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Committees in Community Health Nursing (India)

Overview Table

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1. Bhore Committee (1943-1946)

• Appointed by the Government of India in 1943 under Sir Joseph Bhore
• Report submitted in 1946

Background

• High Crude Death Rate (CDR), Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR)
• Low life expectancy
• Widespread communicable diseases

Key Recommendations

• Establishment of a 3-tier healthcare system: primary, secondary, and tertiary
• Short-term plan: 1 Primary Health Unit per 40,000 population
  • 2 Medical Officers, 1 Nurse, 4 Public Health Nurses, 4 Midwives, 4 Trained Dais, 2 Health Assistants, 2 Sanitary Inspectors, 1 Pharmacist, 15 Class IV workers
• Long-term plan: 1 PHC per 10,000-20,000 population
• Integration of curative, preventive, and promotive health services
• Emphasis on social medicine and community-based care
• "No financial barrier" principle - free healthcare for all
• Massive increase in medical, nursing, and allied health personnel

Note: The targets were not achieved due to lack of doctors, nurses, and infrastructure.

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2. Mudaliar Committee (1959-1961)

• Appointed on 12th June 1959 under Dr. A.L. Mudaliar
• Purpose: To assess progress made since the Bhore Committee (1946)

Six Sub-Committees were formed to analyze:

1. Public Health
2. Medical Relief
3. Population Problem
4. Communicable Diseases
5. Professional Education
6. Drugs & Medical Appliances

Key Findings

• Basic health facilities had NOT reached half the population
• Health services remained unsatisfactory

Key Recommendations

• Strengthen existing Primary Health Centers before creating new ones
• Upgrade district hospitals
• Improve health manpower training
• Focus on maternal and child health services

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3. Chadha Committee (1963)

• Constituted in 1963 by Government of India
• Under Dr. M.S. Chadha, Director General of Health Services
• A team of malariologists reviewed the National Malaria Eradication Programme

Terms of Reference

1. Review planning and requirements of PHCs for the maintenance phase of Malaria Eradication
2. Study staffing patterns needed for the malaria eradication programme

Key Recommendations

• 1 Basic Health Worker (BHW) per 10,000 population
• BHW to visit house-to-house once a month for malaria vigilance
• BHW to serve as Multipurpose Health Worker (MPHW) for family planning and vital statistics

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4. Mukherjee Committee (1965)

• Appointed to review and strengthen existing health services
• Focused on family planning services and integration with health infrastructure

Key Recommendations

• Strengthening of Primary Health Centers
• Better integration of family planning with general health services
• Increased health manpower for MCH (Maternal and Child Health)

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5. Jungalwalla Committee (1964-1967)

• Set up by the Central Council of Health at its 1964 Srinagar session
• Under Dr. N. Jungalwalla, Additional Director General of Health Services
• Report submitted in 1967

Terms of Reference

• Study problems of health services
• Review service conditions
• Address elimination of private practice by government doctors

Key Recommendations

• Unified cadre for all health workers
• Common seniority across departments
• Recognition of extra qualifications
• Equal pay for equal work
• Special pay for specialized work
• No private practice for government health workers
• Good service conditions
• States were left to work out their own implementation strategies

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6. Kartar Singh Committee (1972-1973)

• Formed in 1972 under Kartar Singh, Additional Secretary, Ministry of Health and Family Planning (MOHFP)
• Addressed the growing demand for health staff and the need to reduce population per worker

Key Recommendations

• ANM (Auxiliary Nurse Midwife) to be replaced by Female Health Worker (FHW)
• Introduction of multipurpose worker concept
• 1 PHC = 50,000 population = 16 Sub-Centres
• 1 Sub-centre = 3,000-3,500 population
• 1 Sub-centre staffed by: 1 Male Health Worker + 1 Female Health Worker
• 1 Male Health Supervisor to supervise 3-4 Male Health Workers
• 1 Female Health Supervisor to supervise 4 Female Health Workers
• Programme introduced in 2 pilot areas:
  1. Areas where malaria was in the maintenance phase
  2. Areas where smallpox was in the control phase
• To be implemented during the 5th Five Year Plan

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7. Shrivastav Committee (1974-1975)

• Constituted by MOHFP, GOI in 1974 under Dr. J.C. Shrivastav
• Report submitted in 1975

Problems Identified

• Urban orientation of medical education, heavily dependent on curative medicine
• Failure of training programmes in nutrition and family welfare due to isolation from mainstream medical education
• Rural communities deprived of doctors

Terms of Reference

• Devise curriculum for training Health Assistants
• Improve medical education with emphasis on community care
• Integrate family planning teaching into medical education

Key Recommendations

• Organization of basic health services (nutrition, health education, family planning) within the community itself
• Training of community health workers at the village level
• Re-orientation of undergraduate medical education toward community and primary care rather than hospital-based curative care
• Concept of a community health worker trained locally (precursor to ASHA)

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8. Bajaj Committee (1986)

• Appointed in 1986 under Dr. J.S. Bajaj
• Focused on planning and managing health manpower at the national level

Key Recommendations

• Rational planning of health manpower production
• Improving management of existing health workforce
• Addressing urban-rural imbalance in health personnel distribution
• Strengthening health manpower education and training infrastructure

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Role of the Community Health Nurse in Committees

• Take the initiative to ensure health committees are created where they do not exist
• Facilitate and coordinate health committee activities
• Act as a bridge between the community and formal health services
• Identify, plan and implement health projects
• Educate the community about health matters
• Participate in policy making, problem solving, and handling of community complaints
• Engage in community mobilization and community development

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Summary: Significance of These Committees

1. Primary Health Care (PHC) system in India
2. The multipurpose health worker concept
3. ASHA workers (community health worker model from Shrivastav)
4. Integration of curative, preventive, and promotive services
5. The National Rural Health Mission (NRHM) and current health policies

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COMMUNITY HEALTH NURSING - EXAM ANSWERS

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Q.2 — LONG QUESTIONS (2 × 15 Marks)

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Q.2 (1a) Health Care Delivery System in India at Various Levels [~8 marks]

Definition

Levels of Health Care Delivery in India

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TIER 1 - Primary Level (Grassroots/Community Level)

• Preventive, promotive, curative, and rehabilitative services
• Maternal and child health (MCH) services
• Family planning services
• Immunization
• Health education

• Lowest level of health infrastructure
• Staffed by 1 ANM (Auxiliary Nurse Midwife) and 1 Male Health Worker
• Functions: immunization, ANC, postnatal care, family planning, first aid

• First contact point with a medical officer
• Staffed by 1 Medical Officer, 14-15 paramedical & other staff
• Functions: OPD, MCH services, school health, disease surveillance, health education

• 30-bedded referral hospital for 4 PHCs
• Staffed by 4 specialists (surgeon, physician, gynecologist, pediatrician)
• Functions: specialist care, emergency obstetric care, referrals

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TIER 2 - Secondary Level (District Level)

• District Hospital (DH): Serves district population (approximately 1-3 million)
• Provides specialist services, emergency care, surgery
• Acts as referral center for CHCs and PHCs
• Generally has 75-500 beds depending on district size
• Staffed by specialists in all major disciplines

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TIER 3 - Tertiary Level (State/National Level)

• Teaching/Medical College Hospitals, AIIMS, Apex Institutions
• Provides super-specialist care for complex, rare, or difficult cases
• Serves as training centers for health professionals
• Conducts medical education and research
• Examples: AIIMS, PGI Chandigarh, NIMHANS

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Other Components:

• ASHA (Accredited Social Health Activist): Village-level link worker
• Anganwadi Centers: Under ICDS for maternal and child nutrition
• Urban Health Centers: For urban slum populations

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Q.2 (1b) National Health Policy 2017 [~7 marks]

Introduction

Vision

Key Principles (9 Guiding Principles)

1. Professionalism, Integrity and Ethics
2. Equity - reduce disparities based on gender, caste, poverty, disability
3. Affordability - no financial hardship while seeking healthcare
4. Universality - health care for all citizens
5. Patient-centered - dignity, confidentiality, non-discrimination
6. Community participation in health planning
7. Decentralization - decision-making at local level
8. Pluralism - AYUSH systems integrated with allopathy
9. Accountability - of public health institutions

Key Policy Shifts (from NHP 2002)

1. From selective care → Assured comprehensive primary care
2. From sick care → Wellness and prevention
3. Increased public spending on health to 2.5% of GDP
4. From institution-based care → Community-based care
5. From treatment alone → Health promotion and prevention
6. Make in India for drugs and medical devices

Specific Quantitative Goals (by 2025)

Key Provisions Relevant to Nursing

• Establishing cadres of Nurse Practitioners and Public Health Nurses
• Nursing schools in every large district (population of 20-30 lakh)
• Centers of Excellence for Nursing in each State
• Developing specialized nursing training (critical care, trauma, palliative)

Importance

• Shifts focus from curative to preventive and promotive health
• Aims at Universal Health Coverage (UHC)
• Integrates AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy)
• Addresses epidemiological transition (rising NCDs, aging population)

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Q.2 (2) Epidemiology — Definition, Aims, Uses & Epidemiological Triad [15 marks]

Definition of Epidemiology

• John Last (1988): "Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the prevention and control of health problems."
• MacMahon and Pugh: "Epidemiology is the study of the distribution and determinants of disease frequency in man."
• It studies who gets the disease, when, where, and why.

Aims of Epidemiology

1. To describe the distribution and magnitude of health and disease problems in human populations
2. To identify etiological factors (risk factors) for disease
3. To provide data for planning, implementing, and evaluating preventive and curative measures
4. To study the natural history and prognosis of disease
5. To identify high-risk groups needing priority attention
6. To evaluate the effectiveness of health programs and interventions
7. To develop and test preventive strategies

Uses of Epidemiology

1. To study historical trends in disease occurrence
2. Community diagnosis - assess health status of a population
3. Planning and evaluation of health services
4. Individual risks and chances - assess risk in individuals
5. Completing the clinical picture - understand full spectrum of disease
6. Identifying syndromes - cluster of signs/symptoms
7. Determining causes - causal factors and risk factors
8. Search for risk factors - identify preventable causes
9. Testing hypotheses - etiological hypotheses
10. Health policy development - evidence-based policy making

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Concept of Epidemiological Triad

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1. AGENT

• Infectivity: Ability to invade and multiply in host
• Pathogenicity: Ability to cause clinical illness
• Virulence: Proportion causing severe illness

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2. HOST

• Age, sex, race/ethnicity
• Genetic makeup and heredity
• Immunity (natural or acquired)
• Nutritional status
• Physiological state (pregnancy, stress)
• Habits and customs (smoking, diet, exercise)
• Occupation
• Pre-existing diseases

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3. ENVIRONMENT

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Interaction in the Triad

• Disease occurs when the agent overcomes host defenses in a favorable environment
• If the HOST is strong (good immunity, good nutrition) → disease may not occur even when exposed
• If the ENVIRONMENT is favorable to the agent (e.g., poor sanitation) → disease spreads more easily
• Time is a fourth factor sometimes added (Triangle of Epidemiology) — accounting for incubation periods, duration of illness, life expectancy

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Q.3 — SHORT NOTES (5 × 5 Marks)

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1. Levels of Disease Prevention [5 Marks]

Primary Prevention

• Applied during the pre-pathogenesis phase (before disease develops)
• Goal: Prevent disease from occurring at all
• Two components:
  1. Health Promotion: Improving general health and resistance
     • Balanced nutrition, health education, adequate rest, exercise
     • Good living standards, genetic counseling
  2. Specific Protection: Protection against specific diseases
     • Immunization (vaccines), use of specific nutrients (iodized salt)
     • Protection from occupational hazards, use of condoms

Secondary Prevention

• Applied during early pathogenesis phase
• Goal: Halt the progress of disease at its incipient stage, prevent complications
• Two components:
  1. Early Diagnosis: Screening tests, case finding programs (e.g., Pap smear, mass chest X-ray)
  2. Prompt Treatment: Treating disease before irreversible damage occurs

Tertiary Prevention

• Applied during late pathogenesis phase when disease is established
• Goal: Reduce disability, prevent complications, promote rehabilitation
• Two components:
  1. Disability Limitation: Preventing complications from advancing disease
  2. Rehabilitation: Restoring function — physical, psychological, social, vocational

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2. Home Visits [5 Marks]

Definition

Purpose of Home Visits

1. To provide nursing care to sick persons who cannot visit health facilities
2. To follow up on previously treated patients (e.g., TB, post-delivery)
3. To provide antenatal and postnatal care
4. To conduct health assessment of families
5. To provide health education in the family setting
6. To verify home conditions and identify risk factors
7. To assess and improve environmental sanitation

Types of Home Visits

• Case finding visits: To find unreported or untreated cases
• Follow-up visits: After hospital discharge or clinic visit
• Instructional visits: Teaching patients/family about care
• Emergency visits: For acute illness or injury at home

Principles of Home Visits

1. Plan the visit in advance (review records, prepare bag)
2. Make appointments when possible
3. Carry the nursing bag with necessary supplies
4. Respect the family's privacy, culture, and dignity
5. Observe the home environment (sanitation, overcrowding)
6. Document all findings and care provided
7. Prioritize visits based on need (most urgent first)

Steps in a Home Visit

1. Preparation: Review client records, plan objectives, prepare bag
2. Introduction: Introduce yourself, state purpose
3. Assessment: Physical, social, environmental assessment
4. Care/Teaching: Provide nursing care and education
5. Documentation: Record observations, care given, and follow-up plan
6. Evaluation: Assess effectiveness of care

Advantages

• Care is given in the patient's natural, comfortable environment
• Family members can be involved in care
• Nurse can assess actual living conditions
• Reduces need for hospitalization
• Strengthens nurse-family relationship

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3. Barriers of Effective Communication [5 Marks]

Definition of Communication

Barriers to Effective Communication

A. Physical/Environmental Barriers

• Noise in the surroundings
• Distance between communicators
• Poor lighting or ventilation
• Distractions in the environment

B. Language and Linguistic Barriers

• Use of technical/medical jargon that the patient doesn't understand
• Difference in language or dialect
• Use of unfamiliar words or abbreviations
• Low literacy level of the receiver

C. Psychological/Emotional Barriers

• Fear and anxiety (patient may not listen due to stress)
• Anger, hostility, or frustration
• Prejudice or bias toward the communicator
• Lack of trust or credibility
• Depression or mental illness

D. Cultural and Social Barriers

• Differences in cultural values and beliefs
• Gender differences (especially in conservative settings)
• Caste and class differences
• Taboos related to certain health topics (e.g., reproductive health)

E. Physiological Barriers

• Hearing impairment or deafness
• Visual impairment affecting non-verbal communication
• Speech disorders (stuttering, aphasia)
• Cognitive impairment or dementia

F. Organizational/Structural Barriers

• Lack of time for communication
• Overworked staff
• Lack of privacy
• Hierarchical communication gaps

Measures to Overcome Barriers

• Use simple, clear, local language
• Use visual aids and demonstrations
• Ensure privacy and a quiet environment
• Be culturally sensitive
• Use active listening
• Provide feedback and check for understanding

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4. Health-Illness Continuum Model [5 Marks]

Introduction

Concept

Premature         Disability    Symptoms    Signs    Neutral    Awareness    Education    Growth    High-level
  Death  ←———————————————————————————————————————|——————————————————————————————————————→  Wellness
         [  TREATMENT PARADIGM (illness side)   ] [ WELLNESS PARADIGM (health side)      ]

Key Components

• Neutral Point: The midpoint — neither sick nor optimally well; absence of disease
• Treatment Paradigm (left side): Movement toward illness and death
  • Includes signs, symptoms, disability, premature death
• Wellness Paradigm (right side): Movement toward optimal health
  • Includes awareness, education, personal growth, high-level wellness

Significance in Nursing

• Nurses can identify where a patient stands on the continuum
• Guides nursing interventions toward moving the patient toward wellness
• Emphasizes prevention and health promotion, not just disease treatment
• Helps patients visualize their health status and set goals
• Supports holistic nursing care (physical, mental, social, spiritual)

Application

• A patient recovering from TB is moving from left toward center (treatment)
• A healthy person practicing yoga is moving further right (wellness)
• The nurse's role is to help patients move toward the wellness end

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5. Dimensions of Health [5 Marks]

Introduction

Dimensions of Health

1. Physical Dimension

• Refers to the structural and functional integrity of the body
• Includes: absence of disease, good nutrition, adequate sleep, fitness
• Indicators: BP, weight, BMI, laboratory values

2. Mental/Psychological Dimension

• Refers to emotional and psychological well-being
• Ability to cope with stress, think clearly, make decisions
• Includes: self-esteem, emotional stability, absence of mental illness
• WHO: "Mental health is a state of well-being in which every individual realizes his/her potential, copes with normal stresses of life, works productively, and contributes to the community"

3. Social Dimension

• Refers to ability to maintain satisfying interpersonal relationships
• Ability to function socially in family, workplace, and community
• Includes: social support systems, role performance, community ties

4. Spiritual Dimension

• Refers to belief in a higher purpose, meaning of life, values
• Sense of purpose and meaning in life
• Religious beliefs, values, ethics
• Provides strength during illness

5. Emotional Dimension

• Ability to manage and express emotions appropriately
• Capacity for love, empathy, and self-awareness
• Ability to deal with grief, loss, and stress

6. Environmental Dimension

• The interaction of humans with their physical environment
• Clean air, safe water, healthy housing, absence of pollution
• Occupational and environmental safety

7. Vocational/Occupational Dimension

• Satisfaction derived from work or productive activities
• Ability to contribute meaningfully to society

Significance in Community Health Nursing

• The nurse must assess all dimensions for holistic care
• Interventions must address all dimensions, not just physical illness
• Community health programs must target multiple dimensions simultaneously

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Q.4 — VERY SHORT NOTES (4 × 2 Marks)

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1. Sustainable Development Goals (SDGs) [2 Marks]

• Adopted by UN in September 2015, to be achieved by 2030
• Replaced the Millennium Development Goals (MDGs)
• 17 SDGs with 169 targets covering all dimensions of development
• SDG 3: "Ensure healthy lives and promote well-being for all at all ages" - the health-specific goal
• Key health targets under SDG 3:
  • Reduce MMR to < 70/1,00,000 live births
  • Reduce U5MR to < 25/1,000 live births
  • End epidemics of AIDS, TB, malaria by 2030
  • Achieve Universal Health Coverage (UHC)
  • Reduce premature NCD mortality by 1/3rd
• Other SDGs relevant to health: SDG 2 (Zero Hunger), SDG 6 (Clean Water), SDG 13 (Climate Action)
• India's focus: achieving equity, reducing maternal and child mortality, strengthening primary healthcare

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2. Women Empowerment [2 Marks]

• Women empowerment means giving women the power, resources, and opportunity to make decisions about their own lives, health, and bodies
• Key components:
  • Education and literacy
  • Economic independence (employment, income)
  • Social equality and freedom from discrimination
  • Political participation and representation
  • Legal rights and access to justice
  • Reproductive rights and health decision-making
• Importance in Community Health:
  • Empowered women make better health decisions for themselves and families
  • Reduces maternal mortality, child malnutrition, and domestic violence
  • Improves immunization rates and child survival
• Key programs in India: Beti Bachao Beti Padhao, Mahila Shakti Kendras, Self-Help Groups (SHGs), ASHA workers, Janani Suraksha Yojana

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3. BCC & IEC [2 Marks]

• A strategy to provide health information to the public
• Uses mass media (TV, radio, posters, pamphlets) to spread health messages
• One-way communication (from provider to community)
• Goal: Increase awareness and knowledge
• Examples: Polio vaccination campaigns, TB awareness pamphlets, AIDS posters

• An evolution of IEC - goes beyond knowledge to actual behavior change
• Two-way, interactive communication process
• Based on understanding the audience's beliefs, attitudes, motivations
• Goal: Motivate communities to adopt healthier behaviors
• Uses interpersonal communication, community meetings, peer education
• Examples: Promoting handwashing, healthy diet, contraceptive use, stopping open defecation

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4. Principles of PHC (Primary Health Care) [2 Marks]

1. Sanitation and safe water supply
2. Antenatal and MCH care including family planning
3. Food supply and proper nutrition
4. Education about prevailing health problems
5. Mental health
6. Immunization against major infectious diseases
7. National disease control (TB, malaria, etc.)
8. Community participation
9. Essential drugs availability (+ treatment of common diseases)

1. Equitable distribution: Services available to all, especially rural and poor
2. Community participation: Communities involved in planning and implementation
3. Intersectoral coordination: Health linked with agriculture, education, water, housing
4. Appropriate technology: Cost-effective, acceptable technology
5. Focus on prevention: Preventive and promotive care over curative
6. Accessibility: Geographically, financially, socially accessible to all
7. Sustainability: Affordable within community and national resources

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Sources: Park's Textbook of Preventive and Social Medicine (23rd ed.); National Health Policy 2017, Ministry of Health and Family Welfare, GoI; Alma Ata Declaration (1978); Travis Health-Illness Continuum (1972); UN Sustainable Development Goals (2015).