Community Medicine

Preventive Medicine in
Obstetrics, Paediatrics
& Geriatrics
Chapter 11

Atul K Shankar
31
ESSAY
Define the objectives of the School Health Programme. Discuss the various services
provided under the School Health Programme.
The objectives of the School Health Service are:

- Promotion of positive health

- Prevention of diseases
- Early diagnosis, treatment and follow-up of defects
- Awakening health consciousness in children
- Provision of healthful environment

Health Appraisal:

- Consists of periodic medical examinations and observation of children by the class teacher
- Periodic Medical Examination
o Initial examination should be thorough and unhastened
o It should include a careful history and physical examination of the child, with tests
for vision, hearing and speech
o Routine examination of blood and urine should be carried out
o Examination for nutritional deficiency and examination of faeces for intestinal
parasites are important in India
o Teacher should record medical history, height and weight regularly, annual testing
of vision and prepare the children for the examination
- School Personnel
o Medical examination should also be given to teachers and other school personnel as
they form the environment to which the child is exposed
- Daily Morning Inspection
o Teacher can conduct daily inspections to note any changes in the child’s appearance
or behaviour to suggest an illness, or improper growth and development

Remedial Measures and Follow Up:

- Examinations are followed by appropriate treatment and follow up

- Special clinics should be conducted for children at PHCs in rural areas, and in one of the
selected schools in the urban areas
- Special clinics should be secured or provided for exclusive use of children for examination
and treatment
- There should be a provision for beds in the existing referral hospitals for the children to be
admitted for investigation and treatment as and when required
Prevention of Communicable Diseases:

- Control through immunization is the most emphasised school health service function
- An immunization programme should be drawn up against the communicable diseases
- Record of all immunizations should be maintained as part of the student’s health record
which will accompany the student when they leave school
Healthful school environment:

- Healthful school environment is necessary for the best emotional, social and personal
health of the pupils
Nutritional services:
- Children who are physically weak will be mentally weak and therefore not be able to take
full advantage of schooling
- The diet of the school child should contain all the nutrients in proper proportions, adequate
for the maintenance of optimum health.
- In order to combat malnutrition, the school health committee recommended the school
children should be assured of at least one nourishing meal that provides at least one-third
of the daily calorie requirement and half of the daily protein requirement of the child
- UNICEF implemented the Applied Nutrition Programme to provide facilities that is utilised
in developing school gardens and the produce should be used in the school feeding
programmes.

First-Aid and Emergency Care:

- Responsibility for first aid and emergency care rests with the teachers and therefore all
teachers should receive adequate training during “Teacher Training Programmes” or “In-
service training programmes” to prepare them to carry out this responsibility
- Every school is fully equipped with First Aid Post as per regulations of St John Ambulance
Association of India
Mental Health:

- Mental health of a child affects their physical health and their learning process
- Juvenile delinquency, maladjustment and drug addiction are rising problems among school
children.
- The school teacher should have a positive and preventive role
- The school routine should be planned to allow enough relaxation between periods of
intense work, and every effort should be made to relieve tedium in the class room
- There is an increasing realization that schools need vocational counsellors and psychologists
to guide the children to the careers they are suited to.

Dental Health:
- Children frequently suffer from dental diseases and defects.
- School health programme should have provision for dental examination at least once a year
- In developed countries, schools employ dental hygienists to do preliminary inspection and
prophylactic cleansing of the teach
o This prevents gum troubles and in improving personal appearance
- They also take part in teaching dental hygiene and its importance to the children
Eye Health Services:

- Schools should be responsible for the early detection of refractive errors, treatment of
squint and amblyopia, and the detection and treatment of eye infections such as trachoma
- Administration of vitamin A has shown results
- Basic eye health services should be provided in schools

Health Education:
- The most important element of school health programme is health education
- The goal is to bring about desirable changes in health knowledge, in attitudes and in
practice and not merely to teach the children a set of rules of hygiene.
Education of handicapped children:
- The ultimate goal is to assist the handicapped child and his family so that the child will be
able to reach his maximum potential, to lead as normal a life as possible, to become as
independent as possible, and to become a productive and self-supporting member of
society
- The resources for managing handicapped children vary between countries
- It requires cooperation of health, welfare, social and educational agencies

School Health Records:

- Cumulative health records of each student should be maintained

- It should contain
o Identifying data – name, DoB, parent’s name, address
o Past health history
o Record of findings of physical examination, screening tests, record of services
provided
- This provides cumulative information on the health aspects of school children in order to
give continuing intelligent health supervision
- It will help in analysing and evaluating school health programmes and provides a useful
link between home, school and the community.
 Enumerate the common problems in the geriatric population. Discuss in detail the
care of geriatric population.
Common Problems among the Geriatric Population

- Problems due to ageing process

o Senile cataract
o Glaucoma
o Nerve deafness
o Osteoporosis affecting mobility
o Emphysema
o Failure of special senses
o Changes in mental outlook

- Problems associated with long-term illness

o Degenerative diseases of heart and blood vessels
o Cancer
o Accidents
o Diabetes
o Diseases of Locomotor system
 Fibrositis, myositis, neuritis, gout, rheumatoid arthritis, osteoarthritis,
spondylitis
o Respiratory illness
 Chronic bronchitis,
 asthma,
 emphysema
o Genitourinary diseases
 Enlargement of prostate
 Dysuria, nocturia,
 Frequent and urgent micturition

- Psychological problems
o Mental Changes
 Impaired memory
 Rigidity of outlook and dislike of change
o Sexual adjustment
 Between 40-50 years, there is cessation of reproduction by women and
diminution of sexual activity on part of men
 Irritability, jealousy and despondency are frequent
o Emotional disorders
 Results from social maladjustment
 Failure to adapt can result in bitterness, inner withdrawal, depression,
weariness of life, and even suicide
Lifestyle and Healthy Ageing:
- Diet and Nutrition
o A good diet reduces the chances of developing the diseases of old age
o a major problem is excessive fat intake
o saturated fats and trans-fatty acids are linked to increased risk of cardiovascular
disease
o to avoid this, people should eat a healthy diet since a very early age to avoid or
delay diseases
o it should be balanced with less saturated fats and oils, lots of fruits and vegetables,
less salt and sugar and more calcium and fibre

- Exercise
o Exercise helps to maintain good health, as it helps to control weight, and improves
emotional well-being and relieves stress, improves blood circulation and pressure,
increases flexibility and energy levels, improves balance
o Thus, it reduces the dangers of falls, lowers blood sugar levels and helps in
diabetes, improves bone density and thus helps prevent osteoporosis

- Weight
o Overweight and obese people are at risk of developing heart disease, stroke,
diabetes mellitus, hypertension, arthritis later in life
o To avoid this they should do regular exercise and follow a balanced diet

- Smoking
o Older people have usually smoked for longer and tend to continue being heavy
smokers
o As a result, they are more likely to have chronic diseases, with smoking causing
further deterioration

- Alcohol
o Drinking beyond a specified amount contributes to later life diseases
o Older people achieve a higher blood alcohol concentration, than young people due
to the reduction in body water which helps to dilute the alcohol.
o Older people have a decreased ability to develop tolerance to alcohol
o Drinking is linked to liver diseases, gout, stomach ulcers, depression, osteoporosis,
heart disease, breast cancer, diabetes, hypertension etc.

- Social Activities
o People are become socially isolated, rarely go out and join the community in
activities
o Going out and getting involved with the community creates a sense of belonging and
aids in maintenance of good mental health
o The support gained from others can also aid in recovering from illness by simply
knowing that others care
Health Status of the Aged in India
- The main causes of illness among the elderly are:
o Arthritis, cataract, bronchitis, avitaminosis, ear diseases, hypertension, diabetes,
rheumatism, helminthic infestations and accidents
- The government announced a National Policy on Older persons in January 1999
o It identifies the principal areas of intervention
o It provides for a broad framework for collaboration and cooperation, both within as
well as between governmental and non-governmental agencies
- A National Council for Older persons (NCOP) was commissioned to operationalise the policy
- An integrated programme for older persons has been formulated with the objective of
promoting a society for all ages, to empower and improve the quality of life of older
persons
- As part of the National Social Assistance Programme, old age pension is being provided to
more than 4 million destitute elderly all over the country
- Health care is being provided to the older persons through Bhavishya Arogya Mediclaim and
Rural Group Life Insurance Schemes
- In 2007, the Indira Gandhi National Old Age Pension Scheme was launched to provide
monthly pension to people over 65 years and living below the poverty line

Potential for Disease Prevention in the Elderly

PRIMARY SECONDARY TERTIARY

Health Habits Screening for: Rehabilitation
- Smoking - Hypertension - Physical deficits
- Alcohol abuse - Diabetes - Cognitive deficits
- Obesity - Periodontal disease - Functional deficits
- Nutrition - Dental caries
- Physical activity - Sensory impairment Caretaker Support
- Sleep - Medication side effects
Coronary Heart Disease Risk - Colorectal, breast, Introduction of support
Factors cervical, prostate necessary to prevent the loss
cancer of autonomy
Immunization - Depression, stress
- Influenza - Nutritionally-induced
- Pneumovax Anaemias
- Tetanus - Urinary incontinence
Injury prevention - Podiatric problems
- Fall risk
Iatrogenesis prevention - Tuberculosis
- Syphilis
Osteoporosis prevention - Stroke prevention
- Myocardial infarction
 List out the indicators of maternal and child health. Define ‘Maternal Mortality Rate’.
Describe the preventive & social measures in place to reduce the high maternal
mortality rate in India.
The indicators of MCH are:

- Maternal Mortality Rate

- Mortality in Infancy and Childhood
o Perinatal mortality rate
o Neonatal mortality rate
o Post-neonatal mortality rate
o Infant mortality rate
o 1–4 year mortality rate
o Under 5 mortality rate
o Child Survival rate

Maternal Mortality Rate

Maternal Mortality Rate is defined as “number of maternal deaths in a given period per 100,000
women of reproductive age during the same time period”

Preventive & Social Measures to Reduce Maternal Mortality Rate

- High maternal mortality reflects inadequacy of health care services for mothers, and also
the low standard of living and socioeconomic status in the community.
- The problem of maternal mortality is one of applying obstetric knowledge through
antenatal, intranatal and post-natal services rather than developing new skills

Any attempt to lower the MMR must take into consideration:

1) Early Registration of Pregnancy

2) At least 4 antenatal check ups
3) Dietary supplementations, including correction of anaemia
4) Prevention of infection and haemorrhage during puerperium
5) Prevention of complications
a. Eclampsia
b. Malpresentations
c. Ruptured uterus
6) Treatment of Medical conditions
a. Hypertension
b. Diabetes
c. Tuberculosis
7) Anti-malaria and tetanus prophylaxis
8) Clean delivery practice
9) In India, a large number of maternal deaths can be avoided with the help of trained
village level health workers
10) Institutional deliveries for women with bad obstetric history and risk factors
11) Promotion of family planning – control the number of children to no more than 2, and
spacing of births
12) Identification of every maternal death and searching for its cause
13) Safe abortion services
SHORT NOTES
Integrated Child Development Services Scheme (ICDS Scheme)
- The most important scheme in the field of child welfare
- The scheme was sanctioned in 1975 to the aim to lay a solid foundation for the
development of the nation’s human resource by providing an integrated package of early
childhood services
- The objectives of the ICDS are:
o Improve the nutritional and health status of children in the 0-6 age group
o Lay the foundations for proper psychological, physical and social development of
the child
o Reduce mortality, and morbidity, malnutrition and school dropouts
o Achieve an effective coordination of policy and implementation among the various
departments working for promotion of child development
o Enhance the capability of the mother and nutritional needs of the child through
proper nutrition and health education
- DELIVERY OF SERVICES
o Supplementary Nutrition
 Given to children below 6 years
 Aim is to supplement nutritional intake as:
 Child between 6-72 months to get 500 calories and 12-15g of
protein
 Severely malnourished child 6-72 months to get 800 calories and
20-25g of protein
 Each pregnant and nursing women to get 600 calories and 18-20g
of protein
o Nutrition and Health Education
 Given to all women in the age group of 15-45 years
 Gives priority to nursing and pregnant mothers
 It is imparted by specially organised courses in village during home visits
o Immunization
 Immunisation against 6 vaccine preventable diseases is being done
 For expectant mothers, immunisation against tetanus is recommended.
o Health Check-Up
 Antenatal care of expectant mothers
 Postnatal care of nursing mothers and care of newborn infants
 Care of children under 6 years of age
 Expectant mothers are given iron and folic acid along with protein
supplements & minimum of 3 physical examinations are done
 High risk mothers are referred to appropriate institutions for special care
 Health care of children under 6 consists of:
 Record of weight and height, watch over milestones, immunizations,
general check up every 3-6 months, treatment for diseases,
deworming, prophylaxis against nutritional deficiencies
o Non-formal Pre-school education
 Children between 3-6 years are imparted non-formal preschool education
 Provides opportunities for children to develop desirable attitude, values
and behaviour pattern among children
 Psycho-social problems of the Elderly
Mental Changes:

- Impaired memory, rigidity of outlook and dislike of change are some of the mental changes
seen in the aged
- Reduced income leads to a fall in the living standards of the elderly
- It does have mental and social consequences

Sexual Adjustment:

- Between the age of 40-50, there is cessation of reproduction by women and diminution of
sexual activity on the part of men
- During this phase, physical and emotional disturbances may occur
- Irritability, jealousy and despondency are very frequent

Emotional Disorders:
- Emotional disorders result from social maladjustment
- The degree of adaptation to the fact of ageing is crucial to a person’s happiness in this
phase of life
- Failure to adapt can result in bitterness, inner withdrawal, depression, weariness of life,
and even suicide

Uses of Growth Chart

1) For growth monitoring, which is of great value in child health care

2) Diagnostic tool, for identifying ‘high risk’ children.

a. For example, malnutrition can be detected long before signs and symptoms of it
become apparent

3) Planning and policy making

a. By grading malnutrition, it provides an objective basis for planning and policy
making in relation to child health care at the local and central levels

4) Educational Tool
a. It is a visual character and thus allows the mother to be educated in the care of her
own child
b. It will encourage her to participate more actively in growth monitoring

5) Tool for action

a. It helps the health worker on the type of intervention that is needed
b. It will help to make referrals easier

6) Evaluation
a. It provides a good method to evaluate the effectiveness of corrective measures
and the impact of a programme or of special interventions for improving child
growth and development
7) Tool for teaching
a. It can be used for teaching
b. For example, importance of adequate feeding, deleterious effects of diarrhoea
 Weaning of a Child
- Gradual process starting around the age of 6 months, because the mother’s milk alone is
not sufficient to sustain growth beyond 6 months
- It should be supplemented by suitable foods rich in protein and other nutrients
- Suitable supplement foods include
o Cow’s milk
o Fruit juice
o Soft cooked rice
o Suji
o Vegetables
- The weaning period is the most crucial period in child development
o During this period, children are particularly exposed to deleterious synergistic
interaction of malnutrition and infection
- Improper weaning is followed by diarrhoea and months of growth failure leading to
kwashiorkor, marasmus and immunodeficiency marked by recurrent and persistent
infections
- Knowledge of weaning foods and practices is an important aspect of preventive and social
pediatrics
- There is enough evidence to show that children can be properly weaned by local foods of a
kind usually consumed by the older children and adults in their families.
- Efforts should be made to design and promote the use of adequate home-made weaning
foods

Infant Mortality Rate

- The ratio of infant deaths registered in a given year to the total number of live births
registered in the same year; usually expressed as a rate per 1000 live births
𝐼𝑛𝑓𝑎𝑛𝑡 𝑀𝑜𝑟𝑡𝑎𝑙𝑖𝑡𝑦 𝑅𝑎𝑡𝑒
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐷𝑒𝑎𝑡ℎ𝑠 𝑜𝑓 𝐶ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑙𝑒𝑠𝑠 𝑡ℎ𝑎𝑛 1 𝑦𝑒𝑎𝑟 𝑜𝑓 𝑎𝑔𝑒 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
= 𝑥 1000
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
- It is universally regarded not only as a most important indicator of the health status at a
community but also of the level of living of people in general
- It is given a separate treatment by demographers:
o Infant mortality is the largest single age-category of mortality
o Deaths at this age is due to peculiar set of diseases and conditions to which the
adult population is less exposed or less vulnerable
o Infant mortality is affected rather quickly and directly by specific health programmes
and hence may change more rapidly than the general death rate
- Factors affecting IMR
o Birth weight, birth order, birth spacing, multiple births, family size, high fertility
o Economic factors
o Cultural factors - breast feeding, religion and caste, early marriages, quality of
mothering, maternal education, quality of health care, broken families, illegitimacy,
brutal habits and customs, indigenous dai, bad environmental sanitation
- Preventive and Social Measures
o Prenatal nutrition, prevention of infection, breast feeding, growth monitoring,
family planning, sanitation, provision of primary health care, socioeconomic
development, education
 Baby Friendly Hospital Initiative
- BFHI was created and promoted by WHO and UNICEF, and has proved highly successful in
encouraging proper infant feeding practices, starting at birth
- It is supported by the major professional medical and nursing bodies in India
- The implementation guidelines have been revised recently in the year 2018
- The 10 steps summarise a package of policies and procedures that facilities providing
maternal and newborn services should implement to support breastfeeding
The steps are:

- Comply fully with international code of marketing of breast-milk substitutes and relevant
World Health Assembly resolutions
- Have a written infant feeding policy that is routinely communicated to staff and parents
- Establish ongoing monitoring and data management system
- Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding
with pregnant women and their families
- Facilitate immediate and uninterrupted skin to skin contact and support mothers to initiate
breastfeeding as soon as possible after birth
- Support mothers to initiate and maintain breastfeeding and manage common difficulties
- Do not provide breastfed newborns any food or fluids other than breast milks
- Enable mothers and their infants to remain together and to practice rooming in 24 hours
- Support mothers to recognize and respond to their infants cues for feeding
- Coordinate discharge so that parents and their infants have timely access to ongoing support
and care

Low Birth Weight

- Birth weight is the single most important determinant of its chances of survival, healthy
growth and development
- There are 2 main groups
o Those born prematurely (short gestation)
o Those with foetal growth retardation
- Short gestation period is the major cause
- The majority of cases can be attributed to foetal growth retardation
- Low birth weight is defined as birth weight of less than 2.5 kg (upto and including 2499g)
- Measurement being taken preferably within the 1st hour of life, before significant postnatal
weight loss has occurred
- An LBW infant, is any infant with a birth weight of less than 2.5 kg regardless of gestational
age.
- This includes 2 kinds of infants; Preterm Babies, Small-for-date Babies

Exclusive Breast Feeding

- Breast milk provides the main source of nourishment in the first year of life
- Lactation continues to make an important contribution to the child’s nutrition for 18
months or longer
- In the world’s more affluent societies, breast feeding appears to have become a lost art and
the feeding bottle has usurped the breast
- The content of the feeding bottle is likely to be as nutritionally poor as it is
bacteriologically dangerous
- It is therefore very important to advise the mothers to avoid the feeding bottles
 Juvenile Delinquency
- Not merely juvenile crime
- It embraces all deviations from normal youthful behaviour and includes the incorrigible,
ungovernable, habitually disobedient and those who desert their homes and mix with
immoral people, those with behaviour problems and indulge in antisocial practices

Incidence:

- It is reported that 2% of children between 7 and 17 years attend juvenile courts

- Highest incidence is found in children aged 15 and above
- The incidence among boys is 4-5 times more than among girls
Causes:

- Biological Cause
o Hereditary defects
o Feeble mindedness
o Physical defects
o Glandular imbalance
- Social Causes
o Broken homes
o Disturbed home conditions
- Other causes
o Absence of recreation facilities
o Cheap recreation
o Sex thrillers
o Urbanization
o Industrialization
o Cinemas and television
o Slum dwelling

Preventive Measures:
- Improvement of family life
- Schooling
- Social welfare services
o Recreation facilities, parent-counselling, child guidance, educational facilities,
adequate general health services