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Chapter -1 Community and element of Nutrition: (sir note) 1#Q. Define community? How many types of community/ classify community? Community is a group of people who share a common geographical location, values, culture or languages. Two type of community An urban community is one in which there are many different people from different cultures and backgrounds. An rural community is one in which there is a dominant culture or race. 2#Q. The Concept of Community The concept of community varies widely. The World Health Organization (WHO) defines community as “a social group determined by geographic boundaries and/or common values and interests. Community members know and interact with own another’s function within a particular social structure; and show and create norms, values, and social institution border and others surrounding the legal limits of a city are also an integral part of that cities total community. A second definition of community is demographic and involves viewing the community as a subgroup of the population, such as people of a particular age, gender, social class, or race. A collection of people, even if they are scattered geographically, can have a common interest that binds its members. This is called a common-interest community. Many successful prevention and health promotion efforts, including improved services and increased community awareness of specific problems, have resulted from the work of common-interest communities. 3#Q. Define community nutrition? Community nutrition is a modern and comprehensive profession that includes, but is not limited to, public health nutrition, dietetics/nutrition education, and medical nutrition therapy. Community nutrition deals with a variety of food and nutrition issues related to individuals, families, and special groups that have a common link such as place of residence, language, culture, or health issues. There is an increasing need to focus on community in health promotion and disease prevention because behavior is highly influenced by the environment in which people live. Local values, norms, and behavior patterns have a significant effect on shaping an individual’s attitudes and behaviors. The increasing movement toward using a community approach requires community nutritionists to become more visible and vocal leader of community health. However, before community nutritionist can participate can participate in nutrition and healthcare planning, they must be knowledgeable about the community as client. 4#Q. Mention activities of community nutrition? /THE HEALTHY ROLE OF COMMUNITY Community nutrition encompasses a broad set of activities designed to provide access to a safe, adequate, healthful diet to a population living in a particular geographic area. These activities include

1. Nutrition education, 2. nutrition or health promotion, 3. food programs, supplementation programs (e.g., fluoride), preventive programs, local policy analysis and

development, and 4. The organizational infrastructure that supports it.

5#Q. Indicate step to deliver services in community nutrition “Ideally, community nutrition involves four interrelated steps to deliver services:

1. assessment to identify the problem(s), 2. planning to meet the community nutrition needs, 3. implementation to develop systems to reduce the problem and 4. evaluation to see if the problem has been ameliorated or solved,”

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Chapter-2 Dissemination of Nutrition Knowledge 6#Q. What is Group discussion? Aim of GD Group Discussion! Is a methodology or in a simple language you may call it an interview process or a group activity. It is used as one of the best tools to select the prospective candidates in a comparative perspective. GD may be used by an interviewer at an organization, colleges or even at different types of management competitions. Aim of Group Discussion Formal focus groups have been around since the 1940s, and during this time they have been used for an array of purposes (Höijer 2008).

1) Stimulate new ideas and concepts for both the researcher and the participants 2) Learn about impressions of product and service 3) effectiveness, or management issues 4) Learn general information about a specific topic 5) Generate new hypotheses for future research opportunities 6) Help develop sound quantitative research approaches 7) Learn how respondents communicate about topics of interest 8) (what words they use, what concepts they understand, etc.) 9) Enhance the utility of survey content and delivery mechanisms 10) Determine what additional research tools may be 11) useful for follow-up information collection 12) Better interpret previously obtained quantitative information

7#Q. What Nutritional Group Discussion? Types of group in a community Nutritional Group Discussion is a methodology or a group activity. It is used as one of the best tools to select the nutritional interventions that will achieve goal on nutritional project at Bangladesh. GD may be used by an interviewer at an organization, colleges or even at different types of management competitions or assessments. Some examples of types of community group are:

a) Self-help groups, networks and forums that bring together people who have something in common, and offer advice and support to each other; Residents’ associations and other groups of people who come together to improve their street or neighborhood

b) Faith groups that organize religious activities and community and social events; c) Sports clubs and music groups; d) Committees that organize local community events and festivals; e) Groups of people who meet regularly to socialize and enjoy shared activities, such as youth and retirement

clubs, lunch clubs and mother and toddler groups; f) Groups that form for a short period to campaign on a local issue like traffic problems.

8#Q. What are some common characteristics of groups? 1. People in groups interact with one another. This interaction includes activities that focus on the task at hand (task interaction) and activities that concern the interpersonal relations linking group members (relationship interaction). 2. Groups create interdependence among the group members (unilateral, reciprocal, etc.). 3. Interaction is patterned by group structure, including roles, norms, and interpersonal relations. 4. Groups seek goals, such as those specified in the circumflex model of group tasks (generating, choosing, negotiating, and executing). 5. Group cohesion, or cohesiveness, determines the unity of the group. Entitativity is the extent to which individuals perceive an aggregation to be a unified group. Entitativity, according to Campbell, is substantially influenced by common fate, similarity, and proximity cues

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9#Q. What is Mass media? Types of mass media? Mass media refers to communication devices, which can be used to communicate and interact with a large number of audiences in different languages. Be it the pictorial messages of the early ages, or the high-technology media that are available today, one thing that we all agree upon, is that mass media are an inseparable part of our lives. Entertainment and media always go hand in hand, but in addition to the entertainment, mass media also remain to be an effective medium for communication, dissemination of information, advertising, marketing, and in general, for expressing and sharing views, opinions, and ideas. Mass media is a double-edged sword which means that there are positive as well as negative influences of media. Print Media: Newspapers, Magazines, Booklets and Brochures, House magazines, periodicals or newsletters, Direct Mailers,Handbills or Flyers, Billboards, Press Releases, Books Electronic Media:Television, Radio, New Age Media: Mobile Phones, Computers, Internet 10#Q. Characteristic / important of mass media in nutritional education Using mass media to increase awareness on nutritional educations The mass media were not used widely in nutrition communication until the 1970s. Before then, nutrition communication relied almost entirely on face-to-face instruction in health clinics (Lediard, 1991).

The wide reach offered by mass media is phenomenal. It can target a global national and global audience.

In terms of newspapers and magazines, it can reach a specified target group. besides it is easily accessible.

It can be used for educational purposes in an effective manner.

Audience has great deal of choice

Reach large & vast audience •

Aim messages to attract largest audience possible

Media-based nutrition education projects are now legion. Some have produced changes in behavioral practices, such as campaigns for oral rehydration salts in Egypt, the Honduras, Gambia, and Swaziland, but changes in nutritional status are rare (Hornik, 1985).

Other forms of two-way communication may be needed to persuade the public to adopt a different behavioral approach, for example, to infant feeding.

11#Q. Limitation mass media

Difficult to make specific to local community

Communication is mostly one way

Fixed message can be easily misunderstood

Media bias can occur due to various issues.

Journalist or an editor may give personal preference to an issue.

Influence society & are in turn influenced by society Access often difficult Lacks feedback less appropriate for changing behaviors rooted in culture or reinforced by social norms

12#Q.What FGD? Important of FGD (focus group discussion) A focus group discussion (FGD) is an in-depth field method that brings together a small homogeneous group (usually six to twelve persons) to discuss topics on a study agenda. Importance/Formal focus groups have been around since the 1940s, and during this time they have been used for an array of purposes (Höijer 2008). 1) Stimulate new ideas and concepts for both the researcher and the participants 2) Learn about impressions of product and service 3) effectiveness, or management issues 4) Learn general information about a specific topic 5) Generate new hypotheses for future research opportunities 6) Help develop sound quantitative research approaches 7) Learn how respondents communicate about topics of interest (what words they use, what concepts they

understand, etc.) 8) Enhance the utility of survey content and delivery mechanisms 9) Determine what additional research tools may be 10) useful for follow-up information collection 11) Better interpret previously obtained quantitative information

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13#Q. Variants of focus groups include:

Two-way focus group - one focus group watches another focus group and discusses the observed interactions and conclusion

Dual moderator focus group - one moderator ensures the session progresses smoothly, while another ensures that all the topics are covered

Dueling moderator focus group (fencing- moderator):-two moderators deliberately take opposite sides on the issue under discussion

Respondent moderator focus group - one and only one of the respondents are asked to act as the moderator temporarily

Client participant focus groups - one or more client representatives participate in the discussion, either covertly or overtly

Mini focus groups - groups are composed of four or five members rather than 6 to 12 Teleconference focus groups - telephone network is used creativity groups: band obsessive group: Online focus groups - computers connected via the internet are used 14#Q. Consideration in using FGD/Uses of Focus Groups

1. Information gathered through focus groups is used for a wide variety of purposes. 2. A few of these include… 3. determining program needs, 4. program design, 5. pilot testing curricula and products, 6. program improvement, 7. customer satisfaction, 8. organizational development, 9. policy making and testing, and 10. Outcome evaluation.

Again, it is important to keep in mind that the purpose of a focus group is to gather information, not to make a decision or complete a task. Focus groups are used to gather the information needed for decision-making or guiding action. 15#Q. Focus Group Weaknesses/limitations As with any research method, focus groups are not without weaknesses. Challenges associated with focus groups are most often attributed to two main factors: the facilitator and the basic nature of group discussions (Calder 1977). • Research suggests that group discussion can cause participant attitudes to become more extreme, which could in turn result in greater unification of group opinions or polarize participants. • Focus groups require self-disclosure of information by participants, but the views and values of participants may render certain topics off limits. Participants may also convey information that may portray themselves “more favorably,” which could slightly distort gathered information. • Emotionally charged issues may result in argument. A skilled facilitator and adequate advance planning can lessen and possibly eliminate some of these weaknesses.

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16#Q. What Preparation for a Group discussion work/Prepare for the Individual FGDs Between training field staff and starting the actual field work, an important link is preparing for the individual FGDs. This includes the following:

1) Site Selection and Location for FGD Visit the project site(s) together with the field team and locate a place for the group meeting some days before the scheduled time. This will enable you to familiarize yourself with available logistics. The site for the discussion must be easily accessible to participants and convenient to the field team. The selected site must also be neutral (usually not a health facility) and large enough to accommodate all the participants and the field team.

2) Date and Time For most focus groups in communities the ideal time is evening, while for those involving health staff late afternoon is often the best time, when the daily office routine is over. Make a time table that will guide how you will proceed with the field work after deciding the site(s), day(s), and time(s). See an example of a project time table in the annex.

3) FGD Checklist Ensure that all equipment is ready before the field work. A checklist may include the following:

(a) Arrange Transport Chairs, Mats, etc. Refreshments Other incentives, if any

(b) Bring to the Field Tape Recorder Microphone (if needed) 3 blank 60 minute cassettes Batteries (plus extra) Moderator's guide Recording forms

Test all recording materials a day before you go to the field to ensure that they are in working condition. 17#Q.Practical demonstration/ Practice Sessions Role playing involves a mock discussion in which members of the field team assume roles as moderator, observer and participants as a way of practicing the technique. While the session is going on, other members of the field team observe and give their objective feedback after the role play. More than one trial should be held with field team members while changing roles each time. Pilot testing is essential because it provides:

i. an opportunity to determine if the wording in the guide is appropriate for eliciting discussion, i.e., whether it is understood as intended;

ii. A way of checking the effectiveness of training of field team members; iii. much needed field practice for the staff to develop confidence; iv. A means to identify potential problems likely to be encountered in the actual study.

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Chapter-3 Malnutrition (sir note) 18#Q. Describe the Major nutritional problem in Bangladesh/ Major nutrition-related public health problems / The major nutrition problems in Bangladesh are given below:

1. Chronic Energy Deficiency and under nutrition. 2. Micro-nutrient Deficiencies. i. Anemia due to iron and Foliate Deficiency. ii. Vitamin A deficiency. iii. Iodine Deficiency Disorders. iv. Zinc Deficiency. 3. Chronic Excess Energy and obesity. 4. Multiple deficiencies. 5. Nutrition- related chronic diseases.

The National Micronutrients Survey 2011-2012 collected updated data on the key micronutrients status such as sub-clinical vitamin A, anemia, iron, zinc, foliate, B12, iodine and iodization of salts in Bangladesh population.

Categories Rural (%) Urban (%) Slums (%)

Sub-clinical vitamin A deficiency

Preschool age 19.4 21.2 38.1

School age 20.2 22.1 27.1

NPNL women 5.4 4.9 6.9

Zinc deficiency

Preschool age 48.6 29.5 51.7

NPNL women 57.5 54.5 66.4

Nutritional status

Stunting 31.4 31.3 51.1

Wasting 21.1 12.9 20.3

Underweight 29.6 28.1 47.4

19#Q. Current nutrition situation in Bangladesh- The Bangladesh demographic and Health Survey (BDHS) 2011

Show that 41% of the under-five children are stunted, with 15.3% severely stunted.

The age pattern of stunting shows that it increases with age, being 18% among <6 months children to 52% among children aged 18- 23 months.

Among children of 48-59 months, the prevalence is 42%. Rural children are more likely to be stunted than the urban children (43% compared to 36%). Stunting is the lowest in Khulna and Rajshahi divisions (34%) of Bangladesh.

The prevalence of wasting among the under-five children is 16%, with 4% being severely wasted. Wasting peaks at 18-23 months (17%) of age. The prevalence of underweight children is 36%, with 10% being severely underweight.

The proportion of underweight in children peaks at age 36-47 months (43%). There have been some improvements in nutritional status of children over the past four years.

The level of stunting has declined from 51% in 2004 and 43% in 2007 to 41% in 2011. Wasting has declined from 17% in 2007 to 16% in 2011.

The level of underweight has declined to 36% in 2011 from 41% in 2007. Therefore, it is expected that the HPNSDP 2011-2016 goal for reduction of underweight (33%) and stunting (38%) will be possible to achieve

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21#Q. Define & classify malnutrition by WHO? Under and over –nutrition in the “malnutrition”. The World Health Organization (WHO) defines malnutrition as “the cellular imbalance between supply of nutrient and energy and the body’s demand for them to ensure growth, maintenance and specific functions”. Malnutrition, particularly in early childhood has both short term and long term effects impacting on educability, productivity, morbidity and mortality. These effects perpetuate poverty and retard national economic development. Because so many people are affected, mild and moderate forms of malnutrition, though not highly visible, are of great public health significance. Classification of Malnutrition: WHO recommends five anthropometric indicators for assessment of nutritional status are bellow 1. Wasting(low weight-for- height < -2SD of the median value of WHO reference; 2. Stunting(low height-for-age < -2SD of the median value of WHO reference; 3. Underweight(low weight-for-age<-2SD of the median value of WHO reference; 4. Overweight Weight > 2 SD above median value of WHO reference; BMI > 25 in adults 5. Obesity BMI > 30 kg/Ht2 in adults 22#Q.Some Definitions Nutrition: It is the science of foods, the nutrients, and other substances therein, their action, Interaction, and balance in relationship to health and disease. Food: The edible stuff that provides us with nutrients is termed as food. Food is broadly classified as cereals, pulses, vegetable, fruits, milk, eggs, flesh foods, fats and sugars. Nutrients: are the constituents in food that must be supplied to the body in suitable amounts. These include proteins, fats, carbohydrates, minerals, water and vitamins. Nutrition status: It is defined as the extent to which a customary diet meets the body’s requirement. In other words, it signifies the condition of body after the consumption of food. The condition of health of individuals as influenced by the utilization of nutrients. It can be assessed by dietary survey, anthropometry, clinical and laboratory investigations. A brief outline of the dietary information on the importance of various nutritional constituents that are present in Foodstuffs is given in the following pages. 23#Q. Child nutrition begins with maternal nutrition---explan Maternal and Child under nutrition:

1. Children and women in Bangladesh suffer most from under nutrition. Children 6-23 months have the highest risk of wasting, stunting and underweight. Contrary to common understanding, there is no significant difference in under nutrition rates between boys and girls under five years of age.

2. Almost one in two children under five are chronically undernourished (stunted) and 14 percent suffer from acute under nutrition (wasting).

3. Maternal under nutrition is also of great importance as it is strongly related to the delivery of low birth weight babies. More than one in five newborn (22 percent 8) has a low birth weight in Bangladesh. This means that from the beginning of life the child’s learning and future income earning potential is greatly inhibited.

4. The risk of an early pregnancy and resulting low weight baby is very high. 24#Q. Short-term and long term effect of early nutrition

Short-term effect of early nutrition

long-term effect of early nutrition Nutrients Commonly involved

Brain development

Cognitive and educational performance

Protein energy, iodine, iron.

Growth and muscle mass Body Composition

Immunity work capacity Protein energy, iron, vitamin A, Zinc

Metabolic programming of glucose, lipids, protein hormone/receptor/gene.

Diabetes, obesity, Heart diseases, high Blood Pressure, Cancer, stroke, Ageing .

Protein energy.

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Inadequate dietary intake

Appetite loss, Nutrient loss, Mal absorption Altered metabolism

Weight loss, Growth flattering, Decreased immunity, mucosal damage.

25#Q. Vicious cycle of under nutrition and infection Answer: Infection-Malnutrition Cycle/Vicious Cycle: In practice under nutrition and infection often occur at the same time because one can lead to another. This is illustrated in the cycle below. This vicious cycle needs to be broken by treatment of infection and improved dietary intake. Fig: Vicious Cycle 26#Q. Vita-A deficiency survey 2011-13 VITAMIN -A Vitamins A were discovered in the early nineteenth century by Dr. McCollum and Davis.Dr. McCollum carried out experiments on rats and found that when butter and egg yolk were added to the diet of group of rats, they were healthier, stronger as compared to the other group which was fed on lard and vegetables only. He came to the conclusion that butter and egg yolk contain some vital elements that were absent in lard and vegetables. In 1913, he isolated vitamin A from butter and egg yolk Table: prevalence of vitamin A deficiency (National Micronutrients survey 2011-2012)

Categories no Vitamin A deficiency (%) 95% CI

Preschool age Children

National 873 20.5 15.9-25.0

Rural 306 19.4 13.6-25.2

Urban 305 21.2 15.5-26.8

Slums 262 38.1 28.4-47.7

School age children

National 1267 20.9 17.4-24.4

Rural 432 20.2 16.3-24.1

Urban 431 22.1 12.8-31.5

Slums 404 27.1 21.5-32.7

NPNL women

National 918 5.4 2.8-8.1

Rural 328 5.4 2.1-8.7

Urban 304 4.9 1.7-8.2

Slums 286 6.9 2.9-10.8

Disease: increase in incidence,

duration, severity.

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27#Q. Vitamin- A Deficiency • Irreversible blindness • Increased morbidity and mortality from infection, especially pneumonia and diarrhea • Loss of structure and function of epithelial linings of the body • Impaired cellular immune function • Sources: preformed retinol from animal source foods - carotene from orange yellow red F and V • Massive dosing with Vitamin A capsules (200,000 IU every 6 mos. in <5 y.o. children in developing countries effective) 28#Q.Vitamin- A. Functions 1. Vitamin A is required for normal vision in dim light. The retina has two kinds of cells-rods and cones. Rods are sensitive to dim light, the cones respond to bright light. The rods contain a pigment called rhodopsin. Rhodospin is formed by the combination of a specific form of vitamin A with a protein. Rhodospin in the presence of bright light, breaks down into it components. In the dark these components, Vitamin A and protein again combine to regenerate rhodospin. This rhodospin helps us to see in dim light. This is called a visual cycle. 2. Vitamin A is required to maintain the integrity of epithelium, especially the membranes that line eyes, the mouth and the gastrointestinal, respiratory and genitourinary tracts. These membranes offer resistance to bacterial invasion. 3. Vitamin A is essential for normal skeletal and tooth development. 4. It has a probable role in the immunological defense mechanism of the body. 29#Q. Food Sources of Vit-A Only animal foods contain vitamin A as such; fish-liver oil being the outstanding. Milk, butter, whole milk cheese, liver and egg-yolk contain good quantities of vitamin A. Vitamin A is not present in plant foods, but its precursor, carotene is present which is converted into vitamin A in the body. Carotene is present in plants with green and yellow colorings. There is a direct correlation between the greenness of a leaf and its carotene content. Green leafy vegetable: spinach, turnip tops, beet greens, coriander leaves, curry leaves. Yellow vegetables: Carrot, sweet potatoes, pumpkin Yellow fruit: Papaya, mango, apricots, peaches. 30#Q.Recommended Daily Allowances for Vit-A The recommended allowances for the Indians are given in the table I. One IU of Vitamin A is equal to 0.3 mcg of retinol or 0.6 mcg of Beta – carotene. 31#Q. Methods for the determination of nutritional problem Answer: Methods for the determination of nutritional problem:

Issues of Interest Key indicators

Biochemical assessment

Prevalence of sub clinical Vitamin A deficiency Prevalence of iron deficiency Prevalence of iodine deficiency Prevalence of zinc deficiency Prevalence of folate deficiency Prevalence of B12 deficiency Prevalence of anemia (hemoglobin) Assessment of inflammatory biomarkers (CRP,AGP) Assessment of salt for presence and adequacy of iodization.

Anthropometry Prevalence of underweight (weight-for-age<-2 Z-score) for children aged 6-59 months. Prevalence of wasting (weight-for-height<-2 Z-score) for children aged 6-59 months. Prevalence of stunting (height-for-age<-2 Score) for children aged 6-59 months.

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32#Q. Conceptual framework on nutrition

Nutritional Status

Diet Health

Psychosocial stress and Trauma

Household

Food

Security

Care of

Mother and

Child

Environmental

Health,

Hygiene and

Sanitation.

Education and information

Human, Economic and

Institutional Resources

Political and ideological structure.

Ecological Conditions.

Potential Resources

Consequences

Manifestations

Functional consequences:

Mortality, Morbidity, Educability.

Lost Productivity

Immediate causes

Underlying

Causes

Basic causes

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33#Q. UNICEF & FAO model on concept and determinants of health status, nutrition strategies Nutritional status is the term used to indicate the net outcome of individual food usage (ingestion, absorption and utilization), disease status and work demand. It is the outcome of previous nutrition, and indicates the presence or absence of deficiency signs, the failure of growth or some other aspect of functional capacity. It is a rather broad, multi-faceted concept which is difficult to measure directly. Nonetheless, certain anthropometric measurements are generally considered reliable indicators of nutritional status, particularly for young children. The most frequently used measurements are weight, height and arm circumference. Measurements for an individual child are compared to reference values for the appropriate age and gender and are used to assess the status of a population of children.

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Chapter-4 Public Health Nutrition (sir note) 34#Q. Definition of Public health, Goal of public health and focus of public Definition Public health refers to "the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals Public health is a multidisciplinary field whose goal is to promote the health of the population through organized community efforts. Goal PH: The goal is sustainable improvement in health, nutrition and family welfare status of the people, particularly of the poor and vulnerable groups, including women, children and elderly with ultimate aim of their economic and social emancipation and physical and mental well being. Focus of Medicine: mainly on treating illness in separate individuals Focus of Public Health: activities include

Assessing the health status of the population Diagnosing its problems Searching for the causes for those problems Designing solutions for those problems.

Solutions usually involve community-level interventions that control or prevent the cause of the problem. For example, educational programs to discourage teenagers from smoking, screening programs for cancer, laws requiring seat belt use. Vision of Public Health: The health sector seeks to support creation of an enabling environment whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health. With a vision that recognizes health as a fundamental human right the need to promote health is imperative for social justice. This vision derives from a value framework that is based on the core values of access equity, gender equality and ethical conduct. 35#Q.Public health has had a greater impact on the health of the population than the field of medicine has. Public health achievements include, for example

25 years of the increase in life expectancy can be attributed to improvements in public health and only 5 years can be attributed to improvements in the medical care system.

Routine use of vaccinations for infectious diseases

Improvements in motor vehicle and workplace safety

Control of infectious diseases through improved sanitation and clean water

Smoking cessation and blood pressure control

Safer foods from decreased microbial contamination

Access to family planning and contraception services

Acknowledgement of tobacco as a health hazard and the ensuing anti-smoking campaigns.

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36#Q.ICD_ international classification of Disease 21 points*** What is ICD? The International Classification of Disease (ICD) is the most widely recognized medical classification maintained by the World Health Organization (WHO). Its primary purpose is to categorise diseases for morbidity and mortality reporting. The United States has used a clinical modification of ICD (ICD-9-CM) for the additional purposes of reimbursement.ICD-10 was endorsed by WHO in 1990, and WHO Member states began using the classification system in 1994 for both morbidity and mortality reporting. In the US, however, it has only been used for reporting mortality since 1999. Because of the US delay in adopting its version of ICD-10, it is currently unable to compare morbidity data with the rest of the world. ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines. ICD-10 Version:2015 I -certain infectious and parasitic diseases II -Neoplasms III -Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism IV -Endocrine, nutritional and metabolic diseases V -Mental and behavioural disorders VI -Diseases of the nervous system VII -Diseases of the eye and adnexa VIII -Diseases of the ear and mastoid process IX -Diseases of the circulatory system X -Diseases of the respiratory system XI -Diseases of the digestive system XII- Diseases of the skin and subcutaneous tissue XIII- Diseases of the musculoskeletal system and connective tissue XIV -Diseases of the genitourinary system XV -Pregnancy, childbirth and the puerperium XVI -Certain conditions originating in the perinatal period XVII -Congenital malformations, deformations and chromosomal abnormalities XVIII -Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified XIX -Injury, poisoning and certain other consequences of external causes XX -External causes of morbidity and mortality XXI -Factors influencing health status and contact with health services XXII -Codes for special purposes 37#Q. Branch of public health, Curative medicine, preventive medication** Preventive healthcare (alternately preventive medicine or prophylaxis) consists of measures taken for disease prevention, as opposed to disease treatment. Just as health encompasses a variety of physical and mental states, so do disease and disability, which are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices. Health, disease, and disability are dynamic processes which begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primary, secondary, and tertiary prevention. Curative care or curative medicine is the health care given for medical conditions where a cure is considered achievable, or even possibly so, and directed to this end. Curative care differs from preventive care, which aims at preventing the appearance of diseases through pharmaceuticals and such techniques as immunization, exercise, proper eating habits and other life style issues, and from palliative care, which concentrates on reducing the severity of symptoms, such as pain.

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38#QIndicator for health for all in a Country? *** MAJOR HEALTH INDICATORS Bangladesh has made considerable progress over the last decade in improving the health status;

1. Life expectancy at birth-61 yrs 2. IMR per 1000 live births-56 3. U-5 Child mortality rate per 1000 live births-80 4. MMR per 1000 births-3.2 5. Total Fertility Rate-3.0 6. Contraceptive Prevalence Rate-58% 7. Immunization against 6 diseases-69% 8. Attain almost Polio-free status

39#Q. Public health in post independent status in Bangladesh/Post liberation period (after 1971)

The composition of this unit, the mechanism of its functioning, the availabilities of facilities were so limited that it could not achieve the objective of a National Government for its defined task in the sector of health related nutrition problems & food science research.

As malnutrition situation in Bangladesh is recognized as a major public health problem, it is felt that health sector should play a vital role in identifying the size and magnitude of the problem and should overcome this problem with an integrated national effort involving all.

With this back ground in mind an article titled "Nutrition Organization needed in the country'' were written by the repatriated the then Director of Nutrition organization of Pakistan which was published in the daily news paper of the country in June 1973.

By this time gigantic rural integrated health programme was launched in the country by the health sector establishing of Thana Health Complexes and its sub centers throughout the country with the objective to extend the integrated health services in general and to deliver primary health care to the rural masses in particular.

By this time the Ministry & of Health started to recognize that nutrition should be considered, as an important component of health sector development programmes as viewed by WHO and UNICEF. Primary strategy of this component should be directed towards strengthening of the Nutrition Organization under the health sector to implement nutrition activities as an integral part of the primary health care services of the government. In 1974 the Government established the Institute of Public Health Nutrition (IPHN) to assist it on formulating policy and strategy for nutrition related activities and programs and also to conduct research, training and surveillance. 40#Q. history of public health in Bangladesh/ after liberation history Historical Evolution of Public Health in Bangladesh Antiquity Ayurveda and Unani medicine 1714 Indian Medical Service by the British colonial

government 1938 Formation of National Health (Sokhey) Sub-

committee by INC 1943 Formulation of Health survey and Development

(Bhore) Committee 1947 Independence of British India. Bangladesh as East

Pakistan 1961 Rural Health Center Scheme adopted 1967 Thana Health Complex Scheme to establish 31 bed

hospitals in Thanas 1971 War of Independence: Bangladesh as new

sovereign country 1978 Bangladesh signed Alma Ata declaration: PHC for

achieving HFA2000 1981 Introduction of PHC pilot project in six UHCs 1986 First evaluation of the National HFA strategy 1988 Intensified PHC Program by GoB 1991-DSF; 1994-EOC; 1995-BINP; 1996-HPSS; 1998-HPSP, UPHCP, ESP; 2000-LLP; 2001- IMCI; 2003- HNPSP 2009 National Health Policy introduced. Reestablishment

of CC

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41#Q.What r the health manpower and health institution of Bangladesh. HEALTH MANPOWER Doctor: Total registered 33573 Total- Nurses: Registered 19500 – Dental surgeon-1286 Medical assistant -5503 (2003), AHI_4200 union level Pharmacist-7622 Radiographer-1054 Lab technician -2220 Health Assistant-20889(75%male, 45UHFWC, 16389 word level FWV-5604-UPC, MCWC, UHFWC, Field INSTUTUTIONS FOR HEALTH MANPOWER DEVELOPMENT

1. Medical University # 01 2. Medical College #13 3. Post graduate institute #08 4. Institute of Health Technology -02 5. Medical Assistant Training Schoo-08 6. Nursing College-01 7. Nursing Institute-38

42#Q. National health care delivery system and e-Health/ Public Health Service Delivery Pattern and Mechanisms in Bangladesh./Level of health care? The pattern of Bangladesh’s public health service delivery system is hierarchically structured from the national level to the village level. The structure is based on a top down approach. All the decisions regarding health policy formulation, service delivery mechanisms, allocation and utilization of resources etc. are taken at the central level, while the lower level organizations carry out the decisions. Different levels of health institutions, hospitals, health centers provide different public health care services to the beneficiaries. Level of health care/ health service delivery pattern / mechanisms: Public sector health system is structured as a hierarchical pyramid with 5 layers;

-3 at Primary

-1 at Secondary

-1 at Tertiary HEALTH SERVICE DELIVERY PRIMARY LEVEL -1

Facilities Services

Community clinic & home visitation

FP, MCH, immunization, communicable disease control, treatment of common problems & referral.

Union health & family welfare centre (4300)

Outpatient services: FP, MCH, communicable disease control, clinical care, normal delivery & adolescent health care.

Upazila health complex, (414)

Outpatient services, impatient services (31-50 beds) with diagnostic and operative treatments

HEALTH SERVICE DELIVERY SECONDARY LEV –2

FACILITIES SERVICES

District Hospitals (58)

Outdoor & Indoor Services (50-250 beds) with laboratory, radio graphic & ambulance services

Maternal & Child welfare Centre (MCWC) –(55)

EOC and other relate

HEALTH SERVICE DELIVERY TERTIARY LEVEL-3 -13 Medical college Hospitals -10 Post graduate institutes & hospitals -1 Dental College hospital -20 Specialized Hospitals -1 Homeopathic Medical College hospital -1 Ayurvedic Degree College hospital –

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43#Q. Function / role of public health assistant. WHAT THE JOB INVOLVES: Public Health Assistants, under direct supervision, assist medical and/or professional staff in public health clinics by performing clerical and health-related duties. They perform vision, hearing and simple urinalysis tests; weigh and measure patients; take pulse, respiration rates and temperatures;

1. collect and label specimens; prepare patients for examination and assist during examination; operate related equipment; may administer first aid; explain testing and clinic procedures to clients; answer routine questions and make appropriate referrals; make and receive related telephone calls; interview clients to obtain identifying and routine medical information; comfort patients and report relevant observations and information to the

2. professional staff; may accompany nurses on home visits; organize, maintain, retrieve and replace medical Folders, charts and forms and review for completeness; record and transcribe medical information onto Appropriate forms, documents, charts and computer database; serve as a receptionist; schedule appointments and contact patients via telephone or mail regarding appointments; send, receive and sort mail, medical records and notices; collect and record statistical data; maintain logs and schedules; request, arrange and maintain equipment and supplies; light housekeeping and cleaning of instruments and equipment; and perform related work.

3. Some of the physical activities performed by Public Health Assistants and environmental conditions are: lifting and carrying heavy packages for a distance of 30 feet; with assistance, lifting children onto examining tables;

4. transporting heavy medical equipment via public transportation to healthcare sites; performing duties in confined work areas; wearing protective gear such as gloves, lab coats, and goggles; handling and manipulating laboratory equipment and instruments such as glass slides, Jembac dishes, and other glassware, scissors, etc.; 44#Q. ESP_ Essential service package (Note) What is an EHP? An Essential Health Package in a low-income country consists of a limited list of public health and clinical services which will be provided at primary and/or secondary care level. Effective “vehicles” are needed for EHP implementation Once an essential package has been specified, and resources secured, “vehicles” need to be identified to ensure that the package is actually provided by facilities. Possibilities include: o Clinical or quality assurance protocols, including for referrals. o Contracting providers to provide the essential package. o The regulation and accreditation of individual facilities. o Supervision. o Assigning inputs to meet the needs of the EHP – infrastructure plans, essential equipment lists etc. Essential Health Services Package

For each of the following broad categories, there are specific interventions to be provided at the health post, health centre and district hospital levels:

Family health: ante-natal care; delivery and newborn care; post-natal care; family planning; child health – Integrated Management of Childhood Illness (IMCI); growth monitoring and essential nutrition actions; immunization; adolescent reproductive health

Communicable diseases: TB and leprosy; HIV/AIDS and sexually transmitted infections; epidemic diseases (including malaria surveillance); rabies

Basic curative care and treatment of major chronic conditions. Hygiene and environmental health (N.B. this excludes the provision of mass sanitation and water supplies, which is the responsibility of a different sector)

Health education and communication 45#Q. Why have Essential Health Packages? EHPs are often justified by their potential contribution to high-level goals such as poverty reduction or enhanced equity. There are four main types of justification – which may be cited singly or in any combination:

o Priority setting on the grounds of effectiveness and relative cost. Because EHPs generally identify cost effective interventions, they should increase value for money – for a given level of health spending, the impact on health status should improve. This, along with cost containment, is the most commonly cited rationale for EHPs.

o Equity. EHPs are generally regarded as equitable, because they describe a minimum service which should be available to every person with the same need, regardless of their age, gender or location.

o Political empowerment and accountability. Because EHPs generally provide a clear description of what services will be available for all, they are a tool for holding government, providers and insurers accountable. Obviously there is a risk in using this argument, as limiting access to specific services tends to be politically unpopular.

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46#Q.What is Public Health nursing The American Nurses Association (ANA) defines nursing: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations Public health nursing is a nursing specialty focused on public health. Public Health Nurses (PHN's) "integrate community involvement and knowledge about the entire population with personal, clinical understandings of the health and illness experiences of individuals and families within the population.".[1] Public health nursing in the United States traces back to a nurse named Lillian Wald who, in 1893, established the Henry Street Settlement in New York City and coined the phrase, "public health nurse." 47#Q.What are role nurses on public Health, Hospital, community or private in nursing RNs must work in Skilled Nursing Facilities to supervise the LPNs. RNs usually do not have very much patient contact in this setting. RNs are generally the equivalent of supervisors in this setting, supervising both LPNs and CNAs. They maintain documentation (especially documenting the use of narcotic pain relievers), supervise the staff, assist with IVs and perform life support when needed. 1. Hospitals Medical/Surgical: Administer medications, perform assessments, alert physicians of any problems, provide patient education, and collect lab samples and other similar tasks. Most of a hospital's nurses work on these floors. Floors can also specialize, becoming Pediatric, Respiratory, Oncology and other similar floors. Operating Room: The RN may work as either the scrub nurse or the circulating nurse. The scrub nurse assists the surgeon at the field by passing him instruments and medications and sometimes assisting in surgery by holding a surgical site open or by providing suction. Intensive Care: Intensive Care units are where the sickest patients in the hospital go. Patients in the Intensive Care unit have serious multi-system illnesses. They often have multiple IVs, are on several medications and may or may not be on ventilators. Patients in these areas have suffered from heart attacks, strokes, drug overdoses, traumas, gunshot wounds and other serious illnesses and injuries. RNs here must be well organized and be able to assess patients quickly and accurately. Emergency Room: RNs in the Emergency Room must be able to prioritize well. RNs are usually the Triage Nurses in the ER - LPNs are generally not permitted to serve in this role. Other Areas: The RN might also work in the Cardiac Cath Lab, Obstetrics floor and various other areas. 2. Private duty nursing is the care of clients by nurses, whether an RN (Registered Nurse) or LPN/LVN (Licensed Practical Nurse). Most nurses who provide private duty care are working one-on-one with individual clients. Sometimes such care is provided in the client's home, or an institution, such as ahospital, nursing home or other such facility.[1] Many of the private duty nursing cases involve pediatric patients on Supplemental Security Income (SSI) that have long term illnesses such as Cerebral Palsy (CP)and Traumatic Brain Injuries (TBI). The private duty nurse are in many cases Registered Nurses (RN) or Licensed Vocational Nurses (LVN). Many private duty nurses are self-employed, work as contractors and many work in the ever growing field of Home Care. The practice of private duty nursing was in many senses a precursor to a rise (in the 1980s) of wider-scale nurse entrepreneurs. 48#Q.What is health and public health? Health: The widely accepted definition of health is that given by the world Health Organization (1948). It defines it as “a state of complete physical, mental and social well being and not merely an absence of disease or infirmity”. In recent years, this statement has been amplified to include the ability to lead a “socially and economically productive life”. The WHO definition envisages three specific dimensions–the physical, mental, and social aspect of health and many more may be cited viz. spiritual, emotional, vocational, and political dimensions. Public health has been defined in different ways. In 1920, Charles Edward Amory Winslow said it is “ the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort to ensure everyone a standard of living adequate for the maintenance of health

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49#Q. Determination /Factor affecting community health and nutrition. The determinants of health Introduction Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact. The determinants of health include:

the social and economic environment,

the physical environment, and the person’s individual characteristics and behaviours. the context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate.

These determinants—or things that make people healthy or not—include the above factors, and many others:

Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.

Education – low education levels are linked with poor health, more stress and lower self-confidence.

Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions

Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health.

Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.

Health services - access and use of services that prevent and treat disease influences health

Gender - Men and women suffer from different types of diseases at different ages. 50#Q.Define nutritional education? Important of nutritional education. Nutrition Education: Nutrition Education, as defined by the Administration on Aging, is “A program to promote better health by providing accurate and culturally sensitive nutrition, physical fitness, or health (as it relates to nutrition) information and instruction to participants, caregivers, or participants and caregivers in a group or individual setting overseen by a dietitian or individual of comparable expertise. The importance of nutrition education

Making informed food choices is an integral part of a child’s normal growth and development. Many studies have shown that healthy eating habits developed early in life will encourage healthy eating as an adult.

The link between diet and chronic disease has long been recognized and, as a result, nutrition education has become a necessary and important part of Personal Development, Health and Physical Education.

Learning about healthy nutritional practices has several positive implications for a student’s physical well being.

As well as understanding how the over-consumption of food can lead to health risks, students in home economics courses are taught about the under-consumption of foods and other eating disorders.

Studies have shown that one way to help prevent eating disorders is to educate children about the importance of eating healthy during their adolescent years, and that more of these preventative programs should be in existence.

51#Q.Control of Non-communicable Diseases: Reduction of morbidity and premature mortality due to non-communicable diseases (NCDs) will require appropriate actions at all levels from primary prevention to treatment and rehabilitation in an integrated manner. The government will, in partnership with local government administration and private sector create greater awareness of, and provide services for the control of unhealthy diet and lifestyle related major NCDs like-- cardio-vascular diseases, cancer, diabetes, mental illness, etc. It will also take steps to combat common NCDs, such as, hypertension, asthma, blindness, etc., which particularly afflict the poor. Existing preventive and curative measures with respect to all NCDs will further be expanded and strengthened to increase access of all for health care services. 52#Q. Control of Communicable Diseases: The existing programs along with focus will further be expanded and strengthened to intensify prevention and control of communicable diseases , Such as, acute respiratory infection, diarrhea, dengue, etc. Special measures will be initiated for combating tuberculosis, malaria, fileriasis and kalazar, which are concentrated in specific pockets of the country.

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53#Q. Content of public health nutrition Public nutrition is concerned with improving nutrition in populations in both poor and industrialized countries, linking with community and public health nutrition and complementary disciplines. The term is proposed to include the following activities:

1. Understanding and raising awareness of the nature, causes, and consequences of nutrition problems in society

2. Epidemiology, including monitoring, surveillance, and evaluation 3. Nutritional requirements and dietary guidelines for populations 4. Public education, especially nutrition education for behavioral change 5. Timely warning and prevention and mitigation of emergencies, including use of emergency food aid 6. Advocacy and linkage with, for example, population and environmental concerns 7. Public policies relevant to nutrition in several sectors, for example, economic development, health,

agriculture, and education 54#Q. Role of public health nutritionist in national development. Common phrases used to describe public health nutrition included the following:

1) prevention of nutrition-related diseases and conditions/primary prevention for the population 2) population health approach; including consideration of the needs of the whole population and distribution

of risk across the population 3) addressing determinants of health (root causes); improving the health of vulnerable populations 4) working with communities/community development approaches 5) nutrition/health promotion 6) working with partners in a variety of sectors 7) nutrition education and communication (accurate information provision) to various publics, including

intermediaries (e.g. public health colleagues) 8) use of a variety of strategies (e.g. partnership, policy development, advocacy, systems change, etc.) 9) working for environments, policies and legislation that support access to healthy foods 10) life course (change) and healthy growth and development perspective

55#Q. Health is one of those terms which most people find it difficult to define, although they are confident of its meaning. Therefore many definitions of health have been offered with the terms. (i) Physical dimensions: It is the easiest to understand. The state of physical health implies the notion of “Perfect functioning” of the body. The signs of physical health in an individual are “ a good complexion, a clear skin, bright eyes, lustrous hair with a body well clothed with firm flesh not too fat, a sweet breadth, a good appetite, sound sleep, regular activity of bowels and bladder and smooth, easy coordinated bodily movement. All the organs of the body are of unexceptional size and function normally; all the senses are in tact; the resulting pulse rate, blood pressure and exercise tolerance are all within the range of “normality” for the individual’s age and sex. This state of normality has fairly wide limits, which are set by observing a large number of ‘normal’ people, who are free from evident disease. (ii) Mental Dimensions: Mental and physical dimension of health are inter-related. It is not the mere absence of mental illness. Good mental health is the ability to respond to the many varied experiences of life. Poor mental health affects physical well being also and vice-versa. Psychological factors are considered to play a major role in disorders such as hypertension, peptic ulcer and asthma. (iii) Social Dimension: Social well being implies harmony and integration within the individual, between each individual and other members of the society and between individuals and the world in which they live, social health of a community depends upon its progress, broadmindedness, consideration, through fullness and sympathy towards other. It also depends upon the education, productivity, health and social security of its members. (iv) Spiritual Dimension: Due to stresses and strains of modern life, it is very important for us to consider this dimension of health as well. An individual has to be at peace with himself, before he can be at peace with the world. Attention to moral values, ethics, exercise, and mediation are some of the ways of attaining spiritual health. (v) Vocational Dimensional: The vocational aspect of life is a new dimension. The importance of this dimension is exposed when individuals suddenly lose their jobs or faced with mandatory retirement. For many individuals, the vocational dimension may be nearly a source of income. To others, this dimension represents the culmination of the efforts of other dimensions as they function together to provide what the individual consider in life “Success”

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56#Q. Determinants and indicators of health. DETERMINANTS OF HEALTH Health does not exist in isolation. The factors, which influence health, lie both within the individual and externally in the society in which he or she lives. These factors interact and the result of these interactions may be health promoting or deleterious. Thus, the health of individuals and whole communities may be the result of much such interaction. Some of the important determinants of health are discussed below. i) Heredity ii) Environment iii) Life style. iv) Socio-economic conditions v) Health and family welfare services vi) Others. i) Heredity: The physical and mental traits of every human being are to some extent determined by the nature of his genes at the moment of conception. This genetic makeup is unique, that it cannot be altered after conception. A number of diseases are known to be of genetic disorder, e.g. chromosomal anomalies, sickle cell anemia, hemophilia, errors of metabolism, mental retardation, some types of diabetes, etc. The state of health therefore depends on the genetic constitution of man. ii) Environment: It was Hippocrates who first related disease to environmental e.g. climate, water, food, air, etc. Century’s later Pettenkofer in Germany revived the concepts of disease environment association. The external environment consists of those things to which the man is exposed after conception. It is defined as “all that which is external to the individual human host”. It can be divided into physical, biological, and psychosocial components, any or all of which can affect the health of man and his susceptibility to illness. It has a direct impact on the physical, mental and social well being of those living in it. If the environment is favorable to the individual he can make full use of his physical and mental capabilities. iii) Lifestyle: The term life style implies “the way people live”. Reflecting a whole range of social values, attitudes and activities. It is composed of cultural and behavioural patterns and life long personal habits. (e.g. smoking, alcoholism) that have developed through process of socialization. Lifestyle is learnt through social interactions with parents, peer groups, friends and siblings and through school and mass media. Health requires the promotion of healthy lifestyles, examples include adequate nutrition, enough sleep, sufficient physical activity etc. Health is both a consequence of an individual’s life style and a factor determining it. Many current day health problems especially in the developed countries (e.g. coronary heart disease, obesity, lung cancer, drug addiction) are associated with lifestyles changes. In developing countries such as India where traditional lifestyle will persists, risks of illness and death are connected with lack of sanitation, poor nutrition, personal hygiene, elementary human habits, customs and cultural patterns. In short the achievement of optimum health demands adoption of healthy lifestyles. iv) Socio-economic conditions: It has long been known that socio-economic conditions influence human health, some of the important factors which determine the socio-economic conditions are: a) Economic Status: The per capita GNP is the most widely accepted measure of general economic performance. The economic status determines the purchasing power, standard of living, quality of life, size of the family and the pattern of disease and deviant behavior in the community. It is also an important factor in seeking health care; ironically, affluence may also be a contributory sense of illness as exemplified by the high rates of coronary heart disease, diabetes and obesity in the upper socio-economic groups. b) Education: A second major factor influencing health status is education (especially female education). The world map of illiteracy closely coincides with the maps of poverty, mal-nutrition, ill health, high infant and child mortality rates. Studies indicate that education to some extent compensates the effect of poverty on health irrespective of the availability of health facilities. In India Kerala is an example, Kerala has an estimated infant mortality rate of 29 compared to 104 for all India in 1984, and major factors is the highest female literacy rate of 65.7% compared to 24.8% of all-India. c) Occupation: Unemployment shows a higher incidence of ill-health and death. Form many loss of work does not only mean loss of income and status, but psychological and social damages also. d) Political system: Health is also related to country’s political system. Often the main obstacles to the implementation of health technologies are not technical, but rather political. Recessions concerning resource allocation, manpower policy, choice of technology and the degree to which the health services are made available and accessible to different segments of the society are examples of the manner in which the political system can shape community health services

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e) Health Services: The purpose of health services is to improve the health status of population. The term health and family welfare services cover a wide spectrum of personal and community services for treatment of disease, prevention of illness and promotional of health. Immunization of children can influence the incidence/prevalence of a particular disease. Provision of safe water can prevent mortality and morbidity from water-borne diseases. The care of pregnant women and children would contribute to the reduction of maternal and child morbidity and mortality. All these are ingredients of what is now termed as “primary health care”, which is seen as the way to better health. f) Other factors: Other factors which influence the health of populations are beside the formal health care system. This would include opportunities, increase wages, prepared medical programmes and family support system. In short medicine is not the sole contributor to the health and well being of populations. The contributions of intersectional programmes to the health of communities is increasingly recognized 57#Q. WHAT IS PUBLIC HEALTH NUTRITION? • Problems related to inadequate quantity and quality of the habitual diet • Problems related to excessive intake of quantity of the habitual diet and food additives and supplements • Food safety problems that affect the health and function of a large percent of the general population • Nutrition problems prevented or ameliorated by identification of risk factors and early detection by screening when feasible, in contrast to only specific nutrient treatment •Environmental and life style risk factors. • Global warming, as well as natural disasters (flooding, droughts, civil strife, etc.) 58#Q. Principle of public health administration, hospital administration and public health nursing.

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Chapter-5 Environment protection and Human Development (sir note) 60#Q. What is portable water? Characteristics of portable water Water that is easily accessible, adequate in quality, free from contamination, safe and readily available throughout the year, free from harmful microorganisms and palatable is known as portable water or safe drinking water. Characteristic of PW:

There can be no state of positive health and well being without sage water. Water is not only a vital environmental factor to all forms of life,

Potable water is water that has been treated,

cleaned or filtered and

meets established drinking water standards or is assumed to be reasonably free of harmful bacteria and contaminants, and

considered safe to drink or use in cooking and baking. Examples of potable water would be that from treated municipal water systems, 61#Q. What is non-portable water? Non-potable water is generally all raw water that is untreated, such as that from lakes, rivers, ground water, springs and ground wells. Such water is not considered potable or safe to drink. Without proper water testing, a body of water carries unknown contaminants and is deemed to be non-potable. Although it may taste fine, drinking such water carries uncertain health risks. Non-potable water is generally all raw water that is untreated, such as that from lakes, rivers, ground water, springs and ground wells. Such water is not considered potable or safe to drink. Without proper water testing, a body of water carries unknown contaminants and is deemed to be non-potable. Although it may taste fine, drinking such water carries uncertain health risks. 62#Q. How water is contaminated/pollution or loss its portability? Water is contaminated or loss its portability by:

1. Sewage 2. Leakage in water pipes 3. Flies and mosquitoes, 4. Finger nails, 5. Industrial and trade wastes, 6. Agricultural pollutants, 7. Radioactive substance, 8. Air etc

The World Health Organization (WHO) and various national agencies have drinking water quality standards that specify the acceptable microbial, chemical, and radiological characteristics of safe drinking water. Excessive amounts of microbes or chemicals derived from human and animal wastes, agricultural runoff, industrial chemicals, and even natural pollutants, make some water unsafe to drink and cause water-related diseases. 63#Q. Why we needed purification of water Water is a fundamental human need. Each person on Earth requires at least 20 to 50 liters of clean, safe water a day for drinking, cooking, and simply keeping themselves clean. Polluted water isn’t just dirty—it’s deadly. Some 1.8 million people die every year of diarrheal diseases like cholera. Tens of millions of others are seriously sickened by a host of water-related ailments—many of which are easily preventable. The United Nations considers universal access to clean water a basic human right, and an essential step towards improving living standards worldwide. Water-poor communities are typically economically poor as well, their residents trapped in an ongoing cycle of poverty. Education suffers when sick children miss school. Economic opportunities are routinely lost to the impacts of rampant illness and the time-consuming processes of acquiring water where it is not readily available. Children and women bear the brunt of these burdens. Water is obviously essential for hydration and for food production—but sanitation is an equally important, and complementary, use of water. A lack of proper sanitation services not only breeds disease, it can rob people of their basic human dignity.

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64#Q. Write down the water purification mechanism or chlorination There are three chief methods which are used for the purification of drinking water in municipal supplies

A. Sedimentation: It is done when consists of large sized organic organic meterials such as leaces (lives) and gravels, Suspended particles settle down depending on their size and weight and condition of the stored water. Sedimentation is done in large reservoirs of tanks. The rate of sedimentation is enhanced by adding alum, iron, salts, colloid silicates which act as coagulants. The suspended materials and microorganisms are entrapped by coagulants and settle down rapidly.

B. Filtration: After sedimentation, it is the second steps of purification. There are two types of sands filters: a) Slow sand filter: This plant consists of a concrete floor containing drainage tiles. The tile is covered with first coarse sand and finally 2 to 1 feet of sand at the top of plant. Water passes slowly through the filter and collected by tile drain pipes at the bottom which later on is pumped in to a reservoir. If water is turbid, slow sand filters are clogged soon. Through this plant pathogenic microorganism such as Giardia and its cysts which are not removed by any others method can be filtered Iron water. The capacity of sand filter plan is to filter about five million of water per acre per day. b) Rapid sand filter: This plant consists of layers of sand, gravel and rock. This plant depends on physical trapping of fine particles and flocks of coagulants, The pores of the plants are cragged It is cleaned by forcing cleaned water backward I.e. back washing through the beds of gravels and sands without disturbing thee fine sand. About 99% bacteria are removed by the plant. But unfortunately it does not removed Giardia lamblia cysts, Cryptospordium oocysts, Cyclospora and viruses. It can deliver about 150 to 200 million gallons of water per acre per day. C) Disinfection is the final steps of water purification. Solution of sodium hypochlorite ate treated or chlorination are used. Chlorination involves the release of chlorine gas in water which gets readily mixed up with water. The amount of chlorine required depends on organic matter and number of microorganism present in water and duration of time to act upon. The amount of chlorine required for this infection is called chlorine demand. Water is chlorinated to contain about 0.1 to 0.2 ppm of residual chlorine which reaches to this concentration after 20 minutes of its addition. The simplest method to make water free from microbes and for consumption is boiling for 10-15 minutes. Water react with cl2 to from hydrochloric acid and hypoclorus acid. The hydrochloric acid is newtralize by the alkalinity of water. The hypochlorus acid is ionized to for cl. H2O+ cl2----------- HCl + HOCl HOCl-------------H + OCl The Hypochlorus acid is the most effective form of chlorine for water disinfection 65#Q. Chlorine demand Solution of sodium hypochlorite ate treated or chlorination are used. Chlorination involves the release of chlorine gas in water which gets readily mixed up with water. The amount of chlorine required depends on organic matter and number of microorganism present in water and duration of time to act upon. The amount of chlorine required for this infection is called chlorine demand. Water is chlorinated to contain about 0.1 to 0.2 ppm of residual chlorine which reaches to this concentration after 20 minutes of its addition. The simplest method to make water free from microbes and for consumption is boiling for 10-15 minutes. Water reacts with Cl2 to from hydrochloric acid and hypoclorus acid. The hydrochloric acid is neutralizing by the alkalinity of water. The hypochlorus acid is ionized to for cl. H2O+ cl2----------- HCl + HOCl HOCl-------------H + OCl The Hypochlorus acid is the most effective form of chlorine for water disinfection Chlorine is a highly efficient disinfectant, and it is added to public water supplies to kill disease-causing bacteria that the water or its transport pipes might contain.

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66#Q.What is Environment? Component of environment Environment is the sum total of what is around something or someone. It includes living things and natural forces. The environment of living things provides conditions for development and growth, as well as of danger and damage. Living things do not simply exist in their environment. They constantly interact with it. Organisms change in response to conditions in their environment. The environment consists of the interactions among plants, animals, soil, water, temperature, light, and other living and non-living things. Components PHYSICAL: air, water, soil, housing, climate, geography, heat, light, noise, debris, radiation, etc. BIOLOGICAL: man, viruses, microbial agents, insects, rodents, animals and plants, etc. PSYCHOSOCIAL: cultural values, customs, beliefs, habits, attitudes, morals, religion, education, lifestyles, community life, health services, social and political organization. 67#Q. Role environment to human health.

The key to man’s health lies largely in this environment. In fact much of mans ill health can be traced to adverse environmental factors such as, water, air & soil pollution, poor housing conditions, presence of animal reservoirs and insect vectors of diseases which pose a constant threat to mass health.

Often man his responsible for the pollutions of his environment through urbanization, industrialization and others human activities.

Thus it can clearly understood from the relation between environment and health of the community.

Environmental health threats to the Nation’s citizens are an inescapable consequence of the interactions between people and their physical, chemical, and biological environment

Major health threats also arise from naturally occurring toxicants and anthropogenically derived environmental contaminants.

Such contaminants are increasingly appearing in natural ecosystems. Some of these contaminants are bio-accumulative; they persist in the environment and accumulate in living organisms and tend to increase up the food chain.

The health consequences of chronic exposure of low levels of these substances are commonly unknown but potentially important.

68#Q. What sanitation? (National sanitation foundation of USA from definition) Sanitation is the branch of public health which is concerned with keeping the external environment healthful or healthy. The word sanitation is derived from the Latin word ‘sanitas’ which means a state of health. The dictionary meaning of the word sanitations is “ the science of safe guarding health”. One of the best definitions is that given by the National Sanitation Foundation of the U. S. A. which is as follows: “Sanitation is a way of life. It is the quality of living that is expressed in the clean home, the clean farm, the clean business, the clean neighborhood and the clean communities” Sanitation includes all four of these engineering infrastructure items (even though often only the first one is strongly associated with the term "sanitation"):

Excreta management systems

Wastewater management systems

Solid waste management systems

Drainage systems for rainwater, also called storm water drainage The World Health Organization states that: "Sanitation generally refers to the provision of facilities and services for the safe disposal of human urine and feces. Inadequate sanitation is a major cause of disease world-wide and improving sanitation is known to have a significant beneficial impact on health both in households and across communities. The word 'sanitation' also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal.

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70#Q. What Environmental sanitation? Important environmental sanitation, Define Environmental sanitation: According to WHO Environmental sanitation is the control of all environmental factors in mans physical environment which exercise or may exercise a deleterious effect on his physical development health and survival” Importance EN:

Maintenance of safe drinking water free from pollution and harmful organism

Controls the disposal of sewage

Conducts inspection of sanitary conditions of food supply

Enforces housing regulations and supervises the controls of rats, files, mosquitoes and other intermediate sources of diseases transmission. 71#Q. Define Personal hygiene and hygiene? Important of personal hygiene Hygiene (which comes from the name of the Greek goddess of health, Hygieia), is a set of practices performed for the preservation of health. Whereas in popular culture and parlance it can often mean mere 'cleanliness', hygiene in its fullest and original meaning goes much beyond that to include all circumstances and practices, lifestyle issues, premises and commodities that engender a safe and healthy environment. Personal hygiene involves those practices performed by an individual to care for one's bodily health and well being, through cleanliness. Import ants PH:

Humans are the major source of food contamination. Their hands, hair, and perspiration can contaminate food, their unguarded cough and sneezes, which can transmit microorganisms capable of causing illness.

Transfer of human and animal excreta by workers is a potential source of pathogenic microorganisms that can invade the food supply.

Motivations for personal hygiene practice include reduction of personal illness, 72#Q. Medical hygiene pertains to the hygiene practices related to the administration of medicine, and medical care, that prevents or minimizes disease and the spreading of disease. Medical hygiene practices include:

Isolation or quarantine of infectious persons or materials to prevent spread of infection.

Sterilization of instruments used in surgical procedures.

Use of protective clothing and barriers, such as masks, gowns, caps, eyewear and gloves.

Proper bandaging and dressing of injuries.

Safe disposal of medical waste.

Disinfection of reusables (i.e. linen, pads, uniforms)

Scrubbing up, hand-washing, especially in an operating room, but in more general health-care settings as well, where diseases can be transmitted[4]

73#Q. Step of maintaining personal hygiene The following steps are to taken to maintain personal hygine

1. Hands: the hands should be scrubbed and washed with soap and water immediately after visiting lavatory. 2. Hair; Head covering should be provided, particularly in case of females to prevent hair falling on to the food 3. Overalls: all food handlers should wear clean, white overalls while at work. 4. Health: oral hygiene should be practiced. Any cut, burn or raw-surfaces should be once at cleaned and dressed 5. Habits: Coughing and sneezing in the vicinity of food, licking the fingers before picking up an article of food,

smoking near food should be avoided. 74#Q. Food hygiene and important food hygiene. Food hygiene is concerned with the hygiene practices that prevent food poisoning. The five key principles of food hygiene, according to WHO, are 1. Prevent contaminating food with mixing chemicals spreading from people, pets, and pests. 2. Separate raw and cooked foods to prevent contaminating the cooked foods. 3. Cook foods for the appropriate length of time and at the appropriate temperature to kill pathogens. 4. Store food at the proper temperature. 5. Use safe water and raw materials

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75#Q. Toxin and type of toxin A poisonous substance produced by a living organism. Toxins can be products of ordinary metabolism (such as lactic acid), can beproduced to kill or immobilize prey (such as the toxins in snake venom), or can be produced for self-defense (such as the cyanideproduced by several plants). Toxins produced by bacteria cause disease. According to an International Committee of the Red Cross review of the Biological Weapons Convention, "Toxins are poisonous products of organisms; unlike biological agents, they are inanimate and not capable of reproducing themselves", and "Since the signing of the Convention, there have been no disputes among the parties regarding the definition of biological agents or toxins". A rather informal terminology of individual toxins relates them to the anatomical location where their effects are most notable:

Hemotoxin, causes destruction of red blood cells (hemolysis)

Phototoxin, causes dangerous photosensitivity On a broader scale, toxins may be classified as either exotoxins, being excreted by an organism, or endotoxins, that are released mainly when bacteria are lased. Related terms are:

Toxoid, weakened or suppressed toxin

Venom, toxins in the sense of use by certain types of animals 76#Q. What are the methods of solid waste disposal, write type of waste Different methods of solid waste disposal

i. Landfill Amongst the many waste management methods, using a landfill is probably the most practiced in more areas of the world than any other method. Landfills are often old and abandoned quarries and mining areas. Considered the most cost-effective way of waste disposal, about 75% of the cost of implementation is attributable to the collection and transportation of waste from residential and businesses to the landfills. The waste is layered in thin spreads and then compacted, with a layer of clean earth covering the waste material before more layers are added over time.

ii. Incineration Incineration as a disposal method involves burning the trash. Sometimes this is simply referred to as thermal treatment, as a general category of high temperature treatment of trash material. This method can be used to transform waste into heat, gas, steam and ash. One of the advantages of incineration is that with this method, refuse volume can be reduced by half or more and it requires little usage of land. An incineration facility can be built in a small area to process huge amounts of waste. It definitely saves a lot of space compared with using a landfill only. This method is popular in countries like Japan where space is limited.

iii. Recycling Recycling of waste material means taking the materials and transforming them into new products. This is a key concept in the modern waste minimization philosophy. It's about lessening the strain on the environment through minimizing the need to fully dispose (eg. by incineration and causing air pollution) of the waste generated and reducing the need to introduce new raw materials into the environment and then having to dispose of them later. In your everyday living, you may already be separating out paper products, aluminum soda cans or glass bottles into different waste containers so that these could be recycled. When bring your own shopping bag to the supermarket instead of using a new plastic bag, that's another way of recycling. 77#Q. Liquid Waste Disposal Methods

a. Dewatering and Sedimentation Dewatering can be applied when dealing with nonhazardous liquid waste. Water is extracted, leaving behind the solid components such as metals, oil, grease and other organics. Solid contaminants can be removed by the use of a sediment basin, which is a basin fitted with a controlled-release structure and set up in an embankment where it filters sediment, allowing it to settle at the bottom of the basin. The remaining liquid can be further filtered or chemically neutralized prior to disposal. A permit from the appropriate local agency is usually required to carry out this type of disposal. This method is useful when removing water from construction sites.

b. Root Zone Treatment Method Liquid waste derived from humans such as toilet, bath and kitchen water can be disposed of using the root zone treatment method. This method employs a sedimentation tank to retain solids, inlet and outlet pipes to permit water-flow, inflow and outflow collection systems, a filtration technique such as gravel filtration, and a polishing pond, which is the last purification stop before the water is either released into the natural environment or

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recycled into a water treatment system. The polishing pond is where bacteria and other microbial contaminants are likely to be removed.

c. Incineration Most solid sediments extracted from liquid waste are disposed of in landfills and underground storage tanks, depending on their hazard level. This can, however, become a major source of pollution. Another method of disposing waste water solids is incineration. This utilizes high temperatures to thermally process solid sediments in the presence of air, once all water has been extracted. Two common incineration systems are multiple hearth furnaces and fluidized bed furnaces. Each system must be fitted with air pollution control equipment to control emission of harmful gases such as nitrogen oxides and carbon monoxide.

d. Composting In cases of organic waste, waste water solids can be disposed of by composting. This method transforms solid sediments to an organic fertilizer. Composting removes pathogens and produces an effective product containing important nutrients such as potassium and nitrogen used as fertilizers, which can improve the ability of soil to retain nutrients. 78#Q. Types of waste Waste and by-products cover a diverse range of materials, as the following list illustrates (percentages are approximate values): 1. infectious waste: waste contaminated with blood and its by-products, cultures and stocks of infectious

agents, waste from patients in isolation wards, discarded diagnostic samples containing blood and body fluids, infected animals from laboratories, and contaminated materials (swabs, bandages) and equipment (such as disposable medical devices);

2. pathological waste: recognizable body parts and contaminated animal carcasses; 3. sharps: syringes, needles, disposable scalpels and blades, etc.; 4. chemicals: for example mercury, solvents and disinfectants; 5. pharmaceuticals: expired, unused, and contaminated drugs; vaccines and sera; 6. genotoxic waste: highly hazardous, mutagenic, teratogenic1 or carcinogenic, such as cytotoxic drugs used

in cancer treatment and their metabolites; 7. radioactive waste: such as glassware contaminated with radioactive diagnostic material or radiotherapeutic

materials; 8. Heavy metals waste: such as broken mercury thermometers. 79#Q. What Are the Causes of Solid Waste Disposal?

1. Farming Animal waste causes air pollution, water pollution and solid waste. Irrigation systems that don't collect and store waste lead to pollution of nearby natural habitats and the air. The waste from animals and pesticides from plants gets transported by irrigation systems and rain water. Animal feed, animal waste, pesticides and herbicides contain pathogens, hormones, and ammonia that can be harmful to public health and other wildlife. Animal waste can be controlled by planting grass buffers around waste runoff areas.

2. Mining/Industrial Waste Factories and mining operations have often received the brunt of environmentalist complaints about waste. Facilities such as sewage treatment facilities, paper mills, plastic manufacturers and power plants produce hazardous chemicals. To excavate coal for the purpose of generating electricity and power, mountains have to be blown open or stripped. Waste rock is created when open pits are dug out for mines. Extracting minerals from rocks by crushing, grinding and washing also creates waste called mineral processing waste, or "special waste," that harms natural habitats and pollutes water if not properly disposed.

3. Population Growth Human consumers are a major cause of waste. The most populous countries in the world, such as India, China and the United States, produce the most waste, according to the United Nations. As populations in those countries increase, so does the solid waste disposal and its negative impact on the environment. Large populations of consumers buy more goods and therefore dispose of more waste.

4. Medical Waste Hospitals generate waste from patient care. Solid waste discarded by hospitals includes needles, syringes, scalpels, blood products and radioactive waste. This waste can contain pathogens that are detrimental to the health of communities. Researchers from the International Journal of Integrative Biology have discovered that viruses can survive in discarded solid waste. Specially marked receptacles are used in hospitals to collect hazardous materials to be disposed of according to government regulations.

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80#Q. The major sources of health-care waste are: hospitals and other health-care establishments laboratories and research centres mortuary and autopsy centres animal research and testing laboratories blood banks and collection services nursing homes for the elderly.

81#Q. Health impact Health-care waste contains potentially harmful micro-organisms which can infect hospital patients, health-care workers and the general public. Other potential infectious risks may include the spread of drug-resistant micro-organisms from health-care establishments into the environment. Waste and by-products can also cause injuries, for example:

radiation burns;

sharps-inflicted injuries;

poisoning and pollution through the release of pharmaceutical products, in particular, antibiotics and cytotoxic drugs;

poisoning and pollution through waste water; and

Poisoning and pollution by toxic elements or compounds, such as mercury or dioxins that are released during incineration. 82#Q. Risks associated with waste disposal Although treatment and disposal of health-care waste reduces risks, indirect health risks may occur through the release of toxic pollutants into the environment through treatment or disposal.

Landfills can contaminate drinking-water if they not properly constructed. Occupational risks exist at disposal facilities that are not well designed, run, or maintained.

Incineration of waste has been widely practised but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and of ash residue. Incinerated materials containing chlorine can generate dioxins and furans2, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Dioxins, furans and metals are persistent and bio-accumulate in the environment. Materials containing chlorine or metal should therefore not be incinerated.

Only modern incinerators operating at 850-1100 °C and fitted with special gas-cleaning equipment are able to comply with the international emission standards for dioxins and furans. Alternatives to incineration are now available, such as autoclaving, microwaving, steam treatment integrated with internal mixing, and chemical treatment. 83#Q. Waste management: reasons for failure Lack of awareness about the health hazards related to health-care waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health-care waste. Many countries either do not have appropriate regulations, or do not enforce them. An essential issue is the clear attribution of responsibility for the handling and disposal of waste. According to the 'polluter pays' principle, the responsibility lies with the waste producer, usually the health-care provider, or the establishment involved in related activities. To achieve the safe and sustainable management of health-care waste, financial analyses should include all the costs of disposal. 84#Q. Steps towards improvement Improvements in health-care waste management rely on the following key elements:

building a comprehensive system, addressing responsibilities, resource allocation, handling and disposal. This is a long-term process, sustained by gradual improvements;

raising awareness of the risks related to health-care waste, and of safe and sound practices; selecting safe and environmentally-friendly management options, to protect people from hazards when

collecting, handling, storing, transporting, treating or disposing of waste. Government commitment and support is needed for universal, long-term improvement, although immediate action can be taken locally.

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85#Q. Harmful effect of disposal of inadequate treatment of waste water/product. From being an eyesore to releasing toxins, improper waste disposal on any scale can create environmental problems, health problems and even economic concerns. This is also true for older landfill sites, which are often unlined. The lining of landfills prevents toxic substances from being released into the ground water. Eyesore: Littering causes an eyesore, which devalues the land around it. This impacts tourism, businesses and residents alike. Loss of Resources: Improperly disposing of waste prevents resources from being reused. This is particularly true of plastics, metals and paper. This loss of resources means a heavier reliance on virgin materials, which often require more energy to make new products than required by reusing existing resources. Toxin Release: Some waste contains chemicals that can be released into the environment if not disposed of properly. Some of these wastes include electronics, plastics, batteries, certain types of pressure treated wood and paint. Release of Greenhouse Gases: In addition to releasing toxins into the soil and water, improperly disposed waste also releases greenhouse gases into the atmosphere. Fines: In many municipalities, improperly disposing of waste results in fines for the person or company dumping the waste. These fines are frequently in excess of what they would have paid for properly managing their waste. 86#Q. Lack of sanitation: Lack of sanitation refers to the absence of sanitation. In practical terms it usually means lack of toilets or lack of hygienic toilets that anybody would want to use voluntarily. The result of lack of sanitation is usually open defecation (and open urination but this is of less concern) with the associated serious public health issues. 87#Q. Sustainable sanitation Sustainable sanitation is a term that has been defined with five sustainability criteria by the Sustainable Sanitation Alliance. In order to be sustainable, a sanitation system has to be not only (i) economically viable, (ii) socially acceptable, and (iii) technically and (iv) institutionally appropriate, it should also (v) protect the environment and the natural resources.[5] The main objective of a sanitation system is to protect and promote human health by providing a clean environment and breaking the cycle of disease.