Public Health Lecture Notes PDF

PUBLIC HEALTH COURSE CODE: LECTURER: DR. TIMOTHY BONNEY OPPONG  Course Description This course introduces students to the discipline of public health, focusing on the role of nurses in the promotion of population wellness. The main goal of public health is t...

PUBLIC HEALTH COURSE CODE: LECTURER: DR. TIMOTHY BONNEY OPPONG  Course Description This course introduces students to the discipline of public health, focusing on the role of nurses in the promotion of population wellness. The main goal of public health is to help prevent disease and reduce health risks at the population level through evidenced-based population assessment, policy development and education. The course provides information that will help the student apply skills and methods of teaching in caring for individuals and families including the aged at all levels of the primary health care program.  Course Content Introduction to and history of public health Determinants of health Principles and methods of disease prevention Health disparities Occupational health Health statistics Total family care Family: types and functions Factors affecting the family: cultural and religious beliefs, taboos, social class, status and role; economic (unemployment and poverty); mental illness; aging; separation, divorce, death. Community engagement  CLASS OBJECTIVES 1. To stimulate critical thinking abilities and use good judgement skills 2. To encourage self motivation and personal drive 3. To create an atmosphere where students enjoy learning. RULES 1. Respect for fellow classmates. 2. More than 3 absences without permission results in student being automatically dropped. 3. Lateness to class is ABSOLUTELY NOT ALLOWED. 4. There is NO favoritism, “helping”, and “considering”. NOTE: ONLY SERIOUS STUDENTS PASS THIS COURSE.  INTRODUCTION TO PUBLIC HEALTH The idea of public health is health for all. The broad mission of public health is to “fulfill society’s interest in assuring conditions in which people can be healthy.” Although public health focuses on different populations within the larger population when planning services, we are obligated to ensure health-producing conditions for all people—not just the poor, not just the rich, but people of all incomes; not only the young or the old, but people of all ages; not exclusively Whites or Blacks, or some tribes, but people of all races and ethnicities. The work of public health is a societal effort with a societal benefit. Public health takes the view held by many professions and societies throughout human history that healthy people are more productive and creative, and these attributes create a strong society.  Healthy people lead to better societies. For the welfare of the society, as a whole, it is better for people to be healthy than sick. There will be less dependence, less lost time from productive work, and a greater pool of productive workers, soldiers, parents, and others needed to accomplish society’s goals. Thus, as public health professionals, we believe that society has an interest in the health of the population; it benefits the society, as a whole, when people are healthy. The irony is that, public health acknowledges that a healthy population is not guaranteed. However, a healthy population is a possibility, and public health actions tends to make it highly probable  Public Health Defined The Institute of Medicine (IOM) defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1). This means that the mission of public health is “to generate organized community efforts to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health” (IOM, 1988). Prevention is public health’s historic and ideal approach to promoting health, and the distinguishing public health prevention strategy is to influence the “conditions” (i.e., the environment, in the fullest sense) in which people live.  HISTORY OF PUBLIC HEALTH One of the best ways to understand today and plan for tomorrow is to examine the past. This is certainly true for public health and public health nursing. Nurses use historical approaches to examine both the profession’s present and its future. What worked in the past? What did not work? What lessons can be learned about health care, nursing, and the communities in which care is provided? During times of rapid social change, it is important to examine history and try to learn from the events of the past and build on the events and actions that were effective. Public health is an interdisciplinary specialty that emphasizes prevention. Nurses have worked in communities to improve the health status of individuals, families, and populations, especially those who belong to vulnerable groups  Many varied and challenging public health nursing roles originated in the late 1800s, when public health efforts focused on environmental conditions such as sanitation, control of communicable diseases, education for health, prevention of disease and disability, and care of aged and sick persons in their homes. Although the threats to health have changed over time, the foundational principles and goals of public health nursing have remained the same. Many communicable diseases, such as diphtheria, cholera, and typhoid fever, have been largely controlled in the high income countries, but together with others such as, human immunodeficiency virus (HIV), tuberculosis, hepatitis, poliomyelitis and Ebola virus continue to affect many lives across the globe. Emerging and re-emerging communicable diseases with widespread impact, for example, the Covid-19 virus and influenza A subtypes such as 2009 H1N1 and underscore the truth that health concerns are international.  Even though environmental pollution in residential areas now receives increased public attention, communities continue to be threatened by overflowing garbage dumps and pollutants affecting the air, water, and soil. All people and all cultures have been concerned with the events surrounding birth, death, and illness. Human beings have sought to prevent understand, and control disease. Our ability to preserve health and treat illness has depended on the contemporary level of science, use and availability of technologies, and degree of social organization. The history of public health is a story of the search for effective means of securing health and preventing disease in the population. Epidemic and endemic infectious disease stimulated thought and innovation in disease prevention on a pragmatic basis, often before the causation was established scientifically.  During the past 150 years, two factors have shaped the modern public health system; firstly, the growth of scientific knowledge about sources and means of controlling disease Secondly, the growth of public acceptance of disease control as both a possibility and a public responsibility. In earlier centuries, when little was known about the causes of disease, society tended to regard illness with a degree of resignation, and few public actions were taken. As understanding of sources of contagion and means of controlling disease became more refined, more effective interventions against health threats were developed. Public organizations and agencies were formed to employ newly discovered interventions against health threats. As scientific knowledge grew, public authorities expanded to take on new tasks, including sanitation, immunization, regulation, health education, and personal health care. (Chave, 1984; Fee, 1987)  The prevention of disease in populations revolves around defining diseases, measuring their occurrence, and seeking effective interventions. Public health evolved through trial and error and with expanding scientific medical knowledge, at times controversial, often stimulated by war and natural disasters. The need for organized health protection grew as part of the development of community life, and in particular, urbanization and social reforms Religious and societal beliefs influenced approaches to explaining and attempting to control communicable disease by sanitation, town planning, and provision of medical care. Sometimes, religions and social systems have also viewed scientific investigation and knowledge as threatening, resulting in inhibition of developments in public health, with modern examples of opposition to birth control, immunization, and food fortification.  Before the Eighteenth Century Throughout recorded history, epidemics such as the plague, cholera, and smallpox evoked sporadic public efforts to protect citizens in the face of a dread disease. Although epidemic disease was often considered a sign of poor moral and spiritual condition, to be mediated through prayer and piety, some public effort was made to contain the epidemic spread of specific disease through isolation of the ill and quarantine of travelers. In the late seventeenth century, several European cities appointed public authorities to adopt and enforce isolation and quarantine measures (and to report and record deaths from the plague). (Goudsblom, 1986)  The Eighteenth Century By the eighteenth century, isolation of the ill and quarantine of the exposed became common measures for containing specified contagious diseases. Several American port cities adopted rules for trade quarantine and isolation of the sick. By the end of the eighteenth century, several cities, including Boston, Philadelphia, New York, and Baltimore, had established permanent councils to enforce quarantine and isolation rules. These 18th-century initiatives reflected new ideas about the cause and meaning of disease. Diseases were seen less as natural effects of the human condition and more as potentially controllable through public action. Also in the 18th century, cities began to establish voluntary general hospitals for the physically ill and public institutions for the care of the mentally ill. The Nineteenth Century: The Great Sanitary Awakening The nineteenth century marked a great advance in public health. This period marked the identification of filth as both a cause of disease and a vehicle of transmission and the ensuing embrace of cleanliness—was a central component of nineteenth-century social reforms. Sanitation changed the way society thought about health. Illness came to be seen as an indicator of poor social and environmental conditions, as well as poor moral and spiritual conditions. Cleanliness was embraced as a path both to physical and moral health. Cleanliness, piety, and isolation were seen to be compatible and mutually reinforcing measures to help the public resist disease  At the same time, mental institutions became oriented toward "moral treatment" and cure. Sanitation also changed the way society thought about public responsibility for citizen's health. Protecting health became a social responsibility. Disease control continued to focus on epidemics, but the manner of controlling turned from quarantine and isolation of the individual to cleaning up and improving the common environment. And disease control shifted from reacting to intermittent outbreaks to continuing measures for prevention. With sanitation, public health became a societal goal and protecting health became a public activity.  The Sanitary Problem With increasing urbanization of the population in the nineteenth century, filthy environmental conditions became common in working class areas, and the spread of disease became rampant. In London, for example, smallpox, cholera, typhoid, and tuberculosis reached unprecedented levels. It was estimated that as many as 1 person in 10 died of smallpox. More than half the working class died before their fifth birthday. London was not alone in this dilemma. In New York, as late as 1865, "the filth and garbage accumulate in the streets to the depth sometimes of two or three feet." In a 2-week survey of tenements in the sixteenth ward of New York, inspectors found more than 1,200 cases of smallpox and more than 2,000 cases of typhus. (Winslow, 1923) In Massachusetts in 1850, deaths from tuberculosis were 300 per 100,000 population, and infant mortality was about 200 per 1,000 live births. (Hanlon and Pickett, 1984)  Earlier measures of isolation and quarantine during specific disease outbreaks were clearly inadequate in an urban society. It was simply impossible to isolate crowded slum dwellers or quarantine citizens who could not afford to stop working. (Wohl, 1983) It also became clear that diseases were not just imported from other shores, but were internally generated. ''The belief that epidemic disease posed only occasional threats to an otherwise healthy social order was shaken by the industrial transformation of the nineteenth century." (Fee, 1987) Industrialization, with its overburdened workforce and crowded dwellings, produced both a population more susceptible to disease and conditions in which disease was more easily transmitted. (Wohl, 1983) Urbanization, and the resulting concentration of filth, was considered in and of itself a cause of disease. "In the absence of specific etiological concepts, the social and physical conditions which accompanied urbanization were considered equally responsible for the impairment of vital bodily functions and premature death." (Rosenkrantz, 1972)  At the same time, public responsibility for the health of the population became more acceptable and fiscally possible. In earlier centuries, disease was more readily identified as only the plight of the impoverished and immoral. The plague had been regarded as a disease of the poor; the wealthy could retreat to country estates and, in essence, quarantine themselves. In the urbanized nineteenth century, it became obvious that the wealthy could not escape contact with the poor. "Increasingly, it dawned upon the rich that they could not ignore the plight of the poor; the proximity of gold coast and slum was too close." (Goudsblom, 1986) And the spread of contagious disease in these cities was not selective. Almost all families lost children to diphtheria, smallpox, or other infectious diseases. Because of the deplorable social and environmental conditions and the constant threat of disease spread, diseases came to be considered an indicator of a societal problem as well as a personal problem. "Poverty and disease could no longer be treated simply as individual failings." (Fee, 1987) This view included not only contagious disease, but mental illness as well.  New ideas about causes of disease and about social responsibility stimulated the development of public health agencies and institutions. As environmental and social causes of diseases were identified, social action appeared to be an effective way to control diseases. When health was no longer simply an individual responsibility, it became necessary to form public boards, agencies, and institutions to protect the health of citizens. Sanitary and social reform provided the basis for the formation of public health organizations.  Late Nineteenth Century: Enter Bacteriology Another major set of developments in public health took place at the close of the nineteenth century. Rapid advances in scientific knowledge about causes and prevention of numerous diseases brought about tremendous changes in public health. Many major contagious diseases were brought under control through science applied to public health. Louis Pasteur, a French chemist, proved in 1877 that anthrax is caused by bacteria. By 1884, he had developed artificial immunization against the disease. During the following few years, discoveries of bacteriologic agents of disease were made in European and American laboratories for such contagious diseases as tuberculosis, diphtheria, typhoid, and yellow fever. (Winslow, 1923)  The identification of bacteria and the development of interventions such as immunization and water purification techniques provided a means of controlling the spread of disease and even of preventing disease. The germ theory of disease provided a sound scientific basis for public health  Early 20th Century: Move Toward Personal Care Although disease control was based on bacteriology, it became increasingly clear that individual persons were more often the source of disease transmission than things. It also became clear that providing immunizations and treating infectious diseases did not solve all health problems. Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population. There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified. It also became clear that diseases, even those for which treatment was available, still predominantly affected the urban poor. Registration and analysis of disease showed that the highest rates of morbidity still occurred among children and the poor.  On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education. School health clinics were set up in Boston in 1894, New York in 1903, Rhode Island in 1906, and many other cities in subsequent years (Bremner, 1971). Numerous local health agencies set up clinics to deal with tuberculosis and infant mortality. By 1915, there were more than 500 tuberculosis clinics and 538 baby clinics in America, predominantly run by city health departments. These clinics concentrated on providing medical care and health education. As public agencies moved into clinical care and education, the orientation of public health shifted from disease prevention to promotion of overall health.  Epidemiology provided a scientific justification for health programs that had originated with social reforms. Public health once again became a task of promoting a healthy society. In the twentieth century, this goal was to be achieved through scientific analysis of disease, medical treatment of individuals, and education on healthy habits. In 1923, C. E. A. Winslow defined public health as the science of not only preventing contagious disease, but also of "prolonging life, and promoting physical health and efficiency." History Concluded Although science provided a foundation for public health, social values have shaped the system. The task of the public health agency has been not only to define objectives for the health care system based on facts about illness and health, but also to find means to implement health goals within a social structure. The boundaries of public health [have changed] over time with the perception of new health and social problems and with political, economic, and ideological shifts within the government and the nation. The history of public health has been one of identifying health problems, developing knowledge and expertise to solve problems, and rallying political and social support around the solutions. THE CHANGING CONCEPT OF HEALTH  Biomedical concept Absence of disease" based on "germ theory of disease“ Drawback: minimized the role of the environmental, social, psychological and cultural determinants of health. Ecological concept Health is a dynamic equilibrium between man and his environment, and Disease is a maladjustment of the human organism to environment.  Psychosocial concept: Stipulates that health is not only a biomedical phenomenon, but one which is influenced by biological, social economical, psychological, cultural and political factors of people. Holistic concept : It recognizes the strength of social, economic, political and environmental influences on health. (All the concepts together) Implies that all sectors of society have an effect on health. Ancient view: Sound mind, in a sound body, in a sound family, in sound environment  DEFINITIONS OF HEALTH WHO Definition: “ Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity and the ability to lead a socially and economically productive life”. Operational Definition of Health: “ A condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental” Therefore, Health means; (a) No obvious evidence of disease and that the person is functioning normally (b)(b) Several organs of the body are functioning adequately as well as in relation to one another.  New Philosophy of Health Health is a fundamental Human Right Health is the essence of productive life Health is inter sectorial Health is an integral part of development Health is central to the concept of quality of life Health involves individuals, state and international responsibility Health & its maintenance is a major social investment Health is a worldwide social goal  Responsibilities in health promotion – the individual Individuals have various roles and levels of responsibilities for health promotion. We can consider the following. 1. At the most basic level, every individual has the responsibility to promote his own health. This means the individual has to get educated about health. Examples; risk and protective behaviors, nutrition, etc. They are then expected to make choices that promote their health. 2. Promoting the health of those around them: This includes promoting health to friends, family and acquaintances in home, schools, churches, etc. For example, parents are responsible for providing safe environment, nutrition, etc. for children. Also, among friends, one may encourage her peers to quit smoking or drinking, pick up exercising, etc. 3. Individuals may pick greater roles in healthcare that may place greater responsibilities on them. Example, one becoming a doctor and doing his job very well. Ø The role of the individual may vary depending on his position in the society. Example; a parent may play a different role from a child however, they both can be active in health promotion. Ø The same goes for individuals who choose the medical profession. A nurse may play a different role as compared medical doctor, physiotherapist, etc, 4. With technology being rampant, the individual can promote health by writing a blog, sharing health information on social media, etc.  Responsibilities in health promotion – the community Community groups, including families, schools, religious organization, etc. play very important roles in health promotion and are responsible for health promotion within their community. Many communities also have community health centers and hospitals where much health promotion takes place within the local community. Some communities have recreational places for relaxation which promotes mental health. Religious organizations Religious organizations especially in Ghana take up many responsibilities that help to promote the health individuals in the community. Firstly, they give their platforms for health education on problems such as HIV/AIDS education, personal hygiene education, etc. They may serve as location and encouragement for giving vaccines. Religious organization also may take larger roles with social responsibilities like building and operating clinics, hospitals, etc. Religious organizations increase social health, provide purpose for life, and increase mental health though often they are not thought of when considering health promotion because of a lack of focus on physical health. Schools Schools are the biggest community group and our society’s main provider of education and child care between the ages of 5 and 18. These childhood and teenage years are some of the most important years in developing healthy habits and gaining a solid basis for health literacy and general health knowledge. For example; schools may include a compulsory health promotion courses in curriculums. Dimensions of Health  Physical Dimension This is the perfect functioning of the body in which each organ is working in harmony with the maximum capacity How is it achieved? By exercising, healthy diet, adequate rest & sleep, and no addictions. What are signs of good physical health? A healthy skin texture, bright eyes, good BMI, a good appetite, regular bowel and bladder activities, smooth and easy coordinated movements, etc.  Evaluation of physical health Self assessment of overall health Inquiry into symptoms of ill-health and risk factors Inquiry into medications Inquiry into levels of activity Inquiry into use of medical services Standardized questionnaires for cardiovascular diseases Standardized questionnaires for respiratory diseases  Clinical examination Nutrition and dietary assessment, and Biochemical and laboratory investigations. Community Assessment of Physical Health At the Community Level, state of health may be assessed by such indicators as: Death rate Infant Mortality rate Life expectancy rate  Mental and Emotional Dimension Initially mental and emotional dimensions were seen one MENTAL HEALTH Definition: "A state of balance between the individual and the surrounding world, A state of harmony between oneself and others, A coexistence between the realities of the self and that of other people and that of the environment"  Attributes of a mentally healthy person Free from internal conflicts; he is not at "war" with himself. He is well-adjusted, i.e., he is able to get along well with others. He accepts criticism and is not easily upset. He searches for identity. He has a strong sense of self-esteem. He knows himself: his needs, problems and goals (this is known as self-actualization). He has good self-control; balances rationality and emotionality. He faces problems and tries to solve them intelligently, i.e., coping with stress and anxiety.  Emotional Dimension Emotional health is more about the feelings provoked by processing all the information we encounter. Elements that Constructs Emotional Health Being aware of your emotions Accepting your feelings Processing and managing those feelings Expressing your feelings Appropriately doing all of the above  Intellectual Dimension The intellectual dimension encourages creative, stimulating mental activities. A well person expands his or her knowledge and skills while discovering the potential for sharing one’s gifts with others. The mind should be continually exercised just as the body. To become intellectually well, it is important to explore issues related to problem solving, critical thinking, and adaptation to change. Intellectual wellness involves spending more time pursuing personal interests and reading books, magazines, and newspapers, while staying aware of current events and issues.  It is the ability to open one’s mind to new concepts and experiences that can be applied to personal decisions, group interaction and community enhancement, improve skills, and seek challenges in pursuit of lifelong learning. Tips and suggestions for optimal intellectual wellness: Take a course or workshop. Learn or perfect a foreign language. Seek out people who challenge you intellectual  Social Dimension Definition: “ The quality and quantity of an individuals interpersonal ties and the extent of involvement with the community”. Social health takes into account that every individual is a part of a family and a wider community and focuses on social and economic conditions and well being of the “Whole Person” in the context of his social network. There must be; Harmony and integration within the individual, Between each individual and other members of society and Between individuals and the world in which they live  Spiritual Dimension It refers to that part of the individual which reaches out and strives for meaning and purpose in life. It includes; Integrity principles and ethics The purpose in life, Commitment to some higher being and Belief in concepts that are not subject to "state of the art" explanation  Vocational Dimension When work is fully adapted to human goals, capacities and limitations, work often plays a role in promoting both physical and mental health. Importance of this dimension is exposed when individuals suddenly loose their jobs or are faced with mandatory retirement. For some this dimension may merely be a source of income but for others it may be source of self worth and life success. Goal achievement and self realization in work are source of satisfaction and enhanced self esteem  Other Dimensions Philosophical dimension Cultural dimension Socio-economic dimension Environmental dimension Nutritional dimension Curative dimension Preventive dimension  Hygiene Hygiene is described as the science of health and its preservation. The word hygiene originates from the name of a Greek goddess called Hygiea, who was the daughter of the first god of medicine called Desculapius. Hygiea lived with hygienic standards and also described activities that produce healthy body and mind to prevent diseases. Hygiene is therefore defined as the science of health which includes a system of principles designed for the promotion and preservation of health. This means therefore that hygiene is a matter of creating the physical conditions and personal practices to stay healthy  Hygiene then becomes a away of life, in that it involves what the person does with his body, the physical conditions in which he lives, as well as what goes into his body. Good health is what every individual desires to have and ill- health affects growth and development, as well as, decreasing productivity. People need to learn about good hygiene and ways to be healthy. The Community nurse needs to have knowledge in basic hygienic practices to help perform her role as an effective health promoter  Components of Hygiene There are 3 components of hygiene. 1. Personal hygiene: Personal hygiene is concerned with the individual measures taken to preserve ones own cleanliness, physical fitness and mental health. Eg: personal cleanliness, rest and sleep, exercise, good nutrition, good habit training, etc. Effects of Poor Personal hygiene 1. Not washing the hands after using the toilet, handling food, or touching dirty surfaces can spread bacteria, viruses, and parasites. These can lead to infections and diseases, like food poisoning, gastroenteritis, cold and flu, and hepatitis A. 2. Poor dental hygiene can lead to tooth decay, halitosis, gum disease, etc. 3. Not bathing can result in a skin conditions like dermatitis, itching of the skin, body odor, lice infestation, etc. 4. Lack of proper hygiene can also affect a person’s work and social life  2. Community or Environmental hygiene The total environment of human beings include all the living and non- living elements in their surroundings. Fitzpatrick and Kappos define environmental health as the theory and practice of accessing, correcting, controlling and preventing those factors in the environment that can potentially affect adversely, the health of present and future generations. Eg: Housing, air and ventilation, waste management, drainage system, pest control, food hygiene, port health, etc.  Effects of Poor environmental hygiene Not regularly cleaning areas that breed bacteria, like the kitchen and bathroom can breed insects like cockroaches who carry thousands of microbes and can cause food poisoning among others. Leaving garbage sitting outside can be a secondary cause of infections Not cooking or storing food properly can lead to food poisoning Not doing laundry often (clothing and sheets) can cause body odor. Smoke from fires releases carbon particles into the atmosphere and causes respiratory problems. Car fumes, leaking exhaust pipes contributes to the depletion of the ozone layer. Cross infections such as pulmonary tuberculosis, influenza and other respiratory infections are aided by poor ventilation.  Stuffy and muggy room smells make individuals uncomfortable. Water pollution causes waterborne diseases like cholera, dysentery, typhoid, etc. Lack of household pests control breeds pests like mosquitoes, houseflies, mice, etc. which all contributes to infections. When human excreta is not kept well, it causes contamination of the environment. It aids the spread of diseases like typhoid, cholera, etc. It could serve as breeding place for flies and rodents.  3. Food hygiene. Food hygiene is the practice of ensuring that anything we eat whether solid or liquid is wholesome. Food is an excellent medium for the growth of micro-organisms and so it is very necessary to keep a high standard of hygiene on food to avoid contamination which can lead to food borne-diseases. Since it is not always possible to detect contaminated food by using our senses like tasting, smelling, seeing, and touching, cleanliness in the care and handling of food should be of utmost importance. The care in handling of food should be optimized at all stages of food processing including, Production, Transportation Preparation/ processing, Storage and preservation and Serving and consumption  Effects of Poor Food Hygiene Poor food hygiene primarily leads to; 1. Poor nutrition 2. Infections and diseases  ENVIRONMENTAL HEALTH The relationships of human beings to their environment is reciprocal, in that, the environment has a profound influence on them and they in turn make extensive alterations to the environment to meet their needs and desires. In the course of these, man is day in and day out, polluting the environment to an extent which is threatening human survival in it. The increased production of industries is beneficial to man, but these benefits are offset by the pollution of air, land and water, which the most important natural resources for survival. Environmental health comprises those aspects of human health including quality of life that are determined by physical, chemical, biological, social and psychological factors in the environment.  Waste (Refuse) and its Management Waste/Refuse can be described as anything that is worthless or undesirable for keeping. It mostly consists of human excreta, animal droppings, rubbish from home, sheets and factories. Hospital waste can be soiled gauze, bandages and dressings, used syringes, gloves, etc. Types of Waste Waste can be solid or liquid 1. Solid waste: This can also be divided into wet and dry waste. a. Solid Dry Waste/Refuse: This includes waste materials that do not rot (non-degradable) such as empty cans, polyethene bags, broken bottles, rags, plastics, etc. and so on. In the hospitals dry refuse consists of dirty soiled dressing, used plaster, used disposable equipment e.g. needles, syringes, catheters, etc. ordinary dust that is swept from the ward b. Solid Wet Refuse: Solid wet refuse includes biodegradable materials. These are materials that decay such as, leftover foods, leaves, grass, animal droppings, dead animals, wood, farm produce, and so on. 2. Liquid waste comprises: This comprises of waste water from bathing, cooking washing and other domestic purposes. Waste can also be classified according to the purpose of the waste and where it is produced such as domestic, commercial, or industrial. Methods of Solid Refuse Collection and Disposal Collection and disposal methods depend on the local condition and aims of preventing nuisance;-that is, offensive smell, breeding of mosquitoes and houseflies, pollution of food and water. Considering the widely varying circumstances of developing countries such as Ghana, it becomes clear that no one system is likely to be appropriate to the needs of all communities. It is important, therefore that a wider range of options should be considered with the options varying between simple techniques used by rural communities to the most specialized recent types in cities and big towns.  Collection of Refuse Refuse or rubbish is collected from every part of the home and deposited in refuse bins in the home. The content of the refuse bins are emptied at the disposal site, using the appropriate technique available as follows: 1. House to disposal site: This method is used in the village or smaller towns. The refuse is carried from houses in containers to the final disposal site. 2. House to public refuse (dust) bin: In the big towns and cities refuse is collected from the house into smaller or household bins which are emptied into public dust bins placed at vantage points accessible to all community members. The household dust bins should be placed in an open space conveniently from the kitchen. 3. Public refuse (dust) bin to disposal site - The public dust bins are emptied of the refuse to the final disposal sites with special cart vehicles.  Methods of Solid Refuse Disposal 1. Crude dumping/uncontrolled tipping/mass dumping 2. Controlled dumping or tipping/burying 3. Incineration or Burning. 4. Barging Tipping into the sea 5. Composting 6. Garchey process 1. Crude Dumping or Uncontrolled Tipping: This is the method of refuse disposal where all the rubbish (both dry and wet solid refuse) is dumped at one place without sorting them. This means that rubbish like broken bottles, empty cans, peels of food, leaves, papers and so on are dumped together in the open. This type of method is mostly used in village communities and slum areas Advantages 1. It is a cheap method of waste disposal and not require anyskills to practice it. 2. It does not waste time  Disadvantages 1. It creates a breeding place for flies, mosquitoes, cockroaches, fleas and other vectors which cause a variety of diseases such as cholera, typhoid fever, other diarrhocal diseases and malaria among others. 2. It attracts rats which cause diseases like plague. 3. It makes the environment untidy and stinky. 4. It can choke water ways to cause flooding. 5. The burnable material causes fire outbreaks 6. The decomposition of the organic matter in the refuse renders the air impure for health (pollution). 7. Children may be attracted to defecate on this refuse dump to infect themselves and cause the spread diseases.  Controlled Tipping/Dumping In this method trenches are constructed for the refuse to be dumped in. Refuse is dump near trenches and sorted out. The dangerous part like broken bottles and piecing articles dumped into the trenches with the organic part on top. At the end of the day, the refuse covered with soil after spraying with insecticides. Sometimes trenches which have been previously dug for other purposes like building other construction works and are left uncovered can be used as disposal sites for solid refuse. If this is properly managed as above, it becomes a type of controlled tipping call sanitary landfill.  Precautions under controlled tipping 1. Trenches should be between 5-7 meters long. 2. Layers of refuse should not be more than 2.5 meters deep and should be covered with 40 centimetres of earth. 3. Not more than 23 square meters should be left uncovered at a time. 4. The trenches should not be dug into water 5. If the refuse contains much organic matter it should be covered with about half a meter of earth. 6. Inorganic matter like tins, broken bottles and other pointed and sharp mate should not be near the surface. 7. The dump should be fenced to prevent the light rubbish from being blown about by the wind. 8. Each layer should be allowed to settle before the next is added.  Advantages of controlled tipping 1. It is a satisfactory method especially where there are big trenches to be filled. 2. It may be used to reclaim a land for recreational purposes. Disadvantages 1. If there is a nearby source of water it may be polluted 2. If not well controlled it can become crude dumping and pose health hazards.  Incineration This is a satisfactory and much used method of dry refuse disposal in towns and cities. Here the refuse is put into a specially built enclosed fire place called incinerator and burnt to ashes, To achieve this, the refuse is first dumped into a drying shed near the incinerator for the refuse to dry (exposed). The refuse is then sorted out removing the incombustible ones like broken bottles, iron tins which are then disposed off either by controlled tipping method or by the pulverization method. The dry part of the refuse is then put into the incinerator before the moist part. Fire is then set on the dry part and as the dry refuse burns it dries the moist refuse until the whole refuse catches fire and burns to ashes or clinker (solid ash), which is good manure for farms.  The ashes or clinker are removed and the place prepared for the next refuse incineration. This method needs sanitary men to dry and burn the refuse satisfactory. Advantages 1. It is hygienic 2. Burning reduces the original weight of refuse (to about a quarter) 3. The ashes or clinker produced after burning can be used as manure 4. The incombustible refuse can be used to fill deep trenches and uneven lands. Disadvantages 1. The smoke pollutes the environment 2. If not properly controlled it can cause fire outbreak. 3. The drying and sorting make it tedious to do (will need sanitary men).  Composting This method is used to decompose the refuse. It is mainly for the disposal of dry refuse but sometimes it is combined with human excreta. Composting is a method used to recycling organic or degradable waste for agricultural purposes (as manure). A pit is dug about 4 metres wide and 1 metre deep and organic part of the dry refuse is put into it. Water or excreta may be added to it when refuse is dry, to give moisture and speed up decomposition. This is covered with soil without spraying and allowed to rot. A few days later the material is forked out and spread to dry for one month and used as manure  Advantages 1. Profit is made from the sale of the manure 2. No big area is needed 3. No offensive odour is created 4. Fly breeding is prevented due the heat generated by the decomposition Disadvantage Unsuitable for communities with large quantities of refuse  Barging or Dumping into the Sea This is done where the town is near the sea or big lake. It is carried out with the approval of a health inspection team. The refuse is packed in sacks and taken to a distance well beyond the ebb of the tide in outboard motor boats so that the waste does not flow back to the beach or shore. Advantages 1. No breeding of flies 2. No offensive odour 3. No fire outbreaks 4. Refuse is not seen to cause eye saw Disadvantages 1. It pollutes water and cause danger to swimming 2. If not dumped deep enough it can be thrown back on the beaches to pose a danger to health.  Garchey Process This is mostly used in developed countries and designed to serve blocks of flats. It is suitable for grouped domestic buildings which connect with a system of vertical shafts leading to an underground collecting chamber. The refuse is flashed by waste water into the collecting chamber. The excess water drains through an overflow pipe and the refuse is flashed by waste into the collecting chamber. The excess water drains through an overflow pipe and the refuse is suctioned to a refuse disposal station and is either burned or buried.  Advantages 1. No fly breeding 2. No mosquito breeding 3. No rat infestation 4. No nuisance caused Disadvantages 1. It needs plenty of water to flush the refuse 2. Not suitable for developing countries Scope of Public Health Nursing Dr. Timothy Bonney Oppong The scope of practice for the Public Health Nursing among others is anchored on the concepts of the Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). In this regard, the PHN; Ø Performs professional core functions as a member of the District Health Management Team (DHMT)/Sub District Health Team (SDHT) Ø Demonstrates ability for continuous professional development and life-long learning in a changing society. Ø Contributes to and promote Primary Health Care Services/CHPS in the community especially the vulnerable population and high-risk groups Ø Conducts community assessment, diagnosis, plan, implement and evaluate community programmes towards preventive, promotive and rehabilitative services ØProvides emergency obstetric care and refer patients/clients with conditions beyond his/her competence to appropriate authority Ø Implements national health policies and apply its relevance to nursing and midwifery Ø Participates in the disease surveillance in the community Ø Collaborates with other members of the SDHT and other health related agencies in the community to plan, implement and monitor health activities Ø Provides Family Planning, Testing and Counseling, STI’s/HIV and AIDS, Adolescent, Geriatric, Maternal and Child health services Ø assesses the physical and mental health needs of individuals, diagnose and treat specified diseases and make referrals when necessary Ø Identifies nutritional needs, health and social resources available in the community and mobilize the community to utilize them Ø Undertakes logistics management Ø Practices pharmacovigilance ØPlans and conduct health promotion programmes based on community diagnosis and prevailing health issues Ø Demonstrates leadership and administrative capabilities in managing health care units within the framework of the national health policy and the regulatory framework using reflective/journaling practice Ø Plans, organize, coordinate and implement national immunization programs and Child Welfare Clinics Ø Plans and implement School Health Programs/Services Ø Manages financial resources in accordance with relevance financial regulations Ø Liaises with stakeholders and community leaders to advocate for Positive behavioral change in harmful cultural practices Ø Implements rehabilitative activities in the community Ø Plans and conduct routine and special home visits to families Ø Supervises the work of Nurse Assistants (Preventive) Ø Demonstrates and apply entrepreneurial skills in Nursing Ø Incorporates the use of nursing informatics using the latest versions of available software in the care of patients and the analysis of data generated to improve care outcomes Ø Participates in the conduct of research in public health related issues Ø Demonstrates and apply innovation in practice Ø Keeps all necessary records, ledgers and transmit accordingly Ø Offers end of life palliative care in accordance with nursing standards  Role of the midwife in Public Health Nursing a. Promotive and preventive. The nurse has interaction with clients in the hospitals and communities everyday. Each conversation or encounter with someone is a vital opportunity to help them improve their own health and wellbeing. For some, this might mean providing motivational advice about the importance of staying well to an alcoholic during pregnancy. Others may try engaging school children about healthy eating options. Or through teachings on HIV/AIDS and safe sexual practices. We can also do this by becoming role models in communities improving public knowledge about health and empowering people to make positive choices for themselves.  Preventive care focuses on preventing disease and illness and promoting overall general health and well being. Nurses work to prevent risk factors for disease through patient education. They provide instruction on healthy diets, immunizations, and exercise. They also discuss the dangers of risky behavior, such as tobacco and drug use. Nurses in preventive care identify risk factors and strive to detect disease in the early stages to prevent the spread or worsening of symptoms. In preventive care, nurses work with other medical professionals to provide preventive care to help maintain the good health and quality of life for all individuals. b. Facilitative supervision, monitoring and evaluation. Facilitative supervision is an approach to supervision that emphasizes mentoring, joint problem solving, and two-way communication between the supervisor and those being supervised. It is a system of management whereby supervisors at all levels in an institution focus on the needs of the staff they oversee. Supervisors who use the facilitative approach consider staff as their customers. The most important part of the facilitative supervisor’s role is to enable staff to manage the quality improvement process, to meet the needs of their clients, and to implement institutional goals. Adoption of a facilitative approach leads to a shift from inspection and fault-finding to assessment and collective problem solving to continuously improve the quality of care. c. Case detection, mobilization and referrals Case detection is that form of screening of which the main objective is to find disease and bring patients to treatment. OR “A systematic or opportunistic process that identifies individuals (with a condition) from a larger population for a specific purpose, for example, vaccination. Nurses/midwifes detect cases during the regular nursing assessment process and through clinical consultation with a patient, where the nurse has no preexisting concern of a particular condition. It is essential to identify individuals at risk for disease. Case finding is also important for early diagnosis of those with infectious and noninfectious disease(s), including foodborne and waterborne illnesses. Case detection can also be done through routine home visits and during vaccinations. Another way is also through outreach by the public health nurse. Outreach locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained. Cases that are detected in the communities, homes or during outreaches can the be referred to the appropriate department for necessary care to be given. d. Curative and Rehabilitative Curative care involves treatment intended to alleviate the symptoms or cure a current medical condition. It strives to reduce pain, improve function, and help improve the quality of life for patients. Examples of treatment options include medications, casts and splints for broken bones, dialysis for kidney conditions, and chemotherapy for cancer. Nurses provide and coordinate curative care for patients in various environments. They set up plans for the care of patients, carry out medical treatments, observe patients, and discuss conditions with doctors and other medical staff. They also assist with diagnostic testing and evaluating results. Nurses perform an important role in instructing patients and families on how to manage their medical condition and explain home care and follow up treatments.  In rehabilitative care, nurses assist patients with temporary and long- term disabilities or chronic illnesses. They assist in adapting to their conditions, meeting their highest potential, and living more independent lives. They commonly use holistic approaches to medical treatment to meet all needs of patients. They work with patients and family members to establish a treatment plan and establish short and long-term goals. They also prepare patients and caregivers for changes that occur in rehabilitative treatment. e. Working with the sub-district health team Nurses collaborate with the sub-district health team to implement and monitor health activities.  PREVENTION AND CONTROL OF COMMUNICABLE DISEASES Communicable diseases are caused by infectious agents (Viruses, bacteria, fungi) that can be transmitted to other people from an infected person, animal or a source in the environment. Transmission is often through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air. Some examples of the communicable disease include HIV, hepatitis A, B and C, measles, salmonella, measles and blood-borne illnesses. Most common forms of spread include fecal-oral, food, sexual intercourse, insect bites, contact with contaminated fomites, droplets, or skin contact.  TRANSMISSION OF COMMUNICABLE DISEASES The transmission of communicable diseases depends on the successful interaction of the infectious agent, the host, and the environment. These three factors make up the epidemiologic triangle.  Changes in the characteristics of any of the factors may result in disease transmission. Consider the following examples; a. Antibiotic therapy not only may eliminate a specific pathologic agent, but also alter the balance of normally occurring organisms in the body. As a result, one of these agents overruns another and disease, such as a yeast infection, occurs. b. HIV performs its deadly work not by directly poisoning the host but by destroying the host’s immune reaction to other disease- producing agents. c. Individuals living in a temperate region may not normally contract malaria at home. However, they may become infected if they change their environment by traveling to a climate where malaria- carrying mosquitoes thrive.  The Agent Factor Four major categories of agents cause most infections and infectious disease: bacteria (e.g., Salmonella and E. coli), fungi (e.g., Aspergillus spp. and Candida spp.), parasites (e.g., helminthes and protozoa), and viruses (e.g., hepatitis A and B and HIV). The individual agent may be described by its ability to cause disease and by the nature and the severity of the disease. Infectivity, pathogenicity, virulence, toxicity, invasiveness, and antigenicity, terms commonly used to characterize infectious agents  The Host Factor A human or animal host can harbor an infectious agent. The characteristics of the host that may influence the spread of disease are host resistance, immunity, herd immunity, and infectiousness of the host. Resistance is the ability of the host to withstand infection, and it may involve natural or acquired immunity. Natural immunity refers to species-determined, innate resistance to an infectious agent. For example, opossums rarely contract rabies. Some people have also been found to have natural immunity to HIV. Acquired immunity is the resistance acquired by a host as a result of previous natural exposure to an infectious agent. Having measles once protects against future infection. Acquired immunity may be induced by active or passive immunization. i. Active immunization refers to the immunization of an individual by administration of an antigen (infectious agent or vaccine) and is usually characterized by the presence of an antibody produced by the individual host ii. Passive immunization refers to immunization through the transfer of a specific antibody from an immunized individual to a nonimmunized individual, such as the transfer of antibody from mother to infant or by administration of an antibody-containing preparation (immunoglobulin or antiserum). - Passive immunity from immunoglobulin is almost immediate but short lived. It is often induced as a stopgap measure until active immunity has time to develop after vaccination. - Examples of commonly used immunoglobulins include those for hepatitis A, rabies, and tetanus. Herd immunity refers to the immunity of a group or community. It is the resistance of a group of people to invasion and spread of an infectious agent. - Herd immunity is based on the resistance of a high proportion of individual members of a group to infection. It is the basis for increasing immunization coverage for vaccine-preventable diseases - Through studies, experts determine what percent coverage (e.g., >90%) of a specified group of people (e.g., children entering school) by a specified vaccine (e.g., one dose of measles vaccine) is necessary to ensure adequate protection for the entire community against a given disease and target immunization campaigns and initiatives to meet that goal. - The higher the immunization coverage, the greater the herd immunity Infectiousness is a measure of the potential ability of an infected host to transmit the infection to other hosts. - It reflects the relative ease with which the infectious agent is transmitted to others. Example; - Individuals with measles are extremely infectious; the virus spreads readily on airborne droplets. - A person with Lyme disease cannot spread the disease to other people.  Environment Factor The environment refers to everything that is external to the human host, including physical, biological, social, and cultural factors. These environmental factors facilitate the transmission of an infectious agent from an infected host to other susceptible hosts. Reduction in communicable disease risk can be achieved by altering these environmental factors. Using mosquito nets and repellants to avoid mosquito bites, installing sewage systems to prevent fecal contamination of water supplies, and washing utensils after contact with raw meat to reduce bacterial contamination are all examples of altering the environment to prevent disease.  Modes of Transmission Infectious diseases can be transmitted horizontally or vertically. Vertical transmission is the passing of the infection from parent to offspring via sperm, placenta, milk, or contact in the vaginal canal at birth. Examples of vertical transmission are transplacental transmission of HIV and syphilis. Horizontal transmission is the person-to-person spread of infection through one or more of the following four routes: direct/ indirect contact, common vehicle, airborne, or vector borne. Most sexually transmitted infections are spread by direct sexual contact. Enterobiasis, or pinworm infection, can be acquired through direct contact or indirect contact with contaminated objects such as toys, clothing, and bedding.  Common vehicle refers to transportation of the infectious agent from an infected host to a susceptible host via food, water, milk, blood, serum, saliva, or plasma. Hepatitis A can be transmitted through contaminated food and water, and hepatitis B through contaminated blood. TB spreads via contaminated droplets in the air. Vectors are arthropods such as ticks and mosquitoes or other invertebrates such as snails that transmit the infectious agent by biting or depositing the infective material near the host. Vectors may be necessary to the life cycle of the organism (e.g., mosquitoes and malaria) or may act as mechanical transmitters (e.g., flies and food)  Disease Development Exposure to an infectious agent does not always lead to an infection. Similarly, infection does not always lead to disease. Infection depends on the infective dose, the infectivity of the infectious agent and the immunocompetence of the host. Infection refers to the entry, development, and multiplication of the infectious agent in the susceptible host. Disease is one of the possible outcomes of infection and it may indicate a physiological dysfunction or pathologic reaction. The incubation period is the time interval between invasion by an infectious agent and the first appearance of signs and symptoms of the disease. Examples, the incubation periods of infectious diseases vary from between 2 and 4 hours for staphylococcal food poisoning to between 10 and 15 years for AIDS (HIV stage III).  The communicable period is the interval during which an infectious agent may be transferred directly or indirectly from an infected person to another person. The period of communicability for influenza is 3 to 5 days after the clinical onset of symptoms. Hepatitis B–infected persons are infectious many weeks before the onset of the first symptoms and remain infective during the acute phase and chronic carrier state, which may persist for life.  PREVENTION AND CONTROL OF INFECTIOUS DISEASES 1. Prevention and Control Programs Infectious disease can be prevented and controlled. The goal of prevention and control programs is to reduce the prevalence of a disease to a level at which it no longer poses a major public health problem. In some cases, diseases may even be eliminated or eradicated. The goal of elimination is to remove a disease from a large geographic area such as a country or region of the world. Eradication is removing a disease worldwide by ending all transmission of infection through the complete extermination of the infectious agent  Primary, Secondary, and Tertiary Prevention There are three levels of prevention in public health: primary, secondary, and tertiary. Primary Prevention In prevention and control of infectious disease, primary prevention seeks to reduce the incidence of disease by preventing occurrence, and this effort is often assisted by the government. Many interventions at the primary level, such as freely supplied vaccines national immunization programs, etc, are population based because of public health mandates. Nurses deliver childhood immunizations in public and community health settings, check immunization records in daycare facilities, and monitor immunization records in schools.  Secondary Prevention The goal of secondary prevention is to prevent the spread of infection and/or disease once it occurs. Activities center on rapid identification of potential contacts to a reported case. Contacts may be a. Identified as new cases and treated, or b. Determined to be possibly exposed but not diseased and appropriately treated with prophylaxis. Public health disease control laws also assist in secondary prevention because they require investigation and prevention measures for individuals affected by a communicable disease report or outbreak. These laws can extend to the entire community if the exposure potential is deemed great enough, as could happen with an outbreak of cholera, smallpox or epidemic influenza.  Although many infections are acute, with either recovery or death occurring in the short term, some exhibit chronic courses (AIDS/HIV stage III) or disabling sequelae (leprosy/ Hansen’s disease) Nurses perform much of the communicable disease surveillance and control work in many countries. Tertiary Prevention Tertiary prevention works to reduce complications and disabilities through treatment and rehabilitation.  Role of Nurses in Prevention Prevention is at the center of public health, and nurses perform much of this work. Examples include immunizations for vaccine-preventable disease, especially childhood immunization and the monitoring of immunization status in clinic, daycare, school, and home settings. Nurses work in communicable disease surveillance and control, teach and monitor bloodborne pathogen control, and advise on prevention of vector borne diseases. They teach methods for responsible sexual behavior, screen for sexually transmitted infection, and provide HIV disease counseling and testing. They screen for TB, identify TB contacts, and deliver directly observed TB treatment in the community  REPRODUCTIVE HEALTH The term reproductive health simply refers to healthy reproductive organs with normal functions. Taking the WHO’s definition of health into consideration, we could define reproductive health as “a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity, in all matters related to the reproductive system and to its functions and process” Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.  RH addresses the human sexuality and reproductive processes, functions and system at all stages of life and implies that people are able to have “a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.” Reproductive health is life-long, beginning even before women and men attain sexual maturity and continuing beyond a woman's child- bearing years. Half of the world’s over 3 billion women are now 15 – 49 years of age. Without proper health care services, this group is highly vulnerable to problems related to sexual intercourse, pregnancy, contraceptive side effects, etc.  Demography and Population In the last century an all-round development in various fields significantly improved the quality of life of the people. However, increased health facilities along with better living conditions had an explosive impact on the growth of population. The world population which was around 2 billion in 1900 rocketed to about 6 billion by 2000 and 7.2 billion in 2011. Currently, the world’s population is almost 8 billion people. Population growth in Ghana has been on a similar trajectory. Ghana’s population in 1950 was less than 5.1 million and rocketed to 19.6 million in 2000 and 25.5 million in 2010 to the current estimated 34 million by the close of 2023. A rapid decline in death rate, maternal mortality rate (MMR) and infant mortality rate (IMR) as well as an increase in number of people in reproducible age are probable reasons for this.  Demography is the scientific study of human populations. It involves analysis of three observable phenomena: changes in population size, the composition of the population and the distribution of populations in space. It involves analysis of three observable phenomena: changes in population size, the composition of the population and the distribution of populations in space. Demographers study five processes: fertility, mortality, marriage, migration and social mobility. These 5 processes determine populations’ size, composition and distribution. Basic understanding of demography is essential for public health practitioners because the health of communities and individuals depends on the dynamic relationship between the numbers of people, the space which they occupy and the skills they have acquired.  Understanding the structure of a population in terms of the numbers and proportions of men and women in different age groups informs the planning of preventive and healthcare interventions. One way of depicting the structure of a population is a population pyramid or age pyramid. This is a graphical way of presenting population data by sex and age group as seen in that for India, the UK and Ghana in the next 3 slides.  Population trends World population trends available from the United Nations (UN) show that the following; While the population at the global level continues to increase, that of more-developed regions as a whole is hardly changing. Virtually all population growth is occurring in the less developed regions with rapid population growth being a characteristic of the 50 least developed countries. Collectively, these regions will grow 58 per cent over the next 50 years, as opposed to 2 per cent in more-developed regions. Less-developed regions will account for 99 per cent of the expected growth in world population over this period.  Reasons for Population Trends These overall population trends are underpinned in the main by distinct changes in fertility and mortality across the globe. Migration also plays a part when large numbers of people move from one country to another 1. Fertility Fertility refers to the actual bearing of children, the child-bearing performance of a woman, couple or population. In more-developed regions people bear insufficient children to replace those people who die and this trend, termed below-replacement fertility, is expected to continue to 2050. Conversely, fertility is still high in most of the least-developed countries; it is expected to show some decline but still remain higher than the rest of the world.  Fertility is influenced by various factors. In the developing countries these include universality of marriage, lower age at marriage, low level of literacy, poor standard of living, limited use of contraceptives and traditional ways of life 2. Mortality Mortality describes the death rates due to a range of causes. Trends in mortality have been shifting over time and still vary across the globe. Most people nowadays live longer on average than the wealthiest people did a century ago. Despite these gains there remains a huge preventable burden of premature death and disease worldwide.  In 2009, there were approximately 56 million deaths worldwide, and over three quarters occurred in less-developed regions of the world. A quarter of all deaths occur in children under five; almost all of these deaths occur in low-income countries. Communicable diseases are responsible for over 40% of deaths in low- income regions but non-communicable diseases account for a rising proportion of deaths also. The highest rates of child mortality continue to be in sub-Saharan Africa where 1 child in 8 died before the age of 5 in 2009. By 2021, 1 in 26 children died before the age five in sub-Saharan Africa. The leading causes of death were preterm birth complications, birth asphyxia/trauma, pneumonia, diarrhea and malaria; all of which are preventable.  Maternal Mortality The maternal mortality rate has reduced dramatically over the last two centuries, especially in the developed world, as a result of reforms of obstetric practice and the reduction in puerperal sepsis. Currently, over 500 women die in childbirth for every 1000,000 live births in sub-Saharan Africa. It is estimated that 390 women will die in childbirth for every 100 000 live births by 2030 in sub-Saharan Africa. The current maternal mortality rate in Ghana is 310 out of 100,000 live births. The current cause of maternal deaths in Ghana are hemorrhage (postpartum and antepartum), abortion, miscarriage, sepsis, obstructed labor, ectopic pregnancy, Pre-eclampsia and embolism  Reasons for Reduction in Death Rates 1. In most part, the decrease in death rate is explained by the dramatic changes in the social and economic determinants of health. 2. The implementation of public health interventions have had some effects on the reduction of death rate too. 3. General medical interventions such as simple ORS have had more impact especially on child mortality in low-income countries. 4. “High-tech’ medical interventions have also had some effects although very little.  3. Migration Due to advances in transport, communication and trade the world is experiencing ever-increasing movements of people. Currently, as many as 281 million people are living outside their countries of origin. This movement occurs not only from developing countries to developed countries but also from one developed country to another, as well as between developing countries.  Positive Effects of Migration Increase in level of education: Many young people who travel abroad especially from developing countries to developed ones do so for educational purposes. Some return home with the knowledge they have acquired. It has a positive effect on income (for example, through remittances as migrants send funds home to families).  Negative Effects of Migration Decrease in educational level as young people take up unskilled positions abroad or those educated abroad fail to return home. Migration may also increase socio-economic inequity as some individuals, communities or countries benefit more than others. Increases poverty and inequity within countries where rural-to-urban migration is high (for example China). In rural areas the poorest cannot afford to move and those who move into cities tend to be the more educated. Increases personal vulnerability due to the potential for illegal migration and ‘human trafficking’. For example, women recruited as domestic labor may be vulnerable to sexual exploitation. Leads to racism and isolation. Leads to a reduction in the human capital needed to deliver key services at home  With declining fertility rates and aging populations many developed countries use managed migration as a way of meeting their demographic, economic-development and labour-market needs. Migration that increases population sizes or alters patterns of infectious diseases may result in changing needs for health-care. Public health professionals need to ensure that local health services are culturally sensitive and accessible to migrants (e.g. through appropriate translation services). Many countries have migrant health screening in place to protect the indigenous population from communicable diseases  Demographic Transitions The demographic transition describes the change in birth and death rates from high fertility and high mortality rates in more traditional societies to low fertility and low mortality rates in so- called modern societies. Five stages can be identified during a country’s demographic transition  Family Planning According to the WHO, family planning is defined as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. The ability of individuals to determine their family size and the timing and spacing of their children has resulted in significant improvements in health and in social and economic well-being. Smaller families and increased child spacing have helps decrease rates of infant and child mortality, improve the social and economic conditions of women and their families, and improve maternal health.  Family planning services include methods and practices to space births, limit family size and prevent unwanted pregnancies. Pregnancy by choice and not by chance is a basic requirement for women's health. Unintended pregnancy is associated with the following; Ø An increased risk of morbidity for the mother Øhealth-related behaviors during pregnancy, such as delayed prenatal care, tobacco use, and alcohol consumption, that are linked to adverse effects for the child. The mother may be at greater risk of depression and of physical abuse herself.  Also, her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and may fail to achieve their educational and career goals. Roughly 121 million unintended pregnancies occurred each year between 2015 and 2019. Of these unintended pregnancies, 61% ended in abortion. This translates to 73 million abortions per year. In Africa, the rate of unintended pregnancy averaged 90 per 1000 women between the age 15 to 49.  Unintended pregnancy and abortion in Western Africa In Western Africa, the unintended pregnancy rate declined by 8% between 1990–1994 and 2015–2019. During the same period, the abortion rate increased by 33%. The share of unintended pregnancies ending in abortion rose from 30% to 42%. In 2015–2019, there were a total of 19,900,000 pregnancies annually. Of these, 6,490,000 pregnancies were unintended and 2,740,000 ended in abortion.  The goal of family planning is to assist couples and individuals of all ages to achieve their reproductive goals and improve their general reproductive health. Beliefs and Misconceptions about Family Planning WHAT ARE SOME COMMONLY HELD BELIEFS AND MISCONCEPTIONS ABOUT FAMILY PLANNING DO YOU KNOW??????  Side Effects and Health Risks: Real or Imagined? To understand how myths about contraceptives take shape, it is important to see the link between imagined side effects and the very real ones that women encounter every day. Many modern contraceptives contain hormones that can cause certain side effects in some women. Depending on the method being used, these may include breast tenderness, headaches, weight gain, lack of regular menstrual bleeding, nausea, and/or loss of bone density with continued use over many years. These potential side effects often form the basis for a wide range of misconceptions.  For example, where women’s ability to bear children is key to their socio-economic status, they frequently fear that the temporary prevention of pregnancy with contraception can lead to permanent infertility with sustained use They may believe that lack of a monthly period signals a dangerous buildup of blood inside their bodies. Some believe that nausea that can be caused by an oral contraceptive may be a sign that acid in the pill is burning their stomach or ovaries. Others believe that contraceptive pills accumulate in some other body organ Fear of side effects, both real and imagined, is a major reason why women discontinue using contraception, which can result in unintended pregnancies  Some women believe that contraceptive use at too young an age could result in delayed childbearing or in infertility. Some believe it could lead to birth defects Fears that IUDs could be pushed inward during sexual intercourse and damage the women’s reproductive organs Some people believe that, contraceptives contribute to decreased sexual desires among women, ‘forcing’ men into infidelity.. Some men also fear that, with reduced risks of getting pregnant, their women will increase their sexual frequency and with more partners  Rumors about contraceptives are spread by and among women themselves, often through their informal social networks. Th sources of misinformation on contraceptives are often sourced from community members or peers. In addition, providers who do not understand how contraceptives work can help myths spread by incorrectly addressing the questions about genuine side effects that their patients bring up, which can confuse or scare these women to stop using family planning. A study of Brazilian gynecologists, for example, found that nearly 75 percent of them believed women who have never given birth can become infertile if given an intrauterine device (IUD) Incorrect understanding can also lead providers to deny women access to their desired contraceptive based on inaccurate information. For example, some providers are unaware that adolescents can safely use any modern contraceptive method, including long-acting methods such as the IUD.  The Objectives of family planning To provide information, education and counselling to individuals and couples to enable them to decide freely and responsibly, when to start child bearing, the number and spacing of their children To provide affordable contraceptive services and make available a full range of safe and effective methods To provide information on childbearing To assist couples to achieve pregnancy and have babies To prevent and manage RTIs including STI/HIV/AIDS To promote dual protection  Family Planning Methods in Ghana Temporary Methods Short Term 1. Condoms (Male and Female) Temporary Methods Short Term 2. Spermicides Temporary Methods Short Term 3. Oral contraceptive pills Examples; postinor-2, Lydia post pill, NorLevo, pregnon, Secure, Levon2.  Temporary Methods Short Term Combined injectables Doesn't require daily action. Eliminates the need to interrupt sex for contraception. Decreases menstrual cramps and pain. Lessens menstrual blood flow, and in some cases stops menstruation. Decreases the risk of endometrial cancer. Temporary Methods Short Term Progestin only Injectables Lactational Amenorrhoea Method (LAM) Natural Family Planning Methods (e.g. Standard Days Method)  Temporary Methods Long Term Intrauterine Device (IUD) e.g. Copper bearing, Levonorgestrel intrauterine System The implant releases a low, steady dose of a progestational hormone to thicken cervical mucus and thin the lining of the uterus (endometrium). The implant typically suppresses ovulation as well  Temporary Methods Long Term 2. Hormonal Implants: Jadelle, Zarin, Implanon Once the implant is placed under your skin, it releases small amounts of etonogestrel. The hormone works on your pituitary gland, which tells your ovaries not to release eggs. It also makes the mucus in your cervix thicker. This makes it harder for sperm to get to any eggs that are released Permanent Methods Tubal ligation (Female Sterilization). During tubal ligation, the fallopian tubes are cut, tied or blocked to permanently prevent pregnancy  Permanent Methods Vasectomy (Male Sterilization) Vasectomy, or vasoligation, is an elective surgical procedure for male sterilization or permanent contraception. During the procedure, the male vasa deferentia are cut and tied or sealed so as to prevent sperm from entering into the urethra and thereby prevent fertilization of a female through sexual intercourse  Cervical Cancer Cervical cancer is cancer that starts in the cells of the cervix. The cervix is the lower, narrow end of the uterus (womb). The cervix connects the uterus to the vagina (birth canal). Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which abnormal cells begin to appear in the cervical tissue. Over time, if not destroyed or removed, the abnormal cells may become cancer cells and start to grow and spread more deeply into the cervix and to surrounding areas.  The Cervix has 2 main parts 1. The ectocervix (also called exocervix) is the outer part of the cervix that can be seen during a gynecologic exam. The ectocervix is covered with thin, flat cells called squamous cells. 2. The endocervix is the inner part of the cervix that forms a canal that connects the vagina to the uterus. The endocervix is covered with column-shaped glandular cells that make mucus.  Types of cervical cancer Cervical cancers are named after the type of cell where the cancer started. The two. This is called mixed carcinoma or main types are: adenosquamous carcinoma. 1. Squamous cell carcinoma: Most cervical Very rarely, cancer develops in other cancers (up to 90%) are squamous cell cells in the cervix. carcinomas. These cancers develop from cells in the ectocervix. 2. Adenocarcinoma: Cervical adenocarcinomas develop in the glandular cells of the endocervix. Clear cell adenocarcinoma, also called clear cell carcinoma or mesonephroma, is a rare type of cervical adenocarcinoma. Sometimes, has features of both squamous cell carcinoma and adenocarcinoma  Symptoms Symptoms doesn’t normally show until the cancer has spread, making it harder to detect. Symptoms of Early Stage vaginal bleeding after sex vaginal bleeding after menopause vaginal bleeding between periods or periods that are heavier or longer than normal vaginal discharge that is watery and has a strong odor or that contains blood pelvic pain or pain during sex  Causes, Risk Factors, and Prevention HPV infection causes cervical cancer Long-lasting (persistent) infection with high-risk types of human papillomavirus (HPV) causes virtually all cervical cancer. Nearly all people who are sexually active will become infected with HPV at some point in their lives. HPV16 and HPV18 are the high-risk types that cause most cases of cervical cancer. Most HPV infections go away on their own as the immune system controls the infection. When a high-risk HPV infection lasts for many years, it can lead to changes in the cervical cells that, if untreated, can become cancer. Other factors can increase your risk of cervical cancer Some risk factors make it more likely for a person who has a high-risk HPV infection of the cervix to have a persistent infection that leads to severe cervical cell changes that can develop into cervical cancer. These risk factors include; 1. Having a weakened immune system 2. Smoking or breathing in secondhand smoke 3. Becoming sexually active at an early age and having multiple sexual partners. 4. Other reproductive factors: Both the use of oral contraceptives (birth control pills) and giving birth to many children have been found to be associated with cervical cancer risk. The reasons for these associations are not well understood  Prevention and Control Cervical cancer is highly preventable and highly curable if caught early. Nearly all cervical cancers could be prevented by HPV vaccination, routine cervical cancer screening, and appropriate follow-up treatment when needed. HPV vaccination: HPV vaccination is a safe and effective way to help prevent cervical cancer. Timing of HPV vaccination: Because HPV is transmitted sexually, the HPV vaccine offers the most protection when given before a person becomes sexually active. The CDC recommends routine HPV vaccination for girls and boys at age 11 or 12 years to ensure that they are protected before they become sexually active. For young people who weren’t vaccinated within the age recommendations, HPV vaccination is recommended up to age 26 years.  Cervical cancer screening Routine cervical cancer screening with HPV tests and Pap tests is also an important way to prevent cervical cancer. These tests can find abnormal cell changes and precancers that can be treated before they turn into cancer. So it is important for women to have regular screening tests starting in their early 20s. Because HPV vaccination doesn’t protect against all HPV types that cause cervical cancer, it’s still important to get screened at regular intervals. Condoms Condoms, which prevent some sexually transmitted diseases, decrease the risk of HPV transmission. However, they do not completely prevent it. Exposure to HPV is still possible in areas that are not protected by the condom.  Diagnosis Colposcopy Colposcopy is a procedure in which the health care provider inserts a speculum to gently open the vagina and view the cervix. A vinegar solution will be applied to the cervix to help show abnormal areas The health care provider then places an instrument called a colposcope close to the vagina. It has a bright light and a magnifying lens and allows the health care provider to look closely at the cervix.  Diagnosis Biopsy Biopsy is a procedure in which a sample of tissue is removed from the cervix so that a pathologist can view it under a microscope to check for signs of cancer. The following types of biopsies are used to check for cervical cancer: Punch biopsy, Endocervical curettage, Loop electrosurgical excision procedure (LEEP), Cone biopsy,  Cervical Cancer Stages Cancer stage describes the extent of cancer in the body, especially whether the cancer has spread from where it first formed to other parts of the body. This helps to plan treatment. The stages of cervical cancer are; Stage I cervical cancer Stage II cervical cancer Stage III cervical cancer Stage IV cervical cancer Recurrent cervical cancer  Sexual violence Sexual violence is sexual activity when consent is not obtained or freely given. Sexual violence impacts every community and affects people of all genders, sexual orientations, and ages. Anyone can experience or perpetrate sexual violence. The perpetrator of sexual violence is usually someone the survivor knows, such as a friend, current or former intimate partner, coworker, neighbor, or family member.  How big is the problem? Sexual violence affects millions of people each year worldwide. Researchers know the numbers underestimate this problem because many cases are unreported. Survivors may be ashamed, embarrassed, or afraid to tell the police, friends, or family about the violence. Victims may also keep quiet because they have been threatened with further harm if they tell anyone or do not think anyone will help them. The data shows; Sexual violence is common: One in 4 women and about 1 in 26 men have experienced completed or attempted rape. About 1 in 9 men were made to penetrate someone during his lifetime. Additionally, 1 in 3 women and about 1 in 9 men experienced sexual harassment in a public place. Sexual violence starts early: More than 4 in 5 female rape survivors reported that they were first raped before age 25 and almost half were first raped as a minor (i.e., before age 18). Nearly 8 in 10 male rape survivors reported that they were made to penetrate someone before age 25 and about 4 in 10 were first made to penetrate as a minor. Sexual violence disproportionately affects some groups: Women and racial and ethnic minority groups experience a higher burden of sexual violence. For example, more than 2 in 5 non-Hispanic American Indian or Alaska Native and non-Hispanic multiracial women were raped in their lifetime.  Types of Sexual Violence 1. Sexual Assault: This refers to sexual contact or behavior that occurs without explicit consent of the victim. Some forms of sexual assault include: Attempted rape Fondling or unwanted sexual touching Forcing a victim to perform sexual acts, such as oral sex or penetrating the perpetrator’s body Penetration of the victim’s body, also known as rape Rape is a form of sexual assault, but not all sexual assault is rape. The term rape is often used as a legal definition to specifically include sexual penetration without consent  2. Child Sexual Abuse Child sexual abuse is a form of child abuse that includes sexual activity with a minor. A child cannot consent to any form of sexual activity, PERIOD!. When a perpetrator engages with a child this way, they are committing a crime that can have lasting effects on the victim for years. Child sexual abuse does not need to include physical contact between a perpetrator and a child. Some forms of child sexual abuse include (but are not limited to): Ø Exhibitionism, or exposing oneself to a minor ØFondling ØIntercourse ØMasturbation in the presence of a minor or forcing the minor to masturbate ØObscene conversations, phone calls, text messages, or digital interaction ØProducing, owning, or sharing pornographic images or movies of children ØSex of any kind with a minor, including vaginal, oral, or anal ØSex trafficking ØAny other contact of a sexual nature that involves a minor. What do perpetrators of child sexual abuse look like? The majority of perpetrators are someone the child or family knows. As many as 93 percent of victims under the age of 18 know the abuser. A perpetrator does not have to be an adult to harm a child. They can have any relationship to the child including an older sibling or playmate, family member, a teacher, a coach or instructor, a caretaker, or the parent of another child. Child sexual abuse is the result of abusive behavior that takes advantage of a child’s vulnerability and is in no way related to the sexual orientation of the abusive person.”  Abusers can manipulate victims to stay quiet about the sexual abuse using a number of different tactics. Often an abuser will use their position of power over the victim to coerce or intimidate the child. They might tell the child that the activity is normal or that they enjoyed it. An abuser may make threats if the child refuses to participate or plans to tell another adult. Child sexual abuse is not only a physical violation; it is a violation of trust and/or authority.  What are the warning signs? Child sexual abuse isn’t always easy to spot and some survivors may not exhibit obvious warning signs. The perpetrator could be someone you’ve known a long time or trust, which may make it even harder to notice. Consider some of the following common warning signs: Physical signs: Bleeding, bruises, or swelling in genital area Bloody, torn, or stained underclothes Difficulty walking or sitting Frequent urinary or yeast infections Pain, itching, or burning in genital area Behavioral signs: Changes in hygiene, such as refusing to bathe or bathing excessively Develops phobias Exhibits signs of depression or post-traumatic stress disorder Expresses suicidal thoughts, especially in adolescents Has trouble in school, such as absences or drops in grades Inappropriate sexual knowledge or behaviors Nightmares or bed-wetting Overly protective and concerned for siblings, or assumes a caretaker role Returns to regressive behaviors, such as thumb sucking Runs away from home or school Self-harms Shrinks away or seems threatened by physical contact  3. Sexual Assault of Men and Boys Sexual assault can happen to anyone, no matter your age, sexual orientation, or gender identity. Men and boys who have been sexually assaulted or abused may have many of the same feelings and reactions as other survivors of sexual assault, but they may also face some additional challenges because of social attitudes and stereotypes about men and masculinity. Some men who have survived sexual assault as adults feel shame or self- doubt, believing that they should have been “strong enough” to fight off the perpetrator. Many men who experienced an erection or ejaculation during the assault may be confused and wonder what this means. These normal physiological responses do not in any way imply that the victim wanted, invited, or enjoyed the assault.  Men who were sexually abused as boys or teens may also respond differently than men who were sexually assaulted as adults. The following list includes some of the common experiences shared by men and boys who have survived sexual assault. ØAnxiety, depression, post-traumatic stress disorder, flashbacks, and eating disorders ØAvoiding people or places that remind you of the assault or abuse ØConcerns or questions about sexual orientation ØFear of the worst happening and having a sense of a shortened future ØFeeling like "less of a man" or that you no longer have control over your own body ØFeeling on-edge, being unable to relax, and having difficulty sleeping ØSense of blame or shame over not being able to stop the assault or abuse, especially if you experienced an erection or ejaculation ØWithdrawal from relationships or friendships and an increased sense of isolation ØWorrying about disclosing for fear of judgment or disbelief  4. Intimate Partner Sexual Violence Sexual violence most often is perpetrated by someone a survivor knows, and this includes intimate partner relationships. There are many different terms to refer to sexual violence that occurs within intimate partnerships, including: intimate partner sexual violence, domestic violence, intimate partner rape, marital rape, and spousal rape. No matter what term is used or how the relationship is defined, it is never okay to engage in sexual activity without someone’s consent. How does intimate partner sexual violence relate to other kinds of abuse? Sexual violence in a relationship is rarely an isolated incident. It often occurs alongside other forms of abusive behavior, including physical and emotional abuse. For instance, the majority of women who are physically assaulted by an intimate partner have been sexually assaulted by that same partner¹. Intimate partner sexual violence often starts with controlling behavior that can escalate to further emotional, physical, and sexual abuse.  5. Incest The term incest refers to sexual contact between family members. It can be difficult for an individual to disclose sexual assault or abuse when they know the perpetrator. It can be especially difficult if the perpetrator is a family member. What can keep a victim of sexual abuse by a family member from telling someone? They may care about the abuser and be afraid of what will happen to the abuser if they tell. They may also be concerned about other family members' reactions, fearing they won’t be believed or will be accused of doing something wrong. They may have already tried to tell someone what happened, but the abuse was ignored or minimized.  They have been told by the perpetrator that what is happening is normal or happens in every family, and they don’t realize that it is a form of abuse. They may not know that help is available, or they don’t know who to trust. They may be afraid of getting in trouble for telling, or that the abuser will follow through with threats.  Other forms of sexual violence Sexual Harassment - Sexual harassment includes unwelcome sexual advan