Some points on the MPH entrance examination

1. Epidemiology
Epidemiology is the study of the frequency, distribution, and determinants
of health-related states or events in specified populations, and the
application of this study to the control of health problems.
Scope/use of epidemiology
Its scope in public health ranges from routine surveillance to research strategies for
the testing of hypotheses about causes, measurement of health and disease
risks and evaluations of preventive, diagnostic and therapeutic programmes
and technologies. Epidemiology is also a collection of applied disciplines, i.e.,
every disease entity has its own epidemiology (infectious, cardio-
vascular,cancer, etc.). Other studies focus on health risks (occupation,
smoking, diet,social conditions, etc.). Some of the uses of epidemiology in
public health practice are mentioned below:
1. Elucidate (explain) the natural history of disease.
2. Describe the health status of the population.
3. Establish causation of disease.
4. Provide understanding of what causes or sustains disease in populations.
5. Define standards and ranges for normal values of biological and social
measures.
6. Guide health and healthcare policy and planning.
7. Assist in the management and care of health and disease in individuals.
B. Basic Epidemiologic Assumptions!!!!!
In order to fully grasp the notions of epidemiology it is important to
understand the two basic assumptions in epidemiology:
1. Human disease does not occur at random: there are patterns of
occurrence in which some behavioural and environmental
factors (exposures) increase the risk of acquiring/developing a
particular disease among group of individuals.
2. Human disease has causal and preventive factors that can be
identified through systematic investigation of populations or
group of individuals within a population in different places or at
different times. Thus, identifying these factors creates
opportunity for prevention and control of diseases in human
population either by eliminating the cause or introducing
appropriate treatment.

Measures of Disease Occurrence

The number of cases in a given community can give more epidemiologic sense if
they are related to the size of the population. Such tie of the number of cases with
the population size can be determined by calculating ratios, proportions, and rates.
These measures provide useful information about
the probability of occurrence of health events, population at a higher risk of
acquiring the disease. They are also important in designing appropriate public
health interventions.
Ratio: the value of x and y may be completely independent, or x may be included in y.

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Example: Male: Female (male to female ratio)
Proportion: is a ratio (expressed as a percent) in which x is included in y. Example:
Male/Both sexes (proportion of male in a community)
Rate: measures the occurrence of an event in a population over time. The time
component is important in the definition. Rates are often proportions. Rates must:
1) include persons in the denominator who reflect the population from which the
cases in the numerator arose; 2) include counts in the numerator which are for the
same time period as those from the denominator; and, 3) include only persons in
the denominator who are "at risk" for the event.

 Incidence

Incidence: measures the rapidity with which newly diagnosed patients develop over
time.

Most common way of measuring and comparing the frequency of disease

in populations.

the period of time for the rate must be specifies.

Number of new cases during observation period X100

Incidence Rate = Person – time observed

 Prevalence

Prevalence: the amount of disease that is present already in a population.

indicates the number of existing cases in a population.

All new and pre-existing cases during a given time period X100
Prevalence = population during the same time period

Common Measures of Disease Frequency

The frequency of health related events are measured by risk, prevalence and
incidence rate.
Risk (cumulative incidence):
⎯ Likelihood that an individual will contract a disease.
⎯ The proportion of unaffected individuals who, on average, will contract the
disease of interest over a specified period of time.
Prevalence:
⎯ The amount of disease that is present already in a population. Indicates the
number of existing cases in a population.
Incidence:

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⎯ Measures the rapidity with which newly diagnosed patients develop over time.
Most common way of measuring and comparing the frequency of disease in
populations. The period of time for the rate must be specified. New cases occurring
during a given time period
Risk = Population at risk during the same period all new and pre-existing cases
during a given time period Prevalence = population during the same time period
Incidence Number of new cases during observation period

Rate = Person-time observed

Crude death rate total death/ total population

Crude rates apply to the total population of a given area. Specific rates apply to specific
subgroups in the population (such as by age, sex, or occupation) or specific diseases.
Adjusted rates and age-specific rates are often used to permit comparison of mortality
rates in populations which differ in age structure. Mortality rates computed with
adjustment techniques are called age-adjusted or age-standardized mortality rates.

Case fatality rate. Case fatality rate (CFR) is the measure of severity of illness.
* CFR = Number of deaths from a disease
Number of clinical cases of that disease

Variation in Severity of Illness

The infectious process has a wide spectrum of clinical effects which ranges from in
apparent infection to severe clinical illness or death (Figure 2.12). The effect depends on
the nature of the infectious agent and host susceptibility. Case fatality rate (CFR) is the
measure of severity of illness.
* CFR = Number of deaths from a disease
Number of clinical cases of that disease

Recognizing in apparent infections require the use of laboratory tests on seemingly

healthy individuals. Information thus obtained are useful in planning public health
interventions. A good example could be HIV testing to determine the potentials for the
spread of the disease and to plan appropriate control strategies.

 Level of prevention
Levels of Disease Prevention
Disease prevention means to interrupt or slow the progression of disease.
Therefore, the aim is to push back the level of detection and intervention to
the precursors and risk factors of disease. Fluctuation in patterns of
morbidity and mortality over time in countries and the observation that
migrants slowly develop the patterns of disease of host populations indicate
that causes of disease are preventable.
Hence, epidemiology plays a central role in disease prevention by identifying
those modifiable causes. The levels of prevention in relation to the stage of
the disease process are shown in Table 2.1.

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Table 2.1. Levels of prevention in relation to the stage of the disease.
Level of Prevention Stage of disease Target
Primordial
Existence of underlying condition leading to causation
The aim is to avoid the emergence and establishment of the social,
economic, and cultural patterns of living that are known to contribute to an
elevated risk of disease.
Example: smoking, environmental
pollution
Total population and selected groups
Primary
Specific causal factors exist, The causative agent exists but the aim is to
prevent the development of disease.
Example: immunization
Measles, polio
Total population, selected groups and health individuals
Secondary
Early stage of disease The aim is to cure patients and prevent the
development of advanced
disease.
Example: Early detection &
treatment of cases of
tuberculosis & STD
Patients
Tertiary
Late stage of disease(treatment & rehabilitation) The aim is to prevent severe
disability and death.
Example: Leprosy
Patients

 Screening
Laboratory tests for screening are used in people who are asymptomatic
(apparently healthy individuals) to classify their likelihood of having a
particular disease. A test is anything that produces evidence from a patient
at any stage in the clinical process, based on which a different clinical
course will be taken depending on the different possible test outcomes
(positive or negative, normal or abnormal, present or absent, high or low,
...).

 Sensitivity The concepts of sensitivity (ability to detect true positive)

Sensitivity is defined as the proportion of people with a disease who have a positive test
for the disease (a/a+c).
Specificity is the proportion of people without the disease who have a
negative test (d/b+d).

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 a b
c d
Validity is the extent to which data collected actually reflect the truth. The
concepts of sensitivity (ability to detect true positive) and specificity (ability to
detect true negatives) can be used to characterize the validity of a measure
("measurement validity"). Study results are also described as "valid" when
there is no systematic misrepresentation of effect or "bias" ("validity in the
estimation of effect"). Validity is often described as internal or external.
Internal validity concerns the validity of inferences that do not\proceed
beyond the target population for the study. Internal
validity is threatened when the investigator does not have sufficient data to
control or rule out competing explanations for the results.
External validity, on the other hand, concerns generalizeability, or
inferences to populations beyond the study's restricted interest. External
validity is threatened, for example, when the investigator attempts to apply
the findings of the study to a population which is not comparable to the
population in which the research was completed. Internal validity should be
the primary objective in study design, however, since efforts to

 Specificity (ability to detect true negatives) can be used to characterize

the validity of a measure ("measurement validity").
 Attack rate

Attack rates- Calculate rates of illness in population at risk by exposure to

specific suspected items and other relevant attributes. The identification of
"relevant" attributes may be a crucial step in the solution of the problem.

Estimation of Confidence Interval

The confidence interval represents the range within which the
true magnitude of effect lies within a certain degree of
assurance. It is more informative than just P value because it
reflects on both the size of the sample and the magnitude of the

Hypothesis Testing (Test of Statistical Significance)

A statistical hypothesis is an assumption of a statement which may or may not be true
concerning one or more population
Test of statistical significance quantifies the degree to which sampling
variability may account for the observed results. The "P value" is used to
indicate the probability or likelihood of obtaining a result at least as extreme
as that observed in a study by chance alone, assuming that there is truly no
association between exposure and outcome under
consideration(i.e., H0 is true). The main hypothesis which we want to test is
called null hypothesis since acceptance of it commonly implies no effect or no
difference For medical research, the P value < 0.05 is set conventionally to
indicate statistical significant.

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P value it is the result of observation after the study is completed and is based on the
observed data. it shows the statistical significance of the result. The cut of point is 0.05
conventionally.

Confidence interval

The Chi-square it is a probability distribution which is useful in making a statistical

inference about the categorical data , which the categories are two and above

 Measure of association, property and use

 Cohort and case control ( advantage and )
 Study Design
Cohort: is a group of persons with common characteristics, usually an
exposure or involvement in a defined population group, who are followed or
traced over a period of time.. Cohort study (synonyms: concurrent, follow-
up, incidence, longitudinal, prospective study): is the analytical method of
epidemiologic study in which subsets of a defined population can be
identified who are, have been, or in the future may be exposed or not
exposed, or exposed in different degrees, to a factor or factors hypothesized
to influence the probability of occurrence of a given disease or other
outcome.

 Collection of specific attack rate

 Variable and significance of association

Variation in disease pattern is the foundation of epidemiology. Anything

which varies and has different values is known as variable. In epidemiology
there are two types of variables: exposure and outcome. The common
epidemiological variables such as age, sex, economic status, social class,
occupation, area of residence, religion and ethnicity are all powerful ways of
showing variations in broad range of diseases and health status. However,
most of these variables are markers for complex, underlying phenomena of
interest which cannot be measured directly and easily. For example, sex
may act as a proxy for genetic, hormonal, psychology or social status in
different studies.

Variations in disease occurrence and associations

Changes in disease frequency could be due to two main reasons. The first reason is
that changes are real (natural), and the second reason is that changes are due to
mistakes/errors committed during diagnosing and counting (artefactual). As
demonstration of disease variation is the basis for establishing epidemiological
association it critical to examine whether variations are real or artefact.

Hypothesis Testing (Test of Statistical Significance) P value

Test of statistical significance quantifies the degree to which sampling
variability may account for the observed results. The "P value" is used to

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indicate the probability or likelihood of obtaining a result at least as extreme
as that observed in a study by chance alone, assuming that there is truly no
association between exposure and outcome under
consideration(i.e., H0 is true). For medical research, the P value < 0.05 is set
conventionally to indicate statistical significant.
P value is a function of:
• the magnitude of the difference between the groups
• sample size

2.Health Service Management

 Functions of management

7. Management Functions
Function is defined as a broad area of responsibility composed of many activities
aimed at achieving a predetermined objective.

Functions of Management Include

1. Planning Planning (p)
2. Organizing
3. Staffing Implementation (I)
4. Directing
5. Controlling- Evaluation (E)

In addition to these three broad sequential functions Planning, Implementation &

Evaluation
(PIE).
Two continuous functions of management are:-
Communication
Decision- Making

 Tiers of health delivery system (current & past)

four and Six
 HPost

 Clinic
 Health station
 Health center
 Regional hosptals
 Specialized referral hospitals

 Motivation factor
Motivation is an inner impulse that induces a person to act in a certain way. It is a series
of internal drives within a person at different levels.
Level 1. To obtain the necessities of life — food, shelter, clothing, rest and safety.

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Level 2. To satisfy social needs such as those for companionship, love, and a position of
respect.
Level 3. To ensure some degree of personal satisfaction and to pursue ideals. People
need to feel reasonably satisfied with themselves, with what they make of their lives and
with their talents and abilities.

A team leader should understand what encourages people to apply their ability and
energy to work, and what makes people dissatisfied at work. These two groups of factors
may be called motivators and dissatisfies, respectively.

 SWOT analysis
It is a tool to diagnose the organizational system and to define what best standing
merit and opportunities that the organization has to excel and what are the
weaknesses to be improved and what are the threats to be aware of and are basically
challenging from the external or an out side force

SWOT Analysis
SWOT (strengths and weakness, opportunities and threats) is a strategic planning tool
that matches internal organizational strengths and weakness with external opportunities
and threats. By reviewing strengths, weaknesses, opportunities and threats a useful
strategy for achieving objectives will become evident.

In the health sector, strengths may be considered availability of resources and trained
human power. Weaknesses include lack of managerial talent and obsolete facilities.
Threats include adverse cultural believes towards modern medical practice and growing
cost of essential drugs. Examples of opportunities are clear and supportive government
policies and presence of a functional health committee in the communities. (Figure 8)

 What is district health office?

District is defined as geographical area that is small enough for health and related social
problems to be properly understood and appropriate action to be taken and large enough
to permit the deployment of essential technical and managerial skills for planning and
management of programme while awarding over dispersal of skills
It provide a fully comprehensive range of promotive, preventive, curative and
rehabilitative health activities

Essential characteristics of a district health systems based on PHC are:

Equity
Accessibility
Emphasis on Promotion and Prevention
Inter-sectorial Action
Community Involvement
Decentralization and integration of health programmes

 List Components of primary health care (PHC) = 11

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PHC IN ETHIOPIA
PHC activities in Ethiopia, which formally began in 1980s, include the following
Education on the prevailing health problems and methods of preventing and controlling
them
Locally endemic diseases prevention and control
Expanded program on Immunization
Maternal and child health including family planning
Essential drugs provision
Nutrition promotion of food supply
Treatment of common diseases and injuries
Sanitation and safe water supply
Dental health
Mental health
HIV/AIDS

Since 1980 PHC has been the main strategy on which the health policy has been based.
The 1985 review of PHC implementation attempts in Ethiopia revealed the following
achievements.
o Expansion of health services to the broad masses especially by establishing new
health station and health posts.
o Expansion of Immunization programmes against six major communicable
disease.
o Increasing number of medical and paramedical personnel.
o Increased health propaganda attempts to improve health consciousness of the
population.
o Established PHC committees at the lowest local administrative level.

The health policy which was established in 1976 by the ministry of health includes
o Emphasis on disease prevention
o Priority to rural health service
o Promotion of self reliance and community involvement

The health policy has been further consolidated by the adoption of PHC as a strategy.
Failures to implement these policies can be traced to several factors of which low
government attention and support to the health sector is not the least.
If you were working as health manager
1. what problems do you face and contraceptive utilization rate
2. how did you manage it training HEW net working outreach services health
education

Define
o community diagnosis disease identification with in a given
community ????
o clinical diagnosis institution base clinical investigation laboratory x-ray
…..

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what is the contribution of traditional medical belief system to health care
what is the difference between health professional management and health care
workers management skilled manpower on specific program undertaking
The Roles of Health Manager

The managerial roles are categorized into three major areas with further classification:
Interpersonal role: this role shows the interpersonal contact that a manager does which is
vital in his/her daily activities. The interpersonal roles are designated by
Figurehead: this role symbolizes the legal authority of the manager such as: attending
ceremonies, signing documents, etc.
Leader: as a leader a manager is accountable, responsible, and motivator of the staff he
is working with.
Liaison: a manager creates links in horizontal as well as vertical chain of
communications that facilitate communication in and out side the organization.
Informational role: this role is related to communication and information channelling
Monitor: serving as a focal person for all types of communications
Disseminator: communicating selected information to subordinates
Spokesperson: communicating selected information to outsiders
Decision-making role: a manger has a legal authority to decide on matters that are
assigned to him based on his job description.
Entrepreneur: designing and initiating changes within the organization
Disturbance handler: taking corrective action and handling conflicts
Resource allocator: decides on resources and their distribution
Negotiator: negotiating with other parties representing organizational interests

what was the primry health care coverage in 1997 EC in Ethiopia Health indicator 1998
75%

how would the above coverage change if the privet sector were included?
What are the calculation made in question 1 and 2

Discuss organization and organizational structure

Organization is a process that implies structuring and integrating activities which has an
interdependent nature to execute and fulfill the set objectives. Organizations are Goal
oriented, psychological system(people), Technological system, and an integration of
structured patterned activities and relationships.
Organizing is the function performed after planning. Organizing focuses attention on the
structure and process of allocating jobs so that common objectives can be achieved.

Formal Organization
A formal organization is often described by means of 'organizational chart'. Among the
advantages of formal organization are those they:
Define broad area of responsibility
Provide a basis for writing job descriptions

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Indicate channels of communication
Clarify relationships between people
Avoid complications caused by overlapping of functions

Organization structure has two facets

First:- The form structure
Second:- Function which are to be performed
ORG/Institution, Departments, Divisions, Sections

What is authority, discuss types of authority delegation and leadership

Discuss human resource management
What is the Ethiopian policy look like
What are the priorities of the policy

3.Biostatics

Statistics: A field of study concerned with the collection, organization and

summarization of data, and the drawing of inferences about a body of data when only part
of the data are observed.

•Biostatistics: An application of statistical method to biological phenomena.

Population & Sample• Target population: A

collection of items that have something in
common for which we wish to draw
conclusions at a particular time.• Study
Population: The specific population from
which data are collected Sample: A subset of
a study population, about which information is
actually obtained.

Characteristics of a good measure of central tendency

•A measure of central tendency is good or satisfactory if it possesses the following

characteristics.
1.It should be based on all the observations
2.It should not be affected by the extreme values
3.It should be as close to the maximum number of values as possible
4.It should have a definite value
5.It should not be subjected to complicated and tedious calculations
6.It should be capable of further algebraic treatment

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7.It should be stable with regard to sampling

 Measures of central tendency and their computation

The various methods of determining the actual value at which the data tends to

concentrate are called measures of central tendency .

The most important objective of calculating measure of central tendency is to determine a
single figure which may be used to represent a whole series involving magnitude of the
same variable.

- Mean
- Median  affected by extreme value
- Mode

1. Arithmetic mean (x)

The most familiar MCT is the AM. It is also popularly known as average. a)
Ungrouped data If xx ..., x are n observed values, then
Ungrouped data•
For given set of data there is one and only one arithmetic mean.
•The arithmetic mean is easily understood and easy to compute.
•Algebraic sum of the deviations of the given values from their arithmetic mean is always
zero.
•The arithmetic mean possesses all the characteristics of a central value, except No.2,

which is greatly affected by the extreme values.

•In case of grouped data if any class interval is open, arithmetic mean can not be
calculated

The median of a finite set of values is that value which divides the set of values in to
two equal parts such that the number of values greater than the median is equal to
the number of values less than the median.
•If the number of values is odd, the median will be the middle value when all values
have been arranged in order of magnitude.
•When the number of observations is even, there is no single middle observation but
two middle observations.

•In this case the median taken to be the mean of these two middle observations, when all
observations have been arranged in the order their magnitude
Mode (x)

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a) Ungrouped data•It is a value which occurs most frequently in a set of values. •If all
the values are different there is no mode, on the other hand, a set of values may have
more than one mode.3.

 Measures of dispersion

1.5. Measures of variability

•The measure of central tendency alone is not enough to have a clear idea about the
distribution of the data.
•Moreover, two or more sets may have the same mean and/or median but they may be
quite different.
•Thus to have a clear picture of data, one needs to have a measure of dispersion or
variability (scatterdness) amongst observations in the set.
-
-
- Range affected by extreme value

•R = XL-XS, where

XLis the largest value and XSis the smallest value.

Properities
•It is the simplest measure and can be easily understood
•It takes into account only two values which causes it to be a poor
measure of dispersion

- Standardvation  affected by extreme value

- Interquartile range

Interquartilerange (IQR)

•IQR = Q3-Q1, where

Q3is the third quartile and Q1is the first quartile.

•Example: Suppose the first and third quartile for weights of girls 12 months of age are
8.8 Kg and 10.2 Kg respectively. The interruptible range is therefore,

IQR = 10.2 Kg –8.8 Kg

i.e., 50% of infant girls at 12 months weigh between 8.8 and 10.2
Kg.

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  Probability

Mutually exclusive events: Events that cannot occur together

•Independent events: The presence or absence of one does not alter the
chance of the other being present
.•Probability: If an event can occur in N mutually exclusive and equally
likely ways, and if m of these possess a characteristic E, the probability
of the occurrence of E is P(E) = m/N.
An understanding of probability is fundamental for quantifying the uncertainty that is
inherent in the decision-making process• Probability theory also allows us to draw
conclusions about a population of patients based on known information about a sample of
patients drawn from that population.

Standard deviation The deviation from the mean

It is the positive square root of the variance. (σ, S)

σ=√σ2 and S=√S2

Standard deviation is considered to be the best measure of dispersion and

is used widely because of the properties of the theoretical normal
curve.
•There is however one difficulty with it. If the units of measurements of
variables of two series is not the same, then there variability can
not be compared by comparing the values of standard deviation.

Coefficient of variation (CV)

•In situations where either two series have different units of
measurements, or their means differ sufficiently in size, the
coefficient of variation should be used as a measure of
dispersion.
• CV -It is the best measure to compare the variability of two
series of sets of observations.
•A series with less coefficient of variation is considered more
consistent.
•Coefficient of variation of a series of variate values is the ratio of
the standard deviation to the mean multiplied by 100.

What is probability sampling?

Probability: If an event can occur in N mutually exclusive and equally likely ways, and
if m of these possess a characteristic E, the probability of the occurrence of E is
P (E) = m/N.

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 Probability sampling:

•It is a sample obtained in a way that ensures that every member of the population has a
known, none zero probability of being included in the sample.
•Probability sampling involves the selection of a sample from a population, based on
chance.
•Probability sampling is more complex, more time-consuming and usually more costly
than non-probability sampling.
The following a
re the most common probability sampling methods:–
o Simple random sampling–
o Systematic random sampling –
o Sampling with probability proportional to size–
o Stratified random sampling –
o Cluster sampling –
o Multi-stage sampling

A health survey (sampling) is a planned study to investigate the health

characteristics of a population

What is P value

Hypothesis Testing (Test of Statistical Significance) P value

Test of statistical significance quantifies the degree to which sampling
variability may account for the observed results. The "P value" is used to
indicate the probability or likelihood of obtaining a result at least as extreme
as that observed in a study by chance alone, assuming that there is truly no
association between exposure and outcome under
consideration (i.e., H0 is true). For medical research, the P value < 0.05 is set
conventionally to indicate statistical significant.
What is power of a test?

What is statistical significance?

What are elements for chi- square test, correlation and regression
Properities of normal distribution, t-distribution and probability calculation
Probability sampling
Two points in determining sample size
--*
4.Nutrition

 Protein energy malnutrition (PEM)

Protein-energy malnutrition (PEM) describes a range of clinical disorders. At one end

marasmus is due to a continued restriction of both dietary energy and protein, is well as
other nutrients. At the other end of kwashiorkor, due to quantitative and qualitative

15
deficiency of protein, but in which energy intake may be adequate. These two syndromes
are the extremes. Between them are forms in which the clinical features are due to
varying combinations of deficiency of protein and energy together with deficiencies of
minerals and vitamins and with associated infections. Some children adapt to prolonged
insufficiency of food-energy and protein - by a marked retardation of growth. Weight and
height are both reduced and in the same proportion, so they appear superficially normal,
when weight or height is checked against standards for normal children it is seen that
they resemble children a year or more younger.
o Iron deficiency
Iron deficiency is the world's most common nutritional disorder. It affects around 2
billion people. Half of that number suffer iron deficiency anemia. In developing
countries, 51% of children under the age of four years, 40% of all women and 51% of
pregnant women are affected.

Iron deficiency anemia reduces the ability of the blood to carry oxygen from the lungs to
the brain muscles and other organs. This phenomenon results in reduced capacity to work
and to learn. Fatigue, shortness of breath even after slight exertion, dizziness, headache,
and loss of appetite are also common with anemia.

One of the greatest dangers posed by iron deficiency anemia is that it diminishes the
ability to fight infection and thus increases vulnerability to transmissible diseases.
Anemic expectant mothers face the risk of death resulting either from spontaneous
abortion, the stress of labor or other delivery complications
Interventions

There are several concrete and well-defined actions that, if effectively implemented, can
achieve a dramatic level of success in the prevention and control of iron deficiency with a
modest investment. These are;
o food fortification
o supplementation
o dietary improvement
o public health measures
These strategies usually work best in combination with each other.
o Public health importance

Iron deficiency was for long considered to be of little more public health significance
than an important cause of anemia. Now we know that work capacity may be seriously
and in the young mental development and ability to profit from schooling may be
impaired. In the case of iodine the term IDD (Iodine Deficiency Disorders) has been
coined. It is now known that endemic colloid goiter is not the most significant
consequence for public health of iodine deficiency. Development of the brain in fetal and
early postnatal life may be retarded and relatively minor degrees are much more common
that clinical cretinism.

-Iodine deficiency

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Iodine is a mineral essential to human life. Some of the basic functions of the human
body depend on a steady supply of iodine. Iodine is present in its natural state in the soil
and water.
Goiter is the most visible sign of iodine deficiency. It is a swelling in the neck caused by
an enlarged thyroid gland. The thyroid increases in size when there is not enough iodine
available to it. Without enough iodine, a person can become dull, easily tired and less
active.
Iodine deficiency also results in stillbirths and high rates of infant mortality. In
pregnancy, this deficiency leads to mental and physical defects in the baby ranging from
mild mental retardation to cretinism.
Studies from many countries around the world show that children in iodine-deficient
areas suffer from poor hand-eye coordination and have 10 to 15 IQ points less than
children who get enough iodine in the diet. The effects upon a child born to a severely
iodine-deficient mother are rarely reversed. It is, therefore, best to intervene before or
during pregnancy if the child is not to suffer a lifetime of compromised growth and
development and of mental and other disabilities

-Vitamin A

The term Vitamin A Deficiency (VAD) embraces all forms and degrees of deficiency,
including the most severe, in which the function and structure of the eye are affected. All
stages of the eye changes are covered by the term Exophthalmia (X). It is only in the past
two decades or so that the threat to health and survival of lesser degrees of VAD has
become apparent.

Vitamin A, in all its closely related forms, is only present in nature as a result of enzymic
action on certain precursor compounds within the bodies of most vertebrate animals.
These precursors of vitamin A comprise quite a small proportion of a large group of
compounds known as arytenoids

Vitamin A campaign in Ethiopia

It is streamlined with EPI and polio campaign programs vit A capsules are
provided for under five children during vaccination
Enhanced outreach service where integrated program implementation is
undertaken
Measles vaccine
Vit A supplementation
De-warming
Nutritional assessment and services and
F/P
Polio eradication strategy
Strengthening routine immunization
Supplemental immunization (national and regional campaign)

17
 Mopping up where the case is observed
Surveillance (continuous search for the disease)it can be passive and active
surveillance

- Growth monitoring and Ethiopian situation

- Institutional base, or clinical base assessment
- Community services IMICI (Integrated management of infant and
childhood illnesses
- Health education and primary health care program

Longitudinal Vs cross sectional

Longitudinal Surveys
Cross-sectional survey techniques may be the most efficient approach to an initial
analysis of health (and nutritional) parameters in a population. However, longitudinal
studies will generally be necessary to defi9ne cause and effect relationships and
demonstrate the effectiveness of specific interventions.

Longitudinal studies have the advantage of demonstrating the incidence of malnutrition

and its determinants. Usually, selected members or families in a community are kept
under continuing, regular, systematic observation for a relatively prolonged period.

Cut of point for low birth wt, its determinant (cause and effect)
2.5KG

-What are nutritional surveillance and its purpose?

The assessment of nutritional status of a community
Nutritional surveillance may be used to assist the planning, implementation,
management, and evaluation of programs. Questions which must be addressed include
whether the necessary services are provided as planned, particularly to target groups, as
well as whether and why nutritional status is improving or not. Surveillance may occur
before, during, or after program goals and objectives have been identified; hence its
content and scope must be directed to actions which satisfy these program goals and
objectives.
Use in Policy and Planning
Surveillance may also be used for policy and planning processes with regards to resource
allocations for specific programs or projects or other purposes such as legislation (e.g.
food price controls, etc.)

18
Nutritional surveillance involves watching, on a continuous basis, those factors
responsible for the nutritional status of populations and the early existence of inadequate
nutrition. Surveillance permits timely action to be taken to improve nutritional status in a
given population or to prevent its deterioration. Because of its broad scope, nutritional
surveillance overlaps with health and epidemiological surveillance and cannot be readily
separated from related disciplines such as economic, social, and agricultural studies.
Surveillance requires regular data collection from populations either specifically for
surveillance or from available sources, or both. Such data must be presented in an
understandable manner for informed decision making.
The cycle of nutritional assessment
Nutritional
-----------------------> Problems --------------------------+
Action Data
Collection
+----------------------- Analysis <-------------------------+
Interpretation

-Who is responsible in doing that in Ethiopia?

Ethiopia established a food and nutrition surveillance system with the Relief and
Rehabilitation Commission in 1975. This early warning system included regular rainfall,
place, and agriculture reporting. Resources permitting information on the effects of
drought can also be sought from satellite photographs.
Cross-sectional Surveys
- The assessment of nutritional status of a community will most often be
evaluated of necessity by short-term cross-sectional studies, plus
information from health services, and perhaps some longitudinal data of a
very limited nature. The degree of complexity of a cross sectional survey
varies greatly; from national country surveys through repeat cross-
sectional studies to rapid surveys of a few weeks duration, in times
emergency as a feasibility of pre-survey before a longitudinal study is
planned and implemented.
- Cross-sectional surveys can be used as a baseline or as a periodic
evaluation of a program. They can be focused on a particular age-group or
geographical urban or rural area where malnutrition is believed to be
common, or they can be more general. They should be undertaken with as
careful sampling procedures as possible, but may have to compromise
with a convenient or supposedly representative sample.

19
 - Rapid Nutritional Assessment
- The philosophy of the rapid survey is that in needs to be timely, low-cost,
flexible, and have the ability to measure the problem. Ideally, the findings
should be geared to immediate action. The goal is to identify and sort
populations according to need and then intervene as required. This type of
disaster-natural or man-made (refugees, blockades, floods, droughts,
earthquakes, locust plagues, etc).
-
-Relation ship of infant mortality rate and nutrition
-
-
-
-
-
- List four nutritional problems in Ethiopia?????
The major micronutrient deficiencies of public health importance in Ethiopia are iodine
deficiency disorders (IDD) vitamin A deficiency, and Iron deficiency anemia. Other
deficiencies mainly related to Thiamine, vitamin C and Fluoride are also observed
sporadically in some parts of the country. there is however, little or no information
related to the sporadic deficiency diseases.
Wasting
Stunting
Sever malnutrition
Maternal malnutrition

- List four nutritional interventions that are applicable in Ethiopia

-
- There is also a wide range of measures of primary prevention of
malnutrition which fall under the health sector's responsibility. they
include;

- educational activities for improving dietary practices,
- food fortification,
- supply of safe drinking-water,
- family planning,
- immunization,
- Supplementary feeding programs for vulnerable groups.

- The health sector has an important role within this multisectoral

framework. It provides services for general health care as well as specific
interventions for nutrition promotion. Even in the absence of specific

20
 nutrition intervention, general health measures can have an appreciable
impact on nutritional status.
- Improved sanitation and provision of safe drinking-water can
significantly reduce the incidence of gastrointestinal infections and
parasitic infestations.
- Malaria control is another example of health sector intervention with
considerable impact on nutritional status.
- Immunization programs can control the infectious diseases of childhood.
- The duration and severity of respiratory and gastrointestinal infections
can be reduced.
- Improved child-spacing can also be encouraged.

5. Environmental health

BASIC CONCEPTS/DEFINITIONS
“Health is a state of complete physical, mental, and social well being and not merely the
absence of disease or infirmity.” (Constitution of WHO).

“Environment is the sum of all external influences and conditions which effect health,
life, and growth. This includes the physical, biological, chemical, and psycho-social
environment”
Ecology is the study of organisms in relation to the surroundings (environment) in which
they live. It is also the study of the interactions between living organisms and their
environment.
Human ecology is the study of the interactions between humans with one another, with
other living things, and with their environment in general.
Public Health is “the science and the art or preventing diseases, prolonging life, and
promoting health through organized efforts of society” (WHO). It is an organized effort
carried out for the benefit of community.
Sanitation is “the establishment of environmental conditions favorable to health. It is the
prevention of diseases by eliminating or controlling the environmental factors which
form links in the chain transmission.” (WHO). This definition can be equally applied to
Environmental sanitation. Sanitation in Latin means sanitas meaning health. Hygiene and
sanitation are often interchangeably used.

21
Environmental Health is “the control of all those factors in man’s physical environment
which exercises or may exercise a deleterious effect on his physical, mental, and social
well being.” (WHO).
 DDT
 Incinerator
Incineration: burning of contaminated waste like sharps, gauzes, syringes, pathological
wastes, etc.
 Waste management

On-site storage:
 Needles & sharps be kept in a puncture proof container immediately after use;
 Sorting and segregation of hazardous and non-hazardous and non-hazardous
solid wastes stored in a separate bin of 80-100 litres of different colour.
 Decontamination of hazardous waste: sharps, cultures, discarded linens, etc.;
use of chemical (chlorine solution, hydrogen peroxide, Lysol, etc) or thermal
disinfectants (boiling, autoclaving, dry heating);
 Hazardous waste in red plastic bag wrapped and stored in red bin until
collection.
 Non-hazardous waste in black bin.
 Aelf care during waste handling: i) Provision of personal protective devices:
head cover, thick rubber gloves, plastic aprons, rubber boots covering at least
half of the leg; ii) SOP: type of container by waste type, collection schedule,
training for safe handling;
2. Collection:
Collection of the red and black bins is done manually with the use of cart to the
main storage container (transfer station). The two types of wastes need to be
collected separately in every instance.
3. Transport and Disposal:
 Landfill: The domestic or general type of waste can be disposed in this
way.
 Incineration: sharps, gauzes, syringes, pathological wastes, etc.

22
  A commercial type of incinerator: at 900-1000C0 destructs the waste with
significant volume reduction into ash.
 A domestic type of incinerator: destroys the pathogens with no significant
volume reduction.
 Burial: placenta, blood, excretions, secretions;
 Drainage: only after decontamination.
 Golden rules of food handling

Ten golden rules for safe food preparation and consumption (WHO)
1. Choose food processed for safety
2. Cook food thoroughly
3. Eat cooked food immediately
4. Store cooked food immediately
5. Reheat Cooked foods thoroughly
6. Avoid contact between raw and cooked foods
7. Wash hands repeatedly
8. Keep all kitchen surfaces meticulously clean
9. Protect foods from insects, rodents, and other animals
10. Use pure water.

 Ecology
Ecology is the study of organisms in relation to the surroundings (environment) in which
they live. It is also the study of the interactions between living organisms and their
environment.
Pollution
 Pollution it is contamination with toxic waste. Pollution is the presence of a
substance in a medium with result of change of its “natural” state potentially to
cause an adverse effect to the environment.
 Air pollution: it means the presence in the atmosphere of one or more air
contaminants or combination there of in such quantities and of such duration that
they may be harmful to human, plant, or animal life, or property, or that may

23
 interfere with comfortable enjoyment of life or property or the conduct of
business or other human activities (Purdom 1980).
 Water pollution: is the presence of physical, chemical, and biological matters in
amount that cause adverse effects to man, animals, plants, and materials
Prevention and Control of Pollution
Recycling and reuse of waste materials;
Waste reduction;
Control the use of chemicals
Proper disposal of wastes;
Treatment of wastes before discharge;
Use of “cleaner” energy sources, such as sun energy, wind, etc.;
Reduce emission of air pollutants using different techniques;
Formulation of rules and regulations
Ozone depletion

1 Identity: found in stratosphere in nature as O 3; its detection in troposphere (ground

level) is an indicator of pollution.
What causes Ozone depletion?
 Human activity: release of halogenated hydrocarbons: CFCs; CCI4;
 Are used as refrigerants, propellants, solvents, foam production, etc.
 Are stable under normal conditions in the troposphere.

 Describe the relation between population growth and environmental condition

 The effect of rapid population growth in development and environment

IMPACT OF HUMAN POPULATION GROWTH ON RESOURCES AND

ECOSYSTEM
 There are already 1.9 billion people who are very poor, and who always think not of
the food they are eating but of their next meal.
 Population growth unless matched with corresponding natural resources, growth of
economy and development will create:
a. Unemployment
b. Low literacy rate
c. Shortage of housing

24
 d. Resource depletion
e. Shortage of food
f. Shortage of social services
g. Political and social unrest
h. unstable ecosystem( environmental pollution )

 Types of latrine
 What is the commonest latrine used in Ethiopia? How much percentage? Discuss
its drawbacks
 Environmental health in developing countries are linked to high death of infant
children and adults. Describe how this linkages can be justified
 About 75% registered OPD cases are associated to lack of basic sanitation:
dysentery, diarrhea, skin and eye infections, helminthiasis, protozoal infections
 proportion of diarrhea among under fives is 45%,
 Two week incidence of diarrhea under fives 16.5% at 3-7 episodes per year per
child.
6. Health education

Define health education process

It is a process that aids people to find out their health needs and activate them for suitable behavior.
The education given for identifying the health need and matching it with suitable behavior can be
termed as health education. In other words, the entire process of involving people in learning about
health and disease and aiding them to act suitably for overcoming illness and preserving a positive
health is health education.
Essentials of HE

The following essential points are relevant and applicable to HE in all possible situations.

1. HE may be required for almost every one at some time or other.

2. HE is not a one time affaire. It is a continuing education.
3. HE can be organized as a self-learning process, and also can be a process of learning from
others.
4. HE consists of proper communication of ideas
Since HE aims at change of behavior a health educator has to acquire and develop skills to
educate, to communicate, to motivate and involve the client. He/she should have working
knowledge of social psychology and principles and theories of community organization.
9. HE is not like teaching of medical and health subjects to undergraduate medical, nurses
and paramedical, etc. People in all walks of life have to be educated frequently on health
practices and health related behavior from time to time throughout life and as applicable to
changing conditions.
10. It must be borne in mind that human behavior is governed by various influences and
therefore, HE must take full cognizance of all the influencing factors in any given situation. A good
health educator has, therefore, to combine in himself knowledge and skills of behavioral sciences
with sufficient rational understanding of the health problems and their solutions from a scientific and
logical stand point

25
Write elements of communication process
The process of communication is usually described by models with three distinct parts and
their elements. These are: (1) Sender or communicator; (2) the receiver of the message
or the communicatiee; (3) the message which lies between the communicator and the
communicatee and gets transacted.

Write about predisposition, motivation and reinforcing factor of human behavior

What are components of communication?

What is communication?
To communicate means (dictionary definition) "to impart, pass on or transmit a message,
information, etc.; to exchange ideas or information with, be in touch with, to have access, to be
connected with," and communication means "the act of communication, the things communicated,
the means of communicating."
Essentially communication deals with transmission of information or ideas and sharing and
exchanging of information.

It is needless to emphasize that in learning and education, communication gains great importance
because education implies transfer of knowledge and skill and communication also means transfer
of information and exchange of ideas. In learning information has to be gathered and acquired; and
skills have to be observed, practiced and developed. Therefore, communication forms an indivisible
component of the process of education and the process of learning.

Health promotion
It is an intervention whose purpose is to minimize or curtail illnesses and enhance quality
of life through change and development of health related behavior and condition of
leaving.
Health Promotion Programs operate either at primary (hygiene and health enhancement),
secondary (early detection) or tertiary (therapeutic) stages of prevention, it may
accurately be seen as an intervention whose purpose is to short-circuit illness or enhance
quality of life through change or development of health related behavior and conditions
of living.
Enhance quality of life through change or development of health related behavior and
conditions of living. The PRECEDE framework (predisposing, reinforcing and enabling
constructs in educational / environmental diagnosis and evaluation) takes into account the
multiple factors that shape health status and helps the planner arrive at a highly focused
subset of those factors as targets for intervention. PRECEDE also generates specific
objectives and criteria for evaluation. The PROCEED framework (policy, regulatory and
organizational constructs in educational and environmental development) provides
additional steps for developing policy and initiating the implementation and evaluation
process.

26
PRECEDE-PROCEED works in tandem, providing a continuous series of steps or phases
in the planning, implementation, and evaluation process. The identification of priorities
and the setting of objectives in the PRECEDE phases provide the objects and criteria for
policy, implementation, and evaluation in the PROCEED phases.

Health promotion programs operate at

1. Primary hygiene and health enhancement
2. Secondary early detection and outcome, early detection of out come
3. therapeutic stage of prevention

Relevance of health education

It helps people to find out their health needs and initiate them selves for suitable
behavior. HE is concerned with change in knowledge feeling and behavior of people. It
provides necessary information and create positive attitude to bring about sustainable
behavior change

What is behavioral health?

Various theories and models have been formulated and tested which are used to
understand and predict health related human behavior. These theories attempt to analyze
why people practice certain health behaviors. In other words, it is very important to
know what kinds of activities encourage learning and behavior change. A number of
theories of health education have been proposed, where each attempts to identify what
skills or knowledge must be learned and how they are best learned and performed

Is behavioral health an art or a science

Influence of health education

The goal of HE is to possess the abilities necessary for making informed decisions about
the health and acting on these decisions. These go beyond learning and performing
specific health behaviors. It refers to having the abilities to make ongoing decisions
about the health of oneself and others, as well as being able to organize personal and
social resources to act on these decisions. Decision making abilities include skills that
were described as being intellectual, psychological and social in nature. These include:

1. Seeking and evaluating information

2. Considering one's priorities
3. Comparing the costs and benefits of an action
4. Solving problems
5. feeling confident about one's control
6. Utilizing other's expertise and opinion, and
7. Coordinating the efforts of many people

Mode of communication/ channels of communication?????

27
Face to face Interpersonal channels - such as face to face communication, community
distribution, home visits, training, group discussions, and counseling- are generally best for giving
credibility to messages, providing information, and teaching complex skills that need two -
communication between the individual and a credible source of information.
Media Broadcast channels generally provide broad coverage for communication messages,
reaching a large number of the target audience quickly and frequently. In developing countries,
radio has been a powerful channel to reach large numbers of people with communication
messages, and to model target behaviors and their consequences
Print channels - such as pamphlets, flyers, and posters- are generally considered best for
providing a timely reminder of key communication messages. Pamphlets and other graphic
materials distributed at the individual or home level can provide complex information in a
digestible form, so that the target audience can use that information when it most needs it
Audio-visual materials - such as videos, slide-tape shows, and flip charts- visually portray
key messages during interpersonal communication sessions.

Telephone
Signs and gestures

Elements of communication
Sender
Receiver
Message
Mode of communication
┌──────┐ ┌────────┐ ┌───────┐ ┌────────┐

│Sender├──>│Encoding├───>│Channel├────>│Decoding├─────>│Receiver│
└──────┘ └────────┘ └───────┘ └────────┘ └───┬────┘
^ ┌────────┐ │
└─────────────────────┤Feedback┤<───────────────────────┘

Parameters of effective communication

1. -communicator, the sender of the message should be fully aware of the subject
and shuld know the issue very well
Should instigate credibility and show capability of handling the the subject under
discussion
Should have proper communication skill
Should have proper attitude towards the the receiver
2. -Message, the message containt should be very brief and clear
It should be appropriate ,relevant and timely
Should be supported by factual datas
The channel by which the message is sent should be appropriate
3. -Channel, it should be familiar, appropriate for the message and should be
available and accessible
4. receiver, Should have proper attitude and the desire to receive the communicated
message
Should be in good health and have intact sensory functions

28
Behavioral health research
. A behavior analysis scale is provided to identify what health behaviors should be changed.
Criteria for choosing the target behavior include: high impact on health, observable consequences
of behavior, compatible with existing practices, behavior not too complex or costly or lengthy. The
theory specifies that learning and behavior change take place as a result of reinforcing feedback
from the behavior. The consequences of an action determine whether it will be performed or not.

The most highly influential and widely researched theory of why people practice health behavior is
the health belief model. The health belief model of Rosenstock (1990) and Backer (Janz &
Backer, 1984) emphasize the intellectual dimension of health behavior. Recently it has added the
psychological dimension of Social Learning Theory (Bandura; Rotter), and we might also add the
social dimension from the Theory of Reasoned Action (Ajzen, 1988). The theory identifies the
following knowledge as relevant:

1. Perceived threat is made up of the perception that one is susceptible to the illness (i.e.,
personal risk) and the perception that the illness is serious. If these two perceptions are
high, then the perceived threat is high, and one will be driven to act to avoid the threat.
That is cue for action is triggered by an individual's perception or by reading about health
matters. The perception of personal health threat is influenced by at least three factors:
general health values, which include interest and concern about health; specific beliefs
about vulnerability to a particular disorder; and beliefs about the consequences of the
disorder (i.e., whether or not they are serious. Thus for example, a person may change
his diet to include low-cholesterol foods if he values health, feels threatened by the
possibility of heart disease, and perceives that the threat of heart disease is severe.

2. Outcome expectations are made up of the perceived benefits of the specified action
(e.g., effective, inexpensive) minus the perceived barriers to the action (e.g., costly, time
consuming). If the outcome expectations are high, they will specify exactly what action is
taken. Behavior is evaluated from an estimate of the potential benefits of health seeking
action to reduce susceptibility or severity. The benefits are then weighed against
perceptions of physical, psychological, financial and other costs of barriers inherent in the
health-finding effort. Demographic, social, structural and personality factors are included in
some versions of the model as modifying factors since in theory they indirectly influence
actual behavior. For example, the man who feels vulnerable to a heart attack and is
considering changing his diet may believe that dietary change alone would not reduce the
risk of a heart attack and that changing his diet would interfere with his enjoyment of life too
much to justify taking action. Thus, although his belief in his personal vulnerability to heart
disease may be great, his faith that a change of diet would reduce his risk is low and he
would probably not make any changes.

3. Self-Efficacy is confidence that one has the skill and resources to perform the
specified action. This comes from Bandura's social learning theory. If one has self-
efficacy, one can perform the action with confidence and pride, though not necessarily with
skill or expertise. Practice enhances self-efficacy.

4. Subjective norm refers to one's perception that significant other people will approve of
the action. This comes from Fishbein and Ajzen's (1988) Theory of Reasoned Action. If
you think that most of the important people you know and live with will approve of the
action, you are likely to do it.

2 APPLIED BEHAVIOUR ANALYSIS - HEALTHCOM Group (Graeff, Elder & Booth, 1993

29
Antecedents: stimulate action
Behavior: skill and performance
Consequences: strengthen behavior

3 THEORY OF REASONED ACTION - FISCHBEIN & AJZEN (1977 - 1980)

Another cognitive theory that attempts to integrate attitudinal and behavioral factors is Fishbein
and Ajzen’s Theory of Reasoned Action. According to this theory, a health behavior is a direct
result of a behavioral intention - i.e., of whether or not one intends to perform a health behavior.
Behavioral intentions are made up of two components: attitudes towards the action and subjective
norms about the appropriateness of the action.

4. THEORY OF PLANNED BEHAVIOUR (TPB)

They argue that in addition to knowing a person's attitudes, subjective norms, and behavioral
intentions with respect to a given behavior, one needs to know his or her perceived behavioral
control over that action.
In a test of the revised model, they found that people need not only hold a behavioral intention
toward a particular attitude object but also feel that they are capable of performing the action
contemplated and that the action undertaken will have the intended effect. Thus, feelings of
perceived control and self-efficacy also appear to be important in demonstrating attitude-behavior
consistency; even when there is a clear behavioral intention to act on the attitude.

Similarities and differences of health education and health promotion

Similarities: They both enhance the knowledge and attitude change and assist them in
finding out the health needs in their community and appropriate action to be taken
Differences: health education is confined in knowledge and attitude change through
learning and educating mechanisms
Health promotion is an intervention to enhance quality f life by circumventing the illness
and disease causes through promotion planning and implementation of necessary
interventions
Discuss culture, custom, value, knowledge, attitude and their relation with health
education
Health education is a process of interacting with intellectual, psychological and social
conditions
Culture, it is more or less persistent and organized pattern of habits, customs, attitude
and values which transcend generation to generation.
Custom: Agreed upon practice with in a given society. It is a pattern of action shared by
some or all members of the society
Value: the price or weight given for a given condition the worth or preference or
judgment which has an influence on a given action

Knowledge: it is the information or awareness stored in the memories of the individual to

influence his action
Attitude: it is the predisposition to respond to the situation in favor or against or
unfavorable manner towards it

Determinants of health behavior

Predisposing factors include a person's or population's knowledge, attitudes, beliefs, and
perceptions that facilitate or hinder motivation for change. These are those antecedents to
behavior that provide the rationale or motivation for the behavior.

30
Enabling factors are those skills, resources or barriers that can help or hinder the desired
behavioral changes as well as environmental changes. They can be viewed as vehicles or
barriers, created mainly by societal forces or systems. Facilities and health insurance,
and laws and statutes may be supportive or restrictive. The skills required for a desired
behavior to occur also qualify as enabling factors. Enabling factors thus include all the
factors that make possible a desired change in behavior or in the environment. Enabling
factors are the antecedents to behavior that enable a motivation to be realized.

Reinforcing factors, the rewards received, and the feedback the learner receives from
others following adoption of the behavior, may encourage or discourage continuation of
the behavior. Or in other words, reinforcing factors are factors subsequent to a behavior
that provide the continuing reward or incentive for the behavior and contribute to its
persistence or repetition.

Discuss three principles of learning

Prerequisite for good communication

Health education principles and customs

Health education is aimed at insuring the desired health related behaviour
In principle health education should be
a) Need based, it should be felt with both parties
b) It has to get into the culture and custom of the community and introduce new ideas
with care and caution
c) Discuss the health solution advantages and disadvantages in more clarity
d) it has to take the learning and teaching process
e) There should be free flow of communication
f) The health educator has to make him self acceptable and win the confidence of his
clients
e) He should be role model and practice what he teaches
f) The educator has to have reasoning and rationalizing power of the topic he is
discussing
g) Health education has to be well planed to ensure full understanding of the problem by
his audience
h) Use other supportive accessories ( like audio Visual if available)to support and
reinforce the information
i) Health education should be specific relevant to the problem and should indicate
available solution

Discuss stage of communication

Discuss major barriers of communication and their solution

Source or the sender or the communicator

31
The communicator has to be intelligent and understanding. He should know the need of the
audience. He should have proper judgment.
The communicator should possess the following characteristics:
a. Skill in communicating - verbal, written. including treatment of message, etc.
b. Knowledge of the channel and audience.
c. Attitude towards the subject (topic), channel and audience.
d. Source credibility
e. Skill in encoding and decoding
f. Skill in utilizing the channel
g. Confidence or attitude towards self.

Message

A message is the information, which a communicator wishes the audience to receive, understand,
accept or act upon. Message will, therefore, consist of statements made verbally during
conversation or transmitted through any media.

Channel

The sender and the receiver of the message have to be connected with each other through a
medium or channel of communication. In face to face communication there is no particular medium
except the atmosphere. When message have to be transmitted to distant places we resort to
various types of media or channels of communication. The physical bridges between the sender
and the receiver of the message are the channels.

In general, there are three aspects of communication:

a. Encoding and decoding of message
b. Message vehicle - sound waves, electrical wave, etc.
c. Vehicle - air, wire, microphone, radio, etc.

4. Selection of channels

It is very important for the communicator to find the proper channel for his message. The channel
must be easily available and accessible to the receiver and also the receiver should be acquainted
and accustomed to utilize the message coming through the particular channel. While selecting the
channel the communicator has to make sure that noise is kept to the minimum or eliminated.
Another important precaution is that the medium should not become a barrier.

5. Audience or receiver

In a good communication process the receiver can take the role of source or communicator for the
purpose of giving feedback. Therefore, in teaching/learning situation the communicatee has to
develop skills for proper communication. The receiver should be able to receive the message
physically, mentally and psychologically. He/she should be confident and eager to receive. He
must have faith in the source and must view the source with due regard and cordially.

The level of intelligence or knowledge is of particular importance to the communicator. The position
or status of both the communicator and communicatee should also be considered.

Methods and techniques of health education

What are the common teaching aids`

Slides

Transparencies

32
Picture

Photograph

Poster
Charts & Graphs

Printed materials: books, pamphlets, booklets, brochures

Leaflets, folders, brochure; booklet and pamphlets

Display boards: Flannel Board, Bulletin (notice) Board, and ChalkBoard

AUDIO AIDS

AUDIO-VISUAL AIDS

OTHER AIDS: Folk songs, folk dances, drama, puppet show, puppet stage, puppet plays

These folk media are used to introduce sociological themes.

How do you conduct IEC in your health facility?

Discuss counseling
Through counseling, an individual is encouraged to think about his problems and thus comes to a
greater understanding of their causes. From this understanding that person will hopefully omit
himself to taking action that will solve the problems. The kink of action that a person takes, will also
be that person's own decision although guided, if necessary, by the counselor.

Counseling means choice, not force, not advice. A health worker may think that his advice seems
reasonable, but it may not be appropriate to the situation in which the individual lives. Through
counseling, the solutions are more likely to be appropriate. An appropriate solution will be one that
the person can follow with successful results.

RULES FOR COUNSELLING

Relationships: A counselor shows concern and a caring attitude
Identifying needs: A counselor seeks to understand a problem as the person sees it himself
Feelings: The counselor develops empathy (understanding and acceptance) for a person's
feelings, not sympathy (sorrow or pity).
Participation; A counselor never tries to persuade a person to accept his advice
Keeping secret: A counselor will hear many personal and possibly embarrassing problems. This
information must be kept secret from all other people, even from the person's relatives
Information and resources: Although a counselor does not give advice, he should share
information and resource ideas which the person needs to have to make a resource ideas which the
person needs to have to make a sound decision.
All health or community workers can practice a counseling approach in their work. Parents and
friends can be counselors too. The important thing is friends can be counselors too. The important
thing is that the health worker, teacher, father or friend be willing to listen carefully and encourage
the person in need of advice to take as much responsibility as possible for solving his or her own
problem.

Values, beliefs and customs

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In every community there are sets of beliefs about life, which come from tradition and
religion. There are customs that regulate how people behave towards one another, such as
giving respect to elders, demanding obedience from children.
Customs also determine behavior in marriage and childbirth and at death.
Values shows what people think are most important. Health workers need to understand
very fully the beliefs, customs and values of the people.
7. Reproductive Health

Define RH
Reproductive health has been defined within the framework of the WHO definition of
health as “a state of complete physical, mental and social well-being, and not merely
the absence of disease or infirmity.” Reproductive health is a state of complete
physical, mental, and social well being and not merely the absence of disease or
infirmity, in all matters related to the reproductive system and to its functions and
process.
Reproductive health addresses the human sexuality and reproductive processes, functions
and system at all stages of life and implies that people are able to have “a responsible,
satisfying and safe sex life and that they have the capability to reproduce and the
freedom to decide if, when and how often to do so.”
Components of Reproductive Health
 Quality family planning services
 Promoting safe motherhood: prenatal, safe delivery and post natal care, including
breast feeding;
 Prevention and treatment of infertility
 Prevention and management of complications of unsafe abortion;
 Safe abortion services, where not against the law;
 Treatment of reproductive tract infections including sexually transmitted
infections;
 Information and counseling on human sexuality, responsible parenthood and
sexual and reproductive health;
 Active discouragement of harmful practices, such as female genital mutilation and
violence related to sexuality and reproduction;
 Functional and accessible referral
Describe four important points for eradication of polio

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Describe the top 5 diseases in children

Define RH rights
Men and women have the right to be informed and have access to safe, effective,
affordable and acceptable methods of their choice for the regulation of fertility which are
not against the law, and the right of access to appropriate health care services for safe
pregnancy and childbirth and provide couples with the best chance of having a healthy
infant. Reproductive health is life-long, beginning even before women and men attain
sexual maturity and continuing beyond a woman's child-bearing years.

Indicators show greater disparities among population groups

Indicators in Reproductive Health
Evidence for monitoring: Reproductive health indicators
A health indicator is usually a numerical measure which provides information about a
complex situation or event. When you want to know about a situation or event and cannot
study each of the many factors that contribute to it, you use an indicator that best
summarizes the situation. For example, to understand the general health status of infants
in a country, the key indicators are infant mortality rates and the proportion of infants
of low birth weight.
Which of the following is not used for emergency contraception?

Techniques and services that contribute to the RH wellbeing

 Components of Reproductive Health
 Quality family planning services
 Promoting safe motherhood: prenatal, safe delivery and post natal care, including
breast feeding;
 Prevention and treatment of infertility
Prevention and management of complications of unsafe abortion;
Safe abortion services, where not against the law;
Treatment of reproductive tract infections including sexually transmitted infections;
Information and counseling on human sexuality, responsible parenthood and sexual and
reproductive health;

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Active discouragement of harmful practices, such as female genital mutilation and
violence related to sexuality and reproduction;
Functional and accessible referral
The approach recognizes the central importance of gender equality, men's participation
and responsibility.
Characteristics of gender
Sex is the biological difference between males and females.
Gender refers to the economic, social and cultural attributes and opportunities associated
with being male or female in a particular social setting at a particular point in time
What are the four strategies for polio eradication
What are the main justification for mother and child health services
Why focus on maternal health?
 In developing countries, pregnancy and child birth are the leading causes of death,
disease and disability among women of reproductive age.
 At least 30 to 40 % of infant deaths are the results of poor care during pregnancy
and delivery.
 Poor Maternal health and nutrition contributes to low birth weight in 20 million
babies each year-almost 20 % of all births.
 Motherless children are likely to get less health care and education as they grow
up.
 Maternal health interventions are among the most cost-effective investments in
health.
- US 3$ /person is the approximate cost of ensuring that women in low-income
countries get health care during pregnancy, delivery and after birth; post partum
family planning; and newborn care (WHO).
When a mother dies, the family and community suffer, and surviving children face higher
risk of poverty, neglect or even death.

There is a global effort that aims to reduce deaths and illnesses among women and
infants, especially in developing countries. This effort is called Safe Motherhood
Initiative. The global safe motherhood initiative was launched in 1987 to improve

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maternal health and reduce the number of maternal deaths by half in the year 2000. It is
led by a unique alliance of co-sponsoring agencies that work together to raise awareness,
set priorities, stimulate research, mobilize resources, provide technical assistance and
share information. When the initiative was launched, death from the complications of
pregnancy and childbirth was little known. During the initiative’s first decade, these safe
motherhood partners developed model programs, tested new technologies and conducted
research in a wide range of countries and settings. The essential services that are
identified and the most important lessons we have learned through ten years record
In many developing countries, including Ethiopia, complications of pregnancy and
childbirth are the leading cause of death among women of reproductive age. More than
one-woman dies every minute from such causes. More than 600,000 women die each
year worldwide. From this, 99% is accounted by developing countries. Of these, around
273,000 women die each year in Africa. Particularly being one of the less developed
countries in the world, 46,000 women die each year in Ethiopia.

Around 50 million pregnant women worldwide had morbid illness each year, of which
15% of them have disabilities like fistula, infertility, etc. Over 300 million women in the
developing world currently suffer from short term and long term illness related to
pregnancy and childbirth.

Maternal mortality and morbidity can be reduced or avoided by providing and expanding
resources and services that are principally targeted in achieving maternal health and safe
motherhood.
Among the mortality indicators which is known to have the higest difference b/n the
developed and developing countries
Women’s lifetime risk of death is 40 times higher in developing countries as compared
to developed countries. In general women lifetime risk of death in developing countries is
1 in 48 as opposed to 1:1800 in developed countries.
Mention three points of major reproductive rights

 the right of couples and individuals to decide freely and responsibly the number
and spacing of children and to have the information and means to do so;

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  the right to attain the highest standard of sexual and reproductive health; and,
 The right to make decisions free of discrimination, coercion or violence.

What are the indicators of quality of care in RH?

A health indicator is usually a numerical measure which provides information about a
complex situation or event. When you want to know about a situation or event and cannot
study each of the many factors that contribute to it, you use an indicator that best
summarizes the situation.

Improving the quality of family planning services

Prevention and control of RTIs/STDs
Maternal mortality ratio (MMR):
Total Fertility rate
Contraceptive prevalence rate
Perinatal mortality rate
Antenatal Coverage
Attended Birth
Postnatal care:
Birth spacing
Women's lifetime risk of death
Infant Mortality Rate
Under five mortality Rate
Neonatal Mortality Rate
Post Neonatal Mortality Rate

8. Why do you want to join MPH programe?

I have been working in the area of FP/RH for over 15 years. I had an opportunity to work
in 3 Government hospitals Health centers in different assignments and mostly I was
assigned in the Gyne and FP units. After I joined Marie stops International Ethiopia, one
of the leading NGOs working in the fields of FP/RH I got the opportunity and privilege to
work in different capacities from a FP/RH clinical provider to the level of project
coordinator and program manager. I now work as Adolescent Reproductive Sexual
Health program manager and FP/RH technical advisor for Save children USA country
office.

Demographic data shows that Ethiopia's population size and growth rate are among the
highest in Africa. The population is estimated at more than 77 million, making it the
second most populous Sub-Saharan African country after Nigeria. As per the information
given by Engender Health, with an annual growth rate estimated at 2.4%, Ethiopia's

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population will approach 110 million before 2020. Nearly 2 million people are added to
the country's population each year. Rapid population growth as a result of continuing
high fertility, is a fundamental constraint to sustainable development in Ethiopia. This
unbelievably accelerated population growth sores the reproductive health problems in
general. STI/STD, HIV/AIDS unwanted pregnancy, abortion and abortion related
morbidity and mortality are some of the endemic reproductive health problems.

The experience I have gained from the different working opportunities and progressive
management positions and the fact that we have at hand makes me think critically on the
problematic issues that we all are facing.
I have been working in the FP clinics and have witnessed the progress of FP program the
intervention and also at the same time and in many instances I was confronted with
challenges which some times can not get the right answer to solve the problem. I have
been involved with FP/RH service provisions when I was working as FP/RH nurse and
clinic manager. I have tried to address and voice the problems which the provider and the
clients encounter during service provision and implementation. This work opportunity
has also helped me identify the gaps in quality service provision and the vacuum created
in this regard to forward the FP/RH programs

With regard to the policy issue, we all know that the country is confronted with great
challenge and the policy has to focus and design very practical reconciliation mechanisms
to mach the recourse available with the population size. The policy decisions made in
different policy formulation meetings on population and FP/RH has to be implemented
and the Government and the policy makers have to take the ownership to spear head
these implementations through net working, partnership and resource mobilization.

The Ethiopian youth comprises 34% of the total population. As the future country’s
developmental force and the future leaders the youth have to be be given special attention
in every direction like health, education, security, employment.
Enhancing ,Strengthening and supporting effective youth programs on reproductive
and sexual health, Family planning and HIV/AIDS, and other reproductive health
problems including streamlining livelihood programs together with the other
undertakings should be the priority for the country’s policy program. Sharing experience
and duplicating best practices in the area is one and feasible mechanism to start up and
create awareness and trigger self assertive action at the early age.

The social and cultural factors related to gender influence the extent to which women and
men are able to influence decisions affecting their health and the quality of their lives. 
Streamlining HIV/AIDS with other population and RH activities has to be given a focus
to register an impact
I believe we have done a lot in this regard, but the larger bulk of the work is still dragging
behind. There is still a lot to be done to systematically bridge the observed gaps to
address these observed un met need in the area of FP/RH and population issues.

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Finally I believe that this post graduate study coupled with my motivation and dedication
to the public health services that I have been with, will be very instrumental for my
carrier and future endeavour.

9. REFERENCES

 LECTURE NOTE ON THE MENTIONED SUBJECTS OF CARTER CENTER

Summary of Measures of Association

Attributable risk (AR) or Risk difference (RD) indicate how much of the risk is due to (or attributable to)
the exposure. Quantify the excess risk in the exposed that can be attributable to the exposure by removing
the risk of disease that could have occurred anyway due to other causes.

AR = Risk in exposed – Risk in non-exposed

Relative risk (RR): estimates the magnitude of the association between exposure and disease and indicates
the likelihood of developing the disease in the exposed group relative to those who are not exposed.

RR = Risk in exposed
Risk in unexposed

Odds of disease: is a simple ratio, not a proportion. Indicates odds of diseased relative to the exposure
status.

Odds of disease in exposed = a/b or a:b

Odds of disease in unexposed = c/d or c:d

Odds Ratio (OR): is the odds in the exposed over the odds in the unexposed. Some people call it cross
product.

OR = a/b  c/d = ad/bc

Attributable Risk Percent (AR%) among exposed: estimate the proportion of disease among the exposed
that is attributable to the exposure, or the proportion of the disease that could be prevented by eliminating
the exposure.

AR% = Risk in the exposed – Risk in unexposed

Risk in exposed

= OR – 1 X 100
OR

Population Attributable Risk (PAR) is the risk in total population minus risk in the non-exposed. Estimate
the excess rate of disease in the total study population that is attributable to the exposure.

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 PAR = Risk in population – Risk in unexposed

Population Attributable risk Percent (PAR%) Estimate the proportion of disease in the study population
that is attributable to the exposure and thus could be eliminated if the exposure were eliminated.

PAR% = Risk in population – Risk in unexposed

Risk in population

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