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Community Medicine / Preventive & Social Medicine - University Exam Guide

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1. Epidemiology of Non-Communicable Diseases (NCDs)

Definition

Global Burden

• NCDs kill ~41 million people each year (71% of all deaths globally)
• 15 million deaths occur between ages 30-69 ("premature" deaths)
• 77% of all NCD deaths occur in low- and middle-income countries

Epidemiological Triad (Host-Agent-Environment)

• Tobacco: causes ~7 million deaths/year; responsible for 71% of lung cancer, 42% of chronic respiratory disease, 10% of CVD
• Harmful alcohol use: ~3.3 million deaths/year (5.9% of all deaths)
• Physical inactivity: ~1.6 million deaths/year; 20-30% increased risk of all-cause mortality
• Unhealthy diet (high salt, saturated fats, low fruits/vegetables)

• Raised blood pressure: causes ~9.4 million deaths/year (12.8% of all deaths); global prevalence ~22% in adults
• Overweight/obesity: 2.8 million deaths/year; raises risk of CVD, stroke, diabetes
• Raised blood glucose: major risk for diabetes and cardiovascular complications
• Raised cholesterol

Prevention Levels

• Primordial: prevent emergence of risk factors in population
• Primary: reduce risk factor prevalence (health promotion, behaviour change)
• Secondary: early detection, screening (e.g., BP measurement, blood glucose)
• Tertiary: rehabilitation, preventing complications

WHO Global Action Plan (2013-2030)

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2. Nutrition and Health

Nutritional Requirements (Key Categories)

• Macronutrients: Carbohydrates (55-75% of energy), Proteins (10-15%), Fats (15-30%)
• Micronutrients: Vitamins (fat-soluble A, D, E, K; water-soluble B-complex, C) and Minerals (Ca, Fe, I, Zn)

Major Nutritional Deficiency Disorders

Nutritional Assessment (ABCD)

• Anthropometry: weight, height, BMI, mid-arm circumference, skin-fold thickness
• Biochemical: serum protein, Hb, serum retinol, urinary iodine
• Clinical: signs and symptoms of deficiency
• Dietary: 24-hour recall, food frequency questionnaire

Nutritional Programmes in India

• ICDS (Integrated Child Development Services): supplementary nutrition for children <6 years and pregnant/lactating mothers
• Mid-Day Meal Programme: for school children
• National Nutritional Anaemia Prophylaxis Programme
• National Iodine Deficiency Disorders Control Programme

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3. Preventive Medicine in Obstetrics, Paediatrics & Geriatric Services

Preventive Obstetrics

• Register pregnancy early; assess risk factors
• Tetanus Toxoid (TT) immunization (2 doses or booster)
• Iron and Folic Acid supplementation (180 IFA tablets)
• Weight monitoring, BP measurement, abdominal examination
• Haemoglobin estimation, urine examination
• Identify high-risk pregnancies (previous LSCS, elderly primigravida, severe anaemia, HTN, short stature <145 cm, bad obstetric history)

• Institutional delivery (clean delivery, trained attendant)
• 3 Clean Practices: clean surface, clean hands, clean cut of cord

• Monitor involution of uterus; check for sepsis, haemorrhage
• Breastfeeding promotion (initiate within 1 hour of birth)
• Family planning counselling

Preventive Paediatrics

• IMR (Infant Mortality Rate): deaths <1 year per 1,000 live births
• Under-5 Mortality Rate (U5MR)
• Perinatal Mortality Rate (PMR)

• Immunization (UIP): BCG, OPV, Hepatitis B, DPT, Measles, MMR, Hib, Rotavirus, PCV
• Growth Monitoring: Weight-for-age (Gomez classification), Height-for-age (stunting), Weight-for-height (wasting)
• IMNCI (Integrated Management of Neonatal and Childhood Illness): algorithms for pneumonia, diarrhoea, malaria, malnutrition, measles
• Essential Newborn Care: warmth, breastfeeding, cord care, eye care
• School Health Services: periodic medical examination, health education, immunization

• ORT (Oral Rehydration Therapy) for diarrhoea
• Zinc supplementation reduces diarrhoea severity
• Exclusive breastfeeding for 6 months protects against infections

Geriatric Services (Health of Elderly)

• Cardiovascular disease (HTN, IHD)
• Diabetes mellitus
• Musculoskeletal disorders (arthritis, osteoporosis)
• Mental health issues (dementia, depression)
• Sensory impairment (vision, hearing)
• Urinary incontinence
• Malnutrition
• Falls and fractures

• National Programme for Health Care of Elderly (NPHCE): district hospitals, CHCs and PHCs equipped with geriatric units
• Preventive services: calcium supplementation, fall prevention, regular health check-ups
• Palliative care, home-based long-term care

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4. Disaster Management

Definition

Classification of Disasters

• Natural: Earthquakes, floods, cyclones, tsunamis, droughts, landslides
• Man-made/Technological: Industrial accidents, nuclear disasters, chemical spills, fires
• Complex Emergencies: Conflict-related; combination of factors

Disaster Management Cycle

Mitigation → Preparedness → Response → Recovery
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1. Mitigation: Reduce/eliminate risk (building codes, flood barriers, early warning systems)
2. Preparedness: Plans, training, stockpiling, rehearsals, community education
3. Response: Emergency operations, search and rescue, medical care, evacuation
4. Recovery: Restoration of services, rehabilitation, reconstruction

Health Priorities in Disasters

• Triage and emergency medical care
• Safe water supply and sanitation
• Food security (prevent starvation/malnutrition)
• Disease surveillance (prevent epidemic - diarrhoea, cholera, measles, malaria)
• Shelter and hygiene promotion
• Mental health and psychosocial support (MHPSS)

National Disaster Management Authority (NDMA)

• Set up under Disaster Management Act 2005 (India)
• Headed by Prime Minister
• State Disaster Management Authorities (SDMAs) at state level
• National Disaster Response Force (NDRF): 12 battalions for specialized response

Triage (START method)

• Immediate (Red): Life-threatening, salvageable
• Delayed (Yellow): Serious but can wait
• Minor (Green): Walking wounded
• Expectant (Black): Dead or unsurvivable

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5. Mental Health

Definition (WHO)

Global Burden

• 1 in 8 people worldwide live with a mental disorder
• Depression is a leading cause of disability globally
• Suicide: ~800,000 deaths/year (15.1/100,000)
• Mental disorders account for 13% of global burden of disease

Classification (ICD-10/DSM-5 categories)

• Schizophrenia and psychotic disorders
• Mood (affective) disorders (depression, bipolar)
• Anxiety disorders
• Substance use disorders
• Dementia/Neurocognitive disorders
• Childhood mental disorders (ADHD, autism)

Epidemiology in India

• Prevalence of mental disorders: ~10-14% of population
• NMHS 2016: 10.6% of adults have mental illness; only 1 in 30 received treatment

Prevention Levels

• Primary: Mental health promotion, stress reduction, life skills education
• Secondary: Early detection and treatment (community screenings)
• Tertiary: Rehabilitation, prevent relapse

National Mental Health Programme (NMHP - 1982)

• Objectives: ensure availability and accessibility of minimum mental healthcare
• District Mental Health Programme (DMHP): integration of mental health into general healthcare at district level
• Mental Healthcare Act, 2017: rights-based approach, decriminalization of suicide attempt

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6. Genetics in Community Health

Key Concepts

• Gene: Unit of heredity; segment of DNA coding for a protein
• Genotype vs Phenotype: genetic constitution vs observable characteristics
• Mutation: Permanent change in DNA sequence

Patterns of Inheritance

• Autosomal Dominant (AD): One altered allele sufficient (e.g., Huntington's, Marfan syndrome, Familial hypercholesterolaemia)
• Autosomal Recessive (AR): Both alleles altered (e.g., Cystic fibrosis, PKU, Sickle cell anaemia, Thalassaemia)
• X-linked Recessive: Haemophilia A & B, Duchenne muscular dystrophy, Colour blindness
• X-linked Dominant: Vitamin D-resistant rickets
• Multifactorial/Polygenic: Cleft palate, congenital heart defects, hypertension, diabetes, schizophrenia

Chromosomal Disorders

• Down Syndrome (Trisomy 21): Most common; 1 in 700 live births; risk increases with maternal age
• Turner Syndrome (45,XO): Female phenotype, short stature, streak ovaries
• Klinefelter Syndrome (47,XXY): Male phenotype, tall, small testes, infertility

Genetic Screening & Prevention

• Pre-marital counselling: especially for communities with high prevalence of AR disorders
• Prenatal diagnosis: Amniocentesis (15-18 weeks), Chorionic Villus Sampling (CVS) 10-12 weeks, Triple/Quadruple screen, Fetal anomaly scan
• Newborn screening: PKU, hypothyroidism, congenital adrenal hyperplasia
• Carrier detection: for sickle cell, thalassaemia (CBC + Hb electrophoresis)
• Genetic counselling: Non-directive, supportive, providing recurrence risk information

Recurrence Risks (Important for Exams)

• AD disorders: 50% risk for each child
• AR disorders: 25% risk for each child
• X-linked recessive: 50% of sons affected; 50% of daughters are carriers

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7. Communication for Health Education

Definition

Communication Process (SMCR Model)

• Source (S): health educator/communicator
• Message (M): health information/content
• Channel (C): medium used
• Receiver (R): audience/patient

Barriers to Communication

• Physical: noise, distance
• Semantic: language differences, jargon
• Psychological: fear, prejudice, cultural beliefs
• Organizational: bureaucracy, poor feedback mechanisms

Methods of Health Education

Principles of Health Education (SMART Goals)

• Start where people are
• Build on existing knowledge and practices
• Use simple, clear, relevant messages
• Reinforce messages repeatedly through multiple channels
• Involve community participation

Communication Tools

• Audio-visual aids: flip charts, posters, models, films
• IEC (Information, Education, Communication): material for awareness
• BCC (Behaviour Change Communication): targeting attitudes and practices
• Social and Behaviour Change Communication (SBCC): comprehensive approach including social media

Steps in Planning a Health Education Programme

1. Community diagnosis (need assessment)
2. Setting objectives (SMART)
3. Selecting methods and media
4. Implementation
5. Evaluation (process, impact, outcome)

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8. Health Planning and Management

Principles of Health Planning

Planning Cycle

Situation Analysis → Priority Setting → Goal/Objective Setting → 
Implementation → Monitoring → Evaluation → Feedback

Tools of Health Planning

• SWOT Analysis: Strengths, Weaknesses, Opportunities, Threats
• GANTT Chart: time-based planning of activities
• PERT (Programme Evaluation and Review Technique): network analysis
• Logical Framework Approach (LFA / Logframe): inputs, activities, outputs, outcomes, impact

Health Management Functions (POSDCORB)

• Planning, Organizing, Staffing, Directing, COordinating, Reporting, Budgeting

Levels of Health Planning

• National level: National Health Policy (India: 2017), Five Year Plans, Health sector budgeting
• State level: State-specific plans, NRHM/NHM implementation
• District level: District Health Action Plan (DHAP)

National Health Policy 2017 (India)

• Increase government health expenditure to 2.5% of GDP
• Reduce IMR to 28/1000, MMR to 100/100,000 by 2020
• Achieve 90% immunization coverage
• Reduce premature mortality from CVDs, cancer, diabetes, CRDs by 25%
• Universal Health Coverage (UHC)

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9. Health Care of Community

Community Health Needs

• Defined by epidemiological profile, demographics, disease burden, social determinants of health
• Social determinants: income, education, housing, nutrition, water/sanitation, employment

Primary Health Care (PHC) - Alma Ata Declaration 1978

1. Supply of essential drugs
2. Appropriate treatment of common diseases
3. Food and nutrition
4. Education on prevailing health problems
5. Child and Maternal health care including family planning
6. Adequate safe water and sanitation
7. Management of communicable diseases
8. Preventive medicine (immunization)

Health Infrastructure in India (Rural)

• Sub-Centre (SC): 5,000 population (plain) / 3,000 (hilly/tribal); staffed by 1 Male MPW + 1 ANM; first contact point
• Primary Health Centre (PHC): 30,000 population (plain) / 20,000 (hilly); 1 MO + paramedical staff; 6 inpatient beds; 24/7 care
• Community Health Centre (CHC): 120,000 population; 4 specialists (Surgeon, Physician, OBG, Paediatrician); 30-bed hospital
• District Hospital: referral centre; specialist care; 100-500 beds

Urban Health Infrastructure

• Urban Health Centre (UHC), Urban Family Welfare Centre, Polyclinics, ESI hospitals

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10. International Health

Key International Organizations

WHO Structure

• Governed by World Health Assembly (WHA) - meets annually
• Executive Board of 34 members
• Director-General heads Secretariat
• 6 Regional Offices (SEARO for South-East Asia - New Delhi)

International Health Regulations (IHR 2005)

• Legally binding framework to prevent and control international disease spread
• Covers Public Health Emergencies of International Concern (PHEIC)
• Requires countries to build core capacities in surveillance and response

Millennium Development Goals (MDGs) - 2000-2015 (see also section 12)

• 8 goals, 21 targets
• India: achieved MDG 6 (combat HIV/AIDS); partially achieved MDG 4 (child mortality), MDG 5 (maternal health)

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11. National Health Programmes (India)

Major National Health Programmes

• National Health Mission (NHM): Umbrella for NRHM + NURM
• Janani Suraksha Yojana (JSY): Cash incentive for institutional delivery
• JSSK (Janani Shishu Suraksha Karyakram): Free services for pregnant women in government facilities
• Mission Indradhanush: Achieve full immunization coverage

• RNTCP (Revised National TB Control Programme) / National TB Elimination Programme (NTEP): Target TB elimination by 2025; DOTS strategy; Ni-kshay portal
• National Vector Borne Disease Control Programme (NVBDCP): Malaria, dengue, filaria, kala-azar, Japanese encephalitis, chikungunya
• NACP (National AIDS Control Programme): Phase 1-5; ICTC, ART centres, targeted interventions
• National Programme for Control of Blindness (NPCB): Cataract, refractive errors, corneal blindness, glaucoma

• National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS)
• National Mental Health Programme (NMHP)
• National Tobacco Control Programme (NTCP)

• POSHAN Abhiyan (National Nutrition Mission): Reduce stunting, undernutrition, anaemia, low birth weight by 2-3% annually
• ICDS: Anganwadi-based; supplementary nutrition, immunization, health check-up, referral, pre-school education, nutrition and health education

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12. Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs)

Millennium Development Goals (2000-2015)

Sustainable Development Goals (SDGs) 2015-2030

• By 2030: Maternal mortality ratio <70/100,000 live births
• By 2030: End preventable deaths of newborns (NMR <12/1000) and children under 5 (U5MR <25/1000)
• By 2030: End epidemics of AIDS, TB, malaria, neglected tropical diseases
• By 2030: Reduce premature mortality from NCDs by 1/3
• Achieve Universal Health Coverage (UHC) - SDG 3.8
• By 2030: Halve global deaths and injuries from road traffic accidents
• Achieve universal access to sexual and reproductive health services

• SDG 1 (No poverty), SDG 2 (Zero hunger), SDG 6 (Clean water and sanitation), SDG 13 (Climate action) - all affect health

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13. Occupational Health

Definition (ILO/WHO Joint Committee, 1950)

Objectives

1. Prevention and maintenance of health against occupational hazards
2. Adaptation of work environment to worker's physiological/psychological needs
3. Promotion and maintenance of highest degree of well-being

Occupational Hazards

Important Occupational Diseases

• Silicosis: Most important pneumoconiosis; caused by silicon dioxide; found in quarry workers, miners, stonemasons; characteristic "egg-shell calcification" on X-ray
• Asbestosis: Caused by asbestos fibres; pleural plaques, mesothelioma risk
• Coal Workers' Pneumoconiosis (CWP): "Black lung disease"
• Byssinosis: Cotton dust; characteristic Monday chest tightness
• Occupational Asthma: Isocyanates (MDI, TDI), flour, latex
• Lead poisoning: Painters, battery factory workers; basophilic stippling of RBCs, Burton's lines (blue gum line)
• Mercury poisoning: Minamata disease; neurological features

Legislation (India)

• Factories Act 1948: Cleanliness, ventilation, lighting, overcrowding, safety provisions
• Mines Act 1952: Health and safety of mine workers
• Employees' State Insurance (ESI) Act 1948: Sickness, maternity, disablement, and dependent benefits

Occupational Health Services

• Pre-employment medical examination
• Periodic health examinations
• Environmental monitoring and industrial hygiene
• Health education
• Treatment of occupational diseases and injuries
• Rehabilitation

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Quick Revision Summary Table

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