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📚 PSM Exam Preparation - ESIC Medical College

Community Medicine - Important Questions & Answers

Based on Park's Textbook of Preventive and Social Medicine

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TOPIC 1: CONCEPT OF HEALTH AND DISEASE

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Q1 (Long Essay Type - 10 Marks): Define health. Describe the various dimensions and determinants of health.

Definition of Health

Dimensions of Health (PMSESC)

Determinants of Health (Mandala of Health)

1. Biological/Genetic factors - age, sex, heredity, constitution
2. Behavioral/Lifestyle factors - diet, exercise, smoking, alcohol, sexual behavior
3. Socio-economic factors - income, education, employment, poverty
4. Environmental factors - water, sanitation, air quality, housing
5. Health services - accessibility, availability, affordability
6. Psychosocial factors - stress, social support, coping mechanisms

Positive Health vs Negative Health

• Positive health = complete physical, mental and social well-being (optimal functioning)
• Negative health = presence of disease or infirmity

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Q2 (Short Note - 5 Marks): Define disease. Explain the Iceberg phenomenon of disease.

Iceberg Phenomenon

• Described by John Last (1963)
• In any community, only a small proportion of disease cases come to medical attention - this is the "clinical tip of the iceberg"
• The vast majority of disease cases remain submerged (undiagnosed, subclinical, latent)

        /\        ← Diagnosed cases (visible tip)
       /  \
      /----\     ← Clinical threshold
     /      \
    /        \   ← Subclinical cases, carriers,
   /          \    presymptomatic cases, undiagnosed
  /____________\  (submerged portion = majority)

• Helps estimate true burden of disease
• Guides public health programs
• Relevant for diseases like hypertension, diabetes, TB, iceberg diseases

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Q3 (Short Note - 5 Marks): Explain the Natural History of Disease and Levels of Prevention.

Natural History of Disease (Leavell & Clark)

• Interaction between agent, host, and environment (ecological triad)
• Disease has NOT yet developed

• Phase of early pathogenesis (subclinical)
• Phase of clinical disease
• Phase of outcome (recovery, disability, death)

Levels of Prevention

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Q4 (Short Answer - 3 Marks): What is the Epidemiological Triad?

1. Agent - causative factor (biological, chemical, physical, nutritional, psychosocial)
2. Host - the human being (age, sex, immunity, nutritional status, behavior)
3. Environment - physical, biological, social (the setting where agent meets host)

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TOPIC 2: RELATIONSHIP OF SOCIAL AND BEHAVIOURAL FACTORS TO HEALTH AND DISEASE

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Q5 (Short Note - 5 Marks): How do social and behavioral factors influence health?

Social Determinants of Health (SDH)

Social Factors:

1. Poverty - most important determinant; linked to malnutrition, poor sanitation, illiteracy
2. Education - health literacy, awareness, utilization of services
3. Occupation - occupational hazards, stress
4. Housing - overcrowding causes TB, meningitis; poor sanitation causes diarrhea
5. Social class - Registrar General's Classification (Classes I-V); higher class = better health
6. Social support - family, community networks buffer stress
7. Caste and religion - dietary practices, marriage patterns, healthcare-seeking behavior

Behavioural/Lifestyle Factors:

1. Tobacco use - lung cancer, COPD, cardiovascular disease
2. Alcohol - liver disease, accidents, violence, domestic problems
3. Dietary habits - obesity, diabetes, cardiovascular disease, malnutrition
4. Physical inactivity - non-communicable diseases (NCDs)
5. Unsafe sex - HIV/AIDS, STIs
6. Drug abuse - addiction, blood-borne infections

Key concept: "Lifestyle diseases" (NCDs) are largely driven by behavioral risk factors and are preventable through behavioral change.

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Q6 (Short Answer - 3 Marks): What is Health Belief Model?

1. Perceived susceptibility - belief that one can get the disease
2. Perceived severity - belief that the disease has serious consequences
3. Perceived benefits - belief that action will reduce the threat
4. Perceived barriers - obstacles to taking action
5. Cues to action - triggers (symptoms, media, advice)
6. Self-efficacy (added later) - confidence to perform the behavior

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TOPIC 3: PRINCIPLES OF HEALTH PROMOTION AND EDUCATION

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Q7 (Long Essay / Short Note - 5 Marks): Define health education. What are its objectives and principles?

Definition

Objectives of Health Education (3 Ps)

1. Predispose - create awareness, change knowledge and attitudes
2. Enable - provide skills, resources, access to services
3. Reinforce - positive feedback, social support to sustain behavior

Principles of Health Education

1. Credibility - information must come from credible sources
2. Interest - content should be relevant to audience needs
3. Participation - community should be actively involved
4. Motivation - based on real needs and felt needs
5. Comprehension - use simple, understandable language
6. Repetition - key messages must be repeated for retention
7. Known to unknown - start from familiar concepts
8. Good human relations - respect for the audience

Methods of Health Education

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Q8 (Short Note - 5 Marks): Define Health Promotion. Explain the Ottawa Charter.

Health Promotion

Ottawa Charter for Health Promotion (1986)

1. Build healthy public policy - health in all policies
2. Create supportive environments - safe, stimulating, satisfying environments
3. Strengthen community action - community participation and empowerment
4. Develop personal skills - health education, life skills
5. Reorient health services - shift toward prevention and promotion

Prerequisites for Health (Ottawa Charter)

• Peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity

Key slogan: "Health for All" and "Equity in Health" are central themes.

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Q9 (Short Answer - 3 Marks): What are the behavioral change communication (BCC) strategies?

1. Individual level - counseling, motivational interviewing
2. Community level - peer education, community mobilization
3. Mass media - IEC (Information, Education, Communication) campaigns
4. Social media - digital health promotion
5. Interpersonal communication (IPC) - face-to-face, most effective

• Assess behavior → Set objectives → Develop messages → Choose channels → Implement → Evaluate

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TOPIC 4: NUTRITION

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Q10 (Long Essay - 10 Marks): Discuss nutritional requirements, nutritional assessment methods, and important nutritional disorders.

A. Nutritional Requirements

• Carbohydrates: 4 kcal/g (should provide 50-60% of energy)
• Proteins: 4 kcal/g (10-15% of energy)
• Fats: 9 kcal/g (20-30% of energy)

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B. Nutritional Assessment Methods (ABCD)

• Underweight: < 18.5
• Normal: 18.5-24.9
• Overweight: 25-29.9
• Obese: ≥ 30

• < 12.5 cm = Severe Acute Malnutrition in children
• 12.5-13.5 cm = Moderate Acute Malnutrition

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C. Major Nutritional Disorders

• Grade I (mild): 75-90% of expected weight
• Grade II (moderate): 60-74% of expected weight
• Grade III (severe): < 60% of expected weight

• Bitot's spots - triangular foamy spots on conjunctiva
• Night blindness (Nyctalopia) - earliest symptom
• Xerophthalmia - dryness of conjunctiva
• Keratomalacia - corneal softening → blindness (irreversible)
• Xerosis - dryness of skin

• Most common nutritional deficiency worldwide
• Signs: pallor, koilonychia (spoon nails), glossitis, angular stomatitis
• Lab: low Hb, low serum ferritin, microcytic hypochromic anemia
• Treatment: Iron + folic acid supplementation

• Goitre (thyroid enlargement) - most visible sign
• Cretinism - in fetus/newborn (irreversible intellectual disability)
• Hypothyroidism
• Prevention: Iodized salt (15-20 ppm iodine at household level)

• Rickets in children (bowing of legs, rachitic rosary)
• Osteomalacia in adults (bone pain, fractures)

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D. Diet Planning

1. Adequacy - sufficient nutrients
2. Balance - all food groups represented
3. Calorie control
4. Nutrient density
5. Moderation and variety

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Q11 (Short Note - 5 Marks): Write about National Nutrition Programmes including ICDS.

Integrated Child Development Services (ICDS)

• Launched: October 2, 1975
• Target group: Children 0-6 years, pregnant women, lactating mothers, adolescent girls
• Implementing body: Ministry of Women & Child Development

1. Supplementary nutrition
2. Early childhood care and education (for 3-6 yr)
3. Nutrition and health education (for women)
4. Immunization
5. Supplementation of micronutrients (Vitamin A, Iron-Folate)
6. Health referral services

Other National Nutrition Programmes

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Q12 (Short Answer - 3 Marks): What is nutritional surveillance?

• Anthropometric surveys (weight, height, MUAC)
• Biochemical monitoring (Hb, vitamin levels)
• Food consumption surveys
• Vital statistics (infant mortality, birth weight)

1. Programme surveillance - monitor specific nutrition programs
2. Warning surveillance - early warning of food crisis/famine
3. Advocacy surveillance - data to support policy decisions

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TOPIC 5: DEMOGRAPHY AND VITAL STATISTICS

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Q13 (Short Note - 5 Marks): Define demography. Explain important demographic indicators.

Definition

Sources of Demographic Data

1. Census - decennial (every 10 years); complete enumeration of population
2. Civil Registration System (CRS) - continuous registration of births, deaths, marriages (India: Registration of Births and Deaths Act, 1969)
3. Sample Surveys - NFHS (National Family Health Survey), SRS (Sample Registration System)

Important Demographic Indicators

• = (Live births in a year / Mid-year population) × 1000
• India CBR: approximately 19.7 (NFHS-5, 2019-21)

• = (Deaths in a year / Mid-year population) × 1000
• India CDR: approximately 6.2

• = (Deaths under 1 year / Live births in same year) × 1000
• India IMR: 35.2 (SRS 2019)
• Best sensitive index of health status of a community

• = (Maternal deaths / Live births) × 100,000
• India MMR: 97/100,000 live births (SRS 2018-20)

• = Average number of children born to a woman during her lifetime
• India TFR: 2.0 (NFHS-5) - at replacement level (2.1)

• India: 69.7 years (male: 68.2, female: 71.1)

• = CBR - CDR

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Q14 (Short Note - 5 Marks): Write a note on demographic transition theory.

Demographic Transition Theory (Warren Thompson, 1929)

Population Explosion occurs in Stage 2 because death rates fall (due to medical advances) but birth rates remain high.

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Q15 (Short Answer - 3 Marks): Define and differentiate Fertility rates.

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Q16 (Short Answer - 3 Marks): What are vital statistics? Name the vital events.

1. Births (live births and still births)
2. Deaths
3. Marriages
4. Separations/Divorces
5. Disease (morbidity) - sometimes included
6. Disability

• Measure health status and disease burden
• Plan health services and allocate resources
• Monitor population trends
• Evaluate health programs

• Civil Registration System (CRS)
• Sample Registration System (SRS) - most reliable for vital rates
• Census of India (every 10 years)
• NFHS (National Family Health Survey)

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Q17 (MCQ-type / Short Answer): What is the difference between IMR, NMR, PNMR, and U5MR?

IMR is the most sensitive indicator of the health status of a community and reflects the socioeconomic development.

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QUICK REVISION TABLE - High-Yield Facts

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• Definitions (health, disease, demography, health education)
• ICDS 6 services (very commonly asked)
• ABCD of nutritional assessment
• IMR and its formula (most sensitive health indicator)
• Ottawa Charter 5 action areas
• Levels of prevention with examples
• Demographic transition stages
• Nutritional disorders comparison table (Kwashiorkor vs Marasmus)