---

PSM Answers - Q.P. 6

---

Q1. Objectives of Reproductive and Child Health (RCH) Programme + NHM Initiatives to Reduce Mortality Among Mothers and Children (2+8 = 10 Marks)

Part A: Objectives of RCH Programme (2 marks)

1. Reduce infant mortality, under-5 mortality, and maternal mortality
2. Achieve replacement level fertility (NRR = 1)
3. Promote responsible and planned parenthood
4. Ensure universal access to contraception and safe abortion services
5. Provide quality antenatal, intranatal, and postnatal care
6. Reduce incidence of RTIs/STIs/HIV
7. Promote full immunization of children and pregnant women
8. Improve nutritional status of mothers and children

---

Part B: NHM Initiatives to Reduce Mortality Among Mothers and Children (8 marks)

A. Janani Suraksha Yojana (JSY)

• Cash incentive scheme to promote institutional deliveries
• Targets BPL women, SC/ST women, and women in LPS states
• Cash benefit: Rs. 1400 (rural LPS), Rs. 600 (urban LPS)
• ASHA acts as link worker

B. Janani Shishu Suraksha Karyakram (JSSK)

• Free and cashless delivery, C-section, and newborn care at government facilities
• Free drugs, diagnostics, blood, transport, diet for mother and sick newborn
• Eliminates out-of-pocket expenditure

C. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)

• Fixed day antenatal care on the 9th of every month
• Minimum package of ANC provided to all pregnant women in 2nd/3rd trimester
• Identification of high-risk pregnancies

D. LaQshya (Labour Room Quality Improvement Initiative)

• Improves quality of care in labour rooms and maternity operation theatres
• Aims to reduce preventable maternal and newborn deaths

E. Navjaat Shishu Suraksha Karyakram (NSSK)

• Training of health workers in basic newborn care and resuscitation
• Special Newborn Care Units (SNCUs), Newborn Stabilization Units (NBSUs), Newborn Care Corners (NBCCs)

F. Home Based Newborn Care (HBNC)

• ASHA visits newborn at home (6 visits in first 42 days)
• Promotes early initiation of breastfeeding, skin-to-skin care, cord care

G. Rashtriya Bal Swasthya Karyakram (RBSK)

• Child Health Screening for 4 Ds: Defects at birth, Deficiencies, Diseases, Developmental delays
• Mobile health teams screen children 0-18 years

H. Mission Indradhanush

• Intensified immunization drive to cover unvaccinated/partially vaccinated children under 2 years and pregnant women
• Targets reaching 90% full immunization coverage

I. Integrated Management of Neonatal and Childhood Illness (IMNCI)

• Strategy for managing common childhood illnesses (pneumonia, diarrhoea, malaria, malnutrition)

J. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)

• Comprehensive strategy linking all stages of the life cycle
• Emphasizes continuum of care from pre-pregnancy to adolescence

---

Q2. Factors for Rising Trend of Cancer + Strategies for Control with Reference to Tobacco (10 Marks)

Factors Responsible for Rising Trend of Cancer:

• Age (most cancers increase with age; aging population)
• Genetic predisposition (BRCA1/2, APC gene mutations)
• Hormonal factors (estrogen in breast/endometrial cancer)
• Immunosuppression
• Pre-cancerous lesions (leukoplakia, erythroplakia)

1. Tobacco use - single largest cause (30% of all cancers); smoking causes lung, oral, laryngeal, esophageal, bladder cancer; tobacco chewing causes oral cancer
2. Alcohol - associated with oral, esophageal, liver, breast cancers
3. Dietary factors - low fibre, high fat diet, red meat, preserved foods (nitrosamines), aflatoxins
4. Occupational carcinogens - asbestos (mesothelioma), benzene (leukemia), vinyl chloride, arsenic
5. Radiation - ionizing (X-ray, nuclear) and UV radiation (skin cancer)
6. Infections - HPV (cervical cancer), HBV/HCV (liver cancer), H. pylori (gastric), EBV (lymphoma), HIV
7. Reproductive factors - early menarche, late menopause, nulliparity (breast/ovarian)
8. Urbanization and lifestyle changes - sedentary behavior, obesity
9. Aging population - India's demographic transition
10. Improved diagnosis and reporting - apparent rise due to better detection

Strategies for Control of Cancer with Reference to Tobacco:

1. Primary Prevention (Tobacco Control)

• COTPA (Cigarettes and Other Tobacco Products Act), 2003:
  • Prohibition of smoking in public places
  • Ban on advertisement and promotion of tobacco products
  • Mandatory pictorial warnings on tobacco packages (85% of pack surface)
  • Ban on sale to minors (under 18 years)
  • No sale within 100 meters of educational institutions
• MPOWER package (WHO Framework Convention on Tobacco Control - FCTC):
  • Monitor tobacco use and prevention policies
  • Protect people from tobacco smoke (smoke-free legislation)
  • Offer help to quit tobacco use (cessation services - iQuitline 1800-11-2356)
  • Warn about dangers of tobacco (health warnings, mass media)
  • Enforce bans on advertising, promotion, and sponsorship
  • Raise taxes on tobacco
• National Tobacco Control Programme (NTCP) - launched 2007-08

2. Secondary Prevention (Early Detection)

• Population-based screening for oral, cervical, and breast cancer (under NPCDCS)
• Visual Inspection with Acetic Acid (VIA) for cervical cancer
• FNAC, biopsy for diagnosis
• Cancer screening at Health and Wellness Centres

3. Tertiary Prevention

• Treatment: surgery, radiotherapy, chemotherapy
• Regional Cancer Centres (RCCs) - 28 across India
• Pain relief and palliative care

4. Cancer Registry

• Population-based and hospital-based cancer registries
• National Cancer Registry Programme (NCRP) under ICMR

---

Q3. Causes of Occupational Cancer (5 Marks)

---

Q4. Vaccine Schedule in UIP for Under-Five (5 Marks)

---

Q5. Disaster Cycle (5 Marks)

1. Mitigation Phase (Pre-disaster)

• Activities that prevent disasters or reduce their effects
• Examples: Building codes, land-use planning, flood embankments, early warning systems, vulnerability mapping
• Goal: Reduce risk

2. Preparedness Phase (Pre-disaster)

• Activities that improve ability to respond to disasters
• Examples: Training emergency personnel, stockpiling supplies, developing emergency plans, community education, mock drills, establishing early warning systems
• Goal: Reduce impact

3. Response Phase (During/Immediately after disaster)

• Immediate actions to save lives and meet basic needs
• Examples: Search and rescue, emergency medical care, evacuation, food/water/shelter provision, disease surveillance
• Sub-phases: Heroic phase, Honeymoon phase, Disillusionment phase
• Goal: Save lives, reduce suffering

4. Recovery Phase (Post-disaster)

• Actions to restore normalcy
• Short-term recovery: Debris removal, restoration of services, temporary housing
• Long-term recovery (Rehabilitation/Reconstruction): Rebuilding infrastructure, psychosocial support, livelihood restoration
• Goal: Restore and improve pre-disaster conditions

Mitigation → Preparedness → Response → Recovery → (back to Mitigation)

---

Q6. Self-Care in Diabetes Mellitus (5 Marks)

1. Healthy Eating

• Calorie-controlled, low glycaemic index diet
• Restriction of refined carbohydrates, saturated fats, trans fats
• Increase dietary fibre (vegetables, whole grains)
• Regular meal timings; avoid skipping meals

2. Being Active (Physical Activity)

• Minimum 150 minutes/week of moderate aerobic exercise
• Resistance training 2-3 times/week
• Reduces insulin resistance, promotes weight loss, improves glycaemic control

3. Monitoring

• Self-Monitoring of Blood Glucose (SMBG): Regular finger-prick testing
• Monitoring HbA1c every 3 months (target <7%)
• Daily foot inspection

4. Taking Medications

• Adherence to oral hypoglycaemic agents or insulin as prescribed
• Understanding signs of hypoglycaemia and its management (15-15 rule)

5. Problem Solving

• Recognizing and managing hypoglycaemia, hyperglycaemia, sick day management

6. Healthy Coping

• Managing diabetes-related distress and depression
• Support groups, stress management techniques

7. Reducing Risks (Foot Care + Complication Prevention)

• Daily foot inspection, proper footwear (no barefoot walking)
• Regular eye examination (for retinopathy), annual kidney function tests
• Blood pressure control (<130/80 mmHg)
• Lipid control, smoking cessation
• Dental hygiene

---

Q7. Cancer Registry (5 Marks)

Types:

• Maintains data on all cancer patients treated in a specific hospital
• Used for clinical management, treatment outcomes, survival analysis
• Does not give incidence rates for the general population

• Collects data on all new cancer cases occurring in a defined geographic population
• Used to calculate cancer incidence, mortality, prevalence rates
• Provides epidemiological data for planning and policy

In India - National Cancer Registry Programme (NCRP):

• Established by ICMR in 1981
• Currently 30+ PBCRs and several HBCRs
• Major PBCRs: Bangalore, Mumbai, Chennai, Delhi, Bhopal, Dibrugarh
• Publishes data in "Cancer Incidence in Five Continents" (IARC/GLOBOCAN)

Uses of Cancer Registry:

1. Measure the burden of cancer (incidence, prevalence, mortality)
2. Identify high-risk groups and geographic clusters
3. Monitor cancer trends over time
4. Evaluate screening and prevention programmes
5. Provide data for research and clinical trials
6. Resource allocation and policy planning

Data Collected:

• Patient demographics (age, sex, address)
• Site and histological type of cancer (ICD-10 codes)
• Date of diagnosis, stage at diagnosis
• Treatment details and survival outcomes

---

Q8. Principles of Primary Health Care (5 Marks)

The 8 Essential Components (Mnemonic: FEATS MCE):

1. Food supply and proper nutrition
2. Education about prevailing health problems
3. Adequate safe water and basic sanitation
4. Treatment of common diseases and injuries
5. Safe motherhood and family planning (MCH + FP)
6. Maternal and child health
7. Control of endemic diseases
8. Essential drugs supply + EPI (immunization)

5 Principles of PHC (Alma-Ata):

1. Equitable distribution - services accessible to all, especially underserved
2. Community participation - involvement of community in planning and implementation
3. Intersectoral coordination - collaboration between health, agriculture, education, water, sanitation sectors
4. Appropriate technology - affordable, acceptable, scientifically sound methods
5. Multi-level approach - linkage between primary, secondary, and tertiary care

• Sub-centre: covers 3000-5000 (plain) / 1000-3000 (hilly) population
• PHC: covers 20,000-30,000 (plain) / 3,000-5,000 (hilly) population
• Community Health Centre (CHC): covers 80,000-1,20,000 population

---

Q9. Iodine Deficiency Disorders (IDD) (5 Marks)

Magnitude: ~200 million people at risk in India; goitre belt = sub-Himalayan region.

Consequences of Iodine Deficiency (by life stage):

Daily Iodine Requirements:

• Children: 90-120 mcg/day
• Adults: 150 mcg/day
• Pregnant/lactating women: 200-250 mcg/day

National Iodine Deficiency Disorders Control Programme (NIDDCP):

• Formerly National Goitre Control Programme (1962)
• Renamed NIDDCP in 1992
• Universal Salt Iodization (USI) - iodization of all edible salt at 15 ppm at consumer level
• Iodized salt contains potassium iodate (KIO3) added at 30 ppm at production level
• Ban on sale of non-iodized salt for human consumption
• Sentinel surveillance and IDD surveys

Diagnosis: Urinary iodine excretion (UIE) - median UIE <100 mcg/L indicates deficiency

---

Q10. Hormonal Contraception (5 Marks)

Types:

A. Combined Oral Contraceptive Pills (COCPs)

• Contain estrogen + progestogen
• Mechanism: Inhibit ovulation (primary), thicken cervical mucus, alter endometrium
• Efficacy: Pearl Index = 0.1-0.3 (perfect use)
• Types: Monophasic, biphasic, triphasic
• Examples: Mala-D (govt.), Mala-N (low-dose), Saheli (centchroman - non-steroidal, weekly pill)
• Contraindications: Thromboembolic disease, breast cancer, liver disease, smokers >35 years, uncontrolled hypertension, pregnancy

B. Progestogen-Only Pills (Mini-pills)

• Suitable for lactating mothers (no estrogen to suppress lactation)
• Example: Centchroman (Saheli) - taken weekly

C. Injectable Contraceptives

• Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera): 150 mg IM every 3 months
• MPA (Antara programme in India): 3-monthly injection introduced under FP programme
• Noristerat: 200 mg IM every 2 months

D. Implants (Subdermal)

• Levonorgestrel (Norplant/Jadelle): 5 years protection
• Etonogestrel (Implanon): 3 years

E. Intrauterine System (IUS)

• Levonorgestrel-IUS (Mirena): 5 years; reduces menstrual blood loss

F. Emergency Contraception

• Levonorgestrel 1.5 mg (i-pill) within 72 hours
• Ulipristal acetate within 120 hours
• Cu-IUD within 120 hours (most effective EC)

Non-contraceptive benefits of COCPs:

• Reduced risk of ovarian and endometrial cancer
• Treatment of dysmenorrhoea, endometriosis, PCOS
• Reduced PID risk

---

Q11. Pasteurization of Milk (2-3 Marks)

Methods:

1. HTST (High Temperature Short Time) / Flash method: 72°C for 15 seconds - most common commercial method
2. LTLT (Low Temperature Long Time) / Holder method: 63°C for 30 minutes
3. UHT (Ultra High Temperature): 135-150°C for 2-4 seconds - sterilization, not just pasteurization; shelf-stable for 3-6 months

Phosphatase Test: Used to confirm adequate pasteurization (alkaline phosphatase enzyme destroyed at pasteurization temperatures). A positive phosphatase test = inadequately pasteurized milk.

Pathogens destroyed: M. tuberculosis (test organism - most heat resistant pathogen of public health significance), Brucella, Salmonella, Listeria, Campylobacter, E. coli O157:H7.

---

Q12. Balanced Diet (2-3 Marks)

Components:

• Macronutrients: Carbohydrates (55-60% of total calories), Proteins (10-15%), Fats (25-30%)
• Micronutrients: Vitamins (fat-soluble: A, D, E, K; water-soluble: B-complex, C), Minerals (Ca, Fe, Zn, I)
• Dietary fibre: 25-30 g/day
• Water: 2-3 litres/day

ICMR Recommended Dietary Allowances (RDA) for a reference adult Indian man (60 kg, moderate work):

• Energy: 2730 kcal/day
• Protein: 60 g/day (1 g/kg/day)
• Fat: minimum 20 g/day

Food Groups (ICMR's 5 food groups):

1. Cereals and millets
2. Pulses and legumes
3. Milk and milk products
4. Fruits and vegetables
5. Fats and oils

---

Q13. Panel Discussion (2-3 Marks)

Definition:

Characteristics:

• Moderator/chairperson guides the discussion
• Panelists have different viewpoints or areas of expertise
• Audience can ask questions at the end
• Size of audience: 20-100 or more

Advantages:

• Presents multiple perspectives on a topic
• Audience exposed to expert opinions
• Stimulates thought and discussion
• Good for controversial/complex topics

Disadvantages:

• One-way communication mostly
• Dominance by one panelist possible
• Needs skilled moderator
• May confuse audience with conflicting views

Uses in Health Education:

• Community meetings on health issues (e.g., vaccine hesitancy, HIV stigma)
• Medical/public health conferences

---

Q14. Vitamin A Prophylaxis (2-3 Marks)

National Programme for Prevention of Nutritional Blindness due to Vitamin A Deficiency:

• Total: 9 doses up to 5 years
• Given as oily preparation of retinol palmitate

Indications for therapeutic supplementation:

• Severe acute malnutrition
• Measles
• Persistent diarrhoea (>14 days)
• Night blindness, Bitot's spots, xerophthalmia

Dietary sources: Liver, egg yolk, dairy, yellow/orange vegetables (beta-carotene), dark green leafy vegetables

---

Q15. Health Problems of the Elderly (2-3 Marks)

Common Health Problems:

• Cardiovascular diseases (hypertension, IHD, heart failure)
• Diabetes mellitus (Type 2)
• Arthritis and musculoskeletal problems (osteoarthritis, osteoporosis)
• Cancers (higher incidence with age)
• Respiratory diseases (COPD)
• Sensory impairments: Presbyopia, cataracts, presbycusis (hearing loss)
• Dental problems: Tooth loss, xerostomia
• Urinary incontinence, BPH in males
• Falls and fractures (hip fracture = major cause of disability)

• Dementia (Alzheimer's disease most common)
• Depression and anxiety
• Delirium

• Social isolation, loneliness
• Neglect and elder abuse
• Financial dependency
• Polypharmacy (multiple medications)

---

Q16. Child Abuse (2-3 Marks)

Types:

1. Physical abuse - hitting, burning, shaking, biting
2. Sexual abuse - any sexual activity involving a child (POCSO Act 2012 in India)
3. Emotional/Psychological abuse - verbal abuse, humiliation, rejection, threats
4. Neglect - failure to provide basic needs (food, shelter, education, medical care)
5. Child labour - economic exploitation

Indicators of Physical Abuse:

• Bruises in unusual locations (back, buttocks, face)
• Burns in specific patterns (cigarette burns, immersion burns)
• Fractures inconsistent with developmental stage
• Retinal haemorrhage (shaken baby syndrome)
• Delay in seeking medical care

Management (4 R's):

• Recognize - identify signs of abuse
• Report - mandatory reporting (Childline 1098 in India)
• Respond - immediate medical care and safety
• Refer - to social services, child protection units

---

Q17. Baby Friendly Hospital Initiative (BFHI) (2-3 Marks)

The "Ten Steps to Successful Breastfeeding":

1. Written breastfeeding policy communicated to all staff
2. Train all health care staff in skills to implement the policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within half an hour of birth (early initiation)
5. Show mothers how to breastfeed and maintain lactation even if separated
6. Give newborns no food or drink other than breast milk (no prelacteal feeds)
7. Practice rooming-in (allow mothers and infants to remain together 24 hours a day)
8. Encourage breastfeeding on demand
9. Give no artificial teats, pacifiers, or dummies
10. Foster establishment of breastfeeding support groups and refer mothers on discharge

---

Q18. MDR (Multi-Drug Resistant Tuberculosis) (2-3 Marks)

Types of Drug Resistance:

• Primary resistance: In a patient with no prior TB treatment
• Acquired (secondary) resistance: Develops during or after inadequate treatment
• XDR-TB (Extensively Drug Resistant): MDR-TB + resistance to any fluoroquinolone AND at least one of the second-line injectable drugs (amikacin, kanamycin, capreomycin)
• TDR-TB (Totally Drug Resistant): Resistant to all first and second-line drugs

Causes of MDR-TB:

1. Irregular/incomplete treatment
2. Inadequate drug regimens
3. Poor quality drugs
4. Malabsorption
5. Transmission from MDR-TB cases

Treatment (under PMDT - Programmatic Management of Drug Resistant TB in India):

• Bedaquiline-based shorter oral regimen (6-9 months) - now preferred
• Older longer regimens: 18-24 months
• Managed through NIKSHAY portal in India

India's Burden: India has the highest MDR-TB burden globally (~26% of global cases).

---

Q19. Define Epidemic and Endemic (2-3 Marks)

Endemic:

• Example: Malaria in sub-Saharan Africa; Kala-azar (visceral leishmaniasis) in Bihar/Jharkhand

Epidemic:

• Example: COVID-19 epidemic in 2020, cholera outbreak

Related Terms:

• Pandemic: An epidemic that has spread over several countries/continents, usually affecting a large number of people (e.g., COVID-19 pandemic, Influenza 1918)
• Outbreak: Similar to epidemic but often more localized, or used when the number of cases is small (e.g., food poisoning outbreak at a party)
• Sporadic: Occasional cases occurring irregularly, with no particular pattern
• Cluster: Aggregation of cases in a specific time and place

---

Q20. Principles of Chlorination (2-3 Marks)

Principles:

• Chlorine reacts with water to form hypochlorous acid (HOCl) and hypochlorite ion (OCl-)
• HOCl is the active disinfecting agent (more germicidal than OCl-)
• Destroys cell membranes and inactivates enzymes of microorganisms
• Effective against bacteria, viruses, and some protozoa (not Cryptosporidium)

• Free residual chlorine = 0.2 mg/L (ppm) at the consumer's tap after 30 minutes contact time at pH 7 (Horrock's apparatus used for field testing)
• Ensures continued disinfection during distribution

• Amount of chlorine consumed by organic matter, bacteria, and other reducing agents before residual chlorine remains
• Chlorine demand = Total chlorine added - Residual chlorine

• Sufficient chlorine is added to oxidize all organic matter and ammonia, after which residual chlorine appears. The point at which this occurs is the break-point. Adding chlorine beyond this gives free residual chlorine.

• pH (lower pH = more HOCl = better germicidal action; optimal pH 6-7)
• Temperature (higher temperature = faster action)
• Contact time (minimum 30 minutes)
• Turbidity (organic matter consumes chlorine; hence pre-treatment/sedimentation needed)

• Adding very high dose (1-2 ppm) followed by removal of excess chlorine by sodium thiosulphate

• Chlorine gas, bleaching powder (contains 30-35% available chlorine), chloramines, sodium hypochlorite, high-test hypochlorite (HTH - 60-70% available chlorine)

---