Community

Health Nursing

Health Care Starts at Home

Community

Health Nursing

Health Care Starts at Home

Jaita Mondal Ghosh CVR. MSc (N) MBA
Associate Professor
Head, Department of Community Health Nursing
Maitri College of Nursing
Durg, Chhattisgarh

CBS Publishers & Distributors Pvt Ltd

New Delhi • Bengaluru • Chennai • Kochi • Mumbai • Kolkata

Hyderabad • Pune • Nagpur • Manipal • Vijayawada • Patna

Disclaimer

Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies.

eISBN: 978-93-877-4252-9

Copyright © Authors and Publisher

First eBook Edition: 2017

All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher.

Published by Satish Kumar Jain and produced by Varun Jain for
CBS Publishers & Distributors Pvt. Ltd.

Corporate Office: 204 FIE, Industrial Area, Patparganj, New Delhi-110092

Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: eresources@cbspd.com; marketing@eduport-global.com

Head Office: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India.

Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: publishing@cbspd.com; eduportglobal@gmail.com.

Branches

• Bengaluru: Seema House 2975, 17th Cross, K.R. Road, Banasankari 2nd Stage, Bengaluru - 560070, Karnataka

Ph: +91-80-26771678/79; Fax: +91-80-26771680; E-mail: bangalore@cbspd.com

• Chennai: No.7, Subbaraya Street Shenoy Nagar Chennai - 600030, Tamil Nadu

Ph: +91-44-26680620, 26681266; E-mail: chennai@cbspd.com

• Kochi: 36/14 Kalluvilakam, Lissie Hospital Road, Kochi - 682018, Kerala

Ph: +91-484-4059061-65; Fax: +91-484-4059065; E-mail: kochi@cbspd.com

• Mumbai: 83-C, 1st floor, Dr. E. Moses Road, Worli, Mumbai - 400018, Maharashtra

Ph: +91-22-24902340 - 41; Fax: +91-22-24902342; E-mail: mumbai@cbspd.com

• Kolkata: No. 6/B, Ground Floor, Rameswar Shaw Road, Kolkata - 700014

Ph: +91-33-22891126 - 28; E-mail: kolkata@cbspd.com

Representatives

• Hyderabad

• Pune

• Nagpur

• Manipal

• Vijayawada

• Patna

Preface

The content of this book is written with the intention to cover all information which help students in theoretical as well as in practical fields of Community Health Nursing. The book covers maximum portions of nursing areas lay down by the Indian Nursing Council and followed by all nursing schools and colleges.

I have tried to make this book unique by dividing it into two sections: Community Health Nursing and Nursing Procedures in Community. As being a teacher of community health nursing, I found a few areas in which, all the time nursing students face problems to understand and apply. A few of those areas are nursing diagnosis in community, nursing procedures’ steps to be done specifically in community area and many more. Students are confused with the nursing diagnosis written for clinical areas in hospitals and how to write it for family and individual staying in community. They feel difficulty to choose client to provide care, as they search only for medical cases. But community area is different than hospital setting. Priority need is different in homes and community.

I have given effort to make this book comprehensive by including my practical experience gained while teaching as well as supervising students in field. Whatever the lack I have felt during this experience, I have tried to cover it.

In this book I have explained all these areas to make easier with step by step explanations and applicability in community areas. Hope this book will be helpful for all GNM, BSc, PB BSc and MSc nursing students to learn as well as for nursing teachers while teaching students.

I owe this book to my respected Parents Mr Probir Kr Mondal and Mrs Dipali Mondal and my loving husband Dr Tirthankar Ghosh for being there in each step with me as my strength and inspiration; and to my sweet little daughter Tia who has come to my life in the period of writing this book. My heartfelt thanks go to my all teachers who made me. I would like to express my special thanks to my brother Mr Manoj Sahu, Lecturer, Community Health Nursing, for his valuable time and helping me in various aspects.

Finally, I acknowledge the efforts of Mr. SK Jain, Mr. Varun Jain, Mr. YN Arjuna and Mr. Ashish Dixit from CBS Publishers & Distributors (P). Ltd., New Delhi in publishing this ebook.

Jaita Mondal Ghosh

About the Book

Salient Features

• Informative text with real life examples.

• Deals with in-depth and applied aspects of the subject including recent advances in field.

• Presents illustrations of text in a logical sequence

• Explains the text with the help of flow diagrams, illustrations and tables which helps in memorizing content easily.

• Begins the chapter with a list of contents of the topics covered for a quick glance or revision in a short period.

• Contains procedures with rationales and pictures which will be definitely helpful in community field work.

• Each chapter ends with bibliographic references for further reading.

• Important reference data given in appendices.

• Useful for GNM, BSc, PBBSc and MSc Nursing students and nursing teachers.

About the Author

Jaita Mondal Ghosh CVT, MBA, MSc (N)
is currently Associate Professor and Head, Department of Community Health Nursing, Maitri College of Nursing, Durg, Chhattisgarh. Earlier, she was Lecturer at Manipal College of Medical Sciences, Pokhara, Nepal. She has a long experience in clinical nursing and in teaching ‘community health nursing’, and has guided various research projects. She has to her credit a number of papers published in national and international journals, and she is Editor-in-chief of International Journal of Nursing Research and Practice.

Section

I

Read-Leam-Apply

1. Introduction to Community Health Nursing

2. Concepts of Community Health Nursing

3. Roles and Responsibilities of Community Health Nurse

4. Home Visit

5. Family and Family Health Nursing

6. Health Education

7. Community Health Nursing Process

8. School Health

9. Occupational Health

10. Disaster Nursing

11. A Quick Review on Family Planning

12. Care of Priority Age Group

13. Nutrition: A Part of Health

14. Water and Health

15. Environment and Health

16. Housing

17. Waste Management

18. Health Planning and Management

19. Health Administration in India

20. Primary Health Care

21. Job Description of Different Categories of Health Personnel in Community

22. Voluntary Health Agencies

23. National Health Programs

24. Acts in India

25. Impact of Sociology in Community Health Nursing

26. Legal and Ethical Issues in Community Health Nursing

27. Community Health Nursing Theories and Models

1

Introduction to Community Health Nursing

This chapter contains

▪ Definitions

▪ Historical Perspective of Community Health Nursing in World

▪ Historical Perspective of Community Health Nursing in India

▪ Summary of Development of Community Health Nursing

INTRODUCTION

Community health nursing is the synthesis of nursing and public health practice applied to promote and protect the health of population. It combines all the basic elements of professional, clinical nursing with public health and community practice. Community health nursing is essential particularly at this point in time because it maximizes the health status of individuals, families, groups and the community through direct approach with them.

DEFINITIONS

Community: Community is a social group determined by geographical boundaries and/or common values and interests. Its members know and interact with each other. It functions within a particular social structure and exhibits and creates certain norms, values and social institutions. The individual belongs to the broader society through his family and community (WHO Expert Committee).

A community has three features, location, population and social system.

• Location: Every physical community carries out its daily existence in a specific geographical location. The health of the community is affected by this location, including the placement of the service, the geographical features.

• Population: Consists of specialized aggregates, but all of the diverse people who live within the boundary of the community.

• Social system: The various parts of communities’ social system that interact and include the health system, family system, economic system and educational system.

Health/Optimum Health: Health is the state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity (WHO, 1947).

Community health: Community Health refers to the health status of the members of the community, the problems affecting their health and to the totality (maintaining, protecting and improving health of people) of health care provided for the community by motivation and behavioral changes.

Community health nursing: Is a field of nursing practice for which there exists a body of knowledge and related skills which is applied in meeting the health needs of communities, families and individuals in their normal environment such as at home, at school and a place of work (American Nurse’s Association).

HISTORICAL PERSPECTIVE OF COMMUNITY HEALTH NURSING IN WORLD

Care of the sick is not new. People have cared for their sick throughout recorded history. But that time care of sick was clearly very different because of the needs of and the lifestyles in society and the impact of science and technology. Health practices were varied and based upon ingenuity, prior experiences and the environment. People used plants and herbs to heal, even they believed on evil spirits and magic affected well-being.

1. St. Vincent Depaul (Paris) was a prominent figure in the history of nursing and social welfare as the first recorded visiting nurse in 1683. He organized the sisterhood of the Dames de Charity, which systematically introduced the modern principles of visiting nursing and social welfare with the aim to teach nurses to help people learn to help themselves.

2. St. Francis Desales (1567–1662) conceived a voluntary association of friendly visitors to go to home, visit sick, cleaned and dressed their wounds, made their beds and gave them clothes. They were voluntary women rather than nurses.

3. William Rathbone, Liverpool, England (1859) was another famous name in the history of nursing. Because of the outstanding care provided to his dying wife, he established a district nursing service. Based on his experience he concluded that, many people with longterm illness could be better cared for in their own homes than in hospital and wrote a book titled “Social Organization of Effort in Works of Benevolence and Public Charity by a Man of Business”. In this book he outlined a philosophy for home health care. At his urging Liverpool Relief Society divided the city into “Nursing district” and assigned a committee of “friendly visitors” to each district to provide care to the needy.

In this era the largest religious organization, the “Bible and Domestic Mission” also sent women to slums to read out bible. In 1868, nursing care was added to the program.

4. The Women’s Board of the New York Mission hired Frances Root (1877) who was a graduate of Bellevue hospital, to take the first nursing class. In this time nursing care was limited to visit sick poor, to provide direct care and to deliver religious instruction.

5. In Philadelphia, US, visiting nursing society was started which strictly followed physicians order, used to give selected treatment, kept temperature and pulse records. But as their visit was brief, so they recognized the need to teach family members about basic elements of care. Thus they included teaching and prevention in the routine.

6. In Boston, US, two women approached the Women’s Education Association to seek support for District Nursing. In 1886, the first district nurse was hired in Boston. As the number increased, they worked closely with physician to carry out medical orders. Patients paid no fees and initially two lay managers of the association supervised the nurses. In 1888, the in-structure District Nursing Association became incorporate as an Independent Voluntary Agency to provide care to the sick poor under the direction of a trained physician. They instructed families to take better care of themselves and their neighbors by living a wholesome life.

7. In a time wealthy people became interested in charitable activities and began to fund Settlement Houses in the poorer section of many larger cities. They offered a variety of services for member of the community. In 1893, Kittian Wald and her friend Brewster (both were trained nurses) did a visiting service for the poor in New York.

8. Lillian Wald was very far sighted women graduated from New York Hospitals Training School in 1891. After training she attended classes at a local Medical College while simultaneously conducting classes in personal health care on New York’s lower east side. She was shocked by the neglect of a critically ill woman in an apartment; she conceived the idea of a neighborhood nursing service for the sick poor in the area. Her concept was that the nurses should visit as good friend rather than be an impersonal, paid visitor. According to Christy, Wald was the predecessor of the modern public health nurse in the United States. In 1909, she established the first community health nursing program for workers at the Metropolitan Life Insurance Company. Believing that keeping workers healthier meant their productivity would increase. This project existed for 44 years with several significant progress as:

a. Providing home nursing care on a fee for service basis.

b. Establishing an effective cost accounting system for visiting nurses

c. Using advertisement in both newspapers and the radio to recruit nurses.

d. Reducing mortality rates from infectious diseases.

9. Health Departments and Community Health Nursing (CHN): In 1920, CHN recognized the relationship between health and economic security. All states and most of larger cities had Health Dpt. with the majority of the staff being CH nurses. During this period community health nursing assumed a leadership role in establishing standards for nursing practice. In 20th century, community health nursing includes disease prevention, health promotion and family oriented service.

10. Child Welfare Movement: America and Europe emphasized the need for:

• Well baby clinic

• Clean milk/pasteurization

• Monitoring service

In 1880, the child health movement profited from the establishment of a division of child hygiene in the New York City Health Department. Dr. Josephine Baker proved that infant deaths could be greatly reduced through prevention.

In a congested area of New York’s lower east side, CHN visited each mother and newborn on the day after birth to teach healthy ways to keep the baby well. Simultaneously there was development of well-baby clinics, clean milk was provided by monitoring services and pasteurization. Other development was as follows:

• 1908—Prenatal program was started.

• 1909—Visiting nurses service for pregnant women was begun.

• 1912—President Taft signed a bill creating the children’s bureau to investigate and report matters pertaining to the welfare of children and child life among all classes of people.

• 1935—Title of the Social Security Act reenacted the children’s bureau.

11. Role of Government: CHN improved simultaneously with changes in Govt. Several significant events influenced the further development of Community Health efforts, including two major wars followed by an economic depression.

• 1894—Louisiana recognized the need to care for people with Leprosy.

• 1917—Congress passes a law authorizing the purchase of this facility and named it the National Leprosarium. In the same year the United State of Public Health Services assumed responsibility for providing health examination for all immigrants.

• 1981—Started giving attention to the need for prevention, direction and treatment of sexually transmitted diseases leading to the establishment of the division of venereal diseases within the United State of Public Health Services. This division cooperated with state health departments to control and prevent these diseases.

• 1929—The narcotics division became responsible for the confinement and treatment of narcotic addicts.

In next several decades substantial changes took place at the federal level. So many public health departments have established along with Public Health Act, as Cancer Act, Environmental Protection Act, Department of Health Education and Welfare, Food Control, Drug Act, etc.

12. World War I (1915) and CHN: During World War the role of CH nurses were threatened, as the number of nurses was insufficient to meet the need. American Red Cross helped to sustain CHN by establishing a roster of nurses who could be enlisted to supply health care. The Red Cross emphasized educational program for the community as well as programs directed towards communicable diseases. This time first CH Nursing program was sponsored by the federal Government. In 1934, Pearl Me Iver became the first nurse employed by the United State of Public Health.

13. World War II (1941) accelerated the need of nurses. The National Nursing Council which was comprising six national nursing organization and assisted by the US departments of education, received a million dollars to expand facilities for nursing education. This time expanded scope of nursing moved into rural areas too. In 1946, a committee of representatives for agencies interested in community health meet to establish guidelines for community health nursing. It proposed that a population of 50,000 was required to support a community health program and there should be one nurse for each 2000 people.

14. Current state of CHN (from 1970 to present era): Nowadays needs and demands of care of people expanded the role of community health nurses. School health nurse, nurse counselor, health educator role has come up. Currently community health nursing focuses on care of individuals, families and communities as a whole. It covers administration, specialty area as maternal and child health, school health, industrial health, etc. and emphasizes on Primary Health Care and prevention. It is better to say that the community health nursing has a Holistic approach in current status. It focuses all dimensions of human being, i.e. physical, biological, social, psychological and environmental health.

Fig. 1.1: Few prominent figures in CHN in world

HISTORICAL PERSPECTIVE OF COMMUNITY HEALTH NURSING IN INDIA

Past Period 1: Ancient Civilization

Little is known about nursing during this time because of lack of recorded information. It is known that midwives provided care for the mother and the infant during childbirth. It is thought that much of the nursing cares were provided by slaves. It is also said that care provided for the sick was related to physical maintenance and comfort. In the ancient India, early hospitals were staffed by males. Progress of nursing in India was obstructed by low state of women, the caste system, illiteracy and political unrest.

Past Period 2: 1600–1900s Before Independence

During these times the female head of household was identified as being responsible for providing the nursing care. This included growing and gathers herbs used for healing throughout the year. Nursing care focused on moral elevation and lesson illness prevention. Military nursing was the earliest type of nursing this time. In 1664, the East India Company started a hospital for soldiers in a house at Fort 17 St. George, Madras; First sisters were sent from St. Thomas Hospital, London to this military hospital. In 1797, a lying-in-hospital (maternity hospital) for the poor of Madras was established. Government sanctioned a training school for midwives in Madras in 1854. In 1865, Miss Florence Nightingale drew up some detailed “suggestions on a system of nursing for hospitals in India”. Graduates were sent out from Nightingale School of Nurses to start similar schools in India. In 1867, St. Stephens Hospital at Delhi was the first one to begin training the Indian girls as nurses. The year between 1890 and 1900, many schools, under either missions or government were started in various parts of India. The Trained Nurses Association (TNAI) was formed to uphold the dignity and honor of nursing profession in 1908. In 1918, training schools were started for health visitors and dais at Delhi and Karachi. Two British nurses, Miss Griffin and Miss Graham were appointed to give training and to supervise nurses. In 1924, a subsidized rural practitioner scheme was introduced in Madras and rupees 50 per month was paid to doctors who would settle down in a village and treat patients free of charge for 3 hours a day in 1930, the educational institution provides programs for Public Health Nursing by the All India Institute of Hygiene and Public Health. The year between 1931 and 1939, seven health centers were set up in Delhi, Madras, Bangalore, Lucknow, Trivandrum, Pune and Kolkata with assistance from Rockfeller Foundations.

During Second World War (1942)

This time Auxiliary nurses midwife service was found. This course was shorter than the nursing course and was under supervision to work in hospital or in health center to provide domiciliary care. They were also prepared to meet the demands of health personnel in Community Development Program.

After Independence

In 1947, the community development program and expansion of hospital service created a large demand for nurses, auxiliary nurse midwives, health visitors, midwives, nursing tutors and nursing administrators. Indian Nursing Council (INC) was passed on 31st December, 1947 and was constituted in 1949. In 1980, Diploma in community nursing program was started. In second five year plan, it was decided to prepare six thousand auxiliary nurses and midwives. Government hospitals were given facilities to train ANM in 1955. In this time ANM had vital roles in health centers such as PHC, family welfare center and MCH centers.

Table 1.1: Summary of development of community health nursing

Current Period: Present Day

Nurses in the community today have many roles. They function as the clinician, educator, advocate, manager, collaborator, leader, researcher and many more. Community Health Nurses play an important role in prevention of widespread illness and diseases.

Bibliography

1. Basavanthappa BT. Community Health Nursing. Bangalore: Jaypee; 1999.

2. Finkley-Gue J. History of community health nursing [Internet]. 2011 Feb 18 [cited 2014 Oct 20]. Available from: http://www.scribd.com/doc/49068673/history-of-community-health-nursing.

3. Kamalam S. Essentials in Community Health Nursing Practice. New Delhi: Jaypee Brothers; 2005.

4. Klainberg M. An Historical Overview in Nursing. Ch 2. Jones and Bartlett Publishers.

5. Mengistu D, Misganaw E. Community Health Nursing [Internet]. 2006 [cited 2014 Sep 11]. Available from: http://www.cartercenterorg/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/comm_hlth_nsg_final.pdf.

6. Stanhope L. Community Health Nursing. 3rd ed. London: Mosby; 1992.

2

Concepts of Community Health Nursing

This chapter contains

▪ Concept of Community Health Nursing

▪ Purposes of Community Health Nursing

▪ Objectives or Goals of Community Health Nursing

▪ Functions of Community Health Nursing

▪ Scope of Community Health Nursing

▪ Principles of Community Health Nursing

INTRODUCTION

Believes and attitude towards life and reality leads to a specific act. Each nurse beliefs and follows code of conduct, i.e. philosophy of nurses motivates them to act, guides them to think about what they are going to do and influences their decisions. Philosophy addresses such problems by its critical, generally systematic approach and its reliance on rational argument. It influences how the nurse will function with families, groups and coworkers in the community and is based on the beliefs about the individual, family and community, beliefs about health and nursing. Philosophy is also essential in setting goals for an individual or group.

Philosophies which influence community health nursing activities are:

• Human rights to get good health and a long productive life.

• Individual’s potentialities and resources for managing their own lives.

• Importance of freedom to express one’s individuality.

• Individual’s struggle and strive to improve their life and environment.

• Dignity and worth of the individual.

• Every individual has some kind of health learning needs.

CONCEPT OF COMMUNITY HEALTH NURSING

Community health nursing is a field of nursing practice for which there exists a body of knowledge and related skills which is applied in meeting the health needs of communities, families and individuals in their normal environment such as at home, school and place of work. Community nursing, home visiting, health visiting and public health nursing, all these terms applied to same activities. They all include a combination of skills of nursing. The community nurse is concerned with the care of well families, with sick people who are not in hospital or who have left hospital too soon.

Community health nursing refers to the “health status of the members of the community, to the problem affecting their health, and to the totality of health care provided to the community” (WHO Expert Committee, 1974). Community health care is the integration of curative, preventive and promotive health services. It has a holistic approach where community health is considered as the health problems of the community as a whole.

According to WHO Expert Committees, community health nursing comprises the skills of nursing program for the promotion of health, improvement of conditions in the social and physical environment, the prevention of illness and disability and rehabilitation. It includes all nursing services and health programs organized by government, community, institution or health centers.

Community health nursing includes home visiting, curative works for the sick, health education, control of communicable diseases, MCH and Family Planning, maintenance of records and reports, collection of health statistics and environmental sanitation.

PURPOSES OF COMMUNITY HEALTH NURSING

Purpose denotes “why” a person do something. The purpose of Community Health Nurse is to provide community health promotion services in a designated region in accordance with the philosophy and objectives of the authority and to promote the prevention of disease, maintenance of health and the overall health and well-being of the community.

The primary purpose of community health nursing is to determine health needs of systems, i.e. individual, family and community and to offer comprehensive nursing services. These will help them to attain, maintain or regain high level of wellness.

OBJECTIVES OR GOALS OF COMMUNITY HEALTH NURSING

Objective denotes “what” a person is going to achieve. The main objective of community health nursing is to provide comprehensive care to individual, family and community in their normal environment. Objectives or goals of community health nursing are:

1. To facilitate access and equity.

2. To promote health.

3. Tobuild individual and community capacity.

4. To prevent illness and health protection.

5. To provide curative service and health maintenance.

6. To rehabilitate.

7. To build relationships.

8. To demonstrate professional responsibility and accountability.

FUNCTIONS OF COMMUNITY HEALTH NURSING

To achieve the above mentioned objectives, a community health nurse have to act accordingly.

• To facilitate access and equity: To achieve this objective a community health nurse:

1. Facilitates equitable access to available health care services and promotes comprehensive and holistic care.

2. Adopts a wide range of strategies such as home visits, outreach, follow-up and case findings to ensure equity of access to services.

3. Promotes client centered health outcomes.

4. Advocates for appropriate resource allocation to improve health outcomes.

5. Adapts practice in response to the changing health needs of the individual and community.

6. Is proactive in addressing service gaps, health inequalities and accessibility issues, especially for those most vulnerable and uses culturally appropriate and gender sensitive strategies to address them.

7. Monitors and evaluates access to appropriate community services on behalf of client.

• To promote health: By changing or modifying health practices and beliefs, increasing knowledge regarding health problems, etc. health promotion assumes that patients have a higher potential of health than they presently realize. To achieve this objective a community health nurse:

1. Will apply a “wellness focus” when promoting health.

2. Promotes health and the maintenance of well-being in the community and evaluates the impact of nurse interventions.

3. Assesses individual and community needs in partnership with clients and stakeholders.

4. Identifies which determinants of health require action or change to promote health.

5. Integrates health promotion into all aspects of community nursing.

6. Ensures that National Health Policies and Regulations are taken into account in the implementation of programs.

• To build individual and community capacity: To achieve this objective a community health nurse:

1. Actively involves and collaborates with individuals, groups, organizations and communities in all phases of planned change to increase their skills, knowledge and willingness to promote health outcomes.

2. Coordinates with the individual and community to participate in the resolution of their issues and to gather available resources to support taking action on their health issues.

3. Supports the individual, family, community or population to develop skills for self-advocacy and apply the principles of social justice to support those who are not yet able to take action for them.

4. Supports community action to influence policy change in support of health.

5. Actively works with health professionals and community partners to build capacity for health promotion.

• To prevent illness and health protection:

1. Collaborates with individuals and communities to make informed choices about protective and preventive health measures and identify potential risks.

2. Applies epidemiological principles such as screening, surveillance, immunization, communicable disease response, outbreak management, and education for health prevention activities.

3. Engages in collaborative, interdisciplinary and intersectoral partnerships to address risks to individual, family, community, using follow-up and referral systems where appropriate.

4. Links people to community resources and coordinates or facilitates other care needs and supports.

5. Provides education and counseling to clients as appropriate, respecting individual choices.

6. Identifies short- and long-term health related interventions appropriate to the cultural setting.

• To provide curative service and health maintenance: Curative service helps in time of crisis such as illness, hospitalization, etc. Follow-up of treatment, thorough and continuous assessment help to maintain the optimum state and find out complication in early stage to prevent.

• To rehabilitate: After returning to the optimum state of health from illness, it is important to rehab the client so that they can perform the best with their limitations. It may be psychological rehabilitation or physical rehabilitation such as vocational training, use of artificial limbs, etc.

• To build relationships

1. Establishes and maintains nurse-client therapeutic interactions and relationships.

2. Establishes a supportive environment which also promotes maximum participation and self-determination.

3. Respects the ability of the individual or community to know the issue they are addressing and solve their own problems.

4. Promotes and supports linkages with relevant community resources where appropriate.

5. Maintains a professional and ethical practice in the community.

• To demonstrate professional responsibility and accountability

1. Strives for excellence and is professionally competent and ensures that knowledge, practice and interventions are evidence based.

2. Is accountable to a variety of authorities and stakeholders as well as to the individual and community they serve.

3. Will take preventive or corrective action to protect individuals and communities from unsafe or unethical circumstances/practices.

4. Will ensure that all nursing activities/interventions are documented.

5. Where applicable participate in research activities which strengthen health outcomes and community nursing practice.

6. Participates in the advancement and profile of community health nursing.

7. Provides leadership in community health and takes action on factors which affect autonomy of practice and quality of care.

8. Incorporates quality improvement principles in nursing practice.

9. Works within the principles of infection control in all activities.

10. Acts upon legal obligations to report to appropriate authorities any situations of unsafe or unethical care.

11. Assumes responsibility for ongoing educational activities to enhance nursing practice.

Fig. 2.1: Functions of a community health nurse

SCOPE OF COMMUNITY HEALTH NURSING

Community health nursing is flourishing nowadays. The Scope of Nursing Practice describes the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice. The depth and breadth in which individual registered community health nurses engage in the total scope of nursing practice is dependent on their education, experience, role, and the population served. There is various scopes to work as community health nurse; they can successfully work in the following areas:

• Areas where activities must be on a community basis. As for example survey, home visiting, supervision of health workers as dai, multipurpose workers, anganwadi workers, etc. cause finding of epidemiological outbreak, etc.

• Area dealing with preventable illness, disabilities or premature death

– Health education, finding of risk factors, monitoring, screening, identification of communicable/non-communicable disease.

– Assessment and case finding of nutritional deficiencies and supplementation.

– Counseling and rehabilitation of substance abused, etc.

• Mental health and illness: Counseling, treatment, referral services.

• Allergic manifestations and their community sources by survey.

• Occupational health service as occupational health nurse in various industries.

• School health service: To conduct health check-up, dental check-up, teaching on personal and environmental hygiene, assessment of malnutrition, supervision and management of mid-day meal program, etc.

• MCH (Maternal and Child Health) and FP (Family Planning): Counseling, supply of family planning devices.

• Rehabilitation (physical, psychological and vocational).

• Geriatric care (care of elderly, aged people)

• Areas need organized official leadership

– Community field-continuing education program

– Promoting equitable distribution of health manpower and facilities

• Research (various epidemiological studies)

PRINCIPLES OF COMMUNITY HEALTH NURSING

Principles are laws or rules those have to be followed to maintain dignity of profession. There are a few principles, a community health nurse should follow while providing nursing care to individual, family and community.

1. Community health nurse should be qualified, who has done certified course and registered in State Nursing Council.

2. Care should be planned prior to achieve set goals.

3. Community health nurse should be responsible or accountable for her service, as nursing care is autonomous in community area.

4. The recognized need of individuals, families and communities provides the basis for CHN practice. Its primary purpose is to further apply public health measures within the framework of the total CHN effort. Community people accepts care which is based on their needs and helps to solve their problems.

5. Knowledge and understanding of the objectives and policies of the agency facilities goal achievement. The mission statement commits Community Health Nurses to positively actualize their service to this end. This will help CHN to maintain credentiality by not promising anything which cannot be kept by the agency. As well as knowledge on agency’s policy will prevent in providing wrong information about agency.

6. CHN considers the family as the unit of service. Its level of functioning is influenced by the degree to which it can deal with its own problems. Therefore, the family is an effective and available channel for most of the CHN efforts. Focusing only on individual is the barrier of providing holistic care.

7. Respect for the values, customs and beliefs of the clients contributes to the effectiveness of care to the client. Also it helps to gain their trust and acceptance. CHN services must be available sustainable and affordable to all regardless of race, creed and color or socioeconomic status.

8. CHN integrates health education and counseling as vital parts of functions. These encourage and support community efforts in the discussion of issues to improve the people’s health and to modify their habits towards a healthy life.

Fig. 2.2

9. Collaborative work relationships with the coworkers and members of the health team facilities accomplishments of goals. Each member is helped to see how his/her work benefits the whole enterprise.

10. Periodic and continuing evaluation provides the means for assessing the degree to which CHN goals and objectives are being attained. Clients are involved in the appraisal of their health program through consultations, observations and accurate recording. Evaluation shows that any modification needed in care process to attain goal.

11. Continuing staff education program quality services to client and are essential to upgrade and maintain sound nursing practices in their setting. Professional interests and needs of Community Health Nurses are considered in planning staff development programs of the agency. It keeps CHN up-to-dated with changes in nursing practice and to apply in patient care.

12. Utilization of indigenous and existing community resources maximizing the success of the efforts of the Community Health Nurses. The use of local available ailments, linkages with existing community resources, both public and private, increase the awareness of what care they need what are entitled.

13. Active participation of the individual, family and community in planning and making decisions for their health care needs, determine, to a large extent, the success of the CHN programs. Organized community groups are encouraged to participate in the activities that will meet community needs and interests. It will make community people to be independent to solve their problems themselves.

14. Evaluation of nursing care or health programs should be done to assess improvement as well as to change care process for betterment.

15. Supervision of nursing services by qualified CHN personnel provides guidance and direction to the work to be done. Potentials of employees for effective and efficient work are developed.

16. Accurate recording and reporting serve as the basis for evaluation of the progress of planned programs and activities and as a guide for the future actions. Maintenance of accurate records is a vital responsibility of community as these are utilized in studies and researches and as legal documents.

Bibliography

1. Australian Government Department of Veterans Affairs. Guidelines for the provision of community nursing care [Internet] 2008 Oct 2 [cited 2014 Aug 12]. Available from: http://www.dva.gov.au/health/provider/community_nursing/Commnursing.htm.

2. American Nurses Association. Public health Nursing: Scope and Standards of Practice. 2nd ed. Washington DC: American Nurses Publishing; 2013.

3. Basavanthappa BT. Community Health Nursing. Bangalore: Jaypee; 1999.

4. Kamalam S. Essentials in Community Health Nursing Practice. New Delhi: Jaypee Brothers; 2005.

5. Nurseslabs:12 Principles of Community Health Nursing [Internet] 2014 [cited 2014 Aug 13]. Available from: http://nurseslabs.com/community-health-nursing-principles.

6. Tuitui R. Text book of Community Health Nursing. Kathmandu: Vidyarthi Prakashan; 2006.

3

Roles and Responsibilities of Community Health Nurse

This chapter contains

▪ Roles and Responsibilities of Community Health Nurse in:

– Health Center

– Community Area

INTRODUCTION

The community health nurse acts as a teacher and counselor primarily, but also plays an important role in preventing widespread illness and disease in the community she serves. Community health nurses integrate community involvement and knowledge about the entire population with personal, clinical understandings of the health and illness experiences of individuals and families within the population. They translate and articulate the health and illness experiences of diverse, often vulnerable individuals and families in the population to health planners and policymakers, and assist members of the community to voice their problems and aspirations. Community health nurses are knowledgeable about multiple strategies for intervention, from those applicable to the entire population, to those for the family, and the individual. Community health nurses translate knowledge from the health and social sciences to individuals and population groups through targeted interventions, programs, and advocacy.

ROLES AND RESPONSIBILITIES OF COMMUNITY HEALTH NURSE IN HEALTH CENTER

a. Working relationship: The community health nurse assists the District Medical Officer or District Family Welfare officer in planning, implementing and evaluating Maternal and Child health and Nutrition Program undertaken in the district. Works in collaboration with other functionaries in the District Family Welfare Bureau like the Mass Media and the Extension officer, Health Education officer, Statistical Officer, etc.

b. Duties and functions are to:

• Help in organization of maternal and Child Health Program as a whole and in the implementation of the special plan scheme, centrally sponsored and otherwise in particular like immunization program, training of Dais and their active involvement in MCH/FP work, prophylaxis against nutritional deficiency disease, etc.

• Promote health and nutrition education activities through the Lady Health Visitors, Auxiliary Nurse Midwives by providing them with ‘taking points’ and printed materials produced by various agencies.

• Help in developing school health program in district.

• Ensure regular supply of equipment, records, registers, drugs, vaccines and other sundries necessary for MCH work in the Primary Health Centers and Subcenters by assisting storekeepers in procuring and disturbing the supplies.

• Help the statistical officer in the District Family Welfare Bureau in compiling the periodical progress reports of the MCH activities.

• Give technical guidance, supervision and supports to subordinates.

• Investigate into complaints against female paramedical personnel in the district and submit reports/recommended to the district MO/District Family Welfare Officer.

• Provide continuing education of subordinates.

• Work together with other government departments like social welfare, rural development and education engaged in program for women and children.

• Tour for a minimum ofl5daysina month and visit PHCs, subcenters, village dais, Balwadi, Mahila mandals, etc. according to an advance program duty approved by the District Medical Officer/District Family Welfare Officer.

Fig. 3.1: Role and responsibilities

ROLES AND RESPONSIBILITIES OF COMMUNITY HEALTH NURSE IN COMMUNITY AREA

• Assessor: Assessing the health needs of a community is the starting point for community nurses. They determine the health needs of families and the community at large, as well as any social determinants that impact the health status of that community. Once an assessment is made, the community nurse can develop a plan to address the health care needs of that community, given the resources that are available.

• Direct care provider: Providing care to sick people at their home.

• Counselor: Counseling people (either individual or group) to promote their health behavior.

• Advocate: As someone who seeks to help strengthen and build the community around her, the nurse acts as an advocate as well. As an advocate, nurses can ask for additional resources to help the community and make others aware of the health concerns of that community.

• Manager: As a manager she can arrange, supervise and manage different health programs.

• Advisor: She gives advices in the form of health education to improve health behavior or to solve health problems.

• Case finder: By epidemiological studies she can find the distribution, determinants and risk factors of diseases. As well she helps to find out the case by collecting samples (blood smear/sample, sputum collection, water sample collection, etc.) from community.

• Coordinator/community builder: A healthy community is a strengthened community, and a competent and compassionate community nurse plays a vital role. To that end, a community nurse is responsible for building relationships and partnerships throughout the community, in order to improve the health of individuals and families.

• Observer: While home visiting she observes various sources/risk factors of diseases.

• Leader: She acts as a leader while conducting any health program. She acts as a leader for her subordinates.

• Health planner: As a health planner nurse plans care beforehand of home visiting as well she plans for various national health programs to conduct.

• Collaborator: Acts as a collaborator among different sectors while conducting any health program or whenever needed for providing health care.

• Epidemiologist: Carries out various epidemiological studies as researcher to find out the distribution, determinants and risk factors of the study.

• Potentiator: Potentiate various activities as health programs, national programs, care of acutely ill patients.

• Primary health care practitioner: By providing health teaching to improve lifestyle, treating of minor ailments nurse acts as primary health care practitioner to prevent the diseases.

• Role model: Acts as a role model to her subordinates as well to the community people.

• Clinician: There are courses of nurse practitioner in foreign countries as well as in south India; by completing the courses nurse can act as a clinician.

• Educator: A community nurse can improve the health of families and communities through teaching them about healthy lifestyle choices. Educating the public on eating healthy, the basics of looking after their own health and other information is one of the primary responsibilities of the community nurse.

• Administrator: Acts as administrator in conducting health programs and also in various health centers.

• Evaluator: Implementing a plan to improve the health of a community is not enough. Someone must evaluate the results, and that’s the role of the community nurse. The nurse is then able to effectively deliver care based on evaluations and tailor the care as needed. Evaluations are also helpful to improve preventive strategies, as well as determining the health trends of the population.

• Researcher: Community health nurse does epidemiological studies to find out the causes of any disease and to find out prevalence, morbidity, mortality rate, etc. due to that disease and to find out the control measures.

• Acts in specialized area as

– School health nurse

– Occupational health nurse

– Community mental health nurse

– Geriatric nurse

– Nurse consultant

Bibliography

1. Daphne Mallory D. What Are the Primary Roles of the Community Nurse? [Internet] [cited 2014 May 20]. Available from: http://www.ehow.com/list_6039100_primary-roles-community-nurse_html).

2. Park K. Preventive and Social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

4

Home Visit

This chapter contains

▪ Definition

▪ Purposes

▪ Principles of Work/Home Visiting

▪ Objectives

▪ Steps in Home Visiting

▪ Advantages of Home Visiting

▪ Problems of Home Visits and Possible Solutions

INTRODUCTION

The home visit is one of the most important aspects of community health services. It is a fact that majority of undiagnosed people are at home. Home is the place of service where nursing practice is autonomous and the knowledge, skills and experiences of the nurses are employed. Visiting patients in the home provides a challenge and an opportunity for the nurse and family to function as a team in their own environment. Health service in the home requires technical skills, knowledge of preventive and therapeutic measures, teaching ability, judgment and a full understanding of human relations.

DEFINITION

“A visit made by a health professional (HP) to a client’s home, usually with face to face contact between the HP and the client and the client’s family.”

Home visits are carried out by medical staff, general practitioners (GP), nurses and allied health professionals. Home visits by hospital medical staff are usually initiated by the hospital or by the client’s GP, and are termed as domiciliary consultation.

PURPOSES

A visit to the home may be done:

1. In response to a need felt by an individual in the family as in case of sickness, delivery, surgery.

2. As a part of a planned visiting program as for example, routine prenatal visits.

Home visit is done with main three purposes as:

• Health promotion: Health promotion is the process of enabling people to increase control over, and to improve their health. It can be done while home visiting by motivating people to change their lifestyle and habits towards a healthy one.

• Disease prevention: Disease prevention covers measures to prevent the occurrence of disease such as risk factor reduction, and also to arrest its progress and reduce its complications.

• Evidence based home care: Applying the best available research results (evidence) when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise, observations and client preferences.

Fig. 4.1: Purposes of home visiting

PRINCIPLES OF WORK/HOME VISITING

SI. No.
Principles: What to do?
Rationale: Why to do so?

1.

Plan the work so that visits are made of needs; plan the area to be visited; plan the number of family to be visited in a day.
Proper planning saves time and energy, helps to complete task effectively.

2.

Be sensitive to the person’s feelings and needs at the time of the visit.
Helps to gain acceptance in family easily, gains trust of family members.

3.

Understand the other person’s point of view.
Helps to motivate or direct towards healthy behavior.

4.

Be sure of scientific soundness of the subjects you discuss.
Helps to gain confidence of family members.

5.

Use safe technical skills, including handwashing, inspection, etc.
Helps to gain confidence of family members that they are in safe hand.

6.

Have a full understanding of your agency’s policy.
Helps for further referring and prevents giving wrong information.

7.

Attain a working knowledge of the community resources and use them wisely.
Saves money, energy, more accepted by community people.

8.

Collect facts about the home, the patient and the environment and make an objective analysis of the facts as an initial step in visiting the home.
Helps to set the goal and plan of care.

9.

Work with the person and family—plan jointly.
Helps to plan proper resources and timing of their availability

10.

Evaluate your own work—quality is more important than quantity; one or two home visits that accomplished are of greater value than 8 or 10 casual visits.
Helps to modify the plan of care thus better care can be provided.

11.

Make a note of important facts in your diary.
Helps to remember the important facts, as well as helps to plan care based on priority problem.

12.

On return, record facts in the family folder and/or individual health cards.
Easy to follow through by any other health workers to continue care, also progress can be monitored. Documents can be used for anv research purpose too.

OBJECTIVES

Home visiting has been shown to be effective at helping families as to:

• provide care to those who are reluctant to go to hospital or people who are unable to travel up to hospital.

• diagnose early and treat early to prevent complication.

• reduce mortality and morbidity rate.

• improve health status.

• achieve economic self-sufficiency.

• improve positive parenting.

• reduce child maltreatment.

• achieve goals such as child spacing, education and employment.

• establish links to community resources.

• investigate the source of an infectious disease in which case you may be rejected instead of being wanted.

• follow through on some problems identified in the health center, school, industry or hospital.

• assess nutritional and immunization status, environmental hazards and give health education.

• follow treatment and care given by family members.

• supervise and guide other health workers.

STEPS IN HOME VISITING

Area of home visiting is not like a hospital set up where patients are dependent on medical personnel. Here a CHN has to invade the cultural as well as social barrier of that particular community to work. Community health nursing is a challenging job, but maintaining of a few specified steps can make it easier.

1. Establish rapport: The first step during a home visit is to get an understanding of what has been done, about the norms, culture, values about the particular community. While home visiting introduces yourself, establishes a friendly relationship through courtesy, graciousness and genuine interest.

Fig. 4.2: Steps of home visiting

2. Fact finding: This step is done to collect information regarding family to assess and prioritize problems/needs of the family. While home visiting:

i. Observe inside and outside of the house.

ii. Find out good and bad factors that may influence the situation.

iii. Study the clinical and other records

iv. Talk with the person or persons concerned to find out what they know and understand about the situation. Use simple language.

v. Discuss what has been done and what the person wants to do about the problem now and what plan he may have for the future.

[To collect fact follow the steps of “Assessment” described in “Community Health Nursing Process” Chapter]

3. Examination and analysis of the facts: After data collection, it is very crucial to interpret and analyze the information gathered. True, honest analysis to be done based on fact and not on opinion. The personal, environmental, economic factors, emotional involvements and the spiritual aspects all have to be taken under consideration to find need/problems in family.

A community health nurse analyzes and interprets the information by comparing with known indices, calculations of vital statistics (mortality rate, morbidity rate, etc.), preparing pie diagram, bar diagram, etc.

Analysis begins with a view to plan in mind. Interpretation of data usually arises the questions and search for an answer to what is it? How did it develop? And what can I do? Community health nurse should be able to combine the facts about home conditions, signs and symptoms, attitudes and relationships to identify needs and problems which will become the starting points for actions.

4. Planning Action with the Individual or Family: It is very important to plan action with the person and family. Plan should be done according to the need of the family and availability of resources. It is well to understand that when mother is hungry or when her children are hungry, food is her primary interest and need, and any amount of health teaching will help little. She is not likely to listen until she has talked about the food situation and feels that you can help in this aspect too.

5. Action: Action depends on the findings in fact finding stage. May she enter the home with a definite idea and plan but it has to be changed according to the obtained information at the time of the visit to meet fhe needs. A proper interpersonal relationship makes the work easy for community health nurses.

In this phase nurse is acting according to the set objectives and also according to the situation. Community health nurse provides care to the disabled, doing different procedures, giving health education, teaching/demonstrating family members about different procedures, providing referral services, etc. the community health nurse has to take a role as collaborator, consultant, coordinator, preventer of diseases, promoter of health, health educator and an epidemiologist and takes to implement nursing process.

Use of expert technical skills is very important in this phase. Nursing knowledge and skills are essential to provide care at home. It is needed to carry the home visiting bag, thermometer, weighing machine, sphygmomanometer, dressing articles, essential equipment for treating minor elements, etc. While teaching any demonstration nurse has to do it confidently and has to be scientifically sound enough that family gains confidence and respect for the task.

6. Follow through: Follow through involves periodic visit in such a way that maximum help is given to the needed family. In this stage nurses assess that, family is able to follow the things which have been taught to them in previous visits, clients are continuing their medications or not, etc.

7. Evaluation of services: Review each family record periodically and should answer the objective decided before. Evaluate—what are the immediate problem needs?

• List the helpful factors too, e.g. coping ability of the family.

• List the difficulties and unhelpful factors in the situation.

• What has been done about immediate problem?

• What changes have taken place?

• Has she made effective use of men and material measures?

• Value of referral services?

Evaluation of services helps to decide that any change in care is needed or the service was proper. It provides the base of reassessment, reprioritization and change in care.

8. Termination of visit: Home visit should be stopped abruptly. Termination of visit in proper way is very important to hold the confidence and rapport towards community health nurses. Community health nurse should communicate and inform family members before stopping home visit. Termination of visit can be done when:

• Nurse-client goals are achieved, health is restored and the patient can function without nursing action.

• A client changes his residence or leaves the home to go to another home.

• The nurse transfers the patient care to another nurse or other members to provide health care.

ADVANTAGES OF HOME VISITING

1. Provides opportunity to care at natural environment.

2. Family members will be more relaxed in their own surroundings.

3. The home visit permits the nurse to see the home and family situation in action.

4. It permits more realistic teaching in the actual situation, since socioeconomic background becomes clear.

5. Family practices can be observed to form a basis for teaching.

6. Other members of the family can be contacted who may have greater influence and control on the member under nursing care.

7. The family gains confidence in this direct personalized contact and are then free to raise questions and straighten the problems.

8. The nurse has an opportunity to observe actual care given by family members.

9. The home visit provides an opportunity to look for new health problems.

10. Prompt and proper home visit creates a good understanding between nurse and the family and builds good image of nurses.

11. Home visits are the best option for patients unwilling or unable to travel.

12. It helps the nurses and family members to modify the ways of their care.

PROBLEMS OF HOME VISITS AND POSSIBLE SOLUTIONS

a. Consumes a lot of time and energy and money: To make a trip from health center or hospital or college to home, location is not known, it consumes more time and energy than required to serve actual purpose along with petrol or diesel or travel fare.

To overcome this problem, the nurse has to have proper plan, proper street maps or knowledge of location/orientation to the area prior to visit.

b. Non-acceptance: It may be due to cultural differences between nurse and family, personal characteristics of the nurse and the client’s and also socioeconomic status to some extent.

The nurse must be careful while communicating and should behave in a friendly professional manner, should give an accurate and complete description of the purposes of home visit. She should respect their culture and must show her professionalism.

c. Problems of local language: Nowadays nurses travel so many places for job, different areas, different states and different countries. It sometimes causes language barrier.

This problem can overcome by taking help of colleagues initially and try to learn and practice.

d. Role confusion: Due to lack of knowledge of nurse regarding their job nurse gets confused that what her role at other’s home. As in hospital easy to care sick people but at home they should remember it’s not only curative aspect to take care but preventive and promotive aspects have to be given more importance. Also family gets confused with their role due to lack of knowledge to understand the role of nurses.

This problem can be avoided by community health nurse by proper learning and setting goals to achieve. It is very important to explain their goals and activities with family members. Even community health nurse should plan their care along with family members.

Home visit is not an easy job but if effectively and efficiently done it is a very important means of health services.

HOME VISIT IN WESTERN COUNTRIES

Minnesota Department of Health Family Home Visiting Program developed evidence based home care. Elements of effective programs are listed below which research has demonstrated to improve the effectiveness of any home visiting model.

• Voluntary parents who are voluntarily involved are more receptive to services.

• Family focused and strength based effective programs respond to the unique needs of each individual family, build on family strengths and work to empower parents.

• Respect for diversity families is more likely to engage in services that are culturally and linguistically appropriate. Effective programs value diversity. Quality programs recognize and appreciate the cultural bases of parenting and avoid stereotyping.

• Connection to other community services: effective programs collaborate and coordinate with other community services to ensure that families are receiving all the services they need.

Fig. 4.3

• Targeted: Scarce resources are most effectively utilized when services are targeted to those families with the greatest need.

• Begin early: Effective programs begin services as early as possible, optimally prenatally.

• Intensive: Interventions that are frequent and occur over a long period of time have more significant and sustained effects.

• Long-term: Optimally, services continue until child is at least 2 years old.

• Promote preventative health care: Effective programs support and encourage families to utilize preventative health care and connect with a primary health care provider.

• Promote delay of subsequent pregnancies: Effective programs support and encourage participants to delay subsequent pregnancies when appropriate.

• Limited caseloads: Home visitors with limited caseload are better able to meet the needs of their clients. Caseload limitations will vary with program purpose and focus.

• Carefully recruited and well-trained staff: Effective programs employ well-trained staff. Program staff is selected based on their education, work, and life experiences, as well as their ability to communicate and establish trusting relationships

• Ongoing supervision: Effective programs provide staff with continuous, high quality supervision.

• Are theory driven: Effective programs are based on strong scientific theory and target relevant risk and protective factors that have been shown to impact the healthy development of young children.

• Have clearly defined goals and objectives which home visitors know how to reach: Effective programs have goals which meet the needs of the families served and influence what home visitors do in the home.

• Evaluation and continuous quality improvement (QI): Effective programs determine evaluation and QI processes early and use data to determine if program is being implemented as designed, extent to which goals and objectives are being met and areas which may need refinement.

Bibliography

1. Family Home Visiting (FHV): Minnesota Department of Health [Internet] 2013 Dec 20 [cited 2014 Sep 07]. Available from: http://www.health.state.mn.us/divs/fh/mch/fhv.

2. Gomby D, Larson CS, Lewit EM, Behrman RE (1993). Home Visiting: Analysis and Recommendations. Future of Children [Internet]. 2009 Sep 22 [cited 2014 Aug 17]; 3(3):6–22. Available from: http://www.oregon.gov/OCCF/Mission/BestPrac/besthv/mibesthvEC.shtml.

3. Powers S and Fenichel E (1999). Zero to Three, Home Visiting: Reaching Babies and Families “Where They Live”, A report of the best available information from 20 years of research and practice on home visiting. Based upon the work of Deborah Daro, PhD, Chapin Hall Center for Children, University of Chicago.

4. Small S. Evidence-Informed Program Improvement: Using principles of effectiveness to enhance the quality and impact of youth and family programs [Internet]. 2009 Nov 17 [cited 2014 July 23]. Available from: http://what-works.uwex.edu/attachment/SmallEIPI presentationforlowaStatewebcast.ppt.

5. The Trained Nurses Association of India. A Community Health Nursing Manual. New Delhi: Kumar Book Depot; 2001.

6. Tuitui R. Text Book of Community Health Nursing. Kathmandu: Vidyarthi Prakashan; 2006.

5

Family and Family Health Nursing

This chapter contains

▪ Definition

▪ Concept of Family

▪ Characteristics of Healthy Family

▪ Family Life Cycle

▪ Types of Family

▪ Functions of Family

▪ Family in Health and Illness

▪ Factors Affecting Family Health

▪ Family Health Care

• Objectives of Family Health Care

• Principles of Family Health Care

• Assessment of Family Problems

– Typology of Nursing Problems in Family Nursing Practice

– Family Coping Index

“The secret of national health lies in the homes of the people.”
—Florence Nightingale

INTRODUCTION

It’s no stretch to say that a person has a serious advantage in life if they come from a loving, supportive home. Many people still succeed though they come from less-than-ideal family situations, but having our basic needs met, knowing that our parents love us and learning life lessons at home make all the challenges of day-to-day living that much easier to face.

DEFINITION

Family is commonly defined as “a group of biologically related persons living together and sharing the common kitchen and purse”.

According to Jarris L (1985), “the family involves people who are related in a traditional or non-traditional sense by marriage, blood, adoption or friendship”.

CONCEPT OF FAMILY

Family is the place where a life starts, which teaches us norms, culture, protects us from harms, provides us the basic needs. In human context, a family (from Latin: familia) is a group of people affiliated by consanguinity (by recognized birth), affinity (by marriage), or coresidence/shared consumption. Family is a primary unit in all societies. It is a group of biologically related individuals living together and eating from a common kitchen. Family is a:

• Basic/primary unit in all societies

• Biological unit: Share a poof of genes

• Social unit: Share a common physical and social environment

• Cultural unit: Share a common culture, depends on the part of living

CHARACTERISTICS OF HEALTHY FAMILY

Families that make healthy lifestyle choices together, stay healthy together. A healthy family should have the following characteristics.

• A sense of togetherness that promotes capacity to change: A bond between family members is essential which promotes each other towards a healthy lifestyle. It can be maintained by giving a quality time to your family members, to be trustworthy by keeping any promise done to them, a day out in a week or at least in a month, by planning a healthy diet, by doing regular exercise, being active with kids, by taking care of elderly or sick members.

• A balance between mutual and independent action on the part of family members: Everyone has the right to do what they want. Though in family it should be mutually considered. But no one should be very dominant that family members don’t get enough space in their life. That balance should be maintained.

• Nurturance and resources for growth and substances: Mental and physical growths start from the family. A healthy family follows a healthy diet, healthy lifestyle as regular exercise, proper education, socialization.

• Stability and integrity of structure: In a healthy family a strong bonding is seen among the family members. A stable relationship and an integrated family is considered as a healthy family.

• Mastery of developmental tasks: Leading to interdependence and ability to meet demands for survival and development.

FAMILY LIFE CYCLE

Basic model of nuclear family life cycle is better described as follows:

Table 5.1: Family life cycle

However, this model cannot be applied for all areas as:

• Leaving home is quiet natural in western culture

• Child death may occur

• Variations as one spouse, divorce, childlessness, etc.

A family life cycle also can be described as shown in Fig. 5.1. A family starts from birth then through different stages of life as infant, toddler, school age, adolescent then enters to adult life; gets married, gives birth of child, becomes grandparent and after old age ultimately death occurs.

Fig. 5.1: Family life cycle

Types of Family

Type of family has been classified in various ways as:

A.

1. Family of origin: The family into which one is born.

2. Family of procreation: The family which sets up after marriage.

B. Family of origin and family of procreation can be classified again as follows:

1. Nuclear family/elementary family/conjugal family: The family consists of the married couple and their children while they are still regarded as dependents. The absence of grandparents, uncles, aunts and near relatives causes a greater burden on responsibilities in child rearing.

2. Joint family: The family which consists of a number of married couples and their children who live together in the same household. All men are of blood relation and women are either wives or unmarried girls and widows.

3. Extended family: Sometimes the term is used synonymously with joint family, but extended family covers a greater area than joint family. An extended family is a family that extends beyond the nuclear family, consisting of grandparents, aunts, uncles, and cousins all living nearby or in the same household. An example is a married couple that lives with either the husband’s parent (generally known as joint family) or even with the wife’s parents.

4. Three generation family: This also can be termed as joint family, but it tends to be a household where there are representatives of three generations, i.e. a couple with their parents and their children.

5. Blended family/stepfamily: The family with mixed parents: one or both parents remarried, bringing children of the former family into the new family.

C. On the basis of authority family can be classified as:

1. Matrilineal family: This is the family in which authority descent through the mother and maternal ancestors, i.e. female of the family is authorized to take the major decision of family.

2. Patrilineal family: This is the family in which authority descent through the father and paternal ancestors, i.e. male of the family is authorized to take the major decision of family.

D. On the basis of residence family can be classified as:

1. Patrilocal: The family in which wife moves to husband’s house after marriage.

2. Matrilocal: The family in which husband moves to wife’s house after marriage.

Functions of Family

Family has a broad range of functions to nurture family members. Functions of family are stated below:

• Fulfilling the basic needs of family members: One of the major functions of family is to fulfill the basic needs of family members like proving a clean and decent residence, clean clothes to wear and adequate food.

• Work division: Work should be divided among family members according to the ability. Previously it was like male were supposed to earn and support family where female had responsibility to run the household and child rearing. Nowadays this concept is changing and all members play an important role to manage household as well as child rearing.

• Reproduction and bringing up of children: One of the most important functions of the family is giving birth of child and taking proper care along with its education, teaching the child social tradition and customs.

• Economical support: Family members earn to live comfortably as well to build and save property for their offspring.

• Socialization: Family is the one who follows as well as teaches their children about civilization. Family generates affection among family members, friends, imparts the habit of eating, behaving to people, sense of cleanliness, how to dress, how to talk, brings up the attitude among the children.

• Social care: A child holds status in family due to its family name. Family protects its members from any insult, defamation, etc.

• Care of dependent adult: Family is expected to care of sick, injured, pregnant women, aged and handicapped family members. Studies have shown that the family does more nursing care than the hospital, even in highly developed countries.

• Providing recreation: This is another function of family to provide relaxation, entertainment and personal development to the family members.

Family in Health and Illness

Health and illness of family members depends on their style of living, health habits and heredity. Though hereditary diseases are unavoidable but can be prevented by health promotional activities. Health promotional activities include regular health check-up, healthy habits such as quiting of harmful substance as tobacco, alcohol, drugs; regular exercise; healthy diet; adequate sleep, etc. Style of living depends on the family members, how they want to live their life, their way of nurturance of their children. An unhealthy lifestyle leads to physical, social and psychological problems.

• Way to bring up children: The way of child rearing varies extremely from family to family, society to society and time to time. It depends upon various factors such as capital resources, level of knowledge, state of technology and system of values. A good child rearing depends on proper feeding, proper nutrition, maintenance of personal and environmental hygiene, adequate sleep, clean and suitable clothing, healthy habit, good moral and discipline (Fig. 5.2). Lack of all these may lead to a physically and mentally unhealthy child.

Fig. 5.2: Basics of good child rearing

• Personality development: The capacity of an individual to cope with the stress and the way he responses to the stressors and other people, it depends up to a large extend on his early experience in the family, mainly with the father, mother and siblings. Stressors may be injury, illness, births, deaths, tension, emotional problems, economic insecurity, etc. Certain chronic diseases (e.g. peptic ulcer, hypertension, etc.) are known as stress diseases. Thus a family should help in stabilizing the personality. A good support of family builds the foundation of physical, mental and social health of a child and adult.

• Mingling with society/socialization: Family is the place where the qualities which are essential for functioning effectively in society develop. Schools, religious places along with family are also responsible to socialize a child. They teach the values of society, culture, beliefs, general codes of conduct, etc. though socialization varies in eastern and western cultures. Improper socialization may bring up an individual who is unfit to society.

• Role of heredity in health and disease: Some hereditary diseases as hemophilia, diabetes, color blindness, mental diseases, etc. run through families as family members share a pool of genes. Even communicable diseases as tuberculosis, skin diseases, common cold, diphtheria, diarrhea, etc. spread faster among the family members as they are in close contacts and common environment. On the other hand, a good health, good mental status, texture, height, complexion, healthy gene, etc. are also transmitted through family.

• Shattered family: Separation of child from its father or mother or both is an important factor in child development. Especially it causes mental deprivation which may lead to psychopathic behavior, immature personality even retardation of growth, speech and intellect even may cause juvenile delinquency.

• Problem families: It refers to the families full of problems as poor personality, backwardness, poverty, mental and emotional instabilities, unhappy and unhealthy marital life, etc. children reared in such a family may be the victims of crime, prostitutions or begging.

Thus the family plays an extreme role both in health and illness. How a society or a nation will be, it starts in the basic unit, i.e. family.

Factors Affecting Family Health

• Physical environment: Food, cloth and shelter, according to Maslow’s hierarchy are the basic needs of human being. As for example, availability of adequate food, clean and proper clothing, and a safe shelter can make a family healthy and unavailability of those can make a family unstable.

• Psychosocial environment: Factors which affecting mental health of individual creating the psychosocial environment as for example happy home, congenial working environment, availability of basic needs, etc. can make a person happy and increased his/her productivity; whereas a stressfull environment can make people depressed and unproductive.

• Biological environment: Biological environment consists of living things around a person. As for example, freedom from communicable diseases, small family, healthy reproductive family, etc. can make a fit family.

Family Health Care

Family health can be defined as “the continuing ability to meet defined functions in interaction with family, social, political, economic and health system”.

Objectives of Family Health Care

Objectives of family health care are to:

• identify and appraise health problems of the family

• find out the risk factors present in family

• ensure family’s understanding and acceptance of the problem

• provide nursing services according to the health needs of the family

• help to develop the competence in the members to take care of their family as and when required

• find out remedial measures to solve problems

• use the available resources

• contribute desired materials to personal and social development of the family members

• promote and utilizing of available resources

• provide health educations

• detect epidemiological outbreak

• find out the sources of communicable diseases

Principles of Family Health Care

Family health care can be provided with efficiency if the following principles have been followed:

• Good professional relationship with family is very important to gain their trust. It helps to collect data in detail along with personal information.

• Proper health education and guidance should be given according to the need of the family.

• Gather all relevant information about family to identify problems and set priorities; these will help to determine the set of care.

• Need based care will help to gain family’s attention and acceptance.

• Duplication of health services should be avoided. Need to coordinate services with other disciplines providing health service.

• Proper health management to be communicated to family in every contact; knowing updated care and plan of care will make family members confident.

Assessment of Family Problems

Assessment is the first step of nursing care plan. A detail collection of data will help to determine the problems exist in the specific family. Generally two methods are adopted to assess family problems:

1. A typology of nursing problems in family (Appendix H)

2. Family coping index (Appendix I)

1. A typology of nursing problems in family nursing practice to assess problems: It helps a community health nurse to assess various individual problems, family problems, community problems as well as helps to find out ability of individual or family coping ability with the problem, ability to provide care at home, health resources, etc. Assessment is done in two phases (Fig. 5.3).

2. Family coping index: to assess coping ability of family to a specific problem: Coping is the process of managing stress/stressful circumstances. In this not the underlying problems is being rated. It is used to assess the coping capacity of family and not the individual that is being rated. Purpose of family coping index is to provide basis for estimating the nursing needs of a particular family. It has two parts (Table 5.2):

i. A point on the scale: Community health nurse finds out where family will fall in these points.

• Scaling cues, helps community health nurse to rate family coping. They are limited to 3 parts:

– No competence (1)

– Moderate competence (3)

– Complete competence (5)

ii. A justification statement (explains why)

After assessing family coping according to the above format community health nurse ranks the family and plans for care according to the priority need.

Fig. 5.3: Typology of nursing problem

Table 5.2: Family coping index

Bibliography

1. Basavanthappa BT. Community Health Nursing. Bangalore: Jaypee; 1999.

2. Better health for every age [Internet] 2011 [cited 2014 Sep 23]. Available from: http://www.path.org/annual-report/2011/better-health-at-every-age.php

3. Blended and Blessed-Encouraging Step-Families. [Internet] 2014 Nov 26 [cited 2014 Nov 27]. Available from: blended and blessed, commodified on 26th November 2014 at 15:10.

4. Civil Action No. l:09-cv-10309 paragraph 17. “Department of Social and Developmental Psychology: PPSIS Faculty, Academic Profile”. Sdp.cam.ac.uk. Retrieved 2014–03–26.

5. Family [Internet] 2014 Nov 26 [cited 2014 Nov 27]. Available from: http://en.wikipedia.org/wiki/Family.

6. Human life cycle [Internet] 2013 July [cited 2014 Aug 13]. Available from: http://allassignmentbd.blogspot.in/2013?07/human-life-cycle.html.

7. Park K. Preventive and Social Medicine. 19th ed. Jabalpur: Banarasidas Bhanot; 2007.

8. Stewart et al. BMC Public Health [Internet], 2012 [cited 2014 Sep 12]; 10.1186/1471–2458–12–106.

9. Tuitui R. Text book of Community Health Nursing. Kathmandu: Vidyarthi Prakashan; 2006.

6

Health Education

This chapter contains

▪ Definition

▪ Objectives

▪ Principles

▪ Approaches

▪ Scope of Health Education in Community Area

▪ Audiovisual Aids

INTRODUCTION

Health education is the profession of educating people about health. Health personnel assumes that knowledge on health aspect improves attitude to take care of their own health and to practice healthy habits. Health education teaches people about the health problems and how to take care of these problems to stay healthy. Areas within this profession encompass environmental health, physical health, social health, emotional health, intellectual health, and spiritual health. It can be defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of health.

Health is a desirable objective which can be achieved through education. Man is a creature of prejudice, sentiment, habits, reason and refinement. Health education must take into consideration of these five aspects of human nature.

DEFINITION

Health education is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes (WHO).

Health education is “a process aimed at encouraging people to want to be healthy, to know how to stay healthy, to do what they can individually and collectively to maintain health, and to seek help when needed” (Alma Ata Declaration).

OBJECTIVES

• To cultivate the desirable health practices and health habits.

• To develop the health attitudes.

• To appreciate the health programs.

• To develop health consciousness in the community.

• To teach people about the rules for the preservation and development of their physical, mental and emotional health.

• To eradicate the diseases through health drive programs.

• To combat the superstitions and prejudices in the community.

• To provide a healthful environment for physical and mental growth.

• To improve the general conditions of living in the community.

• To instruct the children and youth so as to conserve and improve their own health.

• To influence the parents and other adults through the health-educative program for better habits and attitudes in children.

PRINCIPLES OF HEALTH EDUCATION

Providing health education is a combination of art and science which should attract people to listen carefully as well as motivate them to modify behavior. Following few principles while giving health education, help to achieve desired goals.

Interest: A person takes interest on that particular topic which will be helpful to him/her. It is only possible when a need based education will be provided then only people will take interest to hear that. People are not interested in health slogans such as ‘take care of your health’ or ‘be healthy’ if it is not focused to their problems. As for example, a person with hypertension will be interested to listen about care of hypertension only, not to listen about diarrhea or any other disease.

Credibility: Trust is the basic of any education. Information given to the people must be true. Any false information or false commitment will lose client’s faith on the educator. Unless the people have trust and confidence in the educator no desired action will be achieved. As for example, proving health education on basic life support but demonstrating first aid on burn will loss the trust of people on health educator.

Participation: Participation is based on the psychological principle of active learning and group discussion, panel discussion, workshop—all provide opportunities for active learning. It motivates people to learn, encourages people to do and generates interest to learn. As for example, involving community people as a character in role play, will get more audience and will make health education more effective.

Comprehension: In health education one must know the level of understanding for which the teaching is directed. One barrier to communication is the use of words which cannot be understood. So the teaching should be given according to the understanding level and mental capacity of the individual. As for example, it is illogical to use medical terminologies while giving health education to nonmedical lay personnel. Because they will not understand the message lied in health education.

Reinforcement: A few people can learn all that are new in a single period and a few cannot. So repetition at intervals is extremely useful. It assists to recall, comprehend and understand the information better. So health instruction needs reinforcement which doctors call booster dose.

Motivation: In every person there is a fundamental desire to learn which comes from either self-motivation or from external motivation. Some of the motivations (positive as well negative) are praise, love, rivalry, rewards, punishment and recognition. In health education motivation is an important factor. The incentives may be positive or negative, but the positive must be emphasized as against the negative. As for example, saying “very good” when they answer correctly to question asked by health educator.

Learning by doing: Learning is an action process; not a ‘memorizing’ one in the narrow sense. The Chinese proverb “If I hear, I forget, if I see, I remember, if I do, I know” illustrates the importance of learning. So health habits like other habits should be cultivated through practice. As for example, after teaching wound dressing, need to take a redemonstration of that person.

Known to unknown: While giving health education, health educator should proceed from known fact to unknown fact. Before starting a health education first ask questions to know how much he/she knows about the topic already then proceed to new knowledge. The existing knowledge of the person should be used as base on which to hang new knowledge. As for example, if health education is on hypertension, then first ask question to assess people’s knowledge on hypertension. As ask “what do you mean by hypertension”, “what are the management of it”, etc. Then add up the point to improve their knowledge level.

Setting an example: The health educator should act as a role model. As if people are seeing him/her to smoke and giving health education on health effects of smoking, definitely the health education will not be effective, people will not listen it.

Good human relations: It can be developed by communication skill. Sharing of information, ideas and feelings happen most easily among people who have a good relationship.

Feedback: Feedback or evaluation of health education helps to understand that any modification message or channel is needed or not. Ask questions on the topic what was taught through health education.

Leaders: Community leaders (village headman, school teacher, political worker, panchayat sarpanch) are the best person to approach for health education program as local people listen to them most.

Fig. 6.1

APPROACHES OF HEALTH EDUCATION

There are 4 well-known approaches to health education:

1. Regulatory approach (managed prevention): Regulated by laws (governmental intervention) placed on people to bring changes in health behavior and improvement of health. As for example, the child marriage restraint act in India, compulsory use of seat-belts in western countries.

2. Service approach: It was started with the aim of providing all the health services needed by the people at their door steps with assumption that people will use them to improve their own health. But as it was not on the basis of felt needs of people so this approach failed to achieve its aim. As for example, water seal latrine was made free of cost in rural areas, but people did not use it as it not their habit.

3. Health education approach: If a person is aware about their health problems and its fatality then they will take care of it themselves. Thus if the necessary behavior changes are to take place, people must be educated and encouraged to make their own choice for a healthy life. As for example, health education on caseation of smoking, use of safe water supply, family planning, etc. Health education can be given through:

• Individual approach (personal contact, home visits, etc.)

• Group approach (lectures, demonstration, group discussion, role play, panel discussion, symposium, workshop, conference, seminars, etc.)

• Mass approach (television, radio, newspaper, printed material, posters, exhibition, folk media, internet, etc.)

4. Primary health care approach: This new approach was started with the aim to make individual self-reliant in matters of health. It is done through full participation of community people and intersectoral coordination (principle of primary health care).

Fig. 6.2: Approaches of health education

SCOPE OF HEALTH EDUCATION IN COMMUNITY AREA

Various topics can be chosen in community for care and health education. It is not mandatory that topic has to be some disease condition or health. In community health education starts from primordial prevention to prevention of complication through care given. Thus any one at risk, not at risk or having any health problem or even any problem in community in general can be taken as health education topic.

• Any age group: Newborn, infant, toddler, school children, underfive children, adolescent, adult, old age (male and female).

• Any normal physiological changes: Antenatal, natal, postnatal mother, pubertal changes.

• Any disease condition: Diabetes, hypertension, HIV/AIDS, diarrhea, heart diseases, gastritis, peptic ulcer, cancer, osteoporosis, etc.

• Any symptoms: Backache, headache, etc.

• Psychological problems: Depression, relaxation technique, etc.

• Health habits: Personal hygiene, smoking, alcoholism, drug addiction, substance abuse, etc.

• Nutritional problems: Malnutrition, obesity, protein energy malnutrition, etc.

• Special groups: Tribals, handicapped, etc.

• Vulnerable groups/at risk: Presence of hereditary disease, low standard of living, low socioeconomic condition, slum area.

• Community problems: Transportation problem, noise pollution, air pollution, water pollution, environmental sanitation, inadequate health facilities, etc.

Health education plays a very important role in community to modify people’s behavior. But health education becomes more effective when health educator uses audiovisual aids (AV aids) along with it. AV aids help to simplify unfamiliar concepts and reinforce learning.

AUDIOVISUAL AIDS

Audiovisual aids are devices that help teacher to clarify, establish, correlate, coordinate, appreciate and interpret to make learning more effective, interesting and meaningful. Observation and research by Cobun (1968) says that people generally remember 10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they hear and see, 70% of what they say and 90% of what they say as they do a thing. As says Chinese proverb “I hear, I forget; I see, I remember; I do, I understand”. A Dutch humanist and writer Desiderious Erasmus (1466–1536) discouraged memorization as a technique of learning and advocated that children should learn through the aids of picture or other visuals.

Definition of Audiovisual Aids

• Audiovisual aids (AV aids) are those sensory objects or images which initiate or stimulate and reinforce learning—Burton.

• Audiovisual aids are anything by means of which learning process may be encouraged or carried on through the sense of hearing or sense of sight—Good’s Dictionary of Education.

Classification of AV Aids

Any type of the following AV aids can be used during health education depending on the understanding level of audience.

1. Projected and non-projected aids

• Projected aids: Films, filmstrips, opaque projector, overhead projector, slides.

• Non-projected aids:

– Graphic aids (cartoons, charts, diagrams, flash cards, graphs, maps, photographs, posters, etc.)

– Display boards (black board, bulletin, flannel board, ped board, etc.)

– 3-dimensional aids (diagrams, models, mockups, objects, puppets, specimen)

– Audio (radio, recordings)

– Visual (television)

– Activity aids (computer assisted instructions, demonstration, dramatics, experimentation, field trips, teaching machines, programd instruction).

2. Audio material, visual material and audiovisual material

• Audio materials: Language laboratories, radio, sound distribution system sets, tape and disco recordings.

• Visual materials: Bulletin boards, chalk boards, charts, drawings, exhibits, filmstrips, flash cards, flannel boards, magnetic boards, models, pictures, posters, slides, silent films.

• Audiovisual materials: Demonstration, films, printed material with recorded sounds, sound filmstrips, study trips, television, videotapes.

3. Big media and little media

• Big media: computer, VCR and TV.

• Little media: Radio, filmstrips, graphic, audio cassettes and various visuals.

Characteristics of AV Aids

They should be:

• prepared as per the understanding level of

audience

• clearly visible

• innovative

• easily portable

• up-to-dated

• simple but attractive

• accurate in every aspect

• meaningful to achieve the goal

Fig. 6.3: Use of chart and model in health education

Advantages of using AV aids

• Antidote to the disease of verbal instruction

• Best motivators

• Vicarious experience

• Provides variety in learning

• Opportunities to handle and manipulate

• Based on maxims of teaching

• Helpful in attracting attention

• Helpful in fixing up new learning

• Saves energy and time

• Provides teaching based on realism

• Vividness generated more interest

• Meeting individual differences

• Encouragement to healthy classroom interaction

• Spread of education in a mass scale

• Reinforcement of learners.

Bibliography

1. Donatelle R (2009). Promoting Healthy Behavior Change. Health: The basics (pp. 4). 8th edition. San Francisco, CA: Pearson Education. Available on: http://community,medchrome.com/2011/06/principles-of-health-education.html.

2. Health Education. [Internet] 2014 [cited 2014 Nov 11]. Available from: www.who.int/topics/health_education/en.

3. McKenzie J, Neiger B, Thackeray R. Planning, Implementing, and Evaluating Health Promotion Programs: A Prime, 5/E [Internet] 2009 [cited 2014 Aug 16]. Available from: http://www.pearsonhighered.com/educator/product/Plarming-Implementing-and-Evaluating-Health-Promotion-Programs-A-Primer/9780321495112.page#sthash.ktzPuvr2.dpuf.

4. Park K. Preventive and social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

5. Sabarish P. Introduction to Audiovisual Aids in Education. (Internet 2014) Cited on 9/8/2015 (Available on: http://sabarishedn.blogspot.in/2014/03/introduction-to-audio-visual-aids-in_18.html).

6. Surbhi. What are the Aims and Objectives of Health Education in India? [Internet] 2012 [cited 2014 Sep 24]. Available from: http://www.preservearticles.com/201105156673/aims-and-objectives-of-health-education.html.

7. Surbhi. What are the Basic Principles of Health Education? [Internet] 2012 [cited 2014 Sep 24]. Available from: http://www.preservearticles.com/201105156674/principles-of-health-education.html.

7

Community Health Nursing Process

This chapter contains

▪ Definition

▪ Characteristics

▪ Advantages

▪ Components

• Assessment

• Nursing Diagnosis

• Outcome Identification

• Planning

• Rationale

• Implementation

• Evaluation

▪ Model Nursing Process

INTRODUCTION

Community is a social group determined by geographical boundaries and/or common values and interests. Its members know and interact with each other. It functions within a particular social structure and exhibits and creates certain norms, values and social institutions. The individual belongs to the broader society through his family and community (WHO Expert Committee).

Process denotes the act of continuously moving forward from one point to another on the way to a goal. Nursing process is a series of planned steps and actions taken to meet the needs and to solve the problems of patients and their families in a systematic way. It is a method for organizing and delivering nursing care.

DEFINITION

“Nursing process is an orderly, systematic manner of determining the patients, problems, making plans to solve them, initiating the plan or assigning others to implement it, and evaluating the extent to which the plan was effective in resolving the problems identified” (Yura and Walsh 1978).

Nursing process is applicable in community, not only to provide individualized care to a single client but to provide a comprehensive care to family, whole community along with individual client care.

CHARACTERISTICS OF COMMUNITY HEALTH NURSING PROCESS

Community health nursing process should be:

• client focused.

• problem oriented.

• goal oriented.

• the base to plan for care.

• a systemic and scientific problem-solving approach.

• a systematic plan of care for individual as well as family and community.

• a series of planned steps as assessment, setting priorities, planning, implementation and evaluation.

• a management process which requires analysis of a situation, decision making, planning, organizing to achieve goal.

• a changing process which helps health workers to improve health related systems and people’s behavior within that system.

• a plan to set the priorities of nursing care.

• an ongoing or cyclical action as reassessment, reordering of priorities, new goal setting and revision of nursing care plan.

Fig. 7.1

ADVANTAGES OF COMMUNITY HEALTH NURSING PROCESS

Nursing process in community helps community health nurse in various ways:

• Creates a health data record of a client, family and community.

• Identifies actual or potential problems.

• Establishes priorities of nursing care to provide need based service.

• Saves time by systematic planning.

• Plans alternatives of nursing actions.

• Fosters nursing accountability

• Increases effectiveness of nursing care.

• Evaluates the effectiveness of nursing care.

• Directs to change plan of actions if needed.

COMPONENTS OF COMMUNITY HEALTH NURSING PROCESS

The community health nursing process involves a series of components. The major components are:

1. A—Assessment (what data is collected?)

2. D—Nursing Diagnosis (what is the problem?)

3. O—Outcome Objectives (what goal is to be achieved?)

4. P—Plan of Action (how to manage the problem?)

5. R—Rational (providing justification of each plan of action)

6. I—Implementation (putting plan into action)

7. E—Evaluation (did the plan work?)

Assessment

Assessment is a deliberate, systematic and logical collection of subjective and objective data that are helpful to identify and define problems of the client, before the nurse proceeds to plan the care.

Community health nurse completes a holistic nursing assessment of the needs of the individual/family/community. Elolistic assessment denotes the gathering of information about a client’s physiological, psychological, sociological, and spiritual status as well as complete family and community history where client belongs. The nurse collects data using a nursing framework.

Types of Assessment

• Initial assessment: Done in first visit to home.

• Focus assessment: It collects data about a problem that has been identified in initial assessment.

• Time lapsed reassessment: Periodic assessment.

• Emergency assessment: Done in acute or life-threatening situations.

Methods of Data Collection

• Client interview

• Physical examination

• Obtaining a health history (including dietary data)

• Family history/report

• Diagnostic data/laboratory investigation reports

• Observation.

Types of Data Collected

1. Subjective data: Information obtained directly from client or family members or caregiver.

2. Objective data: Information collected through observation, physical assessment, nutritional assessment, diagnostic data, etc.

Formats of Data Collection

There are various formats to collect data. The use of an evidence-based nursing framework such as Gordon’s Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses. For accurate determination of nursing diagnoses, a useful, evidence-based assessment framework is best practice (Appendix A). A very commonly used data collection format is given in Appendix B. Also use typology of family (Appendix H) and family coping index (Appendix I) to collect complete data about the family.

After complete data collection by using above formats, own observation and client’s record, community health nurse formulates nursing diagnosis based on priority problems.

Example of Assessment

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one-day nursing care plan (Table 7.1).

Table 7.1: Assessment

Subjective data:

Family member said he has developed a wound in his back by lying down for long time.

Objective data:

He is bed-ridden for last 6 months. Presence of second degree bedsore in his sacral region.

Community Nursing Diagnosis

North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as “a clinical judgment about individuals or community responses to actual or potential health problems/life processes”.

Community diagnosis is a comprehensive assessment of health status of the community in relation to its social, physical and biological environment. Community diagnosis is done based on the collection and interpretations of data. Use direct community problems or NANDA diagnosis (Appendix C).

After selecting nursing diagnosis, validation with client has to be carried out to legitimize the diagnosis. It also helps to find out the significance of the problem to the client.

Purposes of Community Diagnosis

• To define existing problems

• To identify population at risk

• To determine available resources

• To analyze the health status of the community

• To set priorities for planning, implementing and evaluating health action.

Fig. 7.2: Steps of formulating nursing diagnosis

To analyze assessment data is helpful to categorize the data. This may be done as following by dividing data into eight subsystems (Appendix B):

• Physical environment

• Education

• Safety and transportation

• Politics and government

• Health and social services

• Communication

• Economics

• Recreation.

Characteristics of Community Health Nursing Diagnosis

• It is a conclusion resulting from identification pattern or cluster of signs and symptoms.

• It is made based on subjective and objective data.

• It is a statement of community’s problem.

• It refers to a health state or potential problem.

• It is a statement of nursing judgment.

• It refers to physical, psychological, sociocultural and spiritual conditions.

• It is a short and concise statement.

• It has three parts including etiology and causes of diagnosis.

• It refers the conditions that can be treated independently by a nurse.

• It should be validated with community people whenever possible.

• Etiology/risk factors and causes of diagnosis, so changes according to client to client, situation to situation.

Guidelines for Writing Community Health Nursing Diagnosis Statement

• Write in terms of the client response rather than the nursing needs.

• Use “related to” rather than “due to” or “caused by” to connect the diagnosis and etiology of the statements.

• Use “as evidenced by” to connect etiology and causes of diagnosis.

• Write the diagnosis in legally advisable terms.

• Write the diagnosis without value judgment.

• Avoiding reversing the parts of the statement.

• The three parts of the statement should not mean the same thing.

• Avoid using single symptoms in the first part of the statement.

• Express the related factors in terms that can be changed.

• Do not include medical diagnosis in the nursing diagnosis statement.

• State the diagnosis clearly and concisely.

Example: Diarrhea related to use of contaminated water as evidenced by passing watery loose motion more than three times per day, taking drinking water from pot by dipping unwashed hand, dirty nails, etc.

Fig. 7.3: Nursing diagnosis

Areas to Formulate Community Health Nursing Diagnosis

1. Health problems: Any disease and disability; malnutrition; lack of health knowledge and attitude; etc.

2. Health service problems: Lack of qualified health personnel (insufficient staff); insufficiency and inaccessibility of material for treatment (insufficient drugs and other supplies); inadequate working conditions; lack of transport; insufficient visit to community by health staff, etc.

3. Communication problems: No roads to community; bad roads; inadequate transport; seasonal variations, etc.

4. Community problems in general: Inadequate water supply; contaminated water supply; illiteracy; poor environmental sanitation; bad and overcrowded housing; drought; unemployment; poverty, etc.

Concept of Community Diagnosis

1. Individual diagnosis: In the individual diagnosis, the content covers an important category of information such as:

a. What is the specific disease process, its stage of evolution and its progress? Has any treatment already been given and what has been the effect of this?

b. What is the nutritional status of the individual?

c. If the patient is a child or adolescent, what is the level of development?

d. In an adult, is there any physiological state such as pregnancy or lactation?

e. What is the immunological background?

f. What is the state of emotional, mental and social adjustments?

g. What is the socioeconomic and environmental situation in which the individual lives?

h. What is the state of knowledge of the individual or parent and the need for specific health education?

2. Family diagnosis: In the family diagnosis the process becomes more complicated as it depends on individual diagnosis of the family members having been made first. After this there should be process of comparing and contrasting individual diagnosis to obtain some measures of understanding the reason for various levels of health in the family. After family diagnosis formulation of program of care for a single individual.

3. Community diagnosis: In community diagnosis there are similarities to individual and family diagnosis but the amount of the data is much greater and requires more lengthy analysis and usually mechanical processing. This survey data should cover health matters, use of services and their effectiveness, sociological and cultural information and ecological or environmental data.

As for example:

While home visiting community health nurse found that in a house Mr X (50 years of age) has bedsore as he is bed-ridden due to hemiparesis for last few months.

After collecting all data by history taking, observing care giver’s activities, family care for Mr X, socioeconomic condition of family, by analyzing nearby health resources, by reviewing doctor’s records, by doing physical assessment and nutritional assessment of Mr X, community health nurse formulated the following community nursing diagnosis:

Individual Diagnosis (Mr X; 50 years)

1. Impaired integrity related to prolonged immobilization as evidenced by presence of pressure sore on sacral region.

2. Nutrition, less than body requirements related to inadequate intake as evidenced by thin feature, less calorie (approx. 1000 kcal less per day) and protein (approx. 20 gm less per day) intake than required found in nutritional assessment.

3. Self-care deficit related to hemiparesis as evidenced by unable of doing daily life activities (bathing, toileting, dressing, grooming, feeding, etc.)

4. Comfort, impaired related to prolong immobilization as evidenced by observed that he cannot turn himself, he verbalized that he feels very discomfort by lying in same position for long.

5. Urinary elimination, impaired related to inadequate fluid intake as evidenced by less urine output, dark colored urine, fluid intake less than 2 L per day.

6. Social interaction, impaired related to immobilization as evidenced by he cannot go out and talk to neighbors, neighbors avoid to come due to bad smell of bedsore.

7. Loneliness related to impaired social interaction as evidenced by he verbalized that “family members all are busy in own work, no one to talk much.”

8. Sleep pattern, disturbed related to prolong bed rest as evidenced by red eyes, yawing while talking, verbalized that “I get very on and off sleep at night.”

9. Coping, ineffective related to prolong suffering as evidenced by family members verbalized that he is getting irritated nowadays in very small reason, he too verbalized that “I do not want to live more in this condition”.

10. Acute pain (painful shoulder and back) related to hemiparesis and disuse as evidenced by he verbalized that “I feel shoulder and back pain due to lying continuously”, pain was 8 according to pain scale.

11. Spiritual distress, risk for related to prolong suffering as evidenced by his verbalization that “my faith on God is going down as he is not curing me”.

12. Infection, risk for related to open wound as evidenced by presence of pus in bedsore.

13. Constipation, risk for related to prolong immobilization as evidenced by stool not passed for last two days, distended abdomen, bowel sound less approx. 5 per minute.

14. Deficient fluid volume, risk for related to blood loss as evidenced by soaked dressing found during bedsore dressing.

Family Diagnosis

1. Caregiver, role strain related to knowledge deficit as evidenced by family member verbalized “we feel stress as we are scared to do dressing and change position in this condition of him”.

2. Coping, compromised family related to presence of bed-ridden patient at home as evidenced by family members look stressed, family coping index score is as follows:

Table 7.2

3. Knowledge, deficient related to pressure sore care as evidenced by cannot appropriate answer to the questions regarding pressure sore care.

4. Therapeutic regimen management, ineffective family related to management of hemiparesis patient as evidenced by cannot demonstrate bedsore dressing aseptically, cannot change position of patient skillfully.

5. Poverty related to continuous treatment of Mr X as evidenced by verbalization of family members that “doctor’s fee and medicines for Mr X is very costly”.

6. Negative attitude of family related to health care facilities as evidenced by verbalization of family members that “in PHC, medicines are not available, care is not proper”.

Community Diagnosis

1. Lack of qualified health personnel related to taking care of hemiparesis patient with bedsore as evidenced by not maintaining asepsis during dressing in PHC.

2. Insufficient visit to community by health staff related to lack of health staff in PHC as evidenced by no home visit by health staff for a last few months.

3. Inadequate transport related to less bus and taxi service in that area as evidenced by no vehicle available to take Mr X to hospital in emergency.

4. No primary education related to health care and health care service as evidenced by very less botheration of infection, personal hygiene, facilities available in govt sectors.

5. Bad and overcrowded housing related to poverty as evidenced by poor ventilation, poor lighting, and unhygienic environment.

6. Non-cooperation of neighbor related to self-centeredness or social stigma as evidenced by no one helping Mr X’s family while transporting to vehicle to take him to hospital.

Establishment of priority

A priority means to assign greater or lesser importance to various problems identified. After forming nursing diagnosis, it has to be arranged according to the priority needs of the individual, family and community to set plan of care. It can be done by identifying communities “felt needs”, “observed needs” and “real needs”.

Felt needs: Are those health and/or development needs that the people in a community perceive (understand and feel) to be what they need in order to improve their health or socioeconomic status.

Observed needs: Are those health and/or development needs which are often seen by outside experts or community health nurse.

Real needs: Are those results from a jointly developed understanding of priority needs of the local people and priority needs decided by either expert teams or community health nurse.

Principles for prioritization of the problem

There are five basic principles to prioritize the problems:

1. Give more importance to common problems (e.g. diarrhea, malnutrition, etc.) than to the rare ones.

2. Give more importance to serious problems (e.g. dehydration, pneumonia, etc.) than to the less serious problems.

3. Give more importance to more easily preventable health problems (e.g. cholera) rather than to those that are difficult to prevent.

4. Give more importance to the health problems that show upward trend in a given time than to those that are static (not increasing) or declining (not occurring frequently).

5. Consider to the community priorities.

Example of Nursing Diagnosis

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan (Table 7.3).

Table 7.3

Assessment
Nursinv Diagnosis

Subjective data:
Family member said he has developed a wound in his back bv lying down for long time.
Objective data:
He is bed-ridden for last 6 months. Presence of second degree bedsore in his sacral region.
Altered skin integrity related to prolonged immobilization as evidenced by presence of pressure sore on sacral region.

Outcome Identification

Outcome identification or outcome objective refers to formulating and documenting measurable realistic, client focused goals based on prioritized nursing diagnosis. These objectives help the community health nurse, client and family to evaluate client’s progress towards desired outcome as well as the effectiveness of the nursing interventions. The objectives also help to define specific behaviors, demonstrating that the problem has been corrected, minimized or prevented.

Objectives may be

1. Short-term goal: To be completed in immediately or within short time period, e.g. emergency problems; soaked wound.

2. Long-term goal

Outcome Criteria

Objectives should be SMART:

• Specific

• Measurable

• Attainable

• Realistic statements of goal attainment

• Time limited

• Related to problem statement

• Client centered

• Clear and concise

• Determined by nurse and client or family.

Example of Outcome Objective

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan (Table 7.4).

Table 7.4

Assessment
Nursing diagnosis
Outcome objective

Subjective data:
Family member said he has developed a wound in his back by lying down for long time.
Impaired tissue integrity related to prolonged immobilization as evidenced by presence of pressure sore on sacral region.
Client will achieve continuous tissue integrity, i.e. healed bedsore by one week.

Objective data:
He is bed-ridden for last 6 months. Presence of second degree bedsore in his sacral region.

Planning

Planning (also called forethought) is the process of thinking about and organizing the activities required to achieve a desired goal. It is a fundamental property of intelligent behavior. This thought process is essential to the creation and refinement of a plan, or integration of it with other plans; that is, it combines forecasting of developments with the preparation of scenarios of how to react to them.

Planning is the fourth phase in nursing process. For each goal/outcome, the community health nurse selects nursing interventions that will help to achieve the goal/outcome. It provides direction for nursing care. Plan of care is written summary of the care that client, family or community is to receive.

Purposes of Planning

• Provides direction to client care activities.

• Establishes continuity of care.

• Helps to focus on problem/need based care.

Nursing interventions “are any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcome” (Mcdoskey and Bulechek, 1996). Clinical knowledge and practice are required to plan appropriate care. Interventions should be plan on all health dimensions as physical, psychomotor, psychosocial, educational, maintenance, surveillance, supervisory and sociocultural.

Example of Planning

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan (Table 7.5).

Table 7.5

Rationale

Rationale is an explanation of the basis or necessary reasons for something. Rationale is an very important step of planning. A nursing rationale is written next to each nursing intervention planned in the nursing care plan. The rationale is the “why” of the nursing care plan. It is the explanation provided for performing any nursing care.

Example of Rationale

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan (Table 7.6).

Table 7.6

Implementation

It is the action phase. In this phase community health nurse initiates the action which was planned based on need found and documenting all nursing actions done. Implementation means to carry out, to intervene, to perform or to do something. It may be dependent interventions (based on medical orders); interdependent interventions (working along with other health team members); or independent nursing intervention (performed by nurse without doctor’s order).

Guidelines for Effective Interventions

1. Dated: Date of intervention must be specified to evaluate the care.

2. Use action verb: Helps to define specific nursing interventions (Appendix C).

3. Should be consistent with the plan of care.

4. Should be client’s need centered.

5. Documentation of each intervention must be done.

In order to coordinate work effectively the community health nurse must:

1. Coordinate the members of other health members of health care team.

2. Coordinate the activities and arrange an activity schedule.

3. Coordinate plan of action with client, family members and community.

4. Coordinate with community leaders.

5. Use community resources.

Example of Intervention

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan (Table 7.7).

Table 7.7

Evaluation

Evaluation determines the extent up to which the goals of nursing care have been achieved. It is a continuous process carried out throughout all phases of nursing care. It defines client’s progress and effectiveness of nursing care. The community health nurse have to use variety of skills to judge the effectiveness of nursing care as comparing withstandard nursing care, client’s response, nursing theory (conceptual models), comparing with clinical researches, etc.

Definition

Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals; in this phase nurse compares the client behavioral responses with predetermined client goals and outcome criteria (Craven 1996).

Purposes

• Identifies the change in client’s behavioral response to nursing intervention.

• Compares client’s behavioral response with predetermined outcome.

• Evaluates the extent of achievement of set goal (partial or complete achievement of goal)

• Provides strong evidence to reassess and replan to provide more effective care.

• Measures the productivity of available resources to achieve goal.

• Monitors the quality of nursing care.

• Identifies the errors in the plan of care.

Activities in Evaluation Phase

Activities in evaluation phase are shown in Fig. 7.4.

Fig. 7.4: Activities in evaluation phase

Example of Evaluation

(Client with bedsore due to prolonged bed rest due to hemiparesis)—one day nursing care plan.

Evaluation: Wound healing was observed (tissue red, no pus formation).

Model Nursing Process

Table 7.8: Client with bedsore due to prolonged bed rest due to hemiparesis—one day nursing care plan

As nursing process is a dynamic process. In example, it has been shown one day nursing care plan. Each day reassessment has to be done, on that basis nursing diagnosis has to be prioritized and care should be planned. Nursing process should be continued till either one of the following conditions occur:

• the problem has been solved.

• patient cured.

• patient died or migrated.

• duty of the nurse completed in that particular area.

Bibliography

1. Basavanthappa BT. Community Health Nursing. Bangalore: Jaypee; 1999.

2. Edelman CL and Mandle CL (2006). In: D Como, Thomas L (Eds.), Health Promotion Throughout the Lifespan. St. Louis, Missouri: Mosby.

3. Gebbie KM and Lavin MA. Proceedings of the First National Conference on the Classification of Nursing Diagnoses. St. Louis: Mosby; 1975.

4. Gordon M. Nursing Diagnosis: Process and Application. Third Edition. St. Louis: Mosby; 1994.

5. Herdman T. Nursing Diagnoses: Definitions and Classification. Wiley-Blackwell: Singapore; 2009–2011.

6. Kamalam S. Essentials in Community Health Nursing Practice. New Delhi: Jaypee Brothers; 2005.

7. Nancy. Principles and Practice of Nursing. 6th ed. Indore: NR Brothers; 2009.

8

School Health

This chapter contains

▪ History of Schools

▪ Components of School

▪ Responsibilities of Teachers

▪ School Health Service

• Objectives

• Components

▪ Healthful School Environment

▪ Importance of Healthy School Environment

▪ Purposes to Improve School’s Physical Environment

▪ Health Threats and Diseases in School

▪ Preventive Measures

▪ School Health Nursing

INTRODUCTION

A school is an institution designed for the teaching of students (or “pupils”) under the supervision of teachers. School age is the age which is moldable. After home, school is the place where child learns how to behave, how to live, how to gain success in life.

HISTORY OF SCHOOLS

The concept of grouping students together in a centralized location for learning has existed since classical antiquity. According to traditions and encounters, the founding of primary education began in 425 AD and “military personnel usually had at least a primary education”. In ancient India, schools were in the form of Gurukuls. Gurukuls were traditional residental schools of learning; typically the teachers’s house or a monastery. During the Mughal rule, Madrashas were introduced in India to educate the children of Muslim parents. British records show that indigenous education was widespread in the 18th century, with a school for every temple, mosque or village in most regions of the country. The subjects taught included reading, writing, arithmetic, theology, law, astronomy, metaphysics, ethics, medical science and religion. Under British rule in India, Christian missioners from England, USA and other countries established missionary and boarding schools throughout the country. These schools marked the beginning of modern schooling in India.

Components of School

A school should maintain the following criteria to provide adequate facilities to the students:

• A calm and quiet environment

• Specialized classrooms including laboratories for science education.

• Office

• Library, cafeteria, dining hall or canteen.

• Athletic field, playground, gym.

• Auditorium or hall.

• Computer

• Required number of teachers

• Accessibility to potable water

Responsibilities of Teachers

Teacher is the role model of society. Teacher produces the future citizen of country. Thus they have a huge responsibility to build up morally and physically healthy, as well as academically sound students.

• Inoculate model behavior and mannerisms by self-example.

• Prepare teaching programs according to school’s education system.

• Understand and implement the use of information technology in lesson preparation and teaching.

• Shifts between formal and non-formal methods of teaching, debates, discussion, practical activities, experiments, projects and excursions.

• Plan, set and evaluate grade test, exam and assignments.

• Supervise student conduct during class, lunch time and other breaks.

• Understand the diverse background student comes from, their strength, weakness and areas of interest.

• Being honest in honest appraisal, avoid favoritism.

• Enforce discipline by firmly setting classroom rules.

• Resolve conflict among students by encouraging debate.

• Being ready to adjust teaching styles to meet individual need of student.

SCHOOL HEALTH SERVICES

An important branch of community health is “school health”. The primary health centers are at charge to conduct school health program. It requires a whole time medical officer to cover 5,000 to 6,000 children a year.

Objectives of School Health Services

• Promotion of positive health

• The prevention of diseases

• Early diagnosis, treatment and follow-up of defects

• Awakening health consciousness in children

• Provision of healthful environment

Components of School Health Service

1. Health appraisal of school children and school personnel: Students should be assessed daily for dress codes, hygiene and any abnormal change. Periodical check should be arranged to detect any problem. A few signs and symptoms which need urgent attention are unusually flushed face, any rashes, running nose, coughing and sneezing, soar throat, rigid neck, nausea and vomiting, headache, chills, fever, diarrhea, skin diseases, sudden behavioral changes, etc.

2. Remedial measures and follow-up: If any abnormality detected from daily or periodical check-up, child should be treated or referred for needed treatment immediately along with follow-up service.

3. Prevention of communicable diseases: Immunization status has to be checked for respective age of students. A well-planned immunization program can be held in school too (Fig. 8.1).

Fig. 8.1

4. Healthful school environment: Minimum standards for constructing a school has been explained later in this chapter.

5. Nutritional services: Mid-day school meal program is the most common and regular program carried out in schools. According to the diagnosis of nutritional deficiencies specific nutrients should also be provided (Fig. 8.2).

Fig. 8.2

6. First aid and emergency care: Commonly occurred emergency in schools are accidents and injuries, medical emergencies as gastroenteritis, colic, fits, etc. Every school should have a fully equipped First Aid Box and First Aid Post of St. John Ambulance (Fig. 8.3).

Fig. 8.3

7. Mental health (Fig. 8.4): Mental health of the children affects their physical health and the learning processes. Juvenile delinquency, maladjustment and drug addiction are growing problems among school children. School is the place which helps to develop children into mature, well-adjusted and responsible adults.

Fig. 8.4

8. Dental health: Dental diseases and defects are very common among school students. A school health program should carry out dental check-up in regular basis with the help of dental hygienist and school health nurse. They teach students about dental hygiene and encourage their parents to maintain that at home also.

9. Eye health: School should also be responsible for early detection of refractive errors, squint, amblyopia (decreased vision) and detection and treatment of eye infections such as trachoma. Vitamin A is also administered to the children at risk.

10. Health education: With the goal to achieve positive behavioral changes health education on various topics are given to school children. Health education covers various areas as personal hygiene, environmental hygiene, family life, healthy habits, balanced diet, road safety, etc.

11. Education of handicapped children: The ultimate goal is to assist the handicapped chidren and their families to make the child able to her/his maximum level within her/his limitations.

12. Proper maintenance and use of school health records: A cumulative health record of each student should be maintained which should contain identification details and personal details of student, findings of regular health check-up, any medical emergency faced during school life, immunization history, treatment, etc.

Healthful School Environment

The American Academy of Pediatrics defines a “healthful school environment” as “one that protects students and staff against immediate injury or disease and promotes prevention activities and attitudes against known risk factors that might lead to future disease or disability.” The following minimum standards for sanitation of the school and its environments have been suggested in India:

1. Location: The school should be located centrally with access of roads and transportation but at a fair distance from busy places as markets, cinema house; should be away from polluted area as factories, bus stands; away from accidental area as railway tracks.

2. Site: School should be constructed on suitable high land with proper drainage system. The School Health Committee (1961) recommended 10 acres of land for higher elementary schools and 5 acres for primary schools with an additional 1 acre of land per 100 students. In congested areas, the nearest public park or playground should be made available to the students.

3. Structure: Nursery and secondary schools, as far as possible, should be singlestoried. Exterior wall should have a minimum thickness of 10 inches and should be heat resistant.

4. Classrooms: Verandas should be attached to classrooms. No classroom should be accommodating more than 40 students. Per capita space for students in a classroom should not be less than 10 sq. ft.

5. Furniture: At least single desk and chair should be provided to each child. Chair should be provided with proper back rests with facilities for desk work.

6. Doors and windows: The windows should be broad with the bottom still, at a height of 2–6 feet from the floor level; combined door and window area should be at least 25 percent of the floor space. Windows should be placed on opposite wall for cross-ventilation. Ventilators should not be less than 2% of the floor area.

7. Color: Inside color of the classroom should be white and should be periodically white washed.

8. Lighting: Classrooms should have sufficient natural light, preferably from the left, and should not be from the front.

Fig. 8.5: Factors affect school health

9. Water supply: There should be an independent source of safe and potable water supply. Water should be continuous and distributed from the taps.

10. Eating facilities: Vendors only approved by school authority should be allowed inside school premises; there should be a separate room provided for mid-day meal.

11. Lavatory: Clean toilets should be provided. One urinal for 60 students and one latrine for 100 students are recommended. Privies should be separately made for girls and boys.

A healthy school environment can directly improve children’s health and effective learning and thereby contribute to the development of healthy adults as skilled and productive members of society. To maintain healthy school environment:

1. Every school should have a health and safety committee comprised:

• administrators

• classroom teachers

• parents

• maintenance personnel

• school nurse

• teachers from various streams

• laboratory science teachers

• food service personnel

• school resource officer

The committee should develop and ensure the implementation of plans for safe, healthy and well-maintained school buildings and grounds. The committee should be empowered to deal with ongoing maintenance and repair issues, as well as ongoing and emerging health or safety issues related to the physical environment of schools and school grounds.

2. Every school should practice emergency response drills for a variety of likely hazards and situations.

3. Schools should implement programs to maintain good indoor air quality such as the EPA’s Tools for Schools program (Environmental Protection Agency).

4. School maintenance staff should practice Integrated Pest Management (IPM) and cleaning for health also known as green cleaning.

5. Schools should use automated systems such as Computerized Maintenance Management System (CMMS) or well-maintained hand written register to record and analyze maintenance issues and trends.

6. Schools should establish procedures for managing chemicals used in science classes to include storage, reordering, and disposal.

Purposes to Improve School’s Physical Environment

The physical school environment has a strong influence on children’s health for several reasons.

First, the environment is one of the primary determinants of children’s health: contaminated water supplies can result in diarrheal disease; air pollution can worsen acute respiratory infections and trigger asthma attacks; and exposure to lead, arsenic, solvents, and pesticides can cause a variety of health effects and even death.

Second, children may be more susceptible to the adverse health effects of chemical, physical and biological hazards than adults. Reduced immunity, immaturity of organs and functions, and rapid growth and development can make children more vulnerable to the toxic effects of environmental hazards than adults. Relative to their body weight, they breathe more air, consume more food and drink more water than adults. Their exposure to any contaminant in air, water or food will, therefore, be higher than experienced by adults. Children spend much of their day within school environments during these critical developmental stages.

Third, children’s behavioral patterns are distinctively different from adults and place them at risk from exposure to environmental threats that adults may not face. These behaviors include placing fingers and other objects in the mouth and not washing hands before eating. Children lack the experience to judge risks associated with their behaviors. Adolescents, in particular, are more likely to take risks, such as climbing and jumping from unstable structures.

WHO defines a health-promoting school as “one that constantly strengthens its capacity as a healthy setting for living, learning and working”. Provision of safe and sufficient water, sanitation, and shelter from the elements are basic necessities for a healthy physical learning environment. Equally important is the protection from biological, physical, and chemical risks that can threaten children’s health. Infectious diseases carried by water, and physical hazards associated with poor construction and maintenance practices are examples of risks that children and school personnel face at schools throughout the world.

Table 8.1: List of health threats in school

SI. No.
Threats
Example of threats

1.

Biological threats

• Molds

• Unsafe or insufficient water

• Unsafe food

• Vector-borne diseases

• Venomous animals

• Rodents and hazardous insects

• Other animals (e.g. dogs)

2.

Physical threats

• Traffic and transport

• Violence and crime

• Injuries

• Extreme heat and cold

• Radiation

3.
Chemical threats

• Air pollution

• Water pollution

• Pesticides

• Hazardous waste

• Hazardous materials and finishes

• Asbestos, paint

• Cleaning agents

Health Threats and Diseases in School

If school fails to provide shelter, warmth, potable water, safe food, adequate light and ventilation, sanitary facilities, emergency medical care, etc. then students and school personnel can face several threats.

Preventing childhood exposure to environmental hazards may prevent immediate illnesses (e.g. respiratory infections and diarrheal diseases) and chronic illness (e.g. cancer). Students can suffer from several diseases acquired from school environment as discussed below.

1. Respiratory infections: Respiratory infections are the most common among all diseases in children, and pneumonia is the primary cause of childhood mortality worldwide due to indoor and outdoor air pollution. These can be prevented by constructing well-ventilated classrooms and construction of school building away from main roads, industrial area and polluted area.

2. Diarrheal diseases: Diarrheal diseases, the second most common global illness affecting young children and a major cause of death in lower income countries, are closely linked with poor sanitation, poor hygiene, and lack of access to safe and sufficient supplies of water and food. School should have the access of potable drinking water, supply of soap for hand washing, should maintain food hygiene in mid-day meal program and dining area, maintenance of sanitation of toilet, drainage, etc.

3. Vector-borne diseases: Vectors are organisms that transmit diseases and include mosquitoes, ticks, flies, fleas, bugs, worms, and rodents. Mosquitoes can transmit malaria, dengue fever, yellow fever, lymphatic filariasis, Japanese encephalitis. Ticks can transmit Lyme disease, tick-borne encephalitis, relapsing fever, and many other illnesses. Rodents are capable of spreading the plague. Clean surroundings of school and maintenance of environmental sanitation, spraying pesticides regularly may prevent vectors and spread of diseases.

4. Injuries and poisonings: Road traffic injuries are the most common cause of death among children aged 5 to 14. Schools located near busy roads or water bodies have increased risks of these types of injuries. Falls and injuries within the school grounds can occur as a result of poorly maintained schools or poor construction management, broken furniture. Thus speedbreaker should be in front of schools, display board should show the symbol of school ahead, vehicle speed should be limited to 20 km/hr security guard should be posted in front of gate that will help students to cross roads. Poisoning can occur due to unsafe storage of pesticides, paints, cleaning products, rotten foods, etc. School administration should take care of those things to store in a place out of reach of children.

5. Cancer: Children may be at higher risk of developing cancer due to some exposures such as radiation and pesticides, than similarly exposed adults. Other childhood exposures such as excessive exposure to sunlight and environmental tobacco smoke, pesticides, solvents, radon (a radioactive gas) and arsenic may contribute to cancers that develop in adulthood. Therefore, it is important to minimize children’s exposure to such agents in the school environment.

6. Developmental disabilities: Developmental disabilities include a variety of conditions that occur during childhood and cause mental or physical limitations. These disabilities include autism, cerebral palsy, epilepsy, mental retardation, and other neurological impairments. Exposure to toxic substances also places children at risk of developmental disorders. In many developing countries where leaded gasoline is still used, lead presents a threat to more than half of urban children. Schools need to reduce or eliminate student exposures to polluted air.

7. Asthma: Indoor and outdoor air pollution is an important factor in the increasing incidence and severity of asthma. Exposure to house dust mite allergens and secondhand smoke has been associated with the development of asthma as well as the exacerbation of asthma symptoms. Other indoor asthma triggers include allergens from cockroach, pet dander, and mold. Recently, ozone has been implicated as a factor contributing to asthma among children who exercise in urban settings. By controlling wood smoke, environmental tobacco smoke, molds, and many volatile chemicals found in indoor environments can reduce respiratory function in school children.

Sources of Air Pollutants in Classrooms

• Outdoor emissions (e.g. diesel exhaust from school buses or pollutants from main road vehicles through open windows and emissions from nearby industries)

• Carpets

• Tobacco smoke (e.g. faculty lounges)

• Commercial products (e.g. paints, cleaning agents, pesticides, and air fresheners)

• Vapors from supplies and equipment (e.g laboratory chemicals, photo and art supplies, copying and printing equipment, dry erase markers)

• Radon gas, carbon dioxide, carbon monoxide, lead from fuel of vehicles

• Animals and insects

• Molds and fungi

• People (e.g. transmission of bacteria and viruses)

Preventive Measures

Schools can implement policies and procedures that can improve the health of students at little or no extra cost. Some of them include:

• Reducing risk of diseases such as malaria, dengue fever and schistosomiasis by improving drainage to eliminate formation of puddles where mosquitoes and other vectors breed.

• Adjusting behavior to avoid risks. Scheduling outdoor activities during periods of the day when air pollution and sun exposure are lowest can reduce children’s exposure to toxic air pollution, ultraviolet radiation, and insects that transmit diseases.

• In areas where school children cross busy roads, crossing guards or older children can assist younger children and reduce the risk of accidents.

• Prohibiting the idling of school bus engines can minimize exposure to diesel and gasoline exhaust fumes. Buses should not idle in areas around schools where fumes could enter the school building.

• In the developing world, where children dip unwashed hands into a shared drinking water source, a ladle may be used to fill cups or bowls providing a low-cost solution to cleaner water.

• Teaching young children about the basic rules of food safety such as washing hands before eating.

• Establishing safety rules in the handling and preparation of foods.

• Planting shade trees around school grounds to reduce the risk of overexposure to the sun’s ultraviolet rays.

• Creating a health committee with a mission to ensure that classroom facilities and grounds are safe and healthy for children.

• Sorting and recycling waste.

• Reducing respiratory infections by using improved stoves and increasing ventilation when polluting fuels are used inside schools for cooking and heating.

• Reducing asthma attacks by improving ventilation to enhance indoor air quality.

Depending on the location of the school, ventilation in classrooms may often be improved by simply opening a window. Where resources permit, additional options can be considered.

• Reducing pesticide exposure and poisonings by eliminating/minimizing use of pesticides. Schools adjacent to locations where pesticides are routinely applied could learn about the timing of pesticide applications and keep children inside the school with windows and doors closed.

School Health Nursing

School health is the field where nursing care is very important. The school nurse is a registered professional nurse. Educational preparation for the school nurse should be at the baccalaureate level, and the school nurse should continue to pursue professional development and continuing nursing education. School nurses typically practice independently and are called upon to assess student health, develop and execute plans for care management, act as first responders, and engage in public health functions such as disease surveillance, immunization compliance, and health promotion. The school nurse is a vital member of the school team that leads change to advance health and collaborates with school staff members, parents and community members to keep students safe at school and healthy to learn.

Definition: The National Association of School Nurses defines school nursing as “a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement of students.”

School nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning. The following health services are the minimum that should be offered, according to the American Academy of Pediatrics (AAP) manual School Health: Policy and Practice: 19.

• Assessment of health complaints, medication administration, and care for students with special health care needs

• A system for managing emergencies and urgent situations

• Mandated health screening programs, verification of immunizations, and infectious disease reporting

• Identification and management of students’ chronic health care needs that affect educational achievement.

School nurses facilitate normal development and positive student response to interventions. The school nurse serves as the health care expert in the school to meet student health needs with an understanding of normal growth and development in children and youth as well as students with special needs. The school nurse develops plans for student care based on need findings.

School nurses provide leadership in promoting health and safety, including a healthy environment. She provides health-related education to students and staff in individual and group settings and provides consultation to other school professionals, including food service personnel, physical education teachers, coaches, and counselors. Responsibilities include monitoring of immunizations, managing communicable diseases, assessing the school environment for safety to prevent injury and spearheading infection control measures. She also plays a role of leader in the development of school safety plans to address bullying, school violence, and the full range of emergencies that may occur at school.

School nurses provide quality health care and intervene with actual and potential health problems. Health care for chronic and acute illnesses, as well as injuries in the school setting, is a major focus of the role of the school nurse. She/he is responsible for medication administration, health care procedures, and the development of health care plans. School nurses often engage in health screenings that include vision, hearing, body mass index, mental health index or other screening procedures.

School nurses use clinical judgment in providing case management services. The school nurse receives medical orders to guide the health care needed to assist each student to be safe and successful at school. As in other clinical settings, the nurse develops Individualized Healthcare Plans (IHPs) in nursing language to direct nursing care for students as well as Emergency Care Plans (ECPs) written in lay language to guide the response of unlicensed personnel in a health-related emergency. Both plans are tailored to the individual needs of a specific student to improve expected care outcomes.

School nurses actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy and learning. Coordinating the linkage between the medical team, family and school is an important aspect of the role of the school nurse. The school nurse has health expertise that is essential to school educational teams, such as the Committee on Special Education, the Individualized Educational Plan (IEP) team so that health-related barriers to learning can be reduced for each student. The school nurse can provide families with referral information along with available community resources to improve access to health care.

The school nurse may take on additional roles as needed to meet the needs of the school community. Healthy children are successful learners. The school nurse has a multifaceted role within the school setting, one that supports the physical, mental, emotional, and social health of students and their success in the learning process.

Bibliography

1. American Academy of Pediatrics, Committee on School Health. School Health: Policy and Practice. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2004.

2. Park K. Text Book of Preventive and Social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

3. Role of the School Nurse in Providing School Health Services. Council on School Health. This policy is a revision of the policy in 108 (5): 1231. from the american academy of pediatrics [Internet] [cited 2014 July 27]. Available from: http://pediatrics.aappublications.org/content/121/5/1052.full#xref-ref-l-l.

4. Role of the School Nurse. National Association of School Nurses (NASN) [Internet] 2011 [cited 2014 July 27]. Available from: http://www.nasn.org/Policy Advocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/Articleld/87/Role-of-the-School-Nurse-Revised-2011.

5. The Physical School Environment: An Essential Component of a Health-Promoting School. [Internet] [cited 2014 July 27]. Available from: http://www.who.int/school_youth_health/media/en/physical_sch_environment.pdf.

6. Why school health is important [Internet] [cited 2014 July 27]. Available from: http://www.education.nh. gov/instruction/school_health/health_coord_environ.htm.

7. Wolfe LC. Roles of the School Nurse. In: Selekman J (Ed.), School Nursing: A Comprehensive Text. Philadelphia, PA: Davis FA Company; 2006. [Internet] [cited 2014 July 27], Available from: http://www.nasn.org/Policy Advocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/smid/824/ArticlelD/87/Default.aspx.

9

Occupational Health

This chapter contains

▪ Definition

▪ Objectives

▪ Occupational Environment

▪ Common Workplace Hazards

▪ Occupational Diseases

▪ Pneumoconiosis

▪ Workplace Health Management

• Component

• Occupational Health Team

• Prevention of Occupational Diseases

▪ Ergonomics

▪ Child Labor

▪ Women and Work

▪ Workplace Violence

▪ Occupational Health Nursing

▪ World Day for Safety and Health

“Safe Workplace: Increased Productivity”

INTRODUCTION

Workplace health and safety or occupational safety and health (OSH) is an area concerned with the safety, health and welfare of people engaged in work or employment. The goals of occupational safety and health programs include fostering a safe and healthy work environment.

DEFINITION

Since 1950, a common definition of occupational health was adopted by the Joint ILO/WHO. “Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and to summarize the adaptation of work to man and of each man to his job”.

OBJECTIVES

Occupational health deals with all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards. The health of the workers has several determinants, including risk factors at the workplace leading to cancers, accidents, musculoskeletal diseases, respiratory diseases and hearing loss. Main objective of occupational health is adaptation of work to man and of each man to his job. Other objectives given by WHO are:

• To protect the workers against any health hazard which may arise out of their work or the conditions in which it is carried on.

• To contribute towards the workers physical and mental adjustment and particularly the adaptation of the work to the workers and their assignments to jobs for which they are suited.

• To contribute to the establishment and maintenance of the highest possible degree of physical and mental well-being of the workers.

• Hazard identification and risk assessment

• Training employees

• Implementing OSH control measures

• Emergency planning

• Document and record control

• Internal audit programs

• Corrective and preventative action

• Management involvement and management review

• Check out manufacturer compliance issues

• Audit/inspection management

OCCUPATIONAL ENVIRONMENT

Occupational environment refers to all physical surroundings and social environment at a workplace. It denotes all external conditions, have influence at place of work and affect health of working population. A worker faces 3 types of interaction in a working environment:

1. Man and physical, chemical and biological agents

• Physical agent: Heat, cold, humidity, air movement, noise, light, heat radiation, vibrations, ionizing agents, amount of working and breathing place, toilet and bathing facilities, etc. have adverse effect on health in working place.

• Chemical agents: Chemicals, toxic dust, gases, etc. are the potential health hazards for workers.

• Biological agents: Exposure to virus, rickettsia, bacteria, parasite, etc. can cause various diseases to workers.

2. Man and machine: Industry has various machines to increase production.

• Unguarded machines, protruding and moving parts, poor installation of the plant, lack of safety measures, etc. cause accidents.

3. Man and man

• It generally refers psychosocial factors as peer relationships, relationships with authority, type of work, work stability, job satisfaction, leadership style, security, communication, system of payment, trade union activities.

• Domestic environment: Domestic stress also affects worker in their workplace. In other hand, worker carries work stress to home, which may disturb their sleep, may affect relationship with family members.

Common Workplace Hazards

• Mechanical hazards include:

By type of agent:

– Impact force (collisions, falls from height)

– Struck by objects

– Confined space

– Slips and trips

– Falling on a pointed object

– Compressed air/high pressure fluids (such as cutting fluid)

– Entanglement

– Equipment-related injury

By type of damage:

– Crushing

– Cutting

– Friction and abrasion

– Shearing

– Stabbing and puncture

Fig. 9.1: Hazardous effects of dust depends on various factors

• Other physical hazards:

– Noise

– Vibration

– Lighting

– Barotrauma (hypobaric/hyperbaric pressure)

– Ionizing radiation

– Electricity

– Asphyxiation

– Cold stress (hypothermia)

– Heat stress (hyperthermia)

– Dehydration (due to sweating)

• Biological hazards include:

– Bacteria

– Virus

– Fungi

– Blood-borne pathogens

– Tuberculosis

• Chemical hazards include:

– Acids

– Bases

– Heavy metals (lead)

– Solvents (petroleum)

– Particulates

▪ Asbestos and other fine dust/fibrous materials

▪ Silica

– Fumes (noxious gases/vapors)

– Highly-reactive chemicals

– Fire, conflagration and explosion hazards (explosion)

• Psychosocial issues include:

– Work-related stress, whose causal factors include excessive working time and overwork

– Violence from outside the organization

– Bullying, which may include emotional and verbal abuse

– Sexual harassment

– Burn out

– Exposure to unhealthy elements during meetings with business associates, e.g. tobacco, uncontrolled alcohol.

• Musculoskeletal disorders:

– Body pain

– Muscle pain

– Sprain

– Back pain

– Shoulder pain

– Neck pain

– Carpel tunnel syndrome

– Slip disc

Occupational Diseases

An occupational disease is any chronic ailment that occurs as a result of work or occupational activity. Under the Occupational Health and Safety Act, occupational illness is defined as “a condition that results from exposure in a workplace to a physical, chemical or biological agent to the extent that the normal physiological mechanisms are affected and the health of the worker is impaired.” The first such disease was recognized, squamous cell carcinoma of the scrotum, identified in chimney sweep boys by Sir Percival Pott in 1775. Occupational hazards that are of a traumatic nature (such as falls by roofers) are not considered to be occupational diseases.

1. Acute and chronic intoxications with chemical substances and their sequels

2. Metallic fever

3. Pneumoconiosis

4. Chronic obstructive bronchitis which causes airflow limitation

5. Bronchial asthma

6. Extrinsic allergic alveolitis

7. Acute general allergic reactions

8. Nasal septum perforation induced by irritant and corrosive agents

9. Chronic voice disorders due to excessive vocal effort lasting at least 15 years

10. Diseases caused by ionizing radiation

11. Malignant neoplasms induced by human carcinogens present in work environment

12. Skin diseases

13. Chronic diseases of locomotor system (e.g. lesion) related to the way the job is performed

14. Chronic diseases of peripheral nervous system (e.g. carpal tunnel syndrome)

15. Bilateral permanent noise-induced hearing loss

16. Vibration syndrome

17. Diseases induced by work under increased atmospheric pressure (e.g. decompression sickness, barotrauma)

18. Diseases induced by high (e.g. heatstroke, heat exhaustion, heat syncope, burns, etc.) or low (e.g. frost bite, chilblains, trench foot, etc.) temperature of environment.

19. Diseases of visual system induced by physical, chemical or biological agents (e.g. allergic conjunctivitis, occupational cataract, miner’s nystagmus, etc.).

20. Diseases due to biological agents as brucellosis, anthrax, leptospirosis, tetanus, etc.

Pneumoconiosis

One of the vital occupational diseases is pneumoconiosis. The lung tissue in normal people is very elastic. This allows it to expand and contract while breathing. Pneumoconiosis is an occupational lung disease and a restrictive lung disease caused by the inhalation of dust (Table 9.1). Pneumoconiosis causes inflammation of the lungs. Hazardous effects of dust depends on various factors.

Table 9.1: Depending upon the type of dust, the disease is given different names

SI. No.
Pneumoconiosis
Type of dust

1.

Coal worker’s pneumoconiosis (also known as miner’s lung, black lung or anthracosis)
Coal, carbon dust

2.

Asbcstosis
Asbestos

3.

Silicosis (also known as “Grinder’s disease” or Potter’s rot)
Silica

4.

Bauxite fibrosis
Bauxite

5.

Berylliosis
Beryllium

6.

Siderosis
Iron

7.

Byssinosis cane fiber
Cotton

8.

Bagassosis
Cane fiber

9.

Silicosiderosis
Mixed dust containing silica and iron

10.

Labrador lung (found in miners in Labrador, Canada)
Mixed dust containing iron, silica and anthophyllite, a type of asbestos

11.

Stannosis
Tin oxide

Diagnosis

• Occupational history

• Sign and symptoms as shortness of breath.

• Chest X-ray may show a characteristic patchy, subpleural, interstitial infiltrates or small cystic radiolucency called honeycombing (Figs 9.2 and 9.3).

Fig. 9.2

Symptoms of Pneumoconiosis

• Tightness of the chest

• Shortness of breath

• Respiratory problems

• Cyanosis

Fig. 9.3

• Emphysema

• Breathlessness

• Bronchitis

• Chronic cough

Fig. 9.3a: Symptoms of pneumoconiosis

Coal workers’ pneumoconiosis (CWP)/black lung/anthracosis (anthrac-coal, carbon): It is caused by long exposure to coal dust. It is a common disease of coal miners and others who work with coal (Fig. 9.4). Prolonged exposure to large amounts of coal dust can result in more serious forms of the disease. More common symptom is industrial bronchitis, clinically defined as chronic bronchitis (i.e. productive cough for 3 months per year for at least 2 years).

Fig. 9.4

Asbestosis: It is a chronic inflammatory and fibrotic medical condition affecting the parenchymal tissue of the lungs caused by the inhalation and retention of asbestos fibers. It usually occurs after high intensity and/or long-term exposure to asbestos particularly in those individuals working on the production or end-use of products containing asbestos and is, therefore, regarded as an occupational lung disease. People with extensive occupational exposure to the mining, manufacturing, handling, or removal of asbestos, are at risk of developing asbestosis. Sufferers may experience severe dyspnea (shortness of breath) and are at an increased risk for certain malignancies, including lung cancer but especially mesothelioma.

Silicosis (miner’s phthisis or Grinder’s asthma or Potter’s rot): It is a form of occupational lung disease caused by inhalation of crystalline silica dust, and is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lungs. Silicosis (particularly the acute form) is characterized by shortness of breath, cough, fever, and cyanosis (bluish skin) (Fig. 9.5). It may often be misdiagnosed as pulmonary edema (fluid in the lungs), pneumonia, or tuberculosis. Because chronic silicosis is slow to develop, signs and symptoms may not appear until years after exposure. Signs and symptoms include:

Fig. 9.5

• Dyspnea (shortness of breath) exacerbated by exertion

• Tachypnea (rapid breathing) which is often labored cough, often persistent and sometimes severe

• Fatigue

• Loss of appetite and weight loss

• Chest pain

• Fever

• Gradual dark shallow rifts in nails eventually leading to cracks as protein fibers within nailbeds are destroyed.

In advanced cases, the following may also occur:

• Cyanosis (blue skin)

• Cor pulmonale (right ventricle heart disease)

• Respiratory insufficiency

Patients with silicosis are particularly susceptible to tuberculosis (TB) infection known as silicotuberculosis.

Bauxite pneumoconiosis or Shaver’s disease or corundum smelter’s lung or bauxite lung or bauxite smelters’ disease, is a progressive form of pneumoconiosis caused by exposure to bauxite fumes which contain aluminium and silica particulates. It is typically seen in workers involved in the smelting of bauxite to produce corundum. Initially, the disease appears as alveolitis, and then progresses to emphysema. Patients may develop pneumothorax.

Berylliosis, or chronic beryllium disease (CBD), is a chronic allergic-type lung response and chronic lung disease caused by exposure to beryllium and its compounds. As an occupational lung disease, it is most classically associated with aerospace manufacturing, beryllium mining or manufacturing of fluorescent light bulbs (which used to contain beryllium compounds in their internal phosphor coating). The condition is incurable, but symptoms can be treated. Lungs become hypersensitive to beryllium causing the development of small inflammatory nodules, called granulomas. Clinically patients experience cough and shortness of breath. Other symptoms include chest pain, joint aches, weight loss and fever.

Siderosis is the deposition of iron in tissue. Iron oxide present in welding material, iron ore mining also causes Siderosis bulbi, deposition of iron into the eye causing injury as the material chemically reacts with tissues and cells. It can also be caused by powdered hematite, sometimes used by Egyptians to protect tombs.

Byssinosis, also called “brown lung disease” or “Monday fever”, is an occupational lung disease caused by exposure to cotton dust in inadequately ventilated working environments. Byssinosis commonly occurs in workers who are employed in yarn and fabric manufacture industries. It is now thought that the cotton dust directly causes the disease and some believe that the causative agents are endotoxins that come from the cell walls of gram-negative bacteria that grow on the cotton. Breathing difficulties, chest tightness, wheezing, cough are the manifestations of byssinosis. Brown lung can ultimately result in narrowing of the airways, lung scarring and death from infection or respiratory failure.

Bagassosis is the occupational lung disease caused by inhalation of bagasse or sugarcane dust. Symptoms consist of breathlessness, cough, hemoptysis and slight fever. Initially there is acute diffuse bronchiolitis, if left untreated; there is diffuse fibrosis, emphysema and bronchiectasis.

Stannosis is a benign non-fibrotic pneumoconiosis caused by exposure to tin oxides including stannous oxide (SnO) and stannic oxide (SnO₂).

Treatment of Pneumoconiosis

There is no specific treatment for pneumoconiosis other than the treatment of the complications that the disorder might cause. It is essential that anyone suffering with the symptoms of pneumoconiosis that they visit a qualified medical professional to undertake a full checkup before any possible advent of serious complications such as lung cancer.

Prevention of Pneumoconiosis

• A well-fitting facemask should be provided to any worker who is in contact with dust that is at risk of getting pneumoconiosis.

• The workplace should take all necessary steps to keep the levels of dust down to a minimum.

• Ventilation of the workplace is important to maintain adequately.

• Workers should be made aware of safe procedures of self-protection with regard to the washing down of dust laden areas and the removal and washing of clothes that have been exposed to the dust.

• Any part of the body exposed should be cleaned thoroughly and the worker should avoid dust contaminated food, smoking, drinking, and taking medicine in dusty environment.

• Periodic check-up should be done for early detection of pneumoconiosis.

• Change of work sector or job if sign and symptoms persist.

Workplace Health Management

Components

There are four key components of workplace health management:

1. Occupational health and safety

2. Workplace health promotion

3. Social and lifestyle determinants of health

4. Environmental health management

The Occupational Health Team

The professionals involved in the occupational health team include some or all of the following:

1. Occupational health nurses

2. Occupational health physicians

3. Industrial hygienists

4. Safety engineers

5. Work organization specialists

6. Psychologists

7. Counselors

8. Physiotherapists

9. Ergonomists

10. Health economists

11. Academic researchers and others.

Prevention of Occupational Diseases

Fig. 9.6

1. Medical measures

• Pre-placement examination: It is done at the time of employment and includes worker’s medical, family, social and occupational history. Through physical examinations along with blood and urine test, X-ray, ECG, vision test, special test for endemic diseases are done. The purpose of this examination is to place the right person to right job so that he/she can perform optimum (Fig. 9.7).

Fig. 9.7

• Periodical examination: Many occupational diseases take longer period to develop. Periodical examination is done to detect any early signs and symptoms to prevent further complication. Depend on the findings an employee is advised to take precautions or the area of job is changed.

• Medical and health care services: There are various Acts (e.g. ESI Act) which provide complete medical care at a very minimal cost not to the employee only but also to their family. First aid facilities should be there inside the factory.

• Notification: Notification helps to analyze severity, disability, prevalence, etc. statistically of the particular occupational diseases. It is also necessary to initiate measures for prevention and protection and ensures effective application.

• Supervision of working environment: Periodic supervision helps to detect hazardous workplace environment. It helps to determine what all the safety measures to take to prevent occupational hazards.

• Maintenance and analysis of record: Maintenance of records is important for further treatment. Compilation and review of records enable to assess the hazards due to certain types of works.

• Health education and counseling: Health education about rules and regulations, use of protective devices, maintenance of basic sanitation, possible health hazards, etc. to be given from the very fast day of employment.

2. Engineering measures

• Design of building: While preparing blueprint of the industry, prevention aspect has to keep in mind. Construction of emergency exit, well-constructed and durable building with adequate space are of prior importance.

• Good housekeeping: It covers general cleanliness, ventilation, lighting, washing, food arrangements and general management and maintenance. Area of work should be kept clean and hygienic; white wash at least once in a year is mandatory.

• General ventilation: Rooms of factory should be well-ventilated and well-lighted. Opening of ventilators should be in such a way to admit a continuous supply of fresh air. The Indian Factories Act has prescribed a minimum of 500 cu ft of air space for each worker.

Fig. 9.8: Engineering measures

• Mechanization: The plant should be mechanized in such a way to reduce contact with hazardous substances. As hand mixing can be replaced by mechanical devices; acids can be conveyed from one place to another through pipes, etc.

• Substitution: It means replacement of a harmful material by a harmless one, or with a less toxicity.

• Dusts: Dust can be controlled by water spraying at its origin as adding little moisture while grinding or can be controlled by using of vacuum cleaner regularly.

• Enclosure: Enclosing harmful materials and processes prevent the escape of dust and fumes.

• Isolation: Isolate the offensive process in a separate building, so other employees will not be in direct contact with the hazardous materials.

• Local exhaust ventilation: It traps and extracts dusts, fumes and other injurious substances from working rooms.

• Protective devices: Protective devices such as respirators, masks, ear plugs, helmets, safety shoes, aprons, gloves, gumboots, barrier creams, screens and goggles should be used where appropriate.

• Environmental monitoring: It is concerned with periodical environmental survey along with doctors and engineers for growing pollution, sampling of atmospheric air, near water sources to check the permissible limits. Plantation around the industrial site to form green belt is an important aspect.

• Research: Various studies are done to improve work quality, to limit exposure to dust and toxic materials and so on.

3. Legislation: Mainly two Acts regulate the standards of industries and facilities of employees. These are:

• The Factories Act, 1948

• The Employees State Insurance Act, 1948

ERGONOMICS

Ergonomics (Ergon: work; nomos: law) is a well-recognized discipline of any advance occupational health service. Ergonomists study human capabilities in relationship to work demands. Training in ergonomics involves designing of machines, tools, equipment and manufacturing process, layout of the places of work, method of work and environment in order to achieve greater efficiency of both man and machine.

Definition

• “Ergonomics is an applied science concerned with the design of workplaces, tools, and tasks that match the physiological, anatomical, and psychological characteristics and capabilities of the worker”—Vern Putz-Anderson.

• “The Goal of ergonomics is to ‘fit the job to the person/rather than making the person fit the job”—Ergotech.

Generally, two factors enhance work discomfort and cause injury. One is static work in which musculoskeletal effort required to hold a certain position. Even a comfortable position holding for long time causes discomfort. For example, sit and work at computers. Another one is force, i.e. amount of tension our muscles generate. For example, tilting head forward or backward from a neutral, vertical position multiplies the amount of force acting on lower neck vertebrae.

Three main ergonomic principles to prevent injury:

1. Work activities should permit worker to adopt several different healthy and safe postures.

2. Muscle forces should be done by the largest appropriate muscle groups available.

3. Work activities should be performed with joints.

Benefits of ergonomics

• Decreased injury risk

• Decreased mistakes/rework

• Increased efficiency

• Decreased lost work days

• Decreased turnover

• Increased productivity

Ergonomic measures

I. Prevention

a. Warm up and stretch before activities that are repetitive, static or prolonged.

b. Take frequent breaks from any sustained posture every 20–30 minutes.

c. Stop painful activity.

d. Recognize early signs of inflammatory process and treat early.

II. Maintain neutral posture

a. Maintain erect position of back and neck with shoulders relaxed.

b. Position equipment and work directly in front of and close to your major tasks.

c. Keep upper arms close to the body, elbows 90–100 degrees.

d. Keep feet flat on floor, upper body weight resting on “sits bones”.

e. Wrists as neutral as possible; safe zone for wrist movement is 15 degrees in all directions.

f. Avoid bending neck forward for prolonged periods of time.

g. Avoid static positions for prolonged time; muscles fatigue.

Modify Tasks

a. Alternate activities frequently; rotate heavy and/or repetitive tasks with lighter less repetitive ones.

b. Avoid repetitive or prolonged grip activities.

c. Avoid pinching with wrist in flexion or wrist deviation (bending to side).

d. Take frequent breaks to stretch and rest hands.

Body Mechanics

a. Use the largest joints and muscles to do the job.

b. Use 2 hands to lift rather than one, even with light objects and tasks.

c. Avoid lifting with the forearm in full pronation (palm down) or supination (palm up).

d. Slide or push and pull objects instead of lifting.

e. Keep reaching to a minimum.

f. Carry objects close to body at waist level.

Fig. 9.9: Body mechanics

CHILD LABOR

Children carry out a very wide range of tasks and activities when they work. Considerable differences exist between the types of work children do. Some are difficult and demanding, others are more hazardous and even morally disgraceful.

Not all works done by children should be classified as child labor that is to be targeted for elimination. Children’s or adolescents’ participation in work that does not affect their health and personal development or interfere with their schooling is generally regarded as being something positive. This includes activities such as helping their parents around the home, assisting in a family business or earning pocket money outside school hours and during school holidays. These kinds of activities contribute to children’s development and to the welfare of their families; they provide them with skills and experience, and help to prepare them to be productive members of society during their adult life.

Defining Child Labor

The term “child labor” is often defined as work that deprives children of their childhood, their potential and their dignity, and that is harmful to physical and mental development.

It refers to work that is mentally, physically, socially or morally dangerous and harmful to children; and interferes with their schooling by:

• depriving them of the opportunity to attend school;

• obliging them to leave school prematurely; or

• requiring them to attempt to combine school attendance with excessively long and heavy work.

In its most extreme forms, child labor involves children being enslaved, separated from their families, exposed to serious hazards and illnesses and/or left to fend for themselves on the streets of large cities often at a very early age. Whether those work can be called “child labor” or not depends on the child’s age, the type and hours of work performed, the conditions under which it is performed and on countries rules and regulations.

Areas where child labor are prevalent

• The agriculture sector comprises activities in agriculture, hunting forestry and fishing.

• The industry sector includes mining and quarrying, manufacturing, construction, and public utilities (electricity, gas and water).

• The services sector consists of wholesale and retail trade; restaurants and hotels; transport, etc.

The worst forms of child labor

Whilst child labor takes many different forms, a priority is to eliminate without delay the worst forms of child labor as defined by Article 3 of ILO Convention No. 182:

a. All forms of slavery or practices similar to slavery, such as the sale and trafficking of children, debt bondage and serfdom and forced or compulsory labor, including forced or compulsory recruitment of children for use in armed conflict;

b. The use, procuring or offering of a child for prostitution, for the production of pornography or for pornographic performances;

c. The use, procuring or offering of a child for illicit activities, in particular for the production and trafficking of drugs as defined in the relevant international treaties;

d. Work which, by its nature or the circumstances in which it is carried out, is likely to harm the health, safety or morals of children.

Causes of child labor

Primary causes

• International labor organization (ILO) suggests poverty is the greatest single cause behind child labor. Income from working children, even if small, may be between 25% and 40% of the household income.

• Lack of meaningful alternatives such as affordable schools and quality education, according to ILO, is another major factor driving children to harmful labor. Children work because they have nothing better to do. Many communities, particularly rural areas do not possess adequate school facilities. Even when schools are sometimes available, they are too far away, difficult to reach, unaffordable or the quality of education is so poor that parents wonder if going to school is really worth it.

Cultural causes

• Certain cultural beliefs have rationalized child labor and thereby encouraged it.

• Some view that work is good for the character-building and skill development of children.

• In many cultures, cultural tradition is that children follow in their parents’ business; child labor then is a means to learn and practice that trade from a very early age.

• Similarly, in many cultures the education of girls is less valued or girls are simply not expected to need formal schooling, and these girls pushed into child labor such as providing domestic services.

Macroeconomic causes

Macroeconomic causes encouraged widespread child labor across the world, over most of human history. The causes for child labor include both the demand and the supply sides.

Child Labor Acts and Laws

The Constitution of India in the Fundamental Rights and the Directive of State Policy prohibits child labor below the age of 14 years in any factory or mine or castle or engaged in any other hazardous employment (Article 24). The constitution also envisioned that India shall, by 1960, provide infrastructure and resources for free and compulsory education to all children of the age 6 to 14 years. (Article 21-A and Article 45). The major national legislative developments include the following:

The Factories Act of 1948: The Act prohibits the employment of children below the age of 14 years in any factory. The law also placed rules on who, when and how long can preadults aged 15–18 years be employed in any factory.

The Mines Act of 1952: The Act prohibits the employment of children below 18 years of age in a mine.

The Child Labor (Prohibition and Regulation) Act of 1986: The Act prohibits the employment of children below the age of 14 years in hazardous occupations identified in a list by the law. The list was expanded in 2006, and again in 2008.

The Juvenile Justice (Care and Protection) of Children Act of 2000: This law made it a crime, punishable with a prison term, for anyone to procure or employ a child in any hazardous employment or in bondage.

The Right of Children to Free and Compulsory Education Act of 2009: The law mandates free and compulsory education to all children aged 6 to 14 years. This legislation also mandated that 25 percent of seats in every private school must be allocated for children from disadvantaged groups and physically challenged children.

India formulated a National Policy on Child Labor in 1987. This Policy seeks to adopt a gradual and sequential approach with a focus on rehabilitation of children working in hazardous occupations. It envisioned strict enforcement of Indian laws on child labor combined with development programs to address the root causes of child labor such as poverty. Central government funding is also there with the target to eliminate child labor in India. Despite these all efforts, child labor remains a major challenge for India.

WOMEN AND WORK

Women perform dual roles of production and reproduction. They do variety of works but those are not fit into any specific occupation especially when they do household work. Housewife or homemaker is already doing a single shift. If a woman also works outside home, she is consistently working a double shift. When children or family members are ill, she does three shifts day after day. According to International Labor Organization (ILO), 2/3rd of the working hours around the world are worked by women because of the combination of various roles in the workplace, in the family and in the society. Most often, the women’s work go unrecognized but it contributes a major portion to the world economy.

Occupational stress is one of the major problems from a gender perspective. A number of factors cause stress among working women. These include:

• Role confusion as carries multiple overlapping roles as housewives, mothers and workers especially when such roles are physically and mentally demanding with little satisfaction, monetary gain or social rewards.

• Repetitive job and monotonous jobs with little control over workpace and job insecurity all lead to stress.

• Sexual harassment is often faced by women in almost all types of occupations.

• Shift work in certain occupations, such as telephone operators who do different shifts including night shifts, interference with family responsibilities causes lot of stress.

• Musculoskeletal disorders and ergonomic issues are another problem due to heavy manual labor performed by women. Work related musculoskeletal disorders of the neck and shoulders and upper limbs are also known as cumulative trauma disorders (CTD).

• Reproductive health hazards is the another problem women may face in occupation. Many chemicals (e.g. volatile organic solvents, dusts and pesticides, etc.) cause hazards to the embryo especially during organogenesis. This could interfere with ovulation, fertilization or implantation.

Problems affecting occupational health of women in developing countries:

• Still there is gender inequality; especially women workers in developing countries have very little chance of equality.

• A number of factors (e.g. culture, taboos, custom, religion, etc.) are intricately related which ultimately affect the total health of working women.

• In developing and overpopulated countries like India, poor working women are at a great disadvantage as due to availability of excess labor, there is always job insecurity. Introduction of newer technologies often adversely affects unskilled women workers who are the first to suffer loss of job.

• Poverty, illiteracy, malnutrition and infectious diseases are the another causes of low productivity, low income. Undernutrition and infectious diseases leading to lower work capacity. Low literacy level, poor sanitation and lack of public amenities further contribute to ill-health.

• In many communities in India, birth of a girl child is unwelcome and women submit to multiple pregnancies till a male child is born. This adversely affects the health of the mother and reduces her working capacity.

All factors mentioned above have a direct or indirect bearing on the occupational health of women. But in past few decades more women are working outside home for economic necessities.

WORKPLACE VIOLENCE

According to Occupational Safety and Health Administration (OSHA), workplace violence is the violence or threat of violence against workers. It can occur at or outside the workplace and can range from threats and verbal abuse to physical assaults and homicide, one of the leading causes of job-related deaths.

Responsibilities of Management

Management should establish a workplace violence prevention program. It is necessary to ensure that all employees know the policy and understand that all claims of workplace violence will be investigated and actions will be taken promptly. Management also can offer additional protections such as the following:

• Secure the workplace. Where appropriate to the business, install video surveillance, extra lighting, and alarm systems and minimize access by outsiders through identification of badges, electronic keys and guards.

• Provide drop safes to limit the amount of cash on hand. Keep a minimal amount of cash in registers during evenings and late night hours.

• Equip field staff with cellular phones and hand-held alarms or noise devices, and require them to prepare a daily work plan and keep a contact person informed of their location throughout the day. Keep employer provided vehicles properly maintained.

• Instruct employees not to enter any location where they feel unsafe. Provide an escort service or police assistance in potentially dangerous situations or at night.

• Develop policies and procedures covering visits by home health care providers. Address the conduct of home visits, the presence of others in the home during visits, and the worker’s right to refuse to provide services in a clearly hazardous situation.

Self-protective Measures

Nothing can guarantee that an employee will not become a victim of workplace violence. These steps, however, can help reduce the incidence:

• Learn how to recognize, avoid, or diffuse potentially violent situations by attending personal safety training programs.

• Alert supervisors to any concern about safety or security and report all incidents immediately in writing.

• Avoid traveling alone into unfamiliar locations or situations whenever possible.

• Carry only minimal money and required identification into community settings.

• Learn self-protection technique by attending some martial art training program.

Post-Incidence Measures

If any employee faces any type of workplace violence:

• Encourage employees to report and log all incidents and threats of workplace violence.

• Provide prompt medical evaluation and treatment after the incident.

• Report violent incidents to the local police promptly.

• Inform victims of their legal right to prosecute perpetrators.

• Discuss the circumstances of the incident with staff members. Encourage employees to share information about ways to avoid similar situations in the future.

• Offer stress debriefing sessions and post-traumatic counseling services to help workers recover from a violent incident.

• Investigate all violent incidents and threats, monitor trends in violent incidents by type or circumstance, and institute corrective actions.

• Discuss changes in the program during regular employee meetings.

OCCUPATIONAL HEALTH NURSING

Occupational health nursing is one of the special areas of nursing. There are at least three categories of ‘nurses’ commonly found working in occupational health services.

a. Nursing assistants: The nursing assistant or nursing aid is a person without a professional nursing qualification who works as an assistant to, and under the supervision of, a qualified nurse. Nursing assistants are often involved in delivering basic nursing care, under supervision, and can play an important role in supporting nurses.

b. Registered nurses: The registered nurse is a fully trained nurse, with a professional qualification, but without specialist training in occupational health. These nurses, by virtue of their general nurse education, training and clinical experience can play a valuable part in the delivery of nursing services within the clinical setting.

c. Occupational health nurses: The specialist occupational health nurse is a fully trained, registered nurse who, in addition to their general nursing education and training, will have undertaken an additional period of formal study in occupational health, leading to a recognized specialist qualification in occupational health nursing, most often at University degree level.

Specialized/unique occupational health tasks are:

• Workplace surveillance and health risk identification: The occupational health nurse in collaboration with the members of the safety office conducts workplace surveillance, a term used to describe activities which determine whether groups of workers may be suffering actual or potential work related injury or illness; detect, appraise, identify and manage health hazards and exposures to physical and chemical hazards at work.

• Comprehensive interventions or programs to control all actual and potential health risks to employees and provide the worker with education of potential health risks and strategies to prevent injury and illness.

• Intervention measures designed to prevent occurrences, monitor exposure and eliminate the problems.

• Health surveillance: As part of health surveillance, the occupational health nurse conducts activities which determine whether groups of workers may be suffering an occupational illness as a result of exposure to a particular hazard or group of hazards. Health surveillance is always based on environmental assessments with exposures evaluated and documented. Reduction of workplace injuries/illnesses and financial cost by early detection of workplace hazards. Develops statistics to identify significant trends in occupational illness or injuries.

• Health promotion and protection: The occupational health nurse is responsible for employee health promotion and protection by:

▪ Enhancement of employee well-being by gaining knowledge of risk factors in the workplace.

▪ Obtaining management commitment and policies to support development of individual employee and work group programs.

▪ Reduction of health risks by programs targeted to meet goals determined by needs assessment of individual workplace.

▪ Familiarity with community resources and skill in utilizing community resources such as posters, pamphlets, brochures, fact sheets, newsletters, health programs where applicable.

▪ Individual knowledge of risk factors and preventative measures as a foundation for behavioral changes of workers such as smoking cessation, nutrition, fitness, etc.

▪ Timely referrals when applicable.

• Primary care: Primary care is the set of nursing actions that are provided to manage illness or functional challenges in the workplace. She provides immediate treatment, first aid care needed.

• Counseling: Counseling is the process of helping employees to clarify problems and make informed decisions and choices while giving positive reinforcement. It provides strategic interventions and appropriate referrals to deal with a crisis situation and time for the employee to reflect on impending decisions and evaluate actions taken.

• Rehabilitation/Case management: It is the process/provision of services necessary to restore an individual to the fullest physical, mental, emotional, social, vocational and economical independence of which they are capable.

World Day for Safety and Health

On April 28, the International Labor Organization (ILO) celebrates “World Day for Safety and Health” to raise awareness of safety in the workplace; happening annually since 2003, each year it focuses on a specific area and bases a campaign around the theme.

Bibliography

1. Andreoli, Thomas, ed. CECIL Essentials of Medicine. Saunders: Pennsylvania, 2004. p. 737. [Internet] [cited 2014 Aug 16]. Available from: http://www.wikidoc.org/index.php/Pneumo-coniosis_classification.

2. Becklake MR. “Asbestos-related diseases of the lung and other organs: their epidemiology and implications for clinical practice”. Am. Rev. Respir. Dis. [Internet] 1976 [cited 2014 Aug 16]; 114 (1): 187–227.PMID 779552. Available from: http://www.ncbi.nlm.nih.gov/pubmed/779552.

3. Cowie RL (November 1994). “The Epidemiology of Tuberculosis in Gold Miners with Silicosis”. Am. J. Respir. Crit. Care Med [Internet]. 1994 Nov [cited 2014 Aug 16]; 150 (5 Pt 1): 1460–2/10.1164/ajrccm. 150.5. 7952577. PMID 7952577.

4. ILO List of Occupational Diseases, Revised 2010. International Labor organization [Internet] [cited 2014 Aug 16], Available from: http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---safework/documents/publication/wcms_125137.pdf.

5. List of Occupational Diseases. Nofer Institute of Occupational Medicine [Internet] [cited 2014 Aug 16]. Available from: http://www.imp.lodz.pl/home_en/dep/department_of_environ-mental_epidemiologycentral_register_of_occu-pational_diseases/list_of_occupational_diseases.

6. Marine WM, Gurr D, Jacobsen M (January 1988). “Clinically Important Respiratory Effects of Dust Exposure and Smoking in British Coal Miners”. Am. Rev. Respir. Dis. [Internet], 1988 Jan [cited 2014 Aug 16];137 (1): 106–12./10.1164/ajrccm/137.1.106. PMID 3337449.

7. Occupational and Work Related Disease. Occupational Health. WHO [Internet] [cited 2014 Aug 16]. Available from: http://www.who.int/occupational_health/activities/occupatio-nal_work_diseases/en.

8. Occupational Health Hazards and Illnesses [Internet] 2012 April [updated 2014 Oct; cited 2014 Aug 16]. Available from: http://www.labor.gov.on.ca/english/hs/topics/health_hazards.php.

9. Occupational Health Nurse. Waterloo I human resources [Internet] [cited 2014 Aug 16]. Available from: http://www.hr.uwaterloo.ca/.jd/00001550.html.

10. Park K. Text Book of Preventive and Social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

11. Preventing Pneumoconiosis. Information and Advice on Pneumoconiosis [Internet] [cited 2014 Aug 16]. Available from: http://www.pneumoconiosis.org.uk/preventing-pneumoconiosis.

12. Protecting Worker’s Health. WHO [Internet] 2014 April [cited 2014 Aug 16]. Available from: http://www.who.int/mediacenter/factsheets/fs389/en/

13. Robertson Aj, Rivers D, Nagelschmidt G, Duncumb P. “Stannosis: Benign Pneumoconiosis due to Tin Dioxide.” [Internet]1961 May 20 [cited 2014 Aug 16]; Lancet 1 (7186): 1089–93.PMID 13742192. Available from: http://www.unbound-medicine.com/medline/citation/13742192/Stannosis:_benign_pneumoconiosis_due_to_tin_dioxide.

14. Seixas NS, Robins TG, Attfield MD, Moulton LH. “Exposure-response relationships for coal mine dust and obstructive lung disease following enactment of the Federal Coal Mine Health and Safety Act of 1969”. Am. J. bid. Med. [Internet]. 1992 [cited 2014 Aug 16]; 21 (5): 715–34./10.1002/ajim.4700210511.PMID 1609817.

15. The Role of the Occupational Health Nurse in Workplace Health Management. WHO Regional Office for Europe. Copenhagen [Internet] 2001 [cited 2014 Aug 16]. Available from: http://www.who.int/occupational_health/regions/en/oeheurnursing.pdf.

16. The World Day for Safety and Health at Work. Citation [Internet] 2013 April 23 [cited 2014 Aug 16]. Available from: http://www.citation.co.uk/news/the-world-day-for-safety-and-health-at-work.

17. OSHA Fact Sheet. Available on: https://www.osha.gov/OshDoc/data_General_Facts/factsheet-work place-violence.pdf.

10

Disaster Nursing

This chapter contains

▪ Meaning

▪ Types of Disaster

▪ Causes of Disaster

▪ Classification of Victims

▪ Impact of Calamities

▪ Disaster Management

▪ Personal Protection during Different Types of Emergency

▪ Role of Community Health Nurse in Disaster Management

INTRODUCTION

Disaster is an unpredictable, unfamiliar phenomenon comes with a speed which is difficult to manage, create and urgent and emergency situation with known and unknown threats.

The word disaster (“bad star” in Greek) comes from an astrological theme in which the ancients used to refer to the destruction or deconstruction of a star as a disaster. It may also be termed as “a serious disruption of the functioning of society, causing widespread human, material or environmental losses which exceed the ability of the affected society to cope using its own resources.” During disaster need becomes greater than the resources available.

In short disaster is a natural or manmade event that negatively affects life, property, human settlements, livelihood or industry often resulting in permanent changes to human societies, ecosystems and environment, thus exacerbating vulnerable conditions.

MEANING

Disaster means that any occurrence that causes damages, ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to warrant and extraordinary response from outside the affected community of area (WHO, 1995).

Types of Disaster

1. Natural disaster

• Hurricane

• Tornadoes

• Flash floods

• Blizzards (snow storms)

• Typhoons

• Earthquakes

• Droughts

• Thunder squalls

• Volcanoes

• Wildfire

• Avalanches (fall/slides)

• Epidemics

Fig. 10.1: Flood

Fig. 10.2: Drought

Fig. 10.3: Tsunami

Fig. 10.4: Wildfire

Fig. 10.5: Volcano

Fig. 10.6: Hurricane

2. Manmade disaster

• Wars

• Transportation accidents

• Food or water contamination

• Building collapse

• Fire

• Nuclear or dirty bombs

• Bioterrorism, etc.

Causes of Disaster

Manmade disasters are also known as anthropogenic disasters and they as a result of human intent, error or as a result of failed systems. There are various manmade causes of disaster; even the effect of man on nature to cause natural disaster is very high. Man affects nature to the extent of 90% as by excessive cutting of trees, oil leakages, and emissions from factories, atomic experiments, war, soil pollution, air pollution, water pollution, etc.

Natural disaster is a disruption in the balance of the environment.

One common natural disaster is flooding, which occurs when a river bursts its banks and the water spills out onto the flood plain. This is far more likely to happen when there is a great deal of heavy rain.

Earthquakes are another common natural disaster that can cause many fatalities. The movements of the plates in the earth’s crust cause them. These plates do not always move smoothly and can get stuck, causing a buildup of pressure. It is when this pressure is released that an earthquake occurs.

In turn, an earthquake under the water can also cause a tsunami, as the quake causes great waves by pushing large volume of water to the surface. Tsunamies can also be caused by underwater volcanic eruptions.

Volcanic eruptions are another natural disaster, and they are caused by magma escaping from inside the earth. An explosion takes place, releasing the magma from a confined space, which is why there are also often huge quantities of gas and dust released during a volcanic eruption. The magma travels up the inside of the volcano, and pours out over the surrounding area as lava.

One of the most common natural disasters, but also one of the most commonly forgotten, is wildfires. These take place in many different countries all over the world, particularly during the summer months, and can be caused by a range of different things. The two natural causes of wildfires are the sun’s heat and lightening strikes, while they can also be caused by campfires, smoking, fireworks and many other things, but the speed at which they spread is entirely down to nature.

Classification of Victims

Victims can be classified based upon presumed degree of exposure to the traumatizing environment of a disaster as the degree of exposure is closely associated with subsequent post-traumatic stress. Since the intensity of the traumatic event is a strong predictor of later stress responses and disorders, the various subcategories of direct victims and peripheral-immediate victims are expected to be most vulnerable to serious health problems. Victims are classified as given in Table 10.1.

Table 10.1: Victims of disaster

Impact of Calamities

Disasters create an abrupt change in life. The social, economic and health consequences of different types of disaster are:

• Loss of life

• Injury, disability

• Loss of housing, properties

• Disruption of transportation

• Short-term migration

• Permanent migration

• Loss of business

• Disruption of marketing system

• Epidemics of communicable diseases

• Increased mortality and morbidity rate, etc.

• Disaster traumatic stress response

When adults and children are exposed disasters, they experience a constellation of stress responses or symptoms that are seen in victim/survivors as listed in Table 10.2.

Though victims may not require professional intervention, they need to know that the nature of traumatic stress is insidious, and that they would do well to do all they can to protect themselves against losing psychological ground and becoming disabled over time.

Table 10.2: Stress response of disaster victims

Disaster Management

Disaster management (or emergency management) is the managerial function charged with creating the framework within which communities reduce vulnerability to hazards and cope with disasters. Disaster management aims to reduce, or avoid, the potential losses from hazards, assure prompt and appropriate assistance to victims of disaster, and achieve rapid and effective recovery.

Principles of disaster management

In case of disaster, health workers should follow a few guidelines as:

1. Prevent the occurrence of the disaster whenever possible.

2. Minimize the number of casualties if the disaster cannot be prevented.

3. Prevent further casualties from occurring after the initial impact of the disaster.

4. Rescue the victims as fast as possible.

5. Provide first aid to the injured and maintain triage system.

6. Evacuate the injured to medical facilities.

7. Provide definitive medical care.

8. Promote reconstruction of lives.

Stages in disaster management cycle

The disaster management cycle illustrates the ongoing process by which governments, businesses, and civil society plan for and reduce the impact of disasters, react during and immediately following a disaster, and take steps to recover after a disaster has occurred. Appropriate actions at all points in the cycle lead to greater preparedness, better warnings, reduced vulnerability or the prevention of disasters during the next iteration of the cycle (Fig. 10.7). The complete disaster management cycle includes the shaping of public policies and plans that either modify the causes of disasters or mitigate their effects on people, property, and infrastructure. Following are the stages of disaster management:

Fig. 10.7

1. Disaster mitigation—minimizing the effects of disaster.

Examples: Building codes and zoning; vulnerability analyses; public education.

2. Preparedness—planning how to respond.

Examples: Preparedness plans; emergency exercises/training; warning systems.

3. Response—efforts to minimize the hazards created by a disaster.

Examples: Search and rescue; emergency relief.

4. Recovery—returning the community to normal.

Examples: Temporary housing; grants; medical care.

Disaster management cycle

DISASTER MITIGATION

Disaster mitigation measures are those that eliminate or reduce the impacts and risks of hazards through proactive measures taken before an emergency or disaster occurs. Disaster mitigation measures may be structural (e.g. flood dikes) or non-structural (e.g. lands use zoning). Mitigation can be done in personal level as well as in government level.

Personal mitigation is a key to national preparedness. Individuals and families train to avoid unnecessary risks. This includes an assessment of possible risks to personal/family health and to personal property, and steps taken to minimize the effects of a disaster, or take procure insurance to protect them against effects of a disaster. Preventive or mitigation measures take different forms for different types of disasters.

• In earthquake-prone areas, these preventive measures might include structural changes such as the installation of an earthquake valve to instantly shut off the natural gas supply, seismic retrofits of property, and the securing of items inside a building. The latter may include the mounting of furniture, refrigerators, water-heaters and breakables to the walls, and the addition of cabinet latches.

• In flood-prone areas, houses can be built on poles/stilts. The construction of storm cellars and fallout shelters are further examples of personal mitigated actions.

In large scale mitigation activities should incorporate the measurement and assessment of the evolving risk environment. Activities may include:

• Hazard mapping

• Adoption and enforcement of land use and zoning practices

• Implementing and enforcing building codes

• Flood plain mapping

• Reinforced tornado-safe rooms

• Burying of electrical cables to prevent ice build-up

• Raising of homes in flood-prone areas

• Disaster mitigation public awareness programs

• Insurance programs

In most cases mitigation measures aim to reduce the vulnerability of the system.

DISASTER PREPAREDNESS

Emergency preparedness is “a program 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.

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.

Community members, government and non-government organizations, local administrations should take the responsibility of the emergency preparedness program. Disaster preparedness should be an ongoing multisectoral activity.

This drill of disaster preparedness prepares community people to take immediate action during disaster (manpower construction) when emergency external response may not arrived due to disrupted transportation and communication. Funding and other resources supplied by local, government and non-government organizations also can be distributed and kept ready in accordance to high risk area of disaster. Sustained development is best achieved by allowing emergency affected communities to plan, design, manage, implement and evaluation disaster preparedness drill.

RESPONSE

Response to a disaster event must be swift and effective to combat the disaster, to assist those affected by it and to make the area safe. The aim of emergency response is to provide immediate assistance to maintain life, improve health and support the morale of the affected population.

It consists of a number of elements, for example;

• warning/evacuation

• search and rescue

• providing immediate assistance

• proving immediate first aid and shifting to hospitals

• assessing damage

• continuing assistance

• the immediate restoration of infrastructure.

Such assistance may range from providing specific but limited aid, such as assisting refugees with transport, temporary shelter, and food, to establishing semi-permanent settlement in camps and other locations. It also may involve initial repairs to damaged infrastructure. The focus in the response phase is on meeting the basic needs of the people until more permanent and sustainable solutions can be found. This is done by a number of organizations, including Local Government Counter Disaster Committees, State Emergency Service units, Police, Fire, Ambulance and Defense. Flumanitarian organizations are often strongly present in this phase of the disaster management cycle.

Triage is the process of determining the priority of patients’ treatments based on the severity of their condition. In response phase while giving immediate treatment to victims, “S.T.A.R.T” triage system is activated. S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple triage system that can be performed by lightly trained lay and emergency personnel in emergencies. Triage separates the injured into four groups and color code is given to choose the priority of care:

• Immediate or priority 1 (red): The injured who can be helped by immediate transportation; if ambulance available evacuated at once or within 1 hour as they need advanced medical care. These people are in critical condition and would die without immediate assistance.

• Delayed or priority 2 (yellow): The injured whose transport can be delayed until all immediate persons have been transported. These people are in stable condition but require medical assistance.

• Minor or priority 3 (green): Those with minor injuries, who need help less urgently, are not evacuated until all immediate and delayed persons have been evacuated. These will not need advanced medical care for at least several hours. Continue to retriage in case their condition worsens. These people are able to walk, and may only require bandages and antiseptic.

• Priority 4 (black): Victims, who are beyond help (dead or where intervention won’t help in improvement). Care of dead includes:

a. Removal of the dead from the disaster scene.

b. Shifting to the mortuary

c. Identification of body

d. Handover body to bereaved relatives

Relief phase: Immediately following the initial emergency phase, another important aspect of response to disaster management is supply of needed things as foods, blankets, clothing, shelter, medical care, etc.

RECOVERY

Recovery is the process by which an affected community is assisted in regaining a proper level of functioning following a disaster, aims to get back to restoring normalcy. It comprises initial recovery, which satisfies personal and community needs and restores services to the level where local government and the normal responsible agencies can manage the continuing process. It also includes long-term recovery, reconstruction and rehabilitation measures.

During recovery phase various aspects have to be taken care of to prevent further consequences.

Vaccination: Often it is recommended to begin a mass vaccination program of typhoid, cholera and tetanus in disaster ravaged area to prevent epidemics.

Restoration of environmental health: Supplying of safe drinking water and proper disposal of excreta has a significant role to prevent epidemics of communicable disease. Chlorination in emergency situation is recommended. Basic sanitation prevents spread of disease through water, wastes, fecal matter and also prevents vectors breeding.

Vector control: Post disaster a few diseases are very common to be epidemic as dengue fever, malaria fever, leptospirosis, typhus, plague, etc. stagnation of water into debris or during flood increases mosquito breeding. Debris and earth furrows become the shelters of rats. Thus execution of vector control program is very important.

Epidemiologic surveillance and disease control: Disaster can increase the transmission of communicable diseases due to overcrowding, poor sanitation, population displacement, contamination of drinking water, disruption of routine national programs, improper storage of food, etc. Epidemic outbreak following disaster can be prevented by proper surveillance and disease control.

Nutrition: Disaster affects the nutritional status of people due to many reasons. May be due to lack of transportation, no proper food storage, as shelter has been destroyed so no place to cook, loss of nearer people psychologically makes to starve, damage to corps, stock or food distribution system and more. Starting of immediate food relief program is very essential.

Rehabilitation: Physical and psychological rehabilitation is very important stage to restore pre-disaster condition. Though it is very tough for the person to go back to predisaster life who has loss his/her family members, relatives or has lost any body parts or whole property. Rehabilitation includes continuation of treatment if needed, construction of permanent house, vocational training for handicapped, counseling of victims, etc. time is the greater healer to reestablish and wash out the negative effects of disaster and restore the normal condition of life.

It forms an integral part of the national system responsible for developing plans and programs for disaster management.

Personal protection during different types of emergency

Protect yourself first
Be in safe place
Help others to rescue
Listen to information
Keep valuables safe

FLOOD

During flood

• Turn off the electricity to reduce the risk of electrocution (death caused by electric shock).

• Protect people and property as soon as the flood begins, take any vulnerable people and easy to carry valuables to upper floor of house or in a high place or leave the area if possible.

• Be aware of food contamination.

• Evacuate danger zones as ordered by the local authority.

After a flood

• Clean and disinfect any room that has been flooded.

• Sterilized or wash with boiling water all dishes and kitchen utensils.

• Throw food that has been in or near the water, including canned foods and any food kept in refrigerators and freezers.

• Use chlorination to purify drinking water.

STORMS, HURRICANES AND TORNADOES

During an emergency

• Listen to the information and advice provided by the authorities.

• Do not get out in a car or in a boat once the storm has been announced.

• Evacuate the houses if the authorities request this, along with family and carry emergency kit.

• If possible tie down any object liable to be blown away by the wind.

• If caught outside in a storm, take shelter as quickly as possible in a nearer secure place, if there is no shelter lie down flat in a ditch. Never stand under a tree.

• Keep away from doors, windows and electrical conductors, unplug electrical appliances and televisions aerials.

• Do not use any electrical appliances and the television.

After an emergency

• Follow the instructions given by the authorities.

• Stay indoor and do not go to the stricken areas.

• Give first aid to the injured.

• Make sure that water is safe to drink and check the contents of refrigerator and freezers.

EARTHQUAKES

During an earthquake

• Keep calm do not panic.

• People who are indoors should stay in but move to the interior wall or be under table or bed protecting your head from falling objects.

• Stay away from stairs, glass, windows, outside doors and walls, and anything that could fall, such as lighting fixtures or furniture.

• Stay in bed if you are there when the earthquake strikes. Hold on and protect your head with a pillow, unless you are under a heavy light fixture that could fall. In that case, move to the nearest safe place.

• People who are outside should stay there, keeping away from buildings to avoid collapsing walls and away from electric cables.

• Any one in a vehicle should park it, keeping away from the bridges and building and be inside the car only.

Afler an earthquake

• If you are trapped under debris, do not light a match, do not move around or kick up dust. Cover your mouth with a handkerchief or clothing. Tap on a pipe or wall so rescuers can locate you. Use a whistle if one is available. Shout only as a last resort. Shouting can cause you to inhale dangerous amounts of dust.

• Obey the authority’s instructions.

• Do not go back into damaged buildings since tremors may start again at any movement.

• Give first aid to the injured.

• Keep emergency package and a radio near at hand.

Role of Community Health Nurse in Disaster Management

Nurses serve a critical role in emergency at the local, state, and national levels through planning, community and consumer education, and direct care provided during disasters.

Disaster nursing can be defined as the “adaptation of professional nursing skills in recognizing and meeting the physical and emotional needs of people resulting from a disaster.” The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster. A community health nurse:

• Facilitates community participation in preparedness as well as during emergency.

• Provides mock trails or training on disaster management.

• Takes part to initiate or update the disaster plan.

• Assesses the local resources, funding agencies required.

• Takes part in mass awareness program on disaster.

• Assures capacity to respond effectively to disaster and emergency.

• Minimizes vulnerability to effects of an event.

• Provides education about available resources, how to manage various types of disaster, on basic hygiene and sanitation to maintain during disaster, etc.

• Taking part in rescue process, treatment of victims during emergency.

• Setting up first aid post in the particular area.

• Counseling victims of disaster and their family members.

• Restores systems to functional level.

Bibliography

1. About Disaster Mitigation. Public Safety Canada [Internet] [cited 2014 Aug 27]. Available from: http://www.publicsafety.gc.ca/cnt/mrgnc-mngmnt/dsstr-prvntn-mtgtn/bt-dsstr-mtgtn-eng.aspx.

2. Basavanthppa BT. Text Book of Community Health Nursing. 2nd ed. New Delhi: JP Brothers; 2008.

3. Burstein, Jonathan L, Hogan, David. Disaster Medicine. Second Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2007.

4. Disaster Management Phases. Queenland Government Disaster Management [Internet] [updated 2013 Dec 20; cited 2014 Aug 27], Available from: http://www.disaster.qld.gov.au/About_Disaster_Management/Manage-ment_Phases.html.Last.

5. Dr Parson, Erwin Randolph. Victims of Disasters: Helping People Recover from Acute Distress to Healing and Integration, Journal of Contemporary Psychotherapy, 1995.

6. Dr Ravindra D, Krishnamurthy GR (2006), ‘Role of Architects in Diaster Management’, Architecture-Time-Space and People, Vol 6, Issue 10, Oct, Council of Architecture, New Delhi.

7. Gupta JP. Sood. Policy Planning Management. Public Health, p 2.18.

8. Information about Disasters. Disasterium [Internet] [cited 2014 Aug 27]. Available from: http://www.disasterium.com.

9. Kumar, Raj C. Disaster Management and Human Rights, The Hindu, Dec 4, 2006.

10. Langan and James. Text Book of Preparing Nurses for Disaster Management. Jullie Lagan Alexender; 2005.

11. Lexander D. Natural Disasters, Kluwer Academic Publishers [Internet] [cited 2014 Aug 27]. Available from: http://www.geo.umass.edu/faculty/alexander.

12. Ministry of Home Affairs: National Programme for Capacity Building of Architects in Earthquake Risk Management (NPCBAERM), NDMD, New Delhi [Internet] [cited 2014 Aug 27], Available from: http://ndmindia.nic.in/EQProjects/NPCBAERMFlyer.pdf.

13. Park K. Text Book of Preventive and Social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

14. What to do in an earthquake. Victoria State Emergency Service [Internet] [cited 2014 Aug 27]. Available from: http://www.ses.vic.gov.au/prepare/quake safe/what-to-do-in-an-earthquake.

15. Wisner B, Adams J. Environmental Health in Emergencies and Disasters: A Practical Guide. WHO [Internet] 2002 [cited 2014 Aug 27], Available from: http://www.who.int/water_sanitation_health/hygiene/emergencies/em 2002intro.pdf.

11

A Quick Review on Family Planning

This chapter contains

▪ Definitions

▪ Small Family Norm

▪ Objectives of Family Planning

▪ Scope of Family Planning Services

▪ Health Aspects of Family Planning

▪ Contraceptive Methods

• Characteristics of Ideal Contraceptives

• Classification

– Temporary Family Planning Method

– Permanent Family Planning Method

▪ World Contraception Day

“Bigger the family lower the share of basic needs”

INTRODUCTION

Family planning is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sex education, prevention and management of STDs (sexually transmitted diseases), preconception counseling and management, and infertility management. Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy.

DEFINITIONS

Family planning: An expert committee (1971) of the WHO defined “Family planning is a way of thinking and living that is adopted voluntarily upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of a country.”

Eligible couple: Eligible couple refers to a currently married couple wherein the wife is in reproductive age (15–45 years).

Target couple: Target couples are those couples who have 2–3 living children. Now includes families with one child or even newly married couples (eligible couples) to develop acceptance of the idea of family planning from the earliest possible stage.

Couple protection rate (CPR): It is defined as the percent of eligible couples effectively protected against childbirth by one or the other approved methods of family planning, viz. sterilization, IUD, condom or oral pills. CPR is an indicator of the prevalence of contraceptive practice in the community. Sterilization accounts for over 60 percent of effectively protected couples.

Contraceptives: It is defined as preventive methods to help women avoid unwanted pregnancies. They include all temporary and permanent measures to prevent pregnany resulting from coitus.

Small Family Norm

The size of the family is a matter of great importance not only for the country (macrolevel) as a whole, but also for the welfare and health of the individual, the family and the community (microlevel). The objective of the Family Welfare Program in India is that people should adopt “small family norm” to stabilize country’s population at 1533 million by the year 2050 AD. With this view in 1980s campaign brought the two-child norm with three themes: “Sons or daughters—two will do”; “Second child after 3 years” and “Universal Immunization”.

Reports suggest that population of India will overtake that of China’s by the year 2025. Campaigns of “Hum Do Hamare Do” which lately has become “Hum do Hamara Ek”. A few state governments (e.g. Haryana, Pune) have started it but protests from political parties, ethnic groups, religious bodies and other idle social organizations getting yet another issue to raise their voices against, implementing this would not be an easy task.

The size of the family affects the quality of life of human beings. The quality of life does not only pertain to economic standards of living; rather it has a much wider horizon. Family size affects:

• Basic human needs

• Income and growth of the economy and savings

• Food and nutrition—quality and quantity.

• Uses of land and urban public system

• Health, especially that of mother and child.

• Education, particularly that of children.

Advantages for adapting small family norm

• Both the health of mother and child can be maintained.

• Physical and psychological development of child is possible.

• Parents can avail job opportunities.

• Peace and harmony exists in the family.

Objectives of Family Planning

Objectives of family planning are to:

• avoid unwanted births.

• bring about wanted births.

• regulate the intervals between pregnancy.

• control the time at which births occur in relation to the ages of the parents.

• determine the number of children in the family.

Scope of Family Planning Services

A WHO Expert Committee (1970) has stated that family planning service have various scopes. But these changes country to country according to national objectives and policies. Scopes of family planning services are:

• The proper spacing and limitation of births

• Advice on sterility

• Education on parenthood

• Sex education

• Screening for pathological conditions related to the reproductive system (e.g. cervical cancer)

• Genetic counseling

• Premarital consultation and examination

• Carrying out pregnancy test

• Marriage counseling

• Preparation of couples for the arrival of their first child

• Providing services for unmarried mothers

• Teaching home economics and nutrition

• Providing adoption services

Health Aspects of Family Planning

A serious problem for many women can be pregnancy. It may damage mother’s health if proper age of pregnancy, proper spacing between children are not maintained along with nutrition, healthy lifestyle. Even a number of congenital anomalies are associated with advancing maternal age. Issues relating to family planning are highly relevant to pediatrics too. If family planning is introduced appropriately then lots of complications can be avoided.

1. Reduces maternal mortality, morbidity.

2. Improves nutritional status of women.

3. Prevents complications of pregnancy and abortion.

4. Helps to avoid of unwanted pregnancy.

5. Limits the number of births.

6. Helps to space between children, timing the births, 1st and last in relation to the age of the mother.

7. Reduces foetal mortality rate.

8. Reduces abnormal development of fetus.

9. Prevents congenital anomalies which are associated with advancing maternal age.

10. Helps to avoid completely unwanted birth.

11. Prevents neonatal, infant and preschool mortality rates.

12. Maintains birth weight and vulnerability to diseases.

13. Birth spacing and family size have important role in proper child growth, development and nutrition.

14. Children are prone to get more infection in large family. Adopting family planning helps to prevent infectious diseases among children.

Contraceptive Methods

Birth control, also known as contraception and fertility control, is methods or devices used to prevent pregnancy.

Characteristics of ideal contraceptive

• Safe

• Effective

• Acceptable

• Inexpensive

• Reversible

• Simple to administer

• Independent of coitus

• Long-lasting to avoid frequent administration

• Require little/no medical supervision

Fig. 11.1

Classification of contraceptive

Contraceptives are grouped into two classes:

1. Temporary (spacing) method

A. Barrier method

a. Physical

• Male condom

• Female condom

• Diaphragm

• Vaginal sponge

b. Chemical

• Foams

• Creams/jellies

• Suppositories

• Soluble films

c. Combined

B. Intrauterine devices

• 1st generation IUD: Non-medicated/inert IUD

• 2nd generation IUD: Copper releasing

• 3rd generation IUD: Hormone (progestogens) releasing

C. Hormonal method

a. Oral pills

• combined pill (strictly starts at 5th day of menstrual period)

• Progesterone only pill/mini pill/micropill

• Postcoital pill (within 48 hours)

• Once a month (long-acting pill): quinestrol

• Male pill

b. Depot (slow release) formulations

• Injectables

• Subcutaneous implants

• Vaginal rings

D. Postconceptional methods

E. Miscellaneous

2. Permanent family planning or voluntary sterilization

A. Male voluntary sterilization (vasectomy)

B. Female voluntary sterilization (tubectomy)

Fig. 11.2

Temporary Methods

A. Barrier method

i. Physical method

a. Male condom

• NIRODH = prevention

• It is a rubber sheath fitted onto the erect penis during sex, air must be expelled.

• Most widely practiced method used by the male.

It prevents the semen from being deposited in the vagina. Effectiveness increases if use in conjunction with spermicidal jelly inserted in vagina before intercourse. Condoms are available free of cost from government and non-government family planning clinics.

b. Female condom

Female condom is a pouch made of polyurethane, which lines the vagina. There is an internal ring in the close end of the pouch and an external ring remains outside the vagina. It is prelubricated with silicon, spermicidal need not to be used. But it is costly and has low acceptability.

Advantages of condom

• Effective immediately

• Easily available and cheap

• Fairly effective, 95% success rate if properly and correctly used.

• Condom is the only device which gives protection against STD, HIV/AIDS, HBV and their risk of infertility.

Disadvantages of condom

• It may slip off or tear due to incorrect use.

• Requires the use of a new condom with each episode of intercourse allergy.

c. Diaphragm

It is another vaginal barrier. A diaphragm is dome-shaped latex (rubber) cup, 5–10 cm in diameter, has a flexible rim made of spring or metal. It is inserted into the vagina before intercourse. Women to be fitted with diaphragm of the proper size to prevent sperm to enter inside vagina. It should be inserted before sexual intercourse. Spermicidal jelly is always used along with it. The diaphragm should not be left in more than 6 hours after intercourse.

Fig. 11.3

Table 11.1

Advantages of diaphragm
Disadvantages of diaphragm

Almost total absence of risk and medical contraindication

• Initially a physician or trained person is needed to demonstrate the technique

• Unavailability of washing and storing acilities

• Leaving in the vagina for a long time may cause toxic shock syndrome

d. Vaginal sponge

• Previous: Sponge soaked in vinegar or olive oil

• Now: Trade name “Today”

• Small polyurethane foam sponge (5 cm × 2.5 cm)

• Saturated with spermicide, nonoxynol-9

• Far less effective than diaphragm

• High failure rate

Fig. 11.4

ii. Chemical method

• Foams: Foam tablets, foam aerosol

• Creams, jellies, pastes—squeezed from a tube

• Suppositories—inserted manually

• Soluble films—C-film inserted manually

a. Vaginal foam

• Vaginal foam comes in a small aerosol can with a special applicator.

• After shaking the can, the woman fills the applicator with foam and then, lying down, inserts it deep into her vagina.

• This must be done not more than half an hour before each coitus.

• Two applications are better than one.

• The foam kills the sperm and also blocks the cervix mechanically, thus preventing any sperm cells that might have survived from entering the uterus.

• The protection can be increased further if the man uses a condom at the same time.

Effectiveness: about 90 percent; if the man also wears a condom close to 100 percent.

Fig. 11.5

b. Foaming tablets and suppositories

• Can only work when they have time enough to dissolve inside the vagina.

• They must be inserted 10 to 15 minutes before each coitus.

• However, if used alone they do not offer much protection against pregnancy.

Effectiveness: Not very effective.

Fig. 11.6

c. Spermicidal creams and jellies

Less effective than foam because they sometimes disperse unevenly.

Effectiveness: Not very effective without a diaphragm.

Fig. 11.7

B. Intrauterine device

It is one of the most widely used and safest methods of contraception available to women. It is based on the principle of introducing foreign body in the uterus. It has a tail which is easily felt into vagina (at position and helps while removing). IUD are of two types: medicated and non-medicated. Medicated IUD releases either metal ions (copper) or hormones (progestagens). IUD also can be classified as:

• 1st generation IUD: Non-medicated/inert IUD

• 2nd generation IUD: Copper releasing

• 3rd generation IUD: Hormone (progestagens) releasing

Fig. 11.8

1st generation IUD: Non-medicated/inert

IUD

• These were of different shapes and sizes as loops, spirals, coils, rings and bows.

• Among those best known is Lippes Loop which is double S-shaped, nontoxic, non-tissue reactive and extensively durable.

• Contains small amount of barium sulfate to allow X-ray observation.

2nd generation IUD: Copper releasing

Earlier devices of copper releasing IUD are:

• Copper 7

• Copper T 200

Newer devices of copper releasing IUD are:

• Variants of the T device (T Cu-220C, T Cu 380A)

• Nova T

• Ulti load devices (ML-Cu-250, ML-Cu-375)

Fig. 11.9

Second generation IUDs have effective life for at least 5 years with a low expulsion rate and less side effects. These are effective as postcoital contraceptives, if inserted within 3–5 days of unprotected intercourse.

3rd generation IUD: Hormone releasing

Most widely used hormonal device is ‘Progestasert’. 3rd generation IUD is T-shaped device filled with 38 mg of progesterone which is released slowly in uterus (65 meg daily). Progesterone has direct local effect on uterine lining, on cervical mucosa and possible on the sperms. Hormone supply gradually depleted, regular replacement of the device needed. Effective life of 3rd generation IUD is 10 years.

Mechanism of IUD

• Copper: Reduces sperm motility, survival, affects enzymes of uterus.

• Hormone releasing devices: Increases mucus viscosity, prevents sperms to enter cervix.

Advantages

• Insertion takes only a few minutes

• Easily reversible

• Stays for a long time

• Inexpensive in comparison with other method

• High success rate 97%

Fig. 11.10

Disadvantages

• Requires trained person to insert and remove.

• Need to check the string after every menstrual period.

• Increases menstrual bleeding and cramping during the first few months.

• No protection against STD, AIDS/HIV. Contraindication

• Absolute: Suspected pregnancy, pelvic inflammatory disease, vaginal bleeding, CA cervix, previous ectopic pregnancy.

• Relative: Anemia, menorrhagia, purulent cervical discharge, congenital vaginal malformation.

Timing of insertion

Almost anytime IUD can be inserted during a woman’s reproductive age (except pregnancy); but best time is during menstruation or within 10 days of the beginning of a menstrual period as insertion is technically easy as diameter of cervical canal is bigger.

Follow-up

Important aspectod IUD is follow-up. First follow-up should be after 1st menstrual period as there is chance of loop expulsion. Next visit should be after 3rd menstrual period to evaluate problems of pain and bleeding and thereafter at six months or 1 year intervals.

Instructions to IUD wearer

• Regularly check the threads or ‘tail’: To be sure IUD in uterus

• Visit clinic if experiences any side effect (fever, pelvic pain and bleeding)

• If miss a period consult doctor immediately.

• Change IUD after 5 years (copper releasing) or 10 years (hormone releasing)

Complications/Side effects of IUD

• Bleeding

• Pain

• Pelvic infection

• Uterine perforation

• Pregnancy

• Ectopic pregnancy

• Expulsion

C. Hormonal method or physiological method

i. Oral pills

Pills are easy, safe, effective, reversible and reliable contraceptives for the young women wanting to delay her first pregnancy or space the next child.

Mode of action of oral pill

• Combined oral pills: Combination of estrogen (30–35 meg) and progesterone (0.5–1.0 mg) prevents release of ovum from the ovary by blocking the pituitary secretion of gonadotropin.

Fig. 11.11

• Progesterone-only pill/mini pill/micropill: Makes cervical mucus membrane thick and scanty thus reduces sperm motility.

• Male pill: Made of gossypol, a derivative of cotton seed oil. It prevents spermatogenesis, interferes with sperm storage, maturation and sperm transport.

• Long-acting pill: Need to take once a month; contains quinestrol a long-acting estrogen in combination with short-acting progesterone. It is not very effective.

• Emergency pill: Emergency contraception, also called postcoital contraception. It is a form of birth control that may be used by women who have had unprotected sex or being raped, having a condom break or slip off during sex, or missing two or more birth control pills during a monthly cycle. It should be taken within 72 hours of unprotected sex. It prevents pregnancy by temporarily blocking eggs from being released, by stopping fertilization, or by keeping a fertilized egg from becoming implanted in the uterus.

Generally combined pills are used commonly. One strip contains 28 pills. Among those, 21 are hormonal pills and seven are iron tablets. Hormonal pills should be taken for 21 days continuously beginning on the 5th day of menstrual cycle followed by a break of 7 days when iron tablets should be continued.

The pill should be taken every day at a fixed time, preferably before going to bed at night. If the user forgets to take a pill, she should take it as soon as she remembers, but should not skip the dose of the same day. Regular dose should be taken in scheduled time.

Advantages of oral pill

• Easily available for free of cost at health facilities or at low cost from medical shops.

• Make menstrual cycle regular and cure dysmenorrhea.

• Prevents anemia by decreasing the blood loss.

Fig. 11.12

Disadvantages of oral pill

• Must be taken daily, forgetfulness increases failure

• No protection against STD (HIV/AIDS, HBV)

• Minor sick effect may be seen as nausea, breast tenderness, headaches, weight gain, mood changes, dizziness, cardiovascular problems, metabolic effects, etc.

ii. Depo-Provera injection (DMPA)

It comes in a single dose vial containing 150 mg for every 3 months and administered intramuscularly.

Fig. 11.13

Advantages

• Rapidly effective

• Can provide long-term protection

• Reversible

• Effectiveness continues even if the client is up to 2 weeks late for return visit

Disadvantages

• Injection available only at clinics

• Causes menstrual changes in most users

• Weight gain

• May cause depression

iii. Norplant (35 mg Levonorgestrel/stick) It is placed under the skin on the inside of a upper arm in a fan-shaped configuration. Each of the 6 stick capsules is 34 mm long with a diameter of 2.4 mm. It is recommended that Norplant implants be replaced after 7 years. When the capsules are removed the contraceptive effect wears off effectively. Norplant suppresses the release of follicle-stimulating hormone and luteinizing hormone (LH). The LH peak is dampened so that ovulation is inhibited with levonorgestrel implants.

D. Natural method/natural contraception

Natural method is also called “Periodic abstinence”. This is the method for planning and preventing pregnancies by observing the naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle. Avoidance of intercourse during the fertile phase to prevent pregnancy is adviced.

i. Coitus interruption (withdrawal method)

• Removal of the penis prior to ejaculation of the semen.

• Ejaculation must be completely away from the vagina and the external genitalia of the female partner.

ii. Cervical mucus membrane

• Fertile mucous occurs approximately at mid-cycle and is abundant thin, slipping and elastic like an egg white, and infertile mucous is thick, sticky, and is found at the beginning and end of the cycle.

• Abstinence is practiced when fertile mucus is present and for 3 days afterwards.

iii. Basal body temperature

• It monitors the resting body temperature each day just at or immediately after ovulation (mid-cycle), there is 0.3–0.5°C rise in body temperature.

• Abstinence or other method is practiced from the beginning of the cycle until three days after the rise in body temperature.

iv. Safe period and rhythm method

• Ovulation takes place 14 days before the next menstruation period.

• The ovum is destroyed after 1–2 days if it is not fertilized.

• A week before and after the menses is called the “safe period”.

Fig. 11.14

Formula for the safe period

Shortest cycle minus 18 = First day of fertile period.

The longest cycle minus 11 = the last day of the fertile period.

Example: If a woman’s menstrual cycle varies from 26 to 31 days, the fertile period would start on 26–18 = Day 8 of the cycle and the fertile period end on 31–11 = Day 20 of the cycle.

v. Lactational amenorrhea method

Based upon the natural infertility experienced by breastfeeding woman, especially during the early postpartum months.

It delays the ovulation and then the menstrual cycle.

Permanent Family Planning or Voluntary Sterilization

These are operations that make it almost impossible for a man or woman to have any children. Since these operations are permanent, they are only good for those women or men who are certain that they do not want any more children. To have one of these operations, one must go to a health center or hospital. The surgery is fast and safe, and does not cause side effects.

Fig. 11.15

Advantages

• It is simple/small incision

• Easy to perform

• Done in short time

• Less expensive

• Hospitalization is limited

Disadvantages

• Difficult to reverse the action as it is a permanent method.

• May have certain complication after the operation.

• No protection against STD and HIV/AIDS.

a. Male voluntary sterilization (vasectomy)

A vasectomy is a simple operation in which the tubes (vas deferens) that carry the sperm from the testicles to the penis are cut. It is performed in health centers by trained doctors under local anesthesia under strict aseptic technique. It is customary to remove a piece of vas at least 1 cm after clamping and ligate and fold back in such a way that end face from each other. The man’s testicles are not cut. This operation can be done in any health center where there is a trained health worker. It takes only a few minutes to do.

The operation does not change a man’s ability to have sex or to feel sexual pleasure. He still ejaculates semen but there are no sperms in the semen.

Preoperative care of vasectomy

• Preoperative counseling should be done.

• Stop taking all aspirin or blood thinning products one week prior to your vasectomy.

• Arrange to rest and be off from work for 2–3 days after the vasectomy.

The day of the vasectomy

• Informed written consent has to be taken.

• Carefully shave all of the hairs from the scrotum.

• Wear or bring close-fitting underwear that will support the scrotum.

• Be sure to have someone drive you home from the procedure.

Postvasectomy instructions

• Wear close-fitting underwear for 2–3 days to hold the bandages in place.

• Place an icepack on scrotum to minimize swelling during the first 24 hours (30 minutes on/30 minutes off).

• Take pain medication as needed.

• May take showers beginning the day after the procedure, but avoid soaking the scrotum in baths as in ponds, river bath, swimming pools or hot tubs until the sutures completely dissolve (usually 10 days).

• Limit activity for the first 48 hours following procedure, avoid any heavy lifting, pushing or straining.

General instructions

There may be some bruising and redness at the site of the incision. The sutures will dissolve and fall out within 5–10 days. There may be some yellow or white discharge from the incision as the sutures dissolve, this is normal. There may be a small open gap at the site of the incision after the sutures fall out, this is normal and will close up over time. You may notice some firmness in and around the incision site, it will soften, flatten and return to normal within a few weeks.

Follow-up semen test

A vasectomy does not make you immediately infertile; it takes 6–8 weeks (30–40 ejaculations) for all the sperms to leave your body. Follow-up semen testing is needed to confirm sterilization. Within this days need to use another method of contraception.

Complications

Consult to doctor immediately if client experiences any of the following complications:

• Temperature (taken by mouth) above 101.5°F

• Significant increase in scrotal size

• Redness or swelling that does not subside

• Difficulty in urinating

• Blood spot on the dressing larger than a dime

b. Female voluntary sterilization (tubectomy)

A tubal ligation is a slightly more difficult operation than a vasectomy, but it is still very safe. It takes about 30 minutes. A trained health worker inserts a tool through the skin near the belly button to cut or tie the tubes that carry the eggs to the womb. It does not change a woman’s monthly bleeding or her ability to have sex and sexual pleasure.

– Minilap

Operation is done under local anesthesia. A 2–3” incision is given in the lower abdomen. The fallopian tubes are tied off and a small piece of tube is cut out. Then the abdomen is closed. A dry sterile dressing is applied and the client is discharged within 2–4 hours after the procedure.

– Laproscopy

One cm incision is made under the umbilicus and then the laparoscope is inserted to find out the fallopian tube.With the same instrument the tubes are tied using small rubber rings. This operation is also done under local anesthesia.

Preoperative preparations of tubectomy include counseling and measures to improve the outcome of surgery.

1. Informed consent—written consent is obtained from the patient prior to performing the surgery.

2. In preoperative counseling the patient needs to be informed that the procedure of tubal sterilization is permanent and irreversible and that a small chance of failure exists. The relative likelihood of an ectopic pregnancy is increased when sterilization failure occurs.

Fig. 11.16

3. It can be done as day-surgery or may require an overnight stay in the hospital.

4. It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 6 hours before the scheduled operation or after midnight if the operation is planned in the morning.

5. Painkillers and antibiotics may be prescribed before the procedure.

6. A sedative may be useful to relieve the anxiety of surgery.

7. The abdomen and genital area may be shaved and prepared for the surgery.

8. Before surgery or during the previous night a bath may be advisable. During the bath thorough cleaning of the abdomen and genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery.

9. An enema may be administered to the patient prior to performing the surgery. Sometimes a laxative may be given to clear the bowels prior to the surgery.

Postoperative care involves the precautions that need to be followed by the patient after the surgery.

1. The follow-up visit for open or laparoscopic approaches is 1–2 weeks posto-peratively.

2. Notify the health care provider if you develop fever (38°C or 100.4°F), increasing or persistent abdominal pain, or bleeding or purulent discharge from the incision.

3. Medications should be taken as per the doctor’s prescription.

4. Ensure to complete the whole course of the antibiotic.

5. Refrain from sexual intercourse for about a week after surgery or as advised by your doctor.

6. If you have delayed periods, vaginal bleeding/spotting, and severe abdominal pain, consult the doctor immediately, as it could be an ectopic pregnancy.

7. Avoid heavy lifting for at least 3 weeks.

World Contraception Day

September 26 is designated as World Contraception Day, devoted to raising awareness of contraception and improving education about sexual and reproductive health, with a vision of “a world where every pregnancy is wanted”.

Bibliography

1. “Definition of Birth Control”. MedicineNet Retrieved 9 August 2012. [Internet] 2012 [cited 2014 Sep 19]. Available from: http://green.wikia.com/wiki/Birth_control.

2. “Mission Statement”. US Department of Health and Human Services, Office of Population Affairs [Internet] [cited 2014 Sep 19]. Available from: http://www.hhs.gov/opa/index.html.

3. Basavanthappa BT. Community Health Nursing. 2nd ed. India: Jaypee Brothers Medical Publishers (P) Ltd; 2008.

4. Birth Control and Family Planning. Health Guide [Internet] [cited 2014 Sep 19]. Available from: http://health.nytimes.com/health/guides/specialtopic/birth-control-and-family-planning/background.html.

5. Emergency Contraception. Health and Sex [Internet] [cited 2014 Sep 19], Available from: http://www.webmd.com/sex-relationships/guide/emergency-contraception.

6. Family Planning. World Health Organization [Internet] [cited 2014 Sep 19], Available from: http://www.who.int/topics/family_planning/en.

7. Kamalam S. Essential in Community Health Nursing Practice. 1st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2005.

8. One Child Norm in India: Is It Possible? YouthKiAwaaz. [Internet] 2010 June 4 [Cited on 5/12/2014] Available on: http://www.youthkiawaaz.com?2010?06/one-child-norm-in-india-is-it-possible /June 4, 2010.

9. Park K. Park’s Textbook of Preventive and Social Medicine. 20th ed. India: M/S Banarsidas Bhanot; 2009.

10. Permanent Methods of Family Planning [Internet] [cited 2014 Sep 19]. Available from: http://en.hesperian.org/hhg/Where_Women_Have_No_Doctor:Permanent_Methods_of_Family_Planning.

11. Postoperative Care—Tubectomy [Internet] [cited 2014 Sep 19]. Available from: http://www.medindia.net/surgicalprocedures/tubectomy_postoperative_care.htm.

12. Preoperative Preparation—Tubectomy [Internet] [cited 2014 Sep 19]. Available from: http://www.medindia.net/surgicalprocedures tubectomy_preoperative_preparations.htm.

13. Preoperative Preparations—Tubectomy [Internet] [cited 2014 Sep 19]. Available from: http://www.medindia.net/surgicalprocedures/tubectomy_preoperative_preparations.htm#ixzz3I8XClaDg.

14. Rathee R. ‘Hum Do, Hamara Ek’ is the New Mantra. TNN. Oct 2, 2002. http://timeso findia.indiatimes.com/city/delhi/Hum-Do-Hamara-Ek-is-the-new-mantra/articleshow/23880389.cms.

15. Small Family Norms [Internet] [cited 2014 Sep 19]. Available from: http://admis.hp.nic.in/himachal/scert/him_chetnal24_135.htm.

16. Tuitui R, Suwal SN. A Textbook of Community Health Nursing. 2nd ed. Kamal Pokhari: Vidyarthi Prakashan(P) Ltd; 2064.

17. Vasectomy: Pre- and Postoperative Instructions. The Austin Diagnostic Clinic [Internet] [cited 2014 Sep 19]. Available from: https://www.adclinic.com?2012/05/vasectomy-pre-and-post-operative-instructions/#.VFk3yTSUeek.

18. World Contraception Day [Internet] [cited 2014 Sep 19]. Available from: http://www.your-life.com/en/for-doctors-parents-etc/about-wed.

12

Care of Priority Age Group

This chapter contains

▪ Child Development Milestone Chart

▪ Care of Neonate and Infant

▪ Care of Toddler

▪ Care of Preschool Child

▪ Care of School Age Child

▪ Care of Adolescent Child

▪ Antenatal, Intranatal and Postnatal Mothers’ Cares

▪ Care of Old Age People

Priority age group is referred to those ages in which mortality and morbidity rates are quiet high. They need special care, extra nutrition and good family support. Generally newborn, infant, underfive children, adolescent, women and old age fall under this group.

Child Development Milestone Chart

Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range. Although each milestone has an age level, the actual age when a normally developing child reaches that milestone can vary quite a bit as every child is unique.

Table 12.1: Developmental milestone

• 6- to 7-year-old

Motor skill

– Enjoys many activities and stays busy

– Likes to paint and draw

– May lose first tooth

– Vision is as sharp as an adult’s vision

– Practices skills in order to become better

– Jumps rope

– Rides a bike

Cognitive skill

– Understands concept of numbers

– Knows daytime and nighttime

– Knows right and left hands

– Can copy complex shapes, such as a diamond

– Can tell time

– Can understand commands with three separate instructions

– Can explain objects and their uses

– Can repeat three numbers backwards

– Can read age—appropriate books and/or materials

Social skill

– Cooperates and shares

– Jealous of others and siblings

– Likes to copy adults

– Likes to play alone, but friends are becoming important

– Plays with friends of the same gender

– May have occasional temper tantrums

– Modest about body

– Likes to play board games

• 8- to 9-year-old

Motor skill

– More graceful with movements and abilities

– Jumps, skips, and chases

– Dresses and grooms self completely

– Can use tools (i.e. hammer, screwdriver)

Cognitive skill

– Can count backwards

– Knows the date

– Reads more and enjoys reading

– Understands fractions

– Understands concept of space

– Draws and paints

– Can name months and days of week, in order

– Enjoys collecting objects

Social skill

– Likes competition and games

– Starts to mix friends and plays with children of the opposite gender

– Modest about body

– Enjoys clubs and groups becoming interested in boy-girl relationships, but does not admit it.

• 10- to 12-year-old

Motor skill

– Remainder of adult teeth will develop

– Likes to sew and paint

Cognitive skill

– Writes stories

– Likes to write letters

– Reads well

– Enjoys using the telephone

Social skill

– Friends are very important; may have a best friend

– Increased interest in the opposite gender

– Likes and respects parents

– Enjoys talking to others Childhood is vital age for growth and development. Neonatal period refers to first 28 days of life and from 28 days to 1 year is known as infancy.

Care of Neonate and Infant

• Wash your hands with soap and water before handling your baby. Newborns don’t have a strong immune system yet, so they are susceptible to infection. Make sure that everyone who handles your baby has clean hands.

• Be careful to support your baby’s head and neck. Support the head when carrying your baby.

Fig. 12.1

• Be careful not to shake your newborn, whether in play or frustration. Shaking that is vigorous can cause bleeding in the brain and even death. If you need to wake your infant, don’t do it by shaking instead, tickle your baby’s feet or blow gently on a cheek.

• Limit any activity that could be too rough or bouncy.

• Bonding and Soothing. Take your baby firmly so that feels secure.

• Swaddling/mummifying, this works well for some babies during their first few weeks. Swaddling keeps a baby warm, but it seems to give most newborns a sense of security and comfort. Swaddling may also help limit the startle reflex, which can wake a baby. Mummifying a baby:

– Spread out the receiving blanket, with one corner folded over slightly.

– Lay the baby face up on the blanket with his or her head above the folded corner.

– Wrap the left corner over the body and tuck it beneath the back of the baby, going under the right arm.

– Bring the bottom corner up over the baby’s feet and pull it towards the head, folding the fabric down if it gets close to the face. Be sure not to wrap too tightly around the hips.

– Wrap the right corner around the baby, and tuck it under the baby’s back on the left side, leaving only the neck and head exposed. To make sure your baby is not wrapped too tight, make sure you can slip a hand between the blanket and your baby’s chest, which will allow comfortable breathing. Make sure, however, that the blanket is not so loose that it could become undone.

– Babies should not be swaddled after they’re 2 months old. At this age.

• Diapering your baby. To prevent or heal diaper rash, try these tips:

– Change your baby’s diaper frequently, and as soon as possible after bowel movements.

– After cleaning the area with mild soap and water or a wipe, apply a diaper rash or “barrier” cream. Creams with zinc oxide are preferred because they form a barrier against moisture.

– If you use cloth diapers, wash them in dye- and fragrance-free detergents and sundry.

– Let the baby go undiapered for part of the day. This gives the skin a chance to air out.

– If the diaper rash continues for more than 3 days or seems to be getting worse, call your doctor. It may be caused by a fungal infection that requires a prescription.

• You should give your baby a sponge bath until the umbilical cord falls off and the navel heals completely (1–4 weeks). A bath two or three times a week in the first year is fine. More frequent bathing may be drying to the skin.

• Umbilical cord care in newborns is also important. An infant’s navel area shouldn’t be submerged in water until the cord stump falls off and the area is healed. Until it falls off, the cord stump will change color from yellow to brown or black—this is normal. Consult your doctor if the navel area becomes reddened or if a foul odor or discharge develops. Otherwise don’t apply anything.

Fig. 12.2

• Exclusive breastfeeding: Generally, it’s recommended that babies be fed on demand whenever they seem hungry. Your baby may cue you by crying, putting fingers in his or her mouth, or making sucking noises. Provide exclusive breastfeeding up to 6 months of age, i.e. only breast milk, not even water; it is recommended to provide only ORS solution in continuation of breast milk in case of diarrhea. Start weaning after 6 months.

• Burping your baby: Burp your baby after each feeding: hold your baby upright with his or her head on your shoulder. Support your baby’s head and back while gently patting the back or rub the back with your other hand.

• Immunization: Immunization is an important aspect in care of newborn. At birth BCG and zero dose polio to be given. Then DPT, polio and hepatitis B vaccines, total three doses to be given at age of 1.5 months, 2.5 months and 3.5 months; then measles at 9 months.

• Growth monitoring: It is important to maintain growth chart to diagnose malnutrition, growth retardation.

Care of Toddler

Toddler, the age of 1 to 3 years; in this age a child’s life experiences plenty of changes. They gradually join your style of eating and diet. Though food preferences are formed early in life it is ideal to help your child to develop tastes and preferences that is good for her health.

• Dietary guidelines for a 1-to 3-year-old toddler

– Provide several servings in a day

– Add variety of food items

Fig. 12.3

– Take care to provide with complete nutrition within a day

– Add plenty of fruits and vegetables

– Include milk and milk products

– Offer cereals like bread, rice, noodles, pasta and many more

– Offer water to drink a lot of times

– Limit intake of saturated fat and fatty and fried foods

– Prefer giving food with less salt

– Prefer food with low sugar content

– Avoid chocolates, food with empty calories and high sugar content

– Add meat, eggs poultry, legumes

Immunization

Don’t miss any doses of vaccines. Make a list of the vaccines and booster doses that is needed for your child according to age. Keep the list and immunization card in a safe place. Check out whether any new and improved vaccination is needed and how safe and reliable that is.

Height and Weight Monitoring

You should also meet the doctor at intervals and get your toddler’s weight and height checked to ensure right development and proper growth of your child. Calculate weight for height of your baby to check malnutrition (up to 5 years of age).

Expected weight

• 3–12 months

:
[age (m) + 9]/2]

• 1–6 years

:
[age (year) × 2 + 8]

• 6–12 years

:
[age (year) × 7 – 5]/2

Gomez classification of malnutrition:

Normal | 90–110
1st degree/mild | 75–89
2nd degree/moderate | 60–74
3rd degree/severe | <60

Regular Health Check-up

Collect information from different and reliable sources about care of baby, so that you are certain that you are providing with the right thing and amount to your child. Consult with your pediatrician whenever needed.

Personal Hygiene

Cotton is the best fabric and is suitable for all types of skin and climate. Keep your baby clean.

Toilet Training

You also need to see that the child develops a set pattern of bowel movement. Make your child visit the bathroom before sleeping. Your child must be both physically and emotionally ready for toilet training. Most children are ready to start when they are between 22 and 30 months of age. Before children can use the toilet, they must be able to control their bowel and bladder muscles. Some signs of this control are having bowel movements around the same time each day, not having bowel movements at night, and having a dry diaper after a nap or for at least 2 hours at a time. Children must also be able to climb, talk, remove clothing, and have mastered other basic motor skills before they can use the toilet by themselves.

Habit Development

When the toddler is in between 1–3 years of time, you need to teach him and help him to form good habits that are helpful for life. Make him/her to do small work in any form. It can be handling a small bowl from kitchen to the dining space or you can ask to arrange plates or bowls or whatever he finds interesting. This will keep him/her engaged and happy too as well as help to develop helping habits too.

Child safety: Toddler period is very prone to get home accident due to the exploring habit of children.

• Keep poisonous articles/solutions (rat killers, phenyl, floor cleaning acids, etc.) out of her reach and preferably under high rack with lock and key.

• Better to place electronic connections, plug points in such a height that child cannot reach that. If plug points are on ground level, keep your child that she is not putting her fingers in it.

• Discourage playing with big plastic bags; child can put her head in it which may cause suffocation.

• Don’t keep big bowls or buckets full of water in reach of child. She can fall in that and causes drowning.

• Keep your baby away from open well, pond and river side.

• Not to leave your child on a heighted place alone to prevent fall and injury.

Care of Pre-school Child (4 to 5 Years)

As a parent, following are some of the things you can do to help your preschooler:

• Read out books, stories, poems to your child. Encourage him/her love for books by taking him/her to the library or bookstore.

• Let your child help you with simple tasks which will help to grow his/her responsibilities.

• Encourage your child to play with other children. This helps him/her to learn the value of sharing and friendship.

• Teach him/her discipline. Be clear and consistent when disciplining your child. Explain and show the behavior that you expect from him/her.

• Help your child develop good language skills by speaking to him/her in complete sentences and using “grown up” words. Help him/her to use the correct words and phrases.

• Help to solve his/her problems stepwise when he/she is upset.

• Give your child a limited number of simple choices which will improve his/her decisionmaking skill (for example, deciding what to wear, and what to eat for snack).

• Give importance on child safety

– Tell him/her not to play in the street or to stay out of traffic.

– Check outdoor playground equipment has no loose parts or sharp edges.

– Watch your child at all times, especially when he/she is playing outside.

– Be safe in the water. Teach your child to swim, but watch him/her at all times when he/she is in or around any body of water.

– Teach your child how to be safe around strangers as nowadays child trafficking is increasing.

• Try to eat meals with your child whenever possible. Let your child see you enjoying fruits, vegetables, and whole grains at meals and snacks.

• Your preschool child will be very active and busy. They will never sit for long time for eating. To maintain their proper diet better to provide finger foods. Like piece of fruits or vegetable or biscuits, etc. make him/her to hold and eat in between play.

• Provide your child with age-appropriate play equipments like balls and plastic bats, but let your preschooler choose what to play. This makes moving and being active fun for your preschooler.

Care of School Age Child (6 to 12 Years)

As a parent, following are some of the things you can do to help your school-going child:

• Maintain and teach to maintain their personal and environmental hygiene.

• Provide balanced diet.

• Generally parents are the first role model for children. So behave positively and constructively.

• Set and provide appropriate limits, guidelines, and expectations and consistently enforce using appropriate consequences.

• Offer compliments for your child being cooperative and for any personal achievements.

• Encourage to participate in extracurricular activities.

• Help your child to choose activities according to your child’s abilities.

• Encourage your child to talk with you and be open with his or her feelings.

• Don’t overpressurized your child about study; try to motivate in such a way that it will generate self-interest of studying.

• Inspire your child to read and read with your child.

• Encourage your child to get involved with hobbies and other activities.

• Encourage physical activity as exercises, outdoor games.

• Motivate self-discipline; expect your child to follow rules that are set. But be flexible enough to hear his or her point of view.

• Teach your child to respect and listen to authority figures.

• Encourage your child to talk about peer pressure and how to solve those problems.

• Spend uninterrupted time together, giving full attention to your child.

• Limit television, video, and computer time.

• Be free to talk to him or her about child abuse. Teach them about good touch and bad touch so that they can inform you soon if anything happens to them like that.

• Safety is important for school-age children.

– Instruct to see both sides while crossing the road. Not to play road side or on the road.

– School-age children are highly active. They want to try more daring and adventurous behaviors. Children should be taught to play sports in appropriate, safe, supervised areas, with proper equipment and rules.

– Swimming and water safety lessons to be provided to prevent drowning.

– Safety instruction regarding matches, lighters, barbecues, stoves, and open fires can prevent major burns.

– Wearing seat-belts is another important way to prevent major injury or death from a motor vehicle accident.

• Keep close communication with teachers, other school employees, and parents of your child’s friends so you are aware of possible problems.

Care of Adolescent Child (10 to 19 Years)

Adolescence (Latin: adolescere, meaning “to grow up”) is a crucial time of development. It is a transitional stage of physical and psychological human development that generally occurs during the period from puberty to legal adulthood (age of majority).

Be free to talk about the pubertal changes occurs in your child during adolescent period. All children cannot take the changes easily; they need to counsel to accept the changes. Discussing about the following changes will make your child to be free to share his/her problems.

Pubertal Changes in Girls

• Girls may begin to develop breast buds as early as 8 years old. Breasts develop fully between ages 12 and 18.

• Pubic hair, armpit and leg hair usually begin to grow at about age 9 or 10, and reach adult patterns at about 13 to 14 years.

• Menarche (the beginning of menstrual periods) typically occurs about 2 years after early breast and pubic hair appear. It may occur as early as age 9, or as late as age 16. The average age of menstruation in the United States is about 12 years.

• Girls growth spurt peaks around age 11.5 and slows around age 16.

Pubertal Changes in Boys

• Boys may begin to notice that their testicles and scrotum grow as early as age 9. Soon, the penis begins to lengthen. By age 17 or 18, their genitals are usually at their adult size and shape.

• Pubic hair growth as well as armpit, leg, chest, and facial hair begins in boys at about age 12, and reaches adult patterns at about 17 to 18 years.

• Boys do not start puberty with a sudden incident, like the beginning of menstrual periods in girls. Having regular nocturnal emissions (wet dreams) marks the beginning of puberty in boys. Wet dreams typically start between ages 13 and 17, with the average at about 14.5 years.

• Boys’ voices change at the same time as the penis grows. Nocturnal emissions occur with the peak of the height spurt.

• Boys growth spurt peaks around age 13.5 and slows around age 18.

Maintenance of Menstrual Hygiene

Teach your child how to maintain menstrual hygiene.

• Wash private part with water after each urination and to wash with soap and water while bathing.

• Change napkin maximum 4 hourly or more frequently as needed.

• Throw the sanitary napkin in proper place after wrapping in newspaper.

• If using clothes instead of sanitary napkin, wash it with soap and water thoroughly and sundry it.

• Teach to wash hands with soap and water after changing napkin.

Show Your Love

One of the most important parenting skills needed for raising healthy teens involves positive attention.

• Spend time with your teen to show him or her that you care.

• Listen to your teen when he or she talks, and respect your teen’s feelings.

• Praise him/her whenever they had done good or achieved something.

• For every time you discipline or correct your teen, try to compliment him or her twice.

• If your child doesn’t seem interested in bonding as occurs in this age, keep trying. Regularly eating meals together might be a good way to connect. Better yet, invite your teen to prepare the meal with you or some small work with you.

Table 12.2

Minimize Pressure

Don’t pressure your teen to be like you were or wish you had been at his or her age. Give your teen some freedom in clothing and hairstyles. It’s natural for teens to represent themselves in different way from their parents. Allow your teen some self-expression, and try to encourage in such a way that self-motivation grows up for his/her own future.

Encourage Cyber Safety

Find out the technology your teen is using and the websites he or she visits. Keep the computer in a common area in your home. Teach your teen to practice these following basic safety rules:

• Don’t share personal information online.

• Don’t share passwords.

• Don’t get together with someone you meet online.

• Don’t text or chat on the phone while driving.

• Tell to discuss if an interaction or message makes her/him uncomfortable.

Habit Formation

• Fix a time for homework, TV watching and bedtime and be strict to that.

• Prioritize rules but be flexible up to some extent. Prioritizing rules will give you and your teen a chance to practice negotiating and compromising.

• Make sure your teen knows early on that you won’t tolerate tobacco, alcohol or other drug use.

• Calmly explain the unacceptable behavior and the consequences. Correct but don’t scold. Make sure you warning your teen’s behavior, not your teen. Avoid using a sarcastic, demeaning or disrespectful tone. Also, avoid scolding your teen in front of his or her friends.

• Give your teen additional household tasks.

Set a Positive Example

Remember, teens learn how to behave by watching their parents. Your actions generally speak louder than your words. Set a positive example and your teen will likely follow your lead.

Remember the Signs Which Need Help if You’re Teen

• Gets worse in school work suddenly.

• Start to use drugs and alcohol and this becomes a problem.

• Stop coping with problems and day to day activities.

• Begin to have trouble eating or sleeping.

• Complain of lots of physical problems.

• Become aggressive and start getting into trouble like skipping school, stealing or vandalism.

• Become worried about their weight without actually being overweight.

• Become depressed and are negative for a longer period.

Antenatal Care

Objectives of care during pregnancy:

• To promote, protect and maintain health of pregnant mother.

• To diagnose high risk mothers and give them special care.

• To detect danger signs and prevent complications.

• To provide psychological support and counseling.

• To reduce maternal and infant mortality and morbidity rates.

• To teach mother about newborn care, breastfeeding, nutrition, personal hygiene, etc.

• To teach and motivate about family planning methods.

Care

• Antenatal visit: Ideally antenatal mother should visit clinic:

– Once a month during first 7months

– Twice a month during next month

– Once a week thereafter

If not possible to visit so frequent then minimum 3 visits should be done (either mother should come to clinic or health worker should attend them at their home):

– 1st visit at 20 weeks or as soon as pregnancy confirmed

– 2nd visit at 32 weeks

– 3rd visit at 36 weeks.

• Identify and provide special care to high risk mothers:

– Elderly primi (30 years and above)

– Short statured primi (140 cm and below)

– Malpresentation (breech, transverse lie)

– Pervaginal hemorrhage

– Preeclampsia and eclampsia

– Anemia

– Twins, hydramnios

– With history of still birth, abortion, intrauterine death, caesarean

– Elderly grand multiparas

– Prolonged pregnancy (14 days after expected date of delivery)

– Diagnosed other general diseases as diabetes, hypertension, cardiovascular diseases, tuberculosis, HIV/AIDS, etc.

• Detect danger signs and refer to health center:

– Pervaginal bleeding/spotting

– Abdominal pain

– Premature labor

– Severe pitting edema

– Abnormal fetal movement (either very fast or very slow)

– Abnormal fetal heart sound (either very fast or very slow)

– High BP uncontrollable

• Abdominal Palpation

• Nutrition: Extranutrition is needed during pregnancy for growth of baby as well as to maintain health of mother. According to ICMR Nutrition Expert Group, for pregnant women recommended extra allowances are:

– Calorie: 300 kcal per day

– Protein: 10 gm per day

– Calcium: 500–600 mg per day

– Iron: 10 mg per day

– Vitamin supplementation

Fig. 12.4

On an average a healthy woman should gain minimum 12 kg of weight during pregnancy.

• Immunization: Mother should be immunized with tetanus vaccine of two doses: first dose at 16–20 weeks and second dose at 20–24 weeks (within 1 month of first dose).

• Investigation: Antenatal mother should do a few tests to assess fetal condition as well as to prevent complication. As for example, blood test (Hb%, HIV/AIDS, TORCH, Rh status, etc.), USG, weight checking, BP checking, etc.

• Personal hygiene: A health education should be given on maintenance of personal hygiene (daily bath, clean cloth, clean hair, nails, dental care, cleanliness of private parts, etc.).

Fig. 12.5

Fig. 12.6

• Bowel movement: Constipation should be avoided during pregnancy. Thus mother should be advised to consume green leafy vegetables, fruits, extra fluids.

• Healthy habits: Smoking, alcohol intake have to be avoided completely as these may cause fetal growth retardation, mental and physical problems in children and even loss of pregnancy.

• Loose and comfortable clothing to wear to prevent pressure on abdomen and easy movement and breathing.

• Reduction of stress: As a new mother sometimes women feel stress/tension. To overcome this need to do deep breathing exercises, gain knowledge about pregnancy and care of baby from health workers, books, and internet or from any other reliable resources. Mother may need of counseling also. Family support in this time is very important. Hearing music or other entertainment can reduce stress too.

• Rest: Mother should take rest for 8 hours at night and 2 hours at afternoon after lunch. Exercise: Antenatal exercise helps to improve circulation of mother and baby; reduces aches and pains. Walking, jogging, swimming, yoga, pelvic floor exercises, stretching and range of motion exercises are good to do during pregnancy. Diving, cycling, exaggerating work, climbing in high place, etc. should be avoided.

• Sexual intercourse: Should be avoided during first and last trimesters. Sexual hygiene needs to maintain to prevent infection. Drugs: A few drugs need to avoid during pregnancy to prevent fetal malformation. As for example: corticosteroid, streptomycin, LSD, etc. Better not to take any self-medication. Take medication only after consulting with doctor.

• Radiation: Avoid radiation during pregnancy (e.g. X-ray), as it may cause leukemia and other neoplasm.

• Danger sign: Teach mother about warning signs (swelling of feet, fits, headache, blurring of vision, bleeding or discharge per vagina, etc.). If any one of danger sign she feels, should go to doctor immediately.

• Child care: Teach mother about newborn care, breastfeeding, immunization, etc.

• Preparation for emergency: Ask mother to make an emergency fund (make a piggy bank and everyday put some money in it); keep ready blood donor in her locality (with same blood group of mother); keep emergency transport ready (keep phone number of local taxi drivers, phone number of health centers to call for ambulance); keep in touch with local health workers/dais for emergency home delivery).

• Family planning: If first child then teach her about IUD and other temporary family planning method; if two or more than two children teach about permanent family planning methods.

Intranatal Care

Objectives of intranatal care:

• To conduct a safe delivery.

• To reduce maternal and infant mortality and morbidity rates.

• To prevent complication (e.g. septicemia, tetanus neonatorum, etc.) during and after delivery.

Care

• Provide comfort to mother by proper positioning, psychological support, good ventilation, giving small amount of water to drink in between and so on.

• Maintain asepsis and cleanliness while conducting delivery.

– Clean hands and fingernails

– Clean surface of delivery

– Clean cutting and care of cord

– Keeping clean birth canal by avoiding harmful practices.

• Check for any danger sign; if any danger sign is there delivery must be institutional. Danger signs are sluggish pain or no pain after rupture of membrane, good pain but no progress, prolapse of cord or hand, meconium stained show, bleeding during labor, collapse during labor, no separation of placenta after delivery.

• Keep all articles need for delivery.

• Keep emergency fund, blood donor and transportation ready.

• Rooming-in: Keeping baby’s crib by the side of the mother’s bed is called rooming-in. This arrangement gives mother to know her baby.

• Breastfeeding: In normal delivery, baby should be put on breast soon after delivery. If caesarean section then within half an hour breastfeeding should be started.

• Check for any neonatal emergency (resuscitation needed or not)

• Give a perineal care to mother, place sanitary napkin or sterile cotton-gauze pads and shift to her bed in a comfortable position.

Postnatal Care

Objectives of postnatal care:

• To prevent complications

• To restore mother’s health

• To establish exclusive breastfeeding

• To provide basic health education to mother and family members.

Care

• Physical examination: For first 3 days after delivery twice a day health check is important. In case of home delivery, FHW (female health worker) should visit home for check-up of postnatal mother. Routine physical assessment along with giving importance on vital signs, involution of uterus, immediate postnatal complications (puerperal sepsis, thrombophlebitis, secondary hemorrhage), color change of lochia; assess for anemia.

– Lochia Rubra (red): First few days (1–4 days) after delivery

– Lochia Serosa: 5–9 days; becomes progressively pink, yellowish or pale brownish.

– Lochia Alba: 10–15 days; white or yellowish-white color.

• Perineal care: In case normal delivery perineal care plays an important role to prevent infection in episiotomy suture. Provide perineal care with antiseptic solution and teach mother how to do it at home.

• Nutrition: ICMR Nutrition Expert Group has recommended extranutrient during lactation period:

– Calorie: 700 kcal per day

– Proteins: 20 gm per day

– Calcium: 500–600 mg per day

– Iron and vitamin supplementation.

• Psychological support: It is very important to counsel mother and father about their new role. Especially in mother a few psychological problems are common at postnatal period. These are postnatal blues or “third day” blues or baby blues, psychosis, postnatal depression and post-traumatic stress disorder. It is very important to explain the family how to take care of mother’s health along with baby.

• Breastfeeding: Breastfeeding is another most important point to teach mother. Check for any breast tenderness, engorged breast, and cracked nipple. Advice mother that not to throw the first milk (colostrum) as it is the most nutritious milk. In a few cultures, colostrum is considered as the dirty milk and they believe not to give to baby, they throw it. This wrong belief has to be eliminated. Establish exclusive breastfeeding (for first 6 months of life give only breastfeed, no need to give water also, only ORS along with breastfeeding can be provided in case of diarrhea).

• Immunization: Teach immunization schedule and importance of giving immunization to baby.

• Family planning: If first child then teach her about IUD and other temporary family planning method; if two or more than two children, teach about permanent family planning methods.

• Baby care: Teach mother how to bath baby, cord care and assessment of cord, teach proper position and holding of baby during breastfeeding, keeping baby warm, immunization, etc.

• Birth registration: Advice mother to register baby’s birth as soon as possible and get a birth certificate.

Care of Old Age People

Aging is an unavoidable change in life. In eastern culture till today old people stays in joint family and taken care by their children and grandparents. Caregivers should remember the physical as well as psychological changes occur in aged.

• You need to talk to them as talking to other house members. As they become aged they feel alone, segregated from others. This loneliness brings depression, frustration among them.

• Take care of their diet. There is need to provide calcium-rich diet as osteoporosis is a common problem in this age. Avoid food rich in cholesterol, sugar and fat.

• Involve them in any decision making conversation.

• Encourage them to do regular exercises like morning walk, free hand exercises, yoga, and range of motion exercises.

• Encourage to do some activities like gardening, listening or singing music, or to be involved in any other hobby.

• Encourage to go out and talk to other people, friends or to join any club.

• Motivate to avoid consumption of alcohol, drugs and smoking.

• Make a regular routine health check-up for early diagnosis and prompt treatment of common old age problems as diabetes, hypertension, etc.

• Remind him or her to take medication on time or assist to take whenever necessary.

• If possible start some small business or part time job to make him or her busy and productive so that they don’t feel themselves completely dependent on others.

• Provide mobilization equipment as sticks, wheel chair, etc. if needed.

• Encourage your children to play and talk to their grandparents or any other elderly people at home.

• Counsel them in between; show them the reason to live. As it is a very common problem of old age that they stop willing to live.

Bibliography

1. Adolescent Health, http://www.who.int/topics/adolescent_health/en.

2. Feigelman S. Middle Childhood. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011.

3. Health and Parenting. WebMD. [Internet] 2004 [Cited on 2015 Jan 1st]. Available on: http://www.webmd.com/parenting/tc/toilet-training-topic-overview.

4. Marilyn J Hockenberry. Wong’s Essentials of Pediatric Nursing, 9th ed. New York: Mosby; 2013.

5. Parenting Skills: Tips for Raising Teens [Internet] 2014 Feb 14th [Cited on 2015 Jan 1st]. Available on: http://www.mayoclinic.org/healthyliving/tween-and-teen-health/in-depth/parenting-tips-for-teens/art-20044693?pg=l.

6. Preschoolers (3–5 years of age): Child development. [Internet] 2014 Match 11th [Cited on 2015 Jan 1st]. Available on: http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/preschoolers.html.

13

Nutrition: A Part of Health

This chapter contains

▪ Classification of Nutrients

▪ Classification of Foods

▪ Protein

▪ Fat

▪ Carbohydrate

▪ Vitamins

▪ Minerals

▪ Balanced Diet, Food Pyramid and Food Plate

▪ Deficiency Diseases

▪ Vitamin Deficiency

▪ Recommended Dietary Allowances

INTRODUCTION

Nutrition is the process of breaking down food and substances taken in by the mouth to use for energy in the body. By practicing a healthy diet, many of the known health issues can be avoided. A poor diet may have an injurious impact on health, causing deficiency diseases such as scurvy and kwashiorkor; health-threatening conditions like obesity and metabolic syndrome; and such common chronic systemic diseases as cardiovascular disease, diabetes and osteoporosis. Nutritional science investigates the metabolic and physiological responses of the body to diet. With advances in the fields of molecular biology, biochemistry, nutritional immunology, molecular medicine and genetics; the study of nutrition is increasingly concerned with metabolism and metabolic pathways—the sequences of biochemical steps through which substances in living things change from one form to another.

Classification of Nutrients

Nutrients are organic and inorganic materials in food. There are about 50 different nutrients which are normally supplied through foods we eat. Most natural foods contain more than one nutrient.

1. Macronutrients: There are proteins, fats and carbohydrates; also called Proximate Principles as they form the main bulk of food. In the Indian dietary, they contribute to the total energy intake in the following proportions:

Protein | : | 7 to 15%
Fats | : | 10 to 30%
Carbohydrates | : | 65 to 80%

2. Micronutrients: These are vitamins and minerals as they required in a very small amount (from a fraction of milligram to several grams).

Classification of Foods

There are many ways of classifying foods.

1. Classification by origin:

a. Foods of animal origin

b. Foods of vegetable origin

2. Classification by chemical composition:

a. Proteins

b. Fats

c. Carbohydrates

d. Vitamins

e. Minerals

3. Classification by predominant function

a. Body-building foods

b. Energy-giving foods

c. Protective foods

4. Classification by nutritive value

a. Cereals and millets

b. Pulses (legumes)

c. Vegetables

d. Nuts and oilseeds

e. Fruits

f. Animal foods

g. Fats and oils

h. Sugar and jaggery

i. Condiments and spices

j. Miscellaneous foods

Classification of Food by Origin

a. Foods of animal origin

Foods of animal origin are milk and milk products, fish, egg, meat, liver, etc.

b. Foods of vegetable origin

Foods of vegetable origin are green leafy vegetables, pulses, cereals, fruits, etc.

Classification of Food by Chemical Composition

a. Protein

Proteins are complex organic nitrogenous compounds. They are composed of carbon, hydrogen, oxygen, nitrogen and sulfur in varying amounts. Some proteins also contain phosphorus and iron and occasionally other elements. Proteins constitute about 20 percent of the body weight in adult.

Proteins are made up of smaller units, called amino acids. About 24 amino acids (arginine, asparagine, glycine, alanine, leucine, lysine, isoleucine, methionine, phenylalanine, threonine, valine, tryptophan, histidine, proline, serine, tyrosine, cysteine, selenocysteine, glutamine, ornithine, aspartic acid, glutamic acid) are needed by human body, of which 9 are called “essential amino acids” (leucine, lysine, isoleucine, methionine, phenylalanine, threonine, valine, tryptophan and histidine) as the body cannot synthesize them as needed. So these must be obtained from dietary proteins.

Proteins are needed by the body for:

a. Body building

b. Repair and maintenance of body tissues

c. Maintenance of osmotic pressure

d. Synthesis of certain substances (antibodies, plasma proteins, hemoglobin, enzymes, hormones and coagulation factors)

e. Strengthening immune system (secondary function)

Animal sources of protein: Milk, meat, egg, cheese, fish and fowl. These contain essential amino acids in sufficient amount.

Vegetable sources of protein: pulses (legumes), cereals, beans, nuts, oilseed cakes, etc. They are poor in essential amino acids.

The Indian Council of Medical Research (1989) recommended 1.0 g protein/kg body weight for an Indian adult, assuming net protein utilization (NPU) of 65 for the dietary proteins.

b. Fat

Fats are solid at 20°C; if they are liquid at that temperature, they are called oils. Fats and oils are concentrated sources of energy. They are classified as:

• Simple lipids, e.g. triglycerides (human body can synthesize endogenously)

• Compound lipids, e.g. phospholipids

• Derived lipids, e.g. cholesterol (human body can synthesize endogenously)

Fats yield fatty acids and glycerol on hydrolysis. Fatty acids are divided into saturated fatty acids (lauric, palmitic acid and stearic acid), and unsaturated fatty acid which is further divided into monounsatu-rated (MUFA: oleic acid) and polyunsaturated (PUFA: linoleic acid and α-linolenic acid).

Essential fatty acids are those that can not be synthesized by human body, can be 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 (linolenic and arachidonic acids). All PUFAs are not essential fatty acids. Linoleic acid is abundantly found in vegetable oils.

The dietary sources of fats may be classified as:

• Animal fats: Ghee, butter, milk, cheese, eggs, fat of meat and fish. Except cod liver oil and sardine oil, all animal fats are mostly saturated fats.

• Vegetable fats: Seeds of a few plants as groundnut, mustard, sesame, coconut, etc.

• Other sources: Small quantities of fat (invisible fat) found in other foods as cereals, pulses, nuts and vegetables.

Rice | : | 3% of fat
Wheat | : | 3% of fat
Jowar | : | 4% of fat
Bajra | : | 6.5% of fat

Large cereal consumption in India provides considerable amounts of “invisible fat”.

Moreover, the body can convert carbohydrate into fat.

Dietary sources of EFA:

• Linoleic acid: Safflower oil (73%), corn oil (57%), sunflower oil (56%), soyabean oil (51%), sesame oil (40%), groundnut oil (39%), mustard oil (15%), palm oil (9%), coconut oil (2%).

• Arachidonic acid: Meat (0.3–0.5%), eggs (0.3–0.5%), milk fat (0.4–0.6%).

• Linolenic acid: Soyabean oil (7%), leafy greens (varied).

• Eicosapentaenoic acid: Fish oil (10%)

Fats are high energy food, equated with calories. Per gram of fat is providing 9 kcal of energy. By supplying energy, fats spare proteins from being used for energy. Fat also serves 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.

Fat have “non-calorie” role too as essential fatty acids are needed by the body for growth, for structural integrity of cell membrane and decreased platelet adhesiveness. Diet rich in EFA reduces serum cholesterol and low density lipoproteins. PUFAs are precursor of prostaglandin (a hormone needed for 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.

Refined oil: 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 test of oils. Refined oils are costly.

The Indian Council of Medical Research (1989) recommended a daily intake of not more than 20% of total energy intake through fats. At least 50% of fat intake should consist of vegetable oils rich in EFA.

c. Carbohydrate

Carbohydrate is the main source of energy, providing 4 kcal per gram. It is essential for oxidation of fats and for the synthesis of certain non-essential amino acids.

There are three main sources of carbohydrate:

• Starch: Basic to human diet; found in cereals, roots and tubers.

• Sugar: Comprises monosaccharides (glucose, fructose and galactose) and disaccharides (sucrose, lactose and maltose). Water-soluble and along with starches constitute a key source of energy.

• Cellulose: It is the indigestible component of carbohydrate with scarcely any nutritive value, contributes to dietary fiber.

d. Vitamins

Vitamins are other essential nutrients, fall in the category of micronutrients. They are required in a very small quantity by the body. They do not yield energy but enable the body to use other nutrients. Since the body is generally unable to synthesize them in sufficient amount, they must be provided by food.

Vitamins are divided into two groups:

a. Fat-soluble vitamins (vitamins A, D, E, K)

b. Water-soluble vitamins (vitamins B complex, C)

e. Minerals

More than fifty 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:

• Major minerals: Phosphorus, sodium, potassium and magnesium.

• Trace elements: Requires by body less than a few milligrams per day; e.g. iron, iodine, fluorine, zinc, copper, cobalt, chromium, manganese, molybdenum, selenium, nickel, tin, silicon and vanadium.

• Trace contaminants with no known function: Lead, mercury, barium, boron and aluminium.

Classification of Food by Predominant Function

a. Body-building foods

These foods are rich in proteins. For example, milk and its products, pulses, meat, fish, eggs, oilseeds, nuts and low fat oilseed flours, etc.

b. Energy-giving foods

These foods are rich in carbohydrates and fats. For example, cereals, roots, tubers, dried fruits, sugars and fats and oil, etc.

c. Protective foods

These foods are rich in proteins, vitamins and minerals. For example, milk, eggs, liver, green leafy vegetables, fruits, etc. Protective foods are broadly classified into two groups:

• Foods rich in vitamins, minerals and proteins of high biological value, e.g. milk, eggs and liver.

• Foods rich in certain vitamins and minerals only, e.g. green leafy vegetables and fruits.

Classification of Food by Nutritive Value

a. Cereals and millets

Cereals (e.g. rice, wheat) are the main source of energy (carbohydrates). They also contribute significant quantities of proteins (6–12%), minerals and B group vitamins. Considering the large amounts in which they are consumed, cereals contribute 70–80% of the total energy intake and more than 50% of protein intake in typical Indian diets. Cereals provide about 350 kcal per 100 grams. Though cereal proteins are poor in nutritive quality, being deficient in essential amino acids, if eaten with pulse proteins, provides a more balanced and complete protein intake.

Millets are smaller grains which are ground and eaten without removing the outer layer. For example, jowar (sorghum), bajra (pearl millet), ragi, kodo, etc.

b. Pulses (legumes)

Pulses comprise a variety of grams, also known as dhals, e.g. bengal gram (chana), red gram (tuvor or arhar), green gram (mung) and black gram (urad). Others include lentils (masur), peas and beans including soyabean.

Pulses are called “poor man’s meat” as it contains 20–25% of proteins, which is double that found in wheat and three times that found in rice. Even pulses contain more protein than eggs, fish or flesh foods. But in regard to quality, pulse proteins are inferior to animal protein (poor in methionine and cysteine), though they are rich in lysine. In addition they are rich in minerals, B group vitamins (riboflavin and thiamine) and in germinated state rich in vitamin C.

Soyabean is the richest among pulses. It contains about 40% of protein, 20% of fat and 4% of minerals. The proteins of soyabean are of relatively high nutritive value. The limiting amino acid is methionine.

c. Vegetables

Vegetables are known as “protective foods”; they are high in vitamin and mineral contents. Some vegetables are also good source of protein (green peas, beans). Vegetables usually have a large water content, low energy and protein contents and varying amount of dietary fiber. Vegetables are divided into three groups:

• Green leaves (spinach, amaranth, cabbage, fenugreek/methi, etc.): Rich source of carotenes, calcium, iron and vitamin C.

• Roots and tubers (potato, sweet potato, tapioca, yam, carrots, onion, radish and colocasia): Rich in carbohydrates (potatoes, tapioca), β-carotene (carrots).

• Other vegetables (brinjal, tomatoes, cauliflower, etc): They bring variety in diet. Many of them are fairly good sources of minerals and vitamins,

d. Nuts and oilseeds

Nuts and oilseeds contain a good amount of fat and good quality protein. These are peanut, cashewnut, coconut, walnut, almonds, pistachio, mustard seeds, sesame seeds, cotton seeds, sunflower seeds, maize germ and many others from which cooking oils are extracted. Most of the vegetable oils are rich in essential fatty acids.

Nuts and oilseeds | Fat contents
Walnut | 64.5%
Almonds | 58.7%
Cashcwnuts | 46.9%
Groundnuts (peanuts) | 40%

Nuts are good source of B complex vitamin and minerals such as calcium, phosphorus and iron.

e. Fruits

Fruits are protective foods with good sources of vitamins and minerals. As they can be eaten raw and fresh, vitamins and minerals do not get destroyed.

Fruits
Vitamins

Orange, guava,
Indian gooseberry (amla)
Ascorbic acid

Papaya, Mango
Carotene

Fruits
Minerals

Custard apple (sitaphal)
Calcium

Dried fruits (raisins, dates, apricots)
Calcium and iron

Banana and mangos are good source of carbohydrate. Fruits also contain cellulose which assists in normal bowel movements.

Nutrition experts recommend a daily intake of 85 grams or more fresh fruits for maintenance of good health.

f. Animal foods

Animal foods include meat, poultry, fish, eggs, milk and dairy products. They provide a good amount of fats and high quality protein, containing all the essential amino acids. It also contains some vitamins and minerals. Vitamin B₁₂ is one of the rare nutrients found only in animal foods. Among animal foods, cow’s milk and hen’s egg are perhaps natures two most nearly perfect foods.

g. Fats and oils

Fats which are liquid at room temperature are called oils. These are good sources of energy and fat-soluble vitamins. Fats of vegetable origin are rich in polyunsaturated fatty acids excepting coconut and palm oils. Fats of animal origin are poor sources of essential fatty acid.

h. 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 and is consumed in place of sugar. It contains useful amounts of carotene and iron derived from cooking pans.

i. Condiments and spices

These include asafetida, cardamom, chilies, garlic, cloves, ginger, mustard, pepper, tamarind, turmeric, etc. They are generally used to increase the taste of foods and stimulate appetite. The essential oils present in them have carminative properties and may aid in digestion. Excessive consumption of condiments leads to peptic ulcer.

j. Miscellaneous foods

Diet includes beverages and specially water which is essential to life. Beverages include drinks which are appreciated for their flavor or their stimulating properties. They may be classified as follows:

• Coffee, tea, cocoa

• Soft drinks: Aerated water, lemonade, pepsi cola, fruit juices, etc.

• Alcoholic beverages: Wine, beer, whisky and traditional preparations. They are rich in calories.

Balanced Diet, Food Pyramid and Food Plate

A balanced diet is one that provides body the nutrition to function properly. A balanced diet means choosing a wide variety of foods and drinks from all the food groups. It also means eating certain things in limit, like saturated fat, cholesterol, refined sugar, salt and alcohol. The goal of balanced diet is to take in nutrients you need for health at the recommended levels. It is important to choose foods from all food groups (cereals, pulses, poultry and meat, milk and milk products, fruits and vegetables) to get a balanced diet (Appendix J).

Food Pyramid (Fig. 13.1)

A food pyramid or diet pyramid is a pyramidshaped diagram representing the optimal number of servings to be eaten each day from each of the basic food groups. The first food pyramid was published in Sweden in 1974. The food pyramid was changed to “food guide pyramid” and updated in 2005 and then replaced by “My Plate” in 2011.

Fig. 13.1: Food pyramid

New Food Pyramid (Fig. 13.2)

My plate: My plate is the current nutrition guide published by the United States Department of Agriculture, a food circle (i.e. a pie chart) depicting a place setting with a plate and glass divided into five food groups (Fig. 13.3).

Fig. 13.2: New food pyramid

Fig. 13.3: Food plate

Deficiency Diseases

Protein Energy Malnutrition (PEM)

Every cell in human body contains protein. Everyone needs protein in diet for body to repair cells and make new cells. A healthy body regenerates cells in this manner constantly. Protein is also important for growth during childhood and pregnancy. The main diseases caused by protein energy malnutrition are marasmus and kwashiorkor. The first indicator of PEM is underweight for age which will be detected fast if growth chart is maintained.

Marasmus

Marasmus is a severe form of malnutrition that consists of the chronic wasting away of fat, muscle, and other tissues in the body. Malnutrition occurs when body does not get enough protein and calories. Marasmus is one of the most serious forms of protein-energy malnutrition (PEM) among children in the world, especially in developing regions such as Africa, Latin America and Asia, where poverty along with inadequate food supplies and contaminated water are prevalent.

Sign and symptoms

• Visible muscle wasting

• Severe loss of subcutaneous fat (adipose tissue)

• Rapid weight loss

• Chronic diarrhea

• Dizziness

• Fatigue

• Dry skin

• Loose skin folds hanging over the buttocks and armpit, etc.

Treatment

If the disease is caused solely by poor nutrition, then a change in diet should be enough to correct the problem and prevent recurrence. Marasmus that is related to an underlying disease may require additional treatment. Seek prompt medical care if you experience prolonged bouts of diarrhea, dizziness, excessive fatigue, or unexplained weight loss.

Kwashiorkor

Kwashiorkor is the most common and widespread nutritional disorder in developing countries. It is a form of malnutrition caused by not getting enough protein in diet.

Signs and symptoms

• Change in skin and hair color (reddish-orange color)

• Fatigue

• Diarrhea

• Loss of muscle mass but may be hidden by edema

• Failure to grow or gain weight

• Edema (swelling)

• Damaged immune system, which can lead to more frequent and severe infections

• Irritability

• Flaky rash

• Large belly that sticks out

• Shock

Fig. 13.4

Treatment

Kwashiorkor can be corrected by eating more protein and more calories overall, especially if treatment is started early. First should be given more calories in the form of carbohydrates, sugars and fats. Once these calories provide energy, foods with proteins should be started. Foods must be introduced and calories should be increased slowly as child was without proper nutrition for a long period, and body may need to adjust to the increased intake. Vitamin and mineral supplements are also needed.

If treatment of PEM has been delayed, children may not reach their full growth and height potential. Even when treatment comes too late, a child may have permanent physical and mental problems. If left untreated, the condition can lead to coma, shock or death. So it is very important to treat PEM promptly as soon as possible. The following is adopted from the 8th FAO/W1TO Expert Committee on Nutrition for preventing PEM in community:

a. Health promotion

• education and supplement food to pregnant woman

• promotion of exclusive breastfeeding

• supply of low cost weaning food

• nutrition education

• measures to improve family diet

• home economics

• family planning and spacing of birth

• healthy family environment

b. Specific protection

• immunization

• protein-and energy rich-diet for children

• food fortification

c. Early diagnosis and treatment

• maintaining growth chart to early diagnose PEM and treatment

• periodic surveillance

• early diagnosis and treatment of infection and diarrhea

• early rehydration of children with diarrhea

• deworming

d. Rehabilitation

• hospital treatment

• nutritional rehabilitation

• follow-up care

VITAMIN DEFICIENCY

Vitamin A Deficiency (VAD)

Vitamin A deficiency (VAD) is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections. In pregnant women VAD causes night blindness and may increase the risk of maternal mortality. VAD is a public health problem in more than half of all countries, especially in Africa and South-East Asia, hitting hardest young children and pregnant women in low income countries.

Causes

Vitamin A deficiency can result from:

• Inadequate intake

• Fat malabsorption

• Liver disorders.

Deficiency impairs immunity and hematopoiesis and causes rashes and typical ocular effects (e.g. xerophthalmia, night blindness)

Primary vitamin A deficiency is usually caused by prolonged dietary deprivation. It is endemic in areas such as southern and eastern Asia, where rice, devoid of β-carotene, is the staple food.

Secondary vitamin A deficiency may be due to decreased bioavailability of provitamin A carotenoids or to interference with absorption, storage, or transport of vitamin A. Interference with absorption or storage is likely in celiac disease, cystic fibrosis, pancreatic insufficiency, chronic diarrhea, bile duct obstruction, giardiasis, and cirrhosis.

Effects of Vitamin A deficiency

i. Night blindness or nyctalopia—is a condition making it difficult or impossible to see in relatively low light.

ii. Xerophthalmia—is described by pathologic dryness of the conjunctiva and cornea. The conjunctiva becomes dry, thick and wrinkled. If untreated, it can lead to corneal ulceration and ultimately to blindness as a result of corneal damage.

iii. Keratomalacia—if xerophthalmia is left untreated, corneal epithelium becomes opaque; ulceration and bacterial invasion of cornea cause keratomalacia resulting in blindness (Fig. 13.5).

Fig. 13.5: Keratomalacia

iv. Bitot’s spots—are the buildup of keratin located superficially in the conjunctiva, which are oval, triangular or irregular in shape (grayish or glistening white plaques); associated with xerosis (Fig. 13.6).

Fig. 13.6: Bitot’s spots

v. Follicular hyperkeratosis—is thickening of the epithelium lining of the hair follicle, often associated with the presence of an abnormal quantity of keratin, and also usually accompanied by an increase in the granular layer.

Diagnosis

• Serum retinol levels: Normal range is 28 to 86 μg/dL (1 to 3 μmol/L)

• Clinical evaluation

• Response to vitamin A

• Ocular findings

Prevention

The diet should include dark green leafy vegetables, deep- or bright-colored fruits (e.g. papayas, oranges), carrots, and yellow vegetables (e.g. squash, pumpkin). Vitamin A-fortified milk and cereals, liver, egg yolks, and fish liver oils are helpful. Carotenoids are absorbed better when consumed with some dietary fats. If milk allergy is suspected in infants, they should be given adequate vitamin A in formula feedings.

In developing countries, prophylactic supplements of vitamin A palmitate in oil 60,000 RAE (200,000 IU) po every 6 months are advised for all children between 1 and 5 years of age; infants < 6 months can be given a one-time dose of 15,000 RAE (50,000 IU), and those aged 6 to 12 months can be given a onetime dose of 30,000 RAE (100,000 IU).

Treatment

• Dietary deficiency is traditionally treated with vitamin A palmitate in oil 60,000 IU po once/day for 2 days, followed by 4,500 IU po once/day.

• If vomiting or malabsorption is present or xerophthalmia is probable, a dose of 50,000 IU for infants < 6 months, 100,000 IU for infants 6 to 12 months, or 200,000 IU for children > 12 months and adults should be given for 2 days, with a third dose at least 2 weeks later.

• The same doses are recommended for infants and children with complicated measles.

• Infants born of HIV-positive mothers should receive 50,000 IU (15,000 RAE) within 48 hours of birth.

• For pregnant or breastfeeding women, prophylactic or therapeutic doses should not exceed 10,000 IU (3,000 RAE)/day to avoid possible damage to the fetus or infant.

Prolonged daily administration of large doses, especially to infants, must be avoided because toxicity may result.

Vitamin D Deficiency

A person shuns the sun, suffers from milk allergies, or adheres to a strict vegan diet, may be at risk for vitamin D deficiency. Known as the sunshine vitamin, vitamin D is produced by the body in response to skin being exposed to sunlight. It is also occurs naturally in a few foods including some fish, fish liver oils, and egg yolks and in fortified dairy and grain products.

Causes of Vitamin D Deficiency

• Less consumption of the recommended levels of the vitamin D over time.

• Limited exposure to sunlight.

• Dark skin. The pigment melanin reduces the skin’s ability to make vitamin D in response to sunlight exposure.

• Kidneys cannot convert vitamin D to its active form. As people age, their kidneys are less able to convert vitamin D to its active form.

• Digestive tract cannot adequately absorb vitamin D. Certain medical problems, including Crohn’s disease, cystic fibrosis, and celiac disease, can affect absorption of vitamin D.

• Obese. People with a body mass index of 30 or greater often have low blood levels of vitamin D.

The following groups of people are identified as at risk of vitamin D deficiency:

• All pregnant and breastfeeding women, especially teenagers and young women.

• Infants and young children under 5 years of age.

• Older people aged 65 years and over.

• People who have low or no exposure to the sun, for example those who cover their skin

• for cultural reasons, who are housebound or confined indoors for long periods.

• People who have darker skin, for example people of African, African-Caribbean.

• South Asian origin, because their bodies are not able to make as much vitamin D.

Traditionally, vitamin D deficiency has been associated with rickets and osteomalacia.

Rickets—is characterized by bone deformities as pigeon breast, bow legs and knock knees (Fig. 13.7).

Fig. 13.7

Osteomalacia—in this disease softening of bone causes deformities of pelvis, legs and ribs due to the weight of the body.

Prevention

All the UK Health Departments recommend:

• All pregnant and breastfeeding women should take a daily supplement containing 10 μg of vitamin D, to ensure the mothers requirements for vitamin D are met and to build adequate fetal stores for early infancy.

• All infants and young children aged 6 months to 5 years should take a daily supplement containing vitamin D in the form of vitamin drops, to help them meet the requirement set for this age group of 7–8.5 μg of vitamin D per day. However, those infants who are fed infant formula will not need vitamin drops until they are receiving less than 500 ml of infant formula a day, as these products are fortified with vitamin D. Breastfed infants may need to receive drops containing vitamin D from one month of age if their mother has not taken vitamin D supplements throughout pregnancy.

• People aged 65 years and over and people who are not exposed to much sun should also take a daily supplement containing 10 μg of vitamin D.

Treatment

Prescribing of high dose vitamin D should be offered only to individuals with vitamin D deficiency, i.e. levels < 25 nmol/L. Fultium-D3 800 IU capsules, 4 daily for 84 days (12 weeks). Any secondary care prescribing will be for D3–50 50,000 IU tablets, one oral daily for 6 days. Alternatively Colecalciferol 300,000 units IM injection, one monthly for 3 months will be used for patients unable to take or absorb oral replacement.

Vitamin E Deficiency

Dietary vitamin E deficiency is common in developing countries. The main symptoms are hemolytic anemia and neurologic deficits. Vitamin E deficiency causes fragility of RBCs and degeneration of neurons, particularly peripheral axons and posterior column neurons.

Etiology

In developing countries, the most common cause is inadequate intake of vitamin E. In developed countries, the most common causes are disorders that cause fat malabsorption.

Symptoms and Signs

The main symptoms are mild hemolytic anemia and nonspecific neurologic deficits, results in progressive neuropathy and retinopathy in the first 2 decades of life. Vitamin E deficiency may contribute to retinopathy of prematurity (also called retrolental fibroplasia) in premature infants.

Diagnosis

A history of inadequate intake or a predisposing condition may cause vitamin E deficiency. Measuring the serum α-tocopherol level is the most direct method of diagnosis. In adults, vitamin E deficiency is suggested if the α-tocopherol level is <5 μg/mL (<11.6 μmol/L).

Treatment

If malabsorption causes clinically evident deficiency, α-tocopherol 15 to 25 mg/kg po once/day should be given or mixed tocophe-rols (200 to 400 IU) can be given. However, larger doses of α-tocopherol given by injection are required to treat neuropathy during its early stages or to overcome the defect of absorption and transport.

Prevention

Premature neonates may require supplementation, human milk and commercial formulas have enough vitamin E for full-term neonates.

Vitamin K Deficiency

Vitamin K plays a key role in helping the blood clot, preventing excessive bleeding. Low levels of vitamin K can raise the risk of uncontrolled bleeding.

Risk factors of vitamin K deficiencies

• Have a disease that affects absorption in the digestive tract, such as Crohn’s disease or active celiac disease

• Take drugs that interfere with vitamin K absorption

• Are severely malnourished

• Drink alcohol heavily

Signs and Symptoms

In infants, it can cause some birth defects such as underdeveloped face, nose, bones, and fingers. Bruising, petechiae, hematomas, oozing of blood at surgical or puncture sites, stomach pains; risk of massive uncontrolled bleeding; cartilage calcification; and severe malformation of developing bone or deposition of insoluble calcium salts in the walls of arteries.

Prevention and Treatment

Single dose injection of vitamin K at birth is enough to prevent vitamin K deficiency. Good natural food sources of vitamin K include: oils such as olive, cottonseed, safflower, and soyabean oils; vegetables like spinach, asparagus, and broccoli; beans and soyabeans; eggs; strawberries; meat.

Vitamin C Deficiency

Vitamin C is essential for collagen formation and helps to maintain the integrity of skin and connective tissue, bone, blood vessel walls and dentine. It is essential for wound healing and facilitates recovery from burns. It also facilitates the absorption of iron and is an antioxidant. Deficiency of vitamin C causes scurvy.

Scurvy is generally rare, but the incidence of scurvy peaks in children aged 6–12 months who are fed a diet deficient in citrus fruits or vegetables. Incidence also peaks in the elderly.

Risk factors

• Infants who are fed only cows’ milk during the first year of life.

• Alcoholism

• Elderly

• Low-income families, who tend not to buy foods high in vitamin C.

• Victims of famine, and refugee populations.

• Cigarette smoking, which affects the absorption of vitamin C.

Signs and symptoms of scurvy

Infantile scurvy: The early symptoms are loss of appetite and lethargy. Infant cries if legs and arms are moved. Swelling is observed at the ends of long bones. Hemorrhages occur under the skin. Gums are swollen. Convulsion may occur resulting in death of the infant.

Scurvy in adults: The disease is characterized by general weakness, spongy bleeding gums, loose teeth, swollen tender joints and hemorrhages in various tissues and under the skin. Fractures, dislocations, tenderness of bones and bleeding into muscles and joints are possible (Fig. 13.8).

Fig. 13.8

Edema may occur late in the disease. Loss of weight secondary to anorexia is common.

Diagnosis

• Clotting factor deficiencies

• Leukemia

• Gingivitis

• Platelet dysfunction

• Senile purpura

Management

• Treatment is ascorbic acid replacement therapy.

For adult: 100 mg BD, IM for 1 week followed by 500 mg oral OD for 1 month.

For infant: 50 mg BD, IM for a week followed by 100 mg oral OD for 1 month.

• Supplements should be combined with intake of foods high in vitamin C.

• Any other dietary deficiency should also be treated.

Prevention

• An adequate dietary intake of vitamin C is essential.

• Around 90% of vitamin C in the diet comes from fuit and vegetables. Cooking reduces vitamin C content by 30–40%.

• The recommended daily intake of vitamin C in the diet depends on age and sex.

• As a rough guide, one large orange will provide the recommended daily intake of vitamin C for an average adult.

Vitamin B₁/Thiamine Deficiency

Thiamine deficiency or beriberi refers to the lack of thiamine pyrophosphate, the active form of the vitamin known as thiamine or vitamin B₁.

Causes

• By not ingesting enough vitamin B₁ through the diet.

• Through excess use; the latter may result from hyperthyroidism, pregnancy, lactation, or fever.

• Prolonged diarrhea may impair the body’s ability to absorb vitamin B₁

• Severe liver disease impairs its use.

Signs and symptoms of beriberi

• Weight loss

• Emotional disturbances

• Impaired sensory perception

• Weakness and pain in the limbs

• Irregular heart rate

• Edema is common

• In advanced cases, the disease may cause high output cardiac failure and death.

Types of beriberi

• Dry beriberi specially affects peripheral nervous system.

• Wet beriberi specially affects the cardiovascular system and other bodily systems.

• Infantile beriberi affects the children of malnourished mothers.

Dry beriberi: Dry beriberi causes wasting and partial paralysis resulting from damaged peripheral nerves. It is also referred to as endemic neuritis. It is characterized by:

• Difficulty in walking

• Tingling or loss of sensation (numbness) in hands and feet

• Loss of tendon reflexes

• Loss of muscle function or paralysis of the lower legs

• Mental confusion/speech difficulties

• Pain

• Involuntary eye movements (nystagmus)

• Vomiting.

Wet beriberi: Wet beriberi affects the heart and circulatory system. It is sometimes fatal, as it causes a combination of heart failure and weakening of the capillary walls, which causes the peripheral tissues to become edematous. Wet beriberi is characterized by:

• Increased heart rate

• Vasodilation leading to decreased systemic vascular resistance, and high output cardiac failure

• Elevated jugular venous pressure

• Dyspnea (shortness of breath) on exertion

• Paroxysmal nocturnal dyspnea

• Peripheral edema

Infantile beriberi: Infantile beriberi usually occurs between two and six months of age in children whose mothers have inadequate thiamine intake. In the acute form, the baby develops dyspnea and cyanosis and soon dies of heart failure. The following symptoms may be described in infantile beriberi:

• Hoarseness, where the child makes moves to moan but emits no sound or just faint moans, caused by nerve paralysis.

• Weight loss, becoming thinner and then marasmic as the disease progresses.

• Vomiting

• Diarrhea

• Occasionally convulsions were observed in the terminal stages.

• Pale skin

• Edema

• Alterations of the cardiovascular system, especially tachycardia (rapid heart rate).

Prevention and Treatment

Many patients of beriberi can be treated with thiamine alone. Given thiamine 50 mg given intramuscularly for several days. Maintenance is recommended at 2.5–5 mg per day orally unless a malabsorption syndrome is suspected. Rapid and dramatic recovery can occur within hours.

Dietary Thiamine

Foods that are rich in thiamine are as follows:

• Wholegrain foods

• Meat/fish/poultry/eggs

• Milk and milk products

• Vegetables (i.e. green, leafy vegetables; beets; potatoes)

• Legumes (i.e. lentils, soyabeans, nuts, seeds)

• Orange and tomato juices

Vitamin B₂/Riboflavin Deficiency

Riboflavin (B₂) aids in the production of energy in all tissues in the body. It is important for the metabolism on carbohydrates, proteins, and fats. It acts as an antioxidant and is crucial for the maintenance of the nervous system and the skin.

Signs and Symptoms of Vitamin B₂ Deficiency

• Dry itchy eyes

• Cheilosis (roughness of the lips)

• Angular stomatitis (cracking in the corners of the lips)

• Anxiety

• Memory loss

• Photophobia (sensitivity to light)

• Depression

• Neuropathy

• Fatigue

Treatment

Oral riboflavin doses of 2 to 10 mg 3 times daily until signs and symptoms improve, and then the dose is reduced to 2 to 4 mg once daily until complete recovery.

Vitamin B₃/Nicotinic Acid Deficiency

Niacin is also known as vitamin B₃ or nicotinic acid. Dietary niacin deficiency causing pellagra. Clinical manifestations include the three Ds: localized pigmented rash (dermatitis); gastroenteritis (diarrhea); and widespread neurologic deficits, including cognitive decline (dementia). Diagnosis is usually clinical, and dietary supplementation (oral, or if needed, IM) is usually successful.

The most common cause is alcoholism. Other possible causes include disorders of the digestive system and prolonged treatment with the tuberculosis drug isoniazid.

Symptoms of mild niacin deficiency include

• Indigestion

• Fatigue

• Canker sores

• Vomiting

• Depression

Severe deficiency, called pellagra, can cause symptoms related to the skin, digestive system, and nervous system. They include:

• Apathy

• Fatigue

• Thick, scaly pigmented rash on skin exposed to sunlight

• Swollen mouth and bright red tongue

• Vomiting and diarrhea

• Headache

• Disorientation

• Depression

• Memory loss

If not treated, pellagra can lead to death.

Prevention

A diet rich in niacin will prevent niacin deficiency. Good sources of niacin include red meat, fish, poultry, fortified breads and cereals, and enriched pasta and peanuts.

Treatment

Niacin supplements or multivitamin/mineral supplements (20 milligrams of niacin); nicotinamide is given in doses of 250 to 500 mg orally daily.

Vitamin B₅/Pantothenic Acid Deficiency

Vitamin B₅ is critical for normal function of the human body and commonly called the antistress nutrient because it plays a role in the production of stress hormones by the adrenal glands. Deficiency of B₅ contributes to the inability to cope with stress. The highest amounts of pantothenic acid are found in whole grain cereals, eggs, meat, legumes, avocado, and yogurt.

Signs and Symptoms of Deficiency

• Irritability

• Fainting

• Fatigue

• Elevated cholesterol

• Burning and pain in the arms and legs

• Indigestion

• Hair loss

• Burning feet

• Nausea

• Elevated heart rate

• Susceptibility to infection

• Premature graying of the hair

• Hair loss

Vitamin B₅ is commercially available as D-pantothenic acid.

Vitamin B₆/Pyridoxin Deficiency

Vitamin B₆ includes a group of closely related compounds: pyridoxine, pyridoxal, and pyridoxamine. They are metabolized in the body to pyridoxal phosphate, which acts as a coenzyme in many important reactions in blood, CNS, and skin metabolism. Vitamin B₆ is important in heme and nucleic acid biosyntheses and in lipid, carbohydrate, and amino acid metabolisms.

Causes

• Dietary deficiency

• Protein-energy undernutrition

• Malabsorption

• Alcoholism

• Use of pyridoxine-inactivating drugs (e.g. anticonvulsants, isoniazid, corticosteroids, etc.)

• Excessive loss.

Symptoms and Signs

• Peripheral neuropathy

• A pellagra-like syndrome with seborrheic dermatitis, glossitis, and cheilosis

• In adults, can cause depression, confusion, EEG abnormalities, and seizures.

• Seizures in infants.

Diagnosis

• Clinical evaluation; measurement of serum pyridoxal phosphate is most common.

• Any infant who has seizures, any patient who has seizures refractory to treatment with anticonvulsants.

Prevention

Major sources of vitamin B₆ include cereal grains, legumes, vegetables (carrots, spinach, peas and potatoes), milk, cheese, eggs, fish, liver, meat, and flour.

Treatment

If anticonvulsants do not stop seizures in infants, consider giving pyridoxine 50 to 100 mg orally once/day to treat possible vitamin B₆ deficiency.

Vitamin B₇/Biotin Deficiency

Biotin deficiency is a rare nutritional disorder which can become serious, even fatal, if allowed to progress untreated. Deficiencies can be caused by consuming raw egg whites over a period of months to years. Egg whites contain high levels of avidin, a protein that binds biotin strongly. When cooked, avidin is partially denatured and binding to biotin is reduced.

Signs and Symptoms

• Anemia

• Rashes including red, patchy ones near the mouth

• Fine and brittle hair

• Hair loss or total baldness (alopecia)

• Seborrheic dermatitis

• Fungal infections

• Psychological problems as hallucinations, mild depression

• Lethargy

• Anorexia

• Generalized muscular pains (myalgias)

• Paresthesias

Causes

• Total parenteral nutrition without biotin supplementation

• Protein deficiency

• Anticonvulsant therapy

• Severe malnourishment

• Prolonged oral antibiotic therapy

• Pregnancy

• Smoking

• Excessive alcohol consumption

• Excessive consumption of antidiuretics

• Intestinal malabsorption

Diagnosis

The most reliable and commonly used method is excretion of 3-hydroxyisovaleric acid and biotin in urine.

Treatment

Biotin supplements are readily available over the counter and do not require a prescription.

Vitamin B₉/Folic Acid Deficiency

Folic acid, or folate, or vitamin Bg helps to repair DNA, make DNA and to produce red blood cells. Certain foods, like citrus juices and dark green vegetables, are particularly good sources of folate. Folic acid deficiency can cause anemia. Folic acid is particularly important in women of childbearing age. A deficiency during pregnancy can lead to birth defects.

Causes of folic acid deficiency include:

• A diet low in fresh fruits, vegetables, and fortified cereals is the main cause of folic acid deficiency. In addition, overcooking of food can sometimes destroy the vitamins.

• Diseases (Crohn’s disease, celiac disease, etc.) that affect absorption in the gastrointestinal tract.

• Certain medications can cause folic acid deficiency, e.g. phenytoin.

• Alcoholism

Symptoms

• Fatigue

• Grey hair

• Mouth sores

• Tongue swelling

• Growth problems

• Anemia

Diagnosis

Folic acid deficiency is diagnosed with a blood test. Pregnant women will often have folate levels tested during a prenatal check-up.

Signs and symptoms

Folic acid is required for the normal production of RBCs. Complications of a deficiency may include:

• Megaloblastic anemia

• Serious birth defects in the spinal cord and brain of a developing fetus (e.g. spina bifida)

Treatment and Prevention

• Treatment involves increasing dietary intake of folate or folic acid supplement (vitamin B complexes).

• Reduced alcohol intake and completely no alcohol for pregnant women.

• Intake of foods that contain high amounts of folate include green leafy vegetables, such as broccoli and spinach, peas, sprouts; citrus fruits such as bananas and melons; tomato juice; eggs; beans and legumes; mushrooms; kidney and liver meat; chicken; fortified cereals.

Vitamin B₁₂/Cobalamin Deficiency

A deficiency of vitamin B₁₂ can lead to pernicious anemia. If untreated, it may cause symptoms such as:

• Pale skin

• Sore tongue

• Weakness, tiredness, or light-headedness

• Rapid heartbeat and breathing

• Easy bruising or bleeding, including bleeding gums

• Stomach upset and weight loss

• Diarrhea or constipation

Treatment

Replacement of vitamin B₁₂, usually by injection, or by prescription.

Prevention

Most people can prevent vitamin B₁₂ deficiency by eating enough meat, poultry, seafood, dairy products and eggs. If a person does not eat animal products, or has a medical condition that limits proper absorption of nutrients, it is recommended to take a B₁₂-containing multivitamin and eating breakfast cereal fortified with vitamin B₁₂.

Table 13.1: Other vitamin deficiency disease

Other Vitamin deficiency disease

Recommended Dietary Allowances

The recommended dietary allowance (RDA) was developed during World War II by Lydia J Roberts, Hazel Stiebeling, and Helen S Mitchell, all part of a committee established by the United States National Academy of Sciences in order to investigate issues of nutrition that might “affect national defense”. The final set of guidelines, called RDAs for Recommended Dietary Allowances, was accepted in 1941. The allowances were meant to provide superior nutrition for civilians and military personnel, so they included a “margin of safety.” Because of food rationing during the war, the food guides created by government agencies to direct citizens’ nutritional intake also took food availability into account. The Food and Nutrition Board subsequently revised the RDAs every five to ten years (Appendix K).

Bibliography

1. “Nutrition (Meaning of).” Nutrition (Meaning of). N.p., n.d. Web. 13 Dec. 2013. http://www.encyclo.co.uk/define/Nutrition.

2. Anemia of Folate Deficiency, (n.d.). Johns Hopkins Medicine. Retrieved July 15,2012, from http://www.hopkinsmedicine.org/healthlibrary/conditions/adult/hematology_and_blood_disorders/anemia_of_folate_deficiency_85,P00089.

3. Cafasso J. Folic Acid Deficiency. http://www.healthline.com/health/folate-deficiency#Over-viewl.

4. Dieu-Thu Nguyen-Khoa. Beriberi (Thiamine Deficiency), http://emedicine.medscape.com/article/116930-overview.

5. Elson Haas. Vitamins: PABA—Para-Amino-benzoic Acid, http://www.healthy.net/Health/Article/PAB A_Para_aminobenzoic_Acid/2132.

6. Folate Deficiency (2011, August 24). National Library of Medicine – National Institutes of Health. Retrieved July 15, 2012, from http://www.nlm.nih.gov/medlineplus/ency/article/000354.htm.

7. Folate (2011, October 1). Mayo Clinic. Retrieved July 15, 2012, from http://www.mayoclinic.com/health/folate/NS_patient-folate.

8. http://emedidne.medscape.com/article/116930-treatment.

9. http://emedidne.medscape.com/article/126354-treatment.

10. http://towncenterwellness.com/learning-center/vitamins-and-mineral-info/vitamin-b2-riboflavm.

11. http://towncenterwellness.com/learning-center/vitamins-and-mineral-info/vitamin-b5-pantothenic-acid.

12. http://www.drweil.com/drw/u/ART03380/Pantothenic-Acid-Vitamin-B5.html.

13. http://www.healthgrades.com/conditions/marasmus.

14. http://www.healthgrades.com/conditions/thiamine-deficiency.

15. http://www.healthline.com/health/kwashiorkor#Outlook7.

16. http://www.merckmanuals.com/professional/nutritional_disorders/vitamin_deficiency_dependency_and_toxicity/vitamin_e.html.

17. http://www.neneccg.nhs.uk/resources/uploads/files/nhs_northamptonshire_guidelines_on_vitamin_d_deficiency_and_prescribing_final.pdf.

18. http://www.patient.co.uk/doctor/vitamin-c-deficiency-pro.

19. http://www.webmd.com/food-recipes/vitamin-d-deficiency.

20. http://www.webmd.com/vitamins-and-supplements/lifestyle-guide-11/supplement-guide-vitamin-k.

21. http://www.who.int/nutrition/topics/vad/en/.

22. Katsura E, Oiso T (1976). Beaton GH, Bengoa JM, eds. “Chapter 9: Beriberi”. World Health Organization Monograph Series No. 62: Nutrition in Preventive Medicine (Geneva: World Health Organization).

23. Kayla Grossmann. 5 Ways to Get More Choline in Your Diet: Secret of Radiant Living, http://blog.radiantlifecatalog.com/bid/63690/5-Ways-to-Get-More-Choline-in-Your-Diet-Secret-of-Radiant-Living.

24. Last Full Review/Revision December 2012 by Larry E Johnson, MD, PhD. Content last modified August 2013. http://www.merckmanuals.com/professional/nutritional_disorders/vitamin_deficiency_dependency_and_toxicity/vitamin_b6.html.

25. Latham, Michael C (1997). “Chapter 16: Beriberi and Thiamine Deficiency”. Human Nutrition in the Developing World (Food and Nutrition Series-No. 29). Rome: Food and Agriculture Organization of the United Nations (FAO). ISSN 1014–3181.

26. Longe J ed. The Gale Encyclopedia of Alternative Medicine, second edition, 2004.

27. McIntyre Neil, Stanley Nigel N (1971). “Cardiac Beriberi: Two Modes of Presentation”. BMJ 3 (5774): 567–9. doi:10.1136/bmj.3.5774.567. PMC 1798841. PMID 5571454.

28. MedlinePlus: “Niacin (Vitamin B3, Nicotinic Acid), Niacinamide.” http://www.webmd.com/diet/niadn-deficiency-symptoms-and-treatments.

29. MedlinePlus: “Pellagra.”

30. Merck Manual, http://www.merckmanuals.com/professional/nutritional_disorders/vitamin_deficiency_dependency_and_toxicity/niacin.html. Last full review/revision, December 2012 by Larry E Johnson, MD, PhD. Content last modified August 2013.

31. Patel P, Mikhail M. Vitamin K Deficiency eMedicine. Updated: Feb 13, 2014.

32. Sesikeran B. Revised RDA for Indians 2010 (Report of the Expert Group of ICMR). [Internet] 2010 Nov 15th [cited on 2015 Jan 1st], Available on: http://nutritionfoundation ofindia.res.in/PPT-2011/Sevenl7-18teen/Dr-B-Sesikeran.pdf.

33. Sharma K. Balanced Diet and Its Importance. [Internet] Cited on 2015 Jan 10. Available from: http://reliable4you.com/balanced-diet-its-importance-by-kriti-sharma.

34. Shukla M and Behari K (1979). Congenital Bitot Spots, Indian Journal of Ophthalmology, 27(2), 63–64.

35. Solans. R, Bosch JA, Galofre P, others (2001). “Salivary and Lacrimal Gland Dysfunction (Sicca Syndrome) After Radioiodine therapy.”, Journal of Nuclear Medicine, 42 (5): 738–43, PMID 11337569.

36. Stephen Christensen. Treatment for a Riboflavin Deficiency, http://www.livestrong.com/article/427637-treatment-for-a-riboflavin-deficiency.

37. Swaminathan M. Flandbook of Food and Nutrition. Bangalore: The Bangalore Printing and Publishing Co. Ltd; 2007.

38. UK CMO CAS Letter. Vitamin D 02022012.pdf.

39. University of Institute of Food and Agricultural Sciences Extension: “Facts about Niacin.” Oregon State University Linus Pauling Institute: “Niacin.”

40. University of Maryland Medical Center: “Vitamin B₃ (Niacin).”

14

Water and Health

This chapter contains

▪ Definition

▪ Safe and Wholesome Water

▪ Use of Water

▪ Requirement of Water

▪ Sources of Water

▪ Well: Types and Sanitation

▪ Drinking Water Quality Standards

▪ Drinking Water Supply System

▪ Large Scale Purification of Water

▪ Small Scale Purification of Water

▪ Hardness of Water

▪ Fluoridation Program

▪ Water Pollution and its Hazards

▪ Prevention of Water Pollution

INTRODUCTION

“Next to oxygen, water is the most important factor for survival of man and animals. A person can do without food for five weeks or more, but without water he can survive for only a few days”—Dr Oaf Michelsen, National Institute of Health.

Water is a transparent fluid which forms the world’s streams, lakes, oceans and rain, and is the major constituent of the fluids of living things. As a chemical compound, a water molecule contains one oxygen and two hydrogen atoms that are connected by covalent bonds. Water is a liquid at standard ambient temperature and pressure, but it often coexists on earth with its solid state, ice; and gaseous state, steam (water vapor). One of the elements of “Primary Health Care” is “safe drinking water”.

DEFINITION

Water is a transparent, odorless, tasteless liquid, a compound of hydrogen and oxygen, H₂O, freezing at 32°F or 0°C and boiling at 212°F or 100°C, that in a more or less impure state constitutes rain, oceans, lakes, rivers, etc. It contains 11.188% hydrogen and 88.812% oxygen, by weight.

SAFE AND WHOLESOME WATER

Safe and wholesome water is the potable water free from harmful microorganisms and substances, even if it may have color, odor, or taste problem due to dissolved minerals. ‘Wholesome’ water is fit to use for drinking, cooking, food preparation or washing without any potential danger to human health by meeting the requirements of regulations made under Section 67 (Standards of Wholesomeness) of the Water Act 1991. Criteria are to limit on:

• Biological quality (including levels of bacteria and oocysts)

• Chemical quality (including levels of metals, solvents, pesticides and hydrocarbons)

• Physical qualities (including color, taste and odor).

– Pleasant to the taste

– Usable for domestic purpose

– Uncontaminated and hence unable to infect its user with a waterborne disease

Sources of non-wholesome water include:

– Groundwater abstracted from boreholes, wells or springs

– Surface water from watercourses (e.g. streams, brooks, rivers) or ponds and lakes

– Rainwater (generally collected and stored, referred to as ‘harvested rainwater’)

– Greywater (i.e. wastewater from baths, basins and showers)

– Treated wastewater (from sewage treatment plants or industrial processes).

The quality of the water from each of these sources will be different, and even from a single source will vary over time.

Uses of Water

The uses of water in a community are many and the requirements in quantity and quality are varied. The uses of water include:

• Domestic purpose: It is estimated that 8% of worldwide water use is for household purposes. These include drinking water, bathing, cooking, sanitation, and gardening, etc.

• Commercial water use: Includes fresh water for motels, hotels, restaurants, office buildings, other commercial facilities, and civilian and military institutions.

• Public purpose: Cleaning streets, recreational purposes like swimming pool, public fountain, and ornamental ponds, fire protection and public parks.

• Industrial purpose: It is estimated that 22% of worldwide water is used in industry.

• Mining water use: Includes water for the extraction of naturally occurring minerals; solids such as coal and ores; liquids such as crude petroleum; and gases such as natural gas. The category includes quarrying, milling (such as crushing, screening, washing and flotation), and other operations as part of mining activity. A significant portion of the water used for mining, about 32% is saline.

• Livestock water use: Includes water for stock animals, feed lots, dairies, fish farms, and other nonfarm needs. Water is needed for the production of red meat, poultry, eggs, milk, and wool, and for horses, rabbits, and pets. Livestock water use only includes fresh water.

• Agriculture uses: It is estimated that 70% of worldwide water use is for irrigation. It takes around 2,000–3,000 L of water to produce enough food to satisfy one person’s daily dietary need.

• Thermoelectric power water use: Is the amount of water used in the production of electric power generated with heat (hydro-power and steam power). After the steam is used to turn the turbines, it is condensed back to water by cooling it. The condensed water is then routed back to the boiler, where the cycle begins again.

• Carrying away waste: From all manner of establishment and institution.

• Recreational water use: It is usually a very small but growing percentage of total water use (water skiing, swimming pool, water games, etc.).

REQUIREMENT OF WATER

Household requirement: Common household uses consume a lot of water. In India, a daily supply of 150–200 L per capita is considered as adequate supply to meet the needs in urban area and about 40 liters per capita per day in rural areas. In America, it may take between 30 and 40 gallons for one bath. The average toilet uses about 5 gallons of water per flush. It takes 20–40 gallons of water for one shower. Washing machines use an average of 25 gallons per load. The kitchen sink takes roughly 20 gallons per day for preparing food and washing dishes. The bathroom sink, used for washing hands, shaving and brushing teeth, requires about 15 gallons per day.

Body requirement: How much water a person should drink each day, is a simple question with no easy answers. Studies have produced varying recommendations over the years, but in truth, water needs for a person depends on many factors, including his/her health, how active the person is and where the person live.

Although no single formula fits everyone, the Institute of Medicine determined that an adequate intake (AI) for men is roughly about 3 liters of total beverages a day. The AI for women is about 2.2 L of total beverages a day.

SOURCES OF WATER

Life exists on earth due to the presence of water. Nearly three-fourths of the earth’s surface is covered with water. Water is also found below the earth’s surface. It is present in air in the form of water vapor. About 70 % of the human body is water. The bodies of all plants and animals contain water. Rainwater, oceans, rivers, lakes, streams, ponds and springs are natural sources of water. Dams, wells, tube wells, handpumps, canals, etc. are manmade sources of water.

Main sources of water can be divided as

1. Rain

2. Surface water

• Impounding reservoirs

• Rivers and streams

• Tanks, ponds and lakes.

3. Ground water

• Shallow wells

• Deep wells

• Spring

1. Rain: Rain is a major source for depositing most of the fresh water on the earth. It provides suitable conditions for many types of ecosystems as well as water for hydroelectric power plants and crop irrigation.

• Physically: It is clear, bright and sparkling.

• Chemically: It is very soft water containing only traces of dissolved solids.

• Bacteriologically: It is free from pathogenic agents.

• Impurities: Rain water tends to become impure as it passes through the atmosphere. It picks up suspended impurities from the atmosphere such as dust, soot and microorganism and gases such as CO₂, N₂, O₂ and ammonia. These gases react with atmospheric water forming dilute solution of sulfuric acid.

Rainwater can be used in future by rainwater harvesting. It is the accumulation and deposition of rainwater for reuse onsite, rather than allowing it to run-off. Uses include water for garden, water for livestock, water for irrigation, water for domestic use with proper treatment, etc. In many places, the water collected is just redirected to a deep pit with percolation. The harvested water can be used as drinking water as well as for storage and other purpose like irrigation.

Rainwater harvesting provides an independent water supply during regional water restrictions or drought and in developed countries is often used to supplement the main supply.

2. Surface water: Surface water originates from the rainwater. Surface water is water on the surface of the planet such as in a stream, river, lake, wetland, ocean, wadis (water source which are dry except in rainy season) and manmade reservoir. It is the main source of water supply in many areas through: (i) impounding reservoir; (ii) rivers and streams; and (iii) tank, ponds and lakes.

i. Impounding reservoir: These are artificial lakes constructed usually of earthwork or masonry in which large quantities of surface water is stored. Dam built across rivers and mountain streams also provided large reservoir is called “catchment area”. One disadvantage of storing water for long periods in reservoirs is the growth of algae and other microscopic organisms, which impart bad taste and odors to water.

ii. Rivers and stream: The river water is always polluted and is quite unfit for drinking without treatment. River water may be clear but it is always turbid during rainy season. River water contains dissolved and suspended impurities of all kinds including bacteria and other organism. Though stream water looks less contaminated but better not to drink without treatment.

iii. Tanks, ponds and lakes: These are an important source of water supply. As water is stagnant in these sources which are full of slits and colloidal matter, especially immediately after the rains; water is considered contaminated. Water from these sources should not be drunk without being boiled, disinfected or having undergone treatment of any kind.

3. Ground water: Rainwater percolating into ground constitutes ground water. It is the water located beneath the earth’s surface in soil pore spaces and in the fractures of rock formations. It is now realized that there is a limited quantity of ground water in the world. Use of excessive ground water which cannot be renewed causes natural system misbalanced which may be a cause of disaster.

Ground water is the cheapest, most practical and superior to surface water, because the ground itself provides an effective filtering medium. It is likely to be free from pathogenic agents, usually requires no treatment, available even during dry season. Usual ground water sources are: wells and springs.

Shallow well water is quiet polluted and needs treatment before consumption whereas deep well water is the safest water and often the most satisfactory sources of water supply.

Spring water is the subject of many popular misconceptions. Many people believe that spring water is actually “pure” water. On the contrary, spring waters contain many of the same impurities found in drilled wells or even tap water.

Wells

Water well is an excavation or structure created in the ground by digging, driving, boring, or drilling to access groundwater. The well water is drawn by a pump or using containers (such as buckets) that are raised mechanically or by hand. Wells are an important source of water supply in many communities. Wells are two kinds, shallow and deep.

Shallow well taps subsoil water, i.e. the water from above the first impervious (not able to be penetrated) layer in ground. They yield limited quantities of water, and water is notoriously liable to pollution unless care is taken in well construction.

Deep well is one which taps water from the water bearing stratum below the first impervious layer in the ground. Deep wells are usually machine-dug and may be several hundred meters (approximately 10,000 feet or more) deep. Deep well furnishes the safest water, and are often the most satisfactory sources of water supply.

Fig. 14.1

Difference between deep well and shallow well:

Shallow well
Deep well

1. Water is from above the first impervious layer.

1. Water is from below the first impervious layer.

2. Water is moderately hard water.

2. Water is much hard than in shallow well

3. Water is often very contaminated.

3. Water is quiet pure, i.e. free of contamination.

4. Water usually goes dry in summer season.

4. Water is available even in dry weather.

5. Less expensive to construct.

5. Require specific tools and expensive to construct.

Sanitation of Well

Maintenance of sanitation is very important to prevent contamination of water as well as to prevent waterborne diseases. Sanitary well may be defined as a well which is properly located, well-constructed and protected against contamination.

The following points should be taken into consideration while constructing wells to maintain its sanitation:

Location: The first step in well construction is the choosing of a proper site. The well should be located not less than 15 m (50 ft) away from likely sources of contamination. The well should be located at higher elevation with respect to a possible source of contamination.

Lining: The lining of the well should be built of bricks or stones set in cement up to depth of at least 6 m (20 ft) so that water enters from the bottom and not from the sides of the well.

Parapet walls: There should be a parapet wall up to a height of at least 70–75 cm above the ground level.

Platform: There should be a cement concrete platform round the well extending at least lm in all direction.

Drain: There should be a pucca drain to carry off spilled water to a public drain or a soakage pit constructed well beyond the “cone of filtration” (area of drainage) of the well.

Covering: The top of the well should be closed by a cement concrete cover because the bulk of the pollution is introduced into the well directly through the open tap.

Handpump: The well should be equipped with a handpump for lifting the water in a sanitary manner. When a pump is fitted there is marked improvement in the bacteriological quality of water.

Strict cleanliness should be maintained while drawing water and using the well. Washing of clothes, utensils, animals, dumping of waste near well area should be avoided.

Drinking Water Quality Standards

Drinking water quality standards describes the quality parameters set for drinking water. Despite that, water is most needed to survive and drinking water free of harmful constituents is of utmost important. Still there are no universally recognized and accepted international standards for drinking water.

World Health Organization Guidelines

The World Health Organization (WHO) guidelines recommended for drinking water related to:

1. Acceptability aspects

2. Microbiological aspect

3. Chemical aspect

4. Radiological aspect

Acceptability aspect

• Drinking water should be free from turbidity, color, any taste and odor.

• Chlorides: 200–600 mg/L

• Hardness: Water containing calcium carbonate at concentrations below 60 mg/L is generally considered as soft; 60–120 mg/L, moderately hard; 120–180 mg/L, hard; and more than 180 mg/L, very hard.

• Ammonia: Approximately 0.4 mg/L

• pH level: Between 6.5 and 8.5

• Hydrogen sulfide: Test and odor threshold between 0.05 and 0.1 mg/L

• Iron: Between 0.05 and 0.1 mg/L

• Sodium: 200 mg/L

• Total dissolved solids (TDS): Less than 600 mg/L is good.

• Zinc: Test threshold concentration 4 mg/L as zinc sulfate.

• Manganese: Below 0.1 mg/L

• Dissolved oxygen (DO): No specific value has been mentioned. A high level of DO is good.

• Copper: Less than 1 mg/L

• Aluminium: Less than 0.2 mg/L

Microbiological aspect: Ideally drinking water should not contain any pathogenic microorganisms (bacteria, virus, protozoa, helminthes, free living organisms as fungi, alga).

Chemical aspect: Includes the following recommended limits on naturally occurring constituents that may have direct adverse health impact:

• Arsenic 10 μg/L

• Barium 10 μg/L

• Boron 2400 μg/L

• Chromium 50 μg/L

• Fluoride 1500 μg/L

• Selenium 40 μg/L

• Uranium 30 μg/L

For the potential occurrence in drinking water of artificial or synthetic pollutants generated by human activities, the following standards have been proposed:

a. Cadmium 3 μg/L

b. Mercury 6 μg/L (for inorganic mercury)

• Benzene 10 μg/L

• Carbon tetrachloride 4 μg/L

• 1, 2-dichlorobenzene 1000 μg/L

• 4-dichlorobenzene 300 μg/L

• 1, 2-dichloroethane 30 μg/L

• 1, 2-dichloroethene 50 μg/L

• Dichloromethane 20 μg/L

• Di(2-ethylhexyl) phthalate 8 μg/L

• 1, 4-dioxane 50 μg/L

• Edetic acid 600 μg/L

• Ethylbenzene 300 μg/L

• Hexachlorobutadiene 0.6 μg/L

• Nitrilotriacetic acid 200 μg/L

• Pentachlorophenol 9 μg/L

• Styrene 20 μg/L

• Tetrachloroethene 40 μg/L

• Toluene 700 μg/L

• Trichloroethene 20 μg/L

• Xylenes 500 μg/L

Drinking Water Supply System

The objectives of any water supply system are:

a. To supply safe and wholesome water to the users, whether these constitute a family, a group of families, or a community.

b. To supply water in adequate quantity.

c. To make water readily available to the users, in order to encourage personal and household hygiene.

It is essential that the system is properly inspected and maintained so that it continues to supply the quality and quantity of water as intended. These routine checks should include:

• Sources (e.g. check that there is no obvious contamination of the source)

• Storage systems (check for contamination, e.g. a dead bird, in the storage cistern)

• Filters (e.g. that they are not blocked or holed)

• Treatment (e.g. by checking water quality)

• Pumps (e.g. check electrical safety)

• Distribution pipework (e.g. check that there are no leaks or misconnections).

The sanitary quality of drinking water reservoir (e.g. tank) may be considerably improved by observing the following:

• The edge of the reservoir should be elevated in order to prevent the entry of surface washing.

• There should be a fence around the reservoir to prevent access to animal.

• No one should be permitted to go get into the reservoir directly.

• There should be an elevated platform from where people can draw water/or pipe connection to water taps.

• The weeds should be periodically removed.

• The reservoir should be cleaned at the end of the dry season.

Purification of Water

The objective of purification of water is to remove the dissolved and suspended impurities of water. Purification of water can prevent lots of diseases. Method of purification of water is generally divided into:

1. Large scale purification

a. Storage

b. Filtration (slow sand and rapid sand filtration)

c. Disinfection

2. Small scale purification

a. Boiling

b. Chemical disinfection (bleaching powder, iodine, potassium permanganate, chlorine solution and tablets, etc.)

c. Filtration

d. Ultraviolet purifier

e. SODIS method

Large Scale Purification of Water

a. Storage: Water is stored in artificial or natural reservoir for a few days. This storage helps in setting of suspended impurities, oxidation by aerobic bacteria and sunlight may help in certain disinfection. Bacterial counts of river water drop by 90% within 5–7 days of storage. Optimum period of storage of river water is about 10–14 days.

b. Filtration: Filtration is done through either slow sand filter (biological filter) or rapid sand filter (mechanical filter). In case of more suspended solid and high bacteriological content, prefiltration is done through coarse granules.

Slow Sand Filtration

Slow sand filters are used in water purification for treating raw water to produce a potable product. They are typically 1 to 2 m deep, can be rectangular or cylindrical in cross-section and are used primarily to treat surface water. The length and breadth of the tanks are determined by the flow rate desired by the filters, which typically have a loading rate of 0.1 to 0.2 m per hour. It improves the physical, chemical and microbiological qualities of water. It is less expensive, therefore, useful in small community water supplies.

Fig. 14.2

Elements of a Slow Sand Filter

1. A supernatant (raw) water reservoir, the principle function of which is to maintain a constant head of water above the filter medium, this head providing the pressure that carries the water through the filter.

2. A bed of graded sand, acts a filter medium, within and upon which the various purification processes take place. This layer made of four layers: lower layer made of coarse gravel, then fine gravel in 2nd lower layer, coarse sand has made the 3rd layer and in the top most layer there is filter sand.

3. An under drainage system, which fills the dual purpose of supporting the filter medium while presenting the minimum possible obstruction to the treated water as it emerges from the underside of the filter bed.

4. A system of control valves to regulate the velocity of flow through the bed, to prevent the level in the raw water reservoir from dropping below predetermined minimum level during operation, and to permit water levels to be adjusted and backfilling to take place when the filter is put back into operation after cleaning.

Purification of Water in Slow Sand Filter

Slow sand filters work through the formation of a gelatinous layer or biofilm called hypogeal layer or “Schmutzdecke” (also known as vital layer, zoogleal layer or biological layer) in the top few millimeters of the fine sand layer. The Schmutzdecke is formed in the first 10–20 days of operation. The layer is consists of bacteria, fungi, protozoa and a range of aquatic insect larvae.

The Schmutzdecke is the layer that provides the effective purification in potable water treatment, the underlying sand providing the support medium for this biological treatment layer. As water passes through the Schmutzdecke, the particles of foreign matter are trapped in the mucilaginous matrix and dissolved organic material is adsorbed and metabolized by the bacteria, fungi and protozoa. The water produced from a well-managed slow sand filter can be of exceptionally good quality with 90–99% bacterial reduction.

Filter Cleaning

As the Schmutzdecke grows, slow sand filters slowly lose their performance. Thus it is necessary to restore the filter. Two methods are commonly used to do this.

1. Top few millimeters of fine sand is scraped off to expose a new layer of clean sand. Water is then poured back into the filter and recirculated for a few hours to allow a new Schmutzdecke to develop. The filter is then filled to full depth and brought back into service.

2. The second method, sometimes called wet harrowing, involves lowering the water level to just above the Schmutzdecke, stirring the sand and thereby suspending any solids held in that layer and then running the water to waste. The filter is then filled to full depth and brought back into service. Wet harrowing can allow the filter to be brought back into service more quickly.

Unique features of slow sand filter

1. Unlike other filtration methods, slow sand filters use biological processes to clean the water, and are non-pressurized systems. Slow sand filters do not require chemicals or electricity to operate.

2. Cleaning is traditionally done by the use of a mechanical scraper, which is usually driven into the filter bed once the bed has been dried out. However, some slow sand filter operators use a method called “wet harrowing”, where the sand is scraped while still under water, and the water used for cleaning is drained to waste.

3. For municipal systems there usually is a certain degree of redundancy, since it is desirable for the maximum required throughput of water to be achievable with one or more beds out of service.

4. Slow sand filters require relatively low turbidity levels to operate efficiently. In summer conditions and in conditions when the raw water is turbid, blinding of the filters occurs more quickly and pretreatment is recommended.

5. Unlike other water filtration technologies that produce water on demand, slow sand filters produce water at a slow, constant flow rate and are usually used in conjunction with a storage tank for peak usage. This slow rate is necessary for healthy development of the biological processes in the filter.

Rapid Sand Filtration

The first modern rapid sand filtration plant was designed and built by George W Fuller in Little Falls, New Jersey. The rapid sand filter is commonly used in municipal drinking water facilities as part of a multiple-stage treatment system. There are two types of rapid sand filter, Paterson’s filter (gravity type) and Candy’s filter (pressure type).

Elements of Rapid Sand Filter

1. Filter tank or filter box of about 900 sq feet

2. Filter sand or mixed media: sand bed, depth of about 1m

3. Gravel support bed of about 30–40 cm

4. Under drain system

5. Wash water troughs

6. Filter bed agitators

Purification of Water in Rapid Sand Filter

Rapid sand filters use relatively coarse sand and other granular media to remove particles and impurities that have been trapped in a floe (Alum floe). Through coagulation that is, the use of flocculation chemicals, typically salts of aluminium (alum 5–40 mg or more per liter) or iron, water is first treated. Amount of chemicals to add depends upon turbidity, color, temperature and pH value of water. Water and floes flow through the filter medium under gravity or pumped pressure and the flocculated material is trapped in the sand matrix. Later rapid mixing is done in “mixing chamber” with violent agitation. Next in “flocculation chamber” water is treated with slow and gentle stirring (flocculation) for about 30 minutes. The water is now left into “sedimentation tank” for sedimentation processes. Now of the typical treatment stages that precede filtration. In filtration stage water is passed through filter tank which contains sand bed and gravel bed. Water gets filtered through sand and gravel and moves to under drain. The rate of filtration is 5–15 m³/m²/hour. A disinfection system (typically using chlorine or ozone) is commonly used following filtration.

Filter Cleaning

Rapid sand filters must be cleaned frequently, often several times a day, by backwashing, which involves reversing the direction of the water and adding compressed air. During backwashing, the bed is fluidized and care must be taken not to wash away the media, i.e. alum floe.

The advantages of rapid sand filter

• It can deal with raw water directly without having storage.

• Filtration is faster as 40–50 times that of slow filter.

• The washing of the filter is easy.

• Space occupation is less.

c. Disinfection: Water disinfection means the removal, deactivation or killing of pathogenic microorganisms. Sterilization is a process related to disinfection. However, during the sterilization process all present microorganisms are killed, both harmful and harmless microorganisms.

Types of Disinfection

Disinfection can be attained by the means of physical or chemical disinfectants.

Fig. 14.3

For chemical disinfection of water the following disinfectants can be used:

• Chlorine (Cl₂)

• Chlorine dioxide (C1O₂)

• Ozone (O₃)

• Halogens: Bromine (Br), iodine (I)

• Bromine chloride (BrCl)

• Metals: Copper (Cu²⁺), Silver (Ag⁺)

• Potassium permanganate (KMnO₄)

• Phenols

• Alcohols

• Soaps and detergents

• Hydrogen peroxide

• Several acids and bases

For physical disinfection of water the following disinfectants can be used:

• Ultraviolet (UV) light

• Electronic radiation

• Gamma rays

• Sounds

• Heat

Chlorination

Most commonly used chemical disinfectant is chlorine.

Principles of Chlorination

• Water should be clear and free from turbidity.

• Chlorine demand should be estimated to prevent overdoses. The point at which the chlorine demand of water is met is called the “break point”.

• Contact period should be at least 30 minutes to 1 hour.

• The minimum recommended concentration of free chlorine is 0.5 mg/L.

• Correct dose of chlorine to be applied is determined by the sum of the chlorine demand and free residual chlorine of 0.5 mg/L.

Methods and Action of Chlorination

For disinfecting large scale of water, chlorine is used as chlorine gas, chloramines or perchloron. Among them, chlorine gas is considered as convenient and it is quick in action. It is applied to the water supply by the help of special equipment known as ‘chlorinating equipment’.

It kills bacteria, oxidizes minerals, reduces bad odor and prevents green algae formation. The amount needed is adjusted by special equipment known as ‘Patterson’s device’ which measures, regulates and administers gaseous chlorine. In some areas instead of chlorine gas chloramine is used. Chlorine reacts with water and forms hydrochloric and hypochlorous acids. The hydrochloric acid is neutralized by the alkalinity of the water. The hypochlorous acid ionizes to form hydrogen ions and hypochlorite ions.

H₂O + Cl₂ = HC1 + HOC1
HOC1 = H + OC1

The disinfecting action of chlorine is mainly due to the hypochlorous acid and to a small extent to the hypochlorite ions.

Shock chlorination is a process used in many swimming pools, water wells, springs, and other water sources to reduce the bacterial and algal residues in the water. Shock chlorination is performed by mixing a large amount of sodium hypochlorite, which can be in the form of a powder or a liquid such as chlorine bleach, into the water. Water that is being shock chlorinated should not be swum in or drunk until the sodium hypochlorite count in the water goes down to 3 ppm or less. Commercial sodium hypochlorite should not be mixed with commercial calcium hypochlorite, as there is a risk of explosion.

Breakpoint chlorination: Breakpoint chlorination is the point where the demand for chlorine has been fully satisfied in terms of chlorine addition to water. It is the point at which the residual chlorine appears and when all combined chlorine has been completely destroyed and corresponding dosage is the breakpoint dosage (Fig. 14.4).

Fig. 14.4

Ortho toluidine (OT) test: This test is done to determine free and combined chlorine with speed and accuracy. OT is a colorless organic liquid that is oxidized by chlorine into a yellow colored compound called “holoquinone”.

Water sample is collected after 10 minutes of chlorine dose, and 1 ml of ortho toluidine solution is added to 100 ml of sample in a glass tube. When this reagent is added to water containing chlorine, it turns yellow and the intensity of the color varies with the concentration of the gas. The deeper the color, the greater will be the amount of residual chlorine. Orthotolidine reacts with free chlorine instantaneously but reacts more slowly with combined chlorine.

Rapid and accurate determination of free chlorine is usually made with the help of a chloroscope. The triple cell chloroscope is filled with water sample up to the mark and orthotolidine solution is added by means of marked pipette. The color so-formed is matched with the standard colored disc provided with the instrument.

When the water is highly alkaline, a blue tinge is formed instead of a yellow one; the quantity of OT to be added is doubled.

Ortho toluidine-arsenite (OTA) test: One of the biggest limitations of OT test is that it measures free and combined chlorine indiscriminately. Modified OTA method is used to differentiate between free and combined residual chlorines. The OTA test is based on the fact that free chlorine residuals will react immediately within 5–10 seconds while combined residual chlorine (chloramine) will react more slowly.

In OTA test, ortho toluidine is first added to the sample and quickly followed by sodium arsenite. Within seconds, the OT oxidizes the free chlorine forming yellow holoquinone. Due to the subsequent addition of sodium arsenite, the chloramines will be quickly oxidized to form a colorless liquid. Thus in this test only free chlorine is fixed, and its concentration is determined by comparing the yellow color with standard one. The difference of the two tests would give combined residual chlorine.

Small Scale Purification of Water

Boiling: Bringing water to its boiling point at 100°C (212°F), boil the water for 5–10 minutes plus 1 minute for every 300 m above sea level, up to around 5500 m. After that altitude boiling becomes ineffective. For human health, complete sterilization of water is not required, since the heat-resistant microbes are not intestine affecting. The traditional advice of boiling water for 10 minutes is mainly for additional safety, since microbes start getting eliminated at temperatures greater than 60°C (140°F). Boiling is the oldest and most effective way since it eliminates most microbes causing intestine related diseases, but it cannot remove chemical toxins or impurities. So cover the pot of boiling water and let the water sit and settle after boiling. Any dense items in the water will sink to the bottom naturally; strain the pure water from the top to a clean pot with lid or bottle with cap. Need not to do this if the water came from a tap and sure that there are no solid items, minerals, or metals in the water, if you let the water settle.

Filtration: Nowadays, various types of filters are available for household water purification. One simple method is the use of filters with candles. A few filter candles are coated with a silver catalyst (Katadyn filter) so that bacteria coming into contact with the surface are killed by the oligodynamic/antimicrobial action of the silver ions. Candles need to replace periodically (Fig. 14.5).

Fig. 14.5

Granular activated carbon filtering is a form of activated carbon with a high surface area adsorbs many compounds including many toxic compounds. Water passing through activated carbon is commonly used in municipal regions with organic contamination, taste or odors. But many household water filters and fish tanks also use activated carbon filters to further purify the water. If water is held in the carbon block for longer period, microorganisms can grow inside which results in fouling and contamination.

Advance filters use reverse osmosis (RO) mechanism. Mechanical pressure is applied to the raw impure water to force pure water through a semipermeable membrane. Reverse osmosis is theoretically the most thorough method of water purification available, although perfect semipermeable membranes are difficult to create. Unless membranes are well-maintained, algae and other life forms can colonize the membranes.

Chemical disinfection: Disinfect water using household bleach. Bleach will kill some, but not all types of disease-causing organisms that may be in the water. If the water is cloudy, filter it through clean clothes or allow it to settle, and draw off the clear water for disinfection. Add about 20 drops of regular, unscented, liquid household bleach for 10 L of water, stir it well and let it stand for 30 minutes before drinking. Store disinfected water in clean containers with covers. Commercial chlorine drops and chlorine tablets are also available at market. These come along with instructions. Chlorine is usually sold in two forms: sodium hypochlorite (liquid bleach) and calcium hypochlorite (powder or pellets). Sodium hypochlorite is the main ingredient in liquid bleaches which initially contain about 5% available chlorine. The principle of chlorination is to ensure “free” residual chlorine of 0.5 mg/L at the end of one hour contact.

The monsoons are a particularly favorable time for the spread of waterborne diseases. As streets get flooded and groundwater tables rise, they tend to contaminate open wells and borewells alike. Bleaching powder is also used to disinfect well. Steps in well disinfection: Calculating the chlorine dosage for disinfecting a well using calcium hypochlorite (HTH):

Equipment needed: 20 L bucket and HTH chlorine granules or powder

• Calculate the volume of water in well. If height (h) and diameter of well (d) in meter, Volume (L) = (3.14 × d² × h)/4 cubic meter
= [(3.14 × d² × h) × 1000]/4

Liter as 1 cubic meter = 1000 L of water

• Fill the bucket with clear water from the well and add 50 g of HTH and stir until dissolved.

• For every cubic meter (m³) of water in the well add 10 L (half bucket) of the chlorine solution.

Chlorine solution: Prepare 5% chlorine solution by adding bleaching powder with 25% available chlorine. Mix 4 kg of this bleaching powder in 20 L of water. Readymade chlorine solution is also available in market.

Chlorine tablet: This is available in market (e.g. halazone tablet). A single tablet of 0.5 g is sufficient to disinfect 20 L of water.

Iodine: It is generally used for emergency disinfection of water. Two drops of 2% ethanol solution of iodine is sufficient for 1 L of clean water.

Ultraviolet purifier: These purifiers are very easy to use. Deep the pen of the lamp into the water, wait for the light on the side of the pen to turn green, and then stir the pen around in the water until the light turns off. The UV rays kill any bacteria living in the water so that water becomes safe to drink. Keep in mind that this purifier doesn’t filter out the now deceased bacteria, but despite their continued presence in your water though they are not dangerous anymore.

SODIS method: Solar disinfection is a type of portable water purification that uses solar energy to make biologically-contaminated (e.g. bacteria, viruses, protozoa and worms) water safe to drink. Water contaminated with non-biological agents such as toxic chemicals or heavy metals require additional steps to make the water safe to drink. The World Health Organization (WHO), UNICEF, and the Red Cross, therefore, recommend the SODIS method as a way to treat drinking water in developing countries.

Principle of SODIS: Exposure to sunlight has been shown to deactivate diarrhea-causing organisms in polluted drinking water. Three effects of solar radiation are believed to contribute to the inactivation of pathogenic organisms:

1. UV-A interferes directly with the metabolism and destroys cell structures of bacteria.

2. UV-A also reacts with oxygen dissolved in the water and produces highly reactive forms of oxygen (oxygen-free radicals and hydrogen peroxides) that are also believed to damage pathogens.

3. Cumulative solar energy (including the infrared radiation component) heats the water. If the water temperatures rise above 50°C (122°F), the disinfection process is three times faster.

Process of SODIS Method

Colorless, transparent PET (polyethylene terephthalate) water bottles (2 L or smaller size) are chosen for use. The labels are removed and the bottles are washed before the first use.Water from contaminated sources is filled into the bottles. To improve oxygen saturation, bottles can be filled three quarters, shaken for 20 seconds (with the cap on), then filled completely and recapped. Filled bottles are then exposed to the sun (as on top of the roof or veranda well-exposed to sun).

Bottles will heat faster and to higher temperatures if they are placed on a sloped sun-facing corrugated metal roof as compared to thatched roofs. The treated water can be consumed directly from the bottle or poured into clean drinking cups. The risk of recontamination is minimized if the water is stored in the bottles. Refilling and storage in other containers increases the risk of contamination.

Weather conditions | Minimum treatment duration
Sunny (less than 50% cloud cover) | 6 hours
Cloudy (50–100% cloudv, little to no rain) | 2 days
Continuous rainfall | Unsatisfactory performance, use rainwater harvesting

Hardness of Water

Hard water is the water that has high mineral content. Hard water is formed when water percolates through deposits of calcium- and magnesium-containing minerals such as limestone, chalk and dolomite. Hard drinking water is generally not harmful to one’s health, but gives a metallic taste and can pose serious problems in industrial settings, where it can breakdown boilers, cooling towers, and other equipment that handles water. In domestic settings, hard water is often indicated by a lack of lathers formation when soap is agitated in water, and by the formation of lime scale in kettles and water-heaters.

Mainly four mineral compounds cause hardness: calcium bicarbonate, magnesium bicarbonate, calcium sulfate and magnesium sulfate. Hardness in water is expressed in terms of “milliequivalents per liter (mEq/L). Drinking water should be moderately high.

Fig. 14.6

Classification of Hardness

a. Temporary hardness: Due to calcium bicarbonate and magnesium bicarbonate.

b. Permanent hardness: Due to calcium sulfate, magnesium sulfate, chlorides and nitrates.

Classification | Level of hardness (mEq/L)
Soft water | Less than 1 (< 50mg/L)
Moderately hard | 1–3 (50–150 mg/L)
Hard water | 3–6 (150–300 mg/L)
Very hard water | Over 6 (> 300 mg/L)

Removal of hardness

Temporary hardness can be removed by:

• Boiling

• Addition of lime

• Addition of sodium carbonate

• Permutit process or base exchange process

Permanent hardness can be removed by:

• Addition of sodium carbonate

• Permutit process or base exchange process

Boiling: Temporary hardness in water can be easily removed by boiling. On boiling, calcium/magnesium bicarbonate decomposes to give calcium/magnesium carbonate, which is insoluble in water. Therefore, it precipitates out.

Adding Slaked Lime (Clark’s Process)

In Clark’s process, slaked lime Ca(OH)₂ is added to temporary hard water. Insoluble calcium carbonate precipitates out and no longer produces hardness.

Adding Washing Soda/Sodium Carbonate

Calcium and magnesium ions present in hard water react with sodium carbonate to produce insoluble carbonates. The water now contains soluble and harmless sodium salts.

Base exchange or ion exchange process (Permutit process): Permutit or sodium aluminium silicate is a complex chemical compound, which occurs as a natural mineral called zeolite. Permutit or zeolites are insoluble in water and have the property of exchanging ions present in them with the ions present in the solution.

Permutit or zeolites are packed in a suitable container and a slow stream of hard water is passed through this material. As a result, calcium and magnesium ions present in hard water are exchanged with sodium ions in the permutit (Na + Al-silicate). The outgoing water contains sodium salts, which do not cause hardness.

This is the basic concept of ion exchange and hardness removal.

FLUORIDATION PROGRAM

Water fluoridation program has been established in many countries since the 1930s because of the powerful benefits of the right amount of fluoride, to reduce dental caries was first recognized. Many communities worldwide lack sufficient natural fluoride in their drinking water to prevent caries.

A fluoridation program is the artificial and controlled addition of a fluoride compound to a public water supply, in order to adjust its fluoride concentration to an optimal level for prevention of dental caries. The optimal level is usually around 1 mg/L. A fluoride-containing chemical is added to increase the total (raw water plus dosed) level to the predetermined concentration. The chemical is chosen for its ability to dissolve in water, low cost and lack of undesirable side effects. Fluoride is odorless and tasteless, so there is no perceptible change to the water. The usual chemicals used for fluoridation are: hexafluo-rosilicic acid, disodium hexafluorosilicate or sodium fluoride. Fluoridation is carried out at water treatment works. A fluoridation program requires good maintenance and a specially designed plant. Fluoridation chemicals are corrosive in concentrated form and must be stored and handled according to safe working practices (WHO).

In some geographical areas, water may contain a high level of fluorides. In such communities water is defluoridated by phosphate to reduce fluorides to optimum level.

WATER POLLUTION AND ITS HAZARDS

Water pollution is a major global problem which requires ongoing evaluation and revision of water resource policy at all levels (international, down to individual aquifers and wells). It has been suggested that it is the leading worldwide cause of deaths and diseases, and that it accounts for the deaths of more than 14,000 people daily. An estimation of 580 people in India died of water pollution related illness every day.

Water pollution is the contamination of water as in lakes, rivers, oceans, aquifers (a porous deposit of rock such as sandstone, containing water that can be used to supply wells) and groundwater. Water pollution occurs when pollutants are directly or indirectly discharged into water bodies without adequate treatment to remove harmful compounds.

Water contains impurities of various kinds—natural and manmade. The naturally impurities are not essentially dangerous as manmade impurities.

Sources of Water Pollution

The sources of pollution resulting from these human activities:

Natural impurities:

• Dissolved gases (e.g. carbon dioxide, nitrogen, etc.)

• Dissolved minerals (e.g. salt of calcium, magnesium, sodium, etc.)

• Suspended impurities (e.g. clay, sludge, sand, mud, etc.)

• Microorganism

Manmade impurities (due to urbanization and industrialization)

• Sewage: Contains decomposable organic matter and pathogenic agents, e.g. infective organism.

• Industrial waste: Contains toxic agents ranging from metal salts to complex synthetic organic chemical.

• Agricultural impurities: Comprise fertilizers and pesticides.

• Physical pollutants: Heat (thermal pollution) and radioactive substance, carcinogenic agent, etc.

Natural and manmade contaminants may include organic and inorganic substances.

Organic water pollutants

• Detergents

• Disinfection by-products found in chemically disinfected drinking water such as chloroform.

• Food processing waste, which can include oxygen-demanding substances

• Insecticides and herbicides

• Petroleum hydrocarbons, including fuels (gasoline, diesel fuel, jet fuels, and fuel oil) and lubricants (motor oil), and fuel combustion by-products.

• Tree and bush debris

• Volatile organic compounds (VOCs) such as industrial solvents, from improper storage.

• Chlorinated solvents, since they don’t mix well with water and are denser.

• Perchlorate

• Various chemical compounds found in personal hygiene and cosmetic products

• Drug pollution involving pharmaceutical drugs and their metabolites

• Microscopic pollution

Inorganic water pollutants

• Industrial discharges (especially sulfur dioxide from power plants)

• Ammonia from food processing waste

• Chemical waste as industrial by-products

• Fertilizers containing nutrients—nitrates and phosphate

• Heavy metals from motor vehicles (via urban storm water run-off) and acid mine drainage

• Silts (sediments) run-off from construction sites, logging, slash and burn practices or land clearing sites.

• Macroscopic pollution—large visible items polluting the water may be termed “floatables” such as: trash or garbage (e.g. paper, plastic or food waste) discarded by people on the ground washed by rainfall, etc.

Thermal pollution

Thermal pollution is the rise or fall in the temperature of a natural body of water caused by human influence. Thermal pollution, unlike chemical pollution, results in a change in the physical properties of water. A common cause of thermal pollution is the use of water as a coolant by power plants and industrial manufacturers. Elevated water temperature decreases oxygen levels, which can kill fish, and can alter food chain composition, reduces species biodiversity, and foster invasion by new thermophilic species. Urbanization may also elevate temperature in surface waters. Thermal pollution can also be caused by the release of very cold water from the base of reservoirs into warmer rivers.

Hazards of water pollution

The hazards of water pollution are classified into two groups: (1) Biological and (2) Chemical.

1. Biological hazards: These hazards include disease caused by the presence of an infective agent or an aquatic host in water. The presence of virus, bacteria, worms, etc.

2. Chemical hazards: These are an increasing incidence in chemical pollutants in the public water supplies. These pollutants include detergent, solvents, heavy metals, minerals, nitrogenous substances, bleaching agents, dyes, ammonia and organic acids, etc. Chemical pollutants may affect man’s health not only directly but also indirectly by accumulating in aquatic life, e.g. fish used as human food.

• Skin infections

• Dental problems (fluoride 1 mg/L protects dental caries but high level causes mottling of dental enamel)

• High nitrate content in water is associated with methemoglobinemia (causes cyanosis)

• Intestinal disorders (by Polychlorinated biphenyls)

Agent
Waterborne diseases

1. Viral

Viral hepatitis A and E, poliomyelitis, rotavirus diarrhea.

2. Bacterial

Typhoid and paratyphoid fever, bacillary dysentery, E. colt diarrhea, cholera

3. Protozoal

Amoebiasis, giardiasis

4. Helminthic

Roundworm, threadworm, hydatid disease

5. Leptospiral

Weil’s disease (leptospirosis)

Aquatic host
Waterborne diseases

1. Snail

Schistosomiasis

2. Cyclops

Guineaworm, fish tapeworm

• Disorders of liver, bone and circulatory system, birth anomalies (by vinyl chloride)

• Anemia, bone marrow damage, leukemia (by benzene)

• Damage to central nervous system (by phthalates)

• Carcinogenic problems (by nitrosamine)

Though pollution seems to be an unavoidable consequence of modern industrial technology, the challenge is to determine the level of pollution that permits economic and social development without causing hazards to health.

PREVENTION OF WATER POLLUTION

Water pollution is one of the biggest threats to the environment today. The best solution for water pollution is prevention. There are several steps that can prevent water pollution.

• Conserve soil: As soil is eroded by water, it transfers sediment from the land to the eroding body of water. Along with this sediment come a number of nutrients and chemicals (e.g. naturally occurring chemicals like phosphorus and industrial chemicals like glyphosate). When phosphorus levels in water become too great, they can lead to algae blooms that can cause massive fish deaths and make water unsafe for human use. The best way to combat soil erosion is to keep the banks of waterways well-covered with soil-retaining plants. Some great plants to use when trying to control soil erosion are sage, buckwheat, Apache plume, oak trees, etc.

• Dispose of toxic chemicals properly: Dispose in such a way (e.g. in local chemical recycling area) that these cannot be mixed with water sources.

• Clean up beaches and waterways: Waterway is a lot of human recreation. Wrappers, bottles and other trash are unfortunately very common to pollute beaches and river side around the world. Plastics are an especially big issue when it comes to water contamination at beaches and waterways.

• Avoid plastics when possible: Plastic bags are well-documented water pollutants. Using alternatives to plastics or using “less disposable” plastics whenever possible can have a surprising impact on water pollution. Use reusable bags. Instead of using plastic bins to store food, try opting for glass alternatives. Avoid buying packaged water as far as possible. The best policy to adopt is to carry a bottle of water when step out of the house. It reduces the use of plastic bottle.

• Treatment of sewage before dispose: A household or business not served by a municipal treatment plant may have an individual septic tank, which treats the waste water on site and discharges into the soil. Alternatively, domestic waste water may be sent to a nearby privately owned treatment system (e.g. in a rural community).

• Proper disposal of industrial waste water: It needs specialized treatment systems. Some of the industries can install a pretreatment system to remove the toxic components, and then send the partially treated waste water to the municipal system. Some industries have been successful at redesigning their manufacturing processes to reduce or eliminate pollutants, through a process called pollution prevention.

• Agricultural waste water: Better to use natural fertilizers and pesticides as far as possible, or if not, not to overuse them or overwater agricultural field. This will help in reducing the pollutants that get into water systems due to run-offs. Farmers may utilize erosion controls (e.g. use of slit fences) to reduce run-off flows and retain soil on their fields. Common techniques include contour plowing (planting across a slope following its elevation), crop mulching to conserve moisture (e.g. plastic sheathing), crop rotation (growing a series of dissimilar/different types of crops in the same area), etc.

• Do not use colored bathing bars. They are known to contribute more to water pollution.

• Automobile oil should be reused as far as possible. Also, it is important to keep your automobile well-maintained in order to prevent leakages of toxic fluids like antifreeze and oil.

• Don’t lit or defecate in or near water sources.

• Avoid giving bath of livestock’s in pond or river.

Bibliography

1. Backer Howard (2002). “Water Disinfection for International and Wilderness Travelers”. Clin Infect Dis [Internet]. 2002 [cited 2014 Sep 21]; 34 (3): 355–364/10.1086/324747. PMID 11774083.

2. Burton Allen G, Jr. Robert Pitt. Stormwater Effects Handbook: A Toolbox for Watershed Managers, Scientists, and Engineers. New York: CRC/Lewis Publishers; 2001.

3. Centre for Affordable Water and Sanitation Technology, Biosand Filter Manual: Design, Construction, and Installation,” [Internet] 2007 July [cited 2014 Oct 11]. Available from:

4. Cleaning and Disinfecting Wells. WHO Technical Note for Emergencies No. 1 [Internet] [cited 2014 Oct 11], Available from: http://www.who.int/water_sanitation_health/hygiene/envsan/tn01/en/

5. Coping with Water Scarcity [Internet] 2007 [cited 2014 Oct 11], Available from: http://www.unwater.org/wwd07/downloads/documents/escarcity.pdf.

6. Drink More Water. Types of Water [Internet] [cited 2014 Oct 11], Available from: http://www.drinkmorewater.com/types-of-water.

7. Edward A. Aquatic Pollution: An Introductory Text. New York: John Wiley and Sons; 2000.

8. Filtration. [Internet] [cited2014Oct 11], Available from: http://www.mrwa.com/WaterWorksMnlChapter%2018%20Filtration.pdf.

9. Goel PK. Water Pollution: Causes, Effects and Control. New Delhi: New Age International; 2006.

10. Guidelines for Drinking Water Quality – Training Pack WHO [Internet] [cited 2014 Oct 11]. Available from: http://www.nzdl.org/gsdlmod? e=d-00000-00---off-0fnl2.2-00-0---0-10-0---0---0 direct-10---4-----0-11---ll-en-50---20-about---00-0-1-00-0---4-----0-0-1l-10-0utfZz-8-00&a=d&cl=CL1.2&d=HASH018718b0ccc 1000030ef8747.15.

11. Guidelines for Drinking Water Quality. Fourth Edition. World Health Organization; 2011.

12. Gupta MC, Mahajan BK. Textbook of Preventive and Social Medicine. 3rd edition. New Delhi: Medical publishers(P) Ltd; 2003.

13. Healthy Lifestyle. Nutrition and Healthy Eating. Water: how much water should you drink each day? [Internet] [cited 2014 Oct 11]. Available from: http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/water/art-20044256.

14. How to Remove Hardness from Water [Internet] [cited 2014 Oct 11]. Available from: http://www.tutorvista.com/content/chemistry/chemistry-iii/hydrogen/methods-hardness-water.php.

15. Huisman L, Wood WE. Slow Sand Filtration. World Health Organization. [Internet] 1974 [cited 2014 Oct 11]. Available from: http://www.who.int/water_sanitation_health/publications/ssf9241540370.pdf.

16. Kennish, Michael J. Ecology of Estuaries: Anthropogenic Effects. Marine Science Series. Boca Raton FL: CRC Press; 1992.

17. Mathur JS. A Comprehensive Textbook of Community Medicine, Preventive and Social Medicine. 1st edition. New Delhi: CBS Publishers; 2008.

18. McGowan W. Water Processing: Residential, commercial, Light-industrial. 3rd ed. Lisle IL: Water Quality Association; 2000.

19. Park K. Preventive and social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

20. Park K. Textbook of Preventive and Social Medicine. 20th edition. Jabalpur: m/s Banarsidas Bhanot Publisher; 2009.

21. Prince N. Regulations and Standards. When is Water Wholesome? [Internet]. 2010 [update 2010 April; cited 2014 Oct 11], Available from: https://www.thenbs.com/topics/regulations/articles/whenlsWaterWholesome.asp.

22. Public health Importance. Basic Consideration. Chapter 1 [Internet] [cited 2014 Oct 11], Available from: http://www.who.int/water_sanitation_health/dwq/monograph42_chapterl.pdf.

23. Punmia BC, Jain A, Jain A. Water Supply Engineering. Environmental Engineering-1. New Delhi: Laxmi Publication; 2005. http://books,google.co.in/books?id=74HYY31zwhQC&pg=PA379&lpg=PA379&dq=orthotoli-dine+dose&source=bl&ots=lMPeWPiUkn&sig=YEbi-sOyOsOqgkPYOucAulcW-ho&hl=en&sa=X&ei=-2dxVN6IKNCwuQTNoIKICw&ved=0CC0Q6AEwAg#v=onepage&q=ortho-tolidine%20dose&f=false.

24. Rick. Chapter 4: Hygiene & Water Purification from The Backpackers Field Manual [Internet] 1998 [cited 2014 Oct 11]. Available from: http://www.princeton.edu/~oa/manual/water, shtml Sodis method [Internet] [cited 2014 Oct 11]. Available from: http://www.sodis.ch/methode/index_EN.

25. Safe Water [Internet] [cited 2014 Oct 11]. Available from: http://www.businessdictionary.com/definition/safe-water.html#ixzz3IP7FJXeD.

26. Sasidhar N. Rain Water Harvesting by Fresh Water Flooded Forests [Internet], [cited 2014 Oct 11]. Available from: http://www.scribd.com/doc/58789361/Rain-Water-Harvesting-by-Freshwater-Flooded-Forests.

27. Schueler, Thomas R. “Cars Are Leading Source of Metal Loads in California”, Reprinted in The Practice of Watershed Protection. Ellicott City, MD: Center for Watershed Protection; 2000.

28. Shmueli, Deborah F (1999). “Water Quality in International River Basins”. Political Geography [Internet] 1999 [cited 2014 Oct 11]; 18: 437–476/10.1016/s0962–6298(98)00106-l.

29. Solar Water Disinfection. [Internet] 2012 Nov [cited 2014 Oct 11]. Available from: http://en.wikipedia.org/wiki/Solar_water_disinfection.

30. Tuitui R. A Textbook of Community Health Nursing. 2nd edition. Kamalpokhari: Vidhyar-thi Prakashan (P) Ltd; 2064.

31. Uses of Water [Internet] [cited 2014 Oct 11]. Available from: http://www.waterencyclopedia.com/Tw-Z/Uses-of-Water.html.

32. Vaibhav Parakh. What are the Different Sources of Water? [Internet] [cited 2014 Oct 11]. Available from: http://www.preservearticles.com/201101072801/different-sources-of-water.html.

33. Water Fluoridation. Water Sanitation and Health (WSH) [Internet] [cited 2014 Oct 11]. Available from: http://www.who.int/water_sanitation_health/oralhealth/en/index2.html.

34. Water Resources [Internet] 2009 March 12 [cited 2014 Oct 11]. Available from: http://green.wikia.com/wiki/Water_resources.

35. Web Health Center [Internet] [cited 2014 Oct 11]. Available from: Webhealthcenter.com.

36. WHO Guidelines for Drinking Water Quality (GDWQ). Hardness in Drinking Water [Internet] 2011 [cited 2014 Oct 11]. Available from: http://www.who.int/water_sanitation_health/dwq/chemicals/hardness.pdf.

37. WHO. Water Sanitation Health. Guidelines for Drinking Water Quality [Internet] [cited 2014 Oct 11], Available from: http://www.who.int/water_sanitation_health/dwq/guidelines/en.

15

Environment and Health

This chapter contains

▪ Definition

▪ Components/Elements of Environment

▪ Environmental Health Hazards

▪ Environmental Sanitation

▪ Environmental Health

▪ Air

• Structure of the Atmosphere

• Composition of Air

• Factors Affecting Air Composition

• Factors Maintaining Air Composition

• Comfort and Discomfort

• Air Pollution and its Prevention

• Disinfection of Air

▪ Noise

• Sound

• Characteristics of Sound

• Noise Pollution, its Effects and Control

▪ Radiation

• Types

• Sources

• Effect

• Unit

INTRODUCTION

Health of human being depends largely on environment. Major ill-health are due to either direct or indirect effect of water, soil or air pollution.

DEFINITION

Environment can be defined as an aggregate of all the external conditions (living and non-living, material and non-material) surrounding and influencing and affecting the life and development of an organism.

COMPONENTS/ELEMENTS OF ENVIRONMENT

1. Physical (water, air, soil, housing, wastes, radiation, etc.).

2. Biologic (plant and animal lives including bacteria, viruses, insects, rodents and animals).

3. Social (customs, culture, habits, income, occupation, religion, etc.).

Physical Environment

• Applied to nonliving things and physical factors like air, water, soil, housing, climate, geography, heat, light, noise, radiation, etc. with which man is in constant interaction.

• Due to man’s victory over environment, he has created a lots of health problems due to noise pollution, soil pollution, air pollution, water pollution, radiation pollution, etc.

Biological Environment

• Is the universe of living thing which surrounds man, including man himself.

• The living things may be viruses and other microbial agents like insects, rodents, animals and plants.

• These are working together for their survival and in this process some act as disease-producing agent, reservoir of infection, intermediate host.

Psychosocial Environment

• Those factors affecting personal health, health care and community well-being that stem from the psychosocial makeup of individual and the structure and function of social group are social factors.

• Includes cultural values, customs, habit, beliefs, attitude, etc.

It may also refer to

• Built environment, constructed surroundings that provide the setting for human activity, ranging from the large-scale civic surroundings to the personal places.

• Knowledge environment, social practices, technological and physical arrangements intended to facilitate collaborative knowledge building, decision making, inference or discovery.

• Natural environment, all living and nonliving things.

• Social environment, the culture that an individual lives in, and the people and institutions with whom they interact.

• Physical environment, in ecology.

ENVIRONMENTAL HEALTH HAZARDS

Water Related

• Viral: Hepatitis A, hepatitis E, poliomyelitis, diarrhea in infants.

• Bacterial: Typhoid, fever, dysentery, cholera.

• Protozoal: Amoebiasis.

• Helminthic: Roundworm, threadworm.

• Malaria, filaria, etc. are also seen.

Air Related

• Bronchitis, death by suffocation, chronic bronchitis, lung cancer, asthma, respiratory allergies, and cardiovascular diseases.

• Also cause destruction of plants, animal life.

• Corrosion of metals, damage of building, and reduces the visibility of town.

Radiation Related

• Radiation sickness and acute radiation syndrome is seen.

• Some genetic problems like injury to chromosomes, gene mutation, chromosome mutation are seen.

Soil Related

• Decrease fertility of soil

• Cause soil erosion.

• Produce poisonous food

Noise Related

• Noise pollution

• Insomnia

• Deafness

• Difficulty to concentrate

• Irritability, etc.

ENVIRONMENTAL SANITATION

The World Health Organization (WHO) defines ‘Environmental Sanitation’ as “the control of all those factors in man’s physical environment which exercise or may exercise a deleterious effect on his physical development, health and survival.”

Environmental sanitation/hygiene includes all the activities aimed at improving or maintaining the standard of basic environmental conditions affecting the well-being of people. These conditions include:

• Keep your surroundings clean

• Do plantation

• Clean and safe water supply

• Clean and safe ambient air

• Efficient and safe animal, human, and industrial waste disposal

• Protection of food from biological and chemical contaminants

• Adequate housing in clean and safe surroundings

A community health nurse can educate the people regarding environmental sanitation and how people can maintain it. She can take part and make people to participate in these activities. She can approach to local leaders to take care of environmental pollution and use available resources.

ENVIRONMENTAL HEALTH

Environmental health is the branch of public health that is concerned with all aspects of the natural and built environments that may affect human health.

Definition

“Environmental health addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. This definition excludes behavior not related to environment, as well as behavior related to the social and cultural environment, as well as genetics.”

Those aspects of the human health and diseases are determined by factors in the environment. It also refers to the theory and practice of assessing and controlling factors in the environment that can potentially affect health (WHO).

Environmental Health Concerns Include

• Air quality, including both ambient outdoor air and indoor air quality, which also comprises concerns about environmental tobacco smoke.

• Body art safety, including tattooing, body piercing and permanent cosmetics.

• Climate change and its effects on health.

• Disaster preparedness and response.

• Food safety, including in agriculture, transportation, food processing, wholesale and retail distribution and sale.

• Hazardous material management, including hazardous waste management, contaminated site remediation, the prevention of leaks from underground storage tanks and the prevention of hazardous materials releases to the environment and responses to emergency situations resulting from such releases.

• Housing, including substandard housing abatement and the inspection of jails and prisons.

• Childhood lead poisoning prevention.

• Land use planning, including smart growth.

• Liquid waste disposal, including city waste water treatment plants and onsite waste water disposal systems, such as septic tank systems and chemical toilets.

• Medical waste management and disposal.

• Noise pollution control.

• Occupational health and industrial hygiene.

• Radiological health, including exposure to ionizing radiation from X-rays or radioactive isotopes.

• Recreational water illness prevention, including from swimming pools, spas and ocean and freshwater bathing places.

• Safe drinking water.

• Solid waste management, including landfills, recycling facilities, composting and solid waste transfer stations.

• Toxic chemical exposure whether in consumer products, housing, workplaces, air, water or soil.

• Vector control, including the control of mosquitoes, rodents, flies, cockroaches and other animals that may transmit pathogens.

AIR

Introduction

The common name given to the atmospheric gases used in breathing and photosynthesis is air; the immediate environment of man on which all forms of life depend. Apart from supplying the life giving oxygen, air and atmospheric conditions serve several functions. Human beings need a continuous supply of air to exist.

Structure of the Atmosphere

From highest (outermost) to lowest (innermost), these layers are:

• Exosphere: > 700 km (> 440 miles)

• Thermosphere: 80 to 700 km (50 to 440 miles)

• Mesosphere: 50 to 80 km (31 to 50 miles)

• Stratosphere: 12 to 50 km (7 to 31 miles)

• Troposphere: 0 to 12 km (0 to 7 miles)

Composition of Air

• Nitrogen 78.1%

• Oxygen 20.93%

• Carbon dioxide 0.03%

• Argon 0.93%

• Water vapor 0.25%

• Small amount of other gases (neon, krypton, helium, etc.)

Factors Affecting Air Composition

1. Respiration of men and animals (inhales oxygen and exhales carbon dioxide)

2. Combustion of coal, gas, oil, etc. (production of greenhouse gases)

3. Decomposition of organic matter (produces nitrogenous substances)

4. Trade, traffic and manufacturing process which give off dust, fumes, vapors and gases.

Factors Maintaining Air Composition

1. Wind: Dilutes and sweeps away the impurities.

2. Sunlight: Oxidizing impurities and killing bacteria.

3. Rain: Cleanses the atmosphere by removing the suspended and gaseous impurities.

4. Plant life: Plant utilizes carbon dioxide and generates oxygen.

Comfort and Discomfort

Comfort zone is in which majority of adults feel comfortable. And comfort is quiet a complex subject experience and not same for everyone as comfort depends not only on physical and physiological factors but also on psychological factors.

Discomfort is a subjective sensation which people experience in ill-ventilated and crowded rooms. Previous concept was that people feel discomfort if oxygen level reduces and carbon dioxide level increases due to respiration in an ill-ventilated/overcrowding room. But if temperature and humidity is maintained then people can survive without any complication up to the 18% reduced oxygen level and 5% increased carbon dioxide level.

Indices of thermal comfort

1. Air temperature: Air temperature alone is not an adequate index of thermal comfort.

2. Air temperature and humidity: Later, humidity added with air temperature, but still it was not adequate index of thermal comfort.

3. Cooling power: Later, air movement was added along with air temperature and humidity. These three factors together were known as “cooling power” and were measured by “Kata Thermometer”. But still it was not an adequate index of thermal comfort.

4. Effective temperature: It is the temperature of still, saturated air which can induce the same sensation of warmth or cold as that experienced in the given conditions. It is a single combined value of temperature, humidity and movement of internal air on the sensation of warmth or cold felt by the human body. It ignores the effects of a radiation from the surrounding structures.

5. Corrected effective temperature: A glob thermometer is used to monitor radiant heat, i.e. CET scale deals with all the four factors, air, temperature, velocity, humidity and mean radiant heat.

6. McArdle’s maximum allowable sweat rate: McArdle and associates prepared a chart from which “predicted four-hour sweat rate” (P4SR) can be obtained from any combination of air, mean radiant heat, air temperature and air velocity with the help of dry and wet bulb thermometers.

Considering only the environmental factor comfort zones evaluated in India are as follows depending on CET.

1. Pleasant and cool: 20°C

2. Comfortable and cool: >20–25°C

3. Comfortable: >25–27°C

4. Hot and uncomfortable: >27–28°C

5. Extremely hot: 28+°C

6. Intolerably hot: 30+°C

On P4SR

1. Comfort zone: 1–3 L

2. Just tolerable: 3–4.5 L

3. Intolerable: 4.5+ L

Air Pollution

The phenomenon called “pollution” is an inescapable consequence of the presence of man and his activities. The term “air pollution” signifies the presence in the ambient (surrounding) atmosphere of substances (e.g. gases, mixture of gases and particulated mixture) generated by activities of man in concentrations that interfere with human health. Air pollution can further be classified into two sections—visible air pollution and invisible air pollution or indoor and outdoor pollution.

Air pollution is contamination of the indoor or outdoor environment by any chemical, physical or biological agent that modifies the natural characteristics of the atmosphere. Household combustion devices, motor vehicles, industrial facilities and forest fires are common sources of air pollution. Pollutants of major public health concern include particulate matter, carbon monoxide, ozone, nitrogen dioxide and sulfur dioxide. Outdoor and indoor air pollution cause respiratory and other diseases, which can be fatal (WHO).

Sources of air pollution

The main sources of air pollution are:

1. Burning of fossil fuels: Sulfur dioxide emitted from the combustion of fossil fuels like coal, petroleum and other factory combustibles is one of the major causes of air pollution. Motor vehicles (trucks, jeeps, cars, trains, airplanes) are the major sources of air pollution throughout the urban areas. They emit hydrocarbon, carbon monoxide, lead, nitrogen oxides and particulate matter. The combustion of alkyl lead additives in motor fuels accounts for the major part of all lead emission into the atmosphere.

2. Agricultural activities: Ammonia is a very common by-product from agriculture related activities and is one of the most hazardous gases in the atmosphere. Use of insecticides, pesticides and fertilizers in agricultural activities has grown quite a lot. They emit harmful chemicals into the air.

3. Exhaust from factories and industries: Manufacturing industries release a large amount of carbon monoxide, hydrocarbons, organic compounds, and chemicals into the air thereby depleting the quality of air. Combustion of fuel to generate heat and power produces smoke, sulfur dioxide, nitrogen oxides and fly ash. Petrochemical industries generate hydrogen fluoride, hydrochloric acid and organic halides, many industries discharge carbon monoxide, carbon dioxide, ozone, hydrogen sulfide and sulfur dioxide.

4. Mining operations: Mining is a process wherein minerals below the earth are extracted using large equipment. During the process dust and chemicals are released in the air causing massive air pollution.

5. Indoor air pollution: Household cleaning products, painting supplies emit toxic chemicals in the air and cause air pollution. Domestic combustion of coal, wood or oil is a major source of smoke, dust, sulfur dioxide and nitrogen oxides.

6. Miscellaneous: These comprise burning refuse, incinerators, and nuclear energy programs. All these contribute to air pollution. Domestic fires can also produce emission containing sulfur dioxide.

Air Pollutants

An air pollutant is a substance in the air that can have adverse effects on humans and the ecosystem. The substance can be solid particles, liquid droplets, or gases. A pollutant can be of natural origin or manmade. Pollutants are classified as primary or secondary.

Primary pollutants are usually produced from a process, such as ash from a volcanic eruption. Other examples include carbon monoxide gas from motor vehicle exhaust, or the sulfur dioxide released from factories.

Secondary pollutants are not emitted directly. Rather, they form in the air when primary pollutants react or interact. Ground level ozone is a prominent example of a secondary pollutant.

Some pollutants may be both primary and secondary. They are both emitted directly and formed from other primary pollutants. More than 100 substances which pollute air have been identified. But some of the important pollutants are as follows:

1. Sulfur dioxide (SO₂): It is one of the several forms in which sulfur exists in air. The others include H₂S, H₂SO₄ and sulfate salts. SO₂ is produced by volcanoes and in various industrial processes, from combustion of fossil fuels. Even domestic fuel can also produce SO₂.

2. Carbon monoxide (CO): Carbon monoxide is one of the most common and widely distributed air pollutants. It is a colorless, odorless, toxic yet non-irritating gas. CO is a product of incomplete combustion of carbon-containing material, such as in automobile, industrial process, heating facilities and incinerators. Estimates of manmade carbon monoxide emission vary from 350 to 600 million tons per annum.

3. Carbon dioxide (CO₂): Carbon dioxide is a natural constitution of the air. It does not take part in any significant chemical reaction with other substances in air; but excess amount of CO₂ causes air pollution. Enormous amount of it is produced in combustion process using coal, oil and gas.

4. Hydrocarbons: Hydrocarbon is an organic compound consisting entirely of hydrogen and carbon. The majority of hydrocarbons found on earth naturally occur in crude oil. Manmade sources of hydrocarbons include incineration, combustion of coal, wood, processing and use of petroleum. Hydrocarbons exert their pollutants action by taking part in the chemical reactions that cause photochemical smog.

5. Nitrogen dioxide (NO₂): It is one of the groups of highly reactive gases known as “oxides of nitrogen,” or “nitrogen oxides”. NO₂ forms quickly from emissions from cars, trucks and buses, power plants, and off-road equipment. In addition to contributing to the formation of ground-level ozone, and fine particle pollution, NO₂ is linked with a number of adverse effects on the respiratory system.

6. Lead [(Pb) from Latin: Plumbum]: Lead is used in building construction, lead-acid batteries, bullets and shot, weights, as part of solders, pewters, fusible alloys, and as a radiation shield. The major part of all lead emissions into the atmosphere comes from combustion of alkyl lead additives in motor fuel (leaded patrol). Children up to 6 years of age are at high risk of lead pollution as their blood-brain barrier is not yet fully developed. It may cause hematological and neurological effects among children.

7. Cadmium (Cd): The steel industry, waste incineration, volcanic action and zinc production seem to account for the largest emissions of cadmium. Cadmium occurs as a minor component in most zinc ores and, therefore, is a by-product of zinc production. Atmospheric cadmium pollution is of growing concern. Tobacco contains cadmium and smoking may contribute significantly to uptake of cadmium.

8. Hydrogen sulfide (H₂S): It is a colorless gas with the characteristic foul odor of rotten eggs; it is heavier than air, very poisonous, corrosive, flammable, and explosive. Human activities can release naturally occurring hydrogen sulfide into ambient air. Waste water treatment plants, wood pulp production, oil refining and in tanning industry,using sulfate method. Hydrogen sulfide is the main toxic substance involved in livestock.

9. Ozone (O₃): Ozone’s odor is sharp, reminiscent of chlorine. Ozone is one of the strongest oxidizing agents and has many industrial and consumer applications related to oxidation. This same high oxidizing potential, however, causes ozone to damage mucous and respiratory tissues in animals, and also tissues in plants, above concentrations of about 100 ppb (parts per billion).

10. Polynuclear aromatic hydrocarbons (PAH): Also called polycyclic aromatic hydrocarbons are hydrocarbons, organic compounds containing only carbon and hydrogen. PAHs are neutral, nonpolar molecules; they are found in fossil fuels (oil and coal) and in tar deposits, and are produced, generally, when insufficient oxygen or other factors result in incomplete combustion of organic matter (e.g. in engines and incinerators, when biomass burns in forest fires, etc.). PAHs can also be found at in cooked foods, e.g. in meat cooked at high temperatures over open flame. PAHs have been identified as carcinogenic (e.g. causes lung cancer) and mutagenic (as well as teratogenic).

11. Particulate matter: “Particulate matter,” also known as particle pollution or PM, is a complex mixture of extremely small particles and liquid droplets. Particle pollution is made up of a number of components, including acids (such as nitrates and sulfates), organic chemicals, metals, and soil or dust particles. Mass and composition tend to divide into two principle groups: coarse particles large than 2.5 μm in aerodynamic diameter (inhalable coarse particles), and fine particles smaller than 2.5 μm in aerodynamic diameter (fine particles). Particulates are the deadliest form of air pollution due to their ability to penetrate deep into the lungs and bloodstreams unfiltered, causing permanent DNA mutations, heart attacks, and premature death.

12. Others: Hydrochlorofluorocarbons (HCFC), chlorofluorocarbons (CFCs), asbestos, aerosols, etc. are also the air pollutants and causes global warming.

Indoor Air Pollution

Indoor air pollution is one of the four most critical global environmental problems. Around 3 billion people cook and heat their homes using solid fuels (i.e. wood, charcoal, coal, dung, CROP wastes) on open fires or traditional stoves. Such inefficient cooking and heating practices produce high levels of household (indoor) air pollution which includes a range of health damaging pollutants such as fine particles and carbon monoxide. In poorly ventilated dwellings, smoke in and around the home can exceed acceptable levels for fine particles 100-fold. Exposure is particularly high among women and young children, who spend the most time near the domestic hearth. According to WHO, 4.3 million people a year die from the exposure to household air pollution. Indoor air pollution contributes to acute respiratory infection in young children, chronic lung disease and cancer in adults and adverse pregnancy outcomes for women exposed during pregnancy.

Source of indoor air pollution are as follows:

Sources | Pollutants
Tobacco smoking, stove, aerosol spray | Particulate matter
Combustion equipment, stove, gas heaters | Carbon monoxide
Gas cookers, cigarettes | Nitrogen dioxide
Coal combustion | Sulfur dioxide
Respiration, combustion | Carbon dioxide
Electric arcing, UV light sources | Ozone
Building material | Radon
Insulation, fireproofing | Asbestos

Outdoor Air Pollution

It occurs when the environment is contaminated by any chemical, physical or biological agent that modifies the natural characteristics of the atmosphere. Motor vehicles, domestic heating, industrial facilities, poor road condition and forest fires are common sources of outdoor air pollution. Other sources of outdoor pollution are agricultural processes, waste incineration and natural process as thunderstorms and volcanoes. Pollutants of major public health concern include particulate matter, carbon monoxide, ozone, nitrogen dioxide and sulfur dioxide. Industries, households, cars and trucks emit complex mixtures of air pollutants, many of which are harmful to health. Of all these pollutants, fine particulate matter has the greatest effect on human health. Most fine particulate matter comes from fuel combustion, both from mobile sources such as vehicles and from stationary sources such as power plants, industry, households or biomass burning.

Effects of Air Pollution

About 1.3 billion urban residents are exposed to air pollution level above recommended limits. Air quality in the developed countries has generally improved in the past two decades, but in many developing countries air quality has deteriorated. Air pollution can affect as:

1. Health aspects: The health effects of air pollution are both immediate and delayed. The immediate effects are born by the respiratory system; the resulting state is acute bronchitis. If the air pollution is intense, it may result even in immediate death suffocation. The delayed effects most commonly linked with air pollution are chronic bronchitis, lung cancer, bronchial asthma, emphysema, and respiratory allergies. Children in areas exposed to air pollutants are said to commonly suffer from pneumonia and asthma.

2. Global warming: Another direct effect is the immediate alterations that the world is witnessing due to global warming. With increased temperatures worldwide, increase in sea levels and melting of ice from colder regions and icebergs, displacement and loss of habitat have already signaled an impending disaster if actions for preservation and normalization aren’t undertaken soon.

3. Acid rain: Harmful gases like nitrogen oxides and sulfur oxides are released into the atmosphere during the burning of fossil fuels. When it rains, the water droplets combine with these air pollutants, become acidic and then fall on the ground in the form of acid rain. Acid rain can cause great damage to human, animals and crops.

4. Eutrophication: Eutrophication is a condition where high amount of nitrogen present in some pollutants gets developed on sea’s surface and turns itself into algae and adversely affects fish, plants and animal species. The green-colored alga that is present on lakes and ponds is due to the presence of this chemical only.

5. Effect on wildlife: Just like humans, animals also face some devastating effects of air pollution. Toxic chemicals present in the air can force wildlife species to move to new place and change their habitat. The toxic pollutants deposit over the surface of the water and can also affect sea animals.

6. Depletion of ozone layer: Ozone exists in earth’s stratosphere and is responsible for protecting humans from harmful ultraviolet (UV) rays. Earth’s ozone layer is depleting due to the presence of chlorofluorocarbons, hydrochlorofluorocarbons in the atmosphere. As ozone layer will go thin, it will emit harmful rays back on earth and can cause skin and eye related problems. UV rays also have the capability to affect crops.

Also air pollution causes corrosion of metals; damage to buildings; increases cost of cleaning and maintenance and repairs and is an aesthetic nuisance. Air pollution also reduces visibility in towns. It can soil and damage clothing’s too.

Prevention and Control of Air Pollution

WHO has recommended the following procedures for prevention and control of air pollution:

1. Containment: That is, prevention of escape of toxic substances into the ambient air. Containment can be achieved by a variety of engineering methods such as enclosure, ventilation and air cleaning. A major contribution in this field is the development of “arresters” for the removal of containment.

2. Replacement: That is, replacing a technological process causing air pollution, by a new process that does not. Increase uses of electricity, natural gas and central heating in place of coal have greatly helped in smoke reduction. There is a move now to reduce lead in petrol which is cumulative poison.

3. Dilution: Dilution is valid so long as it is within the self-cleaning capacity of the environment. For example, some air pollutants are readily removed by vegetation. The establishment of “green belts” between industrial and residential areas is an attempt at dilution. The capacity for dilution is, however, limited and trouble occurs when the atmosphere is overburdened with pollutants.

4. Legislation: Air pollution is controlled in many countries by suitable legislation, e.g. Clean Air Acts. Legislation covers such matters as height of chimneys, powers to local authorities to carry out investigations, research and education concerning air pollution, creation of smokeless zones and enforcement of standard for ambient air quality. To decrease the nuisance of air pollution, the Govt, of India has enacted “The Air (prevention and control of pollution) Act” in 1981.

5. International action: To deal with air pollution on worldwide scale, the WHO has established an international network of laboratories for the monitoring and study of air pollution. The network consists of two international centers at London and Washington, three centers at Moscow, Nagpur and Tokyo and 20 laboratories in various parts of the world. These centers will issue warnings of air pollution where and when necessary.

Role of Individual in Prevention of Air Pollution

As a responsible individual, we too have some accountability to prevent air pollution. A few tips are as follows:

1. Use public mode of transportation: Encourage people to use more and more public modes of transportation to reduce pollution. Also, try to make use of carpooling. If you and your colleagues come from the same locality and have same timings you can explore this option to save energy and money.

2. Conserve energy: Switch off fans and lights when you are going out. A large amount of fossil fuels are burnt to produce electricity. You can save the environment from degradation by reducing the amount of fossil fuels to be burned.

3. Understand the concept of reduce, reuse and recycle: Do not throw away items that are of no use to you. Infact reuse them for some other purposes. For example, you can use old jars to store cereals or pulses.

4. Emphasis on clean energy resources: Clean energy technologies like solar, wind and geothermal are on high these days. Governments of various countries have been providing grants to consumers who are interested in installing solar panels for their home. This will go a long way to curb air pollution.

5. Use energy efficient devices: CFL/LED lights consume less electricity as against their counterparts. They live longer, consume less electricity, lower electricity bills and also help you to reduce pollution by consuming less energy.

6. Use smokeless chula or put a smoke filter to filter the pollutant from the smoke.

7. Even when we burn candle, agarbatti, ghee, etc. in a large amount during some rituals, it too causes air pollution. Better to use all these things as less as possible. Nowadays smokeless candles are also available at market.

8. Healthy habits: Stop tobacco smoking.

9. Keep your vehicle’s checked and emission test done regularly.

10. Poor road condition is another cause of air pollution. If everyone sprinkles water in front of their house, so that there will be no dry dust; it will prevent air pollution. Community participation to approach to panchayat or corporation for the construction of road will be beneficial.

Disinfection of Air

In recent years, disinfection of air has received much attention. The methods employed are:

1. Mechanical or artificial ventilation: This reduces vitiated air and bacterial density. These are exhaust ventilation, air conditioning, etc.

2. Ultraviolet radiation: The most common air disinfection method is using ultraviolet (UV) radiation. UV radiation (UV-C) kills bacteria and viruses by damaging the DNA/RNA of the cells of microorganisms. However, UV radiation could only disinfect air close to the lamps as UV light has limited penetration capacity. This has been found to be effective in special situation such as operation theatres and infectious disease wards, also public assembly and schools. Since direct exposure to ultraviolet rays is a danger to the eyes and skin, the ultraviolet lamps are shaded and located in the upper portion of the rooms near the inlet of air.

3. HEP A filter: Another well-known air cleaning method is to employ High Efficiency Particulate Air (HEPA) filter. HEPA filter can capture particulate sizes down to 0.3 microns, and so bacteria with size larger than 0.3 microns could be trapped in the filter. Although HEPA filters are effective in reducing airborne bacteria in air, it is not effective to remove viruses, which are nanometer (10–9 m) in size. Also, air must pass through the filter in order for it to be cleaned. Hence HEPA filters can only clean air that is within a short distance of the HEPA unit.

4. Chemical mists: Chemical disinfectants could also be used for air disinfection, usually by means of vaporizing or spraying. However, these chemical disinfectants are usually difficult to decompose, leaving toxic chemical residues that are hazardous to human health. Triethylene glycol vapors have been found to be effective air bactericides, particularly against droplet nuclei and dust.

5. Ozone: It is a well-known powerful oxidizer which could kill microorganisms effectively. Ozone applications in water and waste water treatments are well-documented and it is widely used by most of the modern cities. Although it has been found that ozone could also be an effective air disinfectant as in water. In contrast to UV radiation and HEPA filter, ozone is a gas that could penetrate to every corners of the room, thus it could disinfect the entire room effectively. As ozone is unstable, it is readily converted back to oxygen, leaving no harmful residual ozone after disinfection (still under study).

6. Dust Control: Use of vacuum cleaner reduces indoor dust. Also there are dust control systems for large scale dust control, by which machineries produce dry fogs (or very little moisture) to control airborne dust. Microorganism cannot survive in dry air and cannot be transmitted by the air which has reduced dust.

NOISE

Sound

In physics, sound is a vibration that propagates as a typically audible mechanical wave of pressure and displacement, through a medium such as air or water. In physiology and psychology, sound is the reception of such waves and their perception by the brain.

Characteristics of Sound

A sound can be characterized by the following three quantities:

1. Pitch: Pitch describes the frequency of a sound wave. Higher the frequency; higher the pitch. Hertz (Hz) is the unit of frequency (1 Hz = 1 cycle or one wave per second). Each living creature has a different level of sound perception. For example, sound perception be:

• Humans 20–20,000 Hz

• Dogs 50–45,000 Hz

• Bats 20–120,000 Hz

By this comparison, humans have a relatively low sound perception.

2. Quality: A pure tone is the sound of only one frequency, such as that given by a tuning fork or electronic signal generator. The fundamental note has the greatest amplitude and is heard predominantly because it has a larger intensity. The other frequencies are called overtones or harmonics and they determine the quality of the sound.

3. Loudness or intensity: Loudness describes the amplitude of a sound wave. The greater the amplitude of the wave, the louder the sound that is perceived. It is measured in decibels (dB). It is the ratio between two values of a physical quantity, often power or intensity. Here are some common sounds and their decibel ratings:

• Near total silence—0 dB

• A whisper—15 dB

• Normal conversation—60 dB

Noise Pollution

Noise means any unwanted sound, particularly loud one that disturbs people or makes it difficult to hear wanted sounds. For example, conversations of other people may be called noise by people not involved in any of them; as for example loud music from outside, machinery sound, road traffic sounds, etc. are called noise.

Causes of Noise Pollution

1. Transportation: One of the major causes of noise pollution is vehicle, large number of vehicles on roads, airplanes flying over houses and underground trains produce heavy noise which is difficult to get accustomed to. People who lives in city area, near bus stand, ports, airports, railway station are the sufferers of this problem. The high noise leads to a situation wherein a normal person loses the ability to hear properly.

Table 15.1: Community noise level

SI. No.
Sound pressure levels in decibels
Consequences

1.

150–160
Mechanical damage

2.

140
Threshold of pain

3.

120
Motor car horn

4.

110
Train passing station

5.

85
Recommended maximum

6.

80
Printing press

7.

70
Heavy street traffic

8.

60
Normal conversation

9.

40–50
Quiet library

10.

20–30
Whispering

2. Poor urban planning: In most of the developing countries, poor urban planning also plays a vital role. Congested houses, large families sharing small space, fight over parking, housing near industrial area leads to noise pollution which may disrupt the environment of society.

3. Social events: Noise is at its peak in most of the social events. Whether it is marriage, parties, pub, disc or place of worship, people play songs on full volume and dance till midnight which makes the condition of people living nearby pretty worse.

4. Industrialization: Although industrial noise is one of the less prevalent community noise problems, neighbors of noisy manufacturing plants can be disturbed by sound of big machines which are capable of producing large amount of noise. Apart from that, various equipments like compressors, generators, exhaust fans, grinding mills also participate in producing big noise.

5. Construction activities: Under construction activities like mining, construction of bridges, dams, buildings, stations, roads, flyovers take place in almost every part of the world; construction equipment are too noisy.

6. Household chores: Nowadays people are surrounded by gadgets and use them extensively in our daily life. Gadgets like TV, mobile, mixer grinder, pressure cooker, vacuum cleaner, washing machine, hair dryer, cooler, air conditioners are household noise which people ignore as these all have become as requirements of our life.

Effects of Noise Pollution

1. Hearing problems: Our ears can take in a certain range of sounds without getting damaged. Any unwanted sound that our ears have not been built to filter can cause problems within the body. Constant exposure to loud levels of noise can easily result in the damage of our eardrums and loss of hearing. It also reduces our sensitivity to sounds that our ears pick up unconsciously to regulate our body’s rhythm.

2. Health issues: Excessive noise can influence psychological health. Studies show that the occurrence of aggressive behavior, disturbance of sleep, constant stress and fatigue can be linked to excessive noise levels. These in turn can cause more severe and chronic health issues later in life. Studies suggest that high intensity noise causes high blood pressure and increases heartbeat rate as it disrupts the normal blood flow.

3. Sleeping disorders: Loud noise can certainly hamper sleeping pattern and may lead to irritation and uncomfortable situations. Without a good night sleep, it may lead to problems related to fatigue and your performance may go down in office as well as at home.

4. Trouble communicating: High decibel noise may not allow two people to communicate freely. This may lead to misunderstanding and you may get difficult in understanding the other person; as well as talking in loud pitch put pressure on vocal cord.

5. Decreased work efficiency: Regarding the impact of noise on human efficiency there are a number of experiments which print out the fact that human efficiency increases with noise reduction.

6. Effect on property: Loud noise is very dangerous to buildings, bridges and monuments. It creates waves which struck the walls and put the building in danger condition. It weakens the edifice of buildings.

7. Effect on wildlife: Wildlife faces far more problems than humans because of noise pollution since they are more dependent on sound. Animals develop a better sense of hearing than us since their survival depends on it. The ill-effects of excessive noise begin at home. Pets react more aggressively in households where there is constant noise. They become disoriented more easily and face many behavioral problems. In nature, animals may suffer from hearing loss, may become inefficient at hunting, disturbing the balance of the ecosystem.

Control of Noise

Noise control or noise mitigation is a set of strategies to reduce noise pollution and to reduce the impact of that noise, whether outdoors or indoors. The main areas of noise mitigation are transportation noise control, architectural design, urban planning, and occupational noise control.

1. Careful planning of cities

• Division of zone separation of residential area from industry and transport.

• Separation of residential areas from main streets by wide green belts.

• Front of the should not be less than 15 m from road and intervening space should be thickly planted with trees and bushes.

2. Control of vehicles: Vehicular traffic on residential streets should be reduced; blowing of the horn, use of pressure horn should be prohibited.

3. To improve acoustic insulation of building: Construction of soundproof building where necessary.

4. Special areas should be earmarked: areas as industries, railways, etc. should be earmarked.

5. Protection of exposed persons: Worker exposed to more than 85 dB, 150 Hz be provided ear plugs, periodical check-up of hearing function is mandatory. If any symptom of hearing impairment found, he/she should be rotated in less noisy area.

6. Educations: improved knowledge level can improve the practice of people to prevent noise pollution in personal level.

7. Legislation: Each country has own rules to prevent noise pollution. More than 60 dB sounds in public place is not allowed. Workers have right to claim compensation if gets hearing impairment due to occupational hazard. A few regulations in India are:

• Factories Act Reduction of Noise and OIL of Machinery

• Motor Vehicle Act

• Noise Pollution Control Rule 2000 under Environment Protection Act 1996.

RADIATION

Radiation is energy that comes from a source and travels through some materials or through space. Light, heat and sound are types of radiation. The kind of radiation discussed in this chapter is called ionizing radiation which is produced by unstable atoms. Unstable atoms differ from stable atoms because they have an excess of energy or mass or both. Unstable atoms are said to be radioactive. In order to reach stability, these atoms give off, or emit the excess energy or mass. These emissions are called radiation. Gamma radiation and X-rays are the examples of electromagnetic radiation. Beta and alpha radiations are the examples of particulate radiation.

Types of Radiation

a. Ionizing radiation

b. Non-ionizing radiation

Ionizing radiation: Ionizing radiation is high frequency radiation with large amount of energy. It has ability to penetrate the tissues and deposit its energy within them. Ionizing radiation is of three kinds:

• Alpha rays

– Less penetrating power

– More harmful than X-rays if ingested or inhaled

– Emitted by radioactive particles found in nature

• Beta rays

– Have intermediate penetrating power

– Harmful to soft tissues

– Damage superficial tissues as they have less penetrating power when they are inhaled.

• Gamma rays are electromagnetic radiation

– Have high energy

– Have great penetrating power

– They can irradiate the whole body as they can pass through the body.

Non-ionizing radiation: Non-ionizing radiation has less energy comparative to ionizing radiation but have longer wavelength, e.g. infrared, UV rays and neutron radiation.

Sources of Radiation

1. Natural sources

2. Manmade sources

Natural sources

• Cosmic rays: Originate in outer space; strength is reduced as they pass the atmosphere. It has high importance as jet pilot receives 300 mrad per year at altitude of 20 km.

• Environmental: Found in the environment and are of two types:

– Terrestrial, also known as primordial radiation. It arises from environmental factors like soils and rocks and it is estimated that man derives about 50 mrad per year from it.

– Atmospheric radiation: Mostly found in atmosphere, e.g. radon and thoron gases. The dose from these radiation are rather smaller, i.e. 2 mrad.

• Internal radiation: Radiation that arises from the radioactive matter stored in body tissues. It has been estimated that total average natural radiation to which the person is subjected comes to approximately 0.1 radiation per year.

Manmade sources

X-ray, nuclear explosion, from home appliances as TV, luminous wrist watches, etc.

Effects of Radiation

Acute manifestations

• It occurs when the victim’s exposure is 200 rens or more.

• Intestinal tract damage that leads to nausea, bloody vomiting and diarrhea.

• May cause excoriation of skin, erythema, blistering and dermatitis, ulceration of skin, disturbances of GI tract.

Chronic manifestations

• Here malignant changes may occur in different organs like hemopoietic system, lungs, liver.

• Exposure during pregnancy may lead to congenital abnormalities in child.

• Conditions like sterility, cataract may develop.

• Certain tissues or organs are highly sensitive to radiation mainly bone marrow and germinal cells which may cause leukemia.

• An overdose of radiation may lead to death.

• Genetic disease as chromosome mutation, point mutation.

• Other somatic effect may be carcinogenesis, shortening of life.

Unit of Radiation

As per International System of units (SI system), radiation absorbed dose and effective dose for radiation measurement are “gray” (Gy) and “sievert” (Sv) respectively and radiation absorbed dose, effective dose, and exposure are sometimes measured and stated in units called rad, rem, or roentgen (R).

• Gray (Gy): It is unit of absorbed dose which replaces the rad. Gy is defined as the dose of ionizing radiation that impart 1 joile of energy to 1 kg of absorbing material.

• Sievert (Sv): It replaces the rem. 1 Sv = 100 rems.

• Rad: It is a unit of absorbed dose. It is the amount of radioactive energy absorbed per gram of tissue or any material. 1 mrad = 0.001 rad.

• Rem: It is the product of absorbed dose and the modifying factors, indicates the potential danger to health.

• Roentgen: It is the unit of exposure. It is the amount of radiation absorbed in air at a given point, i.e. a number of ions produced in 1 ml of ion.

Bibliography

1. “WHO Environmental health”, http://www.who.int/topics/environmental_health/en.

2. Conserve Energy Future. What is Air Pollution? [Internet] [cited 2014 Sep 16], Available from: http://www.conserve-energy-future.com/causes-effects-solutions-of-air-pollution.php.

3. Geerts B, Linacre C. “The Height of the Tropopause”. Das.uwyo.edu. [Internet] [cited 2014 Aug 19]. Available from: http://www-das.uwyo.edu/~geerts/cwx/notes/chapOl/tropo.html.

4. IEEE Standard 100 Dictionary of IEEE Standards Terms, Seventh Edition, The Institute of Electrical and Electronics Engineering, ISBN 0–7381–2601–2; [Internet] 2000 Dec 1 [cited 2014 July 24] Available from: http://www.amazon.com/Authoritative-Dictionary-Standards-Seventh-Edition/dp/0738126012.

5. Kenneth KK. LAM. Ozone Disinfection of SARS-Contaminated Areas. [Internet] [cited 2014 Sep 19]. Available from: http://www.ozomax.com/pdf/Ozone_disinfection_of_SARS_Contamina-ted_Areas.pdf.

6. Knowns and Unknowns on Burden of Disease due to Chemicals: A Systematic Review. Press-Ustinov A et al. 2011. Environmental Health 10:9.

7. Miglan D. Pollution Control Equip. Noise Pollution: Sources, Effects and Control [Internet] [cited 2014 July 24]. Available from:/ http://www.legalserviceindia.com/articles/noip.htm.

8. Mathur JS. A Comprehensive Text Book of Community Medicine Preventive and Social Medicine. 1st edition. New Delhi: Satish Kumar Jain For CBS Publishers and Distributers; 2008.

9. Nandy A. Principles of Forensic Medicine Including Toxicology. 3rd edition. Kolkata: New Central Book Agency; 2010.

10. National and Regional Story (Netherlands): Environmental Burden of Disease in Europe: The Abode Project. EEA.

11. Randy Russell R (2008). “The Thermosphere”. Windows to the Universe [Internet], [updated 2008 July 28; cited 2014 Aug 19]. Available from: http://www.windows2universe.org/earth/Atmosphere/thermosphere.html.

12. Schleicher D (1995). Superfund’s Abandoned Hazardous Waste Sites. In Wildavsky A (Ed.), But Is It True? A Citizen’s Guide to Environmental Health and Safety Issues (153–184). Cambridge, MA: Harvard University Press.

13. Sealpump Engineering Ltd. Dust Control System [Internet] [cited 2014 Sep 19], Available from: http://www.sealpump.com/dust-control-systems.php.

14. Source: Boundless. “Characteristics of Sound.” Boundless Physics. Boundless [Internet] 2014 July 3 [updated 2014 Nov 24; cited 2014 Nov 28]. Available from: https://www.boundless.com/physics/textbooks/boundless-physics-textbook/sound-16/introduction-128/characteristics-of-sound-453–11276.

15. The Legal and Regulatory Framework for Environmental Protection in India [Internet] [cited 2014 Sep 19]. Available from: http://www.moef.nic.in/divisions/ic/wssd/doc2/ch2.html.

16. Understanding Noise Pollution. Conserve Energy Future [Internet] [cited 2014 July 24]. Available from: http://www.conserve-energy-future.com/causes-and-effects-of-noise-pollution.php.

17. United State Environmental Protection Agency (EPA). Nitrogen Dioxide [Internet] [cited 2014 Sep 16]. Available from: http://www.epa.gov/airquality/nitrogenoxides.

18. United State Environmental Protection Agency (EPA). Particulate Matter (PM) [Internet] [cited 2014 Sep 16]. Available from: http://www.epa.gov/pm.

19. United State Environmental Protection Agency (EPA). Particulate Matter (PM) [Internet] [cited 2014 Sep 16]. Available from: http://www.epa.gov/airquality/particulatematter/health.html.

20. What Is a Decibel, and How Is It Measured? [Internet] [cited 2014 July 24]. Available from: http://science.howstuffworks.com/question124.htm.

21. WHO. Air Pollution [Internet] [cited 2014 Sep 16]. Available from: http://www.who.int/topics/air_pollution/en.

22. WHO. Indoor Air Pollution. Household (Indoor) Air Pollution [Internet] [dted 2014 Sep 16]. Available from: http://www.who.int/indoor-air/en.

23. WHO. Public Health, Environmental and Social Determinants of Health. Air Pollution [Internet] [cited 2014 Sep 16]. Available from: http://www.who.int/phe/health_topics/outdoorair/en.

16

Housing

This chapter contains

▪ Definition

▪ Goals of Housing

▪ Requirements for Satisfied Housing

▪ Right to Housing

▪ Effects of Poor Housing on Health

▪ Overcrowding

▪ Standard of Housing in India

▪ International Standards of Housing

INTRODUCTION

A house or home is generally a place that is close to the heart of the owner, and can be a prime possession. House is not only a “physical structure” to provide shelter, but also a unit of society, provides social security, psychological security and a future asset. Immediate surroundings of the house are referred as neighborhood.

DEFINITION

Housing is defined as “all places in which a group of people reside and pursue their life goals; the size of settlement may vary from a single family to millions of people.”

GOALS OF HOUSING

1. To provide a safe and hygienic shelter to fulfill the basic need.

2. To provides physical protection, and privacy.

3. To provide adequate space for family life and related activities as preparation and storage of food, meeting, sleeping, individual activities, excretory functions and other basic activities.

4. To provide access to community facilities, e.g. health services, schools, shopping areas, places of worship, etc.

5. To prevent the spread of communicable diseases by constructing well-designed house.

6. To provide protection from hazards of exposure to noise and pollution.

7. To keep free from unsafe physical arrangements due to construction or maintenance, and from toxic or harmful materials.

8. To offer help in times of need, is an important source of friends.

9. To promote social relationships.

10. To provide economic stability as asset or personal savings.

REQUIREMENTS FOR SATISFIED HOUSING

1. For physical well-being, the house must have enough space inside and outside to promote health by good light and ventilation and to prevent respiratory and contact infection.

2. For mental well-being, the house should afford enough privacy and safety against theft. It should be situated at a place away from excessive noise and offensive odors.

3. For social well-being, the size and the construction of house should be compac-table with human dignity and social respect, ability and the neighborhood should be congenital.

RIGHT TO HOUSING

The right to housing is the economic, social and cultural rights to adequate housing and shelter. It is recognized in many national constitutions and in the Universal Declaration of Human Rights and International Covenant on Economic, Social and Cultural Rights. The right to housing is recognized in a number of international human right instruments. Article 25 of the Universal Declaration of Human Rights recognizes the right to housing as part of the right to an adequate standard of living. It states that:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Effects of Poor Housing on Health

The examples of key housing-related health risks include: respiratory and cardiovascular diseases from indoor air pollution; illness and deaths from temperature extremes; communicable diseases spread because of poor living conditions, and risks of home injuries. WHO estimates that nearly 2 million people in developing countries die from indoor air pollution caused by the burning of biomass and coal in leaky and inefficient household stoves.

Inadequate ventilation is also associated with a higher risk of airborne infectious disease transmission, including tuberculosis, as well as the accumulation of indoor pollutants and dampness, which are factors in the development of allergies and asthma. Poor housing quality and design also can exacerbate the health impacts from exposure to temperature extremes, which are occurring more frequently due to climate change.

Due to poor housing different diseases can be caused such as:

• Respiration infection: Common cold, tuberculosis, influenza, diphtheria, bronchitis, measles, whooping cough, etc.

• Skin infection: Scabies, ringworm, impetigo, leprosy.

• Rat infestation: Plague

• Arthropods: Houseflies, mosquitoes, bugs.

Morbidity and mortality are quiet high in substandard house.

A substantial proportion of house accidents is caused by some defect in the home and its environment. Poor living condition also has indirect effects on mental and social health resulting in more school drop out, delinquency, drug abuse and crime.

Overcrowding

According to the World Health Organization, overcrowding refers to the situation in which more people are living within a single dwelling than there is space for, so that movement is restricted, privacy secluded, hygiene impossible, rest and sleep difficult. The effects on quality of life due to crowding may be due to children sharing a bed or bedroom, increased physical contact, lack of sleep, lack of privacy, poor hygiene practices and an inability to care adequately for sick household members.

Standards for Overcrowding

The standards for overcrowding as defined by the World Health Organization are as follows:

The room standard: The room standard is contravened when the number of persons sleeping in a dwelling and the number of rooms available as sleeping accommodation is such that two persons of opposite sexes who are not living together as husband and wife must sleep in the same room. For this purpose, children under the age of ten shall be left out of account, and a room is available as sleeping accommodation if it is of a type normally used in the locality either as a bedroom or as a living room.

Floor space: The WHO accepted standards for floor space are:

Living room should be at least 120 sq. ft for occupancy by more than 1 person and at least 100 sq. ft for occupancy by a single person.

2 persons | : | 10 sq. ft or more
One and half persons | : | 90–100 sq. ft
One person | : | 70–90 sq. ft
Half person | : | 50–70 sq. ft
Nil | : | under 50 sq. ft

Baby under 12 months is not counted; children between 1 and 10 years counted as half a unit.

Sex separation: Overcrowding is considered to exist if two persons over 9 years of age, not husband and wife, of opposite sexes are obliged to sleep in the same room.

Risks due to Overcrowding

• Physical: Spread of infectious diseases

• Psychological: Frustration, anxiety

• Social: Violence

• High morbidity and mortality

When is overcrowding allowed?

Overcrowding is only allowed if it is:

• due to natural growth (such as a child reaching one of the specified ages, see above).

• temporary (e.g. if a member of family comes to live for a short time).

• licensed overcrowding, where the govt, has given permission (e.g. a few old govt, offices).

Fig. 16.1

STANDARD OF HOUSING IN INDIA

Minimum standard of housing should be maintained to get a safe and healthy house. The standards of housing are not fixed, as these depend on culture of each country, socioeconomic condition of the individual, personal choice, family size, standard of living, etc.

Site

• Site should be elevated from surroundings which will prevent from flooding during rain.

• Should have an independent access to a street.

• Should be away from breeding places of mosquitoes and flies.

• Should be away from nuisance as dust, smoke, smell, excessive noise and traffic.

• A pleasing surrounding is best site for housing.

• Soil should be dry and safe for founding the structure and should be well-drained and the level of subsoil water should be below 10 ft.

Set Back

• Set back is the open space all-round the house needed for proper lighting and ventilation.

• It should be in such a way that it causes no obstruction to light and ventilation.

• In rural area maximum build up area should be 1/3rd of total area.

• Build up area in urban should be maximum 2/3rd of total area as land is costly there.

Floor

• Floor should be pacca

• Impermeable so that it can be easy washable and kept clean and dry

• Mud floors are not recommended as these are breakable.

• Must be free from cracks and crevices to prevent breeding of insects, dust accumulation.

• Should be dampproof.

• Height of plinth (base) should be 2–3 ft.

Walls

• Reasonably strong walls should be constructed.

• Wall should have low heat capacity as it should not absorb or conduct heat.

• Weather-resistant wall increases longevity of house.

• Unsuitable for harboring of rats and vermin.

• Should be damageproof and smooth.

This standard can be attained by 9 in. brick wall plastered smooth and colored cream or white.

Roof

• Height should not be less than 10 ft in the absence of air-conditioning for comfort.

• Should have low heat transmittance coefficient.

Rooms

• At least 2 living rooms should be there, one of which can be closed for security.

Fig. 16.2

• Number and area should be increased according to size of family.

2 persons | : | 1 room
3 persons | : | 2 rooms
5 persons | : | 3 rooms
7 persons | : | 4 rooms
10 persons | : | 5 rooms

Additional 2 for each further room.

Floor Area

Living room should be at least 120 sq. ft for occupancy by more than 1 person and at least 100 sq. ft for occupancy by a single person.

2 persons | : | 110 sq. ft or more
One and half persons | : | 90–100 sq. ft
One person | : | 70–90 sq. ft
Half person | : | 50–70 sq. ft
Nil | : | under 50 sq. ft

Baby under 12 months is not counted; children between 1 and 10 years counted as half a unit.

Cubic Space

Unless means are provided for mechanical replacement of air the height of rooms should be such as to give an air space of at least 500 cu ft per capita (per person), preferably 1000 cu ft.

Windows

• Unless mechanical ventilation and artificial lighting are provided, every living room should be provided with at least 2 windows (at least 1 should be open directly to open place).

• Windows should be at a height of not more than 3 ft above the ground in living rooms.

• Window area should be 1/5th of the floor area.

• Doors and windows combined should have 2/5th of the floor area.

Lighting

Daylight factor should exceed 1% over half of the floor area.

Kitchen

• Every house must have a separate kitchen.

• Protected against dust and smoke

• Adequately lighted

• Provided with arrangements for storing food, fuel and provisions

• Provided with water supply

• Provided with a sink for washing utensils and fitted with arrangements for proper drainage

• Floor of the kitchen must be impervious.

Privy

• A sanitary privy must be in every house

• Should be readily accessible

• Good to be equipped with water carriage system

Garbage and Refuse

These should be removed from dwelling at least daily and disposed of in a sanitary manner.

Bathing and Washing

House should have facilities for bathing and washing belonging exclusively to it and providing proper privacy.

Water Supply

Should have a safe and adequate water supply available at all times.

Rural Housing

• At least 2 living rooms

• Ample verandah/build up area not > 1/3rd of total areas.

• Separate kitchen with a sink or platform for washing utensils

• Sanitary latrine

• Window area at least 10% of the floor area

• Sanitary well or tube well within a quarter of mile from the house.

• Cattle shed should be at least 25 ft away from house; open from each side; area 8 ft × 4 ft per cattle.

• Adequate arrangement for disposal of waste water, refuse and garbage.

Standard of housing can be summarized as

1. The site should be on a street of adequate width in pleasing surrounding free from hazards of flooding, landslides, fly breeding, mosquito breeding and from dust, smoke, foul smell.

2. Air space should be 500 to 1000 cu ft.

3. Walls should have minimum thickness of 30 cm and should be plastered on both sides. They should be damproof.

4. The floor area should not be less than 90 sq. ft for one person. Optimum space is 100 sq. ft per person. It should be rat-proof.

5. The number of rooms should be at least two or more as per the size of family.

6. Window should not be placed above 3 ft from the base. Window area should be 20% of floor area and at least there should be two windows facing other (cross-ventilation). Doors should ensure privacy.

7. The house should have a safe and adequate water supply available at all time.

8. Garbage should be removed from the dwelling at least daily and washing belonging in a sanitary manner.

9. There should be facilities for food storage.

10. There should be adequate facilities for preparation; cooking and storage of food should be available.

11. Kitchen should be free from dust and smoke.

12. The house should be regularly disinfected and white washed.

International Standards of Housing

The legal status of the right to adequate housing is based on the following main relevant international human rights provisions:

UNIVERSAL DECLARATION OF HUMAN RIGHTS (1948)

Article 25.1 states that: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

CONVENTION RELATING TO THE STATUS OF REFUGEES (1951)

Article 21 states that: “As regards housing, the Contracting States, insofar as the matter is regulated by laws or regulations or is subject to the control of public authorities, shall accord refugees lawfully staying in their territory treatment as favorable as possible and, in any event, not less favorable than that accorded to aliens generally in the same circumstances.”

CONVENTION ON THE ELIMINATION OF ALL FORMS OF RACIAL DISCRIMINATION (1965)

Article 5 (e) (iii) obliges: “States to prohibit and eliminate racial discrimination in all of its forms and to guarantee the right of everyone, without distinction as to race, color, or national or ethnic origin, to equality before the law, notably in the enjoyment of ... (e) ... (iii) the right to housing”.

INTERNATIONAL COVENANT ON ECONOMIC, SOCIAL AND CULTURAL RIGHTS (1966)

Article 11.1 states that: “The States Parties to the present covenant recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food, clothing and housing, and to the continuous improvement of living conditions. The States Parties will take appropriate steps to ensure the realization of this right, recognizing to this effect the essential importance of international cooperation based on free consent.”

INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIGHTS (1966)

Article 17 states that: “1. No one shall be subjected to arbitrary or unlawful interference with his privacy, family, or correspondence, nor to unlawful attacks on his honor and reputation. 2. Everyone has the right to the protection of the law against such interference or attacks.”

CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN (1979)

Article 14.2 (h) states that: “States Parties shall undertake all appropriate measures to eliminate discrimination against women in rural areas in order to ensure, on a basis of equality of men and women, that they participate in and benefit from rural development and, in particular, shall ensure to such women the right ... (h) to enjoy adequate living conditions, particularly in relation to housing, sanitation, electricity and water supply, transport and communications.”

CONVENTION ON THE RIGHTS OF THE CHILD (1989)

Article 16.1 states that: “No child shall be subjected to arbitrary or unlawful interference with his or her privacy, family, or correspondence, nor to unlawful attacks on his or her honor and reputation.”

Article 27.3 states that: “States Parties, in accordance with national conditions and within their means, shall take appropriate measures to assist parents and others responsible for the child to implement this right and shall in the case of need provide material assistance and support programs, particularly with regard to nutrition, clothing and housing.”

INTERNATIONAL CONVENTION ON THE PROTECTION OF THE RIGHTS OF ALL MIGRANT WORKERS AND MEMBERS OF THEIR FAMILIES (1990)

Article 43.1 states that: “Migrant workers shall enjoy equality of treatment with nationals of the state of employment in relation to ... (d) Access to housing, including social housing schemes, and protection against exploitation in respect of rents.”

CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES (2008)

Article 2 gives the following definition: “Reasonable accommodation” means necessary and appropriate modification and adjustments not imposing a disproportionate or undue burden, where needed in a particular case, to ensure to persons with disabilities, the enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms.”

Article 5.3 states that: “In order to promote equality and eliminate discrimination, States Parties shall take all appropriate steps to ensure that reasonable accommodation is provided.”

Article 9.1 (a) states that: “To enable persons with disabilities to live independently and participate fully in all aspects of life, States Parties shall take appropriate measures to ensure to persons with disabilities access, on an equal basis with others, to the physical environment, (...). These measures, which shall include the identification and elimination of obstacles and barriers to accessibility, shall apply to, inter alia: ... (a) Buildings, roads, transportation and other indoor and outdoor facilities, including schools, housing, medical facilities and workplaces.”

Article 19 (a) states that: “States Parties to this convention recognize the equal right of all persons with disabilities to live in the community, with choices equal to others, and shall take effective and appropriate measures to facilitate full enjoyment by persons with disabilities of this right and their full inclusion and participation in the community, including by ensuring that: (a) Persons with disabilities have the opportunity to choose their place of residence and where and with whom they live on an equal basis with others and are not obliged to live in a particular living arrangement.”

Article 22.1 states that: “No person with disabilities, regardless of place of residence or living arrangements, shall be subjected to arbitrary or unlawful interference with his or her privacy, family, or correspondence or other types of communication or to unlawful attacks on his or her honor and reputation. Persons with disabilities have the right to the protection of the law against such interference or attacks.”

Article 28.1 states that: “States Parties recognize the right of persons with disabilities to an adequate standard of living for themselves and their families, including adequate food, clothing and housing, and to the continuous improvement of living conditions, and shall take appropriate steps to safeguard and promote the realization of this right without discrimination on the basis of disability.”

Article 28.2 (d) states that: “States Parties recognize the right of persons with disabilities to social protection and to the enjoyment of that right without discrimination on the basis of disability, and shall take appropriate steps to safeguard and promote the realization of this right, including measures:... (d) To ensure access by persons with disabilities to public housing programs.”

DECLARATION ON THE RIGHTS OF INDIGENOUS PEOPLE (2007)

Article 10 states that: “Indigenous people shall not be forcibly removed from their lands or territories. No relocation shall take place without the free, prior and informed consent of the indigenous people concerned and after agreement on just and fair compensation and, where possible, with the option of return.”

Article 21.1 states that: “Indigenous people have the right, without discrimination, to the improvement of their economic and social conditions, including, inter alia, in the areas of education, employment, vocational training and retraining, housing, sanitation, health and social security.”

Article 23 states that: “Indigenous people have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous people have the right to be actively involved in developing and determining health, housing and other economic and social programs affecting them and, as far as possible, to administer such programs through their own institutions.”

Article 26 states that: “1. Indigenous people have the right to the lands, territories and resources which they have traditionally owned, occupied or otherwise used or acquired. 2. Indigenous people have the right to own, use, develop and control the lands, territories and resources that they possess by reason of traditional ownership or other traditional occupation or use, as well as those which they have otherwise acquired. 3. States shall give legal recognition and protection to these lands, territories and resources. Such recognition shall be conducted with due respect to the customs, traditions and land tenure systems of the indigenous people concerned.”

Article 27 states that: “States shall establish and implement, in conjunction with indigenous people concerned, a fair, independent, impartial, open and transparent process, giving due recognition to indigenous people’s laws, traditions, customs and land tenure systems, to recognize and adjudicate the rights of indigenous people pertaining to their lands, territories and resources, including those which were traditionally owned or otherwise occupied or used. Indigenous people shall have the right to participate in this process.”

Articles 28 states that: “1. Indigenous people have the right to redress, by means that can include restitution or, when this is not possible, just, fair and equitable compensation, for the lands, territories and resources which they have traditionally owned or otherwise occupied or used, and which have been confiscated, taken, occupied, used or damaged without their free, prior and informed consent. 2. Unless otherwise freely agreed upon by the people concerned, compensation shall take the form of lands, territories and resources equal in quality, size and legal status or of monetary compensation or other appropriate redress.”

Article 32 states that: “1. Indigenous people have the right to determine and develop priorities and strategies for the development or use of their lands or territories and other resources. 2. States shall consult and cooperate in good faith with the indigenous people concerned through their own representative institutions in order to obtain their free and informed consent prior to the approval of any project affecting their lands or territories and other resources, particularly in connection with the development, utilization or exploitation of mineral, water or other resources. 3. States shall provide effective mechanisms for just and fair redress for any such activity, and appropriate measures shall be taken to mitigate adverse environmental, economic, social, cultural or spiritual impact.”

INTERNATIONAL LABOR ORGANIZATION (ILO) CONVENTION NO. 161 CONCERNING OCCUPATIONAL HEALTH SERVICES (1985)

Article 5 (b) states that: “Without prejudice to the responsibility of each employer for the health and safety of the workers in his employment, and with due regard to the necessity for the workers to participate in matters of occupational health and safety, occupational health services shall have such of the following functions as are adequate and appropriate to the occupational risks of the undertaking: (...) (b) surveillance of the factors in the working environment and working practices which may affect workers’ health, including sanitary installations, canteens and housing where these facilities are provided by the employer.”

INTERNATIONAL LABOR ORGANIZATION (ILO) CONVENTION NO. 117 CONCERNING BASIC AIMS AND STANDARDS OF SOCIAL POLICY (1962)

Article 2 states that: “The improvement of standards of living shall be regarded as the principal objective in the planning of economic development.”

Article 5.2 states that: “In ascertaining the minimum standards of living, account shall be taken of such essential family needs of the workers as food and its nutritive value, housing, clothing, medical care and education.”

INTERNATIONAL LABOR ORGANIZATION (ILO) CONVENTION NO. 110 CONCERNING CONDITIONS OF EMPLOYMENT OF PLANTATION WORKERS (1958)

Article 88.1 states that: “Where housing is provided by the employer, the conditions under which plantation workers are entitled to occupancy shall be not less favorable than those established by national custom or national legislation.”

INTERNATIONAL LABOR ORGANIZATION (ILO) CONVENTION NO. 169 CONCERNING INDIGENOUS AND TRIBAL PEOPLE IN INDEPENDENT COUNTRIES (1989)

GENEVA CONVENTION RELATIVE TO THE PROTECTION OF CIVILIAN PERSONS IN TIME OF WAR (1949)

Article 49 states that: “Individual or mass forcible transfers, as well as deportations of protected persons from occupied territory to the territory of the occupying power or to that of any other country, occupied or not, are prohibited, regardless of their motive. Nevertheless, the occupying power may undertake total or partial evacuation of a given area if the security of the population or imperative military reasons so demand. (...) The occupying power undertaking such transfers or evacuations shall ensure, to the greatest practicable extent, that proper accommodation is provided to receive the protected persons (...).”

Article 53 states that: “Any destruction by the occupying power of real or personal property belonging individually or collectively to private persons, or to the state, or to other public authorities, or to social or cooperative organizations, is prohibited, except where such destruction is rendered absolutely necessary by military operations.”

Article 85 states that: “The Detaining Power is bound to take all necessary and possible measures to ensure that protected persons shall, from the outset of their internment, be accommodated in buildings or quarters which afford every possible safeguard as regards hygiene and health, and provide efficient protection against the rigors of the climate and the effects of the war. In no case shall permanent places of internment be situated in unhealthy areas or in districts the climate of which is injurious to the internees. In all cases where the district, in which a protected person is temporarily interned, is in an unhealthy area or has a climate which is harmful to his health, he shall be removed to a more suitable place of internment as rapidly as circumstances permit. The premises shall be fully protected from dampness, adequately heated and lighted, in particular between dusk and lights out. The sleeping quarters shall be sufficiently spacious and well-ventilated, and the internees shall have suitable bedding and sufficient blankets, account being taken of the climate, and the age, sex, and state of health of the internees. Internees shall have for their use, day and night, sanitary conveniences which conform to the rules of hygiene and are constantly maintained in a state of cleanliness. They shall be provided with sufficient water and soap for their daily personal toilet and for washing their personal laundry; installations and facilities necessary for this purpose shall be granted to them. Showers or baths shall also be available. The necessary time shall be set aside for washing and for cleaning. Whenever it is necessary, as an exceptional and temporary measure, to accommodate women internees who are not members of a family unit in the same place of internment as men, the provision of separate sleeping quarters and sanitary conveniences for the use of such women internees shall be obligatory.”

Article 134 states that: “The High Contracting Parties shall endeavor, upon the close of hostilities or occupation, to ensure the return of all internees to their last place of residence, or to facilitate their repatriation.”

Bibliography

1. “Average Household Size”. World Health Organization [Internet] 2013 Feb 3 [cited 2014 Sep 19]. Available from: http://apps.who.int/ceh/indicators/overcrowding.pdf.

2. Edgar Bill, Doherty Joe, Meert Henk. Access to Housing: Homelessness and Vulnerability in Europe. The Policy Press; 2002.

3. Gray A. “Definitions of Crowding and the Effect of Crowding on Health”. Ministry of Social Policy [Internet]. 2001 [cited 2014 Sep 19]. Available from: http://www.msd.govt. nz/documents/about-msd-and-our-work/publications-resources/archive/2001-definitions of crowding.pdf.

4. Gupta MC, Mahajan BK. A Text Book of Preventive and Social Medicine. 3rd edition. New Delhi: Medical Publishers(P) Ltd; 2003.

5. Housing and Health: ‘Healthy Housing’—Experts Call for International Guidelines. Health Impact Assessment. WHO [Internet] [cited 2014 Sep 19]. Available from: http://www.who.int/hia/housing/en.

6. International Standards. United Nations Human Rights [Internet] [cited 2014 Sep 19], Available from: http://www.ohchr.org/EN/issues/Housing/Pages/internationalStandards.aspx.

7. Mathur JS. A Compressive Text Book of Community Medicine. Preventive and Social Medicine. 1st ed. New Delhi: CBS Publisher; 2008.

8. Park K. Preventive and Social Medicine. 20th ed. Jabalpur: M/S Banarsidas Bhanot; 2009.

17

Waste Management

This chapter contains

▪ Definitions

▪ Health Hazards

▪ Methods of Waste Disposal

▪ Liquid Waste (Sewage)

▪ Modern Sewage Treatment

▪ Other Methods of Sewage Disposal

▪ Latrines and Methods of Excreta Disposal

▪ Disposal of Dead Body

▪ Responsibilities of Community Health Nurse in Disposal of Waste and Excreta

INTRODUCTION

Waste management is the process of monitoring, treatment, handling, reuse and residual disposition of waste materials. The term usually relates to materials produced by human activity, and the process is generally undertaken to reduce their effect on health, the environment or aesthetics.

DEFINITIONS

Solid waste: Includes garbage (food wastes), rubbish (paper, plastics, woods, metals, throw away containers, glass), demolition products (bricks, masonry, pipes), sewage treatment residue (sludge, solids from the coarse screening of domestic sewage), dead animals, manure and other discarded material. But strictly there should not be night soil.

Liquid waste (sewage and sullage): Waste water from a community, containing solid and liquid excreta, derived from houses, street and yard washings, factories and industries, resembles dirty water with an unpleasant smell is called sewage. Sullage is the waste water which does not contain human excreta (from kitchen and bathrooms)

HEALTH HAZARDS

Unplanned disposal of waste materials can cause various health hazards as:

• Waste gets decomposed and favors fly breeding.

• Attracts rodents and vermin (insects, paste, etc.)

• Pathogens from wastes may be conveyed back to man’s food through fly and dust.

• Possibility of water and soil pollution

• Unsightly appearance and nuisance from bad odors

• Increase in the incidence of vectorborne diseases, enteric diseases and helminthic diseases.

METHODS OF WASTE DISPOSAL

No single method can be said that it is the best method of waste disposal. Methods can be chosen by local factors as cost, land and labor. Principal methods of refuse disposal are:

1. Dumping

2. Controlled tipping or sanitary land fill (trench, ramp and area methods)

3. Incineration

4. Composting (Bangalore and mechanical methods)

5. Manure pits

6. Burial

1. Dumping/land fill: Refuse is dumped in low lying areas. Bacterial decomposition occurs within a few months. But there are a few drawbacks of open dumping as:

• Wastes are exposed to fly and rodents.

• Generates bad smell, and gives an unsightly appearance.

• Loose refuse is dispersed by the action of wind.

• Waste can be mixed with pond and river during rain and causes water pollution.

Fig. 17.1

2. Controlled tipping/sanitary land fill: It is considered one of the most satisfactory methods. Refuse placed in a trench or other prepared area, adequately compacted and covered with earth at the end of the working day. Chemical, bacteriological and physical changes occur. It takes about 4–6 months for complete decomposition. This method is safe as sealing of refuse prevents fly breeding, rodents and other nuisances.

• Trench method: In ground level; long trench is dug out (6–10 ft deep, 12–36 ft wide); the refuse is compacted and covered by excavated earth. Estimated 1 acre land needed for 10,000 population.

• Ramp method: It is done where terrain is moderately sloping. Some excavation is done to secure the covering material.

• Area method: In this method refuse is used to fill land depression, clay pits, etc. (6–8 ft deep); it should be covered with mud for at least 30 cm thick.

3. Incineration/burning: Where suitable land is not available, refuse is best disposed by incineration. Especially it is recommended for hospital wastes. Community people also can use this method by storing the refuse for a few days and then burn it. But it causes air pollution, manure cannot be formed.

4. Composting: Is a combined method of refuse and night soil or sludge disposal. Waste is decomposed by bacterial action forming “compost” has manurial value. Heat produced during decomposition (60°C or higher) which destroys eggs and larvae of flies and pathogenic agents. Two methods are used in this:

• Bangalore method (anaerobic)

• Mechanical composting (aerobic)

Bangalore method (hot fermentation process): It is the satisfactory method of disposal of town wastes and night soil. Trenches are dug around 3 ft deep, 5–8 ft broad and 15–30 ft long. Depth more than 3 ft not recommended as it may delay decomposition.

Composting procedure

• First a layer of refuse (about 15 cm thick) spread at the bottom of trench.

• Add night soil of about 5 cm

• Alternative layer of refuse and night soil is placed till the heap rises to 30 cm above the ground level.

• Top layer always should be refuse of about 25 cm thick.

• Lastly the pit is covered with excavated earth.

At the end of 4–6 months decomposition completed and a high value, well-decomposed, odorless manure is formed.

Mechanical composting: Compost is manufactured on a large scale by processing raw material and turning out a finished product.

Process

• Refuse is cleared from salvageable (non-destructible) materials as rags, bones, metals, glass and items interfere with grinding operation.

• Then refuse is pulverized (crush/demolish) by pulverizing equipment in order to reduce the size of particles less than 2 inches.

• Next, it is mixed with sewage, sludge or night soil in rotating machine and incubated.

Factors which are controlled in this operation are carbon-nitrogen ratio, temperature, moisture, pH and aeration. Entire process takes about 4–6 weeks.

5. Manure pit: It is considered as the best method of waste disposal in rural areas (home-based). It is recommended to dig two “manure pits” by individual house holders. Garbage, cattle dung, straw and leaves are dumped into one of the pits and cover with earth after each day’s dumping. When one pit is full then it is closed with earth and left for 5–6 months. Within this time refuse gets converted into manure which can be used in field. During this time another pit should be used for disposal of waste in the same manner. This process if very effective and relatively simple in rural community.

6. Burial: This method is suitable for small camps. A trench (1.5 m wide, 2 m deep) is excavated and when the level in the trench is 40 cm from ground level, it is filled with earth and compacted. A new trench is dug out. For 200 persons 1 m length of trench is sufficient for one week.

LIQUID WASTE (SEWAGE)

Composition of Sewage

• 99.9 % of water

• 0.1 % of solids (organic + inorganic)

• Offensive odor mainly due to organic matter

• It is estimated that 1 gm of feces contains about 1000 million E. coli, 10–100 million fecal Streptococci and several others.

Aim of Sewage Purification

• To stabilize the organic matter so that it can be disposed off safely.

• To convert the sewage water into an effluent of an acceptable standard of purity which can be disposed off into land, rivers or sea.

Indicator of organic content: The strength of sewage is expressed in terms of:

A. BOD (biochemical oxygen demand): An amount of the oxygen absorbed by a sample of sewage during a specified period (generally 5 days), at a specified temperature (generally 20°C) for the aerobic destruction or use of organic matter by living organisms.

• 1 mg/L: For natural water

• About 300 mg/L or above: Untreated domestic sewage

• 300 mg/L or more: Strong sewage

• 100 mg/L: Weak sewage

B. COD (chemical oxygen demand): measures oxygen equivalent of the portion of the organic matter in a sample which is susceptible to oxidation by a strong chemical oxidizer. If wastes containing toxic substances, this test may be the only practical method for determining the organic load.

C. Suspended solids: The amount of suspended solids in domestic sewage may vary from 100–500 mg/L (500 mg/L: strong sewage; 100 mg/L: week sewage).

AIMS OF SEWAGE PURIFICATION

• Decreases pathogen content.

• Decreases biochemical oxygen demand.

• Decreases organic materials.

MODERN SEWAGE TREATMENT

The modern sewage treatment is divided into following stages:

1. Primary treatment

• Screening

• Greet chamber

• Primary sedimentation

2. Secondary treatment

• Trickling filter method

• Activated sludge process

3. Secondary sedimentation

4. Sludge digestion

5. Disposal of effluent

1. Primary treatment: Large solids (i.e. those with a diameter of more than 2 cm) and grit (heavy solids) are removed by screening. These are disposed of in landfills (pre-treatment). The water is left to stand so that solids can sink to the bottom and oil and grease can rise to the surface. The solids are scraped off the bottom and the scum is washed off with water jets. These two substances are combined to form sludge.

• Screening: Sewage are passed through a metal screen which intercepts large floating object such as wood, rags, masses of garbage and dead animals. It is used to prevent clogging of the treatment plant. Vertical or incline steel bars usually 5 cm apart is kept as screen which may be fixed or moving. Screenings are removed from time to time by manually or mechanically and disposed by trenching or burial methods.

• Grit chamber: The screened sewage is passed to long narrow chamber called grit chamber or detritus chamber (10–20 m in length). It is designed in a way to maintain a constant velocity of about 1 ft/second with a detention period of 30 seconds to 1 minute. It allows the heavier solids such as sand and gravel to settle down and the organic matters are permitted to pass through. The solid wastes that are collected is removed periodically or continuously and disposed of by plain dumping or trenching.

• Primary sedimentation: Sewage is admitted into a huge tank called the primary sedimentation tank. Sewage is made to flow very slowly across the tank at a velocity of 1–2 ft per minute for about 6–8 hours and during this. Nearly 50–70% of solids settle down by gravity and organic matter is called sludge. A certain amount of fat and grease rise to the surface to form scum which are removed from time to time.

2. Secondary treatment: The sludge is further treated in ‘sludge digesters’: large heated tanks in which its chemical decomposition is catalyzed by microorganisms. The sludge is largely converted to ‘biogas’, a mixture of CH4 and CO₂, which is used to generate electricity for the plant. The liquid is treated by bacteria which breakdown the organic matter remaining in solution. It is then sent to oxidation ponds where heterotrophic bacteria continue the breakdown of the organics and solar UV light destroys the harmful bacteria. Secondary treatment is done by:

• Trickling filter method

• Activated sludge process

• Trickling filter/percolating filter method: It is a bed of crushed stones, 4–8 ft deep and 6–100 ft in diameter. The effluent from the primary sedimentation tank is sprinkled uniformly on the bed by a revolving device (hollow pipes with a row of holes). Over the surface and down through the filter, a very complex biological growth occurs consisting of algae, fungi, protozoa and bacteria of many kinds (zoogleal layer). As effluent percolates through the filter bed, gets oxidized by the bacterial flora in zoogleal layer completing biological filtration. The biological growth or zoogleal layers lives, grows and dies. Dead matters sloughs off, breaks away and is washed down the filter (Humus).

• Activated sludge process: The “heart” of activated sludge process is the “aeration tank”. Effluent from primary sedimentation tank is mixed with sludge drawn from the final settling tank. Mixture is aerated in aeration chamber for 6–8 hours. During aeration process, the organic matter of sewage gets oxidized into carbon dioxide, nitrates and water with the help of aerobic bacteria in the activated sludge.

Activated sludge process

Fig. 17.2

3. Secondary sedimentation: The oxidized sewage is now led into secondary sedimentation tank where it is detained for 2–3 hours. Sludge that collects here, i.e. “aerated sludge” or activated sludge differs from primary sedimentation tank sludge as it is inoffensive and rich in bacteria, nitrogen and phosphate. If it is dried it can be used as valuable manure. A part of activated sludge is pumped back into “aeration tank” in activated sludge process; rests are pumped out into sludge digestion tank for treatment and disposal.

The waste water then joins the liquid that was sent straight to the oxidation pond, where an influent mix of primary and secondary treated waste water and some recycled pond water is received. The mix is precisely calculated to ensure that the amount of organics entering the pond is the optimum amount for the bacteria to process given the amount of oxygen available at that time.

4. Sludge digestion: 1 million gallons of sewage produces 15–20 tons of sludge (thick, black mass containing 95% of water, has a revolting odor). The methods of this sludge disposal are digestion, sea disposal and land disposal.

Digestion: Sludge is incubated in “sludge digestion tank” under favorable conditions of temperature and pH—undergoes anaerobic autodigestion—sludges are broken-down into water, carbon dioxide, methane, ammonia. It takes 3–4 weeks or longer for complete sludge digestion. Residue is inoffensive, sticky and tarry mud; dry readily; excellent manure.

Sea disposal: Pumping into sea

Land: Composting with town refuse.

5. Disposal of effluent: It can be done by:

a. Disposal by dilution: The disposal into water courses such as rivers and streams called disposal of dilution. The effluent is diluted through the dissolved oxygen. It is assumed that to prevent river water pollution the dilution ratio should be 8:1 dilution.

b. Disposal on land: If suitable land is available the effluent can be used for irrigation.

Fig. 17.3: Modem sewage treatment

OTHER METHODS OF SEWAGE DISPOSAL

• Sea outfall

• River outfall

• Land treatment

• Oxidation pond

• Oxidation ditches

Sea outfall: Sea coast towns and cities may dispose of their sewage by discharging it into the sea. Purification takes place by dilution in the large body of sea water and the solids get slowly oxidized. Drawbacks are offensive solid matter may be washed back to shore and create public nuisance. It should be designed to discharge into deep water.

River outfall: Raw sewage should not be discharged into rivers. So before discharging it into river, they should be treated by aeration process or self-purification.

Land treatment (sewage farming): If sufficient and suitable land (porous soil) is available, sewage may be applied to the land after grit removal, screening and a short period of settlement. An acre of land would be required to treat the sewage of 100–300 persons. Sewage is fed into the furrows intermittently and crops are grown on the ridges.

Oxidation pond (waste stabilization pond/redox pond/sewage lagoons): It is the cheap method of sewage treatment. Both sewage and industrial wastes can be treated by this method. It is an open, shallow pool 3–5 ft deep with an inlet and outlet; must be presence of algae, certain types of bacteria which feed on decaying organic matter and sunlight. Organic matter is oxidized by bacteria to simple chemicals (CO₂, ammonia and water) by use of O₂ (from environment or produced by algae under the influence of sunlight). Algae with the help of sunlight utilize those chemicals for their growth. Oxidation ponds are aerobic during sunshine hours and some hours of night; remaining hours of the night, bottom layers are generally anaerobic. Effluent may be used for growing vegetable crops (land irrigation) or may be discharged into a river after appropriate treatment.

Oxidation ditches and aerated lagoons: These methods make use of mechanical propellers for extended aeration. For a population of 5,000–20,000 an oxidation ditch requires area of 1 acre as compared to 22 acres for an oxidation pond and 2.5 acres for an aerated lagoon.

Fig. 17.4

Excreta Disposal

One of the main sources of infection is human excreta, especially in developing countries where open field defecation, pit latrines are still prevalent and there is no proper disposal of the night soil. Improper disposal of human excreta can cause:

• Soil pollution

• Helminthic diseases

• Water pollution and waterborne diseases

• Contamination of food and foodborne diseases

• Propagation of flies and vectorborne diseases, etc.

Diseases can be transmitted from feces through water, fingers, flies, soil and food. Disease can be prevented by breaking the transmission by maintenance of proper sanitation (sanitation barrier).

Latrines and Methods of Excreta Disposal

The term is derived from the Latin: lavatrina, meaning bath. The word latrine can refer to a toilet or a simpler facility which is used as a toilet within a sanitation system. It can be a communal trench in the earth in a camp, a hole in the ground (pit), or more advanced designs, including pour-flush systems. Latrines are nowadays still common for use in emergency situations as well as in army camps. There are several methods of excreta disposal and can be classified as follows:

1. Service type (conservancy system)

2. Non-service type (sanitary latrine)

a. Borehole latrine

b. Dug well or pit latrine

c. Water-seal type

i. PRAI type

ii. RCA type

iii. Sulabh Shauchalaya

d. Septic tank

e. Aqua privy

3. Latrines suitable for camps and temporary use

a. Shallow trench latrine

b. Deep trench latrine

c. Pit latrine

d. Borehole latrine

1. Service type (conservancy system): In this method, collection and removal of night soil was carried out by human agency by using bucket and pan. This process is called the conservancy system and the latrines are called service latrine. After collection, night soil was transported by “night soil carts” to the place of final disposal for composting or burial in shallow trench. This method had lots of drawbacks as it was a source of filth and insanitation, night soil was exposed to flies. There was a chance of water pollution and soil pollution. Buckets and pans are subject to corrosion so required frequent replacement which was costly. Emptying was not always satisfactory. Getting staff was difficult, overall in this job there was no human dignity. The Environmental Hygiene Committee recommended that it should be replaced by sanitary latrine. Nowadays this type of latrine is very rare.

2. Non-service type/sanitary latrine: A sanitary should have the following criteria:

• Excreta should not contaminate the ground or surface water.

• Excreta should not pollute the soil.

• Excreta should not be accessible to flies, rodents, animals (pigs, dogs, cattles, etc.) and other vehicle of transmission.

• Excreta should not create a nuisance due to odor or unsightly appearance.

a. Borehole latrine: It was first introduced by Rockefeller Foundation during 1930s in campaign of hookworm control; consists of a circular hole (30–40 cm or 12–16 inches) in diameter, dug vertically into ground to a depth of 4–8 m (13–26 ft) most commonly 20 ft (6 m). A special equipment “auger” is required to dig a borehole. A concrete squatting plate with a central opening and foot rest is placed over the hole. Suitable enclosure made to provide privacy. For a family of 5–6 members, one borehole latrine is enough for 1 year. When contents of this reach within 50 cm of the ground level; squatting plate is removed and the hole is closed and new hole is dug (Fig. 17.5).

Merits

• No need to remove daily by sweeper

• As pit is dark, unsuitable for fly breeding.

• If located 15 m (50 ft) away from water source, no danger of water pollution.

Fig. 17.5

Demerits

• Small capacity; fills up rapidly.

• “Auger” is not readily available.

• If subsoil water is high, difficult to dig a hole more than 3 m (10 ft).

b. Dug well latrine/pit latrine: This was first introduced in Singur, West Bengal (1949–1950); improvement over borehole. A circular pit about 75 cm (30″) in diameter and 3–3.5 m (10–12 ft) deep is dug. Pit may be lined with pottery rings to prevent caving in the soil. A concrete squatting plate is placed and latrine is enclosed with a superstructure. When pit is filled up, new pit is constructed. This is easy to construct, no special equipment is needed and can be used for longer time (about 5 years).

Fig. 17.6: Pit latrine

c. Water seal latrine: Next improved latrine is hand flushed water seal latrine. Squatting plate is fitted with a water seal. Advantages of water seal latrine are that it prevents fly access as night soil is sealed with small depth of water contained in a bent pipe called the trap, prevents escape of odors and foul gases and once the latrine is flushed, night soil is no longer visible.

Types of water seal latrine:

1. PRAI type

2. RCA type

3. Sulabh shauchalaya

All parts are same in PRAI type and RCA type of latrines, only minor engineering differences are there (Fig. 17.7).

Fig. 17.7: Water seal latrine

Parts

• Squatting plate

• Pan

• Trap

• Connecting pipe

• Dug well

• Superstructure

• Squatting plate should be made of an impervious material which can be washed and kept clean and dry to prevent the survival of hookworm larvae. A minimum dimension of it should be 3 sq. ft and 5 cm thickness at outer edge with slope of % inch towards the pan.

• Pan receives night soil, urine and wash water. Length of it should be about 42.5 cm (17 inches) with front width minimum of 12.5 cm (5 inches) and widest portion width about 20 cm (8 inches). It has a uniform slope from front to back with a smooth finish.

• Trap is a bent pipe (7.5 cm diameter) connected with pan. It holds water to create water seal. Water seal is the distance between the level of the water in the trap and the lowest point in the concave upper surface of the trap. Depth of water seal is around 2 cm. It prevents access by flies and suppresses nuisance from smell.

• Connecting pipe: Trap is connected to the pit by a short length of connecting pipe (7.5 cm in diameter), at least 1 m in length with a bend at the end. When pit is filled, second pit can be put by just changing the direction of the connecting pipe.

• Dug well or pit is about 75 cm in diameter; 3–3.5 m deep and should be covered.

Sulabh Shauchalaya

Sulabh Shauchalaya is the improved version of hand-flush latrine (e.g. RCA). It consists of a specially designed pan and water seal trap and connected to a deep pit of 3 ft square. Excreta undergo bacterial decomposition. This method requires very little water. Sulabh International, the investors, not only builds but also maintains the system of Sulabh Community Latrines. Usual structure of Sulabh Shauchalaya is several dozen seats, with a bathing block adjoining. General public can use it with minimal charge as ₹ 1 or 2. d.

d. Septic tank: A septic tank is a key component of the septic system, a small-scale sewage treatment system common in areas with no connection to main sewage pipes provided by local governments or private corporations. The term “septic” refers to the anaerobic bacterial environment that develops in the tank which decomposes or mineralizes the waste discharged into the tank. A septic tank generally consists of a concrete or plastic tank (or sometimes more than one tank) of between 4000 and 7500 L (1,000 and 2,000 gallons) connected to an inlet waste water pipe at one end and a septic drain field at the other. In general, these pipe connections are made via a T pipe, which allows liquid to enter and exit without disturbing any crust on the surface. It may be double-chambered (expensive) or single-chambered (most satisfactory)

Fig. 17.8

Fig. 17.9

Main design features

• Capacity: Depends upon a number of users. 20–30 gallons or 2.5–5 cu ft per person for household septic tank

• Length: Twice the breadth

• Depth: 1.5–2 m (5–7 ft)

• Liquid depth: Only 1.2 m (4 ft)

• Air space: Minimum of 30 cm (12 inches) between the level of liquid in the tank and the undersurface of the cover

• Bottom: Sloping towards the inlet end.

• Inlet and outlet: Submerged inlet and outlet pipes

• Cover: By a concrete slab with a manhole

• Retention period: 24 hours. Too long retention results in undue septicity of effluent; and if too short then chance of insufficient treatment of excreta.

Working of a septic tank

Solids settle down to form “sludge”; lighter solids including grease and fat rise to surface to form “scum”. Anaerobic digestion occurs thus volume of excreta reduced and becomes inoffensive. In this process, methane is formed and rises to surface as bubbles. Effluents contain numerous bacteria, cysts, ova and organic matter, passes through outlet pipe. Later it percolates into soil in trench (90 cm) where aerobic oxidation produces nitrates, CO₂ and water.

Operation and maintenance

• Avoid soap water and disinfectants such as phenol to flush the pan and these are injurious to bacterial flora in septic tank.

• Remove sludge at least once a year (desludging), else the capacity of septic tank will be reduced.

• Newly build septic tank should be first filled with water up to outlet level and then seeded with ripe sludge drawn from another septic tank, to provide the right type of bacteria to carry out the decomposition process.

e. Aqua privy

The conventional aqua privy is essentially a small septic tank located directly below a squatting plate which has a drop pipe extending below the liquid level in the tank to form a simple water seal. To prevent odor, fly and mosquito nuisance in the toilet, the water seal has to be maintained by adding sufficient water per toilet visit to the tank via the drop-pipe to replace any losses. The excreta are deposited directly into the tank where they are decomposed anaerobically similar to a septic tank. A housing or shed is built over the tank. A vent pipe with a fly screen at the top end is attached to the housing. A watertight tank is desirable to minimize losses. An effluent (overflow) pipe is installed above the level of the drop-pipe. Capacity of aqua privy for a family with 7 users is about 0.6–0.8 m³ which may fill within 6 months. Night soil undergoes anaerobic digestion.

Fig. 17.10

Table 17.1: Aqua privy

Advantages | Disadvantages
No danger of clogging by bulky anal cleansing materials. | Water seal is often broken particularly during cleaning.
Low odor and insect problems. | Needs small but significant amount of water to maintain water level.
Potential for upgrading. | The tank requires de-sludging, usually every 2–3 years.
Minimal risks to health. | Requires watertight tank, hence more expensive and needs skills to construct.

DISPOSAL OF DEAD BODY

Like most animals, when humans die, their bodies start to decompose, emitting a foul odor and attracting scavengers and decomposers. For these reasons, corpses must be disposed of properly. The problem of body disposal consists of two parts: disposal of the soft tissues, which will rapidly decompose, and of the skeleton, which will remain intact for thousands of years under certain conditions.

Several methods for disposal are practiced. In many cases, the manner of disposal is dominated by spiritual concerns and a desire to show respect for the dead, and may be highly ritualized. This event may be part of a larger funeral ritual. In other circumstances, such as war or natural disaster, practical concerns may be forefront.

Generally, dead body disposal is always associated with religious rituals and varies from country to country. However, a few practices as throwing dead body to vultures and to rivers lead to health hazards.

The most common methods of disposal are:

• Burial of the entire body in the earth, often within a coffin or casket (inhumation). Burial has to be done in the corporation allocated area only.

• Permanent storage in an above-ground tomb or mausoleum (immurement)

• Cremation, which burns soft tissue and renders much of the skeleton to ash. The remains, known as “cremains” may contain larger pieces of bone (cremation).

In normal process, both burning (cremation) and burial are satisfactory methods for dead body disposal. Recent introduction of electric crematorium has solved urban problems of sanitary disposal of dead body.

Action in Medical Epidemics

Municipality Acts has given guidelines for the disposal of the body of those who died due to acute infectious diseases. Those guidelines have to be strictly followed. Handling of dead in this case needs use of gloves and other personal protection. In case of burial, dead body should be buried deeply of about more than 3 ft with addition of lime crystals with mud covering.

Where possible, in the case of a medical epidemic, body handling should be left to specialist medical staff. Rather than using lime for disinfection purposes, which has a limited effect on infectious pathogens, it is better to use chlorine solution or other medical disinfectants. Any vehicles used to transport bodies to burial or cremation sites during epidemics should also be disinfected after use. It is important to make communities aware of the risks of contagion from practices such as traditional washing of the dead. Also, any large gathering, including a funeral, can be a way of spreading an epidemic. Consequently, burial or cremation should take place soon after death at a site near the place of death with limits placed on the size of any gathering.

Important Principles during Emergency Disposal of Dead Bodies

• Give priority to the living over the dead.

• Dispel myths about health risks posed by corpses.

• Identify and tag corpses.

• Provide appropriate mortuary services.

• Reject unceremonious and mass disposal of unidentified corpses.

• Respond to the wishes of the family.

• Respect cultural and religious observances.

• Protect communities from the transmission of medical epidemics.

RESPONSIBILITIES OF COMMUNITY HEALTH NURSE IN DISPOSAL OF WASTE AND EXCRETA

1. Initial assessment: She should do an initial assessment regarding:

• Usual methods used for waste disposal, collection and transportation system in particular community.

• Desirable changes in the methods of disposal.

• Assessment of available resources like land, expenditure, etc.

• Finding avenues of cooperation and the related agencies.

• Habits and place of defecation as whether people use open field defecation or sanitary latrine.

2. Health education: Community health nurse can provide health education on various aspects, such as:

• Various methods of waste disposal suitable to their community

• Effects of unhealthy disposal of waste

• Methods to reduce the number of insects, flies, rodents, and other diseasecarrying bacteria.

• Personal and environmental sanitation

• About sanitary latrines

3. Construction of disposal units and supervision

• Selection of appropriate waste disposal techniques, collecting grant or assistance from various organizations and providing help in digging up wells or pits for excreta disposal and in constructing latrines.

• Play an active role in arranging the essential material and financial assistance.

• Timely inspection of pits, incinerators, etc.

4. Evaluation: Evaluation is a very important aspect to assess the effectiveness of programs launched (sanitary latrine) and health education given.

5. Recordkeeping: Keep all the records of community programs held on waste disposal and sanitary latrine construction.

6. Epidemiological studies: Community health nurse carries out epidemiological studies during any epidemics (which may be due to unhygienic waste and human excreta disposal) to find out the causes, risk factors and prevention aspects.

Bibliography

1. A12-More Modern Latrines, with Siphon and Manual or Mechanical Flush. Wikiwater [Internet] [cited 2014 Sep 19]. Available from: http://www.wikiwater.fr/al2-more-modern-latrines-with.html.

2. Aqua Privy [Internet] [cited 2014 Sep 19]. Available from: http://akvopedia.org/wiki/Aqua_privy.

3. Basvanthappa BT. Community Health Nursing. Second Edition. New Delhi: Jaypee.

4. Disposal of Dead Bodies in Emergency Conditions. Water Sanitation Health. WHO Technical Note for Emergencies No. 8. [Internet] [cited 2014 Sep 19]. Available from: http://www.who.int/water_sanitation_health/hygiene/envsan/tn08/en/.

5. Dr Prabhakaran GN. Short Textbook of Community Health Nursing. First Edition. Rana Pratap Bagh, Delhi: PEEPEE; 2007.

6. Gulani KK. Community Health Nursing. First Edition. Pitam Purea, Delhi: Kumar Publishing House.

7. Keshav Swarnkar. Community Health Nursing. Third Edition. Indore: NR Brothers; 2011.

8. Kumari Neelam. A Textbook of Community Health Nursing-I. First Edition, Jalandhar City: S Vikas and Company (Medical Publisher), India: 2009.

9. Lai Sundar. Textbook of Community Medicine. Second Edition. New Delhi: CBS Publishers and Distributors; 2009.

10. Park K. Textbook of Preventive and Social Medicine. 19th edition. Jabalpur: Bhanot; 2007.

11. Prabhakara GN. Short Textbook of Preventive and Social Medicine. First Edition. New Delhi: Jaypee.

12. Suryakantha AH. Community Medicine. First Edition. New Delhi: Jaypee; 2009.

13. XIII-Water-C-Sewage Treatment-2 [Internet] [cited 2014 Sep 19]. Available from: http://nzic.org.nz//water?13C.pdf.

14. Yatiraj Singh. Community Medicine. First Edition. New Delhi: Jaypee; 2009.

18

Health Planning and Management

This chapter contains

▪ Health Planning

▪ Definition

• Steps of Health Planning

• Planning Process/Planning Cycle

▪ Management

• Principles of Management

• Management by Objective (MBO) Method

• Input-Output Model

• PERT (Program Evaluation and Review Technique) and CPM (Critical Path Method)

▪ Planning Committees in India

▪ Planning Commission

▪ Health Sector

▪ Five-Year Plan

▪ Health for All by 2000 AD

▪ National Health Policy, 2002

▪ Millennium Development Goals and Worldwide Achievement

▪ Health Care Services and Care Provider

INTRODUCTION

Establishing health planning in India is a key to improving the health of the Indian Population. The areas to focus on in Health Planning have been laid down by the Ministry’s National Health Policy. Some of them are mentioned below:

• Increasing health care programs: To be implemented in various socioeconomic settings of different states of India.

• Increasing public health infrastructure: More hospitals, outdoor medical facilities, medical equipment.

• Efficient doctors and nurses: To ensure minimum standards of patient care.

• Family medicine: Establishing more personnel for family health care.

• Lo?? cost drugs and vaccines: Keeping in view of the possible globalization induced high costs.

• Mental health: Need for increase in hospitals and professionals.

• Health research: Medical innovation and specialization is needed.

• Disease control: More database needs to be collected in this regard in order to treat and prevent diseases.

• Women’s health: Adequate access to public health care facilities is a necessity which in turn will improve family health as well.

HEALTH PLANNING

Health planning is necessary for the economic utilization of material, manpower and financial resources with the purpose to improve health services of the country.

Definition

“Health planning is the orderly process of defining community health problems, identifying unmet needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible and projecting administrative action to accomplish the purpose of the proposed program”.

Components

Health needs: “Deficiencies in health that call for preventive, curative, control and eradication measures”. There are needs for medical care, safe water supply, adequate nutrition, immunization, family planning and so on.

Resources: resources imply to manpower, money, material, skills, knowledge, techniques and time needed to achieve the objectives. Resources can be simply wasted if there is no proper planning.

Goal: It is defined as the ultimate desired state towards which objectives and resources are directed.

Steps of Health Planning

1. Pre-planning: Pre-planning is the preparation of planning. The important preconditions are:

• Government interest: Any plan for the health and welfare of a country and it is most important to get political support to implement it.

• Legislation: The social and health policies may have to translate into legislation to protect the people from misconduct.

• Organization for planning: The planning commission in India serves as the organizational structure for the planning.

• Administration capacity: It is vested in the central and state ministries of health.

2. Plan: A plan is a blueprint for taking action. It consists of objectives, policies, programs, schedules and budget. Objectives are the end point of all the activities which are planned to achieve. A policy is a principle to guide decisions and achieve rational outcomes. Program is a sequence of activities designed to implement policies and accomplish objectives. Schedule is a time sequence for the work to be done. A budget (derived from old French word bougette, purse) is a quantified financial plan for a forthcoming accounting period.

Planning involves the creation and maintenance of a plan. Planning is defined as “a process of analyzing a system, or defining a problem, assessing the extent to which the problem exists as a need, formulating goals and objectives to alleviate or ameliorate those identified needs, examining and choosing among alternative intervention strategies, initiating the necessary action for its implementation and monitoring the system to ensure proper implementation of the plan and evaluating the results of intervention in the light of stated objectives.”

Planning Process/Planning Cycle

Planning process involves a successive stage.

1. Analysis of health situation

2. Establishment of objectives and goals

3. Assessment of resources

4. Fixing priorities

5. Write up of formulated plan

6. Programming and implementation

7. Monitoring

8. Evaluation

Fig. 18.1

1. Analysis of health situation: Gather community data, assess and interpret to find out the problems of community. Collect data on:

• The population, its age and sex structure

• Statistics of morbidity and mortality

• Epidemiology and geographical distribution of different diseases

• Availability of medical care facilities such as hospitals, health centers, etc.

• Availability of training facilities

• Attitude and believes of population towards disease, its cure and prevention

2. Establishment of objectives and goals: Based on the data analysis objectives have to be set according to the prioritized problems. Objectives may be short-term or long-term. Objectives should guide the action and it is the measures also to evaluate the achievement.

3. Assessment of resources: Resources like manpower, money, materials, skills, knowledge and techniques needed to assess for availability so that those can be utilized during implementation of the program.

4. Fixing priorities: Prioritization is an important phase to decide which problem should emphasized more, which objective to achieve first and which plan has to be implemented to achieve those objectives. Once the priorities have been established, alternate plan for achieving them are also formulated and assessed in order to determine whether they are practicable and feasible. Alternate pain with greater effectiveness is chosen to implement.

5. Write up of formulated plan: Detailed plan has to be written down which should cover the objectives, resources to achieve those objectives, result expected. It must contain working guidance to all those responsible for execution. A “built-in” system of evaluation has to be mentioned. It will be left to the central planning authority and the government to consider modifications to the plan relating to allocation of resources.

6. Programming and implementation: Once the health plan has been selected and approved by the policy making authorities, plan execution begins. Implementation should be on time, delaying may result in failure. Implementation should be done according to planning but as per the situation flexibility brings the plan to success.

7. Monitoring: A day-to-day follow-up is a very important part to check the pros and cons of planning. It is a continuous process of observing, recording and reporting.

8. Evaluation: Evaluation of the program is needed to assess the achievement of the stated objectives, its adequacy, efficiency and acceptance by all parties involved. According to WHO Expert Committee on National Health Planning evaluation “measures the degree to which objectives and targets are fulfilled and the quality of the results obtained. It measures the productivity of available resources in achieving clearly defined objectives. It measures how much output or cost-effectiveness is achieved. It marks possible reallocation of priorities and the resources on the basis of changing health needs.”

Management

The organization and coordination of the activities in order to achieve defined objectives is known as management. It broadly means “getting things done”. Management is the purposeful and effective use of resources.

It consists of four basic activities:

1. Planning: Determining what is to be done.

2. Organizing: Setting up the framework or apparatus and making it possible for groups to do the work.

3. Communicating: Motivating people to do the work.

4. Monitoring!controlling: Checking to make sure the work is progressing satisfactorily.

The current emphasis by WHO and many governments is on improving the efficiency of the health care delivery systems through the application of modern management methods and techniques. Henri Fayol (1841–1925) considers management to consist following functions:

1. Planning

2. Organizing

3. Commanding

4. Coordinating

5. Controlling

Principles of Management

Fayol’s 14 Principles of Management: Fayol’s principles are listed below:

1. Division of work: When employees are specialized, output can increase because they become increasingly skilled and efficient.

2. Authority: Managers must have the authority to give orders, but they must also keep in mind that with authority comes responsibility.

3. Discipline: Discipline must be upheld in organizations, but methods for doing so can vary.

4. Unity of command: Employees should have only one direct supervisor.

5. Unity of direction: Teams with the same objective should be working under the direction of one manager, using one plan. This will ensure that action is properly coordinated.

6. Subordination of individual interests to the general interest: The interests of one employee should not be allowed to become more important than those of the group. This includes managers.

7. Remuneration: Employee satisfaction depends on fair remuneration for everyone. This includes financial and non-financial compensation.

8. Centralization: This principle refers to how close employees are to the decisionmaking process. It is important to aim for an appropriate balance.

9. Scalar chain: Employees should be aware of where they stand in the organization’s hierarchy, or chain of command.

10. Order: The workplace facilities must be clean, tidy and safe for employees. Everything should have its place.

11. Equity: Managers should be fair to staff at all times, both maintaining discipline as necessary and acting with kindness where appropriate.

12. Stability of tenure of personnel: Managers should strive to minimize employee turnover. Personnel planning should be a priority.

13. Initiative: Employees should be given the necessary level of freedom to create and carry out plans.

14. Esprit de corps: Organizations should strive to promote team spirit and unity.

Methods of Management

There are various methods of management. A few of them have been described below:

A. Management by objective (MBO) method

The term “management by objectives” was first popularized by Peter Drucker in his 1954 book The Practice of Management. Management by objectives (MBO), also known as management by results (MBR), is a process of defining objectives within an organization so that management and employees agree to the objectives and understand what they need to do in the organization in order to achieve them. MBO is a participative and democratic style of management. Here, ample a scope is given to subordinates and is given higher status and positive/participative role.

According to George Odiome, MBO is “a process whereby superior and subordinate managers of an organization jointly define its common goals, define each individual’s major areas of responsibility in terms of results expected of him and use these measures as guides for operating the unit and assessing the contribution of each of its members.”

The core of MBO is participative goal setting, choosing course of actions and decision-making. An important part of the MBO is the measurement and the comparison of the employee’s actual performance with the standards set. When employees themselves have been involved with the goal setting and choosing the course of action to be followed by them, they have more efforts to fulfill their responsibilities.

Steps in Management by Objectives Planning

• Goal setting: Organizational objectives are determined by the top management and usually in consultation with other managers. Once these goals are established, they should be made known to all the members.

• Manager-Subordinate involvement: Next, subordinates work with the managers to determine their individual goals. In this way, everyone gets involved in the goal setting.

• Matching goals and resources: Management must ensure that the subordinates are provided with necessary tools and materials to achieve these goals. Allocation of resources should also be done in consultation with the subordinates.

• Implementation of plan: After objectives are established and resources are allocated, the subordinates can implement the plan. If any guidance or clarification is required, they can contact their superiors.

• Review and appraisal of performance: Periodic review of progress should be done together. Such reviews would determine if the progress is satisfactory or the subordinate is facing some problems. Based on fair and measurable standards, performance appraisal at these reviews should be conducted.

B. Input-output model

Wassily Leontief (1905–1999) is credited with developing this type of analysis and took the Nobel Prize in economics for his development of this model. In economics, an input-output model is a quantitative economic technique that represents the interdependencies between different branches of a national economy or different regional economies. Assumptions for the input-output model:

1. Each industry produces only one homogeneous commodity.

2. Each industry uses a fixed input ratio for the production of its output.

3. Production in every industry is subject to constant return to scale.

In the health field “input” refers to all the health service activities which consume resources, and “output” refers to such useful outcomes.

C. Network analysis

Managing a program with network planning involves four steps:

1. Describing the project/program with objectives to achieve plan of implementation, resources to be used, people involved in the project, etc.

2. Diagraming the network: Draw the plan diagrammatically showing the interrelationship between steps of planning. A network diagram should show the activities, precedence relationship, successor and events.

3. Estimate time of completion of the program.

4. Monitor project progress by set criteria.

Methods used for network planning are:

• PERT

• CPM

PERT (program evaluation and review technique) and CPM (critical path method) are most commonly used methods for project management. PERT can be applied to any field requiring planned, controlled and integrated work efforts to accomplish defined objectives. On the other hand, CPM method is consisting of a number of well-defined and clearly recognizable activities.

PLANNING COMMITTEES IN INDIA

Health planning of India started prior independence when government of India in 1943 appointed Sir Joseph Bhoreas the Chairman of the Health Survey and Development Committee. Later, so many committees were appointed by government of India time to time who have surveyed existing health conditions, presented their reports, planned strategies and given recommendations for betterment of health conditions in India.

Table 18.1: Difference between PERT and CPM

CPM
PERT

• CPM uses activity oriented network.

• PERT uses event oriented network.

• Durations of activity may be estimated with a fair degree of accuracy.

• Estimate of time for activities is not so accurate and definite.

• It is used extensively in construction projects.

• It is used mostly in research and development projects, particularly projects of non-repetitive nature.

• Deterministic concept is used.

• Probabilistic model concept is used.

• CPM can control both time and cost when planning.

• PERT is basically a tool for planning.

• In CPM, cost optimization is given prime importance. The time for the completion of the project depends upon cost optimization. The cost is not directly proportioned to time. Thus, cost is the controlling factor.

• In PERT, it is assumed that cost varies directlv with time. Attention is, therefore, given to minimize the time so that minimum cost results. Thus in PERT, time is the controlling factor.

1. Bhore Committee (1946)

Bhore Committee is set up by the Government of India in 1943 to investigate and recommend improvements to the Indian Public Health system. Under the chairmanship of Sir Joseph Bhore the committee made many landmark recommendations in its final report in 1946. It was also known in India as Health Survey and Development Committee. It said “If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about”. Some of the important recommendations of the Bhore Committee were:

• Integration of preventive and curative services to all administrative levels.

• Development of Primary Health Centres in 2 stages:

– As a short-term measure: One primary health center per 40,000 population, 30 beds, 3 subcenters and 2 medical officers, 4 public health nurses, 1 nurse, 4 midwives, 4 trained dais, 2 sanitary inspectors, 2 health assistants, 1 pharmacist, and 15 class IV employees.

– As a long-term program (3 million plans): Primary health units with a 75 bedded hospital per 10,000–20,000 population; secondary health units with 650 bedded hospital; regional health units with 2,500 beds.

• Major changes in medical education which include 3 months training in preventive and social medicine to prepare “social physicians”.

The committee was instrumental in bringing about the public health reforms related to peripheral health centers in India. Though most of the recommendations of the committee were not implemented at the time, the committee was a trigger to the reforms.

2. Mudaliar Committee

By the close of second five-year plan (1956–61), “Health Survey and Planning Committee”, the Mudaliar Committee (1962), is appointed by the Government of India to review the progress made in the health sector after submission of Bhore Committee report. The major recommendation of this committee report was:

• To limit the population served by primary health centers to 40,000 with the improvement in the quality of health care provided by these centers.

• Strengthening of the district hospitals with specialist services to serve as a central base of regional services.

• Regional organizations in each state between headquarter organization and the district incharge of a Regional Deputy or Assistant Director each to supervise 2 or 3 district medical and health officers.

• Constitution of an All India Health Service on pattern of Indian Administrative Service.

3. Chaddah Committee

The Chaddah Committee (1963), under the Chairmanship of Dr MS Chaddah the then Director General of Health Services is appointed to study the arrangements necessary for the maintenance phase of the National Malaria Eradication Program. The committee recommended provision of one basic health worker per 10,000 populations for vigilance operations through monthly home visits under National Malaria Eradication Program. These workers were envisaged as multipurpose health workers (MPHW) to look after additional duties of collection of vital statistics and family planning. The family planning health assistants were to supervise 3 or 4 of these basic health workers.

4. Mukerji Committee

In a short time after implementation of MPHW scheme it was realized that malaria vigilance operations and family planning program could not be carried out satisfactorily. A committee known as Mukerji Committee is formed in 1965 under the Chairmanship of Shri Mukerji, the then Secretary of Health to the Government of India. The committee recommended separate staff for family planning activities so that malaria activities could receive undivided attention of its staff. Also the committee worked out the details of the “basic health service” which should be provided at the block level, and some of consequential strengthening required at higher levels of administration.

5. Jungalwalla Committee

A committee known as “Committee on Integration of Health Services” was formed under Chairmanship of Dr N Jungalwalla, Director, National Institute of Health Administration and Education. Committee in 1967 gave importance to integration of health services and elimination of private practice by government doctors. Integrated health services were defined as “a service with a unified approach for all problems instead of a segmented approach for all different problems”. Care of the sick and various public health programs functioning under a single administrator. The committee recommended towards integration was:

a. Unified cadre

b. Common seniority

c. Recognition of extraqualification

d. Equal pay for equal work

e. Special pay for specialized work

f. No private practice

6. Kartar Singh Committee

“The Committee on Multipurpose Workers under Health and Family Planning” is constituted in 1973 under the Chairmanship of Kartar Singh, Additional Secretary, Ministry of Health and Family Planning, Government of India. The committee laid down the norms about health workers and for ensuring proper coverage the committee recommended, one primary health center to be established for every 50,000 population. Each primary health center to be divided into 16 subcenters each for a population of 3,000 to 3,500. Each subcenter to be staffed by a team of one male and one female health workers. They recommended that the work of 3–4 health workers to be supervised by one health assistant. The doctor in charge of the PHC should have the overall charge of all supervisors and health workers in his area. The program also recommended that the present Auxiliary Nurse Midwives to be replaced by the newly designated “Female Health Workers”.

7. Shrivastav Committee

The Government of India in the Ministry of Health and Family Planning has set up a “Group on Medical Education and Support Manpower” popularly known as the Shrivastav Committee in 1975 suggested:

• Creation of bands of Para-professional and semi-professional health workers from within the community (e.g. school teachers, postmasters, gram sevak, etc.) to provide simple health services needed by the community.

• The development of a “Referral Service Complex” by establishing linkages between the primary health center and higher level referral and service centers, viz. taluka/tehsil, district, regional and medical college hospitals.

• Establishment of a medical and health education commission for planning and implementation of reforms needed in health and medical education on the lines of University Grant Commission.

• One male and female HWs should be available for every 5000 population.

• The Health Assistants for every two HWs should be located at SC and not at PHC.

Following the suggestions of the Shrivastav Committee report, Rural Health Scheme is launched in 1977, wherein training of community health workers, re-orientating medical education (ROME) training of multipurpose workers, and linking medical colleges to rural health was initiated. It was based on principle “placing people’s health in people’s hands”. Also to initiate community participation, the Community Health Volunteer: Village Health Guide (VHG) Scheme is launched. The VHG is to be a person from the village, mostly women, who is imparted short-term training and small incentive for the work.

8. Shivaraman Committee

A Committee on Basic Rural Doctors was framed under the guidance of Shri Shivaraman, the then Member of Planning Commission. The committee recommended establishment of countrywide cadre of basic rural doctors consisting of trained paraprofessionals to extend comprehensive health care delivery to rural community.

9. Ramalingaswamy Committee

This committee under the chairmanship of Dr V Ramalingaswamy, the then DGHS, recommended:

• Involvement of community for health planning and health program implementation

• 30 bedded hospital for every 1 lakh population

• Integration of health services at all levels

• Redefined the role of doctor in the community

• Recommended that PHC and District Health Centers should be under the control of three tier Panchayat Raj System.

10. Bajaj Committee (1986)

An expert committee for ‘health manpower planning, production and management’ is constituted under the Chairmanship of Dr JS Bajaj, the then Member of Planning Commission, to tackle the problem of health manpower planning, production and management. Important recommendations of the Bajaj committee are:

• Recommended for Formulation of National Health Manpower planning based on realistic survey.

• Educational Commission for health sciences should be developed on the lines of UGC.

• Recommended for National and Medical education policies in which teachers are trained in health education science technology.

• Uniform standard of medical and health science education by establishing universities of health sciences in all states.

• Establishment of health manpower cells both at state and central levels.

• Vocational courses in paramedical sciences to get more health manpower.

11. Krishnan Committee (1992)

The committee under the chairmanship of Dr Krishnan reviewed the achievements and progress of previous health committee reports and also made comments on shortfalls. The committee addresses the problems of urban health and devised the health postscheme for urban slum areas. The committee had recommended one voluntary health worker (VHW) per 2,000 population with an honorarium of ₹ 100. Its report specifically outlines which services have to be provided by the health post. These services have been divided into outreach, preventive, family planning, curative, support (referral) services and reporting and recordkeeping. Outreach services include population education, motivation for family planning, and health education. In the present context, a very few outreach services are being provided to urban slums.

12. Working Group (1981)

A working group on Health was constituted by the Planning Commission in 1980 with the Secretary, Ministry of Health and Family Welfare, as its Chairman. The group was formed to identify the goal for Health for All by 2000 AD and to outline with that perspective, the specific programs for the sixth Five–Year Plan.

PLANNING COMMISSION

The Planning Commission is set up by a Resolution of the Government of India in March 1950 in pursuance of declared objectives of the Government to promote a rapid rise in the standard of living of the people. It is an institution in the Government of India, which formulates India’s Five-Year Plans, among other functions. It is located at Yojana Bhawan, Sansad Marg, New Delhi.

The composition of the Commission has undergone a lot of changes since its inception. With the Prime Minister as the ex officio (holds one position by virtue of holding another) Chairman, the committee has a nominated Deputy Chairman, who is given the rank of a full Cabinet Minister. Cabinet Ministers with certain important portfolios act as ex officio members of the Commission, while the fulltime members are experts of various fields like Economics, Industry, Science and General Administration. The Commission works through its various divisions, of which there are three kinds:

1. General Planning Divisions

2. Program Administration Divisions

3. Technical division

Functions: The Planning Commission’s functions as outlined by the Government’s 1950 resolution are given below:

• To make an assessment of the material, capital and human resources of the country, including technical personnel, and investigate the possibilities of augmenting those are related resources which are found to be deficient in relation to the nation’s requirement.

• To formulate a plan for the most effective and balanced utilization of country’s resources.

• To define the stages, on the basis of priority, in which the plan should be carried out and propose the allocation of resources for the due completion of each stage.

• To indicate the factors that tend to retard economic development.

• To determine the conditions which need to be established for the successful execution of the plan within the incumbent sociopolitical situation of the country.

• To determine the nature of the machinery required for securing the successful implementation of each stage of the plan in all its aspects.

• To appraise from time to time the progress achieved in the execution of each stage of the plan and also recommend the adjustments of policy and measures which are deemed important vis-a-vis a successful implementation of the plan.

• To make the necessary recommendations from time to time regarding those things which are deemed necessary for facilitating the execution of these functions. Such recommendations can be related to the prevailing economic conditions, current policies, measures or development programs. They can even be given out in response to some specific problems referred to the commission by the central or state government.

Health Sector

For purpose of purpose of planning, the health sector has been divided into following subsectors:

• Water supply and sanitation

• Control of communicable diseases

• Medical education, training and research

• Medical care including hospitals, dispensaries and primary health centers

• Public health services

• Family planning

• Indigenous system of medicine

All the above subsectors have been received due consideration in the five-year plans. Flowever, the emphasis has been changed from plan to plan depending upon the felt needs.

Five-Year Plan

Five-year plans (FYPs) are centralized and integrated national economic programs. Joseph Stalin implemented the first FYP in the Soviet Union in the late 1920s. Several countries subsequently have adopted them. The first five-year plan is one of the most important because it had a great role in the launching of Indian development after the independence. Thus it strongly supported agriculture production and it also launched the industrialization of the country.

The broad objectives of the health programs during the five-year plans have been:

1. To deal with disparity of income and wealth

2. Control of eradication of major communicable diseases

3. Strengthening of the basic health services through the establishment of primary health centers and subcenters

4. Population control

5. Development of health manpower resources, infrastructure

6. Balanced regional development

List of five-year plans

First Plan (1951–1956) | Seventh Plan (1985–1990)
Second Plan (1956–1961) | Annual Plans (1990–1992)
Third Plan (1961–1966) | Eighth Plan (1992–1997)
Annual plans (1966–69) | Ninth Plan (1997–2002)
Fourth Plan (1969–1974) | Tenth Plan (2002–2007)
Fifth Plan (1974–1979) | Eleventh Plan (2007–2012)
1979–1980 Outlay | Twelfth Plan (2012–2017)
Sixth Plan (1980–1985) |

Eleventh Five-Year Plan (2007–2012)

The eleventh plan had 27 targets at national level fall in six major categories.

• Income and poverty

• Education

• Health

• Women and children

• Infrastructure

• Environment

1. Income and poverty

• Accelerate GDP growth from 8% to 10% and then maintain at 10% in the 12th Plan in order to double per capita income by 2016–17.

• Increase agricultural GDP growth rate to 4% per year to ensure a broader spread of benefits.

• Create 70 million new work opportunities.

• Reduce educated unemployment to below 5%.

• Raise real wage rate of unskilled workers by 20%.

• Reduce the headcount ratio of consumption poverty by 10 percentage points.

2. Education

• Reduce dropout rates of children from elementary school from 52.2% in 2003–04 to 20% by 2011–12.

• Develop minimum standards of educational attainment in elementary school, and by regular testing monitor effectiveness of education to ensure quality.

• Increase literacy rate for persons of age 7 years or above to 85%.

• Lower gender gap in literacy to 10 percentage point.

• Increase the percentage of each cohort going to higher education from the present 10% to 15% by the end of the plan.

3. Health

• Reduce infant mortality rate to 28 and maternal mortality ratio to 1 per 1000 live births.

• Reduce total fertility rate to 2.1.

• Provide clean drinking water for all by 2009 and ensure that there are no slip-backs.

• Reduce malnutrition among children of age group 0–3 to half its present level.

• Reduce anemia among women and girls by 50% by the end of the plan.

4. Women and children

• Raise the sex ratio for age group 0–6 to 935 by 2011–12 and to 950 by 2016–17.

• Ensure that at least 33 percent of the direct and indirect beneficiaries of all government schemes are women and girl children.

• Ensure that all children enjoy a safe childhood, without any compulsion to work.

5. Infrastructure

• Ensure electricity connection to all villages and BPL households by 2009 and round-the-clock power.

• Ensure all-weather road connection to all habitation with population 1000 and above (500 in hilly and tribal areas) by 2009, and ensure coverage of all significant habitation by 2015.

• Connect every village by telephone by November 2007 and provide broadband connectivity to all villages by 2012.

• Provide homestead sites to all by 2012 and step up the pace of house construction for rural poor to cover all the poor by 2016–17.

6. Environment

• Increase forest and tree cover by 5 percentage points.

• Attain WHO standards of air quality in all major cities by 2011–12.

• Treat all urban waste water by 2011–12 to clean river waters.

• Increase energy efficiency by 20%.

• Target growth: 8.33% and growth achieved: 7.9%.

Twelfth Five-Year Plan: Faster, More Inclusive and Sustainable Growth (2012–2017)

Twelfth five-year plan was undertaken with the objective to gain faster, more inclusive and sustainable growth of country.

Goals

• To reverse the current growth slowdown: 5.5 % in 2012–13 aim for 6.5 to 7 % in 2013–14.

• To get back to high growth: 5.5% in 2012–13 to over 9% in last two years (2016–2017).

Objectives

• To reduce poverty

• To improve regional equality across states and within states

• To improve conditions for SCs, STs, OBCs and minorities

• To generate attractive employment opportunities for youth

• To close gender gaps

Twelfth plan lists 25 monitorable indicators; out of those few are:

1. Average GDP growth of 8%

2. Agriculture growth of 4%

3. Reducing head count poverty by 10% point

4. Generating 50 million work opportunities

5. Eliminating gender and social gap in education

6. Reducing IMR to 25, MMR to 100 and TFR to 2.1

7. Enhance infrastructure investment to 9% of GDP

8. Achieve universal road connectivity and access to power for all villages

9. Access to banking services for 90% households

10. Major welfare benefits and subsidies via Aadhaar

There are two routes to inclusiveness:

• Through higher growth which expands income and employment opportunities

• Through government pro-poor programs which target poorer groups

Both of the routes are important. Twelfth plan combines the pro-poor program approach with efforts to get a growth pattern which is faster and inherently more inclusive. Two routes are mutually reinforcing:

• High growth generates more revenues, to finance inclusiveness programs.

• Many inclusiveness programs (health and education) contribute to growth.

Strategies of 12th five-year plan

1. Substantial expansion and strengthening of public sector health care system, freeing the vulnerable population from dependence on high cost and often unreachable private sector health care system.

2. Health sector expenditure by central and state governments, both plan and nonplan, will have to be substantially increased by the twelfth five-year plan. It was increased from 0.94 percent of GDP in tenth plan to 1.04 percent in eleventh plan. The provision of clean drinking water and sanitation as one of the principal factors in control of diseases is well-established from the history of industrialized countries and it should have high priority in health related resource allocation. The expenditure on health should increased to 2.5 percent of GDP by the end of twelfth five-year plan.

3. Financial and managerial system will be redesigned to ensure efficient utilization of available resources and achieve better health outcome. Coordinated delivery of services within and across sectors, delegation matched with accountability, fostering a spirit of innovation are some of the measures proposed.

4. Increasing the cooperation between private and public sector health care providers to achieve health goals. This will include contracting in of services for gap filling, and various forms of effectively regulated and managed public-private partnership, while also ensuring that there is no compromise in terms of standards of delivery and that the incentive structure does not undermine health care objectives.

5. The present Rashtriya Swasthya Bima Yojana (RSBY) which provides cashless inpatient treatment through an insurance based system should be reformed to enable access to a continuum of comprehensive primary, secondary and tertiary care. In twelfth plan period, the entire below poverty line (BPL) population will be covered through RSBY scheme. In planning health care structure for the future, it is desirable to move from a Yee-f or-service’ mechanism, to address the issue of fragmentation of services that works to the detriment of preventive and primary care and also to reduce the scope of fraud and induced demand.

6. In order to increase the availability of skilled human resources, a large expansion of medical schools, nursing colleges, and so on is, therefore, necessary and public sector medical schools must play a major role in the process. Special effort will be made to expand medical education in states which are underserved. In addition, a massive effort will be made to recruit and train paramedical and community level health workers.

7. The multiplicity of Central sector or Centrally Sponsored Schemes has constrained the flexibility of states to make need-based plans or deploy their resources in the most efficient manner. The way forward is to focus on strengthening the pillars of the health system, so that it can prevent, detect and manage each of the unique challenges that different parts of the country face.

8. A series of prescription drugs reforms, promotion of essential, generic medicine and making these universally available free of cost to all patients in public facilities as a part of the Essential Health Package will be a priority.

9. Effective regulation in medical practice, public health, food and drugs is essential to safeguard people against risks and unethical practices. This is especially so given the information gaps in the health sector which make it difficult for individual to make reasoned choices.

10. The health system in the twelfth plan will continue to have a mix of public and private service providers. The public sector health services need to be strengthened to deliver both public health related and clinical services. The public and private sectors also need to coordinate for the delivery of a continuum of care. A strong regulatory system would supervise the quality of services delivered. Standard treatment guidelines should form the basis of clinical care across public and private sectors, with the adequate monitoring by the regulatory bodies to improve the quality and control the cost of care.

Macroeconomic challenges in achieving high growth:

• Must increase the rate of investment, especially in infrastructure.

• Domestic savings must increase even more to reduce the investment saving gap which is necessary to keep the Current Account Deficit under control.

• Government dissavings must be eliminated. This means fiscal deficit must be reduced.

• Growth of subsidies has to be contained.

• 75% of the investment in the economy is private investment (household plus corporate).

• Both the center and the states have to create an ecosystem that encourages private investment.

• Infrastructure, especially quality of power, and availability of skills is critical.

Effectiveness of plan program

• Twelfth plan sets ambitious targets for flagship programs in areas of health, education, rural infrastructure, livelihood development, etc.

• Too much focus on the level of expenditure in these programs. Not enough in effectiveness in terms of end results.

• Implementation in the field is the responsibility of the state government agencies. However, program guidelines are set by the central government.

• There are demands for greater flexibility from states. We are responding as follows:

– Guidelines are being made more flexible to meet the requirements of individual states.

– 10% flexi-fund within each scheme for innovations.

There are a few areas which had given importance in 12th five-year plan:

Energy

• 8% GDP growth requires 6% growth in energy supply from all sources.

• Our fossil fuel resources are limited, and our import dependence is already high.

• Enhanced energy efficiency in all sectors.

• We need to push for renewable energies: wind, solar and storage hydro.

• Difficult policy issues

– Coal vs forest cover

– Petroleum price distortions

– Natural gas exploration framework

– All energy prices: coal, petroleum product, natural gas and electric power are currently underpriced. Fuel adjustment is needed.

Water

• Management of water resource is a mojor challenge. Estimates of water availability have been optimistic.

• Twelfth plan proposes modified AIBP and expanded watershed management program.

• Water sector needs better regulatory framework

– New groundwater law

– Water regulatory authorities in each state

– National water framework law

• Agriculture accounts for 80% of water use at present, must shift to more water efficient agriculture practices.

• Manage urban and industrial water demand through water recycling and rationalize usuer charges.

Alternative scenarios

• 12th plan goal of 8% inclusive growth is not a foregone conclusion.

• Depends on different policy decisions to be taken by center and states.

• For the first time plan presents three scenarios:

– Strong inclusive growth 8%

– Insufficient action 6–6.5%

– Policy logjam 5–5.5%

• Anything much less than 8% will not satisfy aspirations of the people.

Health for All by 2000 AD

World Health Assembly launched “Health for All by the year 2000 AD” in 1977. In 1978, the Alma Ata International Conference on Primary Health Care Reaffirmed Health For All as the major social goal of governments and stated that the best approaches to achieve the goal of HFA is by providing primary health care. World Health Assembly defined health for all as:

“Altammonl of a level of lieallli ilia! will enable everv individual lo lead a socially and economically productive life”.

Health for all does not mean that all the people will be healthy by the year 2000. It does not mean an end to disease and disability, or that doctors and nurses will care for everyone. It means that resources for health are evenly distributed and that essential health care is accessible to everyone.

It also means that health begins at home, in schools, as well as the workplace, and that people use better approaches for preventing means that people recognize that ill-health is not inevitable and that they can shape their own lives and those of their families from the avoidable burden of disease. It focuses to eliminate malnutrition, ignorance, disease, contaminated water supply, etc. by improving in medicine and public health.

In 1981, a global strategy for HFA was evolved by WHO. It provided a global framework which was broad enough to apply to the all member states and flexible enough to be adapted to national and regional variations. On that basis individual countries developed their own strategies.

The WHO has established 12 global indicators to assess the progress towards HFA. A few examples are:

• A minimum life expectancy of 60 years.

• Maximum IMR of 50 per 1000 live births.

Goals to be achieved by 2000 AD:

• Reduction of infant mortality from the level of 125 (1978) to below 60

• To raise the expectation of life at birth from the level of 52 years to 64

• To reduce the crude death rate from the level of 14 per 1000 population to 21

• To achieve a net reproduction rate by one

• To provide potable water to the entire rural population

National strategy for HFA by 2000 AD

World Health Organization took primary health care strategy to promote health, human dignity, and enhanced quality of life and ultimately to achieve goals of HFA by the year 2000 AD. That is to provide an accessible, acceptable and affordable health care to each corner of the country.

National Health Policy, 2002

According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people. Health policy can be defined as the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”

A National Health Policy (NHP) is last formulated in 1983, and since then there have been marked changes in the determinant factors relating to the health sector.

The NHP in 1983 gave a general exposition of the policies which required recommendation in the circumstances then prevailing in the health sector. The noteworthy initiatives under that policy were:

i. A phased, time-bound program for setting up a well-dispersed network of comprehensive primary health care services, linked with extension and health education, designed in the context of the ground reality that elementary health problems can be resolved by the people themselves.

ii. Intermediation through ‘health volunteers’ having appropriate knowledge, simple skills and requisite technologies.

iii. Establishment of a well worked out referral system to ensure that patient load at the higher levels of the hierarchy is not needlessly burdened by those who can be treated at the decentralized level.

iv. An integrated network of evenly spread specialty and superspecialty services; encouragement of such facilities through private investments for patients who can pay, so that the draw on the government’s facilities is limited to those entitled to free use.

Objective

To achieve an acceptable standard of good health amongst the general population of the country.

Approaches

• Decentralization of public health system by establishing new infrastructure in the existing institutions.

• Importance is given to ensure a more equitable access to health services across the social and geographical expanse of the country.

• Priority is given to preventive and first line curative services at the primary health level.

• Focus on the diseases which contribute more burdens on health as tuberculosis, malaria, blindness and HIV/AIDS.

• Emphasized on the rational use of drugs within allopathic system.

Goals

Goals to be achieved by 2015:

• Eradication polio and yaws

:
2005

• Eliminate leprosy

:
2005

• Eliminate kala-azar

:
2010

• Eliminate lymphatic filariasis

:
2015

• Achieve zero level growth of HIV/AIDS

:
2007

• Reduce mortality by 50% on account of TB, malaria, and other vector- and waterborne diseases

:
2010

• Reduce prevalence of blindness to 0.5%

:
2010

• Reduce IMR to 30/100 and MMR to 100/Lakh

:
2010

• Increase utilization of public health facilities from current level of < 20% to > 75%

:
2010

• Establish an integrated system of surveillance, national health accounts and health statistics

:
2005

• Increase health expenditure by government as percentage of GDP from the existing 0.9% to 2%

:
2010

• Increase share of central grants to constitute at least 25% of total health spending

:
2010

• Increase state sector health spending from 5.5% to 7% of the budget

:
2005

• Further increase to 8% of the budget

:
2010

Millennium Development Goals and World-Wide Achievement

The Millennium Development Goals (MDGs) are eight international development goals that were established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 189 United Nations member states at the time (there are 193 currently) and about 23 international organizations committed to achieve the following Millennium Development Goals by 2015:

• To eradicate extreme poverty and hunger

• To achieve universal primary education

• To promote gender equality and empower women

• To reduce child mortality

• To improve maternal health

• To combat HIV/AIDS, malaria, and other diseases

• To ensure environmental sustainability

• To develop a global partnership for development

Goal 1: Eradicate Extreme Poverty and Hunger Target 1.A: Halve, between 1990 and 2015, the proportion of people whose income is less than $1.25 a day.

• The target of reducing extreme poverty rates by half was met five years ahead of the 2015 deadline.

• The global poverty rate at $1.25 a day fell in 2010 to less than half the 1990 rate. 700 million fewer people lived in conditions of extreme poverty in 2010 than in 1990. However, at the global level 1.2 billion people are still living in extreme poverty.

Target l.B: Achieve full and productive employment and decent work for all, including women and young people.

• Globally, 384 million workers lived below the $1.25 a day poverty line in 2011—a reduction of 294 million since 2001.

• The gender gap in employment persists with a 24.8 percentage point difference between men and women in the employment-to-population ratio in 2012.

Target l.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger.

• The hunger reduction target should be almost met by 2015.

• Globally, about 842 million people are estimated to be undernourished.

• More than 99 million children under age five are still undernourished and underweight.

Goal 2: Achieve Universal Primary Education Target 2.A: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.

• Enrolment in primary education in developing regions reached 90 percent in 2010, up from 82 percent in 1999, which means more kids than ever are attending primary school.

• In 2011, 57 million children of primary school age were out of school.

• Even as countries with the toughest challenges have made large strides, progress on primary school enrolment has slowed. One in ten children of primary school age was still out of school in 2012.

• Gender gaps in youth literacy rates are also narrowing. Globally, 781 million adults and 126 million youths (aged 15 to 24) worldwide lack basic reading and writing skills, and more than 60 percent of them are women.

Goal 3: Promote Gender Equality and Empower Women

Target 3.A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.

• The world has achieved equality in primary education between girls and boys, but a few countries have achieved that target at all levels of education.

• The political participation of women keeps increasing. In January 2014, in 46 countries more than 30 percent of members of parliament in at least one chamber were women.

• In many countries, gender inequality persists and women continue to face discrimination in access to education, work and economic assets, and participation in government. For example, in every developing region, women tend to hold less secure jobs than men, with fewer social benefits.

• Violence against women continues to undermine efforts to reach all goals.

• Poverty is a major barrier to secondary education, especially among older girls.

• Women are largely relegated to more vulnerable forms of employment.

Goal 4: Reduce Child Mortality

Target 4.A: Reduce by two-thirds, between

1990 and 2015, the under-five mortality rate.

• Despite population growth, the number of deaths in children underfive worldwide declined from 12.7 million in 1990 to 6.3 million in 2013, which translates into about 17,000 fewer children dying each day.

• Since 2000, measles vaccines have averted over 14 million deaths.

• Despite determined global progress in reducing child deaths, an increasing proportion of child deaths are in sub-Saharan Africa and Southern Asia. Four out of every five deaths of children under age five occur in these regions.

• As the rate of underfive deaths overall declines, the proportion that occurs during the first month after birth is increasing.

• Children born into poverty are almost twice as likely to die before the age of five as those from wealthier families.

• Children of educated mothers, even mothers with only primary schooling, are more likely to survive than children of mothers with no education.

Goal 5: Improve Maternal Health

Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio.

• The maternal mortality ratio dropped by 45 percent between 1990 and 2013, from 380 to 210 deaths per 100,000 live births. All regions have made progress but accelerated interventions are required in order to meet the target.

• In Eastern Asia, Northern Africa and Southern Asia, maternal mortality has declined by around two-thirds.

• The proportion of deliveries in developing regions attended by skilled health personnel rose from 56 in 1990 to 68 percent in 2012.

• The maternal mortality ratio in developing regions is still 14 times higher than in the developed regions.

• The rural-urban gap in skilled care during childbirth has narrowed.

Target 5.B: Achieve, by 2015, universal access to reproductive health.

• More women are receiving antenatal care. In developing regions, antenatal care increased from 65 percent in 1990 to 83 percent in 2012.

• Only half of women in developing regions receive the recommended amount of health care they need.

• Fewer teens are having children in most developing regions, but progress has slowed.

• The large increase in contraceptive use in the 1990s was not matched in the 2000s.

• The need for family planning is slowly being met for more women, but demand is increasing at a rapid pace.

• Official Development Assistance for reproductive health care and family planning remains low.

Goal 6: Combat HIV/AIDS, Malaria and other Diseases

Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS.

• New HIV infections continue to decline in most regions.

• The number of new HIV infections per 100 adults (aged 15 to 49) declined by 44 percent between 2001 and 2012.

• An estimated 2.3 million cases of people of all ages are newly infected and 1.6 million people died from AIDS-related causes.

• Comprehensive knowledge of HIV transmission remains low among young people, along with condom use.

• About 210,000 children died of AIDS-related causes in 2012, compared to 320,000 in 2005.

Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.

• Antiretroviral medicines to treat HIV were delivered to 9.5 million people in developing regions in 2012.

• Over 900,000 pregnant women living with HIV globally were receiving antiretroviral prophylaxis or treatment by December 2012.

Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases.

• Between 2000 and 2012, the substantial expansion of malaria interventions led to a 42 percent decline in malaria mortality rates globally.

• In the decade since 2000, 3.3 million deaths from malaria were averted, and the lives of three million young children were saved.

• Thanks to increased funding, more children are sleeping under insecticide-treated bed nets in sub-Saharan Africa.

• Treatment for tuberculosis has saved some 22 million lives between 1995 and 2012.

Goal 7: Ensure Environmental Sustainability

Target 7.A: Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources.

• Forests are a safety net for the poor, but they continue to disappear at an alarming rate.

• Global emissions of carbon dioxide (CO₂) have increased by more than 50 percent since 1990.

• In the 26 years since the adoption of the montreal protocol on substances that deplete the ozone layer, there has been a reduction of over 98 percent in the consumption of ozone-depleting substances.

• Afforestation and the natural expansion of forests have reduced the net loss of forest from an average of 8.3 million hectares annually in the 1990s to an average of 5.2 million hectares annually between 2000 and 2010.

Target 7.B: Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss.

• Protected ecosystems covered 14 percent of land and coastal marine areas worldwide by 2012.

Target 7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.

• The world has met the target of halving the proportion of people without access to improved sources of water, five years ahead of schedule.

• Between 1990 and 2012, 2.3 billion people gained access to improved drinking water sources.

• Over a quarter of the world’s population has gained access to improved sanitation since 1990, yet one billion people still resort to open defecation.

• The vast majority of 82 percent of people practicing open defecation now live in middle-income, populous countries.

• In 2012, 748 million people remained without access to an improved source of drinking water.

• Despite progress, 2.5 billion in developing countries still lack access to improved sanitation facilities.

Target 7.D: Achieve, by 2020, a significant improvement in the lives of at least 100 million slum dwellers.

• The target was met well in advance of the 2020 deadline. More than 200 million of these people gained access to improved water sources, improved sanitation facilities, or durable or less crowded housing, thereby exceeding the MDG target.

• 863 million people are estimated to be living in slums in 2012 compared to 650 million in 1990 and 760 million in 2000.

Goal 8: Develop a Global Partnership for Development

Target 8.A: Develop further an open, rule-based, predictable, non-discriminatory trading and financial system.

• Official development assistance hit a record high of $134.8 billion in 2013.

• Aid shifted away from the poorest countries where attainment of the MDGs often lags the most.

Target 8.B: Address the special needs of least developed countries.

• Net bilateral aid to Africa (where 34 of the 48 least developed countries are located) fell by 5.6 percent in 2013, to $28.9 billion in real terms.

• Eighty percent of imports from developing countries enter developed countries duty-free.

Target 8.C: Address the special needs of landlocked developing countries and small island developing states.

Aid to landlocked developing countries fell in 2010 for the first time in a decade, while aid to small island developing states increased substantially.

Target 8.D: Deal comprehensively with the debt problems of developing countries.

The debt burden on developing countries remains stable at about 3 percent of export revenue, which was a near 75 percent drop since 2000.

Target 8.E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.

• Resources available for providing essential medicines through some disease-specific global health funds increased in 2011, despite the global economic downturn.

• There has been a little improvement in recent years in improving availability and affordability of essential medicines in developing countries.

Target 8.F: In cooperation with the private sector, make available benefits of new technologies, especially information and communications.

• Two-thirds of the world’s internet users are in developing regions, where the number of internet users doubled between 2009 and 2014.

• In 2014, internet use penetration in developing countries grew by 8.7 percent, twice as fast as in the developed world where its usage rose by 3.3 percent.

• In Africa, almost 20 percent of the population is online, up from 10 percent in 2010.

• Thirty percent of the world’s youth are digital natives, active online for at least five years.

• More than four billion people do not use the internet, and 90 percent of them are from the developing world.

Health Care Services and Care Provider

The purpose of health care services is to improve the health status of the population. Health care services are provided to achieve the goals of health for all by the year 200 AD and MDGs. Health care system is indented to deliver the health care services. It constitutes the management sector and involves organizational matters. It operates in the context of the socioeconomic and political framework of the country. In India, five major sectors or agencies representing health care systems.

1. Public health sector

a. Primary health care

• Primary health centers

• Subcenters

b. Hospitals/health centers

• Community health centers

• Rural hospitals

• District hospital/health center

• Specialist hospitals

• Teaching hospitals

c. Health insurance schemes

• Employees State Insurance

• Central Govt. Health Schemes

d. Other agencies

• Defence service

• Railways

2. Private Sector

a. Private hospitals, polyclinics, nursing homes and dispensaries

b. General practitioners and clinics

3. Indigenous systems of medicine

• Ayurveda and Siddha

• Unani and Tibbi

• Homeopathy

• Unregistered practitioners

4. Voluntary Health Agencies

5. National Health Programs

Bibliography

1. “Twelfth Five-Year Plan (2012–2017)—Social Sectors” (PDF). Planning Commission. Retrieved 29 Nov 2014.

2. Akrani G. Management By Objectives (MBO)—Peter Drucker MBO. Posted 6/12/2010. Cited 30/11/2014. http://kalyan-city.blogspot.com/2010/06/management-by-objectives-mbo-peter.html.

3. Chatterjee P. Textbook on Public Health and Community Medicine, http://www.slideshare.net/prabirkc/human-resourcessection3ctextbookonpublichealthandcommunitymedicine.

4. Differences Between Pert and CPM. http://civilengineersforum.com/pert-cpm/

5. Drucker, Peter F. “The Practice of Management” in 1954. ISBN 0–06–011095–3.

6. Five Functions of Management. Cited 30/11/2014. http://www.provenmodels.com/3/five-functions-of-management/henri-fayol.

7. Health for All. World Health Organization Belarus, http://undp.by/en/who/healthforall/

8. Health Planning in India: Various Health Committees. Indian Association of Preventive and Social Medicine Gujarat. Module 1: Chapter 4. http://www.iapsmgc.org/userfiles/file/MODULES%20OF%20PGCHSMModl_Ch4_Health%20comittes.pdf.

9. Health Planning in India. Last updated on 4/28/2011. http://business.mapsofindia.com/india-planning/health.html.

10. Health Policy. WHO. http://www.who.int/topics/health_policy/en/.

11. Health, Nutrition and Family Welfare. Updated/Modified: September 18 2014 15:19:30. http://planningcommission.nic.in/sectors/health.php?sectors=hea.

12. Henri Fayol’s Principles of Management, Early Management Theory. Cited 30/11/2014. http://www.mindtools.com/pages/article/henrifayol.htm.

13. History. The Planning Commission: Government of India. Updated/Modified: November 05 2014 10:52:52. http://planningcommission.gov.in/aboutus/history/index.php?about=aboutbdy.htm.

14. Kim M. Leontief Input-Output Model, http://www.unc.edu/-marzuola/Math547_S13/Math 547_S13_Projects/M_Kim_Section001_Leontief_IO_Model.pdf.

15. Millennium Development Goals and Beyond 2015. http://www.un.org/millenniumgoals/global.shtml.

16. National Health Policy-2002. 2/9/2011. http://mohfw.nic.in/WriteReadData/1892s18048892912105179110National%20Health%20policy-2002.pdf.

17. ParkK.

18. Twelfth Five-Year Plan (2012–2017): Faster, More Inclusive and Sustainable Growth, http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_voll.pdf.

19. What Next for Faster, More Inclusive and Sustainable Growth. Overview of the 12th Five-Year Plan (2012–2017). Planning Commission of India, http://www.slideshare.net/PlanComlndia/presentation-on-the-12th-plan.

19

Health Administration in India

This chapter contains

▪ Health Administration in India at Central Level

▪ Health Administration in India at State Level

▪ Health Administration in India at District Level

▪ Local/Peripheral Government in India

• Urban Local Self-government

– Municipal Corporation

– Municipality

– Nagar Panchayat

• Rural Local Self-government: Panchayat! Raj

– Village Level Panchayat

– Block Level Panchayat

– District Level Panchayat

INTRODUCTION

The public health system in India comprises a set of state-owned health care facilities funded and controlled by the government of India. Some of these are controlled by agencies of the central government while some are controlled by the governments of the states of India. The governmental ministry which controls the central government interests in these institutions is the Ministry of Health and Family Welfare. The central responsibilities consist mainly of policymaking, planning, guiding, assisting, evaluating and coordinating the work of State Health Ministries. The health system in India has 3 main links:

A. Central

B. State

C. District

A. At the Centre Level

Central level of health system consists of:

1. Union Ministry of Health and Family Welfare.

2. The Directorate General of Health Services.

3. The Central Council of Health and Family Welfare.

1. Union Ministry of Health and Family Welfare

Headed by: A Cabinet Minister, a Minister of State and a Deputy Health Minister. Departments: Department of Health and Department of Family Welfare Service

a. Department of Health

Executive head: Secretary to the Government of India

Executive head is assisted by:

• Joint Secretaries

Fig. 19.1

• Deputy Secretaries

• Administrative Staffs

b. Department of Family Welfare Service

Executive head: Secretary to the Government of India

Executive head is assisted by:

• Additional Secretary

• Commissioner of Family Welfare

• One Joint Secretary

Other departments in Ministry of Health

• Department of AIDS Control

• Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH)

• Department of Health Research

Functions

Major programs under Ministry of Health and Family Welfare are:

• Communicable diseases

• Non-communicable diseases

• Injury and trauma

• Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

• Poor Patients-Financial Support

• Infrastructure Maintenance

• Other National Health Programs

The functions of the Union Ministry of health and family welfare are mentioned in the seventh schedule of Article 246 of the Constitution of India under: Union List and Concurrent List.

a. Union List

• International health relations and administration of port quarantine.

• Administration of central institutes such as the All India Institute of Hygiene and Public Health, Kolkata; National Institute for the Control of Communicable Diseases, Delhi, etc.

• Promotion of research through research centers and other bodies.

• Regulation and development of medical, pharmaceutical, dental and nursing professions

• Establishment and maintenance of drug standards

• Census and collection and publication of other statistical data

• Immigration and emigration

• Regulation of labor in the working of mines and oil fields

• Coordination with states and with other ministries for promotion of health

b. Concurrent list: These are responsibilities of both Union and State Governments.

• Prevention of extension of communicable diseases from unit to another

• Prevention of adulteration of foodstuffs

• Control of drugs and poisons

• Vital statistics

• Labor welfare

• Ports other than major

• Economic and social planning

• Population control and family planning

2. The Directorate General of Health Services (DGHS)

The Directorate General of Health Services, a source of technical knowledge, is an attached office of this Ministry. The DGHS also renders technical advice on all medical and public health matters and in the implementation of various health schemes. In order to implement the policies and programs of the Ministry in an effective manner, there are three subordinate offices located at various places in the country which function directly under the Ministry. The Ministry is also administratively concerned with 29 autonomous/statutory bodies. There are also three Public Sector Undertakings under the administrative control of the Ministry.

Functions: The general functions are surveys, planning, coordination, programming and appraisal of all health matters in the country.

Specific functions are:

• International health relations and quarantine in all major ports of country

• Control of drug standards

• Medical store depots

• Postgraduate training to different category of health personnel

• Medical education

• Medical research

• Central Government health scheme

• National health programs

• Central health education bureau

• Health intelligence

• National medical library

3. The Central Council of Health and Family Welfare

Chairman: The Union Health Minister

Members: State Health Minsters

Functions

• To consider and recommend broad outlines of policy

• To make proposals for legislations related to medical and public health matters

• To make recommendations to the central government regarding distributions and utilizations of grants-in-aid

• To establish any organization.

B. At the State Level

In 1919, States obtained autonomy in matters of public health from the central government. Each state is responsible for all the health services operating within the particular state. In all states, the management sector comprises: the State Ministry of Health and a Directorate of Health.

1. State Ministry of Health

Headed by: A Minister of Health and Family Welfare and a Deputy Minister of Health and Family Welfare.

Health Secretariat: Headed by Secretary (senior officer of the Indian Administrative Services); assisted by Deputy Secretaries, Under Secretaries and a large number of administrative staffs.

2. State Health Directorate

Headed by: The Director of Health Services or Director of Health and Family Welfare (also known as Director of Medical and Health Services in some states).

• Is the chief technical advisor to the State Government on all matters related to medicine and public health.

• Is responsible for organization and direction of all health activities.

Director of Health and Family Welfare is assisted by: Deputy and Assistant Directors (Regional and Functional).

Regional Directors: Inspect all the branches of public health within their jurisdiction, irrespective of their specialty.

Functional Directors: Are usually specialists in a particular branch of public health (e.g. mother and child health, family planning, nutrition, various communicable diseases, health education, etc.)

C. At the District Level

Collector is the head administrator at district level. Within each district there are 6 types of administrative areas:

1. Subdivisions: Districts of India are divided into two or more subdivisions. Incharge is Assistant Collector or Sub-Collector.

2. Tehsils (Talukas): Each subdivisions are again divided into Tehsils (Talukas); one tehsil between 200 and 600 villages. Incharge is Tehsildar.

3. Commonly Development Blocks: After launching of community development program (1952) in India, rural areas in districts were organized into blocks. Blocks may or may not coincide with Tehsils. One block covers approximately 100 villages (80,000 to 120,000 population). Incharge is Block Development Officer.

4. Municipalities and Corporations: These are the institutions of urban local self-government.

5. Village Panchayat: These are the institutions of rural local self-government. All development programs are channeled through these bodies.

Under the Multipurpose Workers Scheme, it has been suggested to the States to set up and integrated health services comprises a Chief Medical Officer with three Deputy CMOs (existing Civil Surgeons, District Health Officers and District Family Welfare Officers). Each Deputy CMO should be the incharge of one-third of the district for all the Health, Family Welfare and MCH Programs. It has been recommended by Planning Commission that the District Hospitals should be converted into District Health Centers and will monitor all preventive, promotive and curative services of one million population.

Local Government in India

Local Government in India

Urban
Municipal Corporation (Mahanagar Palika/Nagar Nigam)
Municipality (Municipal Council/Municipal Committee/Nagar Palika)

Intermediate
Town Panchayat (Nagar Panchavat)

Rural
District Panchayat (Zila Parishad) Block Panchayat/Taluka Panchayat/PanchayatSamiti/Panchayat Union/Cram Panchavat (Sarpanch)

Urban Local Self-government

The English word “Municipality” derivesfrom the Latin social contract “municipium”, meaning duty holders. Municipal Governance in India has been in existence since the year 1687 with the formation of Madras Municipal Corporation and then Calcutta and Bombay Municipal Corporation in 1726.

The urban areas of the district are organized into the following institutions of local self-government:

i. Town area committee: In areas with population of 5,000–10,000.

ii. Municipal Boards: In areas with population of 10,000–200,000.

iii. Corporations: In areas with population above 200,000.

Administration: Incharge of Municipality is Chairman or President and incharge of corporation is Mayors. The Councillors are elected from different wards of the city. The executive agency includes Commissioner, Secretary, Engineer and Health Officer.

As per the Indian Constitution, 74th Amendment Act of 1992, the latter two categories of towns are to be designated as municipalities or nagar panchayats with elected bodies.

After the 74th Amendment is enacted there are only three categories of urban local bodies:

1. Mahanagar Nigam (Municipal Corporation)

2. Nagar Palika (Municipality)

3. Nagar Panchayat (Notified Area Council, City Council)

1. Mahanagar Nigam (Municipal Corporation): In India, Mahanagar Nigam are the state government formed departments that work for the development of a Metropolitan city, which has a population of more than 1 million. The growing population and urbanization in various cities of India are in need of a local governing body that can work for providing necessary community services like health centers, educational institutes and housing and property tax.

They mainly deal in providing essential services in every small town as well as village of a district/city. Their elections are held once in five years and the people choose the candidates. The largest corporations are in the five metropolitan cities of India, namely Delhi, Mumbai, Kolkata, Chennai and Bengaluru.

2. Nagar Palika (Municipality): In India, a Nagar Palika or Municipality or Nagar Nigam is an urban local body that administers a city of population 100,000 or more. However, there are exceptions to that, as previously Nagar Palikas are constituted in urban centers with population over 20,000 so all the urban bodies which are previously classified as Nagar Palika are reclassified as Nagar Palika even if their population is under 100,000. It interacts directly with the state government, though it is administratively a part of the district it is located in. Generally smaller district cities and bigger towns have a Nagar Palika.

The members of the Nagar Palika are elected representatives for a term of five years. The town is divided into wards according to its population, and representatives are elected from each ward. The members elect a president among themselves to preside over and conduct meetings. A chief officer, along with officers like an engineer, sanitary inspector, health officer and education officer who come from the state public service are appointed by the state government to control the administrative affairs of the Nagar Palika.

3. Nagar Panchayat (Notified Area Council):

A Nagar Panchayat or Notified Area Council (NAC) or City Council is a form of an urban political unit in India comparable to a municipality. An urban center with more than 11,000 and less than 25,000 inhabitants is classified as a “Nagar Panchayat”.

Each Nagar Panchayat has a committee consisting of a chairman with ward members. Membership consists of a minimum of ten elected ward members and three nominated members. The NAC members of the Nagar Panchayat are elected from the several wards of the Nagar Panchayat on the basis of adult franchise for a term of five years. There are seats reserved for Scheduled Castes, Scheduled Tribes, backward classes and women. The Councillors or Ward Members chosen by direct election from electoral wards in the Nagar Panchayat.

Functions of Municipal Corporation

• Urban planning including town planning

• Regulations of land use and construction of buildings

• Planning for economic and social development

• Constructions and maintenance of roads

• Sanitation and drainage

• Street lighting

• Slum improvement

• Water supply

• Maintenance of hospitals and dispensaries

• Education

• Urban forestry

• Registration of births and deaths, etc.

Rural Local Self-government: Panchayati Raj

The Panchayati Raj is a South Asian political system mainly in India, Pakistan, Bangladesh and Nepal. It is the oldest system of local government in the Indian subcontinent. The word “panchayat” literally means “assembly” (ayat) of five (panch) wise and respected elders chosen and accepted by the local community. Modern Indian government has decentralized several administrative functions to the local level, empowering elected Gram Panchayats. Panchayat Raj is a system of governance in which Gram Panchayats are the basic unit of administrations. It has 3 levels:

1. Village level Panchayat: Panchayat

2. Block level Panchayat: Panchayat Samiti

3. District level Panchayat: Zila Parishad

1. Village level Panchayat: Panchayat

• Gram Sabha: In this, all the adults of the village meets at least twice a year and hold meeting to decide about taxation, annual program plan and elects members of Gram Panchayat.

• Gram Panchayat: Is the executive organ of gram sabha. They are for planning and development of village.

• Naya Panchayat: They handle various legal matters at village level.

Every Panchayat has an elected President (Sarpanch/Mukhya), a Vice-President and a Panchayat Secretary. Functions of Panchayat Secretary are, they cover civic administration including sanitation and public health; social and economic development of village.

2. Block level Panchayat: Panchayat Samiti

A Block Panchayat (Panchayat Samiti) is a local government body at the tehsil or taluka level in India. This body works for the villages of the Tehsil or Taluka that together are called a Development Block. The Panchayat Samiti is the link between the Gram Panchayat and the district administration.

The constituency is composed of exofficial members (all Sarpanchas of the Panchayat Samiti, the MPs and MLAs of the area and the SDO (Sub-Divisional Officer), co-opt members (representatives of SC/ST and women), associate members (a farmer of the area, a representative of the cooperative societies and one of the marketing services), and some elected members. The samiti is elected for 5 years and is headed by the Chairman and the Deputy Chairman.

The common departments in the Samiti are as follows:

1. General administration

2. Finance

3. Public work

4. Agriculture

5. Health

6. Education

7. Social welfare

8. Information technology,

9. Water supply dept

10. Animal husbandry and others.

Functions

1. Implementation schemes for the development of agriculture.

2. Establishment of primary health centers and primary schools.

3. Supply of drinking water, drainage and construction/repair of roads.

4. Development of cottage and small-scale industries, and the opening of cooperative societies.

5. Establishment of youth organizations.

Sources of income

The main source of income of the Panchayat samiti are grants-in-aid and loans from the State Government.

3. District level Panchayat

The governing system at district level in Panchayat Raj is also popularly known as “Zila Parishad”. Chief of administration is an officer from IAS cadre.

Functions

1. Provide essential services and facilities to the rural population.

2. Supply improved seeds to farmers. Inform them of new farming techniques.

3. Set up and run schools and libraries in the rural areas.

4. Start Primary Health Centers and hospitals in villages. Start vaccination drives against epidemics.

5. Execute plans for the development of the scheduled castes and tribes. Run ashram-shalas for adivasi children. Set up free hostels for them.

6. Encourage entrepreneurs to start small-scale industries and implement rural employment schemes.

7. Construct bridges, roads and other public facilities and their maintenance

8. Provide employment.

Sources of income

1. Taxes on water, pilgrimage, markets, etc.

2. Fixed grant from the State Government in proportion with the land revenue and money for works and schemes assigned to the Parishad.

Bibliography

1. Ministry of Health and Family Welfare. Government of India. Major Health Program [Internet] [cited 2014 Aug 13]. Available from: http://mohfw.nic.in/index4.php?lang=l&level=0&linkid=316&lid=1610.

2. Government of India. Ministry of Health nd Family Welfare. Directorate General of Health Services [Internet] [cited 2014 Aug 14]. Available from: http://mohfw.nic.in/indexl.php?lang=l&level=0&lid=167&linkid=46.

3. The Constitution (Seventy-fourth Amendment) Act, 1992 [Internet] [cited2014 Aug 19]. Available from: http://indiacode.nic.in/coiweb/amend/amend74.htm.

4. Mullick R and Raaj N. “Panchayats Turn into Kangaroo Courts”. The Times of India [Internet] 2007 Sep 9 [cited 2014 Aug 19]. Available from: http://timesofindia.indiatimes.com/home/stoi/deep-focus/Panchay ats-tum-into-kangaroo-courts/articleshow/2351247.cms.

5. India 2007, p 696, Publications Division, Ministry of Information and Broadcasting, Government of India [Internet] [cited 2014 Aug 19], Available from: http://en.wikipedia.org/wiki/Ministry_of_Information_and_Broadcasting_(India).

6. Government of India. Ministry of Panchayati Raj [Internet] [cited 2014 Aug 19], Available from: http://www.panchayat.gov.in/

7. Park K. Preventive and Social Medicine. 20th ed. Jabalpur: Banarsidas Bhanot; 2009.

8. Union Government. Ministry of Finance [Internet] [cited 2014 Aug 14]. Available from: http://goidirectory.nic.in/ministries_index.php?ct=17.

20

Primary Health Care

This chapter contains

▪ Definition

▪ Origin of Primary Health Care

▪ The Declaration of Alma Ata

▪ Elements of PHC

▪ Principles of PHC

▪ Primary Health Care in India

• Village Level

• Subcenter Level

• Primary Health Center Level

• Community Health Center Level

INTRODUCTION

Primary Health Care (PHC) is an approach to health beyond the traditional health care system that focuses on health equity. The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieve that goal:

• reducing exclusion and social disparities in health (universal coverage reforms);

• organizing health services around people’s needs and expectations (service delivery reforms);

• integrating health into all sectors (public policy reforms);

• pursuing collaborative models of policy dialogue (leadership reforms); and

• increasing stakeholder participation.

Health service package should be appropriate, available, accessible, affordable and acceptable. Primary health care was based on that.

Fig. 20.1

DEFINITION

Primary Health Care is an essential health care made universally accessible to individual and acceptable to them, through their full participation and at a cost the community and country can afford.

—Alma Ata Conference

ORIGIN OF PRIMARY HEALTH CARE

World Health Assembly in their 30th meeting recognized that world is faced with health problems of enormous magnitude. Distribution of health resources throughout the world is not only inadequate but also inequitable. So increased recognition of the failure of existing health services to provide health care, alternative ideas and methods have been considered and tried. Joint WHO-UNICEF international conference in 6–12th September, 1978 at Alma Ata (Soviet Kazakhstan, USSR) discussed that matter. The Govt, of 134 countries and many voluntary agencies called for “Revolutionary Approach” to health care declaring that condition is unacceptable. Called for acceptance of the WHO goal of Health for All by 2000 AD and proclaimed PHC as way to achieving HFA. It was left to each country to innovate, according to its own circumstances to provide primary health care.

The Declaration of Alma Ata, 12th September, 1978

The International Conference on Primary Health Care, meeting in Alma-Ata this 12th day of September in the year 1978, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following.

Declaration

I. The Conference strongly reaffirms that health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

II. The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

III. Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

IV. The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

V. Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attain this target as a part of development in the spirit of social justice.

VI. Primary health care is essential health care based on practically, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

VII. Primary health care:

1. Reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience.

2. Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly.

3. Includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.

4. Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors.

5. Requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate.

6. Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need.

7. Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

VIII. All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally.

IX. All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.

X. An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, detente and disarmament could and should release additional resources that could be well-devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.

The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this declaration.

PHC approach has been described as “health by the people” and “placing people’s health in people’s hands”. PHC is accepted by the member countries of WHO as the key in achieving the Goal of Health for All by the year 2000 AD.

Elements of PHC

Alma Ata declaration has outlined 8 essential components of primary health care.

1. Education concerning prevailing health problems and the method of preventing and controlling them.

2. An adequate supply of safe water and basic sanitation.

3. Promotion of food supply and proper nutrition.

4. Maternal and child health care, including family planning.

5. Immunization against major infectious diseases.

6. Prevention and control of locally endemic diseases.

7. Appropriate treatment of common diseases and injuries.

8. Provision of essential drugs.

1. Education concerning prevailing health problems and the methods of preventing and controlling them: Health education is an integral part of all health services and hence all health personnel, including nurses are responsible for educating people as to how they can improve their own health. Health education on the prevailing health problems on certain community (e.g. diarrhea, dysentery, upper respiratory tract infection, leprosy, TB, as in develop country HIV/AIDS, child abuse, sexual abuse, drug addiction, heart diseases, etc.) should be given with main focus on preventive aspect and ways of control it.

2. An adequate supply of safe water and basic sanitation: A safe water supply and clean and proper disposal of wastes can prevent lots of disease burden on community. Until there is an adequate access to safe water and basic sanitation waterborne diseases will be still prevalent. Primary health care focuses to teach the community regarding environmental sanitation, purification of water, etc.

3. Promotion of food supply and proper nutrition: There is direct relation between nutrition and health. In developing countries nutritional deficiency diseases are prevalent causing mortality, morbidity and disability of children. Protein calorie malnutrition, vitamin A deficiencies which increase susceptibility to various infections, e.g. exophthalmia, night blindness, dry skin, iodine deficiency diseases, etc. are common. Community surveillance should be done to find out malnourished child by monitoring growth charts for nutritional monitoring, conducting nutritional education program, making provision to supply iodized salt, vitamin A supplement, food supplement, deworming, iron supplement, etc. in collaboration with other sectors. Measure should be taken to improve personal hygiene, environmental sanitation and we can also assist to grow various types of foods in their kitchen garden.

4. Maternal and child health care including family planning: This aim is taken to reduce the mortality and morbidity of mothers, infants and children by promoting best possible care of mother during her pregnancy (antenatal), delivery (natal) and throughout the child bearing period of life (postnatal); promoting the best possible health condition for infants and children (care of underfive children) with special emphasis on adequate nutrition and protection from infectious disease and by promoting better health within the family by helping parents to plan for the number of children they desire. This may include advice on adequate spacing of children or when it is appropriate by the use of family planning methods.

5. Immunization against infectious diseases: Immunization is to prevent endemic and epidemic diseases. Great stride have been made in immunization of the world’s children against seven major vaccine preventable diseases (measles, diphtheria, pertussis, hepatitis, tuberculosis, polio and TB). These diseases can be easily prevented by active immunization.

6. Prevention and control of locally endemic diseases: Education plays an important role on prevention of locally endemic diseases such as diarrhea, common cold, TB, worm infestation, malnutrition, vaccine preventable diseases, STDs, HIV/AIDS, leprosy, etc. Primary health care aims to teach the community about preventive measures by providing information on mode of transmission, causes and also the preventive measures as maintaining personal hygiene, environmental sanitation, water purification, medications, screening of disease, followup the cases and conduct surveillance in risk population.

7. Appropriate treatment of common diseases and injury: Treatment of minor ailments and first aid measures may be taken at village level to treat common diseases and injuries. These can be done at the subcenter, primary health center and community health center along with appropriate referral services.

8. Provision of essential drugs: Adequate provision of essential drugs at a cost that the community can afford is critical to the success of PHC. Appropriate treatment requires the provision of essential drugs that are safe and effective, of high quality, capable of being adequately supplied, stored and distributed. In addition to provision of essential drugs, many countries are studying the use of herbal and other traditional medicines and treatment in PHC.

Elements also can be listed out as:

• E

=
Education for prevention and controlling of health problem

• L

=
Locally endemic (constant presence of disease within a particular area) disease control.

• E

=
Expanded program of immunization

• M

=
MCH and FP

• E

=
Essential drug supply

• N

=
Nutrition and food supply

• T

=
Treatment of common diseases and injury

• S

=
Safe water supply and basic sanitation

Principles of Primary Health Care

Principles of primary health care are:

1. Equitable distribution

2. Community participation

3. Intersectoral coordination

4. Appropriate technology

Behind these elements lies a series of basic principles identified in the Alma Ata Declaration that should be formulated in national policies in order to launch and sustain PHC as part of a comprehensive health system and in coordination with other sectors:

1. Equitable distribution of health care: Health services concentrated in major town and cities which is a social injustice. According to this principle, primary care and other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, caste, color, urban/rural location and social class, i.e. rich, poor, needy and vulnerable groups as in rural area and urban slums. PHC aims to achieve this principal is to redress this imbalance by shifting the center of gravity of the health care system from cities to the rural areas.

Fig. 20.2

2. Community participation: In order to make the fullest use of local, national and other available resources. It is an essential ingredient of primary health care, involvement of individuals, families and communities in promotion of their own health and welfare as health is not only state or central govt, responsibility. It promotes universal coverage and meaningful involvement of community in:

a. Planning

b. Implementation

c. Maintenance of health service

d. Reliance on local resources (manpower, money, materials)

Example: India: village health guide and trained dais, they are selected by local community and trained locally free of charge who gives care overcoming cultural and communication barrier.

3. Use of appropriate technology: “Technology that is scientifically sound, adaptable to local needs, acceptable to those who apply it and those for whom it is used, and that can be maintained by people themselves in keeping with the principle of self-reliance with the resources the community and country can afford”. Medical technology should be provided that is accessible, affordable, feasible and culturally acceptable to the community. Examples of appropriate technology include refrigerators for vaccine cold storage. Less appropriate could include, in many settings, body scanners or heart-lung machines, which benefit only a small minority concentrated in urban areas. They are generally not accessible to the poor, but draw a large share of resources. Also luxurious hospitals, costly equipment, procedures, techniques totally inappropriate to the local needs but absorb a major part of the national health budget.

4. Intersectoral coordination: Health sector alone cannot provide comprehensive care; other sectors are equally important in promoting the health and self-reliance of communities. These sectors include, at least: agriculture (e.g. food security); education; communication (e.g. concerning prevailing health problems and the methods of preventing and controlling them); housing; public works (e.g. ensuring an adequate supply of safe water and basic sanitation); rural development; industry; community organizations (including panchayats or local governments, voluntary organizations, etc.). To achieve such cooperation need to review administrative system, reallocate their resources, introduce suitable legislation, strong political resource will to translate values into action. The important aspect of this principle is planning with other sector to avoid unnecessary duplication.

Fig. 20.3

PRIMARY HEALTH CARE IN INDIA

In 1978, Alma Ata Conference set the goal of “Health for All by the year 2000 AD”. Keeping in view the WHO goal of “health for all 2000 AD” Government of India evolved a National Health Policy based on primary health care approach. It was approved by parliament in 1983. Steps to implement the National Health Policy objectives towards achieving Health for all by the year 2000 in:

1. Village level

2. Subcenter level

3. Primary health center level

4. Community health center level

1. Village level: One of the basic objectives of primary health care is universal coverage and equitable distribution of health resources. That will be possible when health care will reach into the furthest rural areas and everyone will be able to access and afford it. Following schemes have been taken by government to achieve this goal:

a. Village health guides scheme

b. Training of local dais

c. ICDS scheme

a. Village health guides (VHGs) scheme: This scheme is introduced on 2nd October, 1977 with the idea of securing people’s participation in the care of their own health. The guidelines for their selection are:

• They should be permanent residents of the local community, preferably women.

• They should be able to read and write, with minimum formal education up to 6th standard.

• They should be acceptable to all sections of the community.

• They should be able to spare at least 2–3 hours every day for community health work.

After selection they undergo a short training arranged in the nearest primary health center, subcenter or any other suitable place. Duration of course is 200 hours spread over 3 months with a stipend of ₹ 200 per month. On completion of training, they receive a working manual and a kit of simple medicines as used in their country. They get paid a honorium of ₹ 50 per month and drugs worth ₹ 600 per annum.

Duties of VHGs

• Treatment of simple ailments and providing first aid care

• Mother and child health including family planning

• Health education

• Sanitation

• Referral system.

Training of VHGs involves expenditure, thus Government schedules this training in every 3 years. The training program is being continued during the ninth five-year plan (1997–2002) to achieve the national target of one health guide for each village or 1000 rural population.

b. Local dais: Even in this era of modernization, most deliveries in rural areas are conducted by local dais, i.e. traditional birth attendants (TBA) which is another cause of increased maternal and neonatal mortality and morbidity rate. A widespread program has been undertaken, under the Rural Health Scheme, to train all categories of TBAs to improve their knowledge on maternal and child health care, conduction of normal delivery scientifically, maintenance of asepsis, sterilization, identification of high risk pregnancy, etc.

Training is given for 30 working days with a stipend of ₹ 300 at primary health center, subcenter or MCH center for 2 days in a week. Remaining four days of week they accompany with health worker female preferably in their own village. During training period they need to conduct at least 2 deliveries under supervision of HW (F), ANM or HA (F).

After completion of training they receive a delivery kit and a certificate. She is supposed to get ₹ 3 for registering each infant and ₹ 10 per each delivery if the case is registered in subcenter or primary health center. In eighth five-year plan, one objective is to train all untrained dais practicing in rural areas, though national target is to train one local dai in each village.

c. Anganwadi worker: The word Anganwadi means “courtyard shelter” in Indian languages. They were started by the Indian government in 1975 as part of the Integrated Child Development Services program to combat child hunger and malnutrition. There should be one anganwadi worker for a population of 1000. They are selected from the same community where she will be working. Training is given to them on health, nutrition and child development for 4 months. She gets ₹ 200–250 per month for her job. Government of India has enhanced the honoraria, w.e.f. 1:4:2008 by ₹ 500 above the last honorarium drawn by Anganwadi Workers (AWWs).

Her duties are health check-up, immunization, supplementary nutrition, health and nutritional education to families especially to pregnant women, non-formal preschool education, enhancing breastfeeding practices, motivating family for family planning, care of underfive children, implementation and execution of Kishori Shakti Yojana (KSY) to educate teenage girls and parents by organizing social awareness programs and referral services.

Facilites given to Anganwadi workers: Insurance Cover: The Government of India introduced Anganwadi Karyakarti Bima Yojana’ to Anganwadi Workers/Anganwadi Helpers w.e.f. 1:4:2004 under Life Insurance Corporation’s Social Security Scheme. The amount of premium is ₹ 80. Under this Bima Yojana, a free ad on scholarship is available for the children of the members who are covered under the scheme. Scholarship of ₹ 300 per quarter for students of 9th to 12th standards [including ITI courses] would be provided. Scholarship is limited to two children per family.

Award: In order to motivate the Anganwadi Workers and give recognition to good voluntary work, a Scheme of Award for Anganwadi Workers has been introduced, both at the National and State Levels. The Award comprises ₹ 25,000 cash and a Citation at Central level and ₹ 5000 cash and a Citation at State level.

Uniform: Government has made a provision for a Uniform (saree/suit @ ₹ 200 per saree per annum) and a name badge to Anganwadi Workers and Helpers.

2. Subcenter level: The subcenter is the peripheral outpost of the Indian health care system. One subcenter caters to the health care needs of 5000 population in general and 3000 population in hilly, tribal and backward areas.

Categorization of subcenter

a. Type A

b. Type B

Type A subcenter provides all recommended services except that the facilities for conducting delivery will not be available here. They are:

i. Subcenters not having adequate space and physical infrastructure for conducting deliveries.

ii. Subcenters situated in the locality of other higher health facilities like PHC/CHC/FRU/hospital, where delivery facilities are available.

iii. Subcenters in headquarter area

iv. Subcenters where at present no delivery or occasional delivery may be taking place, i.e. very low case load of deliveries.

Type B (MCH subcenter)

This would include following types of subcenters:

i. Centrally or better located subcenters with good connectivity to catchment areas.

ii. They have good physical infrastructure preferably with own buildings, adequate space, residential accommodation and labor room facilities.

iii. They already have good case load of deliveries from the catchment areas.

iv. There are no nearby higher level delivery facilities.

Staff pattern of subcenter

• 1 female health worker—auxiliary nurse midwife

• 1 male health worker—multipurpose worker

• Voluntary worker to help the auxiliary nurse midwife

1 Female Health Assistant (Lady Health Visitor) and 1 Male Health Assistant at the PHC level are given the supervision of 6 subcenters.

Services provided by subcenter

• Antenatal, natal, postnatal

• Family planning including IUD insertion and counselling

• Treatment of common illnesses like respiratory tract infections, diarrhea, fever, worm infestation

• Immunization and child care

• Prevention of malnutrition

• Implementation of various national health programs

• Simple lab investigation (routine examination of urine albumin and sugar)

• Early detection of complications of pregnancy.

Funding of subcenter

The central government gives salary to the Lady Health Visitor and the Auxiliary Nurse Midwife in addition to contingency fund, drug and equipment supply. The state government gives salary to the multipurpose worker. The voluntary worker is paid from the contingency fund of the Auxiliary Nurse Midwife.

3. Primary health center level: The Bhore Committee in 1946 gave the concept of a primary health center as a basic health unit to provide curative and preventive health care. One PHC should cover 30,000 rural population in plains and 20,000 population in hilly, tribal and backward areas according to National Health Plan (1983).

Staffing pattern

• Medical officer: 1

• Pharmacist: 1

• Nurse midwife: 1

• Health worker (female)/ANM: 1

• Block extension educator: 1

• Health assistant (male): 1

• Health assistant (female)/LHV: 1

• UDC: 1

• LDC: 1

• Laboratory technician: 1

• Driver: 1

• Class IV: 4

Functions of PHC

• Infant immunization programs: Immunization for newborns under the national immunization program is dispensed through the PHCs. This program is fully funded.

• Anti-epidemic programs: The PHCs act as the primary epidemic diagnostic and control centers for the rural India. Whenever a local epidemic breaks out, the system’s doctors are trained for diagnosis. They identify suspected cases and refer for further treatment.

• Birth control programs: Services under the national birth control programs are dispensed through the PHCs.

• Pregnancy and related care: A major focus of the PHC system is medical care for pregnancy and child birth in rural India. This is because people from rural India resist approaching doctors for pregnancy care which increases neonatal death. Hence, pregnancy care is a major focus area for the PHCs.

• Emergencies: All the PHCs store drugs for medical emergencies which could be expected in rural areas. For example, antivenoms for snake bites, rabies vaccinations, etc.

• Medical care: Diagnosis and treatment of minor ailments

• Collecting and reporting of vital statistics

• Provision of Health Education (e.g. safe water supply and basic sanitation, family planning, nutrition, etc.).

• Conduction of N ational Health Programs

• Referral services

• Training of health guides, health workers, local dais and health assistants

• Basic laboratory services

A PHC should have the facilities of selected surgical procedure (vasectomy, tubectomy, MTP, minor surgery, etc.).

4. Community health center (CHC) level: Community health centers are established by upgrading primary health center (31st March, 2003). Each CHC covers a population of 80,000 to 120,000. A CHC should have 30 beds and specialists in surgery, medicine, obstetrics, gynecologist, pediatrics with X-ray and laboratory facilities.

Staffing pattern

• Medical officer: 4

• Nurse midwives: 7

• Dresser: 1

• Pharmacist/compounder: 1

• Laboratory technician: 1

• Radiographer: 1

• Ward boy: 2

• Dhobi: 1

• Sweepers: 3

• Mali: 1

• Chowkidar: 1

• Aya: 1

• Peon: 1

Functions in CHC

• Inpatient and outpatient cares

• Medical care and preventive services

• Minor surgery

• MCH and care of child

• Family planning

• Organization of National health programs (DOTS, immunization, etc.)

• Organization of health camp (special camp as eye camp, vasectomy camp, general camp)

• Laboratory investigation

• Ambulance service

• Referral services

Community Health Centers (CHCs) in the US are neighborhood health centers generally serving Medically Underserved Areas (MUAs) which include persons who are uninsured, underinsured, low-income or those living in areas where little access to primary health care is available. Largely, federally and locally funded, some health clinics are surprisingly modernized with new equipment and electronic medical records. In 2006, the National Association of Community Health Centers implemented a model for offering free, rapid HIV testing to all patients between the ages of 13 and 64 during routine primary medical and dental care visits.

Bibliography

1. Barbara S. “Politics, Primary Health Care and Health: Was Virchow Rights?.” } Epidemiol Community Health, 2011. [cited 2014 Sep 13]; 65:653–655.10.1136/jech.2009.102780.

2. Cueto M (2004). “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004, 94 (11): 1864–1874/10.2105/AJPH.94.11. 1864.

3. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 [Internet] 1978 Sep [cited 2014 Nov 17]. Available from: http://www.who.int/publications/almaata_declaration_en.pdf.

4. Directorate General of Health Services, Ministry of Health and Family Welfare Government. Indian Public Health Standards (IPHS) Guidelines for Subcenter [Internet] 2012 [cited 2014 Nov 21]. Available from: http://tripuranrhm.gov.in/Guidlines/24–07d.pdf.

5. ICDS. Ministry of Women and Child Development. Government of India. Health Education. [Internet] 2014 [cited 2014 Nov 11]. Available from: http://wcd.nic.in/icds/icdsteam.aspx.

6. Park K. Preventive and Social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

7. Primary Health Care. [Internet] 2008 [cited 2014 Nov 11]. Available from: http://www.who.int/topics/primary_health_care/en.

8. Subcenter Level Health Care in India [Internet] 2008 [cited 2014 July 21]. Available from: https://pgblazer.com/sub-center-level-healthcare-in-india.

21

Job Description of Different Categories of Health Personnel in Community

This chapter contains

▪ Public Health Nurse

▪ Medical Officer

▪ Community Health Officer

▪ Block Extension Educator

▪ Health Workers—Male and Female

▪ Health Assistants—Male and Female

▪ Laboratory Technician

▪ Computer

▪ Health Guide

▪ Dai

▪ Anganwadi Worker

▪ ASHA

▪ Traditional Birth Attendant (TBA)

▪ Skilled Birth Attendant (SBA)

INTRODUCTION

Provision of comprehensive health care is not possible by individual effort. It needs a group of various categories of health personnel to work together. Each of them has different job description. Each one has been explained in detail in this chapter.

PUBLIC HEALTH NURSE

a. Working relationship: The public health nurse assists the District Medical Officer or District Family Welfare Officer in planning, implementing and evaluating Maternal and Child Health and Nutrition Program undertaken in the district. Works in collaboration with other functionaries in the District Family Welfare Bureau like the Mass Media and the Extension officer, Health Education officer, Statistical Officer, etc.

b. Duties and functions are to:

• help in organization of Maternal and Child Health Program as a whole and in the implementation of the special plan scheme, centrally sponsored and otherwise in particular like immunization program, training of Dais and their active involvement in MCH/FP work, prophylaxis against nutritional deficiency disease, etc.

• Promote health and nutrition education activities through the Lady Health Visitors, Auxiliary Nurse Midwives by providing them with ‘taking points’ and printed materials produced by various agencies.

• Help in developing school health program in district.

• Ensure regular supply of equipments, records, registers, drugs, vaccines and other sundries necessary for MCH work in the Primary Health Centers and subcenters by assisting storekeepers in procuring and disturbing the supplies.

• Help the statistical officer in the District Family Welfare Bureau in compiling the periodical progress reports of the MCH activities.

• Give technical guidance, supervision and supports to subordinates.

• Investigate into complaints against female paramedical personnel in the district and submit reports recommended to the District MO/District Family Welfare Officer.

• Provide continuing education of subordinates.

• Work together with other government departments like social welfare, rural development and education engaged in program for women and children.

• Tour for a minimum of 15 days in a month and visit PHCs, subcenters, village dais, Balwadi, Mahila mandals, etc. according to an advance program duty approved by the District Medical Officer/District Family Welfare Officer.

MEDICAL OFFICER, PHC

He or she is the captain of the primary health center. Morning hours are utilized by attending patients in the outdoor; in afternoon supervises the field work. Program is so designed as to cover all the basic health services including family planning. Visits each subcenter regularly on fixed days and hours and provides guidance, supervision and leadership to the health team. Spends one day in each month organizing staff meetings at the primary health center to discuss the problems and review the progress of health activities. They ensure that national health programs are being implemented in his area properly. The success of a primary health center depends largely on the team leadership which the medical officer is able to provide. The medical officer must be the planner, the promoter, the director, the supervisor, the coordinator as well as the evaluator.

Second Medical Officer: Performs identical duties.

Functions can be classified as:

1. Curative works

• Organization of dispensary, outpatient department and allotting duties to the ancillary staff to assure smooth running of the OPD.

• Making suitable arrangements for the description of emergency cases which come outside the normal OPD hours.

• Organization of laboratory services for cases where necessary and within the scope of his/her laboratory for proper diagnosis of doubtful cases.

• Making arrangements for rendering services for the treatment of minor ailments at community level and at the PHC through the agency of the Community Health Officer, Health Assistants, Health Workers and others.

• Attending cases referred to him.

• Screening cases need specialized medical attention including dental care, nursing care and referring them to referral institutions.

• Providing guidance to the subordinates, school teachers in the treatment of minor ailments.

• Cooperating and coordinating with other institutions providing medical care services in his area.

• Visiting each subcenter at least once in a fortnight on a fixed day not only to check the work of staff but also to provide curative services.

2. Preventive and promotive work

Ensures that all the members of health team are fully conversant with the various National Health and Family Welfare Programs to be implemented in the area allotted to each health functionary. Taking care of preventive and promotive works like:

a. Family planning

• Provides leadership to the team and takes responsibility for implementing the program.

• Squarely responsible for giving immediate and sustained attention to any complication.

• Extends motivational advice to all eligible couple.

• Gets himself/herself trained in tubectomy, wherever possible and organizes tubectomy camps.

• Seeks help of other agencies.

• Ensures adequate supplies of equipment, drugs, educational material and contraceptive required for the services.

• Organizes regular staff meetings to review the programs progress and to discuss the problems and future plans.

• Ensures proper and up-to-date maintenance of EC registers through spot checking.

b. Maternal and child health

• Provides MCH services such as antenatal, intranatal and postnatal cares of mothers and infants and child care through clinics at the PHC and subcenters.

• Actively involves health team in the effective implementation of the Nutritional Program and administration of vitamin A and folic acid tablets.

c. Universal immunization program

• Plans and implements UIP line with the latest policy and ensures maximum possible coverage of the target population in PHC.

• Ensures adequate supplies of vaccines and miscellaneous items required from time to time for the effective implementation of UIP.

• Ensures proper storage of vaccines and maintenance of cold-chain equipments.

Other preventive and promotive functions are in planning, organizing, supervising in various programs as:

a. National malaria eradication program

b. Control of communicable diseases

c. Leprosy control program

d. Tuberculosis control program

e. Sexually transmitted diseases control program

f. School health program

g. National program for prevention of visual impairment and control of blindness

h. Diarrheal diseases control program

3. Training

• Organizes training programs including continuing education with the assistance of the Community Health Officer and under the guidance of the district health authorities and Health and Family Welfare training centers under MPW Scheme and School Health Services Scheme.

• Educates the community as to the selection of Health Guides and takes the necessary steps to train the Health Guides from his area.

• Makes arrangements and provides assistance to the Health Assistance Female and Health Workers Female in organizing training program for indigenous Dais practicing in the area.

4. Administration work

• Supervises the work of staff working.

• Ensures general cleanliness inside and outside the premises of the PHC and also proper maintenance of all the equipment under his/her charge.

• Keeps up-to-date inventory and stock registers of all the stores and equipments supplied.

• Gets indents prepared timely for drugs, instruments, linen, vaccines, ORS and contraceptives, etc. sufficiently in advance and submits them to the appropriate health authorities.

• Checks the proper maintenance of the transport given in his/her charge.

• Scrutinizes the programs and suggests changes if needed.

• Gets prepared and displays charts in own room to explain clearly the geographical area, location of peripheral health units, morbidity, health statistics and other important information about the area.

• Holds monthly staff meeting with a view to evaluating the progress of work and suggesting steps to be taken for further improvements.

• Ensures regular supply of medicines and disbursement of honorarium to Health Guides.

• Ensures maintenance of the prescribed records at PHC level.

• Receives reports from the periphery, gets them compiled and submits them regularly to the district health authorities.

• Keeps notes of his visits to the area and submits every month of his/her tour reports to the CMO.

• Discharges all the financial duties entrusted to him.

• Discharges the day-to-day administrative functions pertaining to the PHC.

COMMUNITY HEALTH OFFICER

One community health officer is posted at each new Primary Health Center and covers 30,000 population (20,000 in tribal and hilly areas). He became under direct administrative and technical control of MO in charge of PHC. The community health officer carries on the following functions:

1. Control of communicable diseases

• Ensures that all necessary steps are being taken for the control of the communicable diseases in the village.

• Should report any outbreak of an epidemic to Medical Officer in charge.

• Assists the Medical Officer of the PHC in taking necessary action in case of any outbreak of an epidemic in the PHC area.

2. Maternal and child health

Supervises and guides the health assistants and health workers and actively involve the health guides and trained dais in the program for maternal and child health.

3. School health

• Visits schools in the PHC area at regular intervals and arrange for medical checkup by the MO, immunization, environmental sanitation and health education.

• Makes arrangements for the treatment and follow-up of those students found to have defects.

4. Universal Immunization program

Supervises and guides the health assistants and health workers and actively involves the health guides and trained Dais in the effective implementation of the expanded program on immunization.

5. Community involvement and health education

• Participates in the village health committee or village panchayat meetings to assess the health needs of the community, to discuss the health programs with the community and to enlist their cooperation in these programs.

• Maintains a close liaison with the block development officer and his/her staff and other developmental program workers such as those under the National Adult Education program, the Nutrition programs and the program for safe water supply and environmental sanitation.

• Works closely with the community leaders/organizations such as Mahila Mandals, Farmer’s clubs and other voluntary organizations.

• Organizes camps, meetings, health education talks, demonstrations, display of posters, exhibitions and films and involves the health assistants, health workers and health guides in these activities.

He/she also participate in:

1. Family planning

2. Nutrition

3. Environmental sanitation: Ensures that all the steps are being taken for the provision of safe drinking water and for the improvement of environmental sanitation in the villages.

4. Treatment of minor ailments

5. Training of health personnel and community level workers

6. Management and supervision

BLOCK EXTENSION EDUCATOR OR BLOCK HEALTH EDUCATOR

The block extension educator functions under the technical supervision and guidance of district Extension Media Officer. However, he/she would be under the immediate administrative control of the Medical Officer Incharge, PHC. He/she is responsible for providing support to all National Health and Family Planning Programs in PHC, but main functions relate to the promotions of FW and MCH programs.

Duties and functions

• Keeps all the information relevant to development activities in the block, particularly concerning Health and Family Welfare and utilizes the same for program planning.

• Develops work plan in consultation with the Medical Officer of his PHC and the concerned Deputy District Extension Media Officer.

• Collects, analyzes and interprets the data in respect of extension education work at the block level.

• Responsible for regular maintenance of records of educational activities, tour programs, daily diaries and other registers and ensures preparation and display of relevant maps and charts in the PHC.

• Assists MO in conducting training of health workers under various schemes.

• Is a member of the local block level Family Welfare committee and acts as a resource person.

• Organizes orientation training, mass communication programs.

• Monitors preparation and updating of eligible couple registers in PHC area.

• Supervises the field workers in the area of education and motivation.

• Supplies educational material to health workers in MPW.

• Tours for 15 days in a month with a minimum of one night half in every field worker’s area.

• While on tour checks the available stock of conventional contraceptives with the depot holders and the kit with MPWs and other health functionaries.

• Helps field workers in winning over resistant cases and drop-outs.

• Maintains a complete set of educational aids for own use and for training purposes.

• Organizes population education and health education sessions in schools and for out of school youth.

• Prepares a monthly report on the progress of educational activities in the block and sends it to the District EMO.

HEALTH WORKERS—MALE AND FEMALE

Under the multipurpose worker scheme, one health worker female and one health worker male are posted at each subcenter and are expected to cover a population of 5000 (3000 in tribal and hilly areas). However, health worker female limits her activities among 350–500 families.

A. Health Worker Female (HWF)

1. Registration

• She will register

– Pregnant women from three months of pregnancy onwards.

– Married women in the reproductive period.

– Children through systematic home visits and at clinics.

• Maintains maternity record, register of antenatal cases, eligible couple register, children register up-to-date.

• Categorizes the eligible couples according to the number of children, age of mothers.

2. Care at home

• Provides care to pregnant women especially registered mothers, throughout the period of pregnancy.

• Gives advice on nutrition to expectant and nursing mothers without being responsible for storage, preparation and distribution of food.

• Distributes iron and folic acid tablets to pregnant and nursing mothers, children and family planning adopters and vitamin A solution to children.

• Immunizes pregnant mothers with tetanus toxoid.

• Refers cases of abnormal pregnancy and cases with medical and gynecological problems.

• Conducts about 50% of total deliveries.

• Supervises deliveries conducted by dais and whenever called in.

• Refers cases of difficult labor and newborns with abnormalities and helps them to get institutional care and provides follow-up care to patients referred to or discharged from hospital.

3. Care at the clinic: She attends patients coming in health center and provides care accordingly.

4. Care in the community: She goes for community visit, assesses health problems and tries to solve those.

5. Others

• Maintains the cleanliness of the center.

• Attends staff meetings at PHC, CD block or both.

• Lists dais in her area and involves them in promoting family welfare work.

• Coordinates her activities with health workers particularly health worker male.

• Prepares and maintains all registers and records and maps, charts.

6. Coordinated functions under NRHM

• Maternal and child health

• Family planning

• Medical termination of pregnancy

• Nutrition

• Universal program on immunization (UIP)

• Dai training

• Communicable diseases

• Vital events

• Recordkeeping

• Treatment of minor ailments

• Team activities

7. Role of ANM as a facilitator of ASHA

• She holds weekly/fortnightly meeting with ASHA and discusses the activities.

• ANM acts as a resource person for the training of ASHA.

• ANM participates and guides in organizing the Health Days at Anganwadi Centers.

• ANMs educate ASHA on danger signs of pregnancy and labor so that she can timely identify and help beneficiary in getting further treatment.

B. HEALTH WORKER MALE (HWM)

1. Recordkeeping

• Surveys all the families in his area and collects general information about each village/locality in his area.

• Prepares, maintains and utilizes family records and village registers containing columns for recording particulars concerning FP, immunizations, vital events, environmental sanitation, other local health programs, educational activities, services rendered and achievements, etc.

He also participate in:

2. Malaria control program

3. Communicable diseases control

4. Leprosy control program

5. Tuberculosis control program

6. Environmental sanitation

7. Expanded program on immunization

8. Family planning

In the Context of Coordinated Functions Under NRHM

The Health worker Male will make a visit to each family once a fortnight. He will record his visit on the main entrance to the house according to the instructions of the States/UTs. His duties pertaining to different National Health Program are:

A. National Vectorborne Disease Control Program (NVBDCP)

1. Malaria

• From each family, he enquires about:

a. Presence of any fever case

b. Whether there is any fever case in the family in between his fortnightly visits.

c. Whether any guest has come to the family and has fever.

d. Whether any member of the family who has fever in between his fortnightly visit has left the village.

• He collects thick and thin blood smears on one glass slides.

• Assist the Health Supervisor Male in supervising spraying operations and training field spraying staff.

• Participation in ‘National Filaria Day’, etc.

2. Where Kala-Azar is endemic

3. Where Japanese Encephalitis is endemic

4. Where Filaria is endemic

B. National Leprosy Eradication Program (NLEP)

Identifies cases of skin patches especially if accompanied by loss of sensation, refers the above cases to PHC Medical Officer for diagnosis.

C. National Blindness Control Program (NBCP)

Identifies and refers all cases of blindness including suspected cases of cataract to Medical Officer, PHC.

D. Revised National Tuberculosis Control Program (RNTCP)

• Identifies persons especially with fever for 15 days and above with prolonged cough or spitting blood and takes sputum smears from these individuals. Refers these cases to the MO, PHC for further investigations.

• Checks whether all cases under treatment for tuberculosis are taking regular treatment, motivates defaulters to take regular treatment and brings them to the notice of the Medical Officer, PHC.

• Educates the community on various health education aspects of tuberculosis program.

• Assists the ASHA/similar village health volunteer to motivate the TB patients in taking regular treatment.

E. Universal Immunization Program

• Administers DPT vaccines, oral poliomyelitis vaccine, measles vaccine and BCG vaccine to all infants and children in his area in collaboration with health worker female.

• Assists the health worker female in administration of tetanus toxiod to all pregnant women.

• Assists the health supervisor male/health supervisor female in the school health program.

• Educates the people in the community about the importance of immunization against the various communicable diseases.

F. Reproductive and Child Health Program (RCH)

• Utilizes the information from the eligible couple and child register for the family planning program.

• Spreads the message of family planning to the couples and motivates them for family planning individually and in groups.

• Distributes conventional contraceptives and oral contraceptives to the couples.

• Helps prospective acceptors of sterilization in obtaining the services, if necessary by accompanying them or arranging for the ASHA/dai to accompany them to the PHC/hospital.

• Provides follow-up services to male family planning acceptors, and refers those cases that need attention by the physician to PHC/hospital.

• Builds rapport with satisfied acceptors, village leaders, ASHA, dais and others and utilizes them for promoting family welfare program.

• Identifies the male community leaders in each village of his area.

• Assists the health supervisor male in training the leaders in the community and in educating and involving the community in family welfare program.

• Identifies the women requiring help for medical termination of pregnancy, refers them to the nearest approved institution and informs the health worker female.

• Educates the community on the availability of service for medical termination of pregnancy.

• Educates community on home management of diarrhea and ORS.

• Reports any outbreak of diarrhea disease.

• Measures such as chlorination of drinking water to be carried out.

• Proper sanitation to be maintained.

• Encourages for the use of latrines.

• Identifies and refers cases of genital sore or urethral discharge or non-itchy rash over the body to Medical Officer.

G. Communicable Diseases

• Identifies cases of diarrhea/dysentery, fever with rash, jaundice, encephalitis, diphtheria, whooping cough and tetanus, poliomyelitis, neonatal tetanus, acute eye infections and notifies the health supervisor male and MO, PHC immediately about these cases.

• Carries out control measures until the arrival of the health supervisor male and assist him in carrying out these measures.

• Educates the community about the importance of control and preventive measures against communicable disease and about the importance of taking regular and complete treatment.

• Reports the presence of stray dogs to the health supervisor male and assists him in carrying out the destruction of stray dogs.

H. Environment Sanitation

• Chlorinates the public water sources including wells at regular intervals.

• Educates the community on: (a) the method of disposal of liquid wastes, (b) the method of disposal of solid waste, (c) home sanitation, (d) advantage and use of sanitary type of latrines and (e) construction and use of smokeless chulhas.

• Coordination with Village Health and Sanitation Committee.

I. Primary Medical Care

Provides treatment for minor ailments, provides first aid for accidents and emergencies and refers cases beyond his competence to the Primary health center or nearest hospital.

J. Health Education

Educates the community about the availability of maternal and child health services and encourages them to utilize the facilities.

K. Nutrition

• Identifies cases of malnutrition among infants and young children (0–5 years) in his area, gives the necessary treatment and advice or refers them to the anganwadi for supplementary feeding and refers serious cases to the PHC.

• Educates the community about the nutrition diet for mothers and children from locally available food.

L. Vital Events

• Enquires about births and deaths occurring in his area, records them in the births and deaths register and reports them to the Health Supervisor Male/ANM.

• Educates the community on the importance of registration of births and deaths.

M. Recordkeeping

• Surveys all the facilities in his area and prepares/maintains maps and charts for the village.

• Prepares, maintains and utilizes family and village records.

• Assists the Health Worker Female/ANM to prepare the eligible couple and child register and maintaining it up-to-date.

• Maintains a record of cases in his area as to who are under treatment for tuberculosis and leprosy.

• Prepares and submits the prescribed monthly reports in time to the Health Supervisor male.

• While maintaining passive surveillance register for malaria cases, he records:

– Number of fever cases

– Number of blood slides prepared

– Number of malaria positive cases reported

– Number of cases given radical treatment

HEALTH ASSISSTANTS—MALE AND FEMALE

They supervise 4 health workers each of the corresponding category. The job functions of these health assistants regarding:

1. Administration

2. Maintaining human relations skills

3. Methods of supervision are similar. But in the technical aspects, their supervisory functions are different.

Common functions for the health assistants (male and female)

• Supervise and guide the health workers in the delivery of health care services to the community.

• Strengthen the knowledge and skills of the health workers in their different areas.

• Help the health worker in improving their human relations skill.

• Help and guide the health workers in planning and organizing their programs.

• Promote team work among the health workers.

• Coordinate the activities with other workers and agencies.

• Visit each worker periodically, observes and guides the health workers in day to day activities.

• Arrange group meetings with leaders and involves them in spreading the message for various health programs.

• Scrutinize the maintenance of records of the health workers to guide them in their proper maintenance.

• Attend staff meeting at PHC/block.

• Assess the progress of work of the health workers periodically and submit their assessment reports to MO, PHC.

• Assist the medical officers of the PHC in the organization of the different health services in the areas.

• Participate in mass camps and campaigns in health programs.

• Indent, procure and supply material to health workers.

• Prepare, maintain and utilize prescribed records and reports.

• Review, consolidate and submit periodical reports to MO, PHC.

• Attend to cases referred by the workers and refer cases beyond his/her competency to the PHC/hospital.

Specific job functions for the health assistant (female)

• Visits each of the 4 subcenters at least once a week on fixed days.

• Personally motivates resistant cases for family planning

• Carries out supervisory house visiting

• Guides the health worker female in establishing women depot holders for distribution of conventional contraceptives.

• Conducts MCH and FP clinics and carry out educational activities, etc.

Specific job functions for the health assistant (male) are participating in

• Malaria control program

• Communicable disease control

• Leprosy control program

• Tuberculosis control program

• Environmental sanitation

• Expanded programs on immunization

• Family planning

• Nutrition program

• Control of blindness

• Vital events registration

• Collecting and compilation weekly reports of birth and deaths occurring in his area and submit them to the MO.

• Educating the community regarding the need for registration of vital events.

LABORATORY TECHNICIAN

The laboratory technician is under the direct supervision of the Medical Officer, PHC.

1. General laboratory procedures

• Maintain the cleanliness and safety of the laboratory.

• Ensure that the glassware and equipment are kept clean.

• Handle and maintain the microscope.

• Sterilize the equipment as required.

• Dispose of specimens and infected material in a safe manner.

• Maintain the necessary records of investigations done and submit the reports to the MO.

• Prepare the monthly reports regarding his work.

• Indent for supplies for the laboratory through the MO and ensure the safe storage of materials received.

2. Laboratory investigations

a. Carry out examination of urine

• Specific gravity and pH

• Test for glucose

• Bile pigments and bile salts

• Test for ketone bodies

• Microscopic examination

b. Carry out examination of stool

• Macroscopic examination

• Microscopic examination

c. Carry out examination of blood

• Collection of blood specimen by finger prick technique

• Hemoglobin estimation

• RBC count

• WBC count (total and differential)

• Preparation, staining and examination of thick and thin blood smears for malaria parasites and for microfilaria.

• Erythrocyte sedimentation rate

• VDRL

d. Carry out examination of sputum Preparation, staining and examination of sputum smears for Mycobacterium tuberculosis.

e. Carry out examination of skin and nasal smears

Preparation, staining and examination of skin smears for Mycobacterium leprae.

f. Carry out examination of semen

• Macroscopic examination

• Sperm count and motility

g. Prepare throat swabs

Collection of thoat swab and examination for diphtheria

h. Test samples of drinking waters Testing of sample for gross impurities

3. Maintenance of records and registers under NMEP

• He/she maintains all records of slides examined by him/her and must get the positive slides confirmed by the medical officer of PHC.

• Daily progress and output register of blood slide examination.

• The back-log chart of pending radical treatment vis-a-vis collected slide.

COMPUTER

The computer is a member of the health team of the primary health center.

• He keeps information on various components of health and family welfare programs (including mass education and media activities) from the subcenter and the PHC levels and scrutinizes and consolidates the information collected for the entire PHC area.

• He compiles and sends such monthly reports and adhoc returns on malaria, blindness, dental care and family welfare program and other national health programs.

• It compiles the updated information regarding the eligible couple and child register in all the villages received from the subcenter staff and also compiles village-wise information regarding the number of eligible couples, number of couples using different family planning methods, etc.

• Assists the statistical assistant at district level in sample verification of acceptors in the area under the jurisdiction of the PHC.

• Maintains registers of vital events in the area from the register of births and deaths of the village registers and also from reports of the vital events observed by health workers in the area.

• Needed to prepare charts and graphs depicting the progresses of various Health and family welfare program and analytical review of the data collected under the guidance of the MO, PHC and/or statistical staff as district/state levels.

HEALTH GUIDE

A health guide is expected to cover the population of a village or, if a village is a large one, a population of about 1000. He/she receives technical guidance from the health worker (male/female). After training, the health guide is able to carry out the following activities:

1. Malaria

• Identify fever cases.

• Make thin and thick blood smears of all fever cases.

• Send the slides for laboratory examination.

• Administer presumptive treatment to fever cases.

• Keep a record of the persons given presumptive treatment.

• Inform the health worker (male) of the names and addresses of cases from whom blood slides have been taken.

• Assist health worker (male) and the spraying teams in spraying and larvicidal operations.

• Educate the community on how to prevent malaria.

2. Communicable diseases

• Inform health worker (male) immediately an epidemic occurs in his/her area.

• Take immediate precautions to limit the spread of disease.

• Educate the community about the prevention and control of communicable diseases.

3. Environmental sanitation and personal hygiene

• Chlorinate drinking water sources at regular intervals.

• Keep a record of the number of wells chlorinated.

• Assist the health worker (male) in arranging for the construction of the following:

– Soakage pits

– Kitchen gardens

– Composts pits

– Sanitary latrines

– Smokeless chulas

• Educate the community about the following:

– Safe drinking water

– Hygienic methods of disposal of liquid as well as solid waste

– Home sanitation

– Kitchen gardens

– Advantages and use of sanitary latrines

– Advantages of smokeless chulhas

– Food hygiene

– Control of insects, rodents and stray dogs

• Educate the community about the importance of personal hygiene.

4. Immunization

• Assist the health worker (male/female) in arranging for immunization.

• Educate the community about immunization against all killer diseases.

5. Family planning

• Spread the message of family planning to the couples in his/her area and educate them about the desirability of the small family norm.

• Educate the people about the available methods of family planning.

• Act as a depot holder, distribute nirodh to the couples, and maintain the necessary records of nirodh distributed.

• Inform the health worker (male/female) of those couples who are willing to accecpt the family planning method so that he/she can make necessary arrangements.

• Educate the community about the availability of services for medical termination of pregnancy (MTP).

6. Maternal and child care

• Advise pregnant women to consult the health worker (female) or the trained dai for prenatal, natal and postnatal cares.

• Advise pregnant women to get immunised against tetanus.

• Educate the community about the availability of maternal and child care services and encourage them to utilize the facilities.

• Educate the community about how to keep mothers and children healthy.

7. Nutrition

• Identify cases with signs and symptoms of malnutrition among preschool children and refer them to health worker (male/female).

• Identify cases with signs and symptoms of anemia in pregnant and nursing women, children and refer them to health worker for treatment.

• Assist health worker in administering vitamin A.

• Teach families about the importance of breastfeeding and the introduction of supplementary weaning foods.

• Educate the community about nutritious diet for mothers and children.

8. Vital events

• Report all births and deaths in his/her area to the health worker.

• Educate the community about the importance of registering all births and deaths.

9. First aid in emergencies

• Give emergency first aid for the following conditions, refer these cases to the primary health center as necessary and inform the health worker:

– Drowning

– Electric shock

– Heat stroke

– Snake bite

– Scorpion sting

– Insect sting

– Dog bite

– Accidents

• Carry out procedures in dealing with accidents.

• Keep a record of first aid given to each patient.

10. Treatment of minor ailments

• Give simple treatment for the following signs and symptoms and refer cases beyond his/her competence to the subcenter or PHC.

– Fever

– Headache

– Backache and pain in the joint

– Cough and cold

– Diarrhea

– Vomiting

– Pain in the abdomen

– Constipation

– Toothache

– Earache

– Sore eyes

– Boils, abscesses and ulcers

– Scabies and ringworms

• Keep a record of the treatment given to each patient.

11. Mental health

• Recognize signs and symptoms of mental illness and refer cases to health workers.

• Give immediate assistance in emergencies associated with mental illness.

• Educate the community about mental illness.

DAI

• She should contact every pregnant women in her area and see that she is registered at the subcenter or PHC.

• Should attend the weekly prenatal clinic and assist the health worker (female)/ANM.

• Should try to ensure that every pregnant women in her area attends the prenatal clinic at least three times, i.e. after the third month to confirmed pregnancy, during the 7th month, and during the 9th month.

• Try to ensure that every pregnant woman is immunized against tetanus.

• Should try to ensure that every pregnant woman takes iron and folic acid tablets as prescribed.

• If any abnormal pregnancy is detected she should show the case immediately to the health worker (female)/ANM or health assistant (female)/LHV or refer the case to the PHC.

• Should ensure that preparations for delivery are made either at home or at the PHC or hospital.

• If she finds any abnormality during labor she must seek medical aid without delay.

• When she receives a call for delivery she should:

– Take her kit

– Watch the progress of labor carefully

– Allow labor to progress normally without any unnecessary interference

– Observe aseptic techniques while conducting the delivery

• Should seen that her kit is always replenished, clean and ready of use during a delivery.

• Makes the mother and baby comfortable and attend to the nutrition of both.

• Instructs mother and the relatives as to when she should be called immediately, e.g. in case the mother has excessive bleeding or there is bleeding from the baby’s cord.

• In a postnatal period if she finds any complications in the mother, e.g. fever, foul smell/lochia, or in the baby, e.g. cord infection or jaundice, she should immediately inform the health worker (female)/ANM or refer them to PHC.

• Should try to ensure that all infants in her area are immunized.

• Should motivate all the eligible couples in her area to use a contraceptive method or to undergo sterilization.

• Should distribute nirodh, foam tablets and jelly, etc.

• Should report all births and deaths in her area to the health worker (male/female)/ANM.

ANGANWADI WORKER

• Supplementary nutrition for the under five children, pregnant and nursing mothers

• Non-formal preschool education to children of 3–5 years

• Assisting the PHC staff in the implementation of health program

• Giving health and nutrition education to mothers

• Maintenance of records and reports

• Community contacts and liaison

The specific responsibilities in the delivery of health services are as follows:

• Assists the health components of the ICDS schemes, viz. immunization, health checkup, family planning and referral services and for this purpose, maintains effective liaison with ANM and the Community Health Guide of her area.

• Does health check-up for school children, regularly keeps records and identifies high-risk children.

• Renders first aid and medication for common ailments.

• Refers cases of severely malnourished and sick children, pregnant and nursing women to the PHC and follow them up.

• Keeps a watchful eye on the outbreak of any epidemic disease in her area and reports the same to the health staff.

• Assists the health personnel in the prevention of diseases and isolation of infected persons.

• Detects infants and toddlers with childhood impairments and disabilities and refers them to ANM/LHV for the necessary follow-up action.

Role of Anganwadi as a facilitator of ASHA: Anganwadi Worker (AWW) guides ASHA in performing following activities:

• Organizing health day once/twice a week. On health day, the women, adolescent girls and children from the village are invited for orientation on health related issues such as importance of nutritious food, personal hygiene, care during pregnancy, importance of antenatal check-up and institutional delivery, home remedies for minor ailment and importance of immunization, etc.

• IEC activity through display of posters, folk dances, etc. on these days can be undertaken to sensitize the beneficiaries on health related issues including HIV/AIDS.

• Anganwadi worker is depot holder for drug kits and issuing it to ASHA. The replacement of the consumed drugs can also be done through AWW.

• Participation in National Filaria Day.

ASHA

ASHA is a health activist in the community who creates awareness on health and its social determinants and mobilizes the community towards local health planning and increased utilization and accountability of the existing health services. She would be a promoter of good health practices. She also provides a minimum package of curative care as appropriate and feasible for that level and makes timely referrals. Her roles and responsibilities are as follows:

• ASHA takes steps to create awareness and provides information to the community on determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilization of health and family welfare services.

• She counsels women on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including reproductive tract infection/sexually transmitted infection (RTI/STI), HIV/AIDS and care of the young children.

• ASHA mobilizes the community and facilitates them in accessing health and health related services available at the village/subcenter/primary health centers, such as immunization, antenatal check-up (ANC), postnatal check-up (PNC), family planning services, ICDS, sanitation and other services being provided by the government.

• She works with local health committees of panchayats to develop a comprehensive village health plan.

• She escorts/accompanies pregnant women and children requiring treatment/admission to the nearest preidentified health facility, i.e. primary health center/community health center/first referral unit (PHC/CHC/FRU).

• ASHA provides primary medical care for minor ailments such as diarrhea,fevers, and first aid for minor injuries. She is a provider of directly observed treatment, short-course (DOTS) under Revised National Tuberculosis Control Program. She also acts as a depot holder for essential provisions being made available to every habitation like oral rehydration therapy (ORT), iron folic acid tablet (IFA), chloroquine, disposable delivery kits (DDK), oral pills and condoms, etc. A drug kit is provided to each ASHA. Her role as a provider of direct services can be enhanced subsequently. States can explore the possibility of graded training to her for providing newborn care and management of a range of common ailments particularly childhood illnesses.

• She informs about the births and deaths in her village and any unusual health problem/disease outbreak in the community to the subcenters/primary health center.

• Fulfillment of all these roles by ASHA is through continuous training and upgradation of her skills.

• Her skills improve gradually spread over two years or more.

• Participation in National Filaria Day.

• Identify the cases of skin patch with loss of sensation and bring them to the notice of health worker male/female. Ensure that all the patients of leprosy are taking regular treatment.

TRADITIONAL BIRTH ATTENDANT

The term TBA refers to traditional, independent (of the health system), non-formally trained and community-based providers of care during pregnancy, childbirth and the postnatal period (World Health Organization, 2004). Traditional birth attendant (TBA), also known as a traditional midwife (TM), is a primary pregnancy and childbirth care provider. Traditional birth attendants provide the majority of primary maternity care in developing countries, and may function within specific communities in developed countries. Traditional midwives usually learn their trade through apprenticeship, although some may be wholly self-taught. They are not certified or licensed.

Traditional mid wives often provide health advice and education, and health care beyond the field of maternity. In much of the world, one of the criteria for taking the office of midwife is experienced as a mother. Many traditional midwives are older mothers; many are post-menopausal. Many midwives are also herbalists, or other traditional healers. They may or may not be integrated in the formal health care system. They often serve as a bridge between the community and the formal health system, sometimes accompanying women to health facilities.

The focus of their work is usually assisting women during childbirth delivery and in the immediate postpartum period. Frequently their assistance also included helping with household chores. Most traditional midwives travel to the pregnant woman’s house to provide care; women may also travel to them to obtain care. Traditional midwives are usually assisted by the birthing woman’s relatives.

Many traditional midwives live in rural, and often isolated communities. They may work at considerable distance from health facilities.

There has been considerable effort placed on the education of traditional midwives, TBAs, in the last thirty years with little success. Most training programs have focused on training the traditional midwives with little attention paid to the environment in which they work. Other issues must be addressed for traditional midwives to be able to provide optimal care including integration of traditional healers into the formal health care system, conditions for referral, access to equipment, adequate transportation, and other related issues.

SKILLED BIRTH ATTENDANT

The term “skilled health worker” refers to “an accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns” (World Health Organization, 2004).

A skilled birth attendant should be able to perform the following signal functions:

1. Safely conduct a normal delivery using aseptic technique.

2. Active management of the third stage of labor.

3. Provide immediate care of the newborn, including resuscitation.

4. Manage most postpartum hemorrhage through the use of parenteral oxytocics and abdominal massage.

5. Manually remove the placenta.

6. Manage eclampsia through provision of parenteral antihypertensives.

7. Recognize and manage postpartum infection through the use of a vacuum extractor.

8. Manage incomplete abortions with manual vacuum aspiration (MVA).

Bibliography

1. Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward: Bulletin of the World Health Organization [Internet] 2007 Oct 10 [cited 2014 July 15]. Available from: http://www.who.int/bulletin/volumes/85/10/06-038455/en/index.html.

2. Basavanthappa BT. Community Health Nursing. Bangalore: Jaypee; 1999.

3. International Day for the Elimination of Violence Against Women and Girls: Sexual and Reproductive Health [Internet] 2014 [cited 2014 July 15]. Available frorm http://www.who.int/reproductive-health/global_monitoring/skilled_attendant.html.

4. Modified on 26 July 2014.

5. Park K. Preventive and social Medicine. 19th ed. Jabalpur: Banarsidas Bhanot; 2007.

6. Traditional Birth Attendant (TBA) [Internet] [update 2014 July 26; cited 2014 Sep 11]. Available from: http://en.wikipedia.org/wiki/Traditional_birth_attendant.

22

Voluntary Health Agencies

This chapter contains

▪ International Multilateral Health Agencies

• World Health Organization (WHO)

• United Nations International Children’s Emergency Fund (UNICEF)

• United Nations Development Program (UNDP)

• UN’s Fund for Population Activities (UNFPA)

• Food and Agricultural Organization (FAO)

• International Labor Organization (ILO)

• World Bank

▪ International Bilateral Health Agencies

• USAID

• Colombo Plan

• SIDA

• DANIDA

▪ Non-governmental and Other Health Agencies

• Ford Foundation

• Rockefeller Foundation

• CARE

• International Red Cross

• Indian Red Cross

• The Junior Red Cross

INTRODUCTION

Health and disease have no political or geographical boundaries. Disease in any part of the world is a threat to other parts. In order to protect against the spread of the disease from one country to another, many attempts are made like detection of infection and isolation of travellers, quarantine of ships, crews, travellers, etc. So it became necessary for international agreement and cooperation on quarantine matters to control communicable diseases. Thus various national and international health agencies formed which are some autonomous bodies taking actions to improve the health of nations as well as world.

The one country where voluntary health agencies have developed and flourished to an enormous extent is the United States. The voluntary health agencies have been compared to “motor trucks” which can penetrate by ways to reach to the remote areas where always government services cannot reach. The official agencies must have established laws to run.

Definition: “An organization that is administered by an autonomous board which holds meetings, collects funds for its support chiefly from private sources and expends money, whether with or without paid workers, in conducting a program directed primarily to furthering the public health by providing health services or health education, or by advancing research or legislation for health, or by a combination of these activities.”

Functions: The services rendered by voluntary health agencies are:

1. Participation of beneficiaries: Voluntary organizations are nearer to the people and get better response from them in the implementation of programs. Thus it is easy to communicate with the beneficiaries to involve them in the decision-making, implementation, monitoring and evaluation of health programs carried out by the voluntary agencies.

2. Pioneering: The voluntary health agencies step in and takeover the projects for the benefit of the larger numbers by bringing out new things. The family planning program in India is an example of pioneering by the voluntary agencies; when the importance of family planning was realized, the govt, accepted family planning as a national policy.

3. Demonstration: Demonstration and experimental projects taken by those agencies improves public health. The demonstration of ‘Borehole Latrines’ by the Rock Worm in India is a case of point. The borehole latrines and its modification is an essential part of the environmental sanitation program.

4. Education: Health education has a very crucial role in India. Only government agencies cannot cope with the problem, without the help of voluntary effort on the part of people.

5. Working with government agencies: By setting a good example the voluntary health agencies always guide and criticize the work of official agencies. Also these agencies strengthen the work of government agencies by providing funds, equipment and manpower.

6. Advancing health legislation: The voluntary agencies also take part in forming legislation on health matters considering the view of general people for the benefits of the whole community.

Advantages: Voluntary health agencies have the following advantages over government organizations:

• Compared to govt, organizations, VHAs (NGOs) are better accepted to people.

• Community participation is better in the programs undertaken by VHAs.

• They work at fast pace and at low operative costs.

• The programs are flexible and not rigid.

• They are not handicapped by bureaucratism and red tapes.

• They provide an opportunity to those individuals, who are interested in social work.

Limitations: Voluntary health agencies also have some limitations as:

• Their programs are often related to non-critical health problems.

• Their services are not always targeted to those who are in greatest need nor they are conducted in the areas that need them most.

• Their programs often do not run according to modern principles and techniques of management.

Voluntary Health Organizations are divided into National Health organizations and International Health Organizations. International health organizations are usually divided into three groups: multilateral organizations, bilateral organizations, and non-governmental organizations (NGOs).

Bilateral agencies are governmental agencies in a single country which provide aid to developing countries. The largest of these is the United States Agency for International Development (USAID).

The term multilateral means that funding comes from multiple governments (as well as from non-governmental sources) and is distributed to many different countries. WHO, UNICEF, etc. are the examples of multilateral agencies.

Non-governmental organizations (NGOs), also known as private voluntary organizations (PVOs), provide approximately 20% of all external health aids to developing countries. Most of these organizations are quite small; many are church-affiliated. In the very poorest countries, hospitals and clinics run by missionary societies are especially important.

INTERNATIONAL MULTILATERAL HEALTH AGENCIES

World Health Organization (WHO)

WHO is a specialized, non-political, directing and coordinating authority for health within the United Nations system, with headquarters at Geneva. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

Birth of WHO: The WHO has its origin in April, 1945. WHO’s Constitution came into force on 7th April, 1948—a date we now celebrate every year as World Health Day. A World Health Day theme is chosen each year to focus attention on a specific aspect of public health. Constitution is drafted by “technical preparatory committee” under the Chairmanship of Rene Sand and is approved by “International Health Conference” of 51 nations in New York in the same year.

Members of WHO: More than 8,000 people from more than 150 countries work for the Organization in 147 country offices, six regional offices and at the headquarters in Geneva, Switzerland. In addition to medical doctors, public health specialists, scientists and epidemiologists and WHO staffs include people trained to manage administrative, financial, and information systems, as well as experts in the fields of health statistics, economics and emergency relief.

Structure of WHO: WHO is operated through:

1. WHO assembly

2. Executive board

3. Secretariat

1. WHO assembly: The supreme authority of WHO. It meets every year in May. This assembly plans the work and determines international health policy, approves budget needed for following year, elects member states to designate a person for 3 years on executive board and to replace retiring members, appoints Director General on nomination of Executive Board.

2. Executive board: Consists of 18 members (may be up to 24–30). Each designated by a Member state. They meet twice a year. The members of the board are technically qualified in the field of health. One-third of the members are renewed every year. Its main work is to give effect to the decisions and policies of the assembly. It takes initiative in times of emergencies such as epidemics, earthquakes and floods where immediate action is required.

3. Secretariat: It is headed by director general, who is the chief technical advisor and administrative officer of WHO. The directorate general has 5 assistants to help him. The secretariat consists of 14 divisions such as:

1. Epidemiological surveillance and health situation and trend assessment.

2. Communicable disease

3. Vector biology and control

4. Environmental health

5. Public information and education for health

6. Mental health

7. Diagnostic, therapeutic and rehabilitative technology.

8. Strengthening of health services

9. Family health

10. Non-communicable diseases

11. Health manpower development

12. Information systems support

13. Personal and general services

14. Budget and finance

Regions: In order to meet the special health needs of different areas, WHO has established six regional organizations:

Table 22.1: Regional headquarters

Region
Headquarters

1. South-East Asia

New Delhi (India)

2. Africa

Harare (Zimbabwe)

3. The Americas

Washington D.C (USA)

4. Europe

Copenhagen (Denmark)

5. Eastern Mediterranean

Alexandria (Egypt)

6. Western Pacific

Manila (Philippines)

The regional offices are headed by the regional director, who is assisted by technical and administrative officers, and members of the secretariat. Regional committees meet once a year to review health work in the region and plan its continuation and development.

Objectives: The objectives of WHO is “the attainment by all people of the highest level of health” which is set out in the preamble of the Constitution. It states:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political believe, economic and social condition.

The health of all people is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals and states.

The achievement of any state in the promotion and protection of health is of value to all.

Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development.

The extension to all people of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health.

Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.

Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.”

The current objective of WHO is the attainment by all people of the world by the year 2000 AD of a level of health that permits them to lead a socially and economically productive life also known as Health for All by 2000 AD.

Flow chart 22.1

WHO Headquarters’ Structure
(not including partnership secretariats)

Functions: The WHO also has specific responsibilities for establishing and promoting international standards in the field of health, which comprise the following broad areas:

1. Prevention and control of special diseases: The global eradication of smallpox is an outstanding example of international health cooperation. Now their global battle is against AIDS. Almost all communicable diseases are or have been at some time the subject of WHO activities.

• Keeps surveillance of communicable diseases.

• Collects and disseminates epidemiological information on diseases subject to International Health Regulations and occasionally other communicable diseases of international importance through an Automatic Telex Reply Service (ATRS) and the “Weekly Epidemiological Record” (WER).

• Member states can also make use of the “WHO” Emergency Scheme for Epidemics whenever necessary.

• Also paying attention on non-communicable diseases like cancer, cardiovascular diseases, genetic disorders, mental disorders, drug addiction and dental diseases.

• Activities are in different fields such as vector biology and control, immunology, quality control of drugs and biological products, drug evaluation and monitoring and health laboratory technology (as all these are relevant to control both communicable and non-communicable diseases).

• Expanded program on immunization is now a priority program of WHO.

2. Family health: It is one of the major programs under WHO since 1970, and subdivided into maternal and child health care, human reproduction, nutrition and health education.

3. Development of comprehensive health services: Most important single function is to promote and support national health policy development and the development of comprehensive national health programs.

• Performing a wide varieties of activities such as organizing health systems based on primary health care, the development of health manpower and utilization, building of long-term national capabilities, monitoring and evaluation and health services research.

• Another new program launched by WHO is Appropriate Technology for Health (ATH) to encourage self-sufficiency in solving health problems to build up primary health care.

4. Environmental health: WHO encourages Governments on national programs for the provision of basic sanitary services. Activities of WHO are directed for protection of the quality of air, water and food; health conditions of work, radiation protection and early identification of new hazards originating from new technological advancements.

5. Health statistics: WHO conducts epidemiological researches in order to get statistics from different countries which may be comparable to find out the disease burden. WHO publishes ‘International Classification of Diseases’ which is updated every 10th year. Assistance is also given to countries in the improvement of their medical records, and in the planning and operating national health information systems.

6. Biomedical research: The WHO does not itself do research, but stimulates and coordinates research work. There are Regional Advisory Committees on health research which define regional health research priorities and a Global Advisory Committee, which is in close collaboration with regional committee deals with policy issues of global import. Six tropical diseases (malaria, schistosomiasis, trypanosomiasis, filariasis, leishmaniasis and leprosy) are the target of the WHO Special Program for Research and Training in Tropical diseases to develop new tools, strengthen research institutions and training workers in the countries affected.

7. Health literature and information: WHO publications comprise hundreds of titles on a wide variety of health subjects. The WHO library is one of the satellite centers of the Medical Literature Analysis and Retrieval System (MEDLARS) of the US National Library of Medicine. MEDLARS is the only fully computerized indexing system covering the whole of medicine on an international basis. The WHO has also a public information service both at headquarters and each of the six regional offices.

8. Cooperation with other organization: WHO collaborates with various organizations as UN and with the other specialized agencies, and maintains various degrees of working relationships.

Budget and Resources

The framework for the financial resources and expenditures of WHO is derived from the 11th General Program of Work, which covers the period of 2006–2015. From the biennium 2008–2009, a six-year medium-term strategic plan (for 2008–2013) encompassing three biennial budget periods forms the framework for WHO’s result-based management. The strategic plan and the first of its three Program Budgets (for 2008–2009) are adopted by the World Health Assembly in May 2007. The total WHO budget approved by the World Health Assembly for the biennium 2006–2007 is US$ 3.3 billion. The level of the regular budget has increased at a much slower rate than that of voluntary contributions. Voluntary contributions projected for 2006–2007 represent more than 70% of the total financial resources of the Organization.

Contribution to India

WHO’s assistance to India is provided in consultation with Central Government. It is helping India in:

• The control of communicable diseases such as smallpox, leprosy, cholera, malaria and tuberculosis. It has given experts, equipment, supplies and vehicles in relation to these health programs.

• Strengthening the Public Health Administration.

• Improving the environmental sanitation.

• Education and training of all type of professionals (e.g. PCBSc N programs at College of Nursing, Madras and Chandigarh) and auxiliary health workers.

• Assists in biomedical research programs in India, including research in family planning methods.

UNITED NATIONS INTERNATIONAL CHILDREN’S EMERGENCY FUND

UNICEF is one of the specialized agencies of the United Nations. It is established in 1946 by the United Nations General Assembly to deal with rehabilitation of children in war ravaged countries. In 1953, when the emergency functions are over, the general assembly gave it a new name “UN Children’s Fund” but retained the initials, UNICEF. The headquarter is at United Nation, New York. Its regional office is in New Delhi; the region is known as the South Central Asian Region which covers Afghanistan, Sri Lanka, India, the Maldives, Mongolia and Nepal.

In early years, UNICEF and WHO worked together on urgent problems such as malaria, tuberculosis and venereal diseases. Later, its assistance to countries covered such field as maternal and child health, nutrition, environmental sanitation, health centers and health education and programs which would directly or indirectly, benefit child health. More recently, greater attention is given to the concept of the “whole child” meaning that assistance should be done not only to health and nutrition but also to their long-term personnel development and to the development of the countries in which they live.

History of UNICEF in India: Milestones in the history of UNICEF’s work in India.

• 2004 UNICEF joins Government of India’s (GOI) efforts to eradicate polio.

• 2000 UNICEF partners with GOI to ensure eradication of guinea worm.

• 1996 UNICEF supports launch of GOI’s RCH program.

• 1986 UNICEF works with GOI to launch Oral Rehydration Therapy Program for treatment of diarrhea.

• 1985–86 UNICEF supports launch of GOI’s Universal Immunization Program, now reaching millions of children throughout India.

• 1975 UNICEF supports piloting and launch of Integrated Child Development services. Today this program reaches out to 4.8 million expectants and nursing mothers and 30 million children under six years of age.

• 1967 UNICEF’s association with GOI’s rural water program provides emergency relief to tackle severe drought. Since then, the national water program has expanded to provide access to protected sources of drinking water to 95% of India’s villages.

• 1949UNICEF begins working in India. Milk Feeding Program-Partition takes its toll, soon after Independence the Government of India launches a milk-feeding program for refugee children, and UNICEF assists in this program.

India’s first Penicillin Plant established in 1949. India’s first penicillin plant is set up at Pimpri; it is the first public sector undertaking in the Drugs and Pharmaceutical Sector. UNICEF provides equipment and technical assistance.

Functions of UNICEF

1. Child health: UNICEF

• Provides substantial aid for the production of vaccines and sera in many countries.

• Has supported India’s BCG vaccination program from its inception.

• Assisted in the erection of a penicillin plant, near Pune; donated a DDT plant; two plants for the manufacture of triple vaccine and iodized salt.

• Assisted in environmental sanitation programs emphasizing safe and sufficient water for drinking and household use in rural areas. The purpose is not only to reduce child illness and death, but to improve the quality of life in the villages.

• Currently, focusing attention on providing primary health care to mothers and children.

• UNICEF emphasized on:

– Immunizations

– Infant and young child care

– Family planning aspects of family health

– Safe water and adequate sanitation.

2. Child nutrition: UNICEF gives high importance to improve child nutrition. UNICEF:

• Started with supplementary child feeding began to expand in mid 1950s with the development of low-cost protein-rich food mixture.

• Began aiding “applied nutrition” programs through community development, agricultural extension, school and health services so as to stipulate and help the rural population to grow and eat the foods it required for better child nutrition.

• Supplied equipment for modern dairy plants in various parts of India, viz. Maharashtra, Karnataka, West Bengal, etc.

• Specific aids also given for intervention against nutritional deficiency diseases, viz.

– Provision of large doses of vitamin A in areas where Xerophthalmia is prevalent.

– Provision of iron and folate supplements to combat anemia

– Enrichment of foods.

• More recently, FAO, UNICEF and WHO have encouraging the development of national food and nutrition policies those make provision for child nutrition.

3. Family and child welfare: The purpose is to improve the care of children, both within and outside their homes through such means as:

• Parent education

• Day-care centers

• Child welfare and youth agencies and women’s clubs.

These services are carried out not as separate projects but as part of health, nutrition and education or home economics extension programs.

4. Education—formal and non-formal: UNICEF works in collaboration with UNESCO and UNICEF to improve teaching science in India. It supplies science laboratories equipment, workshop tools, library books, audiovisual aids to educational institutions. Emphasis is placed on the kind of schooling relevant to the environment and future life of the children. Currently, UNICEF is promoting a campaign known as GOBI-FFF campaign to encourage “child health revolution”.

• G for Growth charts to better monitoring of child development

• O for Oral rehydration to treat all mild and moderate dehydration

• B for Breastfeeding

• I for Immunization against measles, diphtheria, polio, pertussis, tetanus and tuberculosis.

• F for Female literacy

• F for Family planning

• F for Food supplements.

In short, UNICEF activities cover programs assisting in child survival, protection and development; interventions like immunization, improved infant feeding practices; child growth monitoring, home based diarrhea management, drinking water, environmental sanitation, birth spacing, education of girls and income-generating activities for women.

UNICEF is aiding India in the following:

1. Education: Provides formal and non-formal education by providing science laboratories, workshops, tools, library books and audiovisual aids to educational institutions.

2. Health: Assisted in the building of the Penicillin plant at Poona and DDT plant. It helped in establishing plants to manufacture freeze-dried vaccine. In collaboration with WHO, assisted in upgrading the departments of pediatrics, obstetrics and community health in medical colleges and in teaching hospitals. Also helped with training of nurses and auxiliary health personnel.

3. Nutrition: Supplying milk powder to feed infants, supplied equipments for many dairy plants in different parts of India (Maharashtra, Andhra Pradesh, Karnataka, Gujarat and West Bengal). Along with the Food and Agricultural organization, had started the Applied Nutrition Program in India, providing aid for interventions against nutritional deficiencies like vit A in areas where xerophthalmias is prevalent; iodized salt in areas of endemic goiter, etc.

4. Water supply: It has supplied equipment to dig wells to improve water supply.

UNITED NATIONS DEVELOPMENT PROGRAM (UNDP)

UNDP is established in 1955. Headquarter of UNDP is in New York along with field offices in 166 countries. It’s the main source of funds for technical assistance. Basic objective of UNDP is to help poorer nations develop their human and natural resources more fully.

Functions

• Covers every economic and social sectors (agricultural, industry, education and science, health, social welfare, etc.)

• Advocating for change and connecting countries to knowledge, experience and resources to help people build a better life.

• World leaders have pledged to achieve MDG (Millennium Development Goal) including the overarching goal of cutting poverty in half in 2015.

• Taken challenges on:

– Democratic governance

– Poverty reduction

– Crisis prevention and recovery

– Environment and energy

– HIV/AIDS

– Protection of human rights, women empowerment.

UN’s Fund for Population Activities (UNFPA)

UNFPA is established in 1969. Main function of it is to provide assistance to the population of developing countries, at their request. Activities undertaken to fulfill the objective are:

• To improve reproductive health and family planning service

• To formulate population policies in support to sustainable development

Two-third of its budget is spent for reproductive health, FP, adolescent reproductive health, to decrease MMR, HIV/AIDS, assistance in emergency. UNFPA inputs are designed to develop national capability:

• For the manufacture of contraceptives.

• To develop population education program.

• To undertake organized sector projects.

• To strengthen program management.

• To improve output of grass root level health workers.

• Introduction of innovative approaches to FP and MCH.

Food and Agricultural Organization (FAO)

FAO is the first specialized agency of UN established after Second World War in 1945. The chief aim is to alleviate global malnutrition and hunger along with the following objectives:

• To help nations raise living standards.

• To improve nutrition of the people of all countries.

• To increase the efficiency of farming, forestry and fisheries.

• To better the condition of rural people.

Strategies

• To promote food production by improving the efficiency of agriculture, fisheries and forestry, so that production of food keeps pace with the increase in population.

• To improve the nutritional status of the people of all countries by adequate distribution of food in the communities. In this context, FAO initiated “A world Freedom from Hunger Campaign during 1960 and disseminated to the people”.

International Labor Organization (ILO)

Established in 1919, headquarters in Geneva, Switzerland, as an affiliate of League of Nations to improve the working and living conditions of working population all over the world.

Purposes

• To promote the health and safety of the working population.

• To promote their economic and social stability.

• ILO has developed an International Labor Code to promote social justice.

World Bank

The World Bank is a United Nations international financial institution that provides loans to developing countries for capital programs. It is created at the 1944 Bretton Woods Conference. The World Bank is a component of the World Bank Group, and a member of the United Nations Development Group.

The World Bank’s official goal is the reduction of poverty. For the goals to be realized, six criteria must be met: stronger and more inclusive growth in Africa and fragile states, more effort in health and education, integration of the development and environment agendas, more and better aid, movement on trade negotiations, and stronger and more focused support from multilateral institutions like the World Bank.

Goals of World Bank

1. Eradicate extreme poverty and hunger: From 1990 through 2004, the proportion of people living in extreme poverty fell from almost a third to less than a fifth. Africa’s poverty, however, is expected to rise, and most of the 36 countries where 90% of the world’s undernourished children live are in Africa. Less than a quarter of countries are on track for achieving the goal of halving undernutrition.

2. Achieve universal primary education: The percentage of children in school in developing countries increased from 80% in 1991 to 88% in 2005. Still, about 72 million children of primary school age, 57% of them girls, are not being educated as of 2005.

3. Promote gender equality: Yet more women than men worldwide (more than 60%) are contributing but unpaid family workers. The World Bank Group Gender Action Plan is created to advance women’s economic empowerment and promote shared growth.

4. Reduce child mortality: There is somewhat improvement in survival rates globally; accelerated improvements are needed most urgently in South Asia and Sub-Saharan Africa. Estimated 10 million-plus underfive children died in 2005; most of their deaths are from preventable causes.

5. Improve maternal health: Almost the entire half million women who die during pregnancy or childbirth every year live in Sub-Saharan Africa and Asia. There are numerous causes of maternal death that require a variety of health care interventions to be made widely accessible.

6. Combat HIV/AIDS, malaria, and other diseases: AIDS remains the leading cause of death in Sub-Saharan Africa (1.6 million deaths in 2007). There are 300 to 500 million cases of malaria each year, leading to more than 1 million deaths. Nearly all the cases and more than 95 percent of the deaths occur in Sub-Saharan Africa.

7. Ensure environmental sustainability: Deforestation remains a critical problem, particularly in regions of biological diversity, which continues to decline. Greenhouse gas emissions are increasing faster than energy technology advancement.

8. Develop a global partnership for development: Donor countries have renewed their commitment to match the current rate of core program development. Emphasis is being placed on the Bank Group’s collaboration with multilateral and local partners to quicken progress towards the MDGs’ realization.

INTERNATIONAL BILATERAL HEALTH AGENCIES

USAID

The United States Agency for International Development (USAID) is the United States Government agency primarily responsible for administering civilian foreign aid. USAID’s decentralized network of resident field missions is drawn on to manage the US government (USG) programs in low-income countries for a range of purposes.

• Disaster relief: Since its 1961 funding, USAID has lead United States government relief efforts after wars and natural disasters through its Office of the US Foreign Disaster Assistance. Privately funded the US NGOs and the US military also play major roles in disaster relief overseas.

• Poverty relief: After 1945, many newly independent countries needed assistance to relieve the chronic deprivation afflicting their low-income population. In addition, USAID provides funding to NGOs to supplement private donations in relieving chronic poverty.

• Technical cooperation on global issues, including the environment: Technical cooperation between nations is essential for addressing a range of cross-border interests like communicable diseases, environmental issues, trade and investment cooperation and so forth. USAID administers programs in low-income countries to support these US bilateral interests.

• Environment: Among these global interests, environmental issues attract high attention. Since 1991, USAID has been providing environment assistance to 45 countries. USAID assists projects that conserve and protect threatened land, water, forests, and wildlife. USAID also assists projects to reduce greenhouse gas emissions and to build resilience to the risks associated with global climate change.

Colombo Plan

The Colombo Plan is a regional organization with primary focus of all activities on human resources development. It embodies the concept of collective intergovernmental effort to strengthen economic and social development of member countries in the Asia Pacific region.

Objectives

• To promote interest in and support for the economic and social development of Asia and the Pacific.

• To promote technical cooperation and assist in the sharing and transfer of technology among member countries.

• To keep under review relevant information on technical cooperation between the member governments, multilateral and other agencies with a view to accelerating development through cooperative effort.

• To facilitate the transfer and sharing of the developmental experiences among member countries within the region with emphasis on the concept of South-South cooperation.

The Colombo Plan has 4 Permanent Programs

• Program for Public Administration and Environment (PPA and ENV)

• Program for Private Sector Development (PPSD)

• Drug Advisory Program (DAP)

• Long-term Scholarships Program (LTSP)

SIDA

Swedish International Development Cooperation Agency (SIDA) is a government agency of the country of Sweden with over 650 employees. It is a government agency of the Swedish Ministry for Foreign Affairs. SIDA is responsible for the development of assistance to developing countries. SIDA also affirms respect of human rights, democracy and gender equality.

SIDA channels its resources through NGOs, multilateral cooperation and is interested in promoting the idea of “international development cooperation”. Supporting over 2,000 projects in over 100 countries (over 20 of them are specially designated as target countries), SIDA seeks to create partnerships with companies, popular movements, organizations, universities, and government agencies for its development projects. SIDA’s geographic focus is on countries in Africa, Asia, Latin America, and Central and Eastern Europe.

Goals

• Economic growth. To help increase the production of goods and services.

• Economic and social equality. To help reduce differences between rich and poor and ensure that everyone’s basic needs are met.

• Economic and political independence. To help to ensure that countries can make their own decisions on their economies and policies and create the conditions necessary for national selfdetermination.

• Democratic development. To help to ensure that people are given greater opportunities to influence developments locally, regionally and nationally.

• Environmental protection. To promote the sustainable use of natural resources and protection of the environment.

• Gender equality. To promote equality between men and women.

SIDA seeks to contribute to projects that the partner countries have identified as important. With its 1,500 partners (usually Swedish), SIDA provides funding, skills, and other resources to accomplish this goal. The primary opportunities for cooperation with SIDA are the following:

• NGOs: Most of the SIDA’s fundings are channeled through Swedish NGOs. SIDA is currently working in cooperation with over 300 of them.

• Multilateral cooperation: Approximately 1/3rd of Swedish development funds is given to international organizations including the UN, the World Bank, and several regional development banks. These funds are available either through partnerships with the countries themselves or through the international body. Some funds are also donated to the EU.

• Grant and credit aid: This type of funding goes directly to partners in the developing country requesting the funds.

• Contract-financed development cooperation: SIDA arranges for the creation of a partnership between a Swedish organization with technical skills and a developing country at that country’s request. SIDA finances and oversees the project.

• International training programs: Swedish companies, universities, and government agencies arrange training programs with partner countries for the exchange of knowledge, experience and skills. These take place in Sweden and are evaluated three years after their conclusion.

• Research cooperation: Swedish researchers are given SIDA grants for work in development through one of the following programs: programs for bilateral research cooperation with developing countries (1/3rd of funds), regional programs (1/3rd of funds), international research programs including those of the WHO and CGIAR are funded (1/4th of funds), research work on developing countries conducted in Sweden (1/lOth of funds).

• Consultant trust fund program: 10 consultant funds with regional or global operations are funding through international development banks and organizations.

DANIDA

Danish International Development Agency (DANIDA) is the brand which the Ministry of Foreign Affairs of Denmark, uses when it provides humanitarian aid and development assistance to other countries, with focus on developing countries. Denmark’s development policy aims to combat fighting poverty through promotion of human rights and economic growth. DANIDA has responsibility for the planning, implementation and quality assurance of Denmark’s development cooperation. There are local and posted staffs at Danish embassies and missions abroad who are responsible for the administration and management of Denmark’s development cooperation with the individual country.

Areas of development include social and economic development, women’s participation in development, human rights, democratization and good governance, stability, security and the fight against terrorism, refugees, humanitarian assistance and environment. It has also launched the “Strategy for Denmark’s Support to the International Fight against HIV/AIDS”. The programs are managed locally through the Danish missions in the countries of implementation.

Countries in which DANIDA currently works are: Bangladesh, Benin, Bhutan, Bolivia, Burkina Faso, Egypt, Eritrea, Ghana, Guatemala, India, Kenya, Malawi, Mozambique, Nepal, Nicaragua, Niger, Tanzania, Uganda, Vietnam, Zambia and Zimbabwe.

NON-GOVERNMENTAL AND OTHER HEALTH AGENCIES

Ford Foundation

It is one of the very important non-governmental organizations working actively in India. It has been active in the development of rural health services and family planning.

Activities

• It has established orientation training centers at Singur, Poonamalle and Najaffarh to provide training to medical and paramedical personnel, from all over India, in public health.

• It has helped Research-Cum-Action projects, which are concerned with the improvement of environmental sanitation, with reference to designing and construction of hand flushed acceptable sanitary latrines in rural areas.

• It has also helped the projects in rural health services and rural development.

• Calcutta water supply and drainage scheme master plan is prepared.

• It also contributed for the establishment of National Institute of Health Administration and Education (NIHAE), New Delhi, which is now known as National Institute of Health and Family Welfare, which provides training for health administrators.

Rockefeller Foundation

Rockefeller Foundation is established in the USA in 1913 by Mr John D Rockefeller with the objective of promoting the well-being of mankind all over the world. It started functioning in India from 1920, with a scheme for the control of hookworm disease in the Madras presidency.

Activities: It has helped in the establishment of All India Institute of Hygiene and Public Health, Calcutta; All India Institute of Medical Sciences, New Delhi; King George Medical College, Lucknow; Christain Medical College, Vellore; Christian Medical College, Ludhiana; SGS Medical College, Bombay; Field Demonstration, Ballabhgarh; National Institute of Virology, Pune, etc.

• It sponsors educational visits for advance training of health professional of India to other countries through fellowship and travel agents.

• It sponsors the visit of specialists from the USA.

• It provide grant-in aid to the selected institutions for carrying out researches, libraries and medical education.

• Currently, it is giving active support for the improvement of agriculture, family planning and rural development.

CARE

Cooperative for American Relief Everywhere now renamed as Center for Assistance and Relief Everywhere. It is the largest, independent, non-profit based, non-governmental international organization, founded in 1945 in North America, by the American donors to send food to the people of Europe, devastated by Second World War. After the end of the Second World War, the program is extended in providing food needs for the developing countries, emergency aid and long-term development assistance to all countries. CARE began its operation in India in 1950, by funding through the following services.

• Mid-day school meal program

• ICDS scheme

• Educational and vocational training

• Distribution of garden tools, pump sets and seeds for raising vegetable gardens in schools.

• Improvement of medical care by supplying medical equipment, mobile vans, glass-frames, drugs, books and medicines to Indian hospitals.

• It is helping in the projects such as Nutrition and Health Projects, Anemia Control Projects, Adolescent Girls Projects, Child Survival Projects, Reproductive and Family Health Projects, Konkan Integrated Development Projects, etc.

INTERNATIONAL RED CROSS

The Red Cross is founded by Henry Dunant, a young Swiss businessman. It is a nonpolitical, non-official and International humanitarian organization devoted to the service of mankind in peace and war.

Function: These comprise services to armed forces services to veterans disaster service, first aid and nursing, health education and maternity and child welfare. The core tasks of the Committee, which are derived from the Geneva Conventions and its own statutes are:

• To monitor compliance of warring parties with the Geneva Conventions.

• To organize nursing and care for those who are wounded on the battlefield.

• To supervise the treatment of prisoners of war and make confidential interventions with detaining authorities.

• To help with the search for missing persons in an armed conflict (tracing service).

• To organize protection and care for civil population.

• To act as a neutral intermediary between warring parties.

INDIAN RED CROSS

It is established by an act of Indian legislature in 1920 with three objectives of the improvement of health, prevention of disease and mitigation of suffering. In peace time, the society provides military hospital with such amenities as newspaper, periodicals, musical instruments and other comfort foods. The Indian Red Cross’s programs are grouped into four main core areas: promoting humanitarian principles and values; disaster response; disaster preparedness; and health and care in the community.

• Red Cross promotes the Humanitarian values, which encourage respect for other human beings and a willingness to work together to find solutions to problems.

• Disaster response continues to represent the largest portion of IRCS work, with assistance to millions of people annually ranging from refugees to victims of natural disasters. Disaster services comprise distribution of milk, medicines, vitamin tablets and hundred other items to the famine people and to those who have been hit by the floods.

• The increase in the number of natural disasters countrywide in recent years, Red Cross to devote more attention to disaster preparedness activities. These aim to make Red Cross Societies and communities more aware of the risks they face, how to reduce their vulnerability, and how to cope when disaster strikes.

• Health and community care has become a cornerstone of humanitarian assistance, and accounts for a large part of Red Cross spending. Through these programs, the Red Cross aims to enable communities to reduce their vulnerability to disease, and prepare for and respond to public health crises.

One of the Red Cross’s Societies fundamental tasks are guiding, supporting and development of four core areas and others. Capacity building programs and activities include: management and volunteer training, improving branch structures, planning, fund-raising and gender equality. Other major activities include: hospital services, blood bank, HIV/AIDS programs, home for disabled servicemen, vocational training centers, tracing activities, maternity, child and family welfare, nursing, junior Red Cross activities, preparedness and prevention of communicable and infectious diseases, relief operations in fire, railway and other accidents and events.

The Junior Red Cross

The Junior Red Cross gives an opportunity to lakh of boys and girls all over India to be associated with creativities like the village uplift, first aid, anti-epidemic work and building up of an International friendliness, understanding and cooperation. The program focuses on the following areas:

• Promote life and health through training and education on safety, primary health care and healthy living.

• Encourage community service through training and education.

• Disseminate the seven fundamental principles of Red Cross and Red Crescent movement through activities that encourage the Red Cross ideals.

• Promote international friendship with activities that cultivate a humanitarian spirit.

• Technical support in the development of youth programs, fund-raising, identification of material and human resources.

There are various voluntary health agencies established in India. Those are Indian Red Cross Society, Hind Kusht Nivaran Sangh, Indian Council for Child Welfare, Tuberculosis Association of India, Bharat Sevak Samaj and many more. These agencies work with the same aim to improve the health status of people as well as country.

Bibliography

1. Basvanthappa BT. Community Health Nursing. Second Edition. New Delhi: Jaypee; 2008.

2. Colombo Plan. [Internet] 2014 May 6th [Cited on 2014 Dec 31st], Available from: http://en.wikipedia.org/wiki/Colombo_Plan.

3. DANIDA (Danish International Development Agency) [Internet] 2014 [Cited on2014 Dec 31st]. Available from: http://www.ungei.org/whatisungei/index_735.html.

4. Gulani KK. Community Health Nursing. First Edition. Pitam Purea, Delhi: Kumar Publishing House; 2007.

5. Indian Red Cross Society. [Internet] 2012 [Cited on 2014 Dec 31st]. Available from: http://www.indianredcross.org/program.htm.

6. Keshav Swarnkar. Community Health Nursing. Third Edition. Indore: NR Brothers; 2011.

7. Kumari Neelam. A Textbook of Community Health Nursing -1. First Edition, Jalandhar City: S Vikas and Company (Medical Publisher), India: 2009.

8. Lai Sundar. Textbook of Community Medicine. Second Edition. New Delhi: CBS Publishers & Distributors; 2009, p751–754.

9. Park K. Preventive and Social Medicine. 18th ed. Jabalpur: Banarsidas Bhanot; 2005.

10. Prabhakara GN. Short Textbook of Preventive and Social Medicine. First Edition. New Delhi: Jaypee; 2003.

11. Pravakara GN. Textbook of Community Health for Nurses. Delhi: PEEPEE; 2004.

12. Suryakantha AH. Community Medicine. First Edition. New Delhi: Jaypee; 2009.

13. Swedish International Development Cooperation Agency [Internet] 2001 [Cited on 2014 Dec 31st]. Available from: http://web.mit.edu/urbanupgrading/upgrading/resources/organizations/SIDA.html.

14. The Major International Health Organizations. [Internet] 2014 [Cited on 2014 Dec 31st], Available from: http://www.imva.org/pages/orgfrm.htm.

15. United States Agency for International Development [Internet] 2014 Dec 31st [Cited on 2014 Dec 31st]. Available from: http://en.wikipedia.org/wiki/United_States_Agency_for_International_Development.

16. World Bank. [Internet] 2014 Dec 24th [Cited on 2014 Dec 31st]. Available from: http://en.wikipedia.org/wiki/World_Bank.

17. Yatiraj Singh. Community Medicine. First Edition. New Delhi: Jaypee; 2009.

23

National Health Programs in India

This chapter contains

▪ National Health Program

▪ Programs for Communicable Diseases

• National Vectorborne Diseases Control Program (NVBDCP)

• National Malaria Eradication Program

• National Filaria Control Program

• National Leprosy Eradication Program

• Revised National Tuberculosis Control Program

• National AIDS Control Program

• Universal Immunization Program

▪ Programs for Non-communicable Diseases

• National Program for Control of Blindness

• National Cancer Control Program

• National Mental Health Program

• National Diabetes Control Program

▪ National Nutritional Programs

• National Iodine Deficiency Disorders Control Program

• Integrated Child Development Services Scheme

• Mid-day Meal Program

▪ Programs Related to System Strengthening/Welfare

• Reproductive and Child Health Program

• National Rural Health Mission

• 20 Points Program

NATIONAL HEALTH PROGRAMS (NHPs)

The Government of India has being putting efforts earnestly to promote the health status of the people by implementing various measures. Among those one is launching of different National Health Programs to combat communicable and non-communicable diseases. A number of international agencies such as WHO, UNICEF, World Bank, SID A, DANIDA, NORAD and USAID providing funds and many technical and material assistance.

As per the recommendation of Bhore Committee, Government of India formulated and launched “National Health Programs” right from the inception of five-year plan (from 1951), as the committee found:

• Disease burden is quiet high in country

• Intervention needed to prevent geographical spread of disease

• Adequate infrastructure to fight with diseases are not sufficient

• Resources for program implementation are not available

• Proven strategies for prevention and control of diseases can be use nationally if this kind of program implemented

National health programs are of three kinds:

a. Hundred percent centrally sponsored programs, but implementation is by the state governments.

b. Fifty-fifty centrally sponsored programs, i.e. implementation is by the state governments, however, 50 percent of the expenses are provided by the central government.

c. Vertical programs, in which both the implementation and incurring expenditure is by the central government only. It is easier to get international funds for the centrally sponsored programs.

National Health Programs in India

Programs for Communicable Diseases

• National Vectorborne Diseases Control Program (NVBDCP)

• National Malaria Eradication Program

• National Filaria Control Program

• National Leprosy Eradication Program

• Revised National Tuberculosis Control Program

• National AIDS Control Program

• Universal Immunization Program

• National Guinea Worm Eradication Program

• Yaws Control Program

• Integrated Disease Surveillance Program

Programs for Non-Communicable Diseases

• National Cancer Control Program

• National Mental Health Program

• National Diabetes Control Program

• National Program for Control and Treatment of Occupational Diseases

• National Program for Control of Blindness

• National Program for Control of Diabetes, Cardiovascular Disease and Stroke

• National Program for Prevention and Control of Deafness

National Nutritional Programs

• Integrated Child Development Services Scheme

• Mid-day Meal Program

• Special Nutrition Program (SNP)

• National Nutritional Anemia Prophylaxis Program

• National Iodine Deficiency Disorders Control Program

Programs Related to System Strengthening/Welfare

• National Rural Health Mission

• Reproductive and Child Health Program

• National Water Supply and Sanitation Program

• 20 Points Program

National Vectorborne Disease Control Program

Directorate of National Vectorborne Disease Control Program (NVBDCP) is the central nodal agency for the prevention and control of vectorborne diseases, i.e. malaria, dengue, lymphatic filariasis, kala-azar, Japanese encephalitis and chikungunya in India. Government of India launched NVBDCP in 2003–04 by merging national anti-malaria control program, national filaria control program and kala-azar control programs.

List of Vectorborne Diseases Control Program Legislations

1. National Anti-Malaria program

2. Kala-Azar Control Program

3. National Filaria Control Program

4. Japenese Encephilitis Control Program

5. Dengue and Dengue Hemorrhagic fever

Objectives

The Government of India in its National Health Policy (2002) has pledged commitment to reduce mortality on account of malaria by 50% by 2010 and additional 10% by 2012 and efficient morbidity control and elimination of lymphatic filariasis (ELF) by 2015.

Strategies

Early Diagnosis and Complete Treatment (EDCT)

• Early diagnosis and complete treatments to malaria positive cases and treatment with combination therapy.

• Microscopic centers to examine the blood slides.

• Providing adequate anti-malarial drugs, microslides, pricking needles and other accessories.

• Establishment of FTD (fever treatment depots) at village level

• Screening and treatment in deep forest areas through community involvement and ensuring availability of antimalarial drugs and diagnostic tools with functionaries.

Integrated Vector Management (IVM)

• Indoor Residual Spray (IRS) twice in year during transmission season in selected high risk areas having API > 5 with DDT 50% and SP 5%.

• Distribution of Long-Lasting Insecticidal Nets (LLIN) in high risk areas having API > 2 in a cluster approach.

• Impregnation of community owned bed nets with suitable insecticide.

• Biological control through larvivorous fish.

• Elimination of vector breeding sources.

Supporting strategies

• Capacity building of medical, paramedical, NGO and community volunteers.

• Suitable health communication program and Public Partnership Initiative (PPI).

• Engagement of suitable manpower sources.

Activities

• Early Diagnosis and Complete Treatment (EDCT)

• Integrated Vector Management (IVM)

• Capacity building (Training)

• Behavior Change Communication (BCC)

• Operational Research

• New initiatives: Public-Private Partnership: Partnership with private sector, Non-Governmental Organisations (NGOs), Religious Organisations (FBOs), Community Based Organisations (CBOs) and local self Government (PRIs) are being take up under the program.

• Monitoring Supervision: To facilitate monitoring of Program implementation at field level, visit of state level, district level and block level officers as well as specially designed check list can be circulated and funds under mobility support for all category of staff can be allocated.

1. National Anti-Malaria Program

Malaria is one of the serious public health problems in India. A countrywide comprehensive program to control malaria was recommended in 1946 by the Bhore Committee report that is endorsed by the Planning Commission in 1951. In April 1953, Govt, of India launched National Malaria Control Program (NMCP).

Objective: To bring down malaria transmission to a level at which it would cease to be a major public health problem.

2. Kala-Azar Control Program

Kala-azar or visceral leishmaniasis (VL) is a chronic disease caused by an intracellular protozoan (Leishmania species) and transmitted to man by bite of female phlebotomus sand fly. Currently, it is a main problem in Bihar, Jharkhand, West Bengal and some parts of Uttar Pradesh. In view of the growing problem planned control measures were initiated to control kala-azar.

Objectives: The strategy for kala-azar control broadly included three main activities.

• Interruption of transmission by reducing vector population through indoor residual insecticides.

• Early diagnosis and complete treatment of kala-azar cases; and

• Health education program for community awareness.

3. National Filaria Control Program

Bancroftian filariasis caused by Wuchereria bancrofti, which is transmitted to man by the bites of infected mosquitoes—Culex, Anopheles, Mansonia and Aedes. Lymphatic filariasis is prevalent in 18 states and union territories. Bancroftian filariasis is widely distributed while Brugian filariasis caused by Brugia malayi is restricted to 6 states—UP, Bihar, Andhra Pradesh, Odisha, Tamil Nadu, Kerala, and Gujarat. The National Filaria Control Program is launched in 1955. The activities were mainly confined to urban areas. However, the program has been extended to rural areas since 1994.

Objectives

• Reduction of the problem in unsurveyed areas.

• Control in urban areas through recurrent anti-larval and anti-parasitic measures.

4. Japanese Encephalitis Control Program

Japanese encephalitis (JE) is a zoonotic disease and caused by an arbovirus, group B (flavi-virus) and transmitted by Culex mosquitoes. The case fatality in India is 35% which can be reduced by early detection, immediate referral to hospital and proper medical and nursing care. Government of India has constituted a Task Force at National Level which is in operation and reviews the JE situations and its control strategies from time to time. Though Directorate of National Anti-Malaria Program is monitoring JE situation in the country.

Objectives

• Strengthening early diagnosis and prompt case management at PHCs, CHCs and hospitals through training of medical and nursing staff.

• IEC for community awareness to promote early case reporting, personal protection, isolation of amplifier host, etc.

• Vector control measures mainly fogging during outbreaks, space spraying in animal dwellings, and antilarval operation where feasible.

• Development of a safe and standard indigenous vaccine. Vaccination for high risk population particularly children below 15 years of age.

5. Dengue and Dengue Hemorrhagic Fever

One of the most important increasing tropical infectious diseases is dengue. Dengue Fever and Dengue Hemorrhagic Fever (DHF) are acute fevers caused by four antigenically related but distinct dengue virus serotypes (DEN 1,2,3 and 4) transmitted by the infected mosquitoes, Aedes aegypti. Dengue outbreaks have been reported from urban areas from all states. All the four serotypes of dengue virus (1, 2, 3 and 4) exist in India. The Vector Aedes aegypti breed in peridomestic fresh water collections and is found in both urban and rural areas.

The milestones of the program are as under:

1953 | National Malaria Control Program (NMCP)
1958 | National Malaria Eradication Program (NMEP)
1977 | Modified Plan of Operation (MPO)
1979 | Multipurpose Worker Scheme (MPW Scheme)
1995 | Implementation of Malaria Action Plan, 1995 (MAP–95).
1997 | Launching of World Bank Assisted Enhanced Malaria Control Project in tribal districts of the State (EMCP).
2000 | National Anti-Malaria Program (NAMP).
2004 | National Vectorbome Disease Control Program (NVBDCP).

Objectives

• Surveillance for disease and outbreaks

• Early diagnosis and prompt case management

• Vector control through community participation and social mobilization

• Capacity building

National Malaria Eradication Program

Malaria is one of the serious public health problems in India. Malaria Control Program is being implemented in the State since 1953 with the objective of bringing down malaria transmission to a level at which it would cease to be a major public health problem.

Modified Plan of Operation (MOP)

The worsening malaria situation forced the government to abandon eradication and revert to malaria control. Thus in 1st April, 1977 the Modified Plan of Operation (MPO) is launched by the Govt, of India.

Objectives

• To prevent deaths due to malaria

• To reduce malaria morbidity

• To maintain agriculture and industrial production through intensive anti-malaria measures in such areas

• To consolidate the gains achieved so far

Reclassification of endemic areas

Areas were reclassified based on the Annual Parasitic Incidence (API) as those having API > 2 and those having < 2 for operational purposes.

• Areas having Annual Parasite Index (API) more than 2

– Regular 2 rounds of insecticidal spray with DDT (1 g/sq m)

– Where vector is refractory to DDT: spray 3 rounds of Malathion (2 g/sq m)

– If vector is refractory to both DDT and Malathion: Spray 2 rounds of Synthetic Pyrethroidsat 6 weeks interval (0.25 g/sq m).

• Areas having Annual Parasite Index (API) less than 2

– Regular spray is not carried out but “focal spraying” is carried out around P. falciparum cases detected during surveillance

Establishment of Drug Distribution Points (DDPs) and Fever Treatment Depots (FTDs)

• Established a wide network of Drug Distribution Centers and Fever Treatment Depots as it is not sufficient to distribute drugs only by surveillance workers.

• Drug Distribution Centers: Dispense only anti-malarial tablets as per NMEP.

• Fever Treatment Depots: Collect blood slide in addition to drug distribution.

Urban Malaria Scheme (UMS)

• It was launched in 1971 to overcome the increasing incidence of malaria in urban areas.

• Methodology comprises vector control by intensive antiviral measures and drug treatment.

P. falciparum containment program

• It was launched in October 1977 with the assistance of SIDA (Swedish International Development Agency).

• Purpose is to prevent the spread of falciparum malaria.

Research

Six monitoring teams working in different parts of the country to identify P. falciparum sensitivity to chloroquine. One of those teams is working on testing alternative drugs wherever chloroquine-resistance has been detected.

Health education

Emphasis has been given to the health education of the public to enlist their cooperation in malaria control activities.

Reorganization

• Anti-malarial Units are reorganized.

• Geographical boundaries of the district are conformed and the District Health Officer (DHO) is made responsible for implementation of the program.

• The existing unit officers have been designated as District Malaria Officer (DMO) and posted in district headquarters.

• They are entrusted with the operational and evaluation aspect of the program.

Surveillance

Surveillance means the maintenance of an ongoing watch/vigil over the status of malaria in a group or community. Surveillance is of two types:

a. Active surveillance: Under this, the fortnightly domiciliary visits are made by Multi-Purpose Health Worker (1 MPHW for 10,000 population) for active search of all fever cases and blood slides are prepared and sent to the laboratory for confirmation of the cases. If person is found positive for Malaria, MPHW provides full radical treatment.

b. Passive surveillance: It means the search for malaria cases by the local health agencies (PHC, SC, hospitals, dispensaries and local medical practitioner). Under Passive Surveillance, blood slide of a fever case to confirm malaria is made when he/she attends the OPD.

c. Parameters of surveillance: The following parameters are widely used in epidemiological surveillance of malaria.

ABER (Annual Blood Examination Rate) = (No. of blood smears collected during the year × 100)/Population of the area

API (Annual Parasite Incidence):

= (No. of Positive Malaria Cases in one year × 1000)/Population of the area

Annual falciparum incidence (AFI):

= (Total positive PF in a year × 1000)/Population of the area

Slide falciparum rate = (Total positive PF × 100)/Slides examined.

Enhanced Malaria Control Project (EMCP)

Enhanced Malaria Control Project is launched in April, 1997 with the assistance of the World Bank. This is directly benefiting the Tribal Population of the eight peninsular states covering 100 districts and 19 urban areas. However, the population living in other malaria endemic areas is also benefited, as the strengthening of the components of IEC, Training and Management Information System has covered the entire country. In 1999, the Govt of India to drop the term “National Malaria Eradication Program” and rename it as “National Anti-Malaria Program”.

Selection of PHCs is based on:

• Annual Parasitic Incidence (API) is more than 2 for last 3 years

• Pf cases are more than 30% of the malaria cases

• 25% population of the PHC is tribal

• The area has been reporting deaths due to malaria and also has the flexibility to direct resources to any needy areas in case of outbreak of malaria.

Objectives of EMCP

1. Effective control of malaria to bring reduction in malaria morbidity

2. Prevention of death due to malaria

3. Consolidation of the gain achieved so far.

Strategies

1. Early case detection and prompt treatment

2. Vector control by indoor residual insecticide spray in rural areas with API of 2 per 100 and above in the preceding three years with appropriate insecticide and by recurrent anti-malaria in urban areas

3. Health education and community participation.

Components of EMCP

1. Early case detection and prompt treatment

2. Selective vector control

3. Legislative measures

4. Personal protective measures

5. Epidemic planning and rapid response and intersectoral coordination

6. Institutional and management capacities strengthening

7. Operation research

8. Community participation

Malaria Control in India (2012–2017): A Five year Strategic Plan

Vision: The country has a document ‘The Vision 2002’ which emphasizes the expectations from the health care delivery system for malaria by 2025.

Mission: To reduce the morbidity and mortality due to malaria and improving the quality of life, thereby contributing to health and alleviation of poverty in the country.

Goals

• Screening all fever cases suspected for malaria (60% through quality microscopy and 40% by Rapid Diagnostic Test).

• Treating all P. falciparum cases with full course of effective ACT (Artemisinin-Combination Therapies) and primaquine and all P. vivax cases with 3 days chloro-quine and 14 days primaquine.

• Equipping all health Institutions (PHC level and above), especially in high-risk areas, with microscopy facility and RDT (Rapid Diagnostic Tests) for emergency use and injectable artemisinin derivatives.

• Strengthening all district and sub-district hospitals in malaria endemic areas as per IPHS (Indian Public Health Standards) with facilities for management of severe malaria cases.

Objective: To achieve by the end of 2017, API < 1 per 1000 population.

Outcome indicators

• At least 80% of those suffering from malaria get correct, affordable and appropriate and complete treatment within 24 hours of reporting to the health system, by the year 2017.

• At least 80% of those at high risk of malaria get protected by effective preventive measures such as ITN (Insecticide Treated Net)/LLIN (long-lasting insecticide-treated net) or IRS (Indoor residual spraying) by 2017.

• At least 10% of the population in high-risk areas is surveyed annually (Annual Blood Examination Rate >10%).

Impact indicators

• To bring down annual incidence of malaria to less than 1 per 1000 population at national level by 2017.

• At least 50% reduction in mortality due to malaria by the year 2017, taking 2010 level as baseline.

Strategies: India’s National Malaria Strategic Plan (2012–17) is in line with the following broad strategies of the Regional Malaria Strategy of WHO/SEARO.

• Reform approaches to program planning and management.

• Improve and enhance surveillance and strengthen monitoring and evaluation.

• Scale up coverage and proper use of insecticide treated bed nets.

• Target interventions to risk groups.

• Scale up control of P. vivax.

National Filaria Control Program

WHO has estimated that 600 million people are at risk of infection in South-East Asia and 60 million are actually infected in the region (WHO-SEARO, 1999). There are about 454 million people (75.6%) at the risk of infection with 48 million (80%) infected with parasite are contributed only by India.

Filariasis caused by Wuchereria bancrofti, which is transmitted to man by the bites of infected mosquitoes (Culex, Anopheles, Mansonia and Aedes). The disease may cause severe deformity and disability.

The National Filaria Control Program (NFCP) is launched in the country in 1955 after conducting a pilot project in Odisha from 1949 to 1954. Objective is to delimit the problem, to undertake control measures in endemic areas and to train personnel to man the program. The main control measures were mass DEC administration, antilarval measures in urban areas and indoor residual spray in rural areas.

Objectives

• To carry out surveys in different parts of the state where the problem was known to exist in order to determine the extent of prevalence, types of infection and their vectors.

• To undertake large scale pilot studies to evaluate the known methods of filariasis control in selected areas in different parts of states.

• To train professional and ancillary personnel required for the program.

Strategies

• A single day mass DEC (Diethylcarbamazine) treatment at a dose of 6 mg per kg body weight once a year. Continuation of this program as National level Goal is to eliminate lymphatic filariasis from India by the year 2015.

• Diagnosis and treatment of microfilaria carriers and cases of acute and chronic filariasis episodes to reduce the morbidity associated with frequent acute infections at the doorstep of patients.

• Information, education and communication (IEC) to inculcate individual/community based protective and preventive habits as an integral part of filaria control strategy.

• Control Strategy

– Vector Control through antilarval spray/application at weekly intervals with appropriate larvicides; one or two round of residual insecticide spray with DDT in areas which is known to be endemic for filariasis.

– Biological control through larvivorous fishes.

– Enviromental engineering through source reduction and water management.

– Antilarval measures with temephos in prescribed dosage in water storage tanks every week.

– Application of mineral larvidcidal oils on water surface to practice.

Revised filaria control strategy

The strategy follows the WHO recommendation of annual single dose mass drug therapy with DEC/DEC with albendazole as supplement to exist NFCP strategy for 5 years or more in highly endemic districts to reduce transmission of filaria to a very significant low level.

In pursuit of achieving the goal of elimination of lymphatic filariasis by 2015, Govt, of India has launched nationwide mass drug administration (MDA) of DEC in 202 endemic districts of the country. To alleviate the sufferings of the patients, home based morbidity management and hydrocolostomy at identified hospital/CHCs has been taken up. All sectors including medical colleges, program implementers, private sector health care service providers and community volunteers are involved.

National Leprosy Eradication Program

First, the National Leprosy “Control” Program is launched in 1955. In 1983, the control program is redesigned “National Leprosy Eradication Program” (NLEP) and was a centrally sponsored Health Scheme of the Ministry of Health and Family Welfare, Govt, of India. The Program is headed by the Deputy Director of Health Services (Leprosy) under the administrative control of the Directorate General Health Services Govt, of India. While the NLEP strategies and plans are formulated centrally, the program is implemented by the States/UTs. The Program is also supported as Partners by the World Health Organization, The International Federation of Anti-leprosy Associations (ILEP) and a few other non-govt, organizations. The World Health Assembly in May 1991 adopted a resolution for global leprosy elimination as a public health problem by the year 2000.

The 1st Phase of the World Bank supported National Leprosy Elimination Project started from 1993–94 and completed on 31–3–2000. During this phase, the prevalence rate reduced from 24/10,000 population in 1992 before starting 1st phase project to 3.7/10,000 by March, 2001.

The 2nd Phase of World Bank Project on NLEP started for a period of 3 years from 2001–02. The project successfully ended on 31st Dec, 2004.

After the declaration of the global elimination, a target is reset for the remaining 15 countries to achieve elimination at the national level by the end of December, 2005. India is one of these countries. The National Health Policy of India, 2002 also set the goal of leprosy elimination in India by the end of year 2005.

Important milestones in NLEP in India

• 1955: Government of India launched National Leprosy Control Program

• 1983: Government of India launched National Leprosy Eradication Program (NLEP) and introduced MDT (Multidrug Therapy)

• 1993–2000: World Bank supported NLEP-1

• 2001–2004: World Bank supported NLEP-II

• 2005 (January): NLEP continued with Government of India funds and donor partners support.

• 2005 (December): India achieved elimination as a public health problem. 2012-Special action plan for 209 high endemic districts in 16 States/UTs.

Aim: To reduce the workload to 1 or less than 1 per 10,000 population.

Strategy

• Decentralized integrated leprosy services through General Health Care system.

• Early detection and complete treatment of new leprosy cases.

• Carrying out household contact survey in detection of Multibacillary (MB) and child cases.

• Early diagnosis and prompt MDT, through routine and special efforts.

• Involvement of Accredited Social Health Activists (ASHAs) in the detection and complete treatment of Leprosy cases for leprosy work.

• Strengthening of Disability Prevention and Medical Rehabilitation (DPMR) services.

• Information, Education and Communication (IEC) activities in the community to improve self reporting to Primary Health Center (PHC) and reduction of stigma.

• Intensive monitoring and supervision at Primary Health Center/Community Health Center.

Activities

• Early detection of leprosy cases

– Multibacillary leprosy is labeled when there are 6 or more skin patches and/or 2 or more nerves affected. Skin smear is positive.

– Paubacillary leprosy is labeled when there are 5 or less than 5 skin lesions and/or 1 more nerve affected. Skin smear do not show bacilli.

• Intensified health education and public awareness campaigns.

• Regular treatment of leprosy cases providing multidrug therapy (MDT) at fixed centers near the patient.

– Multibacillary (MB) leprosy: For adults the standard regimen is: Rifampicin 600 mg once a month, Dapsone 100 mg daily, Clofazimine 300 mg once a month and 50 mg daily Duration = 12 months.

– Paucibacillary (PB) leprosy: For adults the standard regimen is Rifampicin 600 mg once a month and Dapsone 100 mg daily Duration = six months.

– Single Skin Lesion Paudbacillary leprosy: For adults the standard regimen is a single dose of: Rifampicin 600 mg Ofloxacin 400 mg and Minocycline 100 mg.

• Disability prevention and medical rehabilitation.

• Monitoring and evaluation.

MDT Dose for Multibacillary Leprosy

Adult | Child 10–14 years | Child 6–9 years
Day 1 | Day 1 | Day 1
Supervised monthly treatment | Supervised monthly treatment | Supervised monthly treatment
Rifampicin | Rifampicin | Rifampicin
600 mg | 450 mg | 300 mg
Dapsone | Dapsone | Dapsone
100 mg | 50 mg | 25 mg
Days 2–28 | Days 2–28 | Days 2–28
Daily dapsone 100 mg | Dapsone 50 mg | Dapsone 25 mg

Revised National Tuberculosis Control Program

Revised National Tuberculosis Control Program (RNTCP) is the state-run tuberculosis control program initiated by the Government of India. It incorporates the principles of directly observed treatment-short course (DOTS) and the global TB control strategy of the World Health Organization. The program provides, free of cost, quality anti-tubercular drugs across the country through various private-sector DOTS-providers and numerous Primary Health Centers.

India has had an ongoing National TB Program (NTP) since 1962. This could not achieve the desired results. Therefore, it is reviewed by an expert committee in 1992 and based on its recommendations

Objectives

a. Long-term objectives: to reduce tuberculosis in the community to that level when it ceases to be a public health problems, i.e.

i. One case infects less than one new person annually.

ii. The prevalence of infection in the age group below 14 years is brought down to less than 1 percent.

b. Operational or short-term objectives

i. To detect maximum no. of TB cases among the outpatients attending any health institution with symptoms suggestive of tuberculosis and treat them effectively.

ii. To vaccinate newborns and infants with BCG.

iii. To undertake the above objectives in an integrated manner through all the existing health institutions in the country.

In 1992, Program reviews showed that only 30% of estimated tuberculosis patients are diagnosed and only 30 percent of those are treated successfully. Based on the findings and recommendations of the review in 1992, the GOI evolved a revised strategy and launched the Revised National TB Control Program (RNTCP) in the country.

The objectives of RNTCP are

• To achieve and maintain a cure rate of at least 85% among newly detected infectious TB cases

• Achieve and maintain detection of at least 70% of such cases in the population

• Involvement of NGOs; information, education and communication and improved operational research

Components of RNTCP: The five principal components of DOTS are:

• Political and administrative commitment

• Case detection by sputum smear microscopy

• Uninterrupted supply of high-quality anti-TB drugs

• Standardized treatment regimens with directly observed treatment for at least the first two months

• Systematic monitoring and accountability

RNTCP Phase I (1997–2006)

The core element of RNTCP in phase I is to ensure high quality DOTS expansion in the country, addressing the five primary components of the DOTS strategy;

• Political and administrative commitment

• Good quality diagnosis through sputum microscopy

• Directly observed treatment

• Systematic monitoring and accountability

• Addressing stop TB strategy under RNTCP

RNTCP Phase II (2006–2011)

The RNTCP has now entered its second phase, approved for a period of five years from October, 2006 to September, 2011. In the first phase of RNTCP (1998–2005), the program’s focus is on ensuring expansion of quality DOTS services to the entire country. There are many challenges remaining that are to be addressed in order to achieve the TB-related targets set by the Millennium Development Goals for 2015 and to achieve TB control in the longer term.

All components of new Stop TB Strategy are incorporated in the second phase of RNTCP. These are:

1. Pursue quality DOTS expansion and enhancement, by improving the case finding are cure through an effective patient-centered approach to reach all patients, especially the poor.

2. Address TB-HIV, MDR-TB and other challenges, by scaling up TB-HIV joint activities, DOTS plus, and other relevant approaches.

3. Contribute to health system strengthening, by collaborating with other health programs and general services.

4. Involve all health care providers, public, nongovernmental and private, by scaling up approaches based on a public-private mix (PPM), to ensure adherence to the International Standards of TB care.

5. Engage people with TB, and affected communities to demand, and contribute to effective care. This will involve scaling-up of community TB care; creating demand thorugh context-specific advocacy, communication and social mobilization.

6. Enable and promote research for the development of new drugs, diagnostic and vaccines. Operational Research is also needed to improve program performance.

Organization and administration

• Central level

– Besides the Tuberculosis Division in the Directorate General Health services, National Tuberculosis Institute, Bangalore and Tuberculosis Research center at Chennai.

• District level

A district constitutes a functional unit of the NTCP and is called District Tuberculosis Control Program.

• Peripheral level

Comprises chest clinics and Primary Health Centers (PHC).

The profile of RNTC in a State is as follows:

State TB Office
State TB Officer

State TB Training
Director and Demonstration Center

District TB Center
District TB Officer

TB Unit

• Medical Officer (TB Control) Senior

• Treatment Supervisor

• Senior Treatment Laboratory

Microscopic Center, Treatment Center

DOTs Providers

Laboratory Network

A nation-wide network of RNTCP quality assured designated sputum smear microscopy laboratory has been set up, providing appropriate, available, affordable and accessible diagnostic services for TB suspects and cases.

Fig. 23.1

Fig. 23.2: Diagnosis of tuberculosis

Diagnosis

Patients complaints of fever, cough, chest pain, hemoptysis are considered as “symptomatic”. Those cases whose sputum is positive for AFB (TB bacilli) are considered as “Open Cases” and those symptomatic whose sputum is negative andradiologicaly positive, are considered as “Suspected Cases”.

Treatment Categories and Drug Regimens

Isoniazid, Rifampicin, Pyrazinamide, Etham-butol, and Streptomycin are the primary antitubercular drugs used. Most DOTS regimens have thrice-weekly schedules and typically last for 6 to 9 months, with an initial intensive phase and a continuation phase. Based on the nature/severity of the disease and the patient’s exposure to previous antitubercular treatments, RNTCP classifies tuberculosis patients into two treatment categories (Table 23.1).

National AIDS Control Program

In 1987, the National AIDS Control Program (NACP) is initiated, with help from the World Bank, to coordinate the national response to HIV/AIDS. In the year 1992, the Ministry of Health and Family Welfare set up a National AIDS Control Organization as a separate wing to implement and closely monitor the various components of the program, the program’s main activity is the screening of the “sexually promiscuous population”, and “blood donors”, and carrying out some educational programs.

Table 23.1: DOTS regimen

Category
New*
Previously treated**

Characteristics
New sputum smear-positive,
New sputum smear-negative,
New extrapulmonary tuberculosis, others
Sputum smear-positive relapse,
Sputum smear-positive failure,
Sputum smear-positive treatment after default, others*

Treatment regimen
2H₃R₃Z₃E₃ + 4H₃R₃
2H₃R₃Z₃E₃S₃ + 1 H₃R₃Z₃E₃ + 5H₃R₃E₃

Duration and type of treatment
2 months intensive phase + 4 months continuation phase
Four drugs at thrice-weekly schedule for 2 months intensive phase and two drugs at thrice-weekly schedule for remaining 4 months continuation phase.
3 months Intensive phase + 5 months continuation phase
Five drugs at thrice-weekly schedule for initial 2 months followed by four drugs for next 1 month intensive phase. Three drugs at thrice-weekly schedule for remaining 5 months continuation phase.

H: Isoniazid (300 mg)
R: Rifampicin (450 mg)
Z: Pyrazinamide (1500 mg)

E: Ethambutol (1200 mg)
S: Streptomycin (750 mg)

1. Patients who weigh 60 kg or more receive additional Rifampicin 150 mg.

2. Patients who are more than 50 years old receive Streptomycin 500 mg. Patients who weigh less than 30 kg receive drugs as per Pediatric weight band boxes according to body weight.

Notes:

*New categories include former categories I and III.

**Previously treated is former category II.

#Others include patients who are Sputum Smear-Negative or who have extrapulmonary disease who can have recurrence or resonance.

Phases of NACP

1. NACP I: 1992–1999

2. NACP II: 1999–2007

3. NACP III: 2007–12

4. NACP IV: 20012–17

NACP I (1992–1999)

NACP I is the first effort in India to develop a national public health program in HIV/AIDS prevention and control. The aims of the program were to prevent HIV transmission, decrease the morbidity and mortality associated with HIV infection, and minimize the socioeconomic impact of HIV infection. NACP I sought to provide certain services: education campaigns, protection of the blood supply, condom promotion, a system to monitor the prevalence of HIV, treatment for sexually transmitted diseases and limited treatment for AIDS-related conditions. Two components are added later: targeted interventions and “intersectoral collaboration”.

NACP II (1999–2007)

In November 1999, NACP-II is launched with financial credit support from the World Bank of US$ 191 million. The focus of NACP II moved from the more diffuse goal of generating awareness on HIV prevention, to targeted intervention, a concept introduced in the latter part of NACP I. The targeted intervention is meant to change high risk behavior in population who are at risk of contracting the infection and spreading it in the general population. On the understanding that the HIV epidemic in India is driven by the groups with high risk behavior, and their partners. NACP II set up more than 1,000 targeted interventions, mostly through nongovernmental organizations, for commercial sex workers, men having sex with men, injecting drug users, street children, prisoners, truck drivers and migrant labor. The projects are meant to use peer educators to counsel, provide condoms through social marketing and provide information to encourage a change in behavior (“behavior change communication”). Some 845 clinics providing STD treatment are upgraded during this program.

NACP II also contained a number of programs directed at the general community. Mass education campaigns are conducted using print media, electronic media and folk art forms, especially directed at people under the age of 25 years. Sex education programs are introduced in schools, colleges and youth forums such as the National Service Scheme, Nehru Yuva Kendras and the Village Talk AIDS programs. By the end of the second phase of the program, the number of licenced blood banks increased to 1,230 including 82 blood component separation centers. In addition to testing for HIV, blood banks are required to test all donated blood for Hepatitis C and an external quality assurance system for HIV testing is set up. By the end of NACP-II, HIV transmission through blood is reduced to less than two percent (from eight percent when surveillance first started in the late 1980s).

Voluntary counselling and testing centers (VCTCs) are introduced early in NACP II. Counselling and testing enabled those at risk to know their HIV status and seek treatment which is becoming available more widely. VCTCs also provided referrals to services for treatment and care. Services for the prevention of mother to child transmission of HIV, and for the provision of antiretroviral drugs to people with AIDS, became linked to the VCTCs as and when these are instituted by the government.

NACP III (2007–12)

The third stage of the National AIDS Control Program is meant to provide an integrated package of prevention, care and support and treatment with the aim of reducing incidence as estimated in the first year of the program by 60% in high prevalence states and by 40% in the vulnerable states. NACP III plans to prevent new infections by “saturation coverage” of high risk groups with targeted interventions (TIs) and by scaling up existing interventions directed at the general population.

It used “behavior change communication” with the further involvement of NGOs and community-based organizations. It planned to set up more than 2,000 TIs across the country for high risk groups and vulnerable groups. Further, it extended the existing infrastructure for care, support and treatment. By developing guidelines and training modules for health care staff and services, it aimed to improve the quality of medical care for AIDS. It further decentralized its activities from the state to the district level and also involve various government departments and the private sector in its efforts. Out of total budget about two-thirds were used for prevention, and one-sixth for care and support.

NACP III adopted the following strategies

• Prevent infections through exhaustive coverage of high-risk groups with targeted interventions (TIs)

• Condom promotion

• Safe blood

• Counselling and testing

• Prophylactic treatment

• Care, support and treatment

• Collaborations

• Mainstream (government activities)

• Surveillance

NACP IV (20012–17)

Health minister Ghulam Nabi Azad launched phase IV of the National AIDS Control Program (NACP) on February 12, 2014. Government of India launched the fourth phase which falls directly under the Department of AIDS Control, Ministry of Health and Family Welfare. The five-year program (2012–17) aims at sustaining and building up on the results of NACP III Phase. The Cabinet Committee on Economic Affairs has approved a gross budgetary support of ₹ 8632.77 crores for implementation of the National AIDS Control Program Phase IV by the Department of AIDS Control, Ministry of Health and Family Welfare.

During third phase of NACP (2007–2012), there has been substantial scale up of coverage of Female Sex Worker (81%), Injecting Drug Users (80%), Men having Sex with Men (64%), Truckers (57%) and Migrants (40%) through a total of around 1,948 targeted interventions (TIs) (including 71 donor-supported TIs) for high risk groups and bridge population.

NACP IV integrates with other national programs and aligns with overall 12th five-year plan goals of inclusive growth and development. Having initiated the process of reversal in several high prevalent areas with continued emphasis on prevention, the next phase of NACP focuses on accelerating the reversal process and ensures integration of the program response.

Goal: Accelerate Reversal and Integrate Response.

Objectives

• Objective 1: Reduce new infections by 50% (2007 Baseline of NACP III)

• Objective 2: Provide comprehensive care and support to all persons living with HIV/AIDS and treatment services for all those who require it.

Key strategies

• Strategy 1: Intensifying and consolidating prevention services, with a focus on HRGs (high risk groups) and vulnerable population.

• Strategy 2: Increasing access and promoting comprehensive care, support and treatment (CST).

• Strategy 3: Expanding IEC (information, education and communication) services for: (a) general population and (b) high risk groups with a focus on behavior change and demand generation.

• Strategy 4: Building capacities at national, state, district and facility levels.

• Strategy 5: Strengthening strategic information management systems.

Key priorities under NACP IV are

1. Preventing new infections by sustaining the reach of current interventions and effectively addressing emerging epidemics.

2. Prevention of Parent to Child transmission.

3. Focusing on IEC strategies for behavior change in HRG, awareness among general population and demand generation for HIV services.

4. Providing comprehensive care, support and treatment to eligible PLHIV.

5. Reducing stigma and discrimination through greater involvement of PLHA (GIPA).

6. Decentralizing rollout of services including technical support.

7. Ensuring effective use of strategic information at all levels of program.

8. Building capacities of NGO and civil society partners especially in states with emerging epidemics.

9. Integrating HIV services with health systems in a phased manner.

10. Mainstreaming of HIV/AIDS activities with all key central/state level ministries/departments is given a high priority and resources of the respective departments are leveraged. Social protection and insurance mechanisms for PLHIV are strengthened.

Package of services provided under NACP IV

Prevention Services

1. Targeted Interventions for High Risk Groups and Bridge Population (Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgenders/Hijras, Injecting Drug Users (IDU), Truckers and Migrants).

2. Needle-Syringe Exchange Program (NSEP) and Opioid Substitution Therapy (OST) for IDUs.

3. Prevention Interventions for Migrant population at source, transit and destination.

4. Link Worker Scheme (LWS) for HRGs and vulnerable population in rural areas.

5. Prevention and Control of Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI).

6. Blood Safety

7. HIV counselling and testing services

8. Prevention of parent to child transmission

9. Condom promotion

10. Information, education and communication (IEC) and behavior change communication (BCC).

11. Social Mobilization, Youth Interventions and Adolescent Education Program.

12. Mainstreaming HIV/AIDS response.

13. Work Place Interventions.

Care, Support and Treatment Services

1. Laboratory services for CD4 Testing and other investigations

2. Free First line and second line Anti-Retroviral Treatments (ARTs) through ART centers and Link ART Centers (LACs), Centers of Excellence (COE) and ART plus Centers.

3. Pediatric ART for children

4. Early Infant Diagnosis for HIV exposed infants and children below 18 months

5. HIV-TB Coordination (cross-referral, detection and treatment of coinfections)

6. Treatment of opportunistic infections

7. Drop-in centers for PLHIV networks

New Initiatives under NACP IV

1. Differential strategies for districts based on data triangulation with due weightage to vulnerabilities

2. Scale up of programs to target key vulnerabilities

a. Scale up of Opioid Substitution Therapy (OST) for IDUs

b. Scale up and strengthening of Migrant Interventions at Source, Transit and Destinations including roll out of Migrant Tracking System for effective outreach

c. Establishment and scale up of interventions for Transgenders (TGs) by bringing in community participation and focused strategies to address their vulnerabilities

d. Employer-Led Model for addressing vulnerabilities among migrant labor

e. Female Condom Program

3. Scale up of Multi-Drug Regimen for Prevention of Parent to Child Transmission (PPTCT) in keeping with international protocols.

4. Social protection for marginalized populations through mainstreaming and earmarking budgets for HIV among concerned government departments

5. Establishment of Metro Blood Banks and Plasma Fractionation Center

6. Launch of Third Line ART and scale up of first and second Lines ART

7. Demand promotion strategies specially using mid-media, e.g. National Folk Media Campaign and Red Ribbon Express and buses [in convergence with the National Rural Health Mission (NRHM)]

National AIDS Prevention and Control Policy (NAPCP), 2002

In April 2002, the Government of India approved the National AIDS Prevention and Control Policy with the aim of bringing AIDS transmission at zero level by 2007. This policy follows a few strategies as given below:

• Blood safety program: Blood transfusion service is considered as utmost important. Blood transfusion councils are set up at national and state levels. Professional blood donation has been prohibited in India since 1st January, 1998. Only licenced blood banks are permitted to operate in the country and voluntary blood donation is encouraged.

• Counselling and HIV testing: Pretest, posttest counselling on a voluntary basis is encouraged and HIV testing is carried out to monitor the trend of HIV infection. NACO has supported to establish VCT (voluntary counselling and testing) centers in all states.

• STD control program: STD control is linked to HIV/AIDS control as behavior resulting in the transmission of STD and HIV are same. Hence early diagnosis and treatment of STD is recognized as one of the major strategies to control spread of HIV infection.

• Condom promotion: Transmission of HIV infection can be prevented by consistent use of good quality condoms. The three major areas in which NACO has made significant progress in relation to condom program were: quality control of condoms; social marketing of condoms and involvement of NGOs and private voluntary organizations in the program.

• HIV surveillance: During 1993 a Sentinel Surveillance System is introduced with a predefined scientific protocol. The objective is to identify trends of seropositivity in specific high risk groups as well as low risk groups.

• HIV sentinel surveillance: As it is fact that HIV infection is present in wide geographic area, the objective of surveillance is redefined to monitor the trends of HIV infection. To start HIV sentinel surveillance (1994) 55 sentinel sites are attached to the existing surveillance centers and were increased to 180 (1998).

• Behavioral surveillance survey: Under NACPII, behavioral surveillance survey is carried out in general population. It is found that, the awareness of HIV/AIDS has increased but still not universal.

• Targeted interventions: This is taken with the objective to reduce the transmission of HIV amongst the most vulnerable population. Main activities are behavior changes, communication, treatment of STD and creating an environment which facilitates behavior especially of vulnerable population (sex workers, IUDs, truckers, homosexual men, migrant labors and street children).

• School AIDS education program: School age is the one, in which behavioral modification is easy. State AIDS control societies are responsible to cover the students of secondary and higher secondary schools. Colleges and universities are covered under “University Talk AIDS Project”.

• Information, education, communication and social mobilization: The objective of the IEC strategy is to raise awareness, improve knowledge and understanding among the general public about AIDS infection and STD, routes of transmission and methods of prevention; to promote safe practices (use of condom, sterilization of sharps, safe blood transfusion, etc.); to create a supportive environment for the care and rehabilitation of persons with HIV/AIDS.

• Family health awareness campaign: The period of campaign is 15 days and dates are decided by the states as per their convenience. Objectives of the campaign are to raise awareness levels regarding HIV/ADIS and its various aspects as services available, treatment, prevention and protection, etc.

• Prevention of HIV transmission from mother to child: In this project; Nevirapine, single dose to the mother and child is used in which result is quiet encouraging.

• Anti-retroviral treatment: It is a new initiative into his program. Government of India decided to provide anti-retroviral therapy in govt, hospitals free of cost. This treatment is provided with priority to pregnant HIV positive women, children up to 15 years of age, full blown AIDS cases and as a postexposure prophylaxis to the health care workers.

• National AIDS telephone helpline: A toll free national AIDS telephone helpline (no. 1097) is set up to provide access to information and counselling of HIV/AIDS related issues.

Universal Immunization Program

Immunization Program in India is introduced in 1978 as Expanded Program of Immunization (EPI). The program gained momentum in 1985 and is expanded as Universal Immunization Program (UIP) to be implemented in phased manner to cover all districts in the country by 1989–90. UIP become a part of Child Survival and Safe Motherhood Program in 1992 Since, 1997, immunization activities have been an important component of National Reproductive and Child Health Program and is currently one of the key areas under National Rural Health Mission (NHM) since 2005.

The Vaccination Schedules under the UIP

• BCG (Bacillus Calmette Guerin) 1 dose intradermal at Birth (up to 1 year if not given earlier).

• DPT (diphtheria, pertussis and tetanus toxoid) 5 doses IM; three primary doses at 6, 10, 14 weeks and two booster doses at 16–24 months and 5 years of age.

• OPV (oral polio vaccine) 5 doses; 0 dose at birth, three primary doses at 6, 10 and 14 weeks and one booster dose at 16–24 months of age.

• Hepatitis B vaccine 4 doses IM; 0 dose within 24 hours of birth and three doses at 6, 10 and 14 weeks of age.

• Measles subcutaneous 2 doses; first dose at 9–12 months and second dose at 16–24 months of age.

• TT (tetanus toxoid) IM, 2 doses at 10 years and 16 years of age.

• TT for pregnant woman, two doses or one dose IM, if previously vaccinated within 3 years.

• JE vaccination (in selected high disease burden districts); subcutaneous 2 doses: 1st dose at 9–12 months of age and 2nd dose at 16–24 months.

• Hib containing Pentavalent vaccine (DPT + HepB + Hib) (in selected States) IM, 3 doses at 6,10 and 14 weeks of age.

Four new vaccines are being added to the arsenal of vaccines in India’s Universal Immunization Program. These include: Rubella, Rotavirus, Injectable Polio and Japanese Encephalitis for adults. This declaration is made on the Press Information Bureau website on the 3rd of July, 2014.

To strengthen the routine immunization, government of India has planned the State Program Implementation Plan (PIP) part C. It consists of:

• Arranging retired manpower to carry out immunization activities in urban slums and underserved areas, where services are deficient.

• Support of alternate vaccine delivery from PHC to subcenter and outreach sessions.

• Mobility support to district immunization officer for monitoring and supportive supervision.

• Review meeting at the state level with the districts at 6 monthly intervals.

• Training of ANM, cold chain handlers, midlevel managers, refrigerator mechanics, etc.

• Printing of immunization cards, monitoring sheets, cold chain chart vaccine, inventory charts, etc.

• Providing responsibilities to ASHA, women self-help groups, etc. for mobilization of children to immunization session.

National Program for Control of Blindness

National Program for Control of Blindness is launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness from 1.4% to 0.3%. This program incorporates the earlier trachoma control program started in the year 1968. As per Survey in 2001–02, prevalence of blindness is estimated to be 1.1%. Rapid Survey on Avoidable Blindness conducted under NPCB during 2006–07 showed reduction in the prevalence of blindness from 1.1% (2001–02) to 1% (2006–07). Various activities/initiatives undertaken during the five-year plans under NPCB are targeted towards achieving the goal of reducing the prevalence of blindness to 0.3% by the year 2020.

Main causes of blindness are as follows: Cataract (62.6%), Refractive Error (19.70%), Corneal Blindness (0.90%), Glaucoma (5.80%), Surgical Complication (1.20%) and Posterior Capsular Opacification (0.90%) and Posterior Segment Disorder (4.70%) and Others (4.19%). Estimated National Prevalence of Childhood Blindness/Low Vision is 0.80 per thousand.

Goals and Objectives of NPCB in the XII Plan

• To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of the overall burden of visual impairment in the country.

• Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of visual impairment; through provision of comprehensive eye care services and quality service delivery.

• Strengthening and upgradation of RIOs to become center of excellence in various subspecialities of ophthalmology.

• Strengthening the existing and developing additional human resources and infrastructure facilities for providing high quality comprehensive Eye Care in all Districts of the country.

• To enhance community awareness on eye care and lay stress on preventive measures.

• Increase and expand research for prevention of blindness and visual impairment.

• To secure participation of Voluntary Organizations/Private Practitioners in eye Care.

Revised strategies

Based upon the finding of the survey conducted

during 1998–99 and 1999–2000, the strategies

are taken as following.

1. To make the NPCB more comprehensive by

• strengthening services for other blindness like corneal

• blindness

• refractive errors in school going children

• improved follow-up service of cataract operated persons

• treating other causes of blindness like glaucoma

2. To shift

• from eye camp approach to a fixed facility

• from conventional surgery to IOL implantation for better quality postoperative vision.

3. To expand the world bank project activities like constructions of eye OTs, eye wards at district level, training of eye surgeons, modern cataract surgery and supply of eye equipments.

4. To strengthen participation of voluntary organizations in the program and to earmark geographic areas to NGOs and government hospital and improve the performance of government units.

5. To enhance coverage of eye care services in tribal and underserved areas through identification of bilateral blind patients, preparation of villagewise blind register and giving preference to bilateral blind patients for cataract surgery.

Activities

The activities and actions of NPCB can be described under three headings:

1. Basic program components

2. Program organization

3. Strategic plan for “Vision 2010: Right to Sight” in India

1. Basic program components: The basic components of NPCB since its beginning include the following:

Extension of eye care services: It is being done through the state and district mobile units by adopting an ‘eye camp approach’ and by enlisting the participation of voluntary organizations. The following facilities are being provided in remote areas:

• Medical and surgical treatment for the prevention and control of common eye diseases. Eye camp approach is of great help in reducing the backlog of cataract by mass surgeries. Recent emphasis is on reach-in-approach.

• Detection and correction of refractive errors.

• Thorough ocular examination including vision of school children for early detection of eye diseases and promoting ocular health.

• Rehabilitation training of visually handicapped.

• General survey for prevalence of various eye diseases.

Establishment of permanent infrastructure: The ultimate goal of NPCB is to establish permanent infrastructure to provide eye care services. It is being done in three-tier system, i.e. peripheral, intermediate and central levels.

Establishment of peripheral sector for primary eye care: A wide range of eye conditions can be treated/prevented at the grass root level by locally trained primary health workers. Peripheral sector for primary eye care at PHC and subcenter levels is being strengthened by: providing necessary equipment, posting a paramedical ophthalmic assistant, and organizing refresher courses for doctors and other staff of PHC on prevention of blindness.

Establishment of intermediate sector for secondary eye care: Secondary eye care involves definitive management of common blinding conditions such as cataract, glaucoma, trichiasis, entropion and ocular trauma.

Establishment of central level for tertiary eye care: Tertiary eye care services include the sophisticated eye care such as:

• retinal detachment surgery

• laser treatment for various retinal and other ocular disorders

• corneal grafting

• other complex forms of management not available in secondary eye care centers.

Intensification of eye health education: It is being done through

• Mass communication media (television talks, radio talks, films, seminars and books)

• School teachers, social workers, community leaders

• Mobile ophthalmic units, existing medical and paramedical staffs

• Main stress is laid on care and hygiene of eyes and prevention of avoidable diseases

2. Program organization: The program is organized in central level, state level and district level with the purpose to reduce the incidence of blindness.

a. Central level: Central level consists of “National Program Management Cell” located in the office of Director General Health Services (DGHS), Department of Health, Government of India (GOI). To oversee the implementation of the program, three national bodies have been constituted as:

• National Blindness Control Board, chaired by Secretary Health to GOI

• National Program Coordination Committee, chaired by Additional Secretary to GOI

• National Technical Advisor Committee, headed by Director General Health Services, GOI

Activities include in central level are:

• Procurement of goods (major equipment, bulk consumables, vehicles, etc.)

• Non-recurring grant-in-aid to NGOs

• Organizing central level training courses

• Information, education and communication activities

• Development of MIS, monitoring and evaluation

• Procurement of services and consultancy

• Salaries of additional staff at the central level

b. State level: A “State Program Cell” is already in place for which five posts including that of a Joint Director (NPCB) have been created. State level activities include:

• Execution of civil works for new units

• Repair and renovation of existing units/equipments

• State level training and IEC activities

• Management of state project cell

• Salaries for additional staff

c. District level: In district level “District Blindness Control Societies” (DBCS) have been established. This society is established with the primary purpose to plan, implement and monitor the blindness control activities comprehensively at the district level under overall control and guidance of the NPCB. Objective of DBCS is to achieve the maximum reduction is avoidable blindness in the district through optimal utilization of available resources in the district.

3. Strategic plan for “Vision 2020”: “Right to Sight” in India: A global initiative has been taken to reduce avoidable blindness by 2020. Plan of action of Vision 2020 are:

a. Target diseases: Cataract, refractive errors, childhood blindness, glaucoma, diabetic retinopathy.

b. Human resource development

c. Infrastructure development: Proposed 4-tier structure includes:

• Centers of Excellence (20)

• Training Centers (200)

• Services Centers (2000)

• Vision Centers (20,000).

Proposed Structure for Vision 2020

The following are main features of the pattern of assistance during 11th five-year plan:

• Strengthening/Setting up of Regional Institutes of Ophthalmology (RIO)

• Strengthening of medical colleges

• Increase in assistance for commodity to various facilities to increase their capacity for treatment of all types of eye ailments.

• Facility for Intraocular Lens (IOL) implantation expanded up to Taluka level.

• Marginal increase in grant-in-aid to Eye Banks, Eye Donation Centers and NGOs due to escalation of costs and to improve quality of services

• Assistance for construction of dedicated Eye Wards and Eye Operation Theatres in North-East States and a few other states as per need.

• Assistance for involvement of ophthalmic equipment supplied under the program.

• Development of Mobile Ophthalmic Units with Teleophthalmology Network and some fixed telemodels to cover difficult hilly terrains and difficult areas.

• Intensification of IEC activities.

• Strengthening of Management Information System.

• Critical posts of 228 Eye Surgeons and 510 Ophthalmic Assistants sanctioned during the 9th Plan and continued during 10th Plan, would be integrated within the State Plan in a phased manner.

• Keeping in view austerity measures and to avoid duplicity of work, State Ophthalmic Cell has been merged with State Blindness Control Society. Due to formation of National Rural Health Mission (NRHM), State Blindness Control Society (SBCS) under NPCB has been further merged with State Health society under NRHM. District Blindness Control Society (DBCs) under NPCB has also been merged with District Health Society under NRHM.

Fig. 23.3: Proposed structure for vision 2020

National Cancer Control Program

Cancer has become one of the ten leading causes of death in India. It is estimated that there are nearly 1.5–2 million cancer cases at any given point of time. Over 7 lakh new cases of cancer and 3 lakh deaths occur annually due to cancer. Nearly 15 lakh patients require facilities for diagnosis, treatment and follow-up at a given time. Government of India has launched a National Cancer Control Program (NCCP) in 1975 and revised its strategies in 1984–85 stressing on primary prevention and early detection of cancer.

Goals

1. The primary prevention by health education (e.g. tobacco related cancers).

2. Secondary prevention of cancer by early diagnosis and prompt treatment (e.g. uterine cervix, mouth and breast cancer, etc.).

3. Tertiary prevention includes extension and strengthening of rehabilitation and palliative services including pain relief on a national scale.

Organizational Structure

It would be at two levels: Central Government and State Government with linkage through the Central Council of Health. Respective executive committee should be assisted by a newly constituted National Cancer Control Board at the central and stage levels by the corresponding Cancer Control Boards. The full time officer-in-charge of cancer control is an oncologist who heads the Cancer Control Cell at the Directorate General of Health Services.

Existing Schemes under NCCP

• Regional Cancer Research and Treatment Centers: There are 17 regional cancer research centers in India at present. Their main functions are:

– Cancer Detection and Diagnosis

– Provision of Therapy

– After care and rehabilitation

– Education and Training

– Cancer Registration and Research.

Coordination with the medical colleges and the general health infrastructure is the essential feature. The core requirements of a Regional Cancer Center are divisions of surgical oncology, radiation oncology, and medical oncology with support from department of anesthesiology, pathology, cytopathology, hematology, biochemistry and radiodiagnosis with appropriate equipment and staff.

• Oncology wings in Medical Colleges: The target of the National Cancer Control Program is to develop such Oncology wings in all medical colleges in the country. Medical Colleges would form an important link between the regional centers on one hand, and the more peripheral health infrastructure (district hospitals, Tehsil hospitals, PHCs) on the other hand. Financial assistance has been released for medical colleges/hospitals for installation of cobalt therapy facilities.

• District Cancer Control Program: This program is launched in 1990–91 and under this program each state and union territory has advised to prepare their projects on health education, early detection, and pain relief measures. The district program has five elements: 1. Health education, 2. Early detection, 3. Training of medical and paramedical personnels, 4. Palliative treatment and pain relief, 5. Coordination and monitoring. The District programs are linked with Regional Cancer Centers/Government Hospitals/Medical Colleges.

• Comprehensive Anti-tobacco Program: It is estimated that 80–85% of tobacco is consumed for smoking either as bidies/cigarettes. Almost 13% chew tobacco either with pan or lime. Almost 15% are addicted to both habit of chewing and smoking. Only 1%–3% use tobacco either in the form of stuff or den paste. In India, more than 2000 person die everyday and about 8 lakh people die every year due to tobacco-related diseases.

• National cancer registry program: National Cancer Registry Program is launched in 1982 by Indian Council of Medical Research (ICMR) to provide true information on cancer prevalence and incidence. Objectives of this are:

– To generate authentic data on the magnitude of cancer problem in India.

– To undertake epidemiological investigations and advice control measures.

– Promote human resource development in cancer epidemiology.

• Tobacco-free Initiatives: WHO established the Tobacco Free Initiatives (TFI) in 1998. Longterm mission of TFI of WHO is to reduce smoking prevalence and tobacco consumption in all countries and among all groups, and thereby reduces the burden of disease caused by tobacco. WHO has developed partnership with UNICEF, World Bank, CDC, Environment Protection Agency, US National Institute of Health, International NGOs, Private Sector, and Academic Centers for tobacco prevention work. The Goals of the TFI are:

– Heighten awareness of the need to address tobacco issues at all levels of society.

– Galvanize global support for evidence-based tobacco control policies and actions.

– Build new partnerships for action and strengthen existing ones.

– Accelerate the implementation of national, regional and global strategies.

– Commission policy research to support rapid, sustained and innovative actions.

– Mobilize resources to support required action.

National Mental Health Program

The Government of India has launched the National Mental Health Program (NMHP) in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. Psychiatric symptoms are common in general population in both sides of the globe. These symptoms are worry, tiredness, and sleepless nights affect more than half of the adults at some time, while as many as one person in seven experiences some forms of diagnosable neurotic disorder.

The World Bank report (1993) revealed that the Disability Adjusted Life Year (DALY) loss due to neuropsychiatric disorder is much higher than diarrhea, malaria, worm infestations and tuberculosis if taken individually.

Aims

• Prevention and treatment of mental and neurological disorders and their associated disabilities.

• Application of mental health principles in total national development to improve quality of life.

• Use of mental health technology to improve general health services.

Objectives

• To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of population.

• To encourage application of mental health knowledge in general health care and in social development.

• To promote community participation in the mental health services development and to stimulate efforts towards self-help in the community.

Strategies

• Integration of mental health with primary health care through the NMHP.

• Provision of tertiary care institutions for treatment of mental disorders.

• Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority, and State Mental Health Authority.

Mental Health Care

• The mental morbidity requires priority in mental health treatment

• Primary health care at village and subcenter levels

• At primary health center level

• At the district hospital level

• Mental hospital and teaching psychiatric units

District Mental Health Program

Components

• Training programs of all workers in the mental health team at the identified Nodal Institute in the State.

• Public education in the mental health to increase awareness and reduce stigma.

• For early detection and treatment, the OPD and indoor services are provided.

Community Health Nursing

• Providing valuable data and experience at the level of community to the state and Center for future planning, improvement in service and research.

Agencies like World Bank and WHO have been contacted to support various components of the program. Funds are provided by the Govt, of India to the state governments and the nodal institutes to meet the expenditure on staff, equipment, vehicles, medicine, stationary, contingencies, training, etc. for initial 5 years and thereafter they should manage themselves. Government of India has constituted Central Mental Health Authority to oversee the implementation of the Mental Health Act 1986. It provides for creation of State Mental Health Authority also to carry out the said functions.

The National Human Rights Commission also monitors the conditions in the mental hospitals along with the government of India and the states are currently acting on the recommendation of the joint studies conducted to ensure quality in delivery of mental care.

National Diabetes Control Program

The worldwide prevalence of diabetes is 4% (1995) which will be 5.4% in 2025. Diabetes is a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas or in its effects. As a result of this there is increased concentration of glucose in the blood. However, noninsulin-dependent diabetes is much more common, occurs principally in adults and results from the body’s inability to respond properly to the action of insulin. Heart diseases, neuropathy, peripheral vascular diseases, etc. are very common in diabetes patients.

Government of India started National Diabetes Control Program on pilot basis during 7th five-year plan in 1987 in some districts of Tamil Nadu, J&K and Karnataka, but due to paucity of funds in subsequent years this program could not be expanded further in remaining years.

Objectives

• Prevention of diabetes through identification of high risk subjects and early intervention in the form of health education.

• Early diagnosis of disease and appropriate treatment morbidity and mortality with reference to high risk group.

• Prevention of acute and chronic metabolic, cardiovascular, renal and ocular complications of the disease.

• Provision of equal opportunity for physical attainment and scholastic achievement for the diabetic patients.

• Rehabilitation of those partially or totally handicapped diabetes people.

National Iodine Deficiency Disorders (IDD) Control Program

About more than 1.5 billion population of the World are at the risk from Iodine Deficiency Disorders (IDD) out of which, it is estimated about 200 million people are in India. It has been found in the surveys conducted by the Central and State Health Directorates, ICMR and Medical Institutes that not even a single State/UT is free from the problem of Iodine Deficiency Disorders. Realizing the magnitude of the problem the Government of India launched a 100 percent centrally assisted National Goiter Control Program (NGCP) in 1962.

Objectives

1. Surveys to assess the magnitude of the iodine deficiency disorders.

2. Supply of iodated salt in place of common salt.

3. Resurveys to assess iodine deficiency disorders and the impact of iodated salt after every 5 years.

4. Laboratory monitoring of iodated salt and urinary iodine excretion.

5. Health Education and Publicity.

In August, 1992; the National Goiter Control Program (NGCP) is renamed as National Iodine Deficiency Disorders Control Program (NIDDCP) with a view of wide spectrum of Iodine Deficiency Disorders.

Policy

On the recommendations of Central Council of Health in 1984, the Government took a policy decision to iodate the entire edible salt in the country by 1992. The important activities being undertaken by the IDD Cell of Directorate General of Health services are:

• Technical guidance to the States/UTs.

• Intersectoral coordination at Central level and maintenance of close liaison with the Ministry of Industry/Information and Broadcasting/Transport, etc.

• Coordination of the various facets of National Iodine Deficiency Disorders Control Program in states/UTs.

• Undertaking independent sample surveys in various states/UTs.

• Imparting training to the State Health personnel involved in National Iodine Deficiency Disorders Control Program.

• Collection, compilation and analysis of relevant data from states/UTs with a view to render more effective and meaningful advice.

• Monitoring of the quality control of iodated salt at production level through salt Commissioner and at the distribution and consumer level through the State Health Directorates.

• Monitoring the procurement and distribution of iodated salt in states/UTs.

• To look after the IEC activities at apex level.

• To monitor the financial and other physical aspects of State Level IDD Cells.

Functions of Salt Commissioner

The Salt Commissioner’s Office under the Ministry of Industry is responsible for licencing, production and distribution and monitoring the quality of iodated salt at production level supplied to states/UTs. The Salt Commissioner’s Office is also responsible in:

• Assisting the small-scale manufacturers in gaining access to the iodization process for the iodated salt produced by them.

• Promotion of cooperative societies in the salt industry and promotion of labor welfare activities of the salt works.

• Arranging along with Ministry of Railways for the movement of iodated salt from the production center to the states/UTs.

• Assisting the small scale iodated salt manufacturers as a result of compulsory iodization of salt is that they are not in a position to install the iodization plant because of high cost involved.

According to the salt commissioner 40 Iodisation plants have also been donated to 40 small scale.

Achievements

The achievements made under the major components of the existing program from its inception to date are as under:

• Ministry of Health is providing 100% financial assistance to all states/UTs for the establishment of an IDD Control Cell, an IDD Monitoring laboratory, Health education and publicity and surveys to assess the magnitude of IDDs.

• The annual production of iodated salt has been raised from 5 lakh metric tons in 1985–86 to 46 lakh metric tons in 2004–05.

• The policy of iodated salt production has been liberalized to the private sectors. Salt Commissioner has so far licenced 930 private manufacturers out of which 552 units have commenced production. They have annual production capacity of more than 130 lakh metric tons of iodated salt.

• Presently 30 states and union territories have established such type of IDD control cell.

• A National Reference Laboratory monitoring of IDD has been set up at the Biochemistry division of National Institute of Communicable Diseases, Delhi for training medical and paramedical personnel and monitoring the iodine content of salt and urine.

• One IDD monitoring lab, in all the states/UTs has been sanctioned for iodine content of salt and urinary iodine excretion.

• Standards of iodated salt have been laid down under the Prevention of Food Adulteration Act. The standards stipulate that the iodine content of iodated salt shall not be less than 30 PPM at the manufacturing level and not less than 15 PPM at the consumption.

Integrated Child Development Services (ICDS) Scheme

Launched on 2nd October, 1975; today, ICDS Scheme represents one of the world’s largest and most unique programs for early childhood development. ICDS is the foremost symbol of India’s commitment to her children—India’s response to the challenge of providing preschool education on one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning capacity and mortality, on the other.

Objectives: The integrated child development services (ICDS) scheme is launched in 1975 with the following objectives:

1. To improve the nutritional and health status of children in the age group of 0–6 years.

2. To lay the foundation for proper psychological, physical and social development of the child.

3. To reduce the incidence of mortality, morbidity, malnutrition and school drop-out.

4. To achieve effective coordination of policy and implementation amongst the various departments to promote child development.

5. To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.

Services: The above objectives are sought to be achieved through a package of services comprising (Table 23.2):

1. Supplementary nutrition

2. Immunization

3. Health check-up

4. Referral services

5. Preschool non-formal education

6. Nutrition and health education.

The concept of providing a package of services is based primarily on the consideration that the overall impact is much larger if the different services develop in an integrated manner as the efficacy of a particular service depends upon the support it receives from related services.

Three of the six services, namely immunization, health check-up and referral services delivered through public health infrastructure under the Ministry of Health and Family Welfare.

Table 23.2: ICDS services

Services | Target group | Service provided by
Supplementary Nutrition | Children below 6 years: Pregnant and Lactating Mother (PandEM) | Anganwadi worker and Anganwadi helper
Immunization* | Children below 6 years: Pregnant and Lactating Mother (PandLM) | ANM/MO
Health check-up* | Children below 6 years: Pregnant and Lactating Mother (PandLM) | ANM/MO/AWW
Referral services | Children below 6 years: Pregnant and Lactating Mother (PandLM) | AWW/ANM/MO
Pre-School Education Nutrition and Health Education | Children 3–6 years Women (15–45 years) | AWW (Anganwadi worker) AWW/ANM/MO

Nutrition including supplementary nutrition: This includes supplementary feeding and growth monitoring; and prophylaxis against vitamin A deficiency and control of nutritional anemia. All families in the community are surveyed, to identify children below the age of six and pregnant and nursing mothers. They avail of supplementary feeding support for 300 days in a year. By providing supplementary feeding, the Anganwadi attempts to bridge the caloric gap between the national recommended and average intake of children and women in low income and disadvantaged communities.

The aim is to provide supplementary nutrition about 200 Kcal and 8–10 gm of protein for children between 1–6 years of age; and about 500 Kcal and 25 gm of protein for pregnant women and nursing mothers.

Growth monitoring and nutrition surveillance are two important activities that are undertaken. Children below the age of three years of age are weighed once a month and children 3–6 years of age are weighed quarterly. Weight-for-age growth cards are maintained for all children below six years. This helps to detect growth faltering and helps in assessing nutritional status. Besides, severely malnourished children are given special supplementary feeding and referred to medical services.

Immunization: Immunization of pregnant women and infants protects children from six vaccine preventable diseases—poliomyelitis, diphtheria, pertussis, tetanus, tuberculosis and measles. These are major preventable causes of child mortality, disability, morbidity and related malnutrition. Immunization of pregnant women against tetanus also reduces maternal and neonatal mortalities.

Health Check-ups: This includes health care of children less than six years of age, antenatal care of expectant mothers and postnatal care of nursing mothers. The various health services provided for children by anganwadi workers and Primary Health Center (PHC) staff, include regular health check-ups, recording of weight, immunization, management of malnutrition, treatment of diarrhea, de-worming and distribution of simple medicines, referral services, etc.

Referral services: During health check-ups and growth monitoring, sick or malnourished children, in need of prompt medical attention, are referred to the Primary Health Center or its subcenter. The anganwadi worker has also been oriented to detect disabilities in young children. She enlists all such cases in a special register and refers them to the medical officer of the Primary Health Center/subcenter.

Non-formal preschool education (PSE): The non-formal preschool education (PSE) component of the ICDS may be well considered the backbone of the ICDS program, since all its services essentially converge at the anganwadi—a village courtyard, where baby are kept for three hours a day. Its program for the three to six years old children in the anganwadi is directed towards providing and ensuring a natural, joyful and stimulating environment, with emphasis on necessary inputs for optimal growth and development. The early learning component of the ICDS is a significant input for providing a sound foundation for cumulative lifelong learning and development. It also contributes to the universalization of primary education, by providing to the child the necessary preparation for primary schooling and offering substitute care to younger siblings, thus freeing the older ones, especially girls to attend school.

Nutrition and health education: Nutrition, health and education (NHED) are the key elements of the work of the anganwadi worker. This forms part of BCC (behavior change communication) strategy. This has the longterm goal of capacity-building of women, especially in the age group of 15–45 years so that they can look after their own health, nutrition and development needs as well as that of their children and families.

The revised population norms for setting up a project, anganwadi center and Mini-AWC are as:

For rural/urban projects

400–800 | 1 AWC
800–1600 | 2 AWCs
1600–2400 | 3 AWCs

Thereafter in multiples of 800 1 AWC

150–400
1 Mini-AWC

For tribal/riverine/desert, hilly and other difficult areas projects

300–800 | 1 AWC
150–300 | 1 Mini AWC

Type of Supplementary Nutrition

Children in the age group of 0–6 months: For children in this age group, states/UTs may ensure continuation of current guidelines of early initiation (within one hour of birth) and exclusive breastfeeding for children for the first 6 months of life.

Children in the age group of 6 months to 3 years: For children in this age group, the existing pattern of Take Home Ration (THR) under the ICDS Scheme continues. However, in addition to the current mixed practice of giving either dry or raw ration (wheat and rice) which is often consumed by the entire family and not the child alone, THR should be given in the form that is palatable to the child instead of the entire family.

Children in the age group of 3 to 6 years: For the children in this age group, states/UTs have been requested to make arrangements to serve Hot Cooked Meal in AWCs and mini-AWCs under the ICDS Scheme. Since the child of this age group is not capable of consuming a meal of 500 calories in one sitting, the states/UTs are advised to consider serving more than one meal to the children who come to AWCs. Since the process of cooking and serving hot cooked meal takes time, and in most of the cases, the food is served around noon, states/UTs may provide 500 calories over more than one meal. States/UTs may arrange to provide a morning snack in the form of milk/banana/egg/seasonal fruits/micronutrient fortified food, etc.

Table 23.3: Nutritional Norms: Revised vide letter No. 5–9/2005-ND-Tech Vol. II dated 24/02/2009.

Table 23.4

Table 23.5: Criteria for the appointment of anganwadi worker/mini-anganwadi worker/helper

Mid-day Meal Program

Mid-day meal program has an important role in providing balanced diet to school children. It is launched by Government of India in 1961 throughout the country.

Objectives

• To attract more children for admission to school, this improves literacy level in country.

• To prevent malnutrition among school children.

Aims

• To fulfill one-third nutrition requirement of school children

• To create intrest about school and education among children

• To reduce absenteeism of children in school

• To provide relief to parents of poor children

Principles

• One-third of energy and half of protein requirement of child should be met in the daily school mid-day meal program.

• The food should be free or at a minimum cost.

• The food should be prepared in the school itself. Hence, easily cooked and prepared food should be chosen.

• Locally available food should be used in preparing the meal. Utensils can be procured with local support but it is necessary to observe food hygiene.

• The menu should be changed frequently to avoid boredom among children.

• The mid-day meal school program is a supplement and not a substitute of home meals.

In case, there is some interruption in the mid-day school lunch program, the children can bring packed or tiffin from home. In any deprived of mid-day lunch.

Sample menu of mid-day meal

Food stuffs | g/day/child
Cereals and millets | 75
Pulses | 30
Oils and fat | 8
Leafy vegetables | 30
Non-leafy vegetables | 30

Some suggestions for preparing nutritious and economical mid-day meal:

• Store food grains in dry place and in airtight container.

• Use whole wheat or broken wheat (dalia) and parboiled or unpolished rice.

• Prepare “Single Dish Meal”: Saves time and fuel [Preparation: cook broken wheat or rice incorporating some amount of pulse or soyabean, a seasonal vegetable or green leafy vegetable in some amount of edible oil; sprouted pulses can be added],

• Mix cereal and pulse in a ratio of 3:1 or 5:1 to have good quality protein.

• Wash vegetables before cutting only.

• Soak rice, pulses to be cooked in a amount of water need to cook. It saves time of cooking as well as fuel.

• Mix left out rice water in dal to improve nutrient value.

• Prepare idli, dosa, etc. as fermentation improves food values.

• Cook with lid to save nutrient value.

• Avoid reheating of oil and over cooking of food.

• Don’t throw leafy tops of carrots, radish, etc. mix in vegetable.

• Use only “iodized salt” to cook mid-day meal.

According to National Institute of Nutrition (NIN), the mid-day meal school program should be organized for at least 250 days in an educational calendar year. Teachers have an important role in school lunch program. Participation of parents is also necessary. It is also necessary to give sufficient importance to nutrition education in the curriculum of general education.

The main objectives of the scheme (as per the 2006 revision) are to:

• Improve the nutritional status of children in classes one through five in government schools and government aided schools.

• To encourage children from disadvantaged backgrounds to attend school regularly and help them to concentrate in school activities.

• As well as provide nutritional support to students in drought-ridden areas throughout summer vacation.

In October 2007, the scheme is revised to cover children in the upper primary section as well, i.e. classes VI to VII. The Scheme estimates a cooked mid-day meal with a minimum of 300 calories and 8–12 gm of protein to all children studying in classes I-V. Upper Primary meals consist of 700 calories and 20 gm of protein by providing 150 gm of food grains (rice/wheat) per child/school day. The central government supplies state and union territory governments with free food grains (wheat/rice) at 100 gm per child per school day from the nearest Food Corporation of India (FCI) godown and compensation of the cost of transporting the food grains from the nearest FCI to the Primary school. The scheme provides assistance for meeting the cooking cost of ₹ 1 per child per school day.

Reproductive and Child Health (RCH) Program

The Reproductive and Child Health (RCH) Program is launched in October, 1997. The main aim of the program is to reduce infant, child and maternal mortality rates. RCH is running in two phases, RCH phase I and RCH phase II.

RCH Phase I

The main objectives of the program in its 1st phase are:

•To expand progressively the scope and content of existing FW services to include more elements of a defined package of essential.

• To improve the implementation and management of policy by using a participatory planning approach and strengthening institutions to maximum utilization of the project resources.

• To improve quality, coverage and effectiveness of existing family welfare services.

• To gradually expand the scope and coverage of the family welfare services to eventually come to a defined package of essential RCH services.

• To give importance to disadvantaged areas of districts or cities by increasing the quality and infrastructure of family welfare services.

Components

1. Family planning

2. Child survival and safe motherhood

3. Client approach to health care

4. Prevention and management of RTI/STD AIDS

Strategies

• All services to be client oriented, on demand and high quality through decentralized participatory planning and target-free approach.

• It integrates all interventions of fertility regulation, maternal and child health with reproductive health for both men and women.

• Program emphasized on upgradation of the level of facilities.

• Obstetric care facilities, MTP and IUD insertion in PHC level have been started. Even IUD insertion is made available in subcenters.

• On STD and RTI, specialized care facilities made available in district and subdistrict levels.

RCH Phase II

The child health program is now its second phase, RCH II which has begun from 1st April, 2005.

The main objectives of the program in its 2nd phase are:

• Improving monitoring and evaluation processes at the district, state and the central levels to ensure improved program implementation.

• Give performance based funding, by rewarding good performers and supporting weak performers.

• Expand services to the entire sector of family welfare beyond RCH scope.

• Decentralization for better services.

• Allowing states to adjust and improve programs features according to their direct needs.

• Holding states accountable by involving them in the development of the program.

• Pool together financial support from external sources.

• Encourage coordination and convergence, within and outside the sector to maximize use resources as well as infrastructural facilities.

Components

• Essential obstetric care

– Institutional delivery

– Skilled attendance at delivery

• Emergency obstetric care

– Operationalizing first referral units

– Operationalizing PHCs and CHCs for round the clock delivery services

• Strengthening referral system

Strategies

Each component has different strategies to achieve the goal as explained below:

• Essential obstetric care

– Institutional delivery: To promote institutional delivery 50% of the PHCs and CHCs would be made 24 hours operational.

– Skilled attendance at delivery: Delivery should be conducted by skilled attendance as ANMs/LHVs in PHC and CHC. ANMs/LHVs/SNs have now permission to use emergency drugs and other emergency interventions during complications of delivery.

• Emergency obstetric care

– Operationalizing first referral units: These should provide:

▫ Emergency obstetric care including caesarean section

▫ Newborn care

▫ 24 hours delivery service including normal and assisted deliveries.

▫ Emergency care of sick children

▫ Safe abortion services

▫ Treatment of STD/RTI

▫ Complete family planning services including laparoscopic services

▫ Blood bank facilities

▫ Laboratory services

▫ Referral services along with transportation setvices.

– Operationalizing PHCs and CHCs for round the clock delivery services

• Strengthening referral system

New initiatives in RCH program

• Training of MBBS doctors in life-saving anesthetic skills for emergency obstetric care.

• Setting up of blood bank at FRUs

• Launching of Janani Suraksha Yojona to encourage institutional delivery

• Vandemataram scheme: Voluntary action by medical practitioner, nursing home, maternity home to distribute iron folic acid tablets, oral pills, inj TT, etc. free of cost which is provided by District Medical Officer.

• Safe abortion services:

– Medical method of abortion: By use of two drugs—Mifepristone followed by Misoprostol within 7 weeks of pregnancy.

– Manual vacuum aspiration (MVA): Feasible and easy method to use in PHC, CHC.

Integrated Management of Neonatal and Childhood Illness (IMNCI)

Integrated Management of Childhood Illness has been renamed as IMNCI. It is the central pillar of child health interventions under the RCH II strategy. It is an integrated approach to child health that focuses on the well-being of the whole child. It focused primarily on the most common causes of child mortality, i.e. diarrhea, pneumonia, measles, malaria, and malnutrition. These diseases are generally affecting children at age of 1 week-2 months and 2 months-5 year.

Beneficiaries of IMNCI

• Care of young infants for newborn (under 2 months)

• Young children (2 months-5 years)

Goal

• To assess current statues of child survival indicators and process indicators for existing program activities in intervention.

Objectives

• To determine baseline mortality among children under 5 years of age (NMR, IMR).

• To determine prevalence of fever, loose stools, cough and any other illness in 2 weeks prior to day of field survey among children under 5 years of age.

• To assess effective program coverage for specified disease condition (cough with fast breathing) occurring in 2 weeks prior to day of field survey.

The IMNCI Package

The IMNCI package has been developed by experts including the Child Health Researchers, academicians, the Indian Academy of Pediatrics (IAP) and the National Neonatology Forum (NNF) to adapt it for the specific requirements of children in India. As newborn care is an important issue for bringing down the infant mortality rate in India, this aspect has been included in the package adapted by India. This package includes the following interventions:

Care of newborns and young infants (infants under 2 months)

• Keeping the child warm

• Initiation of breastfeeding immediately after birth and counseling for exclusive breastfeeding and non-use of prelacteal feeds.

• Cord, skin and eye care.

• Recognition of illness in newborn and management and/or referral.

• Immunization

• Home visits in the postnatal period.

Home visits by health workers (ANMs, AWWs, ASH As) are an integral part of this intervention. Three home visits are to be provided to every newborn starting with first visit on the day of birth (day 1) followed by visits on day 3 and day 7. For low birth weight babies, 3 more visits (total of six visits) are to be undertaken before the baby is one month of age. The details of these visits are given in the training package. Home visits help mothers and families to understand and provide essential newborn care at home and detect and manage newborns with special needs due to low birth weight or sickness.

Care of infants (2 months to 5 years)

• Management of diarrhea, acute respiratory infections (pneumonia), malaria, measles, acute ear infection, malnutrition and anemia.

• Recognition of illness and at risk conditions and management/referral.

• Prevention and management of iron and vitamin A deficiency.

• Counseling on feeding for all children below 2 years

• Counseling on feeding for malnourished children between 2 and 5 years.

• Immunization

Components

Components of IMNCI are:

• Improvements to the health system. The essential elements include:

– Ensuring availability of the essential drugs with workers and at facilities covered under IMNCI.

– Improve referral to identified referral facility.

– Referral system

– Ensuring availability of health workers/providers at all levels

– Ensuring follow-up visits by trained supervisors

• Improvement of Family and Community Practices, Counseling of families and creating awareness among communities. This includes.

– Promoting healthy behaviors such as breastfeeding, illness recognition, early care seeking, etc.

– IEC campaigns for awareness generation.

– Counseling of caregivers and families as part of management of the sick child.

– Home visits provide an opportunity for identification of sickness prompt care.

• Collaboration/coordination with other departments, self-help groups, etc.

Case management according to IMNCI

Danger signs: IMNCI has emphasized on following danger signs among neonates and infants which need to take care immediately. Prompt care of these symptoms can reduce the mortality rate of child.

Fig. 23.4: Danger signs in neonate

The IMNCI guidelines are based on the following principles

• All sick young infants up to 2 months of age must be assessed for “possible bacterial infection/jaundice”. Then they must be routinely assessed for the major symptom, i.e. “diarrhea”.

• All sick children age 2 months up to 5 years must be examined for “general danger signs” which indicate the need for immediate referral or admission to a hospital. They must then be routinely assessed for major symptoms—cough or difficult breathing, diarrhea, fever and ear problems.

• All sick young infants and children 2 months up to 5 years must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems.

• A combination of individual signs leads to an infant’s or a child’s classification(s) rather than a diagnosis. The classifications are color coded according to the severity: “pink” suggests hospital referral or admission, “yellow” indicates initiation of specific treatment, and “green” calls for home management.

• Pink classification: Child needs inpatient care.

• Yellow classification: Child needs specific treatment (initiation of treatment, can be provided it at home, e.g. antibiotics, anti-malarial, ORT).

• Green classification: Child needs no medicine, adivise home care.

• IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children.

OUTPATIENT MANAGEMENT OF YOUNG INFANTS UP TO 2 MONTHS OF AGE

The assessment procedure for this age group includes a number of important steps that must be taken by the health care provider, including:

• history taking and communicating with the caretaker about the young infant’s problem

• checking for possible bacterial infection/jaundice

• checking for diarrhea

• checking for feeding problem or malnutrition

• checking immunization status

• assessing other problems.

Checking for bacterial infection

• Convulsions (as part of the current illness). Convulsions may be associated with meningitis or other life-threatening conditions.

• Fast breathing. Count the breaths in one minute to decide if the young infant has fast breathing (60 or more than 60). Repeat counting to confirm.

• Chest indrawing. A sign of pneumonia and is serious in young infant

• Look for nasal flaring, grunting: Signs of breathing difficulty

• Bulging fontanels may indicate meningitis

• Pus draining from the ear

• Red umbilicus or pus formation

• Skin pustules. Red spot or blister indicates serious bacterial infection

• Temperature. Fever or hypothermia may both indicate bacterial infection

• Lethargy or unconsciousness. Check alertness of baby during assessment.

• Jaundice extended to palm and soles (physiological jaundice does not need to be treated).

Summary of the Integrated Case Management Process

Classification of bacterial infection

Possible serious bacterial infection
Local bacterial infection

• Convulsions

• Umbilicus red or draining pus

• Fast breathing (60 breaths per minute or more)

• Pus discharge from the ear

• Severe chest indrawing

• < 10 skin pustules

• Nasal flaring

• Grunting

• Bulging fontanelle

• 10 or more skin pustules or a big boil or

• If axillary temperature 37.5°C or above (or feels hot to touch) or touch) temperature less than 35.5°C (or feels cold to touch)

• Lethargy or unconsciousness

• Less than normal movement

Classification of jaundice

Severe jaundice
jaundice

• Yellow palms and soles

• Age <24 hours

• Age 14 days or more

• Palms and soles not yellow

• Age 1–13 days

IMNCI case management in the outpatient health facility, first-level referral facility and at home for the sick young infant up to 2 months of age

IMNCI case management in the outpatient health facility, first-level referral facility and at home for the sick child from age 2 months up to 5 years

Checking for Diarrhea

A young infant with diarrhea can be placed in one of the following 3 categories: (1) acute watery diarrhea; (2) dysentery (bloody diarrhea); and (3) persistent diarrhea (diarrhea that lasts for more than 14 days). All young infants with diarrhea should be assessed for: (a) signs of dehydration; (b) duration of diarrhea; and (c) blood in the stool.

Clinical Assessment

• Duration of diarrhea

• Infant’s general condition: Consciousness, restlessness

• Check for sunken eyes, turgidity of skin: Sign of dehydration

SEVERE PERSISTENT DIARRHEA

Diarrhea lasting for 14 days or more.

All young infants with persistent diarrhea should be referred to hospital. As a rule, treatment of dehydration should be initiated first, unless there is another severe classification.

CHECKING FOR FEEDING PROBLEMS AND MALNUTRITION

Classification of feeding problems and malnutrition: Based on an assessment of feeding and weight, a sick young infant may be classified into three categories:

Classification

Severe dehydration
Some dehydration
No dehydration

If any two of the following signs present:

• Lethargic or unconscious

• Sunken eves

• Skin pinch goes back very slowly

Young infants with severe dehydration require immediate IV infusion, nasogastric or oral fluid replacement according to WHO treatment guidelines described in Plan C (under treatment procedures).

If any two of the following signs present:

• Restless, irritable

• Sunken eyes

• Skin pinch goes back slowly It requires active oral treatment with ORS solution according to WHO treatment guidelines described in Plan B (under treatment procedures).

Not enough signs to classify as some or severe dehydration. Although these children lack distinct signs of dehydration, they should be given more fluid than usual to prevent dehydration from developing as specified in WHO Treatment Plan A (under treatment procedures).

Table 23.6

Not able to feed—possible serious bacterial infection or severe malnutrition
Feeding problem or low loeight
No feeding problem

• Not able to feed

• No attachment at all

• Not suckling at all

• Very low weight for age

• Not well-attached to breast

• Not suckling effectively

• Less than 8 breastfeeds in 24 hours

• Receiving other foods or drinks

• Thrush (ulcers or white patches in mouth)

• Low weight for age

• Breast or nipple problems

Not low weight for age and no other signs of inadequate feeding

Urgent prereferral tretments for the sick child age of 2 months up to 5 years

Classification
Treatment

For all children before referral:
Prevent low blood sugar by giving breast milk or sugar water.

Danger sign convulsions
If the child is convulsing, give diazepam (10 mg/2 ml solution) in dose 0.2 mg per kg (0.05 ml/kg) IV or rectally; if convulsions continue after 10 minutes, give a second dose of diazepam.

Severe pneumonia or very severe disease
Give first dose of IV or intramuscular chloramphenicol (40 mg/kg).
Options for an intramuscular antibiotic for prereferral use include ampicillin plus gentamicin combination, or ceftriaxone.

Very severe febrile disease
Give one dose of paracetamol for high fever (38.5°C or above).
Give first dose of intramuscular quinine for severe malaria unless no malaria risk.
Give first dose of an appropriate antibiotic.

Severe complicated measles
Give first dose of appropriate antibiotic.
Give vitamin A.
If there is clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment.

Severe dehydration
WHO Treatment Plan C
If there is no other severe classification, IV fluids should be given in the outpatient clinic according to WHO Treatment Plan C. Give 100 ml/kg IV fluids. Ringer’s lactate solution is the preferred commercially available solution. Normal saline does not correct acidosis or replace potassium losses, but can be used. Plain glucose or dextrose solutions arc not acceptable for the treatment of severe dehydration.
If IV infusion is not possible, urgent referral to the hospital for IV treatment is recommended. When referral takes more than 30 minutes, fluids should be given by nasogastric tube. If none of these are possible and the child can drink, ORS must be given by mouth.
Note: In areas where cholera cannot be excluded, children more than 2 years old with severe dehydration should be given a single dose of doxycycline.

Severe persistent diarrhea
If there is no other severe classification, treat dehydration before referral using W? IO Treatment Plan B for some dehydration and Plan C for severe dehydration. Then refer to hospital.

Mastoiditis
Give first dose of intramuscular chloramphenicol (40 mg/kg). Options for an intramuscular antibiotic for prereferral use include ampicillin plus gentamicin combination or ceftriaxone.
Give first dose of paracetamol for pain.

Severe malnutrition
Give first dose of vitamin A.

Treatment in the outpatient health facility of the sick child from age of 2 months up to 5 years

Classification
Treatment

Pneumonia
Give appropriate antibiotic for five days.
The treatment of non-severe pneumonia can utilize a five-day course of either oral cotrimoxazole or amoxicillin. These two oral antibiotics are usually effective treatment for Streptococcus pneumoniae and Haemophilus influenzae.
Both antibiotics are relatively inexpensive, widely available, and are on the essential drug list of the Ministry of Health. [The advantages of cotrimoxazole are that it is used twice a day, is affordable and compliance is good. It has been shown that with a twice-daily dosing, compliance levels can reach 75 percent or higher. Amoxicillin is almost twice as expensive as cotrimoxazole and standard dosages are usually given three times a day. Tire compliance with three times a day dosing is about 60 percent or less.]
Soothe the throat and relieve the cough with a safe remedy.

No pneumonia, cough or cold
Soothe the throat and relieve the cough with a safe remedy.

Some dehydration
WHO Treatment Plan B
Give initial treatment with ORS over a period of four hours. The approximate amount of ORS required (in ml) can be calculated by multiplying the child’s weight (in kg) 75 times; during these four hours, the mother slowly gives the recommended amount of ORS by spoonfuls or sips.
Note: If the child is breastfed, breastfeeding should continue.
After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin; resuming feeding early is important to provide required amounts of potassium and glucose. When there are no signs of dehydration, the child is put on Plan A. If there is still some dehydration, Plan B should be repeated. If the child now has severe dehydration, the child should be put on Plan C.

No dehydration
WHO Treatment Plan A
Plan A focuses on the three rules of home treatment: give extra fluids, continue feeding, and advise the caretaker when to return to the doctor (if the child develops blood in the stool, drinks poorly, becomes sicker, or is not better in three days).
Fluids should be given as soon as diarrhea starts; the child should take as much as she/he wants. Correct home therapy can prevent dehydration in many cases.
ORS may be used at home to prevent dehydration. However, other fluids that are commonly available in the home may be less costly, more convenient and almost as effective. Most fluids that a child normally takes can also be used for home therapy especially when given with food.
Recommended home fluid should be:
Safe when given in large volumes. Very sweet tea, soft drinks, and sweetened fruit drinks should be avoided.

Easy to prepare. The recipe should be familiar and its preparation should not require much effort or time. The required ingredients and measuring utensils should be readily available and inexpensive.
Acceptable. The fluid should be one that the mother is willing to give freely to a child with diarrhea and that the child will readily accept. Effective. Fluids that are safe are also effective. Most effective are fluids that contain carbohydrates and protein and some salt. However, nearly the same result is obtained when fluids are given freely along with weaning foods that contain salt.

Persistent diarrhea
Encourage the mother to continue breastfeeding.
If yoghurt is available, give it in place of any animal milk usually taken by the child; yoghurt contains less lactose and is better tolerated. If animal milk must be given, limit it to 50 ml/kg per day; greater amounts may aggravate the diarrhea.
If milk is given, mix it with the child’s cereal and do not dilute the milk. At least half of the child’s energy intake should come from foods other than milk or milk products. Foods that are hyperosmolar (these are usually foods or drinks made very sweet by the addition of sucrose, such as soft drinks or commercial fruit drinks) should be avoided. They can worsen diarrhea.
Food needs to be given in frequent, small meals, at least six times a day. All children with persistent diarrhea should receive supplementary multivitamins and minerals (copper, iron, magnesium, zinc) each day for two weeks.

Dysentery

The four key elements of dysentery treatment are:

• Antibiotics

• Fluids

• Feeding

• Follow-up

Selection of an antibiotic is based on sensitivity patterns of strains of Shigella isolated in the area (nalidixic acid is the drug of choice in many areas). Recommended duration of treatment is five days. If after two days (during follow-up) there is no improvement, the antibiotic should be stopped and a different one used.

Malaria
Give oral antimalarial drugs according to the malaria risk in the area. In high malaria risk areas, chloroquine for three days with a single dose of primaquin (to children older than one year) on the first day to all children. If the blood smear is P. vivax positive, the child (older than one year) should be additionally given primaquin for 5 days.
In low malaria risk areas, presumptive treatment is chloroquine for one day. If the smear is positive for P. falciparum, the child should be given chloroquine for one more day and if older than one year, a single dose of primaquin. If the blood smear is found to be P. vivax positive, the child should be given chloroquine for one more day and if older than one year, primaquin for 5 days.

Fever, malaria unlikely possible bacterial infection uncomplicated fever
Give one dose of paracetamol for high fever (38.5°C or above).
Treat other obvious causes of fever.

Measles with eye or mouth complications
Give first dose of vitamin A. If clouding of cornea or pus draining from the eye, apply tetracycline eye ointment. If mouth ulcers, treat with gentian violet.

Measles currently (or within the last 3 months)
Give first dose of vitamin A.

Acute ear infection
Give appropriate antibiotic for five days.
Give one dose of paracetamol for pain.
Dry the ear by wicking.

Chronic ear infection
Dry the ear by wicking.

Very low weight
Assess the child’s feeding and counsel the mother accordingly on feeding.

Not very low weight
If the child is less than 2 years old, assess the child’s feeding and counsel the mother accordingly on feeding.

Anemia
Give iron folic acid therapy for 14 days.
Assess the child’s feeding and counsel the mother accordingly on feeding.

No anemia and not low weight
Give prophylactic iron folic acid if child is 12 months or older.

National Rural Health Mission (NRHM)

Government of India launched NRHM on 5th April, 2005 for a period of 7 years (2005–2012) with the objective to improve rural health care delivery system. The mission adopts a collaborative approach by relating health to determinants of good health as sanitation, nutrition, safe drinking water, etc. It also brings the Indian system of medicine (AYUSH) to the mainstream of health care.

NRHM Vision

• To provide services through the appointment of Accredited Social Health Activist (ASHA) in each village.

• To strengthen the rural hospital to meet public health standards.

• To integrate national health programs to mainstream AYUSH.

• To provide effective health care to rural population throughout the country by making it accessible, affordable, accountable, effective and reliable primary health care.

• To raise the public health expenditure from 0.9% of GDP in 1999 to 2.3% GDP.

• To undertake architectural correction in health care delivery system.

• To decentralize village and district levels health planning and management.

• To define time bound goal.

• To seek access of rural people especially poor mothers and children.

• To provide improved health care services under Janani Suraksha Yojana (JSY) for the Below Poverty Line (BPL) families.

Goals

• Reduction in infant mortality rate (IMR) and maternal mortality ratio (MMR).

• Universal access to public health services such as women’s health, child health, water, sanitation and hygiene, immunization, and nutrition.

• Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.

• Access to integrated comprehensive primary health care.

• Population stabilization, gender and demographic balance.

• Revitalize local health traditions and mainstream AYUSH.

• Promotion of healthy lifestyles.

Strategies

• Core strategies:

– Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services.

– Promote access to improved health care at household level through the female health activist (ASHA).

– Health Plan for each village through Village Health Committee of the Panchayat.

– Strengthening subcenter through more multipurpose workers (MPWs).

– Strengthening existing PHCs and CHC, and provision of 30–50 bedded strength per lakh population.

– Preparation and implementation of an inter-sectoral District Health Plan prepared by the District Health Mission.

– To integrate vertical health and family welfare programs.

– To provide technical support to National, State and District Health Missions, for Public Health Management.

– Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.

– Formulation of transparent policies for deployment and career development of Human Resources for health.

– To promote healthy lifestyles such as reduction in consumption of tobacco and alcohol, etc.

• Supplementary strategies:

– Regulation of Private Sector including the informal rural practitioners to ensure availability of quality service to citizens at reasonable cost.

– Promotion of Public Private Partnerships 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.

– 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.

As per the 12th Plan document of the Planning Commission, the flagship program of NRHM is strengthened under the umbrella of National Health Mission by focusing on urban area too. Union Cabinet, in May 2013, has approved the launch of National Urban Health Mission (NUHM) as a submission of an overarching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other submission of the National Health Mission. Some of the major initiatives under National Health Mission (NHM) are as follows:

• Accredited Social Health Activists: Community Health volunteers called Accredited Social Health Activists (ASHAs) have been engaged under the mission for establishing a link between the community and the health system.

• Rogi Kalyan Samiti (Patient Welfare Committee)/Hospital Management Society: It is a management structure that acts as a group of trustees for the hospitals to manage the affairs of the hospital. Financial assistance is provided to these Committees through untied fund to undertake activities for patient welfare.

• Untied grants to subcenters: These have been used to fund grass-root improvements in health care. As for example Village Health Sanitation and Nutrition Committees (VHSNC) have used untied grants to increase their involvement in their local communities to address the needs of poor households and children.

• Health care contractors: NRHM has provided health care contractors to underserved areas, and has been involved in training to expand the skill set of doctors at strategically located facilities identified by the states.

• Janani Suraksha Yojana (JSY): JSY aims to reduce maternal mortality among pregnant women by encouraging them to deliver in government health facilities.

• National Mobile Medical Units (NMMUs): Many unserved areas have been covered through NMMUs.

• National Ambtdance Services: Free ambulance services are provided in every nook and corner of the country connected with a toll free number and reaches within 30 minutes of the call.

• Janani Shishu Suraksha Karyakram (JSSK): It is introduced to provide free to and fro transport, free drugs, free diagnostic, free blood, and free diet to pregnant women who come for delivery in public health institutions and sick infants up to one year. Rashtriya Bal Swasthya Karyakram (RBSK): A Child Health Screening and Early Intervention Services has been launched in February 2013 to screen diseases specific to childhood, developmental delays, disabilities, birth defects and deficiencies.

• Mother and Child Health Wings (MCH Wings): With a focus to reduce maternal and child mortality, dedicated Mother and Child Health Wings with 100/50/30 bed capacity have been sanctioned in high case load district hospitals and CHCs which would create additional beds for mothers and children.

• Free Drugs and Free Diagnostic Service: A new initiative is launched under the National Health Mission to provide Free Drugs.

• District Hospital and Knowledge Center (DHKC): It provides Multispecialty health care including dialysis care, intensive cardiac care, cancer treatment, mental illness, emergency medical and trauma care, etc.

• National Iron + Initiative: The National Iron + Initiative is an attempt to look at iron deficiency anemia in which beneficiaries will receive iron and folic acid supplementation irrespective of their iron/Hb status.

20-POINT PROGRAMME

The Twenty-Point Program is initially launched by Prime Minister Indira Gandhi in 1975 and is subsequently restructured in 1982 and again on 1986. On August 20, 1986, the existing 20-point program is restructured. Its objectives are spelt out by the government as eradication of poverty, raising productivity, reducing inequalities, removing social and economic disparities and improving the quality of life.

Objective: The basic objective of the 20-Point Program is to eradicate poverty and to improve the quality of life of the poor and the underprivileged population of the country. The program covers various socioeconomic aspects like poverty, employment, education, housing, health, agriculture and land reforms, irrigation, drinking water, protection and empowerment of weaker sections, consumer protection, environment, etc. The 20 points of the Program and its 66 items have been carefully designed and selected to achieve the above objectives. The 20-Point Program consisted following:

1. Attack on rural poverty

2. Strategy for rained agriculture

3. Better use of irrigation water

4. Bigger harvest

5. Enforcement of land reforms

6. Special programs for rural labor

7. Clean drinking water

8. Health for all

9. Two-child norm

10. Expansion of education

11. Justice for SC/ST

12. Equality for women

13. New opportunities for women

14. Housing for the people

15. Improvement for slums

16. New strategy for forestry

17. Protection of the environment

18. Concern for the consumer

19. Energy for the villages

20. A responsive administration

At least 8 of the 20 points are related, directly or indirectly, to health. These are:

• Point 1: Attack on rural poverty

• Point 7: Clean drinking water

• Point 8: Health for all

• Point 9: Two-child norm

• Point 10: Expansion of education

• Point 14: Housing for the people

• Point 15: Improvement of slums

• Point 17: Protection of the environment

With the introduction of new policies and programs it has been finally restructured in 2006 and it has been in operation at present. The restructured program, called Twenty-Point Program-2006 (TPP-2006), is approved by the Cabinet on 5th October, 2006 and operated w.e.f. 1–4–2007.

The TPP further restructured in 2006 has following Points:

1. Poverty eradication

2. Power to people

3. Support to farmers

4. Labor welfare

5. Food security

6. Clean drinking water

7. Housing for all

8. Health for all

9. Education for all

10. Welfare of SC/ST/OBC and minorities

11. Women welfare

12. Child welfare

13. Youth development

14. Improvement of slums

15. Environment protection and afforestation

16. Social security

17. Rural roads

18. Energising of rural areas

19. Development of backward areas

20. IT enabled and e-governance

The monitoring of the program at the center has been assigned to the Ministry of Statistics and Program Implementation, Government of India. The management information system relating to Twenty-Point developed by the Ministry consists of a monthly Progress Report (MPR) and yearly Review of the Program, pointwise, itemwise and statewise. The monthly report covers progress on the implementation of the program for 20 crucial points for which there is preset physical targets and the Yearly Review presents an analytical review of the performance of all the items under the program.

Bibliography

1. Arockia M. National Program for Control of Blindness. Updated 5/12/2012. Cited 8/12/2014. Available on: http://www.slideshare.net/ManojArockia/national-program-for-control-of-blindness.

2. Mishra Gyanshankar, Ghorpade SV, Mulani Jasmin (2014). XDR-TB: An outcome of programmatic management of TB in India. Indian Journal of Medical Ethics 11: 1. 47–52 Jan–Mar.Available online at http://216.12.194.36/-ijmein/index.php/ijme/article/download/932/2179.

3. IMNCI Handbook. Available on: http://www.whoindia.org/LinkFiles/Child_&_Adolescent_Health_IMNCI_Student_Manual_June_03_(2).pdf.

4. Nandan D (2010). “National rural health mission: Turning into reality”. Indian Journal of Community Medicine, 35 (4): 453–454. doi:10.4103/0970–0218.74338. PMC 3026119. PMID 21278861.

5. National Cancer Control Program (NCCP). http://www.aarogya.com/health-resources/health-programs/2722-national-cancer-control-program-nccp.html.

6. National Cancer Control Program. National Institute of Health and Family Welfare [Internet] 2003 [cited on 2015 Jan 10th]. Available on: http://nihfw.nic.in/ndc-nihfw/html/Programs/NationalCancerControlProgram.htm.

7. National Diabetes Control Program [Internet] 2003 [dted on 2015 Jan 10th]. Available on: http://nihfw.nic.in/ndcnihfw/html/Programs/NationalDiabetesControl.htm.

8. National Iodine Deficiency Disorders Control Program. Cited on 2015 Jan 3rd. Available on: http://mohfw.nic.in/WriteReadData/1892s/rtiNICRT-81756647.pdf.

9. National Mental Health Program. National Institute of Health and Family Welfare [Internet] 2003 [cited on 2015 Jan 10th]. Available on: http://nihfw.nic.in/ndc-nihfw/html/Programs/NationalMentalHealth.htm.

10. Navpreet. National Program for Control of Blindness. Cited 8/12/2014. http://gmch.gov.in/e-study/e%201ectures/Community%20Medicine/NPCB.pdf.

11. Pranab. New Vaccines in India’s Universal Immunization Program. [Internet] 2014 July 6th. [Cited on 2015 Jan 3rd]. Available on: http://scepticemia.com/2014/07/06/new-vaccines-in-indias-universal-immunization-program.

12. Reproductive and Child Health Program. [Internet] 1998 [Cited on 2015 Jan 3rd]. Available on: http://www.childlineindia.org.in/Repro-ductive-and-Child-Health-Program.htm.

13. Revised National Tuberculosis Control Program: DOTS-Plus Guidelines. 2010 Jan. Available on: http://health.bih.nic.in/Docs/Guidelines/Guidelines-DOTS-Plus.pdf.

14. RNTCP. [Internet] 2014 July 14th. [Cited 2015 10th Jan]. Available on: http://en.wikipedia.org/wiki/RNTCP.

15. Tuberculosis Control, India, http://www.tbdndia.nic.in.

16. Universal Program of Immunization. [Internet] 2013 [Cited on 2015 Jan 3rd]. Available on: http://www.nhp.gov.in/health-programs/national-health-programs/universal-immunization-program-uip.

17. Welcome to National Program for Control of Blindness. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, [cited on 8/12/2014], Available from http://npcb.nic.in/.

24

Acts in India

This chapter contains

▪ Central Pollution Control Board

▪ Air (Prevention and Control of Pollution) Act, India, 1981

▪ Acts on Noise Pollution

▪ MTP Act, 1971

▪ ESI Act, 1948

▪ The Factories Act, 1948

▪ Prevention of Food Adulteration Act, 1954

▪ Child Labor Acts and Laws

CENTRAL POLLUTION CONTROL BOARD

Central Pollution Control Board (CPCB) of India is a statutory organization under the Ministry of Environment and Forests (MoEF). It is established in 1974 under Water (Prevention and Control of Pollution) Act, 1974. CPCB is also entrusted with the powers and functions under the Air (Prevention and Control of Pollution) Act, 1981. It serves as a field formation and also provides technical services to the Ministry of Environment and Forests of the provisions of the Environment (Protection) Act, 1986. It coordinates the activities of the State Boards by providing technical assistance and guidance and resolve disputes among them. It is an apex organization in country in the field of pollution control, as technical wing of MoEF. The board is led by its chairman, who is nominated by the Central Government.

CPCB has its head office in New Delhi, with seven zonal offices and 5 laboratories. The board conducts environmental assessment and research. It is responsible for maintaining national standards under a variety of environmental laws, in consultation with zonal offices, tribal, and local governments. It is monitoring the water and air quality and maintains respective quality data. The agency also works with industries and all levels of government in a wide variety of voluntary pollution prevention programs and energy conservation efforts. It advises the central government to prevent and control water and air pollution. It also advises the Governments of Union Territories about an industry or the pollution source causing water and air pollution. CPCB along with its counterparts State Pollution Control Boards (SPCBs) are responsible for implementation of legislations relating to prevention and control of environmental pollution.

Functions of CPCB: Functions of CPCB comes under both national level and as State Boards for the union territories. CPCB, under the Water (Prevention and Control of Pollution) Act, 1974, and the Air (Prevention and Control of Pollution) Act, 1981, aims to promote cleanliness of streams and wells in different areas of the states by prevention, control and abatement of water pollution, and to improve the quality of air and to prevent, control or abate air pollution in the country.

• Air quality/pollution: CPCB runs nationwide programs of ambient air quality monitoring known as National Air Quality Monitoring Programme (NAMP).

• Water quality/pollution: Fresh water is a finite resource essential for use in agriculture, industry, propagation of wildlife and fisheries and for human existence. India is a riverine country. It has 14 major rivers, 44 medium rivers and 55 minor rivers besides numerous lakes, ponds and wells which are used as primary source of drinking water even without treatment.

• Urban area programs (EcoCity Program): CPCB programs for urban areas, also known as EcoCity Program comes under 10th plan to improve environment through implementation of identified environmental improvement projects in the selected towns and cities.

• Municipal Solid Waste rules: Every municipal authority comes under the Municipal Solid Wastes (Management and Handling) Rules and responsible for collection, segregation, storage, transportation, processing and disposal of municipal solid. CPCB collects necessary information from municipal authorities and provides them technical assistance.

• Noise Pollution/Rules: Various sources like industrial activity, construction activity, generator sets, loudspeakers, public address systems, music systems, vehicular horns and other mechanical devices have deleterious effects on human health. CPCB has the responsibility to regulate and control noise producing and generating sources with the objective of maintaining the ambient air quality standards.

• Environmental Data Statistics: CPCB manages environmental data statistic in which air quality data and water quality data comes through.

Organizational structure: CPCB is led by its Chairman following by the Member Secretary. The CPCB performs its various functions through the following nine major project budget heads.

• Pollution assessment (survey and monitoring).

• R and D and laboratory management.

• Development of standards and guidelines for industry specific emissions and effluents standards

• Training

• Information database management and library

• Pollution control technology

• Pollution control enforcement

• Mass awareness and publications

• Hazard waste management

AIR (PREVENTION AND CONTROL OF POLLUTION) ACT, INDIA, 1981

The Act provides means for the control and abatement of air pollution. The Act seeks to combat air pollution by prohibiting the use of polluting fuels and substances, as well as by regulating appliances that give rise to air pollution. Under the Act, the establishing or operating of any industrial plant in the pollution control area requires consent from state boards. The boards are also expected to test the air in air pollution control areas, inspect pollution control equipment, and manufacturing processes.

National Ambient Air Quality Standards (NAAQS) for major pollutants are notified by the CPCB in April, 1994. These are deemed to be levels of air quality necessary with an adequate margin of safety, to protect public health, vegetation and property (CPCB: Central Pollution Control Board, 1995 cited in Gupta, 1999). The NAAQS prescribes specific standards for industrial, residential, rural and other sensitive areas. Industry-specific emission standards have also been developed for iron and steel plants, cement plants, fertilizer plants, OIL refineries and the aluminum industry. The ambient air quality standards prescribed in India are similar to those prevailing in many developed and developing countries.

To empower the central and state pollution boards to meet grave emergencies, the Air (Prevention and Control of Pollution) Amendment Act, 1987 is enacted. The boards are authorized to take immediate measures to tackle such emergencies and recover the expenses incurred from the offenders. The power to cancel consent for non-fulfilment of the conditions prescribed has also been emphasized in the Air Act Amendment.

The Air (Prevention and Control of Pollution) Rules formulated in 1982, defined the procedures for conducting meetings of the boards, the powers of the presiding officers, decisionmaking, the quorum; manner in which the records of the meeting are to be set, etc. They also prescribed the manner and the purpose of seeking assistance from specialists and the fee to be paid to them.

Complementing the above Acts is the Atomic Energy Act of 1982, which is introduced to deal with radioactive waste. In 1988, the Motor Vehicles Act, is enacted to regulate vehicular traffic, besides ensuring proper packaging, labelling and transportation of the hazardous wastes. Various aspects of vehicular pollution have also been notified under the EPA of 1986. Mass emission standards are notified in 1990, which are made more stringent in 1996. In 2000, these standards are revised yet again and for the first time separate obligations for vehicle owners, manufacturers and enforcing agencies are stipulated. In addition, fairly stringent Euro I and II emission norms are notified by the Supreme Court on April 29, 1999 for the city of Delhi. The notification made it mandatory for car manufacturers to conform to the Euro I and Euro II norms by May, 1999 and April, 2000 respectively, for new non-commercial vehicle sold in Delhi.

ACTS ON NOISE POLLUTION

Factories Act Reduction of Noise and OIL of Machinery: The Factories Act does not contain any specific provision for noise control. However, under the Third Schedule Sections 89 and 90 of the Act, noise induced hearing loss, is mentioned as notifiable disease. Similarly, under the Modal Rules, limits for noise exposure for work zone area have been prescribed.

Motor Vehicle Act: It has provision relation to use of horn and change of Engine: In Motor Vehicle Act rules regarding use of horns and any modification in engine are made.

Noise Pollution Control Rule 2000 under Environment Protection Act 1996: Further for better regulation for noise pollution there are The Noise Pollution (Regulation and Control) Rules, India 2000 includes the following main provisions:

• The state government may categorise the areas in the industrial or commercial or residential.

• The ambient air quality standards in respect of noise for different areas have been specified.

• State government takes measure for abatement of noise including noise emanating from vehicular movement and ensure that the existing noise levels do not exceed the ambient air quality standards specified under these rules.

• Areas not less than 100 m around hospitals educations institutions and court may be declared as silence are for the purpose of these rules. A loudspeaker or a public address system is not used except after obtaining written permission from the authority and the same is not used at night, i.e. between 10 pm and 6 am.

• A person found violating the provisions as to the maximum noise permissible in any particular area is liable to be punished for it as per the provision of these rules and any other law in force.

MEDICAL TERMINATION OF PREGNANCY ACT, 1971

Before 1971, the Indian Penal Code, which is enacted in 1860 and is written in accordance with British law at the time of its creation, declared induced abortion as illegal. Induced abortion is defined as purposely “causing miscarriage”. Abortion practitioners would either be incarcerated for up to three years, fined, or both; women undergoing abortions could be imprisoned for up to seven years and also be charged an additional fine. The only exception is when abortion is induced in order to save the life of the woman. Despite the fact that this passage in the penal code is changed in Great Britain in 1967, India did not change it until 1971.

It is an Act to provide for the termination of certain pregnancies by registered Medical Practitioners and for matters connected therewith or incidental thereto. Be it enacted by Parliament in the 22nd year of the Republic of India as follows:

Definitions in this Act

a. Guardian means a person having the care of the person of a minor or a lunatic

b. Lunatic has the meaning assigned to it in section 3 of the Indian Lunatic Act

c. Minor means a person who, under the provisions of the Indian Majority Act, 1875

d. Registered medical practitioner means a medical practitioner who possesses any recognized medical qualification, whose name has been entered in a State Medical Register and who has such experience or training in gynecology and obstetrics as may be prescribed by rules made under this Act.

Criteria of termination of pregnancy by registered medical practitioners:

a. A registered medical practitioner shall not be guilty of any offence if any pregnancy is terminated by him in accordance with the provisions of this Act.

b. A pregnancy may be terminated by a registered medical practitioner,

• Where the length of the pregnancy does not exceed 12 weeks if such medical practitioner is, or

• Where the length of the pregnancy exceeds 12 weeks but does not exceed 20 weeks, if not less than two registered medical practitioners are, of opinion, formed in good faith, that:

– the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health. Explanation 1—Where any pregnancy is alleged by the pregnant woman to have been caused by rape, the anguish caused by such pregnancy shall be presumed to constitute a grave injury to the mental health of the pregnant woman.

– there is a substantial risk that if the child is born, it would suffer from such physical or mental abnormalities to be seriously handicapped. Explanation 2—Where any pregnancy occurs as a result of failure of any device or method used by any married woman or her husband for the purpose of limiting the number of children, the anguish caused by such unwanted pregnancy may be resumed to constitute a grave injury to the mental health of the pregnant woman.

c. In determining whether the continuance of a pregnancy would involve such risk of injury to the health may be taken of the pregnant women actual or reasonable foreseeable environment.

d.

i. No pregnancy of a woman, who has not attained the age of 18 years, or who, having attained the age of 18 years, is a lunatic, shall be terminated except with the consent in writing of her guardian.

ii. No pregnancy shall be terminated except with the consent of the pregnant woman.

iii. Termination of a pregnancy by a person who is not a registered medical practitioner shall be an punishable offence.

Places of medical termination of pregnancy—No termination of pregnancy shall be made in accordance with this Act at any place other than

• A hospital established or maintained by Government.

MTP Act (Amendment), 2002 (18th December, 2002)

This is an action taken to amend the Medical Termination of Pregnancy Act, 1971.

Be it enacted by Parliament in the fiftythird year of the Republic of India as follows:

1. This Act may be called the Medical Termination of Pregnancy (Amendment) Act, 2002.

2. For the word lunatic, the words mentally ill person shall be substituted. Mentally ill person means a person who is in need of treatment by reason of any mental disorder other than mental retardation.

3. No termination of pregnancy shall be made in accordance with this Act at any place other than:

• A hospital established or maintained by Government, or

• A place for the time being approved for the purpose of this Act by Government or a District Level Committee constituted by that Government with the Chief Medical Officer or District Health Officer as the Chairperson of the said Committee. Provided that the District Level Committee consists of not less than three and not more than five members including the Chairperson, as the Government may specify from time to time.

4. The termination of pregnancy by a person who is not a registered medical practitioner shall be an offence punishable with rigorous imprisonment for a term which shall not be less than two years but which may extend to seven years under that Code, and that Code shall, to this extent, stand modified.

5. Whoever terminates any pregnancy in a place other than that mentioned places, shall be punishable with rigorous imprisonment for a term which shall not be less than two years but which may extend to seven years.

6. Any person being owner of a place which is not approved under the law shall be punishable with rigorous imprisonment for a term which shall not be less than two years but which may extend to seven years.

Employees State Insurance Act, 1948

The ESI Act passed in 1948 (amended in 1975, 1984 and 1989) is a self-financing social security and health insurance scheme for whole Indian workers. For all employees earning INR15000 (US$240) or less per month as wages, the employer contributes 4.75 percent and employee contributes 1.75 percent, total share 6.5 percent. Employees, getting daily wages of below ₹ 50 are exempted from payment of contribution. The State Government’s share of expenditure on medical care is 1/8th of total cost of medical care; the ESI Corporation’s share of expenditure is 7/8th of total cost of medical care. This fund is managed by the ESI Corporation (ESIC) according to rules and regulations stipulated.

Scope

The ESI Act 1948:

• Covered all power using factories other than seasonal factories.

• Covered power using factories wherein 20 or more persons were employed.

• Did not cover mines, railways and defence establishments.

The ESI Amendment Act 1975 is extended to the following new classes of establishments:

• Small power using factories employing 10–19 persons, and non-power using factories employing 20 or more persons.

• Shops

• Hotels and restaurants

• Cinemas and theaters

• Road motor transport establishments

• Newspaper establishments

Administration

The administration of ESI scheme under the Act is under an autonomous body called the “ESI Corporation”. Head office of the corporation is in New Delhi. It has 23 regional offices, 12 subregional offices, 844 local offices and cash offices all over the country for the administration of the scheme. Administration of the ESI Corporation consists of:

• Chairman of ESI Corporation: The Union Minister for Labor

• Vice-chairman: Secretary to the Government of India, Ministry of Labor

• Members representing central and state governments, employers, employees’ organizations, medical profession and parliament.

• Standing committee: Constituted from the members of the Corporation; acts as the executive body.

• Chief executive officer: Director General; assisted by 4 Principal Officers.

• Principal Officers: 1. Insurance Commissioner; 2. Medical Commissioner; 3. Financial Commissioner; 4. Actuary.

• Medical benefit council: Headed by Director General of Health Services, GOI. Assisted by Medical Commissioner.

Medical facilities are provided by through 1427 ESI dispensaries, over 2100 panel clinics, 307 diagnostic centers, 143 ESI hospitals and 43 hospital annexes with over 27000 beds. For providing super specialty medical care the corporation has tie up with advanced medical institutions in the country, both in public and private sectors. Cash benefits are provided in grass-root level through about 800 branch offices and cash offices.

There are inspection officers throughout the country to inspect factories and for checking insurability of employees and correct payments of contributions.

Benefits to Employees

The section 46 of the Act envisages following six social security benefits:

1. Medical benefit

2. Sickness benefit

3. Maternity benefit

4. Disablement benefit

5. Dependent’s benefit

6. Other benefit

a. Funeral expenses

b. Confinement expenses

1. Medical benefit: Full medical care is provided to an insured person and his family members from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of an Insured Person (IP) or his family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token of annual premium of ₹ 120.

System of treatment: Generally, the allopathic system of medicine is used for providing Medical Benefit. However, where a substantial number of workers demand treatment by Indian system of medicine and Homoeopathy (ISM and H) other than Allopathy and where the State Government has recognized the qualifications in such system, treatment facilities may be provided under the ISM and H as well. Certificates required for the purpose of cash benefits.

Scale of medical benefit:

a. To Insured Persons: IPs are entitled to avail treatment in ESI dispensary/hospital/diagnostic center and recognized institutions, to which he is attached such as:

• Outpatient treatment

• Domiciliary treatment by visits at their residences.

• Specialists Consultation.

• Inpatient treatment (hospitalization)

• Free supply of drugs dressings and artificial limbs, aids and appliances.

• Laboratory services.

• Integrated family welfare, immunization and MCH program and other national health program, etc.

• Ambulance service or reimbursement of conveyance charges for going to hospitals, diagnostic centers, etc.

• Medical certification

• Special provisions.

b. To family members of insured persons: While in all implemented areas, IPs are entitled to medical care as detailed above, members of a family of an IP are entitled to one or other of the following scales of medical benefits:

• “Full” medical care, i.e. all facilities as for IPs including hospitalization.

• “Expanded” medical care, i.e. all facilities as for IPs except hospitalization. A small number of IPs in the States of Gujarat and Bihar fall under this category.

Benefits to Retired IPs: Medical Benefit to Retired Insured Persons and Permanent Disabled Insured Persons: On payment of ₹ 10 per month, in lump sum for one year in advance, medical benefit can be provided to:

• An Insured person and his/her spouse who leaves insurable employment on attaining the age of superannuation after being insured for not less than five years, till the period for which contribution is paid.

• An insured person and his/her spouse who ceases to be in insurable employment on account of permanent disablement due to employment injury is entitled to medical benefit.

Administration of medical benefit in a state: The administration of medical benefit under the ESI scheme is the statutory responsibility of the state government except in the union territory of Delhi where the ESIC has taken over direct responsibility to administer the same with effect from 1–4–1962. The Corporation has also taken the responsibility of directly administering the existing occupational disease centers at Delhi. Mumbai, Calcutta, Chennai and Nagda as well as the scheme in the Industrial pocket of Uttar Pradesh, i.e. Noida and Greater Noida.

Domiciliary treatment: For the domiciliary visit, the IMOs are paid conveyance allowance. The quantum of this allowance is decided by the state government in consultation with the corporation.

Specialist consultation: The standard of Medical Care under the ESI scheme provides for specialist consultation to IP in all cases and to members of their families in areas with “Expanded” and “Full” medical care. Arrangements for specialist consultation may be provided at specialist/diagnostic centers. Such consultation is provided in the following specialties as cardiology, neurology, general medicines, urology, eye, dental, psychiatry, etc.

Inpatient treatment: Inpatient treatment is provided at hospitals constructed by ESIC or by reservation of beds in the hospitals owned by the state government, local fund organization or private bodies or by constructing annexes to such institutions. The ESI scheme pays for these beds on the basis of occupied bed days.

Imaging Services: Imaging and investigations including CT scan, MRI, echocardiography and laboratory facilities are provided free of cost to IPs and their families at state level speciality hospitals or other institutions having tie up with ESI scheme.

Artificial limbs and aids: Insured Persons and their family members are provided following artificial limbs, aids and appliances as part of medical care under the ESI scheme: Artificial limbs, hearing aids, spectacles (Frame costing not more than ₹ 100 and replacement of frames not to be made earlier than 5 years) (to insured persons only), artificial dentures, teeth (to insured persons only), artificial eye (to insured persons only), wigs (replacement not earlier than 5 years) to female beneficiaries only, cardiac pacemaker, wheel chair/tricycle, spinal supports (jackets, braces, etc.), cervical collars, walking callipers, surgical boots, etc. Crutches, hip prosthesis, total hip, intraocular lens (IOL), any other aid or appliance prescribed by the specialist as part of treatment. The expenditure on artificial limbs, aids and appliances is met from the shareable pool of expenditure on medical care.

Reimbursement: Every employer has to arrange for first aid medical care and transport of accident cases till the injured IP is seen by the IMO/IMP and such employer is entitled to reimbursement of expenses incurred in this regard up to the maximum of scale prescribed from time to time.

2. Sickness benefit (SB): Sickness benefit in the form of cash compensation at the rate of 70 percent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months.

• Extended sickness benefit (ESB): SB extendable up to two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 percent of wages.

• Enhanced sickness benefit: Enhanced sickness benefit equal to full wage is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively.

3. Maternity benefit (MB): Maternity benefit for confinement/pregnancy is payable for three months, which is extendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding year.

4. Disablement benefit

• Temporary disablement benefit (TDB): From day one of entering insurable employment and irrespective of having paid any contribution in case of employment injury. Temporary disablement benefit at the rate of 90% of wage is payable so long as disability continues.

• Permanent disablement benefit (PDB): The benefit is paid at the rate of 90% of wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a medical board.

5. Dependents’ benefit (DB): DB paid at the rate of 90% of wage in the form of monthly payment to the dependents of a deceased insured person in cases where death occurs due to employment injury or occupational hazards.

6. Other benefits

• Funeral expeitses: An amount of ₹ 10,000 is payable to the dependents or to the person who performs last rites from day one of entering insurable employment.

• Confinement expenses: An insured women or an IP in respect of his wife in case confinement occurs at a place where necessary medical facilities under ESI scheme are not available.

The Factories Act, 1948 (Amendment Act, 1987)

The act extends to the whole of India and came into force on the 1st day of April, 1949. The Act defines “factory” as any premise including the precincts thereof:

i. whereon ten or more workers are working, or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on with the aid of power, or is ordinarily so carried on.

ii. whereon twenty or more workers are working, or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on without the aid of power, or is ordinarily so carried on, but does not include a mine subject to the operation of the Mines Act, 1952 or a mobile unit belonging to the armed forces of the Union, a railway running shed or a hotel, restaurant or eating place.

Approval, licencing and registration: It is necessary to obtain a licence before a factory is started. Section 7 provides that the occupier of a factory must, at least 15 days before he begins to occupy or use any premises as a factory; send to the Chief Inspector of Factories a written notice containing the following particulars:

1. the name and situation of factory

2. the name and address of the occupier

3. the name and address of the owner of the premises or building

4. the address to which communications relating to factory may be sent.

5. the nature of the manufacturing process to be carried on in the factory during the next twelve months.

6. the total rated horse power installed or to be installed in the factory, which shall not include the rated-horse power or any separate stand-by plant.

7. the name of the manager of the factory

8. the number of workers likely to be employed in the factory

9. such other particulars as may be prescribed

The inspection staff: The Factories Act empowers the state government to appoint inspectors, Chief Inspectors of Factories, Additional Chief Inspectors, Joint Chief Inspectors and Deputy Chief Inspectors. Every District Magistrate is an Inspector for his district.

Certifying surgeons: Section 10 provides that the state government may appoint qualified medical practitioners to be certifying surgeons for the purposes of the Act for specified local areas or for specified factories or class of factories.

Provision regarding the health of workers: Sections 11 to 20 of the Act contain certain provisions intended to ensure that the conditions under which work is carried on in factories do not affect the health of the workers injuriously. The summary of the provisions are explained below:

• Cleanliness: Every factory shall be kept clean and free from dirt, and the outflow of drains, etc. The floors must be cleaned. Drainage shall be provided. Inside walls, partitions and ceilings must be repainted at least once in five years. When washable water paint is used they must be painted once every three years and washed at least every period of six months.

• Disposal of wastes and effluents: The waste materials produced from the manufacturing process must be effectively disposed of.

• Ventilation and temperature: There must be provision for adequate ventilation by the circulation of fresh air. The temperature must be kept at a comfortable level. Hot parts of machines must be separated and insulated.

• Dust and fume: If the manufacturing process gives injurious or offensive dust and fume, steps must be taken so that they are not inhaled or accumulated. The exhaust fumes of internal combustion engines must be conducted outside the factory.

• Artificial humidification: The water used for this purpose must be pure. It must be taken from some source of drinking water supply. The State Government can frame rules regarding the process of humidification, etc.

• Overcrowding: There must be no overcrowding in a factory. In factories existing before the commencement of the Act there must be about 350 cu ft of space per worker. For factories built afterwards, there must be at least 500 cu ft of space. In calculating the space, an account is to be taken of space above 14 ft from the floor.

• Lighting: Factories must be well-lighted. Effective measures must be adopted to prevent glare or formation of shadows which might cause eye strain.

• Drinking water: Arrangements must be made to provide a sufficient supply of wholesome drinking water. All supply points of such water must be marked “drinking water”. No such point is within 20 ft of any latrine, washing place, etc. Factories employing more than 250 workers must cool the water during the hot weather.

• Latrines and urinals: Every factory must provide sufficient number of latrines and urinals. There must be separate provision for male and female workers. Latrine and urinals must be kept in a clean and sanitary condition. In factories employing more than 250 workers, they are of prescribed sanitary types.

Provisions Regarding the Safety of Workers: The Act lay down rules for the purpose of securing the safety of workers. Summary of the provisions of the Factories Act regarding the safety of the workers are stated below: (Sections 21 to 41)

• Fencing of machinery: All dangerous machineries must be securely fenced, e.g. moving parts of prime movers and flywheels connected to every prime mover electric generator.

• Work on or near machinery in motion: Work on or near machinery in motion must be carried out only by specially trained adult male workers wearing tightly fitting clothes.

• Employment of young persons on dangerous machines: No young person works at any dangerous machine unless he has been specially instructed as to the dangers and the precautions to be observed has received sufficient training about the work and is under the supervision of some persons having thorough knowledge and experience of the machine.

• Striking gear and devices for cutting off power: In every factory suitable devices for cutting off power in emergencies from running machinery is provided and maintained in every workroom.

• Self-acting machines: Moving parts of a selfacting machine must not be allowed to come within 45 cm of any fixed structure which is not part of the machine.

• Casing of new machinery: In all machineries installed after the commencement of the Act certain parts must be sunk, encased or otherwise effectively guarded, e.g. set screw, bolt, toothed gearing, etc.

• Women and children near cotton openers: Women and children must not be allowed to work near cot/on openers, except in certain cases.

• Hoists, lifts, chains, etc.: Every hoist and lift must be so constructed as to be safe. There are detailed rules as to how such safety is to be secured. There are similar provisions regarding lifting machines, chains, ropes and lifting tackle.

• Revolving machinery: Where grinding is carried on the maximum safe working speed every revolving machinery connected therewith must be notified. Steps must be taken to see that the safe speed is not exceeded.

• Pressure plant: Where any operation is carried on at a pressure higher than the atmospheric pressure, steps must be taken to ensure that the safe working pressure is not exceeded.

• Floors, stairs and means of access: All floors, steps, stairs, passage and gangways are of sound construction and properly maintained. Handrails are provided where necessary. Safe means of access are provided to the place where the worker carries on any work.

• Pits, sumps, openings in floors, etc.: Pits, sumps, openings in floors, etc. must be securely covered or fenced.

• Excessive weights: No worker is made to carry a load so heavy as to cause him injury.

• Protection of eyes: Effective screen or suitable goggles is provided to protect the eyes of the worker from fragments thrown off in course of any manufacturing process and from excessive light if any.

• Precautions against dangerous fumes: No person is allowed to enter any chamber tank, etc. where dangerous fumes are likely to be present unless it is equipped with a manhole or other means of going out. In such space no portable electric light of more than 24 volts is used. Only a lamp or light of flameproof construction can be used in such space. For people entering such space suitable breathing apparatus, reviving apparatus, etc. are provided. Such places are cooled by ventilation before any person is allowed to enter.

• Explosive or inflammable gas, etc. where a manufacturing process produces inflammable gas, dust, fume, etc. Steps must be taken to enclose the machine concerned, prevent the accumulation of substances and exclude all possible sources of ignition. Extraprecautionary measures are to be taken where such substances are worked at greater than the atmospheric pressure.

• Precaution in case of fire: Fire escapes are provided. Windows and doors are constructed to open outwards. The means of exit in case of the fire are clearly marked in red letters. Arrangements must be made to give warning in case of fire.

• Specifications of defectives, etc. and safety of buildings and machinery. If any building or machine is in a defective or dangerous condition, the inspector of factories can ask for the holding of tests to determine how they can be made safe.

• Maintenance of buildings: If the inspector of factories thinks that any building in a factory, or any part of it is in such a state of disrepair that it is likely to affect the health and welfare of the workers he may serve on the occupier or manager or both in writing specifying the measures to be done before the specified date.

• Safety officers: The state government may notify to the occupier to employ a number of safety officers in a factory: (i) wherein one thousand or more workers are ordinarily employed or (ii) wherein any manufacturing process or operation which involves the risk of bodily injury, poisoning, disease or any other hazard to health of the persons employed in the factory.

• Rules: The state government may make rules providing for the use of such further devices for safety as may be necessary.

Provisions regarding the welfare of workers: Summary of the provisions of the Factories Act regarding the welfare of workers are stated below:

• Washing: In every factory, adequate and suitable facilities for washing are provided and maintained. There must be separate provisions for male and female workers.

• Storing and drying: The state government may make rules requiring the provision of suitable facilities for storing and drying of clothing.

• Sitting: Sitting facilities must be provided for workers who have to work in a standing position so that they may take rest when possible.

• First aid: Every factory must provide first aid boxes or cupboard. They must contain the prescribed materials and they must be in charge of persons trained in first aid treatment. Factories employing more than 500 persons must maintain an ambulance room containing the prescribed equipment and in charge of the prescribed medical and nursing staff.

• Canteens: Where more than 250 workers are employed the state government may require the opening of canteen or canteens for workers.

• Shelters: In every factory where more than 150 workers are employed there must be provided adequate and suitable shelters or rest rooms and a lunch room (with drinking water supply) where workers may eat meals brought by them.

• Crèches: In every factory where more than 30 women are employed, a room is provided for the use of the children (below 6 years) of such women. The room should be in adequate size, well lighted and ventilated, maintained in a clean and sanitary condition and should be in charge of a woman trained in the care of children and infants.

• Welfare officers: Welfare officers must be appointed in every factory where 500 or more workers are employed. The state government may prescribe the duties, qualifications, etc. of such officers.

• Rules: The state government may make rules regarding the welfare of workers.

The Working Hours of Adults

• Weekly hours: No adult worker is required or allowed to work in a factory for more than 48 hours in any week.

• Daily hours: No adult worker is required or allowed to work in a factory for more than 9 hours in any working day.

• Intervals for rest: The periods of work of adult workers in a factory each day are so-fixed that no period exceeds 5 hours that no worker works for more than 5 hours before he has had an interval for rest of at least half an hour.

• Spreadover: The periods of work of an adult worker in a factory are arranged that inclusive of his intervals for rest. They are not spreadover more than 1014 hours in any day. The chief inspector may increase the spreadover up to 12 hours for specific reason.

Restrictions on the employment of women: By Section 66 the following restrictions have been imposed to women workers:

• Maximum daily work is 9 hours: No exemption from the provisions that the maximum daily hours of work is 9 hours can be granted in respect of any women.

• Prohibition of night work: No woman is required or allowed to work in any factory except between the hours of 6 am and 7 pm.

• Change of shift only after holiday: There is no change of shifts for women except after a weekly holiday or any other holiday.

The Factories Act also describes about leave policies, over time, wages and salary, obligation of workers. The Act also describes about child labor, ages and rules for child labor.

Prevention of Food Adulteration Act, 1954

The prevention of food adulteration bill is passed by both the house of parliament and received the assent of the President on 29th September, 1954. It came into force on 1st June, 1955 as the Prevention of Food Adulteration Act 1954.

List of adaptation order and amending Acts

1. The Adaptation of Laws (No. 3) Order, 1956.

2. The Prevention of Food Adulteration (Amendment) Act, 1964.

3. The Prevention of Food Adulteration (Amendment) Act, 1971.

4. The Prevention of Food Adulteration (Amendment) Act, 1976.

5. The Prevention of Food Adulteration (Amendment) Act, 1986.

Objectives

1. To protect the public from poisonous and harmful foods

2. To prevent the sale of substandard foods

3. To protect the interests of the consumers by eliminating fraudulent practices

Meaning of adulterant: Any material which is or could be employed for the purposes of adulteration.

Definition of food: Any article used as food or drink for human consumption other than drugs and water and includes:

• Any article which ordinarily enters into or is used in the composition or preparation of human food

• Any flavoring matter or condiment

• Any other article which the central government may having regard to its use, nature, substance or quality, declare, by notification in the official gazette as food for the purpose of this Act.

Concept of adulteration: An article of food is deemed to be adulterated:

a. If the article sold by vendor is not of the nature, substance or quality demanded by the purchaser.

b. If the article contains any other substance which affects the substance or quality thereof.

If any inferior or cheaper substance has been substituted wholly or in part for the article so as to affect the nature, substance or quality of the product.

c. If any constituent of the article has been wholly or in part extracted to affect the quality thereof.

d. If the article has been prepared, packed or kept under unsanitary conditions whereby it has become contaminated or injurious to health.

e. If the article consists wholly or in part of any filthy, putrefied, rotten, decomposed or diseased animal or vegetable substance or is insect-infested or is otherwise unfit for human consumption.

f. If the article is obtained from a diseased animal.

g. If the article contains any poisonous or other ingredient which renders it injurious to health.

h. If the container of the article is composed, whether, wholly or in part of any poisonous or deleterious substance which renders its contents injurious to health.

i. If any coloring matter other than that prescribed in respect thereof is present in the article or if the amounts of the prescribed coloring matter which is present in the article are not within the prescribed limits.

j. If the article contains any prohibited preservative or permitted preservative in excess of the prescribed limits.

k. If the quality or purity of the article falls below the prescribed limits of variability which renders it injurious to health.

l. If the quality or purity of the article falls below the prescribed standard or its constituents are present in quantities not within the prescribed limits of variability which renders it injurious to health.

Sale of certain admixtures prohibited according to the law

a. Cream which has not been prepared exclusively from milk or which contains less than 25% of milk fat.

b. Milk which containts added water.

c. Ghee which contains any added matter not exclusively derived from milk fat.

d. Selling skimmed milk as whole milk.

e. Mixture of two or more edible oils as an edible oil.

f. Vanaspati to which ghee or any other substance has been added.

g. Any article of food which contains any artificial sweetener beyond the prescribed limit.

h. Turmeric containing any foreign substance.

i. Mixture of coffee and other substance except chicory.

j. Dahi or curd not made out of milk.

k. Milk or milk products containing constituents other than of milk.

Procedure for sampling and analysis: Any food inspector can enter and inspect any place where any article of food is manufactured or stored for sale or stored for the manufacture of any other article of food for sale or exposed or exhibited for sale or where any adulterant is manufactured or kept and take samples of such article of food or adulterant for analysis.

a. Notice issued by the inspector in writing then and there to the seller indicating his intention.

b. Three samples are taken and the signature of the seller is affixed to them.

c. One sample is sent for analysis to public analyst under intimation to the local health authority.

d. The other two samples are sent to the local health authority for further reference.

Penalties: Guilt is punished with imprisonment for a term which is not less than six months and up to 3 years and with fine up to ₹ 1000.

Important miscellaneous provisions

1. If any extraneous additions of coloring matter is added, the same should be indicated on the labels.

2. From the labels the blending composition of ingredients should be clear to the customer.

3. Sale of kesari gram individually or as an admixture is prohibited.

4. Prohibition of use of carbide (acetylene) gas in ripening is prohibited.

5. Sale of ghee with Reichert value less than the permitted level.

6. Sale of admixture of ghee or butter is prohibited.

7. Addition of artificial sweetener should be mentioned on the label.

8. Sale of food colors without licence prohibited.

9. Sale of insect-damaged dry fruits and nuts prohibited.

10. Food prepared in rusted containers, chipped enamel containers and untinned copper/brass utensils are treated as unfit for human consumption.

11. Containers not made of plastic material which is not according to the standards are not to be used.

12. Selling sal seed fat or any other purpose except for bakery and confectionery is prohibited.

13. Store of insecticides in the same premises where food articles are stored is prohibited.

14. Milk powder or condensed milk can be sold only with ISI mark.

15. Use of more than one type of preservative is prohibited.

16. Crop contaminants beyond certain specified level is treated as adulterant.

17. Naturally occurring toxic substances in the food material beyond certain level is considered as unfit for human consumption.

18. No antioxidant, emulsifiers and stabilizing agent is permitted beyond the prescribed level.

19. No insecticide should be sprayed on the food items.

20. Oils can be manufactured only in factories licenced for such purpose.

CHILD LABOR ACTS AND LAWS

India’s Child Labor (Prohibition and Regulation) Act is passed on 1986. After independence from colonial rule, India has passed a number of constitutional protections and laws on child labor. The Constitution of India in the Fundamental Rights and the Directive of State Policy prohibits child labor below the age of 14 years in any factory or mine or castle or engaged in any other hazardous employment. The constitution also envisioned that India by 1960, provide infrastructure and resources for free and compulsory education to all children of the age of 6 to 14 years (Article 21-A and Article 45). The major national legislative developments include the following:

• The Factories Act of1948: The Act prohibits the employment of children below the age of 14 years in any factory. The law also placed rules on whom, when and how long can pre-adults aged 15–18 years be employed in any factory.

• The Mines Act of 1952: The Act prohibits the employment of children below 18 years of age in a mine.

• The Child Labor (Prohibition and Regulation) Act of 1986: The Act prohibits the employment of children below the age of 14 years in hazardous occupations identified in a list by the law. The list is expanded in 2006, and again in 2008.

• The Juvenile Justice (Care and Protection) of Children Act of2000: This law made it a crime, punishable with a prison term, for anyone to procure or employ a child in any hazardous employment or in bondage.

• The Right of Children to Free and Compulsory Education Act of 2009: The law mandates free and compulsory education to all children aged 6 to 14 years. This legislation also mandated that 25 percent of seats in every private school must be allocated for children from disadvantaged groups and physically challenged children.

India formulated a National Policy on Child Labor in 1987. This policy seeks to adopt a gradual and sequential approach with a focus on rehabilitation of children working in hazardous occupations. It envisioned strict enforcement of Indian laws on child labor combined with development programs to address the root causes of child labor such as poverty. In 1988, this led to the National Child Labor Project (NCLP) initiative. Despite these efforts, child labor remains a major challenge for India.

Bibliography

1. Benefits: Employees State Insurance Corporation. Ministry of Labor and Employment, Government of India. [Internet] 2014. [Cited on 2014 Dec 30th]. Available on: http://www.esic.nic.in/benefits.php.

2. Central Pollution Control Board. [Internet] 2014 Oct 21st. [Cited on 2014 Dec 29th]. Available on: http://en.wikipedia.org/wiki/Central_Pollution_Control_Board.

3. Child Labor in India. [Internet] 2014 Dec 24th. [Cited on 2014 Dec 30th]. Available on: http://en.wikipedia.org/wiki/Child_labour_in_India.

4. Food Adulteration Act. [Internet] 2014 [Cited on 2014 Dec 30th], Available on: http://agmarknet.nic.in/amrscheme/amrstandpreven.htm.

5. MTP Act (Amendment), 2002. Government of India, Ministry of Health & Family Welfare. [Internet] 2014 [Cited on 2014 Dec 30th]. Available on: http://mohfw.nic.in/indexl.php?lang=l&level=4&sublinkid=3614and&lid=2599.

6. MTP Act, 1971. Government of India, Ministry of Health & Family Welfare. [Internet] 2014 [Cited on 2014 Dec 30th]. Available on: http://mohfw.nic.in/indexl.php?lang=l&level=4&sublinkid=3615&lid=2598.

7. The Factories Act India 1948. National Laws on Labor, Social Security and Related Human Rights. [Internet] 2014. [Cited on 2014 Dec 30th]. Available on: http://www.ilo.org/dyn/nat-lex/docs/WEBTEXT/32063/64873/E87IND01.htm.

25

Impact of Sociology in Community Health Nursing

This chapter contains

▪ Impact of Sociology on Health

▪ Norms

▪ Customs

▪ Values

▪ Marriage System

▪ Gender and Women Empowerment

▪ Child Abuse

▪ Women Abuse

▪ Female Feticide

IMPACT OF SOCIOLOGY ON HEALTH

Sociology is a social science that uses various methods of empirical investigation and critical analysis to develop a body of knowledge about social order, social disorder and social change. It is the academic study of social behavior, its origins, development, organization, and institutions. The term sociology is coined by Auguste Comte, the French philosopher who is often referred as Father of Sociology. The word sociology is derived from the Latin word “societus”, meaning “society” and the Greek word “logos” meaning “study” or “science”. Thus sociology means “science of the society” or “study of the society”.

Health is determined by several factors including genetic inheritance, personal behaviors, access to quality health care, and the general external environment (such as the quality of air, water, and housing conditions). In addition, a growing body of research has documented association between social and cultural factors and health. Some types of social variables such as socioeconomic status (SES) or poverty shows strong evidence of their links to health. For other kinds of variables, such as social networks and social support or job stress has evidence of their links to health.

Norms

Social norms are the behaviors and cues within a society or group. The social norms indicate the established and approved ways of doing things, dress, speech and appearance. These vary and evolve not only through time but also vary from one age group to another and between social classes and social groups. What is deemed to be acceptable dress, speech or behavior in one social group may not be accepted in another.

Definition: This sociological term has been defined as “the rules that a group uses for appropriate and inappropriate values, beliefs, attitudes and behaviors. These rules may be explicit or implicit. Failure to follow the rules can result in severe punishments, including exclusion from the group.” They have also been described as the “customary rules of behavior that coordinate our interactions with others.”

Table 25.1: Influence of various social factors on health

Political
Economic

• Government type and stability

• Freedom of press, rule of law and levels of bureaucracy and corruption

• Regulation and deregulation trends

• Social and employment legislation

• Tax policy, and trade and tariff controls

• Environmental and consumer-protection legislation

• Likely changes in the political environment

• Stage of business cycle

• Current and project economic growth, inflation and interest rates

• Unemployment and labor supply

• Labor costs

• Levels of disposable income and income distribution

• Impact of globalization

• Likely impact of technological or other change on the economy

• Likely changes in the economic environment

Sociocultural
Technological

• Population growth rate and age profile

• Population health, education and social mobility, and attitudes to these

• Population employment patterns, job market freedom and attitudes to work

• Press attitudes, public opinion, social attitudes and social taboos

• Lifestyle choices and attitudes to these

• Sociocultural changes

• Impact of emerging technologies

• Impact of internet, reduction in communication costs and increased remote working

• Research and development activity

• Impact of technology transfer

Types: Sociologists speak of at least four types of norms: folkways, mores, taboos and laws.

• Folkways, sometimes known as “conventions” or “customs,” are standards of behavior that are socially approved but not morally significant. Informal rules and norms whose violation is not offensive, but expected to be followed. It’s a kind of adjusting, accommodating type of habits. It does not invite any punishment or sanctions, but some reprimands or warnings.

Cultural forms of dress or food habits are examples of folkways. In America, if someone belched loudly while eating at the dinner table with other people, he or she would be breaking a folkway. It is culturally appropriate to not belch at the dinner table, however, if this folkway is broken, there are no moral or legal consequences.

• Mores are norms of morality. They are also informal rules that are not written, but result in severe punishments and social sanction upon the individuals like social and religious exclusions. Religious doctrines are the example of mores.

For instance, parents who believe in the more that only married people should live together, disapproves of their daughter living with her boyfriend. They may consider the daughter’s actions a violation of their moral guidelines.

• Taboos: Certain behaviors are considered taboo, meaning a culture absolutely forbids them. A taboo is a norm that society holds so strongly that violating it results in extreme disgust. Often times the violator of the taboo is considered unfit to live in that society. The word has been somewhat expanded in the social sciences to strong prohibitions relating to any area of human activity or custom that is sacred or forbidden based on moral judgment and religious beliefs.

For instance, in some Muslim cultures, eating pork is taboo because the pig is considered unclean. At the more extreme end, incest and cannibalism are taboos in most countries.

• Law: A law is a norm that is written down and enforced by an official law enforcement agency. It is a formal body of rules enacted by the state and backed by the power of the state. Virtually all taboos like child abuse, are enacted into law, although not all mores are.

Driving while drunk, theft, murder, and trespassing are all examples of laws. If any person violating the law could get cited, owe a fine, or go to jail.

Members of a culture must conform to its norms for the culture to exist and function. Hence, members must want to conform and obey rules. They first must internalize the social norms and values that dictate what is “normal” for the culture; then they must socialize, or teach norms and values to their children. If internalization and socialization fail to produce conformity, some forms of “social control” are eventually needed. Social control may take the form of ostracism, fines, punishments, and even imprisonment.

How Norms Differ?

Norms differ widely among societies, and they can even differ from group to group within the same society.

Different settings: Wherever we go, expectations are placed on our behavior. Even within the same society, these norms change from setting to setting. Example: The way we are expected to behave in church differs from the way we are expected to behave at a party, which also differs from the way we should behave in a classroom.

Different countries: Norms are place-specific, and what is considered appropriate in one country may be considered highly inappropriate in another. Example: In some African countries, it’s acceptable for people in movie theaters to yell frequently and make loud comments about the film. In the United States, people are expected to sit quietly during a movie, and shouting would be unacceptable.

Different time periods: Appropriate and inappropriate behavior often changes dramatically from one generation to the next. Norms can and do shift over time. Example: In the United States in the 1950s, a woman almost never asked a man out on a date, nor did she pay for the date. While some traditional norms for dating prevail, most women today feel comfortable asking men out on dates and paying for some or even all of the expenses.

Customs

Customs regulate the whole social life of man. Law itself cannot cover the whole gamut of social behavior. It is the customary practices that contribute to the harmonious social interactions in a society

Definition: A custom is a cultural idea that describes a regular, patterned way of appearing or behaving that is considered characteristic of life in a social system.

Examples: Shaking hands, bowing, and kissing are all customary ways of greeting people that distinguish one society from another.

Values

A value system is a set of consistent values and measures. A principle value is a foundation upon which other values and measures of integrity are based. Some values are physiologically determined and are normally considered objective, such as a desire to avoid physical pain or to seek pleasure. Other values are considered subjective, vary across individuals and cultures, and are in many ways aligned with belief and belief systems.

Types of Values

• Ethical/moral values

• Doctrinal/ideological (religious, political) values

• Social values

• Aesthetic values.

Values can be defined as broad preference concerning appropriate courses of action or outcomes. As such, values reflect a person’s sense of right and wrong or what “ought” to be. “Equal rights for all”, “Excellence deserves admiration”, and “People should be treated with respect and dignity” are representative of values. Values tend to influence attitudes and behavior.

Marriage System

Marriage is the process by which two people make their relationship public, official, and permanent. It is the joining of two people in a bond that lasts until death, but in practice is increasingly cut short by divorce. The definition of marriage varies according to different cultures, but it is principally an institution in which interpersonal relationships, usually sexual, are acknowledged. In some cultures, marriage is recommended or considered to be compulsory before pursuing any sexual activity.

Definition

According to Horton and Hunt “Marriage is the approved social pattern whereby two or more persons establish a family”.

Mazumdar HT defines marriage as “a socially sanctioned union of male and female, or as a secondary institution devised by society to sanction the union and mating of male and female, for purposes of: (a) establishing a household, (b) entering into sex relations, (c) procreating and (d) providing care for the offspring”.

Forms of Marriage

1. Monogamy: One man, one wife; it is a form of marriage wherein one man marries one woman at a time. This is the leading form of marriage as it produces the highest types of affection and sincere devotion. The children are taken care off well as both parents give attention to upbringing of their offsprings. Monogamy is said to cause extramarital affairs, yet according to Malinowski “Monogamy is, has been, and will remain the only true type of marriage”.

2. Polygamy: Polygamy is a marriage which includes more than two partners. When a man is married to more than one wife at a time, the relationship is called polygyny and when a woman is married to more than one husband at a time, it is called polyandry.

• Polyandry: One wife, many husbands; it is a form of marriage wherein one woman marries more than one man at a given time. Polyandry may take two forms:

a. Fraternal polyandry—one wife is regarded as the wife of all brothers who have sexual relation with her. The children are treated as the offspring of the eldest brother.

b. Non-fratemal polyandry—one woman has many husbands with whom she cohabits in turn. It is not necessary that these husbands be brothers. If a child is born, any one husband is chosen its social parent by a special ritual.

Polyandry is generally exists where there are lesser number of women, poverty, bride price is high; sometimes polyandry is considered as a measure of population control. Other causes of polyandry may be backwardness, strengthening of bond in joint family, etc. But it adversely affects the health of woman due to multiple sex partners, may cause sterility and diminish population.

• Polygyny: One husband, many wives; it is a form of marriage wherein one man has two or more wives at a time. There are various causes of polygyny like earlier aging of female, desire of variety, to obtain more children. Sometimes, having more wives is considered as superiority as single marriage is a sign of poverty. Another well-known cause is, as men do not approach the woman during the period of pregnancy and breastfeeding; due to this long period of enforced celibacy, a second marriage is considered.

3. Exogamy marriage: Marriage outside the group, i.e. no marriage should be between individuals sharing certain degrees of blood or affinal relationships. In a few religions or customs cousin marriage is allowed. But the marriage of parents with their children is universally prohibited.

4. Endogamy marriage: Marriage within the class is known as endogamy. Intercast marriages are not encouraged. However, nowadays endogenous attitude is some what relaxed but in some places it still persists so strongly that it may lead to honor killing also if Intercast marriage done without family concern.

5. Companionate marriage: This is “the marriage of two persons on the understanding that as long as there are no children, the marriage may be dissolved simply by mutual consent”.

6. Experimental marriage: A man and woman may be allowed to lead marital life temporarily in order to find out if they can settle down permanently in matrimonial relationship.

Marriage System in India

Arranged marriages were normal in Indian society from the historical Vedic era and it is still viewed in maximum Indian families. Parents take an important role for their marriage-ready son or daughter. They choose prospective bride or groom for their son or daughter to marry. The tradition of arranged marriage is still continuing today in India but some changes are noticed in this marriage process. Today, parents are anxious about the life of their child and take the consent of their kid, before deciding the marriage. Over the time, people have understood that marriages can only be successful when the parents or family do not force their children to marry someone he or she doesn’t want to marry. Excellent arranged marriage happens when the parents help their children to find their life partners according to their own choice.

Parent or family member set a matchmaker (Ghatak or Ghatki) to choose a prospective bride or groom who usually done via an intermediary role. A matchmaker has some social reputation for maintaining discretion and brokering successful weddings. The family expresses their criteria for a good match to the matchmaker, which is usually heavily influenced by the personal preferences of the son or daughter but also includes family considerations. These considerations vary, but can include:

• Religion and caste: Marriage system in India differs from religion to religion, from caste to castes and from rich to poor. One who belongs to Hinduism always gets married with a Hindus, not any other religion and an upper caste groom always get married with an upper caste not with a lower caste.

• Family status: The financial strength and reputation of both the families should be same and acceptable to each other.

• Profession: A boy always should be established with a good profession.

• Education: Boys should be qualified with comparable educational levels or more educated than the girl.

• Looks and physical attributes: For the brides skin should be lighter and fair, on the other hand, the groom’s height is important and he should be at least a few inches taller than the bride.

• Age: The groom is usually desired to be older but not by more than a few years.

Marriage and Health

Marriage is not only personal but a social institution. It has various effects on individual as well as societal life. A few of them have been explained below:

• Social-cognitive processes: People in happy marriages may think about their relationship differently from people in troubled marriages. Unhappily married people often hold their partner responsible for negative behaviors, but attribute positive behavior to other factors. Blaming one’s partner for their negative behavior is associated with prolonged elevations of the stress hormone cortisol after an argument. Stress in personal life may effect on social life too. Anger and frustration may cause less productivity in working place, misbehavior with others.

• Emotional processes: People in troubled marriages experience more negative emotions, particularly hostility. Negative emotions have been linked to elevated blood pressure and heart rate, and to increased levels of stress hormones, which may lead to ill-health. Emotional disclosure often occurs in well-functioning marriages, and is linked to a host of health benefits, including fewer physician visits and missed work days.

• Health behaviors: Health behaviors such as diet, exercise and substance use, may also affect the interplay of marital quality and health. The health behaviors of married couples converge over time, such that couples who have been married many years have similar behavior. One explanation is that spouses influence or control one another’s health behaviors. Marital support may increase the psychological resources such as self-efficacy, and self-regulation which are needed to improve one’s health behaviors.

• Mental illness: Marital problems predict the onset of mental illness, including anxiety, mood, and substance use disorders. Much research has focused on depression, showing a bidirectional connection with marital conflict. Marital distress interacts with existing susceptibility, increasing risk for depression. The links between depression and ill-health are well-established; depression is associated with poor regulation of immune system, and poor health behaviors, such as lack of exercise, poor sleep and diet, and increased substance abuse.

• Biological pathways: Poor regulation of the cardiovascular, neuroendocrine and immune systems is implicated in the links between marital quality and health.

• Cardiovascular reactivity: Marital conflicts and seeking change from one’s spouse evokes a cardiovascular reaction, increasing heart rate and blood pressure. Couples who are more hostile during arguments have stronger cardiovascular reactions. Heightened cardiovascular reactions are associated with increased risk for cardiovascular disease.

• Neuroendocrine system: Hormones produced by the sympathetic-adrenal-medullary (SAM) axis and hypothalamic-pituitary-adrenal (HPA) axis have wide ranging effects across the body. Both axes have been implicated in the links between psychological factors and physical health. Daily fluctuations in the level of cortisol in lower marital satisfaction, a stress hormone are an important marker of health.

• Immune pathways: Low marital satisfaction and hostility during arguments with one’s spouse are associated with increased inflammation. Chronic and persistent inflammation damages the surrounding tissue; is implicated as a central mechanism linking psychosocial factors and diseases such as atherosclerosis and cancer. Lower marital quality is also related to poorer functioning of the adaptive immune system and causes poorer ability to control the Epstein-Barr virus, a latent virus which infects most adults.

Gender and Women Empowerment

“Development cannot be achieved if fifty percent of the population is excluded from the opportunities it brings”—UNDP administrator.

Gender equality and women’s empowerment are human rights that lie at the heart of development and the achievement of the Millennium Development Goals. Despite the progress that has been made, six out of ten of world’s poorest people are still women and girls, less than 16 percent of the world’s parliamentarians are women, two-thirds of all children shut outside the school gates are girls and, both in times of armed conflict and behind closed doors at home, women are still systematically subjected to violence.

The Status of Women: Current Reality

The past three decades have witnessed a steadily increasing awareness of the need to empower women through measures to increase social, economic and political equity, and broader access to fundamental human rights, improvements in nutrition, basic health and education. Along with awareness of the subordinate status of women has come the concept of gender as an overarching sociocultural variable, seen in relation to other factors, such as race, class, age and ethnicity. Gender is not synonymous with women, nor is it a zero-sum game implying loss for men; rather, it refers to both women and men, and to their status, relative to each other. Gender equality refers to that stage of human social development at which “the rights, responsibilities and opportunities of individuals is not determined by the fact of being born male or female,” in other words, a stage when both men and women realize their full potential.

Despite many international agreements affirming their human rights, women are still much more likely than men to be poor and illiterate. They usually have less access than men to: medical care, property ownership, credit, training and employment. They are far less likely than men to be politically active and far more likely to be victims of domestic violence.

The ability of women to control their own fertility is absolutely fundamental to women’s empowerment and equality. When a woman can plan her family, she can plan the rest of her life. When she is healthy, she can be more productive. And when her reproductive rights—including the right to decide the number, timing and spacing of her children, and to make decisions regarding reproduction free of discrimination, coercion and violence—are promoted and protected, she has freedom to participate more fully and equally in society.

The roles that men and women play in society are not biologically determined—they are socially determined, changing and changeable. Although they may be justified as being required by culture or religion, these roles vary widely by locality and change over time. Of the 1.3 billion people who live in absolute poverty around the globe, 70 percent are women. For these women, poverty doesn’t just mean scarcity and want. It means rights denied, opportunities curtailed and voices silenced. Consider the following:

• Women work two-thirds of the world’s working hours, according to the United Nations Millennium Campaign to halve world poverty by the year 2015. The over whelming majority of the labor that sustains lifegrowing food, cooking, raising children, caring for the elderly, maintaining a house, hauling water—is done by women, and universally this work is accorded low status and no pay. The ceaseless cycle of labor rarely shows up in economic analyses of a society’s production and value.

• Women earn only 10 percent of the world’s income. Where women work for money, they may be limited to a set of jobs deemed suitable for women—invariably low-pay, low-status positions.

• Women own less than 1 percent of the world’s property. Where laws or customs prevent women from owning land or other productive assets, from getting loans or credit, or from having the right to inheritance or to own their home, they have no assets to leverage for economic stability and cannot invest in their own or their children’s futures.

• Women make up two-thirds of the estimated 876 million adults worldwide who cannot read or write; and girls make up 60 percent of the 77 million children not attending primary school. Education is among the most important drivers of human development: women who are educated have fewer children than those who are denied schooling (some studies correlate each additional year of education with a 10 percent drop in fertility).

Key Issues and Linkages

1. Reproductive health: Women, for both physiological and social reasons, are more vulnerable than men to reproductive health problems. Reproductive health problems, including maternal mortality and morbidity, represent a major but preventable cause of death and disability for women in developing countries. Failure to provide information, services and conditions to help women protect their reproduction health, therefore, constitutes gender-based discrimination and a violation of women’s rights to health and life.

2. Stewardship of natural resources: Women in developing nations are usually in charge of securing water, food and fuel and of overseeing family health and diet. Therefore, they tend to put into immediate practice whatever they learn about nutrition and preserving the environment and natural resources.

3. Economic empowerment: More women than men live in poverty. Economic disparities persist partly because much of the unpaid work within families and communities falls on the shoulders of women and because they face discrimination in the economic sphere.

4. Educational empowerment: About two-thirds of the illiterate adults in the world are female. Higher levels of women’s education are strongly associated with both lower infant mortality and lower fertility, as well as with higher levels of education and economic opportunity for their children.

5. Political empowerment: Social and legal institutions still do not guarantee women equality in basic legal and human rights, in access to or control of land or other resources, in employment and earning, and social and political participation. Laws against domestic violence are often not enforced on behalf of women.

Experience has shown that addressing gender equality and women’s empowerment requires strategic interventions at all levels of programming and policymaking.

That is why UNDP, UNFPA, etc. NGOs integrate gender equality and women’s empowerment in their four main areas of work:

• poverty reduction

• democratic governance

• crisis prevention and recovery

• environment and sustainable development.

Child Abuse

Child abuse is the physical, sexual or emotional maltreatment or neglect of a child or children. Child abuse can take several forms: the four main types are physical, sexual, psychological, and neglect.

Physical abuse: Physical abuse involves physical aggression directed at a child by an adult. Bruises, scratches, burns, broken bones, lacerations, as well as repeated “mishaps,” and rough treatment that could cause physical injury, can be physical abuse. Multiple injuries or fractures at different stages of healing can raise suspicion of abuse. Physical abuse can come in many forms, although the distinction between child discipline and abuse is often poorly defined.

Sexual abuse: Child sexual abuse (CSA) is a form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation. Sexual abuse refers to the participation of a child in a sexual act aimed towards the physical gratification or the financial profit of the person committing the act. Forms of CSA include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact with a child, physical contact with the child’s genitals, viewing of the child’s genitalia without physical contact, or using a child to produce child pornography.

Effects of child sexual abuse on the victim(s) include guilt and self-blame, flashbacks, nightmares, insomnia, fear of things associated with the abuse (including objects, smells, places, doctor’s visits, etc.), self-esteem issues, sexual dysfunction, chronic pain, addiction, self-injury, suicidal ideation, somatic complaints, depression,post-traumatic stress disorder, anxiety, other mental illnesses including borderline personality disorder and dissociative identity disorder, propensity to revictimization in adulthood, bulimia nervosa, and physical injury to the child, among other problems.

Psychological/emotional abuse: Emotional abuse is defined as the production of psychological and social defects in the growth of a child as a result of behavior such as loud yelling, coarse and rude attitude, inattention, harsh criticism, and denigration of the child’s personality. Other examples include namecalling, ridicule, degradation, destruction of personal belongings, torture or killing of a pet, excessive criticism, inappropriate or excessive demands, withholding communication, and routine labeling or humiliation.

Victims of emotional abuse may react by distancing themselves from the abuser, internalizing the abusive words, or fighting back by insulting the abuser. Emotional abuse can result in abnormal or disrupted attachment development, a tendency for victims to blame themselves (self-blame) for the abuse, learned helplessness, and overly passive behavior. Because of emotional abuse the child may be a victim of broken mental health or social development and they left lifelong as a psychological scars.

Neglect: Child neglect is the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety, and well-being are threatened with harm. Neglect is also a lack of attention from the people surrounding a child, and the non-provision of the relevant and adequate necessities for the child’s survival, which would be a lacking in attention, love and nurture. Some of the observable signs in a neglected child include: the child is frequently absent from school, begs or steals food or money, lacks needed medical and dental care, is consistently dirty, or lacks sufficient clothing for the weather.

Neglected children may experience delays in physical and psychosocial development, possibly resulting in psychopathology and impaired neuropsychological functions including executive function, attention, processing speed, language, memory and social skills.

It is very important to prevent and control child abuse. A healthy family, teaching of good/bad touch in schools, moral development, etc. can help to prevent child abuse. A mass health education on prevention of child abuse in TV, internet may be effective. Central and state governments should prohibit the programs which stimulate the sensation and sexual activities among people.

Women Abuse

Woman abuse is any use of psychological, physical or sexual force, actual or threatened. Men can also be abused, but the term ‘woman abuse’ recognizes that women are most often the victims of abuse and men are most often the perpetrators. Abuse against women occurs in families of all socioeconomic, educational and cultural backgrounds and is found in both rural and urban settings.

Violence against women can fit into several broad categories. These include violence carried out by ‘individuals’ as well as ‘states.’ Some of the forms of violence perpetrated by individuals are rape; domestic violence; sexual harassment; coercive use of contraceptives; female infanticide; prenatal sex selection; obstetric violence and mob violence; as well as harmful customary or traditional practices such as honor killings, dowry violence, and female genital mutilation, marriage by abduction and forced marriage. Some forms of violence are perpetrated or condoned by the state such as war rape; sexual violence and sexual slavery during conflict; forced sterilization; forced abortion; violence by the police and authoritative personnel; stoning and flogging. Many forms of VAW, such as trafficking in women and forced prostitution are often perpetrated by organized criminal networks.

Effect of abuse on victim may be a temporary physical trauma but a lifelong psychological trauma.

Female Feticide

Female feticide is the act of aborting or terminating a fetus while it s still in the womb, because it is female, is known as female feticide. This can be done after determining the sex of the child before it’s born, through ultrasound scans. Although, sex determination in India is illegal, the practice is widespread and has become a multimillion dollar industry. Coupled with prospective parents desperate for a boy child, and physicians who are carrying out these abortions, female feticide has become a shameful and shocking reality of our nation.

Causes: Today, some of the key reasons that exist for the preference of a male child are as follows:

• Illiteracy, poverty and the tag of ‘burden’ that is assigned to a girl child, makes the desire for a male child even stronger.

• A son is seen as someone who can earn and care for his parents in their later years, while a daughter gets married and goes away.

• The tradition of paying dowry at the time of a daughter’s marriage is alive and kicking. This amount can be so huge that many parents go to extreme lengths to avoid having a daughter in the first place.

• A son can carry on the family name, while a daughter becomes part of her husband’s family.

• Girls are seen as consumers, whereas boys are seen as producers.

• Many families consider it a status symbol to have a son, and a point of shame to have a daughter.

• Often, the pressure to bear a male child on the woman is so great that she herself might choose to get sex determination done and abort the baby if it’s a girl.

• Modern technology has made it very easy to determine the sex of the child while it’s still in the womb, giving parents-to-be the option of aborting the fetus and continuing to try to conceive till they get a male child.

While sex determination has been banned by the Indian government, it does not stop families from going to great lengths to find out anyway. Not only there are plenty of scanning centres that reveal this information, many of the wealthier families fly the pregnant mother to neighboring countries where sex determination is legal, to find out the gender of the baby. Once the gender of the baby is known, families that are keen to have a baby boy choose to abort the female fetus. The law on aborting is also strict, and the Indian government allows it only under certain circumstances. Therefore, by determining the sex of the baby and aborting it because it’s a girl, the parents as well as the participating physicians are breaking two major laws.

Bibliography

1. Bhusan V, Sachdeva DR. An Introduction to Sociology. Allahabad: Kitabmahal; 2008.

2. Ashley D, Orenstein DM (2005). Sociological Theory: Classical statements (6th ed.). Boston, Massachusetts, USA: Pearson Education.

3. Markwell S. Understanding Organizations: Assessing the impact of political, economic, sociocultural, environmental and other external influences. 2009 [Internet], http://www.health knowledge.org.uk/public-health-textbook/organisation-management/5b-understanding-ofs/assessing-impact-external-influences [Cited: 20th Dec 2014],

4. Andersen ML and Taylor HF. Sociology: The Essentials. Belmont, CA: Thomson Wadsworth; 2009.

5. Clement I. Sociology for Nurses. New Delhi: Dorling Kindersley; 2010.

6. Widom CS (1999). “Post-traumatic Stress Disorder in Abused and Neglected Children Grown up”. American Journal of Psychiatry 156 (8): 1223–1229. PMID 10450264.

7. Levitan RD, NA Rector, Sheldon T and Goering P (2003). “Childhood adversities associated with major depression and/or anxiety disorders in a community sample of Ontario: Issues of comorbidity and specificity,” Depression and Anxiety.

8. Cultural Norms. [Internet] Cited on 2014 Dec 29th. Available from: http://www.cliffsnotes.com/sciences/sociology/culture-and-societies/cultural-norms.

9. Divorced or Widowed. [Internet] Cited on 2014 Dec 29th. Available from: http://www.indyatour.com/india/culture/india-marriage-system.php.

10. Marriage and Health. [Internet] Cited on 2014 Dec 29th. Available from: http://en.Wikipedia,org/wiki/Marriage_and_health.

11. Custom. [Internet] Cited on 2014 Dec 30th Available from: http://sociology.about.com/od/C_Index/g/Custom.htm.

12. Female Feticide in India. [Internet] 2014. [Cited on 2014 Dec 30th]. Available on: http://www.mdhil.com/female-foeticide-in-india.

13. Sociology. The American Heritage Science Dictionary. Cited 20 Dec 2014, from Dictionary.com website: http://dictionary.reference.com/browse/sociology.

26

Legal and Ethical Issues in Community Health Nursing

This chapter contains

▪ Definitions

▪ Sources of Law

▪ Types of Law

▪ Legal Concepts of Crime/Torts

▪ Grossly Unethical Behavior in Community Area

▪ Professional and Legal Regulation of Nursing Practice

▪ Nursing Standards (ANA)

▪ Ethical Issues Need to be Considered in Community Interventions

▪ General Ethical Responsibilities

▪ Importance of Ethical Behavior in Community Interventions

The community health nurse experiences many ethical conflicts in health care delivery system. Especially she must be very careful while doing services in the community because; there is a team of people working in the hospital but in community she works alone. Therefore, she must be more careful and she should have enough knowledge on legal issues.

DEFINITIONS

• Law: Body of rules to guide human action. It is a standard or rules of conduct established and enforced by the government. These are intended to protect the public.

• Ethics: Ethics is a system of moral principles, and rules of conduct recognized in respect to a particular class of human actions or to a particular group of people. In other way ethics is a code of thinking and behavior governed by a combination of personal, moral, legal, and social standards of what is right.

Sources of Law

• Constitution: It is a system of fundamental laws or principles that govern a nation or society. It defines the structure, power and limits of government and it guarantees citizens some fundamental rights. Constitution gives the authority to the other sources of law. It has less direct effect in malpractice.

• Statutory or legislative law: Laws passed by the local, state or federal legislative body.

• Administrative agencies: The rules and regulations established by executive branch of the government. They create rules and regulations that enforce statutory law.

• Tort law or court decision: Judicial and decisional laws are made by the court to interpret legal issues are known as tort law.

Types of Law

• Criminal law: Criminal law is the body of law that relates to crime. It regulates social conduct and prescribes whatever is threatening, harmful, or otherwise endangering to the property, health, safety, and moral welfare of people. It includes the punishment of people who violate these laws.

• Civil law: A body of rules that delineate private rights and remedies, and govern disputes between individuals in such areas as contracts, property, and family law; distinct from criminal or public law.

• Administrative law: Administrative law is the body of law that governs the activities of administrative agencies of government. Government agency action can include rule-making, adjudication, or the enforcement of a specific regulatory agenda.

Legal Concepts of Crime/Torts

Crime/torts refer a wrong committed by a person against another person or his/her property.

• Crime: Crime denotes an unlawful act punishable by a state.

• Misdemeanor: A criminal offense that is less serious than a felony and more serious than an infraction is generally punishable by a fine or incarceration in a local jail, or both.

• Felony: The term felony means a serious crime. The word originates from English common law, where felonies were originally crimes that involved confiscation of a convicted person’s land and goods. Other crimes were called misdemeanors.

• Infraction: A violation or infringement of a law or agreement.

• Litigation: An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute.

• Plaintiff: It is also known as a claimant or complainant, is the term used in some jurisdictions for the party who initiates a lawsuit/action before a court.

• Defendants: A defendant is a person or entity accused of a crime in criminal action or a person or entity against whom some type of civil relief is being pursued in a civil case. Terminology varies from one jurisdiction to another.

• Tort: It is a civil wrong that unfairly causes someone else to suffer loss or harm resulting in legal liability for the person who commits the tortious act, called a tortfeasor. Tort may be intentional or unintentional.

Intentional or unintentional torts: An intentional tort is a category of torts that descibes a civil wrong resulting from an intentional act on the part of the tortfeasor. Those may be:

• Assault: An assault takes place when one person acts intentionally in a way that causes another person to reasonably apprehend (or fear) an immediate harmful or offensive contact.

• Battery: A battery is the intentional harmful or offensive touching of another without consent or privilege.

So, an assault involves the threat of harmful contact, while a battery involves the actual harmful or offensive touching itself.

• Defamation: Defamation is a statement that injures a third party’s reputation. The tort of defamation includes both libel (written statements) and slander (spoken statements).

• Invasion of privacy: When a person unlawfully interferes into others private affairs, discloses his or her private information, publicizes him or her in a false light, or appropriates his or her name for personal gain.

• False imprisonment: Forcibly detains the person or confines his or her freedom of movement.

• Fraud: Fraud is an act of dishonesty intended for personal gain or to cause a loss to another party.

• Conversion: It is a voluntary act by one person inconsistent with the ownership rights of another.

• Trespass to land: It is a common tort or crime that is committed when an individual or the object of an individual intentionally enters the land of another without a lawful excuse.

• Trespass to chattels (personal property): Whereby the infringing party has intentionally interfered with another person’s lawful possession of a chattel (movable personal property). The interference can be any physical contact with the chattel in a quantifiable way, or whether by taking it, destroying it, or barring the owner’s access to it.

• Intentional infliction of emotional distress: It is an intentional conduct that results in extreme emotional distress of other.

Unintentional torts: An act that results not form an intention to cause harm or to perform some harmful act, but did not conform his or her conduct to the standard of care required by common law. These are:

• Negligence: It refers to the conduct that falls below the standards of behavior established by law for the protection of others against unreasonable risk of harm.

• Malpractice: Malpractice refers to negligence or misconduct by a professional person such as a lawyer, a doctor, a dentist, or an accountant. The failure to meet a standard of care or standard of conduct that is recognized by a profession reaches the level of malpractice when a client or patient is injured or damaged because of error. All negligence are not malpractice.

• Liability: The state of being legally responsible for something.

• Duty and documentation: These are execution of safety measures.

• Breach of duty: Failure to note and report to higher authority about the seriousness.

• Causation: Failure to use appropriate safety measures.

• Damages: Lengthened hospital stay and need for rehabilitation.

Grossly Unethical Behavior in Community Area

Community programs need to be clear about their own ethical standards, and to hold individuals to them and to any other standard their professions demand. In most cases, staff members guilty of grossly unethical behavior should be dismissed as quickly as possible, and prosecuted where that is appropriate. Some of the more familiar types of grossly unethical behavior include:

• Having sexual relationships even consensual sexual relationships with people with whom you have a professional relationship. Doctor-patient, therapist-client, teacher-student, supervisor-intern, and youth worker-teen are all examples of such relationships. In some of these cases, a sexual relationship both violates the professional’s code of ethics and may be the base for a sexual harassment or sexual assault lawsuit as well.

• Exploiting people for financial gain with whom you have a professional relationship. As for example asking money from whom you should give a free service, asking for some free services he can provide or accepting gifts or money.

• Defrauding funders by billing for nonexistent services, or inventing problems in order to deliver unnecessary services.

• Denying necessary medical services to those uninsured and unable to pay.

• Discriminating in service delivery by race, gender, ethnicity, etc.

• Criminal behavior as redirecting program funds for personal use or sexually abusing children in a day care center. This can also include criminal behavior that a staff member engages in criminal activities as selling drugs or equipment.

Professional and Legal Regulation of Nursing Practice

Every state has “nurse practice act” that protects the public define the legal scope. Violation of rule can result in disciplinary action. Credentia-ling is the ways in which professional competence is ensured and maintained. This can be maintained by following processes:

• Accreditation: Accreditation is the process in which authorized agencies provide certification of competency, authority, or credibility.

• Licensure: It is the procedure that determines the granting of a license, especially to carry out a trade or profession.

• Certification: It refers to the confirmation of certain characteristics of an object, person, or organization.

• Nursing standards: Standard is a benchmark of achievement which is based on a desired level of excellence. Standards of care (SOC) measure the degree of excellence in nursing care and describe a competent level of nursing care.

NURSING STANDARDS

Standards are professionally developed expressions of the range of acceptable variations from a norm or criterion. They reflect a desired and achievable level of performance against which actual performance can be compared. Their main purpose is to promote, guide and direct professional nursing practice (Table 26.1).

Table 26.1

Standards
Definition
Measurement criteria

1: Quality of practice
The registered nurse systematically enhances the quality and effectiveness of nursing practice.

1. Demonstrates quality by documenting the application of the nursing process in a responsible, accountable and ethical manner.

2. Uses quality improvement activities to initiate changes in nursing practice and health care delivery system.

3. Uses creativity and innovation to improve nursing care delivery.

4. Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not achieved.

5. Participates in quality improvement activities.

II: Education
The nurse attains knowledge and competency that reflects current nursing practice.

1. Participates in ongoing educational activities related to clinical knowledge and professional issues.

2. Demonstrates commitment to lifelong learning.

3. Seeks experiences to maintain clinical skills.

4. Seeks knowledge and skills appropriate to the practice setting.

5. Maintains professional records that provide evidence of competency and lifelong learning.

III: Professional practice evaluation
The nurse evaluates one’s own nursing practice in relation to professional practice standards and guideline, relevant statutes, rules and regulations.

1. Engage in self-evaluation on a regular basis.

2. Seeks constructive feedback regarding ones own practice.

3. Takes action to achieve goals identified during the evaluation process.

4. Participates in systematic peer review as appropriate.

5. Practice reflects knowledge of current practice standards, laws and regulations.

6. Provides age appropriate care in culturally and ethnically sensitive manner.

IV: Collegiality
The nurse interacts with and contributes to the professional development of peers and other health care providers as colleagues.

1. Shares knowledge and skills with peers and colleagues.

2. Provides peers with feedback regarding their practice.

3. Interacts with peers and colleagues.

4. To enhance ones own professional nursing practice.

5. Maintains compassionate and caring relationships with peers and colleagues.

6. Contributes to an environment that is conductive to clinical education nursing students as appropriate.

7. Contributes to a supportive and healthy work environment.

V: Collaboration
The nurse collaborates with patient, family, and others in the conduct of nursing practice.

1. Communicates with the patient, significant others, and health care providers regarding patient care and nursing’s role in the provision of care.

2. Collaborates with patient, family and other health care providers in the formulation of overall goals and the plan of care and in the decisions related to care and delivery of services.

3. Partners with others to effect change and generate positive outcomes.

4. Document referrals, including provisions for continuity of care, as needed.

VI: Ethics
The nurse integrates ethical provisions in all areas of practice.

1. Practice is guided by code of ethics for nurses with interpretive statement.

2. Maintains therapeutic and professional patient-nurse relationship.

3. Delivers care in the manner of that preserves patient autonomy, dignity and rights.

4. Seeks available resource in formulating ethical decisions.

5. Reports illegal, incompetent or impaired practice.

6. Maintain patient confidentiality’ within legal and regulatory parameters.

VII: Research
The nurse integrates research findings in practice.

1. Utilize best available evidence including research findings to guide practice decisions. Participates in research activities as appropriate to the nurse’s education and position such as the following:

2. Identifying clinical problems suitable for nursing research.

• Participating in data collection.

• Participating in a unit, organization, or community research committee.

• Sharing research activities with others conducting research.

• Critiquing research for application to practice.

• Uses research findings in the development of policies, procedures, and practice guidelines for patient care.

• Incorporates research as a basis for learning.

VIII: Resource utilization
The nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.

1. Evaluates factors related to safety7, effectiveness, availability and cost when practice options would result in the same expected patient outcome.

2. Assists the patient and family in identifying and securing appropriate and available services to address health related needs.

3. Assigns or delegates tasks as defined by the State Nurse Practice Acts and according to the knowledge and skills of the designated caregiver.

4. Assigns or delegates tasks based on the needs and condition of the patient, the potential for harm, the stability of the patients condition, the complexity of the task, and the predictability of the outcome.

5. Assists the patient and family in becoming informed consumers about the cost, risks, and benefits of treatment and care.

IX: Leadership
The nurse provides leadership in the professional practice setting and the profession.

1. Engages on team work.

2. Works to create and maintain healthy work environments.

3. Teaches others to succeed through mentoring.

4. Exhibits creativity and flexibility during change.

5. Directs coordination of care across settings and caregivers.

6. Serves in key roles in the work settings by participating on committees, councils, and administrative.

7. Promotes advancement of the profession.

8. Displays the ability to define a clear vision, the associated goals, and a plan to implement and measure progress.

9. Demonstrates energy, excitement and a passion for quality work.

10. Willingly accepts mistakes by self and others, thereby creating a culture in which risk-taking is not only safe, but expected.

Importance of Standards

• Outlines what the profession expects of its members.

• Promotes guides and directs professional nursing practice—important for self-assessment and evaluation of practice by employers, clients and other stakeholders.

• Provides nurses with a framework for developing competencies.

• Aids in developing a better understanding and respect for the various and complimentary roles that nurses have.

ANA Standards of Professional Performance

The ANA (American Nurses Association) Standards of professional performance describes a competent level of behavior in the professional role, including activities related to quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. This serves as objective guidelines for nurses to be accountable for their actions, their patients, and their peers. The standards provide a method to assure clients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measure to determine whether the care meets the standards.

In short, nursing standard says:

• Do no harm to patients.

• Respect people.

• Consider and treat everyone as a unique individual.

• Respect patient or caregiver’s participation determining what they need.

• Respect everyone’s human, civil, and legal rights.

• Do what is best for everyone under the circumstances.

• Don’t abuse your position or exploit a participant to gain a personal advantage.

• Don’t attempt an intervention in areas in which you’re not trained and/or competent.

• Actively strive to improve or correct, to the extent possible, the situations of participants in your program and the community.

ETHICAL ISSUES NEED TO BE CONSIDERED IN COMMUNITY INTERVENTIONS

Ethical behavior in community interventions relates to the treatment of people, information, and money, and to the general actions of the workers and the organization or initiative, even when they’re not dealing directly with the community. Maintenance of following ethical issues while carrying out nursing care in community is very important.

• Confidentiality: Probably the most important ethical issue is maintaining confidentiality of client’s information. It is the expectation that communications and information from participants in the course of a community intervention or program (including conversations, written or taped records, notes, test results, etc.) is kept confidential. It protects both participants and the organization from invasion of privacy, and establishes a bond of trust between the participant and the program. Depending upon the program, the staff member’s position, and the participant’s needs, confidentiality may encompass a range of possibilities. Like information is confidential within a program, but may be shared among staff members for purposes of consultation and delivering better services to the participant. Teachers in an adult literacy program, for instance, may confer about a student with a particular learning disability or problem. This type of sharing is consistent with the rules of the Family Educational Right to Privacy Act.

• Consent: There are really three faces of consent: program participants giving program staff consent to share their records or information with others for purposes of service provision; participants giving informed consent to submit to particular medical or other services, treatment, research, or program conditions; and community members consenting to the location or operation of an intervention in their neighborhood.

• Disclosure: Participants have a right to know about the program going to be conduct, or if they will be part of a research study if they enter the program. Disclosure to participants of the conditions of the program, in program policies of confidentiality and when it might be breached, what kinds of services are available and what kinds are not, any time limit on the program, whether it will cost anything, etc. Some organizations or individuals put these disclosures in writing, and make sure that every participant has a copy and that he understands what’s written on it.

• Competence: Competence means more than simply having the appropriate training and experience. A competent organization hires competent staff members, provides supervision and staff development, and does everything it can to assure that the services it offers are the best available. By offering services of any kind, an organization is essentially making a contract with participants to do the job it says it will do. Participants and the community have a right to expect that the program knows what it’s doing and will make its best faith effort to provide effective services. That means that community services need to be offered by folks who are competent at what they do.

• Conflict of interest: A conflict of interest is a situation in which someone’s personal (financial, political, professional, social, sexual, family, etc.) interests could influence his judgment or actions in a financial or other decision, in carrying out his job, or in his relationships with participants. In community interventions, conflicts of interest may change to the community’s disadvantage or how a program is run or how its money is spent. Conflicts of interest are virtually always unethical, to the point where the mere appearance of a conflict needs to be avoided.

General Ethical Responsibilities

Ethical behavior for a community intervention means actively striving to do what is right for participants and for the community, and treating everyone of participants, staff members, funders and the community at large.

• Responsibility to funders: Organizers of community program are responsible for being fiscally accountable, for using funds properly, and for trying to do what they promised to do when took the money.

• Responsibility to staff members: Organizers of community program are responsible for making sure everyone is treated fairly in all dealings with the program; that everyone is paid for the work she does; that everyone has a reasonable amount of control over her job; and that everyone has the opportunity to continue to develop her skills and effectiveness through staff development and/or supervision. Organizers are also responsible for protecting staff from harm to the extent possible, and for warning and training them if some physical or other danger is part of their jobs.

• Responsibility to participants: Organizers of community program are responsible to provide the best and most effective services possible. This means constantly searching for better methods and ideas; paying attention to participant feedback; building on program successes; and acknowledging, learning from, and correcting program weaknesses. They are also responsible for respecting participants’ rights, and for treating all with the respect due them, not only as program participants, but also as human beings.

• Responsibility to the community: Organizers of community program are responsible for trying to understand and meet the needs of the community; for being responsive to community attitudes and opinions; and trying through intervention, to improve the quality of life in some way for both program participants and the community as a whole.

It usually makes both ethical and practical sense to involve the target population and/or the community in planning a community program.

Importance of Ethical Behavior in Community Interventions

By doing right thing, always ethically brings some particular advantages with it. It makes community program more effective; it secures field worker’s stand in the community; it allows to occupy the moral high ground when arguing the merits of program, and to exercise moral leadership in the community.

• Program effectiveness. Consistent ethical behavior can lead to a more effective program. Considering ethical principles in all aspects of a community intervention leads to find the most effective and community-centered methods, and brings extra benefit in participation, community support and funding possibilities.

• Standing in the community. An organization that has a reputation for ethical action is far more likely to be respected by both participants and the community as a whole than one that has been known to be unethical in the past. An organization that’s recognized as ethical is also apt to be seen as competent, and to be trusted to treat people with respect and to do what it says it will do. That community trust makes it easier to work with community people and to get their cooperation.

• Moral credibility and leadership. Ethical action reflects why community intervention is started. Organizers have a moral obligation to self, the individuals work with them, and the community to be ethical in all they do, and to expect the same from others. If they fulfill that obligation, and everyone knows it, community health personnel voice will have greater impact when they speak out for what they believe is right, or against what they believe is wrong, and others follow them.

• Professional and legal issues. Many of the health and human service professions often involved in community interventions which are held to specific codes of ethics by their professional certification or licensure organizations. If members of the profession violate these standards, they can be disciplined, or even lose their licenses to practice.

Bibliography

1. Guliani KK (2005). Community Health Nursing. 1st ed. Kumar Publication: Delhi. p34–37.

2. Kamalam S (2012). Essentials in Community Health Practice. 2nd ed. Jaypee Brothers Publications: New Delhi. p615–629.

3. Qement I (2009). Basic Concepts of Community Health Nursing. 1st ed. Jaypee Publishers: New Delhi. p10–ll.

4. Ethical Issues in Community Interventions. [Internet] Cited on 9/9/2015. Available on: http://ctb.ku.edu/en/table-of-contents/analyze/choose-and-adapt-community-interventions/ethical-issues/main].

5. Tomey AM (2004). Guide to Nursing Mangement and Leadership. 7th ed. Mosby: USA. p467.

27

Community Health Nursing Theories and Models

This chapter contains

▪ Definition

▪ Nursing Process: Feedback System Model

▪ Application of Model in the Nursing Process

▪ Theories and Models for Community Health Nursing

• Maslow’s Hierarchy of Needs Model

• Kalish’s Expanded Hierarchy Model

• General System/Open System Theory

• Nightingale’s Theory of Environment

• Milio’s Framework of Prevention

• Leavell and Clark’s Prevention Model

• Ardell’s Wellness Model

• Travis’ Illness/Wellness Model

• Self-efficacy Model

• MATCH Model

• Rosenstock’s Health Believe Model

• Canadian Model

• Holistic Nursing Model

INTRODUCTION

Theory is referred to the content covered in classroom or someone’s hunches or ideas. Theory almost always connoted an abstraction or generalization.

DEFINITION

A theory is “a set of interrelated constructs (concepts adapted for a scientific purpose), definitions and prepositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena.”

—Kerlinger 1986

A theory has to be applied in nursing process to provide necessary care to individual client/family or community as a whole. Community health nurse judges and considers which model is appropriate to apply in nursing process for the particular client/family or community.

Nursing Process: Feedback System Model

Nursing process is a deliberate activity where the practice of nursing is performed in a systematic manner. Throughout the nursing process, the nurse uses a comprehensive knowledge base to assess the client’s health status, to make judicious judgments and diagnosis, and to plan, implement, and evaluate appropriate nursing actions. As the core of nursing practice, the nursing process provides the structure for nursing care.

Fig. 27.1: Nursing process: Feedback system model (by PJ Christensen).

Description of nursing process component: (ref. Chapter 7)

1. Assessment

2. Nursing diagnosis

3. Planning

4. Implementation

5. Evaluation

APPLICATION OF MODEL IN THE NURSING PROCESS

Nursing models provide a broad framework to interrelate various aspects of the client’s complex health situation. Professional nursing practice is based on knowledge and understanding of various theories, models and principles from the scientific, behavioral and humanistic disciplines. As individual, family and community clients have unique health situations, the nurse uses her broad knowledge base to select the model that is most congruent with the client’s health situation.

The major nursing models each are based on different assumptions and have a unique way of describing four major concepts, i.e. client, nursing, health and environment and their relationships.

While working with a new client, nurse gathers all information regarding her/him, client’s family and about the community he/she belongs. Then nurse synthesizes the information through preceding questions (what, when, how, etc.) along with a broad knowledge base, intuition and experience and constructs a theoretical perspective of the client situation. This perspective serves to:

1. Direct and prioritize further inquiry

2. Organize data into patterns

3. Identify appropriate health concerns

4. Determine which nursing model is most congruent with the nurse’s beliefs and the client situation.

Next, the nurse considers the possible model, their underlying assumptions, concept definitions and the relationships among the concepts. The models are examined to determine acceptance by the nurse and their appropriateness to the client as each model is different. Some models describe nursing as providing assistance, whereas others facilitate the client’s self-care. The nurse examines each model by asking the following questions:

1. What are the major concepts of the model and how are they defined?

2. What are the relationships among the concepts?

3. What is the focus of the model?

4. What are the underlying assumptions of the model?

5. Will the model direct a plan of action that is appropriate for the client’s health status?

The nurse should have a thorough knowledge of each model to respond to those five questions and should be able to compare the client’s health situation with each model. Practice in applying models come with clinical experience.

The chosen model has a major influence on nursing practice and each component of the nursing process. Data collection is guided by the major concepts and subconcepts in the model. Model also can be used to analyze and categorize data; as well it serves as the basis of planning and implementation. Evaluation of the client’s progress is based on the established goals and objectives, which were derived from the chosen model.

THEORIES AND MODELS FOR COMMUNITY HEALTH NURSING

A. Maslow’s Hierarchy of Needs Model

A. Maslow’s hierarchy of needs: Maslow’s hierarchy of needs is a theory in psychology proposed by Abraham Maslow in his 1943 paper “A Theory of Human Motivation” in Psychological Review. Maslow’s hierarchy of needs is often portrayed in the shape of a pyramid with the largest, most fundamental levels of needs at the bottom and the need for self-actualization at the top.

• Physiological needs: Physiological needs are the physical requirements for human survival which should be met first. If these requirements are not met, the human body cannot function properly and ultimately fails, e.g. air, water, food, clothing and shelter.

• Safety needs: Safety and security needs include personal security, financial security, health and well-being, safety net against accidents/illness and their adverse impacts.

• Love and belonging: After physiological and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of belongingness such as friendship, intimacy and family.

• Esteem: All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Esteem presents the typical human desire to be accepted and valued by others. Low self-esteem or an inferiority complex may result from imbalances during this level in the hierarchy.

• Self-actualization: This level of need refers to what a person’s full potential is and the realization of that potential. Maslow describes this level as the desire to accomplish everything that one can, to become the most that one can be. Individuals may perceive or focus on this need very specifically. Maslow believed that to understand this level of need, the person must not only achieve the previous needs, but master them.

Fig. 27.2: Maslow’s hierarchy of needs model

B. Kalish’s Expanded Hierarchy Model

In an expansion of Maslow’s model, Kalish restructured the first two levels of Maslow’s pyramid into three levels and identified more specific subcategories.

The base level is labeled “survival”, the second level “stimulation” and the third level “safety”. The refinement of these subcategories can further assist the nurse to identify the priorities for planning patient care.

General System/Open System Theory

This theory serves a model for viewing a man as interacting with the environment. It was developed by Ludwig von Bertalanffy (1968). A system consists of a set of interacting components within a boundary that filters the type and rate of exchange with the environment. Systems are composed of both structural and functional components. Structure refers to the arrangements of the parts at a given time; function is the process of continuous change in the system as matter, energy and information exchanged within the environment. All living systems are open in that; thus there is continuous exchange of matter, energy and information.

Fig. 27.3: Kalish’s expanded hierarchy model

Fig. 27.4: Open system model

• Input: Energy, matter, information (feedback).

• Throughput/process: Assessment, diagnosis, planning, implementation, evaluation.

• Output: Energy, matter, information.

Matter is the substance that occupies space and can be exchanged between the system and environment. Energy is considered as the ability to perform, carry out tasks and overcome resistance in a physical and emotional sense. Information is exchanged in form of verbal and behavioral communication, visual media, taste, smell and touch. Information is used by the system in the process of selection and decision making.

Nightingale’s Theory of Environment

Florence Nightingale (1820–1910), considered the founder of educated and scientific nursing and is considered the first nursing theorist. One of her theories is the Environmental Theory, which incorporated the restoration of the usual health status of the nurse’s clients into the delivery of health care.

According to her, external influences and conditions can prevent, suppress, or contribute to disease or death. Her goal was to help the patient retain his own vitality by meeting his basic needs through control of the environment. She explained about three types of environment, i.e. physical, psychological and social environments. Physical environment consists of physical elements where the patient is being treated. It affects all other aspects of the environment. Cleanliness of environment relates directly to disease prevention and patient mortality. Aspects of the physical environment influence the social and psychological environments of the person. Psychological environment can be affected by a negative physical environment which then causes stress. It requires various activities to keep the mind active like communication with the person, about the person, and about other people. Social environment includes components of the physical environment as clean air, clean water, and proper drainage. It consists of a person’s home or hospital room, as well as the total community.

Fig. 27.5: Nightingale’s environment model

Her observations suggested that diseases are more prevalent in poor environments and that could be promoted by providing adequate ventilation, pure water, warmth, light and cleanliness.The ten major concepts of the Environment Theory, also identified as Nightingale’s Canons, are:

1. Ventilation and warming

2. Light and noise

3. Cleanliness of the area

4. Health of houses

5. Bed and bedding

6. Personal cleanliness

7. Variety

8. Offering hope and advice

9. Food

10. Observation

Framework of Prevention

A. Milio’s framework of prevention: Nancy Milio a nurse and leader in public health policy and public health education developed a framework for prevention that includes concepts of community-oriented, population focused care. The basic treatise is that behavioral patterns of population and individuals who make up population are a result of habitual selection from limited choices. She challenged the common notion that a main determinant for unhealthful behavioral choice is lack of knowledge. Governmental and institutional policies, she said set the range of options for personal choice making. It neglected the role of community health nursing, examining the determinants of community health and attempting to influence those determinants through public policy.

B. Leavell and Clark’s prevention model: The terms primary, secondary and tertiary prevention are first documented in the late 1940s by Hugh Leavell and E Guerney Clark from the Harvard and Columbia University Schools of Public Health, respectively.

Primary prevention: Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening. Primary prevention strategies emphasize general health promotion, risk factor reduction, and other health protective measures. These strategies include health education and health promotion programs designed to foster healthier lifestyles and environmental health programs designed to improve environmental quality.

Secondary prevention: Secondary prevention focuses on individuals who are experience health problems or illness and who are at risk of developing complication or worsening conditions. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the client to return to normal. Its purpose is to cure disease, slow its progression, or reduce its impact on individuals or communities.

Tertiary prevention: Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions direct at preventing complications and deteriorations. Tertiary prevention strategies are both therapeutic and rehabilitative measures once disease is firmly established.

Ardell’s Wellness Model

Donald B Ardell has been one of the leading figures in the wellness movement for four decades. Ardell outlined five dimensions of wellness that need to be considered by practitioners in the development of wellness approaches and programs. These are selfresponsibility, nutritional awareness, stress management, physical fitness and environmental sensitivity. Self-responsibility is depicted as the center of the other dimensions. It is crucial to the development and implementation of well-related behavior in the other four spheres.

Fig. 27.6: Level of prevention model

Fig. 27.7: Ardell’s wellness model

Travis’ Illness/Wellness Model

The Illness-Wellness Continuum is a graphic illustration of a well-being concept first proposed by John W Travis in 1972. It illustrates the relationship of the treatment paradigm to the wellness paradigm. An individual can move beyond the “neutral” point to increasingly higher levels of wellness. Moving from the center to the left shows a progressively worsening state of health.

The Illness-Wellness Continuum proposes that individuals can move further to the right, towards health and well-being, through awareness, education, and growth. Conversely, worsening states of health are reflected by signs, symptoms, and disability. In addition, a person’s outlook plays a major role moving along the Continuum in either direction. A positive outlook enhances the individual’s health and well-being, while a negative outlook hinders it, independent of present health status.

Self-efficacy Model

Self-efficacy theory is originated from Social Cognitive theory by Alberta Bendura and is modified by Desmond and Price, 1988. Self-efficacy is the belief that one has the power to produce that effect by completing a given task or activity related to that competency. Self-efficacy relates to a person’s perception of their ability to reach a goal. It is the belief that one is capable of performing in a certain manner to attain certain goals. It is the expectation that one can master a situation, and produce a positive outcome. Self-efficacy is an important concept in positive psychology. Bandura’s Social Cognitive Model says that there are 3 factors that influence self-efficacy, i.e. ability to perform a specific health related behaviors, environment, and personal/cognitive factors. They all affect each other, but the cognitive factors are important.

Fig. 27.8: Travis’ illness/wellness model

Fig. 27.9: Self-efficacy model modified by Desmond and Price

Efficacy expectations vary in magnitude, generality and strength, which combined affect performance. Magnitude involves the difficulty level of the task and person’s believe regarding ability to perform them. Generality refers to individual’s perception of whether the expected behavior relates to only one specific situation or to a variety of situations. Strength of efficacy expectation relates to the individual’s determination of belief in the ability to perform the health related behavior.

MATCH Model

MATCH (Multilevel Approach Towards Community Health) is proposed by Simons-Morton and colleagues, 1988. This model deals with the wellness and health promotion from a personal and family perspective. MATCH model conceptualizes intervention directed at individual, organizational and governmental levels.

Fig. 27.10: MATCH model

Individual health is affected through personal behaviors, whereas organizations affect the health of their members through policies and practices. A government affects health of people by public action and legislation.

MATCH model has four phases

• Phase I consists of selection of health goals for the target population.

• Phase II plans appropriate interventions to achieve health goals in the target population through environmental and personal changes.

• Phase II involves several steps as development and implementation of the interventions selected in Ilnd phase.

• Phase IV evaluates the achievement of health goals and intervention objectives from phases I and II.

Rosenstock’s Health Believe Model

The Health Believe Model (HBM) is one of the first theories of health behavior developed by Rosenstock and colleagues, 1977. The health belief model proposes that a person’s health-related behavior depends on the person’s perception of four critical areas:

• the severity of a potential illness

• the person’s susceptibility to that illness

• the benefits of taking a preventive action

• the barriers to taking that action.

HBM is a popular model applied in community health nursing, especially in issues focusing on client compliance and preventive health care practices.

• Perceived susceptibility—refers to a person’s perception that a health problem is personally relevant or that a diagnosis of illness is accurate.

• Perceived severity—even when one recognizes personal susceptibility, action does not occur unless the individual perceives the severity to be high enough to have serious organic or social complications.

Fig. 27.11: Rosenstock’s health believe model

• Perceived benefits—refers to the patient’s belief that a given treatment cures the illness or helps to prevent it.

• Perceived costs—refers to the complexity, duration, and accessibility of the treatment.

• Motivation—includes the desire to comply with a treatment and the belief that people should do what.

• Modifying factors — include personality variables, patient satisfaction, and socio-demographic factors.

Canadian Model

The community health nurse works with individuals, families, groups, communities, populations, systems and/or society, but at all times the health of the person or community is the focus and motivation from which nursing actions flow. The standards of practice are applied to practice in all settings where people live, work, learn, worship and play.

The community health nursing process involves the traditional nursing process components of assessment, planning, intervention and evaluation but is enhanced by community health nurses in three dimensions:

• Individual/community participation in each component.

• Multiple ways of knowing, each of which is necessary to understand the complexity and diversity of nursing in the community; knowledge and utilization of all these ways of knowing forms evidence-based practice consistent with these standards.

• The inherent influence of the broader environment on the individual/community that is the focus of care (e.g. the community is affected by provincial/territorial policies, its own economic status and by the actions of its individual citizens). The standards of practice are founded on the values and beliefs of community health nurses, and utilization of the community health nursing process.

The model illustrates the dynamic nature of community health nursing practice, embracing the present and projecting into the future. The values and beliefs (green or shaded) ground practice in the present yet guide the evolution of community health nursing practice over time. The community health nursing process provides the vehicle through which community health nurses work with people, and supports practice that exemplifies the standards of community health nursing.

Holistic Nursing Model

Another wellness model reflects the holistic nursing perspective (Blattner 1981). This model has many interlocking circles, halfcircles and eclipses that show the relationships and connectedness of the systems and their relationships to the holistic nursing process.

Central to the figure are three circles that represent nurturing, generative and preventive nursing interventions. The nine areas that require processing to achieve wellness are selfresponsibility, caring, stress, lifestyle, human development, problem-solving, communication, teaching-learning, leadership and change. Superimposed on these areas are the interpersonal, intrapersonal and community systems.

Fig. 27.12: Holistic nursing model

Intrapersonal encompasses the nurse/client relationship, interpersonal relationship involves groups such as families and community denotes organizations or persons with common interests. High level wellness is achieved through the nine life processes within these three systems.

There are many well-known models which are used in nursing practice so frequently. These are:

• Agent host environment model

• Pender’s health promotion model

• Orem’s self care model

• Neuman’s health care system model

• Roger’s model of the science and unitary man

• Roy’s adaptation model

Bibliography

1. Allende JA, Spradley BW. Community Health Nursing Concepts and Practice. 5th ed. Lippincott: Philadelphia; 2001.

2. Christensen PJ, Kenney JW. Nursing Process. Mosby: Baltimore; 1990.

3. Craven RF, Hirnle CJ. Fundamentals of Nursing Human Health and Functions. 5th ed. Lippincott: Philadelphia; 2007.

4. Taylor C, Lillis C, Lemone P. Fundamentals of Nursing, the Art and Science of Nursing Care. 5th ed. Lippincott: New Delhi; 2006.

5. Potter PA, Perry AG. Fundamentals of Nursing. 6th ed. Mosby: New Delhi; 2005.

6. Black JM, Hawks JH. Medical Surgical Nursing: Clinical Management for Positive Outcome. 7th ed. Saunders: New Delhi; 2005.

7. Levels of Prevention. January 29,2013. (Available from: http://gwxy.sysu.edu.cn/lxbx/englishepide-miologic%20knowledge/Selected%20Disease%20Concepts%20in%20Epidemiology/Level.html).

8. Davidson, Winston. “Priciples of Prevention: The Four Stages Theory of Prevention”. Academia. Edu. January 29, 2013. (Available from: <http://www.academia.edu/894962/).

Section

II

Observe-Practice-Do

1. Bag Technique

2. Procedures

28

Bag Technique

This chapter contains

▪ Meaning of Bag Technique and Community Bag

▪ Purposes

▪ Principles of Bag Technique

▪ Community Bag Articles

▪ Procedure/Steps of Bag Technique

▪ Aftercare of Articles

INTRODUCTION

A community health nurse has to carry out some tests and procedures while home visiting. The nurse’s bag is a vehicle for carrying the equipment and supplies needed during home visiting to carry out those procedures.

Meaning

Bag technique is the process of performing nursing procedures with ease and skill, saving time and effort to render effective nursing care by using community bag during his/her home visit.

Community bag/Public health bag: Every skilled professional worker needs tools. Community bag is an essential and indispensable equipment/vehicle of the community health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles which are necessary for giving care.

Purpose of the Bag

1. To render effective nursing care to clients and/or members of the family during home visit.

2. To take basic health measurement (physical assessment)

3. To offer basic first aid and simple treatment.

4. To demonstrate promotive aspect of health care.

5. To carry out nursing procedures in home setting.

Principles of Bag Technique

• Maintain cleanliness

– The bag and its contents are must be designed for efficiency and cleanliness.

– The bag and its contents must be kept clean and ready for use at all times.

– Hands must be washed with soap and water each time before touching the bag.

– Follow aseptic and decontamination technique to prevent spread of diseases.

– Must avoid touching dirty or contaminated things between the time of washing hands and handling bag equipment.

– Protect the bag from children, animals and soil.

– Soiled or contaminated articles should be washed and disinfected before placing them back inside the bag.

• Use local resources as much as possible.

• Teach and demonstrated the procedure to responsible family member for more effective teaching.

• Provide privacy and consider comfort to patient and family members.

• Maintain professional relationship.

Community Bag Articles

1. Community bag: To carry the articles needed to test urine.

2. Articles in outer pocket

• Handwashing article—soap dish with soap and towel

• Paper bag—to dispose waste

• Paper pieces (3)

– big one to keep the bag

– half one to make the area for testing urine

– one fourth to make handwashing area

• Paper/diary and pen/pencil, rubber—to record procedure with result

• Apron

• Gloves

Fig. 28.1

3. Articles in the inner-outer compartment

• Urine kit

• Kidney tray

• Candle with stand (1 each)—to warm the test tube

• Test tube 1—to test urine

• Test tube holder—to hold test tube

• Specimen bottle—to collect urine

• Swab stick (6)—to clean test tube and specimen bottle

• Rag pieces (2)—to wipe the outside of the test tube before heating

• Dropper (2)—one to take urine while sugar test

Another to take acetic acid while testing albumin

• Measuring cup—to measure Benedict’s solution

• Match box (1)—to light the candle

4. Articles in inner pocket

• Spirit—to clean thermometer

• Benedict’s solution—to test urine for sugar

• Acetic acid solution—to test urine for albumin

• Betadine and normal saline—to do wound dressing

• Thermometer—to check temperature

• Cotton swab—needed while checking temperature

• Cotton strip—to sterilize thermometer after using

• Dressing set—to do wound dressing

5. Side pockets

Medications and syringes

6. Articles should be carried separately

Physical assessment articles

• Weighing machine

• Measuring tape

• Sphygmomanometer

• Stethoscope

• Fetoscope, etc.

Table 28.1: Procedure/steps of bag technique

Actions
Rationale

1. Upon arriving at the client’s home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put the bag’s handles or strap beneath the bag.

To protect the bag from contamination.

2. Select appropriate place for handwashing nearby water source. Ask for a bucket full of water or mug outside of working area, if water tap is not available.

To protect the workfield from being wet.

3. Unbutton the bag before going for handwashing.

To avoid touching of outside of the bag (inside of the bag is considered as more clean than outside) after handwashed.

4. Take out a 1/4th piece of newspaper/plastic piece, hand towel, soap dish and soap; place them at near handwashing area.

To prepare the area for handwashing.

5. Do handwashing. Wipe, dry with towel.

Handwashing prevents possible infection from one care provider to the client.

6. Touch the inner part of the bag cover while opening the bag.

Inside part is considered more clean than the outside.

7. Put out things most needed for the specific case and place on the corner of the work area.

To make them readily accessible.

8. Place waste paper bag outside of work area.

To prevent contamination of clean area.

9. Cover the bag.

Overexposure of bag leads to more contamination of its content.

10. Proceed to the specific nursing care or treatment.

To meet client’s need.

11. After completing nursing care or treatment, wash and clean the things used, discard paper bag and its waste.

To keep equipment ready for further use.

12. Do handwashing again.

Handwashing reduces the dirt and microorganism thus prevents contamination.

13. Open the bag and put back all articles including handwashing articles in their proper places.

To keep bag readv for further use.

14. Make post-visit conference on matters relevant to health care, taking anecdotal notes pre?>aratory to final reporting.

To be used as reference for future visit.

15. Make appointment for the next visit, taking note of the date, time and purpose.

For follow-up care.

Aftercare of Articles

Wash and clean all articles after using before putting in the bag. Need to boil or autoclave articles which have been used for any infected area. After drying the article, put those in the bag. Replace the articles which have been finished or used while doing the procedure as solutions, cotton swabs, gauze pieces, etc.

Check the bag daily, wash hands before opening it and make necessary replacement. The bag should be washed regularly with soap and water and dry it on the sun. After drying, the bag should be reequipped with articles, drugs or sterile dressing and linen.

Bibliography

1. A Community Health Nursing Manual-TNAI. Noida: Academy Press; 2002.

2. Bag Technique in Nursing [Internet] [cited 2014 Sep 30], Available from: http://nurseslabs.com/home-visits-bag-technique/

3. Blumenfeld H. Romberg Test [Internet] [cited 2014 Sep 11]. Available from: http://www.neuroexam.com/neuroexam/content.php?p=37.

4. Community Health Nursing: Bag Technique [Internet] 2008 June 12 [cited 2014 July 21]. Available from: http://nursingcrib.com/nursing-notes-reviewer/community-health-nursing/bag-technique/

5. Edema Grading. [Internet] [updated 2014 Nov 27; cited 2014 Nov 28]. Available from: http://www.med-health.net/Edema-Grading.html.

6. Hand Hygiene: Why, How and When? [Internet] [cited 2014 Sep 23]. Available from: http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf.

7. How to Perform A Quick Nursing Health Assessment [Internet] [cited 2014 Aug 14]. Available from: http://www.ehow.com/how_5957163_perform-quick-nursing-health-assessment.html.

8. Kamalam S. Essentials in Community Health Nursing Practice. New Delhi: Jaypee Brothers; 2005.

9. Khasnis A, Gokula RM (1st April, 2003). “Romberg’s Test”. Journal of Postgraduate Medicine, 49 (2): 169–72. PMID 12867698.

10. Mayo Dowst L. This focus on the hygiene appointment centers on the patient introduction and chief complaint, vitals, radiographs, intraoral cameras, and caries detection [Internet] [cited 2014 Oct 22]. Available frorm. http://www.rdhmag.com/articles/print/volume-33/issue-12/features/breaking-it-down.html.

11. Nurses labs: Bag Technique in Nursing [Internet] 2014 [cited 2014 June 14]. Available from: http://nurseslabs.com/home-visits-bag-technique.

12. Snake Bites, http://www.healthline.com/health/snake-bites#FirstAid7.

13. Snake Bites: First aid. http://www.mayo-clinic.org/first-aid/first-aid-snake-bites/basics/art-20056681.

14. Standing Orders. [Internet] [Updated 2009; cited 2015 Jan 2]. Available from: http://medicaldictionary.thefreedictionary.com/standing+orders.

29

Procedures

This chapter contains

▪ Handwashing

▪ Vital Signs:(IPH and BP Monitoring)

▪ Quick Physical Assessment

▪ Urine Test for Sugar and Albumin

▪ Hemoglobin Testing

▪ Wound Dressing

▪ Oral Medication

▪ Injection Procedure

▪ Scabies Treatment

▪ Standing Order

HANDWASHING

Thousands of people die every day around the world from infections acquired while receiving health care. Hands are the main pathways of germ transmission during health care. Hand hygiene is, therefore, the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections. Handwashing is a vigorous brief rubbing together of all surface of hand, lathered in soap, followed by rinsing under a stream of water.

Objectives

• To remove dirt and transient microorganisms from the hand

• To reduce total microbial count over time

• To prevent cross-infection

Articles

1. An area with supply of clean water (either tap or bucket of water and mug): To wash hand.

2. Community bag: To carry all handwashing articles.

a. One-fourth piece of newspaper or small piece of plastic: To keep handwashing articles which prevent contamination of article from soil.

b. Soap: To wash hand

c. Soap dish: To carry soap

d. Hand towel: To dry hand after washing

e. Nail brush: If surgical handwashing is needed then to clean inside the nails.

f. Paper bag: To throw waste (e.g. if any banded or leucoplast on hand, etc.).

Fig. 29.1

Table 29.1: Procedure

Nursing action
Rationale

1. Place the bag in proper place.

1. Prevents contamination of bag.

2. Remove wrist watch or any jewelry in hand and keep in a safe place.

2. Prevents spread of infection.

3. Take out newspaper/plastic sheet, soap in soap dish and hand towel.

3. Arranging all articles needed for the procedure saves time and energy.

4. Select a place where water will drain off. Either use the area where home people wash their hands or arrange it outside with a bucket of water and mug.

4. Stagnating of water promotes breeding of flies and insects.

5. Moisten hand with water and apply soap well.

5. To make a good amount of soap leather.

6. Do the following steps:

i. Rub hands palm to palm (step 1).

ii. Rub right palm over left dorsum with interfaced fingers and vice versa (step 2).

iii. Rub palm to palm with fingers interlaced (step 3).

iv. Rub backs of fingers to opposing palms with fingers interlocked (step 4).

v. Rub left thumb in rotation by grabbed in right palm and vice versa (step 5).

vi. Rub in rotation, backward and forward with clasped fingers of right hand in left palm and vice versa (step 6).

vii. Rub wrist of both hands (step 7).

6. Friction of hands with action of soap cleans the hand and destroys microorganisms.

7. Don’t go towards fingers again once reached the wrist.

7. Wrist is considered dirty than the fingers. Cleaning should always be done from most clean area towards the dirty area.

8. Repeat each step for 5 times.

8. Repetition removes dirt and microorganism properly.

9. Scrub for 2–3 minutes with nail brush (if surgical procedure or delivery to be conducted).

9. For surgical procedure or deliver)’ more asepsis technique has to be maintained.

10. Wash soap off with flowing water and holds hands up to prevent water running from elbow to hand.

10. Water should flow from more clean area to less clean area.

11. Pat dry hand using hand towel and place it on the paper or hang it if possible.

11. Moist hand is the vehicle of microbes.

12. Replace articles.

12. Easy to reuse without wasting time when needed again.

Steps of Handwashing

Fig. 29.2

Aftercare of articles

Replace all articles in bag and close the bag. Discard the paper and paper bag if dirty otherwise those can be reused.

VITAL SIGNS

The temperature, pulse, respiration and blood pressure are called vital signs. In a normal healthy individual they remain constant. They are called “vital signs” because these findings are governed by vital organs and any significant variance of those indicate insufficient consumption of oxygen, blood depletion, electrolyte imbalance, bacterial invasion and other problems.

• Normal body temperature: 98.6°F or 37°C.

• Normal pulse rate: 72 beats/minute in adults.

• Normal respiration: 16 breaths/minute in adults.

• Normal blood pressure: 120/80 mm of Hg in adults.

Objectives

1. To establish baseline information

2. To assess for any infection

3. Identifying any abnormality from a person’s normal state

4. To establish required treatment

5. To diagnose the abnormalities of heart

TPR MONITORING

Taking of TPR (temperature, pulse and respiration) is of utmost importance because it can indicate a client’s health status.

Articles

• Community bag contains:

– Handwashing articles: To prevent crossinfection

– Spirit: To disinfect thermometer before use

Fig. 29.3

– Thermometer: To check temperature.

– Cotton swabs: To clean the thermometer

– Paper bag/kidney tray: To throw waste

– Wrist watch with second hand: To maintain required time for checking TPR.

– Pen: To record temperature, pulse am respiration

– Cotton strip: Use to disinfect thermomete after use.

Procedure

The common sites for taking temperatur are:

1. Oral: In community, take oral temperatur if the family has their own thermomete] Take temperature under the tongue fo complete one minute.

2. Axillary: Best method to check TPR ii community. Take 3–5 minutes for checkin; temperature. Within that time, use on minute for counting pulse, one minute fo counting respiration.

3. Groin: Best for neonate and infant.

Table 29.2

Nursing action
Rationale

1. Explain the procedure to the patient (in case of oral method ensure that patient had not taken any hot or cold food and fluid orally or smoked in 15–30 minutes prior to procedures).

1. Encourage client for cooperation. (causes alteration in temperature reading.)

2. Unbutton the bag and take out hand washing articles, pen and diary.

2. Once hand is washed, nurse is not supposed to touch the outer part of the bag.

3. Remove your watch/jewelry on working area and go to wash hands.

3. Prevents cross-infection.

4. Prepare articles needed to check TPR (first take out spirit as it is in most clean compartment of the bag, then remove other articles).

4. Arranging articles prior procedure helps to do the procedure in organized way. Always touch cleanest area than the less clean area to prevent contamination.

5. Take a dry cotton swab and wipe themometer in rotator motion from bulb to stem. Don’t discard it. Keep the swab in hand.

5. Wiping from an area of least contamination to more contamination area prevents spread of organisms.

6. Shake down the mercury below 35°C (95°F).

6. Reduce chances of error in reading temperature.

7. Tell client to wipe her/his axilla by using their own towel or cloth.

7. Presence of sweat alters the temperature.

8. Place thermometer in place and keep it for the time needed. Also check pulse and respiration for complete one minute each.

8. Keeping for specific time gives accurate reading.

9. Remove thermometer and wipe using the same cotton swab from stem to bulb in a rotator manner.

9. Clean up dirt of thermometer which came from client (oral/axilla/groin) before checking the reading.

10. Read the temperature holding thermometer at eye level and rotate it till reading is visible and read it accurately. Check the temperature rate. Ensure accurate recording.

10. Holding at eye level prevents error in reading.

11. Shake down the thermometer level.

11. To down the mercury level for reuse.

12. Take the cotton strip and thermometer to the washing area. Clean thermometer using plain water.

12. Removes organic material.

13. Wet long cotton strip in plain water and rub soap on it make leather. Wrap the thermometer in it and leave for 15–20 minutes.

13. To disinfect the thermometer.

14. In this time record the findings in a piece of paper and write client’s name, age, time, TPR reading and any measure done along with your sign and designation.

14. Recoding will prevent duplication of the procedure and will be helpful document for other health workers for further treatment.

15. Give medications or tepid sponge if temperature more than 101°F Refer to health centre if needed. (high temperature/gasping or labored respiration/galloping pulse rate, etc.)

15. This prevents further complication.

16. Clean the thermometer in plain water and discard the cotton strip.

16. To remove the soap along with microorganism.

17. Bring thermometer in working area. Dry with by wiping with a dry cotton swab from bulb to stem.

17. Wet article is the habitat of microbes.

18. Take another cotton swab and soak it in spirit. Clean the thermometer with this from bulb to stem.

18. To disinfect the thermometer finally.

19. Keep the thermometer in case.

19. Easv to reuse.

Fig. 29.4

Normal pulse rates

Age | Beats per min (8 pm)
In Utero | 150
Birth | 130
2nd year | 105
4th year | 90
10th year | 70
Age ranges | Beats per min ranges (8 pm)
Infant | 120–160
School age | 75–100
Adults | 60–100 (80 is average), sightly higher for women

Normal respiratory rates

Adults | 14-20 slightly higher for women
1 year old | 30
2 year old | 25
8 year old | 20
15 year old | 18

Aftercare of Articles

Keep all articles in bag. Replace cotton swab, cotton strip, paper bag in community bag, which is used during procedure.

BP MONITORING

Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, “blood pressure” usually refers to the arterial pressure of the systemic circulation, usually measured at a person’s upper arm. A person’s blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure and is measured in millimeters of mercury (mm of Hg). Normal resting blood pressure for an adult is approximately 120/80 mmHg.

Articles

• Community bag contains:

– Hand -washing articles: To prevent crossinfection

– Sphygmomanometer: To monitor blood pressure

– Stethoscope: To auscult systolic and diastolic sounds

– Pen and diary: To record findings and management

– Paper bag!kidney fray: To dispose any waste

| Systolic | Diastolic
Normal | < 120 | <80
Prehypertension | 120–139 | 80–89
Stage 1 hypertension | 140–159 | 90–99
Stage 2 hypertension | ≥160 | ≥ 100

Fig. 29.5

Table 29.3: Procedure

Nursing action
Rationale

1. Explain the procedure to the patient.

1. Encourage client for cooperation.

2. Unbutton the bag and take out hand washing articles, pen and diary.

2. Once hand is washed, nurse is not supposed to touch the outer part of the bag.

3. Remove your watch/jewelry on working area and go to wash hands.

3. Prevents cross-infection.

4. Prepare articles needed to check BP.

4. Arrangi ng articles prior procedu re helps to do the procedure in organized way.

5. After washing hands apply deflated cuff evenly over the brachial artery (2 inches/’ 4 fingers above the antecubital fossa) as tubing towards the palm.

5. To apply required pressure to occlude brachial artery.

6. Don’t apply cuff on cloth except patient has any skin infection.

6. Friction with cloth may interfere with the sound.

7. Palpate the brachial artery with fingertips and place the diaphragm of stethoscope.

7. Best area to hear lub-dub sound.

8. Close the valve of BP cuff, palpate radial pulse and pump till the reading of about 20 mm above the point at which radial pulsation disappears.

8. Inflating cuff too high causes unnecessary pain and may produce vasospasm which distorts pressure reading.

9. Permit the air to escape by opening the valve verv slowly. Note the number on manometer where the sound first begins (systolic pressure). Continue to release the pressure slowly. Note the point where sound stops (diastolic pressure).

9. First sound heard when the blood begins to flow through the brachial artery again.

10. Repeat the procedure if any doubt about the reading but don’t take more than 3 times in succession on same hand.

10. Gets a false elevated blood pressure reading due to stagnancy of venous blood.

Aftercare of Articles

Remove the cuff by rolling it and replace in the box. Record the findings in a piece of paper; write client’s name, age, time, BP reading and any measure done along with your sign and designation. Refer to health center and give health education if needed. Wash hands and replace the articles in bag. Wash the cuff cover if it gets dirty.

QUICK PHYSICAL ASSESSMENT

A nurse performs a health assessment every time she comes in contact with a patient. The most important step in the nursing process, the health assessment provides the nurse with the information needed to diagnose a patient and then implement a nursing plan.

Physical assessment is the systematic collection of objective information that is directly observed or is elicited through examination techniques. It involves the use of one’s senses to obtain information or a detailed study of the entire body or some parts of the body to get information about the structures and function of an area being observed or manipulated.

Objectives

• To understand the physical and mental well-being of the client.

• To detect disease in its early stage.

• To determine the cause and the extent of disease.

• To understand any change in the condition of disease and improvement or regression.

• To determine the nature of the treatment or nursing care needed for the client.

• To contribute to the medical research.

• To safeguard the client and his family by noting the early signs especially in case o? a communicable disease.

• To find out whether the person is medically fit or not fit for the particular task.

Articles

Community bag contains:

• Handwashing articles

• Weighing machine: To check weight

• Measuring tape: To measure height

• Articles to check TPR.

• Sphygmomanometer: To check blood pressure.

• Stethoscope: To check BP, to auscult respiratory sound, heart sound and bowel sound.

• Tongue depressor: To assess the condition o? mouth and throat.

• Torch light: To see inside ear, nose, throat.

• Tuning fork: To check hearing problem.

• Percussion hammer: To check superficial and deep tendon reflexes.

• Gloves: To use while handling body fluids and client with skin infection.

• Fetoscope: To auscult fetal heart sound in antenatal mother.

Techniques of Physical Examination

The five basic techniques used in physical examination are explained as follows:

a. Inspection: Visual examination.

b. Palpation: Assessment by touching the client.

c. Percussion: Examination by tapping the fingers on the client’s body (Direct percussion: tap directly on body or Indirect percussion: place one hand on body, tap on it with two fingers of other hand).

d. Auscultation: Process of listening the sound generated within the body by a stethoscope.

e. Manipulation: By moving of a part of the body of client to note its flexibility limitation.

Table 29.4: Procedure

Nursing action
Rationale

1. Explain the procedure to the patient and keep your bag in proper place.

1. Encourage client for cooperation.

2. Prepare area to check weight and height (place weighing machine on a piece of paper near a straight wall and cover it with another piece of paper in such a wav that meter is visible).

2. To prevent from contamination from floor as well as client’s feet.

3. Unbutton the bag and take out hand washing articles, pen and diary.

3. Once hand is washed, nurse is not supposed to touch the outer part of the bag.

4. Remove your watch/jewelry on working area and go to wash hands.

4. Prevents cross-infection.

5. After washing hands, prepare articles needed for physical examination.

5. Arranging articles prior procedure helps to do the procedure in organized way.

6. Observe client’s physical appearance when he/she comes near to you (gait, posture, any visible deformity or discomfort, signs of distress, facial expression, mood, body size, grooming and personal hygiene, etc.).

6. Gives a baseline data about client and to find out any health problem/abnormality which needs more attention.

7. Check height and weight.

7. To assess for obesity or malnutrition (by BMI calculation).

8. Perform Romberg test then make client to sit on flat surface comfortably (bed or floor mat).

8. Romberg to assess motor coordination. Area to conduct head to foot examination.

9. Check vital signs (TPR and BP).

9. Provides baseline information to assess deeply to find out any infection or cardiovascular problem.

10. Start quick head to foot examination

10. To find out any health problem

a. Observe head while taking vital signs injury.

a. To assess for pediculosis, dandruff or any problem.

b. Ask for anv headache, dizziness, history of blackout.

b. To assess any problem in brain.

c. Assess any irrelevant talk or answer while communicating with client.

c. To assess mental status.

d. Palpate sinuses, nasal septum. Observe for any morphological deformity of eye, year, nose, lips while palpating sinuses and nasal septum.

e. Take a torch and put light on eye, inside the ear, nose and mouth (wrap a gauge on tongue depressor and use it if needed; through gauze piece in paper bag once used).

f. Perform Rhine test and Weber test.

g. Ask client to swallow and observe neck movement. Tell client to turn back and palpate neck for tonsillitis as well as for goiter, palpate and enlarged lymph nodes in axilla.

h. Ask client to remove cloths (if female client then don’t expose completely, open part by part needed to examine). Inspect upper part of the body.

Palpate for symmetrical lung movement. Perform percussion on thoracic cage Auscult respiratory sound, heart sound and bowel sound/peristalsis sound. Check abdominal reflex (a superficial reflex)

Palpate liver and spleen.

In case of female ask for any breast pain or lump felt by client: if yes then perform a breast examination.

i. Check for any pain, tenderness, inflamed veins in calf muscle.

j. Check capillary refill, cyanosis, clubbing, edema.

k. Check all the pulses.

l. Check muscle strength of hands and legs.

m. Check for any morphological abnormality in legs.

n. Check deep tendon reflexes (biceps reflex, triceps reflex, knee jerk, achilles reflex), check plantar reflex (a superficial reflex).

o. Ask client for any abnormal foul smelled discharge or continuous itching in genital area or bleeding then refer to health centre.

p. Conduct urine sugar or albumin test if needed.

q. Record all findings. (Appendix E)

d. Assess for sinusitis, nasal septum deviation, entropion (eyelids fold inwards), trichiasis (eyelashes grow inward direction), any tumor, cracked lips (denoting dehydration) on face, etc.

e. Observe for cataract, pupillarv reaction, ear and nose discharge or any growth inside. Check for tonsils, dental condition, gum condition, drv tongue (denoting dehydration), look for gingivitis (inflammation of gum), glossitis (inflammation of tongue), angular stomatitis (inflammation of mucus membrane of mouth and lips), halitosis (bad smell in mouth).

f. To detect any hearing impairment.

g. To assess for goiter, tonsillitis. If enlarged lymph node client may have at risk of tuberculosis (further assessment needed).

h. Inspect for any deformity as kyphosis, scoliosis, lordosis, kyphoscoliosis; any injury, abnormal growth.

Lung movement should be same in both sides. Assess for any abnormal sound.

To detect any abnormal sounds which need attention.

Assessing neurological function.

For assessing hepatomegaly and splenomegaly. To assess for any breast tumor.

i. To diagnose deep venous thrombosis.

j. To asses any respiratory or cardiovascular problem.

k. Assessment of cardiovascular system.

l. For assessing any muscle weakness.

m. Assess for genu varum (bow leg) and genu valgum (knock knee).

n. Assessing musculoskeletal problem. Plantar to check neurological problem.

o. To detect any sexually transmitted disease.

p. If client has diabetes or age more than 60 years (sugar test) or client is hypertensive or age more than 60 years (albumin test).

q. For further reference.

Romberg test: Ask the client to stand with their feet together (touching each other). Then ask him/her to close eyes. Count complete one minute in this condition. Remain close at hand in case he/she begins to sway or fall.

With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception (is the sense of the relative position of neighboring parts of the body and strength of effort being employed in movement; brain integrate information from it), and vestibular sense (vestibule is situated medial to the tympanic cavity in ear).

If there is a mild lesion in the vestibular or proprioception systems, client is usually able to compensate with the eyes open. When client closes their eyes, however, visual input is removed and instability can be brought out. If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, client is unable to maintain this position even with their eyes open.

Sinuses: Palpate sinuses as mentioned in picture to detect sinusitis.

Rinne test: It is performed by placing a vibrating tuning fork against the client’s mastoid bone and asking the patient to tell you when the sound is no longer heard. Once they signal they can’t hear it, quickly position the still vibrating tuning fork 1–2 cm from the auditory canal, and again ask the patient to tell you if they are able to hear the tuning fork.

Normal Rinne finding: Air conduction should be greater than bone conduction otherwise some problems in middle ear, need to refer ENT.

Weber test: A vibrating tuning fork is placed in the middle of the forehead or above the upper lip under the nose over the teeth or on top of the head equal-distant from the patient’s ears on top of the thin skin in contact with the bone. The client is asked to report in which ear the sound is heard louder.

Fig. 29.6

Fig. 29.7

A normal Weber test has a client reporting the sound heard equally in both sides otherwise defective ear need to refer ENT.

Palpate for symmetrical lung movement: Place your both palms on right and left upper part of chest and tell client to take a deep breath.

Percussion on thoracic cage: Normally you will get resonance sound on lungs, flat sound on heavy muscles and bones, dull sound on heart and liver and tympanic sound on stomach.

Resonant sound is low pitched, hollow sound, normally heard over lung tissue.

Dull sound is thud like and medium pitched, normally heard over liver and heart. If heard over lung area means presence of tumor.

Flat sound is soft and high pitched, normally heard over airless tissues as muscles and bones.

Tympanic sound is high, hollow, drum-like sound, normally heard over stomach. If heard over lung area denotes presence of pneumothorax.

Auscultation of Respiratory Sound and Heart Sound

Capillary refill: Is an evaluation of peripheral perfusion and cardiac output. Depress the nail-bed of the finger until it becomes pale. Release pressure and note the time for usual skin color to return. Normal time is maximum 3 seconds.

Cyanosis: Cyanosis is a bluish hue to the skin, gums, fingernails, or mucous membranes caused by a lack of oxygen in the blood.

Clubbing: Clubbing occurs as a compensatory measures in chronic hypoxia. With clubbing nailbed losses its normal angle of 160 degrees between the nailplate and the finger and the angle increases to 180 degrees. In advanced clubbing, fingers look like bulbous or spoonlike appearance. Assess early clubbing by using the Schamroth technique.

Fig. 29.8

Fig. 29.9

Fig. 29.10

Fig. 29.11 Schamroth’s sign

Pulses: Check all the pulses to find out any abnormality in rhymes.

Edema: Check fluid retention in the body. It often causes swelling in the feet and ankles.

Few Prominent Morphological Deformities

Kyphosis, an abnormally increased roundness of the thoracic curve or hump back.

Scoliosis, a lateral deformity of the spine.

Lordosis, an abnormal increase in the lumbar curve, or sway back.

Genu varum or bow leg.

Genu valgum or knock knee.

Assessment of muscle strength: Test muscle strength by asking the client to perform ROM (range of motion). Apply resistance and tell to repeat ROM. Rate muscle strength as:

0 | = | muscle is paralyzed with no visible or palpable contraction, (zero)
1 | = | contraction is palpable but muscle does not move, (trace)
2 | = | full ROM is present with the joint supported to eliminate gravity, (poor)
3 | = | full ROM is present with gravity as the only resistance, (fair)
4 | = | full ROM is present against moderate resistant, (good)
5 | = | full ROM is present against normal resistance and gravity, (normal)

Table 29.5

Fig. 29.12

Fig. 29.13

Fig. 29.14

Deep Tendon Reflexes

Biceps jerk (forearm flexion) is produced by tapping the biceps brachii tendon.

Triceps jerk (forearm extension) is produced by tapping the triceps brachii tendon at elbow. Knee jerk!quadriceps jerklpatellar reflex is produced by tapping the quadriceps femoris tendon just below the patella.

Ankle jerk (plantar flexion of foot) is produced by tapping the Achilles tendon.

Plantar reflex: Scratching the foot’s outer aspect of the plantar surface (outer sole) from the heel towards the toes normally contracts or flexes the toes in clients older than 2 years of age.

While doing quick physical assessment if any problem found in any system then a detail assessment of that particular system has to be done.

URINE TEST FOR SUGAR AND ALBUMIN

Simple procedure can detect life-threatening diseases. Urine test for sugar and albumin at home setting are two of the simple procedures which are used to detect diabetes mellitus and hypertension respectively.

Objectives for Sugar Test

• To assess the level of sugar in urine for client with diabetes mellitus and antenatal mother.

• To teach the diabetic client the method of performing urine-sugar testing.

• To screen the population for diabetes mellitus.

Objectives for Sugar Test

•To screen the population for hypertension.

• To assess albumin level in urine for hypertensive client and antenatal mothers.

Articles

Community bag containing:

• Handwashing article: To wash hands before and after the procedure.

• A half piece of newspaper: T o prepare the area to test.

• Container for specimen: To collect urine specimen.

• Test tube holder: To hold the test tube while heating test tube.

• Two droppers: To pour urine and acetic acid.

Fig. 29.15

• Measuring cup: To measure Benedict solution.

• Spirit lamp/candle ivith candle stand: To heat urine in test tube.

• Match box: To lighten the lamp.

• Rag piece/tom cloth piece: To wipe test tube in between heating if it gets black.

• Swab sticks (six): To clean test tube (3 for sugar test, 3 for albumin test) or test tube cleaning brush can be used.

• Benedict solution: To do urine sugar test.

• Acetic acid: To do albumin test.

Fig. 29.16

Table 29.6: Procedure

Nursing action
Rationale

1. Explain the procedure to the patient and keep your bag in proper place.

1. Encourage client for cooperation.

2. Unbutton the bag and take out hand washing articles, pen and diary.

2. Once hand is washed, nurse is not supposed to touch the outer part of the bag.

3. Remove your watch/jewclry on working area and go to wash hands.

3. Prevents cross-infection.

4. Arrange all articles (except solutions needed) on the piece of newspaper at a place which should be away from kitchen and living room. Keep two swab sticks in handwashing area and one in working area.

4. As urine can contaminate food item as well as produces nasty smell and infection. Arranging articles prior procedure helps to do the procedure in organized wav. One for cleaning with soap, one with plain water and one to dry the test tube.

5. Give the specimen container to client and explain how to collect midstream urine. Then tell her/him to keep the container open (lid in a side) on the kidney tray after collection of urine.

5. Collection of midstream urine reduces the risk of the sample being contaminated with outside dirt/microorganism. If lead is closed then vour hand will be contaminated while opening it.

6. After washing hands take out the solution needed from bag. Take this to your urine testing area.

6. Urine testing articles and solutions should not be taken out together as urine testing article considered dirty whereas solution is considered as sterile.

Test for sugar:

a. Put test tube holder on the upper part of the test tube.

a. As need to boil the lower part of it.

b. Measure 5 ml of Benedict’s solution by measuring cup and pour it into the tesl tube. Heat urine till it boils. Hold test tube in an angle and mouth away from you and others.

b. If there is no color change, then the solution is appropriate for the test. If any color change, discard the solution.

c. Add 8 drops of urine and boil it again approx, for 2 minutes.

c. Regent contains copper sulfate (CuSO₁), sodium carbonate (Na₂CO₃) and sodium citrate. Copper sulfate is reduced by reducing sugars on boiling to form the colored precipitate of cuprous oxide. Color of cuprous oxide depends on the concentration of reducing substances present in urine (Principle).

d. Place it in a side and allow cooling.

d. For getting accurate result (precipitating).

e. Interpret color change.

e. Record the test:

• Blue—negative

• Green—0.5% or +

• Yellow—1% or ++

• Orange—1.5% or ++

• Brick red—2.0% and above or ++

f. Record the finding, inform client and give health education or referral services if needed.

f. Prevents complication.

Test for albumin:

a. Rut the test tube holder on the lower part of the test tube.

a. As upper part of it need to heat.

b. Pour urine into a test tube filling about 3/4th of the test tube.

b. Required amount gives a correct result.

c. Heat upper 1/3rd of the contents.

c. Observe for any white cloudiness/precipitate.

d. If cloudiness or white precipitation appears, add 2-3 drops of acetic acid slowly along the side of the test tube and heat it again. Don’t shake.

d. If disappears then phosphate presence; there is nothing to worry. If more precipitations and forms a white ring, it shows presence of albumin which indicates hypertension.

e. Record the finding, inform client and give health education or referral services if needed.

e. Prevents complication.

Termination of Article

• Wash all articles with plain water.

• Make froth with soap in kidney tray and dip all the articles (except test tube holder) in soap water for 15–20 minutes.

• Take a swab stick, wet it in water and apply soap on it, clean the test tube with that.

• Wash all articles again with plain water using another swab stick to clean inside of the test tube.

• Make all the articles sundry.

• Bring all articles in working area and use one more dry swab stick to dry the test tube.

• Replace in bag.

• After coming back pour solutions, replace swab sticks for reuse.

HEMOGLOBIN TESTING

Estimation of hemoglobin to assess the degree of anemia among pregnant women as well as among adolescent girls is very important. Hemoglobinometer has been supplied to health centres under CSSM (child survival and safe motherhood) program. Estimation of hemoglobin by Sahli’s method is very easy and cost-effective though result is fairly accurate.

Hemoglobin Estimation by Sahli method

Articles

• Community bag contains:

– Handwashing article: To maintain asepsis.

– A piece of paper: To keep articles of Hb testing.

– Cotton swab: To clean the finger for collecting blood.

– Spirit: To clean the finger before collecting blood.

– Paper bag: To throw waste.

– Gloves: To maintain universal precaution to prevent bloodborne diseases.

– Sahli’s kit contains:

▫ Sahli hemoglobinometer: To compare and get client’s Hb level.

▫ Sahli pipette marked to 0.2 mL (20 μL): To draw required amount of blood to test Hb%.

▫ Dropper: To pour N/10 HC1 and sterile water.

▫ N/10 hydrochloric acid: HC1 reacts with the hemoglobin and converts it into acid, haematin, which has a brown color.

Fig. 29.17

▫ Graduated tube: To collect and mix N/10 HC1 and blood.

▫ Glass rod: To stir the blood to mix well with N/10 HC1.

▫ Filter paper: To wipe blood outside the pipette as excess amount of blood gives wrong reading.

▫ Sterile lancet: To prick finger to get blood drops.

▫ Sterile water: To dilute blood and N/10 HC1 mix (N/10 HC1 also can be used instead of sterile water).

Procedure

• Place community bag in proper place.

• Wash hands and keep articles ready to test Hb on a piece of paper.

– Attach the rubber tubing with pipette.

– Fill the graduated tube up to 20 mark with N/10 hydrochloric acid and keep stand in the hemoglobinometer.

– Wear gloves.

• Collect capillary blood by fingerprick method:

– Blood is collected from the side of the middle and ring fingers.

– Clean the site with spirit swab.

– Wipe spirit with a dry swab.

– Press the finger and prick the finger firmly and rapidly with sterile lancet/needle.

– Wipe away the first drop of blood with cotton wool.

– Press the finger to produce a drop of blood.

– Collect the blood in the pipette up to 20 mark; do not allow air bubbles to enter.

• Wipe the extra blood from the outside of the pipette with filter paper.

• Slowly blow out the blood into the acid in the graduated tube.

• Rinse the pipette by drawing in and blowing out the acid solution 3 times.

• Allow to stand for 5 minutes.

• Compare the color of the diluted blood in the tube with the reference tube.

• If the color is same or lighter than the hemoglobin value is less than 4 gm%.

• If the color is darker than the reference tube, continue to dilute by adding 0.1 N HC1 drop by drop. Sterile 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 colors of the two tubes.

• Stop when the colors match. Note the mark reached.

• If found anemic, refer to health centre, advice to take iron-rich diet.

Aftercare of the Article

Clean all the articles with soap and water well. Pipette by blowing water in and out; graduated tube with brush. Soak all the articles in soap water for 15 minutes then wash with plain water. Make sundry and replace in bag. Throw the lancet in proper place after returning to institution or in health centre where sharps are discarded. Autoclave if possible.

WOUND DRESSING

Wound dressing is the process of cleansing a wound or incision and applying sterile protective covering using aseptic technique to prevent further complication and promotes wound healing.

Articles Required

• Community bag containing:

– Handwashing articles: To prevent crossinfection.

– Paper bag: To collect dry waste.

– Plastic slteetlclean neivspaper: To prepare clean area.

– Gloves: To maintain asepsis.

– Betadine solution: To clean wound and to kill microorganisms.

– Normal saline/sterile water: To clean wound.

– Adhesive tapes: To hold dressing in place.

– Clean kidney tray: To throw wet waste.

• Green bag/sheet contains:

– Artery forceps: To hold gauge piece while dressing.

– Thumb forceps: To squeeze gauge piece while dressing.

– Cotton swabs: To clean wound site.

– Gauze pieces: To clean wound and to cover the wound.

– Gallipot: To pour cleansing solution.

– Surgical pads: To cover the wound.

– Kidney tray: To use as sterile tray.

– Scissor: To cut adhesive tape.

– Bandage: To use while sterilizing the articles and to cover the wound.

• Take from client’s home

Big bowl with lid—for boiling dressing articles (if dressing is not autoclaved from institution or health center).

Preparation of Articles (If Autoclaved Dressing Set is not Available)

• Prepare the area by placing clean newspaper/plastic sheet. Keep gloves, scissor, adhesive tape cut into pieces and bandage on it.

• Tie bandage in artery forceps and thumb forceps in such a way that tail of bandage will be out of the bowl in which these will be boiled (easy to take out from boiled water after sterilization).

• Put gallipot with gauze piece/cotton swab, artery forceps and thumb forceps, steel kidney tray in the vessel with lid full of water. All articles should be dipped in water.

• Boil all articles for 15–20 minutes.

• Keep ready gloves to wear.

• Keep the clean kidney tray near dressing area.

• Open the old dressing of client and throw it on paper bag. Observe the wound condition. Place a newspaper or plastic sheet below the area. Then go to wash hands.

Fig. 29.18

• After washing hand take out betadine and normal saline (if client has their own use that solution).

• Hold bandage and take out artery forcep first. Hold only the handle of it and take out kidney tray with help of it and put on the newspaper. Then take out all other articles and keep in the kidney tray (this boiled water can be used if normal saline is not available).

• Empty gallipot by keeping all gauze pieces, cotton swab in sterile kidney tray.

• Take out all bandages and throw on paper bag.

• Wear gloves and start wound cleaning (use non-touch technique to do dressing if infected wound then use sterile gloves).

• Clean the surroundings and inside of the wound with wet swab (if you have sterile dry cotton swab then ask family members to pour normal saline in gallipot).

• If clean wound then clean the inside first then the surrounding of the wound. If infected wound then clean the surrounding first then inside the wound.

• Use one cotton swab or gauge piece for each wipe, discarding each by dropping into the kidney tray or paper bag after wiping.

• Ask family member to pour betadine in gallipot. Clean the wound again as mentioned above. Extra betadine throw in clean kidney tray.

• Ask family member to pour normal saline then clean the wound again as mentioned.

• Soak a gauze piece in betadine. Squeeze it nicely and put on the wound. Or fold a dry gauze piece and apply betadine ointment or as prescribed through the corner of the gauze piece.

• Apply a dry gauze on it and apply adhesive tape or secure with bandage. Wash hand.

• Make a note along with date, time, wound condition and give it to client.

Aftercare of Articles

Burn the wastes. Wash all articles in running water. Deep in soap water for 15–20 minutes. Wash again with plain water. Sundry and keep inside the bag. Replace gauze piece, cotton swab, etc. which are used. If it is a infected wound, take all the articles in plastic bag separately. Autoclave those before putting inside bag.

ORAL MEDICATION

There is no as such difference in the procedure to give oral medication in community setting. Basic rules are same as taught in fundamental of nursing procedure. One main difference is that in home setting you cannot set a tray as we do in hospital setting. Just use the working area or a separate clean piece of paper instead of tray.

Articles

• Community bag contains handwashing articles: To maintain cleanliness.

• Paper bag: To throw the discarded strip after administering medication.

• Pen: To document

• Articles to be arranged from client’s house

– Prescription: To check doctor’s order and to document after administering medication.

– Medicines: To be administered as prescribed.

– A small bowl: To keep the tablets after removing from strip.

– Measuring cup: To administer liquid medicine. Generally, it is available at home only as it comes along with medicine bottle (or else take it from your bag).

– Drinking water in a glass: To offer client to swallow medicine.

– Motor and pestle: Take only when client is not able to swallow tablet. Generally, it is available at home or else wrap the tablet in a piece of plastic or newspaper and use some small heavy utensils (e.g. back of stainless steel glass or small steel bowl) to crush it.

– Duster or small towel: To wipe the outside of the bottle after pouring the medication (only when you are going to administer some liquid medication).

– Client’s towel: To wipe mouth after drinking water if needed.

Procedure

• Keep your bag in proper place.

• Take out handwashing article.

• Check prescription before giving medications and take out the medicine strip.

• Collect from family member all the articles needed and keep on working area (on the paper in which you have kept your bag).

• Wash hands.

• Administer the medication as prescribed by maintaining 6 rights: right client; right drug; right route; right time; right dose; right documentation.

• Document drug name, dose, time, and route; sign the document along with your designation.

INJECTION PROCEDURE

Again there is no difference in basic procedure to give an injection in community setting and in hospital setting. As in oral medication here also need to use either working area to keep the articles or a separate clean piece of newspaper to arrange the article.

Articles

• Community bag contains:

– Handwashing articles: To maintain cleanliness.

– Paper bag: To throw cotton swab, plastic cover of syringe.

– Spirit: To clean the area of injection (sometimes you may get it from client’s home itself).

– Cotton swab: To clean the area of injection (sometimes you may get it from client’s home itself).

– Disposable gloves: To maintain universal precaution to prevent spread of blood borne diseases.

– Pen: To document.

• Articles to be arranged from client’s house:

– Doctor’s prescription: To check which injection to be given.

– Medication which to be injected as prescribed.

– Sterile syringe and needle (if not there take it from your bag).

– Scissor: To cut the plastic cover of syringe (use this cover as the sterile tray to carry syringe filled with medication; keep the needle side towards open end of the cover).

Fig. 29.19

Procedure

• Keep your bag in proper place.

• Take out handwashing article.

• Check prescription before giving medications and take out the medication to be injected.

• Collect from family member all the articles needed and keep on working area (on the paper in which you have kept your bag).

• Wash hands.

• Load proper dose of medicine in syringe (dilute if needed as instructed).

• Keep the loaded syringe inside the sterile plastic cover.

• Wipe the site of injection with spirit swab first then with dry swab.

• Administer the injection according to procedure and as prescribed by maintaining 6 rights:

– Right client

– Right drug

– Right route

– Right time

– Right dose

– Right documentation

• Document drug name, dose, time, and route.

• Recap the needle and bring used syringe needle in health center or in your institution to dispose in proper bag or to burn it.

Safe process of recapping: Though it is said “never recap used needle” as it is high chance to get needle stick injury. But a safe process if used in recapping the needle as in community it is not safe to throw used needle here and there.

It is better to use non-touch technique to recap the needle. Leave the cap on the paper; hold the piston side of the syringe and recap by putting the needle inside the cap without using your other hand and without touching the needle side. Once the needle gets inside the cap, use the other hand to make it tight.

Routes of Injection

• Intramuscular

• Intravenous

• Intradermal

• Subcutaneous.

Fig. 29.20

SCABIES TREATMENT

Scabies is an infestation of the skin by the itch mite, Sarcoptes scabiei. People who should be treated include:

• Everyone who lives with the person.

• Recent sexual partners.

Most people can be cured with a medicine that they apply to their skin. These medicines are often applied to all skin from the neck down. Infants and young children often need treatment for their scalp and face, too.

Most medicine is applied at bedtime. The medicine is then washed off when the patient wakes up. You may need to repeat this process one week later.

Medicines that may be prescribed include:

• 5% permethrin cream: This is the most common treatment for scabies. It is safe for children as young as 1 month old and women who are pregnant.

• 25% benzyl benzoate lotion

• 10% sulfur ointment

• 10% crotamiton cream

• 1% lindane lotion.

Instruction to Client

• The medication should be left on body for 12 to 24 hours then wash thoroughly.

• Wash all clothing, towels, and bedlinens that used in the last three days with soap and hot water. Sundry all clothings well.

• Cut your nails, and clean under them thoroughly to remove any mites or eggs that may be present.

• Thoroughly vacuum carpets, furniture, bedding, and car interiors, and throw the vacuum-cleaner bag away when finished.

• Try to avoid scratching. If any open sores, keep it clean.

• Topical measures to reduce itching such as cool baths or calamine lotion should not be given while the prescription cream is being used because it washes the cream off or prevents it from getting into the skin. These can be used after washing the medications.

STANDING INSTRUCTIONS FOR A COMMUNITY HEALTH NURSING FO MINOR AILMENTS

Standing order is a written document containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical situations. The standing orders are usually formulated collectively by the professional members of a department in a hospital or other health care facility. Standing orders usually name the condition and prescribe the action to be taken in caring for the patient, including the dosage and route of administration for a drug or the schedule for the administration of a therapeutic procedure.

A minor ailment is a less serious medical condition that does not require lab or blood tests. Examples include cold sores, mild eczema, oral thrush, heartburn, hay fever, skin rash, fungal skin infections and yeast infections.

List of Minor Ailments

• Fever

• Sore throat

• Cough

• Eye discharge or swelling

• Earache and ear discharges

• Toothache

• Convulsion and fits

• Diarrhea

• Constipation

• Chronic skin ulcer

• Skin rashes

• Wounds

• Burns

There are standing orders to treat minor ailments that nurses and other health workers may meet in homes, school and industries where the doctors are not readily available. A few of the these have been described below:

FEVER

• Check vital signs—temperature, pulse respiration.

• Assess for other discomfort such as headache, nausea, vomiting, diarrhea, shivering, running nose, cold, cough, stiff neck, convulsion, pain if any part of the body and skin rashes.

• If any rash—note the type and distribution of the rash, isolate the patient, inform medical officer, primary health center, if necessary.

• Take blood smear (thick and thin) for malaria if history of temperature with shivering.

• Provide tab. Paracetamol 500 mg orally BD for adults and half tablet for chidren.

• Advise plenty of oral fluids like water, fruit juice, rice water, etc.

• If temp is more than 101°F, give tepid sponging and refer to health center.

• Ask whether anyone else in the family or in the neighborhood is suffering from similar complaints to identify an epidemic of such cases.

SORE THROAT

• Check and record vital signs: Temperature, pulse and respiration.

• Inspect throat for evidence of redness and white patches. If white patches and other sign of diphtheria, need to refer in health center immediately.

• If possible, take and send a throat swab to a laboratory.

• If pharyngitis is present advise saline gargle (1 teaspoon of salt in a glass of warm water)

• Give aspirin tablets.

• Advice syrup of honey with lemon juice and hot water to drink.

• If there is history of recurrent tonsillitis refer to hospital for treatment or for removal of the tonsils if necessary.

COUGH

• Assess for the duration of cough, type (whooping cough) of the cough, color and consistency and amount of sputum, whether there is fever, sore throat, pain in chest, difficulty in breathing, vomiting, loss of weight, etc.

• If it has been found in history that client has dry cough with weight loss (suspected TB) then refer to hospital for investigation and treatment.

• Advise steam inhalations and demonstrate the procedure.

• Administer tab. Aspirin.

CONVULSION AND FITS

• Make the person lie down on flat surface with head turned to one side.

• Place a bit of wood covered with a clean cloth or a spoon covered with handkerchief, between his teeth to prevent from biting the tongue.

• Do not restrain him during convulsion.

• Protect him from any danger like sharp stones, etc.

• Loosen his cloth and clear the people around him to provide enough ventilation.

• After he recovers from the fit give him hot tea with plenty of sugar.

• Refer to a hospital.

BURNS

• Treat according to the cause of the burn (e.g. burn due to fire, pour water; if electric burn, just detach the power source, don’t pour water, etc.).

• Remove non-adherent clothing; cut adherent clothing away from the wound. Remove rings, bangles, shoes, belt, etc. carefully before the part begins to swell.

• Provide psychological support to client and family members.

• Assess the extent of burns.

• Cover the area with clean clothing.

• Shift the person to hospital.

• If medical aid is delayed start oral rehydration fluid.

DIARRHEA

• Diagnose diarrhea: Loose motion more than three times a day.

• Observe sign of dehydration: Dry mouth, lose of skin turgidity, sunken eyes, and depressed fontanels (if a child), low volume and rapid pulse, and decrease urine.

• Start oral rehydration fluid: Take 1 L of boiled and cooled water; add 1 pack of ORS powder. Stir it well and keep it in a airtight container. Instruct client to drink ORS after each motion.

• Teach homemade preparation of ORS when packet is not available: add 4 teaspoon of sugar, ½ teaspoon of salt in 1 liter of boiled cool water, stir well and keep it in a clean bottle.

• If there is severe dehydration refers to health center or hospital.

• Advise a diet of fruit juice (orange, lemon juices), rice water, coconut water, etc.

• Teach mother to use cloth diaper for the children to prevent further spread of the disease and boil the diapers after washing.

• Teach them to protect the food from fly contamination and fly control measures.

• Encourage eating freshly cooked hot foods, drinking boiled water, washing hands with soap and water before eating and after toilet and using proper latrine.

• Alert the village health committee regarding the diarrheal situation.

• Inform the occurrence of the condition to higher health officials when an epidemic is suspected.

BLEEDING NOSE

• Make patient sit up with head and bent forward.

• Loosen all clothes at neck.

• Ask patient to pinch nose at junction of hard and soft part.

• Do not let him blow the nose.

• Apply a cold compress.

• Refer to hospital or center if bleeding cannot be controlled or if patient is elderly.

FRACTURE

• Immobilize the part with scale, magazines, foot boards, wooden sticks, etc.

• Support the injured part by means of bandages and slings or whatever clothes available.

• Shift the person to the hospital immediately.

• If there is suspected injury in the spinal cord then shift him without bending on a stretcher for transportation to hospital.

• If the neck is injured keep sand bags on both sides of the head and prevent neck from moving.

EARACHE AND DISCHARGE

• Clean the ears with ear buds.

• Apply sulfacetamide ear drops.

• Give analgesic tabs (APC tabs) for 3 days. If not cured within 3 days refer to health center or hospital.

• If there is ear discharge with external ear soreness clean with boric acid lotion and apply sulfacetamide ear drops.

• Give APC tabs for 3 days.

• If there is discharge with fever, along with APC give sulfadiazine tabs.

• If associated with other problems like nose and throat infections or impaired hearing refer to primary health center.

TOOTHACHE

• Give potassium permanganate mouth washes 3 times a day.

• Refer for dental check-up.

• Advise dental care: Brush twice a day, morning after breakfast and night after dinner.

• Encourage to eat diet like guava, amla, orange, lemon, sprouted grams, etc. for healthy gums and teeth.

• Ask client to chew on a clove or guava leaf with affected tooth.

ANEMIA

• Encourage the client to eat iron rich diet as ragi, green leafy vegetables (spinach, amaranth), beans, peas, jiggery, liver, raisins etc.

• Advice oral iron and vitamins supplementation.

• Get Hb % checked and the stool examination for hook worm.

• If the HB is very low (less than 40%) refer to a primary health center or hospital.

• Assess for the cause of anemia as excessive bleeding during menstruation, bleeding piles, worm infestation, etc.

HEATSTROKE

• Provide cool ventilated environment, bed rest and give plenty of fluid.

• Provide a tepid water sponge.

• Remove the person away from the causative factor as quickly as possible.

• Apply ice bags to the head, groin and axilla.

• Refer the person to the hospital.

• Advise to wear protective clothing, sunglasses while exposed to sun.

• Avoid smoking, alcoholism.

• Never leave children or anyone else in a parked car (temperature inside cars can reach 200°F (c. 93°C).

• Try to avoid work while hottest time in a day.

• Be in cool places, under shed or in air conditioned room.

• Avoid strenuous exercise during daylight hours in hot weather.

ANIMAL BITE

• Wash the wound with soap and water for animal bites other than dog bite and refer to primary health center hospital for TT.

• If the bite is not punctured there’s no danger of rabies, treat it as a minor wound. Wash the wound thoroughly with soap and water. Apply an antibiotic cream to prevent infection and cover the bite with a clean bandage.

• If the animal bite creates a deep punctured wound of the skin or the skin is badly torn and bleeding, apply pressure with a clean, dry cloth to stop the bleeding and see your doctor.

• If suspected by an animal that might carry rabies, including any wild or domestic animal of unknown immunization status refer to health center immediately to get antirabies vaccination.

SNAKE BITE

• Ascertain if snake is poisonous.

• Instruct client to be calm, as movement increases spread of poison in blood and lymphatic system.

• Immobilize the bitten part (arm or leg).

• Remove jewelry or tight clothing before the area start to swell.

• Keep the bite area at or below the level of heart.

• Cleanse the wound, but don’t flush it with water, and cover it with a clean, dry dressing.

• Apply a splint to reduce movement of the affected area, but keep it loose enough so as not to restrict blood flow.

• Transfer immediately to hospital for antivenom injection.

There are also several outdated first aid techniques that are now believed to be unhelpful or even harmful. Do not do any of the following:

• Do not use a tourniquet.

• Do not cut into the snake bite.

• Do not use a cold compress on the bite.

• Do not give the victim any medication unless directed by a doctor.

• Do not raise the area of the bite above the victim’s heart.

• Do not attempt to suck the venom out by mouth (CDC, 2012).

• Do not use a pump suction device. While these devices were formerly recommended for pumping out snake venom, it is now believed that they are more likely to do harm than good.

• Don’t try to capture the snake, but try to remember its color and shape so you can describe it, which helps in your treatment.

Bibliography

1. A Community Health Nursing Manual-TNAI. Noida: Academy Press; 2002.

2. Community Health Nursing: Bag Technique [Internet] 2008 June 12 [cited 2014 July 21]. Available from: http://nursingcrib.com/nursing-notes-reviewer/community-health-nursing/bag-technique.

3. Kamalam S. Essentials in Community Health Nursing Practice. New Delhi: Jaypee Brothers; 2005.

4. Nurseslabs: Bag Technique in Nursing [Internet] 2014 [cited 2014 June 14]. Available from: http://nurseslabs.com/home-visits-bag-technique.

5. Hand Hygiene: Why, How and When? [Internet] [cited 2014 Sep 23], Available from: http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf.

6. Mayo Dowst L. This focus on the hygiene appointment centers on the patient introduction and cliief complaint, vitals, radiographs, intraoral cameras, and caries detection [Internet] [cited 2014 Oct 22]. Available from: http://www.rdhmag.com/articles/print/volume-33/issue-12/features/breaking-it-down.html.

7. How to Perform A Quick Nursing Health Assessment [Internet] [cited 2014 Aug 14]. Available from: http://www.ehow.com/how_5957163_perform-quick-nursing-health-assessment.html.

8. Khasnis A, Gokula RM (1st April, 2003). “Romberg’s Test”. Journal of Postgraduate Medicine, 49 (2): 169–72. PMID 12867698.

9. Blumenfeld H. Romberg Test [Internet] [cited 2014 Sep 11]. Available from: http://www.neuroexam.com/neuroexam/content.php?p=37.

10. Edema Grading. [Internet] [updated 2014 Nov 27; cited 2014 Nov 28], Available from: http://www.med-health.net/Edema-Grading.html.

11. Bag Technique in Nursing [Internet] [cited 2014 Sep 30]. Available from: http://nurseslabs.com/home-visits-bag-technique.

12. Standing Orders. [Internet] [Updated 2009; cited 2015 Jan 2]. Available from: http://medicaldictionary.thefreedictionary.com/standing+orders.

13. Snake Bites, http://www.healthline.com/health/snake-bites#FirstAid7.

14. Snake Bites: First Aid. http://www.mayoclinic.org/first-aid/first-aid-snake-bites/basics/art-20056681.

Appendices

1. Appendix A: Gordon’s Functional Health Patterns

2. Appendix B: Format of Data Collection

3. Appendix C: NANDA: Taxonomy II

4. Appendix D: List of Action Verbs

5. Appendix E: Community Health Survey Format

6. Appendix F: Community Performance Evaluation

7. Appendix G: Community Health KAP Survey Format

8. Appendix H: A Typology of Nursing Problems in Family Nursing Practice: To Assess Problems

9. Appendix I: Family Coping Index: To Assess Coping Ability of Family to a Specific Problem

10. Appendix J: Balanced Diet

11. Appendix K: Recommended Dietary Allowances

Appendix A: Gordon’s Functional Health Patterns

The following questions pertain to those asked by the community health nurse to provide an overview of the individual’s health status and health practices that are used to reach the current level of health or wellness.

History (Subjective Data)

Client’s general health? Any colds in past year? If appropriate: any absences from work/school? Most important things you do to keep healthy? Use of cigarettes, alcohol, drugs? Perform self-exams, i.e. breast/testicular self-examination? Accidents at home, work, school, driving? In past, has it been easy to find ways to carry out doctor’s or nurse’s suggestions? (If appropriate) What do you think caused current illness? What actions have you taken since symptoms started? Have your actions helped? (If appropriate) What things are most important to your health? How can we be most helpful? How often do you exercise?

Nutritional metabolic: This pattern describes nutrient intake relative to metabolic need.

History (Subjective Data)

Typical daily food intake? (Describe) Use of supplements, vitamins, types of snacks?

Typical daily fluid intake? (Describe)

Weight loss/gain? Height loss/gain?

Appetite? Breastfeeding? Infant feeding?

Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to follow?

Healing: Any problem?

Skin problems: Lesions? Dryness?

Dental problems?

Examination (Examples of Objective Data)

Skin assessment, oral mucous membranes, teeth, actual weight/height, temperature.

Abdominal assessment.

Elimination: Describes the function of the bowel, bladder and skin. Through this pattern the nurse is able to determine regularity, quality, and quantity of stool and urine.

History (Subjective Data)

Bowel elimination pattern (describe) Frequency, character, discomfort, problem with bowel control, use of laxatives (i.e. type, frequency), etc.? Urinary elimination pattern (describe) Frequency, problem with bladder control? Excess perspiration? Odor problems? Body cavity drainage, suction, etc.?

Examination (Examples of Objective Data)

If indicated, examine excretions or drainage for characteristics, color and consistency. Abdominal assessment.

Activity exercise: This pattern centers on activity level, exercise program, and leisure activities.

History (Subjective Data)

Sufficient energy for desired and/or required activities? Exercise pattern? Type? Regularity? Spare time (leisure) activities? Child-play activities? Perceived ability for feeding, grooming, bathing, general mobility, toileting, home maintenance, bed mobility, dressing and shopping?

Examination (Examples of Objective Data)

Demonstrate ability for above criteria. Gait. Posture. Absent body part. Range of motion (ROM) joints. Hand grip-can pick up pencil? Respiration. Blood pressure. General appearance. Musculoskeletal, cardiac and respiratory assessments.

Sleep rest: Assesses sleep and rest patterns.

History (Subjective Data)

Generally rested and ready for activity after sleep? Sleep onset problems? Aids? Dreams (nightmares), early awakening? Rest/relaxation periods?

Examination (Examples of Objective Data)

Observe sleep pattern and rest pattern.

Cognitive-perceptual: Assesses the ability of the individual to understand and follow directions, retain information, make decisions, and solve problems. Also asesses the five senses.

History (Subjective Data)

Hearing difficulty? Hearing aid? Vision? Wears glasses? Last checked? When last changed? Any change in memory? Concentration? Important decisions easy/difficult to make? Easiest way for you to learn things? Any difficulty? Any discomfort? Pain? If appropriate—PQRST questions: PQRST; P—Palliative, Provocative; Q—Quality or quantity; R—Region or radiation; S—Severity or scale; T—Timing (Morton, 1977). COLDSPA: C—Character; O—Onset; L—Location; D—Duration; S—Severity; P—Pattern; A—Associated factors (Weber, 2003).

Examination (Examples of Objective Data)

Orientation. Hears whispers? Reads newsprint? Grasps ideas and questions (abstract, concrete)? Language spoken. Vocabulary level. Attention span.

Self-perception/Self-concept History (Subjective Data)

How do you describe yourself? Most of the time, feel good (or not so good) about self? Changes in body or things you can do? Problems for you? Changes in the way you feel about self or body (generally or since illness started)? Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? Not able to control things? What helps? Ever feel you lose hope?

Examination (Examples of Objective Data)

Eye contact. Attention span (distraction?). Voice and speech pattern. Body posture. Client nervous (5) or relaxed (1) (rate scale 1–5). Client assertive (5) or passive (1) (rate scale 1–5)

ROLE RELATIONSHIP

History (Subjective Data)

Live alone? Family? Family structure? Any family problem you have difficulty in handling (nuclear/extended family)? Family or others depend on you for things? How well are you managing? If appropriate, how families/others feel about your illness? Problems with children? Belong to social groups? Close friends? Feel lonely? (Frequency) Things generally go well at work/school? If appropriate, income sufficient for needs? Feel part of (or isolated in) your neighborhood?

Examination (Examples of Objective Data)

Interaction with family members or others if present.

Sexuality Reproductive
History (Subjective Data)

If appropriate to age and situation—Sexual relationships satisfying? Changes? Problems? If appropriate—Use of contraceptives? Problems? Female—when did menstruation begin? Last menstrual period (LMP)?Any menstrual problem? (Gravida/Para if appropriate)

Examination (Examples of Objective Data)

None unless a problem is identified or a pelvic examination is warranted as part of full physical assessment (advanced nursing skill).

Coping/Stress Tolerance
History (Subjective Data)

Any big change in your life in last year or two? Crisis? Who is most helpful in talking things over? Available to you now? Tense or relaxed most of the time? When tense, what helps? Use any medications, drugs, alcohol to relax? When (if) there are big problems in your life, how do you handle them? Most of the time, are these ways successful?

Examination (Examples of Objective Data)

None.

Value-Belief Pattern
History (Subjective Data)

Generally get things you want from life? Important plans for future? Religion important to you? If appropriate—does this help when difficulties arise? If appropriate—will being here interfere with any religious practice?

Examination (Examples of Objective Data)

None.

Appendix B: Format of Data Collection

1. Name (Head of the Family): .......................................

Name of Area: .......................................

2. Religion: ...........................

House No.: .................

3. Type of Family: Nuclear/Joint

4. Occupation: .......................................

5. Family Roster: ...................................

Name of Interviewee: ............................

• Family Tree:

6. Immunization history: (If any under five years child present in family)

7. Socioeconomic status:

• Number of earing members:

• Total monthly income by all family members:

8. Housing and sanitory condition

• Floor diagram:

9. Dietary pattern: Vegetarian/non-vegetarian

10. Immediate diseases in the family:

11. Available health services:

1. Municipality dispensary ( )

2. Health center (subcenter/PHC/CHC) ( )

3. Government hospital ( )

4. Private hospital ( )

5. Private clinic ( )

12. Habits affecting health:

• Use of tobacco:

▫ Smoking .......................... Who use it? ....................................................

▫ Chewing .......................... Who use it? ....................................................

▫ Pan .......................... Who use it? ....................................................

▫ Betel-nut .......................... Who use it? ....................................................

• Use of alcohol: Who drinks? ....................................................

▫ How often/amount (peg) per day? ....................................................

• Use of drugs:

▫ Opium group ......................... Which drug? ......................... Who uses it? .........................

▫ Hashish ......................... Who uses it? ..................................................

▫ Other? ......................... Who uses it? ..................................................

13. Previous pregnancies in family: (within last 1 year)

14. Family planning:

• Are you using any family planning method currently:a. Yesb. No

• If yes what do you use?

a. Depo Provera ( )

b. Pills ( )

c. Condom( )

d. Copper T ( )

e. Norplant ( )

f. Tubectomy ( )

g. Vasectomy ( )

h. Withdrawal method ( )

i. Safe period ( )

15. Nutritional assessment of family member with priority need.

16. Head-foot physical exmination of family member with priority need.

17. Laboratory investigation reports of family member with priority need.

18. Recent medication details of family member with priority need.

19. Need identification:

Appendix C: NANDA: Taxonomy II

The current structure of NANDA’s nursing diagnoses is reffered to as Taxonomy II and has three levels: 13 domains, 47 classes, and 216 diagnoses.

2009–2011 Nursing Diagnosis

Organized according to a nursing focus by Doenges & Moorhouse’s Diagnostic Divisions

* = New diagnoses

+ = Revised

Activity/rest: Ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest.

• Activity intolerance

• Activity intolerance, risk for

• *Activity planning, ineffective

• Disuse syndrome, risk for

• Diversional activity, deficient

• Fatigue

• Insomnia

• Lifestyle, sedentary

• Mobility, impaired bed

• Mobility, impaired wheelchair

• Sleep, readiness for enhanced

• Sleep deprivation

• ⁺Slee? pattern, disturbed

• Transfer ability, impaired

• Walking, impaired

Circulation: Ability to transport oxygen and nutrients necessary to meet cellular needs.

• Autonomic dysreflexia

• Autonomic dysreflexia, risk for

• Bleeding, risk for

• Cardiac output, decreased

• Intracranial adaptive capacity, decreased

• Perfusion, ineffective peripheral tissue

• Perfusion, risk for decreased cardiac tissue

• Perfusion, risk for ineffective cerebral tissue

• Perfusion, risk for ineffective gastrointestinal

• Perfusion, risk for ineffective renal

• Shock, risk for

Ego integrity: Ability to develop and use skills and behaviors to integrate and manage life experiences.

• Anxiety [specify level]

• Anxiety, death

• Behavior, riskprone health

• Body image, disturbed

• Conflict, decisional (specify)

• ⁺Coping, defensive

• Coping, ineffective

• Coping, readiness for enhanced

• Decision-making, readiness for enhanced

• Denial, ineffective

• Dignity, risk for compromised human

• Distress, moral

• Energy field, disturbed

• Fear

• Grieving

• Grieving, complicated

• Grieving, risk for complicated

• Hope, readiness for enhanced

• Hopelessness

• identity, disturbed personal

• Post-trauma syndrome

• Post-trauma syndrome, risk for

• Power, readiness for enhanced

• Powerlessness

• Powerlessness, risk for

• Rape-trauma syndrome

• [Rape-trauma syndrome: compound reaction-retired 2009]

• [Rape-trauma syndrome: silent reaction-retired 2009]

• *Relationships, readiness for enhanced

• Religiosity, impaired

• Religiosity, ready for enhanced

• Religiosity, risk for impaired

• Relocation stress syndrome

• Relocation stress syndrome, risk for

• *Resilience, impaired individual

• *Resilience, readiness for enhanced

• *Resilience, risk for compromised

• Self-concept, readiness for enhanced

• ⁺Self-esteem, chronic low

• Self-esteem, situational low

• Self-esteem, risk for situational low

• Sorrow, chronic

• Spiritual distress

• Spiritual distress, risk for

• Spiritual well-being, readiness for enhanced

Elimination: Ability to excrete waste products.

• Bowel incontinence

• Constipation

• Constipation, perceived

• Constipation, risk for

• Diarrhea

• *Motility, dysfunctional gastrointestinal

• *Motility, risk for dysfunctional gastrointestinal

• Urinary elimination, impaired

• Urinary elimination, readiness for enhanced

• Urinary incontinence, functional

• Urinary incontinence, overflow

• Urinary incontinence, reflex

• Urinary incontinence, risk for urge

• Urinary incontinence, stress

• [Urinary incontinence, total-retired 2009]

• Urinary incontinence, urge

• Urinary retention [acute/chronic]

Food/fluid: Ability to maintain intake of and utilize nutrients and liquids to meet physiological needs.

• Breastfeeding, effective

• Breastfeeding, ineffective

• Breastfeeding, interrupted

• Dentition, impaired

• *Electrolyte imbalance, risk for

• Failure to thrive, adult

• Feeding pattern, ineffective infant

• Fluid balance, readiness for enhanced

• [Fluid volume, deficient hyper/hypotonic]

• Fluid volume, deficient [isotonic]

• Fluid volume, excess

• Fluid volume, risk for deficient

• ⁺Fluid volume, risk for imbalanced

• Glucose, risk for unstable blood

• ⁺Liver function, risk for impaired

• Nausea

• Nutrition: Less than body requirements, imbalanced

• Nutrition: More than body requirements, imbalanced

• Nutrition: Risk for more than body requirements, imbalanced

• Nutrition, readiness for enhanced

• Oral mucous membrane, impaired

• Swallowing, impaired

Hygiene: Ability to perform activities of daily living.

• Self-care, readiness for enhanced

• Self-care deficit, bathing

• Self-care deficit, dressing

• Self-care deficit, feeding

• Self-care deficit, toileting

• *Neglect, self

Neurosensory: Ability to perceive, integrate, and respond to internal and external cues.

• Confusion, acute

• Confusion, risk for acute

• Confusion, chronic

• Infant behavior, disorganized

• Infant behavior, readiness for enhanced organized

• Infant behavior, risk for disorganized memory, impaired

• Neglect, unilateral

• Peripheral neurovascular dysfunction, risk for

• Sensory perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)

• Stress overload [Thought processes, disturbed-retired 2009]

Pain/Discomfort: Ability to control internal/external environment to maintain comfort.

• *Comfort, impaired

• Comfort, readiness for enhanced

• Pain, acute

• Pain, chronic

Respiration: Ability to provide and use oxygen to meet physiological needs.

• Airway clearance, ineffective

• Aspiration, risk for

• Breathing pattern, ineffective

• Gas exchange, impaired

• Ventilation, impaired spontaneous

• Ventilatory weaning response, dysfunctional

Safety: Ability to provide safe, growth-promoting environment.

• Allergy response, latex

• Allergy response, risk for latex

• Body temperature, risk for imbalanced

• Contamination

• Contamination, risk for

• Death syndrome, risk for sudden infant

• Environmental interpretation syndrome, impaired

• Falls, risk for

• Health maintenance, ineffective

• Home maintenance, impaired

• Hyperthermia

• Hypothermia

• Immunization status, readiness for enhanced

• Infection, risk for

• Injury, risk for

• Injury, risk for perioperative positioning

• *Jaundice, neonatal

• *Maternal/fetal dyad, risk for disturbed

• Mobility, impaired physical

• Poisoning, risk for

• Protection, ineffective

• Self-mutilation

• Self-mutilation, risk for skin integrity, impaired

• Skin integrity, risk for impaired

• Suffocation, risk for

• Suicide, risk for

• Surgical recovery, delayed

• Thermoregulation, ineffective

• Tissue integrity, impaired

• Trauma, risk for

• *Trauma, risk for vascular

• Violence, [actual/] risk for other-directed

• Violence, [actual/] risk for self-directed

• Wandering [specify sporadic or continual]

Sexuality: [Component of ego integrity and social interaction] ability to meet requirements/characteristics of male/female role.

• *Childbearing process, readiness for enhanced

• Sexual dysfunction

• Sexuality pattern, ineffective

Social interaction: Ability to establish and maintain relationships.

• Attachment, risk for impaired

• Caregiver role strain

• Caregiver role strain, risk for

• Communication, impaired verbal

• Communication, readiness for enhanced

• Conflict, parental role

• Coping, ineffective community

• Coping, readiness for enhanced community

• Coping, compromised family

• Coping, disabled family

• Coping, readiness for enhanced family

• Family processes, dysfunctional

• Family processes, interrupted

• Family processes, readiness for enhanced

• Foneliness, risk for

• Parenting, impaired

• Parenting, readiness for enhanced

• Parenting, risk for impaired

• Role performance, ineffective

• Social interaction, impaired

• Social isolation

Teaching/learing: Ability to incorporate and use information to achieve healthy lifestyle/optimal wellness.

• Development, risk for delayed

• Growth, risk for disproportionate

• Growth and development, delayed

• ⁺Health behavior, risk-prone

• ⁺Health management, ineffective self

• Knowledge, deficient (specify)

• Knowledge (specify), readiness for enhanced

• Noncompliance [adherence, ineffective] [specify]

• [Therapeutic regimen management, effective-retired 2009]

• Therapeutic regimen management, ineffective

• [Therapeutic regimen management, ineffective community-retired 2009]

• Therapeutic regimen management, ineffective family

• Therapeutic regimen management, readiness for enhanced

Appendix D: List of Action Verbs

Appendix E: Community Health Survey Format

Appendix F: Community Performance Evaluation

Appendix G: Community Health KAP Survey Format

1. Name of the Area: Rural/Urban .................................................. House No.: ............................................

2. Name of the head of the family:

3. Religion:

4. Mother tongue:

5. Type of family: Joint/Nuclear

Knowledge, Attitude and Practice (KAP) Related to Personal Hygiene

1. How often do you brush your teeth?

a. Regularly ( )

b. Once a day ( )

c. Twice a day ( )

d. Occasionally ( )

2. What do you use to brush your teeth brush?

a. Toothpaste ( )

b. Datiwon ( )

c. Coal ( )

d. Others ( )

3. Do you wash your hand before eating?

a. Yes ( )

b. No ( )

If yes, what do you use?

a. Soap and water ( )

b. Ash and water ( )

c. Water ( )

d. Others ( )

4. Do you wash your hands after using the toilet?

a. Yes ( )

b. No ( )

If yes, what do you use?

a. Soap and water ( )

b. Ash and water ( )

c. Water ( )

d. Others ( )

5. How often do you take bath?

a. Every day ( )

b. Once in 2–3 days ( )

c. Once a week ( )

d. 1–2 times per month ( )

Disease and Illness

1. What do you think the cause of disease?

a. Dirty water and food ( )

b. Evil spirit ( )

c. Pollution ( )

d. Lifestyle ( )

e. Other (specify) ( )

2. Where do you visit first for care when you get sick?

a. Self-medication ( )

b. Baidhya ( )

c. Health post ( )

d. Hospital ( )

e. Private clinic ( )

f. Others (specify) ( )

3. How can a disease be prevented?

a. By drinking and eating clean water and food ( )

b. By worshiping God ( )

c. By sacrificing a goat and chicken for God ( )

d. No Idea ( )

e. Environmental sanitation ( )

f. Other practices (specify) ( )

Tuberculosis

1. Have you heard of TB?

a. Yes ( )

b. No ( )

If “yes”:

2. TB is transmitted by

a. Air ( )

b. Water ( )

c. Droplet infection ( )

d. Direct contact ( )

3. Is it curable?

a. Yes ( )

b. No ( )

4. Where should you go to treat TB?

a. Health centre ( )

b. Traditional healer ( )

c. Self-medication ( )

d. Medicine shop ( )

Leprosy

1. Have you heard of leprosy?

a. Yes

If “yes”:

2. How is it transmitted?

a. Touching the person ( )

b. Talking with the person ( )

c. Droplet ( )

3. Is it curable?

a. Yes ( )

b. No ( )

c. Don’t know

4. Typical sign of leprosy is

a. Fever ( )

b. Insensitive skin lesion ( )

c. Headache ( )

Diarrhea disease

1. How can a person get diarrhea?

a. Contaminated food and water ( )

b. Overeating ( )

c. Evil spirit ( )

d. Others ( )

2. What do you feed your child when he/she gets diarrhea?

a. ORS packet ( )

b. Salt Sugar Solution ( )

c. Liquid ( )

d. Other ( )

3. How do you prepare it?

a. 1 packet in 1 L water ( )

b. 1 packet in 2 L water ( )

c. 2 packets in 1 L water ( )

d. 2 packets in ½ L water ( )

HIV/AIDS

1. Have you heard of HIV/AIDS and STDs?

a. Yes ( )

b. No ( )

If “yes”:

2. How does it transmitted?

a. Through blood ( )

b. Sexually ( )

c. Both are correct ( )

d. Both are incorrect ( )

e. Other ( )

Care of the neonate and infant

1. What should be put in umbilical cord?

a. Nothing ( )

b. Oil ( )

c. Medicine ( )

d. Ash ( )

e. Other (specify) ( )

2. Do you think colostrums should be fed to your baby? (if they have baby: have you fed colostrum to your baby?)

a. Yes ( )

b. No ( )

If no, why?

a. It is bad milk ( )

b. Relatives did not allow ( )

c. Did not know ( )

d. Others ( )

3. How long should baby be fed only breast milk? (if they have baby: how long have you fed only breast milk to your baby?)

a. 6 months ( )

b. 6–12 months ( )

c. 1–2 years ( )

d. More than 2 years ( )

4. When should weaning be started? (if they have baby more than 6 months: when did you start weaning for your baby?)

a. Before 6 months ( )

b. At 6 months ( )

c. After 6 months ( )

Appendix H: A Typology of Nursing Problems in Family Nursing
Practice: To Assess Problems

It helps a community health nurse to assess various individual problems, family problems, community problems as well as helps to find out ability of individual or family coping ability with the problem, ability to provide care at home, health resources, etc.

First Level Assessment Consists of:

I. Presence of wellness condition

II. Presence of health threats

III. Presence of health deficits

IV. Presence of stress points/foreseeable crisis situations.

I. Presence of wellness condition-stated as potential or Readiness—a clinical or nursing judgment about a client in transition from a specific level of wellness or capability to a higher level. It is a nursing judgment on wellness state or condition based on client’s performance, current competencies, or performance, clinical data or explicit expression of desire to achieve a higher level of state or function in a specific area on health promotion and maintenance.

Examples of this are the following:

a. Potential for enhanced capability for:

• Healthy lifestyle, e.g. nutrition/diet, exercise/activity; healthy maintenance/health management; parenting; breastfeeding; spiritual well-being—process of client’s developing/unfolding of mystery through harmonious interconnectedness that comes from inner strength/sacred source/God.

• Others, specify:___________.

b. Readiness for enhanced capability for:

• Healthy lifestyle; health maintenance/health management; parenting; breastfeeding; spiritual well-being.

• Others, specify:_________.

II. Presence of health threats—conditions that are conducive to disease and accident, or may result to failure to maintain wellness or realize health potential. Examples of this are the following:

a. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome).

b. Threat of cross-infection from communicable disease case.

c. Family size beyond what family resources can adequately provide.

d. Accident hazards

• Broken chairs; pointed/sharp objects, poisons and medicines improperly kept; fire hazards; fall.

• Others, specify:_________.

e. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.

• Inadequate food intake both in quality and quantity; excessive intake of certain nutrients; faulty eating habits; ineffective breastfeeding; faulty feeding techniques.

f. Stress provoking factors. Specify.

Strained marital relationship; strained parent-sibling relationship; interpersonal conflicts between family members; caregiving burden.

g. Poor home/environmental condition/sanitation. Specify.

Inadequate living space; lack of food storage facilities; polluted water supply; presence of breeding or resting sights of vectors of diseases; improper garbage/refuse disposal; unsanitary waste disposal; improper drainage system; poor lighting and ventilation; noise pollution; air pollution.

h. Unsanitary food handling and preparation.

i. Unhealthy lifestyle and personal habits/practices. Specify.

Alcohol drinking; cigarette/tobacco smoking; walking barefooted or inadequate footwear; eating raw meat or fish; poor personal hygiene; self-medication/substance abuse; sexual promiscuity; engaging in dangerous sports; inadequate rest or sleep; lack of/inadequate exercise/physical activity; lack of/relaxation activities; non-use of selfprotection measures (e.g. non-use of bednets in malaria and filariasis endemic areas).

j. Inherent personal characteristics, e.g. poor impulse control.

k. Health history, which may participate/induce the occurrence of health deficit, e.g. previous history of difficult labor.

l. Inappropriate role assumption, e.g. child assuming mother’s role, father not assuming his role.

m. Lack of immunization/inadequate immunization status specially of children.

n. Family disunity, e.g. self-oriented behavior of member(s); unresolved conflicts of member(s); intolerable disagreement.

o. Others, specify: ________.

III. Presence of health deficits: Instances of failure in health maintenance. Examples include:

a. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.

b. Failure to thrive/development according to normal rate.

c. Disability: Whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary paralysis after a CVA) or permanent (e.g. leg amputation secondary to diabetes, blindness from measles, lameness from polio).

IV. Presence of stress points!foreseeable crisis situations: Anticipated periods of unusual demand on the individual or family in terms of adjustment/family resources. Examples of this include: Marriage; pregnancy, labor, puerperium; parenthood; additional member, e.g. newborn, lodger; abortion; entrance at school; adolescence; divorce or separation; menopause; loss of job; hospitalization of a family member; death of a member; resettlement in a new community; illegitimacy, others (specify. ___________).

Second-Level Assessment Consists of:

I. Inability to recognize the presence of the condition or problem.

II. Inability to make decisions with respect to taking appropriate health action.

III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk member of the family.

IV. Inability to provide a home environment conducive to health maintenance and personal development.

V. Failure to utilize community resources for health care.

I. Inability to recognize the presence of the condition or problem due to:

a. Lack of or inadequate knowledge

b. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem, specifically:

• Social-stigma, loss of respect of peer/significant others

• Economic/cost implications

• Physical consequences

• Emotional/psychological issues/concerns

c. Attitude/philosophy in life, which hinders recognition/acceptance of a problem.

d. Others. Specify ________.

II. Inability to make decisions with respect to taking appropriate health action due to:

a. Failure to comprehend the nature/magnitude of the problem/condition.

b. Low salience of the problem/condition.

c. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of the situation or problem, i.e. failure to breakdown problems into manageable units of attack.

d. Lack of/inadequate knowledge/insight as to alternative courses of action open to them.

e. Inability to decide which action to take from among a list of alternatives.

f. Conflicting opinions among family members/significant others regarding action to take.

g. Lack of/inadequate knowledge of community resources for care.

h. Fear of consequences of action, specifically: Social consequences; economic consequences; physical consequences; emotional/psychological consequences.

i. Negative attitude towards the health condition or problem—by negative attitude is meant one that interferes with rational decision-making.

j. In accessibility of appropriate resources for care, specifically:

• Physical inaccessibility

• Costs constraints or economic/financial inaccessibility.

k. Lack of trust/confidence in the health personnel/agency.

l. Misconceptions or erroneous information about proposed course(s) of action.

m. Others, specify, __________.

III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk member of the family due to:

a. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications, prognosis and management).

b. Lack of/inadequate knowledge about child development and care.

c. Lack of/inadequate knowledge of the nature or extent of nursing care needed.

d. Lack of the necessary facilities, equipment and supplies of care.

e. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program).

f. Inadequate family resources of care specifically:

• Absence of responsible member

• Financial constraints

• Limitation of luck/lack of physical resources.

g. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection) which his/her capacities to provide care.

h. Philosophy in life which negates/hinders caring for the sick, disabled, dependent, vulnerable/at risk member.

i. Member’s preoccupation with on concerns/interests.

j. Prolonged disease or disabilities, which exhaust supportive capacity of family members.

k. Altered role performance, specify.

Role denials or ambivalence; role strain; role dissatisfaction; role conflict; role confusion; role overload.

l. Others, specify: ________.

IV. Inability to provide a home environment conducive to health maintenance and personal development due to:

a. Inadequate family resources specifically:

• Financial constraints/limited financial resources.

• Limited physical resources, i.e. lack of space to construct facility.

b. Failure to see benefits (specifically long-term ones) of investments in home environment improvement.

c. Lack of/inadequate knowledge of importance of hygiene and sanitation.

d. Lack of/inadequate knowledge of preventive measures.

e. Lack of skill in carrying out measures to improve home environment.

f. Ineffective communication pattern within the family.

g. Lack of supportive relationship among family members.

h. Negative attitudes/philosophy in life which is not conducive to health maintenance and personal development.

i. Lack of/inadequate competencies in relating to each other for mutual growth and maturation (e.g. reduced ability to meet the physical and psychological needs of other members as a result of family’s preoccupation with current problem or condition.

j. Others, specify: _________.

V. Failure to utilize community resources for health care due to:

a. Lack of/inadequate knowledge of community resources for health care.

b. Failure to perceive the benefits of health care/services.

c. Lack of trust/confidence in the agency/personnel.

d. Previous unpleasant experience with health worker.

e. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically.

• Physical/psychological consequences

• Financial consequences

• Social consequences

f. Unavailability of required care/services

g. Inaccessibility of required services due to:

• Cost constrains

• Physical inaccessibility

h. Lack of or inadequate family resources, specifically:

• Manpower resources, e.g. baby sitter

• Financial resources, cost of medicines prescribe

i. Feeling of lack of support from the community, e.g. stigma due to mental illness, AIDS, etc.

j. Negative attitude/philosophy in life which hinders effective/maximum utilization of community resources for health care.

k. Others, specify: __________.

Appendix I: Family Coping Index: To Assess Coping Ability of Family to a Specific Problem

Coping is the process of managing stress/stressful circumstances. In this, not the underlying problems are being rated. It is used to assess the coping capacity of family and not the individual that is being rated. Purpose of family coping index is to provide basis for estimating the nursing needs of a particular family. It has two parts:

1. A point on the scale: Community health nurse finds out where family falls in these points.

• Scaling cues, helps community health nurse to rate family coping. They are limited to 3 parts:

– No competence (1)

– Moderate competence (3)

– Complete competence (5)

2. A justification statement (explains why)

Appendix J: Balanced Diet (Quantities Given in Grams)

Appendix K: Recommended Dietary Allowances