HPE Book 10_2076 Edition

8.1.4 Chanchroid Chanchroid is a sexually transmitted disease caused by the bacterium called Haemophilus. It causes open sores around the genitals and also causes ulceration of the lymph nodes in the groin. The infection begins with the appearance of painful open sores on the genitals and swollen lymph nodes in the groin. Symptoms in women are often less noticeable and may be limited to painful urination or defecation, painful intercourse or vaginal discharge. These symptoms appear within a week after exposure. The common locations for chanchroid sores in men are the penis and scrotum. In women, the common locations are labia majora, labia minora and inner thighs. Its incubation period falls between 3-7 days. Mode of Transmission M Having unprotected sex M Wearing contaminated fomites M Skin-to-skin contact with an infected person Symptoms Presence of painful ulcer on and around the genitals Draining of grey or yellowish pus from the ulcers Swelling in the groin may occur Bleeding from the ulcers Painful urination Vaginal discharge Prevention e Awaking the community through Practicing safe sex e Consistent use of condom during sexual intercourse e Limiting the number of sexual partners e Promoting abstinence from drugs and alcohol e Avoiding high-risk sex partners Activity Divide the class into different groups. Then discuss about the causes, mode of transmission, signs and symptoms and prevention methods of various kinds of sexually transmitted diseases. Afterwards, present the conclusion in your class. 8.2 Safe Motherhood 8.2.1 Introduction to Safe Motherhood Safe motherhood is considered as one of the important components of reproductive health. It refers to the protection of health of the mother and foetus during prenatal, Health, Population and Environment Education-10 201

natal and post natal period through safe motherhood initiatives. The ultimate goal of prenatal care is to detect any potential complication of pregnancy. Postnatal care includes the concerns about the newborn baby care, mother’s nutrition, breast- feeding, and family planning. The overall goal of safe motherhood initiative program (SMI) is to reduce maternal and neonatal morbidity and mortality rate through intensive maternal and child health care. It is estimated that about half a million women from around the world are dying each year because of complication in pregnancy and delivery. Among them, more than 90 percent of the maternal deaths occur in the developing countries. Every minute, somewhere in the world and most often in a developing country, a woman dies from complications related to pregnancy or childbirth. Furthermore, the maternal mortality rate of our country is still 239 according to Nepal Demographic Health Survey, 2016 AD. Safe motherhood includes the following information and services: i. Pregnancy at appropriate age ii. Appropriate prenatal care iii. Proper care of pregnant women iv. Effective postnatal care and service v. Identify complications promptly and referring to nearby health institution vi. Provide high quality antenatal and postpartum care, post abortion care vii. Provide quality family planning service and treatment of STIs viii. Appropriate age of women for safe conception ix. Ensure all delivery service hygienically and according to accepted medical practices. 8.2.2 Education and Health Service Related to Safe Motherhood There is still a tendency of early marriage in Nepal. It is not considered good from the perspective of reproductive health. From the perspective of reproductive health, an ideal age of conception for the female is after 20 years. Early conception may create many health related complications. It is necessary to aware the people about the pregnancy only after the physical maturity for the good health of mother and infant. There should be limited number of babies with proper birth spacing. Begetting a large number of babies may spoil the health of the mother. There should be birth spacing of 4/5 years so that the first baby can get proper care from the family. People need to get safe motherhood education and serves in time for productive and healthy life. A. Pregnant Woman and Awareness Generation A healthy mother can give birth to a healthy baby. Today’s healthy baby becomes healthy human resource in the future. Prenatal care is essential for the health and proper development of the growing foetus. In this context, the strategy of nutrition, 202 Health, Population and Environment Education-10

care and service carried for the Sunaulo Hazar Din is very effective to promote the health condition of the mother and the baby. The necessary health care during the prenatal period are mentioned below: i. Conventionally, a pregnant woman should go for prenatal check up as per the schedule given below: First antenatal check up Right after conception Monthly antenatal check up From the first month till seven months of conception Fortnightly antenatal check up From 8 months to 9 months of conception Weekly antenatal check up After 9 months of conception until delivery Any time emergency antenatal check up is required in the case of complication ii. In the case of first pregnancy, tetanus toxoid injection should be given two doses intramuscularly. The first dose should be given anytime in the first seventh month of pregnancy and the second dose should be given after one month of the first dose. iii. Once the woman is pregnant, she should increase her food intake as the foetus grows. She must take adequate food that is rich in carbohydrate, fats, proteins, iron, calcium, iodine, etc. The foods such as cereals, beans, nuts, milk, egg, meat, green leafy vegetables and fruits should be there in her daily meal. iv. Women should not carry heavy load during the pregnancy period. v. Attention should be given in personal hygiene. vi. Pregnant women should not consume alcohol, tobacco substance, drugs and should not eat soil and ash as well. vii. Family member should give proper care and support to the pregnant woman. B. Some Risky Factors of Pregnancy Pregnancy may be risky in the following conditions; if a. The woman’s age is less than 18 years and above 35 years old. b. The woman’s weight is less than 40 kg and above 80 kg; height below 145 cm. c. The Woman diseased by HIV and AIDS, Cancer, Diabetes, and other chronic diseases. d. The Woman is malnourished and she already has more number of children. e. The Woman had given birth to twins in her previous pregnancy. f. The Woman’s last baby was born dead or died soon after birth. g. The Woman’s last baby was born less than two years ago. h. The Woman is having the medicines that are harmful to the foetus. Health, Population and Environment Education-10 203

C. Problems of Pregnancy The period between conception and birth is called pregnancy. The pregnancy period generally lasts for 9 months and 7 days. During this period, some health problems are observed. They can be studied as minor problems and major problems. 1. Minor Problems of Pregnancy • Nausea and vomiting • Anaemia • Constipation • Tiredness • Chest pain • Hyper acidity • Piles • Itching in the body • Muscle cramps • Numbness in feet • Backache • Gingivitis (swelling of gums) • Swelling of veins in legs (varicose of veins) 2. Major Problems of Pregnancy In some situation, major problems may occur during pregnancy. In the case of major problems; appropriate care and medical treatment are essential. The major problems of pregnancy are as follows: i. Abortion Abortion refers to the removal of immature foetus before 24 weeks of pregnancy. If the pregnancy date is unknown, the expulsion of foetus with less than 500 gram is also considered as abortion. Abortion can be defined as the termination of pregnancy before the foetus gains survival qualities. There are two types of abortion i.e. spontaneous abortion and induced abortion. a. Spontaneous Abortion The abortion, which takes place without human enforcement is called spontaneous abortion. It is also called a miscarriage. Some of the reasons of spontaneous abortion are as follows: M Abnormal size of Uterus M Chronic infections during pregnancy M Chronic malnutrition M Excessive mental tension and anxiety during pregnancy M RH negative factor in the mother’s blood M Injury in Uterus during the pregnancy period M Toxemia b. Induced Abortion Induced abortion refers to the deliberate termination of pregnancy by using medicine or with the help of trained and authorized health personnel. The main reason of 204 Health, Population and Environment Education-10

induced abortion is unwanted pregnancy. Usually, the pregnancy of unmarried girls, widows, sex workers are found aborted. At present, there is provision of legal abortion in our country in certain conditions. According to this provision (Abortion Act, 2058 BS), women can abort their pregnancy before 12 weeks. At present, safe abortion service is being provided by maternity hospital, Thapathali (Kathmandu), Marie Stope clinics of different districts and Family Planning Clinics. It is hoped that people will be encouraged for safe abortion services from authorized abortion centers and authorized medical personnel’s only. The main reasons of induced abortion are mentioned below: M Unwanted pregnancy M Sex preference (son/daughter) M Health complication of mother M Abnormality or deformity of foetus M Premarital and or extramarital pregnancy M Pregnancy resulted by rape, incest relation, etc. ii. Toxemia Toxemia refers to the illness during pregnancy due to the concentration of toxic substances in the blood. It is also called as pre-eclampsia or eclampsia. This kind of illness is observed in very few pregnant women. Some symptoms of toxemia are as given below: Ü Severe headache Ü High blood pressure Ü Excessive weight gain Ü Swelling of ankles Ü Presence of protein in the urine Ü Blurred vision Ü Abdominal pain Ü Oedema iii. Ectopic Pregnancy The implantation of fertilized zygote at any place other than in the Uterus is called ectopic pregnancy. In other words, the development of foetus at a site other than in the womb is called ectopic pregnancy. Generally, ectopic pregnancy occurs at the site of Fallopian Tube, abdomen and ovary. Obstruction in Fallopian Tubes, improper use of IUD and endometrial tumors are considered as the main reasons of ectopic pregnancy. Health, Population and Environment Education-10 205

iv. Hypertension The normal blood pressure of an adult person has 120/80 mm of Hg. Hypertension refers to the blood pressure which is higher than normal level of blood pressure. Hypertension is also one of the major problems of pregnancy. It is believed that hypertension is resulted by anxiety, tension, toxemia, etc. Some of the symptoms of hypertension are given below: Ü Headache Ü Nausea and vomiting Ü Dizziness Ü Blurred vision v. RH Incompatibility RH incompatibility is a condition that occurs during pregnancy if a woman has RH negative blood and her baby has RH positive blood. “RH negative” and “RH positive” refer to whether the blood has RH factor or not. RH factor is a protein on red blood cells. If the woman is RH negative and her baby is RH positive, her body will react to the baby’s blood as a foreign substance. In this condition, the RH antibodies may cross the placenta and attack the baby’s red blood cells. This can lead to hemolytic anemia in the growing foetus (Hemolytic anemia is a condition in which red blood cells are destroyed faster than the body can replace them). As a result, severe anemia, brain damage, or even death occurs in foetus. 8.3 Maternal and Child Health Care and its Measures 8.3.1 Introduction and Importance of Maternal and Child Health Care Maternal and child health care refers to the health services provided to the pregnant, postnatal and breast-feeding mother and children under five years. It includes preventive, promotive and curative health services of the mother and the children. In the absence of effective and adequate maternal and child health care, maternal mortality rate and child mortality rate are extremely high. For instance, every year more than half a million women die as a result of complication during antenatal, natal and postnatal period. At the same time, it is estimated that about 4 million babies are dying before reaching one month of age in the world. Furthermore, in Nepal about 12 thousand children are dying by gastro-intestinal diseases every year. Similarly, maternal mortality rate is still 239. Actually, this is the great loss to the family, community and nation. Thus, there must be provision of effective and adequate maternal and child health care services in the community and nation. Importance of Maternal and Child Health Care MCH care is essential to have safe pregnancy It helps to prevent the different complications during antenatal, natal and postnatal period 206 Health, Population and Environment Education-10

It provides knowledge and skills to protect and to promote the health status of mother and newly born baby With the assistance of skilled birth attendants, we can protect the health of the mother and child Special attention on immunization, balanced diet, maintenance of hygiene during pregnancy increase the chance of birth of the healthy baby It promotes the status of reproductive health It protects the women from high risk pregnancy and unsafe abortion 8.3.2 Maternal Child Health Care The measures that are related natal care, postnatal care and neonatal care are explained below: A. Care of Pregnant Woman (Prenatal care) Prenatal care is the care to the women during the pregnancy period. It is also called as antenatal care. It plays an important role to protect and promote the health of the mother and foetus as well during pregnancy period. The following aspects are to be considered well during the pregnancy period. 1. Personal Hygiene Cleanliness is very essential during pregnancy and postnatal period. Most of the diseases and infestation can be prevented through cleanliness. It protects pregnant and breast feeding women from Diarrhoea, Cholera, Typhoid, Jaundice, Dysentery, Worm Infestation, etc. So, to maintain personal hygiene, they should take regular bath, clean their genitals well, wear clean and comfortable clothes. At the same time, living rooms, kitchen, courtyard and surrounding should be clean. Besides this, pregnant women should follow the rules of hygiene to keep themselves healthy. 2. Nutritious Food A pregnant woman should take balanced diet. She should eat for herself as well as for her foetus. Once the woman is pregnant, she should increase her food intake as the foetus grows. She must take adequate food which are rich in carbohydrate, fats, proteins, iron, calcium, iodine, etc. In our context, attention is not given on food for the pregnant and breast feeding mother. Therefore, the maternal and child mortality rate is very high in our country. If we can supply foods such as cereals, beans, nuts, green leafy vegetables and fruits adequately; the health of the mother can be promoted. At the same time, she should drink adequate water for sound health. In addition to this, she must not consume tobacco, alcohol and drugs. If necessary, medicine has to be taken only under the consultation with the medical personnels. Health, Population and Environment Education-10 207

3. Light Exercise and Rest Rest and exercise are essential aspects of the pregnant women. The pregnant women can do light exercise and normal household activities. Morning walk in the open air is good for their health. However, heavy and stressful exercise is harmful for them. It may result into miscarriage too. Long journey in the first three months and at least the last first three months of pregnancy period should be avoided. In addition to this, adequate rest and sleep is also equally important in this period. For this, the pregnant women should take rest for 2 hours after lunch and 8 hours sleep for good health. 4. Health Checkup In the context of our country, health examination is a new concept among the pregnant and breast feeding women. Due to lack of Health Education and lack of health care facilities health examination during prenatal and postnatal period is not common among them. Regular health examination is mandatory during pregnancy, delivery and postnatal period. Regular health checkup provides information about the status of mother and foetus. If certain complications are noticed they can be immediately treated. Normally, a pregnant woman should attend the health centre once a month during the first seven months, twice a month during the eighth month and once a week during the last month. 5. Use of Medicine There should not be practice of self medication during the pregnancy period. If needed they should be taken only with the recommendation and prescription of the doctor or authorized health personnel. The intake of drugs without the recommendation of the doctor can adversely affect the health of the mother. Similarly, it may also hamper the health and development process of the foetus. 6. Vaccine/Immunization The pregnant mother and infant should be prevented from the infection of Tetanus. For this, Tetanus Toxoid injection should be given intramuscularly in seven months of pregnancy or two weeks before birth. In the case of first pregnancy, she should be given two doses. The first dose should be given in the first seventh month of pregnancy and the second dose should be given after one month of the first dose. If the woman is already immunized in the past, a booster dose is given in the last trimester of pregnancy period. B. Safe Delivery and Natal Care Labour starts at the last stage of pregnancy. The woman should be especially cared during this period. Labour can be defined as the physiological process by which the 208 Health, Population and Environment Education-10

foetus, placenta and membranes are expelled throughout the birth canal after the full term of pregnancy (38 to 42 weeks). The whole process of labour can be divided into three phases. Normally, the total process of labour lasts for 8 to 24 hours. The duration of labour depends on the various factors like birth parity, physical strength, structure of pelvic bone, height and weight of pregnant woman. 1. First phase of Labour It starts from onset of regular uterine contraction to full dilation of cervical os. This phase generally lasts for 6 to 20 hours. Signs and Symptoms Painful contraction of the Uterus occurs at every 10 or 15 minutes Progressive dilation of the cervical os is observed Amniotic membrane ruptures Vaginal discharges show (i.e. blood mixed mucus) Mother feels to urinate frequently She feels pain at the bottom of her back and abdomen The Cervix softens and fully dilates (cervical os measures 10 cm diameter) Care During the First Phase of Labour Ü Skilled Birth Attendants should be present Ü Encourage the mother to pass urine and faeces Ü Pubic hair should be removed and body should be cleaned Ü Serve her liquid food like juice, milk, soup, sugar water, etc. Ü Ask her to take a deep breath during the painful contraction of the Uterus Ü Do not allow her to push down the baby during this phase 2. Second Phase of Labour The second phase starts from the full dilation of cervical os and ends after the complete expulsion of the baby. This phase lasts for 30 minutes to 1 hour. Signs and Symptoms Expulsive and painful contraction of the Uterus occurs at every 5 minutes Sweating, vomiting and opening of the vagina occurs Mother feels urge to push down the baby Rupture of the membrane occurs At the end, the foetus is expelled out from the Uterus Care During the Second Phase of Labour Ü The mother should be kept in comfortable posture for delivery Ü She should be encouraged to bear down the baby Health, Population and Environment Education-10 209

Ü Vital signs like blood pressure, pulse rate should be examined in every 10 minutes Ü Sweats on her body should be wiped out Ü Separate the baby safely from the umbilical cord after the birth of the baby 3. Third Phase This phase begins after the expulsion of the baby and ends after the placenta, membrane, umbilical cord and little amount of blood come out from the birth canal. It lasts for 5 minutes to ½ hour. Signs and Symptoms The mother feels relaxed and all the vital signs become normal Loss of about 100 ml fresh blood occurs Placenta and membranes are expelled out The mother’s womb becomes hard Care During the Third Phase of Labour Ü Let the placenta, cord and mucus be discharge. Do not pull on the cord Ü The mother should be cleaned, made comfortable and allowed to rest Ü Ask her to urinate and clear her bowl Ü The placenta and cord should be disposed properly Ü She should be provided hot soup Ü Baby should be cleaned with soft cotton cloth and wrapped with the warm cotton clothes Ü Stitch the perineum if it is torn out C. Care of Postnatal Mother Care of the mother approximately for two months (specifically for 42 days) after delivery is called postnatal care. Postnatal care helps to keep mother and the infant fit and healthy. The following points have to be considered in postnatal care: e The postnatal mother should be given comparatively more nutritious foods like milk, fish, meat, eggs, beans, vegetables, fruits etc than the normal period e She should get adequate time for rest and sleep e She should clean her genital organs with soap and clean water after each toilet use e She should breast feed her baby as soon as possible e Baby should be wrapped with warm cotton clothes e She should get regular health checkup during this period e She should keep her body warm with cotton clothes e She should not do heavy work and carry heavy load 210 Health, Population and Environment Education-10

e She should walk slowly every day for half an hour inside the house; it helps in blood circulation process e She should pay attention in breast hygiene e She should be explained about Sunaulo Hajar Din 8.3.3 Infant and Child Health Care A baby is more safe in the mother’s uterus but not as much safe in the external environment. S/he has to face various challenges and problems after birth. A normal new born infant should have 3 kg body weight and 50 cm height. When it is less than 2.5 kg, the infant is considered as low weight. After one year of birth, generally the weight of the baby reaches three times and height reaches around 75 cm. The first Sunaulo Hajar Din plays Polio Immunization an important role for the overall development of the baby. Proper attention should be given for the health and nutrition of the baby during this period. The following points should be considered while providing infant health care: Ü As soon as the baby is expelled out, it should be held upside down so that the mucus and water in the nose and mouth can easily come out there will be easy respiration Ü The baby should be kept at a little low position than the mother’s uterus until the umbilical cord is separated from the baby so that there will be adequate passage of blood from the placenta to the baby Ü Remove the mucus from the nose, mouth and ears of the baby Ü Wrap the baby with warm cotton cloths Ü Umbilical cord should be cut with a sterilized razor or blade Ü The baby should be breast fed as soon as possible Ü Feed colostrums (the first milk of the mother) to the baby instead of throwing it out Ü Periodic health check-up and immunization of the baby should be managed on regular basis A. Breast Feeding and Supplementary Food Breast milk is the ideal food for the infant. There is no alternative food for the breast milk to the infant up to 5 months. It means no other food is required for the baby Health, Population and Environment Education-10 211

till 5 months after birth. Prolonged breast feeding prevents the infants from malnutrition and some infectious diseases. Generally, after 5 months of birth, breast milk is not sufficient for the baby. Hence, after five months, the infant can be given supplementary foods like cow’s milk, fresh fruit’s juice, lentil, crossed vegetables, porridge, lito, etc. Providing supplementary food along with breast- Breast Feeding feeding up to two years of age is called weaning. Weaning, if not done properly may cause malnutrition to the baby. In our culture, there is a weaning practice called ‘Pasni’ (Rice feeding ceremony). It is celebrated after 5/6 months of birth. The following table illustrates rules for the management of food for the children from birth to two years of age. Table 8.1: A Diet Chart of the Children from the Birth till Two Years of Age Age Provision of Food 0-6 months Mother’s milk only 6-7 months Mother’s milk, lito, well cooked soft mixed vegetables 7-9 months Mother’s milk, lito, mixed vegetables and soft fruits 9-12 months Mother’s milk, lito, soft food, pulse, vegetables, eggs, etc. 1-2 years Mother’s milk, cereals, beans, soft food, pulses, rice, vegetables, eggs, fish, meat, curd, etc. Advantages of Breast Feeding Breast milk is a complete diet for a child The first breast milk (colostrums) supplies immunity to the child Creates mutual relationship between mother and the child Prevents mother from the risk of breast cancer Helps to shaping Uterus in the normal size Helps to postpone next pregnancy (postpartum amenorrhea) It works as a natural means of contraception for few months No tension for food preparation for the baby B. Immunization Immunization refers to the development of immunity in the body by artificial means such as vaccines against particular diseases. It can prevent us from many infectious 212 Health, Population and Environment Education-10

diseases. Various research studies revealed that the people who had a complete dose of vaccines in childhood is better in health compared to those who are not immunized. The unimmunized children have high risk of diseases like Measles, Whooping Cough, TB, Pneumonia, Tetanus, Poliomyelitis, etc. The immunization schedule is given in the following table: Table 8.2: The Immunization Chart for the Child Name of Vaccine Doses Age of Route of Against the Administration Administration Diseases BCG(Bacillus- 1 (0.05ml) At birth Intradermal Tuberculosis Calmette-Guerin) DPT-HepB-HiB 3 (0.5ml) 6, 10, 14 weeks Intramuscular Pertusis, Tetanus, Hepatitis B and Hemophilus Influenza B OPV (Oral Polio 3 (0.5ml) 6, 10, 14 weeks Oral Poliomalities Vaccine) PCV 3 (0.5ml) 6, 10 weeks Intramuscular Pneumonia (Pneumococcal and 9 months Conjugate Vaccine) IPV (Injectable 1 (0.05ml) 14 weeks (Add Intramuscular Poliomalities Polio Vaccine) on to OPV) MR (Measles- 2 (0.5ml) 9 and 15 Subcutaneous Measles-Rubella Rubella) months JE(Japanese 1 (0.05ml) 12 months Subcutaneous Japanese Encephalitis) Encephalitis Td (Tetanus 2 (0.5ml) [1st dose] Intramuscular Tetanus and Diphtheria) As soon as Diphtheria [For women] pregnancy is known [2nd dose] One month apart Activity Prepare a neat and clean immunization table for newly born babies on a chart paper and discuss the relation between immunization and child health with friends in the class. Health, Population and Environment Education-10 213

Summary Ü An HIV-infected person is considered to have AIDS when one or more of the following conditions appear: such as the CD4+T cell count falls below 200 cells/ mm3 and opportunistic infection like; T.B., Syphills, Persistent diarrhoea or Kaposis sarcoma (cancer of skin, lymph nodes) develops. Then, the AIDS patient dies within 6 months to 2 years due to the attack of opportunistic diseases. Ü Syphilis is a sexually transmitted infection caused by the bacterium called Treponema Palladium. The primary mode of transmission of this disease is unsafe sexual contact. Ü Gonorrhoea is caused by the bacterium called Neisseria Gonorrhoeae that can grow and multiply easily in mucus membrane of the body. This bacteria can grow in the reproductive tract including the cervix, uterus, fallopian tube in women and in urethra in both men and women. Ü Safe motherhood refers to the protection of health of the mother and foetus during prenatal, natal and post natal period through safe motherhood initiatives. Ü Conception is the sum process of development of the fertilized zygote into a blastocyst and its embedment on the uterine wall. Normally, conception occurs at the fallopian tube and lasts for 8-10 days. Ü Ectopic pregnancy refers to the development of a foetus at any place other than the Uterus, usually at fallopian tube, abdomen and ovary. Ü Safe motherhood is the protection of health of the mother and foetus during antenatal, natal and postnatal period through safe motherhood initiatives like prenatal care, safe delivery service and postnatal care. Ü Maternal and child health care refers to the health services provided to the pregnant, postnatal and breast-feeding mother and children under five years. It includes preventive, promotive and curative health services of the mother and the children. Ü RH incompatibility is a condition that occurs during pregnancy if a woman has RH negative blood and her baby has RH positive blood. Ü Abortion can be defined as the termination of pregnancy before the foetus gains its survival quality. Ü The wishful or deliberate termination of pregnancy by using medicine or with the help of authorized health personnel is called induced abortion. Ü Labour is the physiological process in which foetus, placenta, and membrane are expelled throughout the birth canal after the full term of pregnancy. Ü Immunization refers to the development of immunity in the body by artificial means such as vaccines against particular diseases. It can prevent us from many infectious diseases. 214 Health, Population and Environment Education-10

EXERCISE A. Very short answer questions. 1. What is sexually transmitted disease? 2. Mention any two reasons of high prevalence of HIV and AIDS in Nepal. 3. What is safe motherhood? 4. List down any two signs/symptoms of the 2nd phase of labour. 5. Mention the appropriate food for the child of 6 to 9 month age. 6. What is RH factor? 7. Which diseases are prevented by DPT vaccine? 8. Mention any two symptoms of Chanchroid. B. Short answer questions. 1. Why should a child be properly breast fed till the age of two years? 2. Mention the symptoms and care of the first phase of labour. 3. Explain the role of cleanliness and regular health check up in prenatal care. 4. List down the minor and major problems of pregnancy. 5. Explain the reasons of high prevalence of HIV and AIDS with reference to Nepal. 6. Mention the signs and symptoms of pregnancy. 7. What is Safe Motherhood? Mention any three importance of maternal and child health care. 8. Draw the immunization chart for the children. 9. What is Syphilis? Mention its symptoms and modes of transmission. 10. Give an introduction to first phase of labour and mention its signs and symptoms. C. Write short notes on: 1. Ectopic pregnancy 2. Toxemia 3. Natality 4. Third phase of labour 5. Supplementary food to the Child D. Write difference between: 1. Prenatal and postnatal care 2. Spontaneous abortion and induced abortion 3. Gonorrhoea and Syphilis 4. Breast-feeding period and weaning period Health, Population and Environment Education-10 215

E. Long answer questions. 1. Why is Gonorrhoea called a sexually transmitted infection? Critically examine the causes, mode of transmission, symptoms and preventive measures of Gonorrhoea. 2. Explain the measures that are undertaken natal care, postnatal care and neonatal care. 3. Classify different phases of labour with their specific signs/symptoms and give your suggestions for the care during the first, second and third phase of labour for safe delivery. Project Work Conduct a small sample survey among 20 currently married women with children ever born of your locality and prepare a report analyzing the following aspects: S.N. Indicators Population (%) 1. Age at marriage Below 18 - 35 years Above 35 18 years years 2. Age at first pregnancy Below 20 - 35 years Above 35 20 years years 3. Number of children ever born <2 2-3 >3 4. Birth spacing (in years) <4 4-5 >5 5. Access to hospital for regular <4 times 4 -7 times >7 times antenatal care 6. Age at first delivery Below 20 - 35 years Above 35 20 years years 7. Mother’s weight gain at the <9 kg 9-12 kg >12 kg last month of pregnancy 8. Place at delivery Home On the way to Hospital/ hospital Health Center 9. Weight of the children at the < 2.5 kg 2.5-4 kg > 4 kg birth time 10. Case of miscarriage if any Yes No Don’t know 216 Health, Population and Environment Education-10

UNIT CONSUMER HEALTH AND COMMUNITY HEALTH 9 Learning Achievement After completing this unit, students will be able to: Introduce community health with its importance. Tell the scope of community health. Explain the health service providing agencies at different level and their activities. Mention the role of individual, family and community in addressing major health problems. Mention the activities of voluntary health agencies. Explain the major health problems of Nepal. Evaluate the policies and program of health sector in Nepal. 9.1 Concept of Community Health 9.1.1 Introduction to Community Health The term “Community Health and Community Medicine” are being used in an interchangeable manner. In the beginning; when this approach was introduced as Public Health, it gave priority on sanitation and hygiene. Since this health approach precisely accepted as Community Health its scope has been increased largely beyond sanitation and hygiene. Hence, at present it incorporates various aspects of health services including Community members are busy at discussion preventive, curative, promotive and rehabilitative health services. Community Health is the justice based innovative health approach over the traditional health program. It gives emphasis on organized joint effort of individuals, community and the state to uplift health condition of community people through integrated health programs. Moreover, Community Health programs are based on public participation and mobilization of local resources and expertise for maximization of available Health, Population and Environment Education-10 217

health services. The strength and effectiveness of Community Health depends on the role of individuals, community and the government. For instance, individual effort will be in vain if the community and the government do not support an individual. Similarly, certain community health problems cannot be solved only from the level of community and individual alone. In this condition, the presence of government is also mandatory. Community health includes preventive, curative promotive and rehabilitative health services through the joint effort and coordination between individual, community and the state. Many scholars have defined Community Health in different ways. Some of them are as follows: According to Winslow “Community Health is the science and art of preventing disease, prolonging life and promoting health and efficiency through the organized community efforts.” Similarly, Kasturi Sundar Rao opined that “Community Health is a joint effort of an individual, community and the state in promoting health and maintaining it in the individual and in the community people.” As mentioned above, we can conclude that there must be proper coordination and involvement of statisticians, health experts, sociologists, researchers and paramedics and community members not merely the doctors and epidemiologists to promote the Community Health Programs. Furthermore, all the possible efforts need to be maintained to provide effective and affordable health services at people’s door to materialize the principle of community health. The concept of community health developed in England at the beginning of 19th century. It incorporates the following areas of health services: e Balance diet e Safe drinking water e Good occupation e Safe environment e Safe disposal of wastes e Good education e Acceptable and affordable health services e Good Shelter 218 Health, Population and Environment Education-10

Aspect of Community Health Preventive Aspect Curative Aspect Promotive Aspect Rehabilitation Aspect Safe environment Conciliation and Safe disposal of wastes and accommodation in the family, community and society after human excreta the recovery of health. Vaccination Small family Affordable and sufficient Good occupation health services: (diagnosis, medication, Safe housing surgery, treatment) Balanced diet Various aspects of community health 9.1.2 Importance of Community Health It is obvious that community health is the art and science of promoting health, preventing and curing diseases by means of joint effort of individual, community and the government. Hence, it is almost impossible to promote the status of community health until and unless there is combined efforts of individual, community and the state. Community health encourages people to lead a healthy life. In addition to this, it motivates people for efficient use of health services, adopt self-care practices and participate actively in the design and implementation of health programs. Moreover, community health helps to address public health issues like prevention of STI’s including HIV and AIDS maternal and child health, mental health, nutrition, prevention of cancer and other non-communicable diseases and other many more issues. The importance of community health are described below: A. Environmental Sanitation Bagmati cleaning campaign Environmental Sanitation is an important area of community health. The goal set forth by community health cannot be fulfilled until sanitation is maintained properly. Environmental sanitation denotes clean and safe home, courtyard, surrounding, market, workplace and so on. Community health encourages the people to adopt the healthy habits Health, Population and Environment Education-10 219

and to maintain sanitation of the surroundings. The environment should be clean and free from hazards for safe and productive life. In this sense, environmental sanitation is essential for healthy living. B. Production of Healthy Human Resource Community health educates people about different problems related to health and sanitation and it also teaches people about hygiene and various measures to maintain good health. It eventually helps to acquire physical, mental and spiritual health. At the same time, community health gives emphasis on the preventive, promotive, rehabilitative, and curative health services that helps to produce healthy and productive manpower. C. Excess to health service and Facilities Community health is based on the philosophy of decentralization of health care, which gives emphasis on the availability, accessibility, and acceptability of health services and facilities within the accessibility of community. We know that many people in Nepal are ignorant and are suffering from different health problems. Community health provides health education and services to those marginalized people. It gives priority to establish health service centers at the local level for the benefit of the people by their quick and reliable services. It always get priority to make possible for at least basic health facilities within the reach of the people. D. Feeling of Social Responsibility The ultimate goal of community health is to make community members responsible towards their own health. It makes the community realize that joint effort makes it possible to meet the objective of community health. At the same time, community health makes community responsible to solve the health hazards including endemic and epidemic diseases of the country. When everyone becomes responsible, healthy community is possible. Various organizations like Nepal Paropakar Association, Nepal Red Cross, Family Planning Association of Nepal are conducting various community level programs to promote the health of community people. E. Decentralization of Getting benefits from health service Health Services Community health motivates and prepares different agencies to operate local health camps that provide free or low cost health 220 Health, Population and Environment Education-10

services to the community members. Furthermore, it may run door-to-door health programs in villages and also may establish rehabilitation centers for the people who are addicted to drugs or alcohol including people suffering from chronic diseases like HIV and AIDS, Leprosy, etc. When the health services are made available at the grass root level, it helps to promote health condition of the community and increase the number of health users in the rural area too. At the same time, it also provides health services in affordable cost within the reach of the people at grass root level. Eventually, it helps to create productive and healthy society. Activity Divide the class into different groups and involve in environmental sanitation campaign of the public places as per the need and prepare a report on the impact of those sanitation campaigns on public health. 9.1.3 Scope of Community Health All the subject matters and issues included by community health is considered as the scope of community health. Usually, the activities related to the health of the community are associated in community health. The scope of community is explained below: A. Examination of Foodstuffs, Milk, Water, etc in the Community The articles like food, water, milk, etc are the basic needs of the people. Healthy food, safe drinking water and good environment play important role to protect and promote the health condition of the community people. Shopkeepers may sell sub standard goods and adulterated foodstuffs in the market to make more profit. We know that there is scarcity of water and the water available to us is not free from pollution. Similarly, milk and milk products that are available in the urban area are also contaminated with germs. The quality of these articles must be examined in advance before consumption. It is necessary to check the quality of the goods by the community. Since these aspects are directly associated with public health, it is considered as the scope of public health. B. Prevention and Control of Communicable and Epidemic Diseases Epidemic diseases refer to those diseases, which are prevalent in particular geographical areas within the country. For instance, malaria, kalazar, Japanese encephalitis, diarrhoea, dysentery, cholera, typhoid, common cold, pneumonia, measles, etc are considered as the epidemic diseases of Nepal. There must be prevention and control of such diseases on time to promote the health status of people. These diseases transfer from the infected persons to another through various mediums. It is caused by human’s unhealthy habits, polluted environment, ignorance, and sanitation problem. Health, Population and Environment Education-10 221

Since most of the people are suffering from these diseases, they should be educated for the importance of safe drinking water, personal hygiene, proper use of latrine and sanitation of the surrounding. In fact, prevention and control of communicable disease helps to promote the status of community health. C. Environmental Health and Sanitation Environmental health and sanitation is also considered as one of the major aspects of community health. There must be adequate supply of safe drinking water to ensure hygiene and sanitation of the people. The adequate provision of safe drinking water and sanitation protect people from various infectious diseases like typhoid, jaundice, diarrhoea, cholera, tuberculosis, etc. It is essential for the attainment of quality of life. D. Immunization Program The process of producing immunity to an infectious disease in an individual through vaccination is called immunization. In other words, immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the body’s own immune system to protect the person against the particular diseases. There is provision of comprehensive immunization program for the children and pregnant women to protect from various kinds of targeted infectious diseases. Implementation of such comprehensive immunization program plays an important role in the promotion of community health. E. Prevention of Malnutrition Malnutrition is the condition resulted by lack of balanced diet. Malnutrition among children causes different diseases like rickets, marasmus, kwashiorkor, scurvy, anemia, etc. Small children and pregnant women are more vulnerable to malnutrition in the developing countries like Nepal. Malnutrition problem can be prevented with the joint effort of family, community and the government. Hence, it is considered as one of the scopes of community health. F. Prevention of Accidents and Injures It is also one of the major aspects of community health. Along with the pace of economic and physical development, the rate of accidents and injuries are also increasing side by side. A large number of people are meeting the incidence of accidents like burn, wound, cut, fracture, road accident, drowning, electric shock, etc. People should be provided education and training to prevent them from accidents and injuries. G. Health Education Health education is also one of the most important scopes of community health. Indeed, health education gives insight experiences about the health related issues 222 Health, Population and Environment Education-10

and helps to change attitudes and behaviour accordingly. It also makes individuals to be responsible in health related matters. Health Education aware people about the need and importance of personal hygiene, environmental sanitation, regular health checkup, proper nutrition, etc. It also motivates them in shaping their attitude, life skills and behaviour for better health. H. Prevention of Drug Abuse Drug abuse also creates adverse impact on public health. Specifically, the youths and adolescents have ruined their health and precious life due to drug addiction. Today’s youths and adolescents are the back bone for the development in the future. So, it is necessary to educate them for different measures to prevent from drug abuse and addiction. Activity Prepare a chart paper of scope of community health and discuss with your friends in the class. 9.2 Health Service Providing Agencies and their Activities 9.2.1 Introduction The condition of health in our country is not so good. Most of the people in Nepal are deprived of health facilities and services. In other words, we can say that health facilities are inadequate for the growing population. Majority of the people are suffering from poverty, illiteracy and malnutrition. They have poor knowledge of health and sanitation. It is found that prevalence rate of disease is higher in Nepal than other South Asian countries. The disease and illness including diarrhoea, gastrointestinal disorders, tuberculosis, pneumonia, bronchial, asthma, etc are common in our country. People still believe in ‘Dhami’ and ‘Jhankri’ instead of medical doctors. Every-year thousands of people are vulnerable to premature death due to minor diseases like cholera, dysentery, diarrhoea, pneumonia, typhoid, etc. The government agencies and other different national and international organizations are trying their best to upgrade health facilities in the country but their effort is not in the level of satisfaction. Some available health services in our country are described below: A. Preventive Health Service Preventive Health service encompass a variety of interventions that can be undertaken to prevent or delay the occurrence of disease or reduce further transmission or exposure to disease. Preventive care can include immunizations, lab tests, physical exams and prescriptions. Diagnostic services help your doctor understand your symptoms or diagnose your illness. Routine health care that includes check-ups, Health, Population and Environment Education-10 223

patient counseling and screenings to prevent illness, disease and other health-related problems. Preventive health services are intended to help people remain healthy and to detect any health-related problems early while there is a better chance of recovery. The preventive health services include the following aspects: Family planning and MCH program National Immunization program National T.B. control program Education about STIs Leprosy control program Malaria and Kalazar control program AIDS and STD control program Health Education B. Promotive Health Service Promotive health service is defined as “The process of enabling people to increase control over their health and its determinants, and thereby improve their health”. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health promotion involves public policy that addresses health determinants such as income, housing, food security, employment, and quality working conditions. Health promotion is aligned with health equity and can be a focus of NGOs dedicated to social justice or human rights. Health literacy can be developed in schools, while aspects of health promotion such as breast feeding promotion can depend on laws and rules of public spaces. The promotive health services include the following aspects: Ü Pre-and post-natal health checkup Ü Proper spacing of children Ü Good nutrition practice Ü Personal hygiene Ü Use of boiled drinking water Ü Proper disposal of human waste Ü Anti-smoking campaign Ü Breast feeding counseling Ü Domestic violence counseling C. Curative Health Service Curative health service refers to a medical treatment and therapies provided to a patient to cure the patient’s overall medical problems. In other words, curative health 224 Health, Population and Environment Education-10

service restores and maintains health by treating people after they fall ill. Curative services are provided by various categories of health institutions. There are general hospitals, special hospitals, teaching hospitals, regional hospitals, district hospitals, community hospitals. Curative services are providing comprehensive health care services. The curative health services includes the following aspects: Ü Proper diagnosis Ü Proper treatment Ü Cure of the disease D. Rehabilitative Health Service Special healthcare services that help a person regain physical, mental and cognitive (thinking and learning) abilities that have been lost or impaired as a result of disease, injury, or treatment can be considered as rehabilitative health services. Rehabilitation services help people return to daily life and live in a normal or near-normal way. The rehabilitative health services include the following aspects: Ü Rehabilitation of drug addicts and alcoholic persons Ü Psychiatric rehabilitation for restoration of mental health Ü Rehabilitation of criminal behaviour Ü Rehabilitation of AIDS and Leprosy patients 9.2.2 Health Service Providing Agencies of Nepal A. Hospital A hospital is a health care institution providing treatment to patients by specialized staff and equipment. Hospitals are usually funded by the public sector for profit or nonprofit. They are largely staffed by professional physicians, surgeons, nurses and other supporting staff. In a hospital, more specialized health services are available with advanced equipment, sophisticated laboratories and the team of specialists. There is provision of outdoor and indoor service. Patients are sent to TU Teaching Hospital, Maharajgunj their houses after the diagnosis and treatment of the disease in outdoor service. On the other hand patients are admitted in the hospital and treatment is done with special care in the case of indoor service. Besides this, 24 hours emergency service is also available in hospital. The emergency department provides services to casualties and patients in critical condition. Health, Population and Environment Education-10 225

There are 104 government hospitals in Nepal according to the data of CBS (Nepal in figure, 2016 AD). The recent, involvement of private sectors in health sectors is increasing. At present, there are 413 hospitals in Nepal including government, private, community and cooperative hospitals. Classifications of Hospitals Hospitals can be classified into two types. One is on the basis of service nature and another is on the basis of region. Service oriented hospitals are classified as general, special and teaching hospitals. There is provision of treatment of all kinds of diseases in general hospital. On the other hand, there is the provision of treatment of particular diseases in the special hospital. TB Hospital, Cancer hospital, Orthopedic hospital, etc are the example of special hospital. In teaching hospital different types of treatment is also provided and medical students are also produced from that institution. 1. Description of hospitals according to service i. General Hospital This type of hospital provides treatment of all sorts of diseases. In other words, this hospital provides secondary level of health services. This type of hospital such as Mahendra Adarsha Chikitsalaya are established in different districts. ii. Specialized Hospital This kind of hospital provides specialized health services. In other words, this hospitals render all kinds of health services to the particular group of people. Maternity hospital, Kanti Bal hospital, etc are the examples of this type of hospitals. iii. Special Hospital This type of hospital provides specialized services to specific disease. Eye Hospital, TB Hospital, Cancer Hospital, etc are the example of this type of hospital. 2. Health Service Providing Agencies in Vertical Structure There are various health service providing agencies in Nepal. There is the development of the structure of the health service providing agencies from the central level up to the grass root level. They are explained below: i. Central Level There is the Ministry of Health and Population to systematize the health service providing agencies at the central level. Other health agencies are established under this ministry. Some hospitals are established at the central level to deliver government health services. The hospitals that are located in the national level are called central hospitals. These hospitals are highly sophisticated hospitals. There is provision of more specialized and special treatment of the diseases by the team of specialists. The services like 226 Health, Population and Environment Education-10

CT scan, ECG, EEG, Organ Transplantation, Ultrasonography (USG), Surgery, Pediatric, Gynecology, Cardiac, ENT services are available in the central hospitals. There are generally more than 400 beds in the central hospitals. Some of the government hospitals at the central level are mentioned below: 1. Patan Hospital, Lalitpur 2. Bir hospital, Kathmandu 3. Mental Hospital, Lagankhel Lalitpur 4. Maternity Hospital, Thapathali, Kathmandu 5. B.P. Koirala Cancer Hospital Kathmandu 6. Kanti Bal Hospital, Maharajgung, Kathmandu 7. B.P. Koirala Institute of Health Science, Dharan 8. Sahid Sukraraj Tropical Hospital,Teku Kathmandu 9. Sahid Gangalal National Heart Center, Bansabari Kathmandu 10. Karnali Institute of Health Science, Karnali ii. Regional Level There is the provision of one regional health directorate in each development region. There are five regional health directorates altogether in the country. The regional hospitals and sub regional training centers fall under the regional health directorate. There are only two regional hospitals in Nepal at present. They are Western Regional Hospital (Gandaki Hospital) and Eastern Regional Hospital. The Eastern Regional Hospital is known as B.P. Koirala Institute of Health Science which is situated in Dharan. There is provision of more than 200 beds in regional hospital. The functions of the regional level health service agencies are as follows: M Top execute the policy and guidelines of the Ministry of Health and Population. M To make planning, monitoring and supervision of health program M To make coordination between district and zonal level health institutions M To provide specialized health services at the regional and sub-regional health institutions M To provide laboratory service and the general surgery service M To refer the patients of critical condition to the central hospitals iii. Zonal Level Zonal hospitals are situated in different zones of the country. They are more facilitated than district hospitals. Generally, they are established in zone’s headquarter. There are 50-200 beds in such hospitals. At present, there are 10 zonal hospitals in the country. Similarly, there are some Zonal Ayurved Chikitsalaya and Zonal Ayurved Ausadhalaya also. Some of the functions of the zonal level hospitals are as follows: Health, Population and Environment Education-10 227

M To follow the policy and directions from the central and regional offices M To provide specialized health service M To provide treatment to the patients referred from the district hospital and other lower level health service institutions M To refer the complicated cases to the regional and central hospital M To conduct various preventive and promotive health program iv. District Level There is District Health Office in each district. The District Hospitals come under the District Health Office. There are altogether 60 district hospitals in Nepal. These hospitals provide both indoor and outdoor health services along with diagnostic and emergency services. There is the provision of 25 to 50 beds in district hospitals. In addition, there are also 15 District Public Health Offices in the country. The district hospitals have their own laboratories, X-ray machine, and pharmacy. Some of the functions of the district hospitals are as follows: M To follow the policy and directions from the central and regional offices M To do monitoring and evaluation of the health institutions within the district M To conduct training, workshop and seminar programs M To control infectious and epidemic disease in the district M To execute school health education program effectively M To provide general medicine care through the physicians M To conduct OPD Service, Emergency Service and indoor Service M To provide X- Ray service and Lab Service 3. A brief description of basic health service agencies in vertical structure i. Electro Constituency Level Primary health centers are more facilitated than health posts. The government has aimed to convert the health post into primary health centers. Furthermore, the government has a policy to establish one primary health centre in each electoral constituency. The Constitution of Nepal 2072 BS has made provision of 165 electoral constituencies. At present there are 201 Primary Health Centers in the country. The Primary Health Center is headed by a medical officer. The PHC provides treatment to the common minor diseases and maternity health services. There is the provision of three beds in the PHC. Manpower of the Primary Health Centre Medical Officer (MBBS Doctor) 1 Staff Nurse 1 Health Assistant or Senior Auxiliary Health Workers (HA/SAHW) 1 228 Health, Population and Environment Education-10

Auxiliary Health Workers (AHW) 2 Lab Assistant 1 Auxiliary Nurse and Midwives 2 Assistant Accountant 1 Village Health Workers (VHW) 2 Peon 1 Total 12 Health Services of Primary Health Centre (Electro Constituency Level) Health centre provides better quality services than health posts. There are three beds, one for maternal service and two other beds are for other emergency service. The primary health centers provide the health services that follows: • Maternal and child health care service • Family planning service • Maternity service • Nutrition awareness program • Assists, evaluate and monitor the health post and sub-health post • Controls the prevalence of communicable disease • Provides treatment to the patients and minor injuries • Refers the complicated cases to the hospital ii. Ilaka Level In Nepal, there are seventy five districts and those districts are again divided into many sub-units like Illakas. The government has formulated the policy to establish one Health Post in each Ilaka (Generally, 5 VDCs makes one Ilaka). Health Post is one- step higher level basic health institution compared to Sub-health Post. The number of health workers in health post is confirmed according to geographical region. There are seven staff members in Terai region whereas six health workers are mobilized in Himalayan and Hilly region. Health Post provides basic health services. At present, there are 3,808 Health Posts in Nepal. The government is planning to promote Sub-health Post into Health Post. Manpower of Health Post Assistant /Senior Auxiliary Health worker 1 Auxiliary Health Worker (AHW) 1 Auxiliary Nurse and Midwife (ANM) 1 Maternal and Child Health Worker (MCHW) 1 Health, Population and Environment Education-10 229

Office Assistant 1 Village Health Worker 1 Peon 1 7 Total Health Services of Health Post (Illaka Level) Health post provides the different types of basic health services that include: • To provide door to door maternal health care service • To conduct vasectomy, minilap and eye camps • To provide school health service to the school children • Diagnosis and treatment of the minor diseases • Treatment of minor injuries and wounds • To provide preventive health services iii. Village Council Level (Sub Health Post) The government has adopted the health policy to establish at least one sub-health post in each village council (Gaun Palika). Sub-health post is a bottom level health service institution. It provides basic health services to the people. There are altogether 4 staff in a Sub-health Post. It is headed by Auxiliary Health Worker (AHW). At present, there are 3,176 Sub-health Posts in Nepal. The Sub-health Post provides the following health services: • Sub-health Post provides the different types of basic health services that include • To create public awareness about the preventive measures against the communicable diseases • To conduct awareness campaign about the environmental sanitation in the community • To provide treatment to the minor wounds and injuries • To provide First Aid to the victim or casualties • To mobilize mothers’ group, women health volunteers, birth attendants and NGO activists in health service programs Comparison between Health Post and Primary Health Centre Health Post Primary Health Centre 1. Health post is the bottom level 1. Health centre is one step higher health service centre. level health service centre. 2. Minimum health facilities are 2. Little more health facilities are available. available compared to health post. 230 Health, Population and Environment Education-10

3. It provides health services 10-4 3. It provides 10-4 hours OPD service hours during the day and 24 hours emergency service. 4. There is no bed facility. 4. There is provision of 3 bed facility. 5. It provides outdoor services only. 5. It provides both indoor and outdoor service. 6. It is headed by Health Assistant (HA). 6. It is headed by MBBS doctor. 7. There are 6 or 7 staff members. 7. There are 12 staff members. 4. Community and Ward Level Immunization clinics and community clinics are run in each village council to make the primary health service reachable to the grass root level people. Moreover, at least one woman health volunteer is working in each ward of the village council. The woman health volunteer can provide family planning, immunization, nutrition education, contraceptive services, etc. 9.2.3 Voluntary Health Agencies Health problems is not only the problem of community or a country but it is the concern of the entire world. In this context, the solution of these problems cannot be solved through the government effort only. Hence, there are many nongovernmental organizations putting hands together to solve health problems in Nepal. Among them some of the important organizations are discussed below: A. Nepal Red-Cross Society Nepal Red Cross Society came into being on 4th September 1963 AD. (2020 BS) Nepal Red Cross society became the member of International Committee of Red Cross formally on 1st October 1964 AD. Humanity, freedom, unity, neutrality, voluntary services, worldwide service and nonalignment are the motto of this society. Nepal Red Cross Society is the largest Rally of Junior red cross circle humanitarian NGO in Nepal. It has its district committees in all districts of the country. Objectives M to serve war victims both civilians and army personnel in the time of arm conflict, M to contribute in promoting and improving health condition, preventing diseases and reducing suffering, M to arrange for emergency relief service for disaster victims, M to perform community development and public welfare programs, M to ensure respect for the international humanitarian law. Health, Population and Environment Education-10 231

Programs a. Service oriented activities To provide immediate help to the persons affected by natural calamities Primary health care Environment sanitation First Aid programs Information, Education and Communication Program b. Health service activities Blood transfusion and blood donation Eye camps Water Project Ambulance service School based HIV Peer Education Safe motherhood Reproductive and family health programs c. Organizational activities Trainings Workshops Seminars Camps Awareness program Activity Prepare a report on the activities conducted by junior Red Cross Circle or Scout of your school to manage minor health problems, injuries and emergency care to the students of your school. B. Nepal Paropakar Association Paropakar Adarsha School Nepal Paropakar Association (Paropakar Sanstha) is the first and the oldest non-profit making social organization of Nepal. It was founded by Dayabir Singh Kansakar in 1947 AD 10th Aswin 2004 BS. Its central office is located at Bhimsensthan, Kathmandu. Primarily this organization was established to provide medicine facilities to the poor people suffering 232 Health, Population and Environment Education-10

from Malaria, Dysentery, Cholera and Typhoid. Now it has expanded its service in different sectors of social welfare. Objectives M To provide maternity service. M To provide free medicine to poor and disable people. M To provide rehabilitation. M To provide free education to orphans. M To encourage the youths to involve in volunteer service. Programs Ambulance service in Kathmandu Blood donation program Distribution of free medicine Establishment of Maternity hospital at Thapathali, Kathmandu in 1959 AD Establishment of Paropakar Adarsha Madhyamik School for orphans in 1955 AD Provision of health service to orphans C. Family Planning Association of Nepal (FPAN) Family planning association of Nepal was established in 1959 AD (2016 BS). It became an associate member of International Planned Parenthood Federation (IPPF) in 1960 AD and full-fledged member in 1969 AD. It is a leading national NGO in the field of reproductive and sexual health program. FPAN’s current programs are focused on five areas including: adolescent, abortion, HIV and AIDS, advocacy Logo of FPAN and access. Annually it provides family planning services to 2,10,000 persons, MCH education and service to 1.4 million, STIS and HIV counseling, diagnosis and treatment service to about 1,00,000 and safe abortion counseling and services to more than 50,000 women. Moreover, it had provided integrated services related to reproductive health. It has launched its projects only in three districts in the beginning, but now, it has expanded its service in thirty-two districts. Objectives M To increase public participation in family planning programs, M To manage safe abortion and to reduce high unsafe abortion rate and maternal mortality rate, M To run family planning clinics in different places, M To help in promotion of safe motherhood, M To encourage the couple to make the family size small. Health, Population and Environment Education-10 233

D. Nepal Heart Foundation Nepal Heart Foundation was established in 2045 BS. Its central office is located in Kathmandu and branches have been established in the different parts of the country. Its main objective is to minimize the patients of heart disease which is globally increasing. Nepal Heart Foundation has run the services of diagnosis and treatment of heart disease. This organization is also working in non-medical field, like raising awareness about the heart related disease, encouraging people for healthy and active Logo of Nepal Heart Foundation lifestyle, helping poor heart patients for the treatment, etc. Sahid Gangalal Heart Centre in Kathmandu has been established with the initiation of this organization in 1995 AD. It has started treatment of rheumatic under the initiation of Nepal. Fever and rheumatic heart disease since 2064 BS. Objectives M Treatment and diagnosis of heart diseases M To conduct awareness programs M To minimize the patients of heart diseases M To help the poor people who are victims of heart disease Programs Public awareness programs through Radio and Television Organizes heart camps in different parts of the country Awareness in school children about the importance of heart Carry out heart camps and curative service through heart clinics Screening of Rheumatic heart disease and education about it to the school students E. Nepal Cancer Relief Society (NCRS) Logo of NCRS Nepal Cancer Relief Society is a non-profit community- based nationwide social organization founded in 2039 BS (1982 AD) with the aim of fighting against the spread of cancer in Nepal. The organization has now established its branches in 42 districts of Nepal and has been mobilizing 10,000 volunteers nationwide. NCRS is a pioneer organization for tobacco control in Nepal. NCRS works in both cancer prevention and its cure. Tobacco control is the major preventive activity done by NCRS because it is a 234 Health, Population and Environment Education-10

sole preventable risk factor for several types of cancer. Nepal cancer relief society is playing a leading role in both preventive and curative programs against cancer. Objectives M To control, prevent and cure cancer M To detect the cancer early for prevention M To support the curative aspects of the cancer sufferer M To provide rehabilitative services to those suffering from cancer Programs Conducts cancer awareness classes, workshops, seminars, interaction programs and conferences. Conducts cancer and tobacco awareness classes in schools, colleges, communities, hospitals and rehabilitation centers. Conducts rallies on world no tobacco day, world cancer day for mass public awareness. Several cancer awareness documentaries have been made by NCRS for public awareness. Distributes brochures and posters to most part of the country for raising cancer awareness for prevention. Conducts conferences targeting policy makers for the provision of best cancer control health policies in Nepal. F. Nepal Anti-Tuberculosis Association (NATA) Nepal Anti-Tuberculosis Association is a non-governmental, nonprofit making voluntary organization. It is the second oldest social organization of Nepal. It was established in Kathmandu in 1953 AD, (2010 BS) with a view to raising public awareness about TB. It had run TB Control Project in joint collaboration with Government of Nepal, (WHO) and UNICEF in 1965 AD. NATA has started German Nepal Tuberculosis Project (GENETUP) which has launched Direct Observed Treatment Short Course (DOTS) for the treatment of TB It is a method of treatment of TB by direct observation of medical personnel. It helps to reduce the relapse of disease caused by irregular intake of drug. Since the establishment of NATA, it has formed 32 branches in the country and working for BCG Vaccination, case finding and distribution of medicines. Objectives M To coordinate with government TB Control Program M To study about the problems of TB M To create public awareness about Tuberculosis Health, Population and Environment Education-10 235

M To help the victims of TB and lungs disease M To help in DOTS program Programs Provision of BCG vaccine Community based health education program It has started DOTS very effectively Exchange of ideas through workshop, seminars and trainings It has launched different awareness programs Activities Visit any one health institution available in your community. Prepare a report including the following chapters: 1. Name of the Institution: 2. Objective of the Institution: 3. Activities or Functions of the Institution: 4. Problems and Challenges Faced by the Institution: 5. Measures of Mitigating the Problems and Challenges: 6. Benefits to the Community People: 7. Conclusion: 9.2.4 Major Health Problems of Nepal Nepal is the country recognized with the poor economy, low life expectancy, high infant mortality rate and so on. Many people are uneducated and most of the parts of the country have become remote from the capital city Kathmandu. Poor infrastructure, lack of health facility, ignorance, superstition and difficult topographical structure are other factors leading to various forms of health problems in Nepal. Every year many people are losing their life even from minor diseases like diarrhoea, dysentery, common cold, cholera, pneumonia, etc. Some of the major health problems of Nepal are discussed below: A. Prevalence of Communicable Disease Communicable disease is such a disease which transfers from an infected person to another healthy person through any kind of medium. It is mainly caused by human’s unhealthy habits and polluted environment. Due to ignorance and sanitation problem, thousands of people are at the risk and hundreds of them die from communicable diseases. It is experienced that communicable diseases are the major part of health burden in our country due to poor environmental sanitation, lack of safe drinking water, poor personal hygiene, superstition and poor diet. In Nepal, gastro-intestinal 236 Health, Population and Environment Education-10

diseases have covered more than 80% prevalence rate of communicable diseases and it can be easily prevented through health education and improvement in sanitation. The diseases like diarrhea, dysentery, cholera, typhoid, common cold, pneumonia, measles, etc are the examples of some common communicable diseases prevailed in Nepal. Since most of the people are suffering from gastro-intestinal diseases they should be educated for the importance of safe drinking water, domestic and personal hygiene, proper use of latrine and sanitation of the surrounding as well. B. Malnutrition Malnutrition is the condition resulted by an improper diet. We know that malnutrition is caused not only due to under nutrition but it is also resulted by over nutrition. Proper nutrition is a prerequisite for the normal health and well being of individuals. Poor nutrition creates problem to the entire population in general and Women and children are more vulnerable in particular. Malnutrition among women results in to anemia, having baby with low birth weight and vulnerable to various nutrient deficiency diseases like night blindness, scurvy rickets, etc. According to the Nepal Demographic and Health Survey 2011 AD; • 29 percent of children under 5 years of age are under weight • 46 percent of children are anemic • 18 percent of women are malnourished by under nutrition and 14 percent are obese • 35 percent of women of the age group 15-49 are anemic Under nutrition has become a great challenge in Nepal than other type of nutritional health problems due to poverty, ignorance, unequal distribution of productive land, lack of hygiene and sanitation. C. High Infant Mortality Rate Child mortality rate in general and infant mortality rate in particular are often used as indicators of social development and as specific indicators of health status. In this context, high Infant Mortality Rate is also one of the major health problems of Nepal. Infant Mortality Rate of Nepal is 44 as per the data of Demographic Health Survey, 2011 AD. The real picture of infant mortality rate of the SAARC countries is shown in the table given below: Table 9.1: Trend of IMR in SAARC Countries, 1994 - 2016 AD Countries 1994 2006 2016 Nepal 90 64 33 India 79 58 40 Health, Population and Environment Education-10 237

Pakistan -- 78 67 Sri Lanka 19 11 8 Maldives 38 15 8 Bangladesh 116 65 38 Bhutan -- 40 44 Afghanistan -- -- 68 Sources: World Population Data Sheet, 1994-2016 AD The table shows that the infant mortality rate of SAARC Countries is not at satisfactory level except Maldives and Sri Lanka. Infant mortality rate is the broad indicator of the health and development status of the society and of the nation. In the context of Nepal, infant mortality rate were 90 and 64 in 1994 and 2006 AD respectively and it was decreased to 33 in 2016 AD. It reveals that there is a little progress in social, economical and health aspects of the country. However, Nepal is still having high infant mortality rate compared to other SAARC countries. D. Maternal Mortality Rate Maternal mortality rate of Nepal is high in comparison to the other countries. It is obvious that the causes of high maternal mortality rate in Nepal are low living status, poverty, illiteracy, lack of health services, lack of safe motherhood initiatives, gender discrimination, etc. The maternal mortality rate of Nepal according to the Demographic Health Survey 2011, AD has been recorded 229. The three year interim plan (2068-70 BS) has set the target to reduce maternal mortality rate to 192. It shows that maternal mortality rate is still high in comparison to other developed and neighboring countries. E. Poverty Poverty is one of the major health problems of Nepal. We know that most of the people of our country are still living in poor condition of life. According to the Nepal living standard, survey 2011 AD more than 24%, people in Nepal are living below absolute poverty line. Because of poverty, people cannot manage balance diet, proper shelter, proper clothes according to season and cannot visit health institutions for regular check-up. As a result, they suffer from various kinds of health problems and are supposed to live poor quality of life. It is needless to say that poverty is the root cause of other various problems prevailed in the society. The per capita income (PCI) of Nepal is in 2016 AD US$ 766 only. It means economic condition of the people in Nepal is not satisfactory. To eliminate absolute poverty and to raise the living standard of the people, it is necessary to create environment for 238 Health, Population and Environment Education-10

the generation of employment opportunity and income generating activities. These activities should focus the people at grass-root level. F. Lack of Health Education Majority of Nepali people are deprived of health education. In this situation, people are either ignorant or indifferent towards sanitation, hygiene, balanced diet, immunization including many more health issues. They do not have clear concept on health. Conservative belief is deep rooted in Nepalese society. Most of the people still believe in faith healer instead of medical doctor. They believe that all types of sickness is caused due to super natural power or due to the curse of god and evil spirit. Therefore, a large number of people are losing their lives by very easily curable diseases too. The ultimate solution to solve this problem is to make the people believe in rationality and remove misconception regarding health. Moreover, it is necessary to give education about sanitation, personal hygiene and other healthy habits for healthy life. G. Lack of Health Services It is another major health problem of Nepal because there is no adequate and quality health services as per the need of the people. Many people are losing their life untimely due to lack of quality health services. Health services are expanding in slow pace but the population is increasing rapidly. So, the available health service centers have become out of reach to common people. Furthermore, established health posts and health centers are facing lack of human power and inadequate supply of essential medicines. To solve the existing health problems, health facilities and services should be decentralized and reach the people’s door. The following table shows the present condition of health services in Nepal: Table 9.2: Status of Health Services in Nepal, 2015/2016 AD Health Services Number Health professionals Number Hospitals (Private, Government, Community 405** 16,854* and Teaching: All Types) (govt. - 104) Doctors Primary Health Centers Health Posts (pvt. - 301) Sub-Health Posts 202** Senior A.H.W/HA 9,500 Ayurvedic Services Centres 3,803** 3,176 AHW (Auxiliary Health Worker) 19,098 Village Health Worker 305 Nurses 38,759** 7,175 ANM (Auxiliary Nursing and 25,398** Mid wife) Kaviraj/Vaidhya 741 Source: CBS, Nepal in figures, 2015 AD, ** CBS, Nepal in figures, 2016 AD , *Nepal Medical Council Health, Population and Environment Education-10 239

H. Rapid Population Growth Rapid population growth is another major health problem of Nepal. It has resulted into various problems like lack of food, lack of health facilities and services, lack of employment opportunity, malnutrition, sanitation problem, environment degradation including other many more socioeconomic and environmental problems. Similarly, it has expanded slum areas in the towns and cities and consequently resulted in to the prevalence of communicable disease and poor quality of life. Population growth rate of Nepal is always high since 1941 AD. For instance population growth rate of Nepal in 1952/54 AD was 2.27% and it increased to 2.25% in 2001 AD. If it is not controlled in time there will be severe problem in education, drinking water, cultivable land, residence, etc. It also creates wide gap between rich and poor which will be sufficient cause to create conflict in the society. So, we should put all the possible efforts to control the rapid population growth with effective plans and programs to ensure sustainable living. I. Unhealthy Life Style One of the major causes of bringing health problem in Nepal is the typical Nepalese life style. It denotes the food habits, tobacco chewing, smoking, alcoholism hard physical work with little rest of majority of the people. WHO has explained these things as the causative factors for non-communicable diseases. In Nepalese meal, high content of carbohydrate, spicy food, fried and instant food with low nutritive value are included. They may cause diabetes and heart disease. There is a wrong perception among the common people that is quality of life is to pass the time luxuriously without physical work. It results into obesity which is the cause of many non-communicable diseases. Activity Identify the major health problems of your community. Examine the causes of these health problems? Collect the opinion of the community members about the prevention measures of those diseases. Prepare a report and present it in the class. 9.3 Policies and Programs of Health Sector 9.3.1 Policies of Health Sector Planned development in Nepal has been initiated since 1956 AD. It has already completed more than 5 decade but the government is found far behind in introducing national health policy and programs in its periodic plans. The organized national health program can only be seen from the 5th five year plan (1975-80 AD) onwards. Nepal adopted National Health Policy in 1991 AD to show its commitment and concern to promote health condition of its citizen. 240 Health, Population and Environment Education-10

After the WHO’s declaration “Health for All by 2000 AD” and various promises made in different international conferences, Nepal government has become very responsive and sensitive towards the health issues for the common citizens. In the 11th Three Year Interim Plan, government gave priority on preventive, promotive and curative health services by upgrading sub-health post into the Health post and Primary Health Centers. Similarly, it also concentrated its priority in increasing number of hospital beds, health workers, Ayurvedic dispensaries and improvement of quality health services. In addition, Family Planning, Reproductive health as well as massive immunization program including respiratory disease control program and communicable disease control program are also in priority of this interim plan. The main objective of the 12th three year interim plan was to increase the access to quality health services to citizens of all the geographical regions, class, gender and ethnicity. While analyzing this Interim Plan, there has been a considerable improvement on mortality rates of infants, children and mothers. All the services provided by health posts and sub-health posts and basic health services provided by the district hospitals to the poor and backward communities have been made free. Moreover family planning and safe abortion services are available in all districts. Even though the overall health system has improved there has not been expected improvement in remote districts. Health condition of backward societies and people below poverty line has not been improved as expected. It can be observed that there is lacking of effective co-ordination among the plan implementing and monitoring agencies. We know that 14th Three Year Interim Plan is formulated incorporating health, as a fundamental right of all citizens. The quantitative targets of the 14th Three Year Interim Plan have been illustrated in the following table: Table 9.3: Quantitative Targets of 14th Three Year Interim Plan (2072/73 - 2074/75 BS) Health Indicators 13th Interim 14th Interim Plan (Status) Plan (Target) Population with excess to essential health service (%) Prenatal service at least 4 times before delivery (%) 79 90 Delivery attended by Trained Birth 35 65 Attendants (TBAs) (%) Contraceptive Prevalence Rate (%) 29 40 Total Fertility Rate Maternal Mortality Rate 49 57 Infant Mortality Rate 2.6 2.3 Child Mortality Rate 229 134 Life expectancy at birth(years) 46 38 54 47 69 71 Health, Population and Environment Education-10 241

Population with access to drinking water (%) 85 96.3 Population with access to sanitation (%) 62 90.5 Source: NPC, GoN: Fourteenth Three Year Interim Plan, (2072/73 – 2074/75 BS) The 14th three year interim plan has adopted the following health objective and policies to achieve the set targets: Objective To ensure that all citizens have equitable access to basic and good-quality health services. Health Policies a. Upgrade local health institutions and manage physical and human resources accordingly. b. Make service delivery effective by improving capacity, skill and standard of health service provider organizations, employees and also prepare and implement special encouragement program for the health workers and those working in remote and backward areas. c. Upgrade district hospitals with necessary expert services. d. Monitor the quality of medicine and make its management effective. e. Make health services easily available to all the citizens by increasing the investment in health service organizations. f. Improve the effectiveness and access to reproductive health, infant health and family planning services by operating new program as well as by providing regular and mobile services to the women suffering from Uterus collapse. g. Increase the awareness among the people through education with the partnership of governmental, private and non-governmental organizations. h. Make effective arrangements to prevent and control serious noncommunicable diseases. i. Make effective arrangements for the promotion, regulation and monitoring of the private health service providers. j. Make the referral system to higher level health organization more organized. k. Develop monitoring system with proper representation of relevant stakeholders to make the service delivery of local and district level health organizations more effective. l. Expand free and safe maternal services, encourage to get health services before and after child birth and make 24 hour arrangement of minimum basic infrastructure to provide maternal services from primary health centers and health posts. 242 Health, Population and Environment Education-10

m. Establish insuring mechanism of health service targeted to the poor, senior citizen, freed Kamaiya, Adivasi, Janajati, Dalit and disabled community. n. Expand services and program of mobile camps including special service package, outreach clinic and telemedicine. o. Recognize the interrelationship between Ayurvedic and alternative medical system which includes, natural treatment, yoga, Homeopathy, Yunani, Amchi and Acupuncture to ensure services in an integrated approach. Activity Prepare a chart paper by writing objectives, quantitative targets and working policies of health sector from the 13th interim plan of Nepal (2072/73-2074/75 BS). Cling the chart paper on the magazine wall of your school. 9.3.2 Major Programs in Health Sector A. Expanded Immunization Program In Nepal, Expanded Immunization Program was started after the eradication of Smallpox in 2034 BS (1975 AD). Currently eleven antigens are provided through the routine immunization under National Immunization Program of Nepal. World Health organization established a program called Expanded Program on Immunization in 1974 AD and many countries started implementing EPI. Expanded program on Immunization including BCG, and DPT vaccines started in Nepal in 1979 AD in three districts. However, EPI including BCG, DPT, Oral Polio Vaccine, and Measles was expanded to all 75 districts by 1989 AD only. Since then, government of Nepal is providing free immunization services to everyone. It is one of the accessible services of Nepal and has reached to the 97% of its target population. Nepal is believed to be one of the countries recognized for the well functioning immunization system. This is also considered as the most cost effective public health program. Objectives of Expanded Immunization Program • To protect the children from infectious diseases like Pertusis, Tetanus, Hepatitis B, Hemophilus, Influenza B, Tuberculosis, Measles, Rubella, Japanese Encephalitis, etc. • To immunize every child through complete doses. • To immunize every pregnant woman with TT vaccine. • To provide vaccine against the prevalence of epidemic diseases such as Encephalitis, Viral Influenza, etc. B. Community Based Integrated Management of Childhood Illness (CB-IMCI) WHO and UNICEF jointly formulated the IMCI strategy in mid 1990s in an effort to Health, Population and Environment Education-10 243

provide a more integrated approach for addressing the main causes of childhood morbidity and mortality associated with five major childhood illnesses such as diarrhea, ARI, measles, malnutrition and malaria which accounts for about 70% of child death in developing countries and for improving child growth and development. CB-IMCI program in Nepal developed through the year with preceding program such as; control of diarrheal diseases, a program initiated 1982 AD and acute respiratory infection program initiated in 1987 AD. Emphasis on community level involvement in Nepal started with strengthening program in 1995 AD and for CDD in 1996 AD. The government introduced Community Based Integrated Management of Childhood Illness (CB-IMCI) in 1999 AD. CB-IMCI included the major childhood killer diseases like pneumonia, diarrhea, malaria, measles, and malnutrition. The strategies adopted in IMCI were improving knowledge and case management skills of health service providers, overall health systems strengthening and improving community and household level care practices. CB-IMNCI Program also focuses on identifying malaria, malnutrition, measles, and other common illnesses among children. Objectives M To reduce the morbidity and mortality among children under five due to pneumonia, diarrhea, malnutrition, measles, and malaria. M To promote healthy growth and development of children. M To reduce neonatal morbidity and mortality by promoting essential newborn care services. M To reduce neonatal morbidity and mortality by managing major causes of illness. M To reduce morbidity and mortality by managing major causes of illness among under 5 years children. M Contribute to survival, healthy growth and development of under five years children of Nepal. M Improve newborn and child survival and healthy growth and development. Activities CB-IMCI training in 8 districts (Nuwakot, Nawalparasi, Mugu, Kalikot, Jajarkot, Rukum, Surkhet and Dadeldhura) e CB-IMCI training by the government with the support of UNICEF and WHO e Progress analysis and improvement of CB-IMCI program e Community care of preterm and low birth weight babies born at home using foot length card in Nuwakot and Rasuwa e Supervision and monitoring of CB-IMCI program 244 Health, Population and Environment Education-10

C. Family Planning and Maternal Child Health In Nepal, family planning related activities are being conducted by various organizations and agencies. The family planning program in Nepal was for the first time carried out by Nepal Family Planning Association. After that Nepal Family Planning and Maternal Child Health Project was established under the Department of Health Service. It is taking a leadership role to revitalize the family planning program in Nepal. The program also seeks to expand and sustain quality family planning services throughout the health service network, including hospitals, primary health care centers, health posts, sub-health posts, primary health care outreach clinics and mobile voluntary surgical contraception camps. The Family Health Division has initiated satellite clinics in all 75 districts. Objectives M To examination of health of the mother and child M To provide nutritious food to the babies M To educate about maternal and child health M To provide delivery service M To support family for the prosperous future of the family member Activities e Counselling about the temporary contraceptive measures to the concerned stakeholders e Providing permanent contraception method to the couples having desired number of children e Supporting the married couple to make their conjugal life happy and prosperous e Health examination of mother and child e Provision of antenatal, natal and post natal service D. Vitamin A Deficiency and Blindness Control Project In our country, deficiency of Vitamin A has been considered as a health problem of the children below five years. Vitamin A deficiency weakens the immune system. It is the most common cause of blindness among children in developing countries. It also impairs individuals’ physical and mental development process. The Vitamin ‘A’ Defence Control Project was established in 2046 BS with the joint initiation of the Government of Nepal and Food and Agricultural Organization. Objectives M To improve the nutrition status of the people through training and campaign M To reduce child mortality rate M To decrease the prevalence rate of Vitamin ‘A’ deficiency disease Health, Population and Environment Education-10 245

Activities e Enhancement of the effectiveness and sustainability of supplementation programs e Sound planning, implementation, and quality control of fortification programs e Inclusion of other food-based approaches in programs e Application of appropriate economic analysis to guide the evolution of country programs e Use of monitoring and evaluation to improve program operations e Development of public and private sector alliances to enhance the effectiveness of interventions E. HIV and AIDS Control Program HIV and AIDS is a life threatening disease caused by the Retro virus known as (HIV). It is a sexually transmitted disease. It is spread all over the world and is called as a pandemic disease. It can take many years for people with the virus to develop AIDS. Hence, HIV and AIDS is often called the “silent epidemic” due to its very long incubation period, meaning that a person can be infected for many years without showing any symptoms. AIDS cannot be cured however; it is possible to live a long life with the anti retroviral drugs. The first case of HIV and AIDS was found in the USA in 1981 AD and the first case of AIDS in Nepal was identified in 1988 AD. In the context of Nepal, HIV epidemic is largely concentrated among the intravenous drug users, sex workers, male labour migrants and Trans genders. Prevention is the best policy since it is an incurable disease. The National Centre for AIDS and STD control (NCASC), has been established for the prevention and control of HIV and AIDS in Nepal. Objectives M To aware people about STDs and HIV/ AIDS M To rehabilitate AIDS patients effectively M To give counselling service for condom promotion Activities e Diagnosis of STDs including HIV and AIDS through blood screening e Disseminate awareness about STDs through public campaign e Formulating national policy to control STDs and HIV/AIDS e Carry out activities for the rehabilitation of AIDS patients e Condom promotion counselling service for the prevention of STDs and HIV/AIDS 246 Health, Population and Environment Education-10

F. National Malaria Control Program Malaria is still a public health problem of Nepal where around 84 percent of the population is at risk. Malaria cases are being reported from 65 districts. Out of 65 malaria prone districts, 13 districts have been classified as high risk of malaria (i.e. Ilam, Jhapa, Morang, Dhanusha, Mahottari, Kavre, Sindhuli , Nawalparashi, Banke, Bardiya, Kailali, Kanchanpur, Dadeldhura). The government of Nepal started its Anopheles Mosquito activities in this area by establishing Malaria Eradication Association in 2015 BS (1958 AD). The government has made a significant progress in controlling malaria transmission over the past decades through the activities of National Malaria Control Program. For instance, total confirmed malaria cases were 42,342 and 2,750 in 1985 AD and 2002 AD respectively whereas this number was decreased to 2,092 in 2012 AD. In recent years, malaria control activities have been carried out in 65 DDT Spread to Control Malaria districts. The government has been distributing medicated mosquito nets free of cost in those 13 high-risk malaria prone districts. Objectives M To achieve effective treatment of all confirmed malaria cases M To respond early to new malaria cases and outbreaks M To encourage general population to adopt malaria healthy behaviour M To provide free, efficient and quality preventive and curative service against malaria Activities e Surveillance of malaria cases e Early warning and reporting system e Indoor house and surrounding spraying against malaria e Awareness and health education about the prevention and control of malaria e Vaccination against malaria e Timely treatment of the malaria patients Health, Population and Environment Education-10 247

G. National Health Education Information and Communication Centre (NHEICC) The National Health Education Information and Communication Centre (NHEICC) was established under the Ministry of Health and population in 1993 AD, with the mandate to give high priority to information, education and communication in the health sector. This centre is responsible for developing, producing and disseminating messages to promote and supports specific all health-related programs and services in an integrated manner. For this purpose, health education, information and communication programs have been carried out in all 75 districts since 1993 AD. The NHEICC implements health education and communication activities utilizing various media and methods according to the needs of the local people in the region, district and community. Local media and languages are used in the district and community for the dissemination of health messages so that people can understand health messages clearly in their local context and language. Objectives M Increase positive attitudes towards health care M Increase awareness and knowledge of the people on health issues M Increase access to new information and technology on the health programs for the people M Promote environment health, hygiene and increase healthy behaviour M Increase participation of the people in the health intervention programs at all levels of health services Activities e Establishing national resource centre for proper management and dissemination of information education and communication materials and message e Implementing information education and communication interventions in an effective manner at the national, regional, district and community level e Distributing information education and communication materials about the communicable diseases, non-communicable diseases and reproductive health through private and government sectors e Ensuringandmobilizingtheparticipationofcommunity,INGOs,NGOs,localbodies, social workers and individuals in information Education and communication program e Disseminating accurate, appropriate and adequate health information using multi-media approaches to people of community level 248 Health, Population and Environment Education-10

Activities Prepare a proposal based on any one health program that has been conducted in your community on the basis of the following sub-headings: Name of the health program: Objectives of the Program: Scope of the Program: Target Group of the Program: Budget of the Program: Program Activities: Expected Outcome of the Program: 9.4 Bad Habit, Its Consequences and Preventive Measures 9.4.1 Introduction A bad habit is a patterned habitual behaviour regarded as detrimental to one’s physical or mental health and often linked to a lack of self-control. Alcoholism, drug abuse, consumption of tobacco in any form, over eating, regular junk food consumption, gambling, swearing, sexual addiction, etc are the examples of bad habits. Bad habits adversely affect the physical, mental, emotional, social, economic and spiritual aspects of individuals. If it is not possible to control such bad habits on time, it may aggravate health and well-being of an individual. Hence, we should always be away from the bad habits. Some of the bad habits are explained below: A. Habitual on Junk Food To develop habit on junk food and fast food instead of eating homemade food is also considered as a bad habit. Usually, fast food contains trans fat, spices and artificial preservatives. As fast food is rich in bad fat, it raises the bad cholesterol in the body which may further cause obesity, diabetes and cardio vascular diseases. B. Gambling and Play Cards Gambling and playing cards is very bad habits. Playing cards and gambling just for fun becomes habit in the long run. People play gambling to make fast money without hard work, which is wrong. A large number of Health, Population and Environment Education-10 249

people become homeless because of such bad habit. Hence, we need to stay away from such bad habits. C. Watching too Much TV and Internet Watching television and internet for hours can put your health at risk. Watching too much television and computer can put you at an increased risk of eye strain, heart attack, stroke and obesity. The more you are glued to the TV, mobile and computer the more immobile life will affect your levels of fat and sugar in your blood. It also strains your eyes. D. Sexual Addiction Engaging in persistent and escalating patterns of sexual behaviour acted out despite increasing negative consequences to self and others is called sexual addiction. A sex addict will continue to engage in certain sexual behaviours despite facing potential health risks, financial problems and broken relationships. 9.4.2 Consequences of Bad Habit Ü There is negative effect on the physical, mental and social aspects of the individual Ü Bad habit spoil the health and property Ü There is loss of potential active life due to bad habits Ü Bad habit causes conflict and misunderstanding in the family Ü Bad habit may cause various kinds of sexually transmitted diseases Ü Some kinds of bad habits escalate crimes in the society (i.e. theft, robbery, buglary, pick pocketing, cyber crime, looting, gang fights, etc.) 9.4.3 Preventive Measures from Bad Habit Bad habits interrupt our life and prevent us from accomplishing our goals. They jeopardize our health both mentally and physically. In addition, they waste our time and energy also. Some of the preventive measures of bad habits are as follows: Ü Do not accompany the persons with bad habits Ü Parents should understand the feeling of their children and should observe their friend circle Ü Do not engage in television, mobile and internet unnecessarily Ü Engage the persons with bad habits with income generating creative activities Ü Dare to say no against the bad habits 250 Health, Population and Environment Education-10