7.2.1. education up to the age 14

7.2.1.   Fertility and fertility related statistics.

Fertility  – Fertility means  the actual
bearing of children. 15 to 45 years  is
the reproductive period of a woman. In India Information on fertility indicates
that an average women gives birth to an average of about 3 children if her married
life is not interrupted. Fertility depends on several factors. Eg. Lower age at
marriage, low level of literacy, poor level of living limited use of
contraceptives and traditional ways of life. 2.9% is the total fertility rate
of India for the year 2006.  

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7.2.2.  Family planning  In 1971 WHO Expert Committee defined and described family planning as
“Family planning refers to practices that help individuals and couples to
attain certain objectives such as

unwanted pregnancies

about wanted births

the intervals between pregnancies

the type of which births occur in relation to the ages of the parent and

the number of children in the family.

Family planning has been recognized as a basic human
right by the United Nations in 1908.

In 1977, the Govt. of India redesignated the
National Family planning Programme as the National Family Welfare Programme. It
is to promote the family planning through the total welfare of the family.

The term family welfare is much broader than family
planning. The concept of welfare is basically related to quality of life which
focuses on the following aspects, as they are all essential factors associated
with the concept of welfare.





Women’s Welfare And Rights


Safe Drinking Water

7.2.3.  Population policy

Population policy in general refers to policies
intended to decrease the birth rate or growth rate. Statement of goals,
objectives and targets are inherent in population policy.

2.4.  National demographic goals 

The National Socio – Demographic Goals to be
achieved by the year 2010 are as follows

Address the unmet needs for basic reproductive and child health services.

Make School education up to the age 14 free and compulsory and reduce the drop         outs at primary and secondary school
levels to below 20 percent for both boys and        girls.

Reduce infant mortality rate to below 30% for 1000 live births.

Achieve Universal Immunization of children against all vaccine preventable       diseases.

Reduce Maternal Mortality ratio to below 100 per 100000 live births.

Promote delayed marriage for girls, not earlier than age 18 and preferably
after 20         years of age.

Achieve 80 per cent of  institution
deliveries and 100 per cent deliveries by trained        persons.

Achieve universal access to information/counselling and services for fertility      regulation and contraception.

Achieve 100 per cent registration of births, deaths, marriage and pregnancy.

Contain the spread of AIDS and promote greater integration between the         management of reproductive tract
infections and sexually transmitted infections and           National Aids Control Organization.

Prevent and control Communicable diseases.

Integrate Indian System of Medicine (ISM) in the provision of reproductive and          child health services and in reaching
out to households.

Promote the small family norm.

Bring about convergence in implementation of related social sector programmes           so that family welfare becomes a
people centred programme.


7.3.1. Concept
of disease.

The term disease means without ease.Man’s concept of
disease has evolved down from

Supernatural theory of disease


Germ theory of disease


Modern multi-factorial
theory  of disease


Definition – A physiological/psychological
dysfunction. A condition in which body health is impaired, a departure from
state if health.

Illness – A subjective state of the person who
feels aware of not being well.

Sickness – A state of dysfunction.

Concept of
Causation – Up to the time
of Louis Pasteur, various concepts of disease were in vogue. Germ theory of
disease gained momentum in 19th century. The emphasis had shifted from
empirical causes such bad air to microbes as the sole cause of disease.

triad – The germ theory of
disease describes disease causation has the basic factors of agent, host and
environment. Interaction of these three factors are needed to initiate the
disease in man.  The epidemiological triad
not only determines the onset of disease by also the distribution of disease in

 Agent factors: In the chain of disease transmission is a disease
agent is the first link. “Agent” is defined as a substance, living or
non-living, or a force, tangible or intangible, the excess presence or relative
lack of which may initiate the disease process.

factors  – Some host factors that influence susceptibility to
disease are: Sex, Race, Age, Occupation, Nutrition,  Heredity, Marital status and Socioeconomic

factors – All that which is
external to man is the environment broadly speaking. The concept of environment
is complex.

The external environment
or the Macro-environment is
said to be responsible for millions of preventable diseases.
Micro-environment is the Domestic environment in which man lives.

External environment – “All that is external to the
individual human host, living and non-living, and with which he is in constant
interaction”. The environment
has three components –  physical,
biological, and psychosocial environment.

 Iceberg of disease – A concept closely related to the spectrum
of disease is the concept of the iceberg phenomenon of disease. According to
this concept, disease in a community may

be compared with an iceberg.


             Iceberg of Disease

Epidemiological triad.


            1. Epidemiology is concerned with the patterns of
disease occurrence in human populations and of the factors that influence these

            2. Epidemiology is
the study and analysis of the distribution  and determinants of health and disease conditions in defined populations.

The causative factors of disease may be classified

Agent, Host,
and Environment – These factors are known as epidemiological triad. Even though
these factors are present, disease process will not occur unless there is an
interaction. Diseases cannot occur in the absence of any one of these three

7.3.4. Concepts
of control and prevention .

Concepts of
Prevention  – In modern day the concept of prevention has become
broad – based. It is customary to define prevention in terms of 4 levels.

 Levels of Prevention:

            1. Primordial prevention

Primary prevention

Secondary prevention

Tertiary prevention

Prevention – Prevention of
emergence or development of risk factors in population groups in which they
have not yet appeared.  e.g. Lifestyle

Intervention: Health education.

Prevention  –  Action taken prior to the onset of disease, which removes the possibility
that a disease will occur.

Intervention in
the pre?pathogenesis
phase-  Elimination or modification of risk factors.  e.g. Communicable diseases and Non Communicable

Approaches for
primary prevention: – Adequate
nutrition, provision of water and supply, facilities for the safe disposal of
human excreta and other human wastes and periodic health screening.

Prevention –  Actions which halts the progress of a disease at its
incipient stage and prevents complications.

Intervention in
early pathogenesis phase – Early
diagnosis and adequate treatment. m

Tertiary Prevention –  All measures available to reduce or limit
impairments and disabilities, minimize suffering caused by existing departures
from good health and to promote the patient’s adjustment to irremediable

 Intervention in late pathogenesis phases  – prevention of complication and disability limitation.

Modes of

1. Health
promotion –



Life style and
behavioural changes

2. Specific
protection –

e.g. Vaccine preventable diseases,

nutrient e.g. Iron, protection against injuries (helmet, seat belt) 

e.g. against Malaria.

Control of
consumer product quality and safety of foods, drugs, cosmetics etc.

3. Early
diagnosis and treatment – The
detection of disturbances of homoeostatic and compensatory mechanism while
biochemical, morphological and functional changes are still reversible.  Important in reducing high morbidity and

4. Disability

5. Rehabilitation
– The combined and
coordinated use of medical, social, educational and vocational measures for
training and retraining the individual to the highest possible level of
functional ability.






Concept of

The term “disease control” aims to reduce

of  disease

Distribution of

Effects of

burden to the community

Control activities may focus on primary prevention
or secondary prevention. Tertiary control is less relevant to control efforts.

Controlling sources of infection

1. Supply of safe drinking water

2. Safe disposal of human excreta and animal excreta

3. Control vectors of diseases.

4. Animals – vaccinate dogs against rabies and
eliminate street dogs.

5. Rodent control measures-trapping and killing

6. Hospital waste management

7. Disinfections

8.  Legislation
– Epidemic disease control act.

9. Observe international health regulations

of epidemiology(components, measurements, prevalence and incidence)

Epidemiologic methods : Descriptive,
analytical and Experimental studies.

Epidemiological studies can be classified as
observational and experimental studies.

1. Observational

            a. Descriptive studies – A simple description of the health status
of a community. Based on routinely available data or data obtained
in special surveys.   

            b. Analytical studies

                        i. Ecological or co relational

Cross sectional or Prevalence

Case – control or Case reference

Cohort or Follow up

2. Experimental studies          

            a. Randomized control trial

Field trials

Community trials

Studies – Analyzing
relationships between health status and other variables.


            1. Case-control studies. (Case
reference studies)

Cohort studies. (Follow-up studies)

 Cohort Studies 
– Cohort is group of
people with similar characteristics also called follow-up or incidence studies.
Whole cohort is followed up to see the effect of exposure. Study design of a
cohort study.

Types of Cohort

1. Prospective cohort studies. (Currents cohort

Retrospective cohort studies. (Historical cohort study)

Combination of retrospective and prospective cohort studies.


Interventional or experimental study involves
attempting to change a variable in subjects under study. This could mean the
elimination of a dietary factor thought to cause allergy, or testing a new
treatment on a selected group of patients. The effects of an intervention are
measured by comparing the outcome in the experimental group with that in a
control group.

 Types of Experimental Studies

1. Randomized Control Trials.

2. Field Trials & Community Trials.

Uses of epidemiology 

1. Search of cause/causes of disease/diseases.

2. Helps to describe the health status of population
or groups.

3. Helps to discover and bridge gaps in natural
history of diseases.

4. Helps in controlling the diseases. Break the
weakest link in chain of transmission of communicable diseases and reducing non
communicable diseases.

5. Helps in planning of health programs on evidence
basis and setting up of health priorities.

6. Helps to evaluate health programs and interventions.

7. Helps to determine the chances or probability of
occurrence of disease/ deaths and disability

8. Helps in better management of health services and
hospital services.

9. Helps to set-up cut-off levels between normal and
abnormal population and

establish trigger levels for action or intervention.

7.4. Community
health – Community health
refers to the health status of the members of the community, to the problems
affecting their health, and to  the
totality of health care provided for the community.

Community health implies integration of curative,
preventive and promotional health services.

The focus in community diagnosis is on
identification of community health problems. A community is a whole entity that
functions because of the interdependence of its parts or subsystems.

Diagnosis – The diagnosis of
the individual is based on signs and symptoms. When this is applied to a
community it is known as “community diagnosis.

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.

For diagnosis of community health problems, we have
to study

a. age and sex composition of the population.

b. vital statistical rates such as the death rate, infant mortality

incidence and prevalence of important diseases in the community.

Treatment – which consists
of  eight elements of Primary Health Care
to achieve the goal of Health For All. 

Education of the people about the prevailing health problems and the methods of
                     preventing and

Promotion of food supply and adequate nutrition

Adequate supply of safe water and basic sanitation

Mother and Child Health care and family planning

Immunization against the vaccine preventable diseases

Prevention and control of locally prevailing diseases

Proper treatment of diseases and injuries

Provision of essential drugs

Communicable Non-communicable Diseases

Communicable disease is one that is spread from one person to
another through a variety of ways.  Eg.
contact with blood and bodily fluids; breathing in an airborne virus; or by
being bitten by an insect.

Reporting of cases of communicable disease is important

and evaluation of disease prevention and control programs,

medical therapy,

of common-source outbreaks.

Some examples of the reportable communicable diseases include Hepatitis
A, B & C, influenza, measles, and salmonella and other food borne

How these diseases spread
depends on the specific disease or infectious agent. Some ways in which
communicable diseases spread are by:

Physical contact with an
infected person, such as through touch (staphylococcus), sexual intercourse (
HIV), fecal/oral transmission (hepatitis A), or droplets (influenza, TB)

Contact with a contaminated
surface or object (Norwalk virus), food (salmonella, E. coli), blood (HIV, hepatitis
B), or water (cholera)

Bites from insects or animals
capable of transmitting the disease (mosquito: malaria and yellow fever; flea:
plague); and

Travel through the air, such
as tuberculosis or measles.


Non-communicable diseases (NCDs), also known as chronic diseases, tend to be of long
duration and are the result of a combination of genetic, physiological,
environmental and behaviors factors. Non-infectious are non-communicable diseases and caused by a variety of

Reasons for the non-infectious disease




of the individual

 Examples include cancer, diabetes, hypertension,  cardiovascular diseases (like heart attacks
and stroke),chronic respiratory diseases (such as chronic obstructive pulmonary
disease and asthma) and diabetes.


National and
international health

health programmes in India

            Since India became free, several measures have been
undertaken to improve the health status of the people. Prominent among these
measures are the National Health Programmes which have been launched by the
Central Government for the control/eradication of the communicable diseases,
improvement of environmental sanitation, raising the standard of nutrition,
control of population and improving rural health. Various International
agencies have been providing technical and material assistance in the
implementation of these programmes.

1. National AIDS
Control Program was launched
in India in the year 1987. The aim of the programme is to prevent further
transmission of HIV, to decrease morbidity and mortality associated with HIV
infection and to minimize the socio economic impact resulting from HIV

2. National
Vector borne Disease Control programme – Govt. India provides technical support,
insecticides, larvicides and insecticide treated bed nets for treatment of
malaria, filaria and kala-azar.

3. National
Tuberculosis Control programme has
been in operation since 1962.

4, National
Cancer Control Program – With
the objective of  prevention and early
diagnosis and treatment, the national cancer control programme was launched in
1975 – 76.

5. National
Mental Health Programme – The
Mental Health programme was launched during 1992 with a view to ensure
availability of Mental Health Services for all, especially the community at
risk and under privileged section of the population.

6. National Family
Welfare Program (NFWP) – 100%
Centrally sponsored. Family Welfare Dept was created in 3rd Fifth Five Year
Plan. Family Planning was integrated with MCH services.

Other health
programmes are:-

National Diarrheal Disease Control Program

 National Filaria
Control Program

National Family Welfare Program

National Iodine Deficiency Disorders Control Program

National Leprosy Eradication Program

National Malaria Eradication Program

National Program for Control of Blindness &
Visual Impairment

National Reproductive and Child Health Program

National Program for surveillance Program for Communicable

National Tuberculosis Control Program

Minor Programs

National Mental Health Program

National Japanese Encephalitis control Program

National Diabetes Control Program — National
Kala-azar Control Program

National Water Supply and Sanitation Program

7.5.2. International health(who and other united
nations agencies)

1. World Health Organization  (WHO)
was established shortly after World War II as
a multilateral health organization to unite countries in the common goals of
tackling disease and achieving better health globally.

2. World Bank – As a leading
institution for investments in health and development, the World Bank plays a critical role in shaping global health
policy. The World Bank strives to alleviate poverty by providing loans,
credits, and grants to poor counties to implement various development
projects in areas such as education, healthcare, agriculture, environmental and
natural resource management, infrastructure, and other relevant projects.

3. UNICEF established in 1946 with headquarter at New York.
South east Asia region covers India.

– works in close
collaboration with WHO & other UN agencies on Child nutrition & health
Family & child welfare Education.

4. UNDP United
Nations Development Programme
–  Established in 1966.


 To help poorer nations develop their human & natural resources more

 It covers
every social & economic sector-agriculture, industry, education, science,
health &       


5. FAO It was formed in 1945.


help nation wise living standard.

improve nutrition o the people of all countries.

increase the efficacy of farming, forestry & fisheries.

better the condition of rural people & widen opportunities of all people
for productive work.

The Food and
Agriculture Organization(FAO) was
formed in the year 1945 with headquarters in Rome. It was United Nations
organization specialized agency created to look after several areas of world

International Labour Organization (ILO) is a United Nations agency dealing with labour
issues, particularly international labour standards and decent work for all. 5.
The United States Agency for International Development (USAID) is the United
States federal government agency primarily responsible for administering
civilian foreign aid.

RED CROSS The red cross is a
non-political and non-official international humanitarian organization.

Role of Red

             1)It was largely confined to the victims of the war  – first aid in case of war like              

               2)MCH services

management and has designed emergen