Lecture Page

Lecture 1: INTRODUCTION
Lecture 2: Community Diagnosis
Lecture 3: Reproductive Health Mother and child health MCH
Lecture 4: Family Planning And Contraceptive Methods
Lecture 5: Integrated Management of Childhood Illnesses IMCI
Lecture 6: Cold Chain
Lecture 7: IMMUNIZATION SERVICES
Lecture 8: Human Nutrition
Lecture 9 : Health education
Lecture 10: Health promotion
Lecture 11 : MDGS vs. SDGs

Primary Health Care PHC

By: Alaa Tawfig Siralkhatim
CM coordinator- Batch 92 Bayariq

Revised By: Maaza Ibrahim Osman

CM Prize holder- 2021, Bayariq 92

Participants:
1. Istabraq Isam
2. Sara Naiem
3. Nuha Elhag

This sheet is collected from all the resources of PHC (SHEETS, LECTURES, and EXAMS) to be the main resource for 5th year students in U of K.
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“Health for
All by All”
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 Contents:

Topic Page
1. Introduction 4
2. Community Diagnosis 10
3. Reproductive Health 12
4. Family planning and contraception methods 26
5. IMCI 35
6. Cold Chain 38
7. Immunization 42
8. Human nutrition 48
9. Health Education 65
10. Health Promotion 70
11. MDGs vs. SDGs 78
12. Others 82
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Lecture 1: INTRODUCTION

 Historical Background: Health for All

o The 30th World Health Assembly resolved in May 1977 goal was that (the main
social target of the governments and WHO in the coming decades should be the
attainments by all citizens of the world by the year 2000 of a level of health that
would permit them to lead a socially and economically productive life)
o With increasing recognition of the failure of existing health services to provide
health care alternative ideas and methods to provide health care have been
considered and tried.
o Discussing these issues at the joint WHO-UNICEF international conference in
1978 at Alma-Ata (USSR), the government of 134 countries and may voluntary
agencies called for a revolutionary approach to health care.
o The Alma-Ata conference called for acceptance of the WHO goal for Health of All
by the year 2000 and proclaimed primary health care as a way to achieving
Health for all.
 Before Alma-Ata, PHC was regarded as synonymous with:
1. "basic health services",
2. "first contact care”,
3. “easily accessible care",
4. "Services provided by generalists", etc.
• The Alma-Ata international conference gave PHC a wider meaning.
 The Alma-Ata Conference defined PHC as follows; -
"Primary health care is essential health care made universally accessible to
individuals and acceptable to them, through their full participation and at a cost the
community & country can afford".
• PHC is equally valid for all countries, although it takes varying forms in each
of them.
• The concept of PHC has been accepted by all countries as the key to the
attainment of HFA.
• It is accepted as an integral part of the country's health system.
 Almata declaration = short note qua
 Elements (components) of PHC ASSAY
o Although specific services provided will vary in different countries &
communities, the Alma-Ata Declaration has outlined 8 essential components
of PHC: -
1. Education concerning prevailing health problems & the methods of
preventing & controlling them.
2. Promotion of food supply & proper nutrition.
3. An adequate supply of safe water & sanitation;
4. Maternal & child health care, including family planning;
5. Immunization against major infectious diseases;
6. Prevention & control of locally endemic diseases;
7. Appropriate treatment of common diseases & injuries; and
8. Provision of essential drugs.
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• The first three elements are basically primitive services;

• the middle three preventive and
• The last two with rehabilitative services would form the classical curative care.
• The division into eight elements is not absolute in the sense they are not
independent to the whole extent;
• each element extends to other domain to some extent, &
• Every element is complimentary to each other for the effective implementation
of PHC.
o The concept of PHC involves an effort to provide the rural population in
developing countries with at least the bare minimum of health services. The
list can be modified to fit local circumstances. For example some countries
have specifically included:
-Mental health,
-Physical handicaps and,
-Health and social care of the elderly.

 PHC principles: ASSAY

o The mentioned eight services indicated as elements, are to be organized &
delivered on basis of the principles of: -
 Equity in distribution.
 Appropriate technology.
 Multi-sectorial approach.
 Community participation.
 Health workforce development

1. Equitable distribution
The first key principle in the PHC strategy is equity or equitable distribution of
health services.
Health services must be shared equally by all people irrespective of their
ability to pay.
PHC aims to redress this imbalance by:
 Shifting the center of gravity of the health care system from cities (where three-
quarters of the health budget is spent) → rural areas (where three-quarters of the
people live) = decentralization
 Bring these services as near people home as possible.

Equity means:
1. Services to all
2. More services to needy & vulnerable
i.e. while continuing to provide essential health care for all the population
irrespective of social, economic & cultural preferences, extended care is to be
provided to the "high risk" groups in the community either within the health centers
or through the health centers to a higher level of care (hospital).
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For ensuring equity:

- The population to be served must be known.
- The vulnerable groups are to be identified & reached.
- The "at risk approach" to achieve with limited resources in terms of visible
positive changes in the health status of the community.
- The health services (not necessarily health centers) have to be dispersed into:
- The farthest remote rural areas.
- The deepest parts of the underserved urban population.
- The failure to reach the needy & the majority is usually due to limited
geographical access.
Thus, to ensure equity, accessibility has to be improved by:
- Increasing the number of health facilities.
- Improving transport conditions.
- Organizing outreach services, thus substituting one when the other is not
available.

PHC aims to:

- Correct imbalance in accessibility
- Bring health services as near to people's homes as possible.
- To achieve this, PHC is supported by higher level of health care to which
patients can be referred for extended care.

2. Community participation
o Involvement of individuals, families, & communities in promotion of their
own health & welfare.
o There must be:
A continuing effort to secure meaningful involvement of the community in:
Implementation. Planning.
Manpower. Maintenance of health services.
Money. Evaluation of health services.
Materials. Maximum reliance on local
resources such as: UHC
o Universal Health coverage by PHC cannot be achieved without the
involvement of the local community. In short, PHC must be built on the
principle of community participation (or involvement).

o One approach that has been tried successfully is the use of:
1. Village health guides.
2. Trained dais.
o They are selected by the local community & trained locally in the delivery of
PHC to the community they belong, free of charge.
o By overcoming cultural & communication barriers, they provide PHC in ways
that are acceptable to the community.
o It is now considered that "health guides" & trained dais are an essential feature
of PHC in many countries.
o The key factors in human development are:
- Social awareness.
- Community self-reliance.
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o The people have both the right & duty to participate in the process for:
- The improvement of health.
- Maintenance of health.

o Though, "PHC" considered as essential health services; in reality it is a "practice"

by the people for their own health benefits.

3. Multi-sectoral approach
o There is a ↑ realization of the fact that the components of PHC cannot be
provided by the health sector alone.
o The Declaration of Alma-Ata states that “PHC involves in addition to the
health sector, all related sectors & aspects of national & community
development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communication& others sectors “.
o To achieve such cooperation, countries may have to:
 Review their administrative system.
 Reallocate their resources.
 Introduce suitable legislation to ensure that coordination can take
place. This requires strong political commitment to translate values
into action.

o An important element of inter-sectoral approach is:

PLANNING - PLANNING with other sectors to avoid unnecessary

DUPLICATION of activities.

4. Appropriate technology:
o Definition:" technology that is scientifically sound, adaptable to local needs, &
acceptable to those who apply it & those for whom it is used, & that can be
maintained by the people themselves in keeping with the principle of self-
reliance with the resources the community & country can afford “.
o “Appropriate" is emphasized because in some countries, they build large,
luxurious hospitals, which are: Totally inappropriate to the local needs and
Absorb a major part of the national health budget.
o This also applies to using costly:
Equipment.

Procedures.

Techniques.

o When cheaper, scientifically valid & acceptable ones are available, viz, ORS.
o PHC requires development, adaptation & application of appropriate
technology that the people can use & afford" (Alma Ata 1978).
o The word technology is a total sum of materials, methods, technique,
considered in association with the person who is using it, which is potentially
capable of solving health problems.
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Health technologies are required not only for:

 Diagnostic maneuvers.
 Therapeutic maneuvers.
But also for:

 Disease prevention.
 Disease control.
 Health promotion.
o Appropriateness means that besides being scientifically sound, it is also
acceptable to:
Those who apply it.
Those for whom it is used·

o Though it is commonly perceived that person who is going to apply it is a

trained health professional, in PHC practice there are instance where
technology may have to be applied by:

-- Individual. -- Family. -- Community.

E.g. use of tooth brush, eye glasses, domestic water filters, domestic pest control,
etc. · so, technology should be applicable for "self-use".

o Scientifically sound & acceptable technology has to fulfill certain criteria such
as:

Culturally acceptable. The sensitivity.

Capable of being adapted & Cost.
further developed locally Easy to apply (use) & maintain.
So, the simplicity of the technology is always desirable; examples of such are:
ORS in diarrheal disease control.
Breast feeding in spacing.
Weighing for growth monitoring, etc.

5. Health workforce development: +\- (updated by Dr.Haitham)

o Adequate number and distribution of trained physicians, nurses, allied health
professions, community health workers and others working as a health team
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 Keys of PHC reform:

1. Reducing exclusion and social disparities in health (universal health coverage)
2. Organizing health services around people's needs and expectations (service
delivery reforms)
3. Integrating health into all sectors (public policy reforms)
4. Pursuing collaborative models of policy dialogue (leaderships reforms)

 Functions of PHC in Sudan: short qua

 Medical care  Endemic disease
 Immunization  Health education
 Reproductive health  Referral surface
 Nutritional assessment  Training of health guides and worker
 Prevention and control  Basic laboratory service
 Collection and reporting of vital statistics

 Obstacles to the implementation of PHC in Sudan include:

1. Shortage of health manpower.
2. ↑Curative culture within the existing health system.
3. ↑ Concentration of health services & health personnel in urban areas
compare to that of the rural areas.
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Lecture 2: Community Diagnosis ASSAY QUA

 Definition of a “Community”

A cluster of people with at least one common characteristic (geographic

location, occupation, ethnicity, housing condition……)
A group of people with a common characteristic or interest living together
within a larger society
A community is a whole entity that functions because of the
interdependence of its parts or subsystems. Eight subsystems plus the
community core are identified.

 Community Core:
o History, socio-demographic characteristics, vital statistics,
values/beliefs/religions.
 Eight Subsystems
• Health and social services • Physical environment
• Communication • Education
Safety and
• Economics • transportation
• Recreation • Politics and government

 Definition of Community Diagnosis: mcqs

Community diagnosis generally refers to the identification and quantification
of health problems in a community as a whole in terms of mortality and
morbidity rates and ratios, and identification of their correlates for the
purpose of defining those at risk or those in need of health care.

 The Community Diagnosis Process:

“A means of examining aggregate and social statistics in addition to the
knowledge of the local situation, in order to determine the health needs of
the community”
Involves this stages: Data collection and analysis, Diagnosis, Dissemination

 Goals:

The mission of community diagnosis is to:

Analyze the health status of the community
Evaluate the health resources, services, and systems of care within
the community
Assess attitudes toward community health services and issues
Identify priorities, establish goals, and determine courses of action to
improve the health status of the community
Establish an epidemiologic baseline for measuring improvement over
time.
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 Community Analysis mcqs

Community analysis is the process of examining data to define needs

strengths, barriers, opportunities, readiness, and resources. The product of
analysis is the “community profile”.
To analyze assessment data is helpful to categorize the data. This may be
done as following:

Health resources and Demographic

Services Environmental
Health policies Socioeconomic
Study of target groups.

 Community is diagnosed using Health Indicators

o Indicators of health are variables used for the assessment of community health

1.
Indicators of social and mental
health 7.
Mortality indicators
2.
Environmental indicators 8.
Morbidity indicators
3.
Socio-economic indicators 9.
Disability rates
4.
Health policy indicators 10.
Nutritional status indicators
5.
Indicators of quality of life 11.
Health care delivery indicators
6.
Other indicators 12.
Utilization rates

 Source of information in community Dx:

Screening , Surveys, Contact tracing and Vital registration
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Lecture 3: Reproductive Health (Mother

and child health MCH)

Introduction “IN SUDAN”

• MCH started in 1921.
• In 1978 the MCH/FP program of the MoH started at OMS.
• In 1986 MCH was institutionalized within the FMOH.In 1994, the
directorate of MCH was renamed as DRH,which was attached to the Directorate of PHC
within FMOH
• In 1997 the DRH produced the Sudan Master Plan for the implementation of
RH and safe motherhood initiatives for a period of 1997 to 2001
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 The objectives of the Sudan Master Plan are:

• To ensure that 80% of pregnant women have access to basic maternity care,
this includes quality prenatal care, clean and safe delivery and regular post-
partum care.

• To promote family planning to increase contraceptive prevalence rate to 30%

among married women in reproductive age.

• To increase the awareness and involvement of mothers in the concept of safe

motherhood, including maternity care, clean and safe delivery, family
planning, nutrition and harmful traditional practices affecting the health of
the mother and child.

• To facilitate good and safe care for normal newborn babies, encourage
exclusive breast feeding practices and vaccination against the 6 childhood
diseases and ensure management of complications for 50% of the target
group.

 Definition of Reproductive Health

Reproductive health is a state of complete physical, mental, & social wellbeing& not
merely the absence of disease or infirmity, in all matters related to the reproductive
system & its functions & processes at all stages of life. The concept is centered on
human needs & development throughout the life cycle.

The components of RH care are: ASSAY

(Same to: What dose RH cover? And RH package)
1. Safe Motherhood.
2. Infertility.
3. Prevention of unsafe abortion.
4. STIs & HIV/AIDS.
5. Adolescent RH & Sexual Health.
6. Gender equity.
7. Prevention of harmful traditional practices (FGM, viloance,).
8. RH needs associated with menopause, including reproductive tract ca.
9. family planning
10. newborn health

Reproductive health concepts include:

the wellbeing of men, women and young people as concerns their reproductive
functions throughout the life span
Women should go through pregnancy and childbirth without danger to
themselves or their children
Prevention of unintended pregnancies and diseases spread through sexual
intercourse
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 CHALLENGES IN Reproductive health:

1) Minimum package of services:
RH embraces a wide range of health services far beyond the traditional maternal & child
health services.
A. Traditional maternal & child health is focused on pregnant women & children.
B. RH brings in other non-traditional target groups such as men & adolescents.

2) Availability of Quality care:

 The key element being the availability of skilled attendance at childbirth.
 The availability of essential health services.

3) Functional Referral systems: Most of the maternal & neonatal deaths could be
prevented if only functional referral systems could be put in place.

 Maternal and Child Health(MCH):

Introduction: In majority of the communities catered by the health centers, mothers &
children constitute a priority group, in terms of:

 Sheer number.
 Vulnerability to preventable diseases.

In terms of numbers:

 They constitute approximately 70% of the population.

 Women in child bearing age (15-45) contribute 20%.
 Children under 15 years of age 49%.

In addition, they also form the largest vulnerable group, with risks associated with:

 Childbearing (pregnancy & child birth) in women.

 Growth, development & survival in children.

The recent changes to RH demand re-organization of health services, as in the past

MCH services were rather fragmented & provided as personal health services by
different health care providers.

The current trend is to provide integrated MCH services as a compact family welfare
service, because the mother & child are considered as one unit, due to inherent
physiological & pathological associations from the early period of gestation at least
to the age of 6-9 months.

→MCH services are to be provided as a part of PHC,

→still uniform to all women in child bearing age in continuity & to all children till
they become adults (or at least up to school age).

Thus, the MCH care package is a strategy advocated by MOH to achieve greater
impact of health services on:

1. The health of mothers & children in particular.

2. The health status of the community & Nation in general.
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MCH measured in terms of ↓ in associated mortality & morbidity:

1. Infant mortality rate (IMR).
2. Prenatal mortality rate (PNMR).
3. Maternal mortality rate (MMR).

This package should consist of:

1. Comprehensive (a mixture of promotive, preventive, curative &
rehabilitative).
2. Continuous health care services directed to the triad of:
o Infection.
o Malnutrition.
o The specific medical care requirements of the mother & child.
 Safe motherhood: ASSAY
Safe motherhood means ensuring that all women have access to the information and
services they need to go safely through pregnancy and childbirth.
1. Early booking of antenatal cases.
2. Their timely follow-up.
3. Referral of high risk cases.
4. Managing normal pregnancies.
5. Taking care of them during:
• Delivery.
• Postnatal period.
6. Inter-gestational periods are to be developed
 ANTENATAL CARE: ASSAY
• Antenatal care is the care of the woman during pregnancy.
• The primary aim is to achieve, at the end of pregnancy:
1. A healthy mother.
2. A healthy baby.

Objectives of antenatal care:

1. To promote, protect & maintain the health of the mother during pregnancy.
2. To detect high risk pregnancies & to give them special attention.
3. To foresee complications & prevent them.
4. To remove anxiety & fear associated with pregnancy.
5. To ↓ Infant & Maternal mortality & morbidity.
6. To teach the mother the elements of:
• Child care.
• Nutrition.
• Personal hygiene.
• Environmental sanitation.
• Breast feeding
(At this time the mother is more receptive to advises concerning herself & her baby. So the
opportunity should be fully utilized)
7. To attend to the under-fives accompanying the mother.
8. To promote mutual trust, cooperation & understanding between the Community
& the PHC facility.
9. Birth plan SHORT QUA
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 Components of the Birth Plan:

 Skilled Provider
Make sure the woman knows how to contact the skilled provider or healthcare facility at
the appropriate time.

This person should be trained in supporting normal labor/childbirth and managing

complications if they arise.

 Place of Birth
Assist the woman in making arrangements for place of birth – whether at the district
hospital or health center.

Depending on her individual health needs, you may need to recommend a specific level of
healthcare facility as the place of birth, or simply support the woman in giving birth where
she chooses.

 Emergency Transportation
Make sure she knows the transportation systems and that she has made specific
arrangements for: Transportation to the place of birth (if not the home), and Emergency
transportation to an appropriate healthcare facility if danger signs arise.
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 Funds
Ensure that she has personal savings or other funds that she can access when needed to pay
for care during normal birth and emergency care.

If relevant, discuss emergency funds that are available through the community and/or
facility.

 Support
Assist the woman in deciding on/making arrangements for necessary support, including:
Companion of her choice to stay with her during labor and childbirth, and accompany her
during transport if needed; and Someone to care for her house and children during her
absence.

 Decision Making
Discuss how decisions are made in the woman’s family (who usually makes decisions?), and
decide:

How decisions will be made when labor begins or if danger signs arise (who is the key
decision-maker?); and

Who else can make decisions if that person is not present?

 Blood Donor
Health education session to explain the importance of donation and to ensure that the
woman has identified an appropriate blood donor and that this person will be available in
case of emergency.

 Items needed for clean and safe birth and the new born
Items needed for the newborn, for example: blankets, clothes, waterproof/plastic cover,
cord ties…………. etc.

Note: Items needed depend on the individual requirements of the intended place of birth,
whether in a facility or at home.

 Ensure that the woman knows the:

A. Signs of labor
• Regular, progressively painful contractions
• Lower back pain radiating from the fundus
• Bloody show
• Rupture of membranes
B. danger signs
Which indicate a need to emergency readiness plan:
• Vaginal bleeding
• Difficulty breathing
• Fever
• Prolonged labor (over 12 hours)………..etc.
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Antenatal visit Frequency: Minimum 4 -5 visits. MCQ

1 -30 weeks - once/ month
30 -36 weeks – twice/month
36 – 40 weeks - weekly
Antenatal visit:

General history+ Obstetric History

General examination + Obstetric examination
Investigations: (Hemoglobin estimate, Urine analysis.), “Ultra sound”
Supplementations: (iron and folic acid, tetanus toxoid)
Health education: (antenatal care, diet, vaccination, rest, breast feeding

DOMICILLIARY VISITS

• Even if the expectant mother is attending the antenatal clinics regularly,

she must be paid at least one home visit by the midwife or health visitor in
the course of antenatal care.

It will provide:
1. An opportunity to observe the environmental & social conditions at home.
2. Reassurance of the family members specifically regarding the safety of such service.
• If home delivery is planned more visits are required.

 PRENATAL Advice:

 At this time the mother is more receptive to advises concerning herself & her
baby.
 So the opportunity should be fully utilized.
 The message should overflow to Child Health Care & Family Health Care

Advice regarding:
1. Drugs.
2. Diet.
3. Avoid radiation.
4. Personal hygiene.
5. Rest, sleep and exercise.
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Risk group of antenatal care: (essay)

The central purposes of antenatal care is to identify high risk cases as early as possible to
provide appropriate care for them. These cases compromise the following:
1. Elderly primi (30 years and over).
2. Short-statured primi (140cm and below).
3. Malpresentation, breech, transverse lie, etc

4. Antepartum haemorrhage, threatened abortions.

5. Pre-eclampsia and eclampsia.
6. Anaemia
7. Twins, hydramnious.
8. Previous stillbirth, IUD, manual removal of placenta.

9. Elderly grandmultipara
10. Prolonged pregnancy (14 days after expected date of delivery)
11. History of previous caesarian or instrumental delivery

12. Pregnancy associated with general disease e.g. cardiovascular disease, kidney disease,
DM, TB, liver disease, etc.

INTRA-NATAL CARE

The need for efficient intranatal care is very important even if the delivery is going to
be a normal one.

Hence, a good intranatal care should aim at:

(1) Asepsis (not merely antisepsis).

(2) Minimum injury to the mother & the new born.

(3) Preparedness to deal with complications.

(4) Care of the baby at delivery:

(a) Resuscitation.

(b) Care of the cord.

(c) Care of the eyes.

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POST-NATAL CARE
Definition: Care of the mother & the newborn after delivery.
Objectives:
1. To prevent complications of post-partal period.

2. To restore the health of the mother to the optimum.

3. To check adequacy of breast feeding.

4. To provide basic health education to the mother & family

Steps of POST NATAL CARE
Check the mother:
 Temp, pulse, and blood pressure during staying of mother and baby in-hospital.
 If mother delivered at home midwife will do this and look for any abnormality.
 Check the continuity of breast feeding.
 Check the mother abdomen to ensure uterus contraction and blood loss within
normal.
 Check to ensure healing well and no signs of infection and advice mother with
cleaning.
 Ensure mother able to pass urine without problem (perineal tear !!!).
Baby check:
 Look for baby skin and paler to observe jaundice signs.
 Look for oral thrush.
 Observe the cord.
 Feeding of baby.
 Vaccination.

By home visits (health visitor):

include:
(i) General examination
(ii) Follow-up for:
(iii) Postpartum bleeding.
(iv) Wound care.
(v) Fever “infection”
(vi) Breast care.
(vii) Baby care (congenital anomalies).
(viii) Breast feeding.
(ix) Vitamin A supplementation.
(x) Health education.

PNC VISITS:
1st visit first 24 hour (6hours)
2nd visit (23-) days

3rd (710-) days

4th (6week) visit
6th (6 month) visit
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BREAST MILK
1. Scientists have discovered a source of liquid gold.
2. For decades they have tried to dismantle, analyze, & recreate this amazing
substance - to no avail.
3. The only known source of this magical fluid is a mother’s breast, & it’s not
giving up its secrets easily.

Breast Feeding ASSAY

• An average mother from developing country, although poor in nutritional

status has a remarkable ability to breast feed her infant for a prolonged period, nearly
up to two years.
• This quality of the mother should be fully utilized.
• Up to the age of six months, mother’s milk alone will be adequate for the
growth of the child.

(b) Advantages:

To the mother:
(i) Emotional association & developing good rapport with her child.
(ii) Prolongation of birth interval, which has +ve effects on lowering both maternal &
infant mortality.
(iii) Promotes uterine involution.
(iv) Leads to ↓ breast congestion → protects from developing breast abscess

To the baby:

1. There is no better balanced formula than mother's milk, which is:

-suitable for the baby,
2. Available in a sterile container with no chances of contamination.
3. Protects the baby from majority of infections
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PROECURE:
Follow these steps to position and attach your baby well:

- Hold your baby close with their nose level with your nipple.
- Let your baby’s head tip back so their top lip brushes against your nipple - this should help
them open their mouth wide.
- When your baby’s mouth is wide open, bring them to your breast.
- Aim your nipple to the roof of their mouth.
- When they attach, your nipple and most of the areola (the area around your nipple) should
be deep in your baby’s mouth.
- When your baby is attached properly, their chin will be pressed into your breast.

- Your baby's nose should be clear for easy breathing. Ideally, the nose should be at a tilt
when attached correctly.
- Newborns are nose breathers. If they cannot breathe freely, they will come off the breast.
- In the correct position, your baby will be able to suck, swallow and breathe comfortably.
- If your baby's nose appears to be blocked, move their bottom closer to you. This will create
a head tilt and free up their nose.
- The deeper the attachment the more comfortable you will feel and the better your baby
will feed.
- More of your areola will be visible above their top lip than below their bottom lip.
- Their cheeks will appear fuller.

- They’ll suck quickly at first, followed by longer sucks.

- You will hear them swallowing.
Comparison between breast milk in 1 st month lactation and unprocessed cow’s
milk ( know which has higher/lower component than the other)
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• The principles of infant feeding;

• Milk: the essential food. Breast - feeding is encouraged, then proper bottle feeding,
if not available.
• Dietary supplementation for nutrients not adequately provided by milk, and others if
necessary.
• Weaning practice, to replace milk feeds by different foods. Without exposing the
infant to malnutrition.

• How to feed the preterm, LBW, and sick infants.

• Dietary supplementation in infant feeding Is needed to provide certain nutrients
which may not be adequately given by commonly used infant feeding.
• Supplementation for iron and vitamins C and D, with feeding on non-powder milk
(powder milk is fortified for these nutrients).
• Iron: giving iron – rich foods, as green leafy vegetables (soup then mashed), egg yolk,
liver (chicken then cattle), and beans.
• Vitamin C: orange and tomato juice, green leafy vegetables (soup then mashed, with
precaution to avoid effect of oxidation/ heat on vitamin C).
• Vitamin D: proper exposure to the sun, and giving vitamin d preparation (oral or
parenteral) if necessary
• Supplementation for protein: giving supplementary foods (weaning foods), especially
when dietary protein may be inadequate.
Weaning in infant feeding;
Weaning is the process of replacing milk feeds by different foods, until intimately reaching
regular diet, according to special scheme. Mothers must be fully aware of the proper
scheme of weaning.
 24

Requirements of weaning practice:

• Weaning must proceed gradually over some time: usually starts by the 6 th month,
until the age of 18-24 months.
• Adequate amount of animal milk, or cheese or yoghurt, must be given daily,
throughout childhood.
• Weaning must be associated with supplementation by: Suitable foods which provide
iron,

Complementary Feeding
 Appropriate feeding practices are of fundamental importance for the survival,
growth, development, health and nutrition of infants and children.
 Many young children do not receive adequate feeding. This can result in
malnutrition.
 The aim is to protect, promote and support exclusive breastfeeding for six months
and to provide safe and appropriate complementary foods with continued
breastfeeding for up to two years of age or beyond.
 Exclusive breastfeeding, should continue for the first 6 months.
 From 6 – 12 months, breastfeeding continues to provide half or more of the child’s
nutritional needs, and from 12-24 months, at least one-third of their nutritional
needs.
 Complementary feeding means giving other foods in addition to breast milk. These
other foods are called complementary foods

Energy Gap Chart:

 25

Energy required and the amount from breast milk

Energy (kcal/day) 1000 Energy gap

800
600 Energy from
breast milk
400
200
0
0-2 m 3-5 m 6-8 m 9-11m 12 -23m Age (months)

Risks to starting CF too early;

Adding complementary foods too soon (before 6 months) may:
- take the place of breast milk, making it difficult to meet the child’s nutritional
needs;
- result in a diet that is low in nutrients if thin, watery soups and porridges
are used because these are easy for babies to eat;
- increase the risk of illness because less of the protective factors in breast milk
are consumed;
- increase the risk of diarrhoea because the complementary foods may not be
as clean or as easy to digest as breast milk;
- increase the risk of wheezing and other allergic conditions because the baby
cannot yet digest and absorb other foods well
- Increase the mother’s risk of another pregnancy if breastfeeding is less
frequent.
Risks to starting CF too late;
Starting complementary foods too late is also a risk because:
- the child does not receive the extra food required to meet his/her growing
needs;
- the child grows and develops slower;
- Might not receive the nutrients to avoid malnutrition and deficiencies such as
anaemia from lack of iron.
 26

Lecture 4: Family Planning and Contraceptive

Methods
Family Planning Definition refers to practice that help individuals or couples to attain
certain objectives: SHORT QUA

1. To avoid unwanted births.

2. To bring about wanted births.
3. To regulate the intervals between pregnancies.
4. To control the time at which births occur in relation to the ages of the parents.
5. To determine the number of children in the family.

WHO eligibility criteria >> Choose the method according to the health status of the woman
Category 1: No restriction to use the method

Category 2: Can use the method

Category 3: Do not use the method, the specialist can if necessary
Category 4: Never use the method
 27

 Contraceptive Methods;
Spacing Methods -
Terminal methods: male and female sterilization
Spacing Methods
1. Barrier Methods

a) Physical methods.
b) Chemical methods.
c) Combined methods.

2. Intra-uterine devices (IUD).

3. Hormonal methods.
4. Post conceptual methods.
5. Miscellaneous.

Spacing Methods

1. Barrier Methods

(a)Physical Methods

1. Condom

Most widely known and used barrier by males around the world. It prevents
semen from being deposited in the vagina.

Advantages of Condom MCQ

-Easily available.
-Safe and inexpensive.
-Easy to use (do not require medical supervision).
-No side effects.
-Light, compact and disposable.
-Provides protection not only against pregnancy but also against
STDs.
Disadvantages of condom

2. It may slip off or tear during coitus.

3. Interferes with sex sensation.

2. Diaphragm

It is a vaginal barrier.
Advantages
Total absence of risk and contra indications.
Disadvantages
Need a physician or other trained person to demonstrate the technique of
insertion into the vagina and to ensure a proper fit.
 28

3. Vaginal Sponge
In the past sponge soaked in vinegar or olive oil is used.
Now a small polyurethane foam sponge measuring 5 cm x 2.5cm, saturated with
spermicide.

(b) Chemical Methods

a. Foams: foam tablet, foam aerosols.

b. Creams, jelies and pastes- squeezed from a tube.
c. Suppositories-inserted manually.
d. Soluble Films-C-film inserted manually

Drawbacks

b. They have a high failure rate.

c. They must be used almost immediately before intercourse and repeated before
each sex act.

d. They must be introduced into those region of the vagina where sperms are likely
to be deposited.

e. They may cause mild burning or irritation.

2. INTRA-UTERINE DEVICES
Types of IUDs

First Generation IUDs

Inert or non-medicated devices, usually made of polyethylene, or other

polymers.
Different shapes and sizes-loops, spirals, coils, rings and bows.

Second Generation IUDs

It was found that metallic copper has strong anti-fertility effect
The addition of copper has made it possible to develop smaller devices which
are easier to fit.

Advantages of copper devices MCQ

- Low expulsion rate.
- Lower incidence of side-effects, e.g., pain and bleeding.
- Easier to fit.
- Increased contraceptive effectiveness.
- Effective as post-coital contraceptives, if inserted within 3-5 days of
unprotected-intercourse.
 29

Third Generation IUDs

This generation is based on release of a hormone. The most widely used
hormonal device is progestasert, which is a t-shaped device filled with 38 mg of
Progesterone; the natural hormone. The hormone is released slowly in the uterus at
the rate of 65mcg daily.

It has a direct local effect:

- on the uterine lining,
- on the cervical mucous; and possibly,
- on the sperms

Mechanisms of action of IUDs

-Foreign body reaction in the uterus causing cellular and biochemical changes in the
endometrium and uterine fluids, and it is believed to impair the viability of the gamete and
thus reduces its chances of fertilization rather than its implantation.
Medicated IUDs:
Copper seems to

 Enhance the cellular response in the endometrium.

 Affects the enzymes in the uterus.
 By altering the biochemical composition in cervical mucus, copper ions may
affect sperm motility, capacitation and survival.
Hormone releasing devices
-Increase the viscosity of the cervical mucous and thereby prevent sperm from
entering the cervix.

-Sustaining high level of progesterone in the endometrium, low level of oestrogen

and thus an endomerium unfavorable to implantation.

Advantages of IUD
Simplicity, i.e.no complex procedure are involved in insertion; no
hospitalization is required.
Insertion takes only a few minutes
Once inserted IUD stays in place as long as required.
Inexpensive.
Contraceptive effect is reversible by removal of IUD.
Free of systemic metabolic side-effects associated with hormonal pills.
Highest continuation rate.

Contraindications of IUD MCQ

A. Absolute

- Cancer of cervix, uterus or adenexia

- Suspected pregnancy and other pelvic tumors
.-Pelvic inflammatory disease.
- Previous ectopic pregnancy.
-Vaginal bleeding of undiagnosed etiology.
 30

b)Relative
-Purulent cervical discharge. - Anemia.
-Distortion of the uterine cavity due to - Mennorrhagia.
Congenital malformation or fibroids. -History of PID since last pregnancy.
Side-effects and complications of IUD MCQ = B and P ^ _^

-Pelvic infection. -Bleeding.

-Uterine perforation. -Pain.
-Ectopic pregnancy. -Pregnancy.
-Expulsion.
3. Hormonal Contraceptives

Most effective spacing methods of contraception.

Oral contraceptives of the combined type are almost 100% effective in
preventing pregnancy.
More than 65%in the world are estimated to be taking the (pill).
Gonadal steroids: Oestrogens and Progestogens.
There are;
a) Two synthetic Oestrogens (ethinyleoestradiol and mestranol),and
b) Three synthetic Progestogens (Pregnanes,Oestranes and Gonanes).

A. Oral pills: B. Depot (slow release) formulation:

1. Combined pill. 1. Injectable.

2. Progestogen only pill (POP). 2. Subcutaneous implants.
3. Post-coital pill. 3. Vaginal rings.
4. Once a month (long acting) pill.

5. Male pill.

A. Oral pills:
1. Combined pill

 Original pill contained 100-200mcg of a synthetic oestrogen and 10 gm of

progestogen.
 Now 30-35 mcg of a synthetic oestrogen and 0.5-1 gm of progestogen.
2. Progestogen-only pill (POP)

 Referred to as(minipill)or (micropill).

 It contains progestogen only.
3. Post-coital contraception

 Recommended within 72 hours of unprotected intercourse.

 Two methods are available:
-IUD.
-Hormonal.
 31

4. Once-a-month (long acting) pill

Long acting oestrogen with combination of short acting progestogen (NOT
vice versa) MCQ
Pregnancy rate is high and irregular bleeding.
5. Male pill
Prevent spermatogenesis.
Affect potency and libido.
Mode of Action of Oral Pills
The mechanism of action of the combined oral pill is to prevent release of the
ovum from the ovary. This is achieved by blocking the pituitary secretion of
gonadotropin.

Progestogen-only prepations
- Renders the cervical mucous thick and scanty and thereby inhibit sperm
penetration.

- It also inhibits tubal motility and delay the transport of the sperm and the ovum
to the uterine cavity.

Effectiveness
Combined type is 100% effective in preventing pregnancy.

 Risks and Benefits

a. Adverse effects
1. Cardiovascular effects.
2. Carcinogenesis.
3. Metabolic effects.
4. Other adverse effects;
- Liver disorder
- Lactation
- Subsequent fertility
- Ectopic pregnancy
- Fetal development
5. Common unwanted effect;
 -Breast tenderness
 -Weight gain
 -Headache and migraine
 -Bleeding disturbances

b. Beneficial Effects
-The most beneficial effect is its 100% effectiveness in preventing pregnancy.
-Non contraceptives health benefits is protection against:
i.Benign breast disorders (fibrocystic disease and fibro adenoma).
ii.Ovarian cysts.
iii.Iron deficiency anemia.
iv.Pelvic inflammatory disease.
v.Ectopic pregnancy.
vi.Ovarian cancer.
 32

 Contraindications:
a) Absolute
 -Cancer of the breast and genitals.
 -Liver disease.
 -Previous or present history of Thrombo-embolism.
 -Cardiac abnormality.
 -congenital hyperlipidaemia.
 -Undiagnosed abnormal uterine bleeding.

Duration of Use
- Pills is used for younger women.
- Those over 35 years should go in for other forms of contraception.
- Beyond 40 years of age, the pills are not prescribed or continued because of the
sharp increase in the risk of cardiovascular complications.

Medical Supervision
-Annual medical examination.
-An examination before prescribing the pill.

B. Depot Formulation
• Injectable contraceptives.
• Sub dermal implants.
• Vaginal rings.

a)Injectable contraceptives:
a) Progestogen-only injectable, and
b) Once-a month combined injectable

a) Progestogen-only injectable
These are:
1. DMPA (Depot-medroxyprogestrone)
 Standard dose is an intramuscular injection of 150 mg every 3 months. It
suppresses the ovulation. It has:
An indirect effect on the endometrium, and
Direct effect on the fallopian tubes and on the production of cervical
mucous
2. NET-EN (Norethisteroneenantate)
 Given IM in a dose of 200 mg every 60 days.
Both of them should be given by deep IM injection into the gluteus Maximus.
The injection site should never be massaged following injections.
Side effects Both DMPA and NET-EN have similar side effects, these are:
Disruption of the normal menstrual cycle.
Amenorrhea.
Contraindications
a. Ca breast;
b. All genital cancers;
c. Un-diagnosed abnormal uterine bleeding; and
d. A suspected malignancy.
 33

b) Combined injectable contraceptives

- These injectable contain a progestogen and an estrogen. They are given at
monthly interval plus or minus three days.
- Action mainly by:
suppression of the ovulation, and
The cervical mucous is affected by progestogens.

- Contraindications
o Confirmed or suspected pregnancy.
o Past or present evidence of thromboembolic disorders.
o Cerebrovascular or coronary artery disease.
o Focal migraine.
o malignancy of the breast and
o Diabetes with vascular complications.

c) Sub-dermal implants
- It consist of 6 silastic(silicone rubber) capsules containing 35 mg (each) of
levonorgestrel.
- The silastic capsule or rods are implanted beneath the skin of the fore arm or
upper arm.
- Effective contraception for over 5 years.
- The contraceptive effect is reversible on removal of the capsules.

The disadvantages are:

- Irregularities of menstrual bleeding; and
- Surgical procedures necessary to insert and remove implants.

c) Vaginal rings
- Vaginal rings containing levonorgestrel have is slowly absorbed through the
vaginal mucosa.
- The ring is worn in the vagina for 3 weeks of the cycle and removed for the
fourth.

 Terminal Methods
(1) Male sterilization.

(2) Female sterilization.

 34

Lecture 5: Integrated Management of Childhood

Illnesses IMCI
ASSAY + rich area of MCQs

 Introduction
- WHO/UNICEF initiative launched globally in 1995 (based on common diseases in
under 5 clinics.
- Major killers are (Acute Respiratory Infections – pneumonia-, Diarrheal Diseases,
Malaria, Malnutrition and Measles). Outpatient case load = disease covered by
IMCI = MCQ
- pneumonia kills 1.4 million\ year while diarrhea kills 1.2 = MCQ
- Its “provocative” challenge, was to move from the vertical disease-specific
approach of traditional programmes to a more integrated and horizontal child
approach, in line with the philosophy of primary health care.
- IMCI guidelines adapted to each country alone

Objective:
 Reducing under-5 mortality, morbidity and disability,
 And improving child growth and development.
 And involving parents, households and communities in the care of their children

-IMCI strategy endorsed by the Federal Ministry of Health, November 1996

-Started to be implemented in Sudan in 1998 in two states (Khartoum & Geizera).
-integrated clinical guidelines for the outpatient management of priority conditions in
sick children below 5 years of age
-Health care providers are provided the means of detecting more than one problem in a
child during the same consultation and managing those problems through an integrated
approach at first-level health facilities.
- IMCI includes both curative and preventative measures aim to improve the practices
both at home and in PHC.

 Age groups covered by IMCI: MCQ

1. Infant to 2 months
2. two months to 5 years

 Case management
 Assess and classify sick child
 Identify criteria for urgent referral
 clinical signs of malnutrition
 routine screening for immunization status of all sick children seen opportunities
for immunization
 Counseling the mother assessing feeding practices
 35

 Components of IMCI = ASSAY

1. Improve health providers’ skills: concerns pre-services training and in-service
training, public and private sector.

2. Improve health system to deliver IMCI: concerns policy, planning and

management, financing, organization of work and distribution of tasks at
health facilities, human resources, availability of drugs and supplies, referral,
monitoring and health information system, supervision, evaluation and
research.

3. Improve family and community practices related to child health and

development. This currently refers to key family and community practices
that, if properly promoted and adopted by the targeted communities, would
potentially contribute to improving child survival, growth and development
 36

 Benefits of IMCI:
a. address of childhood problems
b. promotes the cure and prevention
c. improve the health provider performance
d. major impact on health status
e. Major impact on health system = cost saving through: targeting health problems causing
the highest burden of diseases and deaths earlier.
f. Strengthen de-centralization and management of child health services.
g. Reduces overuse = rational use of drugs.
h. Preventive interventions (vit A, nut. advice)
i. Improvement of quality of care leading to greater caretaker satisfaction & increased
utilization of health service.
j. Reducing missed opportunities for immunization or for detection & treatment of
malnutrition
k. >> It is an important determinant of health service utilization.
l. improve the equity
m. Organization of work at health facility

 Key Family and Community Practices

1) Exclusive Breastfeeding.

2) Complementary Feeding.

3) Micronutrients.

4) Immunization.

5) Malaria Prevention And Control

6) Psychosocial Development.

7) Home Care for Illness and Infections.

8) Care-Seeking.

9) Compliance with Advice. = giving the recommended treatments

10) Antenatal Care.

11) Growth Monitoring

12) Family Planning

13) Hygiene: Disposal Of Feces Safely & Hand Washing Practice.

14) Cont. feeding during illness

15) Using of iodized salt

16) tennis toxoid for pregnant

 37

 The role of the families

 The ability to respond appropriately when their children are sick.
 Seeking appropriate and timely assistance when children need additional care.
 Giving recommended treatment.
 Change their behavior and attitude using KFPs

 Role of Medical Students in the field activities

o To assess the key family practices of the IMCH in the rural areas
o To promotion of the key family practices of the IMCH in the rural areas
o To raise the awareness of the families in the in the rural areas about the
key family practices.
 38

Lecture 6: Cold Chain

What is cold chain?

• The system for storing, transportation, and distribution of vaccines, keeping
the vaccines potent from the source of production until it reach the
beneficiary (mother and child).

Components of CC:
• Vaccines • Equipment and containers
• Monitoring system • Personnel
Precautions and Requirements:
• Fast transportation of vaccines and solvents from airport to the central stores
of the cold chain.
• Ensure the standard degree of temp. During the transportation, at central
stores, state stores, locality stores and the health center refrigerator.
• Ensure the standard degree of temp. During distribution to the peripheral
health units and the mobile teams.
• Ensure the standard degree of temp. during immunization session

Cold Chain Equipment:

Different levels need different equipment MCQ
 Central stores: cold rooms, freezing rooms, ice packs, refrigerators, cold boxes.
 Locality stores: ice bags, refrigerators, cold boxes
 Health centers: refrigerators, cold boxes, vaccine carrier, ice bags

Types of refrigerators:
1. Electric( need continuous electricity supply)
2. Gas
3. Kerosene
4. Solar

There should be one person responsible about the refrigerator in order to:
1. Store vaccines, solvents and prepare frozen ice bags.
2. Read the degree of temperature twice daily.
3. Keep the refrigerator and accessories working proper and call for maintainers.
4. Solve any problem facing the cold chain at HC.

Refrigerators at HC:
 Ice lining refrigerator ( could be used for normal refrigeration and freezing)
 Solar refrigerator
 Domestic refrigerator
 Absorbent refrigerator( kerosene)
 39

Storing in Refrigerators

 At the HC the storing capacity should accommodate:

1. One month stock of vaccines and solvents + reserve 25-50%
2. Ice bags at bottom of the refrigerator to safe guard against cutoff of electricity.
3. Keep spaces between vaccine boxes for air circulation

 It is only vaccines and solvents

 Put the vaccines and solvents inside the refrigerator to keep the degree of temp.
Between +2 and +8 ċ. MCQ
 Measles and polio and its solvents at the upper shelve
 BCG, DPT, and HB and its solvents in the middle
 Make spaces between vaccine boxes.
 Put the bags at the freezer to make ice bags

Precautions MCQ
Don’t put vaccines in the refrigerator`s door
Don’t store expired vaccines either destroy it or send it back as losses
Don’t store any food, drinks or drugs with vaccine
Don’t open the refrigerator`s door frequently( more than 3 times /day)
Don’t open the refrigerator`s door and then search for what you want.

ICE BAGS
o Square plastic container already filled with water.
o It will be frozen to be used inside the cold boxes and the vaccine carriers.
o Its sizes between 0.6 liter for CB and 0.4 liter for VC.
o At the health, two sets of ice bags should be available (one in use and
the other in the refrigerator)
Cold Boxes
• Insulator box
• Could be used for transportation of vaccines from state to locality and
from locality to health center
• Protect vaccines and solvents for transient periods
• Used for mobile teams
• There are different types of cold boxes with different cold life span ( 2-7
days)
• Cold life span (the time needed for increasing the temperature inside the
box from -2 to +10 ċ without opening the box cover.
• Preparing the cold box;

1. Put the ice bags to line the box in all its interior side and bottom
2. Close the box for 15 minutes
3. Take the required amount of vaccines and solvents and close the
refrigerator
4. Put the vaccines and solvents in the central of the box

o Don’t put DPT,TT,HB vaccines directly on the ice bags, put insulator in between like
newspapers
o Put the thermometer inside the box
o Cover the box with ice packs
o Close the box perfectly
o Don’t put the cold box under the sun
o Protect it from break
 40

Vaccine carrier
• Small insulator box covered by foam pad
• Cold life span 24-72 hours MCQ
• Used for mobile teams
• Storing vaccines during immunization sessions
• Transporting vaccines from locality to health center
• For emergency and transient period when the refrigerator is out of power
To fill the vaccine carrier, put 4 ice bags interior in the VC, put the vaccine
and cover with foam bad

Monitoring Temperature = SHORT qua

To monitor the temperature of vaccines and solvents during transportation and storage.

a. Dial Thermometer (DT): used to monitor the temperature in the refrigerator,

cold box and vaccine carrier.
b. Cold Chain Monitor (CCM): card with windows, the color of these windows
change when temperature raised. It give the time duration of the vaccine been
exposed to raised temperature.
CCM is attached to BCG, DPT, Polio, Measles, and HB vaccines at the factory
level and make it available for the consumers.
c. Freeze Tag (FT): electronic instrument, it is attached to DPT, TT and HB vaccines
in the refrigerator and the cold boxes.
It monitor those vaccines from been frozen
d. Vaccine Vial Monitor (VVM): it is a label paper attached to the vaccine vial, polio
vaccine in particular. The color changes is sensitive to temp. Raising.
 WHO grading of VVM in OPV: (marker of potency)

- Is based on color changes VVM; only inner square changes color, circles always remain
blue. MCQ

WHO Grade Outer circle Inner circle Inference

Grade I Blue White OPV can be used

Grade II Blue Light blue OPV can be used
Grade III Blue Blue OPV CANNOT be used
Grade IV Blue Purple/Black OPV CANNOT be used

e. Monitor the temp. Of the refrigerator: put thermometer in side and attached
daily temp. Registration card on the refrigerator door. Record the temp. in the
morning and afternoon for every month

Immunization Session
1. Weekly Schedule
2. Available vaccines
3. Registration cards and RTCs
4. Cleaning materials
5. Disposal of wastes
6. No. of children to be vaccinated in each session:
 41

No. of children No. of vials from each vaccine

< 10 children One vial vaccine and one solvent

10-30 child 2-3 vials each

> 30 child > 3 vials

 42

Lecture 7: IMMUNIZATION SERVICES

Introduction
 Immunization services are delivered through health system by State Ministries of
Health and NGOs.
 The units for service delivery are;
o Hospitals.
o Dispensaries
o Mobile teams
o Health centers
o Campaigns
o MCH clinics

- Always, there is scope for further expansion to include any disease, any population
whenever it is deemed necessary &feasible.
Strategies & Targets
Strategies are:
a) Routine immunization of children through passive flow of clients to health units.
b) Reinforced immunization whenever there is an alarming disease situation or
eradication program like neonatal tetanus program and polio eradication.
Targets for immunization are: MCQ
1. Children below 5 years of age.
2. Women in child bearing age WCBA

Objectives
1. To reduce the incidence of immunizable diseases among children below five
years of age.
2. To increase coverage of immunization for eligible children by 100%.
3. To reduce the incidence of Neonatal Tetanus by immunizing women in the child
bearing age with Tetanus Toxoid.

Criteria for Achieving the Objectives

1. Right age of vaccination (under five year and WCBA).
2. Correct dose, dose interval and full regime (the national schedule).
3. Right technique (Oral, IM, SC).
4. Availability of a potent vaccine
5. Well-structured and functioning cold chain.
6. Integration with PHC services especially MCH clinics.
7. Regular supply of potent vaccine.
8. Maintain well-functioning cold chain.
9. Avail feasible and reliable surveillance system.
10. Capacity building of health personnel (Training).
 43

 Immunizable diseases = disease under control of vaccines = ASSAY

Expanded Program of Immunization (EPI)

 Established in 1978 (Alma-Ata) conference.

 5 more vaccines were added to BCG; therefore expanded.
 The target population was children <1year.
 A new schedule of immunization introduced in 1.1.2008. Targets for
immunization are :
1. Children below 5 years of age.
2. Women in child bearing age (WCBA)
Old Schedule of E.P.I
 At Birth: BCG ,Oral Polio Vaccine(OPV0)
 6 weeks: Triple1 + OPV1
 10 weeks: Triple2 + OPV2
 14 weeks: Triple3 + OPV3
 9 months : measles

New Immunization Schedule (children) = MCQ\ SHORT QUA

Age Vaccine Doses Sites

At Birth BCG 0.05 ml Intradermally(I.D)

+ OPV0 Two drops Oral

6 weeks Penta1 0.5 ml I.M,

R thigh(anterolateral)

+OPV1 Two drops Oral

+Rota1 1.5 ml Oral
+PCV1 0.5 ml I.M,
L thigh(anterolateral)
10 weeks Penta2 0.5 ml I.M,
R thigh(anterolateral)

+OPV2 Two drops

+Rota2 1.5 ml Oral
+PCV2 0.5 ml Oral
I.M,
L thigh(anterolateral)
14 weeks Penta3 0.5 ml I.M,
R thigh(anterolateral)
+IM Polio

+OPV3 Two drops Oral

+Rota3 1.5 ml Oral
+PCV3 0.5 ml I.M,
L thigh(anterolateral)
9 months Measles1 0.5 ml + Subcutaneous, upper
Meningococcal arm.
18 months Measles2 0.5 ml
 44

Pentavalent vaccine

 5 vaccines: DPT + 2 B
- Diphtheria protect against Diphtheria
- Pertusis  protect against Pertusis
- Tetanus  protect against Tetanus
- Hepatitis B vaccine  protect against HB
- H.I.B  protect against Pneumonia & Meningitis
 Therefore pentavalent vaccine protect against 6 diseases. (EPI cover 12 diseases)
Newly added vaccines;
 Intramuscular polio vaccine: Killed vaccine (Salk) given at 14 weeks.
 Meningococcal A vaccine: given at 9 month.

ROUTES: MCQ

 Recombinant = cellular fraction + menngiococcal

- Oral polio = OPV = sabin, Inactivated = IPV = salk
- Mengiococcal + hepatitis = half killed vaccine
 45

 Immunization schedule (WCBA)

 Tetanus Toxoid: 0.5 ml. IM Deltoid muscle MCQ \ SHORT QUA

Date Dose

Immediately after the 3rd month First essential dose (no immunity)
After one month 2nd essential dose (immunity for 3 years)
6 months later or next pregnancy First booster (immunity for 5 years)
A year later or next pregnancy 2nd booster (immunity for 10 years)
A year later or next pregnancy 3rd booster (lifelong immunity)

-The above five doses will protect the women for life, and need not to have further
doses in subsequent pregnancies and in case of doubt you can give a booster in present
pregnancy.
Contraindication:
Ill infant that requires hospitalization:

1. Deferred immunization till the infant recovers and could be at discharge.

2. Don`t immunize if the infant is a victim of one of immunizable diseases,
except in case of recovery from tetanus, the child should be immunized with
Tetanus Toxoid.
3. There is no danger in immunizing a child who has suffered from the same
disease in the past and recovered.

Severe Adverse Reactions:

1. Stop vaccination with subsequent doses of DPT if the child develops shock
and convulsions after the first dose.

2. Give a single dose vaccine of diphtheria + tetanus pediatric formula (avoid

pertussis component).

Diarrhea:
1. Contra-indication for OPV immunization,
2. The dose of OPV given during an episode of diarrhea should not be counted and
to give at the earliest opportunity

Hot liquids or food:

1. Avoid giving hot liquids or food for half an hour after OPV.
2. Breast feeding prior to or after OPV dose is not forbidden nor contraindicated.

Tuberculin Testing:
— Not required before BCG administration till the age of 12 years.
 46

Role of Medical Officer

Continuous supervision for:

— Immunization Technique.
— Dosage of vaccines.
— Maintenance of cold chain.
— Health worker`s errors.
— Constraints

— Missed Opportunities: pick up children that did not receive any immunization
or partially immunized, whenever or wherever the child is in contact with
care MCQ

— Defaulters: are those who use the immunization services at some time and do
not complete the doses in the schedule within 4 weeks after the use. MCQ

 Specific contraindications of vaccines: MCQ

- Vaccines contraindicated in pregnancy: ALL live vaccines EXCEPT Yellow fever vaccine.
- Vaccines contraindicated in HIV:
1. Asymptomatic HIV: NONE
2. Symptomatic HIV: All live vaccines EXCEPT BCG vaccine.
- Vaccines contraindicated in Immuno-suppression: all live vaccines.

- Vaccines contraindicated in corticosteroid therapy: all live vaccines.

- Vaccines contraindicated in fever: Typhoid vaccines.
- Vaccines contraindicated together: Yellow fever and Cholera vaccines.
- Vaccines contraindicated in Preterm-premature baby with birth weight < 2kg: Hepatitis B
- Vaccines contraindicated in age < 1 years (infants): Yellow fever vaccines.

- Vaccines contraindicated in age < 2 years (infants):

1. Meningococcal vaccine
2. Pneumococcal vaccine
3. Typhoid vaccines
- Vaccines contraindicated in age > 2 years: Pertussis vaccine (may lead to neurological
complications – 1 per 1, 70,000 vaccines)
- Vaccines contraindicated in progressive neurological disease: Pertussis vaccine (pertussis
vaccine is not contraindicated in epilepsy controlled on medications, cerebral palsy)
- Only absolute contraindication to killed vaccines: Severe local or general reaction to a
previous dose.
 47

 Specific side-effects of vaccines:

- Gullian Barre Syndrome: Killed influenza vaccine
- Vaccine associated paralysis: OPV (Sabin)
- Toxic shock syndrome (TSS): Measles vaccine, MMR
- Shock: DPT, Pertussis vaccine

 General rules for multiple vaccine administration:

- 2 live vaccines can be given together.
- Live and killed vaccines can be given together.
- Cholera vaccine and Yellow fever vaccine cannot be given together.
- OPV is a live vaccine where single dose is not sufficient for immunization.

 Strains of commonly used vaccines: MCQ

BCG  Danish-1331 strain (WHO recommended)
OPV/IPV  P1, P2, P3 strains (Mono or Tri-valent)
Measles vaccine  Edmonston Zagreb strain (MC), Schwartz strain
, Moraten strain
Mumps vaccine  Jeryll Lynn strain
Rubella vaccine  RA 27/3
Yellow fever vaccine  17 D strain
Varicella vaccine  OKA strain
 48

Lecture 8: Human Nutrition

What is nutrition?
Defined by Robinson (the science of food, nutrients and other substances therein;
their action, interaction, and balance in relationship to health and disease; the
processes by which the organism ingests, digests, absorbs, transports and utilizes
nutrients and disposes of their end product).

Simpler definition: (The science regarding the role of food in maintenance of health)
• Also it may be defined as the science of food and its relationship to health.

Definitions

 Nutrient: used for specific dietary constituents, proteins, vitamins, etc.

 Dietetics: practical applications of nutrition principles; it includes planning for

meals in well and sick.

 Good nutrition: maintain nutritional status that enables one to grow well and
enjoy good health.

 Macronutrients: proteins, fats, carbohydrates.

 Micronutrients: minerals, vitamins and trace elements.

 Continue

 Energy requirement: the energy intake in relation to expenditure.

 RDA: the amounts of nutrient sufficient to the maintainous of health.

 Kilocalorie: the measuring value for energy.

1g protein= 4 Kcal

1g carbohydrate= 4 Kcal
1g fat = 9 Kcal
Classification of food
 Animal and vegetable origins
 Chemical composition: proteins, fats, carbohydrates, minerals, vitamins.
 Body-building; Milk, meat etc.
 Energy producer: Cereals, sugar, roots etc.
 Protective : vegetables, fruits etc

Nutrition and Health

 Nutritional problems are due to multifactor rooted in all other sectors rather
than health, but;
 Nutrition is a major determent of health
 49

 Dimensions of health known to be affected by nutrition till last decade are:

1. Achievement of optimal growth and development ( during infancy, childhood

and adulthood)
2. Functional efficiency of body tissues for active and productive life

New Insights

• Knowledge from different sciences like immunology, molecular biology,

geriatrics, and photochemistry during the last three decades lead to identify
more health Dimensions which affected by nutrition.
• These are:

1. Nutrition and immunity

2. Bioactive Photochemical in food
3. Fetal under nutrition and chronic diseases
4. Nutrition and aging
5. Nutrition and CHD
6. Nutrition and cancer

• Assessment of nutritional status ASSAY

1. Individual
2. Communities( cross sectional)
3. Cohort

Anthropometric: the science of measuring physical dimensions and gross

composition of the body

Nutritional status: Expresses the degree to which physiological needs for nutrients
are being met.

Individual nutritional status

Child growth indicators

The 3 most commonly used anthropometric indicators to assess child growth are:

 Weight-for-Height
 Height-for-age
 Weight-for-age
 50

 Anthropometry
•Age

 MUAC(Mid upper arm

circumference);
o<12.5 cm: normal
o11-12.5cm:moderate malnutrition

o < 11cm: severe malnutrition

o< 21.5 cm : malnutrition in
pregnant and lactating

 Height
 Weight
 Skin fold thickness
 BMI (Wt / ht2 )
 Head and chest
circumferences
 Calf circumference
 Pitting edema
 51

BMI INTERPRETATION MCQ

< 16.0 severe thinness

16.0 - 16.9 moderate thinness

17.0 - 18.4 marginal thinness

18.5 - 24.9 normal range for an individual

Over-
25-29.9 weight

> 30 obese

CARD: Road to health

• Designed to follow up the health and the nutrition status of the child below 5
years of age

• Composed of: MCQ

i. growth curves
ii. Information for timing of BF and CF
iii. Timing of FP
iv. Indicators for growth (millstones)
v. >> NO BMI
 Vaccination Schedule for children
 Vaccination schedule for mothers
 Some anti-natal- intranatal and post-natal information
 Vitamin A supplementation

Child growth monitoring

Growth;

 A normal, healthy child grows at a genetically predetermined rate that can be

compromised by imbalanced nutrient intake.
 52

Growth in the first 12 months

 From birth to 1 year of age, normal human infants triple their weight and
increase their length by 50%. MCQ
 Growth in the first 4 months of life is the fastest of the whole lifespan - birth
weight usually doubles by 4 months.
 4-8 months is a time of transition to slower growth.
>> Periodical weighting of children (monthly for the first 3 years & yearly up
to 5 years)
Assessment

 Screening identifies nutritional risk and/or need for further assessment.

- Underweight
- Overweight
- Failure of growth
- Milestones
WHO Child Growth Standards MCQ \SHORT QUA

 Assumed that infants and children between birth and 5 years grow similarly
when needs are met WHO Child Growth Standards Innovative aspects
 Prescriptive approach recognizing need for standards.
 Breastfed infants as normative model.
 International sample
 Reference data for assessing childhood obesity.
 Velocity reference data.
 Link between physical growth and motor development
 Checking developmental milestones (laughing, sitting, standing, walking,
talking…)

When Growth Deviates from the Norm

 Check accuracy of your measurements.
 Note that individual growth may not follow a smooth curve.
 Recognize limitations of a single reading value.
 Obtain serial measurements over time.
 Assess fully, follow closely and refer, if needed.
 Overweight is weight-for-height greater than 2 standard deviations above
WHO Child Growth Standards median; and
 Obesity is weight-for-height greater than 3 standard deviations above the
WHO Child Growth Standards median.
 53

MCQ

Malnutrition

Variables:
- Age - Body weight in kg
- Height (length) in cm - Pitting edema
Methods of analysis:
- Z-score - Gomez
- BMI - Welcome (clinical) classification
Z-score:
Mean and SD
-2 z-score = Moderate Malnutrition
-3 z-score = Severe Malnutrition
Gomez:
< 80% > 70% = Mild
< 70% > 60% = Moderate
< 60% = Severe
Edema = Severe
 54

BMI:
Obesity
>30 <40 = Obesity
> 40 = Morbid obesity

Types of malnutrition:
Acute (Wasting)
Wt/Age Gomez Z-score
Chronic (Stunting)
Ht/Age Gomez Z-score
Overall
Wt/Ht Gomez Z-score

Malnutrition infection cycle

Inadequate intake  mucosal change + low immunity  disease  low appetite +
malabsorption + nutrients loss affection of metabolism  inadequate intake.

Classification
1. Marasmus
2. Kwashikor
>> Early detection = wt/age (acute) through road to health card.

Management
- Manage hypoglycemia and hypothermia and other warning sign.
- Continue breastfeeding.
- Extra food supplement.
- Educate the mother.
- Search for cause = malaria, worms
- Follow up
>> Individual progressing = 10g/kg/day

Feeding
1. Prepare F 75 and F 100 (kwash milk)
2. Planning feeding daily all through 24 hours in schedule and calculate the
appropriate dose of F 75 at each meal
3. Measure the feeds and keep close contact or feeding
4. Record the intake and output of F 75 and vital signs
5. Planning the feeding for the ward
6. Identify the time for changing to F 100

Daily care
- Handling carefully - Weight chart
- Giving antibiotics and other medications
- Caring for the eye - Monitor vital signs

Nutritional surveillance and growth monitoring

- Nutritional surveillance should not be confused with Growth monitoring.
- Growth monitoring is oriented to individual child, and is a dynamic measure of its
health from month to month.
- It focuses on normal nutrition for infants
 55

Growth chart
- It displays weight in kilograms on the vertical axis, and the age in months on the
horizontal axis.
- The child's weight is marked in pencil opposite to the child's age in months.
- The dot is neatly joined to the previous month's dot to see in which direction the
line is going.
- The green zone on the chart indicates normal growth (<-2Z-score).
- The orange zone (-2 to -3 Z) indicates moderate malnutrition. MCQ
- The red zone (below -3 Z) indicates severe malnutrition.

Reference population
Designation of a child as having impaired growth implies means a comparison to a
reference child of the same age and sex.
Ministry of health follows the reference curve adopted by WHO shown in the growth
chart in child health card.
It is based on the child's weight for age Z-score compared to the median Z-score of a
reference standard population.

>> Intrauterine period is a very important period from the nutritional point of view.
>> Period of weaning is the next critical period of childhood.

Clinical assessment

 Physical signs specific to nutrition deficiency; like angular stomatitis, Bitot`s

spots, Calf tenderness, absence of knee or ankle jerk (beriberi).
 Malnutrition cannot be quantified on the basis of clinical signs.
 Standard form have been devised for the surveys
 56

Biochemical assessment
• Serum Iron • Hemoglobin estimation
• Urinary iodine • Serum albumin
Urinary urea per gram
• Measurement of enzymes that • creatinine
need certain vitamins as co • Plasma amino acid ratio

Factors • Stool ( worms) and urine(

• Vitamins estimation Albumin).
• Serum retinol

Functional assessment MCQ

1. Dark adaptation – vitamin A

2. Sperm count – energy and zinc
3. Prothrombin time – Vitamin K
4. Nerve conduction- vitamin B1 and B12

Dietary intake assessment

1. Weighment of raw food
2. Weighment of cooked food
3. 24 -48 hours recall of meals

Vital statistics
1. Mortality and morbidity
2. Age specific morbidity and mortality
3. Disease specific morbidity and mortality

Assessment of ecological factors (environmental factors)

1. Food balance sheet ( general pattern of food consumption in the country)
2. Socio-economic factors
3. Health and educational services
4. Influencing factors ( parasites, bacterial, viral)

Community’s nutritional status

 Through surveys
 Collection of data regarding nutrition behaviour, household food security beside
anthropometric measures
 Usually conducted in disadvantage communities
 Sometimes it could be several periodic surveys for monitoring the community status
 57

Cohort nutritional status

Nutrition surveillance Keep watch over nutrition in order to make decisions that will
lead to improvement in nutrition of population

1. It is for timely warning and interventions.

2. It is for planning for health and development
3. provide inputs for program management and evaluation
4. Nutrition Indicators are, LBW,% BF, HT/Age, Wt/Age, Wt/Ht, MUAC
5. Others: agricultural surveillance indicators

Nutritional problems in public health:

(Multivitamins deficiency problem in Sudan Assay Qua + MCQS)
1. Low Birth Weight( multifactorial)
2. Protein energy malnutrition( energy and protein)
3. Nutritional anemia( Iron)
4. Xerophthalmia( vitamin A deficiency )
5. Iodine deficiency disorders(iodine)

Low Birth Weight ASSAY

 The birth weight should be taken in the first hour after delivery.
 Two groups of LBW: prematurely (short gestation) and FGR.
 The cutoff point is 2500 gram, less than it including 2499 gram is considered LBW.
 Any infant borne with BW less than 2500 gram regardless of gestational age is of
LBW
 It is one of monitoring indicators for health programs.
 Proportion of babies born with LBW is used as monitor to achieve the strategic
goals (a world fit for children up to 2010 and MDG up to 2015).It is computed as
Live Borne Babies (LBB) with LBW / total No. of LBB x 100.
 In developing countries between 10-30% of babies born with LBW, mainly due to
FGR.
 In developed countries LBW is about 4%,mainly due to short gestation.
 Generally, worldwide, about 15.5% of all births are of LBW( 20 million), 95.6 % of
them in developing countries.
 Most of LBW died in early life hood and if grow they are at the risk of PEM.
 The lower the BW the lower is the survival chance.

Risk factors for LBW SHORT QUA

1. Maternal malnutrition
2. Maternal anemia
3. Hard physical labour during pregnancy
4. Maternal infection.
5. Smoking
6. Hypertension
7. Low socioeconomic status.
8. Close birth interval
9. Placental factors, like insufficiency, abnormalities.
10. Foetal abnormalities, chromosomal abnormalities, multiple gestation
11. Short maternal stature.
12. Young age pregnancy
13. High parity
 58

Prevention

 Public health significance: when LBW more than 10% in a community.

 The problem is multi factorial, no universe solution, intervention have to be
cause specific.
 Good prenatal care and intervention programs are of value.

The LBW infant is at – risk of under nutrition due to:

 Impaired suckling and swallowing
 Susceptibility to frequent regurgitation, due to underdeveloped muscles and
reflexes.
 Poor absorption of fat – soluble vitamins.
 Inadequate body stores (reserves) of nutrients, as iron and vitamin D.
It is thus necessary to follow proper feeding system:
 Following the same system of infant feeding: breast. Feeding (or milk
feeding) dietary supplementation, and proper weaning.
 Giving more protein, calcium, iron, and vitamins C and D.
 Managing suckling and other feeding problems.
 Administration of parenteral vitamin K,
Treatment:
Intensive care unit, depends on the severity of the condition.
 Incubator
 Feeding (breast milk) centers
 Prevent infection

Protein Energy Malnutrition PEM

 Commonly affects under five children.

 Usually accompanies with micronutrient deficiencies.
 It leads to morbidity and mortality, further it leads to permanent impairment of
physical and mental growth to survivors.

Factors contributing to the occurrence of malnutrition ASSAY

a. Inadequate intake of carbohydrates and proteins.
b. Diarrhea, ARI, Measles, intestinal worms, frequent attacks of malaria
c. Poor environmental conditions
d. Large family size
e. Poor maternal health
f. Failure of lactation
g. Early weaning
h. Delayed supplementary feeding
i. Adverse culture practices of child feeding (over dilute milk)

Prevention of malnutrition
Direct intervention
>> Prevention of micro nutrient deficiency:
 Supplementation: Iron, Iodine, Vitamin A
 Diversification: different types of food (food pyramid)
 Fortification of food, milk, sugar and salt
 Nutrition education
 59

Indirect interventions
 Health and nutrition education
 Nutrition surveillance
 Promote breast feeding
 Promote adequate complementary feeding
o Family planning
 IGAs to families
 Child immunization
 Food fortification
 Early diagnosis and treatment ( road to health card)
 De worming
 Implementation of IMCH (Integrated Maternal and Child Health)
 Rehabilitation and follow up care

 Nutritional Anemia (Iron Deficiency Anemia)

 Iron deficiency results when insufficient amount of iron is available to meet
body’s requirements.
 Iron deficiency anemia is the end stage of a relatively long process of
deterioration in the iron status of the individual.
ETIOLOGICAL FACTORS IN IRON DEFICIENCY ANEMIA

Factors affecting the bioavailability of dietary iron MCQ

Enhance Ascorbic acid, Meat, Fish, Poultry

Inhibit e.g Tannates (tea, coffee),, Antacids, Clay,

 60

Maternal anemia
• Results in:
1. Intrauterine growth retardation
2. Preterm delivery, LBW,
3. Increased perinatal mortality
4. Increased maternal morbidity and mortality.
5. Mental and motor development is impaired in anemic infants and
children
6. Apathy, inactivity and significant loss of cognitive abilities.

• Generally, Impairs work performance, and productivity.

Transfer of the iron from mother to infant occurs during the 3rd trimester of
pregnancy). MCQ

 Vitamin A Deficiency (Xerophthalmia)

Assessment and prevention = ASSAY qua
Plants: Carotenoids (pro vitamin A)
- Naturally occurring pigment (red, orange, yellow, brown)
- More than 50 of certain Carotenoids are capable to be converted to pro
vitamin Animals: Retinoid ( preformed vitamin A) Mainly stored in livers
other sources are fortified foods.

Animal foods: liver, eggs, butter, cheese, whole milk, fish and meat, fish liver oils are
the richest natural sources of retinol.

Plant foods: green leafy vegetables. The darker the green leaves the higher its
carotene content. Also found in yellow vegetables and fruits, papaya, mango,
pumpkin, carrots

Animal sources

Sources Retinol equivalent ( RE)

Mcg / 100 g

Halibut liver oil

(THE most = MCQ) 900,000

Cod liver oil 18,000

Shark 180000

Liver of Ox 16,500
 61

Storage
• The liver has an enormous capacity to store vitamin A in the form of retinol
palmitate.

• Under normal conditions, a well fed person has sufficient vitamin A reserves
to meet his needs for 6-9 months or more

Functions
• Vitamin A participates in many body functions

1. Vision – production of retinal pigment which needed for vision in dim

light
2. Maintain integrity and functioning of glandular and epithelial tissues
which lines GIT, RT, UT, skin and eye.
3. Cellular differentiation
4. Immune response
5. Haemopoiesis, Iron metabolism?
6. Growth of skeletal system( hormone like)
7. Fertility and reproduction
8. Thermogensis in mitochondria
9. Obesity control
10. Development of fetal nervous system
11. Cancer prevention

Signs of Vitamin A Deficiency (Xerophthalmia) Ocular assessment:

• Bitot`s spots
• Corneal Xerosis
• Corneal ulceration and scaring
• Keratomalacia

Biochemical Assessment
Serum Retinol: SR
Serum Retinol binding protein: RBP
Relative dose response: RDR( assess liver store)
B M vitamin A concentration(new, non-invasive, easy to collect, accepted)

Epidemiology
It is rare during infancy but preschool and school children are at high risk.
The age group 1-3 years has the highest incidence of Xerophthalmia and is
associated with the peak of PEM
Sex: male more susceptible, though the incidence of keratomalacia is similar
in both
Pregnant and lactating women are more susceptible.
Susceptible persons to VAD are:

1. Rural children belonging to families with low income.

2. Children with illiterate mothers
3. Living in communities have negative food taboos
4. Negative culture and food practices
5. Infectious diseases
6. Malnutrition
 62

Public significance of VAD (as recommended by WHO) MCQ

• Night blindness 1.0%
• Bitot`s spots 0.5 %
• Corneal xerosis, Keratomalacia 0.01%
• Corneal scar 0.05%
• SR (less than 0.35 u mole/L) 5.0%

Treatment dose (WHO, UNICEF, IVACG 1997) MCQ \SHORT qua

immediately at Dx
 < 6 month >> 50 000 IU
 6-12 month >> 100 000 IU
 12 month >> 200 000 IU
Next day;
Same dose for age
At least 2 weeks later;
Same dose for age
 If not available depend on food rich in vit A only.
Preventive dose;
-< 6 month;
 None breast feeding >> 50 000 IU
 Breast feeding but mother not received preventive dose »50 000 IU
-6-12 month;
100 000 IU / single dose.
-> 12 month;
200 000 IU / 4-6 month
-Mothers;
200 000 IU 8 weeks after delivery

 Iodine Deficiency Disorders (IDD):

Introduction
Iodine is essential micronutrient needed in minute amounts for growth,
development and wellbeing of human..
Iodine is a trace element needed in a tiny daily amount and not stored in
the body
Required for synthesis of thyroid hormones.

Sources
Sea food
Milk, meat if the animal eat plants grown in soil rich of iodine
Fortified food( salt, sugar, milk)

Clinical feature:
• Goiter
• Cretinism: consequence of hypothyroidism during fetal or neonatal life
• Hypothyroidism;
- Sluggishness
- Sleepiness
- In young children: mental & growth retardation, may be sever or mild
that could not be easily recognize
- In newborns: mental retardation is irreversible
 63

Reduction in intellectual development

-I.Q is less than normal by 13.5 point MCQ
• Reproductive failure:
- Miscarriages
- stillbirth
- Infertility
• Contribute to child mortality through affection of birth weight
Assessment of IDD;
• TGR
• Urinary iodine excretion ( diagnostic less than 10 mcg/deciliter)

• Laboratory tests ( Thyroid Hormones)

• Radioiodine uptake of the thyroid
• Ultrasound of the thyroid

Sudan Situation 1997 national survey

= most affected area = western

Sudan = MCQ

Preventive measures of micronutrients

• Supplementation: Iron, Iodine, Vitamin A
• Diversification: different types of food( food pyramid)
• Fortification of food, milk, sugar and salt
• Nutrition education

Nutritionally Vulnerable Groups SHORT QUA

 Low birth weight Neonates (see above).

 Infants
 preschool children
 school children
 pregnant and lactating mothers are the main groups characterized by:
*Relatively increased biological demand of nutrients
*In need of special feeding scheme, to satisfy their requirements.
* More exposed to the risk of malnutrition and deficiency diseases.

 Elderly population
 64

Infants
• Under any circumstances, breast milk is the ideal food for Infants.
• The energy value is 70 Kcal per 100ml.
• Infant mortality is 5-10 times higher among children who have not been breastfed or
who have been breastfed exclusively for less than 6 months.

 Nutrition surveillance
Keep watch over nutrition in order to make decisions that will lead to improvement in
nutrition of population MCQ
1. It is for timely warning and interventions.
2. It is for planning for health and development
3. provide inputs for program management and evaluation
4. Nutrition Indicators are, LBW, % BF, HT/Age, Wt./Age, Wt./Ht, MUAC
Others: agricultural surveillance indicators.
 65

Lecture 9 : Health education

(Esay question: long essay / barrier to communication)
Teaching process providing basic knowledge and practice of health which affects changes in
the health practices and behavior

 Cognitive domain:
Aspect of health education that comprises information and knowledge.
Information gained from health education can be:

 A new information
 A reinforcement
 Psychomotor domain:
Aspect of health education that deals with skill acquisition and reinforcement.

 Affective domain:
Aspect of health education that is mainly concerned in:

 Habit formation
 Behavior change
 New practice

Health education /Health Promotion?

With rising criticism that traditional H.E. was too narrow, focused on individual’s lifestyle
and could become “victim blaming”, more work was done about wider issues eg: social
policy, environmental safety measures.

(EMERGENCE of HEALTH PROMOTION)

 66

CONTENTS OF HEALTH EDUCATION:

 Nutrition
 Health habits
 Personal hygiene
 Safety rules
 Basic (K) of disease & preventive measures
 Mental health
 Proper use of health services
 Sex education
 Special education for groups ( fd handlers, occupations, mothers, school health etc. )
 Principles of healthy life style e.g. sleep, exercise
PRINCIPLES OF Health Education:

1. INTEREST
2. PARTICIPATION
3. COMPREHENSION: “Teaching should be within the mental capacity of the
audience”.
4. REINFORCEMENT: By repetition of the information in the same session or during
subsequent sessions. Remember: Few people can learn all that is new in a single
sitting.
5. MOTIVATION: By creating the desire in a person to learn
6. GOOD HUMAN RELATIONSHIPS: People must accept you as a friend
7. LEADERS: Try to make use of Sheikh, Omda, School Teachers, etc.

WHAT IS COMMUNICATION? (Essay)

“Communication is the sharing of information, ideas, attitudes or emotions from
one person or group to another”
(Wilson)
Components of communication process are: MCQ
1. Sender (source)
2. Receiver (audience)
3. Message (content)
4. Channel (medium)
5. Feedback (effect)

Barriers of Communication:
 Sender =
1. Negative attitude of the sender
2. without identifying the “needs "of the community
3. Limited receptiveness of receiver
 Receivers' =
1. Physiological: difficulty in hearing or expression.
2. Psychological: Neurosis, emotional disturbance, language or comprehension
difficulties.
3. Environmental: Noise, congestion.
4. Cultural: illiteracy, beliefs, religion, attitude, language variation…etc.
 67

DEVELOPMENT COMMUNICATION
Use of interpersonal, mass and traditional media channels to bring about social
transformation through:
I. Advocacy: to raise resources and political and social leadership commitment
for development goals. MCQ = A continuous process of gathering, organizing
and formulating information into an argument, to be communicated through
various interpersonal and media channels with a view to: Raising resources
AND Gaining political and social acceptance & commitment

II. Social mobilization: for wider participation and ownership

III. Programmed communication: for changes in knowledge, attitudes and

practices of specific participants in programs.

COMMUNITY EMPOWERMENT
Empowerment is a process of facilitating and enabling people to acquire skills, knowledge
and confidence to make responsible choices and implement them. It helps create settings
that facilitate autonomous functioning.
Stages for health education:
 Stage of Sensitization = people are sensitized of an emerging problem, like, “AIDS
causes death”. It’s easy to sensitize literate population, rather than illiterate one.
 Stage of Publicity = media and all possible means of advertising are used to provide
information to the public. The idea here is that people discuss among themselves
and become more knowledgeable.
 Stage of Education = this is the stage of Real education for illiterate population.
During this stage, simultaneous messages on TV and the media should be continued.
 Stage of Attitude change
 Stage of Motivation and Action
 Stage of Community Transformation (social change)

Stages of Change model called Trans theoretical Model MCQ

Changing one’s behavior is a process, not an event
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
 68

Stages of Change as applied to Malaria Program:

Contemplation Decision/preparation\
Precontemplation:
Determination
The individual believes
The individual has
that he The individual is
heard
and his families ready & plans to
about malaria but
are at risk and use bed nets
doesn’t think it is
thinks that he should so goes to a shop
relevant to his life.
do something. to buy them.

Maintenance

Using bed nets Action

has become a habit The individual buys
and The individual and uses bed nets.
regularly buys them

Health Promotion Means Changing Behavior at Multiple Levels

1. Individual: knowledge, attitudes, beliefs, personality
2. Interpersonal: family, friends, peers that provide social identity, support
3. Community: social networks, standards, norms
4. Institutional: rules, policies, informal structures may constrain or promote
recommended behaviors.
5. Public Policy: local, state, and federal policies and laws that regulate or support
healthy actions and practices for disease prevention, early detection, control, and
management.

GROUP Education
Methods:
1. Chalk and talk (lecture):
The group shouldn’t be more than 30, and the talk shouldn’t exceed 15 -20 minutes, or else
people will become bored and restless.
2. Demonstration:
- A carefully prepared presentation to show how to perform a skill or procedure practically.
E.g. demonstration of oral rehydration.
3. Group discussion:
A group is an aggregation of people interacting in face-to-face situation. Group discussions
provide wider interaction among members than is possible with other methods.
4. Panel discussions:
2-8 people who are qualified to talk about the topic sit and discuss a given problem in front
of a large audience. The discussion should be spontaneous and natural.
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5. Symposium:
Series of speeches in a selected topic. Each person presents an aspect of the subject briefly.
There is no discussion among the members like in panel discussions.
6. Workshops:
It consists of a series of meetings, usually 4 or more, with emphasis on individual work
within the group, with the help of a consultant and resource personnel
7. Role-playing:
Role-playing or socio-drama is based on the assumption that many values in a situation
cannot be expressed by words, and the communication can be more effective if the
situation is dramatized by the group. It’s useful for school children, and it should be
followed by a discussion of the problem.
8. Conference:
It contains a large component of commercialized continuing education.
Programs are usually held on regional, state, or national levels.
The length ranges from half a day to a week.
It may cover a single topic in depth, or be broadly comprehensive.
It usually uses a variety of formats to aid learning, from self-instruction to multimedia.
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Lecture 10: Health promotion (Essay question)

MCQ

Determinants of Health percent = MCQs

 Life style (50%)
 Environment (cultural, economic, social and physical conditions of life) (20%)
 Genetic background (20%)

 Health care system (10%)

Definition: “Health promotion is the process of enabling people to increase control over,
and to improve their health”. (Ottawa Charter for Health Promotion. WHO, Geneva, 1986)
It does not mean only responsibility of the health care system, but also individual
responsibility for health expressed via life style. (Kebza, 2005)
It emphasizes not only prevention of disease but the promotion of positive good health.
Health promotion is any combination of health, education, economic, political, spiritual or
organizational initiative designed to bring about positive attitudinal, behavioral, social or
environmental changes conducive to improving the health of populations.
3 basic strategies or methods: MCQS

"Enabling, mediating, and advocacy”

5 key themes: MCQS
1. Build healthy public policy
2. Create supportive environments
3. Strengthen community action
4. Develop personal skills
5. Reorientation of health services
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Logo visualizes the idea that health promotion is a comprehensive multi-strategy approach
Advocate;

Political, economic, social, cultural, environmental, behavioral and biological factors can all
favor health or be harmful to it.

Enable;
Health promotion focuses on achieving equity in health by reducing differences to enable all
people to achieve their fullest health potential.
Mediate;
The prerequisites and prospects for health cannot be ensured by the health sector alone.
People in all walks of life are involved as individuals, families and communities = all have a
major responsibility to mediate between differing interests in society for the pursuit of
health.

KEY THEMES FOR HEALTH PROMOTION

Health Promotion Action Areas (WHO,1986)
• Five key Health Promotion Action Areas (WHO, 1986) were adopted worldwide in
the first International Conference on Health Promotion in Ottawa 1986, named
Ottawa Charter for Health Promotion. These need to be adapted to the local needs
and possibilities, taking into account differing social, cultural, and economic systems
1)Build healthy public policy:
Health promotion policy can and should not be reduced to health care sector.
Therefore, all sectors of society can give a contribution to health; this implies that
• It puts health on the agenda of policy makers in all sectors at all levels like economy,
law, industry, agriculture and education.
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• Directing policy makers to be aware of the health consequences of their decisions

and also to be committed to the holistic concept of health in everyday administrative
live.
Accept their responsibilities for health in all decisions.
• Health promotion policy combines diverse but complementary approaches
including:, legislation, fiscal measures, environmental engineering, economic and
organizational change
-However, joint action for health promotion will contribute to:
• Ensuring safer and healthier goods and services to be delivered to the public.
• healthier public services, and
• Cleaner, more enjoyable environment.
-Therefore, health promotion policy requires;
• the identification of obstacles in each sector and the adoption of healthy public
policies in non-health sector,
• Ways of removing these obstacles. The aim must be to make the healthier choice the
easier choice for policy makers as well.
• Formulating healthy public policy
• Promotes healthy policies in all sectors, e.g. healthy workplaces, schools, homes,
buildings, villages and communities.
• Health aspect should be thought of and included in the policies of the various
sectors.
• Health Policies should also emphasize the prevention and promotion.

2)Create supportive environments.

• Our societies are complex and interrelated. Health cannot be separated from other
goals. The inextricable links between people and their environment constitutes the
basis for a socio-ecological approach for health. The overall guiding principle for the
world, nation, regions and communities alike, is the need to encourage reciprocal
maintenance –to take care of each other, our communities and our natural
environment. The conservation of natural resources throughout the world should be
emphasized as global responsibilities.
• Changing pattern of life, work and leisure have a significant impact on health. Work
and leisure should be a source of health for people.
• The way society organizes work should help create a healthy society. Health
promotion generates living and working conditions that are safe, stimulating,
satisfying and enjoyable.
• Systematic assessment of the health impact of a rapidly changing environment,
particularly in areas of technology, work, energy production and urbanization is
essential and must be followed by action to ensure positive benefit to the health of
the public. The protection of the natural environment and the conservation of
natural resources must be addressed in any health promotion strategy.
• Healthy physical, social and economic environment.
• All development activities should aim for a healthy environment – healthy buildings,
roads, workplaces, homes, surroundings and schools.
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3) Strengthen community actions.

-In this strategy health promotion works through concrete and effective community
action in setting priorities, making decisions, planning strategies and implementing
them to achieve better health.
-At the heart of this process is the empowerment of communities, their ownership
and control over their own endeavours and destinies.
-Community development draws on existing human and material resources in the
community to enhance self-help and social support, and to develop flexible systems
for strengthening public participation in and direction of health matters.
-This requires full and continuous access to information, learning opportunities for
health, as well as funding support

4)Develop personal skills.

That means:
- Health promotion supports personal and social development through
providing information, education and communication for health.
- Enhancing life skills.
- Increases the options available to people to exercise more control
over their own health and over their environments,
- Make choices conducive to health.
- Enabling people to learn, throughout life, to prepare them for all of its
stages.
- To cope with chronic illness and injuries and this has to be facilitated
in school, home, work and community settings.
- Action is required through educational, professional, commercial and
voluntary bodies, and within the institutions themselves.

• Information and education for personal and family health.

• Take account of values, beliefs and customs of the community.
• Continuous process at all stages of life.
• Guided and supported in developing skills (not imposed on them).
• Build on existing knowledge and attitudes.

5) Reorient health services:

1. responsibilities of health services are shared among individuals, community groups,
health professionals,
2. The role of health sector must move increasingly in a health promotion direction,
beyond its responsibility for providing clinical and curative services.
3. Health services need to respect cultural needs. This should support the needs of
individuals and communities for a healthier life
4. Requires stronger attention to health research as well as changes in professional
education and training.
5. Decrease the burden on secondary (curative) health care = e.g. Greater emphasis
and resources placed on health promotion and primary health care.
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Empowering communities to achieve well-being

Involvement of the community in health decisions, a multisectoral and participatory
approach.

Provide communities with the information and tools to take actions to improve health and
well-being.

Building alliances with special emphasis on the media

Media key players, influence on health of people.
Partnership with media ensures their collaboration and that correct information is passed
on.
Free flow of information both ways, on matters vital to health
Develop personal skills = not health provider:

That means:
Health promotion supports personal development through providing information,
education and communication for health,
Increases the options available to people to exercise more control over their own health
and over their environments
Enabling people to cope with chronic illness and injuries and this has to be facilitated in
school, home, work and community settings.
Continuous process at all stages of life.
Relation between Population and High risk Strategy
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‫ مستوى صحي أعلى‬Higher Health Level

‫تعزيز الصحة‬
Health promotion

‫ الرصيد الصحي‬Health Potentials

‫ المراضة‬/‫الكرب‬
Pathogenic stress

‫ مستوى صحي أدنى‬Lower Health Level

Inequalities in health
Inequality: unequal
“Differences in health status, or in the distribution of determinants, between different
population groups”. MCQ
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The Health Promotion Triad

Health education

Health protection Prevention

Health Promotion Approaches: MCQS

Naidoo and Wills (2009) identified five different ‘Approaches’. These approaches are not
theories Or models, but descriptions of the practice of health promotion:
 Medical
 Education
 Behavior change
 Empowerment
 Social change
 Others
 Medical Approach - What is it?
 Aim: Reducing morbidity or mortality, by targeting risk groups or risk behaviors with
medical interventions = through immunization, screening, surgery, medication
 Assumptions

Application of Medical knowledge (evidenced based practice)

Compliance/concordance by patients required

 Education Approach - What is it?

Aim: To provide knowledge and information and develop necessary skills so that people can
make an informed choice about their health behavior by Provision of leaflets, booklets.

 Behavior Change Approach-What is it?

Aim: To increase individuals' knowledge about the causes of health and illness. To bring
about changes in individual behavior through changes in individuals' cognitions by
conceptually under-pinned by psychological theory. Most commonly top-down expert-led or
change model (targeted/population) MCQ

 Empowerment Approach – What is it?

Aim: Empowerment = “the mechanism by which people, organizations and communities
gain mastery over their lives”

To increase control over one's physical, social and internal environments. To empower
individuals to make healthy choices.
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 Social Change Approach - What is it?

Aim: To modify social, economic and physical structures which generate ill health.
To improve health by addressing socio-economic and environmental causes of ill health.
Through the = families, school, work, village, city......
HP in Sudan: Few words

- Health Promotion Directorate is a new establishment in the Sudanese health

structure (2002).
- Is still not more than a composition of small-scale programs and isolated positions
- It has to promote itself first in order to promote the overall health of the
Sudanese.
- It has a commitment to address national and state priorities as well as local health
issues with a strong emphasis on people from culturally and linguistically diverse
backgrounds, on those from socially discriminated backgrounds and on challenges
resulting from war, civil conflicts and the mass wide spread phenomenon of mass
displacements
 The outcome of a health education is knowledge to attain awareness.
 The outcome Health promotion IS EMPOWERMENT to attain healthy life style &
BEHAVIORAL CHANGE.
 Working for health promotion mean make the healthiest choice..the easiest choice .
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Lecture 11 : MDGs VS SDGs MCQ\ SHORT QUA

MDGs
- The United Nations Millennium Development Goals are eight goals that all 195 UN
Member States have agreed in 2000 to try to achieve by the year 2015.
- Each MDG has targets set for 2015 and indicators to monitor progress.
- All the MDGs influence health, and health influences all the MDGs – Directly or
indirectly.
- The MDGs are inter-dependent.
GOAL1:
ERADICATE EXTREME POVERTY & HUNGER
GOAL 2:
ACHIEVE UNIVERSAL PRIMARY EDUCATION
GOAL 3:
PROMOTE GENDER EQUALITY AND EMPOWER WOMEN
GOAL4:
REDUCE CHILD MORTALITY
Target4A;
Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
 Indicators =
 the under-five mortality rate
 Proportion of 1-year old children immunized against measles
 Infant mortality rate
>> To deliver these interventions, WHO promotes four main strategies;
1. Appropriate home care and timely treatment of complications for newborns;
2. IMCI for all children under five years old;
3. Expanded program of immunization; EPI
4. Infant and young child feeding.

>> These child health strategies are complemented by interventions for maternal health, in
particular, skilled care during pregnancy and childbirth.

GOAL 5:
IMPROVE MATERNAL HEALTH
Target5A
Reduce by three quarters the maternal mortality ratio
Target5B;
Achieve universal access to reproductive health
 Indicators:
1. Maternal mortality rate.
2. Proportion of birth attended by skilled health personnel
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GOAL 6:
COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
Target6A;
Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target6B;
Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
Target6C;
Have halted by 2015 and begun to reverse the incidence of malaria and other major
diseases
 Indicators:
1) HIV prevalence among young people aged 25 to 42 years.
2) Condom use rate of the contraceptive prevalence rate.
3) Number of children orphaned by HIV/AIDS.
4) Prevalence and death rates associated with malaria.
5) Proportion of population in malaria-risk areas using prevention and treatment
measures.
6) Prevalence and death rates associated with tuberculosis.
7) Proportion of tuberculosis cases detected and cured under Directly Observed
Treatment, Short course (DOTS).
GOAL 7:
ENSURE ENVIRONMENTAL SUSTAINABILITY
GOAL 8:
DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT
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SDGS
 The Sustainable Development Goals (SDGs), also known as the Global Goals, were
adopted by the United Nations in 2015 as a universal call to action to end poverty,
protect the planet, and ensure that by 2030 all people enjoy peace and prosperity. = 15
years
 The 17 SDGs are integrated—they recognize that action in one area will affect outcomes
in others
 Why shifting from MDG to SDG :
1. Top-down vs. Stakeholder-center approach
There’s been a move from a fragmented approach to a more integrated and aligned
strategy. The SDGs, on the other hand, was designed using a massively collaborative
approach. Civil Society Organizations (CSOs) are a key part of SDG advancement. From
eight goals to 17, from a top-down approach to one of the biggest collaborative efforts

2. Engagement from rich countries vs. poor

The MDGs model was heavily focused on encouraging funding and initiative-building coming
from richer countries to benefit poorer countries. The SDGs, on the other hand, call upon all
countries to generate internal strategies for goal progress, while looking for ways to
collaborate across borders
3. Is the fact that the MDGs were “halfway” goals, while the SDGs are “zero”
goals.
In other words, the MDGs were meant to bring us closer to a world without poverty. The
SDGs are meant to get us all the way there.
4. The MDGs severely lacked monitoring, evaluation, and other frameworks for
impact accountability. The SDGs, on the other hand, pushes us to manage impact
data (ensuring its quality and timely acquisition).
 Goal 3 = good health
 Goals of goal 3 :
By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live
births
By 2030, end preventable deaths of newborns and children under 5 years of age,
By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical
diseases and other communicable diseases
By 2030, reduce by one third premature mortality from non-communicable diseases
Strengthen the prevention and treatment of substance abuse, including narcotic
drug abuse and harmful use of alcohol
By 2020, halve the number of global deaths and injuries from road traffic accidents
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By 2030, ensure universal access to sexual and reproductive health-care services,

including for family planning,
Achieve universal health coverage, including financial risk protection, access to
quality essential health-care services and access to safe, effective, quality and
affordable essential medicines and vaccines for all
By 2030, substantially reduce the number of deaths and illnesses from hazardous
chemicals and air, water and soil pollution and contamination
Support the research and development of vaccines and medicines for the
communicable and non communicable diseases
Trade Related Aspects of Intellectual Property Rights regarding flexibilities to protect
public health, financing and the recruitment, development, training and retention of
the health workforce in developing countries
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#Sphere MCQ \ ASSAY

 (formerly known as the Sphere Project) is a global movement started in 1997 aiming to
improve the quality of humanitarian assistance. The Sphere standards are the most
commonly used and most widely known set of humanitarian standards.
 The Sphere Project is an initiative to determine and promote standards by which the
global community responds to the plight of people affected by disasters.
 Initially developed by non-governmental organisations, along with the Red Cross and
Red Crescent Movement, the Sphere standards have become a primary reference tool
for national and international NGOs, volunteers, UN agencies, governments, donors, the
private sector, and many others.
 Sphere is based on two core beliefs:
first, that all possible steps should be taken to alleviate human suffering arising out of
calamity and conflict, and
second, that those affected by disaster have a right to life with dignity and therefore a right
to assistance
 4 areas:
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 OTHER Topics of assays and short notes

1. Live attenuated vaccines in the schedule of child immunization

2. Emergency obstetric and neonatal care signals

3. Emergency feeding programs
5. Keeping vaccines potent in household refrigerator
6. Prevention of neonatal tenuous
7. Strategies to reduce maternal mortality

8. Contraindications of oral polio vaccine (OPV)

9. Specific definitions of adverse events following immunization
10. Shake Test for vaccines
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