UNIT 1 CONCEPTS OF HEALTH AND

HYGIENE: COMMUNITY HEALTH

AND SYSTEMS OF MEDICINE
Contents
1.O Objectives
1.1 Introduction
1.2 Concept of Health and Hygiene
1.3 Evolution of the Concept of Health and Hygiene
1.4 Changing Philosophy in the Field of Health and Health Care Services
1.5 Health Work in Community and Brief Description of the System of
Medicine
1.6 Various Models of Community Health Work
1.7 Idenming Basic Health and Hygiene Problems and Making Appropriate
Intervention
1.8 LetUsSumUp
1.9 Key Words
1.10 Suggested Readings
1.11 Answers to Check Your Progress

1.0 OBJECTIVES
This unit aims to provide you with an understanding of the concept of health
and hygiene. After going through the unit you should be able to:
explain the meaning of health and hygiene;
understand the indigenous health system in India;
indicate the various health and hygiene problems in India;
describe the health care delivery system in India;
understand the role of social-workers in prevention; and
making appropriate intervention.

1.1 INTRODUCTION
Health is a common theme in the elements of culture. In fact all communities
have their own concept of health as a part of culture, yet health continues
to be a neglected area. However, during the past few decades there has been
a reawakening that health is a fundamental human right and a world wide
social goal. It is essential to the satisfaction of basic human needs and to
an improved quality of life and is to be attained by all. This unit gives an
idea about the concept of health and hygiene and it also deals with the role
that can be played by social workers in promotion of health and hygiene.
This unit also throws light on education and changing philosophy of health,
the M o u s models for community health-work and identifying the basic health
and hygiene problems in India and making appropriate interventions.
Health Information for
Social Workers 1.2 CONCEPT OF HEALTH AND HYGIENE
World Health organization (WHO-1946) defined health as a "state of complete
physical, mental and social well-being and not merely the absence 9f disease
or infirmity". Thus it is a basic human right. Providing conducive condition
for achieving normal health is the duty of state and society. In fact, the
deepest urge of humanity is to be healthy. Health is one of the essentials of
life without which nothing can be achieved. The sick and hungry child can
not learn and the sick and hungry adult cannot produce. In another words,
we can say that health is a condition of equilibrium between physical fitness,
mental balance and social adjustment of human being.
Concept of Hygiene
The term 'hygiene' is derived from "hygeia", the goddess of health in Greek
mythology. Hygiene has been variously defined, such as hygiene is "the science
of health and embraces all factors which contributes to healthfbl living". According
to other definition hygiene is "the science of preventing disease and promoting
health". Thus the aim of hygiene is not only to preserve health but also to
improve it.

An individual may be called a healthy person if helshe is physically fit, mentally

sound and socially well adjusted. Any change in either components i.e., physical,
mental or social may result in discomfort or disease. It may also be regarded
as the disease that is an interruption in the state of equilibrium of all the three
components of health. This concept may easily be understood through a
triangle of 60 degree each with the physical, mental and social arms. Any
variation in either angle or contraction/elongation in any one of the arms will
prodbce imbalance (State of illness) in any individual and on the other hand
exact degree and equal arms are the sign of totally healthy person. Let us
examine the physical, mental or social aspects of health.
Physical Health
Crew (1965) observed that the sign of physical health in an individual constitutes
a good complexion, a clean skin, bright eyes, lustrous hair with a body well
clothed with firm flesh neither too thin nor too fat, a sweet breath, a good
appetite, sound sleep, regular activity of bowels and bladder and smooth,
easy coordinated movements. All the organs of the body are unexceptional
in size and function normally. All the special senses are intact. The resting
pulse rate, blood pressure and tolerance etc. are all within the range of
'normality' in the context of the individual's age and sex. In the young and
growing individual, there is a steady gain in weight and in the mature this
weight remains more or less than the individuals weight at 25.

On the basis of above signs the basic health needs include a hygienic and
balance diet, pure water, a good habitat, neighbourhood and community with
basic sanitation, suitable clothes, well regulated life-style, exercise and personal
hygiene. A periodic health check up is also very essential for good health.
Mental Health
The old saying "healthy mind in a healthy body" confms the inter-relationship
between mental and physical health. Poor mental health affects physical health
and vice-versa. According to WHO Technical Report (1964), the psychological
factors are considered to play a major role in disorders such as hypertension,
 Concepts of Health and
i peptic ulcer and asthma. A mentally healthy person is free from internal Hygiene: Community Healtb
conflicts and external mal-adjustments. He is not swayed by emotions; and and Systems of Medicine
has good self-control.

As such mental health primarily needs physical health. The other important
needs are a good home, a good neighbourhood, a good community and job
satisfaction. The psychologists are of the opinion that the dissatisfaction of
instinctual and basic life needs leads to insanity.

I Social Health
The social health of the people in a community is determined and judged on
the basis of their personal and social characteristics. One who plays one's
roles, according to one's status and is apt in establishing and maintaining
harmonious relationship in family and community and on job is considered
socially a healthy person. On the contrary, when he fails to perform these
roles, neglects social relations, indulges in bad habits and gets involved in
homicide, suicide, crime, gambling, drinking etc., he is considered abnormal.

Therefore, family and social welfare services are important. Social health
needs to deal with the problems connected with social existence of individuals.
But these needs are seldom integrated with health services which is a great
weakness of health care delivery system in most societies. Some of the determinants
of health are-heredity, environment, life-style, socio-economic conditions,
health and family welfare services together with other factors such as food,
agriculture, education, industry, social development, social welfare, etc.
Definitions of Health
Webster's Dictionary, defines health as "The condition of being sound in body
mind or spirit, specially freedom from physical disease and pain". Oxford
dictionary states health as the state of being free from illness or injury and
a person's mental or physical condition. Whereas, according to WHO-1946,
"Health is a state of complete physical, mental and social well being and not
merely the absence of disease or infirmity".

Thus to achieve the optimum health condition there is a need of not only
caring for the sick, but also prevention of illness, and promotion and maintenance
of health. Health promotion and maintenance enables individuals, families and
communities to develop their full health potential. Its scope goes beyond the
prevention and treatment of disease. It encompasses cultivation of healthy
habits and life-styles and other social, economic, environmental and personal
factors conducive to health. Health maintenance does not depend solely on
individual behaviour; the family and community also have a major role in
influencing individual choices and actions. From the care of the sick, social
work is moving towards prevention and promotion of health of individual and
community.

1.3 EVOLUTION OF THE CONCEPT OF

HEALTH AND HYGIENE
All communities have a concept of health as part of their culture. However,
during the past few decades there has been a reawakening that health is a
fundamental human right and a world-wide social goal; that it is essential to
the satisfaction of basic human needs and to an improved quality of life and
Health Information for '
that it is to be attained by all people. In 1977, the 30th World-Health Assembly
Social Workers I
decided that the main social target of Government and WHO in the coming 1
decades should be "the attainment by all citizens of the world by the year
2000 of a level of health that will permit them to lead a socially and economically 1
productive life." Health, while being an end in itself has also become a major
instrument of overall socio-economic development in the creation of new
social order. A brief account of the changing concepts of health is given
below:
1) Bio-medical Concept
Traditionally health has been viewed as an "absence of disease". This concept
was known as the bio-medical concept of health which dominated medical
thought during 20th Century. The medical profession viewed the human body
as a machine and disease as a consequence of the breakdown of the machine
and one of the doctors' tasks as repair of the machine. Thus health in this
narrow view became the ultimate goal of medicine.

The criticism that is leveled against the bio-medical concept is that it has
minimized the role of the environmental, social, psychological and cultural
determinants of health. The bio-medical model, despite its spectacular success
in treating disease was found inadequate to solve some of the major health
problems of man-kind such as, malnutrition, chronic diseases, accidents, drug
abuse, mental-illness, environmental pollution, population explosion etc.
2) Ecological Concept
Deficiencies in the bio-medical concept gave rise to other concepts. The
ecologist put forward an attractive hypothesis which viewed health as a dynamic
equilibrium between individual and his environment and disease as a maladjustment
of human organism to environment. Ecologists Dubos said, "Health implies
the relative absence of pain and discomfort and a continuous adaptation and
adjustment to the environment to ensure optimum functions". Human ecological
and cultural adaptations determine not only the occurrence of diseases but
also the availability of food and the population composition. The ecological
concept also captures imperfect man and imperfect environment. History testifies
that improvement in human adaptation to natural environments can lead to
greater modem delivery services.
3) Psycho-Social Concept
Contemporary development in social science reveals that health is not only
a bio-medical phenomenon, but one which is influenced by social, psychological,
cultural, economic and political factors of the people concerned. These factors
must be taken into consideration while defining and measuring health. Thus
health is both a biological and social phenomenon.
4) Holistic Concept
The holistic model is a synthesis of the all above concepts. It recognizes the
strength of social, economic, political and environmental influences on health.
It has been variously described as a multidimensional process involving the
well-being of a person in the context of his environment. This view corresponds
to the traditional view that health implies sound mind in a sound body and
a sound family in sound environment. The holistic approach implies that all
sectors viz. agriculture, animal husbandry, food, industry, education, housing,
public work, communications etc. have a great effect on health.
 Concepts of Health and
Check Your Progress I Hygiene: Community Health
and Systems of Medicine
Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) List the characteristics of a healthy individual.
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2) What are the essential requirements for good health?
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3) What are the various approaches to health?
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.Activity 1
Visit a slum area around you and enlist the living unhygienic conditions and
health problems observed there.

1.4 CHANGING PHILOSOPHY IN THE FIELD

OF HEALTH AND HEALTH CARE SERVICES
Changing Philosophy
The period following 1500 AD was marked by political, industrial, religious
and medical revolutions. Political revolutions demanding individual's right took
place in France and America. The industrial revolution in the West brought
great benefits leading to an improvement in-the standard of living. Along with
this the concept of health and hygiene also evolved.
Revival of Medicine
For many historians the revival of medicine encompasses the period from
1453-1600 AD. It was an age of individual scientific endeavour. The period
during 17th and 18th centuries were full of even more exciting discoveries
P CT A ; C C . ~ X I P I ? Tnf
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Health Information for Sanitary Awakening
Social Workers
Another historic milestone in the evolution of medicine is the "great sanitary
awakening" which took place in England in the mid-nineteenth century and
gradually spread to other countries. The industrial revolution of 18th century
sparked of numerous problems such as creation of slums, overcrowding with
all its ill-effects, accumulation of filth in cities and towns, high sickness and
death rate especially among women and children, industrial and social problems
etc. causing deteriorated health of the people. Anti crusade "the great sanitary
awakening" led to the enactment of Public Health Act of 1848 in England.
A new thinlung began to take shape i.e. the state has a direct responsibility
for the health of people.
Rise of Public Health
Around 1840 the above events led to the concretization of Public health
concepts in England. While Public health made rapid strides in the western
world, its progress has been slow in the developing countries such as India,
where the main health problems continued to be those faced by western
world 100 years ago. The establishment of the WHO providing a Health
charter for all people provided a great fillip to the public health movements
in these countries. There are three components of modern health concept
which include curative aspect, preventive aspect and social medicine.
Changing Concept in Public Health
When we took into the history of public health, we identify the following four
distinct phases:
a) Disease control (1880-1920)
b) Health promotional (1920-1 960)
c) Social Engineering (1960- 1980)
d) Health for all (1981-2000)
Changing Philosophy in the Field of Health and Health Care Services:
(Indian Perspective)
Health Services in India began in the middle of the 18th century. Earlier there
was the concept of individual cure. The development of health services in
India began only in 1921. The Govt. of India accorded power to the then
provincial Govt. (now state Govt.) for providing medical care and thus health
departments came into existence. It was only after the independence, the
health services began to develop on the basis of health needs of the country.
The guidelines for organising the health services in the country were based
on the following reports.
1 . The B hore Committee- 1943
2. The Mudaliar Committee- 1962
3. The Chaddha Committee-1963
4. The Mukherji Committee- 1965
5. The Mukherji Committee-] 966
6. Jungal Walla Committee- 1967
7. Kartar Singh Committee- 1973
8. Srivastava Committee-1975
n D..-ol hoolth ~ n h a - a 1077
10. Health for All by 2000 AD-Report of the working group-1981 Concepts of Health and
Hygieae: Community Health
abd Systems of Medicine
New Philosophy of Health
In recent years we have acquired a new philosophy of health which may be
stated as below:
Health is a fundamental human right. -
Health is intersectoral.
Health is an integral part of development.
Health is central to the concept and quality of life.
Health involves individual, state and international responsibility.
Health and its maintenance is major social investment.
Health is a world-wide social goal.
Health Care Services
There is broad agreement on the issue that health services should be
comprehensive, accessible and acceptable which should provide scope for
community participation and be available at a cost that community and country
can afford. The purpose of health care services is ,to contribute to the improvement
of the health condition of the population and wider the scope of health services
so that it includes ever changing national, state and local health problems.
In India the health care services is represented by the five major sectors or
agencies applying distinct health technology and having difference sources of
funds for operation. A brief classification of these sectors is given below.
However, it may be noted that there could be sectoral overlapping i.e. indigenous
system can be found in public as well as private sector and so on.
1) Public Sector
a) Primary Health Care:
Primary health care 10,000-20,000 population
Sub Centre Village Level
5000 population Village Health Guide, (Male and
Female), Trained Dais and
Integrated Child Development
Services.
b) HospitalskIealth Centres:
Community Health Centre - 1,00,000 population
Rural Hospital
District HospitaVHealth Centre
Specialist Hospital
Teaching Hospital.
c) . Health Insurance Schemes:
Employees State Insurance
Central Govt. Health scheme
d) Other Agencies
Defence Services
Railways
Health Information for 2) Private Sector
Social Workers
Private Hospitals, Polyclinics (Nursing Homes and
General Practitioners Dispensaries)
3) Indigenous System of Medicine
Ayurveda and Siddha
Unani and ~ i b b i ~ a
Homeopathy
Unregistered Practitioners.
4) voluntary Health Agencies
Indian Red Cross Society
Family Planning Association of India
The All India Blind Relief Society
Tuberculosis Association of India etc.
5) National Health Programmes
National Malaria Eradication Programme
National Tuberculosis Programme
National Family welfare Programme
Expanded Programme on Immunization
National Filarial Eradication Programme
National Programme for Control of Blindness
National AIDS Control Programme etc.
Health ~ a i Delivery
e System and its Structure in India
In India health being state subject, the states are autonomous in matter of
the delivery of health care services to the people. Each state, therefore, is
five with regard to formation, planning, guiding, assisting, evaluating and coordinating
health care services. However, the central govt. also owns certain responsibilities.
The health system in India has three main levels i.e., Central, State and
Peripheral.
I

Health System Infrastructure in India

NATIONAL LEVEL
Ministry of Health and Family Welfare

STATE and UNION TERRITORY

Department of Health and Family Welfare
1
DISTRICT HEALTH ORGANISATIONS
ALL SPECIALISTS
CMO, DMOSI DMEODHEIPHN and OTHERS

SUB-DISTRICT/TALUKA HOSPITALS
SOME SPECIALISTS
 Community Health Centre Concepts of Health and
EIygiene: Community Health
ALL SPECIALISTS and Systems of Medicine

PRIMARY HEALTH CENTRES

AT BLOCK LEVEL
MOIBEEIH. ASSISTANT

(Male & Female Health Worker)

SUB CENTRES-
HEALTH WORKER (M)
HEALTH WORKER (F)

HEALTH GUIDE
DAVTBA

PEOPLE (1 BILLION - YEAR-2000)

1.5 HEALTH WORK [Link] AND A BRIEF

DESCRIPTION OF THE SYSTEM OF MEDICINE
The disease and death are as old as man. Every society develops its own
measures to cope with these miseries which'form an essential part of health
culture in that society. Health Culture, according to Polgar (1963) is of two
types, "the popular health culture and the professional health culture". The
measures which the members of a community take to alleviate their suffering
,are known as popular health culture, whereas the professional health culture
is developed and practiced by medical experts. The popular health culture
develops through a process and on the basis of personal experience which
pass through one' generation to the other. It consists of the body health rules,
folk saying and family prescription (Gharelu-Nuskhas). Since it develops in
local condition it differs from culture to culture.
Ayurveda
Ayurveda as a professional health systems of medicine developed in India
in the ancient times. The services were delivered by individual practitioners
only till king Ashoka established a hospital system in 3rd Century B.C. Ayurveda
by definition implies the knowledge of life or by which life may be prolonged.

Ayurvedic practitioners used to give self made herbal indigenous medicine

for treatment. A great emphasis was laid on prevention of disease by regulating
the diet and life-style of people. Ayurveda is practised throughout India but
the siddha system is practised in the Janul-speaking areas of south India.

Hygiene was given an important place in ancient Indian medicine. The laws
of Manu also contained a code of personal hygiene. Archeological excavation
at Mohenjodaro and Harappa in the Indus valley uncovered cities of two
thousand year old which revealed rather advance knowledge of sanitation,
water supply and engineering.
Unani-Tibb
Unani system of medicine owes its origin to Greece. Among the founders
Healtb Information for of this school of medicine were Hippocrates and Glen who laid the foundation
Social Workers
of scientific medical research in the west. Unani medicine got enriched from
its interaction with the traditional medicines of Egypt, Syria, Iraq, Persia,
India, China and other Middle East and Far East countries. Unani Medicine
had its hey-day in India during the medieval period. The British Gle, withdrew
governmental patronage and Unani Medicine suffered a setback. Since the
system enjoyed faith among the masses it continues to be practiced.

The development of Unani Medicine as well as other Indian systems of medicine

gained considerable momentum after independence. In 1969 the government
established a Central Council for Research in Indian Medicine and Homeopathy
(CCRIMH) to develop scientific research in different branches of Indian
systems of medicine viz. Unani Medicine, Ayurveda, Siddha, Yoga, Naturopathy
and Homeopathy. The research activities in these systems continued under
the aegis of the CCRIMH till 1978 when it was split up into four separate
research Councils, one each for Unani Medicine, Ayurveda and Siddha, Yoga
and Naturopathy and Homeopathy. Further, the Government set up, by an
Act of Parliament-Indian Medicine Central Council Act 1970, the Central
Council of Indian Medicine (CCIM).

At present the Unani system of medicine, with its own recognized practitioners,
hospitals and educational and research institutions, forms an integral part of
the national health care system.
Siddha
The ancient Sidha system of medicine flourished in South India. The word
Siddha comes from the word Siddhi which means an object to attain perfection
or heavenly bliss. Siddha science considers nature and man as essentially
one. According to Siddha medical science, the Universe originally consisted
of atoms which contributed to the five basic elements, viz., earth, water, fire,
air and sky corresponding to the five senses of the human body. They were
considered to be the fundamentals of all the corporeal things in the world.
Homeopathy
Homeopathy, a system of medicine propounded by Samuel Hghnemann, (1755-
1843) came to India sometimes in the mid 18th century. This system could
not get wide popularity in those times. Homoeopathy is an alternative method
of treatment, based on the nature's Law of Cure, namely 'Like Cures Like'.
It is a revolutionary natural medical science. The medicines are prepared
from natural substances to precise standards and work by stimulating the
body's own healing power. But today many people utilize the services as they
believe that homeopathic drugs carry no side effects and are cheaper and
easily administrable.
Modern Medicine and Public Health
During the early period of British rule in India, which was still dominated
by Indian systems, the western system of medicine could not get wide publicity.
The British had introduced modern medicine (allopathic system in India)
systematically in the later half of the eighteenth century.

The need to provide public health services was felt only when there was an
outbreak of plague, cholera and small-pox. During those days there was
widespread prevalence of malaria, tuberculosis, leprosy, small-pox, cholera,
gastro-intestinal infection and infestations and filarasis. A considerable change Concepts of Health and
Hygiene: Community Health
occurred in the health needs of the society due to vast changes in the socio- and Systems of Medicine
economic scene of the country. The demand for medical aids was also caused
by man's attitude towards life and needs.

The first organised step to meet the demand for public health was taken by
the then British Government through the appointment of a Royal Commission
in 1859. The commission was entrusted the task of investigating the cause
of extremely unsatisfactory health condition in India.
Health Work in Community
Health has been declared a fundamental human right. It implies that the state
has a responsibility for the health of its people. Since health is influenced by
a number of factors such as adequate food, housing, basic sanitation, healthy
life-style, protection against environmental hazard and communicable diseases,
the frontiers of health extended beyond the narrow limits of medical care.
Community participation is now recognized as a major component in the
approach to the whole system of health care.
Levels of Health Care

i) Primary Level Care: It is the first level of contact of individuals, the

family and community with the national health system, where primary
health care (essential health care) is provided. As a level of care, it is
close to the people where most of their health problems can be dealt
with and resolved. In Indian context primary health care is provided by
the complex of primary health centre and their sub-centres through
Multipurpose Health Worker, Village Health Guides and Trained Dais.
Primary health care system has been recognized as the most effective
health care delivery system.
ii) Secoddary Level Care: At this level more complex problems are dealt
with. In India, this kind of care is generally provided in community Health
Centres and district hospital which also serve as the first referral level.
iii) Tertiary Level Care: The tertiary level is a more specialised level than
secondary care level and requires specific facilities and attention of high
regional or central level institution e.g. Medical College Hospital, All
India Institutes, Specialized Hospitals, etc.

I Check Your Progress 11 I

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) What is the new philosophy on health?

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2) List the indigenous system of medicine in India.
Health Information for
Social Workers .....................................................................................................
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3) What are the various levels of health care?
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Activity 1
Visit a Community Health Centre. Discribe briefly its main work and staff.
Also give your comments.

1.6 VARIOUS MODELS OF COMMUNITY

HEALTH WORK
The term community health work has emerged during the past few decades;
community treatment or community health work is the sum of steps decided
upon to meet the health needs. The community takes into account resources
available and the wishes of the people as revealed by community diagnosis.
A number of community health models have been developed. They include
the following :
1) ~ e d i c a lModel
Most health education in the past has relied on knowledge transfer to achieve
behaviour change. Originally health education developed at the community
level along the lines of the bio-medical views of health and disease. The
assumption was that people would act on the il~formationsupplied by health
professionals to improve their health condition. In this model social, cultural
and psychological factors were thought to be of little or no importance. The
medical model failed to bridge the gap between knowledge and behaviour.
2) Motivation Model
When people did not act upon the information they received, health education
started emphasising "motivation" as the main force to translate health information
into the desired health action. But the adoption of a new behaviour or idea
is not a simple act. It is a process consisting of several stages through which
an individual is likely to pass. In this regard, sociologists have described
3 stages in the process of change in behaviour.
1. Awareness Intere~t
2. Motivation Evaluation, Decision making
3. Action Adoption or acceptance
3) Social Intervention Model Concepts of Health and
Hygiene: Community Health
and Systems of Medicine
Soon it was realized that the public health problems are so complex that the
traditional motivation approach is insufficient to achieve behavioural change.
Adoption of small family norm, cleanljness, raising the age of maniage, immunization,
safe drinking water etc. were areas where progress was dismal. The motivation
model ignored the fact that in a number of situations, it is not the individual
who needs to be changed but the "social environment" which shapes the
behaviour of individual or the community.

In sum, a coherent strategy needs to be developed involving all the ways

of changing behaviour. A combination of approaches using all methods to
change life - style is required for which appropriate use of medical care and
other non-medical inputs will be necessary.

1.7 IDENTIFYING BASIC HEALTH AND HYGIENE

PROBLEMS AND MAKING APPROPRIATE
INTERVENTION
The etiology of ill health lies in the malfunctioning of the social system in terms
of poverty, ignorance, population explosion, unemployment, old age, unhygienic
living conditions, bad housing, poor nutrition and incompatible dietary habits,
poor quality of drinking water and sanitary facilities etc. Thus, we can say
that ill health is only a symptom of social disequilibrium and not a phenomenon
independent of social affairs of man. Generally health is misunderstood with
treatment which is not necessarily a precondition of good health but it involves
prevention, education, rehabilitation and a number of other interventions in
terms of social services which ensures the vitality of human health.

The main causes of health and hygiene problems in India may be enumerated
as below:
1) Environmental Causes
- lack of safe drinking water
- lack of basic sanitation
- crowded, unsanitary living conditions
- pollution of water, food, soil and air
2) Social Economic Causes
- poverty
- illiteracy
- ignorance
- prejudicial customs, traditions, beliefs and cultural pattern
- inadequate nutrition
- lack of personal hygiene
- rapid population growth
3) Others
- uneven development of health care services and social care
- inadequate primary health care
Health Information for Identifying Basic Health and Hygiene Problems
Social 'Workers
An assessment of the health status and health problem is the ,first requisite
for any planned effort to develop health care services. This is also known
as Community Diagnosis. The analysis of data relating to health situation and
health problems comprises:
- Morbidity and Mortality statistics
- Demographic conditions of the population
- Environmental conditions which have a bearing on health
- ' Socio-economic factors which have a direct effect on health
- Cultural background, attitudes, beliefs and practices which effect health
- Medical and health services available,
- Other services available

A number of committees have been constituted to look into health problems.

In the light of the reports submitted by the committees, National Policies have
also been formulated. Let us look into the brief summary.

Bhore Committee (1946): The government of India appointed this committee

in 1943 to survey the then existing health conditions and health organisations
in the country and to make recommendation for further improvement. The
report published in 1946 recommended a primary health unit for a population
of 20,000, a secondary unit for a population of 6,00,000 and a district
headquarter for a population of three million as long-term programme. The
committee in its short-term programme recommended a primary unit for a
population of 40,000, a secondary unit for a population of one and a half
million (and a district headquarters organisation for a population of three
don).
.
Mudaliar Committee (1962): The committee was appointed by the Ministry
of Health to .undertake a review of the developments since the publication
of the health survey and development committee report in 1946, and to
formulate further health programme for the third and subsequent five year
plan periods.

The Mudaliar Committee found the quality of services provided by the primary
health centres inadequate and stressed the need to strengthen the existing
primary health centres before new centres are created. It also stressed the
need to strengthen sub divisional and'district hospitals so that these could
effectively function as referred centres.

Jungalwala Committee (1967): The committee on "Integration of Health

Services" was appointed in 1964 under the chairmanship of Dr. M. Jungalwala
to examine the various problems including those of service conditions. It
recommended integration of organisations and personal in the field of health
.from the highest to the lowest level in the service.

Shrivastava Group Report (1975): The most significant policy changes

followed the report of this group on Medical Education and support Manpower.
Its recommendations included a nation-wide network of efficient and effective
services suitable for our conditions be created, steps. be taken to create
 bands of para professionals or semi-professional health workers from the Concepts of Health and
Hygiene: Community Health
community itself to provide protective, preventive and creative services, needed and Systems of Medicine
by the community and there be two cadres of health workers and health
assistants between the community and the primary health centres.

Ramalingaswami Committee Report (1981): It is also called ICSSR-

ICMR report. The committee noted that in the last thirty years the capacity
for change and progress was wrongly equated in India with our capacity to
reproduce the western type of institutions, service and values. It suggested
that health cannot be achieved through a linear expansion of the existing
system and even by tinkering with it through minor reforms. It laid exclusive
emphasis on allopathic system and recommended for the community health
centre and allopath or para professionals as support manpower to sustain
the allopathic system.

The National Health Policy (1983): The initiatives taken under this policy
were: A phased time bound programme for setting up a well dispersed network
of comprehensive primary health care services linked with extension and health
education, designed in the context of the ground reality that elementary health
problems can be resolved by the people themselves; intermediation through
'Health Volunteer' having appropriate knowledge, simple skills and requisite
technologies; an integrated net work of evenly spread speciality and super-
speciality services; encouragement of such facilities through private investment
for patients who can pay so that the draw on the governments facilities is
limited to those entitled to free use.

National Health Policy 2002: It acknowledges globalization as a concern

with a critical view of TRIPS and its impact. It recommends for the doubling
of Central Government expenditure and suggests to increase health expenditure
by all concerned in general. It suggests increased proportions of expenditure
on primary health care. It also envisages regulations of the private health care
sector.

An analysis of the health situation in the light of the above facts will bring
out the health problems and health and hygiene needs of the community.
These problems can be ranked according to priority or urgency for allocation
of resources.
*
Major Causes of Morbidity and Mortality
The major causes of morbidity and mortality of India may be conveniently
grouped under the following heads -

Communicable Diseases: Malaria, Tuberclousis; Diarrhoea, Leprosy, Filarial,

AIDS etc.

Nutritional Problems: Protein-energy malnutrition, nutritional anemia, low

birth weight, xerophalmia (nutritional blindness); iodine deficiency disorder.

Environmental Sanitation: The most difficult problem to tackle in this country

is perhaps the environmental sanitation problem. The great sanitary awakening
which took place on England in 1840's is yet to be born in India.

Medical Care Problems: India has a national policy; it does not have a
Health Information for national health service. The existing hospital based disease oriented health
Sacial Workers
care model has provided health benefits mainly to the urban elite.

Population Problem: The population problem is one of the biggest problem

faced by the country, with its inevitable consequences on all aspects of development,
especially employment, education, housing, health care, sanitation and environment.

Modes of Intervention: "Intervention" can be defined as any attempt to

intervene or interrupt the usual sequence in the development of disease in
man. This may be in the form of treatment, education, help or social support.
Generally there are five methods of intervention: .
1) Health Promotion: Health promotion is the process of enabling people
to increase control over and to improve health. The well known intervention
in this area are:
9 health education,
ii) environmental modification,
iii) nutritional intervention,
iv) Life-style and behavioural changes.
2) Specific Protection: Through this intervention we take some special
measure to avoid disease altogether. The following are some of the currently
available intervention aimed at specific protection (a) immunization,
(b) specific nutrients, (c) protection against accidents, (d) control of
specific hazards in the general environment e.g. air pollution, noise pollution.
3) Early Diagnosis and Treatment: Early detection and treatment are the
main interventions of disease control. The earlier a disease is diagnosed
and treated the better it is from the point of view of prognosis and
preventing the occurrence of further case or any long-term disability. For
effective and lasting results, proper supervision, follow-up are essential.

\
4) Disability Limitation: When a patient report late in the pathogenesis
phase, the mode of intervention is to prevent or halt the transition of the
disease from impairment to handicap.
1

5) Rehabilitation: Rehabilitation has been defined as the "combined and

coordinated use of medical, social, educational and vocational measures
for training and retraining the individuals to the highest possible levels
of functional ability". It includes all measures aimed at reducing the impact
of disability and handicapping conditions and enabling the disabled and
handicapped to achieve social integration. Such as, establishing schools
for the blind, reconstructive surgery in leprosy etc.

It is recognized that intervention at earlier stage is feasible, results oriented

and less demanding of scarce resources.
Social Work Implications
Being a professional social worker we can use the various methods of social
work hprevention and promotion of health. Social workers also play very
important role in social intervention and rehabilitation. At individual level use,
can use social case work whereas social group work can be used for groups
and community organisation.
1 Social Casework Concepts of Health awt
Hygiene: Community Healtb
and Systems of Medicine
By using the various techniques i.e. - personal contact, home visits, personal
letters, etc. we can prevent the disease like- drug-addiction, Cancer, TB,
AIDS. Apart from prevention, casework can be used for support to patient
while undergoing treatment and follow-up.
Group Work
Group teaching is an effective way of educating the community. We can use
certain group work techniques i.e. lectures, demonstration, discussion methods,
group discussion, panel discussion, symposium, workshop conferences, seminars,
role play, etc. to communicate to the people about health and hygiene, their
life-style, environmental problem etc. To create awareness among the community
for prevention of disease and promotion of health, the social workers play
very important role by educating the community against the various problems
related to health through awareness programmes.

Check Your Progress I11

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) What are the various health and hygiene problems in India?
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2) What do you understand by Community Health?
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1.8 LET US SUM UP

In this unit we first discussed the meaning and concept of health and hygiene.
We saw that health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity. It is a basic human
right. Health and hygiene are the essentials of life without which nothing can
be achieved. We also examined the evolution of the various concepts of
health like, bio-medical concept, ecological concept, psycho-social concept
and holistic concept.

In the category of indigenous system of health evolved in India, we have

discussed Ayurveda, Unani-Tibbiya and Homeopathy. We also studied the
Health Information fm three levels of promotion of health at'primary level, secondary level and
Social Workers
tertiary level.

We considered the changing philosophy in the field of health i.e. revival of

medicine, sanitary awakening, rise of public health. Besides, the unit also
dealt with the changes in the concept on health in Indian perspective. It
covered the period from ~hore-committet-1943 to Health for All by 2000.
With regard to models of community health we have examined medical model,
motivation model, and social intervention model.

We have attempted to identify the basic health and hygienic problems in

India. We have also analysed various models of intervention such as health
promotion, specific protection, early diagnosis and treatment, disability limitation,
rehabilitation.

1.9 KEY WORDS

Community : The group of people living in a particular
geographical area.
Diagnosis : The process whereby a disease or disorder
is provisionally identified on the basis of its
symptoms and the patient's medical history.
Disease : Lack of health, a disorder or illness caused
by infection, or deficiency with charackristicl
symptoms.
Health : A state of physical, mental and social well-
being and free from illness or pain.
Hygiene : The practice of preserving one's health and
preventing the spread of disease especially
by keeping oneself and one's surroundings
clean.
Intervention : An act to involve oneselfin something which
is happening in order to affect the outcome.
Model : A small scale presentation of something that
serves as a guide in constructing the full
scale version.
Morbidity : The ratio of deaths in an area to the population
of that area; expressed per 1000 per year.
Prevention : To stop the occurrence of something before
hand.
Promote : To work for the cause of something to upgrade
something.
--
1.10 SUGGESTED READINGS
K. Park (17th edition) Nov. 2002 Preventive Medicinc, Banarsidas Bhanot
Publishers, Jabalpur.
 Concepts of Health and
1.11 ANSWERS TO CHECK YOUR PROGRESS Hygiene: Community Health
and Systems of Medicine

Check Your Progress I

1) An individual who is physically fit, mentally sound and socially well adjusted
may be called healthy. Any change in either component i.e. physical,
mental or social may result discomfort means disease.
2) A hygienic and balance diet
Safe potable drinking water
Good habitat
Neighbour and community with basic sanitation
Well regulated life style
Exercise and personal hygiene
A periodic health check,up
3) Bio-Medical Approach - based on germ theory
Ecological Approach - based o i equilibrium between
environment and disease1
mal-adjustment.
Psycho-Social Approach - based on both biological and
social phenomenon
~ o l i s t i cApproach - a synthesis of all the above
concepts.
Check Your Progress I1

1) In recent years we have acquired a new philosophy of health which is

as follows:
Health is a fundamental human right
. Health is intersectoral
Health is an integral part of development
Health involves individual, state and international responsibility
Health is a world wide social goal
2) Following are the indigenous system of medicine in India.
Ayurveda and Siddha
Unani and Tibbiya
Homeopathy
Unregistered Practitioners.
3) Primary prevention - action taken prior to the onset of disease, which
removes the possibility of occurrence of.
Secondary prevention - action which halts the progress of a disease
at its incipients stage and prevents complications -the specific intervention
are early diagnosis and adequate treatment.
Tertiary prevention - all measures available to reduce or limit impairment
and disabilities to minimise suffering caused by existing departures from
good health and to promote the patient's adjustment to irremediable
conditions.
Health Information for Check Your Progress 111
Social \Irorkers

1) Communicable disease
Nutritional problem
Environmental sanitation problem
Medical care problem
Population problem.
2) A Euro symposium in 1966 defined community health as "all the personal
health and environmental services in any community, irrespective of whether
such services were public or private one".
 . UNIT 2 MENTAL HEALTH, MENTAL
DISORDERS AND MENTAL
DISABILITY
i
1 Contents
2.0 Objectives
2.1 Introduction
2.2 Mental Health
2.3 Mental Psychiatric Disorder
2.4 Extent of the Problem in the Indian Context
2.5 Existing Mental Health Services in India
2.6 Legislations Related to Mental Health
2.7 Rehabilitations, Prevention and Promotion in the Area of Mental Health
2.8. Let Us Sum Up
2.9 Key Words
2.10 Suggested Readings
2.11 Answers to Check Your Pragress

2.0 OBJECTIVES
This unit aims to provide you with an understanding of the concept of mental
health and psychiatric disorder. At the end of the unit you should be able to:
explain the meaning of mental health;
understand the various psychiatric disorder;
explain the legislations related to mental health;
indicate the vaIious steps involved in mental health care i.e.- rehabilitation,
promotion and prevention; and
the role of psychiatric social worker.

2.1 INTRODUCTION
Majority 0; psychologists and social workers have agreed that "complete
maturity" terms may be used as mental health. Physical, sexual, and intellectual
maturity is achieved generally around the chronological age of 20 years. It
is also well known that after this age, much changes are not observed in these
areas as far as growth is concerned. But attaining maturity in physical, sexual
and intellectual areas only is not the complete maturity. Besides these areas,
the inclusion of emotional, social and role understanding are of utmost importance,
which together could be considered complete or comprehensive maturity or
mental health.

2.2 MENTAL HEALTH

Definition of Mental Health
Psychologist, social workers and psychiatrist have defined mental health in
different ways. H.B. English, a Psychologist defined as "mental health is a
Health Information for relatively enduring state wherein the person is well adjusted, has a zest for
Social Workers
living, and is attaining self-actualization or self-realization; it is a positive state
and not mere absence of mental disorder". Karl Merringer, a Psychiatrist
says that "let us define mental health as the adjustment of human beings to
the world and to each other with a maximum of effectiveness and happiness.
Not just efficiency, or just contentment - or the grace of obeying the rules
of the game cheerfully, it is all of these together. It is the ability to maintain
an ever temper, an alert intelligence, socially considerate behaviour, and a
happy disposition. This, I think, is a healthy mind". W.W Boehm, a social
worker defined as " Mental Health is a condition and level of social functioning
which is socially acceptable and personally satisfying". In general, such defmitions
emphasize both the individual and the social setting in which he functions.

However finally we can define mental health as "the optimal development and
functioning of the individual consistent with the long-term well being and
progress of the group". This definition implies the development of adequate,
integrated persons who have sound attitudes and values and high degree of
stress tolerance (Coleman- 1964).
Characteristic of a Mentally Healthy Person
There are three main characteristics of a mentally healthy person:
1) He feels comfortable about himself, that is, he feels reasonably secure
and adequate. He neither underestimates nor overestimates his own ability.
He accepts his shortcomings. He has self-respect
2) He is aware of his rights towards others. This means that he is interested
in others. He develops friendship that is satisfying and lasting. He considers
himself a part of a group without being submerged by it. He has the
ability to trust others. He takes responsibility for his neighbours and his
fellow-men.
3) A mentally healthy person is able to meet the demands of life. He reacts
to the problems as they arise. He is able to think for himself and takes
his own decisions. He sets reasonable goals for himself. He shoulders
his daily responsibilities. He is not bowled over by his own emotions
of fear, anger, love or guilt.
r . ,

Check Your Progress I

Notes: a) Space is given below for your answer.
b) Check your answers with thosegiven at the end of this unit.
1) Define mental health.
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2) Spell out any two characteristics of a mentally healthy person.
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 Mental Health,
Mental Disorders and

!
Mental Disability 1

~ e n t a disorder
l and mental deficiency may'be observed on the basis of
deviation from abnormality. It implies deviation from some clearly defined
I
I
norms. Several criteria have been proposed to understand the abnormality
because defining abnormal behaviour has proved to be a most difficult one.
These criteria or norms are as under:
1 Statistical norms
1 Personal adjustment
Personality integration
Personal maturity and growth
Group Well-being and Progress
1 Deviation from normality may be identified on the basis of above norms,
which are already discussed in one way or the other under the Unit 1.

I Here, we will try to understand the mental disorder or abnormal behaviour

on the basis of the social science approach.
A Tentative Definition
The social science have not yet provided a sufficiently comprehensive and
integrated picture of man's nature and behaviour to allow us to see just what
a "model" man would be like. Most of the social scientists would agree that
normal behaviour will represent the "optimal development and functioning of
the individual consistent with the long-term well-being and progress of the
group." Such a norm includes the concept adjustment, integration, maturity,
fulfillment, and social well-being. From this point of view abnormal behaviour
encompasses a wide range of rnaladjustive reaction-including alcoholism, unethical
business practices, juvenile delinquency, racial discrimination, psychoneurosis,
psychoses, drug-addition, peptic ulcers and sexual deviations. All are indicative
of some sort of biological, psychological or social maladjustment which impairs
the functioning of the individual and /or the well-being and progress of the
group. The simplest way to conceptualize a mental disorder is as a disturbance
of :
i) Cognition (i.e. thought), or
ii) Conation (i.e. action) or
iii) Affect (i.e. feeling) or any disequilibria between the three.
..
Another way to define a mental disorder,is as a clinically si&icant psychological
or behavioural syndrome that causes significant distress (Subjective
symptomatology) or loss of freedom, and which is not merely a socially
deviant behaviour or an expected response to a stressful life event (e.g. loss
of a loved one). Conflicts between society and the individual are not mental
disorders. A mental disorder should be a manifestation of behavioural psychological,
andlor biological dysfunction in that person (Definition modified after-DSM-
IV) .
Classification of Mental Disorders
Psychiatry is a fast growing branch of medicine, which has seen rapid changes
in classification to keep up with a conglomeration of growing search data
dealing with epidemiology, symptornatology, prognostic factors, treatment methods
--A -,.. ,,:,,,Lc ,c ,., ,,:c c -,-.-
, ,:,c,:.l 1:
,,.-1,-
-
Health Information for Although the first attempt to classify madness or mental illness can be traced
Social Workers
back to Ayurveda, as indicated in Charak Sanhita - Bhoot Vigyan and Unmad,
Plato (4th century BC) and Asclepiades (1st century BC) Classification in
Psychiatry has come ever since.

There are two major classification in Psychiatry: (i) International Classification

of Diseases (ICD-10th Revision 1999). It is WHO'S classification for all
diseases. Chapter 'F' classifies psychiatric d i s d e r s as Mental and Behavioural
Disorders. (ii)The other classification is made by American Psychiatric Association
as Diagnostic and Statistical Manual of Mental Disorders IV Edition Text
Revision, 2000 (DSM-IV-TR-2000)
Mental and Behavioural Disorders (ICD-10; from F-00 to F-99)
1). Organic (Symptomatic) Disorders and other Organic Mental
Disorders: This group includes mental and behavioural disorders due
to demonstrable cerebral disorders either primary or brain pathology or
secondary brain dysfunction due to systemic diseases.
2) Psycho-active Substance Use Disorder: This group includes mental
and behavioural disorders due to the use of one or more Psycho-active
Substances.
3 ) Schizophrenia, Schizotypal and Delusional Disorders: This group
includes disorders characterized by prominent disturbances of thought,
perception, affect and/or behaviour.
4) Mood (Affective) Disorders: This group includes mental and behavioural
disorders characterized by a prominent disturbance of mood.
5) Neurotic, Stress Related and Somatoform Disorders: This group
includes mental and behavioural disorders that are labeled as neurotic
or psychoneurotic disorders, with an emphasis on psychological causations.
6) Behavioural Syndromes Associated with Psychological Disturbances
and Physical Factors: This group includes mental and behavioural disorders
that are called psychosomatic disorders. The term psychosomatic is no
longer used because its use implies that. the association between the
psychological factors and physical disorder is etiological. Also it presumes
that the psychological factors are not important in other medical illnesses
and physical disorders.
7) Disorder of Adult Personality and Behaviour: This group includes
mental and behavioural disorders that are the persistent expression of
an individual's characteristic life-style and mode of relating to self and
others.
8) Mehtal Retardation: The group include disorders with arrested or incomplete
development of the intellectual abilities and adaptive behaviour, which
may or may not be associated with other physical or mental disorder.
9) Disorders of Psychological Development (Child Psychiatry): This
group includes mental and behavioural disorders with an onset during
infancy or childhood and characterized by an impairment or delay in the
development of functions that are strongly related to biological maturation
of the central nervous system.
10) Behavioural and Emotional Disorders with Onset usually Occurring
in Childhood and Adolescence.
11) Unspecified Mental Disorder (.Multi-AxialClassification): Labeling
 . Mental ~ e a l t h ,
the patient with a diagnosis is not enough. This degrades the individual
Mental Disorders and
to just another case and does not direct attention to the whole individual. Mental Disability

This method helps in a more holistic assessment of an individual patient.

Recently, ICD-10 has also brought out its own multi-axial classification
version:

Cognition

For
normal
function an
equilibrium usually
maintained between
these three
Affect Conation

Check Your Progress I1

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) Describe various traits of normal person.
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2.4 EXTENT OF THE PROBLEM IN THE

1
INDIAN CONTEXT
India is the second largest country of the world. The mental health and prevalence
of mental disorders is comparatively high as usual in any developing country.

The total population of the country is 1027 million as per the report of 2001.
The World Health Organization indicated in its Atlas : Mental Health Resources
in the world-2001 that prevalence of Psychiatric (mental) disorders is 5.8%
(5811000) of Indian population out of them 1% to 2% are severe mental
illness. It is also highlighted that incidence is observed 35 per 1,00000population.
The Psychoneuroses and Psychosomatic disorders are traced 2 to 3% and
Mental Retardation is 0.5 to 1.00% of all the children. Similarly 1% to 2%
of all the children suffer from Psychotic Disorders.

It shows that about one fifth of the patients with physical ailment are also
facing psychosocial and emotional problems of a degree taken into consideration
for professional help by psychiatrists, social workers and psychologists, in
out-patient or in-patient departments of government and private hospitals.
Manpower Available in India
The prevalence of mental illness as shown above is very high and a large
number of population of mentally ill patients and organic patient with psychosocial
Health Information for and emotional problems need much more number of qualified psychiatric
Social Workers
nurses, physiotherapists, occupational therapist and other trained staff, as the
objective of treatment of mental and organic patients is [Link] them total
health. There are 3500 qualified psychiatrists in India. It means there are only
0.3% psychiatrists to serve 10 million population as compared to 3.96%
psychiatrists in the world to serve the same population.

According to WHO Atlas there are 5,03,900 doctors (1999) to serve the
total population of the country. The large majority of Indian population is
rural but most of the doctors/physicians and almost 100% of psychiatrists
are with their head quarters in urban areas.

There is 0.1 clinical psychologists serving 10 million population and the same
is the case regarding the psychiatric social workers. There are only 0.1
psychiatric social workers to serve 10 million Indian population as compared
to 8.64 in the world for the same population. Similarly there are only 0.1
psychiatric nurse to serve 10 million population when 12.6 nurses are serving
same population in the world. There are 7,37,000 nurses in India out of them
only 800-900 are trained as psychiatric nurse.

There are 40 postgraduate centres for psychiatry in the country. Very few
of the 140 medical colleges in India have a psychiatric departments.

There are only 200 seats for MD in Psychiatry and Diploma in Psychological
Medicine against 13000 seats for doctors per year (1990).
Community Psychiatry
The community psychiatry movement has been hailed as the third psychiatric
revolution. The first revolution was the age of enlightenment when mental
illness was viewed as a result of sin and witch craft, the second revolution
was the development of psychoanalysis, which offered hope for a causative
explanation of mental disorders.

As a policy for the developing countries, World Health Organization recommended

the delivery of mental health services through primary health care system in
1975.

Gerald Captain (1967) defined the basic model'of community mental health,
and emphasized on the following characteristics of community Psychiatry.
1) Responsibility to a population for mental health care.
2) Treatment close to 'a patient in community based center.
3) Provision of comprehensive services.
4) Multidisciplinary team approach.
5) Providing continuity of care
6) Emphasis on prevention as well as tre'atment
7) Avoidance of unnecessary hospitalization.
 Mental Health,
Check Your Progress I11 Mental Disorders and
Mental Disability
Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) Enumerate the characteristics of community psychiatry.
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2.5 EXISTING MENTAL HEALTH SERVICES IN

INDIA
There are 48 Government mental hospitals in the country, which provide
19000 beds for mental patients. On the other hand there are around 3000
beds in private psychiatric hospital. There are around 5000 beds for mental
patients in general hospital psychiatric units in the country.

Total health beds in India = 8,70,161 (as per report of 1994-1995). Thus
there are 0.3 psychiatric bed in India for 10,000 population as compared
to 4.36 psychiatric beds for 10,000 population in the world.
National Mental Health Programme and Policy
The Central Council of Health and Family Welfare (India) formed an expert
group in 1980 which recommended about the implementation of National
Mental Health Programme. The group submitted the report in August 1982.
The National Mental Health Programme .appeared almost simultaneously with
the National Health Policy (1993). The objective of NMHP are as under:
1) To assure availability and accessibility of minimum mental health care for
all in the foreseeable future particularly to the most vulnerable and under
privileged sections of population.
2) To encourage application of mental health knowledge in general health
care and in social development.
3) To promote community participation in the mental health service development
and to stimulate efforts towards self-help in the community.

The following three aims specified in the NMHP in planning mental health
services for the country:
1) Prevention and treatment of mental and neurological disorders and their
associated disabilities.
2) Use of mental health principles in total national development to improve
quality of life.
3) Application of mental health principles in total national development to
improve quality of life.

Two strategies, complimentary to each other, were planned for immediate action:
1) Centre to periphery strategy: Establishment in all district hospitals,
with out-patient clinics and mobile teams reaching the population for
mental health services.
Health Information for 2) Periphery to centre strategy: Training of an increasing number of different
Social Workers
categories of health personal in basic mental health skills with primary
emphasis towards the poor and the underprivileged, directly benefiting
about 200 million people.

The mental health care service was envisaged to include three component
or sub programmes: treatment, rehabilitation and prevention.
A) Treatment Sub-programme

1) Multiple levels were planned. Village and subcentre level: Multi-

purpose works (MPW) and health supervisors (HS) under the supervision
of medical officer (MO) to be trained for:
i) management of psychiatric emergencies.
ii) administration and supervision of maintenance treatment for chronic
psychiatric disorders.
iii) diagnosis and management of grandma1 epilepsy, especially in children.
iv) liaison with local school teacher and parents regarding mental retardation
and behaviour problems in children.
.
v) counselling in problem related to alcohol and drug abuse.
2) Mmary health centre (PHC): Medical Officer aided by health supervisor
to be trained for:
i)' supervision of multi-purpose works performance.
ii) elementary diagnosis.
iii) treatment of functional psychosis.
iv) treatment of uncomplicated psychosocial problems.
v) management of uncomplicated psychosocial problems.
vi) epidemiological surveillance of mental morbidity.
3) District hospital: It was recognized that there should be at least one
psychiatrist attached to every district hospital which should have 30-50
psychiatric beds. The psychiatrist in a district hospital was envisaged to
devote only a part of his time in clinical care and greater part in training
and supervision of specialist health workers.
4) Mental hospital and teaching psychiatric units: The major activities
of these higher centre of psychiatric care include:
i) Help in the care of difficult cases,
ii) Teaching,
iii) Specialized facilities like occupational therapy units,' psychotherapy,
counselling and behaviour therapy.
B) Rehabilitation Sub-programme
The components of this sub-programmes include maintenance treatment of
epileptics and psychotics at the community levels and development of rehabilitation
centers at both the district level and the higher referral centers.
C) Prevention Sub-programme
Prevention is to be community based with the initial focus on prevention and
control of alcohol related problems. Later problems like addictiops, juvenile
delinquency and acute adjustment problems like suicidal attempts are to be
 addressed. The other approachks designed to achieve the objective of the Mental Health,
Mental Disorders and
National Mental Health Programme are: Mental Disability

1) Integration of basic mental health care into general health services.

I
2) Mental health training of general medical doctors and para-medical health
workers.
i
A number of activities were planned under action plan for implication of
national mental health programmes in 7th Five Year Plan, like community
1 mental health programmes in primary health care level in states and union
territories; training of existing primary health centre personnel for mental health
care delivery; development of a state level mental health advisory committee
and state level programme officer, establishment of regional centres of community
I mental health care delivery; formation of National Advisory Group on mental
health; development of task forces for mental hospitals and mental health
education for undergraduate medical students; involvement of voluntary agencies
in mental health care; identification of priority areas (child mental health,
public mental health education and drug dependence); mental health training
of at least one doctor at every district hospital during the next five years,
establishment of a department of psychiatry in all medical colleges and strengthen
the existing ones and provision of at least 3-4 essential psychotropic drug
in adequate quantity at the primary health centre level. District mental health
programe was started in 1995 as a component of national mental health
programme.

At the same time the National Mental Health Programme draft proposal for
the 10th Five Year Plan is also being prepared, with a plan to extend the
District Mental Health Programme to 100 districts.

The WHR-2001 has made the following ten recommendations for action:
1) Provide treatment in primary care
2) Make psychiatric drug available
3) Give care in the community
4) Educate the public
5) Involve communities, families and consumers
6) Establish national policies, programmes and legislations
7) Develop human resources
8) Link with other sectors
9) Monitor community mental health
10) Support more research

Check Your Progress IV

I) What are the objectives of National Mental Health Policy?

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Health Information for
Social Workers 2.6 LEGISLATIONS RELATED TO MENTAL
HEALTH
There are certain legal aspects and Act related to mental health, for example;
admission of a mentally ill person in a mental hospital, crime committed by
a mentally ill person, validity of mamage witness, will consents, right to vote,
drug dependence etc.
Indian Lunacy Act, 1912
The Indian laws related to mental disorders were based on British Acts such
as English Lunacy Act, 1890.

This act had 8 chapters. Chapter 1 defined a lunatic as "an indict or person
of unsound mind". In chapter 3 five categories of admission methods were
mentioned-voluntary, reception order with petition, reception order without
petition, inquisition (Judicial), and as a criminal lunatic.

There was a board of visitors appointed by Government for admission of voluntary

patients and their care, treatment and discharge (except in criminal cases.)
The Mental Health Act, 1987
The Mental Health Bill became the Mental Health Act-14 of 1987 on 22nd May
1987. It came in force by the orders of Government of India on April, 1993.

There are 10 chapters consisting of 98 sections. Chapter-I (Preliminary)

deals with the various definitions. The Act uses the term mentally ill persons
and defines it as a person who is in need of treatment by reason of any
.mental disorder other than mental retardation.

The term "mentally ill prisoner" is used instead of "criminal lunatic". The
'Psychiatric hospital' replaced the term 'mental hospital'.

Chapter-I1 provides establishment of Mental Health Authority to regulate and

coordinate mental health services at centre and state levels.

Chapter-I11 lays down the guidelines for establishment and maintenance of

psychiatric hospitals and nursing homes. There is a provision for a Licensing
Authority who will process applications for licenses. The license has to be
renewed every 5 years.

There is a provision for separate hospitals for:

(i) Those under the age of 16 years, (ii) those addicted to alcohol or
other drugs which lead to behavioural changes, (iii) mentally ill prisoners,
and (iv) any other prescribed class or category.
Chapter IV deals with the procedures of admission and detention in
psychiatric hospitals or nursing homes. The following methods has been
incorporated in this regard. (I) Voluntary admission (i) by patients request,
if he is major, (ii) by the guardian, if he is minor.
11) Admission under special circumstance. This is an involuntq hospitalization
when the mentally person does not or can not express his willingness
for admission. Admission is made on the relativelfriends request in writing
and medical officer in charge of the hospital is satisfied. The duration
of admission can not exceed 90 days.
 111) Reception order on application Mental Health,
Mental Disorders and
IV) Reception order without application on production of mentally ill persons Mental Disability
(e.g. wandering, dangerous, ill-treated or neglected) before magistrate.
1 V) Admission as in-patient after judicial inquisition
1 VI) Admission as a mentally ill prisoner.

In addition the magistrate can order detention of an alleged mentally ill person
for not more than 10 days pending report by medical officer.
i
Chapter V deals with the inspection, discharge, leave of absent and removal
of mentally ill persons.

1 Chapter VI deals with the judicial inquisition regarding alleged mentally ill
person possessing property custody of his person and management of his
property.

In case the patient is observed by court, incapable of looking after himself

and his property an order can be issued for the appointment of a guardian.

Chapter VII deals with the liability to meet the cost of maintenance of mentally
ill persons detained in psychiatric hospital or nursing home.

Chapter VIII is aimed at the protection of the following human rights of

mentally ill persons:
9 No mentally ill persons shall be subjected during treatment to any integrity
or cruelty.
ii) No mentally ill persons under treatment shall be used for the purposes
of research unless:
a) Such research is of direct benefit to him
b) A consent has been obtained in writing from the person or from
the guardian.
iii) No letters or communications sent by or to a mentally ill person shall
be intercepted, delayed or destroyed.

Chapter IX deals with the penalities and the procedure while chapter X
provides for miscellaneous section.
In addition the state mental health Rules -1990 and the control Mental Health
Authority Rules-1990 have also been passed by the Government of India
on December 29, 1990.

Check Your Progress V

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) Write a short note on the existing legislations related to mental health
in India:
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Health Information for
Social Workers 2.7 REHABILITATIONS, PREVENTION AND
PROMOTION IN THE AREA OF MENTAL
HEALTH
Rehabilitation
Prologue
There are a number of psychiatric patients suffering from various mental
disorders who are unresponsive to our traditional chemical treatment and
whose problems are elusive. Their dependency on family causes much burden.
The family feels ashamed but helpless. The society abhors them by labeling
and stigmatizing.

However the obvious and practical constraints in restoring the chronically

mentally ill persons to their premorbid personality profile inside the clinical
arena need not make us feel inadequate in offering our therapeutic endeavours.
Instead we should look for an alternative strategy to combat the problem
and lend our shoulders to share the burden of the families and society. The
strategy is Psychatric Rehabilitation. Due to cartain reasons it rarely finds its
real meaning in practice. The inputs are mostly human resources. These could
be mobilised only through intellegent manipulation, skillful taping and dedicated
work. The process often becomes a reality only when motivated team members
of mental health discipline work together, drawing their personal differences
for the sake of attaining common objectives which are conceived for our
psychiatrically disabled patients. This has to be done in order to hand them
over back to our society as its productive members. Thus enhancing their
self-esteem and healing their broken egos (G. Gopalakrishnan, President, the
World Association of Psychosocial Rehabilitation (Indian chapter).
Concept
The conservative concept of rehabilitation has conditioned our cognitive process
to restricting it to concrete appliance and job assignment for the physical
handicapped. Our clients with psychiatric disabilities are comparable with
those with physical disabilities who are crippled with diseases and deformities.
In addition, their potential is further hampered by amotivation, diminished
social skills and dormant psychopathology.

Therefore, rehabilitation also refers to the process desiglied to help the handicapped
individual making maximal use of their residual capacities and enable them
to obtain optimal satisfaction and usefulness in terms of themselves, their
families and their community. It strives to mantain dignity and self-respect
in life which is as independent and self fulfilling as possible.
Process
The concept, the ideas, principles and theories surrounding psychiatric rehabilitation
are put into practice by persons with unique skills through a special programme
and system supports. The over all mission of psychiatric rehabilifation is to
assist in the reintegration of the psychiatrically disabled into the community
and to maintain the ability of the erstwhile psychiatrically disabled to continue
functioning in the community. Rehabilitation goals are always linked with the
environment and therapy aims at improving the client's slulls generating the
resources needed by them to function in special environment. All our efforts
should be directed to ensure that the disabled persons possess the physical, Mental- Health,
Mental Disorders and
emotional and intellectual skills needed to live, learn and work in their own Mental Disability
environment. Dr. G. Gopalkrishnan indicated two aspects addressed by the
approach towards rehabilitation.
i) Develop particular skills in the'clients which they need to function in their
environments; and
ii) Develop the environmental resources needed to support and strengthen
the clients present level of functioning.

These skills when integrated into a "Comprehensive Rehabilitation Programme"

aiming at reinforcement and support for the use of these skills in the community,
are bound to have significant impact on our patients' psychiatric rehabilitation
outcome. It does required a professionally trained psychiatric social workers
and occupational therapist capable of assessing, tapping and teaching the
skills, that need to be taught as well as individualising the way in which the
skill are taught.
Principles
The whole process of psychiatric rehabilitation should work around the set
of principles as proposed by Anthony Cohen and Cohen (1982).
i) Client involvement is necessary in all phases of the rehabilitation process.
ii) Newly learned skill behaviours are usually situation specific.
iii) Each client must have individualized skill goals.
iv) The reduction of a client's personal and environmental discomfort does
not automatically result in improved client skill.
v) The restrictiveness of an environment is a function of the characteristics
of both the environment and the client.
vi) Increased client dependency can produce improved client functioning.
vii) Hope is an essential ingredient of the practice of rehabilitation.
Areas
The above discussion indicates that rehabilitation means restoration of the
handicapped to the fullest physical, mental, social, vocational and economic
usefulness of which they are capable. It is the process of enabling an impaired
person to renew old skills or to achieve new skills that will enable him to
live in the general society to the greatest extent that his particular condition
and circumstances will allow (Sharma 1986).The issue of psychosocial rehabilitation
is much more complex than physical rehabilitation as psychosocial rehabilitation
need a deep understanding of social milieu and culture in which psychosocial
rehabilitation services are to be organised. The rehabilitation process needs
different skills and expertise of psychiatric social worker with different handicapped
at different social milieu. However, a team approach is a must.
Prevention
Prevention is very important aspect of total management of psychiatrically ill
persons as well as the normal one. Our understanding of mental development,
mental health, and of the effects of stress has increased far faster than it has
been applied. Mental symptoms are still widespread and our knowledg is
only beginning to be systematically disseminated. Frustration is increasing due
to industrial development, urbanization, needs and ways of its fulfillment,
Health Information for unrealistic goals of life, parental attitude and behaviour in bringing up their
Social Workers
children, social and cultural changes, increase in demands of time, environmental
hazards, feeling of independency and generation conflict in the family and
community etc.

, We have to follow the following principles to make our mind healthy for
prevention from frustration, tension and mental deficiencies:
1) We try to keep our mind free from tensions, though it is not easy due
to sociopsychological and environmental situations but an individual is
required to avoid the reasons as much as he can.
2) If the situations creating tension are unavoidable the individual needs to
seek help from a competent person to get free from such tensions and
frustrations.
3) It is advisable to avoid complicated social situations by entertainments,
games, outing, yoga and other such recreational activities.
4) There must be creative thoughts and useful ideas in mind. The individual
. is required to have certain positive activities to think over in mind; but
it must be under self-control. The psychiatrist, social workers, psychologists
and other members of psychiatric therapeutic team are given proper
education and training for diagnosis, treatment, prevention and rehabilitation
of psychiatrically ill persons; they have to play an important role in the
prevention of psychiatric problems. They have to impart community health
education programmes in the urban and rural areas. There is social stigma
against the mental illness. The psychiatric social workers are expected
to launch particular programmes to remove the stigma and the misconceptions
widely accepted by the people that mental illness is a result of Witchcraft,
Goddess effect or magic etc. such misconceptions must be removed by
using certain methods of media. Similarly the mental health education
must include the information and facts of mental disorders such as etiology,
causes, place of treatment, available services etc. These methods will be
very useful in the prevention of mental problems.
Promotion of Health
Health promotion is the "process of enabling people to increase control over,
to improve health". It is not directed against any particular disease, but is
intended to strengthen the host through a variety of approaches (intervention)
the well known intervention in this area are:
i) Health Education
This is one of the most cost-effective intervention. A large number of diseases
could be prevented with little echo medical intervention,if people were adequately
informed about them. Our constitution states that "the extention to all people
of the benefit of medical, psychological and related knowledge is essential
to the fullest attainment of health". The targets for educational effects may
include the general public, patients, priority groups, health providers, community
leaders and decision-makers.
ii) Environmental Modifications
A comprehensive approach to mental health promotion requires environmental
intervention etc. Environmental interventions are non-clinical and do not involve
the physician.
L iii) Nutritional Intervention Mental Health,
Mental Disorders and
These comprise food improvement of vulnerable groups, child feeding programmes, Mental Disability
I
t
food satisfaction, nutrition education, etc., the factors which are also good

I I
for mental health.
iv) Life-style and Behavioural Pattern
The conventional public health measures or intervention have not been successful
in making life-style reforms. The action of prevention in this case, is one of
1 individual and community responsibility for health, the physician and in fact
each health worker acting as an educator than a therapists activity. It is of
paramount importance in changing the views, behaviour and habits of people.

Since health promotion comprises a broad spectrum of activities, a well-

conceived health promotion,programme would first attempt to identify the
"target-group'' or sick-individual in a population. Goals must be defined near
and alternative means of accomplishing them must be explored. It involves
"organizational, political, social and economic inte~entionsdesigned to facilitate
environmental and behavioural adaptations that will improve or perfect health.
Role of Social Service in a Total Institutional Process (The Functions
of ~ o c i dWorkers)
The community social worker is after all the lynch pin of community care.
Worker may be the first person to contact the patient and family in distress
and can then provide a range of services from intensive personal casework
to practical advice on total treatment plan. The social worker has an important
role to guiding the patient through the system of care. He can make a referral
to a psychiatrist or draw the patient to the attention of the psychiatric practitioner.

The committee indicated the functions of social workers in relation to institutional

process are given below:
1) Intake
The Social Worker:

0 interprets the hospital facilities and programmers to the patients and his
fdy.
ii) helps the family with problems that arise from the patients admission.
iii) formulates plan which might reduce the urgency of hospitalization or prevent
ill advise in admission.
iv) begins a relationships with the family which will facilitate their functions
in treatment and foster hospital plan.
2) Reception
The process of helping the patient to accept his hospitalization and to make
maximum use of the hospital therapeutic potential. In relation to this the social
Worker .
0 participates in explanation of hospital procedure.
ii) explains to the patient his role in maintaining the patients family and
communities.
3) Diagnosis
The process of analyzing the patient situation with a view to determining the
Health Information for cause of his disorder. This involves the collection and analysis of physical,
Social Workers
psychological and social data. The social worker obtains. the social history
which includes informations about the patient's past and present sound environment
and his response rate. The history constantly reformulated is a product of
a purposeful relationship with the patient, his family and other community
resources and is responsible in treatment as well as diagnosis.
4) Treatment
The process of applying remedial matters to restore the patients to normal
function. The psychiatrist may utilize the skill of psychiatric social work both
with the direct work and with those significant in his life in an effort to
strengthen the patients social relationship and to resolve environmental problem
that are contributing in the mental disorder.
5) Preconvenience
The process of helping the patient to make general and specific depress for
his release from the hospital. In relation to this, the social worker helps the
patient with his possible ambivalence concerning release his future relationship
with his family and with the community. Specifically he may help the patient
to formulate plans for living arrangement, employment etc.
6) Family Care
This is the placement of patient with family other than their whole care and
treatment. The social worker finds homes, interprets the patient's needs to
the family, supervises the arrangements to maintain the standards of care and
facilities to the patient's social adjustment.
7) Convalescent Care
The process of assisting the release of patient to make a satisfactory community
adjustment.

Here the social worker would on an extra-mural basis continue to offer help
with the same problems towards which pre-convalescent assistance was directed.

Check Your Progress VI

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) What are the major areas of rehabilitation required to rehabilitate the
mental patients ?
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2.8 LET US SUM UP

In this unit we have discussed the concept of mental health. Psychologist
defined as, "mental health is a relatively enduring state wherein the person
is well adjusted, has a zest for living and is attaining self-actualization or self-
realization". We also had a brief look on the Mental-Psychiatric Disorder, Mental Health.
Mental Disorders and
Neurosis-mild mental disorder whereby a person is in contact with reality Mental Disability
and his insight is intact.

Psychosis: Where a person is not in reality with contact and his insight is
not intact.

We also had a brief look at the problem in India, which shows that about
one-fifth of the patient with physical ailment are also facing psycho-social and
emotional problems of a degree taken into consideration.

We tried to understand the existing mental health services in India. We also

tried to understand the rehabilitation, prevention of mental illness and promotion
of mental health. In addition to this the social work intervention in mental
health care services i.e. intake, reception, diagnosis, treatment, preconvenience
familiy care and convalescent care, were also dealt with.

2.9 KEY WORDS

Behavioural Way of behaving or manner
Cognition The mental processes
Affect To have an effect on someone or something
Convalescent Regain health after illness
Legislation A group of laws, process of legislating
Adaptive To charge something
Mental Health Mental Health is the optimal development
and functioning of the individual consisting
with long-term well-being and progress of
the group
Community Psychiatry To make the community conscious and aware
about the management of mentally ill person.

2.10 SUGGESTED READINGS

Tred Gold, Roger and Wolff, Heinz (1975), UCH Handbook of Psychiatry,
Duckwoth.
Coleman (1964) (2000), Abnormal Psychology and Modern Life.
Ahuja, Niraj (2002), Comprehensive Book of Psychiatry.
Souvenir, 1st Cong. on current Trent in Psychosocial Rehabilitation and family
intervention (1997), NIMMANS, Bangalore.
Sharma, S.D. (1986), Psychiatric Rehabilitation Psychiatry in Primary Health
Care - PP 119-131.

2.11 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress I

1) The optimal development and functioning of the individual consistent with

the lnnu-term h ~ . i n uand nrnurenn nf the clrniin
Health Information for 2) a) He feels comfortable about himself.
Social Workers
b) He is able to meet the demands of life.
Check Your Progress I1
1) a) A person is free from strain and conflict.
b) He has the self identity.
c) He is well adjusted to the society.
d) The person who is mentally, emotionally and physically sound.
Check Your Progress I11
1) a) Multidisciplinary team approach.
b) Emphasis on prevention.
c) Avoidence of unnecessary hospitalization.
d) Treatment close to a patient in community based centre.
Check Your Progress IV

1) a) To assure availability of minimum health care for all.

b) To encourage application of mental health knowledge in general health
care and in social development.
c) To promote community participation in the mental health service
development.
Check Your ,Progress V

1) The Mental Health Bill became the Mental Act-14 of 1987. It came in
force by the order of Government of India on April 1993. There are
10 chapters consisting of 98 sections. This defines the mentally ill person,
their human rights, guidelines for psychiatric hospitals and nursing homes,
procedure of admission, inspection, discharge and judicial inquisition.
Check Your Progress VI
The major areas of rehabilitation are:
1) a) Social rehabilitation
b) Psychological rehabilitation
c) Vocational rehabilitation.
 UNIT 3 MAJOR HEALTH PROBLEMS:
COMMUNICABLE AND NON-
COMMUNICABLE DISEASES
Contents
3.0 Objectives
3.1 Introduction
3.2 Human Disease and Kinds of Disease
r 3.3 Communicable Diseases
3.4 . Non-communicable Diseases

3.6 Key Words

3.7 Suggested Readings
3.8 Answers to Check Your Progress

3.0 OBJECTIVES
In the Indian context, which does not largely vary from the global context,
some of the communicable diseases and the newly emerging menace of the
non-communicable diseases pose a serious threat. This unit aims at understanding
these problems. This unit will help to know about the basic aspects of the
health problems and the various methods that are necessary as well as important
employed in tackling the health problems both at an individual and social
level. ~his'unitdeals with each of the major diseases. The unit will familiarise
the student with every disease by the magnitude of the problem it poses to
both Indian population as well as the global population. This follows by
diagnosis and treatment of the disorder and preventive and the promotional
measures that are to be taken. National health programmes that combat the
diseases at a large scale have also been included in the unit. After reading
this unit you will be able to:
I . understand major health problems and diseases;
delineate communicable diseases from non-communicable diseases;
describe each of the major diseases and the magnitude of the problem
1 it poses; and
know the Government's National programmes on the effort to combat
diseases.

3.1 INTRODUCTION
India is a country that has a population of one-sixth of the humanity living
in the world. Hence, any problem to people of India is the problem of
humankind. Health is one of the major indicators that are historically used
to understand and acknowledge the well-being of any society. The health of
a nation can best be judged by the health status of its people. Diseases are
one among the major factors that determine the health status of people. This
unit will look at human disease and its kinds. Some diseases pose a major
health problem in India and in other parts of the world. These are classified
into communicable and non-communicable diseases. The Indian government
Health Information for implements National Health Programmes to fight against each of the important
Social Workers
diseases respectively. We shall also deal with those programmes and suggest
further measures to be taken.

3.2 HUMAN DISEASE AND KINDS OF DISEASE

A disease is a condition that impairs the proper function of the body or of
one of its parts and also the social and economic roles of people. Every
living thing, both plants and animals, can succumb to disease. Hundreds of
different diseases exist. Each has its own particular set of symptoms and
elements, clues that enable a physician to diagnose the problem. A symptom
is something patient can detect, such as fever, bleeding, or pain. A sign is
something a doctor can detect, such as swollen blood vessel or an enlarged
internal body organ.

Every disease have causes and these include the biological and social aspects,
although the causes of some remain to be discovered. Every disease also
displays a cycle of onset, or beginning, course, or time span of affliction,
and end, when it disappears or it partially disables or kills its victim. An
epidemic disease is one that strikes many persons in a community. An endemic
disease refers to the constant presence of a disease within a geographic area
or a population without importation from outside and the occurrence is within
the usual or expected frequency. An acute disease has a quick onset and
runs a short course. A chronic disease has a slow onset and runs sometimes
years-long course.
Kinds of Disease
Infectious or communicable diseases are those that pass between persons
by means of airborne or waterborne droplets from cough or sneeze. Tiny
organisms such as viruses, bacteria, fungi, and worms can produce infectious
diseases. Whatever the causative agent, it survives in the person it infects
and is passed on to another. Sometimes, a disease-producing organism gets
into a person who shows no symptom of the disease. The symptomatic
carrier can then pass the disease on to someone else without even knowing
he has it. Various agents such as virus, bacteria, fungi, protozoa, and worms
cause infectious diseases. (a) Diseases caused by Bacteria: Cholera, Diphtheria,
Tuberculosis, Leprosy, Tetanus, Typhoid, Plague, Whooping Cough, Sore
Throat, Pneumonia, Bacillary Dysentery, Gonorrhea, Syphilis and Botulism.
(b) Diseases caused by Viruses: Chickenpox, Measles, Poliomyelitis, Rabies,
~ G m p sInfluenza,
, Hepatitis, Herpes, Vial Encephalitis, and AIDS. (c) Diseases
caused by Fungi: Ringworm, Athlete's foot, Dhobi itch. (d) Diseases caused
by Protozoan: Amoebiasis, Malaria, Sleeping sickness, Kalazar, Diarrhoea.
(e) Diseases caused by Helminthes or Worms: Filariasis, Tapeworm and
Hookworm transmission.

Non-infectious or non-communicable diseases are caused by malfunctions of

the body. These include organ or tissue degeneration, erratic cell growth, and
faulty blood formation and flow. Also included are disturbances of the stomach
and intestine, the endocrine system. Some diseases can be caused by diet
deficiencies, lapses in the body's defense system, or a poorly operating nervous
system. Non-communicable diseases (NCDs) include cardiovascular, renal,
nervous, and mental diseases, musculo-skeletal conditions such as Arthritis
and allied diseases, chronic non-specific respiratory diseases such as Chronic
Bronchitis, Emphysema, and Asthma. Furthermore non-communicable diseases
include permanent results of accidents, senility, blindness, cancer, diabetes, Major Health Problems:
Communicable and
obesity, and various other metabolic and degenerative diseases and chronic NO^-communicab~e
results of communicable diseases. Diseases

Deficiency diseases also part of non-communicable diseases are due to deficiency

in the diet of a nutrient and they can be generally cured by providing the
missing nutrients.

Degenerative, diseases occur due to malfunctioning of some organ or organ

system in the body. The incidence and prevalence of degenerative diseases
in non-communicable diseases is observed to be growing alarmingly. This
transition is principally due to a combination of demographic and lifestyle
changes which result from socio-economic development.

Check Your Progress I

Notes: a) Space is given below for your answers.
b) Check your answers with those given at the end of this unit.
1) What is a disease?
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2) What are symptoms and signs?
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$

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3) What is a communicable disease? List some of the communicable
diseases along with their causative agents.
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3.3 COMMUNICABLE DISEASES

Tuberculosis
Tuberculosis is a serious public health problem in India. India accounts for
nearly one-third of the Global tuberculosis burden. Every year, approximately
22 lakhs new cases are diagnosed in the country of which approximately 10
lakhs are highly infectious. An infectious case on an average infects 10-15
persons in a year. One person dies of tuberculosis in India every minute and
more than 1.000 ~ e o ~everv
l e dav. In India. tuberculosis kills 14 times more
Health Information for people than all tropical diseases combined, 21 times more than malaria and
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400 times more than leprosy.

Tuberculosis is a major [Link] social and economic development. pvery

year, the direct and indirect costs of tuberculosis to the country amount to
Rs. 12,000 crores. Every year, 300,000 children are forced to leave schools
because their parents have tuberculosis, and 100,000 women lose their status
as mothers and wives because of the social stigma of tuberculosis. HIV and
multi-drug-resistant tuberculosis threaten to make this situation even worse.

Tuberculosis is a specific infectious disease caused by an intercellular parasite

known as M. tuberculosis. The disease primarily affects lungs and causes
pulmonary tuberculosis. It can also affect intestine, meninges, bones and joints,
lymph glands, skin and other tissues of their body. The disease is usually
chronic with varying clinical manifestations. The disease also affects animals
like cattle; this is known as "bovine tuberculosis", which may sometimes be
communicated to man. However here we will focus on pulmonary tuberculosis,
the most important form that affects man.
Social Factors
Tuberculosis is a social disease with medical aspects. The social factors
include many non-medical factors such as poor quality of life, poor housing,
and overcrowding due to population density, under nutrition, lack of education,
early marriages, lack of awareness of causes of illness, etc. All these factors
interrelate and contribute to the occurrence and spread of tuberculosis. In
fact, tuberculosis began to decline in the western world long before the
advent of chemotherapeutic drugs. This has been attributed to improvements
in the quality of life.

The control of Tuberculosis: The control of any infectious disease has three
components ngnely prevention, promotion and curative. The preventive component
is the BCG vaccination. However, the preventive component becomes successful
in the end unless it combined with the promotion component that targets the
social factor, i.e., improving the quality of life. The third component, the
curative aspect includes proper case finding through standardized diagnostic
pattern and treating.
Diagnosis
The symptoms of tuberculosis are:
a) persistent cough of about 3 or 4 weeks
b) continuous fever
c) chest pain
d) haemoptysis (expectoration of blood or bloody mucus)

Any person who voluntarily attends any health centre with these symptoms.
should be taken for a sputum-smear examination. The sputum c u l m examination
will yield the results that reveal the status of the patient and if tested tuberculosis
positive, chemotherapy is administered with anti-tuberculosis drugs. Patient
compliance is critically important; the patient must take the correct drugs at
thecorrect dosage for the correct length of time. Incomplete treatment puts
the patient at the risk of relapse and the development of bacterial resistance
and, the community at risk of infection with resistant organisms.
 Treatment Major Health Problems:
Communicable and
Directly Observed Treatment Short-Course (DOTS) is a five-point strategy Non-Communicable
I Diseases
including the components of political and administrative commitment, diagnosis
I primarily through microscopy, uninterrupted supply of good quality drugs,
direct observation of treatment and monitoring and supervision to track diagnosis,
t
progress and outcome of tuberculosis. DOTS, if implemented correctly, can
I
prevent multi-drug resistance. DOTS is also effective among ~ 1 ~ : i n f e c t e d
I patients. The challenge in the years ahead is to maintain the pace and quality
of the programme while achieving national coverage so that tuberculosis is
no longer a significant public health problem in India.
Combating ~ b e r c u l o s i s

I India has long been at the forefront of the global battle against tuberculosis.
Pioneering studies at the Tuberculosis Research Centre, Chennai and the
I National Tuberculosis Institute, Bangalore established the principles of tuberculosis
control, which are followed even to this day the world over. These principles
include the effectiveness of ambulatory treatment of tuberculosis, the effectiveness
of intermittent treatment regimens, the necessity of direct observation of treatment
by a trained individual who is not a family member, the usefulness and practicability
of microscopy as a diagnostic tool among patients reporting to health facilities
and the crushing burden of tuberculosis in our society.

To control TB, National Tuberculosis Control Programme (NTCP) was launched

in the country in 1962. Since the Programme did not make any significant
epidemiological impact in its almost three decades of implementation, it was
reviewed by an Expert Committee in 1992. Based on the findings and
recommendations of the ~e;iew, the Government of India evolved a revised
strategy with the objective of curing at least 70 per cent of such patients.
Revised National TB Control Programme (RNTCP)
Revised National TB Control Programme (RNTCP) using DOTS strategy
was launched in India on 26 March 1997..Overall performance of the RNTCP
for the country has been excellent with curdtreatmentcompletion rate consistently
above 80 percent and death rate reduced by more than 50 per cent. The
aim is to bring the entire country under RNTCP coverage by 2005 in order
to meet the global targets of TB control.

AIDS is the late stage of infection with the Human Immunodeficiency Virus
(HIV). AIDS can take around 7-10 years to develop after infection with
HIV. HIV is transmitted through semen and vaginal fluids, infected blood and
blood products, infected mother to her baby-before birth, during birth or
through breast milk.

The global situation of the disease in 2000 A.D. was an indication of a

looming epidemic. People living with HIVIAIDS are 36.1 million and there
has been an incidence of 5.3 million new HIV infections. Moreover, the
disease has left three million people dead out of them 1.3 million were women.
Almost a third of all people with HIVIAIDS are between the ages of 15
and 24-about 10 million.

The Indian Scenario: The first case of AIDS in India was reported in 1986
from Chennai. Since then there has been an increase in the number of HIV
Health Information for infections over the years. As reported to National AIDS Control Organisation
Social Workers
(NACO) by 3 1" Dec. 1998, India had a cumulative 7 1400 HIV positive
persons from 3.2 million people who have been screened, with a seropositivity
rate of 22.10 per 1000. In Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra,
Manipur, Mizoram and Nagaland, the disease rate is high among the Indian
states. A host of opportunistic infections is seen in increasing numbers in the
AIDS patients. Tuberculosis is the major opportunistic infection accounting
for about 62% of the total cases. Migration of labour, low literacy levels
leading to low awareness, gender disparities, sexually transmitted infections
and reproductive tract infections among the population and some of the factors
attributed to the spread of HIVIAIDS in India.

Recent surveys in 34 countries found young people, particularly girls, know

little about HIVIAIDS. They fail to realize that a person who looks healthy
and still can be infected with the virus. Those who do recognize their risks
do not know how to protect themselves from infection.
Causes of AIDS
1) Infected sexual fluids, saliva and blood;
2) Infected needles;
3) Multiple partners;
4) Infected mother to her baby before birth.

HIV can be passed on by infected people because the virus is present in

the sexual fluids, saliva, and blood. If infected blood or sexual fluid gets into
your blood, then you will become infected. If a manlwoman with HIV has
sex without a condom, infected fluid could pass into their body. This can
be so small that you do not know about it. Other sexual practices are also
equally at risk of infection. If there is any contact with blood during sex,
this increases the risk of infection. Recent researches have found that deep
kissing where saliva is exchanged can infect the partner.
HIV is not spread by drinking water or eating food from the same utensils-
cups, glasses, plates, used by infected person, 2. Sharing toilets or shaking
hands, 3. Hugging, or facial kissing, 4. Donating blood, 5. Working with
people who are HIV infected, 6. Massage and rub each other's bodies,
7. Swimming in pools used by people with HIV/AIDS. (HIV is not spread
by sitting next to someone who is infected, coughing, or sneezing, public
transportation, public telephones, restaurants, air). But if you have any cuts
or sores on your hands make sure they are covered with plasters (band-
aids or bandages).

HIVIAIDS could be avoided through:

1) Use of condoms,
2) Use of disposable syringes, and
3) By avoiding multiple sexual partners.
Diagnosis
HIV infection is diagnosed based on blood tests using three different ELISAI
Rapid tests using different antigen preparation. AIDS cases are diagnosed
based on two different ELISAlRapid tests on different antigens and presence
of AIDS related opportunistic infections.
Western Blot test is used for confirmation of diagnosis of indeterminate ELISA Major Health Problems:
Communicable and
tests. ELISAJRapid test for HIV diagnosis is being carried out all over the NO^-communicable
country. Further, all Microbiology departments in the Government medical Diseases

colleges will provide HIV testing facilities. Moreover, they will be known
Voluntary Blood Testing Centers.
National Aids Control Programme
The Government of India addresses HIVIAIDS epidemic, simply not as a
health problem, but as a developmental issue, which impinges on various
economic and social sectors of government and non-government activity. The
programme has two key objectives: (a) Reducing the rate of growth of HIV
infection in India (b) strengthening India's capacity to respond to HIVIAIDS.
The programme has the following components: (i) Priority targeted interventions
for groups at high risk; (ii) Preventive interventions for the general community.
Under this component, the main activities are: (a) Conduction of educational
and awareness campaign; (b) Promotion of voluntary counselling and testing
facilities; and (c) Blood safety and prevention of occupational exposure.
(iii) Low-cost AIDS care to people living with HIVIAIDS; (iv) Institutional
strengthening; and (v) Inter-sectoral collaboration.

In order to track the progress of HIV epidemic in the country, NACO initiated
nation-wide sentinel surveillance in August-October 1998. Since then, nationwide
sentinel surveillance rounds are being conducted on regular basis. Estimates
based on sentinel surveillance data indicate that there is no upsurge in spread
of HIV infection..
Leprosy
History
Leprosy is probably the oldest disease known to humankind. The word leper
comes from a Greek word meaning scaly. In India, leprosy is known since
ancient times as kustha roga and attributed to punishment or curse from
God. During the middle ages, leprosy was widespread in almost all countries
of the world. Thereafter, it declined slowly in many European countries, partly
due to strict isolation and partly due to improvements in the standard of living
and the quality of life of the people.

Modem-day leprosy dates from 1873 when Hansen of Norway discovered

M. leprae. For long years, there was no effective remedy for leprosy. It
seemed that the only way to handle the patients was to isolate them for life
in special institutions. The introduction of sulphone drugs in the treatment of
leprosy in 1943 marked the beginning of a new era - the era of case-finding
and domiciliary treatment. Later decades witnessed development in the ways
of treating and controlling the disease. The development of the advanced
treatment process has been useful in drastically reducing the disease prevalence
in most of the countries. The disease has been indeed eliminated from most
of the countries. The disease is prevalent currently in fifteen countries and
especially out of which only six countries have the highest concentration of
the disease burden. They are India, Brazil, Myanmar, Madagascar, Nepal,
and Mozambique. Among these countries, India alone represents 64 per cent
of prevalence and 78 per cent of new case detection worldwide. Although
leprosy is widely prevalent throughout India, its distribution is uneven. Leprosy
is endemic in states of Bihar, Jharkhand, Chattisgarh, Uttar Pradesh, West
Health Information for Bengal, and Madhya Pradesh. These states contribute about 64 per cent of
Social Workers
the country's case load. State of Bihar alone contributes about 24 per cent
of the caseload.

Leprosy is caused by M. leprae. They are acid-fast bacilli and occur in the
human host both intracellularly and extracellularly. The bacteria could manifest
in an individual and exhibit after a long and benign incubation period of five
years. The disease infects people from already infected people. It is widely
accepted that nose is a major portal of exit of the bacteria when infected
people sneeze or blow their nose, it also exits through other parts of the
body that are either ulcerated or broken skin or through hair follicles. The
bacteria could live in the environment in dried nasal secretions for at least
9 days and in moist soil at room temperature for 46 days. The risk of
transmission is also governed by spaces that are overcrowded, less ventilated,
dark, and unhygienic. The risk factors that cultivate and spread disease qualifies
it to be called a social disease. Poverty and poverty related circumstances
create the risk factors that help the disease to spread and infect. Moreover,
the social stigma attached to the disease ostracizes the patients and the already
poor individual who is infected is denied a chance to get proper treatment
and rehabilitation. In addition, this allows the individual to be yet another
potential infector thereby the vicious circle of the disease is continued. Two
things stand on the way of the disease elimination. First is creating social
awareness among the public and try to remove the social stigma enabling
the role of modern medicine to combat with the problem. Second is the
overall socio-economic development that entails the elimination of poor and
unhygienic living conditions and the high nutritional status of the individuals
in the society that gives a general resilience to all communicable diseases like
those that the histories of Europe and America have demonstrated.
Diagnosis
The disease is diagnosed through clinical examination and confirmed through
a bacteriological examination. The clinical examination includes analyzing the
family history for the disease. Other aspects of the clinical examination are
involved with physical examination of the symptoms that appear in thickening
or tenderness of specific nerves, hyper-pigmented patches, loss of sensation
to stimuli in the skin patches and paralysis of the muscles of the hands and
feet, leading to the disabilities or deformities. In order to confirm the detection
that is gathered through clinical examination it is necessary to have bacteriological
examination of skin and nasal smears. The tests confirm the disease and
demonstrate the stage of disease hence the necessary medication could be
administered.

It is estimated that approximately 25 per cent of the patients who are not
treated at an early stage of disease develop anaesthesia (absence of sensation)
andlor deformities of the hands and feet. As a single disease entity, leprosy
is .one of the foremost causes of deformities and crippling. Rehabilitation is
therefore an integral part of leprosy control. It [Link] as soon as the
disease is diagnosed. The cheapest and surest rehabilitation is to prevent
physical deformities and social and vocational disruption by early diagnosis
and adequate treatment. The measures that are taken in this direction are
known as 'preventive rehabilitation'. The approach to rehabilitation should
therefore begin with preventing debilitation. We should never allow debilitation
to take place and afterwards take up the uphill task of [Link]
 measures require planned and systemic actions - medical, surgical, social, Major Health Problems:
Communicable and
educational, and vocational -consistently over years with sustained counselling NOD-communicable
and health education for training or retraining of the individual to the highest Diseases

possible level of functional ability. This requires the coordinated efforts by

the Departments of Health, Education, and Social Welfare along with various
voluntary organisations.
National Leprosy Eradication programme

I The National Leprosy Eradication Programme (NLEP) was launched in 1983

as a hundred per cent centrally sponsored scheme. The Programme was
expanded with World Bank assistance from 1993-94. The second phase of
World Bank supported NLEP Project was started from 1st April, 2001 for
a period of three years. The objective is to achieve elimination of leprosy
as a public health problem by the end of 2003-04 thereby reducing the
caseload to less than 1110,000 population. Till March 2002, 13 states, viz.,
Nagaland, Punjab, Haryana, Sikkim, Himachal Pradesh, Meghalaya, Tripura,
Mizoram, Manipur, Jarnmu and Kashmir, Rajasthan, Kerala and Assam have
reached level of elimination. 558 District Leprosy Societies have been created
to provide free Multi-Drug Therapy (MDT) Services in all the districts of
the country. About 288 Voluntary Organisations in coordination with NLEP
are supplementing the Government efforts in the fight against leprosy. The
Government of India provides grant-in-aid to the NGOs engaged in the survey,
education, and treatment activities in the population. Anti-leprosy drugs are
provided free to all StatesIUTs. By March 2002, 4.4 lakh patients are on
record in the country, and 99.5 per cent of them are getting MDT. The
prevalence of leprosy has been reduced from 57 per 10,000 population in
1981 to 4.2 per 10,000 population by March 2002.

Check Your Progress I1

Notes: a) Space is given below for your answers.
b) Check your answers with those given at the end of this unit
1) What are the symptoms of Tuberculosis and how is it diagnosed?
.....................................................................................................
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.....................................................................................................
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.....................................................................................................
2) How does HIVIAIDS spread in a population and recount some of
the common myths on HIVIAIDS infection?
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
3) What are the tests that are done to diagnose HIVIAIDS in a person?
.....................................................................................................
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Health Information for
Social Workers .....................................................................................................
.....................................................................................................
.....................................................................................................
4) Why is the disease Leprosy called a social disease?
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3.4 NON-COMMUNICABLE DISEASES

Cancer
Cancer is a general term used to describe over 200 individual diseases.
These diseases progress differently over a period of time but share certain
characteristics that include development within any tissue of a malignant growth
derived from abnormalities of the host. The abnormal cells grow without any
control, invade through normal tissue barriers, spread to local and distant
sites within the host, and reproduce indefinitely. The masses of such abnormal
cells formed and spread in this way lead to the death of the host if not
eradicated. The incidence of cancer is rising steadily.
Epidemiology *
Estimates show that the number of new cancer cases in India is about 1,000,000
per year. The most common form of cancers seen in the males include cancers
of the lung, stomach, esophagus, mouth, larynx; hypo pharynx, tongue, prostate,
urinary bladder and uterus.

In females, traditionally cancer of the cervix was the leading cancer, but of
late, especially in the urban areas, cancer of the breast seems to be, becoming
a major problem. Cancers of the mouth are commonly seen in both the males
and the females. Cancers of the larynx, hypo pharynx, esophagus and stomach
are seen more in men than compared to females, while cancer of the gall
bladder is seen more often in women.
Etiology
Cancer has been classified as a disease of life-style. It has been noted that
a majority of the cancers are caused by living habits (smoking, alcohol consumption,
and diet) and environmental factors. Tobacco cause about 35% of all cancer
deaths and at least 90% of lung cancer deaths. Alcohol indirectly causes
about 5% of cancer deaths worldwide. Solar Ultraviolet Radiation (UV-B)
is clearly related to an increase in the risk of developing skin cancers.

Dietary Substances are associated with cancers: Fat causes Breast and Colon
cancers, ~ i g Total
h Caloric Intake causes Breast, Endometrium, Prostate,
Colon and Gall Bladder cancers, Animal protein (particularly red meat) causes
Breast, Endometrium and Colon cancers, Salt-cured Smoked or Charred
Foods cause Oesophagus and Stomach cancers, Nitrate and Nitrite Additives
 cause Intestine cancer. Body Habits and Exercise are also causes for cancer Major Health Problems:
Communicable and
risks. Obesity is associated with an increased risk [Link] cancer in women Non-Communicable
over 40 years. Diseases

Chemical and Microbial Agents such as Drugs, Hormones, Microbes and

Viruses are risk factors for cancer. Cancers are also caused due to various
Genetic factors.

Occupational cancers are caused due to the prolonged exposures to various

hazardous chemical agents. Bladder cancers, cancers of the lung, trachea and
bronchus (amongst asbestos miners), skin cancers, etc. are some of the known
cancers caused due to occupational risks.
Characteristics of Cancer Cell

? Under usual circumstances, stem cell populations in body tissues can undergo
one of the three changes: They can differentiate to mature forms as constituent
component cells of the tissue of residence. They can self-replicate. They can
die. With mutation, a fourth change can take place reproduction to a new
form and they form the cancer cells.
Diagnosis
The diagnosis of cancer is required to be conformed by both an examination
of a biopsy using blood tests, x-ray studies, radio nuclide scans and using
C.T. Scans and M.R.I. Scans. The cancer is staged according to staging
I
system, the Tumour Node Metasis system being widely used. On diagnosing,
i the stage of disease is understood and treated accordingly.
Treatment
Cancer treatment consists of surgery, radiation therapy, and systemic therapy
using chemotherapy and hormones. These modalities may be used either singly
or in combination. Developments and advances in imaging, coupled with better

i
understanding and knowledge of the natural history of various cancers have
led to the era of multi-modality therapy, which has changed the cancer treatment
scenario.
Access to Cancer Care
A major-problem facing quality cancer care in India is the access to care
for the patients of cancer. Inadequate education and lack of adequate treatment
facilities are major hurdles.
Disease Care and Intervention
As cancer has a high rate of mortality unless detected and treated early, the
emphasis is on prevention, early detection of cases and augmentation of treatment
facilities in the country. Under the National Cancer Control Programme the
following schemes are under implementation: (i) Development of Regional
Cancer Centres; (ii) Development of Oncology Wing in Medical Colleges;
(iii) Setting up of Cobalt Therapy Units; (iv) District Cancer Control Programme;
and (v) Health education and early detection activities. Nineteen Regional
Cancer Centres in different states have been recognized as Referral and
Research Centres. '

A Modified District Cancer Control Programme has been initiated in eihar,

Uttar Pradesh, Tamil Nadu and West Bengal. Nearly ten lakh women in these
health Information for states are being approached for generating awareness and collection of data
Social Workers
about cancer and other diseases.
Diabetes
Diabetes cases worldwide are estimated to be more than 150 million. WHO
predicts it to double by 2025 and to reach 300 million cases. Developing
regions, particularly Asia and Africa are expected to endure the most of the
increase. Studies show that the population in India has an increased susceptibility
to diabetes. It is estimated that during 1997 about 102,000 persons of diabetes
in India.

The rising prevalence of diabetes in developing countries is closely associated

with industrialization and socioeconomic development. The major determinants
for projected increase in the number of diabetics in these countries are population
growth, age structure, and urbanization. Wlth the rise in the urbdrural population
ratio in all regions, and growing obesity among urban dwellers, diabetes will
increasingly concentrate in the urban areas.

Most alarming, however, is the spread of diabetes across age banier, especially
among the teenagers is extremely worrying. Diabetes is a chronic disease in
which the body does not produce or properly use insulin, hormone needed
to convert sugar, starches, and other foods into energy necessary for daily
life. Both genetics and environment appear to play roles in the onset of
diabetes. The guidelines for diagnosing diabetes are lowering the acceptable
level of blood sugar from 140 mg. of glucoseldeciliter of blood top 126 mgl
deciliter, testing all adults 45 years and older, .and then every 3 years if
normal, and testing at a young age, or more frequently, in high-risk individuals.
Detection at an earlier stage will help prevent or delay complications of
diabetes.

There are 2 major types of diabetes (a) Type 1 (formerly) known as insulin
dependent. The body produces very little or no insulin; disease most often
begins in childhood or early adult hood. People with Type 1 diabetes must
take daily insulin injections to stay alive; (b) Type 2 (formerly) known as
non-Insulin dependent. The body does not produce enough or cannot properly
use insulin. It is the most common form of the disease (90-95% of cases
in people over age 20) and often begins later in life,

Kinds and warning signs of Diabetes Type 1, Diabetes (usually occurs suddenly):
frequent urination; unusual thirst; extreme hunger; unusual weight loss: extreme
fatigue; irritability.

Type 2 Diabetes (occurs less suddenly): any type 1 symptoms; frequent

infections; blurred vision; cuts/bruises slow to heal; tingling1 numbness in hands
or feet; recurring skin, gum, or bladder infections.
Complications of Diabetes
More than half of all individuals with diabetes do not know that they have
the disease until one of its life-threatening complications occurs. Potential
complications include:

Blindness: Diabetes is the leading cause of blindness in people aged 20-

74. Each year many people lose their sight because of diabetes.
 Major Health Problems:
Kidney disease: Ten per cent to twenty one per cent of all people with Communicable and
diabetes develop kidney disease. Non-Communicable
Diseases

Amputations: Diabetes is the most frequent cause of traumatic lower limb

amputations. The risk of a leg amputation is 15 to 40 times greater for a
person with diabetes.

Heart disease and stroke: People with diabetes are 2 to 4 times more
likely to have heart disease. In addition, they are 2 to 4 times more likely
to suffer a stroke.
Combating Diabetes
Diabetes could be either prevented or controlled through the practice of
normal healthy diet regularly and through altering certain life-styles such as
obesity, smoking, and drinking. Various awareness and educational programmes
are necessary to combat the disease at a mass level. People who suffer from
diabetes through early detection could easily control the disease if they undergo
the prescribed medications and follow the necessary instructions. Regular
self-care and medical care greatly helps in controlling the disease. The disease
needs far more research both at epidemiological and clinical levels. Specialized
clinics and voluntary agencies need to be established for the treatment and
management of the patients who are suffering at a more chronic level. There
should be local and national registries for diabetics so that intensity of the
problem could be understood to combat promptly.
' Heart Diseases
Cardiovascular diseases are conditions in which the heart andlor blood vessels
have undergone pathological changes. Diseases of the heart can involve its
muscles, valves, pericardium, blood vessels (especially the coronary arteries),
or the electrical activities. Cardiovascular diseases are the cause of much
morbidity and mortality. Heart diseases can be broadly classified as congenital
(those present at birth) or acquired (which appear after birth).
Burden of Heart Disease
I
~ l o b i burden:
l In 2001, 17 million people died of cardiovascular disease.
More than 7.3 million people died of heart attack. There are about 600
I million patients with hypertension in the world. There are 12 million young
adults and children with rheumatic heart disease of whom 8 million are of
school going age.

Indian scenario: Health statistics in India as in any other developing countries

are not easily available and if available it lacks precision and accuracy. Available
data gives the following information.

The incidence of coronary artery disease has been linearly increasing from
4% in 1960s to nearly 10% now. '1n 1980 coronary bypass surgery accounted
for less than 10% of all cardiac surgeries; today it is more than 60% of all
cardiac surgeries. Every year almost 25000-bypass surgeries are done.
Hypertension, which is one of the important risk factors for cardiovascular
disease, is also on the increase in India. Compared to the 1-3% incidence
in 1950s, hypertension is now seen in 10-20% of the urban and 7- 12% of
the rural Indian population.
Health Information for Let us begin with the heart diseases and various heart conditions that are
Social Workers
present at birth.

Congenital heart diseases: These develop during the growth of the embryo
in the uterus of the mother. The development of modern medicine allows
diagnosing these diseases even before birth. Most of the conditions are very
simple that do not require any treatment, whereas some are very complex
and serious complications involve surgery or non-surgical methods to cure.
However, some conditions do not have any complete cure.
Treatment
The treatment of congenital diseases has become easier and simpler unlike
in the past. The high level of morbidity and mortality level these diseases
.have caused in the past has become reduced. The major reasons apart from
that of the advancement of modern medicine are the increasing acceptance
of the small family norm and awareness about the availability of corrective
surgery for congenital diseases and the relative financial capability of the small
families to meet the high costs that involve the treatment as unlike in the past.

Now we will look into the diseases that are acquired:

Rheumatic Fever and Heart Diseases
Rheumatic fever is a disease that affects children of school going age. It
follows infection of the throat with bacteria called streptococci. About two
weeks after the infection, the child develops pain and swelling of multiple
joints (affecting one after another) along with fever. In about half of these
cases, heart is also affected. Later these children may have heart diseases
of the heart valves-either narrowing or leak.
Treatment
Early diagnosis of the problem and administering the prescribed drug regiment
completely cures the problem. This could be practiced at mass level through
regular health check-ups in all schools. The high prevalence of the disease
and subsequent heart diseases in India urges a more comprehensive and
efficient of implementing the school health programmes so that the problem
could be controlled at an early stage without carrying on the physical, emotional
and financial sufferings to the advanced stage.
Coronary Artery Disease
Coronary heart disease is usually seen in the adult and aged population. The
incidence and prevalence of coronary heart disease has increased as measured
through morbidity and mortality rates. The increases in life expectancies,
unlike in the past, due to socio-economic development and the life-styles
influenced due to increased industrialization and urbanization are widely considered
to be important factors for the coronary heart disease.

Coronary arteries are the blood vessels that carry oxygenated blood to the
muscles of the heart. As the age advances narrowing of these arteries occur
this in medical terms is known as atherosclerosis. Though it is a normal
process, it is relatively slow. As mentioned in the earlier paragraph certain
factors can accelerate the n d ~ o w i n gof the arteries e.g. high cholesterol in
blood (life-style), high blood sugar (diabetes mellitus), high blood pressure
(hypertension), and smoking (life-style) etc.
 Major Health Problems:
When the narrowing of the arteries reaches a critical stage, the patients develop Communicable and
disease manifestation. There is a severe squeezing pain that originates from Non-Communicable
Diseases
the centre of the front of the chest and then may spread to other parts like
arms, throat, lower jaws etc. This condition is known as myocardial infraction
(heart attack) and if emergency aid and medication could not be provided
it might prove to be fatal to the patient.
Hypertension
Hypertension, which is otherwise known as high blood pressure, is a major
cardiovascular disease. The disease is chronic and it could cause heart attack,
heart failure, stroke, kidney failure etc.
t The left ventricle pumps blood to aorta, which carries the pure blood to all
parts of the body. To maintain the blood flow there should be a certain
amount of pressure in the blood vessels. This pressure inside the arteries is
called blood pressure. Two vessels are recorded-mentioned in the form of
a fraction e.g. 120180. The value recorded above (numerator) is called systolic
pressure and the one recorded below (denominator) is the diastolic pressure.
Upper limit of normal blood pressure for an adult is 139189; when the value
exceeds this limit (on multiple recordings - at least three) helshe is said to
have the disease called hypertension (systemic hypertension is the correct
term).

This disease has multi-causal etiological factors. The physical condition that
could cause the disease are attributed to various factors either independently
or a combination of them. Genetic factors that are difficult to modify and
other modifiable risk factors are obesity, high salt intake, saturated fat, high
alcohol intake, increased body weight, and environmental stress.
Treatment
The treatment for the cardiovascular diseases that are myocardial infraction
' and hypertension involve both surgeries and life long medication. The advances

I
I
in modem medical technology have helped the patients to a great deal. However,
the chronic nature of the disease and the huge expenditure involved require
a great deal of patient compliance, resilience along with enormous social
support, especially from the family and friends.
Prevention and Promotion
The cardiovascular diseases apart from the congenital ones are easily preventable.
For rheumatic heart diseases, easy medication is [Link] it could be
cured. The cardiovascular diseases of the adult population are mostly attributed
to the modifiable life-style related risks. These risk factors could be modified
with self-care as an individual strategy. This strategy requires routine medical
check-ups and altering the personal life-styles that cause the risk factors.

There could be also population-based strategy educating the masses in creating

awareness about the risk factors and alternative methods of life pattern that
could be easily adopted. This could both prevent the population from the
disease burden and promote the health status of the population.
Mental Health
The major groups of problems associated with mental health are psychosis,
neurosis, and mental retardation.
Health Information for World: About 500 million people are believed to suffer from neurotic, stress-
Social Workers
related and somatoform (psychological problems, which present themselves
as physical complaints). A further 200 million suffer from mood disorders,
such as chronic and manic depression. Mental retardation affects about 83
million people, epilepsy 30 million, dementia 22 million, and schizophrenia
16 million.

India: Surveys of mental morbidity carried out in various parts of the country
suggest a morbidity rate of not less than 18-20 per 1000 and the types of
illness and their prevalence are very much the same as in the other parts
of the world. The number of mental hospital beds in the country, as per a
1991 survey is 21 147 while based on surveys carried out, the number of
people needing psychiatric treatment will not be less than 11,000,000. The
medical infrastructure availablein the country is far fmm fulfilling this requirement.
Mental Illness
Mental illness is a very vast subject, broad in its limits and difficult to define
precisely. There are major and minor mental illnesses. The major illnesses
are called psychoses. There are three major illnesses: (I) Schizophrenia (split
personality) in which the patient lives in a dream world of his own. (2) Manic
Depressive Psychoses in which the symptoms vary from heights of excitement
to depths of depression and (3) Paranoia which is associated with undue and
extreme suspicion and a progressive tendency to regard the whole world in
a framework of delusions. People suffering from the psychotic disorders are
considered insane by the society.

The minor illnesses are of two groups: (1) Neurosis or Psychoneurosis: In

this', the patient is unable to react normally to life situations. Helshe is not
considered abnormal by the society, but nevertheless exhibits certain peculiar
symptoms such as morbid fears, compulsions and obsessions, (2) Personality
and character disorders: This group of disorders is the legacy of unfortunate
childhood experiences and perceptions. .
Treatment
The causes for mental diseases both minor and major could be attributed
to multiple factors. They are organic conditions, heredity, socio-pathological
conditions, and environmental factors. These factors either independently or
through a combination of the other factors predispose the mental illnesses.
However, there has been hardly any accurate natural history for the disease
and therefore could not be any specific curative rather the patient and the
disease is taken care at all levels: biological, sociological and psychological.
Hence, every mental disorder needs the equal intervention of a psychiatrist,
psychologist, and psychiatric social worker.

Mental health services in a community are concerned not only with early
diagnosis and treatment, but also with the preservation and promotion of
good mental health and prevention of mental illness. The mental health services
compromise:
1) Early diagnosis and treatment
2) Rehabilitation
3) Group and individual psychotherapy
4) Mental health education
 Major Health Problems:
5) Use of modern psychoactive drugs Communicable and
6) After-care services Non-Communicable
Diseases
National Mental Health Programme
The National Mental Health Programme was started in 1982. The District
Mental Health Programme was launched in 1996-97 as a pilot project. The
programme envisaged a community based approach to tackle the mental
health problems within the community at the periphery and aims at early
detection and treatment of cases as well as follow-up of cases discharged
from the mental hospitals at the community level. For this purpose free medicines
are being given. The components of the programme are: (i) Training in basic
mental health care for all primary care personnel; (ii) Provision of essential
psychotropic drugs in every peripheral health care institutions located in rural
areas; (iii) A simple recording and reporting mechanism; (iv) Activities aimed
at community participation; (v) Continuous support and supervision to provide
support for trained personnel as well as run district level referral mental health
clinic. The district clinic sees patients referred by trained health personnel
from the periphery. The district clinic also has an inpatient facility for about
10 patients; and (vii) Work with other sectors such as education and social
welfare.
Mental Retardation
Apart from the above two classifications of mental illnesses, mental retardation
is a major mental health problem.

Mental retardation, or mental handicap, is characterized by impaired intellectual

functioning and a slow rate of maturation, both physical and psychological.
It is also defined as 'a condition of arrested or incomplete development of
the mind which is specially characterized by sub normality of intelligence'.
Mental retardation is a condition and disability does not have any cure.
Rehabilitation is the best way to cope with the problem.

Mentally handicapped persons may be classified based on their intelligence

quotient (IQ). Individuals with less than an IQ of 70 are usually classified
as mentally retarded. However, even among the retarded there are classifications,
which are very important in terms of the rehabilitation of people with mental
retardation. [Link] an IQ of 50 to 70 are termed mildly retarded. Nearly
75 present of India's mentally handicapped children are only mildly retarded.

About 20 percent of mentally handicapped children are moderately retarded,

with an IQ ranging between 35 and 50. Such children can [Link] partial
independence in self-care, can learn acceptable behaviour, and can be economically
useful within the family by taking on sheltered employment. About 20 to 30
per 1,000 of the mentally handicapped population of India are mildly to
moderately retarded, with 2 to 3 per 1,000 being severally retarded. Those
with severe (IQ 20 to 30) are profound retardation. IQ 14 to 20 and below
require constant supervision and custodial care for the duration of their lives.

There are several causes of mental retardation. Poor maternal health, maternal
and foetal infections such as rubella and toxemias of pregnancy can lead to
the birth of a retarded child. Excessive intake of drugs by the mother during
pregnancy can also result in the birth of a mentally handicapped child.
Health Information for Iodine deficiency during pregnancy and the lack of iodine in diets is another
Social Workers
major and important cause of mental retardation. It can also occur due to
faulty delivery methods, which lead to birth trauma, birth asphyxia, and bacterial
and parasitic infections of the central neuroses system. In children, diseases
like encephalitis and meningitis can also cause retardation. It has been noted
that social and cultural deprivation, coupled with malnutrition, can also lead
to mental retardation.
Rehabilitation
Rehabilitation is the best way of dealing with the problem of mental retardation.
.However there are hardly any facilities available both at the public and voluntary
sector. The present scenario requires an understanding of the problem at a
level involving of the family and the community.A holistic rehabilitation including
social, psychological, and vocational aspects should emerge to integrate the
isolated and stigmatized individuals to become part of the mainstream society
rather than creating special environments. The rehabilitation has to be accessible,
affordable, and appropriate.
Rheumatoid Arthritis ,

The problems due to the ageing process are numerous but the attention that
it has received is not satisfying. The process of ageing leads to deterioration
in the vitality or the lowering of the biological efficiency. This process is called
senescence. With the passage of time, certain changes take place in an organism.
These changes are, for the most part deleterious and eventually lead to the
death of the organism. Our knowledge about the ageing process is incomplete.
There is not much knowledge about the disabilities incident to the ageing
process. However, the following are some of the disabilities considered as
incident to it; (a) senile cataract, (b) glaucoma, (c) nerve deafness, (d) bony
changes affection mobility, (e) emphysema, (f) failure of special senses,
(g) changes in mental outlook.

Diseases of locomotors system: A wide range of articular and non-articular

disorders affects the aged. Rheumatoid arthritis is a disorder whoseconditions
cause more discomfort and disability than any other chronic disease in the
elderly.
Health Status of the Aged in India
A few hospital-based studies have been made in India on the health status
of the aged persons, but such studies provide only a partial view of the
spectrum of illness in the aged. The overall data on aged are scarce. The
main causes of illness are arthritis, cataract, bronchitis, avitaminosis, ear diseases,
hypertension, diabetes, rheumatism, helminthic infestations, accidents, etc. There
is no specific data on patients affected by arthritis in spite of it being a major
health problem among the aged, the little data available is clubbed along with
the overall disability disorders without any disaggregate specifics limiting us
in estimating the exact magnitude of the problem.
Implications of the Problem
The ageing population is both a medical and sociological problem. First, it
makes a greater demand on the health services of a community. In England,
about two-thirds of all hospital beds are occupied by those over 65. It is
a huge economic burden on the community to meet the cost of retirement
pensions and support vast medical social services. Besides, a great strain is
 Major Health Problems:
placed on the younger generation to look after them. The modem philosophy Communicable and
is that the old must continue to take their share in the responsibilities and Nan-Communicable
Diseases
in the enjoyment of the privileges, which are an essential feature of remaining
an active member of the community. The community must assist the aged to
fight the triple evils of poverty, loneliness, and ill health.
Disease Prevention
For older individuals, a great proportion of the disease burden derives from
existing conditions, whether this burden is measured by prevalence rates,
indicators of morbidity, disability, mortality, or by health and long-term care

I utilization. In addition, older people with disability, resulting from chronic

diseases, appear at high risk of acute illness and injuries. The evidence argues
for the importance of secondary and tertiary prevention, in combination with
primary screening or prevention for this population. Among older individuals,
I categories of conditions, occmnces, and illnesses exist in a variety of combinations,
and risk factors as well as disease sequel often overlap.

Many factors that contribute to decrements of aging and the burden-of illness
are potentially responsive to preventive interventions. In view of this evidence,
the design of preventive strategies appropriate to this population becomes
crucial for the utility of preventive care, both in reducing risk and maintaining
functional independence.

Much care is bestowed upon the old people in Western societies by providing
Social Welfare measures such as national assistance, supplementary pensions,
I
home services, home care services, meals on wheels services, old folk's
homes, sitters-up service and provision of services of health visitors. By
providing these services, the State ensures that the years of retirement of
those who have worked hard in its service shall be free from anxiety, want,
I
and boredom. In India, traditionally the joint family system by its inherent
cohesiveness took care of the aged thereby there had been any problem that
posed itself in social terms. However, the recent times have seen the emergence

I
1
of new social patterns with the increasingly nuclear families coming into existence.
One of the implications of this change has been a decreased care of the aged
unlike in the past. This situation indeed aggravates the problems of the aged.
This new trend hence warrants the role of the state and a consciousness
I
among the new generation to understand and yecognize the problem and
evolve measures as it has been done in the western societies to take care
of the aged. A step towards it not only takes care of the social and economic
problems but also caters our moral responsibilities.

Check Your Progress I11

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of this unit
1) How is the disease Cancer classified, substantiate with examples?
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Health Information for
Social Workers 2) What is Diabetes and if caused what is the effect on human body?
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3) What are the differences between Neuroses and Psychoses?
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4) What is Senescence and what are disabilities it causes?
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3.5 LET US SUM UP

We have seen in the course of reading this unit some of the diseases that
are major health problems in the Indian scenario. The problems of communicable
diseases in India are similar to that of the other developing and underdeveloped
countries and the problems of non-communicable diseases similar to that of
the problems that prevail in the developed world. This similarity with both
the developed and developing world in India is possible because this country
represents large regional and class variations. While diversities in culture add
richness to the Indian society, the differences with the socio-economic development
do not reflect any sense of pride. The health problems of India represent
the double burden of development and underdevelopment.

Second, the incidence and prevalence of any disease could not be seen in
pure medical terms because that lends to understanding of the disease only
at a clinical level. The clinical understanding of the disease limits its scope
to an individual and thereby denying the whole picture. Therefore, if one
looks beyond the bio-medical causative factor of any disease it becomes
obvious that either socio-economic underdevelopment or changing life patterns
provides the contextual relationship. This understanding of the disease enables
us to fight the disease both at an individual and social level. The disease is
combated through the modem and advanced medical technology, at the same
time measures are taken to prevent the diseases and as well as promoting
the health statuses of the people to keep the diseases at bay. Prevention of
disease and promotion of the health status of the population would require
various steps, some of which we have observed in the unit. They would begin
with proper diagnosis and treatment of any disease occurred to any individual
hence it does not spread, a vigilant disease surveillance unit of the government
 Major Health Problems:
that serve watchdog and report any suspect that hampers the health status Communicable and
of the population. The administration of vaccinations done through a universal NO^-communicable
Diseases
coverage to prevent diseases and health education to keep the population
aware of the diseases and the methods would include some adjustments in
one's life-style so that many of the non-communicable degenerative disease
are prevented and a good health status is promoted. The role of the National
health programmes in this aspect becomes indispensable. And here rests the
role of any social worker who is instrumental in understanding the wider
aspects of any health problem and using his skills and knowledge implementing
various initiatives that help fight the major health problems and help maintain
peace and order in a society.

r 3.6 KEYWORDS
Disease Disorder of structure or function in an animal
or plant of such a degree as to produce or
threaten to produce detectable illness or
disorder; a definable variety of such a disorder,
usually with specific signs or symptoms or
affecting a specific location.
Epidemic A temporary but widespread outbreak of
a particular disease.
Mortality Loss of life on a large scale; abnormal
frequency of death, as by war or pestilence
and expressed in public health terms to the
number of deaths in a given area or period,
especially from a particular cause; the average
frequency of death, the death rate, (also
mortality rate).
I
Morbidity The quality or condition of being diseased
i or ill and expressed in public health terms
to the prevalence of disease and the extent
or degree of prevalence of disease in a given
locality.

3.7
- - -
SUGGESTED READINGS
Park, K. (2002), Textbook of Preventive and Social Medicine, M/s Banarsidas
Bhanot publishers, Jabalpur (India).
Mukhopadhyay, Alok (1997), Report of the Independent Commission on
Health in India, Voluntary Health Association of India, New Delhi.

3.8 ,ANSWERS TO CHECK YOUR PROGRESS

Check YOU; Progress I
1) A disease is a condition that impairs the proper function of the body.
or of one of its parts. Every living thing, both plants and animals, can
succumb to disease.
Every disease has a cause, although the causes of some remain to be
Health Information for discovered. Every disease also displays a cycle of onset, or beginning,
Social Workers
course, or time span of affliction, and end, when it disappears or it
partially disables or kills its victim.
2) A symptom is something patient can detect because it has external
manifestations, such as fever, bleeding, or pain. A sign is something a
doctor can detect, such as swollen blood vessel or an enlarged internal
body organ.
3) Communicable diseases are those that pass or transmit between persons
directly or indirectly.
Various agents such as virus, bacteria, fungi, protozoa, and worms cause
infectious diseases.
a) Diseases caused by Bacteria: Cholera, Diphtheria, Tuberculosis, Leprosy,
Tetanus, Typhoid, Plague, Whooping Cough, Sore Throat, Pneumonia,
Bacillary Dysentery, Gonorrhea, Syphilis and Botulism.
b) Diseases caused by Viruses: Chickenpox, Measles, Poliomyelitis,
Rabies, Mumps, Influenza, Hepatitis, Herpes, Virus Encephalitis, and
AIDS.
c) Diseases caused by Fungi: Ringworm, Athlete's foot, Dhobi itch.
d) Diseases caused by Protozoan: Arnoebiasis, Malaria, Sleeping sickness,
Kalazar, Diarrhoea.
e) Diseases caused by Helrninthes or Worms: Filariasis, Tapeworm and
Hookworm transmission.
Check Your Progress I1

1) The symptoms of tuberculosis are:

a) persistent cough of about 3 or 4 weeks
b) continuous fever
C) chest pain
d) haemoptysis (expectoration of blood or bloody mucus)
The patient on volition attends any health centre with these symptoms
is taken for a sputum-smear examination. The sputum culture examination
will yield the results that reveal the status of the disease in the patient.
The disease is thus diagnosed.
HIV is transmitted through semen and vaginal fluids, infected blood and
blood products, infected mother to her baby-before birth, during birth
or through breast milk.
HIV is not spread by:
1) Drinking water or eating food from the same utensils-cups, glasses,
plates, used by infected person,
2) Sharing toilets or shaking hands,
3) Hugging, or facial kissing,
4) Donating blood,
5) Working with people who are HIV infected,
6) Massage and rub each other's bodies,
7) Swimming in pools used by people with HIVIAIDS. (HIV is not
spread by sitting next to someone who is infected, coughing, or
 sneezing, public transportation, public telephones, restaurants, air). Major Health Problems:
Communicable and
But if you have any cuts or sores on your hands make sure they Non-Communicable
are covered with plasters (band-aids or bandages). Diseases

3) HIV infection is diagnosed based on blood tests using three different

ELISNRapid tests using different antigen preparation. AIDS cases are
diagnosed based on two different ELISARapid tests on different antigens
and presence of AIDS related opportunistic infections.
4) The major role of poverty and other socio-economic condition plays in
causing and transmitting the disease Leprosy and further, the stigma attached
to it qualifies it to be called a social disease.
Check Your Progress I11

1) Cancer is classified a life-style disorder. A majority of the cancers are

caused by living habits (smoking, alcohol consumption, and diet).
2) Diabetes is a chronic disease in which the body does not produce or
properly use insulin, hormone needed to convert sugar, starches, and
'

other foods into energy necessary for daily life. Diabetes causes kidney
diseases, blindness, lower limb amputations, and heart strokes.
3) Neuroses are minor mental illness and the patient's condition does not
affect the society but psychoses are major mental illness mostly chronic,
sometimes harmful, and mostly disoriented hence called insane by the
society.
4) The process or condition of growing old or ageing; Biological loss of
the power of cell division and growth. The disabilities caused are:
a) senile cataract,
b) glaucoma,
C) nerve deafness,
d) bony changes affection mobility,
e) emphysema,
f) failure of special senses,
g) changes in mental outlook.
UNIT 4 HEALTH CARE SERVICES
Contents
4.0 Objectives
4.1 Introduction
4.2 Concept of Health Care
4.3 Level of Health Care
4.4 Principles of Primary Health Care
4.5 National Strategy for HFAl2000
4.6 National Health Policy
4.7 Health Care Delivery
4.8 Health Problems
4.9 Health Care Services
4.10 Primary Health Care in India
4.11 Voluntary Health Agencies in India
4.12 Let Us Sum Up
4.13 Key Words
4.14 Suggested Readings
4.15 Answers to Check Your Progress

4.0 OBJECTIVES
After reading this unit, you should be able to:
assess the health caie delivery system of the country;
evaluate the utility of the primary health care services;
provide the health care services for all;
trace out the drawbacks of health care services and give appropriate
suggestions;
observe the needs of the many must prevail over those of the few; and
acquaint you with the health problems of the country.

4.1 INTRODUCTION
Health has been declared a fundamental human right. This implies that the
state has responsibility for the health of its people. National government all
over the world are striving to expand and improve their health care services,
The current criticism against health'care services is that they are:
a) Predominantly urban oriented.
b) Mostly curative in nature.
c) Accessible only to a small part of the population.

The present concern in both developed and developing countries is not only
to reach the whole population with adequate health care services, but also
to secure accessible and acceptable level of health for all by the 2000 AD,
through the application of primary health care programmes.
 Health Care Services
4.2 CONCEPT OF HEALTH CARE
Since health is influenced by a number of factors such as adequate food,
housing, basic sanitation, healthy lifestyles, protection against environmental
hazards and communicable diseases, the frontiers of health extend beyond
the narrow limits of medical care. It is thus clear that "health care" implies
more than "medical care". It embraces a multitude of "services provided to
individuals or communities by agents *ofpromoting, maintaining, monitoring,
or restoring health." Medical care is a subset of health care system.

Health care is a public right and it is the responsibility of the government

to provide this care to all people in eqyal measure. These principles have
been recognized by nearly all governments of the world and therefore, have
been enshrined in their respective constitutions. In India, health care is completely
P or largely a governmental function.
Health System.
Health services are designed to meet the health needs of the community
through the use of available knowledge and resources. It is not possible to
define a fixed role for health services when the socioeconomic pattern of one
country differs so much from another. The health services are delivered by
the "health system" which constitutes the management sector and involves
organisational matters.

Two major themes have emerged in recent years in the delivery of health
I services:
1) First, that health services should be organized to meet the needs of entire
I populations and not merely selected groups. Health services should cover
I
the full range of preventive, curative and rehabilitation services. Health
services are now seen as part of the basic social services of a country.
2) It is now fully recognized that the best way to provide health care to
the vast majority of underserved rural people and urban poor is to develop
effective primary health care services supported by an appropriate referral
system.

1
Community participation 'is now recognized as a major component in the
i approach to the whole system of health care treatment, promotion, and prevention.
The stress is on the provision of these services to the people representing
a shift from medical care to health care and from urban population to rural
population.

Check Your Progress I

Notes: a) Space is given below for your answer.
b) Check your answers with those given at the end of this unit.
1) Describe briefly the concept of health care.
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Health Information for
Social Workers 2) What two major themes have emerged in recent years in the delivery
of health services?

4.3 LEVEL OF HEALTH CARE

It is customary to describe health care service at 3 levels, vi?. Primary,
Secondary and Tertiary care levels. These levels represent different types of
care involving varying degrees of complexity.
Primary Care Level
It is the first level of contact of individuals, the family and community with
the national health system, where primary health care (Essential Health Care)
is provided. As a level of care, it is close to the people, where most of their
health problems can be dealt with and resolved. It is at this level that health
care will be most effective within the context of the area's needs and limitations.

In the Indian context, primary health care is provided by the complex of

primary health centres and their subcentres through the agency of multipurpose
health workers (MPWs), village health guides and trained dais. Besides providing
primary health care,the village "health teams" bridge the cultural and communication
gap between the rural people and organized health sector. Since India opted
for "Health for All" by 2000 AD. The primary health care system has been
reorganized and strengthened to make the primary health care delivery system .
more effective.
Secondary Care Level
The next higher level of care is secondary health care level. At this level more
complex problems are dealt with. In India this kind of care is generally
provided in district hospitals and community health centres which also serve
as the first referral level.
, Tertiary Care Level
The tertiary level is a more specialized level than secondary care level and
required specific facilities and attention of highly specialized health workers.
This care is provided by the regional or central level institutions e.g. Medical
College Hospitals, All India Institutes, Regional Hospitals, Specialized Hospitals
and other Apex institutions.

A fundamental and necessary function of health care system is to provide

a sound referral system. It must be a two-way exchange of information and
returning patients to those who referred them for follow-up case. It will
ensure continuity of care and inspire confidence of the consumer in the system.
For a large majority of developing countries (including India) this aspect of
the health system remains very weak.
 Health Care Services
Changing Concepts
With political independence, there was a national commitment to improve
health in developing countries. Against this background different approaches
to providing health care came into existence. These are:
1) Comprehensive Health Care
The term comprehensive health care was first used by the Bhore Committee
in 1946. By comprehensive services the Bhore Con I nitt tee meant provision
of integrated, preventive, curative and promotional health services from
"womb to tomb" to every individual residing in a defined geographic area.
The Bhore Committee defined comprehensive health care as having the following
characteristics:
a) Provide adequate preventive,, curative and promotive health services.
b) B e as close to the beneficiaries as possible.
C) Has the widest cooperation between the people, the service and the profession.
d) Is available to all irrespective of their ability to pay.
e) Look after specifically the vulnerable and weaker sections of the community.
f) Create and maintain a healthy environment both in homes as well as
working places.

The Bhore Committee suggested that comprehensive health care should replace
the policy of providing more medical care. This concept formed the basis
of National health planning in India and led to the establishment of a network
of Primary health centres and subcentres.

The Govt. of India has built up a vast infrastructure of rural health services
based on primary health centres and subcentres. However, experience during
the past 45 years has indicated that the primary health centres were not able
to effectively cover the whole population under their Jurisdiction, and their
sphere of service did not extend beyond 2-5 krn radius. These facilities often
did not enjoy the confidence of the people because they were understaffed
and poorly supplied with medicines and equipment; as a result, there was
growing dissatisfaction with the delivery of health services.

Check Your Progress I1

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) How many levels of health care exist in the country?
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2) Mention the changing concepts of health care.
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Health ~nformrtionfor 2) Basic Health Services
Social Workers
In 1965 the terms "Basic health services" was used by UNICEFIWHO in
their joint health policy. The change in terminology from comprehensive to
basic health services did not affect materially the quality or content of health
services. The handicaps or drawbacks of the basic health services are those
shared by the comprehensive health care services viz. lack of community
participation, lack of intersectoral coordination and dissociation from the socio-
economic aspects of health.
3) Primary Health Care
A new approach to health care came into existence in 1978 following an
international conference at Alma-Ata (USSR). This is known as "Primary
health care". It has all hallmarks of a Primary health care delivery. First
proposed by the Bhore Committee in 1946 and now espoused world-wide
by international agencies and national governments.

Before Alma-Ata primary health care was regarded as synonymous with

"basic health services", "First contact care," "easily accessible care" services
provided by generalists etc. Primary health care who not only about providing
comprehensive health services but also inter-sectoral linkages - the importance
of overall development for health. The Alma-Ata Conference defined primary
health care as follows:

"Primary health care is essential health care made universally accessible to

individuals and acceptable to them, through their full participation and at a
cost the community and country can afford."

The concept of primary health care has been accepted by all countries as
the key to the attainment of health for all by 2000 AD. It has also been
accepted as an integral part of the country's health system.
Elements of Primary Health Care -

1) The Alma-Ata declaration has outlined 8 essential components of primary

health care.
2) Education concerning prevailing health problems and the methods of'preventing
and controlling them.
3) Promotion of food supply and proper nutrition.
4) An adequate supply of safe water and basic sanitation.
5) Maternal and child health care, including family planning.
6) Immunization against major infectious diseases.
7) Prevention and control of locally endemic diseases.
8) Appropriate treatment of common diseases and injuries.
9) Provision of essential drugs.

Check Your Progress I11

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) Define basic health services.
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 Health Care Services
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2) Who proposed primary health care delivery and when?
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3) Mention the elements of primary health care.
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4.4 PRINCIPLES OF PRIMARY HEALTH CARE

1) Equitable Distribution
The first key principle in the primary health c m strategy is equitable distribution
'
of health services i.e. health services must be shared equally by all people
I irrespective of their ability to pay, and all (rich or poor, urban or rural) must
I have access to health services. At present health services are mainly concentrated
in the major towns and cities resulting in inequality of care to the people in
rural areas. The worse hit are the n&dy and vulnerable groups of the population
in rural areas and urban slums. This has been termed as "Social Injustice".
The failure to reach the majority of the people is usually due to inaccessibility.

1 Primary health care aims to redress this imbalance by shifting the centre of
gravity of the health care system from cities (where three-quarters of the
health budget is spent) to the rural areas (where three-quarters of the people
live) and bring these services as near people's homes as possible.
2) Community Participation
The involvement of individual, families and communities in promotion of their
own health and welfare, is an essential ingredient of primary health care.
There must be a continuing effort to secure meaningful involvement of the
community in the planning, implementation and maintenance of health services.
In short primary health care must be built on the principle of community
involvement.

One approach that has been tried successfully in India is the use of village
health guides and trained dais. They are selected by the local community and
trained locally in the delivery of primary health care to the community they
belong, free of charge. By overcoming cultural and communication barrier,
Health Information for they provide primary health care in a ways that are acceptable to the
Social Workers
community. It is now considered that "Health guide" and trained dais are
an essential feature of primary health care in India. These concepts are
revolutionary.
3) Intersectoral Coordination
The declaration of Alma-Ata states that "Primary health care involves in
addition to the health sector, all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food industry,
education, housing, public works, communication and other sectors. To achieve
such cooperation, countries may have to review their administrative system,
reallocate their resources and introduce suitable legislation to ensure that
coordination can takes place.
4) Appropriate Technology
The term "appropriate" is emphasized because in some countries, large luxurious
hospitals that are totally inappropriate to the local needs, are built, which
absorb a major part of the national health budget, effectively blocking any
improvement in general health services. This also implies to using costly
equipment, procedure and techniques when cheaper, and scientifically valid
and acceptable ones are available, viz. oral hydration fluid, standpipes which
are socially acceptable, and financially more feasible than house to house
connections.

It will be seen from the above discussion that primary care is qualitatively
a different approach to deal with the health problems of a community. Unlike
the previous approaches (e.g. basic health services, integrated health care,
vertical health services) which depended upon taking health services to the
doors of the people. Primary health care approach starts with the people
themselves. This approach signifies a new dynamism in health care and has
been described as health by the people, placing people's health in people's
hands. In short, primary health care goes beyond the conventional health
services.

4.5 NATIONAL STRATEGY FOR HFAl2000

World health assembly defined HFA.12000 as "attainment of a level of health,
that will enable every individual to lead a socially and economically productive
.life."

In this connection following strategies have been formulated:

9 Reduction of infant mortality from the level of 125 to below 60.
ii) To raise the expectation of life at birth from the level of 52 years to
64.
iii) To reduce the crude death rate from the level of 14 per 1000 population
to 9 per 1000.
iv) To reduce the crude birth rate from the level of 33 per 1000 population
to 21.
v) To achieve a net reproduction rate of one.
vi) To provide potable water to the entire rural population.
 Health Care Services
4,6 +. NATIONAL HEALTH POLICY
The national health policy in India has followings notable elements:
i) A greater awareness of health problems and means to solve these, in
and by the communities.
ii) Supply of safe drinking water and basic sanitation, using technologies that
the people can afford.
iii) Reduction of existing imbalance in health services by concentrating on
the rural health infrastructure.
iv) Establishment of a dynamic health management information system to
support health planning, and health programme implementation.
v) Provision of legislative support to health protection and promotion.
vi) Concerted action to combat widespread malnutrition.
vii) Research in alternative methods of health care delivery and low-cost
health technologies.
viii) Greater coordination of different system of medicine.

Check Your Progress IV

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) Mention the principles of primary health care.
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2) What is the concept of health for all?
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4,7 HEALTH CARE DELIVERY

Today it is necessity for the country to reach the whole population with
adequate health care services and to ensure their utilization. The "large hospital"
which was chosen hitherto for the delivery of health services has failed in
the sense that it serves only a small part of the population, that too living
within a small radius of the building and the services rendered are mostly
curative in nature. Therefore it has been aptly said that these large hospitals
are more ivory towers of diseases than centres for the delivery of comprehensive
health care services. Rising costs in the maintenance of these large hospitals
and their failure to meet total health needs of the community has led the
country to seek alternative models of health care delivery with a view to
provide health care services that are reasonably inexpensive, and have the
basic essential required by rural population.
Health Information for Model of Health Care System
Social Workers
The lnputs are the health status or health problems of the community; they
represent the health needs and health demands of the community. Since resources
are always limited to meet the many health needs, priorities have to be set.

Inputs Health Care Services Health Care System Outputs

Health Status
or 4
Health Problems

[Link]
Promotive Voluntary
Indigenous
Health Status

f i i s envisages proper planning, so that resources are not wasted. The health
care services are designed to meet the health needs of the community through
the use of available knowledge and resources. The services provided should
be comprehensive and community-based. The resources must be distributed
according to the needs of the community. The health care system is intended
to deliver the health care services; in other words, it constitute the management
sector and involves organizational matters. The final outcome or the output
is the changed health status or improved health status of the community which
is expressed in terms of lives saved, death averted, disease prevented, cases
treated, expectation of life prolonged etc.

Check Your Progress V

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What is the concept of health care services?
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2) List three main health analysis data.
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 Health Care Services
4.8 HEALTH PROBLEMS
The health problems of India may be conveniently grouped under the following
heads: .
i) Communicable disease problems
ii) Nutritional problems
iii) Environmental sanitation problems
iv) Medical care problems
v) Population problems
i) Communicable Disease Problems

), Communicable diseases continue to be a major problem in India. Diseases

considered to be of great importance today are:

a) Malaria: Malaria continues to be a major health problem in India. The

upsurge of Malaria cases dropped down from 6.75 million cases in 1976
to 2.1 million cases in 1984, since then the epidemiological situation has not
shown any improvement although total malaria cases has declined compared
to previous year, the proportion of p. falciparum has increased.

Malaria cases has increased in Goa, Madhya Pradesh and Orissa. There
appears little prospect of malaria eradication in the foreseeable future.

b) Tuberculosis: Tuberculosis is another leading public health problem in

India. About 36.5 percent of the total population are infected.

c) Leprosy: Leprosy is also a major public health problem in India.

d) Diarrhoea1 diseases: It is one-of the major causes of morbidity and

mortality, specially in children below 5 years of age.

e) Acute respiratory disease: It is also a major disease infected the children

below 5 years of age.

f) Filaria: The problem is increasing in magnitude every year. 25 million have

filarial parasites in their blood. This has been attributed to gross mismanagement
of the environment.

g) AIDS: The problem of AIDS is also increasing in magnitude every year.

Others: Kala-azar, meningitis, viral hepatitis, Japanese encephalitis, enteric

fever, guinea-worm disease are among the others important communicable
disease problems in India.
ii) Nutritional Problems
From the nutritional point of view, the lndian society is a dual society. It
consists of a small group of well fed and a very large group of undernourished
population. The specific nutritional problems in the country are:
a) Protein Energy Malnutrition: Insufficiency of food the so-called "food
gap" appears to be the chief cause of PEM, which is major health problem
particularly in the first year of life.
I
Health Information for
Social Workers
b) Nutritional Anaemia: India has the highest prevalence of nutritional
anemia in women and children. 60 to 80 percent of pregnant women
are anemic. 20 to 40 percent of maternal deaths are attributed to
anemia. The cause of anemia is iron deficiency and folic and vitamin B,,
deficiency.
c) Low Birth Weight
d) Xeropthalmia (nutritional blindness)
e) Iodine deficiency disorders (IDD) - Goitre and other iodine deficiency
disorders have been highly endemic in sub Himalayan regions.
iii) Environmental Sanitation
The most difficult problem to tackle in this country is perhaps the environmental
sanitation problem. The twin problems of environmental sanitation are lack
of safe water in many areas of the country and primitive method of excreta
disposal. Besides these there has been a growing concern about the impact
of "New" problems resulting from population explosion, urbanization and
industrialization leading to hazards to human health in the air, in water and
in the food chain.
iv) Medical Care Problems
India has a national health policy but, it does not have a national health
service. The financial resources are considered inadequate to furnish the costs
of running such service. The existing hospital based, disease oriented health
care model has provided health benefits mainly to the urban elite. Urban
health problems have been aggravated and include overcrowding in hospitals,
inadequate staff and scarcity of certain essential drugs and medicines.

The rural areas where nearly 74 percent of the population live, do not enjoy
the benefits of the modern curative and preventive health services. Many
villages rely on indigenous systems of medicine. Thus the major medical case
problem in India is in equitable distribution of available health resources
between rural and urban areas.
v) Population Problems
India is facing the biggest population problem, with its inevitable consequences
on all aspects of development, especially unemployment, education, housing,
health care, sanitation and environment. The government has set a goal of
1 percent population growth rate by the year 2000. This calls for the "two
child family norm". The population size and structure represent the most
important single factor in health and manpower planning in India today.
Resources
Resources are needed to meet the vast health needs of a community. No
nation however rich has enough resources to meet all the needs for all health
care. Therefore an assessment of the available resources,-theirproper allocation
and efficient utilization are important consideration for providing efficient health
care services. The basic resources for providing health care are:
1) Health manpower
2) Money and material
3) T m
 Health Care Services
1) Health Manpower
The term "health manpower" includes both professional and auxillary health
personnel who are needed to provide the health care.
2) Money and Material
Money is an important resource for providing health services. Scarcity of
money affects all part of the health delivery system.
3) Time
It is an important dimension of health care services; proper use of man-hours
is also an important time factor.

To summarise, resources are needed to meet the many health needs of a

community. But resources are desperately short in the health sector in all poor
countries.

Check Your Progress VI

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
9

1) List five main health problems.

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2) Enlist the communicable diseases.
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4.9 HEALTH CARE SEVICES - - - - - - - - -

The purpose of health care services is to improve the health status of the
population. The scope of health services varies widely from country to country.
There is now broad agreement that health services should be:

I
(a) Comprehensive (b) available and accessible (c) acceptable (d) provide
I
scope for community participation (e) available at a cost the community and
1 country can afford. These are the essential ingredients of primary health care
which forms an integral part of the country's health system of which it is the
central function and main agent for delivering health care.
I

Health Care System

t
i The health care system is intended to deliver the health care services. It
constitutes the management sector and involves organizational matters. In
T n o . . . . . . 0. . . . .."" " . . .
Health Information for by the health technology applied and by the source of funds for operation.
Social Workers
These are:
i) Public Health Sector
a) Primary health care
Primary health centres
Sub-centres
b) Hospitals/health centre
Rural hospitals
District hospitalhealth centre
Specialist hospitals
Teaching hospitals
c) Health Insurance Schemes
. Employees State Insurance
Central Govt. Health Scheme
d) Other Agencies
Defence Services
Railways
ii) Private Sector
b) Private hospitals, polyclinics, nursing homes and dispensaries
c) General practitioners and clinics
iii) Indigenous System of Medicine
Ayurveda and siddha
Unani and Tibbi
Homoeopathy
Unregistered Practitioners
iv) Voluntary Health Agencies
v) National Health Programmes

I Check YOU; progress VII

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What are the basic resources to provide health care services?

.....................................................................................................
2) What are the essential ingredients of primary health care services?
 Health Care Services
4.10 PRIMARY HEALTH CARE IN INDIA
In 1977, the Government of India launched a Rural Health Scheme, based
on the principle of "Placing people's health in people's hands". It is a three
tier system of-healthcare delivery in rural areas based on the recommendation
of the Srivastav committee in 1975. The Government of India is committed
to achieving the goal of health for all through primary health care approach
which seeks to provide universal comprehensive health care at a cost which
is affordable. In 1983 India evolved a National Health Policy based on Primary
health care approach. Steps are already underway to implement the National
Health Policy objectives towards achieving Health for All. These steps are
described below:
I
1) Village Level
One of the basic tenets of primary health care is universal coverage and
equitable distribution of health resources. That is, health care must penetrate
into the farthest reaches of rural areas, and that every one should have access
to it. To implement this policy at the village level, the following schemes are
in operation :
a) Village Health Guide Scheme
b) Training of Local Dais
C) ICDS Scheme.
a) Village Health Guides
A village health guide is a person with an aptitude for social service and is
not a full time government functionary. This scheme was introduced with the
idea of securing people's participation in the care of their own health. The
health guides are now mostly women. The health guides come from and are
chosen by the community in which they work. They serve as links between
the community and the governmental infrastructure. They provide the first
contact between the individual and the health system the health guides
undergo a short training period of 3 months with the stipend of Rs. 200 per
month.

The health guides are expected to do community health work in their spare
time of about 2 to 3 hours daily for which they are paid an honorarium of
Rs. 50 per month and drugs worth Rs. 600 per annum.
b) Local Dais
Most deliveries in rural areas are still handled by untrained dais who are often
the only people immediately available to women during the perinatal period.
An extensive programme has been undertaken under the rural health scheme,
to train all categories of local dais (traditional birth attendants) in the country
to improve their knowledge in the elementary concepts of maternal and child
health and sterilization besides obstetric skills. The training is for 30 working
days.. Each dai is paid stipend of Rs. 300 during her training period.
C)Aganwadi Worker
There is an Aganwadi worker for the population of 1000 in ICDS scheme.
I There are 100 such workers in one ICDS Project. The Aganwadi worker
is selected from the community she is expected to serve. She undergoes
training in various aspects of health, nutrition, and child development for 4
i
Health Information for months. She is part time worker and paid honorarium of Rs. 200-250 per
Social Workers
month for the services rendered, which includes health check-up, immunization,
health education, supplementary nutrition, non formal pre-school education
etc.
2) Sub-centre Level
The sub-center is the peripheral outpost of the existing health delivery system
in rural areas. At present the function of sub centers are limited to mother
and child health care, family planning and immunization.
3) Primary Health Centre Level
The concept of primary health center is not new to India. The Bhore committee
in 1946 gave the concept of a primary health centre as a basic health unit,
to provide as close to the people as possible, an integrated curative and
preventive health care to the rural population with emphasis on preventive
and promotive aspects of health care. After many changes from time to time
in the structure and working of primary health center the National Health Plan
(1983) proposed reorganization of primary health centres on the basis of one
PHC for every 30,000 rural population in the plains and 20,000 for hilly
regions. ,
Functions of Primary Health Centre (PHC)
The functions of PHC in India cover all the 10 essential elements of primary
health care. They are:
i) Medical Care
ii) MCH including family planning
iii) Safe water supply and basic sanitation
iv) Prevention and control of locally endemic diseases
v) Collection and reporting of vital statistics
vi) Education about health
vii) National health programmes as relevant
viii) Referral services
ix) Training of health guides, health workers, local dais and health assistants
x) Basic laboratory services.

At present in each community development Block, there are one or more

PHCs. The staffing pattern is like this:

At PHC level - Medical officer, pharmacist, nurse, mid wife, health worker
(female)/ANM, block extension educator, health assistant (male), health assistant
(Female)/ LHV, UDC, LDC, lab technician, driver, (each one) and Class IV-
4 - Total 15.

At the subcentre level: Health worker (female) ANM- 1, health worker

(male) 2, voluntary worker (paid Rs. 50 per month) 1 to 3.
4) Community Health Centres
As on 30&June 1996,2424 CHC were established by upgrading the primary
health centres. Each CHC covering a population of 80,000 to 1.20 lakh with
30 beds and specialists in surgery, medicine, obstetrics and gynecology, pediatrics
with X- ray and laboratory facilities. For strengthening preventive and promotive Health Care Services

aspects of health care.

Staff~ngPattern of Community Health Centre: Medical officer - 4, nurse

mid-wives -7, dresser -1, pharmacist/compounder - 1, lab. technician - 1,
radiographer - 1, ward boys - 2, dhobi - 1, sweepers - 3, mali - 1,
chaukidar - 1, aya - 1, peon - 1 - Total 25

Hospital: Apart from the primary health centers the [Link] organization of
health services of the government sector consists of rural hospitals, district
hospitals specialist hospitals, and teaching institutions.
a) Rural Hospitals
It is now proposed to upgrade the rural dispensaries to primary health centres.
These centres will have an epidemiological wing attached to them.
b) District Hospitals
There are proposals to convert the district hospital into district health centre.
A hospital differs from a health centre in the following respects.
i) In a hospital, service. .ovided are mostly curative, in a health centre
the services are prevt -ve, promotive and curative-all integrated.
ii) A hospital has no definite area of responsibility. Patients may be drawn
from any part of the country. A health centre is responsible for a definite
area and population.
iii) The health team a health centre is a optimum mix" of medical and
"

paramedical worker.. in a hospital, the team consists of only the curative

staff, i.e. doctors, pnarmacy, nurses etc. Experience has shown that the
health of the community can not be improved by multiplying hospitals
alone.

Health Insurance: Health insurance is at present limited to industrial workers

and their families. The central Government employees are also covered by
the health insurance under the central government health scheme.

Employees State Insurance Scheme: The ESI scheme is unique piece of

social legislation in India. It has introduced for the first time in India, the
principle of contribution by the employer and employee. The act provides
fo"r medical care in cash and kind benefits in the contingency of sickness,
maternity, employment injury, and pension for dependents; the death of worker
because of an accident in course of duty.

Central Government Health Scheme: This scheme provides comprehensive

medical care to central Government employees. The scheme is based on the
principle of cooperative efforts by the employee and the employer, to the
mutual advantage of both. In this scheme there are following facilities:
i) Out patient care through the network of dispensaries.
ii) Supply of necessary drugs
iii) Laboratory and X-Ray investigation
iv) Hospitalization facilities at Govt. as well as private hospitals.
v) Pediatric services including immunization.
vi) Family welfare services etc.
Health Information for
Social Workers Check Your Progress VIII
Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What are the schemes to implement the health policy at village level?
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2) Mention the essential functions of the PHC.
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Other Agencies

Defence Medical Services

Defence services have their own organization for medical care to defence
personnel under the banner "Armed Forces Medical Services". The services
provided are integrated and comprehensive embracing preventive, promotive
and curative services.
Health Care of Railway Employees
The Railways provide comprehensive health care services, through the agency
of Railway hospitals, health units and clinics. Health check-up of employees
is provided at the time of entry in to service and thereafter at yearly intervals.
There are lady medical officers, health visitors and midwives who look after
the MCH and school health services.
Private Agencies
India's private practice of medicine provides a large share of the health
services available. The doctor population ratio for the country as a whole
is 1:2100. Most of them tend to congregate in urban areas. They provide
mainly curative services. The private sector of the health care services is not
organized. Some statutory bodies like the Medical Council of India, and
Indian Medical Association regulate some of the functions and activities of
the large body of private registered medical practitioners.
Indigenous System of Medicines
The practitioners of indigenous systems of medicine (e.g. Ayurveda, Siddha,
Homoeopathy etc.) provide the bulk of medical care to the rural pcople.
Ayurvedic physicians alone are estimated to be about 3.37 lakhs. The Government
of India is studying the question of how indigenous systems of medicine could
best be utilized for more effective or total health coverage.
 Health Care Services
4.11 VOLUNTARY HEALTH AGENCIES IN INDIA
The voluntary health agencies occupy an important place in community health
programmes.
Functions
The type of service rendered by voluntary health agencies have been classified
as:
a) Supplementing the work of Government Agencies.
b) Pioneering
- C) Education
/ d) Demonstration
e) Guarding the work of Government Agencies
f) Advancing Health Legislation

Voluntary Health Agencies in India:

i) Indian Red Cross Society
ii) Hind Kusht Nivaran Sangh
iii) Indian Council for Child Welfare
iv) Tuberculosis Association of India
v) Bharat Sewak Samaj
vi) Central Social Welfare Board
vii) The Kasturba Memorial Fund.
viii) Family Planning Association of India
ix) All India-Blind Relief Society
x) Professional Bodies
xi) International Agencies as the Rockefeller foundation, Ford foundation,
CARE (cooperative for American relief every where)

Check Your Progress IX

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) List other health schemes in the country.
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2) List the voluntary health agencies in India.
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Health Information for
Social Workers 3) What is the National Health Policy?
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4.12 LET US SUM UP

Since India became free, several measures have been undertaken by the
National Government to improve the health of the people. Prominent among
these measures are National Health Programmes (present health care delivery
system in urban and rural areas) which has been launched by the central
Government for the contderadication of communicable diseases, improvement
of environmental sanitation, nutrition, control of population and rural health.

For the rural health care services the PHCs and CHCs are playing the key
role of providing the comprehensive health facilities to the mass population.
The primary health centres and community health centres came under criticism
as they were not able to provide adequate health coverage, partly because
they were poorly staffed and equipped and partly because they have to cover
a large population of one lakh or more. To obtain a better result the existing
primary health centers should be strengthened and population to be served
by them to be scaled down to 40,000. It is now fully realized that the best
way to provide health care to the vast majority of underserved rural people
and urban poor is to develop effective primary health care services supported
by an appropriate referral system.

4.13 KEY WORDS

Health System : The health system constitutes the management
sector and involves organizational matter.

Health Care : Health care is a public right and it is the

responsibility of Governments to provide this
care to all people in equal measure.

Medical Care : It refers chiefly to those personal services

that are provided directly by physicians or
rendered as the result of physician's
instructions.

Health Manpower : 1he term health manpower includes both

professional and auxiliary health personnel
who are needed to provide the health care.
Health manpower requirements are based
on (a) Health need and demand of the
population (b) Desired outputs.

Basic Health Service : "A basic health service is understood to be

a network of coordinated, peripheral and
 intermediate health unitscapable of performing Health Care Services

effectively a selected group of function essential

to the health of an area and assuring the
availability of competent professional and
auxillaq personnel to perform these functions."

Social Justice : Health services are mainly concentrated in

the major towns and cities resulting in inequahty
of care to the people in rural areas. The
worse hit are the needy and'vulnerable group
of the population in rural areas and slums.
Equitable distribution of health services has
been termed as social justice.

Health for All : In 1978 it was decided at the Alma-Ata

international conference that the principle of
an equal health status for the people. This
conference defined health for all as:
"Attainment of level of health that will enable
every individual to lead a socially and
economically productive life:"

- Voluntary Health Agency : A voluntary health agency may be defined

as an organization that is administered by
an autonomous board which holds meeting,
collects funds for its support, chiefly from
private sources and expends money, whether
with or without paid workers, in conducting
a programme, directed primarily to furthering
the public health by providing health services.

4.14 SUGGESTED READINGS

Park, K. (2002), Textbook of Preventive and Social Medicine, MIS Banarsidas
Bhanot Publishers, Jabalpur (India).

4.15 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress I

1) Health is influenced by a number of factors such as adequate food,

housing, basic sanitation, healthy life-styles, protection against environmental
hazards and communicable diseases, the frontiers of health extend beyond
the narrow limits of medical care. It is thus clear that health care implies
more than medical care. It embraces a multitude of services provided
to individuals or communities by agents of the health services or professions,
for the purpose of promoting, maintaining, monitoring or restoring health.
2) Two major themes have emerged in recent years in the delivery of health
services:
i) First that health services should be organized to meet the needs of
entire population and not merely selected group. Health services
should cover the full range of preventive, curative and rehabilitation
Health Information for It is now fully realised that the best way to provide health care is
Social Workers ii)
to serve majority of underserved rural people and urban poor. The
current social policy throughout the world is to build up health systems
based on primary health care.
Check Your Progress I1
1) There are three levels 'of health care exist in the country. They are:
a) . Primary care level
b) Secondary care level
c) Tertiary care level
2) The changing concepts of health care are:
a) comprehensive health care (provide adequate preventive, curative
and promotive health services)
b) Basic health services (Assuring the availability of competent professional
and auxillary personnel.) '
c) Primary Health Care (A new approach to health care)
Check Your Progress I11
1) A basic health service is understood to be a network of coordinated,
pevteral and intermediate health units capable of performing effectively
a selected group of functions essential to the health of an area and assuring
the availability of competent professional and auxiliary personnel to perform
these functions.
2) The Primary health care delivery was first proposed by Bhore committee
in 1946.
3) There are eight elements of primary health care:
i) Education concerning prevailing health problems and the methods
of preventing and controlling them.
ii) Promotion of food supply and proper nutrition.
iii) An adequate supply of safe water and basic sanitation.
iv) Maternal and child health care, including family planning.
V) Immunization against major infectious disease.
vi) Prevention and control of locally endemic diseases.
vii) Appropriate treatment of common diseases and injuries.
viii) Provision of essential drugs.
Check Your Progress IV
1) There are four main principles of primary health care:
9 Equitable distribution
ii) Community participation
iii) Intersectoral coordination
iv) Appropriate technology
2) The fundamental principle of HFA. Strategy is equity, that is, an equal
health status for people and countries, ensured by an equitable distribution
of health resources. The world assembly define health for all as:
Attainment of a level of health that will enable every individual to lead
onA
o o n n 4 ~ l l s r l xv n~A n n ~ t 4 x r o1;fo
a ~ n n n - 4 ~ ~ l m
 Health Care Services
Check Your Progress V
1) The health care services are designed to meet the health needs of the
community through the use of available knowledge and resources. The
services provided should be comprehensive and community based. The
resources must be distributed according to the needs of the community.
2) The three main health analysis data are as follows:
a) Demographic conditions of the population.
b) Environmental conditions which have a bearing on health.
c) Socio-economic factors which have a direct effect on health.
Check Your Progress VI
1) The five main health problems are:
i) Communicable disease problems
ii) Nutritional problems
iii) Environmental sanitation problems
iv) Medical care problems
v) Population problems.
2) Communicable diseases are the following:
Malaria, Tuberculosis, Diarrhea diseases, Acute Respiratory diseases (ARI),
Leprosy, Filaria, AIDS, Kala-Azar, Meningitis, viral hepatitis, Japanese
encephalitis, enteric fever, guinea worm disease etc.
Check Your Progress VII
1) The basic resources for providing health care are:
a) Health manpower
b) Money and material
c) Time (loss of time)
2) The following are the essential ingredients of primary health care services.
i) Health care should be comprehensive
ii) Accessible to all
iii) Acceptable
iv) Provide scope for community participation
V) Available at .a cost the community and country can afford.
Check Your Progress VIII "

1) There are following schemes which implement the health policy at village
level:
i) Village health guide scheme
ii) Training of local dais
iii) ICDS. Scheme (integrated child development scheme)
2) Following are the essential functions of PHC.
a) Medical care
b) MCH including family planning
c) Safe water supply and basic sanitation
A\ D * a x r a n t < n m - n A nfint--1 Inn-11-r n-An-in Aimnnoao
Health Information for
Social Workers e) Collection and reporting of vital statistics
f) Education about health
g) National health programmes - as relevant
h) Referal services
i) Training of health guides, health workers, local dais and health assistants
j) Basic laboratory services
Check Your Progress IX
1) Apart from the primary health centers; the present organization of health
services of government sector consists of rural hospitals, subdivisional/
tehsiytaluka hospitals, district hospitals, specialist hospitals, and teaching
institutions. Besides these health insurance services, employees state insurance
scheme, central government health scheme, defence medical services,
private agencies, indigenous systems of medicine, voluntary health agencies
are working to provide their services to the people.
2) The voluntary agencies in India are following:
i) Indian Red Cross Society
ii) Hind Kusht Nivaran Sangh
iii) Indian Council for Child Welfare
iv) Tuberculosis Association of India
V) Bharat Sewak Samaj
vi) Central Social Welfare Board
vii) The Kasturba Memorial Fund
viii) Family Planning Association of India
ix) All-India Women's Conference
x) All India Blind Relief Society
xi) Professional Bodies
xii) International Agencies.
3) The National Health Policy in India has the following elements:
i) A greater awareness of health problems and means to Solve these,
in and by the communities.
ii) Supply of safe drinking water and basic sanitation, using technologies
that people can afford.
iii) . Reduction in existing imbalance in health services by concentrating
on the rural health infrastructure.
iv) Establishment. of dynamic health management information system to
support health planning and health programme implementation.
v) Provision of legislative support to health protection and promotion.
vi) Concerted actions to combat widespread malnutrition.
vii) Research in alternative method of health care delivery and low-cost
health technologies.
viii) Greater coordination of different system of medicine.
UNIT 5 SOCIAL, ECONOMIC AND
PSYCHOLOGICAL FACTORS
INVOLVED IN HEALTH CARE.
SERVICES
Contents
5.0 Objectives
5.1 Introduction
5.2 Socio-economic and Psychological Factors Involved i n
Health Care Services
5.3 Concept of Patient as a Person and Rights of the Patient
5.4 Role of Social Worker in Health Care System
5.5 Study, Diagnosis, Treatment, Discharge, Follow-up and Rehabilitation
5.6 Working with Open Community, Health Care Team,
Hospital Staff and Various Levels
5.7 Let Us Sum Up
5.8 Key Words
5.9 Suggested Readings
5.10 Answers to Check Your Progress

5.0 OBJECTIVES
The aim of this unit is to explain the various psychological, social and economic
factors in health and to examine the scope of social worker in community
and in the hospital.

When you complete this unit you will be able to:

state the psychological, social, economic factors involved in health;
understand the concept of the patient as a person and their rights;
describe the goals to be achieved by social worker; and
describe the tasks of social worker in community and in hospital.

5.1 INTRODUCTION
Health is multifactoral. The factors which influence health lies both within the
individual and externally in the society in which heishe lives. It is a truism
to say that what man is and to what disease he may fall victim depends on
a combination of two sets of factors-his genetic factor and the environment
factors to which he is exposed.

These factors interact and the result of these interactions may be health of
individuals and whole communities may be considered to be the result of
many interaction. Some of the important variables are indicated in the diagram
below:

The present unit attempts to explore these determinants and also the role of
social worker at various levels.
Health Information for
Social Workers 5.2 'SOCIAL,ECONOMICAL AND PSYCHOLOGICAL
FACTORS INVOLVED IN HEALTH CARE
SERVICES
According to WHO, "Health is state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity. Providing conditions
for achieving normal health for all is the duty of the state and society. In
fact it is the deepest urge of humanity to be healthy. Health is one of the
essentials of life without which nothing can be achieved. The sick and hungry
child can't learn and the sick and hungry adult can't produce. Health is a
means of social development and vice versa. The success of any health care
delivery system to meet health needs of a society is depending upon the
extent of people's participation or utilization of services by the people. Various
factors social, economic and psychological have important significance in
Health Care Service. On the basis of some of the studies by sociologists,
anthropologists, social workers and medical scientists it has been advocated
that health and diseases are not merely biological phenomena. The socio-
cultural and economic environment, faith in supernatural powers and other
related belief style, nature of medical profession and services and their utilization
also affect the health and disease profile of a community. It indicates that
the consideration of such factors is indispensable to planning, organizing,
implementing and monitoring the medical and health care programmes in any
community for far reaching results.
Social Factors
There are several swial factors which determine the health and disease profile
in a community. The social factors are various like religion, caste, education,
occupation, family, life-style, income and living conditions. The health status
of a social group cannot really be maintained and safeguarded unless the
importance and interrelationship of these factors with health and disease is
understood. The study of religion and caste in a community is relevant to
ensure people's participation in comprehensive community health care programmes.
Various infections and respiratory diseases occur more in particular religious
and caste groups because of their life-styles. It is due to certain rituals and
religious observances which people practise out of belief and faith in their
cult. This factor renders particular religious groups unable to prevent illness.
For example, when small-pox was widespread, Hindus used to refuse for
small-pox vaccination due to the fear of Mata Maiya (Bari Mata) a goddess
- which was considered to cause this epidemic; Muslims for example are reluctant
to accept family planning for obvious religious reasons. Similarly there are
certain occupations which are still caste specific. The unhygienic conditions
related with these occupations are responsible for appended diseases more
prevalent in these castes. Education is supposed to generate understanding
which facilitates utilization of health and social welfare facilities and accomplishes
people's accessibility and participation in such programmes. Education again
prepares individual to make proper choices of therapeutic alternatives, appropriate
medical technologies, physicians and institution. The lifestyle components such
as proper path, proper rest, exercises, smoking, alcoholism etc. also affect
health accordingly.
Economic Factors
Economic conditions have long been known to influence human health. For
the majority of the world's people, health status is determined primarily by
their level of economic development, e.g. per capita GNP, education, nutrition, Social, Economic and
Psychological Factors
employment, housing, the political system of the country etc. The per capita Involved in Health Care
GNP is the most widely accepted measure of general economic performance. Services

No doubt that in many developing countries, it is the economic progress that

has been the major factor in reducing morbidity, increasing life expectancy
and improving the quality of life. The economic status determine the purchasing
power, standard of living, quality of life, family size and the pattern of disease
and deviant behaviour in the community. It is also an important factor in
seeking health care. Ironically, affluence may also be a contributory cause
of illness as exemplified by the high rates of coronary heart disease, diabetes
and obesity in the upper socio-economic groups. Family income is the prime
determinant of social status and there are certain diseases which mostly occur
in lower socio-economic class. The diseases which occur most in lower income
group according to Park (1983) are chronic bronchitis, tuberculosis, gastroenteritis,
leprosy, cervical cancer etc. The upper classes essentially have lower morbidity
and mortality in relation to the diseases indicated.
Psychological Factors
Various psychological factors play an important role in one's health. The living
conditions, hectic life-style, lack of rest and sleep, lack of recreation and
entertainment leads to mental stress, anxiety and depression thus it leads to
mental illness. Sometimes person start smoking and consuming alcohol in
order to reduce their mental stress and develop addiction which affect the
dependants of the earning member. Besides due to negligence and lack of
faith in staffs of hospitals, people do not go there for treatment. Hospital staff,
including doctors have no sympathetic attitude towards patients and the patients
try to avoid going to hospital. Medical social worker understands the feeling,
pain and condition of the patient and can motivate the patients towards their
treatment.

5.3 CONCEPT OF PATIENT AS A PERSON AND

RIGHTS OF THE PATIENT
Introduction
"Patient" is a word by which doctors and medical field differentiate between
healthy and sick person. A normal person acts normally in social atmosphere
but when he contacts a disease, he begins to behave abnormally and gets
influenced by his disease. He gets affected mentally because of negative
attitude of others toward him. Proceeding in this manner, "a patient is also
a person according to humanity. Health is man's normal condition. It is result
of living in accordance with the natural laws pertaining to the body, mind and
environment. These laws are related to fresh air and sunlight, balanced diet,
regular exercise, rest, relaxation and sleep. Cleanliness-internal and external,
right attitudes, good-habits and good patterns of living. In the absence of
any one of the above conditions a person feels unhappy and condemns or
pities himself. In the lack of means he becomes maladjusted and he is not
able to get along well with others. The patient suffering from such type of
chronic diseases like AIDS, T.B., Leprosy and psychiatrically, person feels
always null himself not only physically but mentally as well; consequently, he
looses his recognition, and self assertion, which is more important for a social
being. Such type of demoralization deviates him from normal social activities
and this is the problem where the services of a social worker is required.
Health Information for because, patient is a bona fide citizen or member of a society or of state.
Social Workers
So he has following fundamental human rights.
1) Standard of living adequate for the health and well-being of himself and
his family.
2) The preamble to the fundamental rights of every human being to enjoy
the highest attainable standard of health.
3) Inherent in the right to health or medical care.
4) Some countries have used the term "Right to health protection" which
is assured by a comprehensive system of social insurance that provides
material security in cases of illness or accident.
5) Free medical education.
6 ) Medicaments and other necessary materials.
7) The right to be cared for by society in old age and invalidity.

In the increasing number of societies, health is no longer accepted as a

charity, but demanded as a right for all, however, resources are limited. The
government cannot provide all the needed health services. Under these
circumstances the aspirations of the people should be satisfied by giving them
equal right to avail health care services.

The concept of "right to health" has generated so many questions viz., right
to medical care, right tojesponsibility for health, right to healthy environment,
right to food, the right not to procreate (family planning, sterilization, legal
abortion). Rights of the diseased persons (determinations of death at autopsies,
organ removal) and the right to die (suicide, hunger strike, discontinuation
of life support measures), etc. Many of these issues have been the subject
of debate.
Restoration of Impaired Capacities of the Patient
Negative behaviour of his family members' relatives and hardship is harmful
to patient, and compel the patient to feel inferior and gradually maladjusted.
Restoration of impaired capacity of the patient is required harmonious behaviour
and he may be provided all that is needed to restore his self-respect, to
provide equal opportunity, to participate in every activity in family, as well
as in society. The wardship must be effective to provide all the opportunities
belonging honorable placement in society. The financial establishment is also
an important factor to restore his previous personality. He should not feel
ignored by family.
Diagnosis and Therapeutic Activities
Medical social worker is skilled to study the patient's problem and then,
diagnose for recommending appropriate treatment. The primary function of
a medical social worker is to secure the maximum effectiveness of medical
care for the patient. The problems for which the patient needs the help of
a medical social worker include:
Economic problems like inability to pay for the medicines and prosthetic
aids, transport to attend the clinic or hospital or to return home after
discharge, temporary financial assistance to support the family when bread-
winner is ill etc.
Problems of shelter when the patient after discharge has no place to go
 to or the relations do not accept him because of some handicap or the Social, ~ c o n o m i eand
'
Psychological Factors
other, arrangements for his stay when hospitalization is not possible so Involved in Health Care
Services
that he can continue the treatment.
Problems of irregularity in treatment e.g. refusal to accept the suggested
treatment, inability to follow the instructions of doctors, and problems
in adjusting to the hospital.
Problems in rehabilitation, like difficulties in retaining the job or unemployment
due to illness or desertion by the family members;
Problems in social relationships due to illness, like strained relations with
parents or spouse or empioyers.

The second major function is to share his understanding of the patient's

personality, family and social relationship and his economic and living conditions
with the doctors and other colleagues like nurses, physical and occupational
therapists etc.

An act in the name of "Indian Mental Health Act" was passed by Parliament
of India in 1987 where it was suggested that a mentally ill person would be
called psychiatrically ill person here after.
Rights of Patient
Any Indian who is suffering from any disease, has following rights:
Patient has the right that he can take treatment from any government
hospital or primary health centre free of charge.
Patient has the right to take medicine from hospital (Govt.) free of charge.
Any patient who is admitted in hospital, has right to meet his relatives
time to time.
Patient has the right to have breakfast and lunch free of cost or on
subsidized rate.
There is a provision of concession in particular hospital fees for the
patients living below poverty line.
There must be an emergency treatment arrangement for the vitally and
seriously ill person.
Recreational facilities for patients must be provided in the hospital campus
that may be indoor and outdoor according to the needs of the patient.
The patiefit has right to live in a neat and clean atmosphere and he must
not be deprived of it.
There is a provision of health insurance scheme for the prevention of
health of the individuals.
The state government affords the cost of treatment for economically poor
patient.

Check Your Progress I

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What are social factors involved in health?
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Health Information for
Social Workers .....................................................................................................
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2) What are the rights of patient?
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3) What do you mean by patient?
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5.4 ROLE OF SOCIAL WORKER IN HEALTH

CARE SYSTEM
A) Direct Services to Client
1) ' Social evaluation of individual patient in terms of their ability to participate
in treatment process.
2) Interpretation of nature of illness to the patient and his family on an
individual or group bases.
3) %sits of patient's home, school, work-place for assessment of the psycho-
social situation to help the patient and hislher family to cope with the
illness and further spread of illness and for rehabilitation.
4) Counselling and helping the patient and family to deal with the psycho-
social problems arising out of illness and influencing perpetuation of problems;
prognosis, treatment processes and rehabilitation.
5) Environment modification to work with employers, school, and neighbourhood.
6) Organising therapeutic educational and recreational activities for group
of patient and follow-up programmes of clients.
7) Referring patients and their families to other social welfare agencies if
and when necessary.
B) Teamwork
1) Interpreting the role of social worker to other team member.
2) Interpreting the psycho-social needs of patient to the team members.
3) Participation in diagnosis and planning the treatment.
4) Consultation to and from other members of the team.
5) Work with various members of team to extend better patient care.
 Social, Economic and
The above can be done by individual contacts, group discussions rounds and Psychological Factors
joint conferences. Involved in Health Care
Services
Community Health
Involve the community in carrying out a community survey, collect data
through records, publication, contacts outside the community, use
communication media to identify and interpret needs.
Prepare the people through heath education to initiate and stress various
preventive and promoting programmes.
Development services for the various special group i.e. handicapped,

i aged etc.
Create an awareness of root causes of illness in the community, mobilize
people, discuss and suggest ways and means of techniques and problems
and take action outside and within the community.
Develop training programmes for volunteen in community for implementation
of projects, develop direct leadership in the community for administration
or projects and coordinate the various programmes.
Encourage the use of medicine approved by the treatment team.
Create contacts with other community people facing similar type of problems
to enlist their support.
Provide consultation services through periodical meetings with the community.
Work through contacts with the individual and family and various groups,
with the available health resources in the community.
Administrative Task
Participating in decision making regarding discharge, placement and transfer
of patients.
Programme planning implementation and evaluation of activities related
to own unit.
As representative of social service department participation in planning
and administration of hospital's programmes including hospital's committees.
Maintaining diaries for adequate organisation and ongoing evaluation of
I workload maintaining register, correspondence, files and case records.

I Preparing monthly and annual reports of social work activities and pdcipating
in the preparation of annual report of the social work department.
Interpreting the role of institution to other agencies and the community
at large.
Utilizing various media like T.V., Radio, Newspaper, journals for public
relation with the larger community.
Fund raising for various activities of social work department.
Role in Teaching, Supervision, Staff Developnient and Research
Participation in teaching programme of social work student, medical
students, physiotherapy and occupational therapy, nursing and others.
Training and guide to:
I
Social work students, for their field work.
NSS students.
I
Health Information for Profession and volunteers.
Social Workers
Make the liaison between the hospitals and social work institution to
make the curriculum and field work more relevant to the need of the
people and make the hospital understand the relevance of the institution.
Participation in seminar, conferences, case presentation and other staff
development programmes inside and outside the hospitals conducting
social surveys and research with other social workers and team workers.

5.5 STUDY, DIAGNOSIS, TREATMENT, DISCHARGE,

FOLLOW-UP AND REHABILITATION
Introduction
The diagnosis, treatment, discharge, follow-up and rehabilitation are very
important steps of health preservation. These steps are interrelated to each .
other. First, three steps i.e. study, diagnosis and treatment are known as
process and these are also interrelated among themselves.

The patient is a responsible person or participant at every steps in the solution

of his problem. When any person follows these steps, he achieves a satisfactory
goal.
Study
In this process of study medical social worker studies clients personality,
socio-emnomic condition, problem, factors affecting his problem and environmental
conditions etc. And also studies the feelings, emotions and other psychosocial
problems of the patient.

The fact-gathering process receives its impetus and direction from two sources-
the client's desire to tell about his difficulties and the worker's desire to
understand how they came about and what capacities exist for dealing with
them.
Diagnosis
"The attempt to arrive at an exact a definition as possible of the social
situation and personality of given patient."

According to Mary Richmond, psychosocial diagnosis is based on the collection

of data which are studied and analysed the diagnosis process and these are
also to identify the patient's personality structure and problem solving matter
of his client. After study, medical social worker decides the problem and
tseatrnent plan. So after study and before tseatment is the diagnosis i.e. diagnosis
is the middle step. Perlman said that accurate diagnosis depends upon adequate
study. If the study is good, the diagnosis process will be successful.
Treatment
Treatment process is the last important process. This pro-cess is those type
of phase when social worker, and patient both are interacted together. In
medical social work process treatment means psychosocial treatment and not
physical treatment and the relationship of worker and patient is professional
and medical social worker also tries that his patient adjusted very well in
society.
Treatment is an important process and in this process medical social worker Social, Economic and
Psychological Factors
help to modify the psycho-social problem of the patient. Involved in Health Care
Services

Medical social worker helps the patient and help his patient feel independent
and also show his capability and power.

Medical social worker also helps his patient to be self dependent and adjust
with his environment and social relationship.
Discharge
When any patient feels better and does not need hospital care and also wants
to get discharged, medical social worker can suggest the doctor accordingly.
Follow-up
Medical social worker does not end with the discharge of his patient. He
should do appropriate follow-up. This is specially needed in diseases like
tuberculosis where there is a danger of relapse. The social worker should
observe his patient whether the patient is adhering to the instructions given
to him by the medical team. He should also see whether the patient is able
to adjust to the new situation or not. The attitudes of the family members
and colleagues also can be observed and changes suggested if need be.
Rehabilitation
Rehabilitation has been defined as "the combined and coordinated use of
medical, social, educational and vocational measures for training and retraining
the individual to the highest possible level of functional ability." It includes
all measures aimed at reducing the impact of disabling and handicap to achieve
social integration.

Rehabilitation medicine has emerged in recent years as a medical speciality.

It involves disciplines such as physical medicine or physiotherapy, occupational
therapy, speech therapy, psychology, education, social work, vocational guidance
and placement services. The following areas of concern in rehabilitation have
been identified:
a) Medical rehabilitation - restoration of function.
b) Vocational rehabilitation - restoration of the capacity to earn a livelihood.
c) Social rehabilitation - restoration of family and social relationships.
d) Psychological rehabilitation - restoration of personal dignity at~dconfidence.

The patient must be restored and retrained not only "to live and work with
in the limits of his disability but to the hilt of his capacity." As such medical
rehabilitation should start very early in the process of medical treatment.

Thus every step is very important to remove patient problem and also very
helpful to patients. Without these steps patient does not feel better and with
these steps patient achieves his goal.

Check Your Progress I1

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What are the services provided by the social worker direct to the client?
Health Information for
Social Workers ......................................................................................................
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2) What are the steps involved in diagnosis?
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3) What is the importance of follow-up in the treatment of any patient?
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5.6 WORKING WITH THE OPEN COMMUNITY,

HEALTH CARE TEAM, HOSPITAL STAFF AND
VARIOUS LEVELS
A century ago, medical treatment was thought to be the only alternative of
bodily or mental disarrangement. But this assumption has undergone a radical
change after the scientific progress and the growth of social sciences. Now,
the disease of a patient involves two principal aspects namely:
0 Preventive and diagnostic
ii) Physiological and psycho-social.

As a result of this recognition, the need of social workers has increased in

the field of health and medical care. These medical social workers provide
their services at 3 levels-
i) Individual,
ii) Group,
iii) Community.

On the individual level, they provide their services through social casework
method while on group level, they provide services through social group
work in which emphasis is laid on interaction among members and participation
in group activities or therapies but individual casework is also done alongside.

At the community level, the social worker approaches a community as a

"Community Health Worker" (CHW). CHWs are men and women chosen
by the community, and trained to deal with the health problems of individuals
and the community and to work in close relationship with the health services.
Earlier, it was the belief that provision of sophisticated hospitals and of highly
 trained staff is the most efficient way of improving health. But now, the emphasis Social, Economic and
Psychological Factors
L is being placed on health rather than disease and on health care rather than Involved in Health Care
medical care. Public health is being given the same attention as to individual Services

case. The CHWs work to:

l

a) extend health services to the places where the people live and work,
b) support communities in idenwing their own health needs; and help people
to solve their own health problems.

When a CHW, works in community, he comes across two types of communities-

closed and open. A closed community is one which resists any kind of changes
and the open community is one which readily accepts and adopts changes
and new ways of life for the benefit of the community. So for CHWs, it is

1 easier to work with such community.

While working with a community in carrying out community survey, CHWs

collect data through records, publications and also make contacts outside
community, and use the communication media to identify and interpret needs.
They prepare people through health education to initiate and lay stress on
various preventive and promotional programmes. They develop services for
special groups, handicaps, aged people, their one of the very important task
is to create an awareness of root causes of illness in the community, mobilise
people, discuss and suggest ways and techniques and take action outside and
within the community. They develop training programs for volunteers in community
for implementation of projects and develop direct leadership in the community.
They encourage the use of medicine approved by the medical team. CHWs
help in creating contacts with other communities facing similar problems to
utilize their support. Periodic meetings are held with the community to provide
consultation services. They work through contacts with the individuals and
families and various groups with the health resources in the community.

Several community health workers may work as a team in the same village
with their Supervisor. Their duties will cover both health care and community
development, but what they do is restricted to what they have learned in
training. Certain health tasks may be tackled best by a male CHW and others
by a female CHW, depending on the wishes of the community, its customs
and its resources.

A medical social worker, while working with the health care team has to
maintain his own position and show hisher true worth. They interpret their
work to the other members of the team like the doctor, psychiatrist, psychologist
etc. He interprets to them the psychosocial needs of the patient. Also, he
contacts the family and acquaintances of the patient and finds out the economic
and social background of the patient and discuss with other members of the
team. He also participates in diagnosis and planning for treatment, rehabilitation
and intervening programmes. He consults to and from other members of the
team and work with them to extend better and best possible care to the
patient. Worker also individually contacts the patient and makes home visits
till they are completely healthy in all sense: physical, mental as well as social.

Medical Social Worker has certain roles to play with the hospital staff and
responsibilities towards the public. They participate in decision making regarding
discharge, placement or transfer of patient. They plan out the programmes,
implement them and also evaluate the activities related to their own units or
Health Information for department. Besides, they participate in planning and administration of hospital
Social Workers
as a representative of hospital social service department. They maintain diaries
for adequate organisation and evaluation of areas workload maintaining registers,
correspondence, file or case records. They have to prepare monthly and
annual reports of social work activities and participate in the annual report
of the social work department. They utilize the various media like TV, radio,
newspapers, journals for public relation with the larger community.
'
The social workers do not work in isolation in medical field. They are a part
of the health system and should be regularly supervised. He should know
when and how to seek guidance and to refer patients who are seriously ill
to a doctor for treatment. In spite of the fact, that in present scenario, the
role of medical social worker is very beneficial for the team, community and
the society at large. Their appropriate recopition and true worth is still
awaited in our country. At present the government is running many community
development programs whose success depends largely on the efficiency and
skill of social workers. But even then social work is still not as developed
in our country as its scope actually is and according to the needs of the society.
Roles of Social Worker
A medical social worker can use technical knowledge in preventing the various
diseases. He can play following roles in the medical setting-
1) As an enabler.
2) As a guide.
3) As a counsellor.
4) As a mediator.
1I
5) As an advocate. i
I
!
A medical social worker uses various methods like-social casework, social I
group work, community organization and Social Action in promotion of Health.
I

Check Your Progress I11

Note: a) Space is given below for your answers.
b) Check your answers with those given at the end of the unit.
1) What various methods can be used by the social worker to aware
the community regarding health?

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2) What are the objectives of community health worker?
 Social, Economic and
3) What is the role of social worker in a hospital setting? Psychological Factors
Involved in Health Care
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5.7 LET US SUM UP

In this unit we stated the determinants of health and various psychological,
economic and social factors involved in health and how do these factors
affect the health. In this unit we also tried to find out the patient as a person
proceeding that patient is also a person. We also have studied the rights of
a patient and the facilities in our society.

We identified the various task of the medical social worker that are rendering
direct services to the client, working with the team, the administrative task
in the hospital, promotion of community health and teaching, supervision of
the various students in the hospital.

In addition, we also tried to find out goals to be achieved by the Medical

Social Worker i.e. study of the problem of patient, diagnosis, treatment,
referral, discharge, rehabilitation and follow-up. We also had a brief look
how a health worker works in the open community, how he help in prevention
of disease by using the various methods i.e. educating the people, arousing
the interest, developing the habits and hygiene.

5.8 KEY WORDS

Social Relating to the people and society as a whole.
Psychology The scientific study of mind and behaviour
of human and animals.
Rights A power, privilege title etc. that someone
may claim legally or that is morally due to
them.
Diagnosis The process whereby a disease or disorder
is provisionally identified on the bases of
symptoms.
Discharge To allow someone to leave, to dismiss or
send away a person.
Economic Relating to or concerned with economy, the
organisation of moGy and resource.
Treatment The medical or surgical care that a patient
is given to cure an iilness or injury.
Environment The surrounding or conditions within which,
something or someone exist.
Determinants To fix or settle the exact limit.
Team A group of people working together
Health Information for
Social Workers 5.9 SUGGESTED READINGS
K. Park (17th edition) Nov. 2002, Preventive Medicine, MIS Banarsidas
Bhanot Publishers, Jabalpur.
WHO (1978) Health for All Sr. No. 1.
David, Mechanic (IInd Ed.) (1978), Medical Sociology A Comprehensive
Text
P. K. Bajpai, Social Work Perspective on Health.
Devi Sharan, Sharma (1988), Health, Hospital and Community, Aadhar Publication
Agra.

5.10 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress I
1) The factors are the religion, caste, education, occupation, family, life-
style, income and living conditions.
2) Patient has the right to take treatment, medicine, to get admitted in hospital,
right to meet his relatives, right to live in neat and clean atmosphere.
3) A patient is also a person and should be taken as a person according
to humanity.
Health is man's normal condition, his birth right.
Check Your Progress I1

1) To know the social atmosphere, environment modification, to refer the

patient to another agency, family visit etc.
2) Collection of data, identify the patients personality structure, identify the
problem, treatment plan.
3) Follow-up function after the discharge of patient, to know the patient
adjustment on personal and social adjustment.
Check Your Progress I11

1) By home visits, group discussion, demonstrations and family counselling.

2) - To deal with health problems of individuals and communities.
- To make aware the community dwellers.
- To give them treatment, counselling, case recording.
3) To develop reciprocal relationship between patient and team members.
To interpret the Psycho-social problems of patients to the hospital team.