Community medicine/Session 3

PRIMARY HEALTH CARE

Milestones of PHC: •      The 30TH World Health Assembly Comes with new philosophies: •	Social justice and equity are essential for health •	Recognition of the role of community participation •	The relation between health and development (health is essential for development and development is essential for health) •	The importance of the political will The ideas concluded in the international objective of Health for All (HFA) Definition of HFA: Attainment by all peoples of the highest level of health that permit them to lead socially and economically productive life Alma-Ata Conference (1978) proclaimed PHC as way to achieving HFA

DEFINITION of PHC •	ESSENTIAL HEALTH CARE •	BASED ON SCIENTIFICALLY METHODS, •	ACCESSIBLE TO INDIVIDUALS AND FAMILIES THROUGH THEIR FULL PARTICIPATION

PRINCIPLES •	Equity •	Accessibility •	Appropriate Technology •	Community Participation •	Intersectoral Collaboration Essential COMPONENTS of PHC 1.	Health Education 2.	Mother and Child Health 3.	Nutrition 4.	Expanded Program of Immunization 5.	5. Safe water and Sanitation 6.	Control of Endemic Diseases 7.	Treatment of Endemic Diseases 8.	 Provision of Essential Drugs Supportive (secondary) elements of PHC •	Mental Health •	Occupational Health •	School Health •	Reproductive Health •	Adolescent Health etc Concepts of health care •	Provision of services by health personnel. It includes: o	Prevention o	Diagnosis o	Treatment o	Rehabilitation

Levels of health care •	Primary Health Care (the 1st level of contact between individual and the health system – curative and preventive) •	Secondary Health Care (essentially curative services) •	Tertiary Health Care (super-specialist care) Health Education Definition: PROMOTION OF HEALTHY BEHAVIOUR Components of H.E.: 1.	Sender 2.	Message 3.	Channel 4.	Receiver

Characteristics of sender •	Good skills of communication •	Professional ability •	Clear objectives

Communication Skills •	Listening •	Conversation •	Feeling •	Reading non-verbal communication •	Appraising •	Gaining friends Message Characteristics of message: 1.	In line with the objective 2.	Specific 3.	Based on felt needs 4.	Clear and understandable 5.	Fitting the receiver 6.	Culturally accepted Types/Channels of H.E 1. Direct: •	Individual •	Groups 2. Indirect: •	Posters •	Pamphlets •	Stickers •	Telecommunication Receiver: Characteristics of the receiver: •	Interested •	Motivated OBJECTIVE OF H.E: •	Assesses in changing unhealthy behaviour to healthy behaviour

TOOLS OF CHANGING BEHAVIOUR •	Education (health education) •	Economics •	Engineering •	Enforcement

PRINCIPLES OF HEALTH EDUCATION 1.	Simple language 2.	Interest 3.	Motivation 4.	Participation 5.	Learning by doing 6.	Examples MOTHER AND CHILD HEALTH MOTHER'S HEALTH PREMARRIGE CARE: •	CLINICAL EXAMINATION •	LABORATORY INVESTIGATION •	COUNCELLING (including sexual health) •	IMMUNIZATION (TT)

CAUSES OF MATERNAL MORTALITY: •	BLEEDINGS •	ECLAMPSIA •	ANAEMIA •	INFECTIONS

ROUTINE CARE DURING PREGNANCY: 1.	Proper history taking and clinical examination 2.	Health education for pregnant women nutritional health education, personal hygiene and sanitation avoiding tobacco, alcohol and non-prescribed drugs, explaining minor complications of pregnancy and childbirth, avoidance of occupational hazards etc 3.	Treat coexisting disorders and control chronic diseases 4.	Regular check of weight 5.	Regular check for BP 6.	Regular check for swellings

INTRANATAL CARE •	Clean •	Identification of childbirth complications •	Availability of referral system •	Availability of OEC unit

POSTNATAL CARE •	Checking for infections •	Health education (encouraging breast feeding, nutrition, FP etc) •	Good parenting •	Vaccination •	Rh immune globulin when indicated FAMILY PLANNING

PSYCHOSOCIAL AND LEGAL ISSUES •	COUNCELING AND VOLUNTARISM •	REVERSIBILITY OF TUBAL LIGATION AND VASECTOMY CAN NEVER BE ASSURED

METHODS OF CONTRACEPTIVES:

LACTATION Advantages: •	Encourage infant nutrition •	Safe and available

Disadvantages: •	High individual failure rates

ABSTINENCE FROM SEX Advantages: •	Accessible, safe and reversible •	Acceptable to most religious groups

Disadvantages: •	Requires strong motivation

SPERMICIDES •	Advantages: •	Available without prescription •	Generally safe •	Effective when combined with other methods

ADVANTAGES: •	Safe and •	no chemicals Disadvantages: •	Requires motivation and education

OTHER NATURAL FAMILY PLANNING METHODS •	Dry sex, •	calendar, •	temperature, and •	Cervical mucus analyses Advantages: •	Safe and accessible •	Acceptable to most religious groups Disadvantages: •	Requires education and desire •	High failure rates

COITUS INTERRUPTUS Advantages: •	Safe and available Disadvantages: Requires great control Ineffective for pre-ejaculate sperm

BARRIERS Sponge, cervical cap, diaphragm, male and female condoms Advantages: •	Provide protection against STDs •	Effective when combined with other methods Disadvantages: •	Require education and cooperation •	Not acceptable by some cultures •	Minimal risk of toxic shock

INTRAUTERINE DEVICE (IUD) Advantages: •	Gives protection for years •	Effective Disadvantages: •	Perforation, infections, infertility (Avoid using this method to primigravidae) •	Heavier menstrual flow •	Cost COMBINED Pills (ESTROGEN-PROGESTIN) Advantages: •	Highly effective •	Not coitally related •	Generally safe and reversible •	Protect against anaemia, dysmenorrhea, ovarian cysts and endometrial cancers •	Possibly protective against breast and ovarian cancers Disadvantages of pills: •	Major side effects (increase risk of cardiovascular diseases •	Minor side effects (migraines, bleedings, phlebitis, nausea) •	Needs regular prescription and use

PROGESTIN-ONLY (Minipills, injections and implants) Advantages: •	Effective •	It does not affect lactation Disadvantages: •	Irregular cycle

VASECTOMY Advantages •	Highly effective •	Easy to perform Disadvantages:

•	Surgical complications •	Not accepted in many cultures

TUBAL LIGATION

Advantages: •	Highly effective •	Usually permanent

Disadvantages: •	Surgical risks •	Cost •	Rare re-canalization and ectopic pregnancies

Community Providers of MCH/FP: 1.	Traditional Birth Attendant (TBA) 2.	Trained TBA 3.	Village Midwife 4.	Health Visitors Child health

MAIN CHILD HEALTH PROBLEMS IN SUDAN: 1.	Malnutrition 2.	Infectious diseases 3.	Accidents 4.	Behavioural problems

Preventive measures 1.	Immunization 2.	Growth monitoring 3.	Health education 4.	Supplementation with vit. A

1. Immunization 1.	At Birth	BCG, Polio 2.	6 weeks	DPT, Polio, Hepatitis 3.	10 weeks	DPT, Polio, Hepatitis 4.	14 weeks	DPT, Polio, Hepatitis 5.	9 month	Measles

2. Growth monitoring •	Monitoring by growth charts (road-to-health) for U5 children •	It is weight for age chart Interpretation: •	Wt increasing = appraise the mother •	No increase in wt = ask to increase the food/breast-feeding •	Over/under wt = check for disorders 3. Health Education

4. Supplementation with vit. A (Single massive dose of 200 000 IU every 6 moth for children 1- 6 years - Half the dose for infants)

NUTRITION Common Nutritional Problems in Sudan 1.	PEM 2.	Nutritional anaemia 3.	Vit. A deficiency 4.	Iodine deficiency

Prevention of malnutrition is a comprehensive program of social development of the entire country

Role of primary health care in improving nutritional status •	Health Education •	Nutritional surveillance •	Nutritional rehabilitation •	Nutrition supplementation

Types of routine immunizations in Sudan: Polio and BCG at birth Polio, DPT, HBV (6, 10, 14 weeks) Measles (9 month) Tetanus Toxoid (TT) for pregnant women TT Early in pregnancy TT-1 One month after TT-1 – TT-2 Total 5 doses Interval between 2 doses should not be less than one month Avoid TT 2 weeks before delivery

SANITATION AND SAFE WATER

Safe Water •	Basic requirements •	Free from pathogenic agents •	Pleasant to the taste (free from color and odour) •	Usable for domestic purposes

Biological (Water-borne diseases) Caused directly by the presence of an infective agent: •	Viral (viral hepatitis A and E, polio etc) •	Bacterial (GE) •	Protozoal (amoebiasis, giardiasis) •	Helmenthic (roundworm, threadworm, hydatid disease etc) •	etc

Risks of inadequate water: •	Trachoma •	Scabies

Waterborne diseases caused by the presence of an aquatic host •	Malaria, filarial, Onchocerciasis, African Trypanosomiasis •	Snails (Schistosomiasis, Guinea worms)

Chemical Hazards •	High level of fluoride cause mottling of the dental enamel, low concentrations may cause dental carrier. •	High nitrate (used in fertilizers) levels content of water cause methaemoglobinaemia. •	Hardness of water is a risk factor of cardiovascular diseases. It is always caused by high concentrations of calcium and magnesium •	Low concentration of iodine (simple goiter). •	Cyanides, ammonia and other toxic solvents and metals. •	Carcinogenic chemicals.

Physical Hazards (Radiation)

Water requirement •	For drinking water: 2 liters per day per head. •	For domestic use 150-200 liters per day per head •	Purification of water on large scale

Safe storage of water at large scale: •	Filtration •	Disinfection

Purification of water on small scale (at home) Household purification: •	Boiling (5-10 minute) •	Filtration (by small filters, Zeer) •	Chlorine tabs 0.5g is sufficient to disinfect 20 liters of water. --

EXCRETA Health hazards of improper excreta disposal •	Water pollution •	Soil pollution •	Contamination of food •	Propagation of flies

Measures to prevent faecal-borne infections •	Proper disposing of faeces •	Prevention of water supply •	Protection of food •	Personal hygiene •	Control of flies

Types of proper excreta disposal •	Ventilated Improved pit-latrines •	Septic tank •	Sewage

Solid wastes Components of solid wastes: •	Garbage (food waste) •	Rubbish (paper, plastics wood, metal, throw-away containers, glass etc Destruction products (bricks, pipes etc) •	Sewage treatment residue •	Dead animals Hazards of accumulated solid wastes •	Flies breading •	It attracts rodents and vermin •	Possible water and soil pollution •	Unpleasant appearance •	May infect food through dust Methods of disposal •	Dumping •	Burning •	Recycling

PEVENTION AND CONTROL OF ENDEMIC DISEASES

PREVENTION •	Primary Level (before) •	Secondary (early diagnosis and treatment) •	Tertiary (rehabilitation) CONTROL OF ENDEMIC DISEASES •	Ongoing operations aimed at reducing: o	Incidence of disease o	Duration of disease o	Risk of transmission o	Complication of diseases o	Financial burden Roll Back

Measurable Control

Eradication Elimination (eradication) of the agent --

TREATMENT OF ENDEMIC DISEASES

Guidelines of proper treatment of endemic disease at the PHC canters: •	Find the most common diseases •	Determine the simplest, cheapest and most effective routine for treating these diseases •	Train auxiliaries (paramedical) •	Provide the relevant equipments, drugs etc •	Trace the queues. What are the causes of delay? •	Large number of patients need management by exception •	Ensure communication and referral means ESSENTIAL DRUGS Definition Drugs which are used in treatment of 90% of diseases within a specific community The Problem: •	Countless drugs on use •	Most of used drugs are nonessential •	Inefficient drug supply systems, •	irrational use of drugs •	and lack of objective drug information. Criteria of Essential Drugs •	according to the need •	safe •	efficacy, •	good quality •	acceptable price The National List of Essential Drugs •	In 1977 the WHO compiled a model list of essential drugs. •	The model had 220 drugs, vaccines and diagnostic agents •	In Sudan a comprehensive national drug policy was formulated. •	The list have been subdivided according to the level of use: o	Nurses - list AA, o	Medical assistants at the level of dispensaries and health centers (list A) o	Medical officers (list B), o	list C for hospitals (specialist) o	List (S) for specialized units and centers. Advantages of Essential Drugs 1.	The prescriber makes better use of a smaller number of drugs by knowing thoroughly their indications, contraindications, side effects, dose etc 2.	Training and supervision 3.	quality control, 4.	drug management is easier, 5.	Less costly and more efficient. 6.	Improve national manufacturing of drugs