDS cases with Maharashtra reporting half the number of cases in the country. Even though the officially reported cases of HIV infection, and full-blown AIDS cases are in thousands only, it is realized that there is a wide gap between the reported and estimated figures because of the absence of detailed epidemiological data in major parts of the country. The available surveillance data clearly indicates that HIV is prevalent in almost all parts of the country and has spread from urban to rural areas, and from individuals

452 practicing high risk behaviours to the general population. Studies indicate that more and more women attending antinatal clinics are testing HIV-positive thereby increasing the risk of perinatal transmission. One in 4 cases reported is a woman. Such a situation would be greatly detrimental to child survival and safe motherhood Interventions launched by Government in recent past. Reduction achieved in infant mortality rate

(IMR) and child death rate (CDR) as well as maternal mortality which are showing a sustained decline may be adversely Affected due to rapid transmission of infection in mother and children. The attributable factors for such rapid spread of the epidemic across the country may be low literacy level leading to low awareness among potential high risk groups, gender disparity, sexually transmitted infections and reproductive tract infections both among men and women. The social stigma attached to sexually transmitted infections also holds good for HIV/AIDS, even in a much more serious manner.

HIV AND DEVELOPMENTAL ISSUES AIDS control programme has hitherto been seen as a public health matter dealt by the Ministry of Health and Family Welfare. However, because of the behavioural nature and the strong socioeconomic implications, the disease requires to be treated as a developmental issue which impinges on various -economic and social sectors of Government and non-Governmental activity. About 89% of the reported cases occur in sexually active and economically productive age group of 18-40 years. As economically productive sections of the population are the most susceptible to this disease, ministries like railways, heavy industry, steel, coal and other public sector undertaking employing large work force would be hit the most by HIV/AIDS pandemic and thereby will have a negative impact on the economic growth of the country. At the family level, if the earning members of the family become the victim of this dreadful infection then the socioeconomic development is very much affected leading to poverty and disruption of the family life. Not only this, increasing number of HIV related/AIDS

453 patients will require more beds for their care/ treatment, i.e. overstretching of already overburdened hospital services leading to deterioration in quality of medical care. TUBERCULOSIS AND HIV - A DEADLY DUO Tuberculosis is the most common serious opportunistic infection occurring among HIV-positive persons. Mycobacterium tuberculosis - the bacterium which causes TB - though present in the bodies of almost half of the Indian population, is not able to do any damage in healthy individuals enjoying a normal immune system. HIV is most powerful risk factor for progression from TB infection to TB disease. HIV breaks down the immune system and makes patients highly susceptible to TB; these patients can then spread TB to other people. An HIV positive person infected with M. tuberculosis has a 50% lifetime risk of developing T.B whereas an HIV negative person infected with M. tuberculosis has only a 10% risk of developing TB. HIV infected persons who become newly infected by M. tuberculosis rapidly progress to active TB. Tuberculosis flourishes where there is poverty, malnutrition, overcrowding and inadequate health care. A parallel epidemic of TB following the AIDS - pandemic is already occurring in many developing countries. Over 90% of the dually infected individuals reside in developing nations. In India, about 50-60% of HIV- positive patients will develop TB in their lifetime. In a developing country like India, the potential extra burden of new TB cases attributable to HIV could overwhelm

budgets and support services, as has already happened in countries most heavily affected by the HIV epidemic. TB in turn shortens the survival of patients with HIV infection and may accelerate the progression of HIV to AIDS, as observed by a six- to seven-fold increase in HIV viral load in TB patients. Session – 3 MODES OF TRANSMISSION - FACTS AND FICTIONS

Learning Objectives By the end of this session, all the participants will be able to:

454  Identify the ways and means of HIV/AIDS transmission in the community.  Identify the ways and means by which HIV/AIDS is not transmitted in the community.  Understand the meaning of safe sexual behaviour, and safe blood.  Understand the importance if sterilization of syringes/needles and other body piercing equipment. Time : 45 minutes Method : Exercise and discussion Materials : Paper slips, flip-chart, writing material. Introduction Explain that this session will help the participants to understand the facts about HIV/AIDS transmission. They will understand how the fictions about HIV/AIDS transmission may lead to further spread of the infection in the community. (5 minutes) Procedure 1. Ask the participants to take one standard note book page and divide it into four pieces. All the participants should be asked to write the ways and means by which HIV/AIDS is transmitted. One slip should be used for one mode of transmission. (10 minutes) 2. Ask each participant to read the mode of transmission which he thinks the most important first and then others subsequently. Discuss with the other

participants. Arrange the slips 'according to the modes of transmission. (20 minutes) Outcome of the Session 1. Write down the modes of transmission and HIV infection based on consensus of the participants. (i) (ii) (iii) (iv)

455 2. Write down the ways by which HIV/AIDS is not transmitted. (i) (ii) (iii) (iv) (v) (vi) How HIV Spreads - Routes of Transmission In those infected, HIV found in body fluids like blood, semen, vaginal secretion, tears, saliva and milk have been implicated in the transmission of HIV. ROUTES OF TRANSMISSION There are only three well-defined routes through which HIV can be spread. The most common of is through sexual intercourse with infected partner followed by infected blood and blood products and through contaminated needles and syringes. The third route of HIV transmission is from an infected mother to her child during pregnancy, at birth and after birth due to transmission of virus through breast milk.

SEXUAL TRANSMISSION This refers to transmission through unsafe sexual act, both heterosexual and homosexual (man to man but less likely from woman to woman). Although the probability of transmission of HIV infected, through this route is only one in a hundred to one in thousand, heterosexual contact has emerged as the single largest source for the spread of HIV in South-East Asia. Women are risk of being infected

by their male partners because transmission from male to female is more than from female to male. During sexual intercourse, damage to the lining of sexual organs facilitates transmission of H.I.V infection, the infected partner to 'the un-infected one by exchange of body fluids. It is easier for the virus to be transmitted if the un-infected partner is already suffering from some sexually transmitted disease/reproductive tract infections, because in this case the lining of the organ is already damaged. The risk increases two to

456 ten folds, particularly if the partner has a genital ulcer disease, such as syphilis, chancroid or herpes. It is also possible that the virus is transmitted to the white blood cells which are normally found in the lining of the genital tract. Irritation, infection and damage to this lining spurs on the white blood cells to rush there in large numbers to repair the damage and offer protection from infection, thereby increasing their concentration locally. This in turn increases the risk of HIV transmission. BLOOD-BORNE TRANSMISSION This refers to transmission through infected blood or blood products. That is, this may occur through blood, plasma transfusion where the donor is an infected person, and use of blood contaminated needles, syringes or other skin piercing instruments. It is said that the recipients of a single unit-of HIV-infected blood have a hundred per cent risk of acquiring the infection. Before blood test to screen HIV became available, people with diseases like sickle cell anaemia and haemophilia, which require repeated blood transfusion, acquired HIV infection through contaminated blood. These days, however, this risk can be completely eliminated by routine and mandatory screening of blood samples for HIV. The risk of HIV transmission through sharing of needles and syringes by injecting drug us (IDUs), on the other hand, is very high. This may be because blood is commonly sucked back in to the syringe and then re-injected. In Manipur (North Eastern State), this practice has resulted a dramatic increase in HIV Infection among IDUS. The risk of HIV transmission in health care settings, i.e. from doctor to patient or vice versa from patients to patients, is very low - only 0.3 per cent. For

example, a health care worker, receive a needle stick injury while providing care to an HIV/AIDS case and thus exposing him herself to HIV. Perinatal Transmission This refers to transmission of infection from mother to foetus before, during or after birth, risk of HIV from mother to child transmission is believed to be 30-40 per cent in the uterus, during delivery and after birth. It is believed that during post-natal period,

457 transmission of HIV infection from mother to child occurs through breast milk but the possibility is comparatively low' It is advisable that HIV-infected mother should be counselled during pregnancy not to breast-feed the child on account of risk of HIV transmission through breast milk. She should be made, aware, about safer alternatives to breast milk. However, final option in this regard should be left to the mother. Routes that HIV will not take The range of present attitudes towards AIDS is similar to the attitude once taken towards Syphilis in the early 19th century. Myths and emotional hysteria can be generated due to misinformation about AIDS. Many myths about HIV today centre around the manner in which it can be transmitted. Extensive research has shown that there are only three well-defined routes of HIV transmission, as discussed above. The studies showed that: HIV DOES NOT SPREAD BY  Drinking water or eating food from the same utensils used by an infected person.  Swimming in pools used by people with HIV or AIDS.  Getting bitten by an infected person.  Socializing or casually living with people with HIV or AIDS.  Caring and looking after people with HIV/AIDS.  Getting bitten by a mosquito that has already bitten an infected person.  Use of the same toilets as AIDS patients or people infected with HIV.  Shaking hands with people with HIV or AIDS.  Hugging or kissing a person with HIV or AIDS.

 Casual contact such as sitting next to an infected person, or by coughing and sneezing, or from water, food, clothing, cups, glasses, plates, forks, spoons and other silarecl objects.  Sharing the telephone with an HIV infected person.  Receiving and reviewing literature from areas of the world where there is AIDS.  Donating blood.

458  Working with people who are HIV infected.

BED BUGS, FLIES, LICE, FLEAS, MOSQUITOES AND

OTHER INSECTS AND PESTS DO NOT SPREAD HIV. Session - 4 PREVENTION OF HIV - CRITICAL AREAS FOR INTERVENTION Learning Objectives By the end of this session, all the participants will be able to: 1. Demonstrate a training session for Anganwadi-workers, school teachers, community opinion. leaders on HIV prevention; and 2. Identify key health education messages for community related to HIV prevention. Name : One hour Method : Training role play and group discussion Materials : Flip charts-, writing material, posters, flip book. etc. Introduction Introduce the session by explaining that although all of them have been trying their best to provide quality care to the community in their respective field areas actions in relation to HIV prevention need to be strengthened otherwise achievements made so far in bringing improvements in the health status of the community will be jeopardised. In this session, the group will practice a training session HIV prevention and identify and prioritise key health education messages on it. (5 minutes)

Procedure Training role play on "HIV Prevention". The characters in this role play are: Divide the participants into two groups. One group will observe and then vice-versa. Each group will get 20 minutes.

459 1. Assign the participants who are not participating in the training role play on each of the following guided observations:  What did you observe in the role play?  How participatory was the training session?  What changes, if any, would you recommend for the process of training?  What did you feel about the content of the session? What changes, if any, would you recommend for the content of training? 2. Ask the participants who volunteered to present “training on HIV prevention role play" Encourage them use flip book and charts for the training. (20 minutes) 3. Ask the participants who conducted the training session what they felt could be done differently. Ask the observers to share their observations. (10 minutes) 4. Ask the other group to present the “training on HIV prevention role play” incorporating suggestions made by the group. (30 minutes) 5. Ask the group to test health education messages related to HIV prevention they would like to give to community. Prioritise the messages by consensus. 6. Ask one of the participants to paste the key health education messages on a flip chart. Outcome of the Session Each participant will write the key message on HIV prevention. 1. 1. 2. 3. 4. 5. 6.

Prevention of HIV The strategy to combat AIDS has three main objectives:  To prevent HIV infection  To reduce the personal and social impact of HIV infection  To mobilise and unify national and international efforts against AIDS.

460 Prevention is indisputably the most important objective. No curative drug is universally effective and no affordable prevention vaccine is likely to be available or accessible to developing countries in the foreseeable future. Since AIDS is essentially a sexually transmitted disease, sexual behaviour is the prime focus of action for interrupting transmission. It is, therefore, important to have an information and education programme for all men and women, including adolescents, particularly aimed at those who are at greater risk of HIV infection. It is also necessary to have facilities for the detection and treatment of other sexually-transmitted diseases and to have an environment which promotes use of frank information dissemination without stigmatization and discrimination against known or suspected to have HIV/AIDS. In our country, like other countries of South East Asia region, prevention of sexual transmission is an immediate and topmost priority. PREVENTION OF TRANSMISSION THROUGH SEXUAL INTERCOURSE Safe Sex Safe sex is any sexual practice that reduces the risk of passing (transmitting) HIV from one person to another. The best protection is obtained by choosing sexual activities that do not allow semen, fluid from the vagina or blood to enter into the mouth, anus or vagina of the partner. Safe sex practices include:  Staying in a mutually faithful relationship where both partners are un-infected.  Using a condom for all types of sexual intercourse (vaginal, anal or oral) so that the body secretions that contain HIV do not come in contact with the skin or mucous membranes of the partner.  Avoiding penetrative sex, for example, by replacing with masturbation, massage, dry kissing, and hugging.  Avoiding sex when either partner has open sores or sexually-transmitted infections (STI). Use of Condoms to Prevent HIV and STI Transmission  Condoms are the most effective means of protection against the organisms that cause sexually transmitted infections, including HIV.

461  Condoms are effective only if they are used properly during every sexual intercourse. Instructions on how to use condoms should be clearly given to the users.  Be sure that you have a condom before you need it.  Each time you have sex, put a new and unused condom on the penis before it enters the vagina, rectum or mouth.  Put the condom on only when the penis is erect.  When putting on the condom, hold it so that the rolled rim is on the outside; if you are not circumcised, first pull the foreskin of the penis back.  Do not pull the condom tightly against the tip of the penis but pinch the end of the condom when unrolling it. This leaves a small empty space to hold the semen.  Unroll the condom all the way to the base of the penis.  If the condom tears during sex, withdraw the penis immediately and put on a new condom.  After ejaculation, hold on to the bottom of the condom as you pull the penis out so that the condom does not slip off, then take off the condom carefully without spilling semen.  Wrap the condom in paper (such as newspaper) until you can dispose it of in a toilet, a pot latrine, or a closed garbage bag or by burning it.

Remember Correct and Consistent Use of Condom will protect you from HIV PREVENTION OF TRANSMISSION THROUGH BLOOD TRANSFUSION  Blood transfusion should only be done if the situation is life threatening.

462  Blood transfusion should be avoided as far as possible by avoiding situations requiring them.  If a transfusion cannot be avoided, then one should insist on blood that has been tested for H.I.V antibodies and is found free.  Repeated pregnancies cause anaemia, which can lead to conditions requiring blood transfusion. To avoid such situations, women should get proper care during pregnancy and childbirth so that complications can be avoided. Women should be encouraged to eat foods rich in iron during pregnancy.  Malaria and certain worm infestations can lead to anaemia. Anaemia can be avoided by talking proper treatment and by consuming iron – rich foods like green leafs vegetable. PREVENTION OF TRANSMISSION THROUGH SKIN-PIERCING PROCEDURES Medications by Injection  All injections should be avoided as far as possible. Oral medications should be used if possible.  If injections cannot be avoided make sure that the needles and syringes are either new disposable ones or sterilized properly. Addictive Drugs by Injection  It is best to avoid all addictive drugs.  If not possible, it is better to use them orally.  If injecting drugs cannot be avoided, then injecting equipment should not be shared. If it is not possible to avoid sharing injecting equipment, then either boil the equipment for 20 minutes or use bleach in the following manner.  A level tea spoon of household bleach should be mixed with a litre of clean water in a bowl.

 Flush the syringe and needle first with water and only then flush the syringe and needle twice with bleach solution.

463  Boil or disinfect all instruments used for, ear-piercing, tattooing, circumcision, cutting the skin, etc.  Do not share sharing razors or knives. PREVENTION OF TRANSMISSION FROM MOTHERS TO BABIES HIV/AIDS in a woman brings with it the risk of having on infected child and possibly of a worsening of her own illness. These painful facts are even worse in places where the status of women is influenced by their ability to bear children and where it may be socially unacceptable or very difficult to take the necessary steps to avoid pregnancy, abstain from sexual intercourse to use contraception or to consider terminating a pregnancy. Prevention of sexual transmission of HIV to women is the best to prevent this mode of transmission. Women should know about HIV/AIDS and the means by which HIV transmission can be 'prevented. Risk of vertical transmission of HIV from an infected mother to her child can be reduced significantly by proper ante-natal and intra-natal care, administration of anti- retroviral drugs and be making an informed choice about breast-feeding. HIV/AIDS PREVENTION PACKAGE  Promoting safer sex behaviour through education  Condom promotion/provision of condom venting machine.  STI diagnosis and treatment  Safe blood transfusion  Safe injecting behaviour. Session – 5 CARE AND SUPPORT - MANAGING HIV/AIDS Learning Objectives By the end of this session, all the participants will be able to:  Distinguish between HIV and AIDS  Identify major and minor signs to diagnose AIDS  Understand medical and nursing care required by AIDS patient  Know the precautions to be taken while caring for HIV/AIDS patient

464  Understand the meaning of universal precautions while caring for HIV/AIDS patient Time : One hour thirty minutes Methods : Fish bowl technique as a facilitated group discussion. Materials : Flip chart and writing materials Introduction Introduce the session by explaining that care and support of a person with HIV/AIDS can considerably prolong his or her life and improve its quality. Counselling and support enable the HIV/AIDS case to cope with stress and to take personal decisions relating to HIV/AI'DS. Explain the process of fish bowl technique. Divide participants into two groups - inner and outer rings of fish bowl. While the inner group discusses the issues, the outer group will observe the group process. They should concentrate on the process, content, or body language and interaction between participants. (5 minutes). Procedure 1. Arrange the participants in a fish bowl. Ask the inner, group to discuss the various manifestation of AIDS and how to identify it. What are the precautions which the health care workers should take while caring and nursing HIV/AIDS cases. 2. Assign the outer group definite roles for observations. These include:  Process: What was the group process? How many participants and how many times did the participants discuss with each other or did they just talk to the facilitator or group leader?  Content: What did you think about the content of discussion? Was it accurate and relevant to the issue? How many people were sources of information in the group? In other words, how many people offered suggestions?  Body languages: What were the facial expressions and body postures of the group members? Did they look eager to participate or withdrawn or very authoritative?

465 3. On completion of the discussion, ask the inner group what they felt about the process and content of their discussion. Could they have done it better?

After the inner group's feedback, ask the outer group to share their observations and comments. (15 minutes) 4. Reverse the groups. The outer group now becomes the inner group and the inner group becomes the outer group. Ask the inner group to review the content of the first group's discussion. (15 minutes) 5. Repeat review of observations by the outer group. (15 minutes) 6. Assemble both the groups and ask them to discuss what decisions they would like in order to deal with HIV/AIDS cases. OUTCOME OF THE SESSION 1. What are the precautions to be taken by the health care providers while caring for HIV/AIDS case? 2. What are the important steps in caring of HIV/AIDS case? 3. What are the measures to be taken to care HIV/AIDS patients at home? 4. What are the ethical issues related to HIV/AIDS cases? 5. What are the major and minor signs to diagnose an AIDS case? Major Signs i ii iii iv v Minor signs i ii iii iv v.

466 What do you understand by UNIVERSAL INFECTION CONTROL MEASURES? Care and Support: Managing HIV/AIDS HIV to AIDS It is important to distinguish between being infected with HIV and having HIV/AIDS. People infected with HIV may take 7-10 years to develop AIDS. In developing countries like ours, the progression to AIDS may be sooner because of malnutrition and a poorer state of health. During this interval, HIV-infected individuals may suffer from a variety of disorders and develop signs which are suggestive of being infected with HIV/AIDS. One of the common signs is the painless swelling to lymph's glands in the neck, armpits and groin called persistent generalized lymphadenopathy (PGL). Patient may also suffer from other symptoms such as fever or night sweat, diarrhoea, loss of weight height and infections such as thrush (candidiasis) and herpes. This cluster of signs and symptoms was often designated as the AIDS-related complex. DIAGNOSIS OF AIDS AIDS is diagnosed by demonstrating the presence of one or more opportunistic cancers and other infections like:  type of pneumonia called pneumocystis carinil  A variety of intestinal infections resulting in diarrhoea, weight loss and known as slim disease in some parts of the world.  A skin cancer called Kaposi's sarcoma.  Infection of the nervous system; damage leading to deterioration of intellectual capacity (dementia). In conjunction with opportunistic infections two more factors are taken into account to confirm a diagnosis of HIV/AIDS. First the number of CD4 cells in the blood drops to below number 200/microlitre (normal 800 to 1200/microlitre). Second, it is essential to demonstrate the presence of HIV in the blood using sensitive blood tests, the most widely used being the enzyme-linked immuno-sorbent assay (ELISA) which detects antibodies generated by the body in response to infection by HIV. Blood test for HIV is now, available at all district H.Q. Since sophisticated methods for counting CD4 cells and carrying out blood tests may not be available in many developing countries, WHO has tested few signs that help in the provisional diagnosis of AIDS in adults. The presence of at least two major signs

467 associated with at least one minor sign can be an indication of' AIDS, provided that other causes of depleted immunity like malnutrition have been ruled out.

The major and minor signs tested are appended below: Major Signs  Weight loss greater than 10% of body weight  Fever for longer than one month, intermittent or continuous  Chronic diarrhoea for longer than one month, intermittent or constant.

Minor Signs  Persistent cough for longer than one month  General itchy dermatitis (skin irritation)  Recurrent herpes zoster (shingles)  Oropharyngeal -candidiasis (fungus infection in the mouth/throat)  Chronic progressive and disseminated-herpes simplex infection  Generalized lymphadenopathy (Swelling of lymph nodes) In children, a diagnosis of AIDS is suspected when an infant or child presents with at least two of the following major signs associated with at least two of the following minor signs, provided other causes for depleted immunity such as severe malnutrition or cancer have been ruled out. Major Signs  Weight loss or abnormally slow growth  Chronic diarrhoea for more than 1 month  Prolonged fever for more than 1 month Minor Signs  Generalized lynphadenopathy  Oropharyngeal candidiasis  Repeated common infections (otitis, pharyngitis, etc.)

468  Persistent cough  Generalized dermatitis  Confirmed maternal HIV infection.

Refer such Patients to Hospital for Confirmation of the Diagnosis and Care Medical and Nursing Care HIV-infected persons have repeated episodes of illness and impairment requiring medical and nursing care, including occasional hospitalization. At the minimum, such clinical care requires adequately trained health care provider and reliable supply of essential drugs and medicines. Infection Control It is true that those working in health care settings - doctors, nurses and paramedical staff – run a risk of getting infected accidentally by HIV from an infected patient, if they do not take the necessary steps to prevent it. Such risks can be avoided by following universal precautions. Universal precautions are based on the assumptions that all blood and body fluids are potentially infectious regardless of' whether it is from a patient or health care worker and regardless of their known HIV antibody status, and should be applied in the case of all patients. These measures are:  Safe handling and disposal of sharps.  Safe decontamination of instruments and other contaminated equipment.  Hand Washing  Use of protective barriers to prevent direct contact with body fluids. HIV is an virus which can be easily destroyed by simple methods such as boiling for 20 minutes, using chemicals as household bleaching powder. It is important to remember that infection control measures are intended to isolate the virus and body fluids, not the patient. Home Care

469 Since AIDs is chronic disease lasting months or years, much of the care of those with AIDs must therefore occur at home. Families and other care providers must be helped to provide safe and compassionate home care to people with AIDs. There is no risk of acquiring HIV from people infected with it (or people with AIDs) in the home situation provided you follow certain simple rules.  Wash hands with soap and water after changing soiled bed sheets and clothing and after having contact with body fluids.  Keeping wounds covered. Both care givers and people with AIDS should cover an open wound which they may have on their hands or other places likely to have contact with other people, their bedding or clothing. Cover open wounds with a bandage or cloth  If blood from an infected person is spilled, it should be immediately cleaned with a disinfectant such as bleaching powder (1% solution). Household gloves (rubber gloves) should be worn and if gloves are not available then the hands should be covered with paper or polythene bags. Hands should always be cleaned afterwards with soap and water.  Use a piece of plastic or paper, gloves or big leaf to handle soiled items.  Keeping bedding and clothing clean. Counselling and Support Counselling can help people live and cope with HIV and AIDS by taking into account the client's immediate social and medical environment and his or her social relationship and attitude and belief about HIV/AIDS. Counselling has to provide education and information in a way that is relevant to the day to day life of the person concerned. It has to take into account the patient's sexual needs and history, occupation, education, aspirations, and hopes, and also inspire him/ her for a new approach to safe sex and responsible social relationship. Ethics of AIDS It is unethical to stigmatize or discriminate against people who are HIV-infected or who have AIDs. Human rights demand that people with HIV/AIDS be treated exactly like other people in terms of access to health care, work, education, travel, social welfare services, etc. Nondiscrimination is not only a human rights imperative, but is also a

470 technically sound strategy for ensuring that infected persons. are not driven underground where they become inaccessible to health care programmes and unavailable as credible bearers of AIDS prevention message for their peers. Any attempt to isolate, detain and confine infected persons is therefore not only unethical but also, from a public health point of view, quite irrational.

Session – 6 AN ACTION PLAN FOR INFORMATION, EDUCATION AND COMMUNICATION (IEC) ON HIV/AIDS AND STI

Learning Objectives By the end of this session, all the participants will be able to:  Identify community partners for implementation of HIV/AIDS and STI related IEC activities.  Prepare an action plan for IEC on -HIV/AIDS and STI for the identified community partners (opinion leaders).  Prepare key messages on HIV/AIDS and STI to be used by the community partners (opinion leaders). Introduction Explain to the participants that a major component of the prevention and control strategy is to create an informed environment in the community for scrutinizing their behaviour and adopt safer practices by raising awareness and knowledge about HIV/AIDS and STI transmission and prevention and thus affecting their attitude and behaviour patterns. Tell the participants that for the successful, IEC campaign it is necessary to identify the community opinion leaders who are respected and acceptable to the community.

Time : Two Hours Method : Chapati diagram

471 Training need assessment, Group exercise, demonstration, discussion Material : Flip charts, coloured paper sheet s for,chapati diagram, scissors, writing material and writing cards (100)

Procedure 1. Explain the procedure for using the chapati diagram. Divide the participants into three groups randomly. Each group prepares a chapati diagram which

represents the relationship with important members of their community. Ask them to identify their potential partners. (30 minutes) 2. Bring the groups together and analyse each chapati diagram. (10 minutes) 3. Enlist the community partners identified by the three groups on a flip chart. (10 minutes). 4. Divide the participants again into two groups. They should be provided cards and asked to write important HIV/AIDS and STI related subjects on which they need sensitization /training. One topic should be written on one card only. (30 minutes) The group should write down their need on a flip chart. (30 minutes) 5. Assemble two groups and the participants to discuss the priority areas for sensitization / training. (10 minutes) 6. Divide the participants again into two groups. Ask them to prepare key messages on each selected priority subject and IEC materials on HIV/AIDS and STI to be used by community opinion leaders. (20 minutes) 7. Assemble the two groups and discuss the messages and IEC materials suggested by each group. (10 minutes) Out come of the Session 1. Enlist the community opinion leaders identified by the group after consensus. 1. 2 3 4 5

472 6 7 8 9 10

2. Enlist the topics or subjects identified by the group for sensitisation /training do community opinion leaders. 1 2 3 4 5 6 7 8 9 10 3. Enlist the key message and suggested material for each selected topic Sr. NO Topic Messages Suggested IEC Material 1 2 3 4 5 6 7 8 9 10

473 An Action Plan for Information, Education and Communication (IEC) on HIV/AIDS/STI Information, Education and Communication is a process that informs, motivates and helps people to adopt and maintain healthy practices and life styles. Advocates environmental changes as needed to facilitate this goal.

Objectives Informing People The first directive of IEC is to inform people or disseminate scientific knowledge about prevention of HIV/AIDS/STI and promotion of health. Exposure to new knowledge melts away the barriers of ignorance, prejudices and misconceptions, which the people may have about HIV/AIDS/STI. This creates an awareness of health needs and problems and also of responsibilities on the part of the people. Motivating People Simply telling people about HIV/AIDS/STI is not enough. They must be motivated to change their behaviour and ways of living in order to keep themselves away from HIV/AIDS/STI (active learning). Health education must provide learning experiences, which favourably influence habits, attitude and knowledge relating to individual, family and community health. The efforts should be on motivating the "consumer- to make his own choices and decisions about health matters, that is, what kinds of health actions to be taken, when and under what condition by them. PROCESS OF ADOPTION OF NEW IDEAS AND PRACTICES People appear to pass through a series of distinguishable steps before they adopt one practice. These stages are: Awareness Person comes to know about the new idea or practice. Interest Person seeks more detailed information. He is willing to listen or read or learn more about it. Evaluation

474 The person weighs the pros and cons of the practice and evaluates the usefulness to him or his family. Trial He would need additional information and help at this stage so as to overcome the problems in implementing the idea.

Adoption The person decides that the new practice is good and adopts it. ACTION POINTS FOR IEC ON AIDS  Promotion of safer behaviours that limit the spread of HIV and AIDS.  Removal of myths and misunderstanding about the modes of transmission of HIV and AIDS.  Fostering of positive and caring attitude towards people with HIV and AIDS.  Encouragement of voluntary blood donation.  Development of public support for AIDS control measures carried out by government and voluntary organisations. CHOOSING TARGET AUDIENCE As a first step, it is essential to identify important groups that will need to be reached in the community. Different sections of public will have different information needs and will require separate and distinct approaches and messages. Possible target audience may be: • School children boys and girls • School Teachers All • Young persons - College and Out of' college youths • married couples – husbands and wives • Sex workers and their clients • Patients at STI Clinics • Injecting drug users • Homosexual men

475 • Professional group, eg. health workers • Traditional healers • Quacks • Religious and community leaders /elders • Employers and Trade unions • Parents • Journalists

Involving Community (‘Community based’ or ‘out reach’ approach) Identify people who have influence and are respected within each of the target (Groups listed above, Spend time talking to them and find out what they think about AIDS and the safer sex message. invite them to participate in planning and carrying out health education activities. It ensures that educational messages are relevant and effective. Usually people will be more easily reached and be convinced by a trusted member of their own group than by an outsider Peer education approach.

Learning About The Community

 What people know and feel about AIDS, STI, Condom and safe sex behaviours.

 It is desirable to know the prevalence of risk-taking behaviour.

 Treatment seeking behaviour.

 Local myths and customs that may affect the spread of AIDS and STI.

 Identify local beneficial beliefs that can be reinforced and built upon.

Making information relevant, realistic and acceptable for prevention of aids:  A reduction in the number of sexual partners - ideally a single faithful relationship.  Avoidance of sexual intercourse with someone who has had many partners.

476  'Safe sex' - that restricts exchange of vaginal and seminal fluids, includes correct use of condom during penetrative vaginal and anal sexual intercourse.  voidance of traditional practices, e.g. tattooing.  Sterilisation of syringes, needles and other body-piercing equipment.  Sterilisation of syringes by injecting drug users and avoidance of sharing needles with other injectors. Care should be taken not to pass moral judgments on the sexual life-styles of the people in the communities.

Choosing Appropriate Messages Some key messages are: AIDS is a fatal disease; there is no cure.  It is transmitted only through sex (unprotected), blood (HIV infected and from mother (infected) to children; it is not transmitted through casual contact.  Once infected, it can take from seven to ten years or even longer. in adults to develop AIDS during that period there are no symptoms but such a person can infect others.  Persons living with HIV and AIDS should be treated with compassion and their rights must be protected.  It is impossible to tell by appearance who is infected with the virus, so exercise caution.  Everyone is at risk of becoming infected if he/she does not take necessary precautions.  Young people should delay having sexual intercourse until they are married.  Reduce the number of sexual partners, ideally stick to one regular sexual partner; avoid sex with persons who have many sex partners.  Practice no-risk and low-risk forms of sexual intercourse.  Seek prompt treatment for sexually-transmitted diseases.  Only go to those health workers who sterilize their instruments.

477  Say no to Drugs, Drugs harm health.  Avoid injecting drugs. It is less dangerous to take drugs by mouth or inhalation.  If using drugs - seek assistance to give up.  Sharing needles can spread infection like HIV and Hepatitis. If injecting drugs, never share needles and syringes: if sharing then sterilize syringes and needles in bleach. It is desirable not to frighten the community. The message should focus on reassurance that the disease can be prevented.

Planning Programmes For Priority Groups 1. Reaching Young People at School and College 2. Reaching Young People Out of School 3. Reaching Men There are groups of people that are at special risk of HIV infection. When men are away from their homes and families there is increased likelihood of casual sex and use of sex workers. Such men, at risk, would include those who frequently travel to cities for work or even to another country in search of jobs or as migrant labourers, other men such as in the Army, Navy and seamen may also be vulnerable 4. Reaching Women • Through ante-natal, maternity and child health clinic • Working women - at their workplace 5. Sex Workers 6. Long Distance Truck Drivers 7. Intravenous Drug Users 8. Migrant Labourers

ACTION PLAN FOR PROMOTING CONDOMS Low level of use of condom under family welfare programme is because of:

478 • The availability of contraceptive pill as, an extremely reliable and convenient method. • Complaint by couple that it interferes with making and reduces pleasurable sensations. • Shyness in asking shopkeepers for condoms. • Reluctant to be seen carrying condoms for fear of being called promiscuous. It will be effective to identify men who use condoms regularly and are happy with it - SATISFACTRORY USER. These 'satisfactory users' can be asked their reasons for using the condoms and how they use them. There should be a strong education programme on condom use which should include that using condom is a question of establishing a different routine that can be just as pleasurable.

 Using of a condom can remove the anxiety of catching HIV and other STI, which can also spoil love making.  Condom can be very reliable if used properly.  Shopkeepers should be encouraged to display condoms prominently.  Use of social marketing techniques, where careful attention is given to packaging, brand names, advertising, price and distribution.  Codom venting machines USING EFFECTIVE COMMUNICATION METHODS  Mass media: radio, television and newspapers  Interpersonal communication  Role play  Drama and story telling  Visual aids  Videos  Puppets  Prepared written materials  Body Mapping Using Posters

479 A good poster should have a very simple message and not try to say, too much. It should be eye catching to gain attention through use of striking pictures strong coloures, or interesting contents. Posters should be displayed where intended audience will pass by them and see them.

Availability Of Condoms

It is available from two sources: • Free supply condom. • Branded condom through social marketing. Methods of Participatory Learning for Action (PLA) There are many methods of PLA, of these the following methods 'have been used in this manual

1. Chapati Diagram 2. Relative Ranking

 This method indicates priorities and preferences of the people. It gives them an opportunity to actually rank various items or preferences or some uses. They can also change the ranking if necessary. In addition to giving you information as what needs are more important to them, this method will also give you reason for their choices. Basic steps involved in relative ranking include:

 Ask the participants to enlist various health services that are available to them. They may also add services that are not available but are important for them.

 Write one health service on one card or paper. Thus, you will have as many cards or papers as perceived by the participants.

 Place any one card on the floor. Pick up another card and ask the participant if this is more or less important than the service listed on the card on the floor. If it

480 is more important, place the second card above the first and if it is less important, place it below it.

 Continue placing one card after another by asking if the service tested is more or less important than those listed on the floor. This way you will be able to help the community make decisions on the priorities for the health services.

 Discuss the ranking with participants. You can ask question such as, "why is the service more important to you?", "How can we improve the services?" etc.

 After the relative ranking is completed,-make its copy on the paper for your reference. It will also help you to focus more on the priorities of the community.

3. Fish Bowl Technique The fish bowl is a powerful group involvement method. A fish bowl consists of an inner ring, which is the discussion group, surrounded by an outer ring, which is the observation group: The inner group is given a task to discuss possible solution to a problem and tries to arrive at the best feasible options. This should be done in a limited time. While the inner group is discussing, the outer group observes silently. 4. Body Mapping Large numbers of the women in the villages do not understand the reproductive system through charts, posters, TV and other common media used for dissemination of information. Body mapping technique has been found to be very effective in such a situation. It is however important to remember that unless the women are comfortable to discuss with you, this method will not work.  After the initial greetings and opening sentences, ask the women what are the female organs for reproduction. Ask them to show where these are located in the body and what is the function of each organ.  Ask probing questions so that the women are able to realise the location of various reproductive organs. For example, if you want them to locate the ovaries,

481 ask, if anyone in the group has experienced pain in the abdomen around the middle of a cycle. If yes, where is tile pain located? Why does it appear on alternate sides every month? etc.  It is likely that several women do not know the location and size of the reproductive organs. Tell them that you will help them learn by making an outline of a female body. Ask one of the women to lie on the floor. If they are not willing to, you may lie on the floor yourself and ask a woman to draw your outline with a chalk or charcoal.  The outline will perhaps indicate a much fatter person than the what you or woman who lay on the floor actually is. Ask the women to modify the outline so that it closely resembles the, person who lay on the floor.  Ask the women to mark landmarks on the outline such as legs, mouth, breast, etc. These outlines will give an idea about the location and size of organs they will plot inside the body.

 Ask the women to plot the reproductive organs in the size and locations they think are there. Ask the group to modify the map. You may have to ask leading question occasionally to help the women learn about the sized and location of these organs.  Once the anatomical mapping is completed, discuss with the women what is tile function of each of these organs. Do not explain, ask questions and let the answers emerge from the group itself. Session-1

EDUCATION AND COUNSELLING Health workers and Supervisors as Educators and consellors for STI including HIV/AIDS.

Learning objectives By the end of this sessions all participants will be able to:  Explain why education and counselling are vital in the management of patients with HIV/AIDS/STI.

482  Identify the difference between education and counselling  Explain why counselling can be difficult for both patients and service providers alike.  Identify the main topics on which he needs to educate and counsel his patients. Time : 1hour Methods : Small group exercise, and group discussion Material : Flip chart, cards writing material. Introduction Introduce the session by explaining that to become a good educator and counsellor for STI/AIDS patients. It is important to know why education and counseling are vital to them. What is different between these two skills? What are the main topics to be discussed with HIV/AIDS/STI patients Procedure 1. The facilitator will distribute cards to all participants 2. Ask the participants to think why it is important to educate every patient, write one statement in each card.

3. Collect all cards and read written statements one by one. If the same statement is written on two or more cards discard them. 4. Discuss the statements 5. Ask one of the participants to write the final statements on the flip chart 6. Ask the participants to discuss about education and counselling. Define education and counselling, sort out different between these two skills. 7. Discuss why counselling is difficult for both patients as well for service providers 8. Ask one of the participants to write the end result of discussion on a flip chart. 9. Again distribute cards to all participants and ask them to write one topic on which he wants to educate his patient. Write one topic on one card. 10. Collect all cards, read the topics one by one, if same topics are written on two or more cards discard them and retain only one of them. 11. Discuss the relevance of topics.

483 12. Write the finally accepted topics over a flip chart. Counselling and Education WHY EDUCATION AND COUNSELLING ARE VITAL IN THE MANAGEMENT OF PATIENTS WITH HIV/AIDS/STI It is important to educate and counsel every patient visiting a health facility for- STI treatment because the service provider has an excellent opportunity to help the patient, reduce his/her risk of getting STI again or of getting HIV infection or spreading it to other people. The patient will be interested in the information because of his/her condition. This may be one of the few opportunities when they come in contact with the health system and find out more information about HIV/STI and safe sexual practices. It may be one of the few opportunities for the service provider to break the cycle of transmission of STI in a community. What is the difference between counselling and educating? Counselling can be defined as "face to face communication between a person with a trying to help solve the problem." In this case the problem would be

having STI the person trying to help or solve the problem would be a service provider. Counselling of STI patient could involve a whole range of skill from listening to their problems giving them vital information and helping to solve their problems. Education involves giving patients practical information about STI its name. Symptoms and treatment. But it is also about helping patients to understand how STI spread and why it is so important to treat them. And another vital part of education is helping patients understand how they can protect themselves, their partners and children in future.

484 So education is providing the patients with information on how to stop the spread of STI and counselling is about helping patients to change their attitude and behaviour that may be putting them and their partners at risk. Why are counselling and education difficult ? Counselling and educating are difficult areas of STI management for both patients and service providers. If a service provider seems contemptuous or judgmental or just too busy patients may be reluctant to divulge personal information about sexual or drug use activities. Because of the stigma attached to STI, patients are embarrassed about revealing their symptoms. They have difficulty in talking about their sexual behaviour and may have heard about STI patients having been treated by doctors who branded the patients as sinner’s when referred for treatment to them or the doctor asking for personal information in public waiting areas, or in other ways embarrassed or humiliated the STI patients. Counselling and educating can also be difficult for service providers. Most service providers have very little time, are untrained in human sexuality, uncomfortable talking and asking about sexual behaviour and bring their own Moral religious and cultural values and experiences to the treatment room. Six main topics on which we must educate STI/HIV/AIDS patients are: 1. Cure your infection: Tell your patients to take all their medications as instructed even if their symptoms disappear or they feel better. Warn them that the symptoms may come back if they do not take all of the medications.

2. Beware of spreading S.T.I including H.I.V: encourages your patients to take all these medications as instructed even if their symptoms disappear or they feel better. 3. Help your sexual partners get treatment: Encourage your patient to bring partners (s) for treatment 4. Come back to make sure that you are cured: Explain to your patient that if they still have symptoms they may need more medications to cure their infection

485 5. Stay cured with safe sex practice: Explain to your patient that if they have sex with several partners, there is more risk that one may have STI including HIV. Having sex with one un-infected mutually faithful partner is safe sex behaviour. Encourage your patient about regular use of condom with casual sexual partner(s) and if possible even with the steady partner. 6. Protect your baby: Encourage your female patient to come for an antenatal clinic within the first 3 months of pregnancy for physical examination, V.D.R.L and ELISA TEST 9. Role-play and brain storming This activity is designed to introduce the participants, to the concept of counselling. Ask the participants, to volunteer for a role-play. (Two members are the clients and one plays the counsellor). Neena and Shyam are a married couple who has a one-year-old child. They have been married for two years. Shyam works as an engineer at Mumbai while Neena is a school teacher at Lucknow. He comes home twice or thrice in a year. Neena had to take some months leave during her first pregnancy. Shyam is keen to have a second child but Neena feels this is not the right time for another child. They come to a counsellor for help. Shyam has had casual sex with some unknown women twice or thrice. On one occasion he had an ulcer over his private parts for which he took medicine from a private practitioner. When he returns home his wife insists on sex but Shyam is afraid of the disease which he had suffered, and its transmission to his wife. He loves his wife very much. Both of them visit their friend for consultation to solve the problem. 5. Ask them to enact the play.

6. After the play ask the participants to brainstorm on what they observed and understood about counselling. 7. Make brief notes of the responses on the-flip chart. 8. Ask the participants to discuss amongst them selves keeping in mind sleeping in mind the role-play, enlist communication skill on the flip chart. Why Sexual Behaviour Is The Hardest To Change? If we just tell people about prevention and control of STI and if they follow all our advice, then life would be easier for the service providers. But in the real world it is

486 much more difficult to change human behaviour, especially behaviour linked to activities which are more personal, more private and more intensely pleasurable. Such behaviours are harder to change. The Challenges to Change the Behaviour Behaviour

Behaviour is everything we think, do and feel. Behaviour is not something we are born with. We are born with our temperament and physical characteristics and these interact with our environment to produce our behaviour and our habits - behaviour done over and over again until they become automatic and take place without the person having to think a great deal.

Behaviour is formed by a combination of eight different factors: 1. The body and temperament we are born with: "Intelligence, general health, physical appearance, handicaps, disabilities, talents, etc." 2. Gender: The patient's gender has an impact on what he or she does and what they are able to change, e.g. economic constraints of women, different values for male and female sexuality, powerlessness of woman relative to man, etc. 3. Culture: Particular cultural practices may help or hinder the patient's ability to change, e.g. polygamous marriages, wife inheritance, rituals, cultural practices and values about marriage, sexuality, child rearing, etc. 4. Religion: The extent to which the patient's religious beliefs help or hinder their attempts to, change their behaviour.

5. Economic: Whether the patient has ability to earn or has access to what he/she needs for survival. Do they have the economic freedom to look ahead or make plans for the future? Do they have the economic resources for adequate health care and information?

487 6. Family and community, The values, beliefs and circumstances of patient's social environment, including friends, family and sexual partners. Does the social environment offer support and assistance? Is the patient ostracized from his/her social environment because of his/her behaviour? 7. Physical environment: Whether the patient has, adequate food, clothing, shelter, water. How many people live in the same home? Under what circumstances.? Is the area safe? 8. Personal factors:- What are good interpersonal Communication skills? Few suggestions for crood inter personal communication?

Chapter – 20 NON-COMMUNICABLE DISEASES (NCDS)

488 Objectives

 To understand the importance of non communicable diseases as a public health problem  To understand the determinants and risk factors of non communicable diseases  To understand the concepts of primary and secondary prevention of non communicable diseases  To learn the basic skills required for the surveillance of risk factors of non- communicable diseases in the community  To learn the basic skills in behavior change communication required for health promotion in the community regarding non-communicable diseases

Session - I INTRODUTION TO NON-COMMUNICABLE DISEASES  What are non-communicable diseases? WHO Cluster of non-communicable diseases  Increasing trend in non-communicable diseases- CVD, DM, CANCERS, COPD, Mental health, Injuries  Dual burden of communicable and non-communicable diseases Epidemiological and demographic-transition  Social changes, which favour the rise- in non communicable diseases Lifestyle changes as a dominant factor in the rising burden of non-communicable diseases  Common underlying risk factors predisposing to non communicable diseases

Session - 2 RISK FACTORS OF NON-COMMUNICABLE DISEASES  Difference between risk and cause  Common risk factors of non-communicable diseases

 Tobacco, Alcohol, Obesity, Diet and Physical Activity  Body mass index - concept and calculation Session - 3

489 RISK FACTOR MODIFICATION - How prevention is better than cure - Primary and secondary prevention of non communicable diseases - Strategies on various risk factor modification - Population based approach vs individual approach - Examples from some global and Indian strategies - Counselling, behaviour change communication Session - 4 RISK FACTOR SURVEILLANCE OF NON-COMMUNICABLE DISEASES - Relevance of risk factor surveillance - What is surveillance? Difference between surveillance and survey - WHO Steps approach - Role of primary care health worker-s in health promotion Group assignment To plan for routine surveillance and monitoring of non communicable diseases in the community CARDIOVASCULAR DISIEASES Objectives  To understand the importance of risk factors, their surveillance and modification in cardiovascular diseases Session - I What are cardiovascular diseases? Indian and Kerala scenario Importance of early detection, control of risk factors, diet counseling, other life style modification, treatment compliance Group assignment Plan for a health promotion strategy for prevention of cardiovascular diseases in a grama panchayat. Prepare an action plan for 3 months

Practical session -1 Measurement of height, weight, BMI, waist circumference - theory and demonstration using standard protocol

490 Practical sessions 2 Students exercise Practical session 3 Measurement of blood pressure theory –demonstration using standard protect. Practical session 4 Students exercise DIABETES MELLITUS Objectives  To under-stand the importance of prevention of Diabetes Mellitus  To understand Life style modification in the prevention of complication of Diabetes Mellitus Session - I What is Diabetes Mellitus? Importance of early detection, control of risk factors, diet counseling, other life style modification, treatment compliance Group assignment Plan for a health promotion strategy for prevention of Diabetes in a grama panchayat. Prepare an action plan Practical session -1 Measurement of urine sugar - theory and demonstration using standard protocol Practical session-2 Students exercise BEHAVIOUR CHANGE COMMUNICATION AND COUNSELING SKILLS FOR RISK FACTOR MODIFICATION Objectives  To under-stand the importance of behavior change communication in risk factor modification of NCDs

 To learn the basic skills in behavior change communication required for health promotion in the community regarding non-communicable diseases Session - I

491 Lecture session Practical assignment A health education talk or campaign for the community for any of the risk factors WHAT ARE NON-COMMUNICABLE DISEASES? Non-communicable diseases (NCD) include diseases which do not have infectious agents which make them spread from one person to another. WHO (World Health Organisation) cluster of non communicable disease include Cardiovascular diseases, Cancer, Diabetes, Chronic obstructive pulmonary disorders (COPD) or chronic respiratory diseases, mental illness and injuries. They are causes of enormous morbidity, premature mortality and a threat to the economic resources of many countries. Differences between communicable and non-communicable diseases Understanding the differences is crucial in terms of finding appropriate cost effective strategies for prevention and control. The communicable diseases usually have a single causative agent, sudden onset of symptoms, responds to short course treatments and are curable whereas non-communicable diseases are multi factorial, have a long course with gradual onset of symptoms, requires prolonged care & treatment and affects the quality of life. Most of the non-communicable diseases are linked to common risk factors, namely, tobacco use, alcohol abuse, unhealthy diet, physical inactivity and environmental carcinogens. GLOBAL BURDEN OF DISEASES It is estimated that by 2020, over 70% of the global burden of disease will be caused by non-communicable diseases, mental health disorders and injuries.' Alcohol related problems were the leading cause of male disability and the tenth leading cause of female disability in developed nations. Tobacco use was predicted to cause more disease and disability than any other single cause, and to a greater extent in underdeveloped nations by the year 2020. Chronic diseases are already the major cause of morbidity and mortality in the developed countries. The rapid rise of non-communicable diseases represents one of the major public health challenge that all the countries in the, would face. The world

492 health report 1999 shows that in 1998 non communicable diseases accounted for 77% of global mortality and 85% of the global burden of disease was, from the low and middle income countries. Dual Burden While Communicable diseases are still a public health problem in the developing countries, chronic non-communicable diseases are gradually becoming the leading cause of death and disability, as per the following report of W.H.O 1) WORLD HEALTH ORGANIZATION Non communicable Diseases and Mental Health June 2000 2) WHO The World Health Report 1999: Making a difference. GENEVA: WHO 1999 Why does this happen? Demographic transition The achievements made in the last 50 years in the control of infectious diseases during infancy and childhood, better access to safe delivery practices, relative improvement in sanitation, social developments in terms of education, female literacy, economic development in terms of increase in percapita income etc has resulted in lower infant and child mortality and mortality in the younger age groups. This has in effect resulted in the increase in the number of people surviving and living for longer number of years. This is commonly referred to as increase in the life expectancy at birth. The population of countries also reflects these changes showing more number of middle aged and older adults. This is called demographic transition. Due to demographic transition, people are exposed to risk factors of NCD for longer periods and therefore increase the burden of chronic life style related diseases. Epidemiological Transition This shift or change in the pattern of decline in deaths due to infectious disease to an increase in deaths due to chronic diseases is referred to as Epidemiological transition. It is projected that there will be an alarming rise in the NCD burden in the developing countries over the next 25 years.

493 Lifestyle changes As countries achieve higher economic development increasing urbanization and industrialization take place resulting in mechanisation of labour and access to motorised transport. Therefore it also brings in hazard of high calorie diets, smoking, sedentary lifestyles and vehicular trauma. The change in the dietary patterns in the developing country is linked very closely to the globalisation: arrival of new food items, marketing methods and change in habits. For example, a survey in urban Delhi showed higher prevalence of Coronary heart disease with higher levels of body mass index, Blood pressure, fasting blood lipids (Total cholesterol, ratio of cholesterol to HDL cholesterol, triglycerides) and diabetes. The increasing use of tobacco in the developing countries also results in higher mortality rates of cardiovascular diseases, lung cancer and other tobacco related diseases. Non-communicable diseases are often associated with affluent countries and affluent populations within the developing countries. However evidence suggests that high exposure to risk factors especially tobacco and alcohol is seen among the poorer sections of the population. Leading 12 selected risk factors as causes of disease burden

494 MAJOR NCD RISK FACTORS Developing countries Developed countries High mortality Low mortality Underweight Alcohol Tobacco Unsafe sex Blood pressure Blood pressure Unsafe water Tobacco Alcohol Indoor smoke Underweight Cholesterol Zinc deficiency Body mass index Body mass index Iron deficiency Cholesterol Low fruit & veg intake Vitamin a deficiency Low fruit & veg intake Physical inactivity Blood pressure Indoor smoke-solid fuels Illicit drugs Tobacco Iron deficiency Unsafe sex Cholesterol Unsafe water Iron deficiency Alcohol Unsafe sex Lead exposure Low fruit & veg intake Lead exposure Childhood sexual abuse Source: world health report, WHO 2002 Tobacco Tobacco has been projected by the World Health Organisation to be the largest single cause of death accounting for 12.3% of all global deaths by the year 2020. It is also interesting to note that the developed countries have demonstrated overall decline in the risk factors of NCDs including tobacco. It is suggested by the projections that deaths attributable to tobacco in India will rise from 1.4% in 1990 to 13.3 % in 2020 of which a, major proportion will be due to cardiovascular deaths. Diet and Physical activity The importance of diet and nutrition on the development of chronic non- communicable diseases are well proven. It leads to increased incidence of CVDS, various forms of cancers, diabetes, osteoporosis and also has adverse impact on oral health. The consumption of starch as staple food has declined and that of meat, eggs and diary foods have increased considerably. Frequent eating outside home and snacking often facilitate this increase in the consumption of high fat, animal products. Foods that are processed with high saturated fats, have become common and accessible to a wider section of the population.

495 Obesity Along with the increased consumption of energy and fats, there has been considerably decreased physical activity, which has led to high prevalence of overweight and obesity in the population. Risk Factors of Non-Communicable Diseases - Difference between risk and cause - Common risk factors of non-communicable diseases - Relevance of risk factor surveillance - What is surveillance? Difference between surveillance and survey - WHO Steps approach Rationale for the selection of key risk factors A "risk factor" refers to any attribute, characteristic, or exposure of an individual, which increases the likelihood of developing a non-communicable disease. In the context of public health, population measurements of these risk factors are used to describe the distribution of future disease in a population, rather than predicting the health of a specific individual. Knowledge of risk factors can then be applied to shift population distributions of these factors in a positive direction. Emphasis in surveillance should be given to risk factors that are amenable to intervention. Some factors not amenable to intervention such as sex and age, are also important for estimating trends in NCDS. Intervention strategies can often be delivered cost effectively by community-wide activities, including information and education campaigns, and legislative reform or structural changes that encourage health-preserving behaviour.

Risk factors and disease burden The major risk factors for one NCD are.' also likely to affect one or more of the other NCDS. In addition, some of the NCD risk factors tend to appear in 'clusters' individuals (i.e. physical inactivity often clustering with poor diet and smoking). Furthermore, a relatively limited set of risk factors account for a large fraction of the risk of NCD in the population. It has been estimated, for example, that, social class, tobacco and alcohol use, obesity, blood pressure and diabetes explain about half of the variance in stroke in men and two-thirds in women

496 In the context of public health, population measurements of these risk factors are use to describe the distribution of future disease in a population, rather than predicting the health of a specific individual. Knowledge of risk factors can then be applied to shift population distributions of these factors. Because many factors associated with disease cannot be modified, emphasis in any surveillance system should be given to those risk factors that are amenable to intervention. Surveillance of just eight selected risk factors (which reflect a large part of future NCD burden) can provide a measure of the success of interventions. For example, inappropriate diet and physical inactivity - resulting in high body mass index, raised blood pressure and unfavourable blood lipids - together with tobacco use, explain at least 75% of cardiovascular disease. The rationale for inclusion of core risk factors is therefore that:  they have the greatest impact on NCD mortality and morbidity;  modification is possible through effective primary prevention;  measurement of risk factors has been proven to be valid; and  measurements can be obtained using appropriate ethical standards. MEASUREMENT PROTOCOL (Source) (Source: Surveillance of risk factors or noncommunicable disease-The WHO stepwise approach, WHO,Geneva. Height Measurement Protocol Equipment Infant/Child/Adult Portable Height-length Measuring Boards Assembling the Measuring Board 1. Separate the pieces of board (3 pieces) by unscrewing the knot in the back. 2. Assemble the 3 pieces by attaching each one on top of the other in order. 3. Lock the latches in the back. 4. Make sure the board is placed on a firm surface against a wall.

497 Measuring Height Using the adequate Measuring Boards 5. Ask the participant to remove shoes, socks, slippers and any head gear (hat, cap, hair bows, comb, ribbons, etc). 6. Ask the participant to stand on the board facing you. Put their feet together and heels against the backboard, knees straight. 7. Ask the participant to look straight ahead and not to look up. 8. Make sure the eyes are the same level as the ears. 9. Move the measuring down and place on top of head. Read the height in centimeters to the exact point. 10. Record the height measurement in centimeters in the participant's instrument. 11. Remember to record the code number of the staff who took the measurements in the space provided for in the participant's instrument. Weight measurement protocol Taking the weight 1. Ask participant to remove footwear and socks. 2. Ask the participant to step onto scale putting one foot on each of the footprints. 3. Ask the participant to stand still, fact forward and arms on the side and wait until told to step off 4. The weight will be in kilograms. Record the weight in kilograms on the participant's instrument. Be sure that the initial weight display is 0.0. Blood pressure measurement Preparation of the Participant 1. The file of the participant is obtained from the top of a stack of questionnaires in the Blood Pressure Box.. Verify questionnaires with the participant's identity. 2. Introduce yourself to the participant. 3. Advise participant to sit quietly and rest for 5 minutes with the legs uncrossed. 4. The time the participant is seated is recorded on the Data Collection Summary. 5. The process involved is explained to the participant. Reassure the participant prior to measurement of blood pressure.

498 Sphygmomanometer Protocol Advise participant to sit quietly and rest for 5 minutes with the legs uncrossed. How to apply the cuff 1. Place the right arm of the participant on the table with the palm facing upward. 2. Select the appropriate cuff size for the participant using the following table: Arm Circumference Cuff Size 17-22 Small (S) 22-32 Medium (M) 32-42 Large (L) >42 Extra Large (XL) 3. Align the artery position mark ART with the brachial artery (where the pulse is palpated just above the elbow joint anteriorly). 4. The right arm should be free of any clothing. When necessary, roll up the sleeves of the participant's clothing. Wrap the cuff snugly onto the right arm and securely fasten it with the Velcro tape. The lower edge of the cuff should be placed 1.2 to 2.5 cm above the inner side of the elbow joint. 5. Keep the level of the cuff at the same level as the heart during measurement. 6. Palpate the right radial artery and 'inflate cuff until pulsation disappears. Continue to inflate 3 0mm Hg, beyond this point 7. Apply the bell of the stethoscope to the right ante cubital fossa and listen for pulse sounds while deflating the cuff slowly. 8. Record the systolic blood pressure (SBP) when a pulse is first audible. 9. Record the diastolic blood pressure (DBP) when the pulse sound disappears. 10. Deflate the cuff fully and let the arm rest for one minute before a second reading is taken. A pulse count for one full minute is taken prior to each measurement of the blood pressure. 11. If the difference between the two readings is 10 mm Hg or more then a third reading is required (Source) OMRON Digital Automatic Blood Pressure Monitor (DABPM) Protocol Items 1-5 are the same as the sphygmomanometer protocol

499 Measuring the blood pressure 1. Set the MODE of the machine to AVG and P-Set to Auto. With these settings, the machine will give two consecutive blood pressure measurements. 2. Push START to begin blood pressure measurements. 3. The first reading will be displayed followed by the second after a one-minute interval. 4. Record only the first and second readings and NOT the average pressure reading as displayed. 5. Verify the values for the first and second readings by pushing the DEFLATION button. 6. If the difference between the first and second readings is 10 mm Hg or more then a third reading is required. For a third blood pressure reading, set MODE to SINGLE then press START. Record with third blood pressure reading and the pulse.

500 Chapter - 21 CANCER - PREVENTION DETECTION CONTROL

Cancer may best be regarded as a group of disease characterized by an (i) abnormal growth of cells (ii) ability to invade adjacent tissues and even distant organs, and (iii) the eventual death of the affected patient if the tumors has progressed beyond that stage when it can be successfully removed. INTRODUCTION Even though the incidence of cancer is lower in the developing countries, than in the western societies, more than half of the cancer occurrence in the world is in these countries, as large populations reside in these areas. Unlike in many other states, cancer is likely to emerge as a major public health problem soon in Kerala. The factors conducive for a higher occurrence of cancer such as increased life expectancy and control of communicable disease are operative here. In Kerala, we expect that about 30,000 persons will develop this disease annually and almost 100,000 prevalent cancers will have to, be catered every year. It is well known that 1/3 of the cancer occurrence is due to environmental factors (mainly tobacco) and hence preventable with restriction on the use of tobacco. Another third are detectable in an early stage and curable with the existing methods of treatment. In one third early detection and the present therapy cannot offer cure and as such only symptomatic relief is all that is possible. Controllable Cancers: In Kerala, among the present cancer load, almost 46.7% are tobacco related cancers in males and in women, 13.7% arc tobacco related. In women almost 14.2% are cervical cancers and another 27% are breast cancers. - The above cancers are early detectable by simple affordable detection methods. Thus a major portion, of cancers now present in Kerala are now either preventable or early detectable. Causes of Cancer: As with other chronic diseases, cancer has a multifactorial aetiology.

501 Tobacco Smoking: Lung, pharynx, larynx, nasopharynx, lip, mouth, oesophagus, stomach, bladder, pancreas, kidney. Tobacco Chewing:- Mouth,oesophagus,pharynx.

Alcohol: - Oesophagus(food pipe), liver, pharynx, rectum, mouth. (3% of cancers are due to alcohol.) Diet: - Salted dry fish, preserved and pickled foods, over fried food may contribute to stomach cancer. Fatty foods, fried foods and beef are observed to be associated with the occurrence of cancer colon, rectum, breast, prostate, pancreas, gall bladder and ovary. Occupational exposures: to benzene, arsenic, cadmium, asbestos, polycyclic hydrocarbons etc. may contribute to Cancer lung, bladder etc. Viruses: hepatocellular carcinoma of liver and cancer uterus are increasingly found to be associated with certain viruses. Some lymphomas like Hodgkin's disease and Burkids disease are also caused by virus. The WHO has embarked on large scale immunization by a vaccine to prevent hepatitis B virus infection and subsequently liver cancer. Breast Cancer Breast Cancer is one of the commonest causes of death in many developed countries in middle aged women and is becoming frequent in developing countries as well. In Regional Cancer Centre, Trivandrum, out of 8000 cancer cases coming every year about 911 cases are breast cancers. This cancer is the leading cancer among women of Kerala. Till 1982, breast cancer was the second commonest cancer and uterine cervical cancer was the leading cancer. After that there is an increasing trend for breast cancer and a declining trend for uterine cervical cancer. Breast cancer is easily detectable and completely curable if detected in early stage and treated promptly. More than 60% of women detect breast lumps in early stage when it is curable. But due to fear of mutilating surgery, radiation treatment, and because of shyness, majority of the women do not reveal the matter to a doctor or to her relatives and may consult doctors of other systems of

502 medicine and come in an advanced stage when treatment is difficult, expensive, distressing to the patient and we cannot save the patient also. Screening for breast cancer : There is evidence that screening for breast cancer has favourable effect on mortality from breast cancer. The basic techniques for early detection of breast cancer are 1) Breast Self Examination (BSE)

2) physical examination by a doctor 3) mammography. BSE : Breast cancers are more frequently detected by women themselves than by a physician during a routine examination. 98% of breast cancer patients: who come to RCC detect breast lumps accidentally at the time of bathing when they apply oil or soap. So every woman above 25 years of age should practice Breast Self Examination. If 100 patients come with breast lumps or discharge, only one'. or two may be cancerous all the others being benign harmless conditions. Mammography is the most sensitive and specific test in detecting even small tumors that are sometimes missed on palpation. After the age of 45, every woman should ideally have a mammogram which can detect lumps even smaller than 5mm size. This test should be done by those women who are at high risk for developing cancer especially women having family history of breast cancer. Aetiological risk factors for Breast Cancer In 70% of breast cancer patients the aetiology is unknown. But in 30% of cases the following are the causative factors. The risk for developing breast cancer is more for the following women. 1 . Those women with family history of breast cancer. For eg. if your sibiling sister, or mother, or aunt had breast cancer you are more likely to get breast cancer. 2. Unmarried women, Nuns, Women who married late, Women who do not breast feed carry a high risk. 3. Those women whose first pregnancy is delayed to their late thirties, are at high risk than multiparous 4. Women above the age of 35 years have higher risk than younger women.

503 5. Those women who attain menopause late.(Usually women attain menopause before 50 years) 6. Those girls who attain menarche earlier ie, before I I years. 7. Women who have benign breast conditions like chronic mastititis, fibrocystic disease, breast abscesses. 8. Those who consume plenty of fatty diet, roasted beef, fried foods etc and who take less vegetables and fruits, in child hood.

9. Those who are obese with huge breasts. 10. Those women who take plenty of hormones (oestrogens, contraceptives) for a long period of time (greater than 10 years) 11. Affluent women (higher socio economic groups) Even though women with these risk factors have a relative risk greater than normal women, all women with these risk factors need not get cancer. Prevention and Control: a. Primary prevention: Current knowledge of the aetiology of breast cancer offers little prospect of primary prevention. However, the aim should be towards elimination of risk factors and promotion of cancer education. The average age at menarche can be increased through a reduction in childhood obesity, and an increase in strenous physical activity; and the frequency of ovulation (after menarche) decreased by an increase in strenous physical activity. There is also a good reason for reducing fat intake in the diet. b. Secondary prevention: Breast screening leads to early diagnosis of breast cancer, which in turn influences treatment and, hopefully, mortality. An important component of secondary prevention is follow-up, i.e., to detect recurrence as early as possible; to detect cancer in the opposite breast at an early stage. Cancer of the cervix (uterns) Cancer of the cervix is the most prevalent form, of cancer in developing countries, especially the South East Asia Region. It accounts for 25 to50 per cent of all cancers in Indian women. It is widely prevalent in China, South and Central' America and Africa. In Kerala, Uterine cervical cancer was the leading cancer till 1985. After that there is a declining trend and now it is the second commonest cancer in females. 14.2 % of all

504 females coming to Regional Cancer Centre have uterine cervical cancer. This cancer is easily detectable by a simple test called pap smear test or colposcopy and this cancer is completely curable if detected early and treated promptly. The symptoms of Cervical Cancer: In the early stages there are no symptoms. By the time the symptoms appear, the disease might have already spread. Post menopausal bleeding, post coital bleeding, inter-menstrual bleeding and blood stained discharge p/v can be symptoms.

Natural history of this disease and Early detection: Cancer cervix seems to follow a progressive course taking about 15-20 years. It has been established that there is a precancerous stage in majority of cases. About 20 years before occurrence of cancer, changes in cells take place. The earliest change is called mild dysplasia which may progress to moderate dysplasia and then to severe dysplasia. All dysplasia will not progress to cancers. In some of these patients this may progress to a hidden cancer (Ca insitu) and ultimately it may progress to invasive cancer. Early detection even at this privative stage is possible by doing a pap test. We can identify patients who are at high risk to develop cancer by this test and by constant check up and treatment, we can prevent cancer in these patients. There is constant exfoliation (shedding) of cells from uterus. By pap test, we can collect these exfoliated cells by a simple technique. Advantages of pap test: 1. It is painless. 2. There is no bleeding. 3. No need for anaesthesia. 4. We can detect cancer and precancer. 5. We can diagnose the cause of white discharge. 6. We can identify fungal infections, bacterial infections, viral infections and some sexually transmitted diseases. 7. It takes only one minute. Who should undergo this test:

505 All mothers who have at least one child over the age of 30 should undergo pap test at least once in an year Risk factors for cervical cancers: Multiple aetiological risk factors which increases the risk for uterine cervical cancers are as follows. 1 . This is increasingly found to be associated with a viral infection (Human papilloma B virus) which is sexually transmitted. 2. Early marriage before 20 years. 3. Early sexual intercourse before 20 years. 4. Extra marital sexual relations. 5. Multiple sexual partners for either husband or wife. 6. Repeated M.T.P (induced abortions). 7. Repeated child birth. 8. Early child bearing. 9. Poor genital hygiene of both husband and wife. 10. Usually women above 35 years are affected. 11. It is very common among commercial sex workers and uncommon among virgins. 12. It is more common in the lower socio economic groups. 13. It is extremely rare among wives of Jews and Muslims since circumcision in husbands is protective for the wives. Prevention of Cervical Cancer: 1. Increase the age of coitus and marriage. 2. Improve genital hygiene. Both husband and wife should clean the private parts after coitus, since semon can promote carcinogenesis and facilitate multiplication of Human papilloma virus. 3. Undergo routine pap smear screening test. 4. Reduce the number of children. 5. Use condoms to prevent virus infection. Male Cancers Commonest male cancers: 1) Oral Cancer 2) Lung Cancer Oral Cancer: Oral cancer is one of the ten most common cancers in the world. This is a major problem in India. About 23.7 % of male cancers in RCC are in the oropharyngeal region

506 and this cancer is the first leading cancer among males. Oral cancer is easily detectable and completely curable if detected early and treated promptly. The causes of oral cancer are well established 1. Tobacco chewing. 2. Tobacco smoking. 3. Pan parag chewing. 4. Alcoholism. 5. Lack of nutritious food.

6. Trauma due to sharp carious tooth, broken tooth, dentures etc. 7. Poor oral hygiene. 8. Infections. 9. Low intake of vegetarian diet Natural history and early detection: In some persons who are chewing pan, small whitish patches appear in the buccal mucosa where they keep the chewing quid. These whitish patches are called leukoplakia which is a precancerous condition. If the patient does not stop chewing or smoking, this leukoplakia may progress to cancer in 10-20 years. If they stop the tobacco habit and take Vitamin A capsule or plenty of Vitamin A rich foods(green leafy vegetables, ripe pappaya, mangoes, tomatoes, water melon and pumpkins) these whitish patches may disappear in majority of cases. But high risk leukoplakias usually turns into cancer inspite of treatment. Prevention of Oral Cancer: I . Chewers, smokers and alcoholics should examine their mouth once in a month for any whitish patches, ulcers, growths etc.(Mouth self examination) 2. All people above 35 years should make it a regular practice to examine their mouth in a mirror. 3 . Those who are above 40 years should consult a dentist every year to rule out any changes. 4. Stop smoking, chewing and alcoholism.

507 5. Take plenty of Vitamin A rich vegetables and fruits. 6. Consult a dentist if a white patch is observed. 7. Proper oral hygiene, grinding of sharp tooth etc. are other preventive measures. Lung Cancer- Causes: 11.7% of male cancers in RCC are in the respiratory system. There is a rising trend for lung cancer over the years. At present lung cancer is the leading cause of death in males of many developed countries. 90% of lung cancers are seen among smokers. If the smokers are alcoholic also, then their chance for lung cancer increases. The risk is strongly related to the number of cigarettes smoked, the age of starting to smoke and smoking habits, such as inhalation and the number of puffs and the nicotine and tar content and the length of cigarettes. Those who are highly exposed to "passive smoking" (somebody else's smoke) are at an increased risk for developing lung cancer. The strongest evidence that cigarettes smoking is responsible for lung cancer is the reduction that occurs after cessation of smoking. This has been convincingly demonstrated in a 20 year prospective study on male British doctors. The most noxious components of tobacco smoke are tar, carbon monoxide and nicotine. The carcinogenic role of tar is well established. A study in India has shown that there is no difference between the tar and nicotine delivery of the filter and non-filter cigarettes smoked in India, so that a filter gives no protection to Indian smokers. The "king-size" filter cigarettes deliver more tar and nicotine than ordinary cigarettes. Bidi smoking appears to carry a higher lung cancer risk than cigarette smoking owing to the higher concentration of carcinogenic hydrocarbons in the smoke. Other factors: Besides cigarette smoking, there are other factors which are implicated in the aetiology of lung cancer. These include air pollution, radioactivity, and occupational exposure to asbestos, arsenic and its compounds, chromates, particles containing polycyclic aromatic hydrocarbons and certain nickel-bearing dusts. Lung cancer is not curable with treatment. Majority of lung cancer patients die in one year. However this cancer is preventable by avoiding tobacco. We have discussed only common cancers which are either preventable or curable. Cancers like leukaemias, bone tumours, lymphomas, brain tumours etc. are not discussed

508 since they are not preventable. Cancer organisations in many countries remind the public of the early warning signs("danger signals") of cancer. Danger Signals of Cancer: a a lump or hard area in the breast. b change in a wart or mole. c a persistent change in digestive and bowel habits. d. a persistent cough with hoarseness of voice. e. excessive loss of blood at the monthly period or loss of blood outside the usual dates.

f blood loss from any natural orifice. g a swelling or sore that does not get better. h. unexplained loss of weight. Health Hazards Of Tobacco Twenty five lakhs of people die prematurely due to tobacco related diseases every year in this world.. In India alone more than 8 lakhs of people die every year because of the effects of tobacco and it appears that it is going to worsen in future. Toxic Substances In The Smoke And Their Health Effects Irritants in the smoke cause an immediate coughing, narrowing of the bronchial tubes, increased air-way resistance and mucous production. Irritants have direct effect on mucosa of throat, nose, trachea, pharynx, oesophagus and mouth. Smoke contains three toxic substances tar, nicotine and carbon monoxide. Tar is a mixture of 2000-4000 chemicals of which some chemicals are carcinogenic, capable of causing cancers. The effect of nicotine is on blood vessels and heart. Nicotine could contribute to atherosclerosis by action on lipid metabolism, coagulation and hemodynamic effects. Carbon monoxide interfere with oxygen transport and utilization. Smoking And Heart Diseases: Smoking reduces a man's life span by 2250 days. In certain category of smokers, the incidence of a heart attack is ten times greater than non- smokers. In smokers under 45 years, 85% of deaths due to heart attacks are due to

509 smoking and chances of sudden death during heart attack are twice in smokers than in non smokers. Following cessation of smoking the risk for attack reduces. Other Vascular Diseases: Nicotine in the smoke reduces blood flow to the peripheral arteries just like in coronary arteries and can cause peripheral occlusive vascular diseases like T.A.0 and may be end up with amputation of legs because of gangrene of the legs. Renal artery stenosis leading to hypertension and subarechnoid haemorrhage and cerebrovascular accidents are more in smokers. Smoking can reduce potency in males due to reduce penile circulation. Smoking And Pregnancy: Pregnant woman who smokes is prone to abortion, premature deliveries, and accidental haemorrhage. Due to impaired placental circulation low birth weight babies are bom with increased perinatal mortality. Their children are liable to measurable delay in physical mental and intellectual development. Indian women who chew tobacco increase their risk of still birth 3 fold. The children of smokers get frequent attacks of cold, bronchitis, pneumonia, asthma, otitis media.(ear infection) Passive Smoking: Non smokers who associate with smokers like wives and children, co- passengers, etc. are forced to breathe polluted-.air and they also have an increased risk of getting lung cancers, heart attacks, bronchitis etc. A wife of a smoker has 3 times more chance to get cancer of lung. Smoking And Non Neoplastic Respiratory Diseases: Smoking is directly responsible for increased morbidity and mortality due to diseases like Bronchitis, Emphysema, Asthma, Tuberculosis, Pneumonia, Pneumothorax respiratory infections etc. in smokers. Symptoms of cough, sputum, wheezing and dyspnoea are more found in elderly smokers. They can also get diffuse pulmonary stenosis. Other Health Hazards: Smoking can either cause or worsen peptic ulcers. Impaired glucose tolerance caused by smoking may lead to.retinopathy and microvascular disease in diabetics. Smoking Or Health: You Cannot Have Both: Another matter or grave concern about smoking is the long time interval between the start of smoking habit and the manifestation of deadly diseases like cancer, chronic bronchitis and heart attack The prolonged incubation period of many tobacco-related diseases has prevented recognition of the size of the threat and the grim picture of chronic and life threatening diseases.

510 Tobacco Related Cancers Several epidemiological studies carried out in our country have confirmed the high risk of tobacco habits for cancers of upper gastrointestinal tracts and respiratory tracts. Tobacco-related cancers account for almost a third of cancers of mouth, larynx, pharynx and oesophagus. Changing trends of tobacco related habits during the subsequent periods suggest that with a decline of chewing habit, cancers of the oral cavity are likely to decline. On the other hand cancers related to cigarette and bidi smoking namely pharynx, larynx and lung will be increasing very rapidly.

Chapter -22 COMMON SKIN DISEASES

Bacterial Infections Viral Fungal Bacterial infections These are called pyoderomas. They can be of 2 types (1) primary pyodermas 1) Primary Pyodermas Primary pyodermas Infections occurring without any preexisting skin diseases. They are 1 Impetigo Seen in pre school children. First a fluid filled lesion develops. Later pus accumulates in it & enlarges. This later dries up with a honey coloured crust. 2. Eczema: These are seen as over shallow ulers in legs with bloody crusts. This lesion heals scaring. 3. Folliculitis These are pus filled lesions involving the roof of hair

511 4. Furuncles /boils These pus filled lesions include hair roof by the surrounding area also many such furuncles may join to get and from a carbuncle Predisposing factors Diabetes and Malnutrition 5) Paronychia It is infection the nail folds. On pressing the raid folds yellow pus comes 6. Cellulites Infection involving tissues beneath the skin. It Appears as a warm red tender swelling . This may be associated with fever. II Secondary pyodermas These arise in preexisting skin tissues. Eg: Infected scabies/wound Infected eczema. Others are 1 Hidraderictis suppuration Multiple painful small swellings are present which later break down discharging pus scars are formed later 2) Intertrigo Seen in house wives, dhobis due to constant heat & contact with water. Seen as a macerated red area with fissuring and erosions. Usually between fingers especially 3rd & 4th ones seen in feet also. Other areas where skin surfaces are in close apposition may be involved namely axilla, groin, under a breast. Treatment of pyodermas Antibiotics - oral or local Local soap and water wash Surgical drainage For paronychia & intertrigo keeping the areas dry Viral Infection 1) Viral warts

512 There are seen as dry rough surfaced raised skin lesions. May involve any part of the body. They usually develop in lines of trauma. Different types are Filiform - with finger like projections Digitate - with branching . May be seen around nail, in the sole – resembles a corn may accur in genital areas also. Treatment Cauterization chemical/electro others cryo Surgery. 2) Mollscum contagiosum. Pearly white dome shaped raised skin lesions with central depression usually seen over the face in children. Spreads by skin to skin contact. Widespread lesions occur in head and neck. Treatment cautery.

3) Chicken pox First starts as fever, malaise for 2-3 days. Then fluid filled lesions develop more on trunk. They resumble eardrops/dew drops on rose petals. For 5-7 days new vesicles continue to develop. They later become filled with pus & leads to crusting. Healing occurs in 2 weeks. Complications - Pneumonia, or encephalitis if in pregnant lady – congenital malformation can occur. Treatment Spontaneous healing in 2 weeks. If lesions get infected  antibiotic anti viral agents can be given Herpes zoster Patient who had chicken pox may present years later with similar lesions. This is due to reactivation of dormant virus in the nerves. Triggering factors are local trauma, exhaustion, surgery. Treatment same as above. 4. Measles

513 Develops usually in children with fever, running nose, eye congestion, first a rash appears on forehead & speeds to rest of the body in 3-4 days after 5-6 days it disappears by peeling off. Complication - pneumonia Treatment - supportive German measles Similar but milder and of shorter duration. If German Measles occurs to pregnant mother during the first 3 months – Congenital Malformation to the foetus. FUNGAL INFECTIONS 1) Ring worm/Tinea infection Due to fungi called dermatophytes. Tinia Corporis It occurs in all areas excepting hard, feet, crural region, hard region and scalp. It occur as itchy, scaly raddish well defined circular patches . Appears like a ring by hence the name. - Tinea capitis Scalp with itching - Tinea manum in hands palms - Tinea pedis in soles athelete’s feet – affects toes - Tinea face Annular lesion in face. - Tinea unguim / onycho myeosis nails discoloured by disfigured - Tinea crusis – Fungal infection in the groin. Diagnosis uniformed by scraping active border of the lesion by examination under microscope. Treatment Topical & if required systemic Antifungal tablets 2) Tinea Versicoler Caused by Malasessia furfur multiple spots by parches with pigmentation or brownish/black is pigmentation size varies. They may itch on sweating usually seen in people with only skin confirmed by scraping and microscopy treatment is with antifungal. 3) Piedra

514 Grithy pin head size formatus on hair may be black / white Treatment cutting off affected hais is hest. 4) Candidiasis - caused by candida albicans factors favourable are moisture use of antibiotics, immuno superesents and oral contraceptives - pregnancy - diabetes - malignancies - AIDS Oral candidiasis /Thrush white patches neonates & adults on antibiotics DM etc. Valvovaginitis Thick curdy white discharge itching in genital area. Sometimes adjacent area may have pus filled skin lesions Candial intertrigo Similar to bacterial intertrigo in Palms & soles by areas of skin opposition seen in house wives. - Cooks - hotel workers.

- Dhobis - Infestations Diseases caused by parasites 1) Scabies :- Caused by itch mite Patients are with complaints of itching severe at night. Often other family members are affected. Spread by close personal contact lesions are small raised skin lesions may become fluid / pus filled. Sometimes burrows caused by itch mite may be seen. There are certain typical sites Inter digital spaces Wrists inner aspect Anterior auxillary fold Elbows - outer side

515 Inner Thigh Abdominal wall Females nipple, areola of breast, males essential genitals These may got infected and eczema may develop. There is a risk of causing infection of kidneys in such cases Clean scabies - Seen in healthy individuals spares frequently washed areas. Infants face, palms soles. Bed ridden people – affects sites in contact with bedding. Diagnosis confirmed by scraping and demonstration of mite under microscope. Treatment : Less than 2 years - Crotorax cream More than 2 years – Pormethrasin cream 2) Insect bite reacting Seen as allergic reaction to saliva of insects like mosquito Raised skin lesions are seen with central puncture . Usually over exposed areas Itching with be associated Treatment – Avoidance of bites Anti puritic agents 3) Blisters beetle dermatitis When the blister beettle gets crushed between skin surfaces, toxins in its body causes a severe burning pain and there are skin lessons with a ebizarre pattern. Treated with antibiotics special creams 4) Bed hug bites 5) Flea bites treated as insect bite reaction 6) Pin worm infestation Itching around anus Increases at night Will develop eczema later Treated with Antihelminths 7) Ground itch

516 Caused by hook worm larvae penetrating the skin of feet in the inter digital spaces. There is intense itching. Treated with antiworm measures 8) Filareasis Caused by wucheraria bancrofti & Arugia malayi (filarial wormss) These are spread by culex mosquitoes infections has 2 stages Acute:- There is inflammation of lymph vessels, seens as red streates with high fever and chills. Chronic After repeated attacks, Lymph Vessel obstruction results in Lymphoedema. Switching of legs, hands, scrotum, vulva skin is folded thicken with papillo matous growths. Hydrocele can occur The groin lymph nodes are enlarged Diagnosis conformed by demonstration of micro filarial forms of filarial worm in blood smears taken at midnight Treatment with DEC for 10 – 14 days Mass treatment with DEC in endemic areas in effective in prevention. If gross deformities surgery maybe required.

PSORIASIS It is multifactorial disease both genetic and environmental factors play a role. TRIGGERING FACTORS Various types of trauma physical chemical; thermal immunological slectrical are implecated. It is a chronic disease with exacerations and remissions. It is characterized by development of well defined radish scaly raised lesions of size- The scles are loose dry & silvery. Treatment is Toucal – Fiquied paraffin Systernic – Metholrescale Puva photochemotheraphy Antipresitives

517 Lichen planns It is a puritic skin disease characterized by development of shiny flat-topped polygonal voracious skin lesions. In two thirds of people it heals spontaneously within 8- 12 months Treatment-Steroids - Antipruritis ECZEMAS These are characterized by redness, edema, raised and fluid filled skin lesions with oozing, crusting. There will be associated pain by itching. In chronic areas there is thickening increases in entraxcous marlens and pigmentation It can arise due to external or internal factors Due to External factors Contact Eczeme Due to a locally applied agent like acid/alcohol/detergent which act as irritant at site of contact. Other are dyes, plants, This is Irritant contact Eczema Another variety is allergic contact eczema in sensitive patients. Treatment is with Wet compresses Antibiotics Acute stage Antipruritics For sub acute stages-topical steroids Due to internal factors Atopic eczema People with tendency to develop eczema is more in atopics.

Chapter - 23 DENTAL CARE AND ORAL HYGINE

Dental Care, Especially For Children Oral health care of children is perhaps the most neglected in our country. Lack of general education, poor socio-economic status etc might be the main reason for it, but the ignorance about the importance of dental care even among the educated class is a big problem. The fact that oral health of a child can significantly affect the general bodily health.

518 Also, another cause for neglect in a baseless popular belief that all the problems of the teeth of kids (milk teeth) will get solved by itself as all these teeth will fall off and will get replaced by new permanent teeth, so why then, care about them. Unfortunately people don’t understand that the health of the milk teeth has a big role to play in deciding the health of the permanent teeth to follow them. So caring for the health of milk teeth is as important as caring for the adult teeth. Now the main task of a health worker, who comes across a greater segment of the society than a dentist, is to identify the existing & potential damage of the dental system of children, give primary instructions to maintain good oral hygienic & motivate the parents to take the children to the dentist. The simple & most effective method of maintaining good oral health is to do regular tooth brushing using brush & paste. However brushing can turnout to be ineffective or even harmful if not performed using the right technique. It is not how many times you brush but how you brush that is more important. Technically speaking, the upper teeth should be brushed from up to down & the lower teeth from down to up, using single strokes ie. The teeth should be brushed in the direction it grows. The main objective of brushing in to prevent the accumulation of plaque on the tooth, which is a combination of saliva, microorganisms & food substances. Plaque causes “tooth decay” or ‘caries’. Also, children should be advised to reduce if not avoid, the frequency of taking sweet & sticky food like pastries, chocolates, ice-cream etc.

Even if they take, it should be advised to wash their mouth properly after they take such food items, be it even one toffee. Brushing at night should be emphasized & made a must. Another very important thing which a heath worker can do is to identify a developing crowding & irregularity of the arrangement of teeth, that we call at ‘Mal - occlusion’. It can be effectively treated using ‘Orthodontic treatment’ if detected early. Mostly children report with crowding & protrusion of teeth only after it has reached or progressed to a worse situation. So a health worker should motivate the

519 parents to take the child to a dentist if he comes across a kid having a teeth arrangement crowded or spaced or any abnormal pattern than the normal teeth arrangement. Yet another help which a health worker can do, to the dentist is to instill a positive attitude in the mind of the children & parents about dentistry. The most common stigma that the patients have about dentistry is the fear of pain & discomfort associated with dental treatment. With the use of high quality local anesthetics & latest sophisticated instruments, dentistry is no longer a painful & traumatic treatment regime. This evolution of dentistry should be conveyed to the masses by the health worker, so that the patients will look forward to the dental appointment with a good frame of mind & a pleasant attitude rather than fear & apprehension. Thus a health worker has a very significant role to play in assisting the dental professionals to render effective oral health care to our people, especially children & working together, they can do excellent service to the society.

Chapter - 24 DISABILITY DETECTION & MANAGEMENT & EARLY REFERRAL

Physical Medicine & Rehabilitation or Rehabilitation Medicine is the specialist dealing with assessment and treatment of disability states. Disability is defined in simple words as " inability to perform an act" A simplified classification of disabilities by WHO is as follows: 1.Movement disabilities

520 2. Seeing disabilities 3. Speech and hearing disabilities 4. Learning disability 5. Strange behaviour 6. Fits related disabilities 7. Sensory problems This classification is developed with a view to integrate disability prevention and rehabilitation services at the community level, where basic health workers and community leaders are able to understand the terminology. Assessment of locomotor disabilities Assessment of quantum of disability is necessary to procure various benefits/ concessions and also for obtaining compensation from tribunes, civil courts etc. The quantum of disability is usually expressed as a percentage. Example of quantum of disability in some disabling conditions are:- 1. Below knee amputation of one extremity 40% 2. Bilateral below knee amputation 100% 3. Above knee amputation of one extremity. 50% 4. Post polio residual paralysis of one lower extremity (with above knee involvement) 40% 5. Amputation at the level of wrist or above of one upper limb 50% 6. Amputation of one finger 68% 7. Amputation of thumb 0- 25%

Some of the various benefits/ concessions available to disabled people are:- a) Disability pension b) Travel concessions c) Job reservations

521 d) Special conveyance allowance to physically handicapped employees of state and Central Governments and public sector under takings. e) Income Tax concessions j) Exemption from professional tax g) Financial assistance/loans from banks etc. for setting up small scale units, self employment schemes etc. h) Educational concessions/allowances to school children under Integrated Education of the Disabled. Rehabilitation Of The Disabled Medical care is not complete until the patient has been trained to live and work with what he has been left with . The responsibility of the doctor to his patients cannot end when the acute illness is over. It is well recognized that to ignore a disability is far more costly than an early aggresive programme of rehabilitation that restores the individual to the highest possible level of physical, economic, social and emotional well being., Rehabilitation is now considered as the 'third dimension' in health care, the first and second being preventive and curative aspects respectively. Institutional rehabilitation The main aspects of medical rehabilitation carried out in an institutional set up are 1. Physiotherapy 2. Occupational Therapy 3. Speech therapy 4. Vocational counselling 5. Social evaluation and adjustments 6. Clinical psychology 7. Artificial appliances

Available facilities There are Physical medicine and rehabilitation units headed by qualified specialist doctors in 10 District General Hospitals.

522 There are full fledged Depts. of PM & R in all Medical Colleges. Artificial limb fitting centres function in the district hospitals at Kollam and Kannur and General Hospital Emakulam. There are zonal limb fitting centres attached to Medical Colleges at Thiruvananthapuram, Kottayaxn an Kozhikode. Community Based Rehabilitation- constitute simple rehabilitation measures instituted at the home or community, Viz:- 1. Simple exercises, self administered or performed by somebody else. 2. Modifications in activities of daily living 3. Simple low cost devices 4. Fitment of artificial appliances through rural camps 5. Public education Prevention Of Disability is simple and less expensive. This can be done at three levels:- 1. Primary level prevention Prevention of disease and injuries that produce impairments and disabilities through proper immunisation, proper observance of traffic and factory rules, environmental sanitation, avoidance of drug abuse, proper maternal, prenatal and post natal care etc. 2. Secondary level prevention Prevention of progression of impairment into disability by prompt and dequate treatment methods in various diseases and injuries. 3. Tertiary level of prevention Once a disability has occurred and is found to be irreversible, measures can be taken to prevent its transition to handicap by instituting proper physiotherapy, occupational therapy etc. 4. Health education measures The IEC officers must devise techniques to reach business, Government conomist, legislators, bureaucrats and general public to create awareness about disability prevention, early referral and problems of the disabled.

Chapter - 25 GERIATRIC HEALTH

523 Objectives:  To enable, to gain knowledge with regards to increasing importance of geriatric health due to the increase in life expectancy  To enable to understand the health problems of the elderly as part of the total family welfare.  To enable the other members of family in the community in solving the health problems of the elderly.  To enable to organize and conduct activities for ensuring community participation in maintaining geriatric health.  To enable inter-sectoral co-ordination between other welfare measures andhealth activities for the senior citizens. Methods 1. Lecture cum discussion 2. Brain storming session 3. Visit to an old age home & far houses. 4. The assignment for preparing a plan of action for the better case of old age people. 5. Duration : 3 hours The Govt. of India had recognized geriatric Health as an integral part of the National Family welfare programme. There has been remarkable increase in the life expecting of the Indians. In Kerala, according to 2001 census the elderly constituted 10.5% of its population as against 7.5% for all Indians. According to projections the population aged 60 and above in Kerala will be 11.7% in 2011. The senior citizens are great assets, sure their expertise can be utilized in the implementation of health and other development programmes, provided their health status is maintained properly. A need assessment study of older population of Kerala was conducted by the Health Service Department in 2004. The basic needs included in this study are good health, financial security, comfortable living arrangement, respect within the family

524 and the society and love and affection from the near and dear ones. The study assesses the ground realities in Kerala about these basic needs, finds the gaps and recommends policies & fulfill the needs of the majority of the elderly. The salient features of the results given below are helpful in the planning, providing health care for the elderly. Socio- Demographic Profile 1. Female elderly comprising 55% out numbered their male counterparts. 2. 65% of the surveyed households had only one elderly person where as 35% reported 2 or more elderly. 3. Out of the female subjects 57% were widowed as against 11% widowers among the males. Living Arrangements 1. When one examines the living arrangements it was seen that 5% of the elderly live alone, 8% live with their spouse only and 7% live with their relatives other than children and grand children. About 80% of the aged persons, with or without spouse, live with their children and grand children. 2. Of the elderly living alone, 85% were females. Economic Security 1. About 13% of the elderly had no assets whereas 55% of the aged kept their assets with them, about 13.1 gifted their entire assets to their children. The surrender rate of property and assets by the female subjects was found to be nearly double that of the male subjects. 2. On analyzing the adequacy of income for ensuring sustenance level, the study results indicated that only 36% subjects fell in the positive category. While in 41% cases the income was barely adequate, with remaining 23% cases the situation was pathetic. In the case of elderly living alone the problem was more pronounced as only 24% of the subjects belonged to the class of adequacy. Among scheduled casts and scheduled Tribes, only 13% reported adequate income. 3. Economic dependency was reported by 48% of the subjects, the percentages ranging from 44 in the age group 60-69 & 55% in the age group of 80 and above. The rate was higher among the females.

525 Psychological and Human Aspects 1. Regarding interpersonal channels of consultation on decision making within the house hold, contrary to common belief, two thirds of the elderly reported that they were consulted most of the times, 18% sometimes and 5% rarely. About 10% were side lined and never consulted in the family decision making process. 2. The study revealed that 94% were getting love and affection from their near and dear ones and 92% reported to be receiving the respect and consideration that they deserved. About 88% of the aged reported that they were getting / receiving adequate support from the family members. There could be an element of over estimation in such positive responses. 3. About 20% of the elderly reported strain in adjusting to the changes in environment and living style. Additional Health Aspects Revealed By the Clinical Assessment 1. The enquiry revealed that 56% of the chronic ailments were treated in private hospitals and 44% availed of the facility in Government Hospitals. About 70% of the elderly persons cited convenience for the choice of the facility while 22% choose the facility on account of perceived better care. 2. The system of medicine used for more than 80% of the ailments was Allopathy, Ayurveda accounting for about 15%. The main attraction for Ayurveda came from cases of arthritis and related diseases. 3. About 72% of the elderly persons were found to be suffering from one acute symptom or the other during the previous month. The commonest symptoms in order of priority were difficulty in getting sleep at night, back pain, cough for 3 weeks without fever, acid indigestion, stiffness/ pain/ swelling of joints etc. About 60% consulted doctors for treatment. The main reasons given for not consulting were lack of financial support, lack of support from the family and presumption that the problem was a normal part of old age. 4. The percentage of old reporting feeling of loneliness according to the survey was of the order of 21, the females reporting a higher percentage.

526 Health Status as Revealed By the Study 2. At the aggregate level 92% of the elderly reported to be suffering from one or more chronic ailments. The prevalence rates for the common disease  Problem of joints 46%  Blood pressure 39%  Diabetes 21%  Asthma 13%  Heart diseases 10% 3 For diabetes, blood pressure and heart diseases the prevalence was more amongst the elderly with secondary and higher academic qualifications and also among those engaged in sedentary occupations during their active life. 4 Only 8% of the elderly reported to be not suffering from any chronic ailments. Where 34% had only one ailment, 32% had two ailments and 26% had 3 or more ailments. 5 As regards adequacy of health care about 25% reported needing more intense care than currently receiving. 6 The enquiry revealed that 22% of the aged persons were physically dependent on family members. The proportion of elderly reporting economic dependency was seen to be much larger to the extent of 47%. As age advances physical independence decreases 7 On the basis of the clinical examination and the laboratory findings the subjects were found to be suffering from some chronic ailments of which they were not aware. The commonest ailment detected was cataract, which was seen to be present over 25% of the subjects. The other main ailments detected were high blood pressure, diabetes, high cholesterol and anemia. 8 For each of the 300 elderly persons examined by the medical team, the nature of Body Mass Index (BMI) was computed according to the hard down procedure. The distribution of BMI revealed that 58% were normal 20% below normal 18% over weight and 3% in the obesity grade/ category. The number of women in obesity grade/ category was seen to be 4 times that of men.

527 9 In the case of 40% of the subjects the family members had some difficulty in looking after the elderly, the reasons being mainly the financial burden. 10 Most of the elders have to depend on their limited savings or on the support of children for the medical expenses. The study estimate suggest that the average monthly expenditure was Rs 387/-. This recurring expenditure would result in induce strain for the home holds in the lower and lower middle segments of the society.  Needs Of the needs good health is of supreme importance. It was seen that an elderly person on the average is suffering from two chronic ailments of which he is aware of and perhaps another chronics ailment of which he is not aware. Frequent medical examinations to detect all such ailments and appropriate treatment at affordable cost are essential requirements to ensure good health. It is the duty of the Government to provide financial security secure and comfortable living, love concern and respect to the old. There should be a database about old persons above 60 at village level. Special cell is to be constituted at L.S.G level to deal with the issues of the elderly.

528 Chapter - 26 GENDER ISSUES

Women and girl children occupy a central place in the well-being of a family. The Welfare or well-being of a family is influenced by gender issues viz., to what extent the women are at equal footing with men or to what extent the women are discriminated against men. Therefore, relevance of gender issues cannot either be ignored or be delineated from family welfare. Gender inequality unfavourable to females is an important issue in the social development in India. The neglect of the girl child, is a problem child mortality of females are higher as compared to males, Persistence of female labour, low literacy rate for women, comparatively lower health care and nutrition are all areas where urgent remedial action is needed . Sex ratio is 927 females per 1000 males observed in 1991 Census is indicative of extensive of discrimination against females. Only Kerala has registered a sex ratio exceeding 1000 in 1991, while Union territories of Chandigarh (790), Andaman& Nicobar Islands (818) and Delhi (827) recorded lowest sex ratios. Adverse sex ratio is indicative of wide ranging gender discrimination in the country,. While infant mortality rate upto age of one year is practically the same for girls as for boys, as the child grows, gender discrimination progressively sets in. The need of girls is looked after less than the case for boys whether it is for education, health care or nutrition. An analysis of the latest mortality rates among infants and younger children available from Sample Registration System reveals that:- The Infant Mortality Rate (IMR) for 1994 which was 74 at the national level was lower among females (73) compared to males (75) The trend for rural and urban areas was also similar. However, among the 16 major States for which data was available, 6 States i.e. Gujarat, Haryana, Orissa, Punjab, Uttar Pradesh and West Bengal had a higher IMR among, females than males. The child (0-4) mortality rate for 1994 at the national level has been reported to be 23.9 per 1000 children in the same age group. While child mortality rate is, however, among female children (24.2)

529 when compared to male children (23.6). The trend was similar for rural and urban areas. Among the 16 major States, 9 States i.e. Bihar, Gujarat, Haryana, Himachal

Pradesh, Madhya Pradesh, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal showed a higher mortality among female children as compared to males. It may, however, be of interest to note that the rate of decline in child (0-4 years) mortality rate during the five years 1989-1994 had been more among female children (22.95%) than among males (17.2 %). It is also observed from the data that among the major States it is mostly the northern States where the child mortality rates are higher among females than among male children. Among the 10 districts with the lowest child sex (0-6yrs.) ratio in the country, 4 are in Haryana., 3 in Punjab and 1 each in Madhya Pradesh, Rajasthan and Tamil Nadu. The situation of women is affected by the degree of their autonomy, or capacity to make decisions both inside and outside their households. Autonomy includes the ability to control their own physical movements; to acquire, retain and dispose of earnings and property; to have some say in their reproductive careers- for instance, in choosing a husband and choosing contraceptives; etc. Exposure to a interactions with the outside world which are, instrumental in determining the possibilities available to women, in their daily lives are also very much limited in the case of females, particularly in rural areas. In many families, for many years after marriage, the wife is not in a position to take decisions even on her own affairs, as she is influenced by the decisions of the family members exclusively. However, in nuclear families the women have a larger say particularly in urban areas. The unfavourable status of women in India affects the health status of women and their female children both directly and indirectly. The effects includes a strong preference for sons. Arranged marriages for very young girls, inequitable allocation of resources such as food, health care, education and income and discrimination against widows. In a situation where female children are regarded as a net cost to the family and male children are considered assets because of their potential contribution to family productivity a strong preference for sons is there. In its extreme

530 form, a strong preference results in female infanticide and selective abortion of female foetus. Accurate data measuring the full extent of these practices is lacking, but female infanticide has been documented in studies relating to different parts of the country.

Judging by continuing reports in the media, use of medical techniques such as amniocentesis and ultrasound to determine the sex of a foetus selective abortion appears to be prevalent in many parts of the country. A study of amniocentesis in a large Mumbai hospital found that 95 percentage of female foetuses were aborted, compared with only a small percentage of male foetuses. A statistics on births from Haryana suggest that the sex ratio at birth in that State, especially in rural areas, has become more masculine since the early 1980s. The government has unequivocally stated its strong opposition to ante-natal sex determination and the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 makes such tests, a legal offence. The Act provides for conducting pre-natal diagnostic techniques and offering genetic counselling only Genetic Clinics, Genetic Laboratories and Genetic Counselling Centres register under the Act. Use of pre-natal diagnostic techniues is restricted to detecting any of the following abnormalities:  Chromosomal abnormalities;  Genetic metabolic diseases;  Haemoglobinopathies;  Sex-linked genetic diseases;  Congenital anomalies;  Any other abnormalities or diseases as may be specified by the Central Supervisory Board constituted under the Act. The Act further provides that no pre-natal diagnostic techniques shall be used or conducted unless the person qualified to do so is satisfied that any of the following conditions are fulfilled namely:  Age of pregnant women is above thirty-five years:

531  The pregnant woman has undergone two or more spontaneous abortions or foetal loss;  The pregnant woman had been exposed to potentially teratogenic agents such as drugs, radiation, infection or chemicals;  The pregnant woman has a family history of mental retardation or physical deformities such as spasticity or any other genetic disease; Any other condition as may -be specified by the Central Supervisory Board. Disclosure of the sex of the foetus is prohibited. Punishments are prescribed for violation of the law. One or more Appropriate Authority (ies) have been appointed in all the States/ UTs (except J&K). These Appropriate Authorities have the following functions: • to grant , suspend or cancel registration of a Genetic Counselling Centre, Genetic Laboratory or Genetic Clinic; • to enforce standards prescribed for the Genetic Counselling Centre, Genetic Laboratory and Genetic Clinic; • to investigate complaints of breach of the provisions of the Act or the rules made there under and take immediate action. Any violation of the law is to be notified to these authorities. In recent years, increasing attention has 'been focused on differentials in the allocation of food within households. Although overall rates of malnutrition among children and women are high and weaning practices poor, ethnographic literature suggests that females are, generally, not fed as males. Studies in Uttar Pradesh, Andhra Pradesh, Tamil Nadu all indicate that female children are discriminated against, when it comes to the allocation of food within households. The malnutrition prevalent in a significant proportion of adult Indian women can be attributed primarily to inadequate food intake. Even in house holds that theoretically have enough food, the way it is distributed may leave women in adequately by nourished. Typically, adult men are fed first followed by male children. Women eat only after the men have finished and a young wife must allow her mother-in-law to eat first. Whatever is left is divided among the young mother and her female children. Even when they have enough food, Indian women may be malnourished because of the poor nutritive quality of what is available.

532 Significant proportion of Indian women suffer from malnutrition and anaemia. Distribution of food within households is unfavourable to women and leave them undernourished. It is increasingly being recognised that differences in health care maybe more significant than differences in nutritional status in determining the gender disparity in child mortality.

Like female children, adult women are at a disadvantage in respect of health care. House hold surveys typically report more incidence of illness of females than for males. This finding is especially striking because female morbidity is likely to be under reported, for several reasons: The physical restrictions on women's movements, combined with limited access to financial resources within the households, severely constrain women's ability to seek health care for themselves and their children. Furthermore, a women who wishes to obtain health care. She must obtain the permission from her husband or in-laws and be escorted by a male family member if she travel outside the village. Females are clearly at as disadvantage in India with regard to education. Literacy levels give a clear picture of the educational situation of Indian girls and women. Data from the 1991 census -indicates that only 39 percent of females above age 7 are literate, as opposed to 64 percent of males. Of the 324 million illiterates enumerated in India in 1991, 197 million (61 percent) were girls and women. Enrolment of females in educational institutions has been on the rise recently. More and more women are also coming for and to obtain informal education. Enrolment of women in professional courses is also increasing year after year. The importance of the link between a woman's educational level and her health (and that of her female child) cannot be over emphasised. Studies in developing countries in general, and in India in particular, have consistently documented a strong relationship between a mother's education and her children's survival-that is, the more educated the mother, the more likely that her child will survive. Also educated women have higher age at marriage, more spacing and fewer children. India's reported female labour force participation is low by both developing and industrial country standards. Women's share of the adult labour force is 24

533 percent, compared with 35 percent for all developing countries. Traditionally, women are expected to keep to their homes and courtyards and the household activities that are carried out there. In modest landowning households , women typically work on family lands, and do other works, including caring for animals and gathering fodder and fuel. In landless families, women perform agricultural or domestic labour. Women, especially in, the urban families, are now taking up highly

skilled professions on an equal footing with men. Compared to this, more and more women in the urban families are now taking up high professions like business, industries, medicine, engineering, law etc. on an equal footing with men. Productive responsibilities are hardest on young women in their childbearing years. Typically , women work until late in their pregnancies; no special provisions are made for rest or additional food, and most women resume work before they have fully recovered from child-birth. Then result is often a cycle of "maternal depletion" that can have devastating consequences for a woman's health and undermine her ability to carry out her responsibilities, both productive and reproductive. It is satisfying to note that women have started taking these challenges in a significant way. Women activists groups are very often seen taking successful Actions in reducing or even eliminating gender bias. Women's representation in the elected bodies, particularly in Penchanti Raj institutions is now very significant. Government, in its part, has also taken important steps which are expected to lead to elimination of gender bias. Legislation of Dowery Prohibition act, setting up womans commission etc. are Pioneering examples Government also encourages women by setting up police stations, banks etc. run Exclusively by women. Women now have significant representation in elected bodies, particularly in Panchayati Raj institutions. Policy statement on gender based violence (G.B.V) The Department of health needs to issue a policy statement stating unequivocally that the. issue of gender-based violence is central in his efforts to ensure comprehensive right base high quality health care to all women and men. This policy will also state that the Department would play a major role in reducing the morbidity and mortality associated with GBV, manage its health consequences and lead an intersectoral initiative

534 that will seek to stop the abuse of women in the public and private domains. Adopting such a policy will give visibility to the issue and sensitise the society. Agenda for Action > Department of Health to issue a policy on the role of the health sector and health professionals in addressing and preventing GBV > Develop norms and protocols on screening for GBV and management of women affected by GBV

> Initiate changes within health facilities to support ethical management of GBV > Develop and implement a structured programme of Sustained training for health professionals at different levels > Create a well-equipped independent 'crisis support cell within all tertiary care hospitals, with provision for referral from various departments > Set up an inter-departmental mechanism with the police, judiciary, social welfare and other relevant departments for coordinated action to prevent and manage GBV > Collaborate with nongovernmental organizations and the private sector in setting up support services for those affected by GBVS, e.g. telephone hot-lines, shelters, livelihood projects for rehabilitation > Conduct workshops and courses for media professionals to sensitize them to the negative role of the media in ' reinforcing and promoting GBV, and to draw their attention to their scope for a major positive role in combating GBV > Plan long-term strategies for the prevention of GBV through curricular reforms in schools -and universities (especially-social work, law, journalism); medical and nursing curricula, police training and legal and judicial reforms Institutional reforms to mainstream the Issue of gender based violence Development of norms and protocols is a crucial step needed to provide improved services for survivors of violence. These norms and protocols will provide guidance for identifying and providing a uniform minimum package of services to women affected by GBV. Routine screening especially in reproductive health care, emergency departments and mental health care will contribute to better outcomes for the women as well as improve quality of health care in these areas.

535 Institutional changes Since it is unethical to implement routine screening to identify survivors of violence unless health facilities are equipped to provide privacy and confidentiality, appropriate care and follow up and referral is needed. Therefore a systems approach needs to be taken where institutional changes are made to ensure privacy and confidentiality to the women, training of the providers to respond to them with r sensitivity and prepare them to address the specific need s of the abused women.

Support services within the health system • A crisis support cell may be established in all major government hospitals with a trained medical social worker to provide appropriate services and referral, This should be an independent cell with referral of patients from the emergency department and all other departments carrying out screening for GBV. • Existing mental health facilities and programmes including mental health programe should also be reoriented to provide appropriate care for survivors of gender based violence. Training of staff Routine in-service training programmes are to be developed for health professionals. Such training will sensitise health professionals on gender based violence, equip them to ask women about their experiences of GBV and to document injuries and medico legal evidence which are fool-proof. The training will also develop health professionals' skills to provide basic support for abused women including formal counselling, and provide them with information on sources for, help and-suitable referral to other local services. Special training and skills up gradation in dealing with rape and child abuse cases' needs to be part of the training program me. Medico legal accreditation Some form of Medico legal accreditation is needed to extend quality care to women or children who are raped. Therefore strategies should be made so that only doctors who are accredited to do so should examine rape victims. Accreditation should depend on having undergone some specialist specifically designed short-term course, which will include experience of having examined a minimum number of rape survivors. Plans for

536 such medico legal training and provision of services may be done with the support of the Medical education department Reform of medico legal response Survivors of violence should be provided timely and speedy care and foolproof medico legal evidence. Wound certification procedures, collection of specimens, specimen management, and co ordination with the police with respect of timely intimation and issue of certificates may be streamlined using mandatory procedural guidelines. Health professionals are to be provided with financial and other support, which will enable them to participate in the legal process without hampering their other duties. Medical and Nursing curriculum The issues of gender as a determinant of health issues, gender based violence, its impact on health and care of abused women should be integrated into the medical and nursing curriculum. All measurements of human development have put Kerala on top of all the major states in India. Kerala has a good heritage of socio -economic development. Historically women in Kerala enjoyed a significantly higher states, compared to other states of India. Contributing factors to this could be. 1 Enlightened Policies of Government 2 High literacy rate 3 Awareness of people 4 Health facilities, with in reach of kerala When compared to other parts of India, women in Kerala is better placed in the society.

537 Chapter - 27 BIO-MEDICAL WASTE MANAGEMENT SYSTEM

For health care institutions in Kerala Information, education and communication (I project concept document) CONTENTS 1. INTRODUCTION 2. OBJECTIVES 3. RISK FACTORS 4. ICE PLAN 5. CAMPAIGN STRATEGY 5.1 Lesson Learnt 6. TRAINING AND AWARNESS 7. ACTION PLAN 6.1 Training 7.1 Training 6.1.1 State Level Training 7.2 Awareness 6.1.2 District Level Training 6.2 Awareness 8. INCENTIVES AND 9. NODEL AGENCY MOTIVATION 10. COST ESTIMATE 11. PROJECT MONITORIL

1. INTRODUCTION

The Ministry of Environment, of the Government of India have Promulgated the Biomedical Waste (Management and Handling) Rules, 1998. These rules apply to all hospitals, clinics and veterinary institutions animal house, pathological laboratory, blood bank etc. who generate, collect, receive, store, transport, treat, dispose or handle biomedical waste In any form. It is the responsibility of the health care institutions to establish necessary facilities for segregated collection, storage, treatment and disposal of biomedical waste generated from hospitals. The waste management system warrants

538 involvement of patients, bystanders and hospital staff and administrators of the hospitals for the sustainable working of the system. Awareness of the people and training of the hospital staff is essential for achieving this objective.

The Bio Medical Wastes (Management and Handling) Rules came into force in 1998 as per the provisions of the Environment (Protection) Act, 1986. The term 'bio medical waste by definition in the Rules means 'any waste which Is generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities. Even though four years have elapsed after the Rules came in to force, the situation in the health care institutions in Kerala is yet to be improved. Action is being taken from the Government to establish common bio medical wastes treatment and disposal facilities in three suitable places in the State for the treatment of bio medical waste generated in the State. The acceptance of the public is essential for the successful implementation of the common facilities, which In turn depends on people's awareness and participation. and attitude of hospital management as well as the hospital staff Is to be tuned to get speedy result in case of hospital waste management. Therefore, it is felt, Information, Education and Communication (I.E.C) component to be given thrust along with the implementation of the waste managen. The following are the key element need to be addressed. At present the biomedical wastes generated in the hospitals are disposed off un hygienically and it is a potential source of spreading disease to the core All wastes are mixed together and make the whole waste contagious and hazardous. In the light of Plague, Hepatitis-B and other deadly diseases, which can possibly spread through biomedical waste, hence special care need to be given to biomedical waste. Awareness is the key element in this aspect. As per these rules, it shall be the duty of every occupier of an institution generating biomedical waste to take all steps to ensure that such waste is handled without

539 any adverse effect to human health and environment. Awareness and change in attitude is prerequisite Introduction of the biomedical waste management system alone will not solve the problem. Sustainable working of the system requires participation of stakeholders such as patients, bystanders, and health care workers. Awareness and training Is essential to address this issue. Awareness and training of all stakeholders in different aspects of waste management and responsibilities of each one is be made clear for the successful implementation of the Biomedical Waste Management System.

Role of each category of staff is to be made clear and motivated to perform their role effectively.

2. OBJECTIVES

One of the reasons why institutions are not keeping at pace with the regulatory requirement is probably due to the ignorance of people attending these institutions as well as lack of commitment of the health care workers working in these establishments. The health care institutions are over burdened with excess people especially the seriously sick and desperate patients, many often behave in a way to make the environment more damaged. People have their own reasons for behaving in the odd ways; the association with a diseased person justifies the behaviour. The behaviour of patients, bystanders and health care workers are to be changed for delivering better health services.

The behaviour of people depends on attitude and for a changed behaviour, change of the mindset is important. The proposed plan of Information, Education and Communication (IEC) activities are aimed to achieve this change. The short term objectives of the project are; • To make aware of the stake holders about their critical role of properly handling the biomedical waste. • To strengthen the managerial capacity and responsibility of health care staff and Community for implementing the biomedical waste management • To improve the social acceptance for the establishment and operation of sustainable biomedical waste management system.

540 • To reduce public protest for the establishment of common Biomedical Waste Management System. The long term objectives of the project are; • To improve the living conditions and quality of life through better delivery of health services.

• To Improve the health and well being of health care workers and motivate them, to deliver better services to the community. • To protect the health of the people and environment.

3. RISK FACTORS

One of the major risk while implementing the project is the lack of proper awareness among the Stakeholders. Thereby the objective of the project on bio waste is not fulfilled. By planning proper IEC programme and implementing the same along with the implementation of the project on biomedical waste management the risk factors can be minimized. The following are the major risk factors identified and which may create hurdles while implementing the biomedical waste management project in the State.

 Inadequate Administrative Will.  Lack of acceptance on Policy on Environmental Protection and Pollution Control.  Lack of Co-operation from Patients, Bystanders and health care workers.  Fear about spread of contagious diseases due to waste handling.  Lack of will for sharing finance for Common Facility.  Low Priority for Waste Management in Government sector hospitals  Lack of existing facilities in Government sector hospitals which is not conducive for Waste Management.  NIMSY Syndrome (Not in my Backyard Syndrome) - is prevalent  establishing Common Biomedical Treatment Facilities.  Lack of focus on avoiding reuse/recycle of contagious waste medical gadgets.  Lack of Information about the best technologies and practices in waste treatment and disposal.  Difficulties to find suitable land for installing facilities for Biomedical Waste

541  Management due to public protest.

4. IEC PLAN

Biomedical Waste Management is an activity in which involvement of patients, bye standers and health care workers is the key to success. It is not the

Implementation of biomedical waste management system but public attitude and behavior that is going to make the difference. The risk factors mentioned already are considered for designing the IEC Programme. An IEC Plan focusing on biomedical waste management will therefore basically aim at the following

 To raise awareness on the high health risk when handling the biomedical wastes and the various disease - routes  Training of health care workers in various levels right from administrators to paramedical and cleaning staff.  To introduce a range of feasible options for waste handling within the health care

Institution among the hospital staff.  To create awareness among the hospital staff that the ultimate benefit of introduction of, Biomedical Waste Management System is to themselves.  To impart awareness on the crucial role of skill, knowledge and attitude in facilitating behavioral change towards adopting appropriate segregation, of treatment in the common.  To raise awareness on the need for community will and total participation for installing efficient and sustainable common or individual biomedical  To provide knowledge that waste could be converted to resource  To create awareness to destroy after use the reusable/recyclable items like needles, syringes etc. A system demanding segregation and storage of waste at source would require a very high degree of human behavior change. Hence I.E.C will also focus  No waste on floor

542  Segregation of waste at source and storage as per the BMW Rules requirement  Destruction of reusable items before going into waste streams.  Create willingness to pay for services offered to patients by giving them better hospital environment.  Making community aware of the dangers of present system  The need for reducing protest from people for Installing waste treatment plants.  Creation of education materials on biomedical waste management.

5. CAMPAIGN STRATEGY

By now the State of Kerala has carved out a receptive cultural space for successfully carrying out mass campaigns for social change like the literacy campaign. These campaigns, in fact, had a prototype in the unique reform movements of the last century. It was only when these social endeavors took the dimensions of irresistible social movements and led to mass upsurges that they succeeded in bringing about desirable social changes.

5.1 Lessons Learnt

Following are some significant lessons, observations and aspects, which have direct implications on the present need. These can be seriously considered was the approach/content for planning mass campaigns and developing IEC materials.

 Developing an attractive and meaningful logo/motto, and signature tune for the project with which the community can emotionally identify. Though these may be universalistic, it is desirable that elements of culturally specific symbols are added for flavor and appeal.  Slogan, stickers, and posters are often displayed in hospitals, buses, public places etc to say one thing or the other. But, for this to become really effect has to be innovative approaches. For Instance, if a very popular cine actor/political leader (visually) has some serious advice on our hygiene habits.  Electronic media have very wide coverage in Kerala and it is on the Increase.

543  The most potent situation is the wide coverage of' local cable TV network'. Features like short documentaries of 'experience sharing' can convince viewers that 'they can also do it.  It must be borne in mind that electronic media is not at all a substitute for involved interpersonal conscientisation dialogue.  The strategy of the campaign should be to progressively build a tempo which would mean the right themes at the right stage.  The psychological/cultural barriers that stand in the way of translating knowledge in to attitude and attitude into practice are the real problem to tackle  As a ground rule it must be said that methods and media employed in social mobilization should work within the cultural knowledge level and mindset .  Also any I.E.C material developed/campaign planned should be demand driven, target specific and (Project) phase (situation) relevant. Often there is a rush produce posters, flip chart etc. which will end up as provisioning of messages, with little impact. Community mobilization for sustainable biomedical waste would call for a process oriented IEC Campaign. Phase specific IEC Campaign target is given. PHASE SPECIFIC IEC CAMPAIGN Phase of Activity project Objective Interactive Electronic Print media Preliminary To develop an attractive and Medical meaningful logo/ motto, and college/ signature tune for the project

To develop IEC strategy for the campaign to progressively build a tempo which would mean the right News paper themes at the right stage. District Hospital Level To develop IEC material/ campaign planned for demand driven target specific and (project) phase (situation) relevant. Hospital visit To develop strategy for community mobilization for substainable biomedical waste Patient management call for a process oriented IEC campaign Bystanders

544 Planning and To develop training model News Paper formulation Medical Cable TV To develop awareness Module college/District Hospital Notice To develop Awareness Material Staff Cinema Ciculars To identify trainees and faculty Patients Slides Posters Bystanders Public

6. TRAINING AND AWARENESS 6.1 Training Training of health care workers at various levels such as Administrators, Doctors, Nurses, Paramedical Staff and Last Grade Employees Is Imperative for the successful implementation of Biomedical Waste Management System in the

Government sector hospitals. As a first step, State level training shall be given Administrators and Senior Medical Officers such as Principals of Medical Colleges, District Medical Officers (DMOS) and Superintendent of major hospitals and principals of Training centres. This will serve as training for the master trainers. The master trainers then can impart training to health workers of taluk hospital and primary health centre community health centres. Faculty form State Pollution Control Board, Consultants in the field and experts from other State Government institutions and representatives from other organisations can be utilised for the training. The training shall contain mainly three sessions covering the following. Sensitisation Teaching (Dissemination) Discussion & Feed back The session I is to be devoted to sensitizing the audience on the need to mange waste in the hospital. Relevant aspects of BMW Rules are also to be cover under this session. The following aspects shall also cover this session;  Dangers to the Community through biomedical waste  Spread of Infections through the recycling trade  Dangers to the health workers

545  Dangers associated with Mercury spills  Dangers associated with body fluid spills  Potential risk to health  Hygiene requirement  Use of protective clothing and gadgets  Statutory requirements In the session , It is necessary to cover various aspects of hospital waste management like; Segregation & Packing  On site storage  Sharp management  Mercury spill handling  Care for body fluid spill  Elements of waste treatment  Disinfection  Demonstration of all new materials, which will be introduced in the wards etc. Use of protective gadgets The last session is for Interaction and discussion. Trainees are asked about the problems, if any, they face while following the instructions given and answering of queries. Training sessions should be lively; they may start on a formal note but should be made informal, and one should try to make them interactive at all stages. Training modules should include equipments and other materials to be used later by the staff for waste management, slides on various aspects of waste management, including efforts by a hospital already following the system, slides on health effects of mismanagement of waste etc. 6.1. 1. State Level Training One day orientation training shall be imparted to the Policy makers / Administrators such as Secretary to Government, Addl. Secretary, joint Secretary ; DHS, Addl. DHS, Dy. DHS and Analytical Laboratory Director. Expected number of participants in this group is 20 . WO day's Training programme shall be arranged for DMOS, Dy. DMOS, Heads of Regional Laboratories, Principals of Medical colleges and for the

546 Superintendent of District hospitals, General hospitals, Mental Health Centers and Leprosy Sanatoriums. About 75 participants are expected 2 batches. 6.1.2. District Level Trainings Medical officers are to be trained in the district level. Two Medical Officers each from Taluk Hospital and General Hospital is to be trained. In addition to that Medical Officers of Community Health Centers (CHCs), Primary Health Centers (PHCSO, Mini PHCs are also to be trained. consisting of 30 participants. Five day's training programme for Staff Nurses, Jr.P.H.L, Jr.H.I Nursing Assistants and Last Grade Employees are also to be arranged. Awareness of public as well as the hospital staff is essential for the successful implementation of biomedical waste management. For sustained working of the

Biomedical Waste Management System interest and participation of hospital staff is essential. First the change in attitude and initiation are to be come from the top. The policy makers and administrators of hospital should be aware of the potential threat to the health of the community and to the people working inside the hospital due to careless disposal of biomedical waste. While introducing Common Biomedical Waste Treatment Facilities It has been felt difficulties for finding land for the establishment of the treatment system. Protest from the public due to lack of proper or right awareness is the main drawback. Thereby NIMBY Syndrome (Not in my backyard Syndrome) is very much prevalent In the State. Hence awareness component should focus to address this issue also. There are a few ways to help the hospital to create awareness about the scheme. Those include;  Posters and Circulars  Charts depicting the action to be taken by different categories of staff  Cartoons showing Dos/Don'ts  Proper Labeling of waste collection containers

547  Hospital Magazine  Attitude Survey  Tea Sessions  Infection /waste control Committee meetings  Evaluation of Nursing stations etc.

Chapter-28 DISASTER MANAGEMENT

A "disaster" can be defined as "any occurrence that causes damage, ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area" . A "hazard" can be defined as any phenomenon that has the potential to cause disruption or damage to people and their environment . Emergencies and disasters do not only affect health and well - being of people; frequently, large number of people are displaced, killed or injured, or subjected to greater risk of epidemics. Considerable economic harm is also common. Disasters cause great harm to the existing infrastructure and threaten the future of sustainable development. Disasters are not confined to a particular part of the world they can occur any where and at any time. Major emergencies and disasters have occurred throughout history and as the world's population grows and resources become more limited, communities are increasingly becoming vulnerable to the hazards that cause disaster. Statistics gathered since 1969 show a rise in the number of people affected by disasters.

548 Since there is little evidence that the actual events causing disasters are increasing in either intensity or frequency, it can only be concluded that vulnerability to disaster is growing. For each disaster listed in officially recognized disaster database, there are some 20 other smaller emergencies with destructive impact on local communities that are unacknowledged. There are many types of disasters such as earthquakes, cyclones, floods, tidal waves, land-slides, volcanic eruptions, tornadoes, fires, snow storms, severe air pollution (smog), heat waves, famines, epidemics, building collapse, toxicologic accidents (e.g. release of hazardous substances), nuclear accidents and warfare, sunami etc. Warfare is a special category, because damage is the intended goal of action. Every catastrophic event has its own special features. Some can be predicted several hours or days beforehand, as in the case of cyclones or floods, others such as earthquakes occur without warning.

The relative number of injuries and deaths differ, depending on a number of factors such as the type of disaster, the density and distribution of the population, condition of the environment, degree of the preparedness and opportunity of the warning. Injuries usually exceed death in explosions, earthquakes, typhoons, hurricanes, fires, tornadoes etc. Death frequently exceeds injuries in landslides, volcanic eruptions, tidal waves, floods, sunami etc. The types of emergency vary according to the kind of disaster, and how and when it strikes. In earthquakes, there is a high level of mortality, as a result of people being crushed by falling objects. The risk is greater inside or near dwellings but is very small in the open. Consequently earthquakes at night are more deadly. During the night fractures of pelvis, thorax and spine are common, because earthquake strikes while people are lying in bed. In the daytime injuries to the arms and skull are common. In volcanic eruptions mortality is high in the case of mudslides (e.g.. 23,000 deaths in Colombia in 1985) and glowing clouds (30.000 deaths at Saint - pierre in Martinique). There may be injuries, burns and suffocation. In floods, mortality is high only in case of sudden flooding e.g., flash floods, collapse of dams or tidal waves. Fractures, injuries and bruises may occur. If weather is cold, cases of accidental hypothermia may occur. In cyclones and hurricanes, mortality is not high unless tidal waves occur. The

549 combined, effect of wind and rain may cause houses to collapse. A large number of objects may be lifted in the air and carried along by the wind. This may give rise to injuries. In draughts, mortality may increase considerably in areas where draught cause famines, in which case there may be protein-calorie malnutrition and vitamin deficiencies particularly vitamin A deficiency, leading to xerophthalmia and blindness. In famine conditions measles, respiratory infections, diarrhoea accompanied by dehydration may bring about a massive increase in infant mortality. When people migrate and settle down on the outskirts of famine hit areas, poor hygiene and overcrowding may facilitate the spread of endemic communicable diseases . On the whole, morbidity which results from a disaster situation can be classified into four types

a. Injuries; b. Emotional stress; c. Epidemic of disease; and d. Increase in infections diseases. DISASTER MANAGEMENT There are three fundamental aspects of disaster management: a. disaster response b. disaster preparedness ; and c. disaster mitigation. These three aspects of disaster management correspond to different phases in the so - called "disaster cycle" . DISASTER MANAGEMENT Disaster impact and response Most injured sustained during the impact, and thus, the greatest need emergency care occurs in the first few hours. The management of mass casualties can be further

550 divided into search, rescue, first aid, triage and stabilization of victims, hospital treatment and redistribution of patients to other hospitals necessary. Search, rescue and first aid After a major disaster, the need for search, rescue and first aid is likely to be so great that organized relief services will be able to meet only a small fraction of the demand. No immediate help comes from the uninjured survivors. Field care Most injured persons converge spontaneously to health facilities, using whatever transport is available, regardless of the facilities, operating status. Providing proper care to casualties requires, that the health service resources be redirected-to this new priority. Bed availability and surgical services should be maximized. Provisions should be made for food and shelter. A centre should be established to respond to enquiries from patient's relatives and friends. Priority should be given to victim's identification and adequate mortuary space should be provided. When the quantity and severity of injuries overwhelm the operative capacity of health facilities, a different approach to medical treatment must be adopted. The principle of "first come, first treated", is not followed in mass emergencies. Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelyhood of their survival with prompt medical intervention. It must be adopted to locally available skills. Higher priority is granted to victims whose immediate or long- term prognosis can be dramatically affected by simple intensive care. Morbiden patients who require a great deal of attention, with questionable benefit, have the lowest priority. Triage is the only approach that can provide maximum benefit to, the greatest number of injured in a major disaster situation. The most common classification uses the internationally accepted four colour code system. Red indicates high priority treatment or transfer, yellow signals medium priority, green indicates ambulatory patients and black for dead or moribund patients. Triage should be carried out at the site of disaster, in order to determine transportation priority, and admission to the hospital or treatment centre, where the patient's needs and priority of medical care will be reassessed. Ideally, local health workers should be taught the principles of triage as part of disaster training.

551 Persons with minor or moderate injuries should be treated at their own homes to avoid social dislocation and the added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities- Tagging All patients should be identified with tags stating their name, age, place of origin, triage category, diagnosis, and initial treatment. Identification of dead Taking care of the dead is an essential part of the disaster management. A large number of dead can also impede the efficiency of the rescue activities at the site of the disaster. Care of the dead includes : (1) removal of the dead from the disaster scene; (2) shifting to the mortuary; (3) identification; (4) reception of bereaved relatives. Proper respect for the dead is of great importance. The health hazards associated with cadavers are minimal if death results from trauma, and corps are quite unlikely to cause outbreaks of disease such as typhoid fever, cholera or plague. If human bodies contaminate streams, wells, or other water sources as in floods etc., they may transmit diarrhoea or food poisoning to survivors. The dead bodies represent a delicate social problem. Relief Phase This phase begins when assistance from outside starts to reach the disaster area. The type and quantity of humanitarian relief supplies are usually determined by two main factors (1) the type of disaster, since distinct events have different effects on the population, and (2) the type and quantity of supplies available locally. Immediately following a disaster, the most critical health supplies are those needed for treating casualties, and preventing the spread of communicable diseases. Following the initial emergency phase, needed supplies will include food, blankets, clothings, shelter, sanitary engineering equipment and construction material. A rapid damage assessment must be carried out in order to identify needs and resources. There are four principal components- in managing humanitarian supplies : (a) acquisition of supplies; (b) transportation; (c) storage; and (d) distribution. Epidemiologic Surveillance and Disease Control

552 Disasters can increase the transmission of communicable diseases through following mechanisms 1. Overcrowding and poor sanitation in temporary resettlements. This accounts in part, for the reported increase in acute respiratory infections diarrhoea etc. following the disasters 2. Population displacement may lead to introduction of indigenous populations are susceptible 3. Disruption and the contamination of water supply, damage to sewerage system and power systems are common in natural disasters 4. Disruption of routine control programmes as funds and personnel are usually diverted to relief work. 5. Ecological changes may favour breeding of vectors and increase the vector population density. 6. Displacement of domestic and wild animals, who carry with them zoonoses that can be transmitted to humans as well as to other animals. Leptospirosis cases have been reported following large floods (as in Orissa, India, after super cyclone in 1999). Anthrax has been reported occasionally. 7. Provision of emergency food, water and shelter in disaster situation from different or new source may itself be a source of infectious disease. Outbreak of diarrhoea, which is the most commonly reported disease in the post- disaster period, is closely related to first three factors mentioned above. Increased incidence of acute respiratory infections is also common in displaced population. Vector-borne diseases will not appear immediately but may take several weeks to reach epidemic levels. Displacement of domesticated and wild animals increases the risk of transmission of zoonoses. Veterinary services may be needed to evaluate such health risks. Dogs, cats and other domestic animals are taken by their owners to or near temporary shelters. Some of these animals may be reservoirs of infections such as leptospirosis, rickettsiosis etc. Wild animals are reservoirs of infections which can be fatal to man . The principals of preventing and controlling communicable diseases after a disaster are to - (a) implement as soon as possible all public health measures, to reduce the risk of disease transmission; (b) organize a reliable disease reporting system to identify outbreaks

553 and to promptly initiate control .measures; and (c) investigate all reports of disease outbreaks rapidly. Vaccination Health authorities are often under considerable public and political pressure to begin mass vaccination programmes, usually against typhoid, cholera and tetanus. The pressure may be increased by the press media. The WHO does not recommend typhoid and cholera vaccines in routine use in endemic areas. The newer typhoid and cholera vaccines have increased efficacy, but because they are multi dose vaccines, compliance is likely to be poor. They are not yet been proven effective, as a large-scale public health measure. Supervision of sterilization and injection techniques may be impossible, resulting in more harm than good. And above all, mass vaccination may lead to false sense of security about the risk of the disease and to the neglect of effective control measures. However, these vaccinations are recommended for health workers. Supplying safe drinking water and proper disposal of excreta continue to be the most practical and effective strategy. Nutrition A natural disaster may affect the nutritional status of the population by affecting one or more components of food chain depending on the type, duration and extent of

the disaster, as well as the food and nutritional conditions existing in the area before the catastrophe. Infants, children, pregnant women, nursing mothers and sick persons are more prone to nutritional problems after prolonged draught or after certain types of disasters like hurricanes, floods, land or mudslides, volcanic eruptions and sunami involving damage to crops, to-stocks or to food distribution systems. The immediate steps for ensuring that the food relief programme will be effective include : (a) assessing the food supplies after the disaster ; (b) making available gauging the nutritional needs of the affected population ; (c) calculating daily food rations and need for large population groups ; and (d) monitoring the nutritional status of the affected population.

554 Rehabilitation The final phase in a disaster should lead to restoration of the pre-disaster conditions. Rehabilitation starts from the very first moment of a disaster. Too often, measures decided in a hurry, tend to obstruct re-establishment of normal conditions of life. Provisions by external agencies of sophisticated medical care for a temporary period has negative effects. On the withdrawal of such care, the population is left with a new level of expectation which simply cannot be fulfilled. In first weeks after disaster, the pattern of health needs, will change rapidly, moving from casualty treatment to more routine primary health care. Services should be reorganized and restructured. Priorities also will shift from health care towards environmental health measures. Some of them are as follows : Water supply A survey of all public water supplies should be made. This includes distribution system and water source. It is essential to determine physical integrity of system components, the remaining capacities, and bacteriological and chemical quality of water supplied. The main public safety aspect of water quality is microbial contamination. The first priority of ensuring water quality in emergency situationgs is chlorination. It is the best way of disinfecting water. It is advisable to increase residual chlorine level to about 0.7 mg / litre. Repaired mains, reservoirs and other units require cleaning and disinfection.

The existing and new water sources require the following protection measures : (1) restrict access to people and animals, If possible, erect a fence and appoint a guard; (2) ensure adequate excreta disposal at a safe distance from water source; (3) prohibit bathing, washing and animal husbandry, upstream of intake points in rivers and streams; (4) upgrade wells to ensure that they are protected from contamination; and (5) estimate the maximum yield of wells and if necessary, ration the water supply. In many emergency situations, water has to be trucked to disaster site or camps. All water tankers should be inspected to determine fitness, and should be cleaned and disinfected before transporting water. Food safety

555 Poor hygiene is the major cause of food -borne diseases in disaster situations. Where feeding programmes are used (as in shelters or camps) kitchen sanitation is of utmost importance. Personal hygiene should be moniterd in individuals involved in food preparation. Basic sanitation and personal hygiene Many communicable diseases are spread through faecal contamination of drinking water and food. Hence, effort should be made to ensure the sanitary disposal of excreta. Emergency latrines should be made available to the displaced, where toilet facilities have been destroyed. Washing, cleaning and bathing facilities should be provided to the displaced persons. Vector control Control programme for vector-borne diseases should be intensified in the emergency and rehabilitation period, especially in areas where such diseases are known to be endemic. Of special concern are dengue fever and malaria (mosquitoes), leptospirosis and rat bite fever (rats), typhus (,lice, fleas), and plague (fleas). Flood water provides ample breeding opportunities for mosquitoes. A major disaster with high mortality leaves a substantial displaced population, among whom are those requiring medical 'treatment and orphaned children. When it is not possible to locate the relatives who can provide care, orphans may become the responsibility of health and social agencies. Efforts should be made to reintegrate disaster survivors into the society, as quickly as possible through institutional programmes coordinated by ministries of health and family welfare, social welfare, education, and NGOS. Disaster mitigation in health sector Emergency prevention and mitigation involves measures designed either to prevent hazards from causing emergency or to lessen the likely effects of emergencies. These measures include flood mitigation works, appropriate land use planning, improved building codes, and reduction or protection of vulnerable population and structures. In most cases mitigation measures aim to reduce the vulnerability of the system. Medical casualties can be drastically reduced by improving the structural quality of houses, schools 'and other public and private buildings. Although mitigation in these sectors has clear health implications, the direct responsibility of the health sector is

556 limited to ensuring the safety of health facilities and public health services, including water supply and sewage systems. When water supplies are contaminated or interrupted, in addition to the social cost of such damage, the cost of rehabilitation and reconstruction severely strains the economy. Mitigation complements the disaster preparedness and disaster response activities. Disaster preparedness Emergency preparedness is "a programme of long term development activities whose goals are to strengthen the overall capacity and capability of a country to manage efficiently all types of emergency. It should bring about an orderly transition from relief through recovery, and back to sustained development". The objective of disaster preparedness is to ensure that appropriate systems, procedures and resources are in place to provide prompt effective assistance to disaster victims, thus facilitating relief measures and rehabilitation of services. The individuals are responsible for maintaining their well being. Community members, resources, organizations, and administration should be the cornerstone of an emergency preparedness programme. The reasons of community preparedness are: (a) Members of the community are the most to lose from being vulnerable to disasters and the most to gain from an effective and appropriate emergency preparedness programme; (b) Those who first respond to a emergency come from within the community. When transport and communications are disrupted, an

external emergency response may not arrive for days ; (c) Resources are most easily pooled at the community level and every community possesses capabilities. Failure to exploit these capabilities is poor resource management; (d) Sustained development is best achieved by allowing emergency-affected communities by design, manage, and implement internal and external assistance programme. Disaster preparedness is an on going multi sectoral activity. It forms an integral part of the national system responsible for developing plans and programmes for disaster management, prevention, mitigation, preparedness, response, rehabilitation and

557 reconstruction. The system, known by a variety of names depending on the country, depends on the coordination of a variety of sectors to carry out the following tasks 1. Evaluate the risk of the country or particular region to disaster 2. Adopt standards and regulations 3. Organize communication, information and warning systems 4. Ensure coordination and response mechanisms 5. Adopt measures to ensure that financial and other resources are available for increased readiness and can be mobilized in disaster situation ; 6. Develop public education programmes; 7. Coordinate information sessions with news media ; and 8. Organize disaster stimulation excercises that test response mechanisms. The emergency preparedness and emergency management do not exist in a vacuum. To succeed, emergency programmes must be appropriate to their context. This context will vary from country to country and from community to community. Policy development The policy development is "the formal statement of a course of action". Policy is strategic in nature and performs the following functions (a) establish long - term goals; (b) assign responsibilities for achieving goals; (c) establish recommended work practice; and (d) determine criteria for decision making. While policies tend to be "top - down" that is authorized by higher levels, implementation of the strategies that arise from a policy tend to be "bottom-up", with the higher levels assisting lower levels. The form of emergency preparedness policy varies from country to country. Six sectors are required for response and recovery strategies. These sectors are communication, health, social welfare, police and security, search and rescue and transport. MAN MADE DISASTERS There are many disasters which have large elements of human casualities; either accidental or intended. These can also be divided into three categories. (a) Sudden disasters such as Bhopal Gas Tragedy in India on 3.rd December 1984 in which a leakage in the storage tank of Union Carbide Pesticide Plant released tons of methyl isocyanate into the air.

558 Wind conditions and an atmospheric inversion, along with delayed warning and a population that had not been taught the nature of risks and the appropriate response increased the impact. About 2 million people were exposed to the gas leaving about 3000 dead. People are still suffering from the adverse effects of the gas. The second example is the accident at reactor 4 of the Chernobyl nuclear power station in the Soviet Union on April 26, 1986, which resulted in the largest reported accidental release of radioactive material in the history of nuclear power. It deposited more than 7 million curies of Iodine 131, Cesium 134 and 137, Strontium 90 and other isotopes throughout the northern hemisphere, (3); (b) Insidious disasters, such as insidious chemical exposure and insidious radiation exposure, as in nuclear weapons production factories, research laboratories resulting in release of radioactive substances into the air, soil and underground water. Chemical plants releasing their toxic by- products into rivers and other water sources is another example. Other form of long term and continuing human-made disaster include global warming (the "green house effect") caused by the heat-trapping gases in the atmosphere released by burning of fossil fuels, and depletion of ozone layer due to the use of the aerosolized chlorofluorohydrocarbons and (c) Wars and civil conflicts. The -latest example is the attack on twin buildings of World Trade Centre in New York in which about 6000 people lost their lives and thousands were injured. Since World War 11, there have been about 127 wars and 21.8 million war- related deaths involving more than 50 per cent of civilians (3), Recently the proportion of civilians among dead has been increasing. Air-borne power and wide-ranging nature of modern war puts an entire population at risk, disrupting food production and supply

routes, imperiling fragile ecosystem and forcing refugees by hundred of thousands to flee. More than half of the civilian deaths in current hostilities resulted from war-related famines. As for causes of most wars, most frequent objectives were gain of land assets, and independence. However, civil wars, representing power conflicts within nations, have increased sharply in the twentieth century, and are now, by far the major form of warfare. Terrorism are on the increase. The public health response to man made disaster is the primary prevention, i.e., prevention of occurrence of the disaster. Much can be done to prevent not only the consequences but also the occurrences of fires, explosions, crashes, and sudden chemical and

559 radiation exposures. This includes tighter regulations of chemical plants and other hazardous facilities and insistence that the chemical plants be built away from dense populous areas. Other measures include appropriate engineering and technological measures (like building codes, dam designs, containment of toxic materials),early warning, if possible, and protection against human errors. During the first half of the twentieth century, two world wars and many regional conflicts provided the experience for governments, to develop civil defense programmes. They were reshaped after the introduction of nuclear weapons and massive air attacks occurring with little warning. Weapons of mass destruction are indiscriminate, killing and injuring civilians as well as military personnel, and destroying and contaminating ecosystem over wide areas. People around the world have turned towards efforts to stop the arms race and prevent nuclear war. Disasters in India With a wide range of topographic and climatic conditions, India is the highly disaster-prone country in Asia-Pacific and community involvement plays a vital role here. While floods, cyclones, draughts, earthquakes and epidemics are frequent from time to time, major accidents happen in railways, mines and factories causing extensive damage to human life and property. Northern mountain regions, including the foot hills are prone to snow-storms, land slides and earthquakes. The eastern coastal areas are prone to severe floods and cyclones (Andhra Pradesh, West Bengal, Orissa, etc.). Bihar, Assam and Uttar Pradesh gets major floods almost every year. There is hardly a year when some or the other part of the country does not face the spectre of draught, floods or cyclone. Orissa had super cyclone on 29th October 1999, when thousands lost their lives and many more became homeless. More recently, Gujarat had severe earthquake in which about 16480 people died and lacs became homeless. Some of the natural disasters and the effects they had on human population during 2000-2001 are shown in Table 2. During that period about 416.24 lac people were affected by natural disasters and about 19262 persons lost their lives (6). TABLE 25 Disaster impact in some states in India 2000-2001

560 State Type of disaster Districts Villages Population Human affected Affected Affected life (000) Lost Andra Heavy rains / floods 18 4522 29.35 257 Pradesh Arunachal Heavy rains / floods/ 4 30 0.42 26 Pradesh Land slides Assam Heavy rains / floods 19 3474 36.09 32 Bihar Heavy rains / floods 33 11696 79.72 273 Gujarat Floods/earthquake 10 389 4.08 116 24 16480 Uttar Heavy rains /floods 49 6893 48.40 400 Pradesh West Heavy rains /floods 9 1412 218.18 1320 Bengal

In the federal structure of India, the state governments are responsible for the execution of relief work in wake of natural disasters. Government of India plays a supportive role, in terms of supplementation of financial resources to the states. An administrative system has been developed to combat and minimize the adverse impact of the natural disasters. At the centre, the Ministry of Agriculture is the nodal ministry for coordination of all activities during a natural disaster. Since, health is an important part of disaster management, in the DGHS under the ministry of Health and Family Welfare there is a special wing called the Emergency Medical Relief Wing which will coordinate all activities related to health.

In a vast country like India, it is not practicable for the government machinery alone, to undertake disaster reduction programmes without involvement of NGOs. Public education and community involvement plays a vital role here. As part of the International Decade for Natural Disaster Reduction activities, every year, the second Wednesday of October has been designed as World Disaster Reduction Day. Indian Meteorological Department (IMD) plays a key role in forwarning the disaster. It has five centres In Kolkata, Bhubaneshwar, Vishakhapatnam, Chennai and Mumbai for detection and tracing of cyclone storms. Satellite imagery facilities and cyclone warning radars are provided to various Cyclone Warning Centres. In addition, it

561 has 31 special observation post set up along east coast of India. For all ships out at sea warnings are issued six times a day. Insat Disaster Warning System (DWS) receivers have been installed primarily has proved very reliable form of communication system. The Snow and Avalanche Study Establishment (SASE) in Manali has been issuing warning to people about avalanches 24 to 48 hours in advance. INTERNATINAL AGENCIES PROVIDING HEALTH, HUMANITARIAN ASSISTANCE Every country is a potential source of health humanitarian assistance, for some or other disaster striken nation. Bilateral assistance, whether personnel, supplies or cash is probably the most important source of external aid. Several international or regional agencies have established special funds, procedures and offices to provide humanitarian assistance. United Nation’s Agencies are United Nations Office for the Coordination of Humanitarian Affairs (OCHA), World Health Organization (WHO), UNICEF, World Food Programmee (WFP) , Food and Agriculture Organization (FAO). Inter – governmental organizations are European community Humanitarian Office (ECHO), Organization of American States (OAS) , Centre of coordination for Prevention of Natural Disasters in Central America, Caribbean Disaster Emergency Response Agency. Some Non – Governmental Organizations are CARE, International Committee of Red Cross, International Council of Voluntary Agencies (ICVA), International Federation of Red Cross and Red Crescent Societies (IFRC) etc.

Chapter - 29

NATIONAL RURAL HEALTH MISSION

The National Rural Health Mission (NRHM) is National effort at ensuring effective health care through a range of interventions at individuals, house hold, community, and most critically at the health system levels.

562 NRHM seeks to provide effective health care to the entire rural population in the country, special focus on 18 states which have weak public health indicators. The Mission is an articulation of the commitment of the Government to rise public spending on health. It aims to undertake architectural correction of the health system to enable it to effectively handle increase allocations. Key components proposes a health activist in each village; a village health plan, strengthening of the CHCs to Indian Public Health Standards (IPHS), integration of vertical Health & Family Welfare Programmes, optima Utilization of funds. Public health expenditure has declined from 1.3% of GDP in 1990 to 0.9% of GDP in 1999. The Union Budgetary allocation for health is 1.3% while the State’s Budgetary allocation is 5.5% Union Government contribution in public health expenditure is 15% while States contribution is 85%. Vertical Health and family Welfare Programmers have limited synergisation at operational levels. Lack of community ownership of public health programmers impacts levels of efficiency, accountability and effectiveness. Integration of sanitation, hygiene, nutrition and drinking water issues is needed in the overall sectoral approach for Health. There is striking regional inequalities is health provision. Population Stabilization especially in States with weak demographic indicators is a challenge. Curative service favour the non-poor for every Rs. 1 spent on poorest 20% population, Rs. 3 spent on the richest quintile. Only 10% Indians have some form of health insurance, mostly inadequate hospitalized Indians spend 58% of their total annual expenditure on health care. Over 40% of hospitalized Inddians borrow heavily or sell assets to cover expenses. Over 25% of hospitalized Indians fall below poverty line because of hospital expenses.

Aims of National Health rural Health Mission are affective integration of health concerns with determinants of health live sanitation and hygiene, nutrition and safe drinking water, decentralization of programme for district management, addressing the intra-State and inter-district disparities including unmet needs for public health infrastructure, promoting policies that strengthen public health management and services in the country, defining time-bound goals and report publicly on their progress, and

563 improving access of rural people, especially poor women and children, to equitable, affordable accountable and effective primary health care. NRHM would subsume RCH-II, National Diease Control Programmes, including Integrated Disease Surveillance Programme, and attempt mainstreaming of AYUSH (Ayurveda, Yoga, Unani, Sidha, Homeopathy). Guiding Principles of NRHM are to promote equity, efficiency quality and accountability in Public Health Systems, enhance People orientation and community based approaches, ensure Public Health Focus, recognize value of traditional knowledge base of communities, promote new innovations, method and process development and decentralize and involve local bodies. Further NRHM plans in the reduction in IMR and MMR by 50% by 2012, universalize access to PH services, Women and child health, water sanitationand hygience, immunization and Nutrition, prevention and control of communicable and non-communicable diseases, including locally endemic diseases, access to Integrated comprehensive primary healthcare, assuring Population stabilization, gender and demographic balance and promotion of healthy life styles. The NRHM outcomes would be provision of ASHA (Accredited Social Health Activists), preparation of health action plans by Panchayaths, strengthening SC/PHC/CHC to IPHS, institutionalizing and substantially strengnthening District level Management of Health., increase utilization of FRUs from less than 20% (2002) to more than 75% by 2010. strengthening sound local health traditions and local resources based health practices related to PHC and public health. To reach the outcome, core strategies suggested are; training and enhancing capacity of PRIs to own, control and manage public health services, promote access to healthcare through ASHA, health plan for each village through Village Health Samiti of the Panchayat, strengthening sub-centre through an united fund to enable local planning and action and more Multi Purpose workers, strengthening existing PHCs and CHCs; 30-50 bedded CHC per lakh population as per Indian Public Health Standards (IPHS), implementation of an inter sectoral district District Health Plan prepared by the District Health Mission, including drinking water, sanitation & hygiene and nutrition, integrating relevant vertical Health and Family Welfare programmes at National, State and District levels, technical Support to National, State and District Health Missions, for Public Health Management, strengthening capacities for data collection assessment and

564 review for evidence based planning, monitoring and supervision, formulation of transparent policies for deployment and career development of Human Resources for health, developing capacities for preventive and promoting health care at all levels – such as healthy life styles, reduction in consumption of tobacco and alcohol etc and promoting non profit sector particularly in under served areas. Supplementary strategies to attain the outcome will be regulation of Private Sector to ensure availability of quality service to citizens at reasonable cost, promotion of Public Private Partnerships (PPP) for achieving public health goals, mainstreaming AYUSH - revitalizing local health traditions, reorienting medical education to support rural health issues including regulation of Medical care and Medical Ethics and effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care. Component – 1 is the provision of community health activists. Every village to have a female community health activist – to act as the interface between the community and the public healthcare system. These Accredited Social Health Activists (ASHAs) will be trained on Management of minor ailments. ASHA would act as a bridge between the JPHN and the village and be accountable to the Panchayat. ASHA is an honorary volunteer, receives performance based incentives for promoting construction of household toilets, universal immunization, referral and escort services for RCH, and other healthcare delivery programmes. ASHA will make the Village Health Plan along with Anganwadi worker, community workers and ANM under the leadership of the Village Health Committee

of the Panchayat. ASHA will be promoted all over the country, she will be given a Drug Kit. Training of ASHAs includes various models of training, such as ; Contract plus distance learning model, NGO/private partnership, ICDS training centres and State Health Institute, Comprehensive women’s health & empowerment models, Effective NGO models.

565 Components – 2 is to strengthen the sub centres. Each sub – centre will have an united fund for local action @ Rs.10,000 per annum. This fund will be operated by the ANM in consultation with the Village Health Committee. Supply of essential drugs, both allopathic and AYUSH , to the Sub- centres. Wherever needed, sanction of new Sub – centres as per 2001 population norm. upgrading existing Sub – centres, including buildings for Sub – centres functioning in rented premises will be considered. Component – 3 is to strengthen the Primary Health Centres. Activities include strengthening PHC for quality services, adequate and regular supply of essential quality drugs and equipment to PHCs, provision of 24 hour services in 50% PHC by addressing shortage of doctors, through mainstreaming AYUSH manpower, standard treatment guideline & protocols, supply of Auto Disabled Syringes, for immunization, I intensification of ongoing communicable disease control programmes, new programmes for control of non – communicable diseases, up gradation of 100% PHCs as FRUs , and provision of 2nd doctor at PHC level( 1male, 1 female) would be undertaken if needed. Component – 4 is for strengthening CHCs for first referral care. This includes, operationalizing CHC (30-50 beds) as 24 Hour FRUs, including posting of anesthetists, - 2 CHCs per district initially, SC/PHC/CHC to be upgraded to IPHS, promotion of Rogi Kalyan Samitis for hospital management, developing standards of services and costs in hospital care, creation of new CHCs (30-50 beds) to meet the population norm as per Census 2001. Component – 5 includes, District Health Plan as per Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition. Health plans would form the core unit of action.

Implementing Departments would integrate into District Health Mission for monitoring, district becomes core unit of planning, budgeting and implementation, centrally Sponsored Schemes could be rationalized/modified accordingly in consultation with States. Concept of “funneling” to district for effective integration, all parallel bodies in Health at District and state level merge into one common” District Health Mission” at

566 the District level and the “ State Health Mission” at the state level and Project Management Unit for all districts. Component – 6 converges sanitation and hygiene under NRHM. The total sanitation Campaign (TSC) is implemented in 350 districts – to cover all districts in10th Plan. TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Programme. The TSC is implemented through PRIs. The District Health Mission would guide activities of sanitation at district level – joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote household toilets and School Sanitation Programme. Component -7 is for strengthening disease control programme. National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme shall be horizontally integrated under the Mission, for improved programme delivery. New Initiatives would be launched for control of Non Communicable Diseases. Strengthening disease surveillance system at village level and supply of generic drugs (both AYUSH & Allopathic) for common ailments at village, SC, PHC/CHC level are other initiative under this component. Component – 8 deals with Public Private Partnership for public health goals, including regulation of private sector. 75% of health services are being currently provided by the private sector. Regulation of the sector is to be transparent and accountable. Reform of regulatory bodies/creation where necessary are suggested. District Institutional mechanism for Mission must have representation of private sector and is to develop guidelines for PPP for health sector. Lead role of Public Sector in defining the framework and sustaining the partnership, management plan for PPP initiatives at District/State and National levels and identifying areas of

partnership which are need based, thematic and geographic are other activities suggested. Component – 9 deals with new health financing mechanisms. Under this, there will be a task Group to examine new health financing mechanisms, including Risk Pooling for Hospital Care as follows:

567 Progressively the District Health Missions to move towards paying hospitals for services by way of reimbursement, on the principle of “money follows the patient”; standardization of services and costs will be done periodically by a committee of experts in each state; a National Expert Group is to monitor these standards and give suitable advise and guidance on protocols and cost comparisons. All existing CHCs to have wage component paid on monthly basis. Other recurrent costs may be reimbursed for services rendered from District Health Fund. A district health accounting system, and an ombudsman to be created to monitor the District Health Fund Management, and take corrective action, adequate technical managerial and accounting support to be provided to DHM in managing risk-pooling and health security. It also included activities where will be encouraged as part of the Mission. The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes. The IRDA will be approached to promote such CBHIs which will be periodically evaluated for effective delivery. Component – 10 spells out measures to re-orient health/medical education to support rural health issues. District and tertiary hospitals are in urban areas and form an integral part of the referral care chain serving the needs of the rural people. Medical and para- medical education facilities need to be created in states based on need assessment. Suggestion for Commission for Excellence in Health Care (Medical Grants Commission), National Institution for Public Health Management etc. Need for mainstreaming AYUSH and task groups to improve guidelines/details are activities under these components. Institutional mechanism under NRHM proposes Village Health & Sanitation Samiti, Rogi Kalyan Samiti/Hospital management committee, District Health Mission, State Health Mission, Chaired by CM, Integration of Departments of H & FW, at National and State level, National Mission Steering Group chaired by Union Minister, Empowered programme Committee, Standing Monitoring Group and Task Groups for Selected Tasks. NRHM defines role of States/Districts/Villages. The Mission covers the entire country -18 high focus States. Other States would fund interventions like ASHA,PMU and upgradation of SC/PHC/CHC through Integrated Financial Envelope.NRHM provides broad conceptual framework. States would project operational modalities in their State Action Plans, to be decided in consultation with the Mission Steering Group.

568 States would sign MOU, to increase contribution to Health Budget (preferable by 10% each year). State is to implement performance benchmarks for release of funds. States Action Plan is to include Outlays on RCH-II, National Disease Control Programmes, Integrated Disease Survellance Programme, State health Budget, Funds under State Finance Commission, Rashriya Sam Vikas Yojana, bilateral funding, major NGO funding etc. The Mission envisages the following roles for PRIs; ASHAs would be selected by and be accountable to the Village Panchayat. The Village Health Committee of the Panchayat would prepare the Village Health Plan, and promote intersect oral integration. The united fund at Sub-centres to be deposited in a Bank Account, jointly operated by the ANM and Sarpanch. District health Mission to be led by the Zila Parishad. The DHM would also guide activities of sanitation. States are to be indicate in their MOUs devolution of funds and programmes to PRIs. The DHM will control, guide and manage all public Health institutions in the district, Sub-centres, PHCs and CHCs. PRI involvement in Rogi Kalyan Samitis is to ensure good hospital management. Training to members of PRIs and making available health related databases to all stakeholders, including Panchayats at all levels are planned under NRHM.

Chapter - 30 PANCHAYAT RAJ 1. Panchayat Raj Systems

569 Proper implementation of a programme leads to its success. If the people participate in a national programme, it is bound to succeed so as to optimize the programme planning it involved peoples participation and makes it accountable and responsive to peoples need, it is important to begin to operationalise the concept of decentralization. So while implementing the new RCH programme it was decided to enhance the linkages between the health care delivery system and the Panchayat Raj institutions where we have one-third women members. Panchayat Raj system is a decentralized three - tier structure of rural local self Govt. in India. It is based on three principle - denentralised planning, community participation in development programme and development of leadership at village level. Grama Panchayat • Each village is divided in to 7 to 11 ward • From each ward one person is elected as a member of gram panchayat • Elected members select their leader called as Sarpanch, or President • All the adult in the village meet twice in a year. It is called a Grama Sabha. village level problems & policy decisions are discussed in this meeting. • These policy decisions are guidelines for working for gram panchayat. • Gram sevak is appointed by Zilla Parishad, who implement decision taken by the gram panchayat. Health related functions of gram panchayat • Provision of safe and sufficient water. • Solid waste and excreta disposal • Information about health related important events like epidemic . • Birth and death registration • To help PHC to improve health care delivery • Co-ordinate between various department

Panchayat Sammittee (Block Panchayat) Panchayat Sammittee consists of elected members from the panchayat Sammittee constituencies

570 They select their leader called as (Sabhapati Block Panchayath President) Block Development Officer is public servant and the Ex-officio secretary of the Panchayat Sammittee. His main function is to co-ordinate different departments for smooth functioning of development programme

Zila Parishad (ZP) (District Panchayat)

Zila Parishad is the agency of the rural local self – Government at district level Zila Parishad consists of elected members of Zila Parishad constituencies

They elect president of Zila Parishad Various subjects committee are formed, under the charimanship of chairman Accordingly health committee is formed. Chief executive officer is head of Zila Parishad. He is responsible for implementation of policy decision taken by the Zila Parishad. He co-rodinate between various departments Activities of Pancliayat Raj. • Health and education • Road & Transportation • Sanitation • Disposal of garbage Safe water supply

• Economic & social development of village

Involvement of panchayat in RCH programmes by the following activities

Helping in organising and conducting of ante-natal checking camps by making the local resources available (Place, funds etc): Under RCH programme panchayats are involved in various activities such as organizing and conducting ante natal checking camps. The sub centre and PCH are involved in these activities with them. By these activates there will be co-ordination between them.

Helping for screening camps for under 5 children. They are involved in Organisation of screening camps for children's under 5 years of age. Awareness generation and motivating the people about RCH activities;

571 For the effective implementation of RCH programme awareness and motivation among the people are most important as the Panchayat members are elected from the community they have good rapport with people. They are the formal leaders in the community. So they can create awareness among the people about the RCH activities as per new reservation rule now the 'number of women members are increased in panchayat. They will motivate the antenatal mothers to avail the service provided under RCH programme.

Referring and funding the antenatal cases for delivery at PHC.

Before implementation of this programme at the sub-centre level referral of high risk, - antenatal was very difficult. But now under RCH programme funds are available for transportation of such high risk cases to the PHC or hospital. These funds given through the panchayat. Thus the panchayat can help the antenatal mothers for safe delivery at PHC / Hospital.

Chapter - 31

572 ETHICAL ISSUES RELATED TO ACTIVITIES OF SUPERVISION AND WORKFORCE MANAGEMENT Objectives To provide an overview of Bioethics and to sensitize the supervisors about the ethical issues that can arise in their day to day activities in relation to their interactions with both their colleagues as well as with the community members.

Bioethics has developed as a specialty in the western and industrialized world over the past four decades whereas it is still in its infancy in India. Many problems that we face in our healthcare delivery system from ethical issues which, unfortunately, either go unnoticed or remain unaddressed. The basic reason for such a state of affairs is our limited exposure to this discipline. Often people confuse ethics with law and 'ethical' issues are often mistaken for legal issues. For example, if one notices an ethical issue like misbehavior of a health professional, it needs to be addressed differently, than a criminal act which is usually dealt with in law. Moreover, professions have their own ethical guidelines to safeguard their integrity and credibility and professionals are to be exercising self regulation to adhere to ethical guidelines prescribed by their professions. Thus healthcare providers who constitute one of the largest groups of professionals and who are in daily contact with the public need to be aware of the ethical guidelines that the professions prescribe for them. All legally justifiable actions need not be ethically sound and all ethical actions need not be legally justified. For example, it is ethically not acceptable to kill anyone under any circumstances. But, capital punishment in various forms like hanging till death, electrocution etc. is being performed legally in various parts of the world which may not be acceptable to morally conscious individuals who are against killing in any form. Similarly, an ethically acceptable act like the 'non- cooperation' movement spearheaded by none other than our "Father of the nation" was not legally acceptable to the British Government.

573 Ethical Issues at workplace

In the case of supervisors, these aspects have another added dimension. They are often faced with not only issues related to dealing with public but also with issues related to dealing with their superior as well as inferior officials. In the case of middle level supervisors like the Health Inspectors and Lady Health Inspectors, one observation often made is that being promoted from the cadres of the ranks whom they are expected to supervise; they often identify themselves with the ultimate result that they are hesitant to take a firm stand on issues especially demanding strict disciplinary measures. Similarly, in the case of multipurpose health workers where both the genders play almost the same role and are expected to perform along similar lines, the supervisors are expected to discharge their supervisory responsibilities almost equally. This sometimes leads to gender related problems which are to be dealt with more on an ethical plane. Similar instances can occur in their dealings with the superiors as well. Many issues that have high ethical implications often go unnoticed. This means that middle level supervisors need to be sensitized about ethical issues that can arise in the workplaces.

Basic Tenets of Bioethics

Be in healthcare provision or in research involving human participants, the leading principles in Bioethics remain the same. 'It could be summarized in four simple terms as:

1. Autonomy 2. Beneficence 3. Non-Male ficence and 4. Justice. Autonomy is a very important concept in which we respect the decision making capacity of a competent individual. In the case of healthcare, this often involves decision-making about one's body and often this assumes significance. In the western world where individuals have importance over the families and communities, autonomy assumes added significance. In such 'individual oriented' societies, healthcare providers far more cautious than in other countries like India where the decision-making is often collective and involves not only the individuals but also their families and even the

574 community. In such circumstances, the provider has the added responsibility to see to it

that the interests of the individual is not being neglected. Moreover, the principle of beneficence also stresses that some benefits needs to be accruing to them. From the principle of autonomy evolved the concept of "Informed Consent". Informed decision making at all levels of healthcare is a must and providers can easily land up in trouble if the 'clients' are not taken in to confidence and if their interests are not safeguarded. Sometimes it may look odd to the provider that the beneficiary is refusing to accept some intervention that could be lifesaving. For example, a Jehovah Witness who refuses to accept blood transfusion could be a puzzling dilemma to a providers who knows that the only way to save the life of the patient is a transfusion. But our experience tells that even courts have often upheld the decisions of such individuals and found fault with the providers who have proceeded against the wishes of the patient. In the case of health workers this could be even more troubling. For example, a sputum positive Pulmonary Tuberculosis patient refusing to accept DOTS can present such a dilemma. Our public health awareness tells us that if the person is in a public health hazard and need to be taking medications not only, for his improvement but also to protect others from contracting TB from him/her. When the person refuses to take treatment, our public health awareness will sound a word of caution and we will argue strongly for the treatment. But the principle of autonomy tells us that the person's decision need to be given due weight and still we need to give sufficient information to them 'as Informed Refusal' is equally important as 'Informed Consent'. But the golden rule in public health reminds us that' private rights cease where public harm begins'. If that is the case what are we going to do? Are we going to accept the autonomous decision making capacity of the individual and going to let the patient go spreading the dreaded disease or are we going to inform the authorities, restrain the patient or even confines him and forcibly put him under medications against his/her will? Such questions often are very difficult to address. The principle of Beneficence tells us that whatever we do, should need to be in the interest of the public. This again is the guiding principle of public health. But, one has to remember that several public health interventions that have very high significance and benefit at the 'macro level' may not be that perceptible to the individuals who are to

575 practice them. The best example is provided in the case of using helmets and seat-belts. The chances of any individual who use either of these to meet with an accident and get a

benefit out of them is very meager and hence the individuals may not perceive the good effects of these interventions whereas the benefits accrued to the society in terms of lives saved and morbidity averted is very high and often not noticed by the individuals . This 'preventive paradox' is really a dilemma in public health and leads to ethical issues. Legal enforcement of such public health measures are likely to be resisted ( as we have seen in the case of helmets in Kerala) and these will have to be addressed from a public health point of view with high importance to health education and awareness generation. Though the principle of beneficence is very evident in clinical practice and curative medicine, it is not that evident in the case of public health. The principle of Non-maleficence could broadly be summarized as 'do no harm' and the basic idea is not to inflict harm even if we are not able to provide benefit of any sort. Interventions of dubious benefit or those which are likely to do harm need to be avoided and health workers in the field need to be doubly aware of such aspects. For example when we are advocating a new intervention over an old one it becomes our moral obligation to closely watch it and even in the slightest suspicion of the new intervention causing some harm or not fetching the sort of benefits like that of the older one, the provider is morally bound to stop the intervention and let the people know the real facts about both. In this context the element of autonomy will also play a role as the individuals will have to make an informed choice. The principle of Justice in ethics has a different meaning than that in law. Justice in ethics speaks of equitable distribution of resources and also about fairness in allocation. Many public health interventions are based on this principle of justice. With the resources necessary to provide a second bone marrow transplant to a child suffering from Leukemia, a public health person may opt for a cheap public health intervention like ORS which might save thousands of lives. Though from an individual's point of view the former is the better option, one might not accept the same from the point of view of an equitable distribution of scarce resources. From the foregoing discussions it is evident that ethical issues are very important in healthcare provision. Awareness about basic ethical principles will go a long way in

576 identifying them and continuous updating of healthcare providers will lead to a situation where they will be able not only to identify them but also address them to a significant- extent.

Chapter - 32 VITAL STATISTICS

VITAL STATISTICS 70.0 Life Expectancy at birth (Male) (in years) Health Information Cell, Directorate of Health Services,2004 73.62 Life Expectancy at birth (Female) (in years) Health Information Cell, Directorate of Health Services,2004 1.96 Total Fertility Rate (per woman) NFHS 2. 1998-1999 1058 Sex Ratio (females per 1000 males) Economic Review 2003, Government of Kerala Total 16.9 Birth Rate (per 1000 population) Rural 17.0 Urban 16.4 Sample Registration System Bulletin April 2004 Total 6.4 Death Rate (per 1000 population) Rural 6.4 Urban 6.2 Sample Registration System Bulletin April 2004 Total 10.5 Natural Growth Rate Rural 10.6 Urban 10.2 Sample Registration System Bulletin April 2004

577 SOCIO-ECONOMIC PROFILE 90.86 Literacy Rate (total) (%) Health Information Cell, Directorate of Health Services,2004 87.72 Female Literacy rate (%) Health Information Cell, Directorate of Health Services,2004 .0.638 Human Development Index 2001 Manorama Year Book, 2003 15.3 Female workers participation rate (%) Economic Review 2003, Government of Kerala 31 Suicide Rate (per lakhs year) Economic Review 2003, Government of Kerala 65.95 Total number of Households 2001, Lakhs Economic Review 2003, Government of Kerala 17.23 Number of Families below poverty line 2003, lakhs Economic Review 2003, Government of Kerala Radio 66 Mass Media percentage of households Cable TV 6.8 Economic Review 2003, Government of Kerala News paper (% 6.2 Population) 19.93 Human Poverty Index 1991 Manorama Year Book 2003

578 HEALTH STATUS 10 Infant Mortality Rate (per 1000 live births) Sample Registration System Bulletin April 2004 1.01 Under – 5 Mortality Rate Health Information Cell, Directorate of Health Services, 2004 8.5 Neo-natal Mortality Rate (1998) Health Information Cell, Directorate of Health Services, 2004 80 Maternal mortality rate (per 100,000 live births) Health Information Cell, Directorate of Health Services, 2004 94.1 Deliveries assisted by a health professional (%) NFHS 2, 1998-1999 93 Hospital Deliveries (%) Economic Review 2003, Government of Kerala 7480 Number of public and private hospitalization per lakhs Economic Review 2003, Government of Kerala

579 HUMAN POWER 3271 Number of Doctors in Health Services Department Health Information Cell, Directorate of Health Services, 2004 5529 Number of JPHN Health Information Cell, Directorate of Health Services, 2004 3457 Number of JHI Health Information Cell, Directorate of Health Services, 2004 936 Number of LHI Health Information Cell, Directorate of Health Services, 2004 876 Number of HI Health Information Cell, Directorate of Health Services, 2004 158 Number of LHS Health Information Cell, Directorate of Health Services, 2004 161 Number of HS Health Information Cell, Directorate of Health Services, 2004 Total 5167 No of Doctors in Public Health Care Institutions DHS 3271 Economic Review 2003, Government of Kerala Medical 1342 Collage ESI 554 6162 Doctor Population Ratio Public 2305 Doctor Population Ratio (Private and Public) Health Information Cell, Directorate of Health Services, 2004

580 HEALTH INFRASTRUTURE TOTAL 13 Number of Medical College Hospitals(MCH) Government 5 Co-Operative 2 Economic Review 2003, Government of Kerala Private 6

Number of Dental Collages TOTAL 9 Government 3 Economic Review 2003, Government of Kerala Private 6 Number of District Headquarter Hospital 14 (This includes General Hospitals situated at District Head Quarters also) Number of Total Allopathic Hospitals 1273 Health Information Cell, Directorate of Health Services, 2004 Number of Community Health Centres (CHC) 115 Health Information Cell, Directorate of Health Services,2004 Number of Primary Health Centres (PHC) 944 Health Information Cell, Directorate of Health Services, 2004 Number of sub-centres (SC) Health Information Cell, 5094 Directorate of Health Services, 2004

HEALTH FINANCING Total health expenditure (Medical, Public health and As % of 3.92 Family Welfare) budget

581 Demand for Grants and Detailed Budget Rs. In 10173 Estimates 2004-2005. Government of Kerala Millions Total Budget for Kerala (Voted + Charged) Rs. In 259136 Millions Demand for Grants and Detailed Budget Estimates 2004- 2005. Government of Kerala Average Total Expenditure (Rs) per hospitalization 1927 (Private & Public) Economic Review 2003, Government of Kerala Per capita public health expenditure (Rs) 132 Economic Review 2003, Government of Kerala

Per capita income at current prices (Rs) 2002-03 11388 Economic Review 2003, Government of Kerala Net State Domestic Product (2002-2003) crore 226688 Economic Review 2003, Government of Kerala

OTHER SYSTEMS OF HEALTH CARE

No of Ayurveda Collages 11 Economic Review 2003, Government of Kerala No of Homeopathy Collages 5 Economic Review 2003, Government of Kerala No of Ayurvedic Institution, Public 945 Economic Review 2003, Government of Kerala No of Homeopathy Institutions, Public 557 Economic Review 2003, Government of Kerala

WATER, ENVIRONMENT & SANITATION

Households having access safe drinking water 2001(%) 23.39 Economic Review 2003, Government of Kerala Households with toilet/latrine facility in 2001 (%) 84 Economic Review 2003, Government of Kerala

582 ENERGY, TOURISM, INFRASTRUCTURE

Total Energy Generation (MW) 2038 Economic Review 2003, Government of Kerala Energy Consumption per capita (Units) 392 Economic Review 2003, Government of Kerala Households with electricity 2001 (%) 70.3 Economic Review 2003, Government of Kerala Earning from Tourism 2002 (Crore) 705.67 Economic Review 2003, Government of Kerala Total number of vehicles in the state 2003 (Lakhs) 25.52 Economic Review 2003, Government of Kerala Accident rate per 1000 vehicles 15 Economic Review 2003, Government of Kerala Road Traffic Accident 2002-2003 Total 38967 Death 2839 Economic Review 2003, Government of Kerala Injuries 49450 Telephone Density 2003 per 100 population 10.6 Economic Review 2003, Government of Kerala

Edited by Dr K Sandeep Technical Secretary, Sector Reform Cell Directorate of Health, Trivandrm Email

Chapter - 33 FERTILITY-RELATED STATISTICS

Fertility may be measured by a number of indicators, as given below. Stillbirths, foetal deaths and abortions, however, if are not included in the measurement of fertility in a population. 1. Birth Rate Birth rate is the simplest indicator of fertility and is defined as "the number of live births per 1000 estimated mid-year population, in a given year". It is given by the formula: Number of live births during the year x 1000

583 Birth Rate = Estimated mid-year population The birth rate is an unsatisfactory measure of fertility because the total population is not exposed to child bearing. Therefore it does not give a true idea of the fertility of a population. 2. General Fertility Rate (GFR) It is the "number of live births per 1000 women in the reproductive age-group (15-45 years) in a given year". Number of live births in an area during the year x 1000 GFR = Midyear female population age 15-45 in the same area in same year General fertility rate is a better measure of fertility than the crude birth rate because the denominator is restricted to the number; of women in the child.-bearing age, rather than the whole population. The major weakness of this rate is that not all women in the denominator are exposed to the risk of childbirth. 3. General Marital Fertility Rate (GMFR) It is the number of live births per 1000 married women in the reproductive age group (15-45) in a given year. 4. Age-specific Fertility Rate A more precise measure of fertility is age-specific fertility rate, defined as the "number of live births in a year to 1000 women in any specified age-group". The age-

specific fertility rates throw light on the fertility pattern. They are also sensitive indicators of family planning achievement. 5. Age-specific Marital Fertility Rate It is the number of live births in a year to 1000 married women in any specified age group. 6. Total Fertility Rate (TFR) Total fertility rate represents the average number of children a woman would have if she were to pass through her reproductive years bearing children at the same rates as the

584 women now in each age group. It is computed by summing the age-specific fertility rates for all ages. 7. Total Marital Fertility Rate Average number of children that would be born to a married woman if she experiences the current fertility pattern throughout her reproductive span. 8. Gross Reproduction Rate (GRR) Average number of girls that would be born to a woman if she experiences the current fertility pattern throughout her reproductive span, assuming no mortality. 9. Net Reproduction Rate (NRR) Net Reproduction Rate (NRR) is defined as the number of daughters a newborn girl will bear during her lifetime assuming fixed age -specific fertility and mortality rates. NRR is a demographic indicator. The present level of NRR in India is 1.5 (1990). NRR of 1 is equivalent to attaining approximately the 2 -child norm. If the NRR is less than 1, then the reproductive performance of the population is said to be below replacement level. The Govt. of India in 1983 adopted the policy of attaining a NRR of 1 by the year 1996 (now to be achieved by 2006). Demographers are of the view that the goal of NRR = 1 can be achieved, only if at least 60 per cent of the eligible couples are effectively practicing family planning. 10. Child-woman Ratio It is the number of children 0-4 years of age per 1000 women of child-bearing age, usually defined as 15-45 years of age. This ratio is used where birth registration statistics either do not exist or are inadequate. It is estimated through data derived from censuses.

11. Pregnancy Rate It is the ratio of number of pregnancies in a year to married women in the ages 15-45 years. The 'number of Pregnancies" includes all pregnancies, whether these had terminated as live births, still -births or abortions or had not yet terminated. 12. Abortion Rate The number of all types of abortions, women of child-bearing age. 13. Abortion Ratio

585 This is calculated by dividing the number of abortions performed during a particular time period by the number of live births over the same period. 14. Marriage Rate It Is the number of marriages in the year per 1000 population Crude Number of marriages in the year x 1000 Mid-year Population consider this a very unsatisfactory rate, Comprised primarily of population A more sensitive rate is the general usually per 1000 marriage rate General Number of marriages within one year Marriage = x 1000 Rate Number of unmarried persons age 15-49 years This rate is more accurate when computed for women than for men because more men than women marry at the older ages.

Fertility trends

Researches indicate that the level of fertility in India is beginning to decline. The crude birth rate which was about 49 per thousand population during 1901-11 has declined to about 31.3 per thousand population in 1991, and 25 per thousand population in 2002.

There are considerable inter-state variations in fertility trends. It is significant that at least ten states/UT have achieved net replacement levels. The examples are Kerala, Tamil Nadu, Goa, Delhi, Chandigarh, Mizoram etc. 14 states / UT have a total fertility rate of more than 2.1 but less than 3.0, e.g., Orissa, Karnataka, Andhra Pradesh, Maharashtra, Gujarat, Punjab, West Bengal, Himachal Pradesh etc. However, there are 9 states / UT that have a total fertility rate of over 3.0. They are Bihar, Uttar Pradesh, Madhya Pradesh, Haryana, Assam, Rajasthan etc.

Chapter - 34 HEALTH INDICATORS OF KERALA

Indicator Unit (Year & Source) POPULATION Population Total 31841374

586 (Census 2001) Male 15468614 Female 16372760 Population Density (Person per sq. km) 419 (Census 2001) Male population (%) 48.58 (Census 2001) Estimated Urban Population Total 8266925 (Census 2001) (%) 25.96 Scheduled Caste population Total (Census 2001) (%) Scheduled Tribes population Total 3123941 (Census 2001) (%) 1.14 Sex ratio (Census 2001) 1058 0-6 age group Total 3793146 (Census 2001) Male 1935027 Female 1858119 Disabled persons Total 860794 (Census 2001) Male 458350 Female 402444 Seeing 334622 Speech 67066 Hearing 79713 Movement 237707 Mental 141686 Household size 4.7 (Census 2001) Population above 60 years in 2001 (%) 15 Economic Review 2003

Geography Position of Kerala Longitude 80 17’ 30’’ N 210 47’ 40’’ N Latitude 740 51’ 57’’ E 770 24’ 47’’ E Geographical Area (sq km) 38863

587 High land Sq km 18654 (Manorama Year book 2003) % 48 Mid land Sq km 16230 (Manorama Year book 2003) % 41.76 Costal area Sq km 3979 (Manorama Year book 2003) % 10.24 Costal length km 580 Road length km 125835 (Manorama Year book 2003)

Political Districts 14 Taluks 63 Panchayat 991 Blocks 152 Revenue village 1452 City corporation 5 Municipalities 53 (Health Information Cell, Directorate of Health Services,2004)

Chapter - 35 MAINTENANCE OF RECORDS, REPORTS AND REGISTERS

Learning objectives: With the help of this unit, you should be able to:

588  Explain the importance of records to be maintained and reports to be prepared at all the sub-centres.  Describe the official records to be maintained and the reports to be submitted under RCH Programme at the sub-centre level.  Explain the guidelines to be used for maintaining up-to-date records.  Explain what is surveillance, why it is important and your role in surveillance procedure.  Describe the information to be provided in monthly reports and prepare the reports in the formats , prescribed under RCH programme.

 Use these reports In assessing your own, performance.

CONTENTS:

Records Definition Criteria of good records Importance of records Registers to be maintained Guidelines for maintaining these registers Reports Definition Monthly progress report Reporting formats INTRODUCTION:

This unit would help you understand the importance of maintenance of records and storage of information at subcentres. With this programme, you are supposed to ensure development of an Action Plan, estimation of workload, estimation of demands and assess performance of the Health Worker (Female). In order to perform these activities you have to maintain accurate records. Accordingly, this unit provides guidelines for recording and storing information appropriately. A list of all the registers to be kept up-to-date is also given. This unit would also help you to develop skills in preparation and maintenance of reports at subcentres. Preparation of monthly reports in the format provided and prescribed by the Government of India would be explained. These reports are required to be submitted to PHC by 15th of the every

589 next month. A copy of the format including the information to be supplied is also attached at the end of this unit.

RECORDS:

Records are usually data or written information kept in daily diary, note-books, registers, cards etc. Records consist of information on work done, health status of the community members, in general and also of individuals in particular. Records are also essential for administrative matters such as maintenance of accounts of supplies received and items' used in rendering services in various sub-centre area.

Records should be: Accurate, accessible available when needed and contain - information that is useful for assessments - and making decisions regarding future actions. Hence, records of different services provided need to be maintained at sub- centres. Though there Is wide variation from State to State regarding the registers expected to be maintained at sub-centre, the registers listed below are essential for effective implementation of the RCH programme at the most peripheral level.

Registers Needed to be Maintained at Sub-centres

1. Village records register 2. Household survey register 3. Eligible couple register

590 4. MCH register & immunization card - Maternal Care - Birth - Newborn & Child - Care 5. Registers for recording contraceptives a. Condom distribution b. Oral pill register c. Cu 'T'/IUD register d. Sterilization Male Female 6. Sub-centre clinic register 7. Death register 8. Registers for recording meetings held for consultative process 9. Stock register 10. Referral register, and a duplicate copy of the monthly report submitted for each month 11. Daily diary General Guidelines for Maintaining Records at the Sub-centres by the Female Health Workers: You as the Health Assistant (Female) have to ensure that: 1. Information is entered in the proper place (register/form) - for example, in the particular column in the appropriate register. 2. Information is written down immediately as soon as possible and is not deferred for some other time day. Results are delayed in incomplete and inaccurate records, as one is likely to forget the event. 3. Records are brought up-to-date and avoid letting them piled up. Spend about half an hour at the end of your day so as to check that the records have been entered with all the information regarding that day's work. 4. Records are entered clearly and neatly. It should be legible, otherwise it will be of no use either to you or to your supervisors. 5. Records are entered in order. Also ensure that all the registers are arranged either in alphabetical or numerical order (give a number to each register).

591 6. All the registers are kept in cupboard, dusted regularly and protected from cockroaches, rats-and termites. 7. Do not let unauthorised person to read the records. These should be treated as confidential. 8. An adequate stock of stationary is maintained, registers and all the forms needed to be filled and submitted. 9. All the old records (i.e. more than 5 years old) are to be destroyed.

1. Village Records:

You have to ensure that this register is maintained to store the information regarding an overall picture of each village covered under the sub-centre area. This should record information, on items listed below:  Number of households (a household is defined as consisting of those family members having a common kitchen).  The population of each village.  The population distribution according to age and sex.  Number of Anganwadi centres with the name and address of AWWS.  Number of private practitioners (Allopathic, Ayurvedic, Homoeopathic, RMP etc.).  Dais in each village (Name and Address).  Schools - location.  Panchayat Bhawan - Name and Address of Sarpanch. M.S.S/Mahila Mandal members.  Voluntary Organisation, if any.  Number of deep hand-pumps installed.

2. Household Survey Register:

You have to ensure that the information regarding each and every household are collected during household survey. After the initial survey, it should be revised every three years.

3. Eligible Couple Register:

592 Under your supervision, the Health Worker (Female) has to identify the number of couples where the wife's age is between 15-45 years from household survey register and enter in this register with address. The family status with parity and age of the youngest child should also be mentioned. The couple if using any contraceptive also need to be recorded along with the details of contraceptive methods being used.

4. Sub-Centre Clinic Register:

You must make sure that this register is maintained for keeping records of patients attending the sub-centre clinics. The attendance in ante-natal, immunization, family planning clinics should not be recorded in this register.

The following columns are essential for this register:

Medicines Sl. No Date Name & Address Complaints Remarks given

5. Death Register:

You must ensure that the Health Worker (Female) enters all deaths occurring in the area covered by her sub-centre. The items of information to be recorded should include:

• Date of death, • Name and address, • Age (years/months/days), • Sex, and

• Cause of death.

7. Stock Register:

593 Records of particulars related to all items provided and utilised at sub-centres should be maintained.

8. Register for Recording Consultative Process:

You have to supervise the meetings with village working team constituted for each village and with other members of group of that village. You should ensure recording the details of each meeting in this register. The following information needs to be entered:

Month/ Year Date & Time Venue/Place Members Items of holding the attended discussed meeting

9. Referral Register:

You have to ensure that the details of all referred cases should be entered in this register. This will also help you to undertake follow-up of the referrals made.

Date Name & Address Ag Se Complaint Reasons for Referred Follow up e x s referral to actions taken 1 2 3 4 5 6 7 8

594 10. Daily Diary: You must maintain a daily diary to record all the items of importance in which you will record the daily activities performed in the field as well, as at the clinic with regard to immunization, antenatal check-up and follow-up, distribution of contraceptives, follow up of IUD and OP cases, identification of PID, RTI/STI cases, birth and deaths reported, malaria cases etc. The meetings conducted with the village working team and with the group of village representatives should also be mentioned in this diary.

This daily diary will enable you to up-date all the registers to be maintained and will also be helpful in preparation of monthly report. While visiting houses, you cannot carry all the registers but can always keep the daily diary easily, which can be used for reference.

REPORTING:

The performance or output of services rendered by the Health Worker (M&F) are reported in the formats prescribed to this effect. This information is communicated from the lowest to highest level of health services. These reports can be used as important management tools for assessment of quantity as well as quality of services provided at PHC and its sub-centre levels. These reports are also helpful for making decisions regarding future actions. You should be able to make out from this information whether you have been able to provide all the required services as planned or not. If not, then you should be able to find out the, reasons for not being able to do these and then take action so that you can do it better in the next month.

With regard to RCH programme, you are supposed to ensure preparation of a monthly report at the completion of each month in the format provided by Government of India and submit it to MO (PHC) by 15th of the next month. In this format, there are five columns for entering information against each service. These include: i. Performance in Corresponding Month of Last Year:

595 Performance of that particular month which is being reported during the previous year should be entered in this column. For e.g. If you are preparing the monthly report for June 2005, then you must ensure that the Female Health Worker enters the total number of ANC, registrations done during June 2004 in this column against total ante- natal cases registered. The number of these registrations done before 12 weeks of pregnancy will be in the next line. ii. Performance in the Reporting Month:

How much is done in this particular month should be reported in this column. As per above example - you have to ensure that entry of the total number of ante-natal cases registered in the month of June 2005 is in this column and the number of less than 12 weeks of pregnancy registered in June 2005 in the next line. iii. Cumulative Performance Till Corresponding Month of Last Year:

As the year starts from the month of April every year, cumulative performance should be calculated from the month of April every year. Hence, in this report you have to ensure that the Health Worker (Female) enters total number of ante-natal cases registered in the months of April, May, and June in 2004 in this column. iv. Cumulative Performance Till Current Month:

Under your supervision the Health Workers have to enter the total number of registration done in the months of April, May and June of 2005 in this column.

V. Planned Performance in Current Year:

The total number of ante-natal mother expected which the health workers have estimated through CNA and submitted in Annual Sub-centre Action Plan should be entered in this column.

596 You are advised to keep a duplicate copy of each monthly report submitted to PHC. You should ensure that filing of all these copies are done serially in a file so that these can be retrieved easily whenever needed for reference.

RECORD KEEPING FOR DISEASE SURVEILLANCE:

Surveillance assumes great importance under RCH Programme. OPD registers provide important information to the Health Assistant (Female) regarding various diseases under surveillance and also while visiting the community, she may come across certain disease patterns. Hence accurate record keeping is very essential.

Surveillance can be of two types - active or passive. Passive surveillance is usually done by means of accurate record keeping.

What is Surveillance ?

Surveillance is defined as regular collection and analysis of prevalent mortality as well as morbidity pattern and other health related important events occurring in a given community setting as being reported by the peripheral health workers to higher authorities of health and family welfare department so that the decisions on Management of Changes' occurring at community level could be taken in advance. However, such decision making would be possible only when the Health Workers report the events timely and with certain degree of accuracy.

The dictionary meaning of surveillance is 'close watching' on regular basis. Hence, it is not one time activity to be performed by you. Rather, it is a continuous process requiring your attention throughout the year and even year after year. The information coming to you in this regard by direct, indirect and even from discrete sources is important and you must report the same after preliminary verification.

You have to ensure that the Health Worker (F) along with the Health Worker (M) being responsible to cater the felt needs of health and family welfare services in an area of sub-centre regularly, reports the mortality and morbidity among all age groups of the community. However, you are to be more vigilant about the mortality and morbidity

597 amongst mothers and children under five years of age who happen to be vulnerable group of our society. Generally, such information/data are collected and submitted as a part of the regular monthly reports and the health workers to the concerned MO PHC. Thus, this activity is already being performed by you and this is nothing but surveillance. However, in case of any incidence of AFP or any other vaccine preventable disease, you must inform the MO (PHC) immediately without any delay.

Why Surveillance is Important?

The basic aim of health services rendered through health personnel of various grades and skills is to reduce the sufferings of women and children by providing treatment so as to reduce the chances of mortality. It is, therefore, essential to examine the occurrence of diseases or death for introducing preventive measures whenever possible. The regular collection of number of cases of various conditions, diseases and deaths occurring amongst those areas of the sub-centre, will enable you. to check whether the mortality and morbidity pattern of such, disease is increasing or decreasing over a period of time.

Similarly, detailed investigations on unusual number of deaths or occurrence of certain complaints/diseases can provide information on causes or the circumstances under which such events have occurred and thereby identify steps to be taken for preventing them in future.

Further, regular and complete reporting of the total number of deaths from a particular complaint/disease gives you a true picture about the size and magnitude of the problem.

Conditions/Diseases Expected to be Reported.

Conditions/diseases against which specific activities (i.e. prevention and management) are undertaken under RCH programme include the following:

• Vaccine Preventable Diseases viz., Diphtheria, Pertussis, Tetanus, Poliomyelitis, Measles, Neonatal Tetanus and childhood Tuberculosis, • Diarrhoeal diseases among children, • Acute Respiratory Infections/Pneumonia among children, • Maternal deaths, deaths among children under five years,

598 • Reproductive Tract Infections among women etc., and • Acute Flaccid Paralysis (AFP)-Routine and immediate reporting.

Sources of Information on Diseases and Deaths:

This information can be collected/compiled from the sources mentioned below: 1. Clinic Records/Clinic Register: As mentioned earlier, the health workers have to maintain a clinic register (i.e. OPD register) for the clinics conducted. Cases of diseases, mentioned above, when reported at sub-centre clinic, you must ensure that their name, age, sex and the diagnosis is entered in the clinic register. At the end of each month, these cases can be counted and reported to you or to the PHC. 2. Information from Community: You must ensure that the health workers also get information on these conditions directly during the course of home Visit. They must record such events in their daily diary and report the same at the end of each month or even earlier depending upon urgency of the matter. You can also ensure that the Health Worker (Female) obtain information on such events from identified informants in the community like village dais, Anganwadi Workers or village leaders whom Health Worker (Female) can specifically orient for this purpose. There are a few important points in the process of supervising the Health Workers that you should remember about identifying and recording of diseases and deaths: Firstly, it is important to identify that these events are recorded correctly. For this, simple definitions of these common conditions have been worked out. Secondly, you have to ensure that double counting is avoided: if a child makes two visits to the clinic for the same episode of disease count it as one case only. Thirdly, you must make sure that only those cases are counted, which are confirmed. Count the cases reported by the informants separately and report them

only after the Health Workers have confirmed the condition as per the definition already provided.

599 Fourthly, a specific time-frame needs to be kept for reporting e.g., one week/two weeks. Ensure that cases occurring and reported during this period are counted only and those cases are not included that occurred outside this time-frame.

Remember that correct, complete and regular reporting of events mentioned above is extremely important for understanding the true situation in the community and to help higher authorities to initiate appropriate corrective actions. Non-reporting, under- reporting and over reporting of events can lead to either wrong actions or no action. This may affect the health situation in a community adversely.

Key Points

 Ensure that all records are kept accurately, are accessible and available when needed.  Make sure that all registers should be maintained up-to-date.  Use information recorded in registers for assessment of quantity as well as quality of services provided and also for preparation of future action plan.

 Ensure preparation of monthly report in the format prescribed by the 15th of the next month and keep a duplicate copy of the same at sub-centre.

Registration of Births and Deaths:

Reliable estimation of population, births, deaths and other vital events in the community is an important component in planning the health service delivery at community level. This helps us to assess the impact of various interventions of the RCH package and also estimating the service needs at various levels. It is, therefore, important that data collected and compiled by the civil registration system is used effectively (which contain data on all the vital events including births, still births and deaths etc.) on a continuous basis. In the system, in most of the States the notifiers include health functionaries, who would be using this data for their planning of day to-day work. The following formats are to be filled on receiving information of any live birth, still birth and death in your own area. The different forms are given below:

600 FORM NO 2 LIVE BIRTH REPORT SerialNo. ______Registration Unit/Village/Taluk/Tehsil/Block/Thana/Distt______Town/Municipality ______1. Date of Birth 2. Sex Male/Female 3. Name of Child 4. Place of birth 5. Permanent residential address 6. Father's

i. Name

ii. Literacy

iii. Occupation

iv. Religion

1. Mother's i. Name ii. Literacy iii. Occupation iv. Religion 8. Age of mother in completed years at confinement 9. Order of birth (Number of live births including the birth registered) 10. Type of attention at delivery 11. Informant's i. Name ii. Address Date……………. Signature or left thumb mark of the informant

601 FORM NO. 3 STILL BIRTH REPORT Serial No. ______Registration,Unit/Village/Taluk/Tehsil/Block/Thana/Distt ______Town/Municipality ______1. Date of Birth 2. Sex Male/Female 3. Place of birth* 4. Permanent residential address 5. Father's

v. Name vi. Literacy vii.Occupation viii. Religion 6 Mother's v. Name vi. Literacy vii. Occupation viii. Religion 7. Age of mother in completed years at confinement 8. Type of attention at delivery + 9. Informant's i. Name ii. Address Date……………. Signature or left thumb mark of the informant

* If the delivery took place in hospital or any (their institution, write "hospital" or "institution" giving its name, otherwise give full address of the place of birth.

+ If the delivery was conducted in a hospital or maternity home, write the name of institution and mention whether it was conducted by a qualified or unqualified midwife and give her name.

602 NOTE: 1 In the case of illegitimate birth the word "illegitimate" should be entered in the remarks column and no person's name should be entered as the father, unless there is a joint request of the mother and the person be enter acknowledging himself to be father of the child. 2. In the case of multiple births make separate entry for each and a reference in the remarks. 3. If the person is a non-worker insert the word "Nil" in the column for occupation.

603 FORM NO 4 DEATH REPORT Serial No ______Registration Unit/Village/Taluk/Tehsil/Block/Thana/Distt______Town/Municipality______1. Date of Death 2. Full Name of deceased 3. Place of death 4. Name of father/husband 5. Age 6. Sex: male/Female 7. Marital status 8. Occupation 9. Religion 10. Nationality 11. Permanent Residential Address + 12 *Cause of death 13 Whether medically certified (Yes/No) 14 Kind of medical attention received, if any 15 Informant’s i) Name ii) Address

Date……………. Signature or left thumb mark of the informant

+ The address of the parent, in the case of a child, husband/late husband in the case of married women/widow and deceased if independent, is to be given in this column.

604 *Where the cause of death is medically certified the cause marked in the medical certificate form no. 8/8A is to be entered here.

NOTE: 1 If the deceased was over one year of age, give age in completed years. If the deceased was under one year of age give age in completed months and if below one month give age in completed number of days and if- below one day in hours. 2. If the person is a non-worker, insert the word 'Nil' in the column for occupation.

605 (To be submitted by the 15th of the following month to PHC)

FORM 6

MONTHLY REPORT FOR SUB-CENTRE/Jr.P.H.N/Jr.H.I

General Information

1. State: ______

2. District: ______

3. PHC: ______

4. Sub-centre: ______

5. Population of PHC: ______

6. Population of Sub-centre: ______

7. Reporting for the month of : ______

8. Eligible Couples (as on 1st April of the year): ______

76 SOME IMPORTANT POINTS TO BE RECORDED

Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance S.N Services month of last month corresponding current month incurrent year year month of last year 1 Ante-Natal care 1.1 Ante-natal cases Registered a) Total b) Less than 12 weeks 1.2 No. of pregnant women who had 5 check-ups 1.3 Total no. of high risk pregnant women referred 1.4 No. of TT doses a) TT 1 b) TT 2 c) Booster 1.5 No. of pregnant women under treatment for anaemia 1.6 No. of pregnant women given prophylaxis for anaemia

2 Natal care 2.1 Total No. of deliveries 2.2 Home deliveries a) (i) by Jr.P.H.N (ii) by LHV b) By trained birth attendant c) Untrained birth attendant

77 Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance S.N Services month of last month corresponding current month incurrent year year month of last year 2.3 Deliveries at Sub-centre 2.4 Complicated deliveries referred to PHC/FRU

3. Maternal Deaths 3.1 During pregnancy 3.2 During delivery 3.3 Within 42days of delivery

4 Post Natal Care 4.1 No. of women given 3 post-natal check-ups 4.2 Complication referred to PHC/FRU

5 RTI/STI 5.1 Cases a) Detected b) Treated c) Referred

78 Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance S.N Services month of last month corresponding current month incurrent year year month of last year 6 Pregnancy Outcome M F M F M F M F M F 6.1 a) Live births b) Still births 6.2 Order of Birth a) 1st b) 2nd c) 3rd 6.3 Newborn status at birth a) Less than 2.5 kgs b) 2.5 kgs or more c) No. of high risk newborns referred to PHC/FRU M F M F M F M F M F 7 Immunization 7.1 Infant 0 to 1 year BCG DPT 1 DPT 2 DPT 3 OPV0 OPV1 OPV2 OPV3

79 Measles

S.N Services Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance month of last year month corresponding current month incurrent year month of last year 7.2 Children 1 ½ years DPT Booster OPV Booster 7.3 Children 5 years DT. M F M F M F M F M F 7.4 Children 10 year TT 7.5 Children 16 years TT 7.6 Adverse reaction reported after immunization 8 Vitamin A administration (9 months to 3 years) Dose 1 Dose 2 Dose 3 Dose 4 Dose 5

80 Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance performance S.N Services month of last year month corresponding till current incurrent month of last month year year M F M F M F M F M F 9 Childhood Diseases 9.1 Vaccine preventable diseases a) Diphtheria i) Cases detected ii) Treated iii) Referred iv) Deaths b) Poliomyelitis (AFP) i) Cases detected ii) Treated iii) Referred iv) Deaths M F M F M F M F M F 9.2 c) Neo Natal Tetanus i) Cases detected ii) Created iii) Referred iv) Deaths d) Measles i) Cases detected ii) Treated iii) Referred

Performance in Performance Cumulative Cumulative Planned

81 corresponding in the performance till performance performance S.N Services month of last reporting corresponding till current incurrent year month month of last month year year 9.3 ARI under 5 years (Pneumonia) a) Treated with Cotrimoxozole b) Referred to PHC/FRU c) Deaths 9.4 Acute diarrhoeal diseases under 5 years a) Treated with ORS b) Referred to PHC/FRU c) Deaths

10 Child Deaths a) Within 1 week b) 1 week to 1 month c) 1 month to 1 year d) 1 year to 5 years

Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance

82 S.N Services month of last month corresponding current month incurrent year year month of last year 11. Contraceptive Service 11.1 Eligible couples contacted

11.2 Male Sterilisation a) Total no. of case motivated and done b) No. of cases followed up Female sterilization a) Total no. of cases motivated and done b) No. of cases done 11.4 Total IUD insertions a) Cases followed up b) Complication c) Discontinued i) Removed ii) Expelled 11.5 Total Oral Pillusers a) Old Users b) New Users c) Complications d) Discontinued 11.6 Total condom users

Performance in Performance in Cumulative Cumulative Planned

83 corresponding the reporting performance till performance till performance S.N Services month of last month corresponding current month incurrent year year month of last year 12 Abortions a) No. of women referred for MTP b) No. of MTP done c) Cases followed up d) Complications e) Deaths 13 Communicable Diseases 13.1 Malaria a) No. of fever identified b) No.s of blood smear slides sent to PHC c) No. of fever cases given presumptive treatment d) No. of positive cases of malaria e) No. of positive cases given radical treatment f) No. of anti-mosquito activities co-ordinated g) No. of high risk villages identified

Performance in Performance in Cumulative Cumulative Planned corresponding the reporting performance till performance till performance S.N Services month of last month corresponding current month incurrent year

84 year month of last year 13.2 Tuberculosis a) No. of suspected cases i) Identified ii) Referred b) No. of sputum positive cases c) No of TB cases followed up.

IV Interaction with Community

Serial No Meeting with No. of Meetings 1. Panchayat Health Committee 2. Mahila Swasthya Sangh 3. Anganwadi Workers

85 V Monthly Stock Position

Sl. Item Opening Received Total Consum Balance Require No Balance ption -ments 1 IFA Large 2 IFA Small 3 Vitamin A 4 Cotrimoxozole 5 ORS Packets 6 Methylergometrine 7 Cholorophenaramine 8 Paracetamol 9 Anti-spasmodic tablets 10 Inj Methylergomet- rine 11 Mebendazole 12 Syringes & Needles 13 Vaccine day carrier 14 Sterilliser – Autoclave 15 Chloramphemicol 16 Centrimide Power 17 Povidone ointment 5% 18 Cotton bandage 19 Contraceptives a) Nirodh b) Oral Pills c) IUDs 20 Disposable delivery kit 21 Chloroquine Tab

Vaccine Received From PHC

86 S.N Name of Vaccine Vaccine Vaccine Vaccine Vaccine Total vaccine received received received received received weekly for for for for session 1 weekly weekly weekly weekly Date/Dose session 2 session 3 session 4 Date/Dose Date/Dose Date/Dose

1. DPT 2. OPV 3. DT 4. TT 5. BCG 6. Measles

Last training attended (mention month and year)

Date of inspection made in reporting month by

(i) Jr.H.I (ii) Jr.P.H.N LHI ______MO (PHC) ______BEE______DMO (H) ______

A note on the progress made as well as the handicap or achievement experienced in the field either because of shortage of essential supplies vaccines or personnel essential to the programme and resistance encountered on account of social and cultural; beliefs.

(Do not use more than this space) Signature ANM

Signature (Male Health Worker)

Chapter - 36

87 PROJECT WORK Objective To enable the participant to acquire practical knowledge Methods a) Field visits b) Assignment Duration : Two weeks A Field visits are to be arranged to 1) Primary health centre 2) Centre for Mentally Retarded children 3) Centre of physically Handicapped 4) Public health laboratory 5) First Referal unit (F.R.U) 6) Hindustan Latex 7) Mental Health Centre 8) Sewage farm 9) Milma 10) Garbage Processing Centre 11) Water purification plant, Aruvikkara 12) A.I.R and Doordarsan (Audio Visuals) B. Assignments can be given to the participants for preparing Essay, Skills, Songs, Villupattu, ottan Thullal, collection of materials (Specimens, Pitures, models) preparing charts, diagrams, slogans, news paper cuttings edditing etc. These assignments should be written in a 200 page note book. Opportunities for attending to special events and observant of special days and other programme organized by the D.H.S or D.M.O, State Department etc many also be utilized. A Written report of their experience should be prepared by each participant.

Chapter – 37

88 SOME IMPORTANT DAYS RELEVENT TO HEALTH

SOME IMPORTANT DAYS January 12 National Youth Day 26 Republic day 30 Anti Leprosy day, Martyr’s day February 28 National Science day March 8 International Women’s day 15 World Disabled Day 21 World Forestry Day April 7 World Health Day 18 World Heritage Day 22 Earth Day May 1 Worker’s Day 8 World Red Cross day 12 Nurses Day 15 International Day of the Family 31 Anti Tobacco day June 5 World Environment day 26 International Day Against Drug Abuse and Illicit Trafficking 27 World Diabetes day July 6 World Zoonoses Day 11 World Population Day August 3 International Friendship Day 1-7 Breast Feeding week 6 Hiroshima Day 9 Quit India Day, Nagasaki Day 15 Independence Day 29 National Sports Day Aug-Sep 25-8 Eye Donation Day 5 Teachers Day 8 World Literacy Day 16 World Ozone Day 21 Alzheimer’s Day 26 Day of the Deaf 27 World Tourism Day 30 Blood Donation Day October 1 International Day for the Eiderly 3 World Habitat Day 4 World Animal Welfare Day 13 U.N.International Day for Natural Disaster Reduction 24 United Nation Day 30 World Trift Day November 10 World Immunisation Day 14 Children’s Day December 1 World AIDS Day 10 Human Rights Day

Chapter – 38

89 EXPANSION OF CERTAIN ABBREVATIONS

LIST OF ABBREVIATIONS AND THEIR EXPANSION

A AFP Acute Falccid Paralysis AIDS Acquired Immuno – Deficiency Syndrome Antenatal Care ANC Auxillary Nurse Midwife ANM Antepartum Haemorrhage APH Acute Respiratory Infection ARI Anganwadi Workers AWW B BBT Basal Body Temperature BCG Bacillus Calmeti Guirein BP Blood Pressure C CHC Community Health Centre CHF Congestive Heart Failure CuT Copper T D DDC Drug Distribution Centre DDK Disposable Dai Kit DPT Diphtheria, Pertussis, Tetanus

E EDD Expected Date of Delivery F FA Folic Acid FRU First Referral Unit FTD Fever Treatment Depost H H.Mole Hydatidiform Mole H/O History of HAF Home Available Fluid Hb Haemoglobin Hg Mercury HIV Human Immunodeficiency Virus HLD High Level Disinfectant HPV Human Papilloma Virus HW (F) Health Worker Female I I/M Intramuscular I/V Intravenous ID Intra Dermal IFA Iron Folic Acid ILRS Ice Lined Refrigerators IP Infection Prevention IUD Intrauterine Device IUGR Intraterine Growth Retardation

90 L LA Lactational Amenorrhoea LMP Last Menstrual Period LSCS Lower Segment Caesarean Section M MLV Malaria Link Volunteer MO Medical Officer MR Syringe Menstrual Regulation Syringe MTP Medical Termination of Pregnancy N NGOs Non-Governmental Organizations NMEP National Malaria Eradication Programme NNT Neonatal Tetanus NSV Non – Scalpel Vasectomy O OC Oral Contraceptives OPV Oral Polio Vaccine ORS Oral Rehydration Salt P P/A Per Abdomen P/V Per Vaginum PHC Primary Health Centre PIH Pregnancy Induced Hypertension PPH Post Partum Haemorrhage PROM Premature Rupture of Membranes R RCH Reproductive and Child Health RTI Reproductive Tract Infections S SC Sub Cutaneous SD Single Dose STD Sexually Transmitted Disease STI Sexually Transmitted Infection T TT Tetanus Toxoid U USG Ultra Sonography UTI Urinary Tract Infection V VDRL Venereal Disease Research Laboratory W VVM Vaccine Vial Monitor

A B C CNA Community Need Assessment

D DWACRA Development of Women and Children in Rural Areas E F

91 H HW(M) Health Worker Male I IPC Interpersonal Communication L M MCH Maternal & Child Health MSS Mahila Swasthya Sangh N O P PLA Participatory Learning for Action R RMP Registered Medical Practitioner S T TBA Traditional Birth Attendant U V

92 ABBREVIATIONS ARSH Adolescent Reproductive and Sexual Health CBO Community Based Organization CP-5 Country Program 5 DPMU District Project Monitoring Unit DHS Director Health Services GBV Gender Based Violence GOI Government of India GOK Government of Kerala ICDS Integrated Child Development Scheme IMR Infant Mortality Rate M&E Monitoring And Evaluation MMR Material Mortality Rate MOV Means of Verification NGOs Non Governmental Organizations NYK Nehru Yuwa Kendra OVIs Objectively Verifiable Indicators PDS Population and Development Strategy PHTS Public Health Training School PRIs Panchayat Raj Institutions PS Panchayat Samitee QA Quality Assurance QOC Quality of Care RH Reproductive Health SIRCH Society for Improvement of Reproductive and Child Health SN Staff Nurse SPMU State Project Monitoring Unit TFR Total Fertility Rate UNPFA United Nations Population Funding Agency

93 Copy writing is not allowed to anybody unless they get the permission of Dr.J.Vijayabhanu, Principal Public Health Training School Trivandrum.

94

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