‫ميحرلا نمحرلا هللا‬ ‫بسم‬

Fatima adb-Elraheem

1. Cervical examination to assess sexual development & function &general health.

2. Assessment of heridofamilial risk like sickle cell trait & haemoglobinopathies.
3. Exclusion of frank clinical conditions/ deformities which will affect RH.
4. Blood group& Rh status ; hepatitis B status.
5. Health education related to promotion of RH
6. Nutrition education
7. Rubella immunization (if not immunized )
8. Tetanus toxoid immunization (if not immunized earlier)
9. Periodic follow up ( at least once a year)
10. Referral on indications

ANTENATAL CARE:
 Antenatal care is the care of the woman during pregnancy
 The primary aim is to achieve at the end of pregnancy.
1. A healthy mother
2. A healthy baby
1. To promote, protect & maintain the health of the mother during pregnancy
2. To detect high risk pregnancies & to give them special attention
3. To foresee complications and prevent them
4. To remove anxiety and fear associated with pregnancy
5. To decrease infant and maternal morbidity and mortality
6. To teach the mother the element of
 Child care
 Nutrition
 Personal hygiene
 Environmental sanitation
7. To attend to the under fives accompanying the mother.
8. To promote mutual trust, cooperation& understanding between the community& the
PHC facility.

Methods for achievement of the objectives of antenatal care:

 a-ANTENATAL VISITS b-CONDUCTING ANTENATAL EXAMINATION

c-PRENATAL ADVICE d-SPECIFIC HEALTH PROTECTION

e-MENTAL PREPARATION f-SPACING OF THE BIRTHS

A. ANTENATAL VISITS:
Ideally mothers should attend the antenatal clinic as follow:

1. Once a month during the 1st six months

2. Twice a month during the 2nd two months
3. There after once a week if every thing is normal

However for the sake of convenience to the mother . the following minimum should be
implemented

 1st contact: before 12 weeks of pregnancy, if possible at 6-8 weeks

 2nd contact: 20 to 22 weeks of pregnancy
 3rd contact: 28 to 32 weeks of pregnancy
 4th contact: 34 to 36 weeks of pregnancy
 5th contact: 38 weeks of term

Of these, at least one visit should be paid at the home of the mother , in case home delivery
is decided upon.

One more visit after 36 at home is a must.

These visits are best conducted by the health visitors or a midwife who should utilize these
visits in order to:

1. Build a good rapport between the community and the health centre.
2. Dissipate the health information to vulnerable group of population
3. Assess/prepare for more delivery

Early booking of pregnancy could be ensured through routine enquiries of the family
members during their frequent visits to health centres & enquiries during home visits for any
purpose.

These visits should be so planned, to include all the required revisits for other purpose like:

 Immunization of her children

 Investigation or consultation
 Adequate time should be spent in explaining to the mothers about the importance of
such repeated contacts
  Listing of defaulters could be done on a weekly basis & the family contacted with the
available means
 Home visits should be reversed for hard defaulters

B. CONDUCTING ANTENATAL EXAMINATION:

(a) in 1st contact:

 The diagnosis of pregnancy is confirmed

 History, physical & obstetrical examination in accordance with pre-designed antenatal
record
 Investigation of:
 Urine for albumin & sugar
 Blood for Hb
 Blood group
 Rh-factor
 VDRL
 Malaria parasite
 Other relevant investigations for endemic diseases (whenever indicated) is
done.
 The mother is registered & antenatal card prepared
 Prenatal advise given
 1st dose of tetanus toxoid given for non-immunized mothers.

(b) During 2nd contact:

 Conduct physical & obstetrical examination

 Specially examine for oedema & anemia
 Record weight & blood pressure
 If the mother is anemic … iron and folic acid tablets to be taken throughout
pregnancy
 Investigate any complaint & treat minor aliments
 Re-enforce prenatal advises

(c)At 3rd contact:

 Conduct complete physical examination

 Palpate abdomen to assess fundal height
 Conduct urine analysis for albumin & blood for Hb%
 Continue prescription of iron & folic acid as required
 Impart knowledge about danger signals of pregnancy by re-enforcing prenatal
advise

(d) At 4th contact:

 Complete physical examination

  Exclude associated illness
 Obstetrical examination specially to ascertain presentation
 Look for signs of toxemia
 Look for albumin & sugar in urine
 Estimate Hb%
 If a normal delivery is anticipated, enquiries regarding the place of delivery is to be
made
 If it is to take place at home necessary arrangements are made through the PHC
 Give 2nd dose of tetanus toxoid (36-38 weeks)

(e) At 5th contact:

 Repeat every examination as per fourth contact.

 Look for the engagement of the head especially in primigravida.
 At this juncture prenatal advise should include warning signs of bleeding.
 High risk cases are to be advised for institutional delivery
 Specialist advise, if not already done in high risk pregnancy.

B.1.THE RISK APPROACH:

 The central purpose of antenatal care is:

1. Early detection of high risk pregnancies &arrange for their skilled care.
2. Provision of appropriate care to all expectant mothers

What compromise the “Risk”?

1. Elderly primigravida
2. Short stature primigravida (below 140cm)
3. Malpresentation (breech ,transverse lie etc)
4. APH threatened abortion
5. Pre-eclampsia & eclampsia
6. Anemia (Hb 50% or less)
7. Twin (multiple) pregnancy , hydramnios
8. Previous stillbirth , intrauterine death or manual removal of placenta
9. Elderly grandmultipara
10. Post maturity (prolonged pregnancy, 14 days or more of E.D.D)
11. History of previous caesarian section or instrumental interference
12. Pregnancy associated with general diseases (kidney including persistent UTI, diabetes
, CVD , TB , liver disease etc)

B.2. DOMICILLIARY VISITS

 Even if the expectant mother is attending the antenatal clinics regularly , she must be
paid at least one home visit by the midwife or health visitor in the course of antenatal
care.
 It will provide
 1. An opportunity to observe the environmental and social conditions at home.
2. Reassurance of the family members specifically regarding the safety of such
service
 If home delivery is planned more visits are required.

C. PRENATAL ADVICE:

 At this time the mother is more receptive to advises concerning herself &her baby.
 So the opportunity should be fully utilized.
 The message should be overflow to child health care & family health care

1.Advice regarding diet:

 Malnutrition leads to low birth weight babies thereby increase infant mortality &
morbidity.
 Supplementing the mother with proper diet even in last trimester of pregnancy
improves the birth weight.
 On an average a normal healthy woman gain about 12 kg of weight during pregnancy.
 Her caloric needs increase by 300kcal/day during 2nd & 3rd trimester.
 About 900 G of protein are deposited in the fetus & maternal tissue during pregnancy.
 Hence an additional allowance of 14 g/day of dietary protein during 2nd & 3rd trimester
should be made.
 There must be a regular &continuous intake of all other nutrients drawn from a wide
variety of locally available & economically suitable foods.
 Special emphasis should be made in terms of iron & folic acid.

2.Advice regarding personal hygiene:

*Regular bathing with soap & water * Clean clothing

*Care of the hair * Oral hygiene

*Dental care

3. Advice regarding rest, sleep& exercise:

 Light household work is allowed

 Heavy manual labour is to be avoided especially in later periods of pregnancy.
 Eight hours of sleep is advised out of which two hours rest after mid day meal.

4. other advice:

 Constipation: managed by prescribing proper diet containing increase roughage e.g

green leafy vegatables , fruits , etc
 Avoid the use of purgatives.

5. Advice regarding the use of drugs:

  Certain drugs taken during pregnancy may affect the fetus adversely “ congenital
malformation
 Classical example is that of thalidomide.
 Other examples are:

1-LSD (chromosomal damage) 2-Streptomycin (VIIIth nerve damage)

3-Iodides (congenital goiter) 4-Steroids (growth retardation)

5-Tetracycline (growth of gum & enamel)

 Anaesthetics & pethidine administered during labour  depressant effect delay in

onset of respiration
 Even in puerperium , if child is breast fed, certain drugs can affect the child through
breast milk.
 Exposure to radiation in the early weeks of pregnancy  malformations in the foetus
,So the diagnostic radiology should be avoided during the 1 st four months.

6.Advice regarding warning signs:

 Mother should be given specific and clear instructions to report to the health
center in case of following warning signs:
(1) Swelling of feet
(2) Fits (convulsions)
(3) Severe headache
(4) Blurring of vision
(5) Bleeding or excessive discharge per vagina
(6) Any other unusual symptoms (cessation of foetal movement, lower
abdominal pain, etc).

7.Advice regarding child care:

 Special sessions are to be held for mothers, attending the clinic by a nurse
 Mother craft education should aim at:

(1). Nutrition education (2). Advise on hygiene & child bearing

(3). Cooking demonstrations (4). Family budgeting

D. SPECIFIC HEALTH PROTECTION:

(a) Anemia:
 Majority of the mothers develop anemia in the last trimester of pregnancy
 The common etiological factors are deficiency of iron or folic acid or both

Anemia per se is associated with:

-High incidence of premature births -PPH

 -Puerperal sepsis -Thromboembolism phenomenon

So a daily dosage of 500µg of folic acid & 60mg of elemental iron should be prescribed to
all mothers at least in the 3rd trimester of pregnancy.

(b) Associated nutritional deficiency:

Associated protein & vitamin deficiency can occur due to:
 Increase demands or
 Dietary deficiency
 Or both

So, the mother should be protected by providing:

 Vit. Preparations
 Protein supplements
 This in addition to the dietary advise given during sessions of mother
craft.
(c) Toxemia of pregnancy:
 The presence of albumin in urine&
 High BP, especially on serial observations over a period of time – indicate
toxaemia of pregnancy
 Emphasis should be placed on:
- Early detection
- Early management
 Efficient antenatal care decrease the risk of toxaemia.
 Early signs of toxaemia should be managed by simple procedures like
1. Salt restriction
2. Bed rest
3. Diuretics
 Specialist opinion should be sought whenever necessary
(d) Tetanus:
 Neonatal tetanus = 100% mortality
 Hence , active immunization with tetanus toxoid is recommended for all
mothers attending antenatal clinics, who were not satisfactorily immunized
earlier.
 For non-immunized mothers, two doses of tetanus toxoid at the time &
interval as shown:
1- 1st dose: 16-20 weeks of pregnancy (even earlier)
2- 2nd dose: 36-38 weeks of pregnancy.

When a mother is registered late in pregnancy two doses should be given with an
interval of 4 to 6 weeks.
  For those mothers who are fully immunized with tetanus toxoid in the past a
single booster dose four weeks before the expected date of delivery should be
given.
 For those who are passively immunized with A.T.S in the recent past & never
had active immunization should be treated as non-immunized person.
 If active immunization is achieved during this period there is no need to
immunize the mother or child passively at the time of delivery.
(e) Syphilis:
 Even if the mother is suffering from syphilis, infection of the fetus does not
occur before the 4th month of pregnancy (especially if the mother is suffering
from primary or secondary syphilis rather than late syphilis).
 It is a routine procedure to do S.T.S (serological test for syphilis) early in
pregnancy.
 It is possible to get subsequently infected on a later date.
 So , it is advisable to do S.T.S both in early & in late pregnancy.
 Congenital syphilis is easily preventable by giving ten injections of procaine
penicillin 600.000 units I.M to S.T.S positive mothers.
(f) German measles:
 If the mother suffers from german measles in the 1 st four months of pregnancy
, she may give birth to a child suffering from Rubella syndrome.
 There is no value of gamma globulin in the prevention of rubella syndrome in
an already infected mother.
(g) Rhesus status:
 Rh-ve women as well as women with rare blood groups should again be
tested at 28 weeks of gestation to detect antibodies.
 In order to prevent Rh sensitization in ‘women at risk’ I.M administration of
Rh-immunoglobulin (250 IU) at 28 weeks of pregnancy with a further dose
after delivery. If the baby is Rh +ve has been suggested.
 This should be done under the supervision of a specialist.

E. MENTAL PREPARATION:

 Mental preparation of the expectant mother is as material preparation.

 Sufficient time & opportunity must be given to all mothers to have a free & frank
discussion on all aspects of pregnancy, delivery & child care.
 Every opportunity of her contact with the health staff both in the health center & at
home should be utilized to:
1. Impart adequate knowledge
2. Alleviate the fear misconception
3. Apprehension regarding motherhood
 In addition to the organized mother craft services, the responsibility should be shared
by all the members of the health team including its leader i.e the doctor.
F. SPACING OF BIRTHS:

 Repeated frequent pregnancies contribute to both maternal & infant mortality.

 A minimum period of two years between two successive pregnancies should be aimed
at
 Spacing can be best achieved by encouraging the mother to continue to breast feed
her child for two years.
 In addition it has a collateral benefit on child nutrition & can be practiced by every
mother until otherwise contraindicated.

III.INTRA-NATAL CARE:
 The need for efficient intranatal care is very important even if the delivery is going to
be a normal one.
 A part from unforeseen puerperal complications like PPH. Cord prolapse or abnormal
presentation; preventable complications like puerperal sepsis leading to septicemia,
tetanus neonatorum may result from unskilled & septic manipulation or management.

Hence , a good intranatal care should aim at:

1) Asepsis (not merely antiseptic)

2) Minimum injury to the mother & the new born
3) Preparedness to deal with complications ( such as prolonged labour, APH, convulsions,
mal-presentation, prolapse of the cord, retained placenta etc.)
4) Care of the baby at delivery:
a) Resuscitation
b) Care of the cord
c) Care of the eyes
 The practice of delivery as decided during the antenatal period based on sound
scientific judgment could be either:
A. Domiciliary or
B. Institutional

A.DOMICILLIARY:

 The advantages of domiciliary delivery vis-à-vis institutional delivery, if any should be

weighed against the inherent risks involved in delivering a woman in home setup.
 The advocates of domiciliary delivery have sound argument for doing so :-
(1) The mother delivers in family surroundings:
 The fear factor associated with delivery in hospital could be minimized
 However , many times the contrary is true
 Many mothers will be well assured in the hospital setup as she is aware
of the professional assistance available in hand.
(2) The chances of cross infection could be minimum
  However, tetanus neo-natorum is more common in unattended home
deliveries.
(3) The social satisfaction of the mother & her family supervision can ease her
mental tension.
 STRICTLY SPEAKING MANY HOMES ARE UNSUITABLE EVEN FOR
CONDUCTING THE SO CALLED NORMAL DELIVERIES.
 The argument that child birth is a “natural event” & should take place at
home does not “GUARANTEE” that ever thing will be normal.
 In a domiciliary setup, as it is today & in foreseeable future:
1) The mother would have less medical & nursing supervision than in the hospital.
2) The mother would have less rest as she may resume her domestic duties too soon.
3) Her diet may be neglected
4) Trained midwives to provide out-reach services are not easily available
 In case of health center delivery or domiciliary service, is to be provided due to
sound reasons or under compulsion from the side of the mother,
 The birth attendant (midwife) must be trained to recognize the danger signals
EARLY (in addition to training in aseptic delivery) such as:
a) Sluggish pains or no pains even after rupture of membrane.
b) Good pain for one hour after rupture of membrane, then no progress
c) Hand or cord prolapse
d) Fetal distress (indicated by meconium stained liquor, increase or decrease
in fetal HR)
e) Excessive show or bleeding during labour
f) Collapse during labour
g) Placenta not separated ½ hour of delivery
h) PPH
i) Temperature over 38®C during delivery
 In such situation “quick referral services” should be available.
 Perhaps this may not be possible in many remote areas;
 Hence previous time will be lost leading to loss of previous lives which could have
been saved otherwise.
 Hence all the mothers should be encouraged for institutional delivery, especially for
hospital delivery.
 However, if this is IMPOSSIBLE for various reasons, birth should go attended by a
trained birth attendant either a midwife or trained nurse.

B.HOSPITAL CARE

 About 1% of deliveries tend to be abnormal & 4% difficult, requiring the services of

qualified obstetrician.
 The purpose of antenatal care is to filter these 5%.
 However, certain complications during or following labour can not be foreseen.
  Hospital care is generally recommended for “high risk” pregnancies.
 This is only true & feasible when there is well organized domiciliary obstetrical service
till that time all the deliveries should take place in an institution ( hospital, maternity
center,& health centers) where facilities for such services are available.
 In case of health center delivery the mother is to be observed at least for a period of
two hours. However if possible
 The women delivering early in the morning could be observed till evening.
 Those delivering in the evening or at night could be observed till morning.
 This period can be utilized to educate the mother regarding baby emphasizing on
BREAST FEEDING; its duration and advantages.

IV.POST-NATAL CARE:
Definition: care of mother & the newborn after delivery

CARE OF THE MOTHER:

Objectives:

i. To prevent complications of post-partal period

ii. To restore the health of the mother to the optimum
iii. To check adequacy of breast feeding
iv. To provide basic health education to the mother & family
1. COMPLICATIONS OF POST-PARTAL PERIOD:
 The complications occurring during the post-partal are period are to be
detected early & manage promptly ; these are:
1) Puerperal sepsis
2) Thrombophlebitis
3) Secondary hemorrhage
4) Others

(1) Puerperal sepsis:

 This is the infection of the genital tract occurring within six weeks after
delivery.
 This can be recognized by Î in body temp ; Î pulse rate , foul smelling lochia ,
pain & tenderness in the lower abdomen, etc
 Puerperal sepsis can be prevented by adhering to the principles of asepsis
during & following parturition.
(2) Thrombophlebitis :
 Infection of the veins of the leg & pelvis can occur during post partal period.
 Susceptible mothers ( obese , presence of varicose veins… etc) should be
examined frequently during the post partal period for the occurrence of such
complication.
  This may be associated with:

Pale, tender swollen legs, with or without fever.

Tenderness elicited by dorsoflexion of the foot (Homan’s sign) in the calf muscle
is an early sign of deep vein thrombosis of legs. This test is better to be avoided ,
since the thrombus may detach.
(3) Secondary hemorrhage:
 Definition: Bleeding per vagina occurring any time from twenty four hours after
delivery to the end of puerperium (six weeks)
 Causes: retained placenta or membranes, infection … etc
(4) Others:
 UTI & mastitis are the other common post partal infections which should be kept in
mind in addition to the possibility of locally endemic diseases whenever there is post
partal fever.
 The management of complications is under the view of secondary care.
 Only symptomatic treatment with supportive measures should be attempted at the
primary care level.
 If such complications are detected or reported either in the home or health centre ,
the mother should be referred to the specialist without losing much time.
 Transport arrangements made through the health centre if required.

(2) RESTORATION OF THE HEALTH OF THE MOTHER:

 The second objective of post-natal care is to restore the health of the mother both
physically & psychologically.
A. Physical restoration
B. Post-natal examination

A. PHYSICAL RESTORATION:
 Soon after delivery the physical examination should be frequent, i.e
1- Twice a day during 1st three days &
2- Once a day till the umbilical cord of the newborn falls off.
 At each of these check-ups the following should be done:
1. Examine pulse
2. Examine temperature
3. Examine respiration
4. Breast examination
5. Abdomen should be palpated to know the degree of involution of the uterus.
6. Lochia /discharge per vagina & its characteristic is to be noted.
 Urinary and bowel symptoms are enquired into-advise regarding perinatal toilet &
care of the episiotomy wound stitches ( if any) is given.
 The immediate post-natal complications as mentioned earlier should be kept in
mind.
  At the end of six weeks an examination to check the involution of uterus is
required , the involution should have been complete by then.
 Further, the mother is to be seen& examined in the mother health clinics at least
once a month and thereafter once in 2-3 months, till the end of one year or till she
become pregnant again.
 The common conditions found in late post-natal period ( sub involution of the
uterus, retroverted uterus, prolapse uterus, cervicitis, etc…) are to be kept in mind
and looked for.
 The above schedule of post-natal home visits could be well adhered to in urban
situations or households situated near the health centre.
 In case of adverse geographical conditions such as:
1. Far away houses
2. Non-availability of a suitable transport.
 In these, mentioned conditions a minimum number of two post-natal home visits
should be made in the first week of delivery.
1st fist on the 3rd day to look for immediate complications
2nd visit on the 7th day for taking care of late complications
 Post-natal visits should be conducted irrespective of the place of delivery.
 The health centres should develop a system to know the date of discharge of a
delivery case from the hospital so as to enable to follow them at home as prescribed

LECTURE 4

1. Anemia
2. Nutrition
3. Post-natal exercise
4. Psychological

1.anemia:

 Routine Hb estimation should be done during post-natal visits.

 If anemia is discovered it should be treated.

2.Nutrition :

 if the mother is malnourished she will continue to secrete breast milk as with a well
nourished mother but at the cost of her own health.
 So a balanced diet appropriate for lactating mothers with nutritional supplements &
nutrition education should be given.

3.Post-natal exercise:

 Gradual resumption of normal household duties may be enough to restore the tone of
abdominal muscles.
 Rarely advise may be needed in case of
a. Obese
 b. Grand multipara
c. Debilitated mothers

4.Psycological:

 Psychological problems are generally generated either due to

a. Ignorance
b. Timidity
c. Fear of insecurity of the baby
d. Combination of both
 At this juncture she needs the support & companionship of her husband , cheering up
by other family members.
 Hence , there is a need to educate the husband & other elderly family members, if the
woman is to endure cheerfully the stresses of child birth.

(iii)TO CHECK ADEQUACY OF BREAST FEEDING:

3.Breast feeding:

a) Need
b) Advantages
c) How to ensure breast feeding
d) Contra-indications for breast feeding
e) Frequency of breast feeding

BREAST MILK:
1. Scientist have discovered a source of liquid gold.
2. For decades they have tried to dismantle, analyze, & recreate this amazing substance
– to no avall.
3. The only known source of this magical fluid is the mother’s breast, & it’s not giving up
its secret easily.
4. Shortly after giving birth , chemical messages are sent throughout a woman’ body,
instructing it to produce breast milk.
5. The mechanisms involved in its production are mid-boggling, as are the various
benefits it provides to the infant.
6. Through diet we can increase its potential & help ensure that it is of the highest
possible quality.

a) Need:
 For the majority of children breast milk provides the main source of nourishment in
the 1st year of life.
 Breast feeding appears to have become a lost art in many parts of the world , partly
due to :
 1. The commercial propaganda
2. Late awareness of the medical profession.
 When the standard of environmental sanitation is poor & the educational status low,
the content of the feeding bottle is likely to be:
1. Nutritionally poor
2. Bacteriologically dangerous
 It is very important there for to advise the mothers to:
1. Avoid feeding bottles
2. Continue breast feeding
 An average mother from developing country, although poor in nutritional status has a
remarkable ability to breast feed her infant for prolonged period , nearly up to two
years.
 This quality of the mother should be fully utilized.
 Up to the age of six months , mother’s milk alone will be adequate for the growth of
the child.
b) Advantages:
1) To the mother:
i. Emotional association & developing good rapport with her child.
ii. Prolongation of birth interval, which has +ve effect on lowering both maternal
& infant mortality.
iii. Promote uterine involution.
iv. Lead to decrease breast congestion - protects from developing breast abcess
2) To the baby:
i. There is no better balanced formula than mother’s milk, which is suitable for
the baby.
ii. Protect the baby from majority of infections
Although the immunoglobulins present in breast milk are poorly absorbed
from the child’s gut they exercise a local protective action against invading
pathogens ( e.g polio, E.coli etc….)
iii. Exerts a bacteriostatic effect due to certain enzymes present in breast milk
iv. Vitamins and minerals:

- Lactose present in breast milk is converted to vit B in the GIT of the child

- Availability of the vitamins &minerals (Cu, Fe) depends mother’s diet.

- Hence in tropics it is usually poor in vit D,A and to some extent in Cu & iron

v. breast fed infants usually do not develop the unhealthy habit of thumb-sucking

vi. There is an association between development of arteriosclerosis in late life & the
duration of breast feeding in infancy & childhood , the longer the duration of breast feeding ,
the lesser the chances of developing arteriosclerosis.
(c ) How to ensure breast feeding:

i. Provide adequate atmosphere both at home & maternity wards e.g privacy
ii. Don’t separate the new born from the mother in the nursery , keep the crib by the
side of the mother (rooming in)
iii. Apprehension in the minds of the mothers arising out of the faulty notion regarding
“cry” of the baby should be alleviated by assuring her that the baby is crying for feeds.

-Apprehension & anxiety caused by the cry of the baby --to decrease of ‘let down’
reflex -- lesser secretion of milk.

- Then - inadequate milk -the baby will cry more , which in turn -- temporary
introduction of bottle feeds.

- Thus when the baby gets accustomed to the free flowing , easy to suckle more
sweeter bottle feed. May refuse breast feeding , further reducing the secretion of
breast milk.

- This cycle should not be allowed to take place by educating the mothers.

(d) Contra-indications for breast feeding:

i. Absolute
ii. Relative
1. Absolute:
The mother
Rarely malnourished mothers (PCM) , temporary cessation till the time she recover
carcinoma breast.
2. Relative
i. Mothers suffering from TB
ii. Mother suffering from leprosy
iii. Mothers suffering from breast abcess
1) Mother suffering from TB:
 Breast feeding can be continued even if the mother is excreting AFB under cover of
chemoprophylaxis (INH) & immunoprophylaxis to the new born & effective
treatment of the mother.
 If the mother is AFB –ve & under treatment there is no need for additional
precautions.
2) Mother suffering from leprosy:
 Breast feeding can continue even in lepromatous mothers (bacilli +ve), provided
the mother is under regular treatment.
 Dapsone excreted in the milk is sufficient to protect the child from acquiring
infection
3) Mother suffering from breast abcess:
 There is no ill effect on the baby if he or she continues to suckle.
  It may even be beneficial to the mother in decreasing breast congestion , provided the
mother can tolerate the pain.

(e) Frequency of breast feeding:

 Demand feeding is appropriate & beneficial to the baby than scheduling feeds
 All up to the age of six months breast milk alone is adequate ; the baby should get as
much of feed as he desires & as frequently as he demands.
 Scheduled feeding is not practical

WEANING:

 Weaning does not mean sudden withdrawal of the baby from the breast (mother’s
milk)
 It is gradual process , starting around the age of 5 to 6 months , when the child is
introduced to ‘ supplementary foods’.
 At this time of age & onwards, the mother’s milk alone is not sufficient to cope up
with the growth & development of the baby.
 The weaning diet or feed should be selected on the basis of:
- Availability of food
- Capability of the family to procure food &
- Family dietary habits
 These are usually
 Cow’s milk
 Soft cooked rice
 Mashed potatoes
 Soft cooked vegetables
 Fruit juice
 Soft cooked eggs & meat
 At the age of one year the child should receive solid foods consisting of cereals ,
pulses, vegetables, fruits, meat & egg.
 Commercially available weaning food should be discouraged either they are superior
nor they are safe under the prevailing socioeconomic & educational situation.
 the supplementary foods should be rich in proteins & other nutrients.
 The weaning period is most crucial period in child development
 During this process the children are exposed to the harmful synergistic inter-action of
malnutrition & infection
 Faulty weaning (not started or delayed) can lead to:
- Recurrent attacks of gastroenteritis
- Growth failure- kwashiekor, marasmus & immune-deficiency marked by
recurrent & persistent infections which may be fatal.

(iv) TO PROVIDE BASIC HEALTH EDUCATION:

 Health education during post-natal period should cover :

 I. Hygiene – both personal & environmental
II. Feeding of mother & infant
III. Importance of post-natal examination
IV. Birth registration
V. Importance of visits to well baby clinics
 IN SUDAN:
- MCH started in 1921.
- In 1978 the MCH/FB program of the MoH started at OMS
- In 1986 MCH was institutionalized within the FMOH in 1994 , the directorate of
MCH was renamed as DRH , which was attached to the directorate of PHC with
FMOH.

The components of RH care are:

1. Safe motherhood
2. Infertility
3. Prevention of unsafe abortion
4. STIs & HIV/AIDS
5. Adolescent RH & sexual health
6. Gender equity
7. Prevention of harmful traditional practices
8. RH needs associated with menopause , including reproductive tract cancers.

Reproductive health safe motherhood

Definition of reproductive health:

“reproductive health is a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system
and to it is functions and processes”

Concept of RH:
Reproductive health concepts include:

1-the well-being of men, women and young people as concerns their reproductive functions
throughout the life span.

2- women should go through pregnancy and childbirth without danger to themselves or their
children.
3-prevention of unintended pregnancies and diseases spread through sexual intercourse

Component of RH:
The component of RH care are:

1-Safe motherhood 2- infertility

3- prevention of un safe abortion 4- STIs/HIV and AIDS

5- adolescent reproductive health and sexual health

6-Gender equity 7- prevention of harmful traditional practices

8-reproductine health need associated with menopause and andropause , including

reproductive tract cancers.

Maternal mortality ratio(MMR):

Number of deaths in a period per number live birth during same period

MMR = number of maternal deaths * 100000

Number of live births

Some indicators:

Infant mortality rate 48/1000 live births

Under five mortality rate 83/1000 live births (2010 est)

Maternal mortality rate 311 deaths/100000 live births (2015 est)

Trends in maternal and neonatal mortality:

The maternal mortality ratios in African region are on the rise in some countries.

Most of these maternal deaths occur in the rural areas

The maternal deaths are mostly due to lack of access to quality emergency obstetrics car
when pregnancy-related complications occur

This is due to:

1- The delay in decision making at the individual family and community levels
2- the delay in arriving at the health facility
3- the delay in institution appropriate management at the facility
Complication of unsafe Insafe abortion.

The impact of HIV/AIDS

 Although world-wide more men are infected overall, the virus is spreading faster among
women.

This is primarily due to:

1. Vulnerability of women to STIs including HIV compared to men

2. Biological and sociocultural and economic factors
Adolescents constitute an especially vulnerable group to the infection.

Impact of HIV/ AIDS

Mother-to-child transmission of HIV constitutes today a real public health problem.

HIV/AIDS & STIs

HIV/AIDS is a serious health problem particularly in sub-Saharan Africa

In spite of that several countries still do not recognize HIZ as a major threat to public
health

Cases of STIs occur each year, but many countries do not have the capacity to diagnose
and treat them.

Having an untreated STIs can the risk of HIV infection.

RH programs can reduce levels of STIs including HIV/AIDS, by

1. Providing information and counselling in critical issues such as sexuality and mother-
to-child transmission of HIV
2. Diagnosing and treating STIs
3. Developing strategies for contact tracing
4. Referring people infected with HIV for further service

Challenges of reproductive health:

One of the fundamental principles of PHC is equitable access to quality health care at all
levels.

To respond to this, the following issues need consideration.

1. minimum package of services

2.availibty of quality care

3. functional referral systems

1. minimum package of services:

 RH embraces a wide range of health services far beyond the traditional maternal and child
health services

Traditional maternal and child health focused on pregnant women and children

RH brings in other non-traditional targets groups such as a men and adolescents

2-avilability of quality care:

The un acceptably maternal mortality under-scores the need for the availability of /and
access to essential and obstetric care at PHC level.

The key element being the availability of skilled attendance at childbirth.

The availability of essential health services.

The speed at which STIs/ HIV/AIDS is spreading as seen more and more women being
infected.

As result the maternal to child transmission of HIV infection is on the increase.

Another major problem is complications from unsafe abortions.

All these factors have considerably modified the demands on the health system.

3- functional referral systems:

Most of the maternal and neonatal deaths could be prevented if only functional referral
systems could be put in place to allow pregnant women to reach the appropriate health
services when complications occur.

Why forward:

1-integration 2- capacity building

3- operational research 4- monitoring and evaluation

5- community participation and awareness

1- integration:

Linking the community to the PHC services

Integration of different RH services with other services (e.g. malaria, HIV/AIDS)

2- capacity building:

The emerging needs call for:

1-capacity building in terms of health providers skills (multipurpose health providers)

 2- health systems performance (the minimum package of services modified to includes
the new elements of RH)

3- organization of work (job description, service low, etc.

3- operational research:

Operation reach will be needed to help put together enough data on the best ways the
respond to the demand

4- monitoring and evaluation:

Need to integrate RH indicators into the management information system

5-community participation and awareness:

To support health system responsiveness and to promote the us of services

Key element of RH Include:

1- Meeting the need for family planning

2- insuring maternal health and reducing infant mortality

3-preventing and treating STIs, including HIV/ADIS

4- eliminating traditional practices such as FGM that are harmful to woman reproductive
health and wellbeing

5- countries are increasingly including other elements such as prevention of cervical and
breast cancer and infertility

Save motherhood:
Improving maternal health calls for:

1- better health facilities

2- logistic systems

3- training

To insure appropriate and effective care.

Another challenge is to overcome barriers to access, including men’s understanding of

their roles and responsibilities in woman health.

Care which the mother should reserve during pregnancy

 -Early booking of an AN cases. -Their timely follow up

-Referral of high risk cases -Managing normal pregnancies

-Taking care during: delivery postnatal period and inter gestational period

ANC:
Antenatal care(ANC) is the care of the woman during pregnancy

The primary aim of ANC is to: promote and protect the health of woman and their unborn
babies during pregnancy so as to achieve at the end of a pregnancy a healthy mother and
a healthy baby.

Goals:
to reduce the mortality and morbidity of women and children

to improve the physical, mental, social well-being of women, children, and their families.

Objectives:
To ensure that the pregnant women in a good health status before pregnancy.

To ensure that the pregnant women and her unborn child are in best possible health prior
to delivery.

To ensure that all pregnant women understand, (i) the complication of pregnancy that
may lead to death, (ii)the best approach to safe delivery and, (iii)the best ways of bringing
up their babies.

Principles and scope of services:

Antenatal care provides an essential link between and the health system and offers
essential health care services in line with national policies, including:

Counseling about the danger signs of pregnancy and delivery complications and where to
seek care in case of emergency.

Counseling in birth preparedness, emergency readiness, and the development of a birth

plan.

Providing advice on proper nutrition during pregnancy.

Detecting conditions that require additional care and providing appropriate treatment for
those conditions

Detection complications that influence choice of birthing location.

Supplying Iron and folate supplement.

In certain settings, providing treatment for conditions that affect women’s pregnancies,
such as malaria, tuberculosis, hookworm infection, iodine deficiency, and sexually
transmitted infections, including HIV/AIDS.

Providing tetanus toxoid immunization.

Rapid test for syphilis.

Providing voluntary HIV testing and counseling.

Providing information about breastfeeding and contraceptives.

Immunizations schedule (WCBA):

Tetanus toxoid:0.5 ml. IM.

Deltoid muscle

First dose: essential dose, does not give any protection. Given at the first contact after the
first trimester or before pregnancy in the child bearing age.

Second dose: essential given after a month from the first. Given protection for 1-3 years.

Third dose: booster given after 6 month or subsequent pregnancy, give protection for five
years

Fourth dose: booster dose given after a year or subsequent pregnancy, give protection for
10 years.

Fifth dose: booster dose given after a year or subsequent pregnancy, give protection for
life.

Disseminating the benefits of ANC should be a community commitment; they can be

promoted through: Word of mouth, leaflets, newspapers, and/or local radio.

Antenatal care is an opportunity to promote dialogue with clients and nurture confidence,
as well as to reinforce maternal health messages, particularly the importance of skilled
birth attendant at the time of delivery, and other messages such as:

Nutritional advice, personal hygiene, safe sex.

Importance of place of delivery and skilled birth attendant

Birth preparedness and emergency readiness, including planning referral facility,

transportation, and blood transfusion.

New care, including breastfeeding and immunization

 Family planning for child spacing.

Component of the birth plan:

 Make sure the women know how to contact the skilled provider or healthcare
facility at the appropriate.
 Skilled provider, Assist the women in making arrangements for a skilled provider
to attend the birth; this person should be trained in supporting normal labor /
childbirth and managing complications if they arise.
 Place of birth, assist the women in making arrangements for place birth- whether
at the district hospital or health center. Depending on her individual/ health
needs, you may need to recommend a specific level of healthcare facility as the
place of birth, or simply support the women in giving birth where she choose.
 Emergency transportation,
Make sure she knows the transportation systems and that she made specific
arrangements for: transportation to the place of birth (if not the home) and
emergency transportation to an appropriate healthcare facility if danger signs rise.
 Funds, ensure that she has personal savings or other founds that she can access
when needed to pay for care during normal birth and emergency care. If relevant,
discuss emergency funds that are available through the community and/or facility.
 Decision making, discuss how decisions are made in the woman’s family (who
usually makes decision?), and decide: how decision will be made when labor
begins or if danger signs arise (who is the key decision-maker?), and who else can
make decisions if that person is not presents?
 Support, assist the woman in deciding on/making arrangement for necessary
support, including: companion of her choice to stay with her during labor and
childbirth, and accompany her during transport if needed, and someone to care
her house and children during her absence.
 Blood donor, health education session to explain the importance of donation and
to ensure that the woman has identified an appropriate blood donor and that this
person will be available in case of emergency.
 Item needed for clean and safe birth and the newborn: waterproof/plastic cover,
cord ties. Items needed for the newborn, for example: blankets, clothes, etc.
Note: items needed depend on the individual requirements of the intended place
of birth, whether in a facility or in the home
 Danger signs and signs of labor: ensure that the woman knows the danger signs,
which indicate a need to intact the emergency readiness.
Vaginal bleeding, difficulty breathing, high blood pressure, fever, prolonged, labor
(over 12 hrs), severe abdominal pain, severe headache/blurred vision, and
convulsions/ loss of consciousness.
 Signs of labor, also ensure that she knows the signs of labor, which indicate a need
to contact the skilled provider and enact the birth preparedness plan: regular,
progressively painful contractions; lower back pain radiating from the fundus;
bloody show; and rupture of membranes
Preventing and managing unsafe abortion:
Most countries are strengthening efforts to prevent unwanted pregnancies and some are
working systematically to the health impact of unsafe abortion, which remains a major
public health concern.

Female genital mutilation (FGM):

The FGM, the partial or total removal of external female genitalia, a practice that has
severe health and psychological consequence.

Worldwide, an estimated 130 million girls and women have undergone some form of
FGM, and each year 2 million are believed to be at risk.

Most are in 28 countries in Africa and Arabian Peninsula.

Thousands die each year as a result of FGM, from infections, hemorrhages during
childbirth.

The program of Action called on governments” to prohibit female genital mutilation

wherever it exists and to give vigorous support to efforts among NGOs and religious
institutions to eliminate such practices.

Making pregnancy safer components:

In 18/8/2001- all states ministers of health and the federal minister signed the Sudan
declaration on safe motherhood…….. As the main target- a midwife/skilled attendant for
every village…..

Midwifery training: Revision of the midwifery curriculum.

Women’s, child’, adolescent’s health within the Sustainable Development Goals (SDG):

SDG goals 3. Ensure healthy lives and promote well-being for all at all ages

A subset of goal 3:

-reduce then maternal mortality ratio to less than 70 per 100,000 live births

-end preventable deaths of newborns and under-five children.

-ensure universal access to sexual and reproductive health care services, including for
family planning, in formation and education, and the integration of reproductive health
into national strategies and programs.

-achieve universal health coverage, including financial risk protection, access to quality
essential health-care services and access to safe, effective, quality and affordable
essential medicine and vaccines for all.
Structure of RH:
1- RH is a concept and does not obligatoriously need an own structure (building, services,
personal).

2- the concept of must be introduces in several services and the concerned medical
personnel trained to understand the concept and to perform the necessary services in an
integrated manner.

3- the type of vertical approaches to health problems has long been shown to be less cost-
effective and less equitable than an integrated approach.

4- also the different elements of RH are closely linked and patient are faced often to
cumulating consequences of reproductive problems.

5- therefore, element likes STIs/AIDS prevention, family planning, abortion, sterility,

neonatal care, delivery and breast-feeding cannot be focused separately.

6- integration and an overall understanding of RH are essential.

The services, which provide RH, are spread in the whole health institution
network of the country, they involve:
1- First level care

1-ambulance in rural zone 2-public run health centers in rural zone

3-general practitioner or family physician 4-mother and child consulting centers in

districts

2- Second level care

District maternities and pediatric hospital.

3- Third level care

1- university hospital of OBS/GYN 2- university hospital of pediatrics

The second and third level centers are in the same time referral services for the whole
country.

Who is concerned with RH elements?

1- public health institutions:

-PHC-directorates:

1- sector of RH
 2- sector of hygiene and epidemiology

-Hospital care directorate:

1- gynecological and obstetrical services

2-pediartic services (peri- and neonatal care)

-institute of public health:

1- STIs/AIDS prevention and control program

2-public education institution:

1- ministry of education

2-facutly of medicine, department of OBS/GYN

3- private sector:

1- gynaecologists 2-paediatrician

3-familty physician 4-druggists

5- different NGOs

Definition of RH periods
There are three main periods of RH:

1-period of pre-RH, which corresponds to adolescent age

2- period of RH, which includes: a-maternal period: prenatal, delivery, post-natal, and
breast-feeding period. b-interval between deliveries.

3- period of post-RH, which corresponds to menopause and andropause time.

Period of pre-reproductive health:

Adolescent care:

1- improvement of RH education in school

2- knowledge of STIs and contraceptive

3- prevention of pregnancies in early age

4- prevention of STIs

5- prevention of inadequate sexual behavior

6- safe abortion

Period of reproductive health:

Mother care:

1-Pre-conception 2- prenatal care

3- reduction if pre-term deliveries 4- adequate vaccination of pregnant women

5- labour 6- post natal care

7- promotion of breast-feeding 8- reduction of perinatal mortality

9- reduction of maternal mortality 10- reduction of obstetrical and neonatal

complications.

Checking up of genital and breast tumours:

1- early screening of breast, cervical and prostate cancer

2- counselling and referring 3- reduction of HPV prevalence.

Period of post- reproductive health:

Care or post-RH:

Prevention and treatment of menopause disorders.

Sexual history such as:

1- any symptoms 2- number of sexual partners both now and in the past

3- number of sexual practices 4-sexuall orientation (e.g heterosexual, homosexual or

bisexual)

5-injected drugs 6- tattoos or body piercing, or acupuncture.

Examination:

Look at genital area and other parts of the body. This is to check and to look for any signs
of an STI. Women may have a vaginal examination.

Test: a range of tests may be needed:

1- swabs can be taken from inside the vagina, from the cervix, from the tip of the penis,
and if necessary, from the throat or the rectum (back passages).

2- blood test for several STIs

3- urine tests are useful to look for several STIs.

 4- the pap smear is used to screen for very early changes in the cervix seed before cancer
developed. If these changes are found, they can be treated and cancer is prevented.

What are the symptoms of STIs?

Many STIs do not produce any symptoms. A person can have STI without knowing it.

If there are symptoms, they may include:

In women:

1- an unusual vaginal discharge, itch or soreness

2- a sore, wart, lump, rash or blister on the genitals or around the anus

3- pain or discomfort when passing urine 4- abdominal/ pelvic pain

5- pain during sex 6- bleeding between periods (including women who are
on the pill)

7- bleeding after sex 8- painful, heavy or irregular periods 9- unusual discharge from
the rectum

In men:

1- a discharge from the penis.

2- a sore, wart, lump, rash or blister on the genitals or around the anus

3- an itch or soreness of the penis 4- pain or discomfort

5- pain in lower abdomen 6- painful or swelling testicles

7- unusual discharge from rectum

Clinical information:

Symptoms:

1- blisters, lump, and open sores 2- genital itch

3- pain 4- vaginal bleeding 5- discharge

Presentations:

1- acute proctitis 2- bacterial vaginosis 3- candidiasis

4- cervicitis 5- epididymo-orchitis 6- non-specific urethritis

7- pelvic inflammatory disease 8- trichomoniasis 9- vaginal infection

 Sexually transmitted infection and other conditions:
1- Bacterial vaginosis 2- Candidiasis 3- Chancroid 4- Chlamydia

5- crabs/ pubic lice 6- Donovanosis 7- Genital herpes 8- Genital ulceration

9- Genital warts 10- Gonorrhoea 11- Hepatitis A 12- Hepatitis B

13- Hepatitis C 14- Herpes simplex 15- HIV and ADIS 16- Lymphogranuloma
venereum

17- Molluscum contagiosm 18- Scabies 19- Syphilis 20- trichomoniasis

Information to treatment and counselling issues:

1- taking a sexual health history 2- symptoms 3- general
examination

4- screening at risk population 5- screening injecting drug users 6- screening

young people

7- guidelines for screening sex workers 8- contact tracing 9- notification of

STIs

10-safe sex – prevention 11- drug use risk in pregnancy and breast-feeding

12- emergency contraception 13- post exposure prophylaxis

14- HIV pre- and post-testing counselling

Maternal Mortality:
Maternal health and developing countries:

Most women do not have a good access to the health care and sexual health education.

A woman in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or child birth,

compared to a 1 in 4,000 risk in a developing country- the largest difference between poor
and rich countries of any health indicator.

Maternal mortality: death of a woman while pregnant or within 42 days after

termination of pregnancy, irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or it is management but not from
accidental or incidental causes.

Burden of maternal mortality is an important input to health decision-making.

Critical indicator of population health, reflecting the overall state of maternal health as
well as quality and accessibility of PHC available to pregnant women and infants.

Maternal mortality ratio is measured per 100,000 live birth.

Measuring maternal mortality accurately is difficult except where comprehensive

registration of deaths and of causes of death exist.

Maternal deaths are clustered around the intrapartum ( labour, delivery, and the
immediate postpartum); the most common direct cause globally is obstetric
haemorrhage. Other major causes are: anaemia, sepsis/infection, obstructed labour,
hypertensive disorders and un safe abortions.

Pregnancy is a natural process so it is a tragic situation that maternal deaths are not
caused by disease but occurred during or after a natural process.

Most maternal deaths and pregnancy complications are preventable if :

-pregnant woman have access to good-quality antenatal, natal and postnatal

care(availability of a trained health worker during pregnancy and at time of delivery).

- certain harmful birth practices are avoided.

Direct obstetric death:

Are those resulting from obstetric complications of pregnancy state (pregnancy, labour,
and puerperium), from interventions, omissions. Incorrect treatment, or from a chain of
events resulting from any of the above.

Indirect obstetric death:

Are those resulting from previous existing disease or disease that developed during
pregnancy and which was not due to direct obstetric causes, but which was aggravated by
physiological effects of pregnancy.

About 80% of deaths are due to direct causes:

1- obstetric haemorrhage( account for a ¼ of all maternal deaths), generally occurring

post-partum which can lead to the death very rapidly in the absence of prompt life-saving
care.

2- puerperal infection, often consequence of poor hygiene during delivery, or untreated

reproductive tract infections account for 15% of maternal mortality. Such infection can
easily be prevented

3- hypertensive disorders of pregnancy, particularly eclampsia (convulsions), result in

about 13% of maternal deaths. They can be prevented through careful monitoring during
pregnancy ANC.
4- unsafe abortion, account for 13%, 211 million pregnancies/year, about 46% end in
induced abortion, of which only 60% ae carried out under safe condition.

More than 18 million induced abortions each year are performed by peoples lacking the
necessary skills or in an environment lacking the minimum medical standards or both.

South America 34/1000 woman. East Africa 31/1000 woman. West Africa 25/1000
woman. Central Africa 22/1000 woman.

Unsafe abortion causes 68,000 deaths (about 350/100,000 woman). Two third of unsafe
abortion occur among women aged 15-30 years. 14% of unsafe abortion in developing
countries are among women under 20 years of age.

5- obstetric labour, account of 7%.

6-other direct causes, ectopic pregnancy, embolism, and deaths related to intervention.

7- indirect causes, as result of pre-existing disease that developed during pregnancy,

which is not due to direct obstetric cause but are aggravated with the physiologic effect of
pregnancy, e.g. anaemia, hepatitis, cardiovascular diseases, infectious disease such as”
malaria, TB, HIV/AIDS” and diseases of the endocrine and metabolic system.

Social correlates:
A number of social factors influence maternal mortality, the most important are:

1-woaman’s age: the optimal child bearing years are between the ages of twenty and
thirty years. The farther away from this rang, the greater the risks of woman dying from
pregnancy and child birth.

2- birth interval: short birth intervals are associated with an increased risk of maternal
mortality.

3- parity: high parity contributes to high maternal mortality

Social factors often precede the medical causes and make pregnancy and child birth risky:

- Economic circumstances - cultural practices and beliefs

- Nutritional status - environmental conditions
- Violence against women

Maternal mortality in Sudan:

Maternal mortality rate: 311 deaths/ 100,000 live births(2015 est)

Causes of maternal mortality: the main causes of maternal mortality are:

Haemorhage , sepsis, pregnancy induced hypertension, abortions, and obstructed labour.

Maternal death risk:
Appropriate medical and midwife support.

Access to emergency and intensive treatment if were necessary.

Lack of management capacity in the health system

Another risk to expectant women is malaria. It can lead to anemia, which increases the
for maternal and infant mortality and developmental problems for babies.

A majority of these deaths and disabilities are preventable, being mainly due to
insufficient care during pregnancy and delivery.

HIV infection is an increasing threat. Mother to child transmission of HIV continues to be a

major problem.

Further, HIV is becoming a major cause of maternal mortality in highly affected countries
in southern Africa, especially with the T.B re-emergency.

The way forward:

-Increase MCH coverage. -Maternal mortality audit.

-Referral system. -EmOC services

-Strategic capacity building for VMW cadres.

-Information system. -Structure for averting maternal death.

What is EmOC?
Emergency obstetric care refers to the functions necessary to save lives: include basic
services and comprehensive services.

EmONC: emergency obstetric and neonatal care. Includes services in basic EmOC and
certain services of neonatal care.

Improving accessibility and quality of emergency obstetric care “EmOC”:

 Increasing the coverage of qualified medical doctors providing EmONC services.

Clear referral pathway.

Availing the needed equipment for provision of quality services

……….Availing a comprehensive EmONC facility capable of providing both caesarean

section and blood transfusions……

Health system and health care system

Dr. Haitham Sid Ahmed
Elements of the presentation:

 Introduction
 Definition
 Framework of the HS
 Functions of the HS
 Models of health system
 Health system in Sudan

Issues:

 Health is fundamental human right

 National governments all over the world are striving to expand and improve their
health care services

Health systems:

 Combination of resources, organization, financing, and management that culminates in

the delivery of health service to the population
 All activities whose primary purpose is to promote, restore and maintain health
 All components are interacting with each other in synergy and coherence
 Health system components are interacting with the political, social, economic
environment
 HS are dynamic and evolve time
 To improve health and to reduce health inequalities ( average and distribution )
 To secure fairness of financial contribution ( equity concerns )
 To be responsive to user’s needs

‫في رسمة ما واضحة نهائي‬

Health systems ( Roemer’s model ) ‫رسمة‬

Health system model used to assess HFA ‫رسمة‬

who Health system conceptual framework : WHR 2000 ‫رسمة‬

health system conceptual framework ‫رسمة‬

building blocks combine to meet health system goals ‫رسمة‬

Contribution of health systems:

 Studies have shown that HS do matter:
- Improve equity
- Increase efficacy
- Improve responsiveness: population satisfaction
 Health outcomes are related to the HS development: need to invest in HSD
 Importance of HS performance assessment

Components of health system development:

 Quality care components
 Human resource development
 NGO participation
 Public-private participation
 IEC

Health systems:
 Health system comprises three highly inter-dependent elements
 Ecosystem . social, cultural , demographic, economic and political surrounding
 Health care delivery system. Based on health problems and needs, health inputs,
distribution, output, utilization and outcomes
 Community involvement . organization, awareness, contribution and utilization

HS functions and building blocks:

 Governance
 Financing
 Human resources
 Service delivery
 Health technology support
 Health information support

Health system development:

 It Is a combination of management sector and involves organization matters to translate
policies into services
 In Sudan, health system has three main links i.e. federal, state, and local or peripheral

Conclusions:
 HS are important and deserve to be strengthened
 HS do interact with surrounding political, economic, cultural environments
 HS functions need to be mapped:
- Assess strengths and weakness
- Improve implementation
 HS goal should be monitored and evaluated

Current criticism of health care services:

 Predominantly urban oriented
 Mostly curative in nature
 Limited access
What is health care?
 It is more than medical care
 It embraces a multitude of services provided to individuals and families by health
professionals to promote, monitor, and uphold the status of their health.
 Medical care is a subset of health care

Levels of health care:

 Primary health care
 Secondary health care
 Tertiary health care

Health care delivery – changing concepts:

 Comprehensive health care
 Basic health service
 Primary health care
 Health care system development

Comprehensive health care:

 Provision of preventive, curative and promotional health service to every individual
residing in a defined geographic area

Basic health services:

 It is a network of coordinated, peripheral and intermediate health units capable of
performing effectively a selected group of functions essential to the health of an area
and assuming the availability of competent professionals and auxiliary personnel to
perform these functions

Primary health care:

 It is essential health care made universally accessible to individuals and acceptable to
them, through their full participation and at a cost the community and country can
afford

Principles of primary health care:

 Equitable distribution
  Community participation
 Intersectoral coordination
 Appropriate technology

health for all:

attainment of a level of health that will enable every individual to lead a socially and
economically productive life

Health care system:

 Public system
 Private sector
 Traditional health system

Health care:
 Quality
 Availability
 “ health has improved NOT because of steps taken while we are ill, but because we
are ill less often “
‫رسمة‬

‫رسمة‬

Health system in Sudan:

 The health system is a three-tier system. The federal level is concerned with policy
making, planning, supervision, co-ordination, international relations and partnership
 The state government are empowered for planning policy making and implementation at
state level while the localities are concerned mostly with policy implementation and serve
delivery including health, education, and development
‫رسمة‬
Epidemiologic profile:
Double burden of disease

 Malnutrition and communicable diseases dominate the health scene

 High vulnerability to outbreaks and epidemics
 Repeated occurrence of natural and man-made disasters

Key players in the health system:

 Formal health sector
 Informal health sector ( traditional healers )

Levels of the health system:

 Primary level
 Secondary level
 Tertiary level

Primary level:
 First contact between the patient and health system
 Basic health unit for 5000 population
 The service provided are treatment of the common diseases, and primary health care
services
 Run by medical assistant
 Health centers rural or urban

Secondary level:
 Rural hospitals
 District hospitals or teaching hospitals
 Treatment of common diseases by specialty
 Organization of health system

Health services philosophy

Health care:
- Multitude of services to individuals , families or community
- Provided by organization or professionals delivering health services
- The purpose is promoting , maintaining , monitoring or restoring health
- Prerequisties are staff , organizations or setting administration structure and finance

Health care characteristics:

1- Appropriateness or relevance to actual needs
2- Comprehensive ( preventive , curative , and promotional )
3- Adequacy in quantity and quality ( proportionate to requirement )
4- Availability (ratio)
5- Accessibility ( geographic , economic , culture )
6- Affordability ( the cost of services )
7- Feasibility ( operational efficiency of services )

Health system:
- Intended to deliver health services
- Constitutes of management and organization matters
The aim of health system is health development which is a process of continuous
improvement of the health status of population .

The goal of health system is to achieve HFA by 2000 and now MDGs by 2015 .

Health system component :

1- Hospitals
2- Health centers
3- Health programs
4- Providers
5- Consumers

Level of care:
- First level : PHC
- Second level : first referral ( district hospital )
- Third level : specialized care ( teaching hospital )
Types of health care organization :
- Public ( governmental )
- Insurance
- Private
- Voluntary ( INGO , NGO , associations , societal groups )
Definition :

- The term organization refer to “ any collection of persons , material , procedures ,

ideas or facts so managed & ordered that in each case the combination of parts makes
a meaningful whole that at achieving organization objective .
- In order words the process of organization implies the arrangement of human and
nonhuman resources in an orderly fashion to make a meaningful whole that
accomplishes organization objectives .

Non-human resources:
- Policies and guidelines
- SOPs
- Infrastructure
- Supplies and equipment
- Communication
- IT

HUMAN resources:
- Job description
- Training
- Continuous professional development

Organization charts:
- Formal relationship between people in various position in the organization
- They shown who supervise whom and how various jobs and department are linked
together to make achieve coordinated system
- Main channel of communication ( downward , upward , horizontal and digital )

Responsibilities of federal levels :

- Development op policies and guidelines
- Strategic planning
- Capacity building
- Financing
- International coordination
 - Supervision

Main directorates at federal levels:

- Primary health care
- Preventive medicine
- Curative medicine
- Pharmaceutical
- Human resources and training

Communicable diseases:
- Malaria control program
- Tuberculosis control program
- HIV/AIDS control program
- What others ?

Functions:
- Develop policies related to the major communicable disease
- Development of National Guideline and protocols
- Strengthening the capacity of the states
- Supportive supervision

Mother and child health:

- Included the following program
- Expanded program on immunization
- Integrated management on childhood illness
- Reproductive health
- School health
- Nutrition health

main function:
- Policies and guideline related to PHC
- Increase the coverage of the PHC
- Supportive supervision

Responsibilities of the states levels:

- Implementation of policies and guideline
- States strategic planning
- Annual plans
- Capacity building
- Supervision
Responsibilities of the locality levels:
- Implementation of the states plan
- Delivery of primary health care
- Supervision
- Community participation

IV- centralization and decentralization:

- Refers to the level at which most or the operating decision will be made
- The greater the number of decision made lower down the management Hierarchy the
greater the degree of decentralization generally speaking
- It is advisable that decision concerning day- today matters should be pushed down the
organization structure and not be handled by top management

Advantages of decentralization:
1- Quick action regarding specific problems
2- Facilitates adaptation of decision according to local needs
3- Relieves top management from involvement in routine decision thus saving time and
energy
4- Increase flexibility of action as junior staff are allowed to make prompt decision
without having to wait for approval from to management
5- Is effective in developing the junior staff to hold top management position
6- Decentralization to improve morale of lower employees

Advantages of centralization:
1- Uniform of policy and action
2- Enable maximum use of the skills and knowledge of centralized staff
3- Fosters better control of the organization activates
4- Enable the use of not highly skilled subordinates since every little detail is set by the
top management

Application in the rural residency program:

- To discuss the district health system and rural area
- To know the organization of health services in the rural hospital
- To know the organization chart of the district health team and the health facilities

Rural residency implication:

- The main objective RR program
- To discuss the main responsibilities of the rural hospital
 - To discuss the organizational relationship between the rural health facilities
- The organization chart of the rural hospital

School health

Definition:-
A comprehensive care of the health and well being of pupils and students throughout the school
years.

Objectives:-
 Promotion of positive health.
 Prevention of diseases.
 Early diagnosis, treatment and follow up of defects.
 Awakening health iousness in children.
 Provision of healthful environment.

Aspects of school health services:-

1-Health appraisal of school children and school personnel.

2-Remedical 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 children.

12-Proper maintenance and use of school health records.

Health appraisal of school children and school personnel :-

 Periodic medical examination.

 History ME. Vision, hearing, speech, nut, def.
 Examination of blood and urine.
 Mantoux test.

Should include teachers and school personnel.

Remedical measures and follow-up.

Prevention of communicable diseases.

Healthful school environment.

 Location.
 Site: high land, space, walls, class, rooms, verandas, fumilure, colors, doors and windows,
lighting, water supply, eating facilities and lavatories.

Nutritional services:-

 Diet with full nutrients.

 Nutritional programs.
 Special attention for protein, vitamins, iron, calcium etc..
 Specific nutrients: night blindness, goiter etc..

First aid and emergency:

-Accidents. -Medical emergencies. -GE, epileptic fits etc..

Mental health:-
-Juvenile delinquency. -Addiction.

-Equity. -Relaxation.

-Rate of councillor and psychologists

Dental health:-
 -Dental caries. - Periodontal diseases.
Eye health:-
- Detection of refrqction errors. -Treatment of squint.
- Eye infection e.g trachoma. - Provision of vitamin A to high risk
children.

Health education:-
- Personal hygiene. - Environmental Health.
- Communicable diseases prevention. - Immunization.
- First aid etc...

Education of handicapped children.

- Assist child to be independent. - And reach the maximum potiential.

School health records.

Adolescent Health

Introduction:
Period of life from puberty to adulthood ( roughly ages 12-20) characterized by :

*Marked physiological change . *Development of sexual feelings .

*Effort toward the constructionist identity . *a progression from concrete to abstract

thought .

The word adolescence in Latin in origin , derived from the verb adolescere, which mean " to
grow into adulthood " .

Teens are classified in three groups , pre-teens are boys and girls ages 10-12 years old , a teen
consist of ages 13-16 , and the last set of teen years comprise ages 17-19. Teens girls and
boys grow and go through puberty at different times during teens years . Teens girls can
experience stages of puberty beginning as early as 10 years old . Growth spurts in teen boys
on average happen between ages 14-16 .

Adolescence , beginning after secondary sexual characteristics ( e.g. Pubic hair ) appear and
continues until sexual maturity is complete .

It is a period during which bones are still growing and there is a high risk of skeletal injuries .
Rapid physical changes are accompanied by important psychological changes relating
particularly to the way the adolescent perceives himself or herself .

Body Mass Index:

Average healthy height and weight standards in teens are based on the BMI .

A number is calculated from dividing weight in kilograms by the squired height in meters. BMI
in teens is unstable due to varied growth rates and the fact that during this age the level the
body is constantly developing . There is no set rule that will apply to all . The BMI formula is
meant to give a picture of where the teen might be based on age , height ..

Parents and others , especially sports coaches and teachers , who work with adolescents must
be very sensitive to both the physical & psychological changes taking place during this period
.

Rapid growth requires good nutrition .

Active adolescent boys may need up to 4000 calories a day , about twice the normal adult
requirement .

The protein , vitamin , mineral requirements of adolescents of both sexes are higher than for
adults .

Adequate calcium intake is especially important during adolescence to maximize cone

density and reduce the risk of osteoporosis in later life .

Eating habits acquired during adolescence are often retained for life.

Therefore, adolescents should be encouraged to eat a well balanced diet and not to skip
meals .

Puberty:
Passage from childhood into and through adolescence is composed of a set of transitions .

These transitions are :-

* biological. * cognitive .

* social. * emotional .

*Biological transition:-
The most observable sign that adolescence has begun.

An individual becomes capable of sexual reproduction.

The timing of physiological maturation varies widely .

Menarche ( onset of menstruation ) typically occurred around age 12 .

The duration of puberty also varies greatly : 18 months to six years in girls and 2-5 years in
boys .

The physical changes of puberty are triggered by hormones .

In boys a ajar change incurring during puberty is the increase production of testosterone, a
male sex hormone .

In girls experience increase production of female hormone estrogen.

In both sexes , a rise in growth hormone produces the adolescent growth spurt, the
pronounced increase in height and weight that marks the first half of puberty.

*Cognitive transition:-

Compared to children , adolescence think in ways that are more advance , more efficient ,
and generally more complex .

Moral Development:
*Moral development refers to the development of a sense of values and ethical behavior.

*adolescents cognitive development , in part , lays the groundwork for moral reasoning ,
honesty , and prosocial behaviors such as helping , Volunteerism , or caring for others .

*Emotional transition:-
Marked by change in the way individuals view themselves and in their capacity to function
independently.

For most adolescents, establishing a sense of autonomy , or independent , is as important a

part of the emotional transition out of childhood as is establishing a sense of identity.

*Social transition:-

One of the most noteworthy aspects of the social transition into adolescence is the increase
in the amount of time individuals spend with their peers .

Common problems:
Some adolescents are at risk of developing certain problems , such as :
-eating disorders such as anorexia nervosa , bulimia.

-obesity . -drug or alcohol use .

-depression or suicidal ideation . -violent behavior .

-anxiety , stress , or sleep disorder . -unsafe sexual activities .

->The leading causes of death and illness in the age group 12-24 years
worldwide:
*Accident and injuries- both unintentional and self-inflicted.

*Mental health problems -depression and suicide .

*behavioral problems - including substance abuse .

->Accident and injuries:

Accident and injuries account for more than two thirds of all deaths .

This includes road traffic accident , self inflicted injuries and suicide .

->Mental health:
Mental health and behavioral disorders account for more than half the disease burden among
adolescents.

Up to 20% of adolescents suffer from a mental disorder at any given time .

On average some 400 young people kill themselves each year.

->Substance use:
Drug-related deaths represent 24% of all young deaths .

25% of 14-19 year olds & 40% of 20-24 year olds are regular/ occasional smokers .

38% of 14-24 year olds report marijuana use in the previous 12 months .

Around 70% of 16-17 year olds report that they drink alcohol .

->Sexual health / infectious disease :

Blood borne and sexually transmitted infections such as HIV , HPV , Hepatitis C .

Chlamydia is the main sexually transmitted disease among young people- notification
increase from 98 to 338 per 100,000 between 1991-2001 .
Notifications of gonococcal infection among young people increase by 1.5 times between
1991-2001 , from 47 to 72 per 100,000 - with the notification rate highest for males aged 18-
24 years

The rate of Hepatitis C infection has tripled in the 18-24 years old age group over the last 3
years.

Teenage pregnancy remains a major adolescent health issue .

->Nutrition and physical activity :

Up to 31% of males and 23% of females 12-24 years old are overweight or obese.

Physical activity is declining in young people.

Related disorders , such as type 2 diabetic are increasing.

->Chronic illnesses:
Around 10-20% of adolescents have one or most chronic illness such as asthma , diabetes ,
cystic fibrosis .

->Long term medical conditions:

The most prevalent long term medical condition affecting young people are:

-Respiratory condition ( mainly asthma and hey fever )

-Eye condition

-Disease of the musculoskeletal system .

Protective Factors and Resilience :-

The term " resilience " is used to refer to haying good outcomes despite serious threats to
healthy development ( Masten, 2001)

Factors associated with resilience and Positive outcomes:

1-stable , positive relationship with at least one caring adult:

Numerous studies have found that the presence of an adult- a parent or someone other than
a parent - with a strong positive , emotional attachment to the child is associated with
resilience. This might be a teacher or coach , an extended family member , or a mentor .

2-Religious and spiritual Anchors:

A sense of meaning is one of the major pathways through which youth find their way to a
constructive future .
3-Hight , Realistic Academic Expectations and adequate support:

School that provide students with a sense of shared cooperative responsibility and belonging
, convey high expectations for participation , and provide high levels of individual support for
students tend to enhance resilience.

4-Positive Family Environment:

A warm , nurturing parenting style , with both clear limit setting and respect for the growing
autonomy of adolescents , appears to be associated with resilience in adolescents . Strong ,
positive mother adolescent relations have also been found to be found associated with
resilience among youth when fathers Andre absent from the home .

5-Emotional Intelligence and ability to cope with stress:

Although intelligence per se has been reported to be associated with resilience, the factors
that may be more important , because they are more amenable to change and are also
involved in resilience , are emotional intelligence and ability to cope with stress.

Health of The Elderly

Introduction:
Aging is a natural process.

Sir James Sterling Ross commented: " you do not heal old age , you protect it ; you promote it
; you extend it "

The study of the physical & psychological change which are incident to old Age is called
gerontology

The care of the aged is called clinical gerontology or geriatrics

One aspect of gerontology is social gerontology which deal with ; in one hand with instincts of
humanitarian and social attitudes. And on other hand with problems set by the increasing
number of old people.

Experimental gerontology is concerned with research into the basic biological problems of
aging , into it's Physiology , Biochemistry ,Pathology , Psychology .

The field of studies range from studies of populations through: Individuals , Organs , Systems
, Tissue & cells , Down to the molecular level .

Geriatric gynecology: with the lengthening span of life a new chapter in gynecology.

Geriatric gynecology- is concerned with:

1/repair of prolapse of varying degrees. 2/non-specific vaginitis.

3/ovarian tumors . 4/sexual problems .

Facts about aging:

In 1950 the elderly were 8% of the total world population.

In 2000 , there were 600 million people aged 60 and over which constituted about 10% of the
total world populations , there will be 1.2 billion by 2025 and 2 billion (21%) by 2050 .

Totally , about two third of all older people are living in the developing world ; by 2025 , will
be 75% .

The age structure of the population in the developed countries has so evolved that the
number of old people is continually on the increasing. These trends are appearing in all
countries where medical and social services are well developed and the standard of living is
high .

In the developed world , the very old ( age 80+) is the fastest growing population group.

Women outlive men is virtually all societies; consequently in very old age , the ratio of
women/men is 2:1 .

The majority of older people will be living in developing countries that are often the least
prepared to confront the challenges of rapidly aging societies .

Increased longevity is a accomplishment for public health and the result of social and
economic development.

However many individuals will face , as they age , the risk of having at least one chronic
disease , such as hypertension, diabetes and osteoporosis conditions .

All countries need to be prepared to address the consequences of demographic trends .

Dealing with the increase burden of chronic diseases requires :

-health promotion and disease prevention intervention at community level as well as .

-disease management strategies within their health care system .

*In Sewedan:

Low birth rate ,1.5 per women in reproductive age . This results in a negative natural
population growth.

Life expectancy is high ; 77.5 in men and 81.1 in women .

Today Seweden has the world's oldest population, with almost every fifth person aged 65
years or older ..

This process has important social and political implication and fewer persons in productive
age will support increasing demands on the health care system .

Size of the problem

Health problems of the aged:
1-Problems due to the aging process . 2-Problems associated with long term illness.

3-Psychological problems .

*1-Problems due to the aging process:

No one knows when old age begins . The " biological age " of a person is not identical with his
" chronological age" .

It is said that nobody grows old merely by living a certain number of years .

Our knowledge about the aging process is incomplete. We so not know much about the
disabilities incident to the aging process .

The following are some of the disabilities considered as incident to old age ;

(A) senile cataract . (B) glaucoma .

(C) nerve deafness . (D) bony changes affecting mobility .

(E) emphysema . (F) failure of special sense.

(G) change in mental outlook .

2-Problems associated with long term illness:

Certain chronic diseases are more frequent among the elder people than in the younger
people . These are :

(A) degenerative disease of heart & blood vessels. (B) cancer.

(C) accident. (D) Diabetes .

(E) respiratory of locomotor system . (F) respiratory illnesses .

(G) Genitourinary system.

3-Psychological problems:
Mental changes . Impaired memory, rigidity of outlook and dislike of changes in the aged .
Emotional disorders as a result of social maladjustment.

Health status of the Aged in Sudan:

A survey was done in 2000 . Few studies have been made in Sudan by individuals about the
health status of the aged persons, but such studies provide only a partial view of the
spectrum of illness in the aged .

The overall data on aged are scarce .

The main causes of illnesses are :

1/arthritis . 2/cataract.

3/bronchitis. 4/avitaminosis .

5/ear diseases 6/hypertension

7/diabetes 8/rheumatic

9/helminths infestations 10/accident , etc

Care is provided by family members who lack the scientific knowledge .

There is a gab in health education about:

-nutrition -activities

-medical care and follow up

The majority of the elder are from low socio economic group.

-health service needs . -Economical needs

-skills and rehabilitation needs .

Who in collaboration with partners and Ministries of health from developed and developing
countries , has produced an age-friendly PHC toolkit aimed at sensitizing and educating PHC
providers about the needs of elder clients .

In all countries , and in developing countries in particular , Messi to help older people remain
healthy and active are a necessity , not a luxury .

Who recognizes the critical role that PHC centers play in maintaining health of older people
worldwide and the need for these centers to be adapt and accessible to older populations :
PHC is the principle vehicle for the delivery of health care services at the most local level of a
country's health .

The Sudanese National Program of the Health Care for the elderly started in 2002 .
According to 2003 senses , the elderly constituted about ( 1.360.000) 4% of the total
population ( 33.648.000)

By 2025 the elderly will constitute 8% of the total population .

At PHC:
Building capacity of the health care providers

Using the available PHC units , and appropriate technology within the rural community.

IEC materials about nutrition, community and social activities , suitable accommodation,
prevention from accidents , periodic visits for health facilities and social activities.

The health care providers must know that the needs , medical problems and risk factors of
the elderly differ from that of adults .

This is because they differ anatomically, physiologically , mentally and emotionally .

They must know that the mortality and morbidity indicator also differ .

They must teach this to the family members looking after them , so as to avoid accidents that
could happen to them .

The health care providers have very important role in recruiting :

-relevant community organizations and NGOs to take part in health promotion of the elderly .

-Interested community volunteers to participate in activities related to the elderly .

To convince community leaders in different aspects to establish active , well equipped ,

section for health care of the elderly with well trained persons .

Health care activities in the PHC unit :

-health care activities inside the PHC .

-health care activities outside the PHC .

Health care activities :

1/Medical records for the elderly .

2/Grouping them according to risk factors , disease .. etc

3/promotion and prevention health activities should be held in the health center .

4/curative medicine for diseases of the elderly , this include

a/ periodic medical examinations .

 b/ psychological care .

5/referral for the elder patient for higher medical care if needed.

6/Rehabilitation services for :

- providing care .

- counseling for the family members who look after them.

- referring them to the institutes or organizations which provide instruments for

handicapped..etc

-referral to health units or physiotherapy units according to needs .

History:
From the elderly if he could tell , if not , from one person who is looking after him.

Do not lengthen at the first visit , you have to pay attention to the patient degree of
concentration, especially if you are taking the history from him directly .

Family history .

Drug or treatment history .

Clinical Examination:
Like that of the adults , except you have to pay attention to :

- To choose the suitable position for examination because lying down is uncomfortable
for some of the elderly.

- To evaluate : movement / hearing / vision / teeth / physiological and mental condition .

Life style and healthy aging :

People can do a great deal to influence their individual risk in developing many of the
diseases of later life by paying careful attention to lifestyle factors.

By adopting a healthier lifestyle, the whole range of disease can be reduced .

These Factors are :

-Diet and nutrition . -exercise . -weight.

-smoking. -alcohol. -social activities .

1/Diet & nutrition:

Good diet reduce the chances of developing the disease of old age .

As countries rapidly develop economically, diets and lifestyle change considerably and over-
nutrition replaces under nutrition .

Fat intake , saturated fats and trans-fatty acids , have been linked to raised cholesterol levels
in the blood , leading to increased level of cardiovascular diseases .

People should eat healthy diet since very early age to avoid or delay diseases.

The diet should be balances with less saturated fat and oils .

The diet should contain lots of fruits and vegetables , plenty of calcium , lot of fiber , but less
salt and sugar .

2/Exercise:
Help maintain good health and control weight .

Improves emotional well being and relieves stress .

Improves blood circulation , increase flexibility and increase energy level .

Lowers blood pressure .

Improves balance and thus reduces dangers of fall .

Lowers blood sugar levels thus helps in diabetes .

Improves bone density and hence help prevent osteoporosis .

3/weight:
Overweight and obesity have become major problem worldwide and it contributes to many
diseases of later life .

Obesity is an important factor in heart disease , stroke , hypertension , diabetes, arthritis (

especially of the knees ) , and breast cancer .

4/Smoking:
22% of males and 18% of female aged 60 to 74 years in developed countries are smokers .

Older people have usually smoked for longer period , have been and continue to be heavy
smokers , and are likely to have chronic diseases, with smoking causing further deterioration.

Former smokers live longer than continuing smokers .

Smoking cessation at the age of 50 years reduces the risk of dying within the next15 years by
50%.
For some , but not for all former smoker smokers , the risk of developing smoking - related
diseases reverts to that of live long non smokers .

5/Alcohol:
Research suggests that sensitivity to the effect of alcohol increase with age .

Older people achieve a higher blood alcohol concentration, that younger people after
assuming an equally amount of alcohol .

This is largely a result of the age related decrease in the amount of body water which dilutes
alcohol .

Drinking is linked to liver diseases , stomach diseases , gout , depression , osteoporosis, heart
disease , breast cancer , and hypertension.

6/Social activities:
Socially isolated people are less healthy .

Getting out and keeping involved with others creates a sense of belonging.

Mixing with other people of similar age , at similar stage of life or perhaps with similar health
concerns , can help people realize that they are not alone .

The support gained from others can be important in recovering from illness .

Implications of the aging population in terms of preventive and social medicine .

The aging problem is both a medical and sociological problem .

It makes greater demand on the health services of a community .

The predicted explosion of non communicable diseases like cardiovascular diseases , cancer
and depression is the elder people , will result in enormous human and social costs unless
preventive action is taken .

Aging developing countries will face a double burden on infectious and non communicable
disease , yet they often lack comprehensive aging policy .

The old must continue to take their share in responsibilities and the enjoyment of the
privilege, so remaining active members of the community.

The community must assist the aged to fight the triple evils of poverty , loneliness and ill
health .

Potential for disease prevention in the elderly:

*Primary prevention:
1/health habits ( smoking / obesity / nutrition / physical activity and sleep )

2/coronary heart disease risk factors . 3/immunization ( influenza , tetanus )

4/osteoporosis prevention . 5/injury prevention.

*Secondary prevention:
Screening for :

Hypertension/ Diabetes/ Dental caries.

Sensory impairment/ Cancer/ Nutritional anemia .

Depression/ Stress/ Urinary incontinence/ Fall risk

*Tertiary prevention:
Rehabilitation ( physical , cognitive , and functional deficits ) ..

Mental Health(MH)

Health:-
A state of complete physical , mental , And social well being and Not merely the absence of
disease or infirmity . “WHO Constitution 1948”.

Concepts of mental health:

- Subjective well-being. - Perceived self-efficacy.

- Autonomy . - Competence.

- Self-actualization.

Definition of mental health :

- It is nearly impossible to define mental health comprehensively.
- It is generally agreed that MH is broader than a lack of mental disorders .
- How we think , feel & behave ?
- MH is rooted in our potential to learn , communicate and relate to other.
- MH is fundamentally linked to physical health.
“The capacity in an individual to form harmonious relations with others and to participate in ,
or contribute constructively to changes in the social and physical environment . (Park-2007)
Why Mental health?
- Mental and behavioral disorders are large health problems.
- 450 million suffer yearly – burden .
- Only minority receive basic care .
- There is large treatment gab.
- Many suffer stigma , neglect & discrimination.

The ultimate goal of MH :

“To dispose our knowledge and power to significantly reduce the burden of mental &
behavioral disorders”.

Puplic Health Approach:

- Raise public awareness about mental illness. -Promotion of mental health.
- Prevention of mental illness. -Provision of care at primary health care (PHC).

Health Education (HE)

- What is Health?
- What is Education?
- What is Health Education?

Health Education:
- A major component of PHC .
- An essential part in each of the components of PHC.
- An important element in any Health Programme.
- A Tool / Weapon→ Health definition of HE:
“The process by which individuals & groups of people learn to behave in manner
conductive to the promotion , maintenance or restoration of health”.

Knowledge , Attitude & Behavior:

It is often assumed that :

- Knowledge determines Attitudes (Views) & Attitudes determine Behavior (Action).

Objectives of HE :
1- To make people feel the value of health.
 2- TO make people understand the practices needed for health protection & promotion.
3- To promote proper use of health services.
4- To make people aware of their health problems & participate actively in their health.

Five factors to be considered in planning HE programe:

1-Man is in part an individual in certain culture. 2-Man is a creature of habit.
3-Man is a creature of reason. 4-Man is a creature of sentiment.
5-Man is a creature of rare refinement.

These facts should be:

Considered in motivation for change (Actions).

Motivation in HE:
- Motivation is to act as an impulse for doing something.
- Motivation is essential to change behavior of an individual/community.
Types of Motives :
These are drives / needs that motivate a person for doing certain actions.

1- Intrinsic / Extrinsic motive.

2- Biological, social & psychological motives.

Maslow’s Hierarchy of Needs:

- Self-Actualization needs. -Aesthetic Needs.

- Cognitive Needs. -Esteem Needs.
- Belongingness and love Needs. -Safety Needs
- Physiological Needs , Hunger , Thirst,…etc.
Maslow’s Hierarchy of Needs:

1-Physiological Needs: Hunger, Thirst, Sleep,…

2-Safety Needs:To feel secure and safe/ Out of danger.
3-Belonging & love Needs:To affiliate with others/ Be accepted.
4-Esteem Needs:To achieve/ Be competent/ Gain approval/ &Recognition.
5-Cognitive Needs:To know/ Understand/ & Explore.
6-Aesthetic Needs:Symmetry/ Order / & Beauty.
7-Self-Actualization and Transcedence Needs: To find Self-fulfillment/
Realize one’s potential / & Achieve spiritual fulfillment.

Diagnosis of the problem:

Can be reached by the study of three items:
 A- Health Consciousness.
B- Social Environment.
C- Communication patterns.
A-Health consciousness:
1- The degree of awareness of the problem among :
The professionals/ The patients/ The general public.
2- The Attitudes regarding:
The significance of the disease / problem.
The value of treatment.
3- Professional and patient behavior which increases / decreases risk of disease.
B-Social environment :
-People social structure. - Their family situation.

-Persons of influence. - Laws and Economics influencing health.

-Availability of health services.

C-Communication patterns:
1- Personal Exchange:
Conversation/ Interviews/ Discussions.
2- Mass Media available: Tv, Radio, Film, Newspapers.

Problem Management:
- Means convincing people to make decisions so as to change their behavior that led to
the presence of a certain problem.
Motivation:
- Is the product of :
The individual feelings.
His / Her identification to the problem and
The social pressure to which He / She is subjected.

Reinforcement:
-Refresh knowledge -Strengthen Motivation.

-Counteract doubt , apathy. -& Conflicting Influences.

Convenience:
- Means making easy for individuals to use the health services ( Available & Accessible).
 Health Education(2)

Communication in health education:-

- Communication is the basis of human interaction,
- Has 5 main components:
1-Sender. 2-Message.
3-Channel .
4-Reciever(Awareness – Interest- Evaluation Adoption “Behavioral change).
5-Feedback.
1- Sender(communicator):
- Is the originator of the message . He /She must know :
His objectives , clearly defined.
Audience: It’s interests , needs.
His message.
Professional Abilities & limitations.
Channels of communication.
2- Reciever :
- Single person or group of people.
- Controlled Audience (homogeneous) or uncontrolled (free) Audience.
3- Message :
The information (Technical know- how) the communicator transmits to his audience
to receive,understand,accept& act upon.
May be in the form of words , pictures or signs.
- A good message must be :
In line with the objective(s) / Meaningful & clear.
Based on felt needs/ Specific and accurate.
Timely & adequate/ Fitting the Audience & intersting.
Culturally &socially appropriate.
4- Channels of communication :
- The physical bridges or the media between the sender and the receiver.
- The total communication effort is based on three media systems:
a- Interpersonal communication. b- Mass media. c-Folk media.
5- Feedback :
- The flow of information from the audience to the sender.
- The reaction of the audience to the message ( The Effect).
Modify message?
Feedback ,immediate or later.

Types of Communication:
1-One-way communication. 2-Two-way communication.
3-Verbal communication. 4-Non-verbal.
 5-Formal & informal. 6-Visual communication.
7-Telecomm & Internet.
Practice of Health education:
- Educational material should be designed to :
Focus Attention.
Provide New Knowledge.
Facilitate interpersonal , Group discussion &
Reinforce / clarify prior knowledge or behavior.
Audiovisual Aids:
1- Audiatory Aids:
- Radio ,Tape-recorder ,Microphones , Amplifiers & Earphones.
2- Visual Aids:
a- Not requiring projection:
Chalk-board , leaflets , posters, charts ,models, specimens,…etc
b- Requiring projection :
Slides , film stripes.
3- Combined:
-TV , Sound Films (cinema), slide tape combination.

Methods in health communication:

- Three approaches can be used:
1- Individual Approach. 2-Group Approach.
3- Mass Approach- Education of the General public.
The individual Approach:-
1- Personal Contact. 2-Home visits.
3- Personal letters.
Advantage : Chance to argue, discuss & persuade.
Disadvantage: Small Numbers reached & those in contact.

Group Approach:
- Involves groups , school , children ,Mothers , Patients, …
1-Chalk & talk (lecture). 2-Demonstrations.
3-Group discussion. 4-Symposium.
5-Workshop. 6-Role playing.
7-Seminars.
Mass Approach:
1-TV. 2-Radio.
3-Internet. 4-Newspapers.
5-Printed materials. 6-Posters, billboards & Signs.
7-Museums & Exhibitions. 8-Folk Media.
 9-Direct mailing assignment ( In one page A4 Size).
-What are the barriers of communications .

-list the functions of health communication.

Health Education(3)

Principles of Health Education:-

- It brings together the art & science of Medicine & the principles and practice of
general education .
- Learning And Teaching is a two-way process of transactions in Human relations.
- The principles of health education are those used in learning.
1- Credibility:
The degree to which the message to be communicated is perceived as trustworthy by
the receiver.
2- Interest:
Is a psychological principle , people are unlikely to listen to those things which are not
of their interest (felt – needs- Basis of HE).
3- Participation:
A key word in HE , based on the psychological princible of active learning (planning &
Implementation).
4- Motivation:
In every person there is a fundamental desire to learn- that needs to be
awakened(primary ,secondary motives).
5- Comprehension:
Depends on the level of understanding , Education and literacy of the
target(individual/ population)
6- Reinforcement:
Repetition of the message in different ways at different intervals = people are more
likely to remember.
7- Learning by doing:
This illustrated by the Chinese proverbs:
If I hear , I forget,
If I see , I remember,
If I do , I know.

Other principles of HE:

 8-Known to a Unknown. 9-Setting a good example.
10-Good human relations. 11-Feedback(response).
12-Leaders ( Agents => change ).
Contents of health education:
- It has not definite training curricula.
- Needed information must be integrated in the educational system -> youngs.
Possible contents :-
1-Human biology (school)
- Body structure and functions
- Reproductive biology

2.Nutrition: - Diet, Breast feeding, malnutrition, obesity.

3.Hygiene: - personal hygiene/ - Environmental hygiene
4.Family health :
Family self reliance : child bearing and rearing and adoption of healthy life style.

5.Disease prevention and control : Major locally endemic diseases; malaria, TB, bilharzia etc…

6.Mental health :Prevent breakdown of mental health at time of stress.

7.prevention of accidents :Safety education at home, road, and place of work/ Involve other
sectors.

8.Use of health services : What services available and how they can utilize them.

Planning and management of health :

 Plan in connection with a specific service/program
 Plan in the context of the socio-cultural, psychosocial, political, economic and
situational characteristics of the local community.
 Steps of planning :
-Collect information on specific problems as the seen by the community
-Identification of the problem -Deciding on priorities
-Setting goals and objectives -Assessment of resources
-Consider possible solutions
-Prepare plan of action
What will be done?
When?
By whom?
-Implementing the plan -Monitor and evaluate
-Reassess planning administration and organization of the health governance.
Local level (district)
 Health promotion
Learning objectives:-
 To know the concept of health promotion.
 To identify the key elements of health promotion.
 to discuss the key stratgies of health promotion.
 To discuss the practical issues in rural residency programme.

Health promotion:-
☆is the process of enabling individuals and communities to increase control over the
determinant of health and thereby improve their health.

What is health promotion?

1. Health promotion is the process of enabling people to increase the control over, and
to improve, their health. It is a positive concept emphasizing personal, social, political
and institutional resources as well as physical capacities.
2. Health promotion is any combination of health, education, economic, political,
spiritual, or organizational initiative designed to bring about positive attitudinal,
behavioural, social, or environmental changes conductive to improve the health of
populations.
3. Health promotion is directed towards action on the determinants or causes of health.
4. Health promotion therefore require a close cooperation of sectors beyond health
services, reflecting the diversity of conditions which influence health.
5. Government at both local and national levels has a unique responsibility to act
appropriately and in a timely way to ensure that the 'total' environment, which is
beyond the control of individuals and groups, is conductive to health.

Why health promotion?:-

 Growing recognition of the need to enhance health rather than only prevent diseases.
 Realization that health education can only develop its full potential if it supported by
structural change, legislation and enabling environment.
 Appearance of health problems and diseases that related to the life style and will not
be prevented or cured.
Principals of health promotion:-
The five key principals of health promotion as determined by WHO are as follows:

 Health promotion involves population as a whole in the context of their everyday life,
rather than focusing on people at risk from specific diseases.
 Health promotion is directed towards action on the determinants and causes of
health. This requires a close cooperation between sectors beyond health care
reflecting the diversity of conditions which influence health.
 Health promotion combines diverse but compelementary methods or approach
including communication, education, legislation, fiscal measures, organizationl
change, community change, community development, and spontaneous local
activities against health hazards.
 Health promotion aims particularly at effective and complete public paticipation. This
requires the further development of problem defining and decision making life skills,
both individually and collectively and the promotion of effective particpation
mechanisms.
 Health promotion is primarily a social and political venture and not medical services,
although health professtionals have an important role in advocating and eabling
health promotion.

Health promotion criteria:-

 Encouraging public paticipation by individuals and communities.
 Taking a social and cultural prespective in understanding and responding to health
issues and problems.
 Emphasizing equity and social justice.
 Fostering intersectoral collaboration.
 Including physical, mental, social and spiritual dimensions of health, and.
 Focusing on enhancing health, not just on preventing problems.

Process methodologies for health promotion:-

 Advocacy.
 Enable.
 Mediation.

Setting based health promotion:-

The place of social context in which people engaged in daily activities in which
environmental, organizational and personal factors interact to affect health and wellbeing.

-Homes and families -Health promoting schools.

-Healthy work places. -Healthy market places.

-Healthy facilities( hospitals, centers...). -Healthy villages and healthy cities.

The Setting Approach:-

Expected outcomes:-
 An increase awareness of health issues.
 The development of health promotion policies and creation of dedicated health
promotion budget.
 Improvement of 'structural' and 'psychological' environments.
 The development of discrete health promotion/education project.
 Change in various individual attribute behaviours and functioning, and
 Economic benefits.

Working for health promotion means:-

Make the healthiest choice .. the easiest choice.

Health promotion challenges:-

Integration of technical areas.

Positioning of healthy lifestyle promotion high on political agenda.

Securing infrastructure for healthy lifestyle promotion.

Increasing opportunities andreducing inequities.

Establishing effective intersectoral collaboration.

Conclusion and future directions:-

 Effective health promotion requires full alertness of the public about health risks
associated with consumer products and services.
 Mass media and private sector along with communities , should get involved in
planning process for health promotion programmes and participate in
implementation, monitoring and evaluation of activies.
 Prevention and health promotion can reduce future burden of disease, for decades
health system have been based on treating individual acute episode of illhealth.
 There is an urgent need to invest on preventive stratigies for chronic diseases, and
invest on population based prevention programs.

Application in rural programme:-

 Determine the factors can affect health of population.
 Propose the appropriate intervention for creating healthy environment, school,
hospital.
 Communication in health
Learning objectives:

1. Define communication
2. Explain purpose of communication
3. Describe communication process model
4. Demonstrate effective communication skills when interviewing
5. Discuss concept and application of COMBI
Introduction:

 Communication is vital and essential process.

 Health worker engaged in on a day to day basis.
 In order to change behavior, health workers need to understand the complex nature
of communication and hence adopt appropriate strategies of communications.
 A good communicator is a good doctor

Definition:
 Communication is process of transferring information from one source to another
 It is a process of understanding and ???? meaning
 These are skills required by public health professionals to transmit and receive ideas and
information to and from involved individuals and groups….
 The ability to use language (receptive) and express (expressive) information
 The set of skills that enables a person to convey information so that it is received and
understood

The communication model:

The communication model consists of the following items:

 Source of information (communicator)

 Message
 Receiver
 Channel
 Feedback mechanism
The following is a model for communication known as the SMCRF model where:

S >> source

M >> message

C >> channel
R >> receiver

F >>feedback

Characteristics of the source:

Communications skills: speaking skills, listening skills, writing skills, reasoning skills

Knowledge about:

 The subject (message)

 The receiver (audience)
 The channel, that is, the senses and material channel such as TV, Film, radio or print
Attitude about:

 Subject matter (enthusiasm is useful)

 Receiver (positive attitude is useful)
 Himself or herself (high self- esteem is useful)
 The channel (medium) being used
Social/cultural context awareness of:

 The role of communicator in society

 The groups the communicator belongs to
 The special aspects of culture condition of the communication the source wishes to
encode
 The cultural beliefs held by audience
Characteristics of receiver:

o Communication skills (skills to decode information)

o Knowledge (of subject under discussion)
o Attitude (to the source and himself)
o Social/culture context awareness
Characteristics of message:

All messages have content that is the ideas within the message

Communications methods:

 Verbal
 Non-verbal
 Written
 Electronic
 Use of telephones
 E-Mails

sende
r
 The idea is encoded:

Perception:

 Self-concept
 Family
 Culture
 Skills
 Feeling
 Attitude
 Values
Individuals encode ideas according to their own unique perceptions.

The encoded idea is sent as message

Sender Receiver
 Self- message  Self-
concept concept
 Family  Family
 Culture  Culture
 Skills  Skills
 Feeling  Feeling
 Attitude  Attitude
 Values  Values
To a receiver who decode it according to different individual perceptions

The receiver responds with feedback

Sender Receiver

 Self- message  Self-

concept concept
 Family  Family
 Culture  Culture
 feedback

Feedback helps to ensure that the message received has been decoded correctly
Channel –the mean of conveying the message

Sender Channel Receiver

 Self- message  Self-
concept concept
 Family  Family
 Culture  Culture
 Skills  Skills
feedback
 Feeling  Feeling
 Attitude  Attitude
 Values context
Values

Context, the situation, environment or circumstances of the communication.

Interference:
 Sender Channel Receiver
 Self-  Self-
concept message concept
 Family  Family
iiii
 Culture interference  Culture
 Skills  Skills
 Feeling feedback  Feeling
 Attitude  Attitude
 Values context
Values
interference change or distort the message

the communication process is continuous…

Sender Channel Receiver

 Self-  Self-
concept
message
concept
 Family interference  Family
 Culture  Culture
 Skills feedback  Skills
 Feeling  Feeling
 Attitude context  Attitude
 Values
Values

Where do we get our health information:

 Television 48%
 Magazine and Newspaper???
 Internet 6%
 Radio 5%
 ‫محتويات االتصال الفعال‬
Staging

Style ‫الخطوات‬
Substance

‫الماده‬ ‫االسلوب‬
‫س‬

There are mainly three types of communication skills:

1.expressive skill:

Expressive skills are required to convey message to other through words, facial expression
and body language Eg; telling, questioning, convening

2.listening skills:

Skills that are used to obtain message or information from others. These help to clearly
understand what a person feels and thinks about you or understand the other person closely
Eg; observing

3.skills for managing the overall process of communication:

Skills for managing the overall process of communication help to recognized the required
information and develop a strong hold on the existing rules of communication and interaction
Eg; non- verbal communication.

Communication:
 Exchange of ideas (interaction between two or more) interpersonal- counselling.
 Sender-channel-message-receiver.
 Direct (without instruments)
 Indirect: using an instrument eg; mass media.

Communication techniques in health:

 To shift from knowledge to behavioral change
 Communication for behavioral impact COMBI
 Social marketing
HIC DRAM:

H>>hear
 I>>inform IEC focus on this part

C>>convince

D>>decide

A>>action IMC adopt this part

R>>re-inform

M>>maintain

Application in the rural residency programme:

 Know how and when to communicate

 Used different methods in communication to change behavior
 During focus group discussion and managing patients.

Disaster Management
Zeidan A. Zeidan,

 Layout:
Introduction:
What is disaster medicine?

What is a disaster?

Factors that influence a disaster

Type of disasters

Disaster phases

Summary

 Objectives:
To understand the importance of disaster medicine

To know the different disaster terminology

Overview the types of disasters

To understand the different phases of disasters

 Introduction:
  What is Disaster Medicine?
Disaster Medicine:
“The study and collaborative application of various health disciplines, e.g. Emergency
Medicine, Pediatrics, Epidemiology, Nutrition, Public Health,…………., to the prevention,
immediate response and rehabilitation of the health problems arising from a disaster, in
cooperation with other disciplines, involved in comprehensive disaster management.

 Why disaster medicine?

1. Increase in world population 2. Increase in natural and technological disasters

3. Increase in natural and technological disasters

4. Increase in population in high risk areas:

- Earthquake faults - Flood plains - Hurricane areas

- Areas adjacent to hazardous materials plants

5. Fast expanding industrialization 6. Increase in terrorist acts

7. Increase in armed conflicts 8. Attitude towards disasters

9. Insufficient education and training of the involved personnel

 What is a Disaster?
 Disaster :
“A sudden ecological phenomenon of sufficient magnitude to require external assistance”

WHO

 A medical disaster occurs when the destructive effects of natural or manmade forces
overwhelm the ability of a given area or community to meet the demand for health
care
“American College of Emergency Physicians”

 Disaster
“A situation in which the need for medical care exceeds the available resources”

Hijazi, et al

 Mass Casualty Incident

 Any event resulting in a number of victims large enough to disrupt the normal course
of emergency and health care services.
 The Role of an EP in a Disaster?
“emergency physicians should assume a primary role in the medical aspects of disaster
planning, management, and patient care...[and that] emergency physicians should pursue
training that will enable them to fulfill this responsibility”
American College of Emergency Physicians

 What are the Factors that Influence a Disaster?

Factors that Influence a Disaster:

*Location * Time
*Duration *Available resources
*The magnitude of causative factor
 What are the Types of Disaster ?
Classification of Disasters:
 Man-made vs natural disasters
 Acute vs chronic
 internal vs external
 Chemical vs Biological vs Radiological
 Hijazi’s Classification
 What are the Disaster Phases?
 Disaster Management Phases:
1. Disaster mitigation
2. Disaster preparedness
3. Response
4. Recovery
1. What is Disaster Mitigation?
Disaster Mitigation:

“”Activities which actually eliminate or reduce the chance of occurrence or the effects of a
disaster

“Disasters usually do not affect people randomly, but it usually affects vulnerable
population”

 The objective is to reduce the risk of being affected by a

disaster and even if the hazard cannot be removed, vulnerability can be decreased.

 Disaster Mitigation
↓hazard + ↓vulnerability = disaster mitigation

“Epidemiology of disasters shows that disastersare largely preventable”

 Critical Part of Implementing Mitigation :

Is the full understanding of the nature of the threat:

What type of hazards

Probability of occurrence and magnitude

Physical mechanism of destruction

2. Disaster Preparedness:
1-Develop policy 2-Assess hazards and vulnerability

3-Plan for disasters 4-Train and educate

5-Monitor and evaluate

2.1 Policy Development

-Development of disaster planning and management legislation

-Normally developed by national government

-Subsequent policies must be developed by

 Regional governments (Province)

 Local governments (City)
□ Disaster preparedness policy areas:
 Objectives of health/medical disaster preparedness
 The authority and roles of each level of government, and of non-governmental
organizations
 Medical management structures
 Emergency planning committees and membership
 Medical resource allocation for prevention, preparedness, response, and recovery
 How a health/medical disaster is declared and by whom
 Disaster powers concerning evacuation
 The means for funding prevention, preparedness, response and recovery
 The requirement for training and education, and monitoring and evaluation, including
disaster exercises
2.2 Hazard and Vulnerability Assessment:
How to Identify a Hazard?

 Hazard identification:
-Involve the whole planning committee in the process

-Research the history of previous hazards in the community

-Ensure both natural and man-made hazards are identified

-Go out and inspect the community

-Brainstorm to ensure no hazard has been overlooked

-Hazard identification is a continuous process

 Profile hazards
-Frequency and history
-Severity and intensity (how fast, strong, high, intense, etc.)

-Time frame:

*duration of hazard impact

*prior warning possible?

-Geographical extent

-Manageability: can we do something to control the hazard impact

 Describe receptors
-Description of the community and its environment

-Vulnerable groups need to be given special attention

-Identify those groups in the community that have specialized skills or knowledge that may
be useful in disaster management

 Estimate effects
-Consider the range of effects that will arise from any event, and answer the following
questions:

-what areas are affected?

-who is affected (directly and indirectly)?

-what facilities and services are affected?

 Determine frequency
-Probability of hazard occurrence:

*historical

*predicted or probable

 Estimate and prioritize risks

-Prioritizing risks enables a planning committee to concentrate its initial planning efforts on
those hazards which may have the greatest effect on the community

2.3 What are the Component of the Planning Process?

1-Determine the authority to plan 2- Establish the planning committee
3-Conduct hazard analysis 4-Set planning objectives
5-Apply the management structure 6-Determine responsibilities
7-Analyze resources 8-Develop disaster management
9-Document the plan 10- Test the plan
11-Review and update the plan
3. Disaster Response
  Action taken at the time a disaster strikes or prior to impact, that are intended to:
-provider emergency assistance to victims

-reduce the likelihood of secondary damage

-speed recovery operations

-Issuing warnings ± evacuation -Disaster declaration

-Implementing disaster plans -Mobilizing resources
-Search and rescue -Providing medical assistance
-Providing immediate relief (shelter, food….) -Assessing damage
-Protection of property -Restoring essential public services

4. Recovery

o Effort to restore infrastructure and the social and economic life of a community to
normal
o Short-term recovery returns vital life support systems to minimum operating
standards
o Long-term recovery involves efforts to restore economic activity and rebuilding the
community
o it should also include mitigation as a goal
To Take Home:

-No standardized definition of disaster

-Very little research with regards to disaster medicine

-Planning is a continuous process. The written plan is a living document, constantly being
reviewed and updated

-Plan for the worst and hope for the best