MATERNAL AND CHILD HEALTH SERVICES

INTRODUCTION:

 Mother & children not only constitute a large group, but they are also “vulnerable” or
special group. They comprises 71.4% of population of the developing countries. In India,
women of child bearing age (15-44 years) constitute 22.2% & children under 15 years of
age about 35.3% of total population, together 57.5% of population consists of mother &
children.
 Current population of India as on 1.324 billion (2016)
 Children are the foremost priorities of Community Health Program. Their aim is to
increase the nutrition level of mother & children to ensure the birth of healthy child.
 MCH services started due to different reasons in different countries. Maternal & child
health services were first organized in India in 1921 by a committee of “The Lady
Chelmsford League” which collected funds for child welfare & established demonstration
services on an all India basis.
 Various & s facilities & programme organized for the purpose of providing medical &
social services for mother & children.
 medical services includes prenatal & postnatal services, family planning care, & pediatric
care in infancy.

DEFINITION:

According to W.H.O. (1976), Maternal & child health services can be defined as “promoting,
preventing, therapeutic or rehabilitation facility or care for the mother & child.” Thus maternal &
child health services is an important & essential services related to mother & child’s overall
development.

AIMS & OBJECTIVES:

 Reduce maternal, perinatal, infant & child mortality & morbidity rates.
 Child survival.
 Promoting reproductive health or safe motherhood.
 Ensure birth of healthy child.
 Prevent malnutrition.
 Prevent communicable disease.
 Early diagnosis & treatment of the health problems.
 Health education & family planning services.

INFRASTRUCTURE:

 The MCH service are rendered through the infrastructure of P.H.C. & sub centers. It is
proposed to set up one P.H.C. & sub-centers.
  It is proposed to set up one P.H.C. for every 30,0000 population, & one sub-centers for
every 3000 to 5000 population.
 Each sub-centers are foundation of national health system. Each sub-sub-center is
manned by a team of one male & female health worker. In addition there is a team of one
trained Dai & one health guidein every village.

SUB-AREA:

The components of MCH include the following sub areas:

 Maternal health
 Family planning
 Child health
 School health
 Handicapped children
 Care of the children in special setting such as day care centers.

ACTIVITIES OF MCH PROGRAMME:

 Maternal & child health services are an important part of primary health care.
 Traditional activity areas of these programme:-
 Complete health check-up & care of the child & mother from conception to birth.
 Studying health problems of mothers & children.
 Providing health education to parents for taking care of children.
 Training to professional & assistant workers.

NEED FOR MCH PROGRAMME:

There are 4 main reasons why mother & children health must be given top priorities in health
programme:

1. Mother & child below the age of 15 years makeup the majority of the population in
almost countries
2. Mother & children constitutes a ‘special risk’ or vulnerable group in the case of illness,
death, in the terms of pregnancy, childbirth of mothers, & growth 7 development in the
case of children.
3. by improving the health of mother & children we can improve the health o the family &
community.
4. Ensuring child survival is a future investment for the family & community.

INDICATORS OF MCH PROGRAMME:

Maternal & child health can be evaluated on the basis of the following indicators:
 1. Maternal mortality rate: below 1 (for every 1000 live births)
2. Infant mortality rate: below 30 (for every 1000 live births)
3. Death rate of 1-4 year old age group: below 10.
4. Size o f family: 2-3 members.
5. Perinatal mortality rate: 30-35.
6. Weight of minimum 90% of total children: according to height/weight charts.

RECENT TRENDS IN MCH PROGRAMME:

1. Integration of care: Earlier MCH care services were divide into antenatal, child care &
family planning. Naturally it is helpful in increase the capability & effectiveness of
services.
2. Risk approach: This new thought was born from the lack of resources & their availability.
As per this the risk group among mother & infant is identified special care is given to
them.
3. Man power changes: According to new concept, maternal & child health services should
be left to traditional health workers (ANMs, health visitors) rather than specialist of field
& child volunteers & workers of NGOs.
4. Primary health care: It makes available information about protection & resources for
mother & child health care.
5. Reproductive & child health: As per the decision taken in world women’s conferences,
Beijing (1995), maternal & child health services have been included in reproductive &
child health services.

PRINCIPLES:

The guiding principles for the M.C.H. programme are:

A. Consultation & participation: Consultation with , & participation by, families id integral
to the services. Services will be informed by, & seek to meet, the young needs of young
children & their families.
B. Access & availability: all families with young children should be able to readily access
the information, services & resources that are appropriate for, & useful to them.
C. Primary prevention: Prevention of harm or damage is preferable to repairing it later.
Early detection of risk factors is required, & intervention, where appropriate .
D. Capacity building: Promotion of resilience & capacity is preferable to allowing problems
to undermine health or autonomy.
E. Equity: All children should be able to grow up actively learning, healthy, sociable & safe-
irrespective of their family circumstances & background.
F. Family centered: The identification & management of child & family needs requires a
family centered approach that focuses on strength.
 G. Inclusion: Inclusive practices are essential for all children to get the best start,
irrespective of their family circumstances, differing abilities 7 background.
H. Partnership: Quality services are achieved through integrated services delivered &
partnership with other early childhood & specialist services, & with family.
I. Quality: All families with young children must be confident of the quality of information,
services & resources provided to them.

MCH SERVICE PRGRAMME STANDARD:

1. The MCH services provide universal access to its services for children from birth to
school age & their families.
2. The MCH services promotes optimal health & development outcomes for children from
birth to school age through a focus on the child, mother & family.
3. The MCH services builds partnership with families & communities & collaborates &
integrated with other services & organizations.
4. The MCH services are delivered by competent & professional workplace.
5. The MCH services are supported local government or the governing authority, provides a
responsive & accountable services.
6. Services for children mothers & families through effective governance & managements.
7. The MCH services deliver a quality & safe services.

ORGANIZATIONAL ACTIVITIES OF MCH SERVICES:

 Complete health check up & care of the child & mother from conception to birth.
 Studying the health problems of mother & child.
 Providing health education to parents for taking care to children.
 Training to professional & assistant workers.

ROLE OF COMMUNITY HEALTH NURSE IN MCH SERVICES:

A. Direct care provider:

1. Antenatal care:
 Contact: Contacting every pregnant mother in the primary stage of pregnancy.
 History : Taking history of general health, previous child birth & present
pregnancy.
 Antenatal examination: Conducting physical birth & present pregnancy.
 Antenatal examination:
 Calculate obstetrics examination etc.
 Calculating the expected date of delivery.
 Identifying high risk of mother.
 Providing counseling & health education.
 Helping mother & other family members in planning the delivery.
B. Intranatal care:
1. Preparing the place for delivery.
2. Arranging necessary equipments.
3. Giving mental support to mothers.
4. Preparing mother for delivery.
5. Examine position of fetus, dilatation of cervix, & heart of fetus, observing the
position of bladder & uterine contraction.
6. Noting general condition of the pregnant mother, process of pain & time of
membrane rupture.
7. Ensuring safe delivery, examining umbilical cord & noting abnormalities.
8. If necessary, taking help of doctor or referring patient to a specialist.
9. Maintaining through asepsis during delivery.
10. Should be ready to handle complications like bleeding, malpresentation, cord
prolepses etc
11. Noting the correct time of birth.
C. Postnatal care:
 The week immediately after the child birth is called postnatal period.
Responsibilities of Community Health nurse are-
 Observing the blood pressure, temperature and pulse of mother
immediately after the delivery & then during the following period.
 Collecting information about the general condition of mother, sleep pain
and elimination acceptor and accordingly the nursing care.
 Observing fundus, perineum, lochia, bladder etc.
 Observing breast and nipples.
 Protecting the mother from complication like puerperal sepsis, breast
inflammation, postpartum hemorrhage, urinary incontinence, urinary
retention and thrombophlebitis and providing required treatment.
D. Neonatal care:
 Observing the respiration of newborn, immediately after birth and if necessary
provide resuscitation.
 Taking care of umbilical cord and cutting the cord & tying it using proper
techniques.
 Taking notice of abnormalities or congenital defects and informing the relatives.
 Assessing the physical condition of newborn by his APGAR score (9 or 10 is
ideal score).
 Cleaning the new born child (giving bath to newborn has become less popular).
 Taking care of newborn skin and eyes.
 Keeping the new born child on save bed and providing breastfeeding to baby at
earliest
 Maintaining normal body temperature of the newborn (give kangaroo care).
FUNCTIONS RELATED TO MATERNAL CLINICS:

1. Home visit: During home visit, community health nurse should try to focus the attention
of mother on the following-
 Antenatal check up and its importance.
 Anatomy, physiology and psychology of pregnancy.
 Diet during pregnancy.
 Plans of delivery.
 Neonatal care .
 Family planning.
 Organizing and managing the nursing home.
 Playing the role of liaison officer under referral system, for sending the mother to
hospital for safe delivery.
 Taking part in community activities.
 Explaining the importance of reproductive and child health and community.
 Supervising the work of midwives and female health workers and give them
appropriate suggestions.
 Organizing and managing maternal clinics.
 Coordinating between the doctor, family and patients.
 Storing and maintaining the records of maternal and child health services.
 Assisting the research work in the field of maternal and child health services.

Educational functions:

 Providing health education to mother and family either individually or in the groups.
 Educating using demonstration pregnant mother and relatives about maternal nursing.
 Community health nurse can discuss following topics with pregnant mothers:
 Importance of regular antenatal check up.
 Personal hygiene and proper diet.
 Clean environment including mental environment.
 Importance of hospital delivery or delivery by trained workers.
 Taking care of infants.
 The community health nurse has a multifaceted role in maternal services it is only
through proper discharge maternal and infant mortality can be reduced to targeted rate.

FAMILY WELFARE SERVICES

INTRODUCTION:
 Family planning means planning by individuals or couples to have only the children they
want, when they want them. This is responsible parenthood.
  Family welfare includes not only planning of births, but they welfare of whole family by
means of total family health care. The family welfare programme has high priority in
India, because its success depends upon the quality of life of all citizens
HISTORY OF FAMILY WELFARE PROGRAMME:
1. It was started in the year 1951.
2. In 1977,the govt. of India redesignated the “national family planning programme” as the
“national family welfare programme”, and also changed the name of the ministry of
health and family planning to ministry of health and family welfare.
3. It is a reflection of the government’s anxiety to promote family planning through the total
welfare of the family.
4. It is aimed at achieving a higher end, i.e., to improve the quality of life of the people.
5. India is the first country in the world, that implemented the family welfare programme at
govt. level.
6. Health is a part of concurrent list but center provides 100% assistance to states for this
programme.
7. Government has concentrated on this programme in various five-year plans though
higher priority was accorded to it after 4th five year plan.
8. Due to bad effects of emergency and faulty propaganda, family planning suffered major
set back, during 1977- 1979.
9. It was decided in national health policy 1983,that Net Reproduction Rate (NRR) should
be 1 by the year 2000.
10. The 7th five year plan placed more emphasis on the use of spacing methods between the
births of two children.
11. Family welfare programme has been remained the important aspects of each five year
plan, national health

CONCEPT OF FAMILY WELFARE PROGRAMME

1. The concept of welfare is basically related to quality of life.
2. As such it includes education, nutrition, health, employment, women’s welfare and rights
,shelter, safe drinking water-all vital factors associated with the concept of welfare.
3. It is a Centrally sponsored programme. For this, the states receive 100 per cent assistance
from Central Government
4. The emphasis is on a child family
5. Also, the emphasis is on spacing methods along with terminal methods
6. The current policy is to promote family planning on the basis of voluntary and informed
acceptance with full community participation
7. The services are taken to every doorstep in order to motivate families to accept the small
family norm
AIMS AND OBJECTIVES OF FAMILY WELFARE PROGRAMME:
THE GOVERNMENT OF INDIA IN THE MINISTRY OF HEALTH AND FAMILY
WELFARE HAVE STARTED THE OPERATIONAL AIMS, AND OBJECTIVES OF
FAMILY WELFARE PROGRAMME AS FOLLOWS:
 To promote the adoption of small family size norm, on the basis of voluntary acceptance
 To promote the use of spacing methods
 To ensure adequate supply of contraceptives to all eligible couples within easy reach.
 To arrange for clinical and surgical services so as to achieve the set targets
 Participation of voluntary organizations/local leaders/local self government, in family
welfare programme at various levels
 Using the means of mass communication and interpersonal communication to overcome
the social and cultural hindrances in adopting the programme or extensive use of public
health education for family planning.
GOALS OF THE FAMILY WELFARE PROGRAMME :
Family welfare programme has laid down the following long term goals to be achieved by the
year 2000 AD:
1. Reduction of birth rate from 29 per 1000 (in 1992) to 21 by 2000 AD
2. Reduction of death rate from 10 (in 1992) to 9 per 1000.
3. Raising couple protection rate from 43.3 (in 1990) to 60 per cent.
4. Reduction in average family size from 4.2 (in 1990) to 2.3.
5. Decrease in Infant mortality rate from 79 (in 1992) to less than 60 per 1000 live births.
6. Reduction of Net Reproduction Rate from 1.48 (in 1981) to 1.
IMPACT OF FAMILY WELFARE ACTIVITIES:
1. Nearly 98% of women and 99% of men in the age group of 15 and 49 have a good
knowledge about one or more methods of contraception. Adolescents seem to be well
aware of the modern methods of contraception.
2. Over 97% of women and 95% of men are knowledgeable about female sterilization,
which is the most popular modern permanent method of family planning. While only
79% of women and 80% of men have heard about male sterilization.
3. 93% of men have awareness about the usage of condoms while only 74% of women are
aware of the same.
4. Around 80% of men and women have a fair knowledge about contraceptive pills.
IMPORTANCE OF FAMILY WELFARE PROGRAMME:
 The year 2010-11 ended with 34.9 million family planning acceptors at national level
comprising of 5.0 million Sterilizations, 5.6 million IUD insertions, 16.0 million condom
users and 8.3 million O.P (oral pills). users as against 35.6 million family planning
acceptors in 2009-10.
 Over the decades, there has been a substantial increase in contraceptive use in India.
 IUD Insertions: During the year 2010-11, 5.6 million IUD insertions were reported as
against 5.7 million in 2009-10. Assam, Bihar, Gujarat, Jharkhand, Uttar Pradesh,
 Arunachal Pradesh, Delhi, Goa, Meghalaya, Mizoram, Sikkim, D&N Haveli reported
better performance in 2010-11
 Condom Users and O.P. (Oral Pills) Users: Based on the distribution figures reported,
there were 16.0 million equivalent users of Condoms and 83.07 million equivalent users
of Oral Pills during 2010-11
 Number of Births Prevented: Implementation of various Family Planning measures
prevented 16.335 million births in the country during 2010-11 as compared to 16.605
million in 2009-10. The cumulative total of births avoided in the country up to 2010-11
was 442.75 million
STRATEGIES OF FAMILY WELFARE PROGRAMME (FWP):
 Integration with health services: Family welfare programme (FWP) has been integrated
with other health services instead of being a separate service
 Integration with maternity and child health: FWP has been integrated with maternity and
child health (MCH). Public are motivated for post delivery sterilization, abortion and use
of contraceptives.
 Concentration in rural areas: FWP are concentrated more in rural areas at the level of
subentries and primary health centers. This is in addition to hospitals at district, state and
central levels.
 Literacy: There is a direct correlation between illiteracy and fertility. So stress and
priority is given for girl's education. Fertility rate among educated females is low.
 Breast feeding: Breast feeding is encouraged. It is estimated that about 5 million births
per annum can be prevented through breast feeding.
 Raising the age for marriage: Under the child marriage restraint bill (1978), the age of
marriage has been raised to 21 years for males and 18 years for females. This has some
impact on fertility
 Minimum needs programme: It was launched in the Fifth Five Year Plan with an aim to
raise the economical standards. Fertility is low in higher income groups. So fertility rate
can be lowered by increasing economical standards
 Incentives: Monetary incentives have been given in family planning programmes,
especially for poor classes. But these incentives have not been very effective. So the
programme must be on voluntary basis
 Mass media: Motivation through radio, television, cinemas, news papers, puppet shows
and folk dances is an important aspect of this programme.

ROLE OF COMMUNITY HEALTH NURSE IN FAMILY WELFARE SERVICES:

 Community health nurse has a vast role to play in family welfare services.
1. Survey work:
 Collecting demographic facts
 Making list of homes and finding out housing location
  Collecting information about pregnant mothers, eligible couples, infants and
children below the school going
2. EDUCATIONAL FUNCTIONS AND MOTIVATION:
 Explaining the importance and necessity of family planning to masses.
 Using various techniques of teaching and communication to propagate the
message of family planning to common man.
 Motivating the eligible couple to use contraceptives and educating them about its
uses
 Motivating people for family planning operation or permanent contraception
3. Managerial Function:
 Conducting clinics:
 Deciding the date and place of clinics.
 Arranging equipments and other resources at clinics.
 Arrangements and distribution of contraceptives.
 Insertion and removal of IUDS
 Organizing family planning camps:
 Arranging family planning operations (sterilization male/female)through
special camps.
 Making arrangements at the camps
 Following aseptics techniques.
 Motivating eligible couples and preparing them for the operation
 Assisting the doctor in operation.
 Maintaining the records:
 Keeping the eligible couple register update.
 Maintaining the register of sterilization cases, contraceptives users ,and
pregnant mothers.
 Maintaining other records related to family planning
 Liaison work:
 soliciting the co-operation of NGOs/voluntary organization

ADOLESCENT HEALTH SERVICES

1. RMNCH+A
2. Rashtriya Kishor Swasthya Karyakram (RKSK)
3. Kishori Shakti Yojana : To improve the health and nutritional status of girls
4. Nutrition Programme for Adolescent Girls (NPAG)
5. Balika Samridhi Yojana
6. WIFS
7. National AIDS Control Programme
8. Adolescent Friendly Health Clinics(AFHCs)
 1. RMNCH+A:
 Address- the major causes of mortality among women and children
 The delays in accessing and utilizing health care and services
 2013
 To ensure equal focus on various life stages

National Iron + Initiative:

 Minimum service package for the management of anaemia across life stages
 Iron and folic acid (IFA) supplementation to:
 Pregnant
 Lactating women
 Children in the age group of 6–60 months
 Adolescents ; women in reproductive age group
 Under National Iron+ Initiative, the following age groups are covered :
 Bi-weekly 20 mg elemental iron and 100 microgram (mcg) folic acid per ml of
liquid formulation and age appropriate de-worming for preschool children of 6-
59 months.
 Weekly supplementation of 45 mg elemental iron and 400 mcg folic acid per
child per day for children from 1st to 5th grade in Govt. & Govt. Aided schools,
and at AWC for out of school children (6 to 10 years).
 Weekly dose of 100 mg elemental iron and 500 mcg folic acid with biannual de-
worming in adolescents (10–19 years) under WIFS
 Weekly supplementation for women in reproductive age, Pregnant and lactating
women
2. Rashtriya Kishor Swasthya Karyakram (RKSK):
 The Ministry of Health & Family Welfare
 Launched on 7th January, 2014.
 RKSK has been developed to strengthen the adolescent component of the
RMNCH+A strategy

Objectives:

 Improve Nutrition
 Improve Sexual and Reproductive Health
 Enhance Mental Health
 Prevent Injuries and violence
 Prevent substance misuse
 Prevent non communicable disease
Services provided:

 WIFS
 Clinics and counseling
 Peer Educator & Adolescent Health Day
 Menstrual Hygiene Scheme

3. WIFS Weekly Iron Folic acid Supplementation :

 The programme covers 11.2 crore beneficiaries, 8.4 crore in-school and 2.8 crore
out of school beneficiaries.

Salient features of WIFS:

 To reduce the prevalence and severity of anaemia in adolescent population (10-19

years).

Target groups:

 School going adolescent girls and boys in 6th to 12th class enrolled in
government/government aided/municipal schools.
 Out of school student
 Urban and rural area

Intervention:

 Supervised Weekly Iron-folic Acid Supplements 100mg elemental iron and 500ug Folic
acid
 Screening of target groups for moderate/severe anaemia and referring these cases to an
appropriate health facility.
 Biannual de-worming (Albendazole 400mg)

 Peer Education: To improve life skills, knowledge and attitude of adolescents on

Nutrition, Sexual and reproductive health, Conditions for NCDs, Substance misuse,
injuries and violence and Mental health.
 Adolescent Health Day :
 One of the strategies to achieve the objectives of the adolescent health program
and to Increase awareness among adolescents, parents and families and
stakeholders
 The AHD should be organized in every village
 Once every quarter on a convenient day (preferably on a Sunday)
 AWCs or community spaces may be - venues for organizing the AHD.
  Services should be offered to all the adolescent target groups (male/female; 10-14
and 15-19 age; school going, drop out; and married adolescents)
 Counselling in Improving dietary intake, taking actions for prevention of intestinal worm
infestation and adolescent issues

4. Kishori Shakti Yojana:

• Launched – year 2000
Key component of ICDS
Aim– Breaking the intergenerational life cycle of nutritional & gender disadvantage and
providing a supportive environment for self development

Objectives:

 To improve nutritional and health status of girls in age group of 11-18 years
 To provide required literacy and numeracy skills through the non-formal stream of
education
 To stimulate a desire for more social exposure and knowledge and to help them improve
their decision making capabilities •
 To train and equip the adolescent girls to improve/ upgrade home-based and vocational
skills
 To promote awareness of health, hygiene, nutrition and family welfare, home
management and child care
 To gain a better understanding of their environment related social issues and the impact
on their lives
 IFA supplementation along with deworming
 Education for school dropouts and functional literacy among illiterate adolescent girls
 Non-formal education to adolescent girls. Emphasis on life education aspects including
physical, developmental and sex education is given.

Beneficiaries:

 Adolescent girls who are unmarried and

 Belong to families below the poverty line
 School drop-outs

Scheme- I (Girl to Girl Approach):

 Age group of 11-15 years

 Belonging to families whose income level is below poverty line

Scheme-II (Balika Mandal):

 Age group 11-18 years irrespective of income levels of the family

  Younger girls 11-15 years and belonging to poor families

5. Nutrition Programme for Adolescent Girls (NPAG):

 It was initiated as a pilot project (2002-03)
 Centrally sponsored scheme
 51 identified districts across the country
 Aim - address the problem of under-nutrition among adolescent girls.
 2004-2005 (Stopped)

Objectives:

 To improve nutritional status

 To create gender awareness and development of adolescent girls.

Beneficiaries:

 Adolescent girls (11-15 years) with body weight less than 30 kg

 Adolescent girls (15-19 years) with body weight less than 35 kg

Eligibility criteria:

 Adolescent girls (11-19) - registered in an Anganwadi Centres irrespective of financial

status of the family to which they belong.

Benefits:

 Improvement of nutritional and health status of girls.

 Training and equipment of adolescent girls to upgrade home based vocational skills.
 6 kg of free food grain (rice) per month per beneficiary.
 Promotion of health, hygiene, nutrition, family welfare, home management and childcare.
 Better understanding of their environment related social issues and its impact on their
lives.

6. Balika Samridhi Yojana:

 Launched by Government of India in1997
 Aim - to delay the age of marriage

Objectives:

 To change negative family and community attitudes towards the girl child at birth and
towards her mother.
 To improve enrollment and retention of girl children in schools ,to increase the age of
marriage of girls and to assist the girl to undertake income generation activities.
Beneficaries:

 Girl children belonging to families below the poverty line.

 Who are born on or after 15th August, 1997.
 The benefits are restricted to two girl children in a household irrespective of number of
children in the household.

 A post birth grant amount of Rs. 500

 Payment: Attaining 18 years of age
 Withdrawal of benefit:
 Girl getting married<18yrs she will not be given the benefit
 In case of death all money will be withdrawn

7. National AIDS Control Programme:

 Under NACO Adolescent Education Programme developed which focuses
primarily on prevention through awareness building
 The Adolescent Education Programme is one of the key policy initiatives of
NACP
 Relevant messages on sexuality and relationships are developed and disseminated
for youth via posters, booklets, panels and printed material.

The Adolescence Education Programme (AEP):

 Co-curricular adolescence education in classes IX-XI

 Life skills education in classes I- VIII
 Inclusion of HIV prevention education in pre-service and in-service teacher training and
teacher education programmes.
 Inclusion of HIV prevention education - out-of- school adolescents and young persons
 Incorporating measures to prevent stigma, discrimination against learners/students and
educators and life skills education into education policy for HIV prevention.

8. Adolescent Friendly Health Clinics (AFHCs):

 ‘Maitri’ in Maharashtra
 ‘Udaan’ in Uttrakhand
 ‘Sneha’ in Karnataka

The objective of it being addressing the stigma behind accessing the adolescent services.

Services provided:

 Counselling services:
  Nutrition
 Puberty
 RTI/STI prevention
 Contraception and delaying marriage
 Curative Services available at AFHC:
 Treatment of severe malnutrition
 Treatment of common RTI/STI problems
 Treatment of menstrual disorders
 Treatment for sexual concerns of males and female
 Mental health service/management of depression
 Treatment of non-communicable diseases and other common ailments
 Management of injuries related to accidents and violence
 Management of substance misuse
 Treatment of non-communicable diseases like hypertension, stroke, cardio-
vascular diseases and diabetes
 Other important services:
 Delay first pregnancy
 Decrease teenage pregnancies
 Reduction in maternal deaths among adolescent girls
 Management of anaemia: Iron supplementation and nutritional counselling.
 Appropriate health facility referrals
 Early and safe abortion services are provided to adolescents.
 Reduction in incidence of sexually transmitted diseases and proportion of HIV
positive cases in adolescent

Commodities available at AFHC:

 Weekly Iron & Folic Acid Supplementation & Albendazole

 Sanitary napkins
 Contraceptives
 Medicines

9. LIFE SKILLS: “ the abilities for adaptive and positive behaviour that enable
individuals to deal effectively with the demands and challenges of everyday life” (WHO)

LIFE SKILL EDUCATION:

 Teaching through participatory learning methods like games, role plays , group
discussion and practicing skills through experimental learning in a non threatening
setting.
  It provides individual with wide alternative and creating way of solving problems
pertaining to drug use, sexual abuse, teenage pregnancy, early sexual experimentation,
bullying.
 It’s promotional programs which improve positive health & self esteem.

LIFE SKILLS:

 To be taught at school level - critical thinking & creative thinking - decision making
& problem solving - communication skills & interpersonal relation - coping with
emotion and stress - self awareness & empathy
 Life skills and education are incorporated through schools, ICDS and community
outreach session.
 Teachers, AWW,ANM are to be trained in counseling.
10. SCHEME FOR MENSTURAL HYGINE:
 Scheme promote better hygiene and ensure adequate knowledge and information
about use of sanitary napkins.
 Sanitary napkins are provided by NHM in the name ‘free days’

11. PREVENTIVE HEALTH CHECKUPS:

 New approach in the implementation of school health programme
 Mobile School health camps by a team consisting of two medical officers(
MBBS/ dental/ AYUSH) and two paramedics ( one ANM any one of following :
pharmacist/ ophthalmic assistant/ dental assistant)

12. SABLA:
 Rajiv Gandhi Scheme for empowerment of AG
 200 selected districts
 OBJECTIVES - Enable self development & empowerment of AG. - Improve the
nutrition & health status. - Awareness about health hygiene and ARSH & family
child care. - Upgrade home based skill and vocational skill.

SCHOOL HEALTH SERVICES

INTRODUCTION:
Children between the age of 5-17 years are school age children. They spent most of their
time of the day in the school under the direct supervision and guidance of their teachers. They
are also exposed to various epidemiological factors in the school which influence their present
and future state of health. Hence, school is the best place for giving health education and makes a
strong foundation to the healthy nation. School Health Services are primarily meant for
preserving and promoting health of the students.
DEFINITIONS SCHOOL HEALTH:
 It refers to a state of complete physical, mental, social and spiritual well being and not merely
the absence of disease or infirmity among pupils, teachers and other school personnel.
SCHOOL HEALTH SERVICES:
It refers to need based comprehensive services rendered to pupils, teachers and other
personnel in the school to promote and protect their health, prevent and control diseases and
maintain their health.
HEALTH PROBLEMS OF SCHOOL CHILDREN:
There are some health problems which are common in school children. These are:
1. Malnutrition
2. Infectious diseases
3. Intestinal parasites
4. Disease of skin, eye and ear
5. Dental caries
NEED FOR SCHOOL HEALTH SERVICES:
These are necessary and important because of the following reasons. Students are:
 Vital and substantial segment of population and the future citizens.
 Vulnerable section of population, exposed to various environmental factors.
 Exposed to various stressful situations .it can cause mental health problems, negative
attitudes, affect growth and development, disturb appetite and dietary habits resulting in
malnutrition.
 Belongs to different socio economic and cultural backgrounds which affect their health
and nutrition status .
 Prone to specific health problems like diarrhoea, constipation, dental caries, bleeding
gums, PEM, worm infestation, hepatitis, anaemia, scabies, acne, influenza, measles,
mumps, chickenpox, UTI, eye and ear infection, cardiac problems etc.
AIM OF SCHOOL HEALTH SERVICES:
The ultimate aim of school health service is to promote, protect and maintain health of school
children and reduce morbidity and mortality among them.
Specific objectives:
 Create health consciousness among school children, their parent and teachers.
 Provide healthy and safe environment which is conducive to comprehensive development
of children.
 Impart health information and conduct health education on various aspects of healthful
living in school, home and community.
 Prevent communicable and non communicable diseases.
 Identify and treat the abnormality and defect as early as possible and do the necessary
referral and follow up.
 Involve teacher, student and their parents in management of health aspects of children.
 Help teachers and children make constructive and productive use of co-curricular and
extracurricular activities.
Objectives:
The objectives of the programme of a school health services are as follows:
1. The promotion of positive health
2. The prevention of diseases
3. Early diagnosis, treatment and follow-up of defects
4. Awakening health consciousness in children
5. The provision of healthful environment
PRINCIPLES OF SCHOOL HEALTH SERVICES:
School health services should:
 Be based on health needs of school children
 Planned in coordination with schools, health personnel, parents and community people. A
school health council needs to be set up
 Be a part of community health services.
 Emphasize on preventive and promotive aspect.
 Emphasize on health education to promote, protect, improve and maintain health of
children and staff.
 Emphasize on learning through active and desirable participation.
 Be ongoing and continuous program.
 Have an effective system of recording and reporting.

ASPECTS OF SCHOOL HEALTH SERVICE:

Some aspects of a school health service are as follow:-
1. Health appraisal of school children and school personnel.
2. Remedial measures and follow-up.
3. Prevention of communicable diseases.
4. Healthful school environment.
5. Nutritional services.
6. First aid and emergency care.
7. Mental health.
8. Dental health.
9. Eye health
10. Health education
11. Education of handicapped.
12. Proper maintenance and use of school health records.

1. HEALTH APPRAISAL:- The health appraisal should cover not only the students but
also the teachers and other school personnel. Health appraisal consists of periodic
medical examination and observation of children by the class teacher :-
a. Periodic medical examination:-
  The school health committee(1961) in India recommendation medical
examination of children at the time of entry and thereafter every 4 year.
 The initial examination should include careful history and physical
examination of the child, with tests for vision, hearing and speech.
 A routine examination of blood and urine should be carried out.
 Clinical examination for nutritional deficiency and examination of faeces
for intestinal parasitosis are particularly important in India.
 Tuberculin testing or mass screening should not be withhold.
 Medical inspection by recording the medical history, regular(quarterly)
recording of height and weight, annual testing of vision and preparing
children for medical examination by helping them understand the “how”
and “why” of health appraisal.
b. School personnel:- Medical examination should be given to teachers and other
school personnel as they form part of the environment to which the child is
exposed
c. Daily morning inspection:- The teacher is in a unique position to carry out the
“daily inspection” . The following clues will help the school teacher in suspecting
children who need medical attention:-
☻ Unusually flushed face
☻ Any rash or spots
☻ Symptoms of acute cold
☻ Coughing and sneezing
☻ Sore throat
☻ Rigid neck
☻ Nausea and vomiting
☻ Red or watery eyes
☻ Headache,
☻ Chills or fever
☻ Listlessness or sleepiness
☻ Disinclination to play
☻ Diarrhoea
☻ Pains in the body
☻ Skin conditions like scabies and ringworm
☻ pediculosis
2. REMEDIAL MEASURES AND FOLLOW-UP:-
a. Medical examination are not an end in themselves, they should be followed by
appropriate treatment and follow –up.
b. Special clinics should be conducted exclusively for school children at the primary
health centres in the rural area ,and in one of the selected school or dispensaries for a
group of about 5,000 children in the urban areas.
 c. Considering the high prevalence of dental, eye, ear, nose, and throat defects in the
school children in India, special clinics should be secured or provided for the
exclusive use of school children for examination and treatment of such defects.
d. There should be provision for beds in the existing referral hospital for the children to
be admitted for investigation and treatment as and when required.
3. PREVENTION OF COMMUNICABLE DISEASE:-
☻ Communicable diseases control through immunization is the most emphasized
school health service function.
☻ A well planned immunization programme should be drawn up against the
common communicable diseases.
☻ A record of all immunization should be maintained as part of the school health
records.
4. HEALTHFUL SCHOOL ENVIRONMENT:
The school building, site and equipment are part of the environment in which the
child grows and develops.
a. Location:- the school should normally be centrally situated with proper approach
roads and at a fair distance from busy places and roads, cinema houses, factories,
railway tracks and market place.
b. Site:- the site should be on suitable high land and properly drained. School Health
Committee (1961) recommended that 10 acres for higher elementary schools. 5 acres
for primary school with an additional one acre of land per 100 students. Playground
should be made available to the student.
c. Structure:- nursery and secondary school as far as possible, be single storied. Exterior
wall should have a minimum thickness of 10 inches and should be heat resistant.
d. Classroom:- verandhas should be attacted to classroom. No classroom should
accommodate more than 40 students. Per capita space for student in a classroom
should not be less than 10 sq.ft.
e. Furniture:- furniture should suit the age group of students. Provide single desks and
chairs. Desks should be “minus” type. Chair should be with proper back rests, with
facilities for desk- work
f. Door and windows:- the window should be broad with the bottom sill, at a height of
2’-6” from the floor level combined door and window area should at least 25 per cent
of the floor space; window should be placed on different walls for cross ventilation;
the ventilators should not less than 2% of the floor area.
g. Color:- inside color of the classroom should be white and should be periodically
white washed.
h. Lighting:- classroom should have sufficient natural light, periodically from the left
and should not be from the front.
i. Water supply:- there should be an independent source of safe and potable water
supply, which should be continuous and distributed from the taps.
 j. Eating facilities:- there should be a separate room for mid- day meals.
k. Lavatory:- privies and urinals should be provided- one urinal for 60 students and one
latrine for 100 students. Arrangement should be separately made for boys and girls.

5. NUTRITIONAL SERVICES:- A child who is physically weak will be mentally weak.

Cannot be expected to take full advantages of schooling. The diet should contain the
entire nutrient in proper proportion, adequate for the maintenance of optimum health.
A. Mid-day school meal:- -SHC(1961) recommended that school children
should be assured of at least one nourishing meal. - school meal should
provide at least one- third of the daily calorie requirement and about half
of daily protein requirement of the child.
B. Applied nutrition programme:- -UNICEF is assisting in the
implementation of the Applied Nutrition Programme in the form of
implements , seeds, manure and water supply equipment. - the produce
may be utilized in the school feeding programme as well as for nutrition
education.
C. Specific nutrients:- - Advances in the knowledge of nutrition have
revealed that specific nutrients may be necessary for the prevention of
some nutrient disorders such as:
 dental caries
 endemic goiter
 night blindness
 protein malnutrition
 anemia
 a host of other nutrient disorder

6. FIRST-AID AND EMERGENCY CARE:-

 first- aid and emergency care to pupils who become sick or injured on school
premises rests with the teacher and therefore all teacher should receive adequate
training during “teacher training programme” or “in- service training programme”
to prepare them to carry out this obligation
 Accidents leading to minor or serious injuries, medical emergencies such as
gastroenteritis, colic, epileptic fit, fainting etc.
 In every school a fully equipped first-aid-post should be provided as per
regulations of St. John Ambulance Association of India

7. MENTAL HEALTH:
 The mental health of the child affects his physical health and the learning process
 Juvenile delinquency, maladjustment and drug addiction are becoming problem
among school children
  The school is the most strategic place for shaping the child behaviour and
promoting mental health
 No distinction should be made between race, religion, caste, community, rich,
poor, clever and dull students
 It is now increasingly realized that there is a great need for vocational counselors
and psychologists in school for guiding the children into careers for which they
are suited
8. DENTAL HEALTH:
 Children frequently suffer from dental diseases and defects
 Dental caries and periodontal disease are the two common dental disease in India.
 A school health programme should have provision for dental examination, at least
once a year
 Preliminary inspection of the teeth and do prophylactic cleaning which is of great
value in preventing gum troubles and in improving personal appearance.

9. EYE HEALTH SERVICES:

 school should be responsible for the early detection of refractive error, treatment
of squint and amblyopia
 Detection and treatment of eye infection such as trachoma
 Administration of vitamin A to children at risk, has shown gratifying results.

10. HEALTH EDUCATION:-

 the most important element of the school health programme is health education
 The goal of health education are: To bring about desirable changes in health
knowledge , in attitude and in practice, and not merely to teach the children a set
of rules of hygiene
 Health education in school should cover the following area:- - personal hygiene,
environmental hygiene and family life
11. EDUCATION OF HANDICAPPED CHILDREN:
The ultimate goal is:-
 To assist the handicapped child and his family so that the child will be able to
reach his maximum potential.
 To lead as normal a life as possible
 To become as independent as possible
 To become a productive and self-supporting member of the society.

12. SCHOOL HEALTH RECORD:-

 A cumulative health record of each student should be maintained.
 Such records should contain:-
a. Identifying data- name, date of birth, parent’s name, address, etc.
 b. Past health history.
c. Record of finding of physical examination and screening tests and record of
service provided
 Purpose:-
a. To maintain cumulative information on the health aspect of school children.
b. To analyzing and evaluating school health programme and providing a useful link
between the home, school and community
PRIMARY HEALTH CENTRES:
 PHC’s are charged with the responsibility of administering school health services within
their jurisdiction
 It requires a whole time medical officer to cover 5000 to 6000 children a year
 School Health Committee (1961) has therefore recommended that the staff of the primary
health centres should be augmented by additional staff to carry out effectively the school
health programme
SCHOOL HEALTH COMMITTEES:
 School Health Committee (1961) in India recommended the formation of school health
committees at the village level, block level, district level, state level, and national level.
 These committees should mobilize community resources and make the school health
programme continous and self supporting
 The National School Health Council will be an advisory and coordinating body

SCHOOL HEALTH TEAM:

The members are as follows:
1. The school principal:
Responsibilities are:
 Ensure that school health program has the approval and support of school
administrative authority.
 Set up a school health committee to work out the school health plan and plan for
its implementation.
 Ensure that teachers are adequately trained for health care of school children.
 Make sure that proper health records are maintained. • Ensure that parents are
involved and follow up of the children is done.
2. The school teacher: Teacher is a key person because she is in continuous contact with the
students in a position to make observation of their health. Functions are as follows:
 Daily inspection of children for personal hygiene and cleanliness
 Daily observation of children for detecting any evidence from deviation from
normal health, behaviour, any communicable disease, malnutrition etc.
 Help in control of communicable disease
 Referral of child having any problem to school health clinic for further action
 Informing the parents and maintaining follow up
  Maintaining record of anthropometric measurement and other health record of
children
 Giving first aid and emergency care to children
 Imparting health education on healthful living habits and behaviour etc.
 Participate in investigation of epidemic or any communicable disease etc.
3. The parents:
 They can help in making assessment of health of children providing information
regarding past and present history of medical problems not only of the child but
also of other members of the family.
 They can participate and cooperate in physical and medical examination and
immunization of children.
 They can help in correction of defects if any and follow up of the children if
found sick.
 They can help in foundation of good healthful living habits and behaviour.
 Through parent ‘teacher association’ the parent can be involved in planning,
organizing and implementation of school health programme.
 Above all the parent must relieve the child’s work pressure at home so that the
child can take advantages of school.
 They need to be prepared for such participation in school health programme, they
can be educated while having Parent Teacher Association meetings.
4. The community:
The community can contribute by supporting school health program by:
 Providing suitable land for school building.
 Providing funds and labour in building proper school.
 Participation in school health committees or councils and contribute in
formulation of school health policies and plans.
 Participation in implementation of programme activities e.g. Conduct of medical
examination, immunization of children, maintenance of environmental sanitation,
health education activities.
 Motivating parents to send their children to school and take care of their health.

5. The children: The child has the responsibility to:

 Learn values of medical and health examinations, personal hygiene, good
nutrition, environmental sanitation etc.
 Cooperate in various aspects of school health programme.
 Develop positive habits and healthful living activities as educated upon
 Extends this knowledge to other members of the family, neighbourhood etc.

6. The medical officer: As being one the member of the team he is responsible for:
 Medical examination of the students
  Making diagnosis
 Prescribing treatment
 Making referral to services
 Ensuring follow up of children
 Initiating promotive and preventive programme
 Inspection of school environment and sanitation
 Holding meetings with parents and teachers
 Ensuring maintenance of records and reports
 Evaluation of the programme and redefining programme objectives and activities

7. The school health nurse/community health nurse:

 The community health nurse working in school health setting is responsible for
comprehensive health of the child.
 She takes care of all the factors which influence health of the child such as
biological aspect of the child, school and family environment, living activities,
personal habits, health behaviour followed by the child and his family members,
family and individual health history, family and community resources and their
utilization etc.

COMMUNITY MENTAL HEALTH

Introduction:

The methods of treating mental illness have changed dramatically in the past century.
Community mental health as a treatment philosophy was mandated by the Community Mental
Health Centers Act of 1963. Thus, bringing about the shift of mental health care from the
institution to the community, and heralding the era of deinstitutionalization.

Community mental health development in India:

 Phase I:
 Colonial period prior to India’s attaining independence.
 Establishment of lunatic asylums in different parts of the country.
 Phase II:
 During 1950s – Establishment of mental hospitals at Bangalore (1954), Amritsar
(1947), Hyderabad (1953), Srinagar (1958), Jamnagar (1960) and Delhi (1966).
 Phase III:
 During mid 1960s – Growth of general hospital psychiatry units.
 Phase IV:
 During 1970s – Extension of care from mental hospitals and general hospitals to
the primary health care centers and the community.
  Bengaluru and Chandigarh initiated pilot programs to develop and evaluate an
extension of mental health services for the rural underprivileged population.
 Phase V: – During 1990s
 Substantial increases in funding and improvement in the condition of many
mental hospitals.
 Voluntary and NGOs taking an active interest in various aspects of mental health.
 Growth of private sector in psychiatric services.
 Growth of private consultant psychiatrists.

General attitude towards of mentally ill:

 In general the community responds to the mentally ill through denial, isolation and
rejection.
 There is also a lack of understanding of mental illness as any other illness, and a
tendency to reject both the patient and those who treat them.
 Mentally ill are viewed as people with no capacity for understanding.
 People feel mental illness cannot be cured, and even if the patient gets better, complete
physical rest is considered essential.
 The mentally ill are being perceived as aggressive, violent and dangerous.

Community mental health:

Operationally community mental health means, “the process of involving in raising the
level of mental health among people in a community and reducing the number of those suffering
from mental disorders”.

Community mental health nursing:

Community mental health-psychiatric nursing is the application of specialized knowledge

to populations and communities to promote and maintain mental health, and to rehabilitate
populations at risk that continue to have residual effects of mental illness.

Goals of community mental health nursing:

 To provide prevention activities to populations for the purpose of promoting mental

health.
 To provide interventions as early as possible.
 To provide corrective learning experiences for client-groups who have deficits and
disabilities in the basic competencies needed to cope in society, and to help individuals
develop a sense of self-worth and independence.
 To anticipate when populations become at risk for particular emotional problems and to
identify and change social and psychological factors that diversely affect people's
interaction with their environments.
  To develop innovative approaches to primary prevention activities.
 To assist in providing mental health education to populations about mental health and
illness and to teach people how to assess their mental health.

The predominant characteristics of community psychiatry are:

 Responsibility to a population for mental health care delivery.

 Treatment close to the patient in community based centres.
 Provision of comprehensive services.
 Multi-disciplinary team approach.
 Providing continuity of care.
 Emphasis on prevention as well as treatment.
 Avoidance of unnecessary hospitalisation.

MODEL OF PREVENTIVE PSYCHIATRY:

Levels of prevention:

In the 1960s, psychiatrist Gerald Caplan described levels of prevention specific to

psychiatry. He described:

 Primary prevention as an effort directed towards reducing the incidence of mental

disorders in a community.
 Secondary prevention refers to decreasing the duration of disorder while;
 Tertiary prevention refers to reducing the level of impairment.

MENTAL HEALTH SERVICES:

1. PRIMARY LEVEL
 Prevention is geared to individuals and to larger specialized populations
 E.g. early childhood-parent education programs, infant stimulation programs,
early socialization programs such as play groups attempt to effect primary
prevention of mental disorders.
 Although these programs would be valuable for most families, they are
considered especially preventive in those families where there are more apparent
risk factors (e.g pregnant teenagers, homeless families etc.)
2. SECONDARY LEVEL
 It is provided by crisis intervention services, including hot lines, walk-in-services,
brief psychotherapy and hospitalization when necessary.
 Consumer education groups and self help groups also play a role in providing
support to individuals and families during period of increased stress or
exacerbation of symptoms of mental disorders.
 Psychoactive medications are also therapeutic measures of secondary prevention.
3. TERITERY LEVEL
 Need to be available in the form of family supports, home services, residential
placements and half way homes.
 Liaison workers, reliable friends, family members or sponsors are needed to be
helped to negotiate complex systems of care and to advocate for the client.
 Short term and long term hospitalization may be necessary for certain clients and
should be available as a part of the mental health service delivery system.

NURSES ROLE: Primary prevention:

 Individual centered intervention

 Antenatal care to the mother and educating her regarding the adverse effects of
irradiation, certain drugs and prematurity.
 Ensuring timely and efficient obstetrical assistance to guard against the ill effects
of anoxia and injury to the newborn at birth.
  Dietary corrections to those infants suffering from metabolic disorders. –
Correction of endocrine disorders.
 Liberalization of laws regarding termination of pregnancy, when it is unwanted.
 Training programs for physically, and mentally handicapped children like blind,
deaf, mute and mentally subnormal etc.
 Counseling the parents of physically and mentally handicapped children, with
particular reference to the nature of defects. The parents need to accept the child
and emotionally support the child and be satisfied with limited goals in the field
of achievement.
 Fostering bonding behaviors. Explaining importance of warm, accepting, intimate
relationship and avoiding the prolonged separation of mother and child are
essential.
 Interventions oriented to the child in the school –
 Teaching growth and development to parents and teachers.
 Identifying the problems of scholastic performance and emotional disturbances
among school children and giving timely intervention. School teachers can be
taught to recognize the beginning symptoms of problems and referring to
appropriate agencies.
 Family centered interventions to ensure harmonious relationship
 Consulting with parents about appropriate disciplinary measures.
 Promoting open health communication in families.
 Rendering crisis counseling to the parents of physically and mentally
handicapped children.
 Ensuring harmonious relationship among members of the family and teaching
healthy adaptive techniques at the time of stress producing events.
 Interventions oriented to keep families intact
 Extending mental health education services at Child Guidance Clinics about child
rearing practices; at parent- teacher associations regarding the triad relationship
between teacher, child and parent; and at various extramural health agencies
regarding integration of mental health into general health practice.
 Strengthening social support for the frustrated aged and helping them to retain
their usefulness.
 Promoting educational services in the field of mental health and mental hygiene.
 Developing parent-teacher associations.
 Rendering home-maker services –when there is absence of the mother from home
due to illness or other reasons for prolonged periods, the public health nurse can
arrange for the service.
 Providing marital counseling for those having marital problems.
 Interventions for families in crisis
  In developmental crisis situations such as the child passing through adolescence,
birth of a new baby, retirement or menopause, death of a wage earner in the
family, desertion by the spouse etc. crisis intervention can be given at
 Mental hygiene clinics
 Psychiatric first-aid centers
 Walk-in clinics
 Mental health education
 Conduct mass health education programs through film shows, flash cards and
appropriate audio-visual aids regarding prevention of mental illnesses and
promotion of mental health in the community.
 Educate health workers regarding prevention of mental illness so that they can
function effectively in all the areas of prevention.
 Society-centered preventive measures
 Community development Culturally deprived families need biological and
psychosocial supplies. They need better hygienic living conditions, proper food,
education, health facilities, and recreational facilities. Otherwise, psychopath,
alcoholism, drug addiction, crime and mental illness, will result in such situations.
 Collection and evaluation of epidemiological, bio- statistical data.

Nurses role : Secondary prevention

 Early diagnosis and case finding:

 This can be achieved by educating the public, community leaders, industrialists,
Mahila mandals, Balwadis etc. in how to recognize early symptoms of mental
illness.
 Case finding through screening and periodic examination of population at risk,
monitoring of clients etc.
 Thus in clinics, schools, home health care and the work place, community mental
health nurses detect early signs of increased levels of anxiety, decreased ability to
cope with stress and failure to perceive self, the environment and/ or reality
accurately, and provide direct services as appropriate.
 Early reference:
 The public should be educated to refer these cases to proper hospitals as soon as
they recognize early symptoms of mental illness.
 Screening programs :
 Simple questionnaires should be developed to identify the symptoms of mental
illness, and administration of the same in the community for early identification
of cases.
 These questionnaires can be simplified in local languages, and used widely in the
colleges, schools, industries etc.
  Early and effective treatment for patient, and if necessary, to family members as relevant;
providing counseling services to caregivers of mentally ill patients.
 Training of health personnel :
 Orientation courses should be provided to health workers to detect cases in the
course of their routine work.
 Consultation services :
 Nurses working in general hospitals may come across various conditions such as
puerperal psychosis, anxiety states, peptic ulcer, ulcerative colitis, bronchial
asthma etc.
 These basic care providers need guidance and consultation to deal with these
conditions in an effective manner.
 Crisis intervention :
 If crisis is not tackled in time it may lead to suicide or mental disorders.
 Sometimes anticipating the crisis situation and guiding the individual in time can
help them to cope with the crisis situation in a better way.

Role of a Nurse in Tertiary Prevention:

 Family members should be involved actively in the treatment program so that effective
follow-up can be ensured.
 Occupational and recreational activities should be organized in the hospital so that idling
is prevented.
 Community based programs can be launched through meeting with the family members
when the need for discharge from the hospital should be emphasized.
 These programs can be implemented through day hospitals, night hospitals, after care
clinics, half-way homes, ex-patient hostels, foster care homes etc.
 Follow up care can be handed over to community health nurses.
 There should be constant communication between the community health nurses and the
mental health institution regarding the follow up of the discharged patient.
 The ultimate aim of the hospital and community based programs is to re-socialize and re-
motivate the patient for a functional role in the community, consistent with his resources.
 There are a wide range of services that need to be provided to patients as part of the
tertiary prevention program.
 Nurses need to be familiar with the agencies in the community that provide these
services.
 Collaborative relationships between mental health care providers and community
agencies are absolutely essential if rehabilitation is to succeed.
 Nurses in the community are in a key position to monitor community attitudes and help
in fostering a realistic attitude towards the mentally ill.
  Nurses working with families need to foster healthy attitudes towards the mentally ill
member.

Community Facilities For Psychiatric Patients:

In the community, seven provisions are required to replace long-term care in hospital:

1. Suitable well-supported carers

2. Suitable accommodation
3. Suitable occupation
4. Arrangements to ensure the patient's collaboration with treatment.
5. Regular reassessment, including assessment of physical health
6. Effective collaboration amongst carers
7. Continuity of care and rapid response to crises

Some facilities available include:

 Psychiatric hospitals: – Hospitals have become part of a continuum of mental health

services available to patients and their families, and offer a variety of treatments for
psychiatric disorders.
 Partial hospitalization: – Partial hospitalization is an innovative alternative to
hospitalization. It is ideally suited to most of the psychiatric syndromes, particularly
chronic psychotic disorders, neurotic conditions, personality disorders, drug and alcohol
dependence and mental retardation. Day care centers, day hospitals and day treatment
programs come under partial hospitalization.

Advantages of partial hospitals:

Lesser separation from families,

more involvement in the treatment program – lessening of patient's preoccupation
with the illness, which may be intensified by full hospitalization.
 E.g. Sanjivini, New Delhi; SCARF, Chennai; Association of the Friends of Mentally
Ill, Mumbai; Institute of Mental Health, Ahmedabad; Psychiatric Center, Kolkata;
NIMHANS, Bangalore.
 Quarter way homes:
This is a place usually located within the hospital campus itself, but not having
the regular services of a hospital. There may not be routine nursing staff or routine
rounds, and most of the activities of the place are taken care of by the patients
themselves. Examples of such homes are 13th and 14th psychiatric wards of NIMHANS
at Bangalore.
 Halfway home:
 A halfway home is a transitory residential center for mentally ill patients who no
longer need the full services of a hospital, but are not yet ready for a completely
independent living. It attempts to maintain a climate of health rather than of illness, and
to develop and strengthen individual capacities. At the same time it enables the
recognition of problems that require medical attention, and permits the discovery of
conditions in the community which are acting adversely on the individual. Thus, halfway
homes have a major role in the rehabilitation of the mentally ill individual.

Objectives of Half way homes :

 To ensure a smooth transition from the hospital to the family.

 To integrate the individual into the mainstream of life.

Activities of half way homes:

 Community mental health nurses play a vital role in monitoring the progress of
discharged patients in halfway homes, especially with regard to their medication regimen
and coordination of care.
 E.g. Medico-Pastoral Association, Bangalore; Atmashakti Vidyalaya, Bangalore;
Richmond Fellowship, Bangalore; Puraskara Aftercare Home, Bangalore.

Self-help groups:

 Self-help groups are composed of people who are trying to cope with a specific problem
or life crisis, and have improved the emotional health and well being of many people.
 Usually organized with a particular task in mind, such groups do not attempt to explore
individual psychodynamics in great depth or to change personality functioning
significantly.
 E.g. Alcoholic Anonymous (AA), Association for Mentally Disabled (AMEND). •
Suicide prevention centres:
 There are many suicide prevention centers in India in the voluntary sectors doing good
work and helping those in need. Some of them are: • Helping Hands and MPA in
Bangalore; • Sneha in Chennai [+91(0)4424640050, +91 (0) 44 2464 0060] • Sahara in
Mumbai • Sanjivini and Sumaitri (Helpline 1: 2338 9090) in New Delhi

National Mental Health Program

Launched in 1982 in India

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 service development and to
stimulate efforts towards self-help in the community.

Aims of NMHP:

 Prevention and treatment of mental and neurological disorders and their associated
disabilities.
 Use of mental health technology to improve general health services.
 Application of mental health principles in total national development to improve quality
of life

Approaches of NMHP:

 Integration of mental health care services with the existing general health services.
 Utilization of the existing infrastructure of health services and also deliver the minimum
mental health care services.
 Provision of appropriate task-oriented training to the existing health staff.
 Linkage of mental health services with the existing community development program.

Strategies of NMHP:

 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.

Components of NMHP:

1. Treatment: Multiple levels were planned.

 A Village and sub-center level multipurpose workers (MPW)and health supervisors
(HS), under the supervision of medical officer(MO) to be trained for:
 management of psychiatric emergencies
 administration and supervision of maintenance treatment for chronic
psychiatric disorders
 diagnosis and management of grand-mal epilepsy, especially in children
 liaison with local school teachers and parents regarding mental retardation
and behavioral problems in children
 counseling in problems related to alcohol and drug abuse
 Medical Officer of Primary Health Centre (PHC)aided by HS, to be trained for:
  supervision of MPW's performance
 elementary diagnosis
 treatment of functional psychosis
 treatment of uncomplicated cases of psychiatric disorders associated with
physical diseases
 management of uncomplicated psychosocial problems
 epidemiological surveillance of mental morbidity
 District hospital:
 It was recognized that there should be at least one psychiatrist attached to
every district hospital as an integral part of the district health services.
 The district hospital should have 30- 50psychiatric beds.
 The psychiatrist in a district hospital was envisaged to devote only a part of
his time to clinical care and a greater part in training and supervision of non-
specialist health workers.
 Mental hospitals and teaching psychiatric units: Major activities of these higher
centers of psychiatric care include:
 help in care of 'difficult' cases
 Teaching
 specialized facilities like, occupational therapy units, psychotherapy,
counseling and behavioral therapy
2. Rehabilitation:
 The components of this sub-program include treatment of epileptics and psychotics
at the community levels and development of rehabilitation centers at both the district
level and higher referral centers.
3. Prevention
 The prevention component is to be community based, with initial focus on
prevention and control of alcohol-related problems.
 Later on, problems like addictions, juvenile delinquency and acute adjustment
problems like suicidal attempts are to be addressed.

CARE OF ELDERLY

Introduction:

Over the past few years, the world’s population has continued on its remarkable transition
path from a state of high birth and death rates to low birth and death rates coupled with
improvement in health services & standard of living. At the heart of this transition has been the
growth in the number and proportion of older persons. Such a rapid, large and ubiquitous growth
has never been seen in the history of civilization. The current demographic revolution is
predicted to continue well into the coming centuries.
Changing world Scenario:

 The world will have more people who live to see their 80s or 90s than ever before.
 The past century has seen remarkable improvements in life expectancy.
 Soon, the world will have more older people than children.
 The world population is rapidly ageing.
 Low- and middle-income countries will experience the most rapid and dramatic
demographic change.

Ageing: Indian scenario:

India is one of the few countries in the world where sex ratio of aged is in favour of males.

 Population above 60 years

 10% suffer from impaired physical mobility.
 10% Hospitalized at given point of time.
 Age more than 70 years
 More than 50% suffer form 1 or more chronic conditions like CHD, Cancer and
HT .
HEALTH PROBLEMS IN OLD AGE:

1. Mental health problems:

Multiple social, psychological, and biological factors determine the level of mental health
of a person at any point of time. As well as the typical life stressors common to all
people, many older adults lose their ability to live independently because of limited
mobility, chronic pain, frailty or other mental or physical problems, and require some
form of long-term care. In addition, older people are more likely to experience events
such as bereavement, a drop in socioeconomic status with retirement, or a disability. All
of these factors can result in isolation, loss of independence, loneliness and psychological
distress in older people.
a. Dementia
Dementia is a syndrome in which there is deterioration in memory,
thinking, behaviour and the ability to perform everyday activities. It mainly
affects older people, although it is not a normal part of ageing. It is estimated that
47.5 million people worldwide are living with dementia. The total number of
people with dementia is projected to increase to 75.6 million in 2030 and 135.5
million in 2050, with majority of sufferers living in low- and middle-income
countries.
b. Depression
Depression can cause great suffering and leads to impaired functioning in
daily life. Unipolar depression occurs in 7% of the general elderly population and
it accounts for 5.7% of YLDs among over 60 year olds. Depression is both under
diagnosed and undertreated in primary care settings. Symptoms of depression in
older adults are often overlooked and untreated because they coincide with other
problems encountered by older adults.
c. Abuse: Elder abuse is a general term used to describe certain types of harm to
older adults. Other terms commonly used include: "elder mistreatment", "senior
abuse", "abuse in later life", "abuse of older adults", "abuse of older women", and
"abuse of older men".
 Physical abuse: (hitting, slapping, burning, pushing, restraining or giving
too much medication or the wrong medication)
 Psychological abuse: (shouting, swearing, frightening, blaming, ignoring
or humiliating a person)
 Financial abuse: (the illegal or unauthorized use of a person’s property,
money, pension book or other valuables)
 Sexual abuse: (forcing a person to take part in any sexual activity without
his or her consent - this can occur in any relationship)
 Neglect: (where a person is deprived of food, heat, clothing or comfort or
essential medication)
  An older person may either suffer from only one form of abuse, or
different types of abuses at the same time
2. Physical health problems among older adults:
CV System:
a. Hypertension
b. Ischemic heart disease
c. Heart failure
d. Peripheral vascular disease
e. Varicose veins
f. Stroke attack

Nursing intervention:

 Exercise regularly, pace activities

 Avoid smoking
 Eat a low fat, low salt diet
 Weight control
 Check blood pressure regularly
 Participate in stress reduction activities
 Regular medication

Respiratory system:

a. Chronic pneumonia
b. Obstructive pulmonary disease
c. Dyspnoea
d. Breathlessness

Nursing intervention:

 Deep breathing exercise regularly

 Avoid smoking
 Take adequate fluids
 Prevent pulmonary infections
 Avoid crowds during cold and flu season
 Wash hands frequently

Neurologic Behaviour:

a. • Parkinsonism-characterized by tremor, rigidity, slowness of movement

b. Alzheimer disease- loss of short term memory, deterioration in behavior and slowness
of thought
c. Dementia- it is a chronic or persistent disorder of behavior and higher intellectual
function due to organic brain disease.
d. Depression, anxiety
e. Sleep disturbance

Nursing intervention:

 Advice for hospitalization and encourage visitors

 Teach fall prevention technique
 Environmental safety like sufficient light, proper chairs for seating, elevated toilet
seats
 Encourage slow rising from a resting position
 Reduce the risk of falls

Gastrointestinal System:

a. Problem with speech, chewing and swallowing

b. Constipation
c. Colon gas and fecal impaction
d. Diarrhea
e. Gastro esophageal reflux or hernia
f. Fecal incontinence, prolapsed rectum
g. Dysphagia, anorexia

Nursing intervention:

 Use ice chips

 Mouth wash, brush, massage gums daily
 Eat small quantity, frequent meals
 Eat high fiber, low fat diet, limit laxatives
 Toilet regularly
 Drink adequate fluid
 For appetite serve food attractively and different types of foods

Urinary system:

a. Renal insufficiency
b. Urinary incontinence
c. Urinary tract infection
d. Enlarged prostate
e. Sexual dysfunction
Nursing intervention:

 Regular supervision is necessary

 Ready access to toilet
 Drink adequate fluids
 Avoid bladder irritants e.g. alcohol, caffeine
 Practice pelvic floor muscle exercise
 Maintain perineal hygiene
 Skin should be clean and dry. Apply cream
 Clean underclothes

Reproductive system:

a. Female: breast cancer, cervical cancer , Painful intercourse, Vaginal bleeding, vaginal
itching and irritation
b. Male: prostate cancer, Delayed erection

Nursing intervention:

 Health and sexual counseling

 Advice about personal hygiene

Musculoskeletal system:

a. Paget’s disease
b. Osteoporosis
c. Osteomalacia
d. Rheumatoid arthritis
e. Spondilosis
f. Complaints of back pain and joint pain
g. Stiffness of joints
h. Fractures •
i. Foot pathology gait disturbance

Nursing intervention:

 Exercise regularly
 Eat high calcium diet
 Limit phosphorus intake
 Hormones and calcium supplements may be prescribed

Vision and hearing:

a. Visual impairment
 b. Hearing impairment
c. Diminished smell or taste

Nursing intervention:

 Wear eye glasses or sun glasses

 Use adequate indoor lighting with area light and night light
 Use magnifier for reading
 Use large lettering to label medication
 Avoid night driving
 Advice for hearing examination
 Allow the individual more time to adjust to the environment
 Use gestures and object to help with verbal communication
 Speak slowly and clearly

Dermatologic:

a. Pressure sores
b. Herpes zoster
c. Dermatitis
d. Pruritus
e. bone structure is prominent

Nursing Intervention:

 Avoid solar exposure

 Cloth dress appropriately for temperature
 Maintain a safe indoor temperature
 Bath only 1-2 times weekly
 Excessive use of soap should be avoided
 Apply cream for lubricate skin

HEALTH PROMOTION IN ELDERLY:

 Exercise and activity:

 Balance between exercise and activity is most important for elder person as it
decrease risk of many health issues
 Exercise also improve nutrition and reduce stress. In addition it decrease risk of
hypertension or maintain blood pressure in hypertensive elder person. It increase
oxygen saturation and increase lungs capacity
 Elder person should do exercise on regular basis as tolerated. They should do light
exercise like walking and slow running.
  Nutrition and diet:
 Maintenance of nutritional status in elder persons are also important because with
increase in age digestive capacity diminish. The nutrition should be well balance
that has higher amount of calcium, iron and other essential nutrients. Following
things should be considered by elder person regarding diet
 Meal time should be kept simple and calm.
 Food is cut in to small pieces to prevent choking.
 Liquids food may be easier to swallow.
 Temperature of the food should be checked to prevent burns.
 Encourage for good mouth care.
 Avoid alcohol.
 Review all prescription and over the counter medication with patient and evaluate
nutritional status
 Stress management:
 By the time individuals reach 60-70 yrs of age , they have experienced numerous
losses, and stress has become a life long process.
 In addition hormonal changes also cause stress among elderly. So stress
management is essential for them.
 Long term stress cause hypertension, stroke and heart disease. Explain older
person about stress management techniques like yoga, exercise meditation etc.
 Self care and responsibility:
 Older person also need to learn about self care and responsibility. So following
instruction can be given to them about self care:
 Monitor blood pressure and blood sugar regularly.
 Diet control and balance diet.
 Stop alcohol consumption and smoking
 Get vision and hearing checked periodically.
 Advice to take proper rest and sleep.
 Exercise regularly.

MAJOR GOVERNMENT INITIATIVES:

1. National Policy On Older Persons (NPOP) -1999

Components:
 Support for financial security
 Health Care
 Shelter
 Welfare and other needs of older persons
 Protection against abuse and exploitation
 Opportunities for development of the potential of older persons
  Improving quality of life

NPOP AGENDA FOR HEALTH CARE FOR THE ELDERLY:

 Geriatric ward for elderly at all DH

 Treatment facilities for chronic, terminal and degenerative diseases
 Providing Improved medical facilities at CHCs / PHCs / Mobile Clinics
 Inclusion of geriatric care in the syllabus of medical courses including courses for
nurses
 Reservation of beds for elderly in public hospitals
 Training of Geriatric Care Givers
 Research institutes for chronic elderly diseases such as Dementia & Alzheimer

2. Maintenance and welfare of parents and senior citizens Act-2007

a. Article (20): the state government shall ensure:
 The Government hospital or Govt. funded hospitals shall provide beds for
senior citizens as far as possible.
 Separate queues be arranged for senior citizens.
 Facility for treatment of chronic, terminal and degenerative diseases is
expanded for senior citizens
 Research activities for chronic elderly diseases and ageing is expanded
 Earmarked facilities for geriatric patients in every district hospital.

3. National Programme for Health Care of elderly (NPHCE-2010)

Vision:
 To provide accessible, affordable, and high- quality long-term, comprehensive
and dedicated care services to an Ageing population;
 Creating a new “architecture” for Ageing;
 To build a framework to create an enabling environment for “a Society for all
Ages”;
 To promote the concept of Active and Healthy Ageing;
 Convergence of NRHM, AYUSH & all other dept.

Objectives:

 To provide an easy access to promotional, preventive, curative and rehabilitative

services to the elderly through community based primary health care approach
 To identify health problems in the elderly and provide appropriate health
interventions in the community with a strong referral backup support.
 To build capacity of the medical and paramedical professionals as well as the
care-takers within the family for providing health care to the elderly.
  To provide referral services to the elderly patients through district hospitals,
regional medical institutions

Strategies for NPHCE 2010:

EXPECTED OUTCOME OF NPHCE:

 Regional Geriatric Centres (RGC) in 8 Regional Medical Institutions

 Post-graduates in Geriatric Medicine (16) from the 8 regional medical institutions;
 Video Conferencing Units in the 8 Regional Medical Institutions to be utilized for
capacity building and mentoring;
 District Geriatric Units
 Geriatric Clinics/Rehabilitation units
  Sub-centres
 Training of Human Resources

PACKAGE OF SERVICES:

The range of services will include:

 Health promotion
 Preventive services
 Diagnosis and management of geriatric medical problems (out and in-patient)
 Day care services
 Rehabilitative services
 Home based care
 Districts will be linked to Regional Geriatric Centers for providing tertiary level care.
 Integration with existing primary health care delivery system and vertical at district and
above as more specialized health care are needed for the elderly.

Services at PHC:

 Weekly geriatric clinic by a trained Medical Officer

 Conducting a routine health assessment (eye, BP, blood sugar & record keeping).
 Provision of medicines and proper advice on chronic ailments
 Public awareness on promotional, preventive and rehabilitative aspects of geriatrics
during health and village sanitation day/camps.
 Referral services.
Services at Sub-Centre:

 Health Education related to healthy ageing ◦ Domiciliary visits to home bound /

bedridden elderly persons .
 Arrange for suitable calipers and supportive devices.
 Linkage with other support groups and day care centers.

Services at Community Health Centre:

 First Referral Unit (FRU) for the Elderly from PHCs and below.
 Geriatric Clinic for the elderly persons twice a week.
 Rehabilitation Unit for physiotherapy and counselling
 Domiciliary visits by the rehabilitation worker for bed ridden elderly and counselling of
the family members on their home-based care.
 Health promotion and Prevention
 Referral of difficult cases to District Hospital/higher health
Services at District Hospital:

 Geriatric Clinic for regular dedicated OPD services to the Elderly with Lab facility &
adequate medicine.
 Ten-bedded Geriatric Ward with existing specialties
 Provide services to referred by the CHCs/PHCs etc.
 Conducting camps for in PHCs/CHCs and other sites.
 Referral services to tertiary level hospitals

Services at Regional Geriatric Centre:

 30-bedded Geriatric Ward for in-patient care and dedicated beds for the elderly patients
in the various specialties.
 Laboratory investigation required for elderly with a special sample collection centre in
the OPD block.
 Tertiary health care to the cases referred from medical colleges, district hospitals and
below.

Activities under NPHCE at various levels:

 At Sub Centre level:

 Health Education related to healthy ageing, environmental modifications,
nutritional requirements, life styles and behavioural changes.
 Special attention to home bound / bedridden elderly persons and provide training
to the family health care providers in looking after the disabled elderly persons.
 Arrange suitable callipers and supportive devices from the PHC.
 Linkage with other support groups and day care centres etc. operational in the
area.
 At PHC level:
 The weekly geriatric clinic by trained medical officer.
 Coordination with CHC, district hospital, sub centers, other National Health
Programmes/ Departments for medicines, ambulances
 Training of manpower & Separate registration counter for elderly.
 Public awareness during health and village sanitation day/camps.
 Provision of medicine to the elderly for their medical ailments.
 At CHC level:
 First level medical referral centre for medical care and rehabilitation services
 Twice weekly health clinics for the elderly persons
 Rehabilitation unit
 Domiciliary visits for care of disabled persons by Multi rehabilitation worker
 Referral Services to DH
  Training of staff
 At District Hospital level:
 Regular Geriatric OPD with Specialty Care for Elderly.
 Geriatric Ward (10-bedded) for in-patient care to the Elderly.
 Training to the Medical officers and paramedical staff of CHC’s and PHC’s
 Camps for Geriatric Services in PHCs/CHCs and other sites
 Referral services for severe cases to tertiary level hospitals/ Regional Geriatric
Centers
 At Regional Geriatric Center level:
 Provide tertiary level services for complicated/serious Geriatric Cases.
 Post graduate courses in Geriatric Medicine.
 Training to the trainers of identified District hospitals and Medical Colleges.
 Developing evidence based treatment protocols for Geriatric diseases prevalent in
the country.
 Developing/and updating Training modules & guidelines and IEC materials.
 Research on specific elderly diseases.
 State level:
 State will monitor release of funds and expenditure incurred under various
components of the programme in the State.
 Submit monthly statement of expenditure in the prescribed format to the State
Health Society

Role of Nurse in elderly:

1. Healer
 Nursing plays a significant role in helping individuals stay well, overcome or
cope with disease restore function and purpose in life and mobilize internal and
external resources.
 In this healer role, gerontological nurse recognizes that most human beings value
health, are responsible and active participants in their health maintenance and
illness management, and desires harmony and wholeness with their environment.
 Holoistic approach is essential viewed in context of their biological, emotional,
social, cultural and spiritual elements.
2. Care giver
 Conscientious application of Nursing process to care of elders.
 Inherit in this role is the active participation of older adults and their significant
others and promotion of highest degree of self care in elderly.
 Providing care, efficiency and best interest that rob them of their existing
independence.
3. Educator
  Formal and informal opportunities to share knowledge, skills related to care of
older adults.
 Educating others including normal aging, pathophysiology, geriatric
pharmacology and resources.
 Essential to this role is effective communication involving listening, interacting,
clarifying, coaching, validating and evaluating.
4. Advocate
 Advocacy including aiding older adults in asserting their rights and obtaining
required services, facilitating a community or other group’s effort to affect change
and achieve benefits for older adults.
5. Innovator
 Assumes an inquisitive style, making conscious decisions and efforts to
experiment for an end result to improved gerontological practices.

OCCUPATIONAL HEALTH

Definition:

"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 among
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 equipment, and, to summarize, the adaptation of work to man and of each man to
his job.

(The Joint ILO/WHO Committee on Occupational Health,1950)

Ergonomics:

 The term “ergonomics” is derived from the Greek word ‘ergon’, meaning work and
‘nomos’ meaning law
 It simply means “fitting the job to the worker”

Objective

 The maintenance and promotion of workers’ health and working capacity

 The improvement of working environment and work to become conducive to safety and
health
  Development of work organizations and working cultures in a direction which supports
health and safety at work and in doing so also promotes a positive social climate and
smooth operation and may enhance productivity of the undertakings

Occupational hazards:

a. Physical hazards:
 Heat and cold:
 Heat: The direct effects are: Burns, Heat exhaustion, Heat stroke , Heat
cramps The indirect effects are: Decreased efficiency, Increased fatigue,
Enhanced accident rates.
 Cold effects are: Chilblains, Erythrocyanosis, Immersion foot, Frostbite as
a result of cutaneous vasoconstriction, General hypothermia
 Light:
 The acute effects of poor illumination are: Eye strain, Headache, Eye
pain, Lacrymation, Congestion around the cornea, Eye fatigue.
 The chronic effects on health include "miner's nystagmus"
 Noise:
 Auditory effects: Temporary or permanent hearing loss
 Non auditory effects: Nervousness, Fatigue, Interference with
communication by speech, Decreased efficiency, annoyance
 Vibration: Exposure to vibration may also produce injuries of the joints of the
hands elbows and shoulders.
 Ultraviolet radiation: Conjunctivitis, Keratitis (welder's flash)
 Ionizing radiation:
 The radiation hazards comprise Genetic changes, Malformation, Cancer,
Leukaemia, Depilation, Ulceration, Sterility, in extreme cases death.
 The International Commission of Radiological Protection has set the
maximum permissible level of occupational exposure at 5 rem per year to
the whole body
b. Chemical hazards
 Local action: dermatitis Eczema Ulcers Cancer by primary irritant action
 Inhalation
 Dusts:
 Dusts are finely divided solid particles with size ranging from 0.1
to 150 microns
 Dust particles larger than 10 microns settle down from the air
rapidly
  Particles smaller than 5 microns are directly inhaled into the lungs
and are retained there and is mainly responsible for
pneumoconiosis
 Gases:
 Simple gases (e.g., oxygen, hydrogen),
 Asphyxiating gases (e.g. carbon monoxide, cyanide gas, sulphur
dioxide, chlorine)
 Anaesthetic gases (e.g., chloroform, ether, trichlorethylene)
 Metals and their compounds: Lead, antimony, arsenic, beryllium,
cadmium, cobalt, manganese, mercury, phosphorus, chromium, zinc and
others
 Ingestion : Occupational diseases may also result from ingestion of chemical
substances such as lead, mercury, arsenic, zinc, chromium, cadmium, phosphorus
c. Biological hazards: Brucellosis, Leptospirosis, Anthrax, Hydatidosis, Tetanus,
Encephalitis, fungal infections, Schistosomiasis and a host of others
d. Mechanical hazards: about 10% of accidents in industry are said to be due to mechanical
causes.
e. Psychosocial hazards: Frustration, Lack of job satisfaction, Insecurity, Poor human
relationships, Emotional tension
 Psychological and behavioural changes: anxiety, depression, alcoholism, drug
abuse etc
 Psychosomatic ill health: fatigue, headache, pain in the shoulders, neck and pain,
hypertension, heart disease

Occupational Diseases:

I. Diseases due to physical agents:

1) Heat: heat hyperpyrexia, heat exhaustion, heat syncope, heat cramps, burns and
local effects such as prickly heat
2) Cold: trench foot, frost bite, chilblains
3) Light: occupational cataract, miner’s nystagmus
4) Pressure: caisson disease, air embolism, blast
5) Noise: occupational deafness
6) Radiation: cancer, leukaemia, aplastic anemia, pancyopenia
7) Mechanical factors: injuries, accidents
8) Electricity :Burns
II. Diseases due to chemical agents
1. Gases
2. Dusts (Pneumoconiosis):
i. Inorganic dusts:
a. Coal dust – Anthracosis
 b. Silica – Silicosis
c. Asbestos – Asbestosis, cancer lung
d. Iron - Siderosis
ii. Organic dusts:
a. Cane fibre – Bagassosis
b. Cotton dust – Byssinosis
c. Tobacco – Tobacossis
d. Hay or grain dust - Farmers lung
3. Metals and their compounds: toxic hazards from lead, mercury, cadmium,
manganese, beryllium, arsenic, chromium etc
4. Chemicals: acids, alkalies, pesticides
5. Solvents: carbon bisulphide, benzene, trichloroethylene, choloform etc
III. Diseases due to biological agents:
 Brucellosis, leptospirosis, anthrax, actinomycosis, hydatidosis, psittacosis,
tetanus, encephalitis, fungal infections etc
IV. Occupational cancers:
 Cancer of skin, lungs, bladder
V. Occupational dermatosis:
 Dermatitis, eczema
VI. Diseases of psychological origin:
 Industrial neurosis, hypertension, peptic ulcer etc

PNEUMOCONIOSIS

Dusts within the range of 0.5 micron to 3 micron is a health hazard producing, after a
variable period of exposure, a lung disease known as pneumoconiosis, which may gradually
cripple a man by reducing his work capacity due to lung fibrosis and other complications.

1. Silicosis:
 Caused by inhalation of dust containing free silica or silicon dioxide
 Snow storm appearance in X-ray
 There is no effective treatment for silicosis
 Controlled by: rigorous dust control measures and regular physical examination of
workers
2. Anthracosis:
 It is caused by inhalation of dust containing coal miners.
 First phase is called simple pneumoconiasis which is associated with little
impairment.
  Second phase is characterized by Progressive massive fibrosis: this causes
severe respiratory disability and frequently results in premature death.
3. Byssinosis:
 Inhalation of cotton fibre dust over long periods of, time.
 The symptoms are Chronic cough, Progressive dyspnoea, Chronic
bronchitis, Emphysema
4. Bagassosis:
 Caused by inhalation of bagasse or sugar-cane dust.
 Bagassosis has been shown to be due to a thermophilic actinomycet for
which the name.
 The symptoms are Breathlessness, Cough, haemoptysis, slight fever.
 Preventive measures includes Dust control (wet process, enclosed
apparatus, exhaust ventilation), Personal protection, Medical control
(initial and periodic medical examination), Bagasse control (keeping the
moisture content above 20% and spraying the bagasse with 2% propionic
acid
5. Asbestosis:
 Asbestos is of two types- serpentine or chrysolite variety and amphibole
type.
 Clinically the disease is characterized by dyspnea, Clubbing of fingers,
Cardiac distress and cyanosis.
 The sputum shows "asbestos bodies"
 An X-ray of the chest shows a ground-glass appearance in the lower two
thirds of the lung fields.
 PREVENTIVE MEASURES: Use of safer types of asbestos (chrysolite
and amosite) , Substitution of other insulants: glass fibre, mineral wool,
calcium silicate, plastic foams, etc., Rigorous dust control, Periodic
examination of workers; biological monitoring (clinical, X-ray, lung
function), and Continuing research.
6. Farmer's lung:
 Farmer's lung is due to the inhalation of mouldy hay or grain dust.
 Acute illness is characterized by general and respiratory symptoms and
physical signs.
 Repeated attacks cause pulmonary fibrosis and inevitable pulmonary
damage and corpulmonale.

LEAD POISONING:

 Mode of absorption : (1) inhalation. (2) ingestion. (3) skin

 CLINICAL PICTURE:
  The toxic effects of inorganic exposure -abdominal colic, Constipation,
loss of appetite, blue-line on the gums, stippling of red cells, Anaemia,
wrist drop, foot drop.
 The toxic effects of organic lead compounds are mostly on the central
nervous system: Insomnia, Headache, Mental confusion, Delirium.
 DIAGNOSIS:
 History of lead exposure
 clinical features like loss of appetite, intestinal colic, persistent headache,
weakness, abdominal cramps, constipation, joint and muscular pains, blue line on
gums, anemia
 laboratory tests:
i. (Coproporphyrin in urine (CPU),
ii. Amino levulinic acid in urine (ALAU),
iii. Lead in blood and urine,
iv. Basophilic stipling of RBC)
 PREVENTIVE MEASURES: Substitution, Isolation, Local exhaust ventilation, Personal
protection, Good house-keeping, Working atmosphere- Periodic examination of workers,
Personal hygiene, Health education

OCCUPATIONAL CANCER:

 Skin cancer: gas workers, oil refiners, tar distillers, oven workers.
 Lung cancer: gas industry, nickle and chromium work, mining of radio active substance
 Bladder cancer: dye stuff, dyeing industries, rubber, gas and electrical cable industry.
 Leukemia: benzol, roengent rays and radioactive substance.
 The control measures: Elimination or control of industrial carcinogens, Medical
examinations, Inspection of factories, Notification, Licensing of establishments, Personal
hygiene measures, Education of workers and management, research.

OCCUPATIONAL DERMATITIS:

Causes:

 Physical: heat, cold, moisture, friction, pressure, x-rays, and other rays
 Chemical: acids, alkalis, dyes, solvents, grease, tar, pitch, chlorinated phenols etc
 Biological: virus, bacteria, fungi and other parasites
 Plant products: leaves, vegetables, fruits, flowers, vegetable dust etc

Classification of dermatitis producing agents:

a. Primary irritants
b. Sensitizing substances
Prevention:

a. Pre-selection:
 Workers should be medically examined before employment
b. Protection: by providing protective cloths, long leather gloves, aprons and boots
c. Personal hygiene,
d. Periodic inspection (periodical medical checkup)

RADIATION HAZARDS:

Effects of radiation:

 Acute Burns, dermatitis and blood dyscrasias

 Chronic exposure may cause malignancies and genetic effects
 Lung cancer may develop in miners working in uranium mines due to inhalation
of radio-active dust

Preventive measures:

 Inhalation, swallowing or direct contact with the skin should be avoided

 In-case of x-rays, shielding should be used
 Employees should be monitored at intervals
 Suitable protective clothing
 Adequate ventilation of work place
 Replacement and periodic examination
 Pregnant women should not be allowed to work in places where there is continuous
exposure

OCCUPATIONAL HAZARDS OF AGRICULTURAL WORKERS:

1. ZOONOTIC DISEASES :
 The close contact of the agricultural worker with animals or their products
increases the likelihood of contracting certain zoonotic diseases such as
brucellosis, anthrax, leptospirosis, tetanus, tuberculosis (bovine) and Q fever.
2. ACCIDENTS :
 Agricultural accidents are becoming more frequent, even in developing countries,
as a result of the increasing use of agricultural machinery.
 Insect and snake bites are an additional health problem in India.
3. TOXIC HAZARDS :
 Chemicals are being used increasingly in agriculture either as fertilizers,
insecticides or pesticides. Agricultural workers are exposed to toxic hazards from
these chemicals.
 Associated factors such malnutrition and parasitic infestation may increase
susceptibility to poisoning at relatively low levels of exposure.
4. PHYSICAL HAZARDS :
 The agricultural worker may be exposed to extremes of climatic conditions such
as temperature, humidity, solar radiation, which may impose additional stresses
upon him.
 He may also have to tolerate excessive noise and vibrations, inadequate
'ventilation and the necessity of working in uncomfortable positions for long
periods of time.
5. RESPIRATORY DISEASES :
 Exposure to dusts of grains, rice husks, coconut fibres, tea, tobacco, cotton, hay
and wood are common where these products are grown.
 The resulting diseases - e.g., byssinosis, bagassosis, farmer's lung and
occupational asthma, appear to be widespread.

ACCIDENTS IN INDUSTRY

Causes:

1. HUMAN FACTORS :
a. PHYSICAL:
 The physical capabilities of the worker may not meet the job
requirements; his visual acuity may be inadequate; his hearing may be
inadequate.
b. PHYSIOLOGICAL FACTORS :
 Sex : Studies have shown that women are known to have less accidents
than men, doing comparative jobs.
 Age : Younger ages are known to be involved more in accidents than older
age groups.
 Time : Accidents are minimum at the beginning of the day and increase
gradually as fatigue sets in.
 Experience : Approximately 50 per cent of the employees had accidents in
their first 6 months of employment, 23 per cent in the next 6 months and
only 3 per cent subsequently in certain industrial undertakings.
 Working hours : An increase in accidents is found whenever the daily or
weekly working hours increase.
 c. PSYCHOLOGICAL: carelessness, inattentiveness, overconfidence, slow
cerebration, ignorance, inexperience, emotional stress and accident proneness.
2. ENVIRONMENTAL FACTORS: temperature, poor illumination, humidity, noise and
unsafe machines.

Prevention

 adequate preplacement examination

 adequate job training
 continuing education.
 ensuring safe working environment.
 establishing a safety department in the organization under a competent safety engineer.
 periodic surveys for finding out hazards
 careful reporting, maintenance of records and publicity.

SICKNESS ABSENTEEISM

Causes:
1. Economic causes : Studies have shown that if the worker is entitled to sick leave with
pay, he tends to avail of this privilege by reporting sick. It is so well remarked that in
industry the workers declare themselves fit or unfit for work, at their choice.
2. Social causes: Certain social factors appear to influence sickness absenteeism in India.
These are the social and family obligations such as weddings, festivals, repair and
maintenance of ancestral house and similar other causes. Some of the workers who come
from rural areas go back to their villages, for short or long periods, during sowing and
harvest seasons.
3. Medical causes: About 10 per cent of the days lost were found to be due to occupational
accidents. Respiratory and alimentary illnesses have also been found to be important
causes.
4. Non-occupational causes : Certain non-occupational causes such as nutritional disorders,
alcoholism and drug addiction have also been found to be responsible for sickness
absenteeism.

Prevention:
 good factory management and practices
 adequate preplacement examination
 good human relations and
 application of ergonomics

HEALTH PROBLEMS DUE TO INDUSTRIALIZATION:

1. ENVIRONMENTAL SANITATION PROBLEMS:
a. HOUSING :
 A rise in the number of slums and insanitary dwellings is one of the chief
problems in all industrial areas due to migration of people from the
country-side for employment.
b. WATER POLLUTION :
 Water pollution is one of the tragic aftermath of rapid industrialization due
to discharge of industrial wastes without treatment, into water courses.
 Industrial wastes may contain acids, alkalies, oils and other organic and
inorganic chemicals, some of which may be toxic; synthetic detergents
and radioactive substances.
 It requires legal, administrative and technical measures to deal with the
situation.
 Pollution control measures should be instituted in the planning stage itself
in the process of industrialization.
c. AIR POLLUTION :
 Air pollution is due to the discharge of toxic fumes, gases, smoke and
dusts into the atmosphere.
 It requires proper town planning and zoning to eliminate this hazard.
d. SEWAGE DISPOSAL :
 Lack of facilities for the disposal of sewage leads to pollution of water
supply, contamination of soil with parasites and their ova.
2. COMMUNICABLE DISEASES :
 The main problems in industrial areas are tuberculosis, venereal diseases,
and food and water borne infections.
 Industrial areas without proper sewage disposal have become hot-beds for
filariasis owing to the breeding of the mosquito vectors in contaminated
water.
3. FOOD SANITATION :
 The standards of food sanitation are bound to be lowered due to industrialization,
if proper precautions are not taken.
 Food-borne infections such as typhoid fever and viral hepatitis are all too
common in India.
4. MENTAL HEALTH :
 Mental health problems are due to altered living conditions.
 People are removed from the warmth of village community life and are
transplanted in an alien environment which calls for certain adjustments.
 Failure of adjustment leads to mental illness, psychoneurosis, behaviour disorders,
delinquency, etc
 5. ACCIDENTS :
 Accidents are a public health problem in industrial areas due to congestion,
vehicular traffic and the increased tempo of life.
6. SOCIAL PROBLEMS :
 Alcoholism, drug addiction, gambling, prostitution, increased divorces, breaking
up of home, juvenile delinquency, higher incidence of crime are some of the
social problems due to industrialization.
7. MORBIDITY AND MORTALITY :
 Vital statistical rates indicate that industrial areas are characterized by high
morbidity and mortality from certain diseases.

MEASURES FOR HEALTH PROTECTION OF WORKERS :

1. Nutrition:
 In many developing countries, malnutrition is an important factor contributing to
poor health among workers and low work output.
 Under the Indian Factories Act, it is obligatory on the part of the industrial
establishments to provide a canteen when the number of employees exceeds 250.
 The aim is to provide balanced diets or snacks at reasonable cost under sanitary
control.
2. Communicable disease control:
 The industry provides an excellent opportunity for early diagnosis, treatment,
prevention and rehabilitation.
 It is a general objective everywhere, to detect cases of communicable disease and
to render them non-infectious to others by treatment removal from the working
environment, or both.
 There should be an adequate immunization programme against preventable
communicable diseases.
3. Environmental sanitation:
a. WATER SUPPLY: A sufficient supply of wholesome drinking water is one of the
basic requirements in all industrial establishments. The common glass tumbler for
drinking water should be abandoned as it spreads infection. Installation of
drinking water fountains, at convenient points should be encouraged.
b. FOOD : If food is sold, its sanitary preparation, storage and handling are essential.
Education of food handlers and other measures may be necessary to prevent
outbreaks of gastro-intestinal disease.
c. TOILET: It is recommended that there should be at least one sanitary
convenience for every 25 employees (males and females separate) for the first 100
employees, and thereafter one for every 50.
d. GENERAL PLANT CLEANLINESS:
  The walls, ceilings and passages should be painted with water washable paint and
repainted at least once in 3 years and washed at least once in every 6 months.
 The dust which settles down on the floor and machinery should be promptly
removed by vacuum cleaners or by wetting agents before it is redistributed into
the atmosphere by the vibration of the machinery or buildings.
 A high standard of general cleanliness is of accident one of the fundamentals
prevention.
e. SUFFICIENT SPACE :
 Sufficient floor space and cubic space are essential to prevent not only respiratory
infections but also to ensure a comfortable working environment.
 The recommended standard is a minimum of 500 Cu. ft. of space for every
worker; space more than 14 feet above the floor level is not to be taken into
consideration.
f. LIGHTING :
 There should be sufficient and suitable lighting, natural or artificial or both, in
every part of a factory where workers are working or passing through.
 The standards of illumination for different kinds of work have been set out
precision work for a high degree of accuracy may require 50-75 foot candles;
where people work regularly, 6 to 12 foot candles may be sufficient.
g. VENTILATION, TEMPERATURE:
 Proper ventilation is also needed for the control of noxious vapours, fumes and
dusts and prevention of fatigue and industrial accidents.
 Effective and suitable provision should be made for maintaining adequate
ventilation by circulation of fresh air in every work room; and such a temperature
which will secure to workers therein, reasonable conditions of comfort and
prevent injury to health.
h. PROTECTION AGAINST HAZARDS: There should be adequate environmental
controls designed to protect the workers against exposure to dusts, fumes and
other toxic hazards.
i. HOUSING:
 The housing of workers near a plant must be correlated to essential community
amenities and to social and sanitary facilities.
 Town planning and zoning are highly desirable.
4. Mental health:
The goals of mental health in industry are :
 to promote the health and happiness of the workers,
 to detect signs of emotional stress and strain and to secure relief of stress and
strain where possible,
 the treatment of employees suffering from mental illness, and
 the rehabilitation of those who become ill.
 5. Measures for women and children:
Women workers require special protection because:
i. the developing embryo may be more susceptible to noxious agents than the
exposed mother (e.g., in the case of methyl mercury poisoning,
ii. females may be less suited for some work tasks than men; pregnancy may
decrease the capacity to cope with many work factors,
iii. women tend to feed themselves less substantially than men and also restrict their
nourishment in difficult economic circumstances,
iv. the infant mortality is higher amongst children of women employed in industrial
work.
The following types of protection are available for women workers in India :
a. Expectant mothers are given maternity leave for 26 weeks, of which upto 8 weeks
precede the expected date of confinement; during this period they are allowed
‘maternity benefit', which is a cash payment, under the Employees State Insurance
Act, 1948. After 2 children, the duration of paid maternity leave shall be 12 weeks
(6 weeks pre and 6 weeks post delivery)
b. Provision of free antenatal, natal and postnatal services.
c. The Factories Act (Section 66) prohibits night work between 7p.m. and 6 a.m.;
Section 34 prohibits carrying of excessive weights beyond a certain schedule
which has been laid down.
d. The Indian Mines Act (1923) prohibits work underground.
e. Maternity Benefit Act, 2017 provides for creches in factories where more than 50
women workers are employed (35), and also prohibits the employment of women
and children in certain dangerous occupations. Regarding protection of children,
the Constitution of India declared: “No child below the age of fourteen shall be
employed to work in any factory or mine or engaged in any other hazardous
employment" (Chapter III, Fundamental Rights - Article 24). Further, The Child
Labour (Prohibition and Regulation) Amendment Rules were notified on 20th
April, 2017 giving protection to children (38).
6. Health education:
 Health education in the industrial setting should be envisaged at all levels the
management, the supervisory staff, the worker, the trade union leaders and the
community.
7. Family planning:
 Family planning is now recognized a decisive factor for the quality of life, and
this applies to industrial workers also
 The workers must adopt the small family norm.

PREVENTION OF OCCUPATIONAL DISEASES

I. MEDICAL MEASURES
 1. Pre-placement examination:
 It is done at the time of employment and includes the worker's medical, family,
occupational and social history; a thorough physical examination and a battery of
biological and radiological examinations, e.g., chest X-ray, electro-cardiogram,
vision testing, urine and blood examination, special tests for endemic disease.
 A fresh recruit may either be totally rejected or given a job suited to and mental
abilities.
 The purpose of preplacement examination is to place the right man in the right
job, so that the worker can perform his duties efficiently without detriment to his
health. This is ergonomics
2. Periodical examination

 Ordinarily workers are examined once a year.

 But in certain occupational exposures (e.g., lead, toxic dyes, radium) monthly
examinations are indicated.
 The periodical examinations may be supplemented, where necessary by biological and
radiological examinations.
 Particular care should be given to workers returning from medical leave, to assess the
nature and degree of any disability and to assess suitability or otherwise of returning to
the same job.

3. Medical and health care services

 The medical care of occupational diseases is a basic function of an occupational health
service.
 Within the factory, first aid services should be made available.
 Immunization is another accepted function of an occupational health service.

4. Notification
 The main purpose of notification in industry is to initiate measures for prevention and
protection and ensuring their effective application; and to investigate the working
conditions and other circumstances which have caused or suspected to have caused
occupational diseases

5. Supervision of working environment

 Periodic inspection of working environment provides information of primary importance

in the prevention of occupational disabilities.
 The physician should pay frequent visits to the factory in order to acquaint himself with
the various aspects of the working environment such as temperature, lighting, ventilation,
 humidity, noise, cubic space, air pollution and sanitation which have an important
bearing on the health and welfare of the workers.

6. Maintenance and analysis of records

 Proper records essential for the planning, development and efficient operation of an
occupational health service.
 The worker's health record and occupational disability record must be maintained.
 Their compilation and review should enable the service to watch over the health of the
workers, to assess the hazards inherent in certain types of work and to devise or improve
preventive measures.

7. Health education and counseling:

 All the risks involved in the industry in which he is employed and the measures to be
taken for personal protection should be explained to him.
 The correct use of protective devices like masks and gloves should also be explained.
 Simple rules of hygiene hand-washing, paring the nails, bodily cleanliness and
cleanliness of clothes, should be impressed upon him.
 He should be frequently reminded about the dangers in industry through the media of
health education such as charts, posters and hand bills.
 The purpose of health education is to assist the worker in his process of adjustment to the
working, home and community environment.

II. ENGINEERING MEASURES:

1. Design of building:
 Measures for the prevention of occupational diseases should commence in the
blue-print stage.
 The type of floor, walls, height, ceiling, roof, doors and windows, cubic space are
all matters which should receive attention in the original plan of the building
which is put up by the industrial architect.
 Once the building is constructed, it would be difficult to introduce alterations
without much trouble and expense.
2. Good house-keeping:
 Good house-keeping is a term often applied to industry, and means much the
same as when used domestically. It covers general cleanliness, ventilation,
lighting, washing, food arrangements and general maintenance.
 Good housekeeping is a fundamental requirement for the control or elimination of
occupational hazards. It also contributes to efficiency and morale in industry.
 The walls, ceilings, and passages should be white-washed at least once a year.
  The dust which settles down on the floor, ledges, beams, machinery and other
stationery objects should be promptly removed by vacuum cleaners or by wetting
agents.
 Masks, gloves, aprons and other protective equipment should be kept clean and in
a state of good repair.
 To prevent accidents, the right thing should be in the right place. Not only the
inside, but the outside of the plant should also be kept clean and tidy.
3. General ventilation:
 It has been recommended that in every room of a factory, ventilating openings
shall be provided in the proportion of 5 sq. feet for each worker employed in such
room, and the openings shall be such as to admit a continued supply of fresh air.
 In rooms where dust is generated there should be an efficient exhaust ventilation
system.
 Good general ventilation decreases the air-borne hazards to the workers,
especially hazards from dusts and gases.
 The Indian Factories Act has prescribed a minimum of 500 cu. ft. of air space for
each worker.
4. Mechanization:
 The plant should be mechanized to the fullest possible extent to reduce the hazard
of contact with harmful substances.
 Dermatitis can be prevented if hand-mixing is replaced by mechanical devices.
 Acids can be conveyed from one place to another through pipes.
 There may be other similar situations where mechanization can be substituted to
hand-operation.
5. Substitution:
 By substitution is meant the replacement of a harmful material by a harmless one,
or one of lesser toxicity.
 A classical example is the substitution of white phosphorus by phosphorus
sesquisulphide in the match industry, which resulted in the elimination of necrosis
of jaw (Phossy jaw).
 Zinc or iron paints can be used in place of harmful lead paints; silver salts can be
used in place of mercury salts; acetone can be used in place of benzene.
 But substitution is not always possible in industry. Where possible, it should be
used to the fullest possible extent.
6. Dusts:
 Dusts can be controlled at the point of origin by water sprays, e.g., wet drilling of
rock.
 Inclusion of a little moisture in the materials will make the processes of grinding,
sieving and mixing comparatively dust-free.
  Wet methods should be tried to combat dust before more elaborate and expensive
methods are adopted.
7. Enclosure:
 Enclosing the harmful materials and processes will prevent the escape of dust and
fumes into the factory atmosphere.
 For example, grinding machinery can be completely enclosed. Such enclosed
units are generally combined with exhaust ventilation.
8. Isolation:
 Sometimes it may be necessary to isolate the offensive process in a separate
building so that workers not directly connected with the operation are saved from
exposure.
 Isolation may not be only in space, but also in the fourth dimension of time.
Certain operations can be done at night in the absence of the usual staff.
9. Local exhaust ventilation:
 By providing local exhaust ventilation dusts, fumes and other injurious substances
can be trapped and extracted “at source" before they escape into the factory
atmosphere.
 The heart of the local exhaust ventilation is the hood which is placed as near as
possible to the point of origin of the dust or fume or other impurity.
 Dusts, gases and fumes are drawn into the hood by suction and are conveyed
through ducts into collecting units.
 In this way, the breathing zone of workers may be kept free of dangerous dust and
poisonous fumes.
10. Protective devices:
 Respirators and gas masks are among the oldest devices used to protect workers
against air-borne contaminants and they are still used for that purpose.
 There are two classes of respirators : (i) those which remove contaminants from
air. (ii) those to which fresh air is supplied.
 The workers should know what kinds to use, and when and how to use.
Respiratory devices should not be used as substitute for other control methods.
 The other protective devices comprise ear plugs, ear muffs, helmets, safety shoes,
aprons, gloves, gum boots, barrier creams, screens and goggles.
 The worker should be instructed in the correct use of protective devices.
11. Environmental monitoring:
 An important aspect of occupational health programme is environmental
monitoring. It is concerned with periodical environmental surveys, especially
sampling the factory atmosphere to determine whether the dusts and gases
escaping into the atmosphere are within the limits of permissible concentration.
 The use of “permissible limits” has played an important part in reducing
occupational exposure to toxic substances.
  Thermal environment, ventilation, lighting would also have to be monitored. Such
monitoring should be done by joint collaboration of doctors and engineers.
12. Statistical monitoring:
 Statistical monitoring comprises review at regular intervals of collected data on
health and environmental exposure of occupational groups.
 The main objective of these reviews is to evaluate the adequacy of preventive
measures and occupational health criteria, including permissible exposure levels.
13. Research:
 Research in occupational health offers fertile ground for study which can provide
a better understanding of the industrial health problems.
 There are two kinds of research - pure research and research for the improvement
of, or in connection with manufactured product. Both are important.
 Study of the permissible limits of exposure to dusts and toxic fumes, occupational
cancer, accident prevention, industrial fatigue and vocational psychology are
some aspects of research in occupational health.

III. LEGISLATION:

(1) The Factories Act, 1948

(2) The Employees' State Insurance Act, 1948

The Factories Act, 1948

The first Indian Factories Act dates as far back as 1881. The Act was revised and
amended several times, the latest being the Factories (Amendment) Act, 1987. A brief
description of the Act is given below:

(1) SCOPE:
 The Act defines factory as an establishment employing 10 or more workers where
power is used, and 20 or more workers where power is not used. There is no
distinction between perennial and seasonal factories.
 The 1976 amendment modifies the definition of the term 'worker' so as to include
within its meaning contract labour employed in the manufacturing process.
 The Act applies to the whole of India except the State of Jammu and Kashmir.
 The State Governments are authorized to appoint besides the Chief Inspector of
Factories as many Additional Chief Inspectors, Joint Chief Inspectors, Deputy
Chief Inspectors and Inspectors as they think fit to enforce the provisions of the
law.
(2) HEALTH, SAFETY AND WELFARE: (Chapter III, IV, IVA, & V):
 Elaborate provisions have been made in the Act with regard to health, safety and
welfare of the workers.
 In addition to such matters as cleanliness, lighting and ventilation, the Act
provides for the treatment of wastes and effluents so as to render them innocuous,
and for their disposal, the elimination of dusts and fumes, the provision of
spittoons, control of temperature, supply of cool drinking water during summer
and for the employment of cleaners to keep the water closets clean.
 A minimum of 500 Cu.ft of space for each worker has been prescribed (not taking
into account space more than 14 feet above the ground level). For factories
installed before the 1948 Act, a minimum of 350 Cu.ft of space has been
prescribed.
 The Act also prescribes in detail the precautions which should be taken for
ensuring the safety of workers. Some of the safety provisions relate to the casing
of new machinery, devices for cutting off the power, hoists and lifts, cranes and
other lifting devices, protection of the eyes and precautions against dangerous
fumes, explosive and inflammable material.
 The Act provides that no worker shall be required to lift or carry loads which are
likely to cause him injury. The State Governments are empowered to prescribe
maximum weights which may be lifted or carried by men, women and children.
The 1976 amendment (Section 40 B) provides for the appointment of 'Safety
Officers' in every factory wherein 1,000 or more workers are ordinarily employed.
 The Act contains a separate Chapter (Chapter V) relating to specific welfare
measures, e.g.. washing facilities, facilities for storing and drying clothes,
facilities for sitting, first-aid appliances, shelters, rest-rooms and lunch rooms,
canteens and creches.
 The Act specifies that wherein more than 250 workers are ordinarily employed, a
canteen shall be provided.
 The 1976 amendment provides for creches in every factory wherein more than 30
women workers are ordinarily employed. In every factory, wherein 500 or more
workers are ordinarily employed, there should be a Welfare Officer.

(3) EMPLOYMENT OF YOUNG PERSONS:

 The Act prohibits employment of children below the age of 14 years and declares
persons between the ages 15 and 18 to be adolescents.
 Adolescents should be duly certified by the "Certifying Surgeons" regarding their
fitness for work.
 Restrictions have been laid down on employment of women and children in
certain dangerous occupations.
  Child who has not completed his fourteenth year of age has been restricted from
employment in any factory.
 Adolescent employee is allowed to work only between 6 A.M. & 7 P.M.

(4) HOURS OF WORK:

 The Act has prescribed a maximum of 48 working hours per week, not exceeding
9 hours per day with rest for at least / hour after 5 hours of continuous work.
 For adolescents, the hours of work have been reduced from 5 to 44, per day.
 The 1976 amendment makes a provision to increase the spread-over period of
work (including rest intervals) of an employee in a factory upto 12 hours from the
existing 1042 hours.
 The total number of hours of work in a week including overtime shall not exceed
60.

(5) LEAVE WITH WAGES:

 The Act lays down that besides weekly holidays, every worker will be entitled to
leave with wages after 12 month's continuous service at the following rate; adult -
one day for every 20 days of work, children - one day for every 15 days of work.
 The leave can be accumulated up to 30 days in case of adults and 40 days in case
of children.

(6) OCCUPATIONAL DISEASES:

 It is obligatory on the part of the factory management to give information
regarding specified accidents which cause death, serious bodily injury or
regarding occupational diseases contracted by employees. The Act gives a
schedule of notifiable diseases.
 The 1976 amendment includes Byssinosis, Asbestosis, occupational dermatitis
and noise-induced hearing loss among the list of notifiable diseases and provides
for enquiry in every case of a fatal accident.
 Provision has also been made in the 1976 amendment for safety and occupational
health surveys in factories and industries.

(7) EMPLOYMENT IN HAZARDOUS PROCESSES:

 The Central Govt. has incorporated a new Chapter IV-A by the Factories
(Amendment) Act, 1987, relating to hazardous processes.
 Site Appraisal Committee consisting of Chief Inspector and other members, not
more than 14 in number, for examination of service conditions of employees in a
factory, involving hazardous processes, is to be constituted for recommendations.
 Specific responsibility of the occupier in relation to hazardous processes was also
made with workers' participation in safety management.
 
List of industries involving hazardous processes is prescribed in 1st schedule of
the Act.
OCCUPATIONAL HEALTH TEAM:

Occupational health nurse, Physiotherapist, Specialist doctor, Industrial manager, Supervisor,

Shift in charge, Rehabilitation specialist , Labour welfare officer , Labour union representative.,
Representative of voluntary organizations, Other invited members as per the need

ROLE OF OCCUPATIONAL HEALTH NURSE:

 Clinician : Primary prevention, Emergency care, Treatment services, Nursing diagnosis,

General Health advice and health assessment, Research and the use of evidence based
practice
 Specialist: Occupational health policy, and practice development, implementation and
evaluation, Occupational health assessment, Health surveillance, Sickness absence
management, Rehabilitation, Maintenance of work ability, Health and safety, Hazard
identification, Risk assessment, Advice on control strategies
 Home care, Cooperation of plant department, Special provision for services for women
and children, Creche work, Rehabilitation of the ill and injured workers, Industrial plant
survey, Administrative responsibilities
 Other roles: Manager, Co-ordinator, Adviser, Health educator, Counsellor, Researcher

ERGONOMICS:

Ergonomics is the study of men at work with a view to identify stress factors operating in
work environments and impairing the physical, mental and psychological health of workers and
interfering with their work performance.

ENVIRONMENTAL HEALTH

ENVIRONMENT:

 Old French word, En=In; Viron = Circle.

 The circumstances, objects, or conditions by which one is surrounded. Or
 The complex of climatic, edaphic (soil-based), and biotic factors that act upon an
organism or an ecologic community.

Environment is the total of the natural conditions under which animals live, including
climatic, geographic, physiographic and faunal conditions; all that which is external to the
individual human host.
PUBLIC HEALTH DEFINITION OF ENVIRONMENT:

All that which is external to the individual host. [It] can be divided into physical,
biological, social, and cultural factors, any or all of which can influence health status in
populations. (Last, J. M. (Ed.). (1995). A Dictionary of Epidemiology (3rd ed.). New York:
Oxford University Press.)

CONTRIBUTORS OF ENVIRONMENT:

1. Physical:
 Air, water, soil, housing, climate, geography, heat, light, noise, debris, noise etc.
 Air pollutants, toxic wastes, pesticides etc.
2. Biological:
 Virus, bacteria and other microbes, insects, rodents, animals and plants
 Disease producing agents, reservoir of infection, intermediate host and reservoirs
of infection,
3. Social/psychosocial/socioeconomic:
 Culture, values, customs, habits, morals, religions, education, lifestyle,
community life, health services, social and political organizations.

BASIC REQUIREMENTS FOR A HEALTHY ENVIRONMENT:

 Clean air
 Safe and sufficient water
 Safe and adequate food
 Safe and peaceful settlements
 Stable global environment

SCOPE OF ENVIRONMENTAL HEALTH:

 Water supplies
 Waste water treatment
 Waste management
 Vector control
 Prevention and control of land pollution
 Food hygiene and safety
 Air quality management
 Environmental radiation hazards
 Occupational health and safety
 Environmental noise management
 Accommodation establishment
 Environmental impact assessments
  Port health
 Accident prevention
 Environmental health aspects of public recreation and tourism
 Environmental health measures associated with epidemics, emergencies, disasters and
migrations of populations
 Establishment of an effective environmental health surveillance and information system
 Research on environmental health issues

WATER AND HEALTH

Safe and wholesome water:

 Free from pathogenic agents

 Free from harmful chemical substances
 Pleasant to taste, i.e. free from color and order,
 Useable for domestic propose

Water requirement :

 For drinking purpose: 2 liter/person/day

 Domestic purpose : 150-200 liter /person/day

Uses of water:

 Domestic uses;
 Public purpose;
 Industrial purpose;
 Agricultural purpose;
 Hydropower production.

Source of water:

 Rainwater,
 Surface water;
 Ground water.

Water pollution:

 Sewage,
 industrial and trade pollutants,
 agricultural pollutants,
 physical pollutants
 radioactive substances.
Water Purification:

1. Purification in small scale:

 Household level: boiling, chemical disinfection & filtration.
 Disinfection of well
2. Purification in large scale:
 Slow sand filter
 Rapid sand filter

WATER BORNE DISEASES:

1. Viral: Viral Hepatitis A, Hepatitis E, Poliomyelitis, Rotavirus diarrhoea etc.

2. Bacterial: Typhoid & Paratyphoid fever, Bacillary dysentery, Cholera, Esch. Coli
Diarrhoea etc.
3. Protozoal: amoebiasis, giardiasis.
4. Helminthic: round worm, thread worm, hydiatid disease.
5. Snail: schistosomiasis.
6. Cyclops: guinea worm, fish tape worm.

WATER RELATED DISEASES:

 Acute and chronic toxic effect of chemical pollutants

 Disease associated with inadequate use of water
 Dental health problem: 1gm fluoride/liter water is beneficial for dental health.
 Vector borne disease: Malaria, filaria etc.
 Cardiovascular disease: hardness of water have beneficial effect on hardness of water.

WATER QUALITY CRITERIA AND STANDARDS:

The guideline for drinking water quality recommended by WHO (1993 and 1996) relate to
following variables:

 Acceptability aspects
 Microbiological aspects
 Chemical aspect
 Radiological aspects

ACCEPTABILITY ASPECTS:

A. Physical parameters:
 Turbidity: < 5NTU (Nephelometric Turbidity Unit)
 Colour: free from colour; upto 15 TCU (True Colour Unit)
 Taste and odour: pleasant to taste and no odour
  Temperature: cool water is more palatable.
B. Inorganic constituents:
 Chloride: upto 200mg/liter
 Calcium: 100-300mg/liter
 Ammonia: <0.2mg/liter
 Hydrogen sulphide: 0.050.1mg/liter
 Iron: 0.3mg/liter
 Sodium: 200mg/liter
 Sulphate: <250mg/liter
 Zinc: 0.3mg/liter
 Manganese: <0.1mg/liter
 Cupper: <1mg/liter
 Aluminum: 0.2mg/liter
 PH value: 6.5-8.5
 Dissolved oxygen: no guideline
 Total dissolved solids: <100mg/liter

MICROBIOLOGICAL ASPECTS:

1. Bacteriological indicator:
a. Coliform organism
b. Faecal streptococci
c. Cl. Perfringens
2. Virological aspects
3. Biological aspects
a. Protozoa
b. Helminthes
c. Free living organism

BACTERIOLOGICAL INDICATORS:

a. Coliform organism: Several region for choosing coliform indicators of faecal pollution
are:
 Easy to culture; even single E. coli can be culturable in 100 ml of water.
 They are foreign to the water and generally not present to water.
 They are present in greater number (normal human can excrete 200-400 billion E.
coli)
 They resist natural purification
 They live longer than other pathogens
 b. Faecal streptococci: It is the confirmatory test for faecal contamination. Some times (very
rarely) E. coli doesn't present in water but if present streptococci than there is 100%
faecal contamination.
c. Clostridia: The spores of clostridia are highly resistance against the disinfection. If only
one spore of clostridia is present in water; it shows faecal contamination taken place in
remote time.

VIROLOGICAL ASPECTS:

Drinking water should be free from any virus infectious to man. At the level of 0.5% FRC all
pathogenic virus will be destroyed including hepatitis A. when bleaching powder mix with 2.5
gram mix with 1000ml of water then Free Residual Chlorine (FRC) will be 0.7%/liter in water.

BIOLOGICAL ASPECTS:

A. Protozoa: Entomoba Histolytica, Giardia Lambia both should not present in drinking
water and both slow and rapid sand filter are effective in removing protozoa.
B. Helminthes: Round worm, Flat worm etc. Even a single egg/larva can produce disease in
man; should not in water. Guinea worm and schistosomiasis is hazard of unpiped water
supply and source protection is the best approach in prevention.
C. Free living organism: free living organism that occurs in water supply include fungi,
algae etc. which interfere colour, odour, taste, turbidity etc.

CHEMICAL ASPECTS:

1. Inorganic constituents
 Arsenic, Cadmium, Chromium, Cyanide, Fluoride, Lead, Mercury, Nitrate &
Nitrite, Selenium,
2. Organic constituents
 Poly nuclear aromatic hydrocarbons and pesticides

INORGANIC CONSTITUENTS:

 Arsenic: upto 0.01mg/liter

 Cadmium: upto 0.003mcg/liter
 Chromium: upto 0.05mg/liter
 Cyanide: upto 0.07mg/liter
 Fluoride: upto 1.5 mg/liter
 Lead: upto 0.01mg/liter
 Mercury: upto 0.001mg/liter
 Nitrate & Nitrite: upto 50mg/liter
 Selenium: upto 0.01mg/liter
ORGANIC CONSTITUENTS:

Organic constituents Upper limit (mcg/liter)

Carbon tetrachloride 2
Vinyl chloride 55
Dichloromethane 20
Dichloroethene-1.1 30
Dichloroethene-1.2 50
Benzene 10
Toluene 700
Oxylenes 500
Ethyl benzene 300
Styrene 20
Benzolalpyrine 0.7

GUIDELINES FOR PESTICIDES:

PESTICIDES UPPER LIMIT (mcg/liter)

Aldrin/ Dieldrine 0.03
Chlordane 0.2
DDT 2
2.4-D 30
Heptachlor 0.031
Hexachlorobenzene 1
Lindane 2
Methoxychlor 20
Pentachlorophenol 9 (P) *proximate value

AIR

 Daily requirement of air: about 10-20 cubic meter/day

 Composition of air:
 Nitrogen: 78.1% by volume
 Oxygen: 20.93% by volume
 Carbon dioxide: 0.03% by volume
 Other gases (Ar, Ne, Kr, He etc.): 0.94% by volume

AIR POLLUTION:
 Presence of harmful gases, mixture of harmful gases and other particles in atmosphere,
generated by human activity that interfere with human health, safety or discomfort and also
affect other environmental media resulting in chemical entering of food and drinking water etc.

SOURCES OF AIR POLLUTION:

1. Automobiles: Co2, Co, Pb, No2, Black Smoke.

2. Industries: So2, No2, Fly Ash, smoke, Hydrogen fluoride, HCl, Hydrogen sulphide,
Ozone etc.
3. Domestic Source: smoke, dust, So2, No2
4. Miscellaneous: burning refuse, incinerator, pesticide, spraying, Natural source (fungi,
bolds, bacteria etc.)

AIR POLLUTANTS AND HEALTH EFFCTS:

 Co: Carboxyhaemoglobin
 So2: Acid rain
 Pb: Lead poisoning, decrease IQ level in young children
 Co2: global warming and climate change
 Hydrocarbon: Eye damage
 Cadmium: Cancer
 So2/H2S: unpleasant odour, conjunctival irritation, mental and neurological damage.
 Ozone: ozone layer depletion
 Polynuclear Aerometric Hydrocarbon(pah): Lung cancer
 Particulate matters: COPD, respiratory problems.

EFFECTS OF AIR POLLUTION:

1. Health Aspect
 Acute effect: ARI, Acute pneumonia, Acute bronchitis, immediate death by
suffocation
 Chronic effect: COPD, Lung cancer, Emphysema, Respiratory allergy etc.
2. Social and Economic aspect
 Destruction of animal and plant life, corrosion of metals, damages to buildings,
cost increase in cleaning and maintenance, aesthetic nuisance, reduction of
visibility of town, damage of soil, damage of clothing.

PREVENTION AND CONTROL OF AIR POLLUTION:

WHO recommended procedure

1. Containment: Prevention of escape of toxic substance in atmosphere by enclosure,

ventilation and air cleaning
 2. Replacement: replacement of coal, firewood, lead petrol by new technology e.g.
electricity, natural gases, central heating, solar power etc.
3. Dilution: self cleaning capacity of environment. E.g. establishment of greenbelt.
4. Legislation: Formulation, implementation and monitoring of environmental act and
regulation
5. International Action: WHO established an international network of laboratories for the
monitoring and study of air pollution.

MEDICAL ENDOMOLOGY

 A study of the arthropods of medical importance is known as medical entomology. It is

an important branch of preventive medicine.
 Some arthropods are beneficial as they help in fertilization of flowers and crops and some
are harmful to human being as they are vector and reservoir of disease and also destroy
the men’s crops and foods.

ARTHROPODS BORNE DISEASES:

 Mosquito: Malaria, Filaria, JE, Dengue fever, West Nile fever, yellow fever etc.
 Housefly: Typhoid and paratyphoid fever, Diarrhoea, dysentery, cholera, Gastroenteritis,
amoebiasis, helminthes, poliomyelitis, trachoma, conjunctivitis, anthrax etc.
 Sandfly: Kala- azar, oriental sore, sandfly fever, Oraya fever etc.
 Tsetse fly: Sleeping sickness
 Louse: Epidemic typhus, relapsing fever, trench fever, pediculosis etc.
 Rat flea: Bubonic plague, epidemic typhus, chiggerosis, hymenolepsis diminuta etc
 Black fly: Onchocerciasis
 Reduviid bug: Chagas disease
 Itch-mite: Scabies
 Hard tick: Tick typhus, viral encephalitis, viral fevers, viral hemorrhagic fever,
tularemia, tick paralysis, babesiosis etc.
 Soft tick: Q fever, relapsing fever.
 Trombiculid mite: Scrub typhus, reckettsial-pox
 Cyclops: Guinea worm disease, fish tape worm
 Cockroaches: Enteric pathogens

TRANSMISSION OF ARTHROPOD BORNE INFCTIONS:

1. Direct contact: arthropods are directly transferred from man to man through direct
contact. E.g. scabies and pediculosis.
2. Mechanical transmission: disease causing agents are transmitted mechanically by
arthropods. E.g. transmission of diarrhoea, dysentery, cholera, typhoid, trachoma etc by
housefly.
 3. Biological transmission: Disease agent multiplies or under goes some developmental
change or with multiplication in the arthropod host.
A. Propagative: disease agent undergoes no cyclic change, but multiplies in the body of
vector e.g. plague bacilli in rat fleas.
B. Cyclopropagative: disease agent undergoes cyclic change, and multiplies in the body
of vector e.g. malaria parasite in anopheline mosquito.
C. Cyclo-developmental: disease agent undergoes cyclic change, but does not multiplies
in the body of arthropods e.g. filarial parasite in culex mosquito.

PRINCIPLES OF ARTHROPODS CONTROL:

1. Environmental control: Elevation of breeding places, filling and drainage operation,

carefully planned water management; provision of piped water supply; proper disposal of
waste; proper house keeping etc.
2. Chemical control: Use of insecticides e.g. organochlorine, organophosphorus, carbamite
groups compound to control vectors but yield the harmful effects to environment.
3. Biological control: control arthropods by using other organisms to minimize
environmental pollution. E.g. use of larvivorous fish (Gambusia) to control malaria.
4. Genetic control: male sterile technique, cytoplasmic incompatibility and chromosomal
translocations are found to be effective in small trials.
5. Newer methods: insect growth regulators, chemosterilants, sex attractants etc.
6. Integrated approach: combining two or more methods with the view to obtain maximum
result with minimum effort and adverse consequences.

HUMAN EXCRETA DISPOSAL

 Human excreta is a important cause of environmental pollution and source of infection.

 Safe disposal of excreta is the responsibility of everyone.
 The hazards of improper disposal of excreta are:
 Soil pollution
 Water pollution
 Food contamination
 Propagation of flies
 The disease caused by improper disposal of human excreta disposal are: Typhoid and
Paratyphoid fever, Dysentery, Diarrhoea, Cholera, Round worm, Hook worm, Viral
hepatitis and Other Intestinal infection.

METHODS OF EXCRETA DISPOSAL:

A. Unsewered area:
1. Service type latrine (conservancy system)
2. Non service (Sanitary Latrine):
  Bore hole latrine
 Dug well or pit latrine
 Water seal latrine
 Septic tank
 Acqa privy
3. Sewered area
 Water carriage system and sewage treatment a
a. Primary treatment:
 Screening
 Removal of grit
 Plane sedimentation
b. Secondary treatment:
 Trickling filters
 Activated sludge process
c. Other methods : Sea outfall, river out fall, sewage farming, oxidation ponds.

SERVICE TYPE (NON-SANITORY):

It is unhygienic and unsocial method.

It involves manual collection and removal of excreta to the disposal point.
It is not a recommended and yield various harmful effects on human health.

NON SERVICE TYPE (SANITARY):

A sanitary latrine is one which fulfills the following criteria:

Excreta should not contaminate the ground or surface water .

Excreta should not pollute the soil.
Excreta should not be accessible to the flies, rodents, animal and other vehicle of
transmission.
Excreta should not create nuisance due to odour or unsightly appearance.

BORE HOLE LATRINE:

First introduced by Rockefeller foundation in 1930’s in campaign of hookworm control.

The latrine consist of a circular hole of 30-40 cm (16 inch) diameter with 20 feet (6
meter) depth.
A special equipment “Auger” is needed to make hole.
The whole is lined with bamboo mating or earthen wire rings to prevent caving of soil.
A concrete squatting plate is placed over the hole.
A suitable in closure is put up to provide privacy.
It is not very much in use today.
DUG WELL OR PIT LATRINE:

It is an improvement over the borehole latrine

A circular pit about 75 cm (30 inch) in diameter and 3-3.5 meter (10-12 feet0) deep id
dug into the ground for the reception of nightsoil.
The pit may be lined with pottery or cement ring.
A concrete squatting plate is placed at the top of the pit.
A suitable in closure is put up to provide privacy.
It is easy to construct.
The pit has longer life than bore hole latrine because of greater capacity.
Deep will last for about five years for a family of 4-5 members.
When pit is filled , a new pit is constructed.

WATER SEAL LATRINE:

Water seal latrines are of two types:

Direct type: where the waterseal pan is placed directly over the pit.
Indirect type: Where the pit is cited away from the squatting plate.
Hand flushed waterseal latrine is used in rural areas where water closet or mechanical
flushed latrine is used in urban areas
Nightsoil is sealed by small depth of water contained in a bent pipe called the trap.
The trap prevent the escape of odour and foul gases and there by eliminates the nuisance
from smell.
Once the latrine is flushed , nightsoil is no longer visible.

Essential Features:

1. Location: Minimum 50 feet far from the source of water supply and no in flooding areas.
2. Squatting plate: Cement concrete with minimum 3 square with 5 cm thickness and at
least 0.5 inch slope towards hole.
3. Pan: The Pan receive the nightsoil, urine and water. The length of pan is 42.5 cm (17
inch) and the wide of the front portion of the pan must be atleast 5 inch (12.5 cm).
4. Connecting pipe : When pit is dug away from squat plat, the trap is connected to pit by
connecting pipe 7.5 cm in diameter and at least 1m in length with a bend at the end. This
type is called indirect type.
5. Dug well /pit: The dug well or pit is usually 75 cm in diameter and 3 to 3.5 m deep and is
covered.
6. Superstructure: The desired type of superstructure may be provided for privacy and
shelter.
7. Maintenance: People should be educated to flush the pan after use with adequate quantity
of water. 1-2 L of water is needed for sufficient flush of RCA latrine.
SULAB SHAUCHALAYA
o The invention of a Patna based firm
o It consists of specially designed pan and a water seal trap.
o It is connected to a pit 3 feet square and as deep.
o Excreta undergoes bacterial decomposition and require very little water.
o Sulabh international, the investors not only build but also to maintain community
latrines. Their usual structure is lavatory block of several dozen seats, with bathing
block adjoining. Rupess 2 per user .

SEPTIC TANK

Features of a septic tank

Capacity
The minimum capacity of a septic tank should be at least 500 gallons Length The length
is usually twice the breadth.
Depth
The depth of aseptic tank is from 1.5 to 2m. Liquid depth The recommended liquid depth
is only 1.2m.
Features of a septic tank Air space
A minimum air space of 30cm between the level of liquid in the tank and the
undersurface of the cover.
Bottom
The bottom is sloping towards the inlet end. Inlet and outlet There is an inlet and outlet
which is submerged.
Cover
The septic tank is covered by a concrete slab of suitable thickness and provided with a
manhole. Retention period Septic tanks are designed to allow a retention period of 24 hours.

Operation and maintenance

o The use of soap water and disinfectants such as phenol should be avoided.
o Contents of the septic tank should be removed at least once in a year. This operation is
called desludging and it is disposed by trenching.
o Newly built septic tanks are first filled with water up to the outlet level and then seeded
with ripe sludge drawn from another septic tank
o It consists of a water tight chamber filled with water
o A short length of a drop pipe from the latrine floor dips into the water.
AQUAPRIVY
Function like septic tank. It consist of water tight chamber filled with water. It is
designed for public use also.
 Advantages:
Cannot be blocked with bulky anal cleaning material
Nil problem with odor or flies
Can be connected to a sewerage system at a later date
Disadvantages:
Expensive to build
Need large volumes of water to work
Water seal may be hard to maintain
Tanks must be emptied about every 3 years

LATRINES SUITABLE FOR TEMPORARY USE AND CAMPS

Shallow trench latrine
 The trench is 30cm wide and 90-150cm deep.
 Its length depend on the number of users; 3-3.5 m for 100 people.
 The trench is 1.8 to 2.5 m deep and 75-90cm wide.
 It is rudimentary arrangement for a short period (upto 1 week)
 After each use cover the faeces with earth. When the trench filled to 30 cm below
ground level, it must be covered with earth, heaped above ground level and compacted
and new trench be dug.

Deep trench latrine

 Intended for camps of longer duration, from few weeks to few months.
 The trench 1.8 – 2.5 m deep and 75-90 cm wide.
 Squatting plate and seat provided. Others are same as shallow trench latrine.

DISASTER MANAGEMENT

Definition:

Disaster is any occurrence that causes damage, ecological disruption, loss of human life
and deterioration of health and health service on a scale sufficient to warrant an extraordinary
response from outside the affected community or area. (WHO)

Disaster can be defined as an overwhelming ecological disruption, which exceeds the

capacity of a community to adjust and consequently requires assistance from outside. -(PAHO)

Principles of Disaster management:

 Comprehensive – disaster managers consider and take into account all hazards, all
phases, and all impacts relevant to disasters.
 Progressive – anticipate future disasters and take preventive and preparatory measures
  Risk-driven – use sound risk management principles (hazard identification, risk analysis,
and impact analysis) in assigning priorities and resources.
 Integrated – ensure unity of effort among all levels of government and all elements of a
community
 Collaborative – create and sustain broad and sincere relationships among individuals and
organizations .
 Coordinated – synchronize the activities to achieve a common purpose.
 Flexible – use creative and innovative approaches in solving disaster challenges.
 Professional – value a science and knowledge-based approach for continuous
improvement.

Disaster management:

There are three fundamental aspects of disaster management (disaster cycle):

a. Disaster response
b. Disaster preparedness
c. Disaster mitigation

1. DISASTER IMPACT AND RESPONSE:

The management of mass casualties can be further divided into search and rescue, first
aid, triage and stabilization of victims, hospital treatment and redistribution of patients to
other hospitals if necessary.
i. Search, rescue and first-aid:
 For search and rescue the team should be organized and work as one. Even
with a good team the search may be a small fraction in major disasters.
 The immediate help is usually obtained from the uninjured survivors.
 ii. Field care
 The injured people are brought to nearest health care immediately by
available means of transport and people converge into health facilities.
 The hospitals must get ready to deal with mass input of injured with new
priorities for bed availability and surgical services.
 Provision for food, shelter should be done
 A centre to respond for the enquiries from patient’s relatives and friends.
 Priority is given to :victims identification and adequate mortuary space.
iii. Triage
 It consists of rapidly classifying the injured on the basis of the severity of
their injuries and their likelihood of their survival with prompt medical
intervention.
 The principle of “First come, first serve” is NOTFOLLOWED.
 High priority is given to those whose immediate or long term prognosis
can be changed dramatically with simple intensive care.
 It is the only approach that can provide maximum benefit to large
population in a major disaster.
 Colour coding in a Triage :Internationally accepted four colour coding
system
 Red – High priority treatment or transfer.
 Yellow –Medium priority.
 Green –Ambulatory patients.
 Black – Dead or Moribound patients
 Triage should be carried out at the site of the disaster.
 Local health workers should be taught the principles of triage as a part of disaster
training.
 People with minor injuries should be treated in their homes to avoid social dislocation
and drain the resources which are needed by severely injured person
iv. Tagging
 All persons should be tagged with details – name, age, place of origin,
triage, initial diagnosis and treatment
v. Identification of dead
 Dead people care is most important in disaster management because they
impede the efficiency of rescue activities.
 Care of dead includes :
 Proper Respect.
 Removal of dead from the scene.
 Shifting to mortuary.
 Identification.
  Reception of bereaved relatives.
 Cadavers must be removed from water sources as they may cause outbreaks of
gastroenteritis or food poisoning.
 The health hazards from the cadavers are outbreaks of cholera, typhoid, leptospirosis,
anthrax, plague etc.

Relief phase

 This phase begins when assistance from outside area starts reaching the disaster
site.
 The relief supplies are determined by two factors :
a. The type of disaster
b. Availability of local supplies.
 Important needs are :
 Critical health supply and casualties.
 Food, blanket, clothing, shelter, sanitary engineering.
 Measures to prevent outbreak of communicable diseases.
 Donations(Funds)
 Transportation, Storage and distribution of food, medicines, vitamins.
 The four distinct components in Relief phase are : Acquisition of
supplies, Transportation, Storage and Distribution.

Surveillance/early warning system :

 Rapid detection of cases of epidemic-prone diseases is essential to ensure rapid

control. A surveillance/early warning system should be quickly established to
detect outbreaks and monitor priority endemic diseases.
 Priority diseases to be included in the surveillance system. In some situations, the
threats may include rare diseases such as viral haemorrhagic fevers, plague or
tularaemia.
Communicable diseases :

 The potential risk of communicable diseases are influenced by six types of adverse
changes. These are :
 Changes in pre existent levels of disease:
 Usually the risk of a communicable disease in a Community affected by
disaster is proportional to the endemic level.
 There is generally no risk of a given disease when the organism causes it
is not present beforehand
 Relief workers can conceivably introduce communicable disease into
areas affected by disaster.
 Ecological changes:
 Natural disasters, particularly droughts, floods and hurricanes, frequently
produce ecological changes in environment which increase or reduce the
risk of communicable disease.
 Vector borne and water-borne diseases are the most significantly affected.
 Population displacement:
 Movement of populations away from the areas affected by a disaster can
affect the relative risk from communicable diseases.
  If the population moves nearby, the existing facilities some distance, the
chances increase that the displaced population will encounter diseases not
prevalent in their own community, to which they are less susceptible .
 Population density :
 Because of the destruction of houses, natural disasters almost invariably
contribute to increased population density.
 Survivors of severe disaster seek shelter, food and water in less affected
areas.
 When the damage is less severe, crowding may occur in public places like
school and churches.
 Disruption public utilities:
 Electricity, water, sewage disposal and other public utilities may be
interrupted after a disaster.
 Insufficient water for washing hands &bathing also promotes the spread
of diseases transmitted by contact.
 Interruption of basic public health services:
 The interruption of basic public health services like vaccination,
ambulatory treatment of tuberculosis and programs for the control of
malaria and vectors are frequent, after disaster in a developing country.
 The risk of transmission increases proportionally to the extent and the
duration of the disrupt.

Principals of preventing and controlling communicable diseases:

 Implement as soon as possible all public health measures, to reduce the risk of disease
transmission
 Organize a reliable reporting system to identify outbreaks and initiate suitable control
measure
 Investigate all reports of disease outbreaks immediately.

Preventive measures incommunicable diseases:

 Ensure safe water, sanitation

 Primary health-care services
 The immediate impact of communicable diseases can be mitigated with the following
interventions:
 Ensure early diagnosis and treatment of diarrhoeal diseases and ARI, malaria.
 Ensure availability of drugs included in the interagency emergency health kit.

VACCINATION:
NUTRITION:

 Disaster affects nutritional status of the population by affecting one or more components
of food chain.
 Infants, children, pregnant women, nursing mothers and sick persons are most commonly
affected ones
 Steps for ensuring food relief program will be effective:
 Assessing the food supplies after the disaster
 Gauging the nutritional needs of the affected population
 Calculating daily food rations and need for large population
 Monitoring the nutritional status of affected people

RELIEF V/S REHABILITATION:

 Relief and rehabilitation come immediately after the disaster.

 The basic difference between them is that relief relates to the immediate days and weeks
after the disaster when attempts are made to provide basic needs to the victims.
 Rehabilitation relates to the work undertaken in the following weeks and months, for the
restoration of basics services to enable the population to return to normalcy
 Rehabilitation phase starts from the moment disaster strikes and ends with restoration of
normality.
 Water supply:
 Survey of all public water supplies to be made
 Priority of ensuring water quality is by chlorination.
 Increase the residual chlorine level to about 0.2 to 0.5mg/litre
 Existing and new water resources require the following:
 Restrict access to people and animals.
 Ensure excreta disposal at a safe distance from water source
  Prohibit water washing methods
 Upgrade wells to ensure they are not contaminated.
 Estimate maximum yield of wells.
 In case of emergency ,water has to be trucked to disaster site or
camps
 Food safety
 Poor hygiene is the major cause of food borne diseases in disaster areas.
 Where feeding programmes are used, kitchen sanitation is of utmost
importance.
 Personal hygiene should be monitored in individuals involved in food
preparation
 Basic sanitation and personal hygiene:
 Many communicable diseases spread through fecal contamination of
drinking water and food.
 Hence every effort should be made to ensure sanitary disposal of excreta.
 Emergency toilet facilities should be made available wherever they are
destroyed.
 Washing, cleaning and bathing facilities should be provided to displaced
persons.
 Vector control: Control programme for vector borne diseases should be
intensified in the emergency and rehabilitation period

2. DISASTER MITIGATION :
 Mitigation is a key to national preparedness.
 This includes an assessment of possible risks to personal/family health and to
personal property.
 Specialists can be hired to conduct risk identification and assessment surveys.
 Mitigation involves Structural and Non-structural measures taken to limit the
impact of disasters.
 Structural mitigation are actions that change the characteristics of a building or its
surrounding, examples include shelters, window shutters, clearing forest around
the house.
 Non-structural mitigation on personal level mainly takes the form of insurance or
simply moving house to a safer area.

3. DISASTER PREPAREDNESS OR EMERGENCY PREPAREDNESS:

Disaster preparedness is “a programme of long term development activities whose
goals are to strengthen the overall capacity and capability of a country to manage
efficiently all types of emergency it should bring about an orderly transition from through
recovery, and back to sustained development “
 OBJECTIVE: 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 .

Tasks to be followed in emergency preparedness:

 Evaluate the risk of the country or particular region to disaster. India is

vulnerable, in varying degrees, to a large number of natural as well as man-made
disasters.
 Adopt standards and regulation
 Organize communication ,information and warning system
 Ensure coordination and response mechanism
 Resource availability
 Develop public education programmes
 Coordinate information with news media
 Organize disaster simulation exercises that test response mechanisms

POLICY DEVELOPMENT

It is “the formal statement of a course of action”. Policy is strategic in nature and performs the
following functions

 Establish long term goals .

 Assign responsibilities for achieving goals.
 Establish recommended work practice.
 Determine criteria for decision making.
 The form of emergency preparedness policies varies from place to place .
 Six sectors are required for response and recovery strategies . They are Communication,
Police and security, Health Search and rescue, Social welfare , Transport

International Organisations:

1. OCHA : United Nations Office for the Coordination of Humanitarian Affairs

 It was designed to strengthen the UNs response to complex emergencies and
natural disasters by creating the Department of Humanitarian Affairs (DHA)
2. WHO : World Health Organization
 The role is to reduce avoidable loss of life and the burden of disease and
disability.
3. FAO :The Food and Agriculture Organisation of the UN provides early warning of
impending food crises, and assesses global food supply problems.
4. IOM : The International Organisation for Migration is an intergovernmental agency
which helps transfer refugees.
5. IRP : The International Recovery Platform serve as a catalyst for the development of
tools, resources, and capacity for disaster recovery
6. WFP : The World Food Programme is the principle supplier of relief food aid.
7. UNDP : The United Nations Development Programme
8. UNICEF : The United Nations Children’s Emergency Fund
NGO’s
9. IFRC : International Federation of Red Cross and Red Crescent Societies: Pivotal roles in
responding to emergencies
10. Field Assessment and Coordination Team –(FACT) to the affected country if requested
by the national Red Cross or Red Crescent Society.
11. CARE : The Cooperative for Assistance and Relief Everywhere is a humanitarian
organisation fighting global poverty .It also delivers emergency aid to survivors of war
and natural disasters, and helps people rebuild their lives.
12. NetHope :Founded in 2001, is international NGOs that specializes in improving IT
connectivity among humanitarian organizations in developing countries and areas
affected by disaster . Organization has partnerships with Microsoft, Cisco Systems, Intel,
and Accenture.
13. HVO :Health Volunteers Overseas is a network of health care professionals,
organisations, corporations and donors united in a common commitment to improving
global health through education
14. IRC :International Rescue Committee offers lifesaving care and life-changing assistance
to refugees forced to flee from war or disaster
15. HI: Handicap International works in partnership with local organisations and government
institutions.
16. MSF: Médecins Sans Frontières provides medical services in emergency situations.
17. RI: Rehabilitation International is a global network of expert
Indian NGO’s
18. Aniruddha’s Academy of Disaster Management (AADM) :Non-Profit Organization in
Mumbai, India with Disaster Management as its principal objective. Basic aim of AADM
is to save life and property in the event of a disaster, be it natural or manmade.
Successfully trained 60,000 citizens, the Disaster Management Volunteers (DMVs) to
handle various disasters and disaster situations effectively. AADM has built up a
volunteer base, that assists the Government authorities during the disaster relief and
rehabilitation work.
ORGANIZING CLINICS AND CAMPS

HEALTH CAMPS:

These are organized to provide need based specific services to a defined population.

INDICATIONS:

 To provide health services such as diagnostic, curative, family planning, referral and
immunization
 To inform, motivate and guide the people for health action
 To conduct orientation and training programme on health and family welfare for
community health leaders to impart knowledge about various measures to promote health

TYPES OF CAMPS:

 Service camps
 For specialized services such as eye camps, antenatal camps, family planning
camps and immunization camps
 Education and training camps
 To provide in-service training and orientation to health care workers

GENERAL STEPS:

 Securing adequate publicity of the camp

 Procuring and arranging of all the equipments required before the camp
 Mobilizing all community resources for the successful running of the camp
 Making adequate arrangements of supplies
 Procuring educational and publicity material written in simple and non-technical
language for distribution
 Organizing exhibitions to display health messages at the venue of the camp according to
the theme.
 Involving school teachers, community leaders and other voluntary workers for imparting
knowledge, changing people’s attitudes and developing desirable health practices.
 Keeping the records about the community in hand

STEPS:

1. Selection of the participants

2. Planning for the camp
3. Decide on the content and schedule
4. Implementation
5. Follow up
 6. Recording and reporting

TYPES OF CLINICS:

 GENERAL CLINICS:
 Any person can be attended with any of the health problem. These are more
convenient because:
 All clients can be dealt with at the same time.
 An individual person can use the same visit to have all the problems seen
on one single occasion.
 SEPARATE CLINICS:
 There are a number of separate clinics run on different days of the week. This
system of clinics is used where access is very easy and client’s number is very
large. The important clinics under this category includes: • Antenatal clinics •
Postnatal clinics • Under five clinics • Family welfare clinics • Reproductive and
child health clinics
 It must be seen that community health nurse must not spend all the days in the
clinic. It is useful to spend time for community health care activities. Clinic must
be a part of community programme so that the clinic can provide service to the
needy people.
 SPECIALITY CLINIC:
 These provide medical and counseling services for specific disorders. These
clinics are run by specialist Doctors and Nurses.
 Some of the important clinics under this category includes: • TB clinic • Diabetes
clinic • STD’s clinic • Nutrition clinic • Cardiac clinic • Chest clinic

LOCATION OF THE CLINIC:

 Clinic should be set up within the community or as near to the community as possible.
 No one should need to travel more than 1 hour of easy journey.
 The location should be acceptable to all.
 The clinic and waiting area must be safe for children.

CRITERIA FOR A GOOD CLINIC:

 Clinic is located close to the community. The location should be acceptable and
accessible.
 The clinic should be well organized with effective flow pattern from one station to
another.
 Provision for follow up care and referral.
 There should be effective system of recording and reporting.
 There should be effective system of health education for people coming to the clinics.
FUNCTIONS OF COMMUNITY HEALTH NURSE:

 Setting up of clinic and arranging equipments and supplies.

 Placement of health worker at a particular service area and assigning responsibilities
accordingly.
 Assessment of health status of patients.
 Proving need based nursing care services.
 Giving necessary instructions to patient and family members.
 Conducting health education sessions as needed.
 Assisting the Doctor/Specialist.
 Supervision and guidance of health workers.
 Monitoring of health records and registers.
 Maintaining and preserving the health records, registers and reports of the clinic services
provided.
 Helping in promoting good working environment at the clinic.