UNIT ONE: INTRODUCTION TO In this section you will start by defining the

community before moving on to explore the

COMMUNITY HEALTH concept of community health. You will also look at
how people organise themselves in the
This unit gives an introduction to the concept of community as individuals and families and how
community health and is divided into five sections. their behaviour can affect community
The first section looks at the concept of health. Finally you will look at home visiting.
community health nursing and how people
organise themselves within the community. The Objectives
second section looks at the principles of
community health nursing and the roles and By the end of this section you will be able to:
functions of a community health nurse. The third
section looks at vital statistics and epidemiology in
the community. The fourth and fifth sections  Define a community
describe the organisation of health care services  Define the concept of community health
in the community and how you can apply nursing
Information, Education and Communication (IEC)  List the aims of family health care
to promote health.  Describe the process of home visiting

This unit is composed of five sections: The Community

Section One: Concept of Community Health A community is a group of people (a large or small
Nursing group) living in a certain geographical area and
Section Two: Principles of Community Health working together for a common goal. They share
Section Three: Vital Health Statistics and the same resources such as water, climatic and
Epidemiology geographic conditions, health services,
Section Four: Organisation of Health Services administration and leadership, as well as
Section Five: Information, Education and disadvantages such as shortages, risks and
Communication (IEC) dangers.

Unit Objectives The community is made up of individual persons

By the end of this unit you will be able to: and each of these individuals belongs to a family.
The graphic on the right illustrates these three
components, with the individual surrounded by the
 Describe the concept of community health
nursing immediate and extended family, all of whom are a
part of the larger community.
 Describe the principles of community
health nursing
 Explain the role of a community health You will now look at the components that make up
nurse in the provision of health care a community starting with the individual.
 Explain vital health statistics
 Describe the principles of epidemiology Individual
 Describe the organisational structure of
the Ministry of Health Each individual you know is different and unique.
 Explain the health sector reforms Each has a mixture of characteristics, some of
 List the IEC skills in sharing health which they share with others and some of which
messages are part of a particular culture. Culture is all those
things which people learn, share and pass on to
later generations. One of the most important of
these things is language, for it is the means by
SECTION 1: CONCEPT OF which people communicate with one another.
COMMUNITY HEALTH NURSING
As a health worker you must be able to
Introduction communicate with individuals in the community
As mentioned in the introduction to this module, where you work and acquire some knowledge of
community health is concerned with the promotion the language they speak. It is important to be able
of health and prevention of diseases through to show respect and understanding for other
close community participation. people and their culture as well as knowing their
local practices like greetings.

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Individuals learn beliefs and customs about right Often there is an important figure in the family
and wrong behaviour as they grow up. For who makes the decisions or whose opinions are
example, in some areas, young people are taught highly valued. The opinion of people in the family
that dead ancestors can influence the lives of may be more important to a person than the
living people. If the ancestors become angry they opinion of a health worker. This has important
can cause disease and misfortune. Therefore, effects on health behaviour and the use of health
when you teach such individuals about the effects services. For example, in some communities
of germs on their health status, they may not be women may not be free to go to or take their
convinced and may opt to follow their traditional children to a health centre, even if they want to,
beliefs. because their husbands do not allow them. These
are important things to remember when you
Sometimes, people follow both sets of ideas – advise individuals about a health problem.
traditional and modern, whereby they consult the
dispensary for treatment of the symptoms and Types of Families
return to the traditional healer to get rid of what
they think is the „real‟ cause of the illness. As a There are different types of families in a
community health worker you need to understand community.
human behaviour and the factors that influence
their behaviour in order to be effective in your The Nuclear Family
community health activities.
This consists of a husband and a wife with or
An individual can only attain full health if they without children. This type of family brings forth
have wholesome growth. The place where this children (family of procreation). Children born in
wholesome growth can best be cultivated is the
this family consider it to be the family of their
family.
origin.
The Family
The Extended Family

The family is the smallest recognised group of This is also called a joint extended family. This
individuals in a community. It begins with a
family includes members of nuclear families and
marriage union in which husbands and wives other relatives, aunts, uncles, cousins, nephews
have certain rights and obligations. It is one of the
and grandparents.
oldest institutions that mankind has known. It
defies time, boundaries, cultures and human
understanding. Single Parent Family
It is therefore not surprising that scholars from all
over the world who have studied the family of This is formed when one parent brings up children
mankind do not agree on one single definition of alone either because of divorce, separation, death
the family. Rather than look at every available or desertion of their spouse.
definition of the family, you will consider one
which tends to agree on many aspects of the The Blended Family
family.
This type of family is formed when husband and
The family is a group of two or more persons, who wife bring into the new marriage unrelated
share emotional bonds and material things, children from their previous marriages.
usually live in the same household, are related by Cohabitation and homosexual marriages are also
blood, marriage or adoption, and sexual referred to as blended families.
relationship is socially approved for the parents.
Functions of the Family
The family is a very important social group in
community health. The family has many important functions, these
The family provides love, security and a sense of include:
belonging for individuals from the time they are
born. Many of a person‟s characteristics are
influenced by their family. For example, a child  Bringing about a sense of togetherness
learns from their family what behaviour is and a balance between individual and
acceptable in the community and the language its shared (mutual) action by each family
member; nurturance and trust; stability
parents speak. Families have a strong influence
and integrity of the group;
on what each member does.

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 interdependence and the ability to meet External Factors
demands for survival and development
 Socialising its members into the larger The external factors which influence the health of
community a family include:
 Teaching respect for individual members
and their property. This includes respect  Family locality
for differences among the family members  Terrain
and others
 Climate
 Teaching tolerance, fairness and a sense
 Water supply
of right or wrong among its members and
 Air
others
 Caring for its members and developing a  Biological environment (insects, rodents,
sense of trust between and among its etc.)
members  Housing and residence
 Providing an environment for learning and
internalising individual and gender roles Having seen the different components that make
and responsibilities up a community, now look at the functions of the
 Inducing its members to its religious faith community.
and teaching respect and tolerance for
religious differences The functions of a community include:
 Sharing leisure and recreation together
 Seeking external help from the community  Transmitting and sharing information,
for itself and its members ideas and beliefs
 Providing security and refuge for its  Educating its children about their culture
members in times of need (socialising) and welcoming newcomers
 Providing a socially sanctioned into the group‟s culture (acculturation)
environment for sexual expression  Producing and distributing services and
amongst married adults goods
 Seeking health care for its sick members  Providing companionship and support to
and providing nursing care for its sick, individual members and smaller groups
disabled or dependent members  Sharing and utilising space for living,
 Maintaining a healthy home environment schools, health facilities, fields, roads etc.
conducive to the development of its  Protecting individual and group rights and
members welfare

Factors Affecting Family Health Remember: The greatest human possession is

health.
The health of the family can be influenced by both A healthy community is a productive
internal and external factors. In order for you to be community.
able to assess and improve the health of a family,
you need to have knowledge of these factors. From the previous page, you can see that a
Look at each group of factors in turn. community functions as a medium for the growth
and development of its individual members. It
Internal Factors imposes the standards by which the individuals
are evaluated, if the community has high
The internal factors that influence the health of the expectations of its members, their performance
family include: also tends to be high. A good community is
judged by the kind of people it produces.
 Family size
 Structure Characteristics of a Healthy Community
 Type, members
 Relationship  Safe and healthy environment, relatively
 Biological characteristics and values free from natural and man-made hazards
 Community members have high
standards of personal hygiene
 Adequate supply of wholesome water
 Availability of adequate nutritious food
 Suitable housing

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  Harmonious interpersonal relationships Political System
among members
 Availability and accessibility of health care This sub-system is made up of the government
facilities and its development policies as well as political
 Availability and accessibility of suitable organisations.
educational, social and recreational If there is political support towards improving
facilities health care delivery, the government provides the
 Gainful occupational activities (availability mechanism and structure for the planning,
of stable or reliable sources of income) implementation and evaluation of the health care
 Sound communication infrastructure delivery system. The constitution of Kenya
 Communal approach to and participation contains a declaration for the elimination of
in tackling community problems poverty, ignorance and disease; hence the
establishment of the Ministry of Health and
Problems that Affect the Health of the several other ministries.
Community
Economic System
 Unsanitary environment
 Overcrowding The government‟s ability to provide health and
 Poverty other services to its citizens depends on the state
 Unclean and inadequate water supply of the economy. The poorer the economy of the
 Lack of nutritious food country, the more disadvantaged its people will
be. Low economic status is highly associated with
 Unsafe environment
malnutrition and communicable diseases.
 Epidemic and endemic disease
 Unstable family life
Education System
 Illiteracy and ignorance
 Poor leadership and lack of participation
 Adverse weather conditions Education is the main tool of changing behaviour
 Poor infrastructure and improving individual and community health.
Low educational status perpetuates under-
 Political instability
development, harmful traditions and superstitions.

Community Sub-systems The educational system can be effectively used to

A community is made up of various sub-systems, pass health related information and messages
all of which have a bearing on how people live that could significantly transform the perception of
and behave. For a community to function the communities on healthy living and prevention
smoothly the various sub-systems must work in of illnesses.
harmony. In the next sub-section you will look at
the eight sub-systems found in a community and
Religious System
how they influence the health of its people.

The religious system may be a source of health

A community has eight essential sub-systems,
promotion when its values and teachings
which interact and interrelate continuously. Take a
look at each of these sub-systems in detail to positively influence lifestyles and healthy
understand how they influence the health of behaviour, for example, forbidding smoking,
alcohol consumption, pre-marital and extra-marital
people living within a community.
sex.
On the other hand, religious teachings may
Socio-cultural System promote ill health, for example, by forbidding the
followers from seeking treatment in hospitals.
This system is made up of all the customs and
beliefs, family and kinships, leadership and power Environmental System
structures in society. This sub-system exerts a
powerful influence on the lifestyles of the
community members, their priorities and their Environmental sanitation is one of the leading
promoters of individual and community health.
attitudes and values towards health and illness.
Clean water supply, proper disposal of waste and
adequate housing are key to community wellness.
For example some cultural factors promote either Environmental pollution is a cause of various
acceptance or stigma towards a certain illness. illnesses.
High-risk behaviour may be a result of cultural
traditions.

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Communication and Transport System  Case/contact tracing and treatment
 Empowerment of all individuals to realise
Communication includes all the means of their rights and responsibilities for the
contacting and exchanging information with one attainment of good health for all
another such as roads, bridges, railroad,
telephone, television, radio, computers, internet, The main goals of community health are to:
fax, and postal services.
 Identify community health problems and
The communication system is important in needs
spreading health messages. Transport aids in  Plan ways of meeting community health
communication by moving people from place to needs
place.  Implement activities geared towards
meeting the community health needs
Health Care system  Evaluate the impact of community health
services/activities
The health care system exists to provide
promotive, preventive, curative and rehabilitative A successful community health programme is one
services in hospitals, nursing homes, clinics, in which the community and health care providers
health centres, dispensaries, and through special collaborate to achieve the following benefits:
health projects and programs.
 Increased life expectancy (life span) of
The health care system is enhanced through every individual
linkages that bring together the government, non-  Decreased mortality rates particularly of
governmental organisations, private institutions mothers and children
and individuals in providing continuous and  Decreased morbidity rates from all causes
comprehensive health services. These linkages  An increase in the total well being
strengthen the multi-sectoral approach of (physical, mental and social) of every
achieving health for all. individual
 An increase in the quality of life for all
Concept of Community Health people
So far, you have defined the community and  Overall social and economic development
described its functions, characteristics, and sub- of the population
systems. You should now have acquired a good  Equitable distribution of resources
understanding of the community as it is the main
focus of attention in community health. Having looked at the aims, goals, and benefits of
community health, you will now explore the
Community health is the science and art of activities which you are expected to undertake in
promoting health and preventing diseases community health, also referred to as the scope of
through organised community participation. community health.
The term „community health‟ is also referred to as:
Examples of Community Health Activities

 Population medicine
 Health education, counselling, and the
 Social medicine
training of other health workers
 Community medicine
 Community health assessment and
 Preventive medicine diagnosis
 Information, education and
Aims of Community Health communication
 Environmental sanitation and supply of
Community health aims to achieve the following: adequate clean wholesome water
 Food hygiene and household food
 Improved sanitation in the environment security
 Prioritisation of the community‟s needs  Personal hygiene
 Control of communicable diseases  Vector and pest control
 Health education to promote healthy  Control of communicable diseases
behaviour and practices  Provision of prenatal services to pregnant
 Early diagnosis and prevention of disease women
 Disease surveillance  Provision of family planning services

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  Provision of child health/welfare services Principles and Process of Family Health Care
for children under five years old
 Provision of school health services In order for you to work successfully with a family
 Home visiting and home-based nursing and achieve your goals of promoting health and
care preventing disease, you must observe the
 Occupational/industrial health following principles:
 Care of the disabled, the elderly, the
disadvantaged, the chronically ill  Establish a good working relationship with
 Inter-sectoral collaboration the family
 Plan relevant health education and
Many of these activities are described at length in sharing of clear health messages, which
subsequent units of this module. will guide them on how to take care
of themselves
Earlier on in this section, you saw that the family  Gather relevant information about the
is an important group in the community and that it family which will enable them to identify
exerts a lot of influence on the health seeking health problems and set priorities
behaviour of individuals. It is therefore clear that  Provide need-based support and services
the description of the concept of community health to the family regardless of sex, age,
would not be complete without investigating family income, and religion, in order to improve
health care. In the following sub-section, you will their health status
therefore examine the concept of family health  Work in collaboration with other health
care, giving attention to its aims, principles service agencies to avoid duplicating
and process. family health care

Concept of Family Health Care To succeed in your family health care activities,
Family health care is a holistic approach to the following these principles alone is not enough.
achievement of wholesome health for the family. You also need to employ the nursing process
approach in the care of families.
Aims of Family Health Care
Step 1: Assessment
 Identifying and appraising health
problems of the family You need to assess the family so as to identify
 Providing health education for the (diagnose) the family health problems, needs and
promotion of health and prevention of resources.
diseases This involves collecting data using interviews,
observation, communication, subjective appraisal,
 Sharing health information with the family
to enable members to understand and and reviewing available records and reports.
accept health problems
 Providing community health nursing Step 2: Planning
services according to the needs of the
family This involves planning for health action by
 Helping the family to develop competence choosing effective and affordable alternatives and
at assessing their health problems and at setting priorities after considering the available
carrying out remedial health action internal and external resources. You should work
through health education, instructions and hand-in-hand with the family members at all
demonstrations stages of planning.
 Contributing needed materials for
personal and social development of family Step 3: Implementation
members
 Helping and encouraging the family You should implement the interventions or health
members to utilise available resources to actions agreed with the family members.
maintain all aspects of the health of the Implementing also includes increasing the family‟s
family ability to function effectively and removing barriers
to health care as well as assisting the family to do
those things which they cannot do by themselves.

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Step 4: Evaluation Principles of Home Visiting

This involves evaluating or measuring whether the Home visits should be:
expected outcome has been achieved. If no
achievements have been made, find out what  Planned and of benefit to the patient
factors interfered and change your approach  Purposeful, clear and meet the patient„s
accordingly. needs
 Regular and flexible according to the
Home Visiting needs of the patient
 Educative to the patient. Home visits
Assessment is the first step in the process provide an excellent opportunity
approach to family health care, but when do you for health education
carry out this assessment?  Used to demonstrate principles of health
You could assess family members when they visit  Convenient and acceptable to the patient
your health facility. However, in order to get a  Respectful of the patient„s right to refuse
comprehensive picture of a family‟s health, you care
need to visit them at home. Home visits are an  Recorded in the appropriate case file
important part of your work as a community health
nurse as they allow you to see families and their
If you follow these basic principles when planning
needs in their own homes.
your home visits, you will find your home visits fun
and productive.
Home visiting is one of the essential community
health services that you should provide. It has two
The Process of Home Visiting
main purposes:
The process of home visiting is carried out in five
 It allows you to follow up individual phases.
families at home to find out why some
health problems persist in the community
despite efforts to prevent or control them, Entry or Initiation Phase
for example malnutrition, communicable
diseases, or repeated failure to attend The community health nurse shares information
clinics, especially if the family is at risk with the patient on the reason and purposes for
 It keeps you aware of what is going on in home visits.
your catchment area This interaction may occur in a hospital ward or at
a clinic
In order for you to conduct home visiting
successfully, you need to have the following skills: Pre-visit Activities

 Good technical skills and knowledge of Before the actual home visit, you have to look for
preventive and therapeutic measures information regarding the patient and the family.
 Good communication skills and You also need to gather information regarding the
teaching ability location of the house, distance from your health
 Good leadership skills and rational facility and the physical address. During pre-visit
thinking to make sound judgments activities, you should investigate the community
 Good counselling skills and an resources, assemble supplies and prepare for the
understanding of human relations first contact with the patient at their doorstep.

Activities During Home Visiting

During home visits you act on your own, making
decisions on the spot and carrying them out.
You need to be prepared. When planning and This is the working phase during which you put
implementing home visits, you should be guided into action your planned health activities. During
by some basic principles in order to make a this phase you must establish trust and rapport
success of it with the patient and the family so that there can
be a positive interpersonal relationship
(a professional nurse-patient relationship). This
relationship will enhance the achievement of the
mutually determined health-oriented goals.

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Termination Phase of Visit  It creates a good understanding between
the nurse and the patient and builds a
This occurs when the health oriented goals have good image of nurses.
been met. Termination of home visits can occur  It provides an opportunity to clarify the
due to any of the following reasons: doubts and misconceptions raised by
family members.
 The patients‟ health has been restored  It provides an opportunity to observe and
and the patient can function without the appreciate family practices and progress
nurse of care given by the nurse and others.
 The patient has changed their residence
 The community health nurse has Home visiting provides an excellent
transferred the patients‟ care to another opportunity to implement health care which
nurse or agency was planned or was started in the hospital.
Disadvantages of Home Visiting
Post-visit Activities
The disadvantages of home visiting include the
Post-visit activities include recording and reporting following:
important events of the home visits, and sharing
the reports with the appropriate authorities and  Home visits consume a lot the nurse's
individuals about the patient family. time and energy as well as transport fuel
(petrol or diesel) or bus fare.
Advantages and Disadvantages of Home  Unforeseen events may occur during
Visiting home visits, which will interfere with
planned activities.
 The patient‟s family may not accept the
There are many good nursing reasons
nurse due to various factors such as
(advantages) for carrying out home visiting.
cultural or religious differences, personal
Though the activity does have its disadvantages,
characteristics of the nurse and the
they are quite insignificant compared to its
patient or to some extent, socio-economic
advantages. You should therefore try to overcome
status of the nurse and the patient.
them through careful planning so that they do not
prevent you from carrying out this important  Confusion of the nurse‟s role in a
activity. community where there may be a lack of
knowledge and understanding of the role
of the community health nurse.
Advantages of Home Visiting
SECTION 2: PRINCIPLES OF
 Home visiting gives a more accurate
assessment of the family structure and COMMUNITY HEALTH
behaviour in their natural environment.
 Home visits provide an opportunity to Introduction
observe the physical environment of the In this section you are going to cover the
home and identify barriers to, and principles of community health nursing. In
resources for achieving family health. addition, you will look at the role and functions of
 At home, the nurse works with the patient a community health nurse.
first hand to implement health action
using realistic resources. Objectives
 By meeting the family on its home ground By the end of this section you will be able to:
the nurse will be enhancing the family‟s
sense of control and active participation in
meeting its health needs.  List the principles of community health
 It provides an excellent opportunity to  Describe the functions of a community
implement planned health care. health nurse
 It provides an opportunity to learn about
the home and family situation. Principles of Community Health
 It provides an opportunity to render health
care services to the family members in Before you explore the principles of community
their own surroundings. health, first look at the definition of the word
„principle‟. A principle can be defined as:

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A basic belief, theory, or rule that has a major by the workers most suitably trained for
influence on the way in which something is performing these activities.
done.
- Macmillan English Dictionary for Advanced Principles of Community Health Nursing
Learners (2002).
So far you have looked at the principles of
Principles are the basic ideas of conduct or rules community health.
of action. Now look at the principles of community health
They provide the community health nurse with a nursing.
clear and rational framework to guide their work.

Principles of Community Health (Alma Ata  Community health nursing services

Declaration - WHO 1978) should be available to all, according to
their health needs regardless of sex, age,
culture, religion, social or economic
 Availability of health care for all people status, race, political affiliation, ethnicity or
and at a cost they can afford nationality.
 Promotive and preventive aspects of  A community health nursing programme
health care must have clearly defined objectives and
 Integration of curative and preventive purposes for its services.
services  Community health nursing should not be
 Active participation of individuals and a vertical programme. A community
communities in the planning health nurse must work with other
and provision of care stakeholders in the development,
 Development of maximum potential for implementation, monitoring and
self-care evaluation of the community health
 Utilisation of all levels and types of programme.
community manpower  Community health nursing should involve
 Inter-sectoral approach the community right through the planning
implementation and evaluation of the
programme.
Principles of Community Health (Hentsch -  The community health service should
1985) build the capacity of the community to run
their own health programme for the
 Health care should be shaped around the purpose of sustainability. These include
life patterns of the population. It should training of the Communities Own
meet the needs of the community. Resource Persons (CORPs).
 Primary health care should be an integral  Health education and counselling for the
part of the national health system. individual, family and community are
 Health care activities should be fully integral parts of community health
integrated with the activities of the other nursing.
sectors involved in community  Community health nursing services
development such as agriculture, should be based on the identified needs
education, public works, housing and of the patient and there should be
communication. continuity of services to the patient.
 The local population should be actively  Community health nursing should work
involved in the formulation and within the community‟s culture and norms
implementation of health care activities, without compromising professionalism.
so that health care can be brought into  Community health nursing is a service
line with local needs and priorities. and there should therefore be no room to
 The health care offered should place a demand favours, gifts or bribes from
maximum reliance on available clients.
community resources, especially those  Community health nursing is dynamic and
that have hither to remained untapped the nurses should therefore actively
and should remain within the cost participate in continuing professional
limitations relevant to each country. development so as to keep abreast with
 The majority of interventions should be new developments.
undertaken at the most peripheral  Community health nursing services
practice level of the health services and should develop proper guidelines and
maintain proper records and reports.

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Remember: The community health nurse must In your role as a nurse, you have developed ideas
maintain ethics as well as a professional about what is appropriate to say or do within this
relationship with all the individuals and role. The role of the community health nurse is to
groups in the community, at all times. prevent illness and maximise the health of
individuals in the community.
The Roles and Functions of a Community
Health Nurse Your function, on the other hand, refers to the job
that you are expected to perform as a nurse. That
As a nurse, you have achieved the right to is, the broad areas of responsibility which you
perform your duties through merit (formal assume as a nurse. Your functions as a nurse
training). You are trained to play a certain part as may vary according to your training, experience,
a member of a health team which is bound by the and designation. The functions of a community
legal and moral expectations of your profession. health nurse are many and emanate from your
This is what you call your role. role.

Roles and Functions of a Community Health Nurse

The Roles and Functions of a
Roles Functions
Organising and managing health care programs, being a team leader for nursing and supervising
Manager
community health nursing activities.
Implementing community health action/programs in collaboration with the other stakeholders in
community health. Creating community awareness and interest in their health. Developing the
Implementer
community’s ability to assess their health status and resources. Sharing knowledge and skills
with the community on how to improve their health and to prevent illness.
Advise the health care providers, planners and other agencies on the needs/problems of the
Advocator
community.
Advisor Sharing technical health information with individual families and communities.
Teaching individuals and families how to prevent disease and improve
Health educator
their health.
Assessing the health status of the community. Identifying existing and potential health
Assessor/Identifier
needs/problems and resources in the community.
Planning for health action with the other health team members and
Planner
community members.
Evaluator Evaluating the performance and the outcome of community health activities.
Carrying out surveys, studies and research to identify problems related to
Researcher
your work.
Training other community health workers, both designated and voluntary community-based
Trainer
health workers.

 Define the term 'statistics'

SECTION 3: VITAL HEALTH  Describe the various types of descriptive
STATISTICS AND EPIDEMIOLOGY statistics used in community health
 Describe the 'catchment area'
 Describe the various sources of health
Introduction information
 Calculate vital health statistics
In the last section you covered principles of  Describe epidemiology concepts
community health and the roles and functions of a  Describe the measures for preventing
community health nurse. In this section you are diseases
going to learn the types of statistics collected in
community health, the various methods used to
measure disease burden and death, and the Statistics
meaning of epidemiology and its relevance in
community health. You can see from this definition that a statistician
is primarily concerned with numbers. There are
two types of statistics. The first is concerned with
Objectives clarifying the hidden (but significant) relations that
By the end of this section you will be able to:

Jesse Daniel Omolo.. Page 10

exist between the figures. This is known as Ungrouped Frequency Distribution
descriptive or summary statistics. Descriptive
statistics are used to describe values obtained Ungrouped frequency distribution lists variables in
from measurement of variables. the form of a column of the values and the
frequency of occurrence of the values. It is used
The other type of statistics is known as inferential when dealing with discrete data or variables.
statistics. It uses various mathematical devices to Discrete data are types of variables that can only
draw useful conclusions from summarised data. In take whole number values, such as the daily
community health nursing, you mainly use attendance in your health facility or the number of
descriptive statistics also called summary syringes in a box. Obviously, you can not have
statistics. In the next sub-section you will consider 13.5 people attending your clinic or 30.4 syringes.
the various types of descriptive statistics and their Consider the following example.
uses.

Statistics is the science that deals with the

mass of numerical data emanating from
various activities and the environment, and
which seeks to mould such data into forms
from which you can draw useful
conclusions. Onyango & Plews (1987).

Descriptive Statistics

Descriptive statistics are used to describe

frequency distribution, measures of dispersion (or
variability), standardised scores and measures of
central tendency.
Suppose you survey ten families and find that
Remember: Descriptive statistics summarise, three of them had two members, two of them
describe and organise data. three members, one of them had four, and the
other four had six members. This information may
Now look at some of the types of descriptive be displayed as illustrated in the table above. As
statistics that you use regularly in your work. you can see from this example, the variables are
These include: given without any grouping

 Frequency distribution Grouped Frequency Distribution

 Proportions, rates and ratios
 Percentage distribution Grouped frequency distribution is used when
 Measures of central tendency: there are a large number of figures with many
- Mode values and frequencies. The values are grouped
- Median in what is known as 'class intervals' (for example
- Mean 0-5 years) thus making the data easier to
 Measures of dispersion: understand.
- Range
- Variance Consider the following example: suppose you
- Standard deviation interview 50 members from your community at
random and ask them to give their age. The data
You will now look at each in turn in the following may then be tabulated as shown in the table
pages opposite. As mentioned earlier, one advantage of
a grouped frequency distribution table is that it
Frequency Distribution makes large amounts of data easier to
understand. For instance, one can quickly see
that 20 out of the 50 people in the sample (40%)
This is a method used to organise data in tabular
form according to the frequency of their fall in the under-fives age group.
occurrence. There are two types of frequency
distribution: Ungrouped and Grouped.

Jesse Daniel Omolo.. Page 11

 Measures of Central Tendency

These are generally referred to as 'average'

measures. The three measures of central
tendency commonly used are the mode, median,
and mean. They describe how closely related the
data is.

Mode

Mode is the numerical value or score that occurs

most times - it is the most frequently occurring
item or value. The mode is the most suitable
measure of central tendency for nominal data
(naming category type of data).
Proportion
Median
These types of measures are used to describe
data in relation to the wider population. The
numerator is usually a part of the denominator. Median is the score at the exact centre of a
distribution; it is also called the 50th percentile.
The median is the most central value when raw
For example the proportion of people suffering data is arranged on a scale from the highest to the
from malaria in a population may be expressed lowest - it is obtained by rank ordering of
as; one person out of six people in a community is the scores.
suffering from malaria.
Mean
Ratio
Mean is the measure most commonly used. It is
A ratio is a type of descriptive statistic in which the the total sum of scores divided by the number of
numerator is not connected to denominator. It is scores being summed. The mean is the most
mainly used for comparison of various populations suitable measure of central tendency for interval
in relation to a given variable or disease. and ratio level data.

An example is when you say that the ratio of Some of the Symbols and Formulae used
women to men suffering from malaria is three to in Statistics
one (3:1).
There are some symbols and formulae used in
Rate
statistics, especially in the calculation of the
mean. Study the symbols and the formulae
A rate is the most commonly used measure for opposite, as you will be using them in your
descriptive statistics. It is widely used since it statistical work.
includes the events, the population affected and
the time specifications within which the event has
occurred. The morbidity rate (prevalence) of
malaria in a community can be expressed as 20
per 1000 cases in the last three months.

Percentage Distribution

This is another type of descriptive statistic used to

indicate the percentage of the samples whose
scores fall into a specific group, as well as the
number of scores in that group.
The numerator is described in relation to the
denominator per a hundred. Percentage
distribution is mainly useful for comparing the
present data with findings from other studies that
have differing sample sizes.

Jesse Daniel Omolo.. Page 12

Measures of Dispersion catchment area. There are two ways you can find
out the catchment area of your health facility:
The measures of dispersion are used to measure
the individual differences of scores in a sample.  You can outline the administrative
Measures of dispersion give an indication of how boundary around the area.
scores in a sample are dispersed around the  You can draw a circle with a radius of 5,
mean. They show how different the scores are or 10 or 20km from the health facility,
the extents to which individual scores deviate from depending on the distances at which
one another. If the individual scores are similar, people live.
the measure of variability is small and the sample
is relatively similar or homogeneous in terms of It is important for the community health nurse to
those scores. A wide variation in scores may establish their catchment area and mark it out on
indicate a heterogeneous sample. The most a map or draw the map.
common measures of variability used are range,
variance and standard deviation.
The area from where most of the patients in
your health facility come from is called the
Range Catchment Area.

The range is a simple measure of dispersion that Once you have established your catchment area,
is obtained by subtracting the lowest score from you still need to know how many people are there
the highest score. The range is the difference in the area and whether they are scattered all
between the highest and lowest score. It is not a around or concentrated at certain areas/sections.
very significant statistical measure.
Information about the catchment area's population
Variance distribution can be obtained from recent local or
national census estimates. You would then have
The variance is a measure of how individual to adjust this information according to the birth
scores in a set of data vary in their distribution and death rates in the catchment area. Another
from one to the other. To understand the method would be to conduct a simple survey of
calculation of variance, it is recommended that the catchment area. This would provide you with
you read further on this topic from any textbook on information such as the location of houses, the
statistics or research methodology. density of houses, and the number of people in
each house. You will learn the skills of conducting
Standard Deviation a health survey in module four.

The Standard Deviation (SD) is the other measure One of the most important sources of information
of dispersion. Standard deviation is calculated by on health and disease are the records you keep in
finding the square root of variance - that means your routine work at health centres, clinics and
you have to calculate the variance first. hospitals. Outpatient cards, inpatient notes, daily
registers, monthly and annual reports, clinic
Having seen the different types of descriptive records and health visiting books are examples of
statistics that you use regularly in the work, now such records. If information is carelessly or
move on to find out how to look for information incompletely entered into these records, they do
and measure disease. not provide accurate or reliable information for
measuring disease. It is the responsibility of each
health worker to endeavour to keep accurate or
Looking for Information and good records.
Measuring Disease in a Community
You now know how to locate your catchment area
The Catchment Area and where to look for information. Next, you will
examine the types of information you need to look
In order to look for information in your community for.
and measure disease, you need to be familiar with
the area served by your health facility. Indeed, In order to work effectively, you have to plan. To
you will agree that an effective health care plan, you need information. To plan for people,
provider is one who is familiar with the area from you need information about people. This kind of
where their patient comes from and their common information is called demographic information. In
health problems. This area is known as the the next sub-section, you will consider the types of
demographic information that you will use in

Jesse Daniel Omolo.. Page 13

health care planning, how to obtain this people in between one census and the next. To
information and how to use it for planning find out more about people, you need to employ
activities at your health facility. other demographic methods, such as civil
registration
Demographic Information
Civil Registration
Demography is the study of population dynamics
in relation to births, deaths, migration and related In Kenya, births and deaths are recorded by the
factors such as age, sex and geographical Registrar of Births and Deaths. Births and deaths
distribution are important events in a community. The
among others. information recorded in the birth and death
certificates can be useful for finding out more
Demographic information is information about about the people in different areas. The number of
people -- how many people there are, where they births and deaths have an important effect on the
live, how many are born, how many die. total population, that is, the population gets
smaller if there are fewer births than deaths; it
Demographic information is very useful in health remains the same if the numbers remain the
care planning. Some of the common methods same; and gets larger if there are more births than
used to collect demographic information include: deaths.

You should now appreciate the importance of

 Population census
accurately recording information on births and
 Civil registration for example identity card deaths in your community. Next, you will look at
issuing, birth and death registration
special surveys.
 Special community surveys
 Hospital and health centre records
Special Surveys
 Epidemiological studies
Surveys are studies that are carried out over a
Population Census
short period of time in a given population to
generate baseline data that is then used for
A census is the procedure of counting people. In describing specific situations and planning
many countries including Kenya, a census is intervention measures.
conducted every ten years (decennially). In
Kenya, the last census was carried out in 1998.
Often, when you want to carry out a specific task
in a specific area, the information from the census
Some of the information collected about each or civil registration is not enough. To obtain more
person included the following: information, you have to make more inquiries
using a survey. A good example is the Kenya
 Sex Demographic and Health Survey (KDHS) carried
 Age out every five years. In practice surveys require
 Level of education money, skilled people and extra equipment and
 Marital status supplies. For this reason, surveys are carried out
 Profession, number of children etc for specific circumstances.
 Migration status (where the person came
from) In unit five, you will look at a common type of
survey method used in community health known
The government uses the results of census for as Community Diagnosis.
formulating long-term developmental plans
including provision of health care services. A Having looked at the various methods used to
census enables the government to estimate the collect demographic information, you will now look
annual population growth rate. Currently the at some specific measurements of the population
population growth rate of Kenya is estimated at and how they help you in planning for your health
2.56% per year (2005 estimates). At the care services.
community level, it helps you to carry out specific
measurements that allow you to plan for your Population Distribution and Density
health services more effectively.
In order to plan effectively, you need to know how
A census is carried out only once every ten years the population in your area is distributed.
so it can not tell you about what happens to One effective method of presenting this type of

Jesse Daniel Omolo.. Page 14

information is called a population pyramid. as ours is towards urban migration, that is, for
You construct a population pyramid by making a people to migrate from villages to towns and big
horizontal bar for each age group, according to cities.
sex.
As you saw earlier, the number of people who are
As you can see from the graphic opposite, the born and the number who die have an important
length of each bar in a population pyramid effect on the total population. In order to study
represents the number of people of that age and what will happen to the population in the future
sex. The longer the bar, the more people there (say in the next 5-15 years) you need information
are in that group. The shorter the bar, the fewer on the birth rate and the death rate. In the next
people there are in that group. The population sub-section you will learn how to measure the
pyramid for Kenya is broader at the base because crude birth rate and the crude death rate.
there are many young children. This in turn is
because there is a high birth rate. However, the
death rate among very young children is also
high; so not all the children at the base of the
Crude Birth Rate and Crude Death Rate
pyramid survive to reach a higher age group. That
is the reason that the bars get shorter as you go
towards the top of the pyramid. Crude Birth Rate

The Crude Birth Rate (CBR) measures the

number of births per 1000 population in a
specified period.

Suppose for example that in a population of

15,000,000 (15 million) there were 750,000 births
in one year. The CBR would be calculated
as illustrated.

The second factor you need to consider when

looking at the population is the population density.
This means how many people live in a given area
of land.

To calculate the population density, you divide the

number of people by the available land area (in
square kilometres). In some towns, where there
are a lot of people occupying little land, the
population density is high. In some villages, where
there are fewer people and a lot of land,
population density is low.

The population of a community does not always

stay the same. This is because there are always
people moving in or out. One way in which the Crude Death Rate
population of a place can change is by migration,
that is, people moving from one place to another. You calculate the Crude Death Rate (CDR) in the
When people move out of a place, the population same way.
of that place gets smaller. The place is said to be
losing population due to migration (emigration).
When people move into a place, the population of Again, suppose the total population is 15,000,000
that place gets bigger. (15 million). If there were 225,000 deaths in one
That place is said to be gaining population by year, you would calculate the crude death rate as
migration (immigration). illustrated.
The tendency in many developing countries such

Jesse Daniel Omolo.. Page 15

 example, if the majority of your community
members are made up of children under ten
years; if this number will get even larger because
of the high birth rates; and whether there are more
deaths in this age group, therefore pointing to the
critical need for medical services for this group.

Besides numbers, you also need to look at what

health problems are most important in an area.
You will now explore how to measure disease in
the community.

Measuring Diseases in a Population

Measuring diseases in a population helps you to
determine what health problems are important in
your community so that you can plan accordingly.
It also helps you to determine what resources and
how much you need to promote health, prevent
illnesses and
treat diseases.
Growth Rate
As stated earlier, one of the most important
Once you know the crude birth rate and the crude sources of information on health and disease are
death rate, you can calculate the population the records you keep in the routine work at health
Growth Rate (GR). The GR is the percentage centres, clinics and hospitals. Outpatient cards,
increase in population. It tells you by how much inpatient notes, daily registers, monthly and
the population got bigger or smaller. To calculate annual reports, clinic records and health visiting
GR, you subtract the death rate (in percent) from books are examples of such records.
the birth rate (in percent).
If records are carelessly or incompletely entered
Growth Rate = Crude Birth Rate (%) - Crude they will not provide you with accurate or reliable
Death Rate (%) information for measuring disease. It is therefore
your responsibility to endeavour to keep accurate
In this example, the crude birth rate was 5% and records.
the crude death rate was 1.5%, so the growth rate When you measure disease, you should observe
would be: 5% - 1.5% = 3.5%. the following three important aspects:

According to the 1999 census estimates,  Measuring disease by incidence and

Kenya’s population growth rate has fallen prevalence
from 3.8% in 1978 to 2.5% in 1998.  Expressing diseases by rates (with
Besides births and deaths, there are other things specification of time
to consider while studying the growth of a and population)
population. These things include:  Accuracy in measurements

Consider each of these aspects in turn over the

 Rate of migration in and out of the country
next few pages.
 The number of women who can bear
children (women of reproductive age
from 15-49 years) Incidence and Prevalence of Disease
 The occurrence of birth and death events
 The rate of family planning acceptance What do you understand by the terms
and practice incidence and prevalence?
 The occurrence of major natural or man-
made disasters such as war, epidemics, Incidence
floods, famine, volcanic eruptions etc
Incidence measures new cases during a period of
As you can see, the demographic information you time among those at risk of acquiring the disease
collect can assist you a great deal in planning at the beginning of the duration in a given
your health services effectively. It can tell you, for population.

Jesse Daniel Omolo.. Page 16

 accurate guide. In the example above, the malaria
For instance, if there were 12 new cases of case rates are:
malaria in your area which has 1,200 people in
January, then the incidence of malaria in January Area A: 100/2,000 x 1,000 = 50 per 1,000
would be (12/1200 = 0.01) 1 case per 100 people population
in the population. Area B: 150/6,000 x 1,000 = 25 per 1,000
population

Incidence measures new cases during a Thus malaria is more common in village A even
period of time among those at risk though the total number of cases (prevalence)
of accruing the disease at the beginning of reported in village A are less than in village B.
the duration in a given population.
Reports from two clinical officers on the occurrence of
Prevalence malaria in their villages
Village A Village B
Prevalence gives information about the total
number of cases of a disease or condition at a Area 500 sq km 500 sq km
particular time - whether new or old cases. Population 2,000 6,000
Prevalence helps you to know how big a problem Malaria Cases 100 150
is. For example, if on the 1 January you did a
survey of your area, containing 1,000 people and Expressing Diseases by Rates Measuring a
found that the total number of cases of malaria disease by rates can also help you to compare
was 41, you would say that the prevalence of
two diseases in the same village, when you want
malaria on 1 January was 41 cases per 1,000
to know not only which disease is more common
people in that area. This knowledge would help
but also which disease is more serious.
you to plan your drugs, surgical and equipments To decide how serious a disease is, you use Case
supplies among Fatality Rates (CFRs).
other things.
Case Fatality Rates measure how many people
Prevalence measures all cases during a
who have a certain disease die from that disease.
period of time in a specified population. Suppose that you have received the information
shown below from one of the villages in your
Expressing Diseases by Rates catchment area, how would you calculate the
case fatality rate?
Read the following paragraph carefully and try to
answer the questions about it. To calculate the case fatality rate, you use the
following formula:
Pretend for a minute that you are the District
Medical Officer (DMO). You have a stock of No of deaths x 100
mosquito spray that is sufficient for one village Total cases diagnosed
only. You want to send your spraying team to one
village. The clinical officers from each of the two
Using the equation above you can see that the
villages have reported that malaria is very
answers indicate a CFR of 1% for malaria and 8%
common in their areas. Their reports are shown in for cholera. What this really means is that, even
the table opposite. though malaria is more prevalent or common than
cholera, cholera is more serious because it has a
Consider the following two questions:
higher case fatality rate.

 In which village is malaria more common?

 To which village should you send the
spraying team?

Expressing Diseases by Rates It is clear from

the questions that the total number of cases is not Measuring Diseases in a Population
very useful when you want to make comparisons. Remember: Rates are useful for making
For comparisons, Case Rates are the most comparisons.

Jesse Daniel Omolo.. Page 17

 Finally, there are two more rates that are useful All deaths occurring in children from the date of
to know about. These are: Infant Mortality Rate birth to the age of one year are grouped under
(IMR) and the Child Mortality Rate (CMR). These Infant Mortality Rate or infant deaths. All deaths
are two important indicators used to express the occurring in children after one year to the age
health of children. A country is considered healthy of five years are grouped under Child Mortality
when the children of that country are healthy. Rate or child death.
Deaths among children are an important indicator
of the health status of a community/country.

Vital Health Rate Formula

Number of new cases of a disease x 100
Incidence rate
Population at risk from that disease
Number of all existing (old and new) cases of a disease x 100
Prevalence rate
Population at risk from that disease group
Number of deaths from specified disease x 100
Case fatality rate
Number of persons with the disease (old and new)
Number of deaths from specified cause x 100
Cause specific death rate
Total population in the year who died from different causes
Number of deaths in a specified age group x 1000 (%)
Age specific death rate
Estimated midyear population of that age group
Total number of live births x 1000 (%)
Crude birth rate
Estimated midyear population
Total number of deaths during a given year x 1000 (%)
Crude death rate
Estimated midyear population
Number of live births x 1000 (%)
Fertility rate
Estimated number of females aged 15-49 at midyear
and how to ask the questions in the
Accuracy of Measurements questionnaire.
 All staff should undergo thorough training
Why would you want the temperature of a and be supportively supervised to see
patient recorded accurately? that they are following agreed procedures.
 Staff should initial case histories, physical
 To see whether the patient has fever examinations or laboratory tests which
they perform so that it is clear who did
 To check the effect of a treatment you
them. This also helps when checking
have given
records for missing information.
 To make a graph that can provide a clue
to diagnosis/effectiveness of medication
Having learnt how to measure diseases, you now
need to be able to predict which people are at
Most errors are made by the people taking the
high risk of getting them and work to prevent that
measurements and not by the instruments used or
from happening. You will learn that in the next
by the patients. This type of inaccuracy is called
sub-section which covers epidemiology.
observer error. There may also be problems with
the instruments such as weighing scales,
particularly if the zero reading is not checked
regularly. Other errors may occur when writing
down the figures on the record card. In measuring
the effects of a disease or treatment, you need to
take your measurements and record them
accurately.

To reduce inaccuracies, there are three important

things that medical staff can do:

 All staff should follow agreed standard

methods; for example, how long the
thermometer should be left in the mouth;

Jesse Daniel Omolo.. Page 18

Common Formulae for Calculating Health Rates determinants) and their effects on the health of
Vital Health the people is known as epidemiology.
Formula
Rate
No. of foetal deaths at 20 weeks In epidemiology you look at three components of
Foetal death a disease.
or more gestation x 1000 (%)
rate
(No. of live births plus foetal deaths of
(Still birth rate) Disease Frequency
20 weeks or more gestation)
No. of deaths under one year of age
Infant mortality Disease frequency is the measurement of how
(in defined population) x 1000 (%)
rate often a disease occurs and the disability or death
Number of live births
caused. This information is summarised in the
No. of deaths from puerperal causes
form of rates and ratios, that is, prevalence rate,
Maternal (pregnancy, labour, etc) x 1000 (%)
incidence rate, death rate etc.
mortality rate No. of live births during that
year
Distribution of Disease
Number of deaths under 28 days of
Neonatal
age x 1000 (%)
mortality rate Distribution of disease is concerned with
Number of live births
describing how widespread a disease is in terms
No. of foetal deaths 28 weeks or more of person, place and time. In measuring the
and infant death under 7 days of age x distribution of a disease you ask the following
Perinatal
1000 0/00 questions:
mortality rate
No. of live births and foetal deaths 28
weeks or more during the same year
 Who are the people affected?
No. of deaths at age 28 days 1 year
 Where do they come from?
Postnatal x 1000 0/00
 When are they affected (during dry
mortality rate No. of live births minus neonatal
death season or rainy season)?
No. of deaths of males or
Determinants of Disease
Sex specific females x 1000 0/00
death rate Estimated male or female population
at midyear Determination of disease involves interpretation of
the distribution of disease in terms of its possible
Total number of persons less than 15
causal factors. Disease determinant factors are
Dependency yrs and those over 60 yrs (65) of age
the agent, the host and the environment.
ratio Total number of people aged 15-60
(15-65) yrs in the same population)
In epidemiology you use data on the frequency
and distribution of disease in order to help you
understand whether the disease is an epidemic,
Epidemiology endemic or sporadic.
Epidemiology is the branch of medicine that
studies the patterns of disease occurrence in An epidemic disease is one that occurs
human population and the factors that influence unexpectedly and may give rise to many new
these patterns. cases in a short period of time. An endemic
It studies the disease distribution and disease is one that is present all the time in a
determinants in the populations. community.
A sporadic disease is one that occurs only
Before you go further, consider the following occasionally and without a regular pattern.
definition of disease.
An endemic disease is that which occurs at a
Disease is the inability of the individual to constant rate over a long duration of time
function, physically, mentally, socially at a (several years or decades) in a given
level that is both individually satisfying and population.
appropriate to the stage of growth and In some parts of Kenya, malaria is an endemic
development of the individual disease as it is present in the population all the
- Hardley (1974). time, as indicated by the pink areas on the map
on the right.
Simply put, you can say that any condition that
causes health to decline is called a disease. The An epidemic disease is that which occurs in a
detailed study of diseases (distribution and higher rate than it normally does in a given

Jesse Daniel Omolo.. Page 19

population over a given duration of time  Patterns of health as well as patterns of
(weeks or months). disease.
It is also referred to as an outbreak.  Mass phenomenon and effects of disease
or conditions on groups or individuals.
A good example of an epidemic is cholera.  Distribution and causes of human health
problems.
 Multiple causation factors of disease.
When you say that a disease is epidemic, you  Measures used to prevent and control
use the information about both frequency and disease.
distribution.  Variations in occurrence and distribution
of communicable diseases in the
community.
For example, the chart below could be used to  The presence, nature and distribution of
describe a cholera epidemic. community disorders through morbidity
and mortality rates along with identifying
high-risk population, with a view to
There are very frequent cases of establishing a community diagnosis.
diarrhoea and Frequency  Causes of communicable disease by
vomiting in the community defining various geographic,
Both children and adults are affected demographic, genetic, environmental,
(WHO) disease agent and social factors.
 Estimates of individual risks and chances
People living in conditions of bad
toward disease occurrence in general or
sanitation Distribution
specified segments of population.
are affected (WHERE)
 Clinical and sub-clinical forms of disorders
The disease comes in the rainy season in communities for early diagnosis
(WHEN) through screening mechanisms.
 Knowledge, attitude, beliefs and practices
Epidemiological studies aim to: of communities toward communicable
problems and develop intervention
 Describe the distribution and extent of a programmes.
disease problem in human population.  Epidemic problems and their appropriate
 Identify aetiological factors in the intervention programmes.
pathogenesis of disease.  The natural history of disease affecting
 Provide the data essential to the planning, the general population.
implementation and evaluation of services  Develops strategies for planning,
for the prevention, control and treatment organising, implementing, integrating and
of disease and to set up priorities among evaluating services in communities.
these services.
In order to study the things listed effectively,
The community health nurse has an important role epidemiology uses a number of methods and
to play in the prevention and control of tools which you will now learn.
communicable diseases. This includes
participating in the early diagnosis and treatment, Epidemiological Methods and Tools
sending notification of notifiable diseases, tracing
the contacts and keeping them under surveillance, Epidemiological studies are classified into two
identifying sources of disease and educating the groups according to their purpose.
members of the community.
Descriptive Studies
So far you have looked at the definition of
epidemiology, its components and aims.
These studies focus on the amount and
distribution of disease or health status within a
Areas Studied in Epidemiology population by person, place and time. The studies
involve determining the incidence, prevalence and
 Whole populations in their living and mortality rate for disease in large population
working environment. groups, according to characteristics such as sex,
 Factors that determine state of health and age, race and geographical area. These are
disease. studies of factors associated with distribution of
health and disease in human population.

Jesse Daniel Omolo.. Page 20

Analytical Studies Observational Studies

These types of epidemiological studies focus on In observational studies you observe events in the
disease determinants, that is agents of disease community as they occur. They may occur in
causation, host related factors, vectors (where seasons or be triggered by certain events such as
applicable) and environmental factors. floods that may lead to waterborne diseases or an
outbreak of malaria. Another example is the
Analytical epidemiology studies the underlying increased incidence of fractures among children
causes of health problems. during the fruit picking season. As an
It seeks to uncover the source and mode of epidemiologist, you need to put measures in place
spread of disease; looking at multiple factors that to prevent these problems. There are two main
bring about the disease in different population categories under these type of studies, that is
groups. Analytical epidemiology looks for reasons cohort studies and case control studies.
behind the relatively high or low frequency of
disease in specific human groups (cause-effect Cohort studies look at certain exposures over a
relationships). period of time (prospectively) and how they are
related to certain outcomes. Subjects are followed
There are three main types of descriptive studies. up over a period of time.

Case Series Case control studies look at certain outcomes

and try to establish what might have caused them
in the past.
In case series, clinicians describe the experience
For example people suffering from a skin disease
of a single patient or group of patients with similar
may be asked to recall where they have worked or
diagnosis. This is common among clinicians
lived previously so as to understand what they
whereby they use the unusual features of a
unique disease among patients to make a had been exposed to and that might have caused
diagnosis. It is through case series studies that the disease. They are also referred to as
clinicians are able to diagnose new or emerging retrospective studies.
diseases, such as ebola and chloroquine resistant
malaria. Experimental Studies

Cross-sectional Studies In experimental studies, you set up experiments

with controls in order to see the cause and effect.
For example, you can decide to give malaria
Cross-sectional studies provide information about
the frequency and characteristics of a disease by prophylaxis or mosquito nets to one community
studying the disease status in a population at a during the rainy season and deny the same to
specific time period in a given year. Data is another similar community.
gathered over a large geographical area from a
large sample over a short duration of time for, You then observe the two to see if they have the
example a few months. same incidence of malaria or if they have different
incidence of malaria.
Correlation Studies
The Epidemiological Triad
Correlation studies use data of the entire
population to compare disease frequencies The triad describes the relationship between
between different groups of people during the various factors that cause disease and how they
same period of time. These types of studies are interact to determine disease occurrence.
concerned with how a certain independent The factors, namely agent and host, interact in the
variable is related with one or several dependent environment to cause disease in humans.
variable(s). The natural progression of a disease is influenced
by the following factors:
Analytical studies are divided into two types;
observational and experimental studies. The bulk  The causative agent(s)
of analytical studies are observational. This is  The susceptible host
because they are less invasive and less likely to  The environment
raise ethical issues.  The vector(s) in some diseases

This is illustrated in the graphic opposite.

Jesse Daniel Omolo.. Page 21

 Excessive or Relative Lack

Endocrine disorders, for example diabetes

mellitus (lack of insulin), thyrotoxicosis (excess
thyroid hormone).

Immunodeficiency (HIV infection, some drugs).

The human or animal that comes into contact with

and is affected by the agent is the host. Some
factors within the host determine its interaction
with the agent.

The Epidemiological Triad Age

The agent is the harmful aetiological factor that Some diseases are more common in certain age
causes health problems. groups:
The aetiological factor (agent) may cause disease
either by its presence or by its absence. The  Childhood: measles, whooping cough,
causative agent may be a substance, living or chickenpox.
non-living, excessively present or lacking, tangible  Adulthood: diabetes mellitus,
or non-tangible. cardiovascular diseases.
 Old age: pneumonia, cancers and
Physical Agents arteriosclerosis.

These include mechanical forces such as friction, Sex

extreme heat, cold, humidity, pressure, sound,
radiation, electricity, etc.  Females: disorders associated with
pregnancy and childbirth.
Biological Agents  Males: prostate hypertrophy.

Living organisms, such as bacteria, fungi, Race

chlamydia, rickettsiae, protozoa, viruses,
mycoplasma, helminthes. Only the black race suffers from sickle cell
disease.
Chemical Agents
Lifestyle
Endogenous chemical agents are those which are
made by the body as a result of abnormal Lifestyle choices such as: dietary habits, smoking,
metabolism, for example urea (uraemia), serum alcohol consumption, substance abuse, casual
bilirubin (jaundice), ketones (ketosis, keto- sexual intercourse.
acidosis), uric acid (gout), calcium
carbonate(renal stones), etc.
Nutrition
Genetic Agents
Nutritional status is a major factor where food is
either of inadequate quantity, quality or both.
Transmitted from parent to child through genes.
Tradition
Nutrient Agents
Tradition (culture, custom): food beliefs, child-
Excessive or deficient intake of nutrients. This rearing practices, rituals (for example female
results in malnutrition related diseases such as genital mutilation).
the most common Protein Energy Malnutrition
(PEM), for example kwashiorkor and marusmus.
Mobility
Other examples include iron deficiency anaemia.
International and local travel, which may expose
an individual to new diseases.

Jesse Daniel Omolo.. Page 22

Immune Status A three-level model for intervention, based on the
stages of the disease, was developed by Leavel
Lack of previous exposure to a disease, lack of and Clark (1965). The three levels of the model
vaccination, or poor natural immunity (immune are:
deficiency). All these are referred to as intrinsic
factors.  Primary prevention of disease
 Secondary prevention of disease
Social and Economic Status  Tertiary prevention of disease

A person's social and economic status has an Primary Prevention

effect on both their exposure to disease agents
and also their access to appropriate health care. This is the actual prevention of a disease. Primary
prevention is carried out before the disease or
The environment includes all the external dysfunction has occurred in the body. It is directed
conditions and influences that affect the life and at decreasing the risks of acquiring the disease.
development of an individual and their community.
The environment may enhance or inhibit the Primary prevention methods applied to people
interaction between the host and the agent. and the environment include: health education;
environmental sanitation; supply of clean safe
Physical water; adequate nutrition; rest; sleep; recreation;
personal hygiene; good working conditions; good
The physical environment is made of the non- housing; regular medical checkups; screening for
living things and physical factors such as water, disease; genetic screening and counselling;
air, soil, light, heat, radiation, noise, housing, immunisation against specific disease; avoidance
climate and geographic location. Changes in the of home, traffic, and industrial accidents.
environment due to various factors may, for
example, lead to pollution of water, air, soil and Secondary Prevention
noise. This in turn cause disease in the members
of the community. Secondary prevention aims at diagnosing a
disease early and treating it even before the
Biological symptoms have appeared. This is the second
stage of disease which is called sub-clinical or
This includes all the living things in and around pre-symptomatic. The main goal is to cure the
where humans live. The living things include disease completely in its early stages or slow
animals, plants and micro-organisms. down its progression, in order to prevent the
development of complication and disability.
This kind of prevention often requires screening,
Social and Economic
to find the people who have the illness but don't
know they have it.
This is the human society in which every human
being lives. Men and women live among others in
Activities of Secondary Prevention
groups in which there are shared values, customs,
habits, beliefs, attitude and culture. Conflicts
among human beings lead to tension which may  Screening tests to detect early the pre-
cause mental and behavioural disorders. symptomatic physiological and anatomical
indicators of disease, for example pap
Examples of social economic factors include; smear, random blood sugar test, etc.
Housing, water, lighting, sanitation, area of  Case finding and case-tracing.
residence, food, education, occupation, working  Screening surveys and examinations.
environment and health care among others.  Mass treatment and campaigns.
 Adequate treatment of disease.
 Follow-up of treated patients at special
Levels of Disease Prevention clinics and at their homes.
Diseases evolve over time and the pathological
changes become less reversible as the disease
process continues. There are three stages in the Remember: Secondary prevention detects
development of a disease, namely, healthy, sub- disease early by screening and starts
clinical or pre-symptomatic, and clinical. It is treatment promptly.
obvious that the best sort of prevention is that
applied before the person becomes ill. Tertiary Prevention

Jesse Daniel Omolo.. Page 23

This means diagnosing and treating people who The Ministry of Health is the main provider of
are already sick with a disease, in order to reduce health services to all the citizens of this country.
suffering, cure the disease, and prevent disability.
If a permanent disability such as blindness or Functions of the Ministry of Health
paralysis remains, then special rehabilitation
services may be necessary. Most of the curative
 Planning (for the delivery of health care
work that goes on in the outpatient and inpatient
services)
departments occurs at this stage of disease.
 Maintaining effective health information
systems
Remember: Tertiary prevention diagnoses,  Manpower training, recruitment and
treats and rehabilitates. development
 Promotive and preventive services
 Curative services
 Health care financing
SECTION 4: ORGANISATION OF  Registration and licensing of health
HEALTH SERVICES facilities
 Health care policy development
Introduction  Health care quality assurance
As a health worker, you do not function in
isolation. You are part and parcel of a well The Ministry of Health operates at four main
designed and thought out system that is working levels, which are based on our country's
towards improving the health of the nation. administrative setup. The four levels are:
Therefore, in this section you shall learn about this
system, its activities and different levels of  National (Central)
operation, so that you know where you fit in and  Provincial
what role you are expected to fulfil in your routine  District
work.  Community (Peripheral)

You shall also look at the health sector reforms As you are well aware, the country is divided
that the government has initiated to improve into administrative units called provinces. Each
health care delivery. Move on to look at the province is further divided into smaller units called
objectives for this section. districts, which are in turn divided into locations
and sub-locations.
Objectives
By the end of this section you will be able to: National (Central Level)

 Describe the organisational structure of The national (central) level is the headquarters
the Ministry of Health where political, professional and administrative
 Describe the health institution's matters are coordinated and policy decisions
management made. It is headed by a minister, assistant
 Describe the composition of the District minister and a permanent secretary, in that order
Health Management Team of seniority. These leaders are politically
 Describe the functions of District Health appointed and need not be health professionals.
Management Team members
 Describe Kenya's health sector reforms Next in this hierarchy comes the technical leader
of health services, that is, the Director of Medical
Services (DMS). The Director of Medical Services
Organisational Structure of the supervises all matters pertaining to preventive,
Ministry of Health promotive and curative health services. They are
The development of a country or nation is done by assisted by Deputy Directors, who are responsible
its people. for the various divisions which deal with the
People can only contribute and participate in the different responsibilities, such as mental health,
development of their country if they are healthy. communicable diseases and health planning,
Thus one of the important activities of the among others.
government is to look after the health of the
people. The government carries out this activity
The administrative setup of the Ministry of Health
through the Ministry of Health.
is illustrated opposite.

Jesse Daniel Omolo.. Page 24

 The district hospital provides limited specialised
medical services and also logistic and technical
support to the health centres and dispensaries in
the periphery. It is a crucial link in the
administrative support and referral chain of health
services being provided to the population in
the communities.

The duties of the MOH include:

 Administration of the district health

services
 Hospital work and other clinical duties
 Training of staff in the district
 Planning and coordinating all health
activities in the district
 Supervision of health care delivery in the
district

The MOH does not work in isolation. They head a

Provincial Level team of health professionals who form the District
Health Management Team (DHMT).
The Ministry of Health is represented at the
provincial level by the Provincial Medical Officer, The DHMT is charged with the responsibility of
who is a senior medical officer in charge of monitoring and supervising all health care
organisation and administration of health services services in the district. Most of the members of the
within the province. DHMT are found at the district hospital. The other
key members of the DHMT are found at the
The Provincial Medical Officer is answerable to district administrative headquarters.
the Director of Medical Services at the Ministry of
Health headquarters. At the provincial level, they The members of the DHMT include:
are assisted by other health officers responsible
for various provincial health care departments, for
example, provincial matron. At the provincial level,  The District Medical Officer of Health
there is usually a provincial hospital. (Chairman)
 The District Public Health Nurse
District Level  The District Hospital Matron
 The District Public Health Officer
 The District Public Health Education
The district is the basic organisational unit of the
Officer
government health services. It is a key level in the
 The District Health Administrative Officer
health sector administrative setup because the
government decentralised almost all of its  The District Health Information Officer
activities and made the district the focus for rural  The District Pharmacist
development. The government delivers health
care to the district population through: The DHMT has other co-opted members who
include:
 A district or sub-district hospital
 Health centres  District HIV/AIDS/STD Coordinator
 Dispensaries  District Physiotherapist
 Mobile (outreach) units  District Clinical Officer
 District Nutritionist
The district health service is headed by a District  District Laboratory Technologist
Medical Officer of Health (DMOH) also refered to  District Orthopaedician
as Medical Officer of Health (MOH). The
administrative headquarters of the district health Important functions of the DHMT include:
services are usually at the district or sub-district
hospital, where the DMOH is in most cases also  Formulating relevant health objectives for
the medical superintendent of the hospital. the district in keeping with the provincial
and national health policies.

Jesse Daniel Omolo.. Page 25

  Identifying health problems and needs in based health workers provide basic curative,
the district. promotive and preventive services. They may be
 Training and deployment of staff to health augmented by the activities of special
facilities. programmes, such as KEPI, or various mobile
 Planning and coordinating health activities services. These health services together form the
for optimal utilisation of district resources. backbone of rural health service where about
 Supervising all health care activities and 80% of the population live.
services within the district.
 Collecting and analysing data on As you well know, not everyone gets all their
community health needs and assessing medical care from government facilities. People
health coverage. are also treated by other health institutions
 Monitoring and supporting the rural health supported by private and religious organisations.
staff and community health workers.
 Licensing health facilities/clinics. Private Institutions Offering Health Care
Services
Remember: All health services and activities
within the district are monitored and Through supplementing the government health
supervised by the DHMT. services, private institutions play a significant role
in health care delivery. Many patients, who might
Since all community health nurses are supervised not otherwise receive health care, are treated in
by the district public health nurse, it is important private clinics. Some of the drugs and services not
that you understand their duties and available in government units can be obtained in
responsibilities. private clinics.

The District Public Health Nurse Religious Groups

The District Public Health Nurse (DPHN), also  Roman Catholic Church
known as the District Community Health Nurse, is  Presbyterian Church of East Africa
an important member of the DHMT and is  Seventh Day Adventists
responsible to the DMOH (is supervised by the  Anglican Church in Kenya
DMOH).  Quakers (Friends Kaimosi)
 African Inland Church
The main duties and responsibilities of the DPHN
are: Non-Governmental Organisations (NGOs)

 Planning, organising and supervising all  Africa Medical and Research Foundation
community health activities in the district. (AMREF)
 Deploying nursing staff to community/rural  Kenya Red Cross Society
health facilities.  Aga Khan Foundation
 Conducting staff update courses.  Plan International
 Collecting health information and
compiling reports about community health Private Health Care Institutions
services.
 Planning and coordinating health
campaigns.  The Nairobi Hospital
 Procurement, storage and distribution of  MP Shah Hospital
EPI vaccines.  The Aga Khan Hospital(s)
 Implementing health development  Mombasa Hospital
projects for the district development  Gertrude Garden Children Hospital
committee.
United Nations Special Bodies
Community/Peripheral Level
 United Nations International Children
The last level in this hierarchy is the Emergency Fund (UNICEF)
community/peripheral level. This is really at the  World Health Organisation (WHO)
community level where there are divisions,  United Nations Population Fund UNFPA
locations and sub-locations. Here health centres,
dispensaries and in some places, community

Jesse Daniel Omolo.. Page 26

Health Sector Reforms The achievement of these objectives required a
Many Kenyans have for a long time lacked access lot of effort and resources at a time when the
to basic health care, safe drinking water, proper government was faced with donor embargos and
sanitation and adequate nutrition. Kenyans suffer other problems. The government of Kenya,
from preventable or easily treatable diseases. through the Ministry of Health, came up with a
Old diseases which had earlier been contained, strategy called the National Priority Health
such as tuberculosis, have come back, while new Package. This package ranks the health problems
diseases and viruses like HIV/AIDS have in Kenya according to the associated morbidity
emerged. and mortality.

The deteriorating situation in health caused the High Priority Health Packages
government of Kenya to develop a Health Policy
Framework Paper in 1999 outlining the strategies  Malaria prevention and treatment
for the development and management of the package.
health services in the country. To implement this  Reproductive health package.
paper, a Health Sector Reform Secretariat was  HIV/AIDS/TB prevention and
established to spearhead the reform process. management package.
 Integrated Management of Childhood
The effects and institutional arrangements put in Illnesses (IMCI).
place to implement the Kenya's Health Policy  Expanded program on immunisation.
Framework Paper (KHPFP) were slow. The  Control and prevention of major
downward trend in the poor health of Kenyans environmental health related
continued to raise concern to both the Ministry of communicable diseases such as cholera,
Health and other key stakeholders in the health typhoid, dysentery and food safety.
sector.
Medium Priority Health Packages
Many consultative meetings and workshops were
held under the guidance of the Ministry of Health
 Non-communicable diseases (diabetes
to explore ways in which the KHPFP policy mellitus, cardiovascular diseases,
objectives could be translated into actions to rheumatic fever).
reverse the deteriorating health situation in the
 Reproductive cancers (cancer of cervix,
country.
breast, prostate).
 Mental health, drug/substance abuse.
From these meetings, the National Health Sector  Injuries and accidents.
Strategic Plan 1999-2004 (NHSSP) was
 Control of other vector-borne diseases.
established to address the constraints in the
health sector. This was a five year strategic plan
which started in 1999. It had the following Low Priority Health Packages
objectives:
 Eye infections.
 To ensure the equitable allocation of  Skin diseases.
government resources to reduce  Ear infections.
disparities in health resources distribution.  Worm infestations.
 To increase the cost effectiveness and
the cost efficiency of resource allocation SECTION 5: INFORMATION,
and use. EDUCATION AND COMMUNICATION
 To continue to manage population growth.
 To enhance the regulatory role of the
government in all aspects of the health Introduction
care provision. You are now in the last section of this unit. In the
 To create an enabling environment for previous section you looked at how our health
increased private sector and community services are organised and the health sector
involvement in health service provision reform programme initiated by the Ministry of
and financing. Health.
 To increase and diversify per capita
financial flows in the health sector. In this section you shall look at the Information,
Education and Communication (IEC) skills you
need to positively influence the attitudes, practices

Jesse Daniel Omolo.. Page 27

and behaviour of people in your community to youth for example, they get more information
adopt healthy living. through music and so radio is a powerful tool for
them. Adult learners on the other hand prefer
Objectives discussions and interpersonal communication.

What is the purpose of IEC?

By the end of this section you will be able to:

Some of the main purposes of IEC are to:

 Describe the concepts of IEC
 Describe the principles of IEC
 Describe factors influencing adult learning  Inform the people about health and health
 Describe the process of mobilising IEC related issues relevant to them
materials  Dispel rumours, fears and misconceptions
 Describe how to conduct effective health about certain health issues and to
talks reassure them
 Motivate the patients and members of
communities to seek health care when
Concepts and Principles of IEC sick and promote healthful living by
keeping good habits and behaviour
What is IEC?  Empower the individuals, families and the
community to participate in the
IEC is a systematic attempt to influence positively implementation of programmes that
the attitudes, practices and behaviour of promote healthful living
individuals, families and the community, to adopt
healthy living. IEC therefore is not only health education but it is
a comprehensive approach. It builds the capacity
Information, Education and Communication is a of communities, families and individuals by giving
process that empowers individuals, family and them relevant information communicated in a way
communities to make decisions concerning their that they can understand, internalise and take
health. It encourages people to change their appropriate action. The information may not
behaviours and social conditions. necessary be directly health information as long
as it will impact on people's life. For example you
IEC combines strategies, approaches and can give people information on the cash crops
methods that enable communities, groups and they should grow even if it means getting the
organisations to play active roles in preventing Agriculture Officer to show them. Cash crops can
diseases, thereby promoting and sustaining help in alleviating poverty which as you know has
good health. a negative impact on people's health.

With IEC, activities are developed based upon the Now move on to briefly look at factors that
assessed needs, sound planned educational influence adult learning. You will learn adult
principles and continuous monitoring and education in more detail when you come to the
reviewing of the objectives and planned activities. unit on Teaching Methodology in module four.

In order to increase access to knowledge by Factors that Influence Adult Learning

different people on various issues, products and
behaviour, health information must be From your own experience, you may have
communicated through various channels. realised that various conditions and reasons
These include: influence adult learning. You are now going to
look at these conditions and reasons that promote
 Face-to-face or interpersonal learning in the adults.
communication such as individual
discussions, counselling sessions, group What are some of the factors that influence adult
discussions and community meetings or learning?
events
 Mass media such as newspapers, radio As you may have indicated adults learn faster and
and television better when:

The main reason of using a variety of media is

 They make the decision to learn on their
because it has been found that people are
own
influenced differently by different media. Take the

Jesse Daniel Omolo.. Page 28

  The information or skills acquired are of if you are talking to a group of mothers about a
immediate use to them weaning diet, it may be necessary that you put
 Information or skills given/shared relate to together nutritious foods which are locally
their immediate or future activity available and culturally acceptable to give an
 They know what to expect or what is infant. If you are talking about family planning, you
expected of them will need to have all the contraceptives methods
 Learning takes place in an atmosphere of as you may even have to demonstrate, for
trust, acceptance and encouragement example wearing a condom.
 There are no distractions during the
learning session In some health talks, you might not get a chance
 The information to be learnt is clear and to have the actual items on display but a poster
relevant to their needs showing the same will do. A good example is the
 They are involved in what is being taught poster shown above. Before you use a poster, you
and are actively involved in the should ensure that it is developed and pre-tested
learning activities on the target audience in order to ensure that the
 The material being learnt is based or community understands the message you want
related to what they already know to communicate.
 They receive immediate feedback from
the teacher about their performance Mobilising materials may also mean, checking the
channels/media of communication so that the
Most of the teaching that you are going to carry individuals, families and indeed entire
out as a community health nurse will be focused communities can get the message as and when
on adults. You are going to be talking to the youth, planned. The media may be print, radio, television
parents, family planning patients, household or face-to-face. Some of the materials may be the
heads, community members and community actual items such as food, while others may be in
leaders. form of handouts or posters. There are many
posters, charts, calendars and even pamphlets
that have been developed for different messages
Since learning is a process of acquiring
which you may have seen in your health facility.
knowledge, skills and attitudes, which results in
These are some of the resources that you may
modification or change in thinking and behaviour,
have to assemble before you start your talk.
you should always bear in mind that the people
you are teaching have some knowledge no matter
how inaccurate it may be. You should therefore Organising resources does not only include the
start with what they know and what they would media that you want to use but also may mean
like to hear. Once you have their confidence, it is organising the space you are going to use or even
easy to then carry them with you. Always avoid seeking permission to organise such
offending people even when tackling the harmful a meeting.
cultural habits, you have to be very tactful and
make them diagnose the problem themselves. The animation opposite shows some ideas for
Use problem-based learning which makes the handouts, posters, pamphlets, etc.
learners discuss their problems more openly and
search for solutions. You will learn about this in
greater detail in the Teaching Methodology unit in
module four. What is meant by organising space or seeking
permission?
Mobilising IEC Materials
As mentioned earlier, when you are sharing Whether you are talking to an individual, family or
information you should not assume what the community, you need a place where you can all
learner's level of knowledge is. It is therefore very assemble. You should check the place to ensure
important for you to prepare yourself and put that it has a conducive environment for a talk. For
together all the necessary resources you will example, you do not want to be in a noisy place or
need. This is what is known as mobilising the in an open space when it is either raining or very
IEC materials. sunny. Once you select the place you will need to
check on the seating arrangements if you want
What are some of the materials you may people to be seated and make the necessary
require during IEC? arrangements.

The materials you need to mobilise depend on the As for seeking permission to hold a meeting, it is
message you want to communicate. For example, important to operate within the law as this could

Jesse Daniel Omolo.. Page 29

affect your programme. If you need permission to  The need to respect and work with
hold a Baraza, it is important for you to seek it Community's Own Resource
from the relevant authorities. In fact it may be Persons (CORPS)
helpful to involve the authorities concerned, such  The need to empower and work with
as the chiefs and other respected members of that others (volunteers, field health workers,
community. staff, community based health workers
This means you would have to brief them well in etc.) in promoting IEC
advance and give them detailed plans.  The need to use counselling skills in
health talks
Organising Health Education Talks
This is a method of teaching/learning in which During health talks, you should give
relevant health messages are shared with the client/audience the right information through
individuals or groups to enable them to meet direct or face-to-face communication. The process
identified health needs and make informed of communication in teaching is covered in detail
decisions about their lives. in the Teaching Methodology unit in module four.

Before organising a health talk, it is very

important, you understand the health problems
and needs of the individual, family or the particular
group that you are going to talk to.

Why is it important for you to understand the

health problems of your target group?

Knowing the problems affecting the target

audience of your talk and what they need to solve
the particular problem is important because it:

 Enables you to determine the desires,

concerns and interest of the
client/community and identify what
information will be presented
 Helps you to ensure that the health talk is
aimed at the current needs of the
client/community and what materials and
resources are needed
 Enables you to set specific objectives
thereby assisting the learners to know
what is covered in the discussion
 Enables you to evaluate the outcome of
learning

Whether the aim of your health talk is to educate,

dispel rumours/misconceptions about health
problems or to provide instructions and/or
demonstrations on health actions and practices,
you must organise it well so as to effect any
change.

You should bear in mind:

 The individuals or community's health

needs and problems
 The need for clear, simple culturally
relevant health messages
 The use of appropriate teaching/learning
materials (posters, charts or models)

Jesse Daniel Omolo.. Page 30

UNIT TWO: PRIMARY HEALTH CARE world by the year 2000 of a level of health that will
permit them to lead a socially and economically
In this unit you will cover the concept, principles productive life' (WHO, 1977).
and elements of Primary Health Care (PHC). You
will look at the implementation of each element in However, many countries in the developing world
the seven levels of health care intervention in recognised the fact that it was not possible in the
Kenya, giving emphasis to the importance of all foreseeable future for them to achieve this
the components of community participation. worldwide social objective. This was because
many lacked the resources needed to develop
This unit is composed of four sections: and run health services. They needed to adopt a
strategy that allowed them to use the available
resources to give some benefit to everyone and
Section One: Concept and Principles of PHC. provide special attention to those at high risk. The
Section Two: Implementation of PHC Elements. member governments endorsed the PHC strategy
Section Three: Responsibilities of the Key for the provision of health services for all.
Implementers of PHC.
Section Four: PHC Achievements, Challenges
and the Way Forward. The strategy for the implementation of PHC was
adopted by the Kenya government to provide
health services to its population, the majority
Unit Objectives (80%) of whom live in the rural areas.
By the end of this unit you will be able to:
Definition of PHC
 State the principles and concept of PHC Write down your definition of Primary Health
 Describe the implementation of each Care.
element in the seven levels of health care
intervention In 1978, the Alma Ata international conference on
 Explain the responsibility of each key PHC defined primary health care as:
player in the implementation of PHC
activities
 Describe the achievements, challenges 'Essential health care based on practical,
met and the way forward for PHC in
scientifically sound and socially acceptable
Kenya methods and technology, made universally
accessible to individuals and families in the
SECTION 1: CONCEPT AND PRINCIPLES community through their full participation, and at a
OF PHC cost that the community and country can afford to
maintain at every stage of their development in
Introduction the spirit of
self-reliance and self-determination.
In this section you will look at the historical
background of PHC and its concept, paying In addition, it forms an integral part both of the
special attention to its definition, fundamentals, country‟s health system, of which it is the central
elements and principles. function and main focus, and of the overall social
and economic development of the community. It is
the first level of contact of individuals, the family
Objectives and the community with the national health
By the end of this section, you will be able to: system, bringing health care as close as possible
to where people live and work'.
 Describe the concept and principles of
PHC PHC is not only:
 List the PHC elements according to WHO
 List the PHC elements according to  Primary medical care
country added elements  First contact medical or health care
 Explain each PHC element  Health services for all

Background of PHC
In the 1977, World Health Assembly, the
government of Kenya along with other member
states of WHO, endorsed the worldwide social
objective of 'The attainment by all people of the

Jesse Daniel Omolo.. Page 31

PHC is and does the following: PHC is a strategy of health care delivery which
creates a partnership between the consumer of
 It is intended to reach everybody, the health services and health care professionals.
particularly those in greatest need They both actively participate in the achievement
 It is intended to reach the home and of the common goal of improved health.
family level, and not to be limited to health
facilities Key players in the implementation of the
 It is intended to involve a continuing primary health care programme
relationship with persons and families
Key players include the government, non-
Preventive and Promotive Health Care (PHC) governmental organisations, Primary Health Care
includes the basic clinical, preventive, and workers and community members, amongst
promotive health services that should be readily others.
accessible to all members of the population.

Emphasis is on improving family health, with

particular focus on mothers and children;
increasing coverage and accessibility of essential
health services; improving the quality of services;
and pursuing an integrated inter-sectoral and
multi-disciplinary approach with community
participation in the planning, delivery, and
monitoring of health services.

From the definition, you need to note the following

key statements which identify PHC as essential
health care. These are:

 PHC is universally accessible to

individuals and families in the community.
 PHC is socially acceptable to all, meaning
that the health care is appropriate and
adequate in quality to satisfy the health
needs of people, and is provided by
methods acceptable to them within their
social cultural norms.
 PHC is affordable, that is, whatever
methods of payment used, the services
should be at a price the community can
afford.
 PHC promotes full participation of
individual, families and communities.
 PHC is appropriate technology that is, the
use of methods and technology which use
locally available supplies and equipments.

A concept is an idea about an issue, event or

practice.

The concept of PHC can be described as ideas

about the implementation of health care for all. It
is easily identified using the five 'A's as follows

Primary Health Care should be available to

everyone.

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 The Seven Pillars of PHC
Aspect Definition Comment
Health Primary Health Care. The first elements of a continuing health care process, sustained by
System integrated, functional and mutually support referral systems, leading
to the progressive improvement of the comprehensive health care for
all, and giving priority to those in most need.
Priority Essential health problems. Addresses main health care problems in the community providing
promotive, preventive, curative and rehabilitative services.
Practical, scientifically
Science Based on application of the relevant results of social, biomedical and
sound.
health services research.

Culture Socially acceptable Reflects and evolves from the economic conditions and socio-cultural
methods and technology. and political characteristics of the country and communities.
Made universally
Equity The attainment of health care for all people of the world by the year
accessible to individuals
2000 and beyond, of the level of health that would permit them to
and families.
lead socially and economically productive lives. The existing gross
inequality in the health status of the people particularly between
developing countries, as well as within countries is politically, socially
and economically unacceptable.

Through their full

Participatory The people have the right and duty to participate individually and
participation.
collectively, in the planning and implementation of health care.

Sustainability At a cost that the

community can afford to
maintain at every stage of To exercise political will to mobilise the country‟s resources and to
their development in the use available external resources rationally.
spirit of self-reliance and
self-determination.
Fundamentals of PHC 4. PHC involves, in addition to the health
sector, other sectors such as agriculture,
Fundamentals of PHC are basic rules or beliefs animal husbandry, food industry,
that are essential to the existence, development education, housing, public
or success of Primary Health Care. works, communication and other sectors.
It demands the coordinated efforts of
1. PHC reflects and evolves from the all these sectors.
economic conditions and socio-cultural 5. PHC requires and promotes maximum
and political characteristics of the country community and individual self-relianceand
and the communities, and is based on the participation in the planning, organisation,
application of the relevant results of operation and control of health services,
social, biomedical and health services making fullest use of local, national and
research and public health experience. other available resources.
2. PHC addresses the main health problems Through appropriate education the
in the community, providing promotive, communities themselves are
preventive, curative and rehabilitative empowered to participate.
services accordingly. 6. PHC should be sustained by integral,
3. PHC includes, at least: education functional and mutually supportive
concerning prevailing health problems referral systems leading to the
and the methods of preventing and progressive improvement of
controlling them; an adequate supply of comprehensive health care for all, and
safe water and basic sanitation; maternal giving priority to those most in need.
and child care including family planning; 7. At local and referral levels, PHC relies on
immunisation against the major infectious health workers, including physicians,
diseases; prevention and control of locally nurses, midwives, auxiliaries and
endemic diseases; appropriate treatment community workers, as well as traditional
of common diseases and injuries and practitioners who are suitably trained both
provision of essential drugs. socially and technically, to work as
a health team and to respond to the

Jesse Daniel Omolo.. Page 33

 expressed health needs of the Health education today has extended its scope
community. beyond disease prevention and control to health
promotion. It gives individuals and communities
PHC is a universal strategy for achieving the incentive to promote the conditions that
health for all globally. maintain good health.

Elements of PHC You can see that health education is an integral

In the Alma Ata conference of 1978, eight part of all health services, all health personnel
essential elements of PHC were identified. including yourself have an important role to play in
However, individual countries were given the organising appropriate health educational
liberty to add any other elements they felt were programmes at all levels in the community.
relevant to their own country. Kenya has added
other elements.

Promotion of Food Supply and Proper

Nutrition

The PHC elements listed at the Alma Ata Nutritional deficiency states are particularly
Declaration were as follows: noticeable among pregnant and lactating mothers,
infants and children. This may be due to the
1. Education concerning prevailing health prevailing cultural or economic factors in the
problems and the methods of preventing community.
and controlling them
2. Local disease control As a community health nurse, it is your
3. Expanded programme of immunisation responsibility to take suitable measures to prevent
4. Maternal and child health care and family and treat diarrhoea diseases, intestinal parasites
planning and other diseases, which lead to nutritional
5. Essential drug supply deficiency states. It is also your responsibility to
6. Nutrition and adequate food supply support health promotional measures such as
7. Treatment and prevention of common child spacing, nutrition education, kitchen garden
diseases and injuries and food hygiene. In coordination with other
8. Safe water supply and good sanitation sectors, you should also encourage community
members to grow more foods, prevent post
Use the acronym 'ELEMENTS' to help you harvest spoilage through construction of simple
remember these eight elements. food stores, and to keep poultry and dairy cattle.

The Kenyan government has added additional Water Supply and Basic Sanitation
PHC elements to the ones identified at the Alma
Ata conference These are: Safe water and sanitation is not available to a
major section of our population, yet, it is essential
 Mental health for life. Many water borne diseases which are
 Dental health prevalent in the community can be prevented if
 Community based rehabilitation communities gain access to safe water and adopt
 Malaria control proper refuse and faecal disposal.
 STI and HIV/AIDS prevention and control
So under this element, effort is being made to
You will now look at each element and what it bring together the different factors from related
entails. sectors to survey and identify sources of safe
water and carry out proper analysis of the water.
At the same time, community health workers
should educate community members on how to
Health Education
protect wells and springs from contamination, how
to construct latrines, compositing facilities and
Health education is education that is intended to soakage pits.
have a positive impact on health. It is a process of
dialogue with community members to find out
Maternal and Child Health and Family Planning
appropriate responses to health problems, as well
as to empower them with the knowledge and
insight they need, to understand how their Children make up one-half of the community and
behaviour affects their health. their mothers another fifth. On numbers alone,

Jesse Daniel Omolo.. Page 34

health care for mothers and children forms the Write down the definition of an ‘endemic
greater part of community health. Mothers and disease’ and give some examples of these in
children also run a great risk of injury and disease Kenya.
because their lives are concerned with beginnings
and growth. MCH/FP services are therefore aimed An endemic disease is a disease which is present
at promoting the health of mothers and children, in a community all the time.
by reducing the maternal and child mortality rates,
and enabling women of childbearing age to have
Examples of endemic diseases in Kenya include
the desired number of pregnancies and at the
the following:
right interval. MCH/FP care has the following four
main functions:
 Malaria
 Schistosomiasis
 Antenatal care / Prenatal care
 Filariasis
 Perinatal care
 Hookworm
 Postnatal care
 Trachoma
 Family planning
 Onchocerciasis
Since 1980, the issue of family planning has
As you can see, these are mainly communicable
gained momentum and highlighted an issue that
diseases. You will learn more about them in unit
was formally regarded as unimportant. In
response, our government established the four of this module.
National Council for Population and Development
to coordinate all population and family planning Malaria Control
activities. It also set up the service component of
the family planning program within the Ministry of Each district in Kenya is required to determine
Health. Also, NGOs such as FPAK, CHAK, and malaria endemicity and plan and implement an
the Catholic Secretariat play an important role in appropriate control strategy. The other factor to be
both motivation and service provision. considered is the objective of control activities.
Four levels of control are possible as described
The practice of family planning is an old African below.
tradition. What is new is the variety of methods
which have been introduced to prevent or delay Level 1
pregnancy.
The objective is to prevent malaria mortality and
Immunisation hence the control strategy is to make
chemotherapy available as close as possible to
Kenya has for some time now implemented every family.
immunisation activities through the Kenya
Expanded Programme on Immunisation (KEPI). Level 2

Immunisation is a very effective means of primary The objective is to control mortality and morbidity
prevention against certain endemic and epidemic due to malaria. The control strategy here involves
diseases. Kenya has a long history of chemotherapy as close to each family as possible
immunisation programmes. and chemoprophylaxis with simple anti-mosquito
measures.
Health workers have been trained on how to
motivate and encourage mothers to bring their Level 3
children for immunisation, as well as how to
identify suspected cases of immunisable diseases The objective is to control malaria mortality,
such as, measles, poliomyelitis and neonatal morbidity and prevalence. This requires
tetanus, using standardised case definition chemotherapy and chemoprophylaxis with
(disease surveillance). effective mosquito control.

Local Disease Control Level 4

There are many endemic diseases in this country, The objective here is to eradicate malaria
some of which are confined to particular areas. completely.
Can you remember what an endemic disease is?

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Given the economic situation in Kenya, the health Mental health services should not be viewed in
infrastructure and the complexity of the logistical isolation but as an integral part of the other
demand of the methods of control mentioned services that are needed to achieve the complete
above, the first priority of malaria control for you health of individuals, families and communities.
has to be that of mortality and morbidity
Health workers should therefore:
particularly in areas of unstable malaria.

Treatment and Prevention of Common  Be oriented to look at mental health as

Diseases and Injuries part and parcel
of PHC
 Promote good mental health practices
Curative care is important in its own right as it
provides a powerful mechanism for teaching through health education of the family and
community in order to
preventive and promotive care.
create awareness
 Provide facilities in all health institutions
List four of the most common conditions in and service delivery points for education,
your catchment area. detection, treatment or referral of mental
health problems
 Diarrhoea diseases
 Skin diseases Dental Health
 Worm infestation
 Common accidents requiring first aid; Dental health is a strategy of care focusing on the
burns; wounds; bites and stings; allergic promotive and preventive care of teeth and the
shock oral cavity. From your experience you are aware
 Eye conditions that dental diseases are one of the most
 Acute respiratory infections widespread diseases in our communities, and yet
they are largely preventable. The Ministry of
You can arrive at an accurate list of the common Health has established fully fledged dental care
diseases in your area by reviewing the clinic or units in all health facilities.
health centre records over a period of time.
Community Based Rehabilitation
Supply of Essential Drugs
Many developing countries such as Kenya
Essential drugs are basic drugs used to treat included this element in order to give special
minor ailments or conditions at the dispensary and attention to the management and prevention of
health centre levels. disabilities arising from congenital defects, chronic
non-communicable diseases such as cancers,
Kenya has been a pioneer in the establishment of and accidental injuries. Rehabilitation services are
an effective drug kits system which regularly now being integrated at all levels of health care
delivers drugs to health units. delivery including at the family and community
level.
Community pharmacies have also been
established in remote rural areas to improve HIV/AIDS Prevention
access to drugs in the community.
The Kenyan government has set out technical and
As a community health nurse you have a major ethical approaches aimed at meeting the
responsibility in ensuring that patients have challenges presented by the HIV/AIDS pandemic.
access to essential drugs and know how to These include:
manage their drug regimens for optimal effect.
 Adequate and equitable provision of
Mental Health health care to the growing numbers of
HIV infected
The WHO defined health as „a state of complete people falling sick
physical, psychological, spiritual and social well-  Treatment of other sexual transmitted
being and not merely absence of disease or diseases that increase peoples biological
infirmity‟. vulnerability to HIV infection
 Reduction of women‟s vulnerability to HIV
infection by improving their health,

Jesse Daniel Omolo.. Page 36

 education, legal status and economic Manpower Development
prospects
 A supportive socio-economic environment Primary Health Care aims at mobilising the human
for HIV/AIDS prevention potential of the entire community by making use of
available resources. This principle facilitates the
The PHC approach emphasises the need to identification and deployment of the necessary
involve individuals, family members, and health personnel as well as the training and
community members in the prevention and control development of new categories of health workers
of HIV/AIDS. to serve the community. Comprehensive PHC
requires health workers to identify solutions that
You now know the fundamentals of PHC as well involve the community, as follows:
as all the elements adopted by our country. Next
you will look at the principles of Primary Health 1. It is not enough to provide oral
Care. rehydration solution and medical
treatment to a sick child with diarrhoea.
Maintaining the health of the child also
Principles of PHC requires providing family education on
child care and environmental hygiene, as
To implement the Primary Health Care elements a well as improving access to food.
number of principles are involved. Although the 2. In addition to counselling on breast
details vary from country to country each principle feeding, growth monitoring, nutrition
must be considered during the implementation of rehabilitation, and child care, a nutrition
PHC. program should promote weaning foods
that are available locally.
A principle is a rule or basic belief that has a 3. PHC services for healthy people (prenatal
major influence on the way in which something is care, immunisation, health education)
done. Therefore principles of PHC are rules or should be established as soon as
guidelines that govern the implementation of PHC possible through community based health
activities. interventions.

There are five basic principles which govern the Community Participation
implementation of PHC. These are:
As you learnt in unit one of this module,
 Equity community participation is the process by which
 Manpower development individuals, families and communities assume
responsibility in promoting their own health and
 Community participation
welfare. The PHC strategy underlines the
 Appropriate technology
importance of full community participation,
 Multi-sectoral approach especially in health decision making. Community
members and health providers need to work
Equitable Distribution together in partnership to seek solutions to the
complex health problems facing communities
Equity is the fair and reasonable distribution of today. In addition to the health sector, families and
available resources to all individuals and families communities need to get actively involved in
so that they can meet their fundamental and basic taking care of their own health. Communities
needs. Services should be physically, socially and should participate in the following:
financially accessible to everyone. People with
similar needs should have equal access to similar  Creating and preserving a healthy
health services. environment
To ensure equal access, the distribution of  Maintaining preventive and promotive
resources and coverage of Primary Health Care health activities
services should be greatest in those areas with  Sharing information about their needs and
the greatest need. wants with higher authorities
 Implementing health care priorities and
This principle should be taken into account when managing clinics and hospitals
deciding on the location of new health facilities,
outreach services points, or during introduction of
new health programmes, especially those that
require payment for services.

Jesse Daniel Omolo.. Page 37

Appropriate Technology must work in close collaboration with other sectors
Appropriate technology is the kind of technology in the community in order to succeed in promoting
that is scientifically or technically sound and the community‟s health and self-reliance.
adaptable to local needs, and which the
community can afford to maintain at every stage Multi-Sectoral or Intersectoral Approach
of their development in the spirit of self-reliance
and self-determination. It includes issues of costs Try to name four sectors which you need to
work with in order to improve the health of the
and affordability of services, type of equipment
community where you work.
and their pattern of distribution throughout the
community. An increasing complexity in health Often, the health sector works in collaboration
care methods should be observed upward in the with the following sectors:
PHC pyramid (see graphic). Care givers should
be trained to deliver services using the most  Agriculture
appropriate and cost effective methods and  Water and sanitation
equipment for their level of care.  Animal husbandry
 Education
Appropriate technology does not necessarily  Housing
mean low technology.  Public works
 Transport and communication
 Roads and housing
 Reclamation, development of arid and
semi arid wastelands

These sectors need to coordinate their plans and

activities in order to contribute towards the health
of the community and avoid conflicts or
duplication of efforts.

Summary

To summarise, this is what you need to remember

about the principles of PHC.

 Every individual has a right to a high

quality of life.
 The community must be allowed to take
charge of the resources available from
both within and outside their environment.
This empowers them to be more
responsible and accountable for their
quality of life.
 There should be equitable distribution of
Multi-Sectoral or Intersectoral Approach
resources among the community
members so that they can meet their
PHC requires a coordinated effort with other fundamental and basic needs.
health related sectors whose activities impact on
health. For example, agriculture, water and Health Promotion and Prevention - PHC requires
sanitation, transportation, education, etc. This is a comprehensive approach that is based on the
necessary to achieve social and economic
following interventions:
development of a population.
The health sector should lead this effort.
 Promotive - addresses basic causes of ill
health at the level of society. Preventive -
The commitment of all sectors may increase if the
reduces the incidence of disease by
purpose for joint action and the role of each sector
addressing the immediate and underlying
is made clear to all concerned. Lessons drawn
causes at the individual level
from past experience clearly indicate that the
health sector cannot achieve much in isolation. It

Jesse Daniel Omolo.. Page 38

  Curative - reduces the prevalence of The major milestones achieved by the
disease by stopping the progression of government in health care development are
disease among the sick captured in the following chronology of events.
 Rehabilitative - reduces the long term
effects or complications of a health In 1965 the government introduced free medical
problem treatment in government medical facilities in line
with the policy guidelines of the KANU manifesto.
Comprehensive PHC combines facility based
health services (curative and rehabilitative) with In 1967 the national family planning programme
multi-sectoral public health interventions was started.
(promotive and preventive).
In 1970 the central government took over the
Because this approach is more effective in running of health services from
sustaining the overall wellbeing of a population, it local councils.
should be supported by the community.
In 1971 - 1972, a joint GOK/WHO mission
SECTION 2: IMPLEMENTATION OF PHC formulated the proposal for the improvement of
ELEMENTS rural health services in the country and
established six Rural Health Training Centres
Introduction (RHTCs). This was done in order to provide
adequate health coverage to the rural population.
In this section, you will start by reviewing how the
government implemented health care before Rural health demonstration centres in Kenya.
adopting the PHC strategy and then look at the
major health policies which are currently guiding  Karurumo rural training centre
health development in Kenya.  Chuluaimbo rural training centre
 Mbale rural training centre
Lastly you will look at how the PHC elements  Maragua rural training centre
should be implemented at the four different levels  Mosoriot rural training centre
of health care provision in Kenya.  Tiwi rural training centre

Objectives In 1984 a community based health care unit was

By the end of this section you will be able to: set up within the integrated rural health and family
planning project.
 Give an overview of health services in
Kenya before PHC Indeed, the concept of community participation in
 Look at the major health policies which development activities is not new in Kenya. You
are guiding the current health might remember the introduction of the Harambee
development plan (self-help) movement which encouraged people to
 Describe how PHC elements have been contribute their resources and participate in the
implemented at the following levels of development of healthcare and education.
health provision in our health system: People‟s efforts were directed towards
Family level; Community level; District; construction of physical facilities like classrooms
Provincial/National level and wards with the hope that the government
would take over their management. Similarly,
Health Services in Kenya before community participation is an important
cornerstone of the PHC strategy. The PHC
Implementation of PHC
strategy relies on the abounding spirit of self-help
among community members and endeavours to
Since Kenya became independent in 1963, the empower them to improve their health.
government has all along demonstrated its
commitment towards the provision of quality
health services for its people. In its various Having seen where health services in Kenya have
manifestos and development plans, it has come from, next you will look at the direction that
identified health as one of the basic needs and an health care delivery services are taking. This can
essential precondition for the overall economic be accomplished by looking at some of the key
health policies that have influenced health
development and social progress of this country.
development.

Jesse Daniel Omolo.. Page 39

Major Health Policies Guiding Current Health Efforts were also made to support preventive and
Development Plan promotive health programmes, and further
investment in the rural health infrastructure, by
The steady development of PHC has necessitated improving service delivery methods, and
a continuous review of existing policies in the increasing the number and quality of trained
health sector. health manpower.

Name at least one policy which has guided the Consolidating Urban/Rural, Curative,
development of PHC in Kenya. Preventive and Promotive Services

 The district focus for rural development Here emphasis was put on training all health
strategy cadres in preventive and promotive methods.
 Increasing coverage and accessibility of Personnel located at hospitals and other static
health services in rural areas facilities were encouraged to include health
 Consolidating urban and rural curative, education as a routine component of PHC.
preventive and promotive services
 Intersectoral collaboration Intersectoral Collaboration

The District Focus for Rural Development Intersectoral collaboration means working
Strategy together with other sectors whose activities have
a direct influence on health. Health is too
This policy was introduced by the government in important to be the responsibility of the health
July 1985, to decentralise decision making to the sector alone.
grass roots, and turn the district into a centre for Other sectors whose activities have a direct
the planning and implementation of government influence on health include ministries of
projects. agriculture, water, housing, culture and social
services, and so on.
As a result of this strategy, the management
capabilities of health personnel at the district level he current development plan has set out the
were strengthened, thus reducing many following policies to guide health development:
challenges which they experienced before.
 Increasing emphasis on MCH/FP services
Name three problems that were resolved by in order to reduce morbidity, mortality and
the introduction of the district focus strategy? fertility rates
 Strengthening Ministry of Health
Problems that were resolved by the introduction of management capabilities with an
the district focus strategy were: emphasis on the district level
 Increasing inter-ministerial coordination
 Increasing alternative financing
 Facilities management
mechanism for health care
 Drug supplies
 Transport
These major policy guidelines show the explicit
 Maintenance of equipment
direction in which health care delivery services in
Kenya have taken. For instance, there has been a
The role of the District Health Management clear shift from the earlier policy which provided
Teams (DHMT) was strengthened in line with the free medical services, to one which has
district focus for rural development strategy. introduced cost sharing.
The development of the Community Based Health
Increasing Coverage and Accessibility of Care (CBHC) approach as a basic component of
Health Services in Rural Areas PHC is another important milestone. This
approach emphasises community participation in
It was realised that development of the rural environmental health activities, prevention of
health infrastructure had lagged behind because diseases, establishment of community health
of financial constraints. Yet experience had shown funds, and income generating activities.
that preventive and promotive health programmes
were more cost effective if adequately supported. The introduction of community based health
So the government made a deliberate effort to care as a strategy for achieving the goals of
redirect capital from major capital projects to small PHC was a major policy step in Kenya.
scale projects at the district and sub-district levels.

Jesse Daniel Omolo.. Page 40

The Alma Ata conference set as its target „Health 3. Good governance and greater
for All by the Year 2000‟. Since then the Ministry commitment of our political leadership to
of Health has reviewed and revised its strategies the concepts of Primary Health Care.
to follow the Primary Health Care guidelines. 4. Intensification of community involvement
Through the implementation of the policies you and existing community initiatives, for
have just covered, it has organised a number of health and development through
healthcare activities within communities according increased awareness.
to their needs and conditions. 5. Extension of the existing health services
infrastructure, in support of PHC, to
What kind of development activities has the remote areas through outreach
community in your catchment area programmes or creation of new health
undertaken? units.

Some example activities are: As these steps are adopted, it is important to

ensure that priority is given to the underserved
areas. This can be achieved through proper
 Water project
coordination of funding agencies, making effective
 Kitchen gardens use of committees at all levels, and improvement
 Construction of schools of monitoring
 Construction of VIP toilets and evaluation.

While these efforts have led to an improvement in Having seen the policies which the government
accessibility, availability, affordability and
has put in place to guide health development
acceptability of health services, there are still
considerable constraints and a lot more needs to before and after PHC, you will now briefly look at
be done to completely integrate PHC. the organisation of health services in Kenya and
the functions of the Primary Health Care
The year 2000, which was set as the target for the committee, then you will see how the PHC
achievement of health for all, came and passed. elements have been integrated in the seven levels
Even five years later, health for all has not been of our health care system.
achieved. For this target to be met, a number of
things need to change that continue to get in the Organisation of Health Services in Kenya
way. These are:
Headquarters Level
 A change in the attitude of health
personnel and At headquarter level, the Ministry of Health (MOH)
the community is responsible for setting policy, coordinating
 A change in the motivation of both health activities of government and non-governmental
workers and organisations, managing the implementation of
the community policy changes regarding government services,
 Greater intersectoral collaboration such as user charges, monitoring and evaluating
 Political will the impact of policy changes.
 Equitable redistribution of the available
resources Provincial Level
 More appropriate and affordable health
technology At the provincial level, the roles of the Provincial
Medical Officer of Health (PMOH) and members
There are certain rational steps which can be of the Provincial Health Management Team
adopted in order to effect the necessary changes (PHMT), are to act as a strong intermediary
at the community and location level. between the central ministry and districts, and to
oversee the implementation of health policy
1. Training and retraining of health (maintenance of standards of quality,
personnel, the community and community performance, coordination, regulation and control
leaders, using appropriate methodology of all health services in the public and private
and exposure of health personnel to the sectors in their areas of jurisdiction).
communities.
2. Strengthening intersectoral collaboration The role of the PMOH and PHMT with regard to
at the community level. the cost sharing programme, is to issue Authority
to Incur Expenditure (AIEs), guide, monitor and

Jesse Daniel Omolo.. Page 41

supervise the District Medical Officers of Health  Look into urban sanitation problems, for
(DMOHs) and facility managers in the province, in example, inadequate refuse collection, unsafe
the management of cost sharing activities. water points, etc. and promote clean up and safe
water supply operations where needed. Also
PMOs are ex-officio members of the District receive complaints and recommend solutions.
Health Management Boards (DHMBs) in their  Work with the DHMT/HMT to establish
provinces. They receive copies of all minutes of contingency plans for epidemics and provide the
DHMB meetings and all long term plans for the necessary support during such epidemics.
district approved by the board. The boards should
inform them of any suspected irregularities in the Implementation of PHC Elements at Different
running of district health services. Levels of Health Care Provision

District Level The seven levels of health care provision

in the health care system
At the district level, the DHMBs oversee all health
sector activities, their functions are not limited to The seven levels of health care provision are:
the management of cost sharing funds. The
government established DHMBs with 1. Family level
representatives of consumers and other interested 2. Community level
groups, to ensure prudent use of such funds. 3. Locational level
4. Divisional level
The Primary Health Care Committee 5. District level
6. Provincial level
This is one of the committees under the District 7. National level
Health Management Team (DHMT). The Primary
Health Care committee oversees all Preventive 1. Family Level
and Primary Health Care (P/PHC) activities in the In unit one of this module the family was defined
district or hospital. as the „basic unit of social organisation in a
community‟.
Specific responsibilities
Being the basic unit in a community, the family is
 Participate with the Primary Health Care (PHC) therefore the nucleus and main focus of each
core team in developing annual PHC plans. This essential element of PHC.
involves a review of services, assessment of You will now briefly look at how each element is
needs and setting of priorities for P/PHC activities implemented at the family level.
in the district/hospital.
 Ensure that the DHMT is submitting plans for Education
the expenditure of 25% of cost sharing revenue
and is spending the funds as planned. The family does not only provide its members with
 Receive reports on preventive, promotive, food, clothing and shelter, it also gives its
community based and Primary Health Care members basic education in language, beliefs and
activities in the district (GOK and NGO) customs. Families have a strong influence on
or hospital. what each member does, thus when educating
 Obtain annual reports of health statistics with families on how to promote their health and
epidemiological data and preventive measures prevent disease it impacts positively on the health
being taken to address the major problems. of the entire community. Education for the
 Promote intersectoral collaboration on issues promotion of health and the prevention of disease,
of sanitation, water, nutrition and health is most effective in the home environment
education. because it creates an ideal atmosphere for
effective teaching. Demonstrations can be done in
 If applicable, review reports on Bamako the home setting with the active participation of all
Initiative activities. family members.
 Receive periodic reports from the PHC
coordinator on activities being carried out in each Nutrition and Food Supply
of the eight components of PHC, and insist on
setting targets for expanding coverage of these
Good nutrition is a basic component of the healthy
services, and thereafter, monitor the achievement
growth and development of each family member.
of these targets. In order to strengthen food and nutrition activities
at the family level, you need to teach the

Jesse Daniel Omolo.. Page 42

members about good food and nutrition practices
including appropriate methods of growing and Treatment of Common Conditions
storing food.
List down some of the common conditions
Water and Sanitation that you have come across in your catchment
area.
You should motivate the family to start the „three
pots‟ system where applicable. They should also Common conditions are diseases which tend to
be trained on how to protect springs and wells; occur very often in the family. They include:
how to construct and use latrines; simple personal
hygiene measures such as hand washing and the  Malnutrition
use of rain roof catchments to harvest water.  Anaemia
 Malaria
Maternal, Child Health and Family Planning  Diarrhoeal diseases
 Acute respiratory infection
As you well know, certain traditional practices in  Worm infestation
the family towards pregnancy, labour and  Schistosomiasis
puerperium can impact positively or negatively on  Scabies
the health of a mother and child. It is your  Conjunctivitis
responsibility to encourage good practices and  Otitis media
discourage harmful ones. Families need to be
educated on the importance of antenatal care,
immunisation and family planning. This can be The role of the family here is to recognise the
done through community health workers and signs and symptoms of these conditions, and
opinion leaders such as teachers, religious seek help from the nearest health facility.
leaders, social workers. Model families in the
community can also be used to reinforce our In addition it is their responsibility to ensure the
teachings. prescribed treatment is taken correctly and to fully
support the patient until they fully recover.
Immunisation
They should also understand the causes of these
It is the responsibility of families to take children diseases, and take the necessary measures to
for immunisation. Your role as a health worker is prevent them.
to educate them on how to read the road to health
card, the need for immunisation and how it works. Mental Health
With the assistance of TBAs and CHWs, you
should also assess and refer children in the The role of the family in the implementation of the
homes for immunisation. mental health element is as follows:

Control of Endemic Disease (Malaria)  Recognising and accepting that mental

health problems are like any other
The main objective is to control mortality disease
particularly in stable malaria areas. The role of the  Seeking help as soon as abnormal
family here is to identify the nearest source of anti behaviour is detected among any of the
malarial treatment; determine the dosage for the family members
treatment of various age groups in the family;  Adopting practices that promote good
manage fever by tepid sponging and know when mental health, such as breast feeding and
to take the patient to the nearest health facility; family support in times of crisis
continue feeding the sick person as normally as  Avoiding behaviour and practices that
possible; determine where and when to seek help; contribute to poor mental health such as
recognise and use simple protection methods over permissiveness and rejection of their
such as mosquito treated nets; ensure family young ones
members at risk of dying from malaria receive
chemoprophylaxis; and clear bushes and stagnant Dental Care
water around the dwelling.
The family plays a very important role in the
If the family implemented these simple measures, implementation of dental health care element.
they would considerably reduce mortality due to This is because the family is able to reinforce
malaria. habits that lead to healthy teeth and gums, such

Jesse Daniel Omolo.. Page 43

as the use of local tooth sticks; eating of Water and Sanitation
indigenous foods, regular dental checkups and
avoiding consumption of large amounts of The role of the community in the implementation
refined sugar. of this element is to work closely with the public
health technician to protect and improve sources
Community Based Rehabilitation (CBR) of clean water. They should also promote the
construction and use of VIP latrines in the
Family members should be educated and community, and identify leaders to represent them
sensitised by CHWs on how they can reduce in village health committees, where issues of
disability in the community. They should take their water sanitation are discussed.
children for immunisation to prevent diseases like
polio; attend antenatal clinics for early detection Maternal, Child Health and Family Planning
and management of those with complicated (MCH/FP)
pregnancies; participate in the care of members
with rehabilitative needs and seek support from Since health workers are members of the local
organisations communities,
whenever necessary. they should train, support and supervise
traditional birth attendants, who manage
HIV/AIDS/TB Prevention pregnancy and labour in most rural communities.
They should ensure availability of contraceptives
Since families have a very strong influence on and create awareness on the need to fully utilise
what each member does, they can achieve a lot in the MCH/FP services available in the community.
HIV/AIDS/TB prevention by encouraging single
sex partners; talking openly to their children about Immunisation
the importance preventing HIV/AIDS; nursing their
members with HIV/AIDS at home and referring The role of the community in the implementation
appropriately for medical care; advocating the use of this element is to ensure that they take all the
of condoms; accepting family members with children for immunisation.
HIV/AIDS; and helping them to socialise and
interact in
Health workers at the community level should
the community. ensure that there is a constant supply of vaccines
and that the cold chain is well maintained.
2. Location and Divisional Level
Immunisation should be provided on a daily basis
These two levels have been consolidated and at all health service delivery points and should be
shall be referred to as the community level. integrated with other MCH/FP services.

Education Health workers should also train and supervise

CHWs and provide outreach and mobile services
Individuals and communities can protect where there are no static facilities.
themselves against diseases and improve their
health if they are well informed. Thus the role of Control of Endemic Disease (Malaria)
the community here is to seek information and
education from health care providers on how they
The role of the dispensary and health centre is to
can improve their health, and also accept to
support the malaria control activities at the
change negative habits and customs which are
community level. The type of support given
harmful to their health.
depends on the local situation and the objectives
of the malaria control strategy.
Nutrition and Food Supply
What activities are undertaken to control
endemic diseases in the community?
The activities at this level include: supervision of
the CHWs by health committees; identification of
The following are the activities undertaken to
high risk individuals and groups; providing
control endemic diseases at the community level:
relevant information to the District Development
Committees (DDCs); and providing food security,
promoting better food production, storage and  Training supervision and follow up of
marketing. CHWs and any other field staff

Jesse Daniel Omolo.. Page 44

  Ensuring constant supply of drugs and HIV/AIDS, TB/STI Control
other supplies required by the community
 Keeping records of clinical cases, At the community level health workers should
parasitological cases, treatments and facilitate health promotion activities; carry out
results of treatment given at this level outreach services including immunisation and
 Compiling reports from CHWs/TBAs and distribution of condoms; provide the correct
providing them with feedback treatment using national guidelines; promote early
 Passing on information to the next level diagnosis and treatment; support home based
on frequency of malaria diagnosis and care givers; and implement the HIV/AIDS and TB
clinical results of treatment package.
 House alternative drugs for those who
need it 3. District Level
 Setting out the criterion for referral and
how to deal with emergencies due to The district focus for rural development strategy
malaria was an important policy shift in support of PHC. It
provided new grounds for practical collaboration
Treatment of Common Conditions between the government sectors and NGOs
based at the district level.
The role of the CHWs should be strengthened so
that they can diagnose these conditions and refer
or treat them early before complications set in. The coordinator of PHC at the district level
The health centre or dispensary should train and
monitor CHWs; maintain records and reports of The District Health Management Team (DHMT)
activities as well as forward them to higher levels. coordinates PHC at the district level. The main
They should also ensure that field staff, including members of this team were covered in unit one of
shop keepers, are well informed and equipped this module. From time to time this team co-opts
with necessary supplies such as ORS. other members depending on the need at hand to
bring in special expertise.
Essential Drugs
The District Level Health System
At the community level, the health centres are
responsible for technical supervision of the use of A health system where the central authorities
drugs by CHW. They should train the community within the Ministry of Health (MOH) are
on rational use of drugs. responsible for running the health services for the
entire nation, is known as a centralised health
system.
Dental Health Primary Health Care is best implemented in a
decentralised system, which transfers the
At this level the role of health workers is providing authority and responsibility for planning, managing
health education to the other community members resources and/or decision making from the central
on good dental health practices. Dispensary and MOH to the district and local levels.
health centre staff together with CHWs may need
training on simple procedures for treating dental Transferring management functions closer to the
diseases. local health authorities gives the local
communities a louder voice in determining how
Community Based Rehabilitation (CBR) clinics and hospitals can improve the quality of
health care being provided.
At the community level health workers have been
trained to cater for CBR services within PHC. Defining the District Level Health System
Their role here is to mobilise the community to
adopt measures that promote good physical A district health system is based on Primary
health, and accept people with disabilities. They Health Care.
should also train CHWs on how to identify and It serves a well defined population living within a
prevent disabilities; basic techniques of disability clearly delineated administrative and geographical
rehabilitation at the community level; referral area. It includes all relevant health care agencies,
methods and integration techniques of the in an area (government, private, professional or
disabled. traditional) which cooperate to create a district
system and work together within it.

Jesse Daniel Omolo.. Page 45

The district health system contains a variety of Coordination
inter-related elements that contribute to health in The highest authority in the district level health
homes, schools, work and communities, and is system should be made responsible for organising
multi-sectoral in orientation. It includes
and coordinating comprehensive PHC services for
self-care and care provided through health care
workers and facilities, including the hospital, with the entire population. However, coordination
supportive services (laboratory, logistical, etc.). It depends on adequate logistical financial support
needs to be managed by an individual with public and training from the central authorities.
health and curative responsibilities in order to
combine the elements and institutions into Health Management Teams
providing a fully comprehensive range of In a district level health system, decision making
promotive, preventive, curative and rehabilitative is shared among the central MOH, the district
health activities and to monitor progress. health offices, the health facilities and the
community. This can only be achieved through
Expected benefits of a well functioning district formation of health management teams at every
health system include: level of health care, for example:

 A rational and unified health system that  District health management teams should
meets the basic health needs include the medical superintendent, the
 Flexible management of health services, senior nursing officer (matron), the
with minimum logistical and administrative hospital secretary, and elected community
delays leaders.
 More equitable health services to the  At the health centre level, the
entire population management team may include the
 Improved management of resources clinical officer or the nurse in charge,
other staff, and members of the
 Coordination and integration of health
community.
care with activities of other sectors
 At the community level, a health
 A means for facilitating community
committee may include the health
participation and accountability to the
auxiliary, the community health worker
community
and the village elders.
 Better performance through an efficient
and motivated workforce
Local authorities from other health related sectors,
representatives from NGOs and other interested
As health centres are often the first contact the
groups may be included in these health
community has with the formal health system, and
management teams. Each team should be given
most of the district level health workers are based
advisory roles and regulatory powers for
there, health centres should be equipped to
managing the PHC services (immunisation,
function as the focal point for comprehensive
maternal health/prenatal care, water and
PHC.
sanitation, treatment of tuberculosis/leprosy,
Resources should be readily available at this level
clinical services).
to maintain adequate and stable levels of staffing
and supplies.
Community Participation
Community participation may be interpreted in
Health centres should function in the following
various ways. It may range from district authorities
ways to reflect their important role:
informing community leaders about what the
health sector has planned, to community leaders
 The centre for community participation being actively involved in making decisions (for
 The base for preparing community health example, determining health priorities or
programs (for example, health education, strategies).
immunisations, sanitation)
 The focal point of intersectoral teamwork The level of participation may greatly depend on
within the district level health system the community leaders in local health committees,
how they were selected, their capacity to mobilise
Key Issues of a District Level Health System community action and to demand accountability
and the amount of social and political support they
The following key issues should be addressed to can rally. The community should be encouraged
ensure a well functioning district health system: to join forces with other sectors, organisations and
groups when planning comprehensive
PHC programs.

Jesse Daniel Omolo.. Page 46

Resources for PHC committee on family planning and population. The
Implementing PHC requires resources to be DDC selects priority areas and allocates
readily available, particularly at the health centre resources to ensure adequate coverage. It also
level. vets and clears all PHC activity sites within the
Adequate and stable levels of staffing and district.
essential supplies need to be maintained. In
addition, district health authorities should Immunisation
encourage all levels to make maximum use of
resources available locally.
The DHMT is responsible for the distribution of
supplies, evaluation of district immunisation
Sometimes these resources are not available coverage, and assisting the community level to
because of logistical, financial or managerial maintain and repair their cold chain equipment.
problems. In such situations, appeals for funding
may be sent to donors that are interested in Control of Endemic Diseases (especially
strengthening the district health system
Malaria)
infrastructure. Otherwise, local NGOs and existing
community groups may be supported to extend
services to outlying areas. The role of the district level is to keep records and
recognise outbreaks of endemic diseases and
take the appropriate action. They should also
Health Information
provide adequate and appropriate malaria
Indicators for monitoring the PHC program should diagnostic and management referral backup, as
be defined for all essential PHC services. well as coordinate tests which measure the
Information from monitoring these indicators can sensitivity of malaria parasites to the drugs being
be used for making decisions and setting policy. used.

Health Education Treatment of Common Conditions

At this level the DHMT is in charge. Their job is to The DHMT is responsible for the monitoring and
coordinate and integrate the various health training of health workers in the field; recognising
education programmes in the district as well as outbreaks and epidemics and taking appropriate
produce and distribute simple learning materials action; production and upgrading of operational
to health facilities at the community level. manuals for use in the communities; distribution of
supplies and the management of referrals.
Nutrition and Food Supply
Essential Drugs
The role of the DHMT is to ensure food security
for the district, establish an early warning system The district level ensures delivery of drug kits to
and analyse district nutrition surveillance data. all health units and is responsible for continuing
education and monitoring.
Water and Sanitation
Mental Health
The DHMT works closely with the District
Development Committee (DDC) to evaluate It is the responsibility of the district level to ensure
coverage of safe water supply. The DHMT also that the mental health policy is implemented in the
organises training for public health technicians in district. In addition, they provide training and
water systems, maintenance and latrine continuing education of health workers in mental
construction; procures the necessary materials health; provide transport for mobile community
and ensures coordination of water and sanitation based mental health activities; maintain a register
activities with other sectors and NGOs. of mental health activities at inpatient and
outpatient levels and regularly evaluate mental
Maternal and Child Health and Family Planning health activities in the district.

The role of the DHMT in the implementation of Dental Health

this element is mainly training and continuing
education of health workers. They also monitor It is a government policy to have a dental unit and
and evaluate MCH/FP activities in the district and qualified dentist in every district hospital.
share their findings at the DDC meeting. The DDC Therefore the district level acts as a major referral
also plays an important role through its sub centre for the management of dental conditions

Jesse Daniel Omolo.. Page 47

beyond the scope of the community health  Coordination of donor assistance and
facilities. The district level also refers dental technical expertise
patients to the provincial hospital where better  Making provision for renovations and
equipment for dental x-ray and laboratory services modernisation of hospitals as referral and
for dentures are found. teaching hospitals as well as introduction
of psychiatric and dental units in
Community Based Rehabilitation provincial and district levels
 Implementing strategies for promotion
The responsibility of the district level is to and propagation of good mental health
integrate community based rehabilitation services practices
with other health services in the district.  Ensuring implementation of HIV/AIDS
policies, creating awareness and
4. Provincial /National Level undertaking advocacy in respective
sectors
The provincial/national level is the highest level in
the hierarchy of PHC implementation. The Responsibilities for P/PHC Planning
responsibility here is shared between the
provincial teams and national programme Responsibilities for planning, approval and
managers. This is where policies are translated implementation of expenditures of the 25% P/PHC
into strategies for implementation in the other funds are as follows:
levels. It is also where the major referral hospitals
are found.
 PHC core team prepares annual plan and
As such, the activities that they undertake in the
quarterly AIE requests for use of cost
implementation of each PHC element tend to be
sharing revenue on P/PHC, in
similar. To avoid repetition, they will be listed
consultation with all relevant district health
together, instead of grouping them under each staff, including the family planning
element. coordinator, AIDS coordinator, KEPI
coordinator and others
 DHMT confirms cost sharing annual
The role of the provincial/national level in the
P/PHC plan and prepares quarterly AIE
implementation of PHC elements includes the
requests
following:
 DHMB reviews and approves (or returns
to DHMT for revision) annual plan and
 Provision of training and continuing AIE requests
education programmes for all health  District accountant certifies availability of
personnel uncommitted funds in bank
 Development of mass media, using  PMO issues AIEs on behalf of the
materials and language relevant to accounting officer in accordance with
specific provinces and districts current cost sharing expenditure rules
 Preparation of health education material,
(posters and pamphlets)
Responsibilities for P/PHC Planning
 Formulation of policy guidelines on food
and nutrition, immunisation, family
planning and the management and The specific functions of the DHMB on 25% of
control of diseases cost sharing
 Collaboration with other relevant revenue are:
ministries and NGOs
 Monitoring and evaluation of activities at  Providing public education on P/PHC
the district level  Reviewing, advising on and endorsing
 National and provincial disease district annual cost sharing plan and
surveillance and monitoring of drug budget for P/PHC
resistance  Reviewing, advising on and endorsing
 Participation in planning national district AIE requests on a quarterly basis
immunisation activities  Reviewing and commenting on the
 Provision of logistical support (financial, quarterly report of P/PHC activities and
transport, material, and manpower) expenditures prepared by the P/PHC
 Ensuring a steady supply of coordinator (P/PHC integrated planning
contraceptives, essential drugs, and other and activity report)
supplies

Jesse Daniel Omolo.. Page 48

The last function is particularly important. The Identify the Major Health Problems
quarterly P/PHC integrated planning and activity
report gives the DHMB a concise picture of From the DHP it should be possible to identify the
activities planned, achievements made, funding major health problems in the district.
sources (including GOK inputs and donor/NGO
contributions), expenditures planned, For instance, is maternal mortality unusually high?
expenditures made and reasons for any
Is measles coverage below the national target? Is
differences. family planning coverage low in particular
divisions? Is the incidence of malaria high in other
Steps for P/PHC Priority Setting and divisions? Is the HIV positivity in antenatal clinics
Budgeting increasing significantly?

How can a district organise and use the diverse Choose Cost Effective PHC Interventions
information required to set priorities among such
widely different activities as AIDS prevention, For each major health problem, there are several
provision of clean water, family planning services, possible P/PHC activities.
immunisation, and control of high impact diseases
such as malaria, diarrhoea and Acute Respiratory
Infections (ARI)? Malaria control may include distribution of
impregnated bed nets, chemical spraying,
improved diagnostic services, better drug supply,
How can districts plan to achieve the greatest and so on.
health impact with the available resources?
Choices must be made based on the most cost
To assist in making such decisions, the ministry
effective measures, that is which measures give
has developed guidelines on district P/PHC
the best value for money?
priority setting (22 June, 1994). The district
planning and budget process are tools to assist
DHMTs and DHMBs to identify the major P/PHC Set One Year Targets
problems in the district, set P/PHC programme
priorities and prepare district P/PHC plans. For each major health problem, a one year target
is set.
The intent of the Ministry is to allow the DHMTs,
DHMBs and District P/PHC Core Teams For example, if measles immunisation coverage is
maximum flexibility in the use of cost sharing only 50%, the one year target might be to
revenue, subject only to the constraints and increase it to 60%.
accountability requirements of the government.
Prepare the District PHC Plan
The steps in the district P/PHC priority setting
process are listed below. After the major problems have been identified,
interventions have been selected and targets
Prepare the District Health Profile have been set, the P/PHC core team prepares the
district P/PHC plan.
The district medical records/Health Management
Information System (HMIS) office prepares a This plan should take the form of the P/PHC
District Health Profile (DHP) to summarise all key integrated planning and activity report described
health indicators. in the facility improvement fund supervision
manual.
The district HMIS office should always be able to
prepare the DHP from information routinely Agree on Cost Saving Measures and Prepare a
available from the HMIS reporting system, the Budget
District Health Management Information System
(DHMIS), KEPI, family planning reports, district Limited district funds for P/PHC can be stretched
statistics office, district population officer and to have a greater impact through two main cost
other local sources. saving measures: community participation and
cost recovery.

Community participation can come in the form of

community contributions of labour, locally
available materials, or other in kind donations for

Jesse Daniel Omolo.. Page 49

activities such as TBA training, spring protection,  Care should be taken to limit the
VIP latrines, and malaria control. percentage of funds being applied to non-
core activities such as purchase of non-
Cost recovery usually means user charges for essential motor vehicles, decoration of
such things as bed nets, laboratory tests and the
offices, holding of numerous seminars
treatment fee charged for drugs and other
treatments provided at health centres and and meetings, etc.
hospitals. Once P/PHC activities and cost saving
measures have been agreed, a budget should be Primary Health Care in Relief Programs
prepared.
Goal of PHC in Emergencies
Finalise Plan and Obtain Approvals
Primary health care in emergency relief programs
aims to do the following:
The district P/PHC plan and budget should first be
approved by the district P/PHC core team, then
the DMOH and DHMT and finally the DHMB.  Reduce morbidity and mortality rates of
the displaced population to regional
norms
Once the plan has been thoroughly discussed and
 Build on existing knowledge and skills of
approved by the DHMB, it is forwarded to the
the displaced community to improve
PMO who issues the AIE.
overall health
 Link emergency relief to rehabilitation,
Monitor Implementation of PHC Plans reconstruction and development by
building the capacity of the affected
Finally, the DHMT and DHMB are responsible for population. This will make it possible to
monitoring the implementation of P/PHC activities, sustain resources.
to ensure that funds are spent according to the
plans, and that the community is benefiting as Lessons in PHC Planning
intended.
Planning and implementing PHC into reality in
This means reviewing progress on the plans and relief programs can be a slow and challenging
submitting a quarterly P/PHC integrated planning process. Reasons for this include centralised
and activity report, which should list the decision making, administrative delays, lack of
achievements for each planned activity, the supervision and insecure professional health
funding source, and the actual expenditure. workers. The following lessons have been learned
over the years about how a PHC program should
Choosing Among P/PHC Programmes be planned:

If the district P/PHC core team is active the 1. PHC can be adapted to all types of
demand for P/PHC funds will inevitably outstretch situations, including complex
the funds available. How can the DHMB decide emergencies, provided the long term
which proposals to approve? There are at least goals are clear.
five important questions that the DHMB should 2. Factors that may influence planning PHC
ask: in emergencies include the political
support of the host country, the historical
 Based on the District Health Profile, the experience of the health care system, the
problem being addressed should be a capability of the affected community and
the presence of NGOs and donors.
major one for the district.
3. Decentralised planning helps to make
 Check whether funds have relief programs more relevant to the
been allocated, and whether donors are needs of the displaced population, rather
active in the area. than responding to the wants of the
 Assess the relative cost effectiveness for leadership.
common P/PHC interventions. 4. When setting priorities, encourage active
support and communication with the
 Ways should be sought to reduce costs
displaced community. This will lead to a
by encouraging greater community consensus. The methods used will
participation or through cost recovery depend on the existing political structure.
initiatives.

Jesse Daniel Omolo.. Page 50

Establishing an Emergency PHC Program all PHC services in the area and establish a
network of CHWs to extend services into the
The type of emergency health services set up community.
depends on several factors, including:
Community participation and inter-sectoral
 The health system of the host country teamwork should be promoted from the beginning.
 The available resources Peripheral health units or dispensaries may be set
 The context of the disaster up later if necessary.
 The health needs of the affected
population All levels of the PHC system, from the home and
community level to the district hospital, should be
provided with essential resources (for example,
Providing hospital based care alone is appropriate
staff, equipment, drugs) and logistical support.
only where a displaced population is concentrated
This will ensure PHC services are equitable and
within a limited space and the facility is accessible
to all (located near a road or at the centre of the increase access to care. The map on the next
camp). Setting up a field hospital is only justified page shows the health centre functioning as a
focal point of the district level health system.
when access to a referral hospital for surgical and
obstetric emergencies is difficult or delayed.
Establishing an Emergency PHC Program
Establishing an Emergency PHC Program
Emergency PHC services should be coordinated
within a functioning referral system so that the
To ensure a more cost effective and sustainable
lowest skilled workers with minimum training
program, relief agencies should establish an
provide the appropriate care at lower levels of the
emergency PHC program within the framework of
a district level health system. This program should PHC system.
be:
At the same time, these workers must screen for
conditions that require referral to higher levels of
 Based on the policies, standards and
the system for care by more skilled PHC workers.
treatment protocols of the host country
Supervision should be arranged for all levels,
and integrated within the national health
carried by supervisors from the next higher level
system
of the health system.
 Functioning in a decentralised manner
For example:
that reflects the community‟s identified
health needs and priorities
 Comprehensive, involving all components  One auxiliary nurse/midwife based at a
of the health and other health related peripheral maternity unit may supervise
sectors ten traditional birth attendants within the
 Having clearly defined decision making community
authority and responsibility for each level  A nurse/midwife at the health centre can
 Balanced in terms of the distribution of supervise the auxiliaries at peripheral
resources between curative, preventive, health units
and promotive health programs  Senior health workers based at the first
 Sharing health information and promoting referral hospital may supervise health
cooperation between all levels of the centre staff
health system and with other sectors and
the community This approach to supervision will ensure that a
larger number of people receive quality health
Relief agencies should aim at strengthening the care more efficiently than when all patients are
existing public health infrastructure (basic health required to see only the most highly trained
facilities, community health network, the local health workers.
referral system and water supply, disease control,
etc.) and at limiting dependence on external Each level of health care should also form a
resources. health committee in order to be accountable to the
communities they serve. In addition, training
community health worker teams to report their
Establishing an Emergency PHC Program findings to different levels of referral system, can
greatly promote the effectiveness of PHC services
To establish emergency PHC services, first set up at the peripheral health units.
the health centre to function as the focal point for

Jesse Daniel Omolo.. Page 51

Division of Responsibilities  Initiating dialogue in the community and
promoting active community participation
Implementing PHC for emergency situations in planning the district level
requires the community and other sectors to be health system
involved in decision making, and on the job  Ensuring that community health workers
training and supportive supervision to be have enough support and supervision
organised for all levels of the emergency PHC  Collecting, compiling, and regularly
system. A unified approach for making referrals to forwarding health information to the
other sectors or levels within the PHC system can central government
be developed in the following way:
If the administrative capacity of the district level
 All field workers understand the PHC health authorities is weak, relief organisations
system, their responsibilities, functions of may strengthen it by providing on the job training
neighbouring levels, and the procedures in PHC principles, district level management,
for cooperation information systems, supervision and health
 Each sector sets its own targets for related support. Training should target all senior
services in terms of quality and coverage managers from the district health office, the
to make the system more effective implementing agency and other health related
 Collaboration within the referral system is sectors who need to broaden their skills.
promoted to maximise the use of
resources and labour and to provide the Relief Program Level
appropriate level of care Every relief sector (for example, food and
nutrition, water and sanitation, basic health care,
Specific responsibilities of each include: etc.) should organise on the job training for its
Central Level staff in the following:
For PHC to be effective, the central Ministry of
Health must be committed to its role of  Comprehensive PHC using problem
coordinating the emergency health system, solving techniques that emphasise
mobilising resources and encouraging district- integrating preventive and promotive
level decision-making. The main functions at this health interventions with the hospital
level should include the following: based curative and
rehabilitative care.
 Making policies on emergency PHC  Developing and reinforcing standard ways
operations and drawing formal of delivering services in order to improve
agreements or memoranda with relief the quality of the service. Standard
organisations and other providers methods should be adapted to the local
 Regulatory authority for monitoring the situation
level and quality of emergency PHC and regularly reviewed.
services and supplies  The planning process, so all staff
 Promote inter-sectoral cooperation and members will understand the program
inter-agency collaboration within the goals and objectives, their roles and
defined geographical area duties, and the available resources.
 Restrict relief organisations from setting
up emergency PHC programs without Relief Worker Level
considering the overall health needs of In any emergency operation field workers are
the affected community, in order to avoid recruited in order to implement the PHC program,
duplication of services however, they must change from being the major
 Give formal support in the training of 'providers' of PHC services to becoming
emergency PHC service providers 'enablers'. Many field workers may be unwilling to
take over new responsibilities since they, like
District Level many health workers, are only trained to deliver
The function of the district level should include: services to the beneficiaries rather than to make
decisions about the program. Therefore, field
workers need training in the following:
 Coordinating health services in all PHC
facilities in the district (including the
referral hospital), based on the local  How to increase the community‟s
budget and available resources awareness of the association between
 Encouraging all sectors to work well poor health and poor living conditions or
together unhealthy behaviour. This will help

Jesse Daniel Omolo.. Page 52

 strengthen active community support for  Maternal and child clinics, later
multi-sectoral actions. reproductive health programs with family
 How to meet regularly with the community planning
to build support for the PHC program and  Immunising against major infectious
to strengthen community participation. diseases
 How to involve community  Immunisation against measles,
representatives in determining priorities sometimes meningitis
and in planning, implementing, and  Preventing and controlling locally endemic
monitoring relief programs. diseases
 Control of communicable disease
It is important to recruit staff from among the outbreaks including control of vectors and
displaced community. Recruiting an adequate surveillance
number of female CHWs will increase access  Fostering education on common health
to individuals and households with the problems, their prevention, and control
greatest need. measures
 Health education based on a community
Community Level health workers program
A partnership should be forged involving everyone  Treating common diseases and injuries
who can improve the wellbeing of the community.  First level health services and a referral
This includes social groups, community groups, system
and traditional practitioners. Getting communities  Access to essential drugs, provision of
to actively participate in decision making on the essential drugs
emergency PHC program takes time and effort.
They need to learn how to identify health priorities Emergency health care is built on the principles of
and the importance of cooperating and PHC. As resources for health care are always
participating in PHC activities to improve their limited, both strategies reflect the basic needs
overall health. The most important role of the approach toward addressing the priority health
community is to give regular feedback to the relief problems of a population.
agency about the delivery of PHC services in
terms of the following:
As a result, benefits of both strategies become
clear when a large fraction of the total population
 Equity in how services are provided has access to comprehensive health services on
 Access to care a regular basis (curative, preventive and
 Relevance between the services offered promotive), and when those most in need are
and the needs of the affected population cared for.

In some situations the local power structure may SECTION 3: RESPONSIBILITIES OF

have to be readjusted to ensure satisfactory
THE KEY IMPLEMENTERS OF PHC
community participation. This can be achieved by
including members from different social groups,
such as women, youth, traditional healers and Introduction
school teachers in the health committees. This will In this section you will learn the responsibilities of
ensure that the interests of the displaced the key players in the implementation of PHC.
population will be represented. Objectives
By the end of this section you will be able to:
Components of Primary Health Care
Describe the responsibilities of the following key
Emergency Health Care Priorities
players in PHC implementation:

 Promoting good nutrition, provision of

 Community health workers
food rations and selective feeding
 The community
programs
 The government
 Access to safe water and basic sanitation,
access to potable water and waste  Other government ministries
disposal systems  Non-governmental organisations
 Protection against cold (shelter, blanket,
clothes)
 Improving maternal and child health care,
including family planning

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Key Implementers of PHC in Kenya  An observer and recorder who is capable
The following are key implementers of PHC in of thinking, reacting and assessing
Kenya: progress
 An organiser and mobiliser for community
 Community health workers activities
 The community  A leader and manager
 The government  A person who is receptive to new ideasso
 Non-governmental organisations as to form a channel through which new
health information can reach the
Community Health Workers community
 An advisor and a counsellor
Community Health Workers (CHWs), are
individuals who are selected by their communities Often the people who are selected as CHWs
command some respect within their communities.
for training on how to deal with village health
They include traditional birth attendants,
problems and treat common diseases. Once they traditional healers, or leaders of women groups.
are trained they work part-time as volunteers.

The selection process of CHWs is usually carried Often the people who are selected as CHWs
out by the community after its members have command some respect within their communities.
been fully sensitised on the role and advantages
They include traditional birth attendants,
of CHWs, as well as their obligations towards the
CHWs. Often, several candidates are selected traditional healers, or leaders of women groups.
and interviewed by the trainers and members of Supervision is particularly crucial in PHC because
the community health committee. Those selected many of the workers are volunteers.
are required to possess the The CHWs are supervised by the community
following qualities: through leaders of village health committees.
They are also supervised by health workers from
 Be a permanent resident in the the nearest health facility to make sure they are
community
doing the right thing. Community participation in
 Be a mature responsible individual
the supervision of CHWs is one of the key
 Be acceptable and respected by the
whole community determinants of success for PHC activities. It is
 Be self supporting and ready to volunteer well documented that regular supportive and
 Be able to relate to others and a good frequent supervisory visits are essential for
communicator effective PHC activities.
 Be physically fit
 Be of a gender acceptable to the local
culture for the kind of health activities to
be undertaken Ways in which supervision is carried out
 Be intelligent with education/literacy that
suits the community Motivation
 Be ready to learn
 Be of an age suitable for training and for This is achieved by showing appreciation, giving
continued work in the community rewards, and providing more education to the
CHWs.
Roles
Support
 A motivator through education and
communication The CHWs are supported by providing them with
 An example and model of good health the necessary equipment and supplies as well as
behaviour technical back up.
 A link with the health system and other
sectors Recognition
 A technician with certain skills of
community importance e.g. latrine
construction or basic treatment of This is done by establishing the credibility of the
common ailments CHW in the eyes of the community.

Jesse Daniel Omolo.. Page 54

Planning  To monitor and evaluate their activities
as necessary
Helping them to plan their objectives and logistics.
The community meets these responsibilities
Problem Solving through the following activities:

Assisting the CHWs to solve the problems they  Community participation

encounter in the community.  Community awareness
 Community involvement
Training
Community Participation
On going education and skill development for the
CHW. Community participation is defined as the process
by which a community mobilises its resources,
Performance Measurements initiates and takes responsibility for its own
development activities, and shares in decision
This is the only 'controlling' activity. It includes making and implementation of all other
collection of basic performance measurements development programmes. The expected
and evaluating them against laid down objectives. outcome of community participation is the overall
improvement of the community‟s health status.
Area Covered
The emphasis on community participation
The area covered by Community Health Workers represents an enormous shift from former
is determined by the following factors: healthcare approaches, which viewed the
community as passive recipients of services
planned and provided by others.
 Primary health care workers
 The population of community
Community Awareness
 The government
 Non-governmental organisations
The community is made aware of its problems
and the available resources, such as, manpower,
Apart from the geographical coverage, the money, materials, ideas and time.
number of families served by each CHW also Community awareness can be achieved through
matters. participation and involvement of the community in
The standard number of families should range community diagnosis (self diagnosis), and through
between 25 and 125. exposure of the community to another with
successful development programmes and by
You now understand the role of CHWs in the creating demand. Creating awareness is done
implementation of PHC. Next we shall look at the through meetings, various groups and
responsibilities of the community. development committees.
At the division level, this is done through barazas
The Community or small groups, community elders, TBAs,
churches, and women groups. In addition, health
You already know, the community is the centre of workers brief the Division Development
focus in the implementation of primary health Committee who in turn involve NGOs and the
care. Therefore, its responsibilities include the local Member of Parliament.
following: At location level, PHC awareness is created by
the Location Development Committee, NGO‟s,
politicians, and opinion leaders.
 To recognise priority problems relating
This can be done through barazas, mobile clinics,
to health
church gatherings, and women groups.
 Decide on what needs to be done to
overcome the problems
 Decide on what the community itself can Community Involvement
do to solve the problems
 To organise and implement whatever they
themselves can do either on their own or Community involvement entails active and willing
with the support of governmental or participation of the community in planning,
non-governmental agencies management and evaluation of programmes
which contribute to their well being. It can lead to
the creation of partnership between the

Jesse Daniel Omolo.. Page 55

establishment (government), other development Development Committees
agencies and the community. It also contributes to
the attainment of community responsibility and List down the committees found in the
accountability over all development programmes. community where you serve.
Participation and involvement leads to
development of self reliance and helps a
The following are common committees found in
community to develop social control over its own
the community:
infrastructure.
The level at which any community participates in
its own development process varies from place to  Village health committee
place. A number of factors could influence the  Sub-location development committee
degree of community involvement.  Location development committee
These are:  Divisional development committee
 District development committee
 A favourable political atmosphere
 The educational status of the community Development committees found at grassroots
(literacy may influence the speed at which level such as village development committee are
full participation and involvement is usually concerned with planning, financing,
achieved) implementing and evaluating projects. They are
 The community infrastructure (such as the evidence of community participation in PHC.
communication network)
 Economic factors The Government
 The level of intersectoral coordination at
the community level The political and economic stability of the
government has significantly contributed to the
The community should be involved in the following successful development of PHC in Kenya. It has
areas of PHC implementation: provided an enabling environment for
re-orientation and change towards greater
Setting of Priorities community involvement and self reliance in health
and health related matters.
Through self diagnosis, a community can identify
As you learned in section two of this unit, the
its priorities and identify the methods to solve
Kenyan government has also continuously
them. reviewed and revised its strategies in order to
integrate the PHC strategy in our health care
Supervision system. Existing policies have been reviewed and
new ones added in order to guide health
The community can play an important role in the development in this country.
supervision of CHWs through the local
health committees. In keeping with the government broad health
policies, the following objectives have guided the
Income Generating Projects allocation of resources and programme
development during the years:
The community can engage in income generating
projects, in order to raise funds to initiate projects. 1. Strengthening in real terms the elements
of PHC and their implementation
Health Services 2. Encouraging widespread community
participation and the mutual social
responsibility of all Kenyans in health and
This is only practical in the following areas where
development through PHC
the community can be involved, Liaising with
3. Increasing provision of preventive and
health workers to help in problem solving. Helping
promotive services and improving
to improve environmental sanitation and water
methods of early detection and treatment
supply for the health unit and visiting the hospital
of communicable and vector borne
to assess what assistance they can provide,
diseases with an emphasis on high risk
helping with the construction of shelter for the
groups
patient‟s waiting bay. 4. Increasing the number of health workers
trained in preventive and promotive health
methods (such as, environmental,
nutrition, maternal child health and family

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 planning, communicable and vector borne Responsibilities of Government at National
disease control etc. Level
5. Pursuing an intersectoral and The responsibilities of the government at the
multidisciplinary approach to health care national level are to:
at all levels with particular emphasis on
increasing inter-ministerial coordination in  Ensure a consistent policy and strategy
water, sanitation, base for Primary Health Care (PHC)
education and nutrition activities activities throughout the country
6. Improving manpower development  Recommend activities that should be
policies in order to increase the number undertaken to overcome these problems
of skilled manpower in hospitals, health  Avail resources to address these
centres and dispensaries problems from other sectors, NGOs, and
7. Designing development projects which international sources
favour construction of smaller but more
 Ensure collaboration among the different
cost effective facilities aimed at increasing
government sectors in planning activities
coverage and accessibility of health
that have a bearing on health. The health
services, i.e. health centres and
sector must come out of its relative
dispensaries isolation and collaborate with other
8. Selectively increasing the number of
sectors. Health goals and criteria need to
district and sub-district hospitals
be incorporated into policies and
9. Increasing basic and post-basic
programmes of other sectors
opportunities for all health workers
 Ensure the co-ordination of inputs from
10. Strengthening the overall management
both bilateral and multilateral sources in
(planning, implementation
accordance with the national plan for PHC
and evaluation) capability of the Ministry
development
of Health in the provinces and districts
11. Developing and strengthening logistics  The health sector needs to assist other
sectors in monitoring and evaluating the
and the drug supply system
health impact of development projects.
12. Improving and consolidating various
components of the national health This way, negative health effects are
information system (including data anticipated and countered
gathering, processing, analysis reporting  High priority should be given in
and dissemination methods) development policies and plans to the
13. Improving the facilities, management of special needs of vulnerable population
out patient services and the quality of groups. Such groups are at greatest risk
care for in-patient services of ill health. The health sector needs to
14. Standardising treatment and operational identify the vulnerable groups and the
procedures in hospitals, health centres conditions of risk in which they live
and dispensaries
15. Consolidating existing facilities with an A primary health care unit was established in the
emphasis on maintenance and office of the Director of Medical Services (DMS).
rehabilitation The unit has a full-time coordinator with a team of
professionals and support staff.
List the seven levels of our health care
system. Functions of the PHC unit

The seven levels of our health care system are:  Provide overall coordination of PHC
activities in the country
 Family level  Review and evaluate PHC activities with a
 Community level view to identify areas in need of
 Location level strengthening
 Divisional level  Provide technical and financial support for
 District level PHC activities
 Provincial level  Promote intersectoral collaboration in
 National level PHC at all levels
 Establish and maintain relevant guidelines
for implementation of PHC
 Establish training guidelines in
collaboration with relevant institutions and
NGOs

Jesse Daniel Omolo.. Page 57

  Liaise with WHO, UNICEF and other District Health Committee is the sub-committee of
agencies on matters relating to PHC the DDC responsible for PHC implementation.
 Maintain a data base on PHC
development and provide quarterly and District Health Management Committee
annual reports of progress
This committee‟s responsibility is to:
The various heads of departments in the Ministry
of Health have been given specific responsibilities  Provide a forum for joint training
in the implementation of PHC elements. They  Discuss and plan PHC activities
meet regularly under the chairmanship of the  Advice DDC on the development and
Director of Medical Services to discuss progress implementation of PHC activities
and problems relating to each of the elements.  Receive technical guidance from the
DHMT through the medical officer of
Provincial Level health (MOH)

The responsibility of the government is to provide The other district team that is responsible for PHC
technical support in the planning and implementation is the District Health Management
management of PHC at the district level. Team (DHMT). It was actually established to
The provincial health management team is strengthen the implementation of PHC activities in
responsible for all PHC activities. the district. The DHMT is responsible for the
planning and implementation of all health services
District Level in the district. It is a member of the DDC and
provides technical advice to the DDC on health
At the district level, the government‟s matters. In order to ensure the full coordination of
responsibilities include: health services in the district, the DHMT works
closely through joint memberships.
It delegates its responsibility of day-to-day
 Identifying the existing health problems in
management of PHC development activities to the
the district
PHC CORE TEAM, which is made up of members
 Identifying what action needs to be taken of the health sector staff. This team plays an
to reduce these problems important part in the implementation of PHC in the
 Identifying the resources available within district, especially in the area of training.
the community, from other Government
sectors and NGOs, to deal with the
Divisional Level
identified problems
At the division level, the Government implements
 Preparing plans to use the resources
PHC activities through the Division Development
available in a coordinated manner to
Committee. This committee usually finds it useful
improve health
to delegate this responsibility to a PHC
 Providing technical support to PHC coordinating team. The team may be headed by a
activities in the community
member of the health team in the division or any
 Monitoring the implementation of the of the divisional heads. The main responsibilities
district plan both in terms of activities of the team are to plan PHC activities such as
carried out by each of the actors in the training; support the community health workers;
plan and their effect on the health and maintain contact with village health
development committees.
The government has set up the District In addition, the team monitors the PHC activities
Development Committee (DDC), which is carried out by other sectors in the division and
responsible for the planning and coordination of provide information to the Divisional Development
all development work in the district, including PHC Committee.
activities.
The DDC is usually chaired by the District The Divisional Development Committee is made
up of the following people:
Commissioner and typically includes
representatives from all government ministries
 The District Officer
and departments in the district plus
 Divisional heads
representatives of NGOs working in the district. It  Chiefs
operates through sub-committees charged with  Political leaders
advising on various sectoral activities.  Religious leaders
 Self-help group leaders.

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Community Level coordinating committees. Indeed, it was through
such joint efforts with assistance from WHO and
In keeping with its policy of decentralisation and UNICEF that National Guidelines for the
implementation of PHC in Kenya were formulated
support for community based health care
approaches, the government has assisted
communities to set up village health development
Non-Governmental Organisations
committee. This committee is selected by the
Many NGOs have on-going CBHC schemes.
members of the villages according to their own set
Some of the NGOs actively involved in CBHC
up. The committee may have a membership of six programmes include the following:
to twelve members, which is normally drawn from
community groups or from people with good  African Medical and Research Foundation
organisational skills or a high educational level. (AMREF)
 Aga Khan Health services
List down some of the responsibilities of the  Christian Health Association of Kenya
village health development committees. (CHAK)
 Kenya Red Cross society
The main responsibilities of the village health  Action Aid - Kenya
development committee are to:  Catholic Relief Services - Kenya
 Family Planning Association of Kenya
 Assist with the identification of health  Institute of Cultural Affairs
problems in the community and setting of  National Christian Churches of Kenya
priorities (NCCK)
 Assist with the identification of community  The Undugu Society
resources and coordinating them in  World Vision
planned activities aimed at overcoming
specific health problems SECTION 4: PHC ACHIEVEMENTS,
 Assist the community to select community
CHALLENGES AND WAY FORWARD
health workers (CHWs) and to provide
administrative supervision of their work
Introduction
 Provide a channel of communication
In this section you will look at the achievements
between the community and the health
made in the implementation of PHC, the
and development committees at the
challenges faced and the way forward.
division level
 Assist with the monitoring of the health of
the community Objectives
 Initiate and participate in communal
income generating activities At the end of this section you will be able to:

Households
 Give an overview of the achievements
made in the implementation PHC
The government recognised households as key  Explain the challenges met during the
community units in health care delivery. Efforts implementation of PHC
were geared towards developing their capacity to  State the way forward for PHC in Kenya
recognise ill health in time and treat minor
ailments. Under the NHSSP, this was to be Achievements of PHC
achieved by providing households with
appropriate information and assisting them in When Kenya adopted the Alma Ata declaration of
decision making, obtaining and administration of 'Health for All' by the year 2000 and beyond, she
became committed to the integration of all health
simple, safe and effective medication.
programmes necessary to bring everyone to a
level of health that would permit them to lead
Non-Governmental Organisations (NGOs) have
a socially and economically productive life.
been actively involved in developing Community
Based Health Care (CBHC) projects since the mid
It has been observed that it is difficult to attribute
1970‟s.
all the achievements in the health sector to PHC
Although collaboration between the Ministry of
interventions alone. Indeed, no attempt has been
Health and NGO‟s has so far been good, it could
made to directly link PHC with the changes that
be improved even more by creation of joint

Jesse Daniel Omolo.. Page 59

have been observed, because PHC is considered  Use of local community workers at the
to be part and parcel of the overall health care first level of health care, drawn from and
systems, and general socio-economic supported by the community
development of this country.  Involvement of the community in the
planning and running of their own health
However, there has been a number of notable services
achievements. For example, the shift in emphasis  Use of traditional methods and resources,
from curative to preventive programmes has led to e.g. the traditional birth attendant
a reduction in mortality and morbidity.
Hygiene and Prevention of Disease
Five preventive programmes were introduced
through the PHC strategy, these are:  Promotion of mother and child health
services including immunisation and
 Kenya Expanded Programme of nutrition
Immunisation (KEPI)  Environmental and public health given
 Environmental health equal stress as curative care
 Nutrition  Emphasis on health education
 Maternal child health and family planning
 Control of communicable and vector
borne diseases. Planning for Services

 Identification of major health problems

PHC has won widespread acceptance among and adoption of specific programs that are
government ministries, NGOs and international relevant to the local needs
agencies. Formal commitment has been made to  Regular evaluation to ensure continual
'Health for All' (HFA) by most countries, improvement of health programme
including Kenya.  Strategies for improving coverage and for
developing low-cost technology e.g.
PHC has had considerable influence in promoting limited drug formularies, low cost waste,
a more equitable distribution of health disposal systems, etc.
resources and in the development of new types of  Integration of health with other aspects of
health workers in the country. There has been development e.g. agriculture, education
extensive expansion of coverage of several PHC and community development.
elements.
Organisation of Services
Epidemiologically, childhood diseases such as
poliomyelitis, measles, tetanus and pertussis have
 Provision of basic health care facilities
decreased owing to the rapid expansion of
within walking distance for the majority of
immunisation coverage. This decrease has
the population to improve the utilisation
contributed significantly to the overall decline in
and quality of care
infant and child mortality rates.
 A hierarchy of levels of health care
comprising three key elements: local
PHC has led to encouraging achievements in the community; health centre/sub-centre
global targets for eradication and control of complex; district hospital
selected communicable diseases.  Different levels of district health facilities
PHC has made an important contribution to becoming supportive of each other and of
greater social justice and equity by reducing the community-based health activities
gap between those who have access to an
appropriate level of health care and those who do
not. Training
There are also other features of Primary Health
Care which are increasingly being adopted.  Health workers at each level of care
trained in preventive and environmental
Focus on the Community health based on locally assessed needs
as well as to diagnose and treat common
illnesses, less common diseases not
 Emphasis on health care at the village or included in their basic training are referred
community level
to the next level of care

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  Continuing professional development to account for almost 50% of all reported diagnosis
improve skills at all level of care is in public health facilities with diarrhoea increasing
becoming mandatory for all health this to almost 60%.
workers in Kenya
Guidelines
Challenges Faced in PHC Implementation Despite the seven tier system in health care
delivery, there are no clear guidelines on the
Considerable progress has been made in the referral procedures from one level to the other.
implementation of PHC. The Kenyan government
has continued to face a number of challenges. Sustainability
Large gaps may be found in the planning and Maintenance of the present level of coverage
implementation of PHC achieved by many PHC programmes, such as
KEPI, has remained highly dependent on
Morbidity and Mortality continued support from donors, thus raising
The major causes of morbidity and mortality in concern about
Kenya still remains diseases and conditions that their sustainability.
can be easily prevented through immunisation,
improved personal hygiene and environmental Integration
manipulation. For example, it has been Improper translation of PHC as primary level of
documented that 36% of the under five population care (first level health care in the pyramid), which
die before their fifth birthday due to preventable ignores the overall integrated nature of PHC.
diseases and conditions. Diarrhoea alone
accounts for 12.8% of under five deaths in Kenya, Others
while 12.2% are due to malaria.
According to Kenya demographic and health  The community may not be willing to take
surveys of 2003, one out of every nine children responsibility for the health care system
born in Kenya dies before attaining their first  Drugs may not be available at lower
birthday, while 40% of infant deaths occur during levels of the PHC system. Therefore,
the first month of life. patients will go directly to hospitals
 Prolonged delays in health worker
Curative Services salaries may result in hostile attitudes
Curative services remain an expensive aspect of towards patients
Kenya‟s health care delivery accounting for about  Lack of supervision and training may
70% of health budget. Most of these funds are result in poor quality of services
held up in tertiary and secondary level facilities,  Different sectors may not be used to
which are mainly located in urban areas. This working together
situation has tended to impact negatively on the
allocation of resources thereby undermining the
principle of equity in health delivery.
These challenges have raised a lot of concern not
only within the Ministry of Health, but also among
Disease Burden
other key stakeholders in the health sector. To
The burden of diseases due to emerging and re-
address these concerns, the Ministry of Health
emerging diseases, as well as natural and human
held a series of consultative meetings and
disasters. AIDS related illnesses such as
workshops to try and reverse the deteriorating
pneumonia and TB have a national prevalence of
health situation in the country. A major outcome of
nearly 10% and account for 14.2% of the burden
this consultative process was the National Health
of disease measured in terms of life years lost.
Sector Strategic Plan (NHSSP).
Safe Water and Sanitation
Studies have shown that 55% of Kenyans lack This plan was developed to address the
access to safe water and sanitation, a situation constraints in the health sector and to adopt a
that puts the population at risk of contracting sector wide approach in their resolution.
diarrhoea and other communicable diseases. It was in response to the daunting challenge of
operationalising the 1994 Health Policy
Framework Paper, that the Ministry of Health with
Air pollution, poor waste management and poor her development partners developed the National
food control measures have also been on the Health Sector Strategic Plan NHSSP (1999 -
increase. 2004), and set up the Health Sector Reform
Secretariat to spearhead the reform process.
Malaria and Respiratory Diseases
Malaria and respiratory diseases combined

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The NHSSP seeks to implement appropriate communicable diseases such as cholera, typhoid,
structural, financial and organisational reforms dysentery and food safety.
within a sector wide approach to resolve the
inherent constraints in the health sector. It In the prioritisation, expenditures should favour
specifically provides a well articulated vision for lower level facilities that have lower per capita
health care financing as well as the requisite costs to enhance efficiency and functioning of the
support systems, and governance structures. referral system.

Through the NHSSP, the ministry commits itself to If services are not available at the right level of
decentralisation by providing increased authority facilities, people delay seeking treatment or get
for decision making, resource allocation and admitted to hospitals for conditions that could
management of health care to the district and have been prevented much earlier.
facility levels. This is in part to allow greater
participation of the community in the management
Underfunding of the rural health facilities that
of health funds and implementation of the
essentially provide PHC, coupled by the
essential clinical and public health package at the
impression that the quality of care is better at the
lower levels. higher level hospitals, has led to many patients
bypassing the primary facilities in preference for
In building commitment to the process of change,
the costly district, provincial and national
these guidelines have been developed to support
hospitals.
the ongoing decentralisation efforts, aimed at
strengthening the implementation of activities at
the district level, fostering closer coordination and The coordination of cross-sectoral planning has
collaboration amongst the line ministries, donors, been the responsibility of the District Development
organisations and other stakeholders. Committee (DDC), with health sector plans
The guidelines focus on appropriate health produced and submitted to the DDC by the
systems and improved coordination necessary for DHMB. The District Local health planning has
the delivery of efficient and effective health therefore, no reference to a realistic resource
services at the district level. framework without „budget ceilings‟ provided by
the Ministry of Health. The district plans are rarely
taken into consideration in national planning and
Emphasis on improvement in district level budgeting, and the central level does not usually
planning, budgeting and, financial management provide any feedback to districts. Local planning
and control systems. Commitment is made to and self-help efforts do not take into account
transfer financial management through the national policy goals since they are usually
release of block grants. concerned with capital development planning and
'projects'. There is thus, little relationship between
Enhancing the capacity of the local DHMBs and plans, available funds and actual implementation.
DHMTs and extending „guided autonomy‟ to a few
hospitals. In the efforts, the DHMTs and DHMBs
In order to implement the reform agenda, a
would gradually assume responsibilities for
ministerial reform committee known as the Health
running of the facilities under their jurisdiction
Sector Reform Committee was established.
through a single line grant, effective annual work
It was charged with the responsibility of
plans and procurement plans. implementing the reforms and marketing the
respective policies. The committee established
Meanwhile, centre support would be restricted to guidelines and responsibilities of all the levels of
technical, logistic, financial and administrative health provision in this country in the marketing
issues. and implementation of the reform policies

Interventions to be given priorities should be

based on the available data on the burden of MOH Headquarters
disease, cost effectiveness of the interventions, The role of the headquarters was restricted to
impacts of the interventions and health outcomes policy formulation and development, strategic
in relation to health expenditure used.
planning, setting standards and regulating
mechanisms. In addition, it was charged with the
From the national perspective however, the public
health and clinical priority package includes: responsibility of regulating and coordinating health
Malaria prevention and treatment, Reproductive training, coordinating donor activities, overseeing
Health, HIV/AIDS/TB prevention and the implementation of the reform process, and
management, IMCI and the control and prevention
of major environmental health related

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ensuring the equitable allocation of national health number of things you can do at your level to
resources. improve the implementation of PHC. These are:

The Provincial Level  Rational and effective use of resources

The role of this level was strengthened to such as drugs, time, and funds which are
supervise district projects, implement, enforce and allocated to your health facility.
maintain health standards for services and One way of ensuring the rational use of
drugs is for example, by making the
infrastructure. The Provincial Health Management
correct clinical diagnosis and prescribing
Teams were to be equipped with the necessary appropriately.
tools and management skills and empowered to  Continuously updating our knowledge,
perform these activities. They were also supposed skills, and attitudes to ensure that we are
to assist the districts in developing their respective current in terms of new diseases,
plans and training activities. treatment regimes, and government
policies.
The District Level For example, the management of malaria
At this level the District Health Management is continuously changing as the parasites
Teams complemented by the District Health become resistant to drugs.
Management Boards were to play a central role in You need to keep updating yourself on
implementing health reforms at district level. The this through continuing professional
specific roles of this tier were to include: development.
 Advocating for policy change and good
 Preparing work plans governance at all levels.
 Implementation and maintenance of  Effective disease surveillance and
district plans reporting so that measures can be taken
in good time.
 Provision of curative, rehabilitative,
preventive and PHC services  Implementing the primary health care
elements at your level.
 Coordination and supervision of other
health providers
 Enforcement of health standards UNIT THREE: ENVIRONMENTAL
 Prioritisation of health problems HEALTH
 Collaboration with other sectors, donor
agencies, NGOs and other partners in This unit focuses on the components of
health and health related activities environment and their effect on humans, water
 The management of district based HMIS and sanitation, appropriate methods of handling
and the implementation of district specific food, and the effects of housing on health. The
health reforms final section will focus on how the community
nurse should mobilise the community in the
Local Institutions control of vectors and pests in their environment.
Local institutions such as the Bamako initiative, Environmental health is one of the most important
Village Health Committee, Community Health aspects of primary prevention of diseases. The
community health nurse and all the other health
Workers, Traditional practitioners and Community workers have a responsibility to assist their
leaders existed in communities. The government‟s communities to improve their environment.
intention here was to strengthen these structures
in order to enhance their participation in health This unit is composed of five sections:
and health related activities at the local level. To
this end, local health campaigns were planned in Section One: Health and the Environment
order to control endemic diseases. In addition, the Section Two: Water and Sanitation
structures would further be empowered to Section Three: Appropriate Methods of Handling
manage local health initiatives and funds. Food
Section Four: Housing
Way Forward Section Five: Control of Vectors and Pests

The government is committed to improving the

country‟s health status. It has introduced policies
and constantly reviewed and revised its strategies
in order to implement PHC. However, there are a

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Unit Objectives among others. They also influence weather
patterns. Flowers are a natural beauty and are
By the end of this unit you will be able to: often used for decoration. Plants provide
vegetables, fruits, tubers and seeds as food.
 Explain the importance of environment to
community health A number of plants are used as herbal medicine
 Describe water and sanitation in relation for the treatment of various diseases, for example,
to health the Neem tree locally known as muarobaine, is
 Outline appropriate methods of handling used for the treatment of malaria, among many
food other diseases. Garlic is used to treat
 Describe the effects of housing on health hypertension. The aloe vera plant is used for
 Mobilise the community in the control of prevention of cancer of the stomach and healing
vectors and pests of wounds. On the other hand, some plants may
adversely affect health. Occasionally, people react
to pollen from blooming plants and may develop
SECTION 1: HEALTH AND THE
hay fever or asthma. Ingesting or touching some
ENVIRONMENT poisonous plants may have devastating effects.
Introduction
People
Welcome to section one of the Environmental
Health unit. Since the environment comprises all Human beings and their activities can be a big
things that make up your surroundings, source of infection. For example, overcrowding
environmental health, therefore, describes the and slum settlements brought about by
aspects of health related to or emanating from urbanisation, can promote the transmission of
your interaction with the environment. diseases, especially those diseases that are
spread through droplets and contact.
Objectives
Explosions from quarries produce a lot of dust,
which causes respiratory and eye problems.
 Define the environment
When it rains, these quarries collect water and
 Explain the components of the become breeding sites for mosquitoes and risky
environment places for children.
 Describe the effects of environmental
factors on health
The felling of trees provides firewood and
charcoal but, at the same time, it destroys the
Environmental Components and their Effect water sources. Cultivating along riverbanks may
on your Health contaminate the water supply through seepage of
the fertilizers and pesticides used on the crops.
The following factors can have an effect on your Overgrazing causes soil erosion, destroys
health: vegetation and contaminates water sources.

 Biological environment Animals

 Physical environment
 Socio-cultural environment Domestic animals such as cattle, sheep, goats
 Economic and political components of the and poultry provide meat, milk and eggs for
environment consumption. Some of them supply hides and
wool for commercial purposes. They also provide
Biological Environment manure, which is used to increase food produce.
Wildlife is often a tourist attraction and acts as a
The biological component of the environment is source of income for our country. Cats and dogs
made up of living things, which include plants, are kept as pets, but they can also transmit
people and animals. The adjacent figure shows diseases such as cat scratch fever and rabies,
some examples of biological components. respectively.

Plants Other hazards include snakebites, which can be

fatal and insect bites, which may act as vectors of
various diseases. For example, mosquitoes are
Vegetation prevents soil erosion and also protects
vectors of malaria, yellow fever and filariasis.
our water sources. Trees act as windbreakers,
Houseflies are vectors of dysentery and other
provide firewood, charcoal, timber and paper

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diarrhoeal diseases. Bacteria, rickettsia and fungi
are also part of the biological environment and are
disease-causing organisms in man.

Each type of climate has its own pattern of

vegetation and animals to control. Man has to
adjust to the animals and the vegetation since
they affect health. Additionally, to adjust to the
different temperatures man has to use appropriate
Physical Environment clothing.

The physical components of the environment are

divided into geographical and man-made Remember: Most micro-organisms that cause
components. Land is used for settlements. When disease are transmitted through air, water and
the land is fertile and well used, it provides food.
enough food for consumption. On the other hand,
when the land is infertile, the food supply will be Therefore, constructing houses too close to a dam
inadequate, resulting into or where animals are kept facilitates the
nutritional problems. transmission of vector borne diseases. Industrial
wastes that consist of chemicals and toxic
substances, may also pollute the water, air and
The type of soil, climate and altitude determine
the type of crops that can be grown in a specific food.
area. Some crops will do well in a hot climate, Moreover, dampness in houses favours the
others will not. transmission of airborne diseases.
For example, tea, peas and pyrethrum thrive in
cool climates. However, cold climates encourage It is your responsibility as a health worker to
respiratory diseases and joint problems such as identify ways of helping the community to improve
arthritis. In hot climates, most legumes and fruits their environment. You have to be a role model in
such as oranges and mangoes do well. Diseases your homes, health facilities and also in assisting
associated with hot climates include malaria. various community development projects.

Snakes are also common in hot areas and their Pollution is the term used to describe the spoiling
bites can be fatal. Some disease outbreaks occur of natural resources such as air, food and water
during the rainy season, for example, cholera, by harmful substances. Industrial waste such as
typhoid and malaria. Similarly, during dry seasons smoke can pollute the air and water. Other
there may be a shortage of food leading to industrial wastes can pollute the soil and
malnutrition. Persistent crop failure will lead to
food insecurity and famine. vegetation. In the rural areas, where people are
involved in agricultural activities, pollution may
result from the use of insecticides, pesticides and
industrial waste.

Jesse Daniel Omolo.. Page 65

Environmental health problems however are feeding practice considering it to be primitive. This
usually more prevalent in towns and slums than in denies the child all the benefits of breast-feeding.
rural areas. As a health worker you can make a Other people do not make use of the available
prenatal and delivery services. This affects the
difference in the community by assisting
growth of the baby and the health of the mother.
individuals, families and the community to make
their environment healthy.
Customs and beliefs have an effect on human
health. Identify those beliefs that you think you
Socio-Cultural Environment
need to discuss with the community to change
and those to uphold. It is important to listen to the
The figure on your right illustrates some of the
community‟s reasons for their beliefs and
socio-cultural factors that may affect health and
practices. This will facilitate the choice of the
health practices.
health measures and suitable solutions after
discussion.

Economic and Political Components of the

Environment

These components include work, money and

government. The economic factor relates to both
rural and urban economies as well as local
community organisation. Rural and urban
economics will determine to a great extent the
quality of environmental health.
People can change their environment either
positively or negatively. Some of these changes
are described as development.

Some development projects may make the

environment healthier, while others make it a
suitable habitat for diseases. An example is that of
irrigation schemes for growing rice, which is a
cash crop. This improves the peoples‟ income, but
at the same time, rice fields are breeding sites of
mosquitoes and snails, which are vectors of
Some of the health issues affected by these malaria and schistosomiasis respectively.
factors are food habits and cooking practices.
Different communities have different food habits Other examples of the relation between health
and cooking practices. For example, the Kikuyu
and economic status abound. People of low
community have maize and beans (Githeri) as
their staple food whereas the Luo community economic status may resort to drinking as a way
have a cooked preparation of maize flour (Ugali) of relieving their stress. This is usually at the
as their staple food. expense of the family budget for basic needs and
may lead to health problems. The rich also may
Food taboos also vary from one community to the suffer from diseases of life style such as obesity,
other. Examples of food taboos include prohibiting gout, and hypertension among others. The
pregnant mothers from taking some types of
government involves political influences into
meat, believed to affect the foetus.
development policies.
Wife inheritance and polygamy practices
encouraged by some communities provide an Think of leadership in the catchment area of
opportunity for spreading sexually transmitted your health facility. List three examples of
diseases and HIV/AIDS. Tattoos performed for health activities that have been affected by
beautification and circumcision are other practices leadership at their implementation stage.
where the procedures may be carried out using
unsafe instruments and can easily transmit
From your experience, relate how leadership
diseases like HIV/AIDS among others.
influences the implementation of health activities.
Female genital mutilation can lead to difficult Your answer should include health activities such
deliveries. Some people discourage breast- as home visiting, school health services, outreach

Jesse Daniel Omolo.. Page 66

services and local development projects. This What role does water play in the transmission
gives you insight into the role leadership plays in of the following diseases?
health care delivery services.
 Scabies
The government develops policies, which enforce  Cholera
environmental health. It also plays a great part in  Schistosomiasis
influencing the implementation of health activities.
Political instability causes unrest, insecurity and Water may contribute to the spread of diseases in
psychological problems. Management of disease several ways. When there is not enough water,
outbreaks may be lacking as health facilities may and people cannot observe basic personal
be destroyed. hygiene, diseases like scabies, non-specific
diarrhoeas, dysentery and trachoma spread. Such
You have now understood the influence the diseases whose spread is promoted by lack of
economic and political component of the adequate water are called water-washed (water
environment can have on health. You need to scarce) diseases. Simply improving the quantity of
identify yourself with local community water can prevent them.
organisations in your area and work in
cooperation with the government officials at Water can also contribute to the spread of
various levels. This will facilitate the diseases when it carries a specific disease-
implementation of various health activities causing organism. Examples are typhoid, cholera,
successfully. amoebiasis, hepatitis A, or poliomyelitis. Such
diseases caused by contaminated water are
called water-borne diseases, and the only way to
prevent them is to improve the quality that is, the
SECTION 2: WATER AND SANITATION cleanliness of the water.

Introduction Finally, water can contribute to the spread of

disease when it is necessary in the life cycle of a
The section is divided into three sub-sections. In disease vector, for example malaria and
the first one, you will look at water, identifying schitosomomiasis. These diseases are called
various water related diseases as well as sources water-related diseases. Other water related
of water, water contamination and the purification diseases include: onchocerciasis (river blindness)
of water. In the second sub-section you will and dracunculosis (guinea worm).
examine types of waste and finally, in the last sub-
section, you will study methods of waste disposal.

Objectives

By the end of this section you will be able to:

 Describe the importance of water in

relation to health
 Explain different types of waste
 Describe various methods of waste
disposal

Water

Water is essential for life. It is found in every cell

in our body and is necessary for most basic
functions, like respiration, digestion and other
chemical processes. More than 50% of human
body weight is made up of water. Water is thus
vital to health and survival but it may itself become
the source of diseases, therefore, it should be
properly treated and made safe for domestic use.

Jesse Daniel Omolo.. Page 67

Uses of Water Surface Water

Water is used in various ways. These include: This type of water includes shallow springs and
shallow wells, streams, rivers, dams, ponds
and lakes.
 Human consumption for body needs
 Animal watering
 Industrial use for manufacturing A spring is a natural issue of underground water.
When the rainwater falls on the surface it sinks
 For recreational activities such as
into the ground until it reaches the impermeable
swimming
layer of rock, which it cannot go through.
 To produce electricity
 Sustaining of aquatic life, for example,
fish for consumption and export All the water above this layer is called surface
 Household purposes like washing and water. If it finds a point of issue it is called a
cooking shallow spring. If a well is dug into it, it is called a
shallow well, despite its depth. The quantity of
water yielded by shallow springs or wells varies
Simple improvements at the community level are according to the season. They may dry up during
required to ensure adequate quality and quantity droughts and are liable to contamination by
of water. latrines.

Sources of Water A river is a large mass of flowing water. During the

rainy season, its waters become turbid, while in
Water does not stay in one place for very long - it the dry season they are clear.
goes round in a cycle. It evaporates from seas
and lakes and falls back to the earth as rain. After River water has a lot of impurities obtained from
rainfall, some of the water evaporates and the rest human and animal waste, washing, sewage,
is drained into streams, rivers, lakes and ponds. agricultural waste and industrial waste.

The most important water for a community is the Other sources of water are dams, ponds and
water that is held in the soil, by the roots of the lakes. All these sources provide fresh water.
trees in the forest. This is a community‟s long-
term underground water store. This is why it is Remember you have fresh water lakes in this
important for you to educate the community on the country, which includes Lake Victoria, Lake
need to preserve their forests. Baringo, Lake Turkana and Lake Naivasha.
However, the water from these sources is often
There are four main sources of water namely rain unclean and not safe for drinking. It is therefore
water, surface water, underground water and sea important to identify suitable ways of rendering
water. it safe.
The quality of water depends on the location of its
Rain Water sources. If the water source is from the forest, hills
and valleys, it is clean and suitable for household
This water is relatively pure and clean. Its state of use with little or no prior treatment. This is
cleanliness depends on levels of atmospheric because there is no human settlement, which
pollution and how it is collected. The cleanest might be a source of potential pollutants, at or
natural water available is that which is collected around the water source.
from iron sheets into gutters and led by pipes into
clean closed tanks. When the first rainwater falls, On the other hand, streams, rivers and lakes
the last part of the gutters leading to the tank around or within towns and villages are likely to be
should be removed for some time to ensure that contaminated by human and animal waste. It is,
dirt on the roof does not enter the tank. One therefore, important to protect water sources from
disadvantage of this water source is that it is human settlement or animal grazing.
difficult to collect from thatched roofs.
Underground Water
The community health nurse can assist the
community members to ensure collection of clean The water that gets under the impermeable layer
water. of rock is called underground water. It is the water
between two impermeable layers of rock, one
above and the other one below. This water finds
an outlet through a fissure or crack in the upper

Jesse Daniel Omolo.. Page 68

layer of the rock. Water from this issue is obtained Rain Water
as a deep spring, a well or a borehole.
The protection of rainwater sources is done by the
Sea Water use of gutters led by pipes into a small waste
drain tank and into a clean closed tank. As you
This water is salty and requires expensive have seen earlier, the first rainwater cleans the
purification processes to make it suitable for roof and the last part of the gutter should be
drinking. In your country you have several salty disconnected to render the water clean.
lakes, which are Lake Magadi, Lake Bogoria and
Lake Elementaita. There are also the salty waters You can identify the need to discuss with the
of the Indian Ocean. community simple methods of water protection
Underground water is plentiful, has less chances during home visits.
of contamination and does not normally dry off
during dry seasons. This water is usually salty and Surface Water
it is necessary to remove the salts. It also needs
to be pumped into tanks or reservoirs before use.
To protect surface water, people should not settle
around springs, streams and rivers. People and
Sources of Water Contamination animals should be kept away from water
catchments areas, normally in the forest or up the
Water has the ability to absorb substances and hills.
gases, for example, oxygen and carbon dioxide as
it falls as rain. It also absorbs minerals, for Springs
example, different salts from rocks or even
dangerous chemicals from industrial wastes.  Clear the bush or long grass around the
site of the spring.
Collecting surfaces for rainwater may have  Put up a fence around the spring to
leaves, insects, bird droppings and animal faeces prevent animals from grazing and children
on them. When water runs over the earth it may from playing around it.
become contaminated with human or animal  Dig a drain about 15 metres from the
excreta, refuse, fertilizers or industrial wastes. spring to divert surface water.
 Build a strong retaining wall around the
Excreta and refuse may contaminate shallow 'eyes' point from which water flows out
wells. Wells may also be contaminated by the use from underground. This wall holds water
of dirty containers for drawing water or by oil from from the 'eyes' of the spring.
a pump. Bathing, urinating, defecating in water,  Fix the delivery pipe at a height close to
washing clothes and animal watering may the level of the 'eye' but high enough to
contaminate rivers, lakes or dams. allow the water containers to stand below
the pipe.
Even piped water may become contaminated from  Build steps to the spring as well as a
leaks in the pipes, especially when they pass near platform on which to place the containers
dirty drains or when it is collected in contaminated when collecting waters. The area behind
containers. Water may go bad if it is uncovered or the retaining wall should prevent
stored for too long in a pot or cistern. Finally, it is contamination without interfering with the
important to remember that water from any source water flow.
may become contaminated if it is drunk from dirty  Design an area for washing and for
or communal watering the animals.
drinking vessels.  Select a caretaker to maintain the
protected springs.
Remember: It is easier to prevent water from
getting dirty than it is to clean it. Protection of Water Sources

Protection of Water Sources With this knowledge, you will be able to work with
the public health technician or officer in protecting
Water sources are precious and must be kept free water sources in the catchment area of your
from contamination.
health facility.

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Wells Safe Water System

 The site should be selected at least The safe water system is a household-based
100 metres from a pit latrine or other likely water quality intervention in response to the need
source of contamination. for inexpensive, alternative means of water
 The sides of the well should be built with treatment and storage in the short to medium
stones, rocks, or cement culvert. terms. The intervention has
 The sides above the surrounding ground three components:
should be constructed with a sloping
water-proof area to avoid dirt from getting  Water treatment in the home
into  Safe storage
to the well.  Behaviour change techniques
 A strong well cover should be put in
place. The main goals of safe water systems are:

The well should be dug during the dry season

 To improve the microbial quality of water
to obtain adequate depth, filtration and
in the home by means of sustainable
constant water supply.
technology
 To reduce morbidity and mortality of
diarrhoea diseases related to
Protection of Water Sources
contaminated water
 To improve hygienic behaviour related to
The community health nurse and community water use
members should identify practical methods for
protecting the water sources in the community.
Chlorination
The public health technician or officer can offer
technical knowledge on silting of springs and
wells. Chlorine is added to water that has been filtered
on a large-scale for supply in cities and towns.
Chlorination is the final safeguard of the quality of
Purification of Water Sources
water.
Chemicals can be used to purify water sources.
The amount of chlorine added to the water should
Iodine is a disinfecting agent used as 2% tincture.
be proportioned to the volume of flow and to the
Two drops are sufficient to disinfect one litre of
chlorine demand of water. Chlorine should be
water. Iodine tablets such as Globaline® and
properly mixed and there should be a minimum
Potable Aqua® (trade names) are also used in the
contact period of 30 minutes, for it to be effective
sterilisation of small amounts of water as directed
against pathogenic organisms in water.
by the manufacturer.
For household use, 1% of chlorine is
Purification of Water Sources
recommended. This is normally in the form of
Jik®, Milton® or Water Guard® which are trade
After the treatment of water, it is important to store
names. Chlorine should be properly mixed and
the water safely to prevent recontamination. A
there should be a minimum contact period of 30
safe storage container is a narrow mouthed
minutes.
container that has a lid. The drinking water should
not be removed from its container by dipping a Sanitation
potentially contaminated vessel. Instead, it should
be poured out of the container or the container Types of Waste
should be fitted with a tap.
You are now going to turn your attention to
The community should be educated on simple different types of waste. Man produces waste
and practical ways of protecting their water such wherever he is and it is necessary to manage this
waste properly to prevent diseases.
as the safe water system.
There are two types of waste: solid and liquid.
Liquid waste includes excreta and wastewater.
Solid waste is also known as refuse.

Jesse Daniel Omolo.. Page 70

Liquid Waste Solid Waste

Human excreta are faeces and urine. They are a Solid waste or refuse is defined as any unwanted
source of pathogenic organisms. discarded material, the remains, residual or by-
products of human activities which are no longer
Excreta are offensive to both sight and smell and required for further use by the initial producer.
can also lead to the contamination of water and This is normally in the process of:
foods. Faecal organisms may infect people
directly or indirectly through an intermediate host.  Preparation
Human excreta may spread the following  Manufacture
diseases:  Packing
 Other human related activities
 Typhoid fever
 Cholera If solid waste is not disposed of properly, it may
 Intestinal worms create a number of problems:
 Poliomyelitis
 Infective hepatitis A  It may produce an offensive smell
 Bacillary and amoebic dysentery  It attracts insects, vectors/pests
particularly flies, cockroaches and rats
Liquid Waste  Spreads diseases
 It can cause pollution of air, water or food
Urine carries the infective ova of schistosoma  It can cause accidents, for example, fires,
heamatobium while faeces spread the cuts and falls
schistosoma mansoni.
Solid Waste
Faeces should not be accessible to fingers, feet,
flies and food. The fingers and flies transfer the
There are various sources of solid waste. These
faeces to the food through the faecal-oral route
transmission, known as the 4F connection, which include domestic waste, street waste, industrial
is illustrated in the adjacent figure. waste, hospital objectionable waste and
garden/agricultural waste. Now look at each of
It is, therefore, necessary to help people these sources in more detail.
understand the importance of proper excreta
disposal by use of simple and cheap facilities. Domestic Waste

As a nurse, you should be able to identify possible This usually consists of all the garbage that
customs and beliefs, which hinder proper excreta emanates from inside a house, for example, food
disposal in the community and educate the people leftovers, potato and banana peelings, waste
accordingly. paper, worn out clothes, shoes, broken utensils,
bottles and tins.

Street Waste

This type of refuse consists of paper, food and

commercial refuse in public places such as
markets and hotels.

Scrap metals may also be included in this

category.

Industrial Waste

This varies with the type of industry. Modern

industries produce chemical wastes, which are
potentially hazardous to man and other living
things. The wastes may be toxic, caustic, acidic or

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flammable. This means that they need special water passing through the pit latrine or
disposal. If the chemical waste is to be discharged cesspool
into a stream it should be processed first. If it is
solid, it should not be dumped on land as it may The excreta disposal system is divided into two
eventually seep underground and contaminate categories. These are: water carriage system and
non-water carriage system.
water sources.

Hospital Waste In the water carriage system, excreta are

disposed by the use of a flush toilet, which is also
This is the most familiar waste that nurses are called a water closet. The flush toilet is the most
aware of. It includes permanent and hygienic method of excreta
the following: disposal. This system is used where there is a
permanent, continuous and adequate piped water
supply system. This is mainly in cities and towns.
 Sharps, that is, needles and syringes
 Gauze and cotton wool swabs
Water closets are reliable and convenient for any
 Vials and Lotions
permanent building. The excreta are carried by
 Drugs and vaccines water pressure into a septic tank or sewage pit.
 Tubing, gloves and papers The clear fluid effluent needs further
 Foetuses bacteriological treatment to become inactive. It is
then led over stones and sand in underground
Health workers have the responsibility of drains for completion of biological decomposition.
maintaining infection prevention by proper The solid part of the excreta (sludge) settles at the
decontamination and disposal of the above waste. bottom. The sludge relies on natural
decomposition. It is reduced in volume and is
Garden/Agricultural Waste ultimately converted into inoffensive unstable
product. However, the water carriage system is
Agricultural waste from coffee, sugarcane, sisal, very expensive, technical and requires sewage
treatment works.
pesticides and fertilizers may result in the pollution
of natural resources such as air, food, and water
Now look at the non-water carriage system.
Waste Disposal
In this method, excreta are disposed of by
deposition in a pit latrine. The pit latrine is the
You will now look at various methods of waste
most important waste disposal method in the rural
disposal, covering the disposal of both liquid and
areas. In its simplest form, the pit latrine consists
solid wastes.
of the following:
Liquid Waste Disposal
 A hole in the ground
 A squatting place for sitting or standing
The best method of excreta disposal in rural areas
 A hut or shelter for privacy
is a pit latrine, while toilets are suitable for urban
areas. As a health worker, it is important for you to
know how a pit latrine is constructed. There are In this way the excreta is safe from fingers, feet,
some general guidelines that should be flies and food. Making a concrete slab, which is
considered when choosing the site for a pit latrine easier to wash and keep clean, should strengthen
to ensure that water sources among others are the squatting place. The hole should have a cover
not contaminated. with a handle, which ensures that flies do not
breed or get in and out of the latrine.
Some of these guidelines are:
The main advantages of a pit latrine are:
 Pit latrines and cesspools should be at
least two to three metres respectively  It does not require piped water supply
above the water table  It is cheap to construct as the materials
 Latrines should be located at least six are locally available
metres away from the buildings  The community does not need close
 Wells should be located upstream to supervision during the construction
avoid contamination of the well by ground

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As already mentioned, there are various other In towns collection should be regular, systematic
types of pit latrines. The borehole latrine is bored and reliable. Specially constructed vehicles for
into the ground about six metres deep and four this purpose can be found in big towns such as
metres in diameter instead of digging a pit. It has Nairobi, Kisumu, Nakuru and Mombasa.
a smaller volume and fills up faster than a pit. It is
faster to install, and is appropriate following In rural areas you should get the support of the
disasters where there is urgent need to install village health committee and arrange for refuse to
many latrines. be collected and disposed of regularly, especially
after market days. Simple methods of refuse
The trench latrine is a latrine where a trench is collection should be encouraged in rural areas.
dug and a number of holes with dividing partitions
constructed over it. These types of latrines are
used in temporary work camps. Advantages of Proper Waste Disposal

Bucket latrines are also known as pail closets and Proper solid waste disposal has several
are used where the water tables are high. A advantages. These include the prevention of:
squatting slab or seat is placed above the bucket,
which is filled within a few days. Some of the
 Breeding of pests and vectors
negative aspects of this type of latrine are the
unpleasant job of emptying it and the spillage,  Foul smells
which attracts flies.  Contamination of water sources
 Accidents from sharp objects
 Overcrowding where space can be
Finally, the composting pit latrine is suitable where
created for better utilisation
the water table is too high for a deep pit latrine to
be dug.
The health department and municipalities are
responsible for refuse disposal in towns. The
From this description of liquid waste disposal, you
choice of disposal method is determined by its
should now be in a position to assist the
cost. In the rural areas the health worker and the
community to construct and use hygienic disposal
village health committee are responsible for
methods.
refuse disposal in individual houses, shops, hotels
and markets.
Solid Waste Disposal
Dumping
The amount and type of refuse produced varies
from one community to another, as does the
This can be in the sea or river. In Kenya, this
means of disposal. Usually, solid refuse disposal
method is most often used in the towns along the
is not a problem in the rural areas except around
coast. This becomes a health hazard and the
shops, markets or other places where people
littering of the shoreline is an unpleasant sight.
aggregate. However, in big cities such as Nairobi,
Another commonly used method is open dumping,
Kisumu and Mombasa, there is indiscriminate
which should be discouraged. Open dumps
dumping of domestic and industrial refuse.
provide breeding places for rats, mosquitoes and
flies.
Health facilities, especially, should set a good
example by employing hygienic methods of refuse
Burning
disposal.
This may be done in a number of ways. These
Refuse in towns should be stored in proper
include:
containers. These containers should be:

 Simple open air burning

 Watertight plastic or metal with a tight-
fitting lid or polythene bags  Burning in a trench
 Rust resistant  Using a simple mud-brick incinerator
 Easily filled, emptied and cleaned
 Have side handles The open burning of combustible refuse is
 Rest on a concrete slab to ensure frequently used but it is not very effective. This
cleanliness of adjacent ground method often leaves tins and broken bottles
littering the surrounding area. This can cause
accidents, especially to children. The smoke and
odour contribute to air pollution. There is a fire risk

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and the rubbish sprawls all over while awaiting
burning. It may become a breeding place for
rodents and insect vectors.

Incinerators are an improved way of burning

combustible refuse. Incinerators can be simple
and cheap, or complex and expensive. Among the
cheap ones is the bin incinerator made out of a
drum with fire bars across it and air holes
underneath. A more expensive one is built out of
brick and fitted with chimneys. These incinerators
allow more complete combustion and produce
less smoke. Most hospitals use incinerators.
Controlled Tipping
Composting
This method involves depositing refuse into
Composting is “a process in which, under suitable
environmental conditions aerobic micro-organisms Recycling
break down organic matter to fairly stable humus”
(A. D. Luca and H.M. Gilles, 2003). The This is a method of re-using non-biodegradable
decomposition process occurs naturally on the refuse such as paper, bottles, plastics, metal cans
ground when droppings from the trees and and so on. Although it requires special processes
animals are converted by micro-organisms to to render the items suitable for reuse, it is a
humus. Aerobic composting is normally odour method that should be encouraged.
free.
SECTION 3: APPROPRIATE METHODS
This method is, cheap, convenient and
recommended especially in rural areas. Wet and OF HANDLING FOOD
dry refuse is heaped in alternative layers on to a
plot about 2.5 square metres to a depth of about Introduction
1.5 square metres. The refuse is then covered
with grass and earth. Compost requires frequent Welcome to section three of this unit. In this
turning after 30 days then after 60 days. This section you will cover food and principles of food
turning helps to distribute all parts of the heap to hygiene. Food is essential for growth,
undergo the high temperature of the interior. After development and in the provision of energy.
90 days the refuse is ready to be used as manure. However, food could also be responsible for the
spread of some diseases. The aim of food
hygiene is to prevent the contamination of food at
Controlled Tipping
any stage.
This method involves depositing refuse into
These stages are production, collection, storage,
depressions or large holes in the ground. These
sale,
tips should be situated at least half a kilometre
preparation and consumption.
away from settlement, preferably out of sight and
down wind. This is an effective method for
hygienic disposal of refuse. It can be used where Objectives
sufficient land is available. The method consists of
three steps as illustrated in the diagram below. By the end of this section you will be able to:

 Describe the sources of food

 Describe methods of food storage
 Describe preparation and preservation of
food

Sources of Food

Sources of food vary widely. They include rearing,

feeding, marketing, crop production and slaughter
of animals. Foods that are of animal origin should
only be derived from animals that are legally

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allowed for human consumption, for example, continuous metabolism to produce the end
some countries ban game meat. Meanwhile, crop product. This applies to food of both animal and
production should follow rules in agricultural plant origin, for example, meat, milk, fish, leaves,
practice, which involve spraying crops against tubers and seeds. When an animal or plant dies,
pests. Farmers are advised on safe use of they lose the mechanism of protection from
pesticides. bacteria, fungi and moulds.

During food processing certain standards of food Thus, you preserve food in order to:
hygiene are applied, for example, in milk
treatment, drinks and tinned foods. The chemicals  Increase its shelf-life, for example,
used as preservatives are also regulated for the canned foods
safety of the consumers. The slaughter of animals  Render the food safe for consumption, for
is governed by several rules and acts, for example, highly perishable foods like milk
example, the Meat Control Act, the Veterinary Act  Conserve the food for use during the
and the Public Health Act. periods of scarcity, for instance, dried
cereals and vegetables
Food can be contaminated by excreta, dirty  Avail seasonal foods, like fruits,
fingers, flies, poisonous insecticides or pesticides throughout the year
on vegetables or chemical preservation of food. It
can also be contaminated if it is derived from
Principles of Food Preservation
infected animals, for example, animals with
tapeworms or brucellosis.
There are two principles of food preservation.

You will now look at the recommended conditions Principle 1

for storing different types of food.
Destroy organisms responsible for spoilage
Food Storage through heat treatment.

Storage will depend on the type and packaging of Principle 2

the food.
Inhibit the micro-organisms through cold
Dry Foods treatment.

These include foods like maize, beans, and wheat Moulds

(cereals). Such foods should be stored in dry, airy
conditions in improved granaries. Affect the surfaces of foods containing high sugar
and salt. They also affect dry foods that may
Bagged Foods become damp due to poor storage.

These foods should be stored on raised shelves Yeasts

at least 18 inches above the floor or ground level.
This enables the store to be swept and washed Affect foods that have acid or sugar in high
easily. It also allows for easy inspection for pest concentration, for example, dried fruits, and
detection. concentrated fruit juices.

Perishable Foods Bacteria

These are foods that go bad within a short time. Affect foods under various conditions apart from
Such foods include dairy products, meat and fish. dry food.
They should be refrigerated to inhibit the
multiplication of bacteria. Heat Treatment

Food Preservation The following are methods of destroying

organisms through heat treatment.
This is defined as any method used to treat food
for the purpose of prolonging its life without
appreciable loss of its quality and appeal. Most
human food is of biological origin and there is

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Cooking Food must be deep-frozen at 0-4°C to remain
palatable. This keeps food fresh for weeks or
This is a heating process, which aims to produce months.
more palatable food. Cooked food generally
keeps longer than raw foods as long as re- Salting
contamination is minimised. Cooking destroys or
reduces micro-organisms and potential toxins in This is the saturation of food with salt or sugar, for
food. Cooking also inactivates undesirable example, ham, jam and jelly. The added solute
enzymes in food. It alters the colour, texture and reduces microbial activity due to its dehydrating
flavour and improves the digestibility of food. On effect. The salt and sugar solutions are more
the other hand, cooking may cause degradation of concentrated than the cytoplasm inside the cell.
food nutrients, for example, over cooking Therefore, the water passes out of the cell into the
vegetables destroys vitamin C. concentrate, dehydrating the cell.

Blanching Smoking and Drying

This is the process where most vegetable foods Drying and smoking makes food unsuitable for the
are heat treated at 70 - 100°C for 2 - 10 minutes. bacteria to grow and multiply. Fish or meat may
This is done by immersing food in boiling water or be preserved by these methods. A wood rack is
exposing it to steam. Blanching is used before made and fish or meat is placed on it. A wood fire,
freezing, canning or drying. This process which generates heat and thick smoke, is made
inactivates enzymes, drives out air bubbles under the rack. The heat will dry the fish or meat,
trapped in food, enhances retention of green and the smoke gets inside the food to act as a
colours and reduces micro-organisms. preservative. Green vegetables, cereals and
legumes can be preserved by drying them in the
Pasteurisation sun. If food is preserved by drying, it must be
stored in a dry place until it is used.
This is a relatively slow method of heat treatment.
Pasteurisation is generally carried out at a Food Safety
temperature of below 100°C. This method is used
to increase the life span of the product. This Preparation of Food
method reduces organisms that cause spoilage
and eliminates pathogens. Adequate personal hygiene must be observed
when preparing food in order to prevent disease.
Sterilisation

In this method heat is used to kill all micro- Health

organisms and their spores at a temperature of
above 100°C. The sterilised food must be stored Individuals suffering from respiratory infections
in an airtight container to prevent the entry of and such as colds or sore throat should not work with
recontamination by micro-organisms. food until they get well. This also applies to people
with infected cuts, skin eruptions and diarrhoeal
Canning diseases like dysentery and typhoid.

In this method, the food is first heated at a Clothing

temperature that kills all bacteria and it is then
sealed up in sterile cans or bottles. This prevents Individuals working with food should wear clean
bacteria from getting into it and enables it to washable outer garments. Every worker in the
remain safe for a long time at room temperature. kitchen or washing dishes should wear a clean
uniform or apron. These clothes should be worn
Cold Treatment and Other Methods when the worker is in the premises where food
preparation is taking place. This avoids cross-food
Freezing
contamination.
This is the most satisfactory method currently
available for long-term preservation of food. When
properly done, freezing is effective for retaining
the colour, texture, flavour and nutritive value.

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Head Covering washed before eating. The food should be
hygienically prepared and cooked adequately. All
To avoid hair from getting into food, hair bands, food utensils should be cleaned properly after use
caps or nets should be used to cover the head and left to dry before being stored in a clean
when handling food. place.

Personal Hygiene Environment

A daily bath is necessary for every individual. The environment pertaining to the preparation of
Wash hands before handling the food, use clean food should be clean throughout. The area should
utensils and avoid habits such as nose picking. be dust free. This includes the floors and all the
Nails should be kept short and clean. surfaces used for food preparation. The facility
itself should be clean and with adequate
Food ventilation and lighting.

Raw food should be separated from cooked food. Common Food Borne Diseases and Their
All vegetables should be cleaned thoroughly Causes
before preparation for cooking. Fruits should be

it prohibits residing or sleeping in kitchens or food

Food Safety Regulations stores.

The safety of food is so important that our Part (II) deals with 'milk, meat and other articles of
government has passed laws to protect the public. food'. This part prohibits the sale of unwholesome
These laws cover many aspects of food handling foods. It gives powers to authorised officers to
and health officers are generally responsible for inspect and examine food, seize and recommend
enforcing these laws. Agricultural personnel assist disposal at any time. These laws aim at protecting
them, where necessary. the public and the public health officers are
responsible for enforcing them. As a community
You will look at some of the factors that should be health nurse you need to work closely with public
considered when preparing or handling food and health officers to apply the food safety regulations.
some of the food-borne diseases.
The following are some of the areas that need
Remember: The Public Health Act Cap 242 is close supervision.
an Act of Parliament to make provision for
securing and maintaining health. This act is Meat
divided into 15 parts. Each part deals with a
specific aspect of public health.
Meat is one of the commonest foods that cause
Part 10 of the Act deals 'with protection of problems to the public. Therefore, it is important
foodstuffs'. This part regulates the construction of that inspection of slaughterhouses, cows, sheep,
buildings used for storage of foodstuffs. Secondly,

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goats and pigs be carried out. The same case fruits and cooked foods. The market should be
applies to butcheries where meat is sold. kept clean and proper refuse disposal maintained.
The food sold should be clean and fit for human
Milk consumption. This, therefore, explains the
importance of inspecting markets by public health
Milk is one of the foods that are easily officers. These officers have the power to close
contaminated and cause problems to the public. markets and condemn foods to prevent disease
Inspection of shops where milk is sold is of outbreaks.
paramount importance. The milk should be safe
and clean. It should be obtained from healthy Hotels
cows as it can transmit bovine tuberculosis among
other diseases. The room for handling milk should Hotels, restaurants and food shops should also be
inspected under hygiene regulations. They require
be clean, dustless and separate from the barn.
regular inspection by the public health officers. All
The pails, cans, bottles, coolers and other the food handlers should be supervised and a
equipment, which comes into contact with the regular medical examination is mandatory for
milk, should be thoroughly cleaned. them to prevent spread of diseases through food
handling. Licenses should only be given to hotel
Homes owners who have met the requirements.
Laboratory examinations may be necessary for
It is the responsibility of the community health food such as pre-cooked meat. The use of
nurse to share health messages with community uniforms, aprons, head coverings, as described
earlier, should be observed in the hotels. Proper
members on food hygiene. These include
personal and environmental hygiene in the hotel
maintenance of personal hygiene as covered premises should be maintained.
earlier, that is cleaning the utensils, handling them
with clean hands, and storing them in clean and The hotel should store, preserve, prepare, cook
dry cupboards or containers. and serve the food according to public health
regulations. The law also empowers closure of
Farms hotels which do not meet the regulations.

The community should follow the regulations on SECTION 4: HOUSING

the use of insecticides and pesticides in form of
sprays and fertilizers. This will help them to use The provision of good housing is an essential
each of them correctly depending on the age of aspect of environmental health. Good housing is a
the crop. Your role as a community health nurse is requirement for every human being because it
to encourage the community to adhere to the provides shelter and protection from
instructions from the agricultural field educators. environmental hazards.
Moreover, instructions are given on the respective
containers of these pesticides. You should teach Think of some health problems that would be
associated with the following poor housing
the community about regulations of food storage
conditions:
and preservation of different types of food. The
harvest should be carried out when the crops are
 Overcrowding and poor ventilation
completely ripe or ready to facilitate longer  Unscreened windows
preservation. The cereals and legumes should be  Cooking fires on the floor
dried properly before storage to avoid spoilage. All  Earth walls and dirty floors
perishable foods should be consumed at the right
time. Housing Condition Health Risk
Overcrowding and poor Airborne droplet
Markets ventilation infections
Unscreened windows Malaria
All types of foodstuffs are sold in markets. The Cooking fires on the floor Accidents and burns
markets should be designed in a manner that in children
considers stations where similar types of food Earth walls and dirty Breeding of flies and
should be stored and sold, for example, floors bedbugs
vegetables of all kinds, dry foods like cereals,

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A combination of dampness, lack of light, poor roofed. If you work in a rural community then you
ventilation and overcrowding will contribute to the must have come across this type of a house. It is
spread of airborne and droplet infections. satisfactory and easy to keep clean. However,
appropriate preservatives for timbers have to be
Earth floors and walls permit the entry and used or else termites destroy it. In many places
breeding of flies and bedbugs, while unscreened
mud bricks are used and they are an appropriate
windows permit entry of mosquitoes.
method of improving houses. Since it is less
Cooking fires on the floor are hazards to small expensive than a permanent house, you have the
children. Inadequate space to talk and play, responsibility of encouraging members of the
especially in town houses, is one of the reasons community to try and acquire at least this type of a
why fathers and children leave home thereby house.
adding to social problems.
Temporary Houses
For these reasons it is important to improve the
quality of housing. You can help your community This type of house may be found in rural and
live in safe houses, by making simple slums areas. The floor is earthen, the walls are
improvements using locally available materials. made of cardboard, polythene paper, grass or
mud. The roof is thatched with the same material
Objectives as the walls. This type of a house does not
provide for privacy and can easily catch fire.
By the end of this section you will be able to:
Temporary houses are a health hazard and do not
meet the requirements for good housing. They
 Describe the types of houses
should be discouraged as much as possible.
 Describe the criteria for an adequate
house
 Describe a suitable building site Criteria for an Adequate House
 Describe the characteristics of poor
housing A good house should meet biological, physical
 Describe how you would involve the and social criteria.
Biological Criteria
community in improving housing
Good housing minimises the risk of transmission
Types of Housing of diseases. The spread of gastro-intestinal
infections is minimised by some important factors.
A house can be permanent, semi-permanent or These include:
temporary.
These structures will be considered in turn.
 Good water supply
 Good food storage, preservation and
Permanent Houses preparation
 Adequate facilities for washing utensils
and well designed kitchens
This type of house has a stone foundation, a
 Adequate methods of refuse disposal
cemented floor and plastered walls. The roof is
covered with iron sheets, tiles or stones in the Physical Criteria
case of flats or maisonettes. This type of house
has advantages in that it is easy to keep the floor The house should be safe for every occupant.
and walls clean. However, the floor should be kept This means that home accidents should be
dry to avoid accidental falls. Permanent houses prevented. It is, therefore, necessary that
are not cheap to construct and it is necessary to appropriate safety devices be provided for. The
budget for the activity. house should also be free from air pollution.
Semi-Permanent Houses Social Criteria

This is a type of house whereby the floor is Good housing should be designed to enable the
usually cemented but does not necessarily have a family function effectively in regard to its cultural
stone foundation. The walls are made of iron background. This means that the required privacy
sheets or sometimes timber. The house is iron

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for adults should be catered for. It should have a for example, composting, burning or burying
suitable setting for bringing up children. waste. The house should be dry. The cooking
arrangements should be satisfactory to avoid
Characteristics of Adequate Housing home accidents. Generally, there should be an
effort to protect against all types of home
The following are the characteristics of a good
house. accidents, for instance, those caused by fire, tools
and chemicals.

Natural Light Remember: It may not always be possible to

meet all the necessary requirements for
The sun provides natural light, which is essential adequate housing. However, housing can be
for physical growth, especially in young children. improved in a number of simple and practical
Lighting is also essential for proper vision. The ways.
presence of sunlight into the house kills some
Suitable Building Sites
micro-organisms. This underscores the need for
sunlight in the house. Some insects are also The following factors should be considered when
driven away by adequate lighting. selecting a suitable site for a house:

Artificial Lighting  The soil should be suitable for

construction.
This type of lighting is needed at night. The  The site should be dry, sunny and
sources are electricity, oil lamps and gas. The exposed to free air.
type of lighting used should correspond to the  The surroundings should be hygienic and
purpose for which it is needed in the house. healthy.
 The site should be away from noisy
Ventilation factories, cinema halls and heavy traffic.
 It should be on high ground to avoid water
Fresh air is necessary for our health. Ventilation of from standing and stagnating. This will
prevent breeding of mosquitoes.
a house is the removal of impure air and pouring
in pure air. This is achieved through windows and Characteristics of Poor Housing
door ventilators. Good ventilation in the house is
important, because it keeps the air on continuous A poor house does not protect its inhabitants from
movement without creating draught, cools the environmental hazards. It may have some or all
housing and maintains the room temperature at a the following negative characteristics:
constant.
 Dampness due to poor drainage.
Room Separation  Overcrowding is a common feature in
poor housing. This is due to an insufficient
The house should have adequate rooms to number of rooms. Dampness and
provide separate accommodation for adults and overcrowding enhance the spread of
common respiratory diseases such as
children. The shelter for animals should be
colds, influenza, tuberculosis and
separate from the main house. There should also pneumonia.
be separate rooms for food storage and  Earthen floors and walls encourage
preparation. breeding of fleas and bed bugs while
unscreened windows encourage entry of
Others mosquitoes.
 Unprotected fire places with poor cooking
The house should have, where possible, arrangements cause home accidents with
cemented floor and plastered walls to protect children. Working tools can cause
accidents if not
against insects and should be rodent-proof. It
properly stored.
should also have water supply in adequate and  Water supply and storage, which lacks
reliable quantity and quality. It should have a good hygiene, poses a health hazard for the
latrine and a clean compound. It should be transmission of water-borne diseases.
equipped with proper methods of refuse disposal,

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  Proper storage of clean utensils is often Sensitisation
lacking in poor housing. This is
accompanied by poor personal hygiene in Sensitisation is the process of creating
the preparation and serving of food. awareness. Community health nurses come in
 The home environment may lack a good contact with the communities and should make
latrine, usually accompanied by improper use of these opportunities to share health
excreta and inadequate refuse disposal. messages with them. You should start at the
This increases the chances of getting health facility then extend your efforts to their
hookworm infestation. homes. The health team will have conducted a
 Compounds with tall grass, pools of water community diagnosis so as to have valid
and sprawling litter may provide good information on the problem.
breeding places for mosquitoes, rodents
and other vectors responsible for The following steps can be followed when
transmission of many communicable trying to involve the community.
diseases.
1. Meeting the Health Team Members
Community Involvement in Improving Housing
The first step involves planning to meet
It is very important to explain to the community the
reasons they need to adopt new hygienic and explain the need for community
practices. If the members of the community are involvement, with the health team
not well convinced, your environmental health members. Ensure that the relevant
measures will fail. This is because new practices consultants and government officers
mean a change in people‟s behaviour and they dealing with housing are invited so that
will not be willing to change unless they see they can give pertinent information on
personal advantages in it. Avoiding diseases,
making more money or just being more housing matters according to the Housing
comfortable are some of the advantages that must Act. In this meeting, the health team
be emphasised to the community. You must make members will deliberate on community
the new idea attractive. The following are only sensitisation and identify ways of
some ways of how to introduce change. improving housing in the community. All
the health team members should be
 Find out what people think about the committed to carrying out their plans for
problem. Do they see it as a problem? solving the housing problem.
If they do not, then you will have to help
2. Sharing Health Messages Daily at the
them understand that the problem exists
and needs to be given attention. Health Facility about Improving
 Encourage them to think of possible Housing
solutions and guide them towards those
that are technically possible and suitable The second step will be to start
for the situation. sensitising the community at the primary
Encourage community participation. health care facility.
 Aim to set an example in your health This will be accomplished by sharing
facility or home.
health messages on improved housing. In
 Talk and work with people, encourage
them to ask for advice or help in solving this way, the patients and clients will get
their problems, for example, inadequate pertinent information on types of houses,
water supplies, waste disposal, food criteria for adequate housing, effects of
safety regulations and hygiene, improved housing on health, characteristics of poor
housing, controlling of vectors housing and diseases associated with
and pests. poor housing. This will make the
community aware of the problem and the
The community would enjoy living in good
need to improve housing for the family.
housing. A little effort is needed to improve
housing by using locally available resources. 3. Meeting the Community Leaders

The third step is where the community

health nurse organises to meet and go
over the subject with the community

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 leaders of the area. These leaders include are encouraged to explore solutions to
formal leaders in government offices, for their housing problems. They also
example, the District Commissioner, the encourage mutual respect and
District Officer, Chief and Assistant Chief. understanding between the health team
The informal leaders, such as opinion and community members.
leaders, community own resource
persons, leaders of women, men and The effectiveness of these health
youth groups should also be involved. activities will be determined on monthly
Moreover, you should target community- basis when outreach and school health
based health workers, traditional birth services are carried out. It is necessary to
attendants and community-based let the community know the time frame for
distributors of family planning. These evaluation of the activity. A period of
leaders will be aware of the problem and about six months would be appropriate.
the need for improved housing in their
community. They will identify and suggest Evaluation of Housing Activities
ways of improvement. You should be able
After the implementation of the housing activities it
to guide them on the techniques of will be necessary to evaluate the extent of
carrying out the health activities. You may community participation. Community participation
use clinical records to confirm the health builds the confidence of the community members.
problem and the need for community It enables the members to examine their situation.
involvement.
4. Identifying Ways of Improvement You are able to obtain information from reports on
home visiting, outreach clinic services, also from
the public health technician and community-based
Through the previously-mentioned
health workers. The reports can be gathered from
meetings and activities, the health team
the community‟s formal leaders.
and the community leaders will identify
The Ministry of Housing will also give their reports.
many ways of improving housing. From
their list they will select the best
alternative and then plan and organise Finally, the patients and clients will also be
their resources, that is, manpower, interviewed on improved housing. It will be
money, materials, and time to carry out necessary for the nurse to carry out a community
the selected activities. Some of these survey in the area to assess the community
activities will be the provision of outreach participation. This will be carried out at the time
clinic services. During the clinic session, suggested for evaluation. The questionnaire will
the same content on improved housing include all the necessary aspects of housing and
will be covered in the health messages. focusing on new improvements. The findings of
this survey will be communicated to the
community leaders and the community. This will
During home visits, the nurse, public
enable the community to take appropriate action.
health technician and community-based
health worker should inspect the houses
and focus on simple practical ways of SECTION 5: CONTROL OF VECTORS
improvement. This will enhance the AND PESTS
implementation as the solutions are being
provided directly Introduction
at home.
This is the final section of unit three.
A school health service is another
community health activity where this In this section you will learn about vectors and
knowledge may be imparted for the pests.
children to share with their parents. The
community health nurse, with her team Objectives
members, conducts regular supervisory By the end of this section you will be able to:
visits to the centres of community-based
health care activities. These supportive  Describe diseases associated with
visits help the groups to build their self- vectors and pests
confidence and improve their skills. They

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  Describe methods of control of vectors Biological Transmission
and pests
 Describe how you will involve the The vector acquires the infective agent from the
community in the control process blood or skin tissue of the infected host and the
infective organism undergoes some development
in the vector. The infective vector may also
Diseases Associated With Vectors inoculate the infective agent from its salivary
secretion into a new host to cause disease, for
A vector is an organism, usually an insect, which example, in the transmission of malaria.
transmits a pathogen from a source of infection to
a susceptible host. Insects are controlled because Contamination of Skin or Mucous Membranes
of the role they play in disease transmission,
destruction of food and building materials. To The host may be infected through contamination
control vectors you have to deprive them of of skin or mucous membranes by the infective
suitable breeding places, food and harbour.
faeces of the vector, for example, louse borne
relapsing fever.
Mechanical Transmission
Ingestion
In this mode of transmission, the vector carries
the infective pathogen or agent on its body or The host may acquire infection by ingesting the
limbs. Alternatively, the infective agent may be vector, for example, guinea worm.
ingested by the vector and excreted unchanged in
its faeces.

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Pest-Related Diseases also pests. Pests have to be numerous in order to
cause a serious problem.
A pest is an organism, which in a given
circumstance adversely affects human health or Insecticides and pesticides are used to eliminate
the economy. Rats and mice are pests and they pest infestations. The safest and the most
belong to a group of animals called rodents. economical methods available are used.
Insects such as white ants, weevils, aphids are

Clothing
Insects and rodents also cause property
destruction. Clothing should be washed at least once a week
and ironed.
 Rodents destroy all types of dry grains
in houses' granaries and in the fields. Bedding
 In food processing regulations, the
evidence of rodent droppings and urine Bedding should be cleaned thoroughly at least
stains causes condemnation and disposal weekly and dried well in the sun. If infested with
of large quantities.
mites and lice it should be boiled and ironed, in
 They can destroy buildings by gnawing
wood, water pipes, electric cables and order to kill them.
they can cause fire outbreaks.
Food
Methods of Pest Control
Food stores, cupboards and tables should be kept
The following methods may be used to control clean. All foodstuffs should be covered to prevent
pest infestations. flies gaining access to them. All food utensils
should be kept clean and dry. Make use of the
Personal Hygiene improved methods of preservation of food that
have previously been covered.
This includes thorough hand washing, which
should be practised before preparing or eating Environmental Hygiene
food and after visiting the toilet. Short and clean The following factors should be considered.
nails should be kept and a daily bath should be
taken. Wearing of shoes will prevent infestation by Drainage of Water
jiggers and hookworms. The hair should be kept
short and clean. The use of shampoo, which has The aim of proper water drainage is to destroy all
a suitable insecticide, is helpful for cases of head mosquito-breeding sites. Drain any stagnant water
lice. or slow moving water around the house. All holes
and ditches should be filled to avoid standing
water. All receptacles likely to retain water, for
example, used cans and tins, bottles, coconut

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husks, vehicle tyres and so on should be collected Farmers are advised on the safe use of
and properly disposed of. Slow moving streams pesticides, for example, spraying vegetables such
should be canalised to facilitate faster water flow. as cabbages, tomatoes, sukumawiki (kale) and
spinach. There are instructions on the containers
Roof gutters should be cleared regularly to of these pesticides, which indicate the right age of
prevent blockage of water flow by leaves and the plant for specific use of a pesticide.
other materials. Clearing of the vegetation around Precautions are also given concerning protective
the buildings, and water banks removes damp clothing and washing after using the chemicals.
areas where mosquitoes breed.
After harvesting, the cereals and legumes are
Cleanliness dried in the sun and then treated with pesticides in
the form of dust or powder. This protects the
grains against pests for at least six months.
The home or village environment should be kept
clean. Animal shelters should be at a reasonable
Remember: Crop production should follow the
distance away from the main house. rules of agricultural practice, which involves
spraying crops against pests.
Waste and Excreta Disposal

This should follow the proper methods of waste For cats, dogs and cows, the appropriate
disposal as described in section two of this unit. insecticide is used to dust or wash them regularly
to kill any fleas and ticks. Rodents are controlled
Improved Housing by the use of rodenticides, which are available in
most shops, for example, Rat & Rat, Rat Rid,
Floors and Walls Fuko Kill and so on.

These should be cemented so that they can easily The floors and walls of houses may also be
be swept and washed. The floors should be treated with insecticides regularly. Mattresses and
bedsteads can be treated in the same way.
cleaned after meals to clear all the food on the
Heavily infested buildings should be treated with
floor. All the crevices and cracks in the walls and residual insecticidal sprays. Kerosene is also used
floors should be plastered. to kill bed bugs and white ants when worked into
cracks and crevices by use of an applicator like a
Beds and Other Furniture feather. Insecticides and larvicides in the form of
oils and emulsion are sprayed on the water
People should not sleep on the floor but on raised surface to kill insects in water.
beds. Beds and mattresses should be regularly
taken outside in the sun to kill any lice, mites and Molluscides may be applied in water to kill the
bed bugs. Boiling water can be poured on the bed snails, which spread schistosomiasis.
stands for the same purpose. Joineries of furniture
with cracks and crevices should be filled up with Community Involvement
plastic wood filler.
Community health nurses and other health
Buildings and Food Stores workers have the responsibility to share health
messages in the community. This facilitates
community participation in keeping the
Rat proof buildings and food stores should be environment safe.
constructed. In malaria areas, buildings should be
mosquito proof, with wire gauze to cover all Identification of Resources
ventilation openings, doors and windows.
Buildings should be inspected regularly for pests. You can conduct a community diagnosis. Make an
effort to utilise the skills of, and work with the
Use of Chemical Substances such as agricultural field officers in the community. Identify
Pesticides and Insecticides the shops or chemists where community members
can buy agro-chemicals, for example,
Chemicals used to kill the pests are in the form of rodenticides, insecticides, fungicides and
insecticide sprays, dusting powders, miticides, fertilizers.
rodenticides, emulsions, oils and molluscides.

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You should also identify and utilise co-operative SECTION 1: PATTERNS OF
societies depending on the crops grown in the
region, for example, tea, coffee, horticulture,
COMMUNICABLE DISEASES
pyrethrum, grains and cereals.
Introduction
Utilisation of Insecticides In unit three, you covered environmental health
and learnt that although the environment can be a
The health team will meet with community leaders source of ill health, you can prevent many
including the agricultural field officers. This diseases and health problems through simple
meeting would be most effective in a chief's measures such as good personal hygiene and
baraza where many community members will be proper waste disposal. However, despite your
best efforts, you can still contract diseases from
present. This will serve to give the implementers,
different sources. The common cold is a good
that is, the health and agricultural officers and the example. It takes just one person infected with the
community a big moral boost. They will gain flu virus to spread it round to the others in the
confidence in the utilisation of agro-chemicals. office or at home. A disease that is passed from
The information can also be distributed as the one person to another person is called a
officers visit the homes during their fieldwork. communicable or transmissible disease.
Transmissible diseases include: measles, HIV
infection, tuberculosis, chickenpox, gonorrhoea,
UNIT FOUR: COMMUNICABLE scabies, malaria, cholera, and roundworms
DISEASES among others.

In this unit, you will explore the common Communicable diseases are among the most
communicable diseases found in this country. important diseases in this country. They are
The unit is divided into eight sections. In section important because:
one and two you will cover patterns
and principles of communicable diseases,  Many of them are common
respectively. In sections three to eight, you will  Some of them are very serious and cause
examine specific communicable diseases death and disability
classified according to their modes of  Some of them cause widespread
transmission. This eight units are as follows: outbreaks of disease – epidemics
 Most of them can be prevented by fairly
Section One: Patterns of Communicable Diseases simple means
Section Two: Principles of Communicable
Disease Control In this section you will cover disease patterns in
Section Three: Contact Diseases the community, the meaning of host and infection,
Section Four: Vector-borne Diseases as well as the transmission cycle of
Section Five: Diseases Caused by Faecal-oral communicable diseases.
Contamination
Section Six: Airborne Diseases
Section Seven: Helminthic Diseases Objectives
Section Eight: Diseases of Contact With Animals
or Animal Products By the end of this section you will be able to:

By the end of this unit you will be able to:  Describe the patterns of diseases in the
community
 Describe the interaction between the host
 Describe the pattern of communicable
and the infecting agent
diseases in a community
 Describe a typical transmission cycle
 Explain the principles of communicable
diseases
 Describe the causative factors of
communicable diseases
 Explain the mode of transmission of
communicable diseases
 Describe the management approaches for
communicable diseases
 Describe the preventive measures for
communicable diseases

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Patterns of Communicable Diseases in the
Community

Different diseases are common in different places

and at different times. To understand why this
happens, you need to consider the disease
causative organisms (the agents); the people they
infect (the hosts); and the surroundings in which
they live (the environment).

A delicate balance exists between the agent, the

host and the environment and it can change in
different ways. For instance, the agent needs a
suitable environment in which to grow and multiply
and thus be able to spread and infect other hosts. Some Common Epidemic Diseases in Kenya
If the environment does not support the agent it
dies or transforms to a dormant state. The host  Cholera
(person) is also affected by the environment. For  Typhoid fever
example, a person may live in a hot, wet climate  Highland malaria
where there are many mosquitoes. However they  Acute bacterial meningitis
can change this environment by draining swamps,
clearing the vegetation and adding competing
hosts such as animals. If the balance is shifted
against the agent, the disease will be controlled In Kenya, malaria is endemic in the lowlands,
and the number of cases will go down such as the Tana River basin, the coastal strip,
and the Lake Victoria region. Schistosomiasis
which is related to water use is endemic around
When the balance between the agent, the host the Lake Victoria region and the Mwea irrigation
and the environment is fairly constant, you tend to scheme. Leishmaniasis is endemic in Baringo,
see approximately the same number of cases of along Tana River, and along the River Athi in
the disease every month. When this happens the Machakos.
disease is said to be endemic. When the balance
is shifted in favour of the agent (organism), for In some parts of the country, some disease
example, when many non-immune children have outbreaks occur only occasionally without a
been born in an area since the last measles regular pattern. Such diseases are said to be
epidemic, a large number of cases of measles sporadic in their occurrence.
may occur in a short time. This is called an
epidemic. Epidemic diseases occur during certain
periods or seasons and cause sudden deaths and Opposite is a map of Kenya illustrating the malaria
much suffering in the community. patterns.
An endemic disease can be termed as that which
occurs in a given population at a constant rate Now, look at what happens once an infecting
over a period of several years. An epidemic organism enters a person's body and causes
disease is that which occurs in a population at a disease.
higher rate than is usually the normal for that
population over a given time interval.

Diagrammatically the endemic and epidemic

disease patterns can be illustrated as shown
below.

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 overcoming the host's immune system and has
started causing abnormal functioning of some
body cells and tissues. This produces overt signs
and symptoms of the disease.

The Host and Infection

It is important for you to understand these stages

because people with symptoms are easier to
identify as they come to your health facilities for
treatment. People with sub-clinical infections do
not allways know they are infected and hence are
a danger to other people. They are also difficult to
detect in the general population without special
tests. An individual who is suffering from a sub-
clinical infection is also likely to infect others, as in
the case of HIV infection which leads to AIDS
after a long period. They are therefore known as
carriers. An individual who develops a clinical or
sub-clinical infection is said to be susceptible to
the disease. A susceptible individual is one whose
body lacks resistance to the disease. Resistance
of the body to a disease occurs due to various
immunity mechanisms.

Write down the two types of immunity found in

The Host and Infection
our body.
A person who is invaded by a disease-causing
A disease transmission cycle is a series of steps
micro-organism is called a host. An infection
that a disease-causing organism undergoes in its
occurs when this micro-organism begins to
disease-causing process.
reproduce (multiply) and grow. When an organism
infects a person, there are three possible stages
to consider. Disease-causing organisms are living things that
need somewhere to live and reproduce. This may
be within inanimate or animate environment
Incubation Period
(example in rodents, insect, or the human body),
which is known as the reservoir of infection. The
The incubation period is the time between human being is the main reservoir of most of the
infection and the appearance of symptoms and communicable diseases that affect humanity.
signs of an illness. During the incubation period
the host does not realise that they have an
When an infection spreads to a new host, the
infection until several days later when detectable
place, animal or human from which the organism
symptoms and signs of the illness occur.
came from is called the source of the infection.
The way in which an organism leaves the source
Sub-clinical Infection (the infected host) and passes to a new
susceptible host is called the route of
At this stage, infection does not produce clear transmission. Each disease-causing organism has
signs and symptoms. The host's immune particular routes which play a large part in how
system is trying to fight off the agent. these organisms spread in the community. For
example, some organisms are spread through
In some cases, the organism is overcome by the water and food, while others are spread by
host immune cells hence no signs and symptoms vectors like mosquitoes and snails.
are felt and the infection process is terminated.
The diagram above illustrates the differences
Clinical Infection between the disease transmission cycle in
measles, and in malaria where the causative
This is the period when the host develops organism passes from human being to mosquito
detectable symptoms and signs of an illness. At and back to the human being.
this time the agent has multiplied within the host

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 with AIDS have a high risk of developing
tuberculosis.
 Malnutrition
 Certain drugs such as those used to treat
cancer can lower a person‟s resistance to
disease.

SECTION 2: PRINCIPLES OF
COMMUNICABLE DISEASE CONTROL

Introduction

Welcome to section two. In this section you will

look at the main methods (also known as
principles) that are used to control the occurrence
Every transmission cycle is made up of three and spread of communicable diseases. It is a
parts. short but intense section which will give you the
foundation you need to prevent and control the
The Source diseases you shall cover in subsequent sections.

This is where the disease-causing organisms Objectives

spreads from. It could be an infected person,
animal, place, or object. The reservoir is the By the end of this section you will be able to:
source of infection.
 Explain the principles of communicable
Transmission Route disease control
 Describe the methods used to prevent
The main routes of transmission are: communicable diseases
 Explain the role of the community
 Direct contact, for example sexual members in prevention of communicable
contact, contact with skin or mucous diseases
membranes
 Vectors Methods of Communicable Disease Control
 Faecal-oral (ingesting contaminated food
and water) Communicable disease can be controlled and
 Airborne eradicated from the community. When thinking
 Transplacental (mother to foetus) about the control of diseases it is always good to
 Blood contact (transfusion, surgery, think of all the possible methods. In most
injection) cases one or two specific methods will have the
greatest effect and should be the focus of your
 Contact with animals or their products
activity, in other cases some methods will be
useless against the disease. The aim of control is
Susceptible Host to tip the balance against the agent.

An individual who has low resistance to a The control and eradication of communicable
particular disease is said to be a susceptible host diseases can be
for that disease. There are a number of factors done by:
which lower the body's resistance to a disease:
 Attacking the source of the disease-
 Not having come in contact with the causing organism
disease-causing organisms before and  Interrupting the transmission route
therefore not having any immunity to
 Protecting the susceptible host
it. For example, passive immunity against
measles is lost at the age of 6 - 12
months. Therefore if a child comes into You will now look at each method in turn.
contact with the measles virus after this
age, they may develop the disease.
 Having a serious illness like AIDS which
suppresses a person‟s immunity. People

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Attacking the Source covered in detail in unit three of this module. They
include the following:
There are various specific measures which can be
used to control the spread of an infectious  Personal hygiene
disease. They include:  Environmental health
 Water and sanitation
 Treating the infected person or animal  Vector control
with the appropriate antibiotics that  Good and adequate housing
destroy the disease causing-organism.  Effective food handling and adequate
 Treating the carriers and sub-clinical nutrition
cases after carrying out screening tests
among suspected individuals or groups. Please review each one of these measures in unit
 Treating specific groups of persons who three of this module so as to complete this section
are at high risk of being infected(mass successfully. In addition to the measures covered
treatment). This is called in unit three, add sterilisation of medical
chemoprophylaxis. equipment and the use of sterile surgical
 Isolating those persons who are infected equipment. These methods are useful for
with highly infectious diseases such as interrupting the transmission of diseases such as,
ebola, marburg fever, lassa fever; so as to Human Immunodeficiency Virus (HIV) infection
prevent the spread of the organism to and hepatitis-B infection.
other healthy people.
 Treating sick animals such as cattle Remember: A clean environment and good
suffering from brucellosis, immunising personal hygiene are the most important
animals such as cows from anthrax, and measures in the primary prevention of
dogs from rabies; killing sick animals such diseases.
as rats to control plague and dogs to
prevent rabies; separating humans from
animals. Protecting the Host
 Notifying the local health authorities
immediately you suspect a patient is This is the third principle of controlling the spread
suffering from an infectious disease. of communicable disease in the community. Any
Though this does not directly affect the person who is not yet infected by a specific
source, it is an essential way of keeping disease-causing organism is known as a
watch on the number of new cases and susceptible host. This is because they are at risk
thereby monitoring the effectiveness of of contracting the infection. All susceptible hosts
the control programme. must be protected from contracting the infection.

All of the methods mentioned on the previous Remember: The most effective way of
page are methods of controlling the reservoir - controlling communicable diseases is to use a
where an animal is the reservoir. combination of methods: attacking the source
of the infecting organism, interrupting the
In summary you can state that the measures for route of transmission, and protecting the
attacking the source are: susceptible host.

 Treating the infected person/s

 Treating the carrier Specific Measures
 Mass treatment of persons at risk
 Isolating the infected person/s  Immunisation using vaccines such as the
 Treating the sick animal such as cows KEPI vaccine
 Immunising animals such as dogs and  Chemoprophylaxis using for example:
cattle - Proguanil (PaludrineR) to suppress
 Killing the animal reservoir such as rats malaria parasites
 Separating humans and animals - Tetracycline during cholera outbreaks
- Cotrimoxazole during plague outbreaks
Interrupting the Transmission Cycle

A number of methods are used to interrupt the

transmission cycle. Some of the measures were

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General Measures diseases are reported by the Ministry of Health to
the World Health Organisation (WHO).
 Use of barriers such as bed nets, gowns,
gloves to prevent insect bites Application of Communicable Disease Control
(especially mosquitoes) Measures
 Use of chemicals for example insect The actual application of the control methods you
repellents to prevent mosquito bites have just seen can be undertaken by different
 Wearing shoes to prevent penetration by groups of people and institutions at various levels.
hookworms These include individuals and village level,
from the soil dispensary and health centre level and the district
 Adequate housing to reduce and central government (Ministry of Health)
overcrowding
 Improved nutrition Remember: A successful communicable
 Adequate ventilation disease control program is the one that
involves members of the community.
 Health education

Other Control Measures Control Measures at Individual and Village

Level
There are other useful measures that can be
taken to control the spread of communicable At this level, each person and indeed every
disease. Among these is the notification of member of the village is responsible for:
disease. Notification requires you to keep watch
(surveillance) on the number of new cases of
communicable diseases in your area of work and  Completing the immunisation
to immediately inform the local health authority  Personal and environmental hygiene
when you come across a patient suffering from an  Food hygiene and adequate nutrition
infectious disease. One of the main reasons for  Using bed nets and protective wear
notification is to help the health authorities take  Abstaining from casual sex, being faithful
measures to confirm your suspicion and to control to one sexual partner or using condoms
the spread of the disease. Notification of  Protecting water supply and using clean
infectious communicable diseases is the water
responsibility of all health care workers. It is also a  Digging and using pit latrines
legal requirement according to the Public Health  Controlling vectors
Act, Chapter (cap) 242, section eight of the laws  Healthy habits, for example not smoking,
of Kenya. consuming alcohol and abuse of drugs

Remember: It is your responsibility to notify Control Measures at Dispensary and Health

your local health authority immediately should Centre Level
you suspect the presence of an infectious
disease. The health care workers should support and
Notifiable Diseases in Kenya encourage their clients and community to
establish and sustain community based disease
 Plague control programs. In addition, the health care
 Cholera workers should:
 Measles
 Poliomyelitis  Increase immunisation coverage
 Diphtheria  Participate in vector and reservoir control
 Tuberculosis  Emphasise water protection and
 Anthrax purification
 Trypanasomiasis  Inspect food, markets and eating places
 Typhoid fever  Encourage sanitation and refuse disposal
 Whooping cough  Promote health and prevent diseases
 Meningococcal meningitis using Information, Education and
 Rabies Communication (IEC)
 Yellow fever  Notify diseases

The diseases in bold spread so quickly that they

need international control measures. These

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Control Measures at District, Regional and
National Level

At these higher levels, health care workers are

responsible for:

 Vector control schemes

 Mass immunisation campaigns
 Mass treatment and chemoprophylaxis
 Mass media IEC programmes
 Health statistics registration
 Research on disease control methods
 Emergency, epidemiology and control Factors Increasing the Transmission of
teams Contact Diseases.
 Manpower training and continuing
education for staff  Close personal contact (for
example:sexual intercourse)
SECTION 3: CONTACT DISEASES  Inadequate housing leading to
overcrowding
Introduction  Poor personal hygiene usually due to
Welcome to the third section of this unit. From this inadequate water supply
section onwards, you will group communicable  High population density as in urban
diseases according to their mode of transmission (slums) areas
and then investigate their individual causes, mode
of transmission, diagnosis, treatment and Scabies
preventive measures. You will start with contact
diseases (also known as contagious diseases). This is a parasitic infection of the superficial layer
This is a group of communicable diseases that are of the skin characterised by severe itching. It is
transmitted through direct or indirect contact caused by the female of an insect called
between susceptible and infected persons. Sarcoptes Scabiei (itch mite). The female mite
burrows in to the skin and makes a small tunnel.
Objectives Within the tunnel, the insect deposits its eggs and
faeces. The eggs hatch in four to five days and
By the end of this section you will be able to: the larvae leave the mother's tunnel and bury
themselves in the skin and in other places. The
 List factors that favour the transmission of larvae do not make tunnels.
contact (contagious) diseases
 Identify signs and symptoms of infections, Mode of Transmission
namely; scabies, fungal skin infections
and trachoma
Scabies is spread through direct close body
 Describe the management of contagious contact, as in bed, or through contact between
diseases parents and children or among children playing
 Describe the control measures of together in schools. Transmission of scabies can
contagious diseases also occur indirectly through clothing or
bedclothes. Poor living conditions and poor
Transmission of Contact Diseases hygiene promotes the spread of scabies.

A large number of patients seen in your health Clinical Picture

facility, particularly school children, are suffering
from contact diseases which are easily
preventable. Contact diseases tend to occur in The patient presents with intense itching,
clusters within households, children‟s play groups, especially at night, and eczema-like signs. You
schools and workplaces. They are passed from will also find an itchy rash with typical distribution
especially where the skin is curved (between
one person to another either directly by skin-to-
fingers, elbows, buttocks, etc). Because it is very
skin contact or indirectly by handling
contaminated objects such as clothing, bedding or itchy, you might also find that the skin is torn
combs. Such groups of infected people are known with scratches and thus secondary infection
as clusters. often follows.

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There are a number of reasons why people with personal appearance rather than illness, but it is
scabies do not seek early medical attention. The important to distinguish them from leprosy and
skin lesions may be so common that they are not syphilis. Also, fungal skin and mucous membrane
considered to be a disease. Also people who
infections are sometimes indicators of
suffer from leprosy or other diseases which
interfere with normal sensation may not feel the immunosuppression as occurs in AIDS, cancer
itching caused by scabies. and tuberculosis.

Remember: Severe itching accompanied Mode of Transmission

by typical distribution especially at the folds is
suggestive of scabies Fungal infections are usually spread by direct and
Management indirect contact. Genital infections such as vulvo-
vaginitis may be spread during sexual intercourse.
The whole family should be treated together with
the patient to prevent re-infection. The Clinical Picture
management of scabies is as follows:
A fungal infection typically produces a flat patch or
 The patient should take a warm bath. shamba-like growth on the human skin. This patch
 Rub a handful of 10% Benzyl Benzoate may be found on the head, on dry exposed body
Emulsion (BBE) all over the body. skin, between the toes, or in moist places like the
 After 24 hours, the patient should bathe mouth or private parts. Each of these patches
again and put on clean clothes. (depending on where they are found) looks
 BBE does not kill the eggs of Sarcoptes slightly different and has a different name, but
Scabiei and therefore the treatment must they are all fungi. Fungal infections can be divided
be repeated after four to seven days to kill into two groups: ringworms and candiadiasis.
those larvae which have hatched since
the first treatment. Ringworms
 If itching is severe treat it symptomatically
with calamine lotion. Ringworm manifestations are described in Latin
after the areas of the body they commonly affect:
Prevention of Scabies
 Tinea capitis (ringworm of the scalp)
The best way of preventing and treating scabies is  Tinea corporis (ringworm of the body)
good personal hygiene. Regular firm bathing,  Tinea pedis (ringworm of the foot)
washing of clothes and frequent use of soap will  Tinea unguium (ringworm of the nails)
control scabies.  Tinea versicolor or pityriasis

Remember: All these activities require regular

supply of water.
Characteristics of Ringworm Diseases
Dermatomycosis

The term dermatomycosis means fungal (Adapted from Communicable Diseases Manual,
1999, Characteristics of Fungal Skin Infections.)
infections of the skin and mucous membranes.
Fungal skin infections are mainly a problem of

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  Vulvo-vaginitis
Candiadiasis  Balanitis
 Intertrigo
Candiadiasis which is also known as moniliasis or
yeast infection manifests in the following ways: Characteristics of Candiadiasis Diseases

 Oral thrush – patchy white dots which (Adapted from Communicable Diseases Manual,
appear on the mucous membrane of the 1999, Characteristics of Fungal Skin Infections.)
mouth

Chlamydiae group cause non-gonococcal

Trachoma ophthalmia neonatorum, non-gonococcal
This is a chronic inflammation of the conjunctiva urethritis, cervicitis and salpingitis. Trachoma is a
and the cornea of the eye. It is caused by an major cause of blindness especially in those parts
organism called Chlamydia trachomatis of the of East Africa where water is scarce, such as
Chlamydiae group. Other organisms of the

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among the pastoralist communities who inhabit Stage 4: Entropion and Trichiasis Formation
the drier grasslands.
The scars formed after the healing
Mode of Transmission process,several years after the onset of the
disease,are the ones that do the greatest
Trachoma is very common among communities damage. Due to this scarring, the scar tissue
living in dry areas where there is scarcity of water. retracts (shortens), thereby causing the eyelids to
Transmission of trachoma is by direct contact with become thick and to turn inwards. This is called
the eye discharge of an infected person. Flies and entropion. As the thick, rough eyelids turn
fingers are important in the transmission of the inwards, the eyelashes point inwards and rub
disease. After infection, the disease progresses against the cornea. This is called trichiasis.
very slowly all the time destroying the cornea and trichiasis adds to the damage already done to the
the conjunctiva, eventually leading to permanent eye and results in blindness
blindness in one or both eyes. The early stages of
the diseases are the most infective and Remember: The combination of entropion and
transmission is high among children. trichiasis completely destroy the cornea
leading to blindness.
Clinical Picture
Management
Trachoma develops in four stages.
The drug of choice for the first three stages is 3%
Stage 1: Early Trachoma tetracycline topical eye ointment twice a day for
five days every month for six months. Stage four
of the disease with entropion must be treated
Initially the eyes are red and watery (as in
ordinary conjunctivitis). After 30 or more days, surgically. It is essential to do this as soon as
possible because every time the patient blinks it
follicles (small pinkish-grey lumps) form inside the
increases corneal damage. If it is not possible to
upper eyelids. To see these you would have to
turn back the lid. Usually there is a little pus in the perform surgery in your health facility, you can
remove the in-turned eyelashes by pulling them
eye, but if the pus is copious this may indicate a
out with sterile forceps. This should be done
secondary infection by bacteria. Examination of
scrapings from the conjunctiva in the laboratory before you refer the patient. While entropion
show the cells with a characteristic dark object in operations can be carried out at the health centre
level, pannus and opacity of the cornea have to
the cytoplasm. The dark object is called an
inclusion body and its presence in the cell helps to be done by eye specialists.
confirm the diagnosis of trachoma.
Prevention and Control of Trachoma
Stage 2: Pannus Formation
Trachoma is an example of diseases that are
associated with lack of water in the community
Normally, the cornea has no blood capillaries on
it. But during this stage, many tiny blood vessels (water scarcity). The most effective way of
are found to be growing towards the edge of the controlling and eradicating trachoma is through
supply of adequate water to the community.
cornea. These tiny blood vessels which grow in
Regular bathing and washing of children's faces
the cornea are called pannus. You can see the
pannus by using an ordinary magnifying glass. with water and soap should be encouraged.
Again, the presence of both the follicles and the
pannus strongly suggests the diagnosis of Other additional measures include:
trachoma.
 Where water is scarce, the community
Stage 3: Scarring of the Conjunctiva should be taught how to use the „leaky tin‟
(a technique where water for hand
After several years the follicles on the conjunctiva washing is put in a container that has a
slowly begin to disappear leaving behind whitish small hole near the bottom, the hole is
scars on the conjunctiva. In the cornea, the small closed with a piece of stick and when the
blood vessels degenerate. The vision becomes sick is removed water trickles slowly. It
hazy and remains so for many years unless there minimises wastage of precious water in
is rupture of the cornea scars, in which case water scarce areas and improves
blindness occurs. personal hygiene) and be motivated to
use it

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  Reducing the fly population in the - Trypanosomiasis
community through proper disposal of - Schistosomiasis
refuse and waste - Leishmaniasis
 Early treatment of infected individuals - Plague
 Mass treatment especially of school - Relapsing fever
children who live in trachoma endemic - Onchocerciasis
areas using 3% tetracycline eye ointment
twice a day for three to five days each Vector-borne Diseases
month for six months
The organisms which cause vector-borne
diseases usually undergo part of their
development inside the vectors themselves. The
time taken by the disease-causing organism to
develop inside the vector is called the extrinsic
incubation period. Although the housefly is an
insect that is known to carry bacteria and
chlamydia, it is not considered a vector. This is
because it is merely a mechanical transmitter of
disease; the organisms do not develop inside its
body.

The majority of vectors are insects with the

mosquito being the most common. This is
because the mosquito is responsible for
transmitting more diseases than any other vector.
Insect vectors usually acquire disease organisms
by sucking blood from infected persons. They
SECTION 4: VECTOR-BORNE then transmit the infection by depositing infected
DISEASES faeces or body fluids in skin cracks or abrasions.
Most vectors have quite specific breeding, feeding
Introduction and attacking behaviour. They therefore only
thrive in areas where suitable conditions exist for
In this section you will examine communicable their survival. As a result, vector-borne diseases
diseases which are transmitted by invertebrate tend to be present all the time (endemic) in a
hosts, that is organisms without a backbone. This given geographical area or population.
section is longer than the previous one due to the
large number of important diseases which fall Many of the diseases transmitted by vectors can
under this group. As usual you will look at each also become epidemic, especially when there are
type of disease, its causative organisms, clinical environmental or other changes leading to
features, management and prevention. increased transmission. Some serious epidemics
which have occurred in Africa have been as
follows:
Objectives
 Yellow fever: Ethiopia, Sudan, Nigeria,
By the end of this section you will be able to: Ghana
 Trypanosomiasis: Uganda
 List at least nine common vector-borne  Kala Azar: Kenya, Sudan
diseases  Plague: Uganda, Kenya, Tanzania
 Describe the clinical features of vector-  Typhus fever: Burundi, Rwanda, Ethiopia
borne diseases
 Describe the transmission cycle of vector- When communicable diseases are present in
borne diseases animals all the time, such as the case of yellow
 Explain the management of vector-borne fever in monkeys and plague in rats, the disease
diseases is said to be enzootic (epidemic in animals).
 Discuss the preventive measures of
vector-borne diseases namely:

- Malaria
- Filariasis
- Yellow fever

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Some Diseases and Their Vectors

In Kenya 98% of malaria is caused by

. plasmodium falciparum. The other 2% of the
Malaria cases are caused by plasmodium malariae and
plasmodium ovale. Malaria caused by
Malaria is an acute infection of the blood caused plasmodium vivax is very rare. Malaria due to
by protozoa of the genus plasmodium. For a long plasmodium falciparum is usually the most severe
time in Kenya, it was found mainly in humid low- form of malaria and is called malignant malaria.
lying areas of the coastal plains and the shores of The mortality rate due to malaria is highest in
Lake Victoria. However, these days it is also children under five years of age.
common in the highlands. Malaria is directly or
indirectly responsible for much ill-health and Malaria Epidemiology
death, especially of children.
In Kenya, malaria occurs in two patterns:
The vector responsible for the transmission of
malaria is the anopheline mosquito (anopheles Endemic Malaria
gambiae and anopheles funestus), which thrive in
humid, warm climates where water is available.
The parasites develop properly in the mosquito in Endemic malaria (also called „stable malaria‟) is
places where the mean temperature is 16 - 32°C. transmitted all the year round. This type of malaria
The cooler the environmental temperature the is found around Lake Victoria and the coastal
longer it takes for the parasites to develop in the region of Kenya. Endemic malaria causes severe
mosquito. The parasite takes about 35 - 36 days infection in children under five years of age and in
to develop at a mean daily temperature of 16°C, pregnant mothers. The mortality rate is high
and nine days when the mean daily temperature among infected children. After repeated bites by
is 30°C or above. Mosquitoes have an average infected mosquitoes older children and adults
life span of two to four months. develop partial immunity to malaria.

Malaria Epidemiology
Remember: Endemic malaria is transmitted all
the year and severely affects children under
Malaria is caused by the plasmodium (parasite) five years old and pregnant mothers.
that is transmitted to human beings by the bite of
the infected female anopheles mosquito. There
are four plasmodium species and any of them Epidemic Malaria
can cause malaria. They are:
Epidemic malaria (also called „unstable malaria‟)
 Plasmodium falciparum occurs seasonally and affects people of all ages.
Seasonal malaria occurs in Machakos, Embu,
 Plasmodium malariae
Kitui, Tharaka and Marigat in Baringo.
 Plasmodium ovale
 Plasmodium vivax

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Another form of epidemic malaria occurs in the
highlands and those areas bordering endemic
zones. This type of malaria is called highland
malaria and is seen seasonally and affects all
people severely. Highland malaria epidemics have
had high mortality rates. The areas in Kenya
which have been affected by highland malaria
include Kisii, Nyamira, Kericho, Turkana and
Narok.

Remember: Epidemic malaria occurs

seasonally and affects people of all ages.

Transmission and Life Cycle of Malaria

Malaria parasites develop in two cycles: The first

cycle takes place in the mosquito and the other
cycle in the infected human being. The first cycle
which takes place in the mosquito is called the
sexual cycle, while that which takes place in the
human being is called the asexual cycle. You will
now examine each transmission cycle starting Sexual Cycle
with the asexual cycle.
The sexual cycle of the malaria parasite takes
Asexual Cycle place in the body of the female anopheles
mosquito. This cycle begins when the feeding
The asexual cycle of transmission takes place in mosquito sucks blood containing the male and
the body of the infected human being and starts female gametocytes. In the stomach of the
when the infected female anopheles mosquito mosquito, the male gametocytes mate with the
bites a person. female gametocytes. The fertilised gametocyte is
called the ookinete (6). The ookinete stays in the
Upon biting humans, the infected female mosquito stomach of a mosquito for about 12 - 18 hours
injects sporozoites via its proboscis into the blood after which it penetrates the stomach wall.
stream (1). The sporozoites circulate in the blood
for about one hour and then they enter the liver Upon reaching the outer surface of the stomach
cells (2). In 10 - 14 days the sporozoites develop wall, the ookinete changes into an oocyst (7). The
into liver schizonts while still in the liver (3). The oocysts grow rapidly and burst releasing large
liver schizonts later burst releasing large numbers numbers of sporozoites into the body cavity of the
of merozoites. The merozoites leave the liver and mosquito. Many of the sporozoites move to the
enter the blood stream (4) where they penetrate salivary glands of the mosquito (8) from where
the red blood cells. they are injected into the body of the next human
being when the mosquito feeds.
Inside the red blood cells, the merozoites develop
into trophozoites. The trophozoites then develop Clinical Features of Malaria
into erythrocytic schizonts.
The incubation period of malaria is about 10 - 14
These erythrocytic schizonts burst releasing a days after the infection. The symptoms appear
shower of merozoites, which invade fresh once the invaded erythrocytes rupture to release
erythrocytes (5). Some of the released new merozoites. This stimulates the body's
erythrocytic merozoites form male and female immune system and the signs and symptoms of
gametocytes, which are sucked by the feeding malaria then appear:
mosquito.
 Headache and dizziness
 Joint pains
 Backache
 Fever and chills (high body temperature,
rigors)
 Nausea and vomiting
 Diarrhoea

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  Excessive sweating Liver Malarial hepatitis with hepatomegaly and
 Jaundice jaundice.
 Enlargement of spleen Shock Development of a shock syndrome
 Convulsions probably caused by the amount of toxins
 Anaemia produced (toxic shock).
Kidney Acute tubular necrosis due to anoxia.
Result: anuria with consequent uraemia.
A typical attack of malaria progresses through
Spleen The normal function of the spleen is to
the following three stages: take away old and abnormal erythrocytes. Due to
the infection the spleen has to absorb a huge
The Cold Stage number of cells and increases in size. Therefore,
splenic enlargement is a common finding in acute
This stage starts suddenly and lasts for fifteen malaria.
minutes to one hour. The patient's body
temperature rises and they shiver. During this Diagnosis of Malaria
stage, the infected erythrocytes rupture releasing
merozoites in the blood circulation. Diagnosis is made through:

The Hot Stage  Clinical symptoms

 Laboratory examination of thick and thin
The hot stage last for two to six hours. The body peripheral blood films/slides (smears)
temperature is high (40 - 41°C) with severe which demonstrate the parasites
headache, nausea and vomiting. The skin is hot (Trophozoites)
and dry.
Management of Malaria
The Sweating Stage
The treatment of malaria depends on whether the
The fever drops rapidly and the patient sweats disease is complicated malaria or uncomplicated
profusely. This stage last for two to four hours. malaria (severe malaria). Uncomplicated malaria
is usually treated on an outpatient basis.
Complications of Malaria
Treatment of Uncomplicated Malaria
Severe malaria can cause serious complications
and is life threatening. Dosage of tablets of sulfadoxine (500mg) plus
pyramethamine (25mg) and paracetamol for all
Brain Mental disturbance appearing as acute age groups.
psychosis, meningitis-like symptoms and coma.

Patients presenting with coma, convulsions,

respiratory distress, acute renal failure, jaundice,
shock, hypoglycaemia, or acidosis due to malaria
should be admitted into the ward for complicated
malaria.

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Treatment of Complicated Malaria

second and last dose of three tablets of SP is

Adapted from the National guidelines for given between 24 and 36 weeks of gestation.
diagnosis, treatment and prevention of malaria for (MoH, 2002)
health workers, MoH, January 1998.
Vector Control
Intravenous quinine in dextrose is used in severe
complicated Malaria where the patient presents Actions to reduce mosquito-breeding areas
with vomiting and coma. include:

Remember: The treatment of malaria keeps  Using insecticide-treated bed nets

changing depending on current research  Using mosquito screens in houses
findings. Please check on the current  Using chemical mosquito repellents
treatment and adjust your notes accordingly.
 Cleaning drainages and water disposal
systems
 Clearing bushes and burying or burning
Prevention and Control of Malaria
rubbish heaps
Chemoprophylaxis  Use of larvicides and insecticides

Health education
Antimalarial chemoprophylaxis using oral
proguanil (PaludrineR) may be given according to
the national guidelines for diagnosis, treatment You should encourage community members to
and prevention of malaria for health workers. seek early diagnosis and prompt treatment for
Individuals who will benefit from malaria and to use insecticide treated bed nets
chemoprophylaxis include: every night.

 Patients with leukaemia

(lowered immunity) Filariasis (Elephantiasis)
 Patients with sickle cell disease
 Patients with tropical splenomegally This is a disfiguring disease caused by a tiny
 Non-immune visitors to malaria-endemic worm (nematode) called wuchereria bancrofti. It is
mainly transmitted by mosquitoes; the culex
areas
quinquefasciatus found in heavily contaminated
water especially in the urban areas and the culex
Intermittent Preventive Treatment (IPT) pipiens and the anopheles mosquito in rural
areas. These mosquitoes transmit the worm from
IPT is based on the assumption that the pregnant person to person in the same way as malaria. The
woman is infected with malaria. According to the parasitic worm lives in the lymphatic system of the
Ministry of Health (MoH) guidelines, the drugs patient causing inflammation of the lymphatic
used for IPT are the ones that contain Sulfadoxine vessels and lymph glands (lymphangitis,
and Pyrimethamine (SP) such as FansidarR, lymphadenitis), filarial fever, and eventually
MalaraxinR, FansidinR, MetakelfinR, OrodarR, elephantiasis of the arms, legs and genitals. The
and FalcidinR. The first single dose of three disease is most frequent in the tropical coastal
tablets of SP is given to the pregnant woman belts and the lake region.
between 16 and 24 weeks of gestation; the

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Mode of Transmission where they moult twice and develop into the
infective stage.
The microfilariae ingested by the feeding
mosquito exsheath in the stomach and become Mature infective microfilariae migrate to the
first stage larva. They then penetrate the mosquito mouthparts of the mosquito. The extrinsic
stomach wall and migrate to the thorax muscles incubation period takes 10 -12 days.

Clinical Features Chronic Phase

The presence of mature filarial worms in the  Lymphoedema

lymphatic vessels triggers an inflammatory  Elephantiasis
reaction in the walls of these vessels. When the  Chyluria
worms die, more foreign proteins are released  Hydrocele
causing calcification of the lymphatic walls which
eventually leads to obstruction of the flow of Diagnosis
lymph fluid. If the obstruction of the lymph flow is
extensive, chronic oedema develops in the
affected areas of the body. Filariasis progresses  Fluid aspirated from swollen lymph glands
through three stages. or from hydrocele can be examined under
a microscope to show the microfilariae.
Acute Phase  Thick blood slides for microfilariae should
be taken between 10:00pm and 2:00am.
This is because microfilariae are not
 Fever present in the peripheral blood during the
 Eosinophilia day.
 Enlarged lymph nodes  Blood slides for microfilariae may be
 Inflamed lymph vessels (lymphangitis) taken 45 minutes after administration of a
provocative dose of diethylcarbamazine
Sub Acute Phase 100mg.

 Fever Management
 Eosinophilia (severe)
 Attacks of dyspnoea (asthma-like) The drug of choice for filariasis (adult worms and
 Funiculitis (pain and swelling of the microfilariae) is diethylcarbamazine (DEC,
spermatic cord/s) hetrazan, benocide, notezine) 6mg/kg body
 Epididymitis weight daily in divided doses (150mg) eight hourly
 Hydrocele for 12 days for an adult. Diethylcarbamazine may
 Lymphadenitis (tender lymph nodes) be combined with levamisole. This combination
kills microfilariae and reduces the parasite worm
count in the body more rapidly.

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Prevention and Control  Nausea and vomiting
 A bleeding tendency (epistaxis, bleeding
The prevention and control of filiariasis includes: gums, haematemesis, malaena)
 Liver cell necrosis (in severe illness)
 Anti-mosquito measures; the same as resulting in jaundice
those used for control and prevention of  Nephritis leading to albuminuria which
malaria may proceed to anuria and renal failure
 Use of larvicides such as polystyrene
powder in the pit latrine
 Reduction of human-mosquito contact
including the use of insecticide treated Management
bed nets and screening of houses
Yellow fever like most other viral haemorrhagic
Yellow Fever diseases has no specific drug for treatment. You
only give supportive treatment and ensure that the
Yellow fever is an acute viral disease transmitted patient is nursed in strict isolation using ordinary
to human being by the aedes aegypti mosquito. barrier nursing techniques. You also ensure that
the patient has no further contact with the
Yellow fever can spread rapidly, and case fatality
mosquitoes through the use of insecticide treated
rate may reach as high as 30% in non-immune bed nets and ensuring that the room is well
populations. Yellow fever is a disease of forest screened. This is to prevent further spread of the
monkeys (zoonoses) and is transmitted among disease from the patient to other healthy people.
them by the aedes africanus mosquito. Humans
may be bitten outside the forest by mosquitoes Prevention and Control
which have acquired the disease from monkeys
feeding on bananas and other agricultural  Administering yellow fever vaccine to all
plantations. In urban areas, yellow fever is travellers coming from or going to yellow
transmitted by the aedes aegypti. Yellow fever is a fever endemic areas.
 Spraying aircraft coming in from yellow
disease of tropical African countries, especially in
fever endemic
the rain forests.
areas with insecticides to kill imported
mosquitoes, which may be infected.
Mode of Transmission
 Isolating all persons who have been in
contact with the infected persons. Such
The mosquito becomes infected after feeding on individuals should be quarantined in
the blood of an infected monkey or person on the screened houses for seven days.
third day of fever. The incubation period takes 18  Mass immunisation campaign for the
days at a daily temperature of 18°C and four days community in areas infested with the
at 37°C. The cycle takes four days and once aedes aegypti mosquito.
infected, the mosquito remains infected and  Spraying of larvicides in all possible
infective for its entire life (about two to four mosquito breeding places including water
months). holding plants.

A person may also become infected with yellow Trypanosomiasis (Sleeping Sickness)
fever through handling of blood from an infected
individual in the first three days of the disease or Trypanosomiasis is a tropical disease caused by
handling infected monkeys in the early stages of protozoa called Trypanosoma brucei gambiense
viraemia. Laboratory staff may become infected (Tbg) and Trypanosoma brucei rhodesiense (Tbr).
when working on infected monkeys or infected The important reservoir of Tbr in the wild is the
mosquitoes. bushbuck. Trypanosomiasis affects both humans
and cattle and is invariably fatal over varying
Clinical Picture periods of time if not treated. Trypanosoma brucei
gambiense causes an acute, rapidly progressive
The onset is sudden with the following signs and illness with death from cardiac complications
symptoms: within several weeks or months. Reservoirs
include antelope and pigs. Tbr is found in eastern
 Fever Africa, now mostly in south-east Uganda.
 Headache
 Backache

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Trypanasomiasis spreads very rapidly unless the Clinical Features
source (the very first case) is identified early,
isolated and treated properly. Trypanasomiasis is There is considerable variation in the clinical
found in the same areas in Africa where yellow picture of African trypanosomiasis (AT). Within a
fever is found. few days of a tsetse bite, fever develops due to
the invasion of the blood stream by the
Mode of Transmission trypanosomes. The incubation period between the
tsetse bite and the onset of fever varies from as
Trypanosomiasis is transmitted by tsetse flies short as a few hours following the chancre to
which live in areas of wooded vegetation. Tsetse several weeks. The early stages of
flies are usually not found in flat plains, closely trypanosomiasis are characterised by irregular
cultivated areas or areas densely inhabited by episodes of fever with headaches, malaise, weight
people. There are two important types of tsetse loss, muscle and joint pains, pruritus, anaemia,
flies known to transmit the disease to humans. skin rash, and deep hyperaesthesia (Karandel‟s
There is glossina palpalis, a riverine type which sign).
breeds along rivers and lakes, and glossina
morsitans the woodland type which lives away The clinical features of trypanosomiasis depend
from water. glossina palpalis is the main vector of on the infecting parasite as follows:
Tb gambiense, while glossina morsitans is the
main vector for Tb rhodesiense and it prefers to  Trypanosoma brucei gambiense (Tbg)
bite cattle and game but will also bite humans. Of infection causes a slow chronic sleeping
the two types of tsetse flies, glossina palpalis sickness, resulting in death from the
(which transmit Tb gambiense parasite) is the disease in several months or years. Pigs,
main vector in East Africa. dogs and antelopes are the reservoirs.
 Trypanosoma brucei rhodesiense (Tbr)
Tsetse flies become infected with sleeping infection is acute and rapidly progressive
sickness parasites when they take a blood meal unless prompt treatment is administered.
from infected persons or animals. After a period of The parasites damage the heart causing
time, during which the trypanosomes undergo cardiac complications and death within
development changes, the fly is able to transmit several weeks or months. Pigs and
the infection when it bites another susceptible antelopes are the reservoirs for Tb
animal or person. rhodesiense.

Clinical Features

Trypanosomiasis presents in the following three

stages:

Primary Stage (chancre stage)

Within a few days of the tsetse bite, a painful

indurated erythematous nodule may appear at the
site of the bite. This chancre may last for one to
two weeks and then resolve spontaneously. The
chancre occurs in 70% of cases in Europeans but
is rare in Africans.

Blood Stage (systemic illness)

During this stage, the trypanosomes spread to the

blood, lymph and lymph nodes. There is fever,
which does not follow any typical pattern but
recurs at intervals of days or weeks. After the
fever resolves, the patient develops anaemia,
debilitation and general body weakness. The
spleen becomes enlarged as well as the lymph
nodes. The cervical lymph nodes especially of the
lower back of neck become visibly enlarged in
80% of patients - this is called Winterbottom's

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sign. The other signs and symptoms of Management
trypanosomiasis include:
Late stage
 Pruritic rash (beginning six to eight weeks
after infection) 1) IV melarsoprol (3.6% mel-B; arsobal) in
 Hepatosplenomegaly propylene glycol for three consecutive days per
 Poor appetite resulting in weight loss, week for four weeks as follows:
debility, pitting oedema of face and lower
legs Day 1 Day 2 Day 3 Week 2 Week 3 Week 4
 Impotence and menstrual irregularities 0.5ml 1.0ml 1.0ml 2.5ml* 3.5ml* 5.0ml*
 Heart failure *daily for 3 days

Cerebral Stage (Sleeping sickness stage)

2) IV difluoromethyl ornithine (eflornithine) 200 -
400mg per kg body weight daily for four weeks.
This is the terminal stage of trypanosomiasis.
This is for the treatment of cerebral Tb gambiense
During this stage of the disease, the parasites
invade the brain leading to mental deterioration infection.
and coma. Convulsions and localised signs such
as hemiplegia and facial palsy may occur. 3) Oral nitrofurazone (nifurtimox) 10mg/kg eight
Patients are very weak, they sleep during the day hourly daily for ten days for those cases resistant
but are restless at night. As the disease to mel-B.
progresses, the patients become severely ill and
die if not treated. Common Side Effects of Trypanosomiasis
Drugs
Diagnosis
Remember: The drugs used for the treatment
 Microscopic examination of the chancre of trypanosomes are highly toxic. As such the
fluid to demonstrate the trypanosomes patient should be monitored carefully and the
 Examination of blood (buffy coat) for drugs administered very carefully.
trypanosomes
 Wet blood smear for microscopy
 Thick blood smear for microscopy
 Serological test (card agglutination test)
 Lymph node aspiration (microscopy)

those working in endemic bush land areas

Prevention and Control such as wildlife personnel.
 Bush clearing (which may harm the
The following measures are effective in the environment) and establishment of
prevention and control of sleeping sickness. agricultural settlement will in the long run
destroy tsetse fly breeding areas.
 Chemoprophylaxis; IM pentamidine  Use of baited flytraps which have an
250mg single dose protects against Tb efficacy of 95% at reducing the tsetse fly
gambiense infection for six months in population.

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Schistosomiasis S. mansoni is spread in infected stool while S.
haematobium is spread in infected urine. When
This disease is commonly known as Bilharzia the schistosome eggs in the urine enter a body of
after Theodor Bilharz who discovered it in Cairo in water such as a lake, dam, rice paddy or pond,
1861. The incidence of schistosomiasis is related they hatch into free-swimming larvae called
to water use. Irrigation schemes or water projects miracidia. The intermediate host for S. mansoni is
for electricity provide the habitat for the snail a vector snail of the genus biomphalaria pfeifferi;
vectors. Up to 75% of schistosomiasis is while for the S. haematobium it is bulinus
transmitted by infected humans while 25% is said africanus. The miracidia, after being shed from the
to be transmitted by dogs, cows, rats, and ovum, must enter the appropriate snail host within
baboons. In East Africa, there are two types of 24 hours or die.
schistosomiasis, both of which are named after
the causative parasite. They are schistosoma Transmission Cycle of Schistosomiasis
mansoni and schistosoma haematobium.
Inside the body of the snail host, it takes the
miracidia four to seven days to develop and
Schistosoma Mansoni
multiply into numerous infective cercariae.

This infection is caused by schistosoma mansoni. The snail sheds them in water where they can
The human being is the natural host of this type. only live for 48 hours unless they infect a human.
The disease affects the liver (leading to portal A human being becomes infected when they enter
hypertension) and the walls of the large bowel, cercariae-infested water, such as when bathing,
where it causes polyps and haemorrhage swimming, laundering, cultivating or fishing.
(malaena) leading to severe anaemia.
The cercariae penetrate the skin and enter the
Schistosomiasis Haematobium bloodstream from where they are carried to the
liver or bladder to develop into adult worms.
Schistosoma haematobium lives in the walls of Within four to six weeks, paired adults reach
the urinary bladder causing terminal haematuria, mesenteric and pelvic veins.
frequent micturition, and fibrosis or calcification of
the bladder wall.

Mode of Transmission

Invasion Stage

Clinical Features When the cercariae penetrate the skin of a

person, its tail falls off and the head enters the
Schistosomiasis as a disease develops in four bloodstream. The entry provokes a local
stages, each of which is characterised by specific inflammatory reaction characterised by pruritis.
signs and symptoms.

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Maturation Stage Effects of Late Stage Schistosomiasis
 Obstruction to and dilation of
When cercariae reach the liver (S. mansoni), they ureters leading to
mature into adult worms. This stage is associated hydronephrosis which may
with Katayama syndrome in which the patient has cause kidney failure
fever, abdominal pain, eosinophilia, and transient Urinary  Pyelonephritis
Bladder:
generalised urticaria. After maturing, the adult  Bladder polyps
worms migrate through the portal vein to the  Calcification of bladder
mesenteric veins of the colon, where they pair,  Cancer of bladder
conjugate and begin laying eggs for the rest of
their life. The same happens to S. haematobium
in the venous  Portal vein fibrosis leading to
plexuses of the urinary bladder. portal hypertension
 Portal hypertension leading to
Established Infection oesophageal varices which
Liver: may cause massive
haematemesis
The eggs are laid near the surface of the colon in
the case of S. mansoni and the bladder wall in the  Caput medusae and ascites
case of S. haematobium.  Hepatomegally
Most of the eggs laid penetrate the wall and enter
the lumens of the colon or bladder and are passed  Pulmonary fibrosis leading to
out of the body through urine or stool. Some of pulmonary hypertension,
those that do not penetrate the wall are carried in Lungs: causing congestive heart
the blood stream to the liver (S. mansoni) and to failure
the lungs (S. haematobium).
 Bowel fibrosis and glanulomas
The rest of the eggs which remain on site are
 Gastric varices
trapped within the walls of the colon and the Bowel:
bladder where they provoke inflammatory  Haemorrhoids
reactions, which result in the formation of
granulomas. It is this inflammatory reaction that
causes the early signs and symptoms of
schistomiasis, that is, colitis and cramps for S Diagnosis
mansoni and terminal haematuria and dysuria for
S. haematobium. The diagnosis of schistosomiasis is confirmed by
finding eggs in stools or urine during a
Late Stage microscopic examination. If this test is found to be
negative, a colonic or urinary bladder biopsy can
As the adult schistosomes continue to lay eggs, be done. Serological tests are also highly
large numbers of eggs get trapped in the tissues sensitive and yield specific results.
causing fibrosis and calcification.
Management

The main aim of treatment is to kill the adult

worms and to stop their egg-laying activity.

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Drugs Used in the Oral Treatment
of Schistosomiasis

 Phlebotomus longipes
Prevention and Control  Phlebotomus pedifer

The prevention of schistosomiasis can be In Kenya, the main vectors are phlebotomus
achieved through the following measures: martini which transmit the parasite leishmania
donovani, responsible for visceral leishmaniasis.
 Prevention of ova-containing urine and The species P. orientalis is common in Sudan
stool from reaching the water by: while P. longipes and P. pedifer are commonly
- Digging and using pit latrines found in Ethiopian and Kenyan highlands.
- Safe water supply Together they transmit the parasite leishmania
- Treating the infected persons aethiopica which is responsible for cutaneous
 Attacking the intermediate host (the snail)
using molluscicides such as copper
sulphate which kills snails and their eggs.
 Avoiding contact with infested water by
using protective clothing when laundering,
cultivating, swimming and wading.
Bathing should be done at home (storing
water at home for three days will kill the
cercariae).
 Conducting mass treatment campaigns
for communities at risk using oral
praziquantel, especially school-going
children. Mode of Transmission

Leishmaniasis (Kala Azar) The zoonotic hosts of leishmaniasis are mainly

This is an infection caused by a parasite of the dogs and rodents, although in some parts of
leishmania group. The disease is also known as Kenya humans have become the reservoir as well
Kala Azar. There are three forms of leishmaniasis as host. The parasites of leishmaniasis are
which are caused by different parasites. transmitted when the sandfly bites an infected
person and ingests amastigotes. On reaching the
The vector of leishmaniasis is the female sandfly sandfly‟s stomach, the amastigotes change into
(phlebotomus). The four types of sand flies are: promastigotes. After four to seven days, they
migrate to the foregut where they develop into
 Phlebotomus martini infective promastigotes. The infective
 Phlebotomus orientalis

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promastigotes are then conveyed in the saliva of P. pedifer are the vectors. Phlebotomus longipes
the sandfly during feeding. bites human beings in their houses at night
transmitting the parasite leishmania aethiopica,
During feeding, the sandfly tears the host‟s tissue which is responsible for cutaneous leishmaniasis.
to feed on blood and at the same time deposits
infective promastigotes at that site. From here the Clinical Picture of Cutaneous Leishmaniasis
promastigotes enter the bloodstream and into the
macrophages. On entering the macrophages, the In about two to eight weeks following a bite from
parasites escape detection by the body‟s an infected sand fly, a small itchy papule appears
defences and are spread to various body tissues. at the site of the bite. Over several weeks, the
papule grows in size expanding to form a single
Visceral Leishmaniasis indolent ulcer or multiple ulcers. The disease may
be mistaken for leprosy. There may be
Visceral leishmaniasis is found in many areas of enlargement of the local lymph nodes. The lesions
the North Eastern region of Kenya in Machakos, begin to heal spontaneously two to twelve months
Kitui, Masinga, Tseikuru (Mwingi), Makueni, later. Cutaneous leishmaniasis does not spread to
Kibwezi, and Wajir. other body organs.

Clinical Features of Visceral Leishmaniasis Management of Cutaneous Leishmaniasis

Visceral leishmaniasis is characterised by fever, Small lesions may be treated surgically by

splenomegaliy, hepatomegally accompanied by curettage or by freezing, using liquid carbon
anaemia and weight loss. Visceral leishmaniasis dioxide or by infiltrating them with 1 - 2ml sodium
has a rather long incubation period of four to ten stibogluconate. Large disfiguring or multiple skin
months or longer, before definitive signs and lesions are treated in the same way as for visceral
symptoms manifest. Most of the patients (96%) leishmaniasis using IV or IM sodium
are killed by secondary bacterial infections of the stibogluconate 20mg/kg daily for 20 - 30 days.
lesions. The drug of choice for visceral leishmaniasis
caused by leishmania aethiopica is IM
Diagnosis of Visceral Leishmaniasis pentamidine isothianate 3 - 4mg/kg once or twice
a week.
The diagnosis is made by finding the parasites in
Mucocutaneous Leishmaniasis
stained smears obtained from splenic puncture or
by the formal gel test.
This form of leishmaniasis occurs primarily in the
tropics of South America. The disease begins with
Treatment of Visceral Leishmaniasis
the same sores noted in localised cutaneous
leishmaniasis. Sometimes these primary lesions
Either one of the following drugs are effective in heal, other times they spread and become larger.
the treatment of visceral leishmaniasis: Some years after the first lesion is noted (and
sometimes several years after that lesion has
 IV or IM sodium stibogluconate 20mg/kg totally healed), new lesions appear in the mouth
daily for 20 - 30 days (dose is reduced if and nose, and occasionally in the area between
not well tolerated by patient). the genitalia and the anus (the perineum). These
 IM pentamidine isothianate 3 - 4mg/kg new lesions are particularly destructive and
one to two times per week for patients painful. They erode underlying tissue and
who fail to respond to cartilage, frequently eating through the septum
sodium stibogluconate. (the cartilage which separates the two nostrils). If
the lesions spread to the roof of the mouth and
Cutaneous Leishmaniasis the larynx (the part of the wind pipe which
contains the vocal cords), they may prevent
speech. Other symptoms include fever, weight
Cutaneous leishmaniasis is found in West Pokot,
Turkana, Baringo, Laikipia and Kerio valley. It is loss, anaemia (low red blood cell count). There is
characterised by single or several painful chronic always a large danger of bacteria infecting the
ulcers in those parts of the body exposed to already open sores.
sandfly bites, such as arms, legs or face. In the
lower hotter areas of Kenya such as Baringo, the Treatment is similar to that of cutaneous
vector is the P. orientalis, while in the highlands of leishmaniasis. Prevention or early detection and
Kenya, the high altitude sandflies, P. longipes and

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appropriate treatment are preferred. Corrective
surgery can be done where need arises.

Prevention and Control

Kala Azar can be prevented through:

 Use of insecticide treated curtains in

homes (these have been used with
success in Baringo district)
 Destruction of infected dogs and rodents
 Early diagnosis and treatment of the
infected persons
 Health education for communities on
preventive measures

Plague

This is a highly infectious disease caused by

bacteria called yersinia pestis. Plague is a disease
of rodents, especially rats and is spread from rat Clinical Picture
to rat by a rat flea called xenopsylla cheopis.
Plague is a very rare but serious disease because
it can spread very rapidly unless the first case is Plague has three clinical presentations, bubonic,
recognised early and appropriate action taken. It septicaemic and pneumonic.
is also a serious disease with a high mortality rate
(case fatality rate in the absence of treatment can Bubonic Plague
be as high as 60%).
Bubonic plague is characterised by swelling of the
Mode of Transmission lymph glands (bubo) which appears 24 hours after
the bite. The patient presents with rigors, high
Plague occurs when infected wild rats, especially fever, dry skin and severe headache
the sewer rat (R. norvegicus) die from the disease accompanied by pain and swelling of the lymph
and their fleas look for substitute domestic rat nodes at or near the site of the fleabite. The groin
(rattus italia) hosts. The domestic rat becomes is the common site for buboes. Many of the
infected and after it dies the fleas start biting patients with bubonic plague develop septicaemia
human beings. When the first human is infected, (toxaemia) in which there is a rapid pulse,
the disease causes bubonic plague. People hypotension, mental confusion
working in the fields may also be bitten by fleas and splenomegaly.
from the dead infected wild rats and develop
bubonic plague. Septicaemic Plague

Some infected persons do not develop the bubo;

instead these patients develop septicaemia and
their condition usually deteriorates rapidly. The
patient is prostrated, febrile, weak, pale and
apathetic. Stupor coma and death may follow on
the first, second or third day. In the septicaemic
stage, the bacilli are spread everywhere in the
organs, including the lungs and brain.
Septicaemic plague is highly contagious. The
patients may cough and spread the bacilli to
attendants who then develop the pneumonic type
of plague. The bloodstained sputum obtained from
a coughing patient contains the bacillus yersinia
pestis.

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Pneumonic Plague  Isolation of the infected and quarantine of
the contacts for ten days
Pneumonic plague is an advance stage of either  Use of insecticides to kill fleas
bubonic or septicaemic plague. It mostly affects  Eradication of rats, for example using rat
people who attend to patients with septicaemic poison
plague, such as relatives, visitors and caregivers;  Vaccination during epidemics using an
through inhalation of the bacilli. Pneumonic anti-plague vaccine
plague is characterised by very sudden onset of  Health education for communities on
cough with dyspnoea, rigors, intense headache, preventive measures
body aches, cyanosis and prostration. The patient
coughs copious bloodstained frothy highly Relapsing Fever
infective sputum.
This is an acute infectious bacterial disease which
Diagnosis is characterised by alternating febrile periods. It is
also known as Recurrent fever, Spirillum, Tick
The diagnosis of plague can be confirmed by fever, or Tick Bite fever. It is transmitted by ticks
doing a microscopy (staining) of sputum or pus and lice. There are two types of relapsing fever,
from the bubo to demonstrate the bacilli. namely:

Remember: Plague is an internationally  Louse-borne relapsing fever

notifiable disease.  Tick-borne relapsing fever

Management The louse-borne relapsing fever is spread by the

human head louse, pediculus capitis, and the
You must start treatment as soon as you confirm body louse, pediculus corporis. They transmit
the diagnosis from clinical and laboratory findings. spirochaetes of the genus borrelia reccurentis.
The plague bacillus (Yersinia pestis) is sensitive The tick-borne relapsing fever is transmitted by
to most common antibiotics except penicillin. Drug soft ticks (ornithodoros moubata) which live in
treatment with any of the following antibiotics is cracks and crevices of walls and floors. They
effective: transmit spirochaetes of the genus borrelia
duttoni, which cause tick-borne relapsing fever.
 IM streptomycin 30mg/kg two to four Children, visitors and pregnant women travelling
times daily for ten days to endemic areas are more susceptible to the
 Oral or IV tetracycline 10mg/kg six hourly disease. Adults in endemic areas are semi-
for ten days immune to relapsing fever.
 Oral cotrimoxazole two tabs twelve hourly
for seven days Mode of Transmission
 Oral chloramphenicol 500mg six hourly
for seven days The disease is transmitted from person to person
by the bite of the head louse, body louse or soft
Remember: Early recognition of plague tick.
followed by correct action is a matter of life or
death. Louse-borne

The human louse transmits louse-borne relapsing

Prevention and Control fever from person to person. When the louse
feeds on the blood of an infected person, it takes
The prevention and control of plague depends on up the bacteria. The bacteria multiply within the
the following measures: body of the louse (but these spirochaete are not
found in the saliva or the excreta of the louse).
The infection is transmitted to another person only
 Early diagnosis and notification so that
when the louse is crushed on the body surface
the patients are not moved or referred to
near a bite wound. The offspring of an infected
the hospital
louse does not carry the spirochaetes. Epidemics
 Chemoprophylaxis of all contacts of the of louse-borne relapsing fever are associated with
patients such as family, visitors and times of war and famine when refugees are
health care workers using tetracycline crowded together in unsanitary conditions, which
or cotrimoxazole promote infestation with human body lice.

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Tick-borne collapse. This reaction is characterised by chills,
rapid breathing, elevated temperature (40 –
Tick-borne relapsing fever is transmitted when a 42°C), confusion, delirium, and sometimes
tick sucks blood from an infected person. The convulsions and coma. The patient then develops
spirochaetes are taken up and multiply in the tick's very severe hypotension, and may go into heart
body. In seven days, the spirochaetes appear in failure. This complication is however not seen in
the tick's salivary glands and the coxal fluid ready tick-borne infections. Patients must be nursed flat,
to be transmitted to a new host. The organisms given adequate fluids and be confined to bed for
can either be injected directly when the tick feeds at least 24 hours.
on the host, or they can
infect a new host by penetrating intact mucous The treatment of relapsing fever is IM procaine
membranes (for example in laboratory infections). penicillin 400,000 units stat, followed the next day
by oral tetracycline 500mg six hourly for five to
Unlike in louse-borne fever where the offspring seven days. An alternative to tetracycline is oral
does not carry the organism, in tick-borne fever doxycyline 200mg once (single dose).
the borrelia duttoni organisms pass into the ovary
of the tick, thus automatically infecting the Remember: Tetracycline should not be given
offspring of the ticks (vertical transmission). In this to children and pregnant women because it
way, a house once inhabited by infected ticks will discolours the teeth permanently and also
remain dangerous for up to ten years. In an causes premature calcification of bones.
infected pregnant woman, the spirochaete can
cross the placenta to the foetus resulting either in
abortion, stillbirth, premature delivery, or Prevention and Control
congenital infection in the newborn.
Louse-borne
Clinical Features
To eradicate lice you should advise the patient to
The patient presents with sudden onset of fever do the following:
which ranges between 39.5°C - 40.5°C. There is
rapid pulse, headache, aching joints, vomiting and  Improve their personal hygiene
infected conjunctiva. Often there is potential rash,  Use insecticides to kill lice, for example
epistaxis, and herpes labialis. After five to seven malathion powder
days, the temperature drops by crisis. In about  Boil clothes to kill lice and eggs
60% of the patients, a less severe relapse of the (delousing)
symptoms occurs five to ten days after the first
attack. A second relapse may occur in about 25% Tick-borne
of the patients. In untreated cases, there may be
up to ten relapses. The fever and clinical
symptoms become less severe each time after the Similarly to eradicate ticks, the patient should
relapse. Relapsing fever has a high mortality rate apply the following measures:
of 40%. Common complications of relapsing fever
include meningitis, iritis, optic nerve atrophy  Improve the housing condition by applying
(blindness), myocarditis and liver failure bleeding. plaster over the mud walls to seal cracks
where ticks hide
Diagnosis  Use corrugated iron sheet roofs to
eliminate grass-thatched roofs which
provide hiding places for ticks
You can confirm relapsing fever by doing a
microscopic examination of a thick blood smear  Spray insecticide (for example using
for the spirochaetes. gammexane) on the floors and walls of
the mud houses
 Avoid sleeping on the floor of mud houses
Management
Onchocerciasis
Treatment should eradicate the spirochaete from
the body without eliciting Jarisch-Herxheimer
reaction. Some deaths occur after starting Onchocerciasis is a chronic disease caused by a
treatment as a result of a severe Jarisch- filarial worm called onchocerca volvulus. It lives in
Herxheimer reaction. The antibiotics suddenly kill the subcutaneous and connective tissue of the
a large number of spirochaetes which release infected person. It manifests mainly as skin
toxins into the circulation causing the patient to nodules on bony surfaces, and causes eye
lesions which result in blindness. That is why it is

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also known as river blindness. The vector for O.
volvulus is the female black fly of the genus
simulium. In western African countries where the
disease is more prevalent, the vector is simulium
damnosum, while in East Africa the vector is
simulium neavei. The disease is found in western
Uganda, southern Sudan, and eastern Democratic
Republic of the Congo (DRC). Blackflies are able
to travel up to 80km in a day.

The simulium fly breeds in fast running well

aerated rivers or turbulent areas of a river such as
at the waterfalls and rapids. The eggs of the
simulium fly are able to develop into larvae only in
water that is rich in oxygen, such as fast flowing
rivers. Larvae are attached to submerged plants,
rocks and living crabs. The female O. volvulus
worm is only about 0.3mm in diameter but can be
as long as half a meter (50cm) long. The male is
about 0.2mm in diameter and 4 - 13cm long.

Mode of Transmission Clinical Features

River blindness is spread from person to person After the adult O. volvulus has lived in the body of
by the bite of an infected blackfly. Black flies feed an infected person for about one year, it begins to
during the day both inside and outside houses. give birth to microfilariae. One adult female worm
They usually bite early in the morning or late in can produce up to one million microfilariae every
the evening. year. The microfilariae of O.volvulus have a strong
liking for the skin and eyes of the infected host.
The blackfly takes up microfilariae when it sucks Adult worms live up to 17 years in nodules in the
the blood of an infected person. Once in the subcutaneous and connective tissue. Most
stomach, the microfilariae penetrate the stomach nodules are found on the bony skin surface such
wall and travel to the thoracic muscles where they as the elbow, skull, ribs, iliac, crests, and shoulder
develop further for about seven days. They then scapula. The disease has four different clinical
move to the head of the fly ready to be transmitted presentations:
to the next susceptible person when the fly feeds.
Severe Itching
When the fly bites again, it injects the larvae of O.
volvulus into the skin of the healthy host. The This is one of the early symptoms and mainly
larvae mature in the human subcutaneous tissue affects the buttocks. The severe itching is often
into adult worms in about one to three years. accompanied by skin depigmentation giving rise
to a „leopard skin‟.

Skin Nodules

These are caused by the adult worms which

you saw earlier like to live in the skin. They
contain adult worms and are painless, rubbery,
and firm; ranging in diameter from 3mm - 3cm.

Dermatitis

This is caused by a reaction to the presence of

microfilariae in the epidermis and manifests as
itchy papules and macules. Later, the skin
becomes loose, scaly, atrophic and depigmented.

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Blindness  Mass treatment of communities using
ivermectine
This is caused by the presence of microfilariae in
the cornea and the anterior chamber of the eye. It SECTION 5: DISEASES CAUSED BY
starts with oedema of conjunctiva; then corneal
spots and a pannus begin to develop. Finally
FAECAL-ORAL CONTAMINATION
cataracts, iritis, sclerosing keratitis, and glaucoma
develop leading to blindness. You can Introduction
differentiate between trachoma and river Diseases caused by faecal-oral contamination are
blindness because in river blindness the pannus those whose causative organisms are excreted in
start at the lower limbus, while in trachoma it the stool of an infected person and then, by
affects the upper limbus. various ways, enter the mouth of a susceptible
person.
Diagnosis
Water that looks clean to the eye may be
The diagnosis is made by examining skin snips dangerously polluted. Contaminated food may
from the thighs, buttocks and iliac crests under a look, smell and taste delicious and yet harbour
microscope for microfilariae. dangerous organisms. Food and water transmits
diseases if contaminated by infected hands, soil,
flies, animals, animal products or polluted water.
Treatment
Flies transmit diseases by vomiting on food or by
carrying pathogens from faeces and transferring
Onchocerciasis is not a fatal disease. If the patient them to food. Indeed, most of the primary
has no serious complaints and is likely to be re- diarrhoeal diseases are caused by direct
infected, there is no urgency for treatment, since contamination of food or water by faeces, through
the traditional drugs used have been known to flies and fingers.
cause severe reactions. However, the following
groups of patients
By the end of this section you will be able to:
do need treatment:
 List eight common diseases spread by the
 Patient with eye lesions
faecal-oral route
 Patients with severe skin lesions  Describe the methods used to interrupt
 Patients with heavy infections the transmission cycle of faecal-oral
transmitted diseases
Two types of treatment are used in the  Describe the clinical features, of faecal-
management of this disease. The first one is to kill oral route transmitted diseases
the microfilariae. Give the patient oral  Describe the management of faecal-oral
Ivermectine (mectizan) 150 microgram/kg single route
dose repeated once every six to twelve months. transmitted diseases.
The second type of treatment is aimed at killing or
removing the adult worms by surgical resection
Now move on to look at the diseases one by one
of the nodules.
starting with enteric fevers.
Prevention and Control
Enteric Fevers
Enteric fevers include typhoid fever and
The following measures have been found to be
paratyphoid A and B fevers. Typhoid fever is an
useful in
infectious disease characterised by high
preventing onchocerciasis:
continuous fever, malaise and involvement of
lymphoid tissue and spleen. Diarrhoea is not a
 Addition of insecticide to the water of common symptom in typhoid fever.
rivers known to be breeding places of the
simulium fly
Paratyphoid fever may present like typhoid fever,
 Wearing of long clothing which covers but in most cases it presents as gastroenteritis or
most of the body transient diarrhoea. Both are mainly spread by the
 Moving the whole community away from faecal-oral route through contaminated food,
sites near where black flies breed water and milk. Flies are also important in the
 Treating infected people with transmission of enteric fevers.
microfilaricides

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Typhoid Fever Fourth Week
This is an infectious bacterial disease caused by
salmonella typhi. For the patients who do not suffer the serious
complications of the third week, the fourth week is
Typhoid fever is endemic in many regions of East a period of convalescence.
Africa, although epidemic outbreaks have
occurred when a source of water or food used by The temperature drops back to normal and the
many people has been contaminated. patient recovers gradually.

The disease has a case fatality rate of 3% with Diagnosis

treatment and 10% without adequate antibiotic
treatment. Human beings are the only known The best way to diagnose typhoid fever is through
reservoir and host. a blood culture. This may be positive during the
first week and for a variable period after this. Stool
Clinical Features and urine cultures can also be made although
they are only positive after the first week. Other
The incubation period of typhoid fever is 7 - 21 tests which are undertaken include:
days. The disease has a gradual onset which
progresses through the following four stages.  Widal test during the first and second
week, that is indicative of high and rising
First Week titres
 WBC count which indicates low levels
During the first week and early in the disease, the (leucopenia) with raised lymphocyte count
patient has severe headache, malaise, loss of  Stool to check for presence of occult
appetite, body pains and aches and a tendency to blood which is found in 100% of the cases
nose-bleed.
How reliable is the Widal test in typhoid
The body temperature rises day by day or in steps diagnosis?
to 39.5ºC or higher. Most patients cough because
they develop bronchitis and may also complain Although the Widal test is still very useful,
of constipation. especially when two tests are performed four to
five days apart after the end of the first week, its
Second Week interpretation is full of difficulties especially in
endemic areas and in people who have had the
In the second week, temperature continues to typhoid vaccine. That is why it is a good idea to
rise, but the pulse rate is slower than would be also carry out one of the other laboratory tests.
expected for that temperature. There is swelling of
lymphoid tissue in the intestines as well as Treatment
Peyer's patches, necrosis and ulcers, which cause
the abdomen to become distended and tender. The treatment of typhoid fever includes the
following:
The high temperature and toxaemia causes
mental confusion and disorientation in the patient.  Fluid replacement due to diarrhoea
Half the patients may develop greenish watery  Oral norfloxacin 400mg 12 hourly for 10 -
('pea-soup') diarrhoea and broncho-pneumonia. 14 days
 Oral ciproxacin 500mg bd. for 14 days
 Oral corticosteroids to prevent Jarisch-
Third Week Herxheimer's reaction
 Patient should be isolated in fly-proof
Body temperature decreases step by step and the room
patient improves slowly. If there is no  Contaminated articles should be disposed
improvement, the Peyer's patches in the intestines by incineration
perforate and toxaemia increases.  Stools and urine should be disposed of in
a pit latrine or septic tank
The patient becomes delirious and incontinent of  Surgical treatment for perforated bowels
urine and stool, muscles twitch and coma may
precede death. Note: When treatment is started early it is not
usually necessary to refer typhoid patients.

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Prevention and Control Cholera occurs in all parts of the world where the
living conditions are unsanitary.
The prevention and control of typhoid fever is
similar to that of many diarrhoea diseases. It The human being is the reservoir and host.
includes: Vibrios prefer brackish (salty) water. In seawater,
the organisms can live even longer multiplying in
 Identification of the carriers especially crabs and shrimps. Vibrios also multiply in certain
those who work as food handlers and foods such as milk and boiled rice.
treat them promptly
 Administration of typhoid vaccine What is the role and importance of carriers?
 Safe water supply
 Improvement in food hygiene The reservoir of infection in cholera is formed
mainly by the carriers. For every clinical case of
Paratyphoid Fever cholera there may be 50 - 100 asymptomatic
This is the second type of enteric fever which was carriers. Although the carriers excrete a smaller
mentioned earlier. It is caused by bacteria known number of vibrios than the patients, they form the
as salmonella paratyphi types A, B and C. The greatest danger to the community because of their
disease runs a milder course than typhoid fever
sheer number and freedom of movement.
and also has enlargement of the spleen,
bloodstained diarrhoea and swelling of the Peyer's
Clinical Features
patches.
Cholera has a short incubation period of two to
Treatment
three days. The vibrios remain in the digestive
tract from where they cause water loss and
The treatment of paratyphoid fever is as follows: electrolyte imbalance.

 Intravenous fluid if diarrhoea is severe What signs and symptoms would lead you to
 Oral rehydration if diarrhoea is mild suspect cholera?
 Oral contrimoxazole two tablets bd. for
five to seven days Unlike typhoid, cholera is not a systemic infection
and therefore fever is generally low or absent.
Prevention and Control Cholera progresses through the following three
stages.
The prevention and control measures are similar
to those that were covered under typhoid fever. First stage: This stage lasts for 3 - 12 hours.
During this stage profuse watery stool is passed
Cholera by the patient until faecal matter disappears. The
Cholera is an intestinal disease which is stool becomes almost clear fluid with flakes of
characterised by sudden onset of profuse watery mucus, giving it the classical rice-water stool
stools and vomiting, leading to severe appearance. Vomiting follows diarrhoea. Initially
dehydration, acidosis and circulatory collapse. the patient vomits food but soon after only clear
fluid or rice-water is vomited. The patient develops
severe cramps in the abdomen and limbs due to
Epidemiology of Cholera
electrolyte loss.
It is caused by a small comma-shaped motile Second stage: The patient becomes severely
organism called vibrio cholerae. There are about dehydrated, the skin is cold, dry and inelastic.
four sub-strains of the cholera vibrio, namely,
Blood pressure drops severely, and it may not be
El Tor, Ogawa, Luaba and Hikojima. The El Tor
recordable. The pulse becomes weak and rapid,
sub-strain causes cholera epidemics in
urine production ceases, patient collapses and
East Africa.
may go into irreversible shock.
Cholera is transmitted through the faecal-oral
Third stage: This is the stage of recovery. Some
route, mostly by water which has been
patients recover spontaneously or with treatment.
contaminated with faecal matter. The vibrios are
The general condition rapidly improves, diarrhoea
very sensitive to the hydrochloric acid found in the
becomes less profuse and the patient is able to
human stomach, and so a large number of
take oral fluids.
organisms must be ingested for infection to occur.

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Diagnosis  Oral tetracycline, 500mg six hourly for five
days. This speeds up recovery and
Cholera should be suspected in any outbreak of prevents convalescent carrier state.
diarrhoeal diseases. The diagnosis is made on  Oral cotrimoxazole, two tablets 12 hourly
clinical grounds and also through laboratory for three days can also be
isolation of vibrio cholerae from a rectal swab, used effectively.
stool or vomitus specimen.
Prevention and Control
Management
The following measures are useful in the
The management of cholera is easily done at prevention and control of cholera.
health centre level and so there is no need to refer
patients to hospital. This is because the main  Surveillance: early detection is central to
cause of death in cholera patients is dehydration. the success of cholera control because it
This can occur very quickly and early in an enables immediate action to be taken as
outbreak before the urgency of treatment is soon as there is an outbreak of the
recognised. Therefore early rehydration is the disease. Surveillance leads to immediate
most important part of management. notification of
an outbreak.
Management  Provision of clean safe water to the
community can easily control cholera
Other measures taken in the management of because it is mainly a water borne
cholera include the following: disease.
 Teaching and demonstrating to members
 The immediate notification of district of the community cheap and effective
medical officer. Cholera is an methods of purifying water at their home.
internationally notifiable disease.  Foods which can transmit cholera such as
 Admission of patients in temporary milk, should be pasteurised or boiled; raw
treatment centres, such as school or or uncooked food should be avoided or
church and the treatment of patients on washed in safe water, foods should be
protected from flies and markets
'cholera beds', that is beds with a central
hole through which the stools can pass inspected.
into a bucket and measured.
 Barrier nursing and patient isolation Measures that are useful in the prevention and
should be practiced to prevent spread of control of cholera also include.
the disease.
 Disinfection of hospital equipment and  Encouraging the digging and use of pit
proper disposal of stool and vomitus into latrines.
a pit latrine or septic tanks.  Provision of chemoprophylaxis to all
contacts of the patients including family,
Now move on to see more measures that are friends and visitors using oral tetracycline.
taken in the management of cholera.  Administering cholera vaccine to health
care workers in contact with the patients
Management during the epidemics.
 Enrolling the assistance of formal and
informal community leaders to address
Measures taken in the management of cholera
negative cultures and customs that
also include the following:
contribute to the spread of cholera. Such
communities should be targeted with
 Immediate introduction of intravenous information, education and
fluids to correct the severe fluid and communication messages.
electrolyte loss. If this is started in time it
can save many cholera cases. As soon as
a patient is able to drink, Oral Rehydration
Bacillary Dysentery (Shigellosis)
Solution (ORS) should be given in water Bacillary dysentery, also known as shigellosis, is
at a rate of 200 - 300ml per hour. an acute bacterial disease of the intestines. It is
 Intravenous fluids for patients who are in common especially in areas where the standards
of hygiene are low, particularly, where there is
shock or too weak to drink.
scarcity of safe water, improper human excreta
disposal, large population of flies and child

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malnutrition. Once again humans are the only  Stool culture for shigella spp.
known reservoir.
Management
It is caused by a non-motile gram-negative bacilli
of the genus shigella spp. The organisms Mild bacillary dysentery is self-limiting and all it
responsible for outbreaks are: requires is prevention or treatment of dehydration.
However, in the case of severe infection, you will
 Shigella sonnei need to combine rehydration with antibiotics as
 Shigella dysenteriae follows:
 Shigella flexneri
 Shigella boydii  Antibiotics: oral ciprofloxacin 500mg
12 hourly for five to seven days
However, the first three organisms are the most  Analgesics for colic such as codeine
common causes of outbreaks. phosphate and loperamide, belladonna,
or paracetamol
Mode of Transmission  Rehydration due to diarrhoea and fluid
loss. Oral rehydration using ORS in water
is always useful as an aid to parenteral
The mode of transmission of the disease is the
faecal-oral route. The organisms are transmitted rehydration. It also carries less danger of
disturbing electrolyte balance. However,
directly through flies or contaminated hands.
intravenous fluid should be given to the
very ill who cannot take anything orally.
Indirect transmission may also occur through
dishes which are poorly washed. The shigella
Prevention and Control
multiply in food which when ingested causes
dysentery.
The prevention and control of bacillary dysentery
Clinical Features depends on stopping the faecal-oral transmission
through the following ways:
The disease has a short incubation period of one
to four days. The onset is sudden with fever,  Safe water supply
headache, diarrhoea with streaks of blood, and  Improvement in personal hygiene
colicky abdominal pains.  Digging and use of pit latrines
After a few motions (usually in a few hours)  Practising food hygiene
diarrhoea stops and is followed by severe colicky  Giving health education that emphasises
abdominal pain known as dysenteric syndrome, environmental hygiene and breastfeeding
and painful contractions of the sphincter ani which  Inspection of public eating places,
produce an irresistible urge to defecate markets, boarding schools and camps
(tenesmus). When the patient goes to the toilet
they pass small amounts of purulent mucus and Giardiasis
blood. Vomiting may also occur. Toxins produced This is an infection of the small intestines by
by the shigella on the wall of the colon may be protozoa called giardia lamblia. The disease may
absorbed into the blood stream resulting in be mild (asymptomatic) in some individuals, while
toxaemia. Toxaemia causes high fever and rapid in others it may cause diarrhoea, malabsorption of
pulse. Dehydration is also common and digested nutrients and weight loss.
dangerous as it may cause muscular cramps,
oliguria and shock. In infants, rectal prolapse may
Giardiasis is found in all the countries of the world,
occur as well as convulsions.
but it is more common in developing countries
such as Kenya, where the water supply may be
Diagnosis contaminated by human faeces or sewerage.

The following laboratory examinations are Mode of Transmission

undertaken:
Often, the disease is spread from person to
 Stool examination which shows the person, especially within families by asymptomatic
presence of blood and mucus carriers.
 Stool microscopy which shows presence
of large numbers of white blood cells and Cysts which are excreted in the stool of an
erythrocytes
infected person remain infectious for up to three

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months in cold water or four days if the Prevention and Control
temperature is 37ºC. As soon as the cysts are
ingested by a human being, they are activated by The cysts of giardia lamblia are not affected by
the hydrochloric acid in the stomach. Trophozoites chlorine treatment of water or by iodine. However,
emerge and adhere to the wall of the upper they are highly susceptible to heat, therefore, the
portion of the small intestine. Here they begin to following preventive measures are important:
multiply and in about 10 - 14 days, the symptoms
manifest.
 Cooking food and boiling drinking water to
kill the cysts
Clinical Features  Advise people to avoid eating raw salads,
ice cream, unpeeled fruit and ice cubes in
Acute giardiasis is characterised by sudden onset endemic areas
of nausea, loss of appetite, abdominal distension  Use of sand filters is also effective in
(bloating sensation), prominent bowel sounds, protecting water from giardia cysts
and diarrhoea with frequent, frothy, yellowish  Tracing and treatment of healthy human
stools with offensive odour. Fatigue, lethargy and carriers
weight loss often occur.
Amoebiasis
After about three weeks the symptoms reduce in This is a protozoal infection mainly of the intestinal
severity and for many of the patients, this is the mucous membrane in humans caused by
beginning of spontaneous recovery. Some entamoeba histolytica. The disease is found in all
patients however, remain symptomatic and parts of the world but more common where
continue to lose weight because of ongoing
sanitary conditions are poor. Amoebiasis can
malabsorption of nutrients, mostly fat, vitamin B12
occur in families or spread through institutions but
and lactose. The disease may persist for months
usually does not occur in epidemics. It can be
or years. endemic in a population in which many individuals
are asymptomatic cyst-passers with only a few
Diagnosis getting the disease.

Diagnosis of giardiasis is often difficult to establish Mode of Transmission

because stool examination rarely reveals motile
trophozoites. However, approximately 60% of Cysts are passed from person to person by the
samples will show cysts. The diagnosis is
faecal-oral route, by fingers soiled with faeces
therefore made through the following ways: either directly into the mouth or via food.
Infections may also occur from drinking
 Stool microscopy to show cysts (three contaminated water. Amoebiasis can occasionally
separate stool specimens should be spread from the bowels to other organs of the
collected to increase sensitivity of body, especially to the liver leading to amoebic
the test) liver disease.
 Serology (giardia antigens can be
detected in stools) - Pathogenesis
immunological test
Once the cysts are ingested, the emerging
Management trophozoites take up residence in the intestinal
mucosa.
Any one of the following three alternative
treatments is effective enough to clear the The organisms multiply in the mucosa (causing
infection: the formation of bottle-shaped ulcers each 1-2cm
in diameter). Too many such ulcers may cover the
 Oral tinidazole 50mg/kg body weight large intestine. Some of the ulcers may become
single dose perforated leading to severe peritonitis with shock.
 Oral metronidazole 2g single dose. In the small intestines, the entamoeba histolytica
Repeat the dose after ten days to may pass through the mucous membrane and
increase the cure rate enter the liver. After a variable incubation period a
 Oral metronidazole 250mg eight hourly for liver abscess may form.
seven days

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Clinical Features  Advise people to boil drinking water
(chlorination does not kill the cysts)
The signs and symptoms of amoebiasis include:  Search for and treat carriers among
food handlers
 Colicky abdominal pain  Commence a campaign for more latrines
 Watery foul smelling diarrhoea containing in an area with endemic amoebiasis
blood-streaked mucus  Conduct community campaigns about
 There may be a hard large tender good personal hygiene practices, such as
abdominal mass (amoebic) regular hand washing

Remember: Amoebic infection is usually Viral Hepatitis

asymptomatic. This is an acute viral disease which mainly affects
the liver, causing inflammation of the liver cells
Diagnosis (hepatocellular inflammation) followed by
jaundice. The disease is found in all the countries
of the world. There are five types of viruses which
This is reached by doing a stool microscopy for cause hepatitis. These are:
cysts of entamoeba histolytica.
 Hepatitis A Virus (HAV)
Management
 Hepatitis B Virus (HBV
 Hepatitis C Virus (HCV)
No treatment is necessary for asymptomatic
 Hepatitis D Virus (HDV)
patients as in time they clear the infection.
 Hepatitis E Virus (HEV)
However, for invasive disease either one of the
following treatments is effective:
Hepatitis A virus causes infectious hepatitis and is
the most infectious of these viruses, while
 Oral metronidazole 800mg eight hourly for
hepatitis B virus causes serum hepatitis (also
five to seven days
called epidemic hepatitis). The hepatitis B virus
 Oral diloxamide furoate 500mg eight causes chronic active infection of the liver
hourly for ten days (hepatitis) which may be followed some ten years
later by liver cirrhosis (in 10 - 20% of the patients).
In hepatic amoebiasis, oral metronidazole is very In some of the patients who develop cirrhosis, the
effective. disease progresses to liver cancer (hepatocellular
A three day course of 1.4g - 2.4g a day will treat carcinoma). Hepatitis B infection occurs in about 1
the disease. - 3% of the human beings, but the incidence may
be higher in patients undergoing kidney dialysis
Extra-intestinal Amoebic Disease and in cancer wards (due to repeated blood
transfusions), and among children because of
The most common site for extra-intestinal close personal contact. It is difficult to tell the
amoebiasis is the liver where it forms a liver difference between infectious hepatitis and serum
abscess. Other secondary sites include lungs and hepatitis on clinical observations alone.
skin leading to:
Mode of Transmission
 Amoebic infection of the skin
 Amoebic balanitis Hepatitis A and E infections are transmitted
 Amoebic lung abscess through faecal-oral route and are both called
 Amoebic brain abscess infectious hepatitis. Hepatitis B, C and D are
transmitted through blood products and close
personal contacts and are called serum hepatitis.
Prevention and Control
Serum hepatitis may cause chronic liver infection
and liver cirrhosis.
Who is responsible for the spread of
amoebic dysentery?
The human being is the only known reservoir and
host of viral hepatitis. The disease is transmitted
It is the cysts-passers who are usually from the infected person to the susceptible host
asymptomatic. Therefore in order to prevent and through faeces, contaminated food and objects,
control this disease, you need to do the following: blood, blood serum and other body fluids.

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In the case of hepatitis B infection, transmission immunological markers in the blood. The most
takes place through two main routes: important is the hepatitis B surface antigen
(HBsAg) which is present when the virus is in the
 Percutaneous route - this is through blood in the acute stage and in the chronic carrier
injections and transfusion of blood and state.
blood products.
 Non-percutaneous routes - these include Management
close personal contact for example,
kissing and sexual intercourse, from
No specific treatment is available for both hepatitis
mother to foetus through placenta or to
A and B.
baby during delivery.
The patient should be given symptomatic
Clinical Features
treatment together with diet and bed rest at home
to prevent the spread of the disease. If admission
All types of hepatitis infections are characterised is indicated for one reason or the other, you
by a similar clinical picture. should ensure that the patient is isolated and
The incubation period is one to four weeks in the extra precautions taken during handling and
case of hepatitis A and 12 weeks or longer in the disposal of excreta. Since alcohol increases the
case of hepatitis B. Hepatitis infections manifest in risk of cirrhosis, you should advise the patient to
two phases. avoid alcohol for at least six months.

Pre-icteric Phase (no jaundice) Prevention and Control

 Fever of sudden onset Just like in the other diseases that have been
 Malaise covered, improvement of environmental sanitation
 Loss of appetite will prevent the transmission of hepatitis A.
 Nausea
 Abdominal discomfort Other control measures include:

Icteric Phase  Isolating patients suffering viral hepatitis

 Administration of hepatitis vaccine
 Appearance of jaundice  Screening blood for hepatitis B surface
 Enlarged tender liver (hepatomegaly) antigen before giving it for transfusion and
 Extreme tiredness and myalgia excluding all donors with a history of
 Feelings of deep sadness (depression) jaundice
 Pale stools  Effective sterilisation and high level
 Dark urine (contains bilirubin) disinfection of all instruments, needles
and syringes
Those At Risk of Hepatitis
Bacterial Food Poisoning
Reservoirs of hepatitis B virus include sexually Food poisoning is a sudden, acute and sometimes
promiscuous individuals, spouses of acutely life threatening illness which follows ingestion of
infected persons, health care workers exposed to contaminated food, drink or water. The major
blood, family members of chronically infected causes of food poisoning include intoxication with
persons, anyone who requires repeated blood chemicals, toxins produced by bacterial growth,
transfusions. and a variety of organic substances such as
poisonous plants and mushrooms. Food
Diagnosis poisoning occurs in small outbreaks and mortality
is usually low. In this country, you often hear of
severe cases of food poisoning caused by
How would you diagnose viral hepatitis in a
consumption of cheap alcoholic drinks ('Kumi
patient? Kumi'). It is also suspected that some cases
diagnosed as gastroenteritis in health facilities are
The urine of a person suffering from viral hepatitis actually caused by food poisoning.
is dark and contains bilirubin, while the stool is
usually pale. In the blood, both direct and indirect There are two common types of bacterial food
bilirubin levels are raised. In the case of hepatitis poisoning found in communities. These are:
B, diagnosis is made by detecting various

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  Staphylococcal food poisoning Diagnosis
 Clostridium botulinum food poisoning
Diagnosis is difficult when only one person is
Staphylococcal Food Poisoning affected because the signs of botulism are similar
to those of acute polio, myasthenia gravis and
This type of poisoning is caused by contamination Guillain-Barre syndrome. However, diagnosis can
of food (for example, with pus from a septic finger) be made when a group of people who had
by an infected person). The staphylococci in the consumed the same food (especially tinned or
pus multiply and produce toxins when the food is canned foods) suffers from the same neurological
allowed to stand for several hours before being symptoms without mental confusion or loss
served. Although the bacteria itself is harmless if of awareness.
ingested, the toxins it produces are very
poisonous. Following ingestion of the toxin- Management
contaminated food, there is sudden severe
abdominal cramping, nausea, vomiting, diarrhoea, The main cause of death in botulism is respiratory
headache and excessive salivation. failure.
The patient therefore must be managed in a high-
Diagnosis dependence unit.
A tracheostomy is performed and mechanical
This disease is usually recognised when people respirator used. Cleansing enemas are
who have shared food all fall sick within a administered to remove unabsorbed toxin from
short time. the colon and botulinum autotoxin serum is given
and repeated after two to four hours
Clostridium Botulinum Food Poisoning
Prevention and Control
Botulinum poisoning occurs when food
contaminated with botulinum spores (from the What points would you emphasise when
soil) is kept warm and in tightly covered giving a health education talk on prevention of
containers for many hours. The organisms bacterial food poisoning?
multiply in warm anaerobic (low oxygen)
environments especially in protein-rich foods. Your list should include the following
preventative measures:
When such food is contaminated, clostridium
botulinum multiplies and starts producing toxins.  Health education to encourage people to
The contaminated food may appear spoiled serve meals immediately they are
(greenish) and emit an offensive odour. Once a prepared in order to prevent growth of
person eats this food, they may suffer a mild organisms, such as staphylococci
illness that requires no medical treatment or a  Keeping food covered to keep off dust
rapidly fatal illness terminating in death within and rodents
24 hours.  Thorough reheating of left over foods (to
kill toxins food must be heated to over
Clostridium Botulinum Food Poisoning 140°C)
 Excluding persons with skin infections
The symptoms of botulism begin to manifest from food handling
12 - 36 hours after ingestion of toxin contaminated  Refrigerating cooked food
food. The patient presents with the following signs  Keeping the kitchen and cooling areas
and symptoms: clean

 Nausea and vomiting

 Dizziness and tinnitus
 Seeing double images (diplopia)
 Inability to speak clearly (dysphasia)
 Difficulty swallowing (dysphagia)
 Difficulty breathing (dyspnoea)
 Muscle weakness (neck, limbs,
respiratory)
 Death may occur from sudden respiratory
paralysis and airway obstruction

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SECTION 6: AIRBORNE DISEASES droplets remain in the air for some time and may
be inhaled by a new host. The bigger droplets fall
Introduction to the ground and mix with the dust.

In this section you are going to learn about those Some organisms survive the drying conditions
communicable diseases whose main route of and may be inhaled with the dust. Once they get
into the body, they may affect the immediate
transmission is the air you breathe. That is, the
organs involved in respiration, for example, nose
organisms which cause these diseases enter the and lungs, or they may pass through and spread
body through the respiratory tract. Most to the blood or other distant organs like the brain
respiratory tract infections are airborne diseases. or middle ear.
In module one unit four on paediatric nursing, you
covered quite a number of respiratory tract Overcrowded conditions such as congested
diseases. Can you remember which ones were houses, classrooms and public transport vehicles
covered? (matatus, buses and commuter trains), make the
spread of these diseases very easy. Therefore,
good ventilation and good manners such as
List the respiratory tract diseases you learnt in covering one's mouth when sneezing or coughing
the unit on paediatric nursing. can go a long way to reduce transmission of these
diseases.
In module one unit four on paediatric nursing, you
covered Acute Respiratory Infections (ARI),
streptococcal sore throat, Acute Laryngo-Tracheal Influenza
Bronchitis (ALTB) and pneumonia. This is an acute viral infection of the respiratory
tract caused by any one of the three strains of the
In this section you will look at other airborne influenza viruses, types A, B and C. Influenza
diseases, namely: influenza, measles, whooping occurs in all countries of the world. It has a high
cough, mumps, chickenpox, meningococcal attack rate with high mortality rates, especially
meningitis, tuberculosis among the elderly and those suffering from
and leprosy. chronic illness such as diabetes, kidney and
heart disease.
Objectives
By the end of this section you will be able to: Influenza viruses are also found in domestic
animals (dogs, horses, pigs, ducks and chicken)
 List at least eight common airborne and wild birds. Influenza spreads rapidly. Mortality
diseases is caused by secondary bacterial infections of the
 Describe the methods used to interrupt respiratory tract.
transmission cycles of airborne diseases
 Describe the clinical features of airborne Mode of Transmission
disease
 Describe the management of airborne The viruses are transmitted through secretions
diseases from the respiratory tract of an infected person. A
 Explain the preventive measures of susceptible host may be infected by:
airborne diseases namely: influenza,
measles, whooping cough, mumps,  Direct contact with secretions from an
chickenpox, meningococcal meningitis, infected person
tuberculosis and leprosy  Inhaling droplets secreted when an
infected person sneezes, coughs or talks
Airborne Diseases  Handling contaminated handkerchiefs and
other articles belonging to an infected
Airborne diseases have remained a major public person
health challenge in Eastern Africa. As mentioned
in the introduction to this section, the organisms
which cause these diseases enter the body
through the respiratory tract.

When a patient or carrier of pathogens talks,

coughs, laughs or sneezes, droplets of fluid are
discharged into the air. The smallest of these

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Clinical Features Measles (Morbili, Rubeola)
This is an acute and highly contagious disease
The signs and symptoms of influenza include the that mainly affects children. Measles is a major
following: cause of child mortality in less developed
countries such as Kenya. Together with
 Sudden onset of fever (39°C - 40°C) pneumonia it accounts for about a quarter of all
 Malaise and prostration deaths occurring in hospitals in Eastern Africa.
 Sore throat
 Coughing Non-immunised and malnourished children under
 Running nose (rhinorrhoea) the age of three years are at high risk of
 Headache contracting measles. The severity of measles is
 Muscle pain (myalgia ) related to the viral load one gets from the source.
That is, children who live in overcrowded
 Nausea and vomiting
dwellings and who are in close contact with the
 Abdominal pain
index case for the whole infective period obtain a
 Diarrhoea high dose of the virus. Such children develop
severe measles with high case fatality rates.
Complications
Mode of Transmission
Some of the common complications of influenza
are: The measles virus spreads through invisible
droplets secreted from the respiratory tract of an
 Pneumonia infected person. Measles spreads very easily and
 Chronic bronchitis fast. The virus infects the skin and the layer of
 Myocarditis cells that line the lungs, gastrointestinal tract,
 Meningitis eyes, mouth and throat. In addition, the measles
virus weakens the child's immune system for
Management many weeks after the onset of the illness, leaving
the child at risk of other infections.
As with many viral diseases, there is no specific
treatment. You should prescribe bed rest and give Clinical Features
paracetamol to relieve pain and fever.
Prophylactic broad spectrum antibiotics may also The clinical features of measles depends on the
be prescribed to prevent secondary bacterial nutritional status of the affected child. The skin
infections. rash of measles is characteristic and is said to
'match' from one region of the body to another in a
Prevention and Control systematic way. It begins on the face and
neck, then spreads to the chest and abdomen
after 24 hours. On the third day, the rash spreads
Since the infective particles are spread by
to the arms and lower limbs. Depending on the
droplets from patients or carriers, an important
nutritional status of a child, measles can either be
part of the control of this disease is based on
complicated or uncomplicated.
preventing droplets from being inhaled by others.
That is, people must not inhale 'second-hand' air.
Uncomplicated measles generally occurs in
well-nourished or slightly underweight children. It
This can be achieved through the following
presents with the following signs
measures:
and symptoms:

 Avoiding overcrowded places especially

 Fever
where ventilation is poor
 Conjunctivitis
 Immunisation using anti-influenza vaccine
about once every year  Rhinitis
 Avoiding close contact with an infected  Coughing
person or handling the patient's personal  Koplik's spots
articles, such as handkerchiefs  Stomatitis
 Covering one's mouth when coughing or  Skin rash
sneezing
All these may disappear after a few days with or
without treatment.

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Complicated measles occurs in malnourished Remember: Weigh all children suffering from
children and those who are underweight. It measles.
presents with the following signs
and symptoms:
List five complications of measles that you
 Nasal flaring have come across.
 Rapid respiration (pneumonia)
 Dyspnoea
 Hoarse voice (laryngitis) You should watch out for the following
 Barking cough complications and treat them accordingly.
 Inspiratory stridor
 Skin rash  Convulsions: give anti-convulsants
 Loss of interest to feed  Gastroenteritis: give oral rehydration
 Vomiting (this causes malnutrition)  Xerophthalmia: give vitamin A 200,000
 Diarrhoea (gastroenteritis) units
 Dryness of eyes, hazy cornea (keratitis)  Meningitis, pneumonia, conjunctivitis,
 Photophobia (encephalitis) otitis media:
 Convulsions give broad spectrum antibiotics
 Ear discharge (otitis media)  Fever: give antipyretics and apply fever
reduction measures such as tepid
Diagnosis sponging

The diagnosis of measles is usually based on the Prevention and Control

following signs and symptoms:
The only successful method of preventing
 WHO Diagnostic criteria: measles and its serious complications is
immunisation. This should be given to all children
Rash of three or more days from the age of nine months; both the healthy and
Fever of 38°C or higher the sick who have not been previously immunised.
Presence of 3Cs: coryza, cough and
conjunctivitis Whooping Cough (Pertussis)

 Febrile xanthema in which there are red This is an acute infectious disease of the
eyes and a cough respiratory tract caused by bacteria of the genus
bordetella called bordetella pertussis. Whooping
 Typical skin rash ('matching' skin rash) cough is also known
as pertusssis.
 Koplik's spots
The disease causes production of very sticky
Management mucus that blocks the lumen of the bronchioles.
This leads to a persistent cough in an attempt to
Uncomplicated measles is usually treated on an get rid of the mucus. Usually, the cough occurs
outpatient basis. You should advise the mother to after feeding thereby causing the child to vomit.
give the child adequate fluids, a light nutritious This robs the child of the little breast milk or food
diet, and paracetamol for pain and fever. they may have eaten thus causing them to be
malnourished. Mortality from whooping cough is
highest in children aged one year
Give a single dose of vitamin A 200,000iu in order
or less.
to speed up recovery from measles and prevent
the development of complications. Also, advise
the mother to bring the child to the Mode of Transmission
clinic everyday for follow up.
It is spread by droplets from secretions of the
In the case of complicated measles, you should upper respiratory tract. The disease can also be
admit the child to hospital and give them a spread by direct contact with freshly contaminated
balanced diet to improve their objects.
nutritional status.

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Clinical Features Diagnosis of whooping cough is made through a
postnasal swab for culture and sensitivity of
The incubation period of the disease ranges from bordetella pertussis and clinical symptoms
six to ten days after infection, after which the (paroxysmal cough with a 'whoop').
clinical features appear. In babies aged three
months or less, there is no 'whoop' experienced Remember: Young babies do not 'whoop'.
during coughing. As such the diagnosis may be
missed. Management
The characteristic 'whoop' is seen in children over
three months of age. The management of whooping cough requires
Whooping cough progresses through three stages supportive treatment such as good nutrition,
as follows. plenty of fluid intake and avoidance of factors
which provoke coughing. Broad-spectrum
Catarrhal Stage antibiotics are also given to kill the pertussis
organisms. However, antibiotic therapy does not
This stage begins after the incubation period and shorten the paroxysmal stage of the disease. You
lasts for one to two weeks. The patient has slight should also avoid giving sedatives and cough
fever and a cough that is troublesome especially suppressants because they may make the illness
at night. The cough often ends with vomiting. worse.
Gradually the cough becomes paroxysmal in
character with a running nose. Prevention and Control

Paroxysmal Stage Just like in the case of measles, the only way to
control whooping cough is by high immunisation
During this stage, the fever and the running nose coverage. To prevent whooping cough three
disappear but the cough becomes more doses of the pentavalent vaccine, starting at the
troublesome. The cough occurs in paroxysms. age of six weeks is currently being administered.
The child coughs with his mouth open and tongue It is given at intervals of four weeks.
protruding out. This severe persistent cough
causes cyanosis, protrusion of eyeballs, Why is the administration of the vaccine
congestion of face and neck veins, sweating, and started so early?
exhaustion. The patient may vomit suddenly, pass
urine or stool, bleed from the nose, bite their This is because very little or no passive immunity
tongue or suffer convulsions. is inherited from the mother, yet it is in the first
three months of life that whooping cough has a
Convalescent Stage high mortality rate.

Most patients improve gradually within one to Mumps (Epidemic Parotitis)

three weeks, but some patients may continue to This is an acute viral disease, which usually
have paroxysms of coughing for months. affects school aged children and is characterised
by fever and painful swelling of the salivary
glands.
Clinical Features
Mumps is not a major cause of death, but if
If whooping cough is not treated it can lead to a contracted after puberty it can cause infertility due
number of complications: to its effect on the testis and ovaries. Other rare
complications of mumps include; meningitis,
 Inguinal hernia encephalitis, pancreatitis, thyroiditis and
 Broncho-pneumonia unilateral deafness.
 Collapse of the lung (atelectasis)
 Convulsions Mode of Transmission
 Rectal prolapse
 Sub-conjunctival haemorrhage The virus is transmitted by droplets and by direct
 Pneumothorax contact with the saliva of an infected person, or
 Surgical emphysema indirectly through freshly contaminated articles.
 Retinal detachment (which may lead to
blindness) The incubation period is 17 - 19 days.

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Clinical Features  Scrotal support for orchitis
 Corticosteroid therapy to reduce swelling
The general signs and symptoms of mumps are: and pain of orchitis (oral prednisolone
40mg od. for four days)
 Headache
 Sore throat Prevention and Control
 Fever (pyrexia)
 Difficulty in swallowing It can be prevented by the administration of live
 Swelling and tenderness of salivary attenuated mumps vaccines where it is available.
glands This live attenuated vaccine is combined with
measles and rubella.
There is no rash and the fever and swelling
disappear after a few days. However, in some Chickenpox (Varicella)
patients complications do develop.
This is a mild viral disease characterised mainly
Orchitis by a skin rash. It mainly affects children under ten
years of age and its case fatality is very low. The
This is a very common complication which occurs causative organism is the Varicella-Zoster Virus
in about 20% of post-pubertal males. Orchitis is (VZV). Chickenpox is highly contagious. An adult
usually unilateral. The fever returns and the testis person who becomes infected suffers a severe
become swollen and painful. The affected testis form of the illness. Once a person develops
may atrophy leading to infertility. In girls, chickenpox they develop immunity against the
oophoritis may develop. It is less common than disease. However, the virus stays within the body
orchitis. The child complains of severe lower and may reappear as herpes zoster (shingles)
when the immunity of a person is weakened, for
abdominal pain and vomiting.
example in AIDS and diabetes.
Pancreatitis
Mode of Transmission
Pancreatitis may occur but it is not common. It
presents with severe upper abdominal pain, fever The virus is spread by droplets from the upper
and vomiting. respiratory tract or from the discharges of ruptured
lesions on the skin.
Meningitis
The incubation period is 14 - 21 days.
This is a common complication of mumps. It
Clinical Features
presents with fever, headache, vomiting, neck
rigidity and spinal rigidity. The condition resolves
spontaneously. The disease begins with mild fever, sore throat
and a sore palate. After two days, a characteristic
Encephalitis rash appears on the trunk, and within a few hours,
the rash spreads to the face, axilla, and scalp, and
sometimes to the arms and legs. The rash
This is rare and may occur with or without vesicles are superficial. The infection usually
meningitis. The patient presents with disturbed clears spontaneously and the vesicles usually
behaviour, drowsiness, convulsions, and coma. collapse and dry after three to four days, leaving
Mumps encephalitis is a serious condition, and skin spots but no scars. The spots clear after a
has a mortality while. Complications usually do not occur.
rate of 2%.
Management
Management
The treatment of chickenpox is symptomatic. Give
The treatment of mumps is supportive and the patient calamine lotion to relieve itching. A
includes: local antiseptic can also be given for infected skin
lesions for example chlorhexidine (hibiscrub,
 Analgesics/antipyretics hibitane).
 Nutritious fluid diet
 Regular mouth washes
 Bed rest preferably at home

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Prevention and Control  Circulatory collapse (Waterhouse-
Friderichson syndrome)
Chickenpox is a self-limiting non-fatal disease.
Healthy school children should be kept off school Diagnosis
if there is an outbreak among schoolmates.
The following tests are useful to confirm
Meningococcal Meningitis (Epidemic a diagnosis:
Meningitis)
This is an acute and dangerous bacterial disease,  Lumbar puncture
which occurs sporadically and in epidemics. The  Positive Kernig's sign
causative bacterium is the neisseria meningitides,  Positive Brudzinki's 1 and 2 signs
also known as meningococcus. There are two  Blood culture for neisseria meningitides
types of meningitis.
Management
The first type known as meningococcal meningitis
is spread by droplets from one person to another The patient must be admitted in the hospital and
and may cause epidemics in crowded institutions antibiotic therapy started immediately. Either one
such as army barracks, boarding schools, prisons of the following drugs can be given:
and camps.
 IM crystalline penicillin (benzyl penicillin)
The second type is caused by a variety of other six mega units stat followed by three
organisms usually occurring as a complication of mega units every six hours
some other disease in the body, or by direct
 IM chloramphenicol 500mg every six
extension from neighbouring structures such as
hours
the middle ear (otitis media). This type of
 IM cefotaxine
meningitis occurs one case at a time, that is, it is
sporadic.

Mode of Transmission

About 20 - 25% of people may be healthy carriers

of the meningococcus and the other organisms
which cause meningitis, such as, haemophilus
influenzae type B and streptococcus pneumoniae
(pneumococci). Transmission of the neisseria
meningitides occurs by direct contact and by
droplets from nasal and throat discharges of
infected persons.

Clinical Features

When a susceptible host is infected the organism

causes blood poisoning (septicaemia) and
pyogenic meningitis. The onset is sudden with the
following signs and symptoms:

 Severe headache and neck rigidity

 Fever and rigors Prevention and Control
 Pain in the back and limbs
 Irritability and confusion The prevention of meningitis follows the same
 Drowsiness and coma principles that were covered in the other airborne
 Positive Kernig's and Brudzinki's signs diseases. They include:
 On lumbar puncture, Cerebral Spinal
Fluid (CSF) is under pressure and  Improvement in housing: adequate space,
contains high levels of White Blood Cells good ventilation
(WBCs), has raised protein and lowered  Proper disposal of respiratory secretions
glucose  Health education to avoid overcrowding in
 Petechial haemorrhages poorly ventilated houses

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  Isolation of the suspected patients This happens when a person with pulmonary TB
 Notifying the District Medical Officer of coughs out heavily infected sputum into the air.
Health Though many people may thus become exposed
 Immunisation during epidemics using to TB infection, only a few will progress to develop
meningitis A and C vaccine actual disease. This is because the majority have
 Chemoprophylaxis (single dose of oral acquired active natural immunity to the disease.
floxacillin 500mg or rifampicin) for all However if this immunity is depressed by for
household and other contacts of the example, age or HIV infection, tuberculosis may
patient including the health care workers flare up again and cause obvious clinical disease.
 Use of gowns, gloves and masks while
caring for these patients As mentioned earlier, there are three organisms
that cause tuberculosis.
Tuberculosis (Koch's Disease)
Tuberculosis (also known as Koch's disease) is a Mycobacterium Tuberculosis
chronic bacterial infection caused by bacteria that
belongs to the family of mycobacterium. These This is the main cause of pulmonary tuberculosis
are mycobacterium tuberculosis, mycobacterium and extra-pulmonary tuberculosis.
bovis and mycobacterium avium. The lungs are
affected in most cases, but other organs such as Mycobacterium Bovis
the skin, bones, brain, lymph nodes, and intestine
are also affected (extra-pulmonary tuberculosis). This causes disease in cattle and is spread to
humans through infected milk.
Tuberculosis is found in all parts of the world and It also causes extra-pulmonary tuberculosis.
affects all age groups and sexes equally. If
untreated, tuberculosis causes death and severe Mycobacterium Avium
disability. After many years of immunising children
against tuberculosis with the BCG vaccine,
tuberculosis was almost controlled. However, the This causes disease in birds. Bird droppings
HIV infection which can lead to AIDS has led to spread pulmonary tuberculosis in individuals
the resurgence of tuberculosis. The cases of AIDS whose immunity is depressed (opportunistic
related tuberculosis have risen and continue to mycobacterium).
rise. The prevalence of tuberculosis increases as
social and economic status decrease. Types of Tuberculosis

List down three types of tuberculosis?

Your answer should include: pulmonary

tuberculosis, extra-pulmonary tuberculosis and
miliary tuberculosis.

 In pulmonary tuberculosis the disease is

confined to the lungs only.
 In extra-pulmonary tuberculosis the
disease may spread outside the lungs
and settle in other body organs such as
the meninges of brain and spinal cord,
kidney, bones, joints, pleura, pericardium
or the periosteum.
 In miliary tuberculosis mycobacterium
enter the blood stream and are
disseminated widely to the lungs and
other body organs. Miliary tuberculosis is
a very severe form of tuberculosis.

Mode of Transmission

Tuberculosis is spread from an infected person to

a healthy susceptible host by droplet infection.

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Clinical Features the type of tuberculosis as well as the age of
patient.
The clinical features of tuberculosis can be
divided according to the early and late signs and The drugs used for the treatment of tuberculosis
symptoms. are abbreviated as follows:

Early Signs and Symptoms of Tuberculosis S - streptomycin

E - ethambutol (plain 400mg tablet)
 Productive cough lasting three or more H - isoniazid (150g combined with ethambutol
weeks 400mg, tablet)
 Night sweats R - rifampicin (tablet or capsule)
 Unexplained weight loss Z - pyrazinamide (500mg tablet)
rifater (rhz): a combination of rifampicin 120mg,
 Loss of appetite
isoniazid 50mg and pyrazinamide 300mg
 Fatigue
rifinah (rh): a combination of rifampicin 150mg
 Evening fever (pyrexia)
and isoniazid 100mg
 Positive tuberculin test ethizide: a combination of ethambutol 400mg and
isoniazid 150mg
Remember: TB bacteria are shed in the air in
droplets whenever a patient coughs, sneezes, The following gives guidelines on dosages for
talks or even breathes. anti-tuberculosis drugs as set down in the
National Leprosy and Tuberculosis Programme
Late Signs and Symptoms of Tuberculosis (NLTP), Diagnostic Flow Chart for Pulmonary
Tuberculosis.
 Coughing blood stained sputum
(haemoptysis) Dosage for Anti-Tuberculosis Drugs
 Difficulty breathing
 Enlargement of lymph nodes (Ministry of Health (2002), National Leprosy and
 Extreme loss of weight Tuberculosis Programme (NLTP), Diagnostic Flow
 Signs and symptoms of other body Chart for Pulmonary Tuberculosis.)
organs affected for example meningitis,
pleurisy, pericarditis, peritonitis and
pleural effusion

Remember: TB bacteria are shed in the air in

droplets whenever a patient coughs, sneezes,
talks or even breathes.

How to Diagnose Tuberculosis?

The best way to diagnose tuberculosis is by

means of a direct sputum smear examination
(Acid Fast Bacilli - AFB test) in the laboratory.
If possible, at least three early morning specimens
must be examined within two days.

Other tests include skin tests such as the Mantoux

test and chest x-rays.

Management
Children are not treated with ethambutol because
it is known to impair vision and small children
The Kenya National Leprosy and Tuberculosis would not complain if affected.
Programme (NLTP) coordinate the treatment of
tuberculosis and leprosy. The NLTP, which is a
Ministry of Health project, has developed the
treatment guidelines for these two diseases.
Treatment regimen for tuberculosis depends on

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 came up with a TB treatment strategy known as
DOTs (Directly Observed Treatment short
course).

Remember: For the DOTs strategy to succeed

the government must be committed to the
programme.

When using the DOTS strategy, you must adhere

to the following rules:

First Regimen  Follow the national treatment guidelines

 Ensure that there is an adequate supply
(For AFB smear positive or very sick patients.) of anti-TB drugs
 Ensure each patient is on the correct
 2ERHZ/6EH treatment regimen
- Intensive therapy phase > 2ERHZ  Administer the initial (intensive) phase of
- Continuation therapy phase >6EH treatment under supervision
 Encourage all patients to attend the TB
Second Regimen clinic regularly during the continuation
treatment phase
 Promptly trace defaulters
(For AFB smear negative and extra-pulmonary
 Maintain accurate records on patient
TB, and not severely ill patients.) personal data and
clinic attendance
 2RHZ/6EH
- Intensive Treatment phase > 2RHZ Common Complications of Tuberculosis
- Continuation treatment phase >6EH
The following are some of the common
Third Regimen
complications of tuberculosis:

(For defaulters and drug resistant cases.)

 Severe haemoptysis
 Respiratory failure
For re-treatment of resistant tuberculosis and  Meningitis
treatment defaulters and opportunistic  Kidney failure
mycobacterium infection as in AIDS associated
 Pleural effusion
TB.
 Pericardial effusion
 Potts disease (collapse of the backbone)
 Intensive Treatment Phase
- IM streptomycin daily for two months,
Prevention and Control
and
- Oral rifater daily for one month, and oral
ethambutol daily for two months The following measures are important in the
 Continuation Treatment Phase I prevention and control of tuberculosis.
- Oral rifater daily for one month, and oral
ethambutol daily for one month  Immunising the newborn babies with
 Continuation Treatment Phase II BCG vaccine
- Oral rifinah daily for five months and oral  Case finding and treatment (completing
ethambutol daily for five months treatment)
 Health education to the patients so that
The treatment of tuberculosis keeps changing they can stop spitting carelessly
depending on current research findings. Please  Encourage them to use a sputum mug
check on the current treatment and adjust your  Health education to the community
notes accordingly. members to avoid overcrowding and to
improve ventilation in their houses
The aim of tuberculosis treatment is to kill the  Drinking only pasteurised or boiled milk
mycobacteria as efficiently as possible and within
the shortest possible time. That is why the WHO

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Remember: To eliminate TB, find the people  Absence or presence of very few of bacilli
who have infectious TB and cure them so that in the skin smears or skin biopsy (skin
they do not continue to spread the infection. smear is negative)
 Skin patches 1 - 5cm
Leprosy (Hansen's Disease)  Reaction type I
 Nerve involvement/damages affects one
or more peripheral nerves
Leprosy is one of the oldest diseases of human
beings. It is caused by a bacteria belonging to the  Disability and deformities are common as
a result of irreversible nerve damage and
same family as the mycobacterium that causes
tuberculosis, known as mycobacterium leprae. most are disfiguring
Leprosy is a major public health and socio-
economic problem because it is a disabling and Multi-Bacillary Leprosy (MBL), also called
deforming disease. Leprosy is not a killer disease lepromatous leprosy, is characterised by:
in that it runs a chronic course and does not
significantly reduce the life expectancy of the  Presence of numerous bacilli in most
infected individual. tissues of the body, except brain and
spinal cord
In some communities patients suffering from  Skin patches six or more cm
leprosy are discriminated against or stigmatised  Skin smears positive (numerous bacilli
due to ignorance and unfounded traditional present)
beliefs. This causes a lot of distress and misery to  Reaction both type I and type II
those infected and their families. In Kenya,  Nerve damage comes late
leprosy has almost been eradicated except for a  Disability and deformities usually develop
few endemic areas in the Coast, Eastern, Nyanza at a later stage of the disease
and Western Province.
Nerve Involvement in Leprosy
Mode of Transmission
The main cause of disability in leprosy is the
Leprosy has a long incubation period and runs a destruction of the nerves. Damage to the sensory
chronic course if it is not adequately treated at an nerve fibres causes anaesthesia, while damage to
early stage. The mycobacterium leprae bacillus the motor nerve fibres causes paralysis. Impaired
multiplies very slowly (dividing only once every 14 circulation, loss of sweating and skin atrophy is
- 30 days). That is why the incubation period is caused by damage to autonomic nerve fibres.
long, about five to eight years. Just like
tuberculosis, the leprosy bacillus is transmitted by Leprosy patients may get burned or injured on
droplets, by sneezing, coughing, spitting and their limbs and fail to notice because of
unhygienic nose cleaning habits. The organism is anaesthesia. The patient may walk on an injured
also suspected to enter the body through broken foot without realising it.
skin such as small wounds. Leprosy is common
among family members of the infected.
In the eye, the cornea may become anaesthetic
so that foreign bodies may enter unnoticed
There are certain factors that increase the leading to corneal damage. Anaesthetic eyelids
incidence of leprosy in the community: may lose the blinking reflex or fail to close the eye
(lagophthalmos) leading to dryness, iritis,
 Presence of many untreated cases adhesions, glaucoma and blindness.
 Overcrowding in living houses
 Presence of susceptible new comers in a Clinical Features
leprosy endemic area
 Hiding patient with leprosy and starting After infection, the mycobacterium leprae bacilli
treatment late multiply in macrophages of the skin and the
schwann cells of the peripheral nerve fibres. The
Classification (Types) of Leprosy bacillus has a preference for the relatively cool
places in the body such as the face and the limbs.
Broadly speaking, there are two forms of leprosy: The early signs of leprosy are as follows:
the tuberculoid form and the lepromatous form.
 Hypopigmented patches on the skin with
Pauci-Bacillary Leprosy (PBL), also called loss of sensation to pain, touch
tuberculoid leprosy is characterised by: and temperature

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  Loss of sweating or loss of hair over the Remember: Drugs for leprosy do not cause
affected part reactions and therefore should not be
 Burning sensations in the skin stopped.
 Weakness of eyelids, hands or feet
 Thickening of cutaneous nerves
especially the ulnar, median and lateral Late Deformities of Leprosy
popliteal nerves
 Nodules in the skin especially of the nose, The following are the late deformities of leprosy:
face and ears
 Painless wounds (ulcers) and burns on  Paralytic deformities including claw hand,
the hands and feet claw fingers, wrist drop, food drop, claw
toes, lagophthalmia, corneal ulcers, and
Reaction Types facial paralysis
 Depression of the nasal bridge
Reactions are sudden unexpected changes which  Wrinkling of facial skin
occur in all types of patients with leprosy. These  Disfigured ears
reactions are caused by a change in the balance  Stiffness of finger joints
between the immunity of a patient and the bacilli.  Shortening and loss of fingers and toes
There are two main types of reactions, type I or
reversal reaction and type II or erythema
nodusum leprosum. Diagnosis

Type I Reaction (Reversal Action) The diagnosis of leprosy can be made using the
following:
Type I reaction (reversal action) is common in
Pauci-Bacillary Leprosy (PBL). It occurs after a
 Clinical signs: presence of pigmented
sudden increase in immunity results in a rapidly
anaesthetic patches on skin and
increased response of the body to the leprosy
thickened nerves
bacilli. This reaction causes sudden inflammation
 Bacteriological examination: skin slit and
in places where the leprosy bacilli are present. It
skin crap, nasal smears for leprosy bacilli
causes nerve damage, inflamed and raised red
 Chemical tests: histamine test, lepromin
skin lesions and oedema of hands, face or feet.
test
Type II Reaction (Erythema Nodosum
Management
Leprosum)

This appears six months or more after treatment The aim of leprosy treatment is to prevent nerve
and is caused by a reaction between dead leprosy damage, deformity, blindness and defaulting. The
bacilli and circulating antibodies. Nerve damage is National Leprosy and Tuberculosis Programme
(NLTP) in Kenya uses the WHO recommended
not common in this reaction. Eyes, joints and
multiple drug therapy for the treatment of the two
testes become inflamed, nerve become tender
and ulcerating tender nodules appear on the skin. classes of leprosy.
Thus, reaction is usually of sudden onset and
tends to recur. Pauci-Bacillary (Tuberculoid) Leprosy (PBL)

Generally, reactions in leprosy are provoked by a This type of leprosy is treated for six months as
number of factors. These include: shown in the table below.

 Malaria, malnutrition, anaemia Six months treatment for pauci-bacillary leprosy

 Severe emotional or physical stress for all ages*.
 Menstruation, pregnancy, abortion,
puberty and childbirth 0-5 6-14 Over 14
 Using drugs containing iodine years years years
 BCG vaccination Rifampicin every four
 Osteomyelitis 150mg 300mg 600mg
weeks supervised
 Septic wounds Dapsone daily 25mg 50mg 100mg
*Adapted from the Kenya National Leprosy and
Tuberculosis Programme (NLTP)

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Multi-Bacillary Leprosy (MBL) Exercises

Multi-bacillary or lepromatous leprosy is also It is common knowledge that joints which are not
treated for six months as shown in the following used become stiff, while muscles atrophy and
table. become weak. Also scar tissue tends to retract
resulting in contractures. That is why all patients
Six months treatment for Multi-Bacillary Leprosy with weak or damaged hands should do suitable
for all ages* exercises. For paralysed muscles, passive
exercises help to loosen the stiff joints and
lengthen the skin. The exercises should be done
6-14 Over 14 for five to ten minutes daily on a regular basis.
0-5 years
years years
Dapsone daily 25mg 50mg 100mg Prevention and Control
Clofazimine
(lamprene) four weekly 100mg 200mg 300mg The cornerstone of leprosy control is to reduce the
supervised number of infective cases and interrupt
Clofazimine 50mg on transmission. These can be achieved through the
50mg 50mg
(lamprene) alternate following preventive measures:
daily daily
unsupervised days
Rifampicin every 4  Treatment of all infective cases until cured
150mg 300mg 600mg
weeks supervised  Searching for unknown cases, registering
and treating them
 Administration of BCG vaccine which
Having looked at drug therapy you will now find gives some immunity against leprosy
out what else can be done to prevent blindness
and deformity. SECTION 7: HELMINTHIC
Wound Prevention in Leprosy DISEASES

Wounds are caused and made worse by the loss Introduction

of sensation to pain, pressure or burning. In this section you will look at helminthic diseases
Therefore to prevent further damage you should or diseases caused by worms. There is a wide
advise the patient to do the following: variety of worms that can, like viruses and
bacteria get into the body of a human being.
 Wear protective footwear
 Wear heatproof gloves when working and Sometimes they present without causing any
handling hot objects symptoms, sometimes they cause disease. Some
 Inspect the feet and legs regularly for only infect mankind and have a simple life cycle,
swelling, cracks, bruises, injuries, dryness entering the body through the mouth, living in the
- a small mirror can be used to inspect the gut and leaving in the stools. Others have more
soles of feet complicated life cycles, entering the body through
 Soak feet for 20 minutes twice daily in the skin, living in different organs, and having
salty water, then rub oil on the skin to intermediate hosts for transmission.
keep it moist and prevent cracks
 Remove grit from inside the shoes In this section you will consider the common
intestinal worms that fall under two groups, that is
Eye Care nematodes and flatworms.

For the patients who are suffering from Objectives

lagophthalmos, you should advise them as By the end of this section you will be able to:
follows:
 List at least six common intestinal worms
 Wear sun glasses  Describe the mode of transmission of
 Check the eye daily in front of a mirror for helminths
inflammation and foreign bodies namely; threadworm, whipworm,
 Cover the eyes with pads at night roundworm, tapeworm
 Avoid rubbing the insensitive eyes and hookworm

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  Describe the clinical features of helminthic migrate to the rectum where they discharge eggs
infections on the perianal skin, especially during the night.
 Describe the management of helminthic This causes itching and consequently scratching.
infections
 Explain the preventive measures of The graphic illustrates the life cycle of
helminthic infections the pinworm.

Helminthic Diseases Clinical Features

Helminthic diseases are still a very common List four clinical features of pinworm
problem in Kenya, despite the fact that it is known infestation.
how to prevent and treat them. They are common
in low income areas such as slum settlements due  Mainly pruritus ani leading to intense
to lack of proper facilities for human waste scratching of the perianal region
disposal as well as poor attitudes.  Disturbed sleep
 Restlessness
The other factors which promote the spread of  Loss of appetite and weight loss
some helminths are:
Diagnosis
 Moist warm soil in the case of hookworms Diagnosis is mainly made by a laboratory
 Cattle keeping areas in the case
examination of stool microscopy for ova and cyst.
of tapeworms
 Lack of latrines in the case
Management
of roundworms
You should treat the whole family with
 Unwashed hands in the case
of threadworm mebendazole 100mg given as a single dose.
During treatment you should impress on the
Helminthic diseases can be categorised into two patient the importance of avoiding auto-infection.
groups: nematodes and flatworms.
Prevention and Control
Nematodes (Cylindrical-Shaped The prevention and control of this disease lies in
improved personal hygiene and proper disposal of
Worms)
faeces. You should give health education on the
This group is made up of cylinder shaped worms importance of bathing and hand washing, keeping
and includes threadworms, whipworms, nails short, and how to prevent reinfection.
and roundworms.
Whipworm
Threadworm or Pinworm
This infestation is called trichuriasis because it is
The threadworm is caused by enterobius caused by an intestinal worm called Trichuris
vermicularis. It has a worldwide distribution and trichiura. The worm infects the large intestine and
mainly affects school aged children, especially in infestation is usually asymptomatic.
boarding schools. The children reinfect
themselves when they scratch their anus and then Mode of Transmission
transfer the eggs on their fingers to the mouth. The transmission of trichuriasis is indirect, as the
eggs passed in the faeces require embryonation
Mode of Transmission in soil. Therefore unlike the threadworm, auto-
infection is not possible.
Infection with enterobius vermicularis is
maintained by direct transfer of infective eggs When the embryonated eggs are ingested, they
from the anus to the mouth (auto infection) or hatch and eventually the mature worms attach
indirect contact through clothing, bedding, food themselves to the mucosa of caecum and colon.
and other articles. They are mainly transmitted through food that is
contaminated by soil or dirty fingers.
After ingestion, the eggs hatch in the stomach and
small intestine. The worms mature in the lower
small intestine and upper colon and then they

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Clinical Features The graphic illustrates the life cycle of Ascaris
Often, mild infections are asymptomatic, but lumbricoides.
heavy infections may result in abdominal
discomfort, bloody diarrhoea, loss of weight and Clinical Features
prolapse of rectum. Infection with a few ascaris is usually
asymptomatic and if symptoms are present, they
Diagnosis are not characteristic.
Diagnosis is made by examining a stool sample
There may be vague abdominal discomfort or
microscopically for ova and cyst.
occasionally the worm may leave the body in
vomitus or stool. Also during the stage of larval
Management
migration through the lungs there may be
You can eliminate this infection by giving oral temporary symptoms of pneumonitis (cough).
mebendazole 100mg 12 hourly for three days.

Prevention and Control

Just like the threadworm, the prevention of
trichuriasis can be achieved through good
personal hygiene and proper disposal of faeces.

Roundworm (Ascariasis)
This disease is caused by Ascaris lumbricoides,
which infects the small intestine.

Ascaris is a large intestinal parasite which often

infects children because of their habit of putting all
kinds of things in their mouth.
It is one of the commonest and most widespread
infections of the small intestine. The worms may
multiply in large numbers in the intestinal lumen
and cause intestinal obstruction at the
ileocaecal valve.

The worms also contribute to severe malnutrition Diagnosis

and vitamin A deficiency, and may wander out of Diagnosis is by stool microscopy which should
the intestinal lumen into the peritoneal cavity. show ascaris ova and cyst.

Mode of Transmission Management

Any one of the following drug treatments is useful
Ascariasis is a soil transmitted parasite. Once the in the management of ascariasis.
eggs are passed out in faeces, they require
embryonation in the soil before they can become  Oral mebendazole 100mg 12 hourly for
infective. This takes 8-50 days. Embryonated three days
eggs can be carried away from the contaminated  Oral levamisole (3 tabs or 5mg/kg body
place into houses by feet, footwear or in dust by wt) single dose
the wind.  Oral piperazine 150mg/kg body wt single
dose
Human beings may injest the eggs as they eat or
drink using contaminated hands and utensils, or Note: For intestinal obstruction, surgical operation
through eating raw contaminated foods like fruit. is indicated
Once the eggs are ingested by a human being
they hatch into worms.

In order to reach maturity, the larvae need to pass

through the lungs and trachea to the pharynx.
Once in the pharynx they are swallowed and
return to the gastrointestinal tract where they can
live for about a year.

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Prevention and Control When they reach the stomach they attach
The prevention and control of ascariasis involves themselves to the wall of the abdomen with hook-
the following measures: like teeth and start to suck blood from the patient‟s
body.
 Improved environmental sanitation such
as proper excreta disposal, clean supply
of water
 Discouraging the use of raw (fresh)
human faeces for manure (Composting
for six months kills the ascaris eggs)
 Washing of fruit and vegetables before
eating
 Use of drying racks for utensils so that
they do not come into contact with soil
and dust
 Washing hands after opening bowels
 Washing hands before handling food

Hookworm (Ancylostomiasis)

This is an infection of the small intestine by a

blood-sucking worm called Ancylostoma
duodenale or necator americanus.

In East Africa, necator americanus is the cause of

the disease. Clinical Features
The worm causes severe iron deficiency anaemia
and protein loss.
How would you diagnose a hookworm
infection?
Each adult necator americanus worm causes a
daily loss of 0.03ml of blood from the patient. In
many infected individuals the disease is In most of the cases, hookworm infestation tends
asymptomatic because the hookworm load is to be asymptomatic. However the following signs
light. and symptoms are indicative of hookworm
infestation:
Mode of Transmission
 Itching of the skin at the site of entry (local
irritation)
Hookworm eggs are embryonated by the time
 Anaemia (due to haemorrhage), pallor
they are passed out with faeces. Indeed, when the
faeces stand for a long time before examination  Weakness, puffy face, malnutrition
the free larvae can be found.  Flatulence, constipation
 Pain in abdomen
When an infected person passes faeces in the  Some little blood in stool
soil, the larvae bury themselves in the moist damp
soil. The larvae are called rhabditiform and only Diagnosis
become infective after five days, when they Diagnosis of hookworm infestation is made by
change into the sheathed filariform stage. stool microscopy which should show ova and
cysts and in some cases occult blood. More than
As soon as the filariform larvae come into contact 100 eggs in an ordinary faecal smear indicate
with a human leg or foot, they penetrate actively heavy infection.
through the skin and reach the lungs via the
venous system and the right side of the heart.
Management
The following drugs are commonly used in the
Once in the lungs they penetrate the alveoli and
treatment of hookworm infections:
are carried to the larynx and pharynx, from here
they are swallowed into the stomach.
 Levamisole 25mg/kg body weight as a
single dose

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  Mebendazole 100mg bd. for three days The eggs are not laid singly and appear only
 Albendazole 400mg stat accidentally in the stools.

Flatworms Management
This group is made up of flat or segmented Drug treatment with oral niclosamide is effective.
worms, their intermediate hosts are mainly The dose is 1gm chewed and swallowed with
animals, such as cattle, pigs and dogs. water followed one hour later with 1gm (a total of
2gm).
You will look at two worm diseases under this
group, namely tapeworms and hydatidosis.

Tapeworm (Taeniasis)

There are various types of tapeworms, but in

human beings the infestations are commonly
caused by:

 Taenia saginata or beef tapeworm

(commonest infection)
 Taenia solium or pork tapeworm

You will now consider each type in turn.

Taenia Saginata or Beef Tapeworm

Infection with the beef tapeworm is common in

areas where beef is eaten raw or lightly cooked.

Mode of Transmission Taenia Solium (Pork Tapeworm)

The eggs of adult tapeworms living in the small
intestines of human beings are passed in the This disease occurs when a person ingests pork
stools. infected with the taenia solium larvae. Whereas in
the beef tapeworm the embryo attaches itself to
They are then ingested by cows as they feed on the wall of the small bowel and grows into an adult
contaminated grass. Once in the gastrointestinal worm, the pork tapeworm behaves differently.
tract of the cow, the embryos hatch and penetrate The embryo penetrates the intestinal wall of the
the bowel wall and are carried via the bloodstream human as it does the pig, and it is carried to
to striated muscles. Here the larvae grow and organs like striated muscle or the brain. This can
form infective cysts called cysticerci. cause serious problems such as epilepsy and
death.
When human beings ingest cow meat containing
these cysts, the cysts are dissolved by the gastric Clinical Features
acid in the stomach to release embryos. Taenia solium is a dangerous worm and the signs
and symptoms depend on the organ it has
Clinical Features invaded as follows:
Most tapeworm infections caused by taenia
saginata do not cause any signs or symptoms.  In the brain it causes epilepsy
 In the skeletal muscles it causes myositis
However, some people may complain of loss of (severe pain), which may make
weight, abdominal discomfort and itching around movement temporarily impossible
the anus (pruritis ani).  In the laryngeal muscles it causes
difficulty in speaking
Diagnosis  In the myocardium it causes
Diagnosis of tapeworm infestation can be made (myocarditis), heart failure or cardiac
by the presence in the stool of segments or eggs. arrest
 In the eyeball it can cause unilateral or
bilateral blindness

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Diagnosis as sheep, goats, cattle, camels, donkeys, and wild
Diagnosis of taenia solium infections can be made antelopes. The eggs hatch in the animal‟s
by doing the following tests: intestine and penetrate through the intestinal wall
to the portal circulation. They are then carried to
 Biopsy examination of the infected tissue the liver and lungs where they form many cysts.
 X-ray examination to locate the calcified
cysticercus When a dog eats the diseased animal it becomes
 Stool microscopy for ova and cyst infected with these cysts, which then proceed to
develop into mature worms.
Management
The management involves both the surgical Human beings become infected when they
removal of calcified cysticercus where possible as accidentally ingest eggs from dog faeces. The
well as drug treatment with niclosamide 2gm. larvae migrate from the intestine to the liver or
lungs causing cysts. The larvae can also cause
The dose is 1gm chewed and washed down with cysts in other tissue in the body.
water followed one hour later by 1gm.

The prevention and control of taeniasis can be

achieved through the following simple measures:

 Proper disposal of human faeces in toilets

instead of in the field and within reach of
cattle and pigs
 Ensuring that beef, pork and fish are
thoroughly cooked
 Eating only meats that have been
inspected
 Burying in deep pits or incinerating the
carcases of heavily infected cattle and
pigs
 Washing hands thoroughly after handling
carcases and raw meat
 Early diagnosis and treatment of infected
persons
Clinical Features
In the liver, the cyst grows slowly over time
thereby enlarging the liver. The abdomen may
Hydatidosis (Hydatid Disease)
also become grossly distended.
The hydatidosis disease is actually a disease of
Diagnosis
dogs (zoonotic).
This is done through a chest x-ray or an
abdominal ultrasound investigation. A serological
Human beings become infected only by accident.
Nevertheless, the disease is a serious problem test can also be done to assist in making the
among the Turkana community of northern Kenya. diagnosis.

It is also known as echinococcosis or Management

hydatid disease. The treatment of hydatid disease can either be
medical or surgical.
Mode of Transmission
The medical treatment is as follows:
Hydatidosis is caused by the cysts of the dog
tapeworm known as Echinococcus granulosis.  Oral albendazole 20mg/kg in divided
Dogs and other carnivores such as jackals and doses twice daily for 30 days (The cure
lions are the hosts of the dog tapeworm. rate with this treatment is 20%). The
treatment can arrest the growth of the
cyst and reduce its size
The eggs are passed in the faeces of an infected
dog and ingested by domesticated animals such

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  PAIR (Puncture, Aspiration, Instillation of Similarly in other diseases like rabies and
95% alcohol and Re-aspiration). This is brucellosis, the disease transmission ends with
the treatment for the liver or spleen. The mankind, though possibilities of further
ultrasound machine is used to guide the transmission can occur if for example, a rabid
PAIR procedure. This treatment is very patient bites another person, or a patient with
effective and has a high cure rate brucellosis accidentally transmits it to another
person.
The surgical treatment is known as
endocystectomy. It is the surgical removal of the In this section you will cover anthrax, rabies and
cysts contents, especially those cysts that are brucellosis, looking at their mode of transmission,
easily accessible like abdominal cysts. clinical picture, diagnosis, management and
prevention.
Prevention and Control Zoonoses are transmitted between animals and
The prevention and control of the hydatid disease humans through the following means
can be achieved by eradicating stray dogs and
deworming them. Deworming should be done Vectors
every six weeks with praziquantel. These include:

You should also provide health education on the  The rat flea which transmits plague
dangers of close contact with dogs (licking), among rats and
especially among children. Also, infected meat other rodents
should not be fed to dogs.  The tsetse fly which transmits
trypanosomiasis among game animals
and nagana in cattle
SECTION 8: DISEASES FROM  Mosquitoes which transmits yellow fever
CONTACT WITH ANIMALS OR among monkeys
ANIMAL PRODUCTS (ZOONIC Ingestion of Contaminated Material
DISEASES) Ingestion of meat or dairy products from sick
animals, leading to diseases such as:
Introduction
In this section you will look at infectious diseases  Anthrax (meat from cattle and
which are transmitted between animals and game animals)
humans.  Brucellosis (milk from infected cattle)
 Taeniasis (milk and meat from infected
Objectives cattle and pigs)

Animal Bites
By the end of this section you will be able to: Bites, resulting in diseases such as:

 List three diseases transmitted through  Rabies (from rabid domestic and wild
contact with animals or animal products dogs or foxes)
 Describe the management of zoonotic
diseases namely; anthrax, rabies and
Direct Contact with Infected Animal
brucellosis
Close contact resulting in diseases such as:
 Describe the control measures of zoonotic
diseases
 Hydatidosis (close contact with infected
domestic dogs or other carnivores)
Diseases from Contact with Animals
 Cutaneous anthrax (contact with infected
cattle or their products)
Diseases that are transmitted between infected
vertebrate animals (animals with a backbone) and
humans are called zoonotic. Anthrax

In some of these diseases, humans are usually Anthrax is an acute bacterial disease of
the last in the transmission cycle or the final host herbivores (plant eating animals). However, it
as in the case of hydatidosis, unless of course the occasionally also infects human beings especially
person‟s body is eaten by a predator. those who process hides, skins and wool or work

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in slaughterhouses. Anthrax is caused by a rod specimen (fluid from vesicles, sputum or stool) for
shaped bacteria (bacilli) called bacillus anthracis. a culture to confirm gram-positive rods

The disease can occur in large numbers among Management

cattle (epizootic), especially during drought and Bacillus anthracis responds to penicillin and most
flooding when they are moved from one place to other antibiotics.
another. In humans, this infection takes various
forms depending on the route of entry. Patients with anthrax of the respiratory tract need
respiratory support and oxygen therapy in a high
There is anthrax of the skin which affects people dependence care unit.
who handle cattle, anthrax of the lungs which
occurs in people working with infected wool; and Those with anthrax of the digestive tract may
anthrax of the bowels which affects families who need fluid replacement due to diarrhoea and
eat the meat of dead animals. vomiting

The type of disease caused depends on the route Prevention and Control
of entry of the bacillus or its spores. In animals, Although the main responsibility for the prevention
anthrax causes a fever which is followed by and control of anthrax falls on the veterinary
septicaemia and death. Vultures, which feed on department, you as a health worker also have a
the dead animal can spread the spores. role to play.

Mode of Transmission You should ensure that all meat offered for sale is
The bacillus anthracis forms spores when inspected and educate the community on proper
exposed to the air. disposal of all infected animals. The carcasses
The spores can survive for years in the soil even must be burnt or buried two meters deep in the
under harsh weather conditions. The spores enter ground in calcium oxide powder (quick lime).
the animals orally (through the mouth or
ingestion). Other measures include annual vaccination of
cows at risk, proper disinfection of hides and
The body of a sick or dead animal contains skins, and vaccination of members of the
millions of anthrax bacilli. These bacilli are shed community who are at risk of getting anthrax.
through animal urine, droppings, saliva milk and
blood.
Rabies
If any of these body fluids are touched or the meat
of an infected animal eaten, a person becomes Rabies is a serious viral disease of canines which
infected with anthrax. is incidentally transmitted to humans by the bite of
a rabid animal.
Clinical Features
The clinical features depend on the route of entry It is caused by a virus known as lassa virus type I.
of the The disease is of public health importance
anthrax bacillus. because it has a case fatality rate of 100%. If a
patient is not treated immediately after the bite,
once the clinical signs appear it is too late.
Skin or cutaneous anthrax presents with a
malignant pustule with a black necrotic centre.
The wound is usually painless and has swollen Rabies is found all over the world and in canines.
edges. Skin anthrax has low mortality. It occurs all the time and in great numbers
(enzootic and epizootic). In human beings, rabies
is a zoonotic disease, and humans usually do not
Respiratory tract anthrax on the other hand has a transmit it any further.
high mortality rate and presents with severe
respiratory distress and shock.
The main reservoirs of lassa virus type I are
felines, hyenas, and mongoose.
Digestive tract anthrax is characterised by fever,
sepsis, watery diarrhoea and vomiting.
Mode of Transmission
Diagnosis
The rabies virus is transmitted to humans through
The diagnosis of anthrax is made by taking a the saliva of an infected animal such as a dog or
cat.

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This happens when humans get bitten by a rabid reach this stage do not survive for more than a
animal or when its saliva comes into contact with week.
the mucous membranes or open wound of a
person. Diagnosis

The main reservoirs of the disease are wild Diagnosis of rabies is made if a person is bitten by
animals such as mongooses, jackals and hyenas. a dog with abnormal behaviour and without any
These wild animals infect domestic animals provocation. In addition the presence of negli
including cattle, donkeys and horses, which in turn bodies in the brain of a suspected animal should
infect mankind. confirm the disease.

In North and South America, rabid bats have been Management

known to infect humans. All warm blooded
animals are susceptible to rabies. There is no cure for rabies once the disease has
started. It is however possible to prevent it from
Clinical Features reaching that stage by doing the following:

The incubation period of rabies ranges from two Post Bite Prophylaxis
weeks to a year, with an average of two to three Immediately someone is bitten you should give
months. The length of the incubation period is first aid treatment of the bite with the aim of
influenced by the following factors: removing as much virus as possible. This involves
immediate flushing of the wounds and scratches
 The size of the bite - the deeper the bite preferably with running water and washing the
the shorter the incubation period surrounding skin with a lot of soap and water.
 Distance of the wound from the brain - the Puncture wounds should be irrigated with a sterile
nearer the wound is to the brain the catheter using methylated spirit and povidone.
shorter the incubation period Iodine is also virucidal and may be used to clean
 Type of wound - if the wound is big with the wound.
extensive tissue damage the shorter the
incubation period Bite wounds should not be sutured immediately to
prevent more traumas from the suturing needle,
The earliest symptoms usually consist of which will increase the areas for viral entry into
increasingly severe pain in the bite wound, the body tissue. Suturing may be done 24 to 48
depression, irritability, nausea, sore throat, hours after the bite using very few sutures under
headache and loss of appetite. the cover of anti-rabies serum locally.

Later, two clinical presentations emerge: Anti-Rabies Vaccine

This is a very safe and effective treatment
following a rabid animal bite.
Furious rabies whereby the infected person The vaccine HDCV (Human Diploid cells tissue
develops convulsions, intense fear of death and Culture Vaccine) is administered in
irrational excitement, which alternates with six doses sub-cutaneously as follows:
periods of alertness and calmness. The patient is
also unable to tolerate noise, bright light and cold
drought (aerophobia - fear of cold air). There is 1ml immediately after exposure (day 0), 1ml on
increased reflexes, muscle spasms, excessive day 3, 1ml on day 7, 1ml on day 14,
sweating, dilatation of pupils, excessive salivation 1ml on day 30, 1ml on day 90.
and lacrimation. The patient develops intense
hydrophobia (fear of water) because of the Other Drugs
intense pain experienced when swallowing water In order to prevent wound infection and tetanus
due to spasms of the pharyngeal muscles. This you should give the patient broad spectrum
stage is also known as the „furious‟ rabies stage antibiotics.
and it lasts for two to three days and sometimes
for five to six days. Death usually occurs due to Prevention and Control
cardiac or respiratory failure during a convulsion.
Rabies is a notifiable disease. It is very important
The next stage is the paralytic rabies stage which to give immediate first aid to a person who has
is characterised by paralysis of muscles causing been bitten by a suspect animal.
paraplegia, quadriplegia and coma. Patients who

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In addition, you should educate the community Blood cultures rarely give positive results but a
members on the importance of immunising their bone marrow aspirate culture gives better yields
domestic dogs and cats every three years and of up to 90%. Full haemogram - normochromic,
eliminating all stray dogs and cats. normocytic anaemia, neutropenia and
lymphocytosis is common.
Brucellosis
Treatment
Brucellosis is a zoonotic disease or disease of The treatment of brucellosis is doxycycline 200mg
animals. It is caused by a bacteria called brucella daily for 14 - 21 days and cotrimoxazole tabs 2
melitensis in goats, sheep and camels, brucella bd. for 14 - 21 days.
abortus in cattle and brucella suis in pigs. All
these bacteria however can be transmitted to Prevention
mankind causing brucellosis You should educate the community and especially
farmers on the importance of boiling or
Distribution pasteurising milk.
Brucellosis has a worldwide distribution,
predominantly in rural areas among pastoral Animal handlers and those at special risk should
communities. be advised to take extra precautions.

It is also an occupational health hazard of UNIT FIVE: COMMUNITY

farmers, veterinarians, abattoir workers and
butchers.
DIAGNOSIS

Transmission In this unit you will cover the concept of

Brucellosis is transmitted through ingestion of community diagnosis and how to help a
unpasteurised milk or milk products such as community manage its health problems.
cheese.
This unit is composed of five sections:
It can also be transmitted by contact with blood,
urine, tissues, through splashing of amniotic fluid Section One: Concept and Purpose of Community
or milk on the conjunctiva and blood transfusion. Diagnosis
Section Two: Planning a Community Diagnosis
Clinical Presentation Section Three: Developing and Pre-testing Tools
The incubation period takes about two to four for Data Collection
weeks. Initially the signs and symptoms are non- Section Four: Execution of the Survey, Data
specific and include the following: Analysis and Presentation
Section Five: Report Writing, Dissemination and
Community Action
 Headaches
 Fever
 Weakness
Unit Objectives
 Anorexia
By the end of this unit you will be able to:
 Rigors
 Night sweats
 Constipation  Describe the concept and purpose of
community diagnosis
 Explain how to plan a community
Patients may also complain of pain in the large
diagnosis survey
joints like the hips and knees although any other
 Describe how to develop and pre-test
joint may be affected. Hepatomegally,
tools for
splenomegally and lymphadenopathy may also be
data collection
present. If untreated, the disease can continue for
many months and the patients may become  Explain how to execute a survey
depressed.  State how to write and disseminate a
community diagnosis report and plan
community action
Diagnosis
A serological diagnosis of brucellosis can be
made by doing an agglutination test in dilutions. A
level of 1:160 or above is associated with the
infection.

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SECTION 1: CONCEPT AND dependency, lack of self-initiative to improve
themselves or even a belief that they are helpless.
PURPOSE OF COMMUNITY
DIAGNOSIS Luckily, this notion has changed. It is now realised
that people have the ability to help themselves if
they are given some facilitation or guidance.
Introduction People want to be independent and self-reliant. It
is also true that people tend to cherish and care
When you care for an individual patient, you make for what they have acquired through a struggle.
a patient diagnosis and organise the appropriate Such involvement empowers individuals and
treatment. Similarly, in order to look after a makes them resourceful and self-reliant.
community you must make a community
diagnosis and organise appropriate community
The community diagnosis concept therefore
health programmes. It is therefore important for
stresses that the community must identify its
you to learn the approaches to community
problems, prioritise them and draw a plan of
diagnosis and what its purpose is, and how it
action to address the identified problems. The
differs from patient diagnosis. You will also learn
community then implements this plan to resolve
the terminologies used in community diagnosis.
the problems. It emphasises total community
involvement. This is because the community
Objectives knows its problems and priorities better than the
health worker. When they actively participate in
By the end of this section you will be able to: solving these issues they become bound by the
decisions they make and feel motivated to see the
 Describe the concept of community plans through.
diagnosis
 Explain the difference between patient Sometimes, one of the problems you experience
diagnosis and community diagnosis as health workers is that communities may be
 Explain the purpose of community more concerned about water or access to markets
diagnosis than they are about medical problems. In such
 Describe the terminologies used in situations, you need to look at all aspects of
community diagnosis community development, that is, adopt an
intersectoral approach, so that the real needs are
The Concept of Community Diagnosis tackled

Community diagnosis is a process through which There is no need to rush into a programme before
health workers together with members of the there is understanding and commitment. This will
community identify the community‟s priority health just lead to failure. Sometimes you may even
problems, and together make plans of action and have to show your willingness and interest in what
implement them. It points out where the health the community wants before you can concentrate
services should put their main efforts and on the main health problems.
resources. You learnt in unit three on Primary
Health Care (PHC), a community‟s full As health workers, you talk all the time about
participation depends on the four concepts of patient diagnosis. Is this the same as community
PHC or the 4As. diagnosis? Move on to look at the difference
between patient diagnosis and community
diagnosis.
The four A‟s are acceptability, accessibility,
affordability and availability using appropriate and Patient Diagnosis versus Community
local technologies. In the past, professionals Diagnosis
including health workers always considered
themselves experts on various issues. Health In your basic training and in unit one of module
workers would visit a community and without one you learned how to diagnose a disease in a
consultation, impose certain sanctions or patient.
treatments without the community‟s consent. Also,
some communities have received assistance
particularly when there is a disaster and then
been abandoned without being helped to address
the causative factors. This has often resulted in

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Steps you would follow when making a patient and plan a community health programme or
diagnosis treatment to solve these problems.

 Collecting basic information or history This is because health centres often have limited
taking resources and many demands on those
resources. There are simply not enough
 Planning a programme or diagnosis
resources to solve all the health problems in the
 Implementation or treatment
community. Therefore, the health care worker
 Follow up and evaluation together with the community must select priorities
for health action. Remember, it is important to
Patient Diagnosis Steps choose only those problems that the community
can do something practical about with the help of
1. Greet and welcome the patient and give the local health team (health centre or dispensary
them a seat. staff).
2. Ask for the patient's name, age, sex,
marital, status and patient's residential The final step is follow up to evaluate the
address. programme and see if it has made the community
3. Take history including details of the healthier. You can evaluate an activity by counting
patient‟s progress so far. or measuring things or simply by using your
4. Perform a physical examination. judgement. For example, to evaluate whether
5. Carry out or request special nvestigations. women are attending your antenatal clinic, you
Make a differential diagnosis, followed by can check how many of the total number of
a specific diagnosis once results of pregnant women in your catchment area attend
investigations are confirmed. You may the clinic. You can also assess whether they are
even state the expected outcome satisfied with the service by talking to women who
6. Prescribe the most appropriate treatment. attend the clinic and also to some who don‟t.
7. Give the patient a date to return for
review. A patient with an acute condition The tools you use in patient diagnosis are,
should be for example:
hospitalised for monitoring and review.
Depending on the presenting signs and
 Sphygmomanometer (BP machine)
symptoms, each time they are reviewed
their diagnosis may change.  Stethoscope
8. As the patient improves discharge them  Weighing scales
 Thermometer
 Chairs
Remember: People are individuals, no two
 Record books
people are alike. Some may have started
treating themselves before coming for your
In community diagnosis, you use survey tools
help. for example:
In community diagnosis, you follow the same
basic steps as the ones you have seen in patient  Maps
diagnosis. The only difference is that the amount  Weighing scale
of data is much greater and requires more lengthy  Specimen bottles
analysis and processing.  Questionnaires

In community diagnosis you start by collecting Now you have looked at the difference between
basic information. You collect information patient diagnosis and community diagnosis. You
about the following: can now consider the purpose of conducting a
community diagnosis.
 Local people and their environment
 The number of people and their Purpose of Community Diagnosis
distribution
 The diseases the local people suffer from The main purpose of carrying out a community
 The organisation of local health services diagnosis is to collect information on the following:

You then make a community diagnosis by  Demographic data plus all the vital
identifying the main health problems and the health statistics
reasons for them. Identify priority health problems

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  Utilisation of health services especially of infant deaths during calendar year by the number
maternal and child health clinics of live births in the same year
 The causes of morbidity and mortality (by
age and sex) Crude Birth Rate
 State of nutrition, diet, weaning patterns This is the number of births per 1,000
and the growth of preschool and population. It is calculated by dividing the total
school-going children number of births in a year by the
 Patterns of leadership and communication mid-year population.
within the community
 State of mental health and common Crude Death Rate
causes of stress This is the number of deaths in one year per
 State of the environment including water, 1,000 population. It is also called Crude Mortality
housing and disease vectors Rate. It is calculated by dividing the total number
 The community‟s knowledge, attitudes of deaths (D) by mid-year population (P) and
and practices (KAP) in relation to expressed per a
health-related activities thousand population.
 Epidemiological details of
Rate of Natural Increase
endemic diseases
RNI in a country can be calculated by finding the
 Available resources and services for
difference between birth rate and death rate per
overall development of health-related
1,000 then expressing such a difference as a
activities for example, education,
percentage. It is the percentage annual rate of
agriculture, veterinary and social services
population growth without regard for migration.
 Socio-cultural and socio-economic class
divisions within the community
(social stratification) A negative number means the death rate is
greater than the birth rate and so the population is
decreasing.
Although a community diagnosis can yield a lot of
data, it is not possible to collect it all in detail.
Therefore, you need to tailor your survey to suit Dependency Ratio
the specific information you want to collect. This is the ratio of (potentially) economically active
population to the retired population and children
Terminologies Used in Community under 18 years of age, giving a rough estimate of
the number of depedants per worker. It is
Diagnosis
calculated by dividing under 18's and over 64's by
Many of the terminologies used in community 18's to 64's.
diagnosis have already been defined in unit one,
section one and three of this module. In addition to the terminologies listed, there are
two other terminologies used in community
diagnosis, namely, indicators and variables.
Community health
Indicators
Community health is the science and art of Events or facts that can be measured to reflect
promoting health and preventing disease through the health status of an individual or community.
organised community participation
Variable Part 1
Incidence
Gives information on the number of new cases of Characteristic within the study sample whose
a disease or condition occurring over any value changes among the study subjects. It is an
specified time. observation made on the study subjects. Often
two or more observations are made on a number
Prevalence
of subjects. These observations either increase or
Gives information about the total number of cases
of a disease or condition at a particular time; decrease simultaneously or at varying levels. The
whether new or old. two or more observations are called variables and
their relationship is called correlation. For
Infant Mortality Rate example, in a study of youths you may decide to
This is the probability of dying between birth and observe their age and weight. In this case, the
exactly one year of age expressed per 1,000 live weight and age are the variables. There are two
births. It is calculated by dividing the number of

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types of variables, namely, independent and  Describe the process of community
dependent variables. In the example just given, diagnosis
age is an independent variable while weight is a  Explain how to conduct initial exploration
dependent variable. Independent variables are and interaction with the community
plotted on the horizontal axis of a graph while a  Explain how to plan a community
diagnosis survey
dependant variable is plotted on the vertical axis.
 Describe how to select a representative
sample for the survey
Variable Part 2

The Process of Community Diagnosis

Variables can also be described as qualitative or
quantitative. Quantitative variables are expressed The process of community diagnosis requires
in numerical terms. For example, age, height, careful planning right from the beginning. It
area, weight and so on. Qualitative variables are involves initial exploration and interaction with the
adjectives that describe the subject of study, for community, planning of the survey, developing
example, farmer, teacher, nurse, male, female, and pre-testing the survey tools and methods, and
green, yellow, white, sadness, happiness, executing the survey and analysing the results.
Once all the information has been gathered it
satisfaction, religion.
must be documented and its conclusions
disseminated to the community. The process of
Ethical Considerations in Community community diagnosis is made up of the following
Diagnosis steps:
When conducting community diagnosis, it is very
important to avoid taking any action that may be
1. Exploration
considered offensive by the community. You need
2. Planning of the survey
to make sure that the tools you use to collect
3. Developing and pre-testing survey tools
information are not in any way offensive to the
4. Execution of the survey and data analysis
community. They should not cause any physical,
5. Report writing, dissemination and
emotional, spiritual or cultural harm to
community action
that community.
In this section you willl only learn the first two
You should consider some of the following:
steps, that is, exploration and how to plan a
survey. The rest will be considered in subsequent
 Obtaining permission to enter into the sections of this unit.
community boundaries
 Obtaining informed consent before
interviewing patients, families or groups
Exploring the Community (Community
 Establishing rapport before exploring Inventory)
sensitive areas Exploration simply means mapping out of a
 Ensuring confidentiality of the data community in order to learn or discover about it. It
collected is also known as community inventory. Ideally,
 Selecting good interviewers you should only carry out a community diagnosis
 Training interviewers after a request by the community or the people
involved in providing health care. The exploration
phase is made up of three main activities:
SECTION 2: PLANNING A COMMUNITY
DIAGNOSIS  Seeking permission and informing the
various leaders
Introduction  Seeking reactions of members of
Welcome to section two of this unit on community the community
diagnosis. In the last section you covered the  Gathering background data about
concept and purpose of community diagnosis. In the community
this section you will learn how to plan a
community diagnosis survey. Now look at the Although these activities are listed separately,
objectives of this section. they actually can take place at the same time.

Objectives You will now look at each activity in turn.

By the end of this section you will be able to:

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Seeking Permission and Informing Authorities the population and maps of the area. The District
in the Community Education Officer will give information about
educational activities and literacy levels of the
For the survey to succeed you must seek community members. Other district heads will give
permission from community leaders. information related to their areas of jurisdiction.
Although some of the records might not contain
the most recent data, you can make projections
Start by channelling your request through the
official hierarchy of administrative leaders in by estimating the current population figures in
that community: the community.

Similarly by looking at other government reports

 Health personnel such as Medical Officer
you can gather information regarding the climate
in Charge
and weather conditions, water sources and the
 Governmental officials such as Chiefs or road network. The older people in the community
District Officers are a little used resource and yet they can provide
 Community leaders through, for example, you with a lot of information on the community‟s
the village health committee history.

You should approach all these people, introduce

yourself and clearly state the objectives of the
survey and your plan of action. Remember, for Gather information as you move around the
them to give you permission to proceed they need community by:
to understand what you intend to do and how it
will benefit the community.  Questioning
 Observing
So be well prepared. The community leaders are  Smelling
extremely important to the success of the survey  Listening
as they clearly understand what, how, when, and
why things happen. They also influence other You should also look at findings of previous
members of the community more directly than surveys so that you can adequately address any
administrators who do not live in the community. new problems.
You should therefore seek their assistance in
implementing the survey. They will only cooperate Once you explore the community and gather all
if they perceive some beneficial results from their the information you need you are now ready to
cooperation. So you should always plan a survey plan your survey.
with the intention of carrying out an appropriate
action programme for the community.
Planning the Survey
Seeking Reactions of Members of
This is a very important part of the process of
the Community
community diagnosis. There is a popular adage
which says ‟If you fail to plan you plan to fail‟. So if
During this period of exploration, you also sound you fail to plan the survey carefully and properly,
out the reactions of members of the community. your study will be unsuccessful or will give you
This can be done by talking to people informally in unreliable results.
market places and eating places. This way, you
will easily find their opinions or problems in the
During the planning phase, you should attempt to
community and their likely solutions. Also by
answer the following questions.
talking to them you can gather information
regarding possible resistance to the survey and
how to approach different members of the Why is the Survey Being Done?
community.
A survey is not carried out just to obtain
Gathering Background Data interesting information. There must be good
reasons and the reasons must be useful to the
community. This question must therefore be
The period of exploration also presents you with
answered to the satisfaction of all the leaders who
the opportunity to gather background data about
are concerned with the community.
the community. For instance, the Medical Officer
of Health in charge of the district will give you an
overview of the health profile of the district. The If the community has given you permission to
District Commissioner will give you boundaries, carry out the survey, it will expect and have a right

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to expect some beneficial results from its consulting the community members so that they
cooperation. You should therefore plan the survey are prepared for you.
with the intention of carrying out a proper action
programme for the community. This information What Will be Covered in the Survey?
would most likely have been communicated
during the exploratory phase. This will depend on what you want to learn about
the community‟s health status and the information
Once the community leaders understand the you have gathered during the exploratory phase.
reasons and are ready to cooperate with you, a
meeting of the members of the community should However, some topics like nutritional status of
be called to explain why there is a survey, why children under five are often covered in a
they have been chosen, what will be involved, community diagnosis survey. Think of some of the
when it will be done and what will happen to the common health problems that you see in your
results. During this meeting you should invite area for; children under five years, women aged
government, health and community leaders so from fifteen to forty nine years, and older people
that the community can see who is supporting of sixty years and over.
your work and who will be moving around their
community and homes. You will agree that each group of people has its
own unique problems. It is important to find out
Where Will it Take Place? what these problems are and then decide with the
community which problems are the most
You will have made this decision right at the important.
beginning when exploring the community and
seeking permission from various community and Some of the specific areas that surveys
government leaders. address include:

Who Will be Interviewed?  Screening people for diseases

 Seeking to understand and identify ways
It is usually not possible to interview everybody in of getting rid of negative cultural beliefs
a community unless of course it is very small. You and behaviour that is causing ill health in
will therefore need to select a sample from the the community
total population which will be considered  Assessing the utilisation of the available
representative of what is happening in the entire health services
population. The sample could be made up of
individuals or households depending on the Why are certain variables included and others
available resources and time. There are certain
left out?
techniques used to choose a sample. These are
covered in detail later in this unit.
Although it is your responsibility to determine what
It is also useful to talk to the local opinion leaders is included or omitted, it is very important to
such as, the chief, village elders, members of explain the reasons to leaders and members of
organised groups such as church leaders and the community. If you do not explain this clearly
traditional healers, professionals in the area such they may become disappointed and stop
as teachers and medical staff, and other cooperating with you.
extension workers.
What instruments will be used to measure the
When Will the Survey Take Place? community’s health status?

If you intend to visit people at home, then you Usually questionnaires are used to cover most of
should avoid days when people are less likely to
be at home, such as market days. It is important the topics. However, in some instances,
to choose carefully the days when the anthropometric measurements, physical
interviewers will be in the field in order to ensure examination and laboratory tests may also be
that they find the people they want to interview. necessary. You will cover questionnaires in more
The exercise should also not coincide with detail later in this section.
seasons of important community activities such as
planting, circumcision etc. Ideally you should
decide when to conduct the survey after

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How will data be collected and with what  Be able to establish good rapport with
resources? individuals, families or groups they will
meet
To answer this question you will need to specify  Be good listeners and sensitive towards
the tasks that need to be done and then identify other people's feelings
who will do them and how long it will take them.  Be able to relate well to the community
Consider the members
following factors:
You should impress on the interviewers the value
 Time to travel to the study area of working well with all sections of the community.
 Time to locate the groups If one of your tools addresses a specific group like
 Time and number of times each group will the youths, you should select an interviewer of the
be visited. Allow time for following up same age or sex who can identify with the group.
defaulters This helps to elicit the salient points from their
 Calculate the number of interviews that responses. Whenever possible, select people who
can be completed in a day speak the language of the study group.
 Calculate the number of days that will be
needed to complete the whole sample The people who are selected as interviewers have
 Calculate the time needed for other parts different educational backgrounds from yours and
of the study for example five days for may interpret questions and answers differently.
preparation and So you must train them on how to administer the
pre-testing and twenty days for actual survey tools. When training interviewers you need
work to explain the following:

How do we select and train the official  The purpose of the survey
interviewers?  The method to record the various
expressions used by people to answer
Ideally, the interviewers should come from the particular questions
community so that they are well known to its  The procedure they should follow to get
cooperation from the people being
members. School teachers, school children,
surveyed
health centre staff, village elders and young
educated people are some of the people who can If you intend to use a questionnaire you should go
help you to survey your area and fill in the through it several times with the interviewers to
questionnaires. However, if your interviewers are ensure that they all have a common
not from that community, then you will need to understanding of the questions and are able to
introduce them to the community leaders and if ask them properly. The interviewers should
possible to the community members in a public understand the need to follow the questionnaire
closely and in a standardised manner. If each
meeting. Once the survey begins, they should
interviewer asks questions in their own manner
wear identification badges and the answers will be unreliable because they may
introduce themselves. refer to different things.

Remember: It is advisable to over estimate the During the training you should hold mock
time needed for data collection to allow for interviews with the interviewers so that you can
unseen delays. ensure that each one of them can handle the
assignment. Use this opportunity to correct them
and also to clarify issues about the questionnaire
The people you select for training as interviewers such as wrong translations and questions. Once
should have the following qualities: you are confident that your interviewers can
handle the job, you should carry out a trial test or
 Be literate and well known to the pilot test on a section of the community who have
community similar characteristics as the study group. This
 Have the ability to display the right gives them a feel of the real situation and helps
attitudes and opinions you to assess them further.
 Be able to explain the questionnaire
effectively to the community Remember that the pilot group should not be
 Be able to use the tools presented in included in the study group.
your package

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Interviewers should conduct themselves in an This must be clearly defined for example,
appropriate manner when approaching according to age, sex, or residence. A study
respondents. The points below should be population may also be selected for example,
followed: according to villages, institutions, records. Each
population is made up of study units identified by
 Establish rapport by greeting the the type of problem that you want to study.
respondents and introducing themselves
 Explain carefully why they have come and A study population can be divided into two main
what is the purpose of the survey groups, namely, accessible population and the
 Ask if they are welcome to interview the representative sample.
family and if it is convenient for them at
that time The accessible population is a group of
 Explain that they will be recording the individuals, objects and events with characteristics
information comparable to the target population and relevant
they collect to the study.
 Emphasise that all information collected is
confidential The representative sample is a group from the
 Give them a chance to ask questions for study population, which has all the
clarification important/relevant characteristics of the total
population.
Having planned your survey and trained your
interviewers, you now need to identify a
representative sample which will answer your
questions and provide you with the information Sampling Methods
and results you need. You will now look
at sampling.
Before you sample you need to develop a
sampling frame. A sampling frame is a list of all
Sampling for a Survey units that make up the study population. It enables
you to sample the study units in such a way that
Sampling is the process of selecting a number of the probability or the different units to be selected
individuals or units of the study population in such in the sample are known. Sampling techniques fall
a way that the individuals selected represent the under two main groups, namely, probability
larger groups from which they are selected. You sampling and non probability sampling.
will agree that it is neither practical nor
economical to survey a whole population. That is You will now consider each group starting with
why the part of the population studied is called a probability sampling.
sample. The aim is to get the the same
information from that sample that you would have Probability sampling looks at the entire group of
got if the whole population had been surveyed. individuals, events or objects that have common
For this reason, when you are selecting a sample observable characteristics. It has been found to
for a survey, you must make sure that it is give accurate results when one is studying groups
representative of the whole population. that are too large to study in their entity. It also
provides you with an efficient system of capturing;
Also, in the sampling process you have to give an in a small group the variations or similarities that
equal chance for each person in the population to exist in the target population.
be included in the sample. Otherwise you can
come to wrong conclusions.
Probability Sampling
A Study Population
The following are the most commonly used
methods in probability sampling:
A study population is the entire group of
individuals, events or objects that have common
observable characteristics. For example:  Simple random sampling
 Systematic sampling
 Stratified sampling
 All first years in nursing
 Cluster sampling
 All under fives in a given community
 Multi-stage sampling
 All qualified nurses with mental
health qualifications
You will now look at each in turn.

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Simple Random Sampling samples in order to enable you to capture the
variable aspects of each subgroup.This method is
This is the simplest form of probability sampling. It used when the study population is very variable,
means that every sampling unit in the population
for example, different ethnic groups, different
has an equal chance of being included in the
sample. You can draw a simple random sample ecological areas, or age groups. It allows you to
using the following steps: subdivide the population into sub populations
which are more homogeneous.You then apply
 Make a list of all the units in the simple random sampling to each subgroup
population to be studied or stratum.
 Decide on the sample size
 Select the required number of units using Cluster Sampling
ballot or lottery method or random
numbers In this method, you randomly select groups or
clusters and not the individuals or cases. This
For example to draw a random sample of five method is used when it is not possible to obtain a
patients from a list of 250 using the ballot method, sampling frame because the population is either
you follow
too large or scattered over a large geographical
this method:
area. In cluster sampling you select an intact
group and include all the members of that group in
 Give each client a number (1 - 250)
 Write them on a small piece of paper the sample. For example, say you want to study
 Fold them individually and put them in a patients suffering from malaria in your district. It
box would be expensive and time consuming to
 Shake the box vigorously to mix them compile a list of all malaria patients who have
 Pick five pieces one by one and note the been hospitalised in your district.
numbers and record
So the logical thing to do would be to list all health
Each patient is a unit and the names of the facilities in your district and then randomly select
patients on these numbered papers form the them according to your sample size. Once you
sample or study population. select them, you would then include all the
malaria patients in those health facilities in your
Systematic Sampling sample.
Here you first decide the sample size you want The methods of sampling you have just covered
and then proceed to select the individuals or units
using a systematic method. are known as probability sampling. You will now
look at another group of sampling methods known
For example, let us assume that the population as biased sampling or non-probability sampling
size you want to study consists of 1000 women. methods.
Out of this population, you only want to pick a
sample of ten women for your study. This gives Non Probability Sampling Methods
you a ratio of 1:100 or a sample fraction of 1/10.
Non probability sampling methods are used when
Now, with this ratio you can proceed to pick the a researcher is not interested in selecting a
sample population as follows: sample that is representative of the population.
They are mainly used in qualitative studies where
 Select the first file randomly. Let us the focus is on in-depth information rather than
assume that you have selected file making generalisations. Some examples of non-
number 25. probability sampling methods are convenient
 Starting with file no. 25, proceed to pick sampling, quota sampling and purposive
every 100 file, that is, file 125, 225, 325, sampling.
525, 625, 725, 825, and 925. You now
have your random sample of ten files. You will now look briefly at each method.

Stratified Sampling

This is dividing the sample frame into smaller sub

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Convenience Sampling samples tend to have higher sampling errors than
large samples.
In this method, you select cases or units of
observation as they become available. SECTION 3: DEVELOPING AND PRE-
For example, a health worker wanting to study
TESTING TOOLS FOR DATA
attitudes of villagers towards family planning may COLLECTION
decide to interview all adults visiting Maternal
Child Health or Family Planning (MCH/FP) clinic Introduction
on that day. Such a sample is useful for giving a
first impression of a situation. However, it is not Welcome to the section three of this unit on
representative of the community. This sample is community diagnosis. In section two you learnt
considered unrepresentative because some units about community exploration and how to plan a
can easily be missed out or under selected. survey. You also looked at different sampling
techniques which can help you to select a
Quota Sampling representative sample for your survey.

In this method, the researcher simply selects In this section you will consider yet another step in
subjects to fit in identified quotas, say for the process of community diagnosis. You will look
example, a certain religion or social class. Quota at how to develop and pre-test tools for
data collection.
sampling ensures that various groups or quotas of
the population are included in the study according You will start by looking at the objectives for
to some criteria. The selection is not random as this section.
the individuals are just picked as they fit into
the identified quotas. Objectives
Purposive Sampling By the end of this section you will be able to:

Here the researcher simply picks individuals or  Name at least two tools that can be used
cases that have the information or characteristics during a community diagnosis exercise
which they requires. It is sometimes used in one  Explain how to develop a questionnaire
of the stages in the sampling procedure, for  Describe how to organise a focus group
instance, to get the location or district in which the discussion
units of observation have the required  Describe how to pre-test the survey
instruments
characteristics. Once the units are selected, the
researcher may then apply random sampling to
obtain the actual sample of cases. Tools

Tools are implements that help us with our work.

Bias and Sampling Errors
Before you embark on any procedure, you ensure
that you have all the tools you need to do it
As you noted in probability sampling, selecting a effectively and that they are in the best possible
sample requires special techniques which ensure condition. Similarly, before you embark on a
that each person in a population has an equal community diagnosis survey you need to ensure
chance of being selected into the sample. If a that you have all the tools and instruments you
sample is not randomly selected or if the need for measuring the community‟s health
interviewers do not follow a similar and consistent status. The tools used to measure a community‟s
method, there will be errors in the data gathered. health status are:
These types of errors are called bias. Further,
even when the sampling techniques which reduce
 Questionnaires
bias are correctly applied during the selection of a
sample, the results of the study may be subject to  Focus group discussions
another error known as sampling error. This is  Measurements, physical examination and
because within the small group selected to laboratory tests
represent a larger one, there may be people  Key informant interviews
whose characteristics are very different from
anyone else‟s in the same group. Very small You will now look at the first two tools in detail
starting with questionnaires.

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Questionnaire questions, you may end up with
'information overload‟.
A questionnaire is a set of standardised questions  Questions are acceptable to the people
designed to collect information about a specific included in the survey.You should view
aspect or issue in the community. It is therefore a the questions through the respondents
tool for collecting information. Information from a eye and ask yourself the following:
questionnaire helps you to make plans for your - Will the question be seen as
health services and to evaluate them. reasonable?
- Will it infringe on the respondents
Before you design a questionnaire it is important privacy?
for you to know what information you need to - Will the respondent be able and willing
collect and how it will be used. It would help you to answer the question?
to make a list of what you want to know. In other  Questions should not screen disease if no
words, what do you really want to find out or effective treatment can be offered for the
achieve with the questionnaire? cases found or if the condition is rare.
 Type of question should either be open-
or closed-ended.
Qualities of a Good Questionnaire
 Questionnaire must be pre-tested before
executing the survey. This helps to
A good questionnaire has the following qualities: identify and eliminate questions that are
defective or may lead to wrong
 Has simple and specific questions. Avoids information. You may even need to
wording that is above the vocabulary or rephrase the questionnaire so that it can
reading skills of the respondents. elicit the correct responses.
 Has short and precise questions. The
number of questions should not be too Types of Information
many or else they will put off the person
being interviewed. In other words, keep it
Questionaires can help you collect four different
short and simple (KISS).
types of information.
 Avoids use of abbreviations or jargon.
 Avoids questions that are too demanding
i. Understanding
and time consuming.
 Avoids bias in questions. Biased
questions influence people to answer in a Information about what people know or how well
way that does not accurately reflect their they understand something, that is, knowledge.
position. For example, a question like ‟Do For example, what is the major cause of
you agree with the majority of the people accidental deaths among children in the home?
that health standards are falling?‟ implies
that the respondent should agree. ii. Beliefs, Attitudes and Opinions
 Avoids making assumptions. Questions
such as ‟How many children do you Information about people‟s beliefs, attitudes and
have?‟ assume that the respondent has opinions. Here you would be asking people to
children. You should only ask this
share with you their thoughts, feelings, ideas,
question after establishing the situation
with the question ‟Do you have children?‟ judgment or their way of thinking. For example, in
 Avoids double questions. For example, your opinion does positive self-esteem prevent
‟Did the MCH talk help to identify ways to drug abuse among adolescents?
improve the sanitation and nutrition of
your children?‟ It is better to ask about iii. Behaviour
sanitation and nutrition separately.
 Has clear wording. Words such as Information about people‟s behaviour. That is,
majority, older people, regularly, might what people have done in the past, present, and
mean different things to different people what they plan to do in the future. For example,
and so should be avoided. have you ever attended an antenatal clinic?
 Questions ask about simple common
happenings. iv. Attributes
 Questions range from known to unknown
and from simple to complex. Information about peoples attributes. That is, their
 All the questions should relate to the personal or demographic characteristics. For
purpose of study. Eliminate ‟nice to know‟
example, age, education, occupation and income.

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When you design a questionnaire you should be Closed-ended Question
very clear about the objectives and type of
information you desire to collect. Otherwise you These are questions that offer the respondents a
may end up collecting peoples opinions when in list of possible answers to choose from. They are
actual fact you wanted to document their specific and useful when you are interested in
behaviour. certain aspects of an issue. Although they
produce more uniform answers than open-ended
Remember: The response or information you questions, they depend upon our knowing and
obtain is only as good as the question. To get including all the relevant answers in the list.
correct information you must ask the right
question. Example 1

What is your marital status? Tick the correct

Types of Question answer.
Single
A questionnaire should be laid out in such a way
that it provides easy flow from one topic to Married/living together
another. It should have both open- and Seperated/widower/divorcee
closed-ended questions. They should be arranged
in such a way that they allow natural flow of
discussion.

Example 2
Open-ended Question
Did you eat any of the following foods yesterday?
An open-ended question is a type of question that Circle ‟Yes‟ if you ate any of the foods listed.
allows the respondent to provide their own
answer. It encourages the respondent to think and 1. Peas, bean, lentils Yes/No
describe a situation in their own words. The 2. Fish or meat Yes/No
respondent is not given any answers to select 3. Eggs Yes/No
from. The answer given is best recorded in the 4. Milk or cheese Yes/No
respondent‟s own words. Although it is the easiest
way to ask for information the responses are not Example 3
easy to analyse. The answers are bound to be
varied and so you need to categorise How useful have the activities of the village health
and summarise them. committee been in the development of this
Open-ended questions are useful because they village?
give more information on: Tick the box corresponding with the correct
answer.
 Facts and details which the researcher
may not be familiar with 1. Extremely useful 3. Not very useful
 Opinions, attitudes and suggestions 2. Very useful 4. Not useful at all
 Sensitive issues
A good questionnaire should cover the following
The following are examples of open-ended topics:
questions:
 Measurement of the community‟s
1. What did the traditional birth attendants health status
do when your labour started?  Anthropometric measurements
2. What do you think are the reasons for the  Physical examination
high dropout rate of health committee  Laboratory tests
members?
3. What would you do if you noticed that Once your questionnaire is ready, your next
your daughter (a schoolgirl) has a challenge will be to pre-test it. However, before
relationship with her teacher? you look at how to pre-test your instruments, you
will look at the other type of tool used in a
As you can see, these questions require deeper community diagnosis survey, namely, focus group
thinking and provoke the respondent to elaborate discussions.
when responding.

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Focus Group Discussions (FGDs) You can use the method to see what the
community identifies to be major problems or
This is a group discussion that gathers together difficulties in existing programmes and incorporate
people from similar backgrounds or experiences their needs into the new programme. Focus
to discuss a specific topic of interest to the groups can give you an understanding of how
researcher. The group of participants are guided
appropriate the new plan may be in terms of
by a moderator (or group facilitator), who
introduces topics for discussion and helps the culture or technology.
group to participate in a lively and natural
discussion amongst themselves. Solving Specific Programme Problems

A focus group is not a group interview where a Sometimes programmes have been running for
moderator asks the group questions and some time and do not appear to be having the
participants individually provide answers. The expected impact. A focus group can be used to
focus group relies on group discussion and is
explore such issues and identify the problems that
especially successful where the participants are
able to talk to each other about the topic of may be hindering the success of the programmes.
interest. This is important as it allows the
participants the opportunity to disagree or agree
with each other. It can provide insight into how a
group thinks about an issue, about the range of
opinions and ideas, and the inconsistencies and
variation that exist in a particular community in
terms of beliefs and their experiences and Conducting a Focus Group Discussion
practices.
In order to conduct a successful focus group
The discussion is usually ‟focused‟ on a particular discussion you should adopt the following four
area of interest. It does not usually cover a large steps:
range of issues, but allows you to explore one or
two topics in greater detail. Step One: Preparation

First you recruit participants. Focus groups are

Focus Groups in a Community Diagnosis ‟focused‟ because the participants usually share a
Survey common characteristic. This may be age, sex,
educational background, religion or something
Focus groups can be used in the following ways: directly related to the topic. This encourages the
group to speak more freely about the subject
Exploratory Studies
without fear of being judged by others who are
thought to be superior. For example, young
Focus groups are a valuable method to explore a
women may not be as forthcoming in their ideas
topic about which little is known, or little has been
and opinions in the presence of their mothers or
written in the past. For example, in order to set up
mothers-in-law. The participants should have prior
a successful health education programme you
knowledge so that they can come prepared.
need to understand people‟s traditional health
beliefs. Focus groups can begin this process by Step Two: Physical Arrangment
providing the first in-depth descriptions of how the
community sees the cause and treatment of It is good to make sitting arrangements that allow
certain illnesses. Focus groups can also be used participants to see each other. Circular seating is
to discover local terms used for signs and the best as everybody can see each other. Avoid
symptoms of illness, types of illness, and other the traditional classroom type of sitting. Ensure
concepts relating to health. the room is well lit and ventilated and has
minimum or no disturbance so that the
Testing Ideas about New Programmes
participants can concentrate on the discussion.
The environment should promote talking and
In the planning phase of a new programme, it is
sharing.
possible to use focus group discussions to find out
what the community feels about the new plan.

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Step Three: Preparing a Discussion Guide questions. The facilitator should identify and
manage individuals who dominate the discussion
You should prepare a set of questions that will and deny others a chance to respond. One way of
help you to guide the discussion. These questions managing domineering members is to ignore them
should also allow free flow from one aspect of the and instead give attention to the other members
topic to the next in a relevant fashion. This helps when they want to give an opinion. Maintain eye
the participants to think logically and build on the contact with the shy ones and prompt them to talk
topic you are investigating. Have a mixture of by calling them by name and posing questions
general and more specific questions. If your directly to them. Build rapport and empathise as
questions are all general, you may not elicit necessary. You should also watch their
detailed responses from the participants. On the expressions, mannerism and non-verbal
other hand, if your questions are all specific, you communication. Try to understand what they are
may neglect to address and receive information saying, communicating or insinuating. If
on the ‟bigger picture.‟ something is not clear ask for elaboration. Avoid
being an expert.
Make sure you have a variety of follow up ‟probes‟
for each of your questions in the event that you The members may ask for your opinion. Re-direct
the question back to them by asking for their
need to clarify questions or have participants
opinion instead or what action they would take in
elaborate on their responses. respect of the question.
Step Four: The Discussion
After the session is over, you could share with
them the information they were asking for. Control
Before you proceed you should identify among the discussion without blocking their freedom of
your team one facilitator and one recorder and expression and keep within the time allocated for
introduce them to the group. this. At the end of the session you should thank
them for sharing their time and ideas with you.
Functions of the Facilitator
What the Recorder Records
The functions of the facilitator are to stimulate and
support the discussion by: The recorder records all key issues raised in the
session and other factors that may influence the
 Introducing the topic and all the other interpretation of information in as much detail as
participants. Self introduction is better possible. This involves noting down the responses
because it already sets in motion the tone from the group and observing and documenting
of sharing for everybody. any non-verbal messages that could indicate how
 Reassuring them and explaining the a group is feeling about the topic under
purpose of the discussion and the type of discussion.
information required. The participant also
needs to know how and where the The following must also be recorded:
information will to be used.
 Encouraging discussion by being  Date, time, place
enthusiastic, lively, humorous and  Names of participants
showing interest in the group‟s ideas. The
 Description of the group level of
facilitator formulates and asks questions participation including any
following the prepared guide. The dominant participant
facilitator should involve all the members
 Details of opinions of participants as
but must remain neutral to all responses
much as possible using their own words
so that the participants can freely express
especially for key statements
their feelings, opinions and views.
 Details of emotional aspects and the
 Encouraging involvement of all the
vocabulary used. This will be particularly
members of the group
useful for developing questionnaires or
health learning materials. If possible, a
Functions of the Facilitator tape recorder should be used as well

To encourage involvement of all members of the The recorder may also help the moderator if
group the facilitator should ask open-ended necessary. She or he may point out questions that

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are not well explored; questions missed, or  Does any part of the questionnaire
suggest areas that could be investigated. The suggest bias on the part of the
recorder should not be especially obvious to the researcher?
group but should be able to communicate with the  Is the questionnaire too long?
facilitator if required and help them resolve
conflicting issues. Procedure for Pre-testing

At the end of the discussion, the facilitator should During pre-testing, you examine individual
sit with the recorder and review the discussion questions as well as the whole questionnaire
and complete the notes and evaluate how the critically by:
discussion went. They should then prepare a full
report of the discussion using the participant‟s
Asking colleagues to review the questions
own words. It is necessary to list the key
statements, ideas and attitudes expressed during critically
each topic. These statements are usually coded
and written on the left-hand margin while the This helps you to identify if the questions are clear
comments are written on the right-hand side. It and whether they meet the study objectives.
may be necessary to formulate additional
questions at this stage for those issues that were Pre-testing the questionnaire on people who
not yet clear or controversial. are very similar to your target group

Next, you will look at how you can pre-test your It is also important to pre-test your instruments on
instruments in order to ensure that they are
a community that is very similar to the one in
capable of collecting the data you need.
which the survey will be done.
Pre-testing the Instruments Simulating the actual data collection
procedure
It is very important to pre-test all the instruments
you intend to use before they are finally
administered. It enables the interviewing team to If for instance you are going to administer a
discern, alter or delete questions which are being questionnaire, you should give each
misinterpreted or are too sensitive to be asked interviewer/interpreter a copy and ask them to
without offending people. It also gives you the administer it to the group. Each interviewer should
opportunity to discover if the various parts of the pre-test at least one complete questionnaire.
questionnaire flow in a logical order.
Obtaining feedback about the form and
content of the questionnaire
Points to Look for When Pre-testing
a Questionnaire
Were any questions misunderstood? Were the
directions clear? Was the questionnaire too long
According to Salant and Dillman (1994), any pre-
test aims to answer the following questions: or too difficult? How long did it take to fill it out?
Was there enough space for the responses? You
 Does each question measure what it is should leave in each questionnaire more space
intended to measure? for answers than is planned for the final one. This
 Do respondents understand all the gives the interviewer more space to fill in
words? responses to questions which had not been
 Are questions interpreted similarly by anticipated.
all respondents?
 Does each closed ended question have Checking if the questions produce the
an answer that applies to each information we need
respondent?
 Does the questionnaire create a positive
Does the question illicit the information that you
impression, one that motivates people to
answer it? need?
 Are the answers which respondents can
choose from correct? Are some
responses missing? Do some questions
elicit uninterpretable answers?

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Trying out your tabulation and analysis Stage One: Interviewing the Respondents
procedure
By the time you get to this stage, you have
Does the questionnaire yield data that can be already developed the survey instruments, trained
analysed in the way that is needed. the interviewers on how to use these instruments
and even pre-tested them. You do this in order to
Revising ensure that the correct standards are adhered to
during the actual survey. Once the real survey
begins, you should continue to work closely with
Check the final draft by going over each question. the interviewers.
Ask yourself what the information gathered from
each question means and whether it will Your presence reassures them and they also get
contribute to the study. the opportunity to clarify issues that may arise. On
your part, you get assured that the interviewers
are continuing to follow the techniques you
taught them.
SECTION 4: EXECUTION OF THE
When the interviewers approach a respondent,
SURVEY, DATA ANALYSIS AND they should:
PRESENTATION
 Introduce themselves by name
Introduction  Show their identity cards for the activity
 Show their letter of permission to carry
Welcome to the fourth section of this unit on out the exercise
community diagnosis. In this section you will learn  Explain why they have come and
how to execute the survey and how to analyse the purpose of the survey
and present the results.  Establish rapport with the respondent/s so
that they can feel at ease with each other
Before you proceed, look at the objectives for  Ask if it is convenient to interview the
this section. person at that time
 Should the person refuse to cooperate,
Objectives the interviewers should do their best to
persuade such a person to agree
By the end of this section you will be able to:
If it is convenient to interview the person at the
 Describe the process of data collection time you have requested, give the client/family
 Explain how data is analysed time to be comfortable and proceed. If not, ask for
 Describe the various methods of a more convenient time when this will be possible.
presenting data
This must be within the prescribed period of the
Execution of the Survey exercise as indicated in the permit. In which case
the interviewer must return punctually as agreed
This is another important step in the process of upon with the family or individual.
community diagnosis. It requires just as much
care as the planning stage. It involves going out to If the person refuses to cooperate and remains
the field to collect information from the sample adamant, the interviewers should politely thank
population you have selected. There are three the person for their time spent and proceed to the
stages involved in data collection. next interview. Sometimes people may refuse to
respond to the question raised.
These are:
Remember the rights of the individual. The
1. Interviewing the respondents respondent has the right to refuse to
2. Data collection participate in an interview or experiment or
3. Data handling medication.

You will now look at these stages in turn. There are various reasons why people do not
answer questions in a survey. These include:

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  If the people were not informed of the avoid mistakes. They should also check the forms
survey, its objectives and when it would before they leave the respondent in order to be
be performed sure that all relevant information is satisfactory
 If for some reason the person to be filled in the appropriate space provided.
interviewed is temporarily away from
home
 Lack of interest in cooperating or active If the survey involves the collection of laboratory
opposition to the survey specimens, then you should make arrangements
for their safe storage before they are transported
In order to reduce the incidence of such to the appropriate place for analysis. Laboratory
opposition from your sample group, you should specimens need special care especially when
always make sure that the community is well handling, storing and transporting them because
one lapse could cause the loss of an entire
informed about the study. If the target respondent
day‟s specimens.
is temporarily away from home, the interviewer
should make arrangements to return when he or At the end of the day, all the forms should be
she is in. People who lack interest need a clearer checked thoroughly by someone other than the
explanation and persuasion so that they can see interviewer. If data is missing it may be necessary
how they will benefit from the exercise. Activists for the interviewer to return the next day to collect
can be difficult; if they remain adamant just it. At this stage it may be possible to begin tallying
politely thank them and let them free. They are the results so that when the analysis begins all
you have to do is add up the tallies instead of
just exercising their rights. If you find that a large
going through all the forms since the first
number of people in your group are non- interview.
respondents, you will need to do a random
selection from that group and re-approach them. You will cover tallying later in this section.

The results you get from the new sample will be The appropriate time for data collection was
representative of the entire non-respondent group. already covered in the sub section on how to plan
Compare the results with the original sample of all a survey. Can you remember what
respondents and calculate the difference. you covered?

Stage Two: Data Collection

 When the sample population will be
available
Interviewers should be advised to use a pencil
 When the team will be available
when filling out forms so that it is easier to make
 During an appropriate season when
corrections. They should not erase a wrong
people are not too busy planting
response. If a mistake is made, the incorrect
response should be crossed out and the correct  On days other than public holidays and
response marked above it. Incorrect responses weekends when people are less likely to
should not be erased because it is possible that if be at home
the erasure is incomplete, the response might not
be legible or might be confused with a different During data collection, it is very important to
response. The interviewer should fill in the ensure that there is quality control so that you do
responses at the time they are given. No not end up with false or misleading conclusions.
response should be filled in afterwards because
the interviewer may remember the
To ensure quality data you should:
response incorrectly.

Ensure that every interviewer has all the tools  Avoid bias when designing the
they need to collect data such as tools for questionnaire as explained earlier
anthropometric measurements and laboratory  Provide an instruction sheet on how to
specimen containers. ask certain questions and how to record
answers
You should avail a convenient carrier for these  Select interviewers with care
tools and check the packs daily to ensure that any  Select and train the assistants carefully in
specimens collected were handled correctly. It is all the procedures together with
good to remind the interviewers to recheck their interviewers
measurements before they leave the client to  Involve them in the pre-testing phase

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  Limit the number of interviews that These steps are covered in detail in module four
interviewers can conduct in a day so that unit three on Research in Nursing. You will now
they do not become too exhausted look briefly at them.
 Identify assistants to carry out quality
checks everyday Data Cleaning

This is the stage where you check data for Data cleaning was covered earlier in the sub-
completeness and organise it for analysis. The section on data handling. Can you remember
following guidelines will help you. what was covered? In addition, you will also need
to do the following:
 Check to confirm that all the forms have
been completed satisfactorily  Find ‟missing data‟. If one question is
 Ensure that questionnaires are numbered missing information in the majority of the
 Identify one person to be responsible for questionnaires, then you can ignore it
storing data and specimens securely from the study.
 Record forms should be sequenced and  Correct mistakes committed by
stored with clear labels interviewers after confirming with
 Make sure that all the information you them, for example, putting a tick against
need has been collected in a standard smoker instead of non-smoker.
way  Exclude all inconsistent information if you
 Develop an insight into the possible ways can not verify its correctness.
of analysing data
 Ensure availability of any resources Sorting and Tallying Data
needed for analysis, such as a computer
Once you have collected data from the field, you
Once you have collected the data, it is completely need to organise it in a systematic manner that
meaningless unless you can extract meaning facilitates analysis. You do this by sorting and
through analysis. tallying the data.

Sorting is arranging raw data in groups or in a

Data Analysis
particular order. You should select a system of
sorting which facilitates data analysis. For
The data you obtain from the field is known as example, if you are collecting data on users of
‟raw data‟. In this state, it does not give much family planning, you may decide to sort your data
information and is therefore difficult to interpret. into two groups, that is, users and non-users of
That is why it needs further work known as data family planning. If your questionnaire is made up
analysis. of closed-ended questions, such as the yes and
no type, then you can assign numbers to these
Data analysis is the separation and categorisation questions. For example, 1 to Yes and 0 to No, and
of numerical data into groups in order to sort them accordingly. On the other hand, if your
understand its meaning. Statistical methods are questionnaire has open-ended questions, then
used to do this because they: you need to categorise all the responses given
and assign numbers to them.
 Summarise the data.
 Make inferences about the data. This Data which has been sorted or arranged into
means that data which has been gathered some order according to magnitude is called an
on a sample can be used to indicate what array. The following tables show examples of raw
is probably happening to the entire data and arrayed data.
population so as to make judgement
about them. Table of Raw Data of Ages in Years of 25
Patients Seen in a Survey
The process of data analysis involves the
following steps:
2 23 28 11 3
 Data cleaning 15 7 13 8 21
 Sorting or tallying 6 15 5 16 13
 Coding and entering data 1 3 2 1 2
 Analysis of results 27 24 3 6 2

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Sorting and Tallying Data burden of calculation. Researchers recommend
that the coding process should start with the
Table of an Array of the Same Data Arranged preparation of a code book which describes in
in Ascending Order detail the codes assigned for each response
1 3 6 13 21 category and item in the questionnaire. When
coding data you should include as much
1 3 7 13 23 information as you can. The use of computers has
2 4 8 15 24 simplified the process of data coding and entry.
2 5 11 15 27 Computers save time and increase the accuracy
2 6 12 16 28 of results.

Raw and arrayed data are ungrouped. To help Analysis of Results

you group data you use a tally sheet.
Once you sort and code your data you are now
Tallying is one of the methods used to help you ready to analyse it. There are two types of
organise data before you analyse it. You will analysis that are carried out on data.
already familiar with the tally sheets you used in
the outpatient or MCH/FP clinic. These are:

Tallying is the setting up of classes or clusters  Qualitative analysis

which are tied by a slanting stroke. Usually four
 Quantitative analysis
vertical strokes are made then a fifth stroke is
drawn through them to represent the fifth item.
Each cluster represents specific identifiable Qualitative analysis is usually applied on data
characteristics of the specified data. This data is which can be counted but can not be measured,
then presented using a frequency distribution such as, colour. It allows you to analyse the
table. information in a systematic way in order to reach
some useful conclusions and recommendations.
Frequency Distribution Table of the Ages of
Patients seen at Health Centre X Quantitative analysis on the other hand, is usually
applied to data that can be given a numerical
basis or can be measured, fro example, age in
Age in Number of years, weight in kilograms.
Tally Percentage
years patients
IIIII You will learn more about data analysis in module
0-4 10 33
IIIII four unit three on research in nursing.
5-9 IIIII II 7 23
10-14 IIII 4 14 Data Presentation
15-19 III 3 10
20-24 III 3 10 Once you have grouped your data, there are
many ways of presenting it. You have already
25-29 III 3 10
covered the frequency distribution table with a
Total 30 100 tally sheet. The other ways of presenting data are:

 Tabular presentation
In the frequency table, you can see how the  Graphical presentation
number of patients has been tallied in the second
column. All these forms will be discussed in detail in
module four unit three on research in nursing.
You will now look at data coding.
Tabular Presentation
Coding and Entering Data
This covers the various tables that are used to
This involves the conversion of data into present data, for example, frequency distribution
numerical codes which represent attributes or table and a contingency table. The presentation of
measurements of the variables. Coding eases the

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data in a frequency table shows the classes and the line goes down, it means that the quantity is
the frequency of each class. decreasing, for example fewer people attending
your outpatient services.
Table of Weekly Dispensary Attendance
According to Plews and Onyango (1987), the
Age Male Female Total % construction of a good graph requires the
0-4 25 25 50 27 following:
5-9 20 25 45 24.5
10-14 15 15 30 16  Clear, concise and unambiguous titles
 Clear and concise statement of units in
15-50 15 30 45 24.5
which the figures
51+ 5 10 15 8 are measured
All Ages 80 105 185 100%  Correct vertical and horizontal scaling
Another type of table is known as a contingency  Statement of units used on vertical and
table. It shows how two variables of the horizontal axis
 A key/legend to explain the various
individuals in a survey relate to each other.
features of a graph, if need be
Graphical Presentation  Correct graphing according to the scales
specified on the horizontal and vertical
axes
This type of presentation makes the data you
have collected more easily understood at a
glance. It emphasises any fluctuations which may Some common types of graphs will now be
be present and tries to make the material as described.
attractive to look at as possible. Graphical
presentations are also useful for purposes of Histogram
forecasting the future magnitude of a series of
figures given according to time. This type of graph uses vertical blocks to
represent class frequencies in a frequency
Graphical Presentation distribution. You show the classes on the
horizontal axis and the frequencies of the classes
on the vertical axis. While the horizontal axis need
There are various types of graphical
not start from zero, the vertical axis must always
presentations, these include:
start with zero. It is used to illustrate any data
where the variable concerned changes with time.
 Histogram
 Frequency polygon
 Bar graph
 Pie chart
 Maps

Graphs are a very familiar method of presenting

information. They are more attractive to the eyes
because even without looking at figures, you can
easily see and appreciate the rise and fall in the
figures presented and can tell when they are high
or low. For example, the temperature chart that
you maintain for inpatients is an example of a
graphic presentation. Making graphs of
monthly/weekly clinic attendees, epidemic
diseases, hospital referrals or admissions is a
useful practice that can help you to assess what
you are doing and what needs to be done.

A straight horizontal line on a graph indicates that

there has been no change in the aspect being
measured. When the line goes up, it indicates that
there has been an increase for example, more
people attending your outpatient services, when

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Frequency Polygon represents a total percentage of a specific group
or cluster. A pie chart is especially useful for
A polygon is a many sided figure. A frequency dealing with data where actual numerical
polygon is derived from a histogram by joining the quantities are not so important. For example,
midpoints of the tops of the rectangles of the when you want to find out what percentage of
histogram in straight lines. The resultant figure your population has access to water rather than
does not have vertical bars but is made up of the actual number. It is therefore used for
straight lines joining the different points on the comparisons based on percentages. For a pie
graph. For comparison purposes, you can even chart to give a good visual impression, you should
draw two frequency polygons on the same make sure that the total data is not sub divided
graph paper. into too many separate components. Ideally, the
sectors should not exceed seven.

Maps

Maps are another effective way of presenting

information. They are used to describe, for
example, differences in the frequency of a disease
in different areas.

SECTION 5: REPORT WRITING,

DISSEMINATION AND COMMUNITY
ACTION

Introduction
Bar Chart Welcome to the final section in this unit on
community diagnosis. In the last section you
This is a graph which comprises a number of learnt how to execute a survey, analyse
spaced rectangles whose length varies with the and present data.
magnitude represented. The rectangles have the
same width and may be vertical or horizontal. Usually after all the struggle of collecting and
They are used to represent a large variety of analysing data is over, you tend to feel like your
statistical data, including data that can be job is complete. However, an important and time
represented in other ways. Bar charts can also be consuming part still lies ahead. That is, giving
multiple, that is, representing two or more sets feedback, report writing and community action.
of comparable data.

Objectives
By the end of this section you will be able to:

 Describe the different types of feedback

and their targets
 Explain how to compile a preliminary,
non-medical and medical report
 Explain the types of community action
needed to implement survey
recommendations

Feedback and Report Writing

Pie Chart Feedback means giving comments about how

well or badly a person is doing in order to help
them do better. It is a form of communication. You
You will have already come across pie charts in will recall that during the planning stage, it was
textbooks. It is basically a circle divided into
said that the community will only cooperate if they
sectors or pieces. Each piece of a pie chart
perceive some beneficial results from their

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cooperation. So after your survey is done, those in specimens and tests deserve to be given
the community who cooperated with you are feedback on your findings. You should tell them at
entitled to receive some form of feedback. They the time of examination that they will be contacted
want to know what you found. later if anything abnormal is found. Those who
you took specimens from or on whom you
When planning feedback you need to consider to conducted tests should be told if anything
whom it shall be given and in what form. This will abnormal was found. When giving such feedback
help you to deliver the message effectively and in you should be cautious not to arouse anxiety
a way that it is well understood by the people about harmless conditions.
concerned.
You should only give feedback on those
All individuals in the community who are conditions that require treatment. If you diagnose
concerned with the health of the people are a condition that requires treatment, you should
entitled to feedback. The feedback table below start it at once or refer the person to the nearest
health facility for follow-up care. If during the
gives a summary of the different types of
survey you find specific notifiable diseases you
feedback, who should receive it and when.
should report to the relevant
Feedback Table
Preliminary Report
Data Analysis
This goes to the community in which the diagnosis
Forms of was conducted in order to thank them for their
feedback cooperation. It is given soon after the field work is
Targets of
x= completed by arranging meetings for the people
feedback
receives and their leaders. This report covers your general
feedback impressions of the community‟s health status as
Non well as preliminary survey findings. Do not give
Individual Preliminary Medical
medical specific information on this day, since analysis will
results report report
report not be ready yet. Give them information on
Patients obvious points like disease outbreak, hygiene,
X X sanitation, attitudes, nutrition, practices and
population
Non utilisation of health services.
medical
leadership You should promise them a more detailed report
later. By giving them the findings of the report, you
X increase their awareness of their real health
- Local x
level needs and how these can be solved.

X Non-medical Reports
- National
level
Medical This report is less scientific and is usually
leadership produced for non-medical people. It comes out
after full analysis has been done and conclusions
X and recommendations have been formulated. It is
- Local X an important report because its message can
level
influence social and political leaders to start doing
X X something about improving the health of
- National
the population.
level
Medical
X According to Bennett F.J (1979), the contents of
professional
this report should cover the following aspects of
Timing of the survey:
Immediate Soon Delayed Delayed
feedback
 The reasons for doing the
community diagnosis
Individual Results  The findings which help to define the
situation. Here you select only those
The individuals who formed a part of your survey characteristics which describe the real
sample as well as those who provided you with characteristics of the health situation in

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 this population. Often it is sufficient to information about what your survey was about
describe findings in words and it also helps the librarian to index the
book properly.
However if you feel that tables would be
indispensable then they should be short Table of contents
and easy to understand. You can also use This is like a map which helps the readers to
the graphical forms which were described locating various sections of the survey report
earlier. They have been found to be very
quickly and easily. It often contains chapter
helpful in conveying survey findings at a
glance. headings, main headings and sub headings with
their corresponding page numbers.
 The conclusions and recommendations
Lists of tables and figures
you make should be of practical
significance. You should leave out those This follows the same format as the table of
that are of scientific or academic interest contents and lists the titles of the tables,
to be documented in the medical report. diagrams, graphs, charts used in the report and
This report is a social or political tool to their corresponding page numbers.
shed light on the improvements that need
to be done in the community‟s health List of abbreviations and acronyms
services. So make your recommendations An abbreviation is a short form of a word, for
practical. example, Tb for tuberculosis. An acronym is a
contraction formed by taking the first letter of
Communities are made up of people with varying several words, for example, HIV which stands for
educational levels. Some are illiterate or are of Human Immunodeficiency Virus. In this section of
low educational standards. Such people would a report you give a list of all the abbreviations and
benefit more from personal contact or a acronyms you have used in the document with a
discussion type of feedback. That is why in our full explanation of what they stand for. When
communities Barazas are commonly used to using abbreviations in the body of your report, you
communicate matters to people. However, if you should take note of the following rules:
are dealing with a literate population you can
disseminate the report through the mail or even  The first time you use an acronym or
the mass media that is newspapers, radio and abbreviation you should write what it
television. Newspapers are a good medium stands for in full
because they have a wide coverage and people  Use only those abbreviations that your
from elsewhere might also benefit from the report audience will understand
findings.  Do not abbreviate days of the week or
months
Lastly, you will look at the community diagnosis
report also known as the medical report. Acknowledgements
You should acknowledge all those who made it
The Medical or Community Diagnosis Report possible for you to accomplish this task. In your
list include:
This is a detailed scientific report which provides
an account of the planning and execution of the  Names of individuals
survey as well as the results. It should present the  Organisations
data you collected fully and adequately and give  Institutions
accurate interpretations of the analyses. Its  Administration
dissemination can be done in a workshop setting  Community
and tailored to meet the needs of the various
levels of health personnel who are invited.
Introduction
This section gives the background to your study. It
A well written community diagnosis report is made
up of distinct sections or components which fall seeks to explain why the survey was undertaken
under the following headings: and which questions it was designed to answer. It
is written in the form of broad and specific
Title objectives which also reflect on the purpose of the
Use a title that is short and simple and yet study. Usually before embarking on a survey one
informative. The title of your survey report is reviews the relevant literature. If you consulted
important because at a glance it gives the reader any literature you should make reference to this

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fact in this section as it lends support to the  Incomplete records due to poor
arguments you put forward in the introduction. supervision

Aims and objectives of the study Results/Findings

Indicate both the broad and the specific objectives
of your survey. This section deals with presentation of results in
any one of the formats you covered earlier, that is,
Good objectives should be „SMART‟: figures, tabular and graphical formats. It does not
matter which format you choose as long as it
 Specific brings out clearly those characteristics which you
 Measurable think are important. If you want to show the trend
in certain age groups or time periods, then you
 Attainable
may consider using a graphical form such as a
 Realistic
frequency polygon. A list of figures or a table may
 Timely be indicated if you want to describe in detail a
distribution or size of characteristics. However,
Materials and methods when presenting figures you should take note of
Here you describe your survey design, techniques the following:
and the instruments or tools you used to collect
the data. In particular, you include information
 Do not use figures with several decimal
about:
places unless the precision of the
measurement justifies this
 The sources of the data collected that is  It is misleading to present percentages
the type of records, where they were with one or more decimals if the sample
found, and how complete they were. If the size is small
source of data was people, you should  It is a good practice to present means and
describe them and their characteristics, rates together with their standard error
for example, were they from the same
village, location.
Discussion
 How interviewers were selected and
trained.
This is mainly your interpretation of data, a
 What percentages of the sample were
formed by non-respondents and how their process in which logical thinking, judgement and
age and sex distribution compared to that common sense all play a major role. You will be
of the sample? asking questions such as how reliable and valid
 The methods of investigation you used to are the observations, whether the figures are high
collect data, such as questionnaire, or low, and if there are associations between
physical or laboratory examinations. It is variables which may indicate a causal
useful to describe these in detail so as to relationship.
guide other investigators who would like
to replicate your study.
When interpreting your results it is often
Limitations of study necessary to compare them with and refer to
This section calls for honesty and openness in other studies on the same topic. In surveys which
admitting the difficulties you may have cover a variety of independent health problems
encountered. It helps other researchers not to this section may be combined with that of results.
make the same mistakes you made. This is the
essence of learning and maturity. You are actually Conclusions and recommendations
taking a step back to ask yourself the question ‟If I This is your brief summary of the essential
was to do this survey all over again, what would I findings and careful consideration of how the
do differently?‟
community health problem you have diagnosed
can be reduced and/or controlled. You should also
Some of the difficulties which are commonly
encountered in surveys have to do with: explain the causes of the health problems and
how they can be prevented.
 Sampling methods
 Standardisation of tests and You need to describe what the community should
measurements and can do to control diseases for all concerned
 Observation variation

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References You have already covered these interventions in
It is almost impossible to conduct a survey without great detail in different units and modules of this
consulting published and unpublished documents course. However, you will now briefly look at them
in the community. These could be hospital from the perspective of community diagnosis.
records, maps and others. You must give credit to
Creating Awareness and Promoting Primary
authors of any work you quote from or refer to by
Health Care
listing them.
As you will recall from the lesson on PHC in unit
Generally a reference gives the name of the two of this module, the essence of the community
author, the year of publication of the document, based health care approach is to stimulate
the title of the book or paper and the publisher. community interest and participation in health
promotive, disease preventive and simple curative
Appendices activities. For the community to participate
These are attachments, which you may wish to effectively they require a number of support
annex to your report to help readers understand structures. These are:
some statements appearing in the body of the
report. These may include:  A multi-disciplinary or inter-sectoral team
which includes health workers as well as
experts from other sectors such as
 A copy of the questionnaire used agriculture, water, energy, and so on.
 Statistical tables from data analysis  Establishment of community structures.
 A copy of the map if necessary  A consensus of opinion between
 Letters of approval to carry out the study community and professionals. Research
has shown that communities have the
Once you have produced your reports and given ability to not only identify their problems
feedback to all the concerned parties, the next but also rank them in order of importance.
and last step in the process of community
diagnosis is the action phase. A community The only difference between them and
survey should lead to community action. professionals might be the way they determine the
cause of the problem. While professionals see
Remember: To enhance the effect of your causation in scientific terms, communities may
feedback, it must be rapid, personal, see it in terms of evil spirit. If you can succeed in
pragmatic, constructive and tactful. making them see that in addition to evil spirits
poor latrine usage has something to do with the
prevalence of intestinal parasites, then your job
Community Health Action would be well done.

A community survey identifies a host of health Structures that are in place to establish care of a
problems that need to be addressed. It may have community‟s health include the establishment of
revealed a need for greater emphasis on MCH health committees as well as the selection of
services or environmental sanitation. Therefore, individuals for training as community health
you need to sit down with the community to workers. The village health committees and
prioritise and plan what you going to do about the community health workers play a very important
identified health problems. In short, you need to role in the implementation of activities that have
mobilise them to take action. been agreed on. Your role as a community health
nurse is to facilitate the process and guide them to
Mobilse Community Action work efficiently.

You can mobilise the community through a Health Education

number of interventions, namely:
Health education is not just about sending out
 Making them aware of their problems and posters and pamphlets to the community. It is
promoting primary health care about listening and finding out why people do
 Health education things the way they do. It is about stimulating their
 Immunisation interest in their health problems through
 Environmental improvement discussion and sometimes by example. It is also
about giving people information and helping them
to set priorities and improve their own health.

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Health education cannot be prescribed in doses! UNIT SIX: SPECIAL HEALTH
You will therefore need to target individuals,
families and the community at large with health ISSUES
messages using the media that is available
and affordable. In this unit you will cover provision of health
services for special groups of people.
Remember: Health education cannot be
handed out to the community; it must be This unit is composed of 4 sections:
shared with them.
Section One: Individuals and Groups with Special
Health Needs.
Section Two: Disaster Management.
Section Three: School Health Programmes.
Immunisation Section Four: Occupational Health Services.

If the results of your survey indicated low

Unit Objectives
immunisation coverage as one of the reasons
behind the high morbidity and mortality rates
By the end of this unit you will be able to:
among children, then you need to plan
immunisation action. You will need to identify all
non-immunised and inadequately immunised  Identify individuals/groups who need
persons, and ensure that they receive special health services in the community
immunisation. You will also need to ensure that and take appropriate action
you have a good supply of vaccines and that they  Mobilise and sensitise the community to
are well maintained in order to preserve their respond appropriately in emergencies and
viability and potency. Remember for your disease outbreaks
campaign to succeed you must plan it with  Manage school health programmes
community leaders.  Identify occupational health hazards in the
community and take appropriate action
Environmental Improvement
SECTION 1: INDIVIDUALS AND
Most of the health problems found in our GROUPS WITH SPECIAL HEALTH
communities indicate the need for environmental
improvement. Most surveys reveal need for NEEDS
housing improvement, construction of more
latrines, protection of springs, and improvement of Introduction
food storage. These require major education and
motivation campaigns involving village health In this section you will look at individuals and
committees in order to get the necessary groups with special health needs. You will also
improvements in place. look at the needs of people with hearing and
visual impairment, children in need, the elderly,
The community must take action and the initiative chronically ill patients, displaced persons, widows
to bring about the necessary changes. There is and widowers.
also need for intersectoral collaboration in order to
bring in useful expertise from other sectors, such
as agriculture. Objectives
By the end of this section you will be able to:

 Define the term disability

 Identify and manage individuals and
groups in need of special health services
 Describe services available for people
with special health needs

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Definition of Disability services available for people with these
impairments and how they can be prevented.
In life anything that stops a part of your body from
functioning fully is known as impairment. There
What is hearing impairment?
are many different types of impairments such as
motor, sensory, and emotional or intellectual
Hearing impairment is a disability that hinders
impairment.
successful processing of sound waves through
audition, that is the inability to
How you would define the term 'disability' hear or interpret/perceive sound waves.

A disability is a physical, emotional or mental Hearing impairment is classified according to the

injury or illness that is severe or permanent, that units used to measure the loudness of sound.
interferes with an individual‟s normal growth, These units are known as
development or ability to learn or work. decibels (db). Human contacts and relationships
depend on communication by means of speech. A
In this section you will see the words disability and person who has profound hearing impairment
impairment used interchangeably. Most cannot converse with others unless they can
both use and understand sign language.
disabilities start at birth or in childhood. Those that
start later in life are often as a result of accidental
Impairment in hearing may also cause changes in
injury. In many cases the loss of a function due to personality and attitude, awareness of the
disability need not make a person useless. surroundings and ability to protect oneself. This
calls for a great deal of patience and tolerance
Often disabled people have other faculties which from other people when dealing with the patient.
they can put into good use and therefore be able
to earn a living for themselves and their family. People with hearing impairment try to conceal
For example, blind people can work as telephone their disability by developing some defence
operators, those with disabilities affecting the legs mechanisms, such as withdrawing from contact
can do any work that requires the use of their with others and displaying unreasonable irritability
hands. In order to help them you will identify their and aggressiveness.
abilities and modify the environment to avoid
overtaxing them. You will also provide them with It is therefore important for health workers to bear
appliances and the appropriate apparatus, in this in mind as they help a person with hearing
order to develop their potential ability and impairment. Sometimes the person may even
compensate for the defect. reject the help required to facilitate their hearing.
For example, they may refuse to wear hearing
The following are types of common disabilities: aids because they feel it advertises their disability.

Physical Disabilities It is therefore important to teach family members

and the community how to cope and live with a
These include: person who has hearing impairment. This is better
than educating or training anyone with moderate
 Motor defects due to congenital causes hearing impairment.
such as missing limbs, trauma, cerebral
palsy (spastics). There are two terms used to describe hearing
 Sensory defects such as blindness and impairment, which are based on time of onset of
deafness. hearing loss and the functional status of hearing.
 Chronic illness, for example, epilepsy. These are total hearing loss and hard of hearing.
You will now look at what each means.
Mental Disability
A person who is born completely deaf and who in
Due to mental deficiency, these include: the past has never developed speech is described
mongolism, birth injuries, meningitis and as deaf and dumb
emotional problems. (Davies, B.M, 1978).

You will consider two types of impairments, This person has total hearing loss and the sense
namely hearing and visual impairment. You will of hearing is non functional for ordinary purpose of
also learn their causes, management, and life. The person is dumb not due to a defect in

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voice production but because normal speech is Causes of hearing loss in the inner ear include the
only learnt by copying what is heard. following:

Deafness is classified into:  Congenital causes due to infections in

utero such as german measles or rubella,
 Congenital deafness, which is loss of cytomegalovirus, syphilis.
hearing before speech  Brain damage especially intracranial
is developed. injury in cases of difficult labour and
 Adventitious deafness, which is when one delivery.
is born with normal hearing, but later  Neonatal jaundice due to
suffers some illness or accident causing hyperbilirubinemia which can lead to
the hearing to become non functional. kernicterus. Kernicterus causes brain
damage thus interfering with interpretation
of the sound wave.
'Hard of Hearing'
 Acoustic trauma caused by loud
environmental noise, which distorts the
'Hard of Hearing' is the term used to describe a
tympanic membrane making it unable to
person who although has defective hearing, it is
vibrate.
serviceable with or without hearing aids.
 Minieres disease which causes a
considerable loss of frequency analysis.
This term indicates that although the person is
deaf the person has normal speech.  Postnatal incidentals, such as infections
due to measles, mumps and meningitis,
and the overuse of drugs such
Examples are people with: as aminoglycosides (especially
neomycin), quinine, or salicylates.
 Conductive hearing loss  Tumours of the auditory nerve such as
 Sensory hearing loss acoustic neuroma
 Psychogenic hearing loss
Resources Available for the Hearing
Causes of Hearing Impairment Impaired
Middle Ear What services are available for the hearing
impaired in your community?
Diseases or defects that may affect or damage
the middle Include Community teachers, family, institutions, special
schools and associations are some available
 Tubal catarrh, which is the occurrence of resources for the hearing impaired.
the middle ear being permanently under
pressure due to malfunctions of the Community Teachers
eustachian tube.
 Acute middle ear infections.
In most communities it is possible to find people
 Chronic otitis media which is caused by
excessive growth of the cranial who have hearing impairment and who can be
bone, thus leaving little room for the requested to mentor and train a child with hearing
ossicular chain (which is malleus, incus impairment.
and stapes) to operate in. These fail to It is important to identify and use such persons
transmit sound vibrations to the inner ear because they relate easily to the emotions and
leading to considerable hearing loss. difficulties the child may be going through. Some
may even be trained which would be an added
Inner Ear
bonus.
The diseases and defects of the inner ear are the
most serious contributors to hearing loss. They Other Families with Hearing Impaired
affect both perception and the recording of the Members
four parameters of sound loudness, that is, pitch,
quality and duration. These may cause other Families with children who have hearing
problems apart from serious hearing loss. impairment in the same community can come
together and form a support group where they

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share experiences. This serves as group therapy As a health worker it is important for you to know
and they learn very well as a group. As a about these associations so that you can refer
community nurse you can again motivate these your patients appropriately.
families to come together and support each other,
as well as support them with information and Management of Hearing Impairment
ideas about prevention, and the different services
The effective management of hearing impairment
available for their children.
is based on early detection. It is important that you
remember that in most cases impairment starts in
Institutions for the Hearing Impaired
childhood. Therefore you should ensure that
all under fives are properly managed in order to
There are a number of institutions where special
prevent diseases that cause hearing impairment.
education and programmes for the persons with
The management of hearing impairment starts
hearing loss take place.
with assessment which then leads to the choice of
an appropriate treatment option, such as surgery,
You can find these through the ministry of hearing aid, or ear syringing.
education in our country and refer our patients to
them. What does assessment mean?

Special Schools Assessment is the process of identifying persons

with impairment and quantifying it through reliable
Persons with hearing impairment need special tests. In the case of hearing impairment
training in special schools where they can learn. assessment tests are carried out by an
In our country there are many schools for persons audiologist.
with hearing impairment. Once the problem is diagnosed and the cause
and degree of hearing loss is established, then a
They assist them to develop skills that make them number of treatment options can be applied
feel important and useful members of the depending on diagnosis. However, the process of
community. Special schools are largely public managing hearing problems starts right from your
institutions run like any other school. Visiting well-baby clinic, where children under five years of
these special schools helps us to understand and age come for treatment of ear infections, or
appreciate their services to persons with hearing diseases such as otitis media.
loss.
Screening tests also need to be carried out
Associations routinely on all the under fives to diagnose and
assess if impairment exists. If this is done a child
In many countries, persons with hearing who has hearing loss or a hearing problem will be
impairment have formed associations to look after identified early and treated.
their needs and welfare. Some of them meet to
discuss issues affecting them, and arrange for Surgery
short training courses in communication skills.
This can be performed if the hearing loss is not
The Kenya National Association for the Deaf congenital. Operations can be performed on the
advocates for the deaf to have equal access to tympanic membrane and the ossicles (malleus,
public services such as schools and hospitals. incus and stapes).
They also have a job placement activity which
helps deaf persons get employment as well as Ear Syringing
start income generating activities, such as small
enterprises of fishing, carpet making, carpentry,
Ear syringing may be done in cases where the
sweater making amongst others.
hearing problem is due to excessive wax and
there is no ear infection. This is mainly in the
Another NGO known as the Kenya National Deaf
external ear.
HIV/AIDS Education Programme is involved in the
reduction of stigma among deaf persons affected
Hearing Aid
and infected by the virus, establishment of deaf-
friendly VCT sites, and development of materials
These appliances are used to correct the hearing
for the deaf.
defect in cases of mild and moderate hearing.

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Alternative Communication Skills very important that you identify early and
manage mothers who may present with
It is known that the development of speech labour complications. Early diagnosis is
reaches its peak during the first three to four years very important in order to minimise
and that the optimum period for development of chances of intracranial injury to the
hearing is during the first year. newborn.
 Early diagnosis and treatment of
To give a child with hearing loss a chance to learn infections and trauma such as otitis
words and language, you should advise the media, ear discharge or a foreign body in
parents to train them from an the ear is very important, so as to prevent
early age. complications which may lead to hearing
impairment.
The child is taught:  The community should be educated on
the importance of identifying these signs
and seeking prompt medical advice.
 Lip reading to help in communication
 Avoid drugs which may cause ototoxicity,
 Gestures or actions of the body to or use them under medical supervision.
express issues
 Avoid excessive noise, which may result
 Sign language to temporally or permanent hearing loss.
 Integration and rehabilitation
Visual Impairment
The integration and management of hearing
impaired persons should start at home and
Visual impairment is the lack or inability to see,
involve the whole community. This means
which may be caused by diseases or injuries to
encouraging the deaf to manage better at home
the eye.
and work in
the community.
Clarity of vision is called visual acuity and ranges
from full vision to no vision.
In the home you need to encourage and educate
the family on how to support and live with a
hearing impaired person. You should try to Visual impairment is a fairly common impairment
introduce them to other families who share the in our country which needs specialised medical
same problem in order to relieve their fears and care.
promote acceptance of the person with hearing
loss. The following are possible causes of visual
impairment:
Your role and that of other health workers will be
to support the family and the community by  Trachoma.
providing them with information, equipment and  Vitamin A deficiency.
training.  Allergy.
 Cataract.
Above all they will also need encouragement to  Macula degeneration.
strengthen social integration of the person with  Some types of cancer such as
hearing impairment. retinoblastoma and pituitary gland
tumours.
Prevention of Hearing Impairment  Glaucoma.
 Childhood blindness, for example,
congenital cataract and corneal blindness.
 Prenatal labour and delivery services
 Diabetic retinopathy.
need to be improved to prevent
occurrence of hearing impairment.  Disorders of the nervous system such as
Pregnant mothers should be vaccinated multiple sclerosis and stroke.
against german measles (rubella). The  Refractive errors.
mother should also be advised to avoid  Ocular complications of HIV/AIDS.
taking drugs unless prescribed by the  Accidents which cause injury to the eye.
doctor. She should also have her blood
checked for rhesus negative status which
brings about rhesus incompatibility. Since
deafness can also be caused by
complications of labour and delivery, it is

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Services Available for the Visually Education Institutions: Schools for the Blind
Impaired
These are special schools that provide special
At the Family Level services to the visually impaired. Some of these
schools are owned and managed by the
Normally, activities of daily living such as feeding, government. Others are owned and managed by
socialising, playing, verbal skills, and mobility are non-governmental organisations and missions.
learnt at home. A normal child learns how to do
every day activities by watching what others are You should be able to identify some of these
doing and imitating them. schools in your catchment area. It is beneficial for
you to visit them in order to know what they do.
If a child is under five years of age and is visually
impaired, then they need special help from the In these schools the visually impaired are taught
family in order to learn these skills. braille, a system of reading specially developed
for blind people which uses small raised marks
The family needs to train the child to recognise that they feel with their fingers. Visually impaired
common domestic objects by touching. They need persons can start learning from the age of five
to provide the child with toys to play with in a room years.
that does not put the child at risk from accidents.
Braille is also taught to all persons under the age
Parents also need to be educated about the of 50 years who have been blinded after enjoying
importance of keeping the child‟s articles and toys good sight for many years.
in their regular places, so that they can find them
easily. For example, the victims of the 1998 August
terrorist bomb blast in Nairobi who lost their sight
Children who are visually impaired also need were trained on how to read braille depending on
more body contact, especially when talking to their occupation. After learning how to use braille,
them to facilitate communication. visually impaired persons are able to pursue their
studies and careers up to the university level,
When the child is old enough to attend nursery becoming lawyers, administrators and teachers in
school, the family should recite nursery rhymes society.
and songs with the child, in order to prepare the
child for integration into the community, In addition, they are taught survival skills and
where they will identify with the learning activities skills of daily living, such as how to get around
of other nursery from point A to B using a cane.
school children. Special schools play a very big role in increasing
their participation in the community and facilitating
Encourage a person who is visually challenged to their integration.
have contacts relatives and friends to
be contactable when the need arises. Educational Assessment and Resources
The family needs to modify the environment to Centres (EARCs)
prevent accidents.
These are centres which were created
Encourage the person to participate in activities countrywide to offer assessment and referral, as
they can perform and enjoy. well as placement of children in schools which are
nearest to their homes.
Your role is important in providing support and
encouragement
to the family and availing them with information on CBOs/NGOs/Collaborators
the available resources.
These are organisations which look after the
Institutional Level interests of the visually impaired. They provide
assistance in the form of materials and
There are a number of educational institutions and equipment, education, finances, and provision of
associations that care for visually impaired guidance for the visually impaired.
persons.
Sight Savers International

The headquarters of this organisation is in

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England. The organisation provides resources Prenatal Stage
and materials to help the visually impaired.
 Advise pregnant mothers to avoid taking
This organisation channels the grants through any medicines unless prescribed by the
regional offices in Nairobi to the beneficiaries. The doctor.
sight savers international is the sponsor of the  Educate pregnant mothers on the need
integrated programmes through the Kenya for proper prenatal care in order to
Society for the blind. prevent infections, early diagnosis and
management of conditions if they occur
Salvation Army and their complications.

This organisation collaborates with Thika school Administration

for the blind.
Administration of the following measures:
Thika school for the blind offers primary and
secondary school education for the blind.  All primary immunisations should be
completed
Low Vision Project  Application of tetracycline eye ointments
to newborns at birth
This project is based in Kikuyu pentecostal church  Giving vitamin A capsules to children
of east africa hospital, and it provides services to suffering from measles
people with low vision.  Control of diabetes and the blood
pressure
Other Organisations
Nutrition
 Christofell Blinden Mission (C.B.M)
 Sallus Ocullic The diet should be rich in Vitamin A and B to
 Catholic church avoid changes in the retina, conjunctiva and
cornea.
Management and Prevention of Visual
Impairment Wearing Protective Devices

The management of persons with visual In activities that pose a danger of injury to the eye
impairment starts with the proper assessment of from foreign objectives, for example, hairsprays,
the condition followed by treatment, integration ultraviolet rays and bright sun.
and rehabilitation.
Lighting
Assessment can be done either in a hospital or
through mobile outreach units including school Adequate and well placed lighting in the rooms to
visits by health workers. Once the problem has
avoid straining of the eyes.
been properly diagnosed, then the treatment may
include surgery or visual aids, such as the fitting
Personal Hygiene
of eye glasses.

If after assessment a person is found to be Educating members of the community of

completely visually impaired, they will need to be the importance of good personal hygiene, for
integrated and rehabilitated into the community. example, a daily bath, keeping eyes clean
especially when they are infected, in order to
The process of integration and rehabilitation once avoid attracting flies.
again starts at the family level, and continues into
the community through special schools and other Early Diagnosis and Treatment
institutions for the visually impaired.
Prompt and correct treatment of all common eye
Prevention of Visual Impairment infections and especially trachoma.

There are a number of measures you can take to

prevent visual impairment in your communities.

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Care of Children in Need Integration and Rehabilitation

A child in need is one who has been abandoned, When these children grow and attend school or
orphaned, or one whose parents are incapable of acquire some skills they are able to be
looking after them properly. Such a child needs independent by getting employment or by
the best possible alternative arrangements for becoming self-employed. In this way they become
their care in the absence of the parents. useful members of the community.

Reduction of Children in Need

Needs of the Children
You can reduce the number of children in need
 Nutritional needs. Most of these children by:
are malnourished.
 Parental love.  Strengthening family relationships in the
 Lack of education. community, so that such children are
 Lack of access to health care. such taken care of by their immediate family
as AIDS orphans who are themselves members, especially orphans. This will
infected. provide a conducive environment for the
 Security and protection from harmful child to grow in.
practices like female genital mutilation,  Providing family life education to the
child labour, forced marriage. youth on consequences of pre-marital
 Stigma and discrimination such as those sex, as many of the abandoned children
orphaned by AIDS. are as a result of unwanted pregnancies.
 Social burden such as care for the other  Implementing safe motherhood initiatives
children or for a terminally ill parent. in order to prevent maternal deaths.
 Poverty due to lack of a source of income  Providing family planning services, so
to care for themselves and the family. that families get the number of children
 Inadequate or lack of shelter. they can manage.
 Providing information to the community
What kinds of services are available for members on the services available for
children in need in your community? adoption. This would help those members
in the community who have no children of
Children’s Homes their own, as well as those with unwanted
pregnancies.
These homes are owned and run by individuals
with the help of donors and well wishers. They Care of the Elderly
provide the children with their basic needs and
education. These homes are supervised by the The ageing process is often defined in terms of
department of children under the ministry of social physical changes that negatively affect the body‟s
services. function and appearance. Old age is associated
with poor health, poverty and dependency.
Approved schools, for example Kirigiti in Kiambu,
Wamumu in Mwea and many others. These are In the past, our traditional support systems were
run by the government. so effective that they made the problems of the
elderly insignificant. However, today these support
Remand Homes systems have disintegrated due to socio-
economic changes in our society.
These are available in your communities and they
are run by social services. In Kenya, the elderly are defined as persons aged
64 years and above, although the retirement age
is 55 years of age. In this sub-section you will
Hospitals consider an elderly person as anyone who has
attained the age of 60 years and above.
Most of the abandoned children are brought to the
hospitals. The number of elderly citizens in this country has
Here they are cared for and then handed over to been on the increase. This increase would not be
the children‟s department for adoption, or are later of much concern if you already had support
taken to homes or institutions. structures in place to take care of them. However,
as mentioned earlier, these systems have

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disintegrated leaving them vulnerable to medical During home visiting you should be able to
and social problems. provide direct care to the elderly. Churches also
provide spiritual support as well as material
Problems of the Elderly support to the elderly persons. The women and
youth groups offer different types of care. When
The following are problems of the elderly: these groups visit the elderly they alleviate their
loneliness and improve their nutrition status by
providing them with meals. They also help them
 Poverty with cleaning, repair work and gardening.
 Loneliness
 Poor nutrition
As a health worker, one of your important roles is
 Physical handicap to become their advocates. You should let their
 Dental problem needs be known by the community and motivate
 Mental problems them, especially the youth, to have a positive
 Lack of energy to provide activities of attitude towards care of the elderly, so that you
daily living add life into their days.
 Inadequate housing
 Chronic illnesses Institutions for the Elderly
 Age related changes such as immobility
and presbyopia
In Kenya, there are a number of homes for the
 Lack of care in sickness elderly and day
care centres.
These problems are experienced by the elderly
throughout the world, although they may vary in
Do you have any in your district?
some cases, depending on the kind of support
available in the community.
If you do not know, then you need to identify these
homes.
Available Services for the Elderly
They provide the following services:
At the Family Level
 Nutrition
In Kenya most elderly people live with their
nucleus and extended family. These are the  Activities of daily living such as personal
hygiene
people who care for them.
 Treatment of any sickness
 Recreational activities
As a community health nurse, it is your
 Safety and comfort
responsibility to encourage families to care for
their elderly persons. You need to educate them
on the needs of the elderly, equip them with the The best care for the elderly is the one provided
necessary knowledge, skills and attitudes to by the family.
provide effective care.
Hospitals
You also need to educate members of the
community on the importance of planning for Geriatric hospitals are well established in
retirement. The aim for this preparation is to help developed countries.
the elderly persons remain independent and
comfortable in their own homes as long as In Kenya the elderly do not have any special
possible. There is need to discuss the payment of health services targeting them. In some
pensions and allowances early for better planning. communities it is commonly believed that old age
is a cause of illness. This leads to delay in
At the Community Level seeking health care for the elderly.

Elderly persons require community health Another reason why the elderly may delay to seek
services. It is your responsibility to identify them health care, is that they live far from the health
and make sure they are available and accessible services. As a community health nurse, it is your
to the elderly persons. Encourage them to join responsibility to sensitise and encourage
recreation facilities to improve their mobility and to community members to seek health care for their
join peer groups to help them psychologically. elderly persons.

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The Chronically Ill When they think about the future, they may worry
about how far down they may slide, and about
An illness is said to be chronic if it meets one or becoming dependent or financially destitute. They
more of the following criteria: may feel at times that they have lost control over
their bodies, and over their ability to plan
 Permanent and predict.
 Leaves a residual disability
 Caused by non-reversible pathological Varies Greatly in Severity
conditions
 Requires special rehabilitative training of Just as chronic illness is comprehensive in its
the patient effects, so too is it tremendously varied. Some
people have relatively mild cases, while others
 Requires long term supervision and care
may be bedridden. Most people are somewhere in
between.
Examples of chronic illnesses include:
There are many different patterns of symptoms.
 Diabetes mellitus The bottom line is that each person's illness is
 Arthritis different.
 Hypertension
 Sickle cell disease Adding to the complexity, an individual‟s illness
 Renal disease may vary over time. Some symptoms may
 Heart disease disappear, only to be replaced by new ones.
 Terminal carcinoma and other debilitating Some people may have a relatively stable course,
diseases while others may fluctuate between times of
 AIDS severe symptoms and times of remission.

Characteristics of chronic illness Varies Depending on Life Situation

Imposes Limits The financial situations of patients vary

enormously.
The idea of limits is sometimes expressed Some continue to work, have spouses who work,
metaphorically, as living within an energy or receive generous disability payments. They
envelope, having an energy bank account with a may find their financial situation to be similar to
very low balance, or seeing available energy as a what it was before becoming ill.
bowl of marbles, which must be spent very
carefully. For others, however, financial pressures can be
overwhelming. Some patients have little or no
Living well with chronic illness means learning to income.
live within limits and learning to manage powerful
emotions. Qualifying for disability can be a long and stressful
ordeal. Those with disability may worry about
Affects Many Parts of Life losing it. Others feel forced to work even when
their bodies cry out asking for rest.
Chronic illness affects many parts of life, such as,
The quality of relationships may vary greatly too.
the ability to work, relationships, motions, dreams
Some patients receive good support from family
for the future and personal integrity. and friends.
For others, relationships are a source of great
Brings Uncertainty stress. For all, however, chronic illness changes
relationships, creating new strains and
Chronic illness brings great uncertainty, both on a frustrations.
day to day basis, as symptoms wax and wane,
and over longer cycles.
Will be Affected by One's Response
They may be concerned about their finances, Chronic illness calls for a different role for patients
worrying about whether they will be able to and doctors than is typically true for short-term
support themselves, or whether they can qualify illness.
for or keep up with the disability.

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The doctor has limited powers, because there are caregivers all issues concerning care, and also
no cures for chronic conditions and medications make follow up visits at home, where the patients
often have limited effectiveness. are being cared for.

In chronic illness, much more responsibility falls Management of Chronically Ill Patients
on the shoulders of patients, the people who
manage their illness on a day to day basis. The management of chronically ill patients
depends on the stage of adaptation to the illness
Available Services for the Chronically Ill that the patient is in.

A chronic condition does not only affect the In the first stage, they tend to be in denial and
patient, but also all the family members who live disbelief. During this stage you need to be actively
with the affected person. involved in the care of this patient even if they are
being cared for at home. Educate the family
This is because most chronic diseases bring members to listen to all the expressions of feeling
about dependency and an extra financial burden by the patient without criticising them. They
on the family. A number of services are available should also be empathetic and listen to the
for the chronically ill at the family, community and arguments without being judgmental.
institutional levels.
Patients in the second stage of adaptation to their
illness commonly manifest with anger. During this
Family stage the patient develops an awareness of the
chronic illness. You should educate the caregivers
Often, chronically ill patients are taken care of at to exercise restraint and self control.
home by family members. This is known as home-
based care which you will learn more about it in In the third stage the patient undergoes
the next unit of this module. In order for a family to reorganisation and is nourished by the concept of
care properly for a chronically ill patient, they need hope. You should therefore give hope generously
to be prepared and educated on the requirements. within acceptable limits. You should also provide
the patient and family with suitable and practical
coping methods, and encourage the use of self-
It is your responsibility to provide them with the
help devices if necessary.
necessary information and to follow up on the
patient‟s progress from time to time. This is
important as it helps the family and the patient to Knowing the patient‟s values, religion and beliefs
feel confident in the care at home. will go along way in assisting you help the patient.

Community Prevention of Chronic Illnesses

Primary Prevention
Community Health Workers (CHW), as well as
Community Owned Resource Persons (CORPS), These include:
can assist the family to care for a chronically ill
person at home. This can take the form of medical  Provision of good prenatal,
advice, material support and spiritual support. intrapartum and delivery care.
 Genetic counselling is done in cases
Institutions where there is a genetic risk, for example,
in diabetes mellitus and sickle cell
Institutions that provide services to the chronically disease.
ill include hospitals, hospices, and support groups  Discouraging risky habits, such as
depending on the type of chronic illness. smoking and over consumption of alcohol,
in order to reduce chances of lung
Hospitals admit these patients during the acute conditions, liver cirrhosis and mental
stage for management. Once this stage is over, disorders.
they are then discharged and followed up at the  Early diagnosis and treatment of these
consultant clinics, from where they are given conditions.
medication to take at home.  Regular exercises.
 A healthy diet low in calories and animal
Hospices usually take care of terminally ill fat, to prevent obesity, heart and blood
patients. They teach the patients and their vessel diseases.

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Secondary Prevention The problems experienced by displaced persons
include:
 Regular medical checkups.
 Screening measures, such as, pap  Housing
smear, self breast examination. Screening  Sanitation
should take place at home, school and  Water supply
community levels.  Lack of inadequate nutrition which may
result in malnutrition
Tertiary Prevention  Security risk and human rights violation
 Overcrowding which may cause rapid
Tertiary prevention includes, first aid, treatment spread of diseases
and rehabilitation of diseases. It aims at  Lack of education opportunities
preventing complications and disability.  Lack of health services
 Emotional needs
Displaced Persons  Poverty

These are people who have been displaced from Displaced persons tend to develop health
their communities or even countries. problems due to poor living conditions, as well as
psychological and physical trauma caused
The displacement of people can be caused by a by displacement.
number of factors, the most common being armed
conflict. Natural disasters, famine, political Some displaced persons are separated from their
reasons and economic changes are some of families and relatives and have lost homes, jobs
the others. and schools for their children. They need material
as well as psychological care. Some may develop
They can be divided into two categories: antisocial behaviour as a defence mechanism, as
they are unhappy with the displacement. It is
important that some measures be taken to help
 Internally displaced persons
them.
 Externally displaced persons
Apart from the above problems, people who have
Internally Displaced Persons been displaced may bring new diseases, such as
diarrhoeal diseases, typhoid, measles, meningitis,
These are people who have been displaced within sexually transmitted diseases, and HIV/AIDS.
their country, following ethnic clashes or disasters
such as floods and earthquakes. Even their animals can bring in diseases such as
rabies, anthrax, foot and mouth and brucellosis.
They get help from local organisations, churches So as you can see, they can also pose as a health
and individuals. risk to the community where they settle.
The government has the main responsibility of
settling internally displaced persons. Effects of Displacement of People

Externally Displaced Persons Displacement often leads to dramatic changes in

the family structure and gender roles, relations
These are people who have run away from and identities.
their country as a result of civil war or political
persecution.
In conflict situations, many women are suddenly
thrust into the role of head of the household
They are also known as refugees. For example in because the men are recruited to combat, they
Kenya there are many refugees from stay behind to maintain land, or migrate in search
neighbouring countries such as Sudan and of work.
Somalia.
There is also:
The government works closely with the United
Nations High Commission for Refugees (UNHCR)
to settle all externally displaced persons.  Escalation in the level of poverty
 Reduction in the level of foreign aid
 Demographic consequences
 Religious effect

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  Conflicts between the host community
and the There will be a need to set up relief centres which
displaced group provide the following services:
 Political effect
 Screening and first aid to all new arrivals.
Services Available  Food assistance, especially to infants and
children, as food is a basic need. The
The services available for displaced persons tend adults also need food for survival.
to be those provided by relief agencies, NGOs,  Temporary shelter so that individuals can
the government through the provincial and district sleep and rest.
administration, the church, and institutions such  Reproductive health services; antenatal,
as UNCHR which take care of external refugees. labour, delivery and post natal, family
planning services are also provided.
They provide them with shelter, medical care,  Medical care services, where curative
food and clothing, and sometimes rehabilitation in care for common diseases and injuries
the form of teaching them new skills. will be provided.
 Immunisation programmes for children
Refugees have some sort of international and pregnant mothers.
protection. Their needs are catered for by UNHCR  Health education and community
and their rights are also protected. mobilisation.
 Identification and the use of the
Internally displaced people are still citizens of their community health workers in the area is
country, and are not afforded protection. necessary.

The International Committee of the Red Cross As these emergency services are given, the
(ICRC) protects the rights of internally displaced families should be encouraged to settle down,
people. It conducts protection and assistance especially if the situation requires them to stay
programmes for these victims. there for a long period. They should be
encouraged to start growing their own food and
Problems resulting from displacement are the rearing their own animals.
government's responsibility, the government also
bears the primary responsibility for internally Having looked at the special health services
displaced people. needed by displaced persons, Next you will
consider the needs of another group, that is,
Aid is only a temporary measure, but it is the widows and widowers. Do they require any care
government in question that must solve the and what can you do for them?
problem.
Widows/Widowers
UNHCR seeks to make sure that states are aware
of their obligations in protecting refugees and The death of a spouse makes one to become a
those seeking asylum. widow or widower and you have many of them in
your community. Some of the leading causes of
Countries who attempt to forcibly return refugees death today in Kenya include diseases and road
to their country of origin break international law, traffic accidents.
as refugees may face danger or discrimination The following diseases are a major cause of
between groups of refugees. morbidity and mortality in Kenya:

Internally displaced people can be forced to leave

 HIV/AIDS.
camps or designated areas by their own national
 Malaria.
officials, and no aid organisation or government
 Hypertension.
has the authority to prevent this.
 Typhoid.
 Diabetes mellitus.
Management of Displaced Persons
 Heart diseases.
 Diarrhoeal diseases.
Your role as a community health nurse, will be to  Obstetric complications, such as
work with other health workers as a team, in order pregnancy induced hypertension, ante
to deal with the various problems of displaced partum haemorrhage and postpartum
people. haemorrhage.

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As mentioned earlier, apart from disease, the  Love and belonging. Some may be
second most common cause of death in Kenya is rejected by the family.
road traffic accidents.  Health needs for the whole family or the
left spouse. This is especially so if she
The factors that contribute to road traffic accidents was sick, as in the case of AIDS or if both
include: were involved in an accident, which killed
one and left the other injured.
 Unroadworthy vehicles.  Marriage, especially where men are
 Careless driving, usually under the culturally supposed to marry when their
influence of substance abuse. spouses die.
 Poor enforcement of traffic regulations by  Intense loneliness due to lack of
the concerned authorities. previously established relationship. This
 Unskilled drivers. may result in hurried replacement of
 Poor roads. the wife.
 Severely affected health and well-being
When a spouse dies the effect of the loss affects because widowers are not able to care for
the entire family. They not only lose the love and themselves since most of the care was
care from that parent or spouse, but sometimes provided by the wife.
also the financial support. Therefore  Immense feelings which may result in
widows/widowers require a lot of support, physical and psychological symptoms
empathy, understanding, love and care. They such as sexual fear due to loss of a loved
need to surround themselves with people who one, social isolation.
they can trust and rely on.
Services Available for Widows and Widowers
This tends to be people who have been close,
understanding and supportive to the family. They In developed countries there are well established
are people whom the family has shared important systems in place for helping widows or widowers.
aspects of their life with, and are referred to as However in Kenya there are no formal systems,
significant others. They include members of the although within many communities there are
extended family, friends, colleagues, church various support systems which can be mobilised
members, and so on. They help the family to cope to assist a widow or widower.
with feelings of loss.
The Extended Family Members
As a community health nurse, your role is mainly
to counsel the widow or widower, and to support In many communities, the traditional support
them as they go through the grieving process. system for a widow or widower is the extended
family. They support the widow during the grieving
Needs of Widows period and sometimes take the responsibility of
caring for the family. They also identify ways of
assisting the widow or widower and in many
 Psychological effects following the death cases conduct fund raisings or 'harambees' to
of the husband, such as loneliness, and help them meet expenses such as hospital bills or
cultural practices not allowing the widow school fees for the children. This is a spirit which
to re-marry. you need to cherish.
 Poverty, due to not having the right to
inherit property or have their right
Clan
enforced, being evicted from their
property, no support from family or
relatives. In certain communities, clans play a very big role
 Basic needs such as food and shelter can in the care of a widow. The clan takes the
not be met due to poverty, resulting from responsibilities of the children‟s education, and
unemployment and illiteracy. may even assign individual members of the
 Support to care for the left children. family, the responsibility over the children, in order
Children especially girls are in an
to ensure that the burden is well shared out.
extremely vulnerable position, due to
early marriage and child labour.
 Vulnerable to violence, sexual abuse and
rape. Support Groups
 Exploitation at work place due to
homelessness, illiteracy and poverty. Support groups for widows and widowers are

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common and exist in most of our  Describe how to prepare the community
communities. They come together to share their for disaster management
problems and help each other in solving them.  Describe the concept of triaging in
They also contribute money, and sometimes look disaster management
for donors to help them establish income-  Describe the health care activities during
disaster recovery
generating activities. A good example is the group
known as Widows and Orphans of AIDS Kenya
Overview of Disasters
(WOFAK).
Kenya has had its share of disasters. You will
Institutions
have heard of fires in boarding schools, hotels
As mentioned earlier, in Kenya there are no and slum areas; natural disasters such as
established institutions designed to take care of droughts, landslides and floods; and disease
widow and widowers. However, the government outbreaks such as cholera, yellow fever and
has established a system known as the widow currently HIV/AIDS. All these are different forms of
and widowers pension scheme. disasters.

This scheme pays a pension to the widow or

Like many other developing countries, Kenya only
widower as well as allowances for the children. It
deals with disasters after they have occurred.
is important to remember that the widow and
Although the people are always ready to act in
widower pension scheme only covers those who
emergencies and have in the past put up valiant
are employed by the government. For the
rescue efforts, there is a great need for the
unemployed the family and community takes the
government to train different personnel on
responsibility.
disaster preparedness and management. The
experience of the 1998 bomb blast in Nairobi was
SECTION 2: DISASTER a good indicator. Indeed, all communities need to
MANAGEMENT be prepared to be ready for such eventualities.

A disaster is a catastrophic phenomenon or series

Introduction
of phenomena natural or man-made, that
Welcome to the second section of the unit on threaten(s) or cause(s) widespread severe injury
special health issues. In this section you shall or loss of life or property or both on a scale
cover disaster management, its elements, as well sufficient to warrant extraordinary response from
as disaster prevention, mitigation, response, outside the community. It can also be defined as a
recovery and development. sudden, accidental event that causes many
deaths and injuries. Most disasters also result in
In all forms of injury or disease it is possible to significant property damage.
apply first aid measures before the actual
diagnosis and treatment can be applied. Such What are the Common Causes
measures aim at reducing complications or of Disasters?
preventing the injury from becoming worse. The
measures may be performed by the victims Today, forces of nature such as earthquakes,
themselves or by other people who are around the accidents, or even terrorist activities
victim. If the measures are conducted in a can cause disasters.
professional manner then the victim is assured of
a good prognosis. The same rationale applies to
The natural causes of disasters include:
disaster management.

 Earthquakes
Objectives  Floods
By the end of this unit you will be able to:
 Hurricanes
 Typhoons
 Define disaster  Tornadoes
 Describe the causes and effect of disaster  Tsunamis (popularly, but incorrectly,
in the community known as tidal waves)
 Explain the Kenya national plan for  Volcanic eruptions
disaster management  Wildfires
 Landslides and

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  Avalanches bruising, fractures and hypothermia. Although
cyclones and hurricanes do not cause high
Disasters, which are caused by accidents, include mortality rates like tidal waves, they cause houses
those due to plane crashes, sinking ferries, to collapse and carry objects in the wind which
collapsing buildings, bridges or mines as well as can cause injuries like fractures, cuts and bruises
explosions and fires accidentally triggered by on the victims they strike.
man.
Drought causes famine that leads to malnutrition,
Thus disasters can be classified into two, namely: for example, protein calorie malnutrition,
kwashiorkor, marasmus and vitamin A deficiency
or xerophthalmia.
 Natural disasters
 Man-made disasters War can result into either internal or external
displacement of people.
Each type of disaster has its own special features.
Some disasters can be foreseen several hours, You shall now look at the situation analysis for
days, months or even years beforehand, for Kenya, that is, the recent history of disasters in
example, hurricanes, cyclones and earthquakes. the country, the hazard profile and government
Others such as a plane crash or road traffic policy on disaster management.
accident occur without the slightest warning.
Situation Analysis for Kenya
Effects of Disasters
Disasters that have hit Kenya in the last 30 years
The most obvious effects of disasters are physical
and psychological trauma, sickness and death. have been caused by different types of hazards,
These depend on the type of disaster, whether it such as, droughts, fires, flooding, bomb blast and
is an earthquake, fire, drought, floods or a disease accidents in the transport industry. Dealing with
outbreak and its severity. some of these disasters has at times required
major national and international response and
Earthquakes have a high level of mortality as recovery operations.
victims tend to be crushed by falling objects.
The risk of injury is greatest inside or near Hazard Profile
dwellings but is very small in the open field.
Also, earthquakes, which take place at night are
The Kenyan government has identified the
more deadly with larger numbers of injuries such principal hazards that need to be addressed in the
as fractures to the pelvis, thorax and spine. This is
country.
because most people are caught sleeping and are
oblivious of what is going on. Earthquakes that
take place during the day tend to cause injuries of  HIV/AIDS and disease epidemics
the limbs, collarbone and skull as the victims  Livestock and wildlife diseases
attempt to flee from collapsing buildings.  Transport accidents
 Lightening
Disasters which involve fire, such as explosions or  Pest invasion
electrical malfunctions tend to cause varying  Drug, alcohol and substance abuse
degrees of burns in the victims. The victims may  Fires
also suffer from suffocation due to smoke
inhalation or air pollution as in the case of volcanic These are:
eruptions.
For example, in 1985 23,000 people died in  Drought
Colombia following volcanic eruptions which were  Floods
accompanied by mudslides and glowing clouds.
 Landslides
 Earthquakes and
More recently you have heard of the “tsunami” volcanic activity
tidal wave which killed thousands of people in  Terrorism
Indonesia and left many others homeless. The
 Civil conflict
survivors were suffering from varying degrees of
 Industrial hazards and pollution

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Recent History of Disasters in Kenya

n Analysis for Kenya  The disaster management system needs

How do Disasters Affect the Development of long term funding. This is a state of
an Area? preparedness for any eventuality.
 The disaster management system needs
Disasters throw everybody and everything in flexible budgeting and rapid financial
disarray both at individual, family or community disbursement procedures. You need to
levels. There is loss of life, property and harness the good will of communities to
infrastructure. All these cause delay and be responsive to your call when in need.
retardation of development in the area.  The system must facilitate community
However life must go on, and so people need to participation. In the absence of finances
be mobilised to rescue, recover, readjust and the community might be in a position to
reconstruct. In some instances people must start provide aid in other forms. It is good to
from zero. have this on record so that they can be
called upon when need arises.
There are many lessons which can be learned  The system must be able to collect,
after a disaster, which if properly used may document and disseminate information
reduce the impact of damage should the disaster and undertake research.
strike again, or prevent the disaster altogether.  The system must emphasise public
education and awareness on disaster
Lessons Learned from Disasters in Kenya management.
 That the government should set aside
funds to cater for disaster management.
Following disasters which have taken place in
Kenya several committees have met and  That a policy should be formulated to
specifically address disaster issues in
discussed information gathered and lessons
consultation with experts from within
learned.
and without.
They have come up with the following
recommendations: Kenya National Policy on Disaster
Management
 That disaster management must include
all key actors in a multi-agency and In view of the experiences gained and lessons
intersectoral approach. learned during management of various disasters,
 There is need for effective early warning the government has committed itself and
and quick dissemination of information to formulated a policy that emphasises proactive and
all actors. A combined effort helps to preventive strategies in addressing disaster
utilise resources and is more cost situations.
effective.
The policy outlines the need to reduce exposure

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of vulnerable communities to risk and promote a Organisational Structure of the Proposed
sustainable disaster management system. The NADIMA
policy also outlines the goals, objectives and
guidelines for disaster management.

To establish and maintain an efficient, flexible and

coordinated system for managing disasters, in
order to minimise losses and resulting disruptions
on the population, economy and environment

Objectives

The specific objectives to be met by Kenya are

as follows:

 To establish an institutional framework

that will manage disasters
 To ensure that institutions involved in
disaster management are well
coordinated and focused on both risks
and vulnerability reduction
 To promote the linkages between disaster
management and development planning
 To foster partnerships, between the The government has also come up with policy
government and stakeholders at all levels, elements which form the basis of the country‟s
including regional and international bodies disaster management policy. You will now briefly
 To promote programmes and strategies look at the policy elements. Policy on
that reduce the vulnerability of Kenyans
to hazards Disaster Management
The Policy Elements
 To provide adequate and specific funds
for disaster management
There are four policy elements which underpin
 To mobilise adequate resources to ensure
Kenya's disaster management policy. These are:
effective implementation of the policy,
subsequent strategies and programmes.
 To promote disaster management culture,  Prevention
training, research, information  Mitigation
dissemination, community awareness  Preparedness
and preparedness.  Response and recovery

Although these are broad objectives for the entire Prevention

country, they can guide you to plan disaster
management strategies at the community level. This element focuses on measures aimed at
Various countries today have set up systems for preventing the occurrence of a disaster and
protecting the civilian population in the event of
minimising its harmful effects on the community,
disasters. Since the August 7th1998 bomb blast,
Kenya has also embarked on organising such property and the environment.
preparations. A National Disaster Management
Authority (NADIMA) has been proposed. Mitigation

Mitigation is increasing the population's ability to

cope with disaster most likely to affect them.

Importance of mitigation

This is because in a well organised community, it

is easier for you to improve the quality of outside
assistance and reduce the shortcomings that
often occur during disaster.

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Shortcomings of mitigation Training

 Lack of background information For effective disaster management and

 Poor educational requirements sustainability of programmes capacity building
 Provision of inappropriate type of aid and training in disaster management will be
emphasised. The training includes all people of a
Information systems, risk information, vulnerability community making use of their respective areas
of specialisation.
analysis, early warning system, advocacy and
public awareness, training, resource inventory,
Resource Inventory
public safety and research and development
are issues that must be singly addressed under In order to increase the capacity to respond
mitigation. quickly to disasters, a comprehensive and all
inclusive resource inventory will be established.
Information Systems The government is prepared to fund research
whose findings will be disseminated to users for
The National Disaster Management Authority decision-making and utilised in the development
should generate and collate early warning planning process.
information from relevant ministries and other
sources. This information should be disseminated Public Safety
to users in the government‟s disaster
management network and external networks, right The promotion of public safety must be given
priority.
down to the communities.
The government will ensure adherence to
professional and safety standards and ethics.
Risk Information
Research and Development
A disaster management system should be
established at all levels to coordinate the
Research will be funded and findings will be
collection, collation, analysis and dissemination of disseminated to users for decision making and
risk information. utilised in development and planning process.

Vulnerability Analysis Preparedness and Response

This links directly to mitigation activities and Preparedness can be defined as the readiness to
provides the context of understanding the effect of take action, before, during and after a disaster. To
any hazard on the population, property and the be prepared therefore means to take
environment. precautionary measures before an imminent
threat or disaster takes place and to help people
Early Warning System and institutions respond to and cope with the
effects. Disaster preparedness also means
improving the quality and effectiveness of the
Provides early warning information on impending existing community services in order to cope with
disasters and helps to plan for preparedness and any eventualities.
response activities. The policy encourages
involvement of all stakeholders with regards to A good state of preparedness can reduce the
information provision, analysis and decision- impact of disasters.
making. A greater number of lives and property can be
saved in advance or within the first few hours of a
disaster. With proper prior planning many
Advocacy and Public Awareness
problems of survival and health resulting from a
disaster can be dealt with more efficiently.
This should be undertaken to sensitise the
population on the policy and increase people‟s
understanding of the disasters they are likely to The government has recommended the following
face. The policy supports the development of strategies to be put in place for preparedness.
community based disaster initiatives. They require a comprehensive assessment of
risks and vulnerabilities in order to target potential
disaster areas with management programmes.

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National Contingency Plans You are probably asking yourself the question
“How are these related to the prevention or
The National Disaster Management Authority mitigation of disasters?” You will now look at
(NADIMA) has drawn up plans defining the this relationship.
actions to be taken to prevent and mitigate
disasters as well as how to deal with You can encourage your community to set up
preparedness, response and recovery. The disaster management support structures within
contingency plans are as follows: the existing primary health care system. You can
adopt a multi-disciplinary approach in which you
Response enlist resource persons from the community or
what is referred to as Community Own Resource
Persons (CORPS).
In the event of a disaster, the government,
community and other partners will direct Why Should You Use a Multidisciplinary
resources towards saving lives, property and Approach?
environment.
This is because each member brings along their
Recovery specialised skills to mobilise community interest.
These people can be called upon in the event of a
The government in collaboration with disease outbreak, floods or other disaster.
development partners will put in place
mechanisms to ensure fast recovery and Once you identify CORPS you need to obtain a
reconstruction after a disaster. consensus of opinion. This is very important so
that you can harness the community's
Insurance Initiatives in Response and commitment to the proposed action.
Recovery
As a supervisor and technical expert you should
respect their views in order to woo them to
Insurance firms are being encouraged to develop
respect your scientific input.
affordable products that can be made available to This will enhance their participation in the
the society in order to underwrite some of the recommendations which you have collectively
disaster related issues. made.

Strategic Food Reserves and Stockpiles

Health Education
The government intends to strengthen
maintenance of strategic food reserves and You should motivate and educate community
adequate stockpiles of other basic necessities members to adopt and sustain habits that reduce
required in the event of a disaster. the risk of diseases and accidents. Your health
education should lay more emphasis on problem
The Disaster Trust Fund solving or action oriented efforts. You can help
them to identify potential disasters that could
The establishment of a disaster fund to be happen and ask them to suggest how they can be
managed by the National Disaster Management managed and prevented. Remember to explain to
Authority, in order to facilitate immediate disaster them in simple ordinary terms and encourage
response. them to share the information with others.

Preparing the Community for Disaster Immunisation

Management
From your past experience you will agree that
While going through the various units of this
module, you should note that one of your respiratory and diarrhoeal diseases are major
responsibilities is not only to identify problems and causes of morbidity and mortality in children.
create awareness about them, but also to promote There are effective vaccines against the nine
community based primary health care, health childhood immunisable diseases that manifest
education, immunisation and environmental with respiratory and diarrhoeal disease
improvement. complications

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Environmental Improvement disaster at hand, some people may be buried in
debris, as happened during the 1998 bomb blast,
There are many improvements that a community or cut off by floods.
can make to their environment in order to mitigate
the effects of a disaster. These include: After a disaster how would you decide which
victims need urgent medical attention?
 Housing improvement
 Good latrine construction When disasters happen the health facilities tend
 Protection of springs to be overwhelmed by casualties. It is easy to get
 Improvement of food storage confused and wonder who to attend to and who to
keep waiting. Yet it is very important for you to
make the right judgment in order to save lives.
You have already covered how these can be
Fortunately, there is a process that is used to help
improved in earlier units of this module. However,
in the context of disaster management, housing in this. It is known as Triaging.
improvement is important in areas which are
prone to landslides and earthquakes. You should Concept of Triaging
point out that a permanent wall and floor helps to
prevent the building from collapsing easily and Triaging is a French term, coined into an English
reduces leakages and vermin. Construction and word. It originated from the army where injured
use of latrines is also important to curb disease soldiers were evacuated and methodically aligned
outbreaks which are caused by poor excreta for treatment.
disposal. How about improvement of food
storage? Triaging is the evaluation and classification of
You will have heard about the aflatoxin food casualties for purposes of treatment and
poisoning that keeps recurring in the eastern evacuation, so as to carry out resuscitation,
province of Kenya due to poor storage of maize emergency surgery or futility surgery (radical
after harvest. As a community health nurse, you amputation) because of the severe results
can team up with other experts to teach the (intrinsic lethality) of the wounds. This means that
community simple and affordable technologies through triaging you can establish priorities for
which can help them prevent such disasters from treatment and evacuation during a disaster.
taking place
Triaging used to be a doctor‟s domain. However,
due to advances in the nursing profession and the
Emergency Response gradual expansion of our roles to provision of
expert care, today more and more nurses have
What is the usual reaction in the event of a acquired triaging skills.
catastrophe?
What psychological and emotional reactions occur In any emergency situation,
in people? patients/victims/casualties are suddenly
You covered this in module one, unit two the introduced into the emergency care system. You
section on adrenal glands. If you have forgotten now have regular patients as well as victims of the
you should go back and review it again. disaster competing for your attention. Some of the
regular cases may also be of an urgent nature. In
When disaster strikes, the public reacts with terror order to manage this “chaos”, you have to quickly
and panic. Everybody is terrified and fearful for create an organised flow of receiving and handling
their safety and that of their family and friends. regular patients as well as emergency
People tend to help themselves to safety before casualties. Often, the regular patients who do not
external help arrives. Panic is most common in have medical emergencies usually comply when
crowded places, especially where there are no asked nicely to leave so that you can attend to the
obvious exit points. Depending on the type of emergency cases.

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Rapid Triage in Multiple Patient
Scenes

Importance of Creating an Organised Flow Goals of Triaging

An organised flow shows that people know what The goals of triaging are as follows:
they are doing.
It instils confidence in both the workers and
 Early patient assessment
victims. The flow seeks to achieve the following:
 Brief overall patient assessment
 Determination of urgency of need of care
 Sets the tone and pace of the department  Implementation of the policy that the most
 Assures the patient and their relatives or critically ill patient receives priority
friends that their medical problems are  Documentation of the triage findings
being given priority regardless of the
 Control of patient flow through the
financial implications
emergency department
 Guards against denial of immediate care
 Assignment of care area
to anyone who requires it
 Assignment of care provider
 Initiation of diagnostic measures
Colours are used in prioritising patients in a  Initiation of therapeutic measures
disaster scene according to their state and the  Infection control
urgency in which they require care.  Promotion of good public relations
 Health education for patients and their
families

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Early Patient Assessment with a specialist/physician. A physician can do this
after ascertaining that the victim is not in
You need to be flexible enough to adapt to the immediate danger but requires review later. It can
influx of patients. Spend at least four minutes and only be done when there is full documentation and
four seconds per patient. Although you are the patient has given written informed consent.
expected to be fast, you must be thorough while Usually it is the most senior/skilful health officer
at the same time you strive to avoid creating a who oversees the assignment of duties in the
backlog of unserved patients in the waiting area. areas of operation.

For a minimum assessment, you must at least do Initiation of Diagnostic Measures

the following:
If the number of patients is low, diagnostic
measures can be put in place. Make sure that
 Elicit the chief complaint
appropriate approved protocols are in use by all
 Perform a quick head to toe examination
staff and are adhered to
 Take the temperature, pulse, and BP
Qualities and Qualifications of a Triageur
Determining Urgency of Need of Care

You should be able to determine who is to be A triageur has specific duties which they are
seen first based on the urgency of the condition. expected to perform. In order to understand them,
In the Military, if severe casualties occur in the following are the qualities and qualifications
conditions where transportation is difficult, that a triageur is expected to have:
casualties who are so severely injured that death
seems imminent are placed in a delayed category.  A nursing practice license
This may sound callous but after consideration  At least six months experience in a
you might see the sense in it. However, following general emergency unit in the recent past
a disaster the most severe injuries and illness are  Be physically and mentally healthy to
generally taken in first regardless of the apparent meet the demands of the position
prognosis of the emergency room or department.  Broad knowledge of patient assessment
and care
Documentation of Triage Findings  Ability to set priorities and determine
urgency of need of care
Documentation in triaging is very important.  Ability to function in stressful situations
Indeed if it is done carelessly it can even change  Ability to relate to patients, families and
your fate as a professional overnight! co-workers without bias of
You should organise the record sheet/form such any kind
that there is space for triage notes in a  Ability to promote good public relations
conspicuous place. Remember that the time spent  Knowledge, acceptance and adherence to
on important paper work can deny the patients legal aspects of triage
precious time to be triaged. Even their relatives  Ability to accept the responsibility inherent
and friends get concerned if the patient stays too in the position
long in the triaging area before any treatment is  A good understanding of the philosophy
started. You should therefore arrange to speed up and objectives of the institution, the
this process because early documentation emergency department and the triage
reduces time spent on diagnosis, treatment and system
discharge.
Duties and Responsibilities of a Triageur
Triage Notes are Your Primary Form of
Communication
These are as follows:
Triage notes provide baseline data for the clinician
 Assess all incoming patients within five
who may care for the patient. Important decisions
minutes of arrival
are based on this information. That is why you
must ensure that they are factual, honest and  Determine the urgency of need of care
informative. and assign
urgency ratings
 Designate the appropriate care areas and
Assignment of Care Providers
care providers
 Document initial patient assessment
You should plan for the victim‟s next appointment

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  Measure and record initial signs wherever Subjective Assessment
possible
 Teach health care to patients, families as This is the evaluation of a patient‟s illness and
time allows health history as the patient sees it. The data you
 Take phone calls regarding incoming collect is made up of what the patient remembers
patients
or the medical history that brought the patient to
 Notify other care providers of incoming
patients seek for care. Sometimes you may encounter
 Provide immediate care and seek patients who are hostile, delirious, confused, who
assistance as necessary do not speak or understand a common language,
 Initiate diagnostic measures as indicated or are deaf. In this case you should get the
by protocol information from a close relative or a friend who is
 Keep a log of unusual or noteworthy agreeable to the victim and understands the victim
situations, that is, shootings, assaults or well.
unidentified patients and report these
situations to the appropriate persons In such a situation you must document the name
 Control the flow of patients and visitors of the informer and their relationship to the victim.
 Advise waiting families of the patient‟s
progress if time allows When carrying out a subjective assessment you
 Obtain past history records if needed should make sure you cover the following areas:
 Maintain a balanced caseload in different
care areas: History of Present Illness or Injury
i) Maintain an awareness of care activity
in the care area (for example cardio- This helps you to determine the urgency of need
pulmonary arrests, delays in care) for care. Determine the chief complaint and write it
ii) Supervise clinical staff activities in the patient‟s own words. Summarising what the
patient says is often inaccurate and does not
Although in the past any health personnel could provide a good basis for evaluation.
be called upon to triage, it has become mandatory
that triageurs receive medical education. Nurses Duration of the Chief Complaint
of all levels with triaging skills are becoming more
and more in demand. If you are an experienced
emergency department nurse you may require a That is, for how long has this complaint been
short in-service triage course. However, for large present?
evacuations you will require a more intensive Here, use calendar days or hours of the clock.
course. They help to determine urgency of need for care
or may help diagnosis of the disorder.
How is Triaging Done?
Nature of Chief Complaint
Triaging involves what is known as subjective and
objective assessment. That is, carrying out a This helps to determine the cause of disease or
patient diagnosis. You evaluate or assess the urgency for need of care. You may choose to
victim using medical knowledge to collect data
follow the systems of the body, that is, the
and make decisions at the same time. As you will
recall, one of the steps in patient diagnosis is the nervous system, visual or auditory disturbances,
head to toe examination. This is done respiratory, cardiovascular, and gastrointestinal.
methodically so that you do not leave any part of
the The most significant symptoms are pain,
patient out. In triaging the acronym SOAP is used abnormal bleeding, loss of function, weight
as a useful assessment guide. It stands for: loss/gain, fever, weakness or fatigue.
S - Subjective assessment Analysing Symptoms in Subjective
O - Objective assessment Assessment
A - Assessment of clinical impressions /diagnosis
P - Plan of care You could analyse each symptom using the
following sub headings:
You will now consider the first two steps of this
assessment guide in turn.

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Location Medication
Record all current medications the victim may be
Be specific, ask the victim to point at the region of taking including those that have been
the symptom. Use the known names of the discontinued in the recent past. You should also
regions of the body including measurements if record those that are taken on a regular basis.
possible, for example, 2cm to the left of Record the name of drug, dosage and
umbilicus. The regions of the body compliance.
are: anterior, posterior, superior, inferior, medial,
lateral, proximal, distal. Having looked at the subjective assessment, you
will now move on to the objective assessment.
Onset
Objective Assessment
You need to document whether it was abrupt or
gradual or during an activity. This is what you, the triageur, measures and
What were the circumstances surrounding the observes in the patient. Before you assess the
onset, that is, what was going on at the time when victim, you should prepare a suitable venue. This
the complaint was elicited? should be a room as quiet as possible with no
distraction for both the triageur and the patient so
Timing that you can both concentrate on the interview. It
should be a one-on-one interview unless the
Does the event, for example pain, recur and at patient is unable to express themselves. In this
what intervals? What other activities are case a member of the family or close friend can
associated with it? do so on behalf of the patient. Before the interview
you should, wherever possible, establish rapport
Character and ensure patient‟s comfort.

Describe what the victim feels during the pain or Remember: During history taking use simple
event, for example, is the pain radiating, terms.
throbbing, tightness in the chest, breathlessness,
and so on. Is the pain gnawing or tearing? Is it
referred pain? Is there any discharges or Before you finish with the victim summarise your
abnormal stool? notes aloud for the victim to hear. This helps to
verify that their complaint has been heard and
recorded correctly/accurately. Ask the victim to
Analysing Symptoms in Subjective
clarify what they mean by the expressions used
Assessment
so that you can add or delete as necessary.
Intensity
As previously mentioned, the objective
Does it interfere with the patient's activities of daily
assessment of the patient is based on what you
living? Does it prevent you from doing any
observe and measure in the victim. This falls
activity? If so, then there is urgency for care, if not
under three categories:
the person can be held at the back of the queue.

Aggravating and alleviating factors  General appearance

These too can help either to identify disease  Vital signs
process or specific injuries. Is there anything that  Localised examination
makes the symptoms better or worse?
General Appearance
Associated symptoms
These are those that occur simultaneously, that is, This calls for an experienced nurse/triageur. You
bleeding, pain, dysfunction and so on. assess the colour of the skin and mucus
membranes, the temperature, hygiene and gait.
Pertinent past medical history You should also assess the level of
This must be very brief that is why it is called consciousness and behaviour.
“pertinent‟‟. You should note any chronic illness,
surgery, hospitalisation or previous injury to same Vital Signs
area.
Here, you check for:
Allergies
Record the name and nature of the drug.  Temperature.

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  Heart rate. percentage of surface area. You have already
 Pulse for: rhythm, volume and rate. covered this topic in module one, unit five, the
 Respiration: depth and rate. section on management of critically ill patients.
 Blood pressure for hypertension (mild, The other components you should describe when
moderate, severe, accelerated, assessing burns include:
malignant) or hypotension. Hypertension
is dangerous because it shows that the  Surface area of the body
pressure is insufficient to perfuse the  Thickness of the tissues destroyed (that
tissues of the body adequately. is, 1st, 2nd, and 3rd degree of burns)
A previously hypertensive patient with a  Location of their burn
blood pressure of 200/140 can suffer from  Pre existing health status of the patient
hypotension if it drops suddenly to normal  Associated injuries
120/70. However, if the blood pressure of
a patient who is warm, alert, active and
Types of Burns and Resultant Tissue Injury
making urine is 94/60, then this is
absolutely normal. There is danger if a
The table below will help you to identify the types
hypertensive victim develops tachycardia
of burns and resultant tissue injury.
because this can be an indication of
hypovolaemia. Such a victim should have
blood pressure checked in both standing
and sitting positions. It is important to rule
out hypoadrenalism (Addison‟s disease)
malnutrition, cachexia, chronic bed rest
and neurologic disorders.

Localised Examination

Extensive physical exam is not required due to the

semi private nature of the venue and emergency Areas of the Body that Present with Special
situation. Therefore, just examine the injured Problems for Burn Victims
parts. X-rays are permissible if time and facilities
allow. When assessing injuries, look out for the The table below will help you identify the areas of
following: the body that present with special debilitating
problems for the victim in the future.
Injury to Distal Limbs

Observe for swelling, tenderness, obvious bone

deformity, haematoma, ecchymosed type of
movement, colour, temperature and neurological
status. Document all the findings.
There should be a room for immediate attention to
obvious amputations as well as severe
unstoppable haemorrhage. The danger of burns and especially those that
cover a large surface area is loss of fluid and
Lacerations electrolytes. This is more serious in the young
robust victim than older debilitated patient.
Deep major lacerations require immediate Since you already covered burns in module one,
attention to avoid permanent functional difficulty unit five, you shall not go into details
and haemorrhage. You should therefore forward
the victims to the physician. Eye Injuries
When assessing lacerations, you must record
their location, length, depth, and if any vital These are important because of their location and
structures are involved. sensitivity. You should have the visual acuity of
the victim measured using the standard Snellen
Burns chart. Depending on your location when you are
carrying out the assessment, measuring of visual
Use the “Rule of Nines“ to estimate the body acuity may be delayed if you do not have the chart

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near you. You should also look for foreign bodies Illness
if the victim has a penetrating wound. If you find a
foreign body in the eye cover it with an eye shield Be specific and look out for sore throat, earache,
and refer the victim immediately to an rashes, cellulites, abscess and document them
ophthalmologist. Hyphema or blood in the anterior accordingly.
chamber of the eye needs immediate care.
Victims who present with this problem should be Criteria for Triage Decisions
positioned with the head angled at 40° and kept in
a dark room. In the case of chemical burns you The table below shows the criteria for triage
should irrigate the affected eye with one litre of decisions during assessment
normal sterile saline as soon as possible.

Documentation in Triaging care team. Such a record

should therefore:
When you were covering subjective and objective
assessments in triaging, you looked at the  Have complete and accurate data
importance of documenting your findings. But  Be written in clear concise terms
what is documentation in triaging? You shall now  Be legible
look at the meaning of documentation in triaging,
 Use an institutions protocol data collection
its principles and some of the abbreviations you
tool
can use to refer to the common conditions.
 Use SOAP format to elicit both subjective
and objective assessment information
A document in triaging is a brief and accurate  Sign the document using full name and
patient record which uses an urgency rating in title, for example, H. Khamati, R.N., MBN
order to help you base your decisions for onward  Indicate all the procedures you have
care. Your urgency rating establishes a baseline carried out
data on which other care decisions will be made.
Common Abbreviations and Symbols Used in
Principles of Documentation
Triage
Purpose of a Medical Record
The table below shows the common abbreviations
The purpose of a medical record is to provide and symbols that are commonly used in triage
communication between members of the health notes.

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 that existed before the disaster occurred. If before
Emergency the disaster the health status of the community
A medical record is a legal document in that it can was low, then it will need massive assistance to
provide evidence in a court of law if issues of recover from the disaster.
litigation arise against the triageur.
The guidelines and laws of how a triaging record Post Disaster Health Problems
should be maintained are usually developed by
the institution. It is important to observe these Immediately after a disaster, it is important to take
guidelines and laws. stock of what is available and reusable. Often
people want to re-establish themselves as soon
Below is an example of details or information that as possible and continue with activities of daily
must be included in a triage record: living.
However, some very specific health problems may
arise following the disaster. These are:
 Patient identification
 Time, date and means of arrival
 Complications arising from injuries
 Patient‟s history of illness, injury and
sustained during the disaster
physical findings including patients initial
 Prevalence of poor sanitary and living
SOAP
conditions
 Emergency care given to the patient prior
 Outbreak of diseases or spread of old
to arrival
ones that were
 Diagnostic indications prescribed
already there
 All observations and effect of treatment
 Psychological suffering (post trauma
given
syndrome) that befalls the members of
 Accurate accounts of their results the community due to incurred losses and
 A discharge summary and any special suffering
instructions to the referral unit
 Record of patient‟s discharge against
Post Disaster Health Problems
medical advice
As a health worker you need to organise yourself
Disaster Recovery urgently and rally up the available community
groups and external agencies to help the
Recovery from a disaster depends on the situation community recuperate. Using your knowledge of

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the community as explained earlier you will be Nutrition
very resourceful in providing relevant information
to guide the external agencies like Red Cross, If previously the nutritional status of the
Red Crescent, Medecins Sans Frontiers (MSF), community was satisfactory there should be no
African Medical and Research Foundation alarm during famine. What you should do with the
(AMREF), Catholic Relief Services (CRS), among help of agricultural extension staff is to assess the
others in settling the community. damage to stores of food supplies and take the
necessary measures. During famine, the following
Activities Connected with Resumption of groups are most likely to suffer more than
Health Care anybody else and therefore require special
attention. These are:
There are a number of activities which are related
to resumption of health care during disaster  Infants
recovery. These are:  Children
 Expectant and lactating mothers
 Reopening of health facilities for relative  Those who are chronically sick
care  Elderly
 Health education  The disabled
 Instituting disease monitoring systems
 Conducting a survey to establish Health Education
baselines for operation
 Resumption of previous health This is extremely important especially in
programmes in the community, that is, conditions where people are living in makeshift
MCH/FP and so on temporary shelters. The following is a list of useful
 Setting up an office and activities for post topics to include in your health education talks:
trauma syndrome
 Cleanliness of the temporary dwellings
Activities Connected with Resumption of  Proper waste disposal
Health Care  Cleanliness and protection of drinking
water and proper disposal of waste water
 Re-establishing CORPS (Community  Control of parasites and pests
Own Resource Persons) for coordination  Control of vectors such as flies,
and consultation mosquitoes
 Drawing an inventory of required
materials and supplies The public health technician of the area can
 Liaising with hospitals for onward referral mobilise volunteers to maintain this.
of needy victims for specialised care
 Re-establishing means of communication
Mental Health
Monitoring the Health Status of the
Community At the beginning of this section you covered the
fact that when disaster strikes, people tend to
Your team of CORPS is very useful in collecting react with panic, fear, daze and confusion. This is
useful data concerning the health status of often followed by the urge to act spontaneously in
individuals and other health issues impinging on rescue work. It is like the individuals‟
families. They are well placed to conduct psychological barriers and defences disappear
education activities, assist in food resource and are replaced by spontaneous solidarity and
distribution, and so on. It is extremely important to an outpouring of emotions. This is a useful
contain negative propaganda in order to control a
situation and avoid panic. reaction because it helps people to “cope” with the
situation. Unfortunately, once the adrenaline goes
Vaccination down, this may be followed by depression, lack of
confidence, fatigue and passivity. Some people
It is extremely important to strengthen the existing are overcome with fear of the hard times ahead,
routine vaccination practice instead of launching a their losses and fear of favouritism or preferential
new campaign. treatment during relief supplies.

Sometimes disastrous situations improve some

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mental disorders. This occurs due to the  State the objectives of a school health
atmosphere of solidarity and the new wave of programme
intense emotional relationships that develop after  Explain how to plan and implement school
the disaster. health services
There may be cases of insomnia and bed wetting  State the activities undertaken during a
school health service
among children, anxiety states or psychosomatic
 Evaluate school health programmes
disorders, sweating breathlessness, feeling giddy
and some depression. Some people may present
with confusion and instability as occurs in head
injuries. Fortunately these disappear without Organisation of School Health
treatment in due course. Programmes

When confronted by this situation, the local health In Kenya, it is your responsibility as a community
personnel must try to maintain and strengthen all health nurse to design school health programmes.
the initiatives taken by the community. In order to organise a practical school health
Experiments conducted in the past after disasters programme you need to involve the rest of the
have shown that community action influences the health team members, the school administration
state of mind of the population. It also represents and the community.
an effective means of preventing and controlling
reactions of disquiet and depression. In fact, Members of school health committees
activities to maintain a community's mental
wellbeing coincide with the capacity to encourage  Teachers
and stimulate the association of groups with  Pupils and students
projects aimed at achieving objectives. Such  Parents
capacity aims at stirring the community to act for  Community formal and informal leaders
itself. This is necessary for any project to
 Community health nurse
succeed.
To organise a good school health programme,
SECTION 3: SCHOOL HEALTH you need to do the following:
PROGRAMMES
 Assess the problems of school children
Introduction  Establish practical goals for the school
population
When a child reaches school going age, it is  Carry out the needed activities
necessary that, the health care that was provided  Evaluate the process and results of the
when they were under five years is continued. programs

School health focuses on ensuring health The whole idea behind a school health
promotion, conservation, protection and correction programme, is to ensure that the needs of the
of abnormalities of the school population. school child are met.

A school health programme is an integral part of The needs of the school child
community health. A school health approach is
advocated in the provision of health services as A Stable Home
school children are easy to reach, they also The home should provide basic needs especially
disseminate health messages to the shelter and security.
larger population.
Proper Nutrition
It is therefore important to consider school health The child needs to grow well physically and
programmes as a priority need of the community. mentally. It is therefore important for the child to
take adequate nutrition at least three times a day.
Objectives The diet should have extra proteins and vitamins
By the end of this section you will be able to: to meet there nutritional needs.
This will help the child to cope with demands of
 Describe how to organise a school health school life. The meals may be provided at home,
programme school, or may be packed.

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Freedom from Fatigue The following activities are undertaken to achieve
The child needs to have enough rest at home the objectives of the school health programme:
from school activities.
The evening meal should be taken early so that  Carrying out observation, screening,
the child will have enough sleep and rest. physical examination and epidemiological
investigations.
Clothing  Rendering emergency services and care
This is normally provided as school uniform, which of a continuing illness.
should be clean and tidy. The child needs to wear  Counselling or arranging for counselling
shoes to prevent injuries and hookworm of pupils, teachers and other persons in
infestation. the school population.
 Involving parents, pupils and teachers in
Good Sight, Hearing and Speech planning and conducting health care
Defects of sight, hearing and speech interfere with activities.
the learning process of a child. Early detection of  Contributing to the development of a
all disabilities and referral to appropriate specialist curriculum in health related matters,
is a very important activity of a school health through clubs such as, biology,
programme. mathematics, scout association, Red
Cross, social clubs and home science.
Freedom from Infection  Consultation with teachers and other
All school children should be immunised against personnel.
childhood diseases. Treatment of common  Referral for specialised/continued care.
conditions, for example colds, skin rashes, sore
throat and cuts should also be given. The Planning and Implementation of School
treatment could take place in the school clinic or
Health Services
in the local health care facility.

Pure and Safe Water The first step in organising a school health
This should be provided in the school and at programme is to assess the health problems. One
home to prevent water related diseases. way of doing this is by conducting a survey.
Adequate sanitation, proper excreta and refuse
disposal is important at home and in school. Assessing Health Needs

Clean Buildings Where can you source information about

The home and school environment should be kept school health needs in your catchment area
clean.
The Clinic Records
Objectives of School Health
Clinic records from the health care facility near the
The health programmes aim at: school. This will provide information about the
health problems that are commonly seen among
 Promoting and maintaining the health of school children who attend the centre.
the school children.
 Promoting positive health behaviour Reports
among staff and students.
 Bringing up citizens who understand basic Previous reports on school health services at the
good health habits. health centre and at the district level. These
 Ensuring general community health by reports are given monthly and quarterly.
using the child as a channel for health
messages to the family. Health Team Workers
 Improving the physical and social
environment of the school.
You can hold discussions with the health care
 Providing the following aspects of
teams in your catchment area, to find out health
prevention of disease; Primary
problems of school children and their possible
prevention, for example eating diets rich
solutions.
in vitamins A and C, iron and protein;
Secondary prevention, that is, early
diagnosis and treatment; Tertiary
prevention which includes rehabilitation.

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Teachers, Students and Parents Money

Discussions with teachers, students and parents Funding for school health programmes mainly is
will yield useful information about their problems, the responsibility of the government.
and will also give you a chance to explain the Stakeholders also give financial support to the
importance of school health services. government through procurement of equipment,
drugs and supplies, vehicles, training of
Personal Observations and Experiences personnel, supporting advocacy,
meetings and development of policies, guidelines
and standards.
You can gather a lot of information merely by
observing and listening to people, as you make
Manpower
contact and interact with them.

Formal and Informal Leaders Personnel from the ministry of health and
education need to be trained on relevant issues
for the implementation process.
Village leaders usually have a repotoire about the
most disturbing health care problems, and can More human resources can also be sourced from
assist you to plan school health services. the community by training the community leaders,
and the communities own resource personnel to
Once you gather the information regarding the ensure support and sustainability of the
health needs of school children in your catchment programme.
area, you then need to discuss your findings, and
plan your programme with stakeholders from the Materials
Ministry of Health.
Policies, guidelines and training materials, drugs,
These include the: vaccines, supplies and transport.

 District medical officers of health Time

 District public health nurse
 Transport officers
Time is required for the planning, implementing
 District health administrative officer and evaluating.
 District health education officer The time for the programmes should not interfere
 District public health officer with school activities, and should be convenient
 District medical records officer for both the implementers and the beneficiaries.
There should be sufficient time for the
Implementing a school health programme requires implementation process.
quite a lot of resources. You will require funds for
equipment, drugs, supplies, fuel and staff. You will During the planning phase you also need to
also need cooperation from your team members. consider the following supporting activities.
It is therefore very important for you to carefully
identify each member of the team, and discuss Effective partnerships between teachers and
with them their roles during the school health health workers, and between the education and
services. health sectors.

The success of school health programmes

Resources Required for School Health demands an effective partnership between
Programmes ministries of education and health, and teachers
and health workers.
Like all good programmes, you will require some
resources to implement a school health The health sector retains the responsibility for the
programme. health of children, but the education sector is
responsible for implementing, and often funding
What resources do you think you would you the school based programmes. These sectors
require for a school health programme need to identify responsibilities and present a
coordinated action, to improve health and learning
outcomes from children.

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Pupil Awareness and Participation Eyes

Children must be important participants in all  Visual acuity.

aspects of school health programmes, and not  Colour of conjunctiva.
simply the beneficiaries.  Discharge.
 Pallor would indicate anaemia.
Children should participate in health policy  Yellow discolouration would indicate
development and implementation efforts, to create jaundice.
a safer and more  Redness would indicate conjunctivitis
sanitary environment. such as trachoma.
 Check for ulceration and softness, which
Health promotion aimed at their parents, other would indicate signs of keratomalacia
children, community members is taught during (vitamin A deficiency).
school health services. Children in turn  To determine the eye sight. A snellen eye
disseminate. This is an effective way to help chart is used to check left and right eyes.
young people and the community acquire the
knowledge, attitudes, values and skills needed to
Nose
adopt healthy lifestyles, and to support health and
Check for, nasal discharge, deviated septum and
education for all.
polyps.

Implementing School Health Services Ear

Ear discharge or pain, tinnitus and impacted wax.
You should start by preparing a work plan
together with members
Mouth
of your health facility team. Make sure you allow
Cleanliness or oral hygiene, smooth appearance,
enough time, depending on the number of schools
swollen beefy red sores and atrophic papillae.
to be covered and their health needs.
Teeth and Gums
You should also organise the resources you will Dental cavities, malpositioned, molted
need to perform the tasks at hand, so that you appearance (fluorosis), bleeding and cleanliness.
and your team can be punctual on the day of the
service. Since some of the resources at your
Neck
disposal will be teachers, pupils and community
Enlarged cervical glands, distended jugular veins
leaders, remember to promote teamwork during
and enlarged thyroid gland.
implementation.
Arms
Their morale and enthusiasm should be kept high
Absence or presence of B.C.G scar.
as they participate.
Weak and tender or swollen arms and presence
of oedema.
Physical Examination
Hands
The objective of carrying out a physical Cleanliness.
examination is to recognise the signs of common
ailments, treat the minor ones and refer those Nails
which require specialised attention. This If short and clean. Colour: Pallor indicates signs of
examination should be done systematically from anaemia.
head to toe for every child. A cumulative record of Shape: Spoon shape indicates iron deficiency
anaemia.
a child‟s history, medical examination and
immunisations should be kept for each child.
Skin
Head Rashes, cuts, scabies, lack of fat under the skin.
Tinea capitis(ring worms), hair colour, texture, Rough and dry swollen.
cleanliness and lice.
Body
Tinea corporis, cleanliness and signs of
malnutrition.

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Legs Promotion of Proper Nutrition
Orthopaedic problems, jiggers, injuries,
deformities, bowed and knock knees. This consists of the importance of eating a
balanced diet and good feeding habits, if there is
Clothing
a feeding programme observe the following:
Cleanliness.
 Methods of cooking and storage of food
Height and Weight  Personal hygiene of food handlers and
Screening the children for height and weight to children
assess their development.  Cleanliness of the utensils
 Cleanliness of the kitchen
Referral Services  Screening of the food handlers

This service is given to children who have

ailments needing care outside the school. They Sharing Health Messages
are referred to the nearest health facility or
hospital, depending on the nature of illness and if You should identify and plan to share the
it requires to be seen by a specialist. appropriate health messages with the school
population. The health messages
shared should include, prevention of common
Inspection of the School Environment health problems, such as, sexually transmitted
infections, HIV/AIDS, skin conditions amongst
Since the children spend a lot of the time in others.
school, it is important to ensure that their
environment is safe and clean. Promotion of Personal Hygiene

This is done by advising the children to do the

Location of the School
following:
Surroundings should be clean, free from noise
pollution, away from industrial and other waste or  Taking a daily bath
swampy area.  Brushing teeth after meals
 Washing of hands before eating and after
Sanitation visiting the toilet
 Keeping the hair and nails short and clean
The school should have a good water supply,  Wearing clean clothes
clean and enough latrines, and solid waste
disposal systems. There should be separate Record Keeping
toilets for female and male students. The
environment should be clean and well maintained. It is important to record every health activity that
you undertake.
Playground This applies to school health service activities.
These records are used for evaluation.
It should be dry with no potholes or stones to
prevent accidents. The records should reflect:

This should be clean, well ventilated with  The number of schools covered.
adequate lighting. It should not be overcrowded  The number of pupils treated and types of
and the students should be able to hear the ailments
teacher and see the black board from where they  The number of pupils referred
sit.  Activities carried out
 Health messages shared
Furniture  Information on the environmental health
 Effectiveness of the school health
The seats should be simple and not attached to services
each other so that the pupils can move them. The
children‟s feet should be able to touch the floor When you started planning your school health
when they are seated. services, you formulated objectives. It is important
to find out whether you have achieved them. This

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is where you start when evaluating your school SECTION 4: OCCUPATIONAL HEALTH
health services. You should also ask yourselves
the following questions:
SERVICES

Introduction
 Did you follow the work plan?
 Were the services geared towards
You are now in the last section of unit six. In this
meeting the priority health needs?
section, you will cover occupational health
 Did you carry out all the necessary
services. Health is a basic human right. You
activities during the school health
should therefore endeavour to provide health
services? services such as promotive, preventive and
 How effective were the services you curative care, to all people, of all ages, wherever
provided? they live and work. There are groups, however,
who for various reasons need special health
You can use the following steps to evaluate your services. In this section, you will examine the
school health services. health services needed by workers.

Gathering Information
Objectives
This is done using the same sources that you
used earlier during planning. By the end of this section you will be able to:

Analysing Information  Describe occupational health

 Describe the aims and objectives of
Compare the work actually done with what you occupational health services
had indicated in your work plan.  Describe occupational health hazards and
their management
For example,  Describe the function, duties and role of
an occupational health nurse
 How many schools were included in your
plan and how many actually received the At independence, the government identified health
services? as one of the basic needs and an essential
 What is causing the difference between precondition for the overall economic
planned activities and the actual work development and social progress of this country.
done?
Primary Health Care should therefore be available
to everyone. But, as you know, some groups of
Identify Areas Needing Improvements
people are at higher risk than others of becoming
You can gather this information from your analysis ill. That is why you will examine health services for
once you identify the type or nature of special groups, such as occupational health.
improvement needed, you will then need to decide
your course of action. Concept of Occupational Health Services

It might be that you will need to change the roles At independence, the government identified health
and activities of the team. as one of the basic needs and an essential
precondition for the overall economic
Take Corrective Action development and social progress of this country.
Primary Health Care should therefore be available
Make a list of things that should be done and then to everyone. But, as you know, some groups of
go ahead and do them. people are at higher risk than others of becoming
ill. That is why you will examine health services for
special groups, such as occupational health.

What is occupational health?

Occupational health is the physical, mental and

social well being of a person in relation to their
work and working environment, as well as

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their adjustment to work and the adjustment of both with the effects that work may have on health
work to them. People at work are an important as well as the effects of health on work.
group to be considered in planning health
services. Effect of Work on People’s Health

Reasons why workers require special health Work can have both negative and positive effects
services on people‟s health.

 At work, people often come together in Physical Injuries

large numbers that can be conveniently
cared for at a single service point. The use of new tools and machines, for example,
 At work, healthy people can be exposed a wood maker may lose a finger in a circular saw
to health risks. if not well trained. There is a risk of health
 They may work in very isolated areas problems from fumes, dust, noise and extreme
where no other health services are temperatures.
available.
 When an employment group is Chemical Injuries
considered as a unit, sickness caused by
certain occupations can be identified and
prevented. Risk of poisoning from chemicals, for example
 Illness among workers creates a loss to pesticides.
both individual and national productivity.
Thus every effort should be made to Diseases
decrease the chances of workers
becoming sick. Infections, for example, anthrax due to poor
handling of animals or animal products. Other
Occupational health is also concerned with the diseases like cancer may result from exposure to
following: toxic substances.

 The effect that work may have on health Emotional Injuries

that is in causing injury or disease
 The effect that injury or disease may have Stress related effects from work environment
on ability to work or people.
 The effect of hazardous industrial fumes
or toxic wastes, which pollute the air, In developing countries, occupational health
sewers and rivers.
services are not yet well established. This is
because of many factors ranging from shortage of
The first occupational health services were started
by large companies for workers in dangerous jobs occupational health personnel to affordability of
such as mining, large tea farms or factories. Then the services by the companies. However, more
it was referred to as industrial medical services, and more companies are today providing their
because it was concerned with the treatment and workers with occupational health services.
prevention of injuries and special diseases, for
workers in mines and factories who contracted
Philosophy of Occupational Health
things like lung diseases due to
dust inhalation.
The guiding philosophy of occupational health
services is based on the belief that the health and
Gradually the aims have been broadened to cover
safety of the worker and workforce is the concern
workers in all occupations including: of the employer, employee and the nation at large.
This should be reflected through:
 Agriculture
 Transport  The promotion and protection of workers
 Commerce throughout the working community
 Respect for workers‟ rights and
The care offered to workers includes promotive, adherence to principles of self
preventive and curative services for all diseases determination and non discrimination in
whether they arise at work or at home. In this the receipt of quality healthcare while
broader context, occupational health is concerned protecting employee confidentiality

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  Dynamics of the work environment and  The placing and maintenance of the
diversity of the workers population worker in an occupational environment
 Employer and employee responsibility for adapted to their physiological equipment.
health and safety
 The benefits of the occupational health The aims of occupational health look at the
services to the worker population and adaptation of work to a person and
company each person to their job.
 Collaborative multidisciplinary
relationships that support and enhance
worker‟s health and safety Objectives of Occupational Health Services
 The relationship of the occupational
health and the community There are three main objectives which
occupational health services are set to address.
With the philosophy of occupational health These are:
services in mind, it is important to design
occupational health programmes just the same  Primary Prevention
way programmes are designed for other special  Secondary Prevention
groups. In Kenya, the community health nurse  Tertiary Prevention
carries the responsibility of organising practical
occupational health programmes. It is therefore
your responsibility to carry out these activities at Primary Prevention
the different levels of the health system, from the
provincial down to the community level where In the context of occupational health, primary
industries, factories and farms are found. prevention anticipates problems
and tries to avoid them before they occur.
Which actors would you involve in your Promotion of good occupational health involves
the following:
occupational health programmes?
 Good construction of machines and
 The health team buildings.
 Employers  Training of the workforce on how to work
 The employees with machines.
 The community‟s formal and informal  Proper utilisation of protective, safety
leaders equipment and clothing.
 Good personal hygiene and health.
Aims and Objectives of Occupational  Adequate rest when working with
Health machines.

The practice of health care provision among Primary prevention is also concerned with
people at work has much in common with the preventing and dealing with the following:
practice of any other type of medicine. Indeed,
nearly all kinds of health staff deal with workers in  Wounds and cuts caused by machines
one way or another. However, there are special and tools.
aspects of medical care provided at the work  People falling over equipment or
place which are important and unique for working equipment falling on people.
groups.  The effect of a toxic substance entering
the body through inhalation, skin or
Aims of Occupational Health Services eye contact.
 Increased risk of any of the above
 The promotion and maintenance of the because of the employee‟s own poor
highest degree of physical, mental and personal habits, attitudes or physical
social well being in all occupations. condition.
 The protection of workers in their
employment, from any risk factors Occupational health strives to ensure that
adverse to health. employers and employees take the necessary
 The protection of workers in their precautions when working in areas with special
employment from risk resulting from
hazards. There are a number of hazards that can
factors adverse to health.
occur in the workplace which can be easily

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prevented or managed if the right systems are in There are two main types of medical
place. examinations:

Ways in which these hazards can be  Preplacement examinations

prevented  Routine, periodic and special
examinations
 Accidents from toxic gases, for example,
carbon monoxide. These can be Objectives of Preplacement Examination
prevented or managed easily if gas
detection warning systems are installed.  Determine suitability for a particular job.
Oxygen cylinders with reducing valve  Detect untreated pathological conditions
masks and bags should be readily at and 'asymptomatic' disease.
hand, preferably in the supervisor‟s office.  Provide a baseline record against which
 Risk of liquid or chemical burns. In this any future findings or routine
case plunge baths or showers should be examinations can be compared.
sited alongside the working area.
 Deployment of vulnerable groups, such as How do the results of the preplacement
the elderly, hypertensives, diabetics, or examination assist both the worker and the
epileptics away from areas where they organisation?
can easily injure themselves.
Care should be taken to ensure that such
The results enable the occupational health worker
groups are not deployed in areas where in
the event of sudden illness they can injure to advise the personnel department on the
themselves or jeopardise the safety of suitability of the applicant for the particular job.
others. The workplace should have The applicant also benefits in the sense that the
employees who are trained in first aid and examination could discover a medical condition
are familiar with the treatment of such they were not aware about and be able to seek
illnesses. early treatment for it. In addition, a well run
 Injuries caused by equipment or materials
preplacement examination programme may help
at the workplace. A first-aid box or
cupboard should be provided and to reduce a high labour turnover, absenteeism,
maintained according to the standard by a injury and illness thus increasing productivity.
responsible person. There should be a
system in place that ensures immediate Secondary Prevention
treatment of all injuries anticipated at the
work place and referral for This objective concentrates on three types of
further management. screening:

Occupational health workers need to know the  Screening of employees at risk of a

treatment of minor injuries and illnesses common particular hazard.
in the working environments.  Regular screening for non occupational
illness during employment.
Another important activity which contributes  Screening of the working environment to
significantly to primary prevention is good record check that recommended preventive
keeping. Good record keeping provides useful measures are put in place by employers,
and easily retrievable information on the health of to be used by employees.
the individual and of groups of workers. A record
of preplacement examination gives a baseline of For prevention - be observant. Study the
the worker‟s health. workers and their environment.
Once an employee has been recruited, it is the
Preplacement Examination responsibility of the enterprise or organisation to
maintain a persons health through two separate
This is the medical examination that is done but complementary methods. These are:
before a person is employed. Routine medical
examinations are one of the essential  Maintaining a safe and healthy
cornerstones of occupational health services. environment. if necessary, through
They can be of value to the worker, their sampling and measuring exposure to
employer, their fellow workers and the community. physical or chemical agents.
 Periodic medical examinations.

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Periodic Medical Examination Almost all occupational diseases can be
prevented because they have specific known
This is an effective method which enables the causes. It is, therefore, important to:
occupational health worker to stay informed about
the health of individuals and groups, and at the  Be observant.
same time detect adverse trends which may be  Make simple epidemiological studies of
caused by work. Periodic physical examinations workers and their environment when an
are essential in the early detection of intoxications occupational illness and injury occurs.
and other effects of occupational hazards, for  Have good knowledge of dangerous
early management. chemicals and dusts so that you can
identify an occupational risk before it
The maintenance of a safe and healthy work happens.
environment is crucial for enterprise. Thus
investigation, control and evaluation of the Occupational Hazards
working environment together with medical
surveillance are the cornerstone of a good An occupational hazard is any condition of a job
occupational health service. Remember that the
that can result in illness or injury, a source of
average worker spends at least one third of their
day at the workplace, where they may be exposed danger, a possibility of incurring a loss or
to many factors that could adversely affect their misfortune. The types of occupational hazards are
health. Therefore, it is the responsibility of the categorised according to the agents, which cause
occupational health worker to identify such the hazard or disease. Therefore, occupational
exposures and to assist with their control through hazards can be classified into five categories:
routine and special surveys of the working
environment. General surveys should be
performed by occupational health workers  Physical Hazards
accompanied by members of the health and  Chemical Hazards
safety committee at least once every six months.  Mechanical Hazards
The use of a standardised design format should  Biological Hazards
assist one to capture and cover all the areas of  Psychosocial Hazards
importance.
Physical Hazards
Designing an Environmental Inspection Tool
Physical hazards are any hazard associated with
When designing an environmental inspection tool a reagent that could cause physical harm,
you need to include specific issues to meet the included but not limited to corrosive properties,
particular situation. These include: flammable or explosive hazards. This category
includes exposure to hot, cold, light, noise,
 Statutory regulations which are applicable vibration and ultra violet light. Each type of
exposure will be considered in turn.
 Personal information of all employees
including their sex and age
 General condition of the buildings Hot and Cold
 Welfare services in place
 House keeping and any components that The effects of exposure to heat range from burns,
elaborate the details heat stroke, and heat cramps, while the effects of
 Hazards anticipated exposure to the cold include erthrocyanosis,
 Safety measures in place immersion foot, frost bite, vaso constriction and
 Medical and nursing services in place hypothermia.
 Action recommended
Light
Tertiary Prevention
The effects of poor illumination result in eye strain,
Tertiary prevention includes the whole spectrum headache, eye pain, lachrymation congestion
of healthcare from first-aid to treatment and around cornea and eye fatigue, and blurring
rehabilitation. However, the main emphasis is
placed on first aid in order to minimise of vision.
complications and disabilities.

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Noise Pollution Mechanical and Electrical Hazards

Auditory effects leading to temporary or Machinery including its parts, tools, objects and
permanent loss of hearing materials used are often a source of mechanical
hazards leading to injuries. Machinery, along with
Vibration power supply systems, can also create electrical
hazards, leading to severe or fatal accidents.
It has been proven that continuous vibration
Psychosocial Hazards
hinders the proper function of blood vessels. In
turn this may produce injuries to joints, elbows
Psychological hazards effect the mental and
and shoulders. physical well being of people. The most significant
psychological hazard in the workplace is
Ultraviolet Radiation occupational stress which results from negative
harmful stress or distress. The more obvious
This occurs mainly in welding work causing forms of stress are severe stress reactions from
intense conjunctivitis and keratitis (welder flash). exposure to trauma or violence at work. This is
often referred to as critical incident stress.
Occupational hazards may occur in the following Occupations that see and work with trauma
ways: include the paramedical and health care
professionals, community care workers, police
 Contact and prison officers.
 Inhalation
Common Methods of Dealing with Hazards
Contact
When a hazard has been detected, the preventive
Chemicals in the work place can cause one or measures to be adopted depends on the nature of
more of a variety of toxic effects. (A toxic the hazard or harmful substance and its route of
compound is one that causes illness or death). absorption
Toxic chemicals include teratogens systemic
poisons, mutagens, carcinogens, or behavioural
toxins according to the nature of damage caused. Remove the Hazard or Toxic
The damage can be apparent immediately or later Substance from the Work Place
after some years and symptoms may be obvious
or subtle. Frequent skin contact with chemical
substances can lead to occupational dermatitis, The best preventive measure is to get rid of the
eczema, ulcer, and cancer. substance, chemical or machine altogether and
find a less dangerous alternative.
Inhalation
Reducing Exposure to the Hazard
Inhalation of dust is responsible for dust
allergy, anthracocis, silicosis, asbestosis, cancer  Sucking or blowing away the dust or
of the lung, siderosis. Inhalation of gases may fumes from the place where they are
cause asphyxia due to carbon monoxide and produced.
cyanide gas. Presence of metal and other  Wetting a substance that gives off dust
components may cause toxic effects to body when cut or worked on dry, this is
organs. common in wood industries where there is
a lot of drilling and grinding.
 Carrying out a process entirely in a closed
Biological Hazards system of tanks and pipes or in a closed
room or space.
Workers may be exposed to infective and
parasitic agents at the place of work. General Ventilation
This can result to infection with diseases such as
brucellosis, anthrax, hydatidosis, tetanus, The ventilation of work rooms is improved so that
encephalitis, fungal injection, and HIV infection. the atmospheric contaminants and heat are
removed or reduced. This is mainly achieved by
installing wide windows and ventilators in areas of

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work and ensuring that there is enough operating Functions and Responsibilities of an
space for the workers. Occupational Health Nurse

General Cleanliness Occupational health is one of the responsibilities

of a community health nurse. In the communities
General cleanliness is a very important method of where you work, there are small scale industries
dealing with certain hazards and harmful using machinery and toxic substances such as
insecticides. You therefore need to be aware of
substances. Good factory cleanliness reduces these hazards and harmful substances, and be
exposure, encourages tidiness and safer methods prepared to advise workers, managers and
of working. development committees on health matters.
The responsibility starts and stops with you as
Personal Hygiene there is often no local occupational health service
in the community.
It has been documented that good washing habits
can greatly protect workers from hazardous The occupational health nurse looks at the health
substances. Thus good washing facilities should of a worker from two angles: health in relation to
be available so that workers may wash dirt and their occupation and the health care of non
occupational illness and injuries. Therefore, the
chemicals off their hands before eating. Where functions of an occupational health nurse include
the work is very dirty, or irritant chemicals are the following:
used showers should be provided in changing
rooms.  Physical and psychological assessment of
workers to facilitate proper selection and
Protective and Safety Equipment placement
 Prevention of occupational and non
Protective clothing should be worn all the time in occupational illness
order to protect oneself from health hazards.  Provisions of treatment
However, it has been observed that in practice it  Fostering a high level of well being of the
is difficult to get workers to use protective devices
workers
regularly. Therefore it is better to try to eliminate
hazards by other means. Examples of protective
clothing include: Responsibilities of an Occupational Health
Nurse
 Rubber gloves
These include the following:
 Goggles to protect your eyes and face
during
surgical procedures  Participating in the health assessment
 Respirator or masks program that is, both preplacement and
 Aprons and gumboots routine medical examination of workers.
 Keeping a continuous watch on working
conditions, equipment and materials for
Accident Prevention and Promotion of
safety precautions and possible dangers.
Safety in Working Places Counselling workers regarding personal
and family health problem.
An accident is defined as an unexpected and  Cooperating with management in the
unplanned occurrence, which can lead to bodily application, enforcement and training on
injury. Although it is an unexpected and the use of protective measures.
unplanned occurrence, situations in which  Giving advice on environmental sanitation
accidents occur generally can be foreseen. For and safety education activities.
example, a sharp bend or curve on a road can be  Carrying out nursing administrative duties,
identified so that motorists can avoid overtaking which assure the efficient management of
and over speeding at that point. Thus by the occupation health services.
identifying these situations, many accidents can  Maintaining simple records on which to
be prevented, before they occur. base surveillance, prevention and control
of occupational illness or accidents.
 Evaluating health programme and
activities.

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Bearing in mind the responsibilities of the  Periodic inspection of the plant be carried
occupational health nurse you covered previously, out to check on ventilation, cleanliness,
occupational health nurses have four major roles dust gases, light, sanitary facilities.
in occupational health programmes. These are:  Periodic medical checks up of the workers
be undertaken to detect any signs
 Professional Role of sickness.
 Environmental Role  Precaution be taken to prevent accidents
 Managerial Role by the workers and also by the
 Educational Role management, through supply of protective
devices and institution of precautionary
measures in the handling of machines
Environmental Role
and other hazards.
 Adequate lighting and ventilation should
An occupational environment is the combined be provided in order to avoid hazards like
effects of external conditions and influences which eye defects, accidents, minor ailments.
prevail at the place of work and have a bearing on  There should be proper washing facilities
the health of the working population. For example to maintain cleanliness and prevent
in industry, the worker interacts with three infection.
different types of agents:
 Workers should be given health educated
safety, prevention of health hazards and
 Physical, chemical and biological agents, need for regular medical check up.
for example  Proper measures must be taken for the
Physical - heat, cold, radiation promotion of mental health and
Chemical - toxic dust liquids and prevention of mental illness.
gases  Health education should be a component
Biological - viral, bacteriological, of the total health programme.
rickettsia
 Machines and electricity
Managerial Role
 Fellow man
Occupational health nurses work closely with
One of the roles of the OHN is to periodically management. Their role is to report and give
assess the environment and all the facilities in the recommendations on unsafe and hazardous
organisation in order to detect and appraise health conditions as well as the health condition of
hazards and therefore maintain a healthy working employees.
environment.
There is close interaction between an industry and
In addition to the agents mentioned, the OHN also the community where it is located. Workers bring
assesses the optimum condition of work such as their knowledge skills, attitude and personal
lighting, ventilation temperature, humidity and problems to the work setting and these may
cleanliness of all areas in the organisation to influence work productivity. In addition they also
prevent contamination. bring illnesses which may affect others in the
organisation. It is therefore the role of the OHN‟s
These assessments in conjunction with the to manage this interaction between the industry
knowledge of plant process, modes of and other organisation and community resources,
transmission of causative agents and conditions such as, social, health, or welfare systems, in
for optimal work output, give baseline information order to meet the overall health needs of the
which enables the individual to make workers. It may involve setting up a referral
recommendations to management for preventive system to arrange care for workers and their
corrective measures. families or it may involve compiling data on
absenteeism owing to illness to be used in
To provide a safe environment in the occupational calculating illness rates for the community.
setting, particularly in industrial setting, it is
recommended that: Educational Role

 Working hours should be organised in Occupational health nurses are expected to play a
such a way that they allow the worker to vital role as advisors, counsellors, educators,
have breaks in between. environmentalist, hygienist, rehabilitators,
researchers, safety experts and supervisors.

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Health education is essential for the promotion of UNIT SEVEN: HOME-BASED
optimal health for workers and their community.
The OHN should plan, organise, and implement CARE
health education programmes for the workers and
their community members. In this unit you will focus on Home-based Care
(HBC). You will look at the concepts and
The following topics should be included in your principles of HBC, the principles of infection
health education talk during occupational health prevention and control, the types of patients that
services: require HBC, the components of HBC, community
mobilisation, community resources and the
referral network for HBC. This is what will
 The effects of work on health and vice
constitute the sections in this unit.
versa.
 Importance of periodic examinations
related to identified risk. This unit is composed of seven sections:
 Monitoring of the environment and
development of Section One: Concepts and Principles of Home-
control methods. based Care
 Disaster planning. Section Two: Principles of Infection Control and
 Health supervision of welfare facilities. Prevention
 Rehabilitation and resettlement. Section Three: Patients for Home-based Care
Services
Section Four: Components of Home-based Care
Section Five: Community Mobilisation
Section Six: Community Resources
Section Seven: Referral and Networking for
Home-based Care

Unit Objectives
By the end of this unit you will be able to:

 Describe concepts and principles of

home-based care
 Describe the application of the principles
of infection prevention and control during
home-based care
 Describe the major components of home-
based care
 Describe the management of various
patients requiring home-based care
 Describe the process of community
mobilisation
 Describe the community resources
needed for effective and sustainable
home-based care
 Describe an effective referral and
networking system

SECTION 1: CONCEPTS AND

PRINCIPLES OF HOME-BASED CARE

Introduction
In the last two decades, there have been dramatic
changes in the health needs of our populations
due to the rise in non-communicable diseases,
terminal illnesses, injuries leading to disability and
HIV/AIDS. These changes have led to an increase
in the need for long-term care and the need for
care to manage everyday living.

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To meet this challenge, the Ministry of Health patient has not been well diagnosed and treated,
(MoH) has had to adopt a different approach to don't you think the purpose and spirit of home-
health sector policy and health care services. based care would be defeated?
It has adopted the home-based care approach.
Can you think of reasons why a patient may not
In this section, you shall look at the concepts and receive good quality home-based care? One
principles of home-based care. reason is that complications may arise from the
disease that the patient is suffering from. When a
Objectives patient is well diagnosed and rationally cared for
By the end of this section you will be able to: at a health facility, it is easier to anticipate and
plan for complications and how to manage them.
 Describe the concept of home-based care
Nursing Care
 Describe the major components of home-
based care
 Explain the rationale behind home-based Patients for HBC need nursing care to promote
care and maintain good health, hygiene and nutrition.
As a community health nurse, it is your
 Describe the objectives and principles of
responsibility to provide this care and extend it to
home-based care
the home. By training family and community
 Describe the advantages and
members, it is possible to extend the continuum of
disadvantages of home-based care to
care to the home. Do you think this is possible?
different sections in society
What do you think happens to all those patients
 Explain the roles of the various players in who are discharged from hospital with residual
home-based care
effects of diseases and complications?
 Describe the relationship and functions of Somehow, their families, friends and community
the care team and the HBC services provide some form of nursing care. In home-
based care, care is extended by contributing skills
The Concept of Home-based Care together with other professionals and also training
family and community members to give care to
Home-based care is the care of persons with those that require it.
chronic or terminal illnesses extended from the
hospital or health facility to the patients' homes Counselling and Psychospiritual Care
through family participation and community
involvement within available resources and in The main aim of providing care to people with
collaboration with health care workers. chronic and terminal illnesses and injuries is to
prolong their life and make it bearable. This
cannot happen unless there is positive living and
It is a holistic and comprehensive care which decisions are made on the basis of informed
relies on collaboration between the hospital, the choice. Counselling and psychospiritual care
family of the patient, and the community, in order reduces stress and anxiety for both the patients
to enhance the quality of life of the patients and and their families. It also helps individuals to make
their families. In home-based care, the care of the informed decisions on say HIV testing, planning
patient is extended from the hospital or health for the future, making behavioural changes and
involving sexual partner(s) in such decisions.
facility where they are initially seen to their homes.
This therefore implies that these patients require
Social Support
certain services. These services form the
components of home-based care.
On many occasions when patients are discharged
from health facilities, you fail to realise the
Components of Home-based Care network of social and support services that they
can benefit from. Patients with chronic and
Clinical Care debilitating conditions need information and
referral to support groups such as church
Clinical care comprises early diagnosis, rational organisations, youth groups and other social
and targeted treatment and planning for the care organisations. They also need to be referred to
of persons suffering from chronic or terminal and welfare services provided by social workers,
debilitating illnesses. The patients who are children's department and other services, which
assessed and referred for home-based care need may be provided by various governmental and
the continuum of care extended rationally. If a non-governmental organisations. These

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individuals also need to be accepted by society well as those who are bedridden and unable to
and get involved in community activities care for themselves.
depending on their capabilities.
These individuals and their families may also So far you have looked at the definition and
require legal advice and material assistance. components of HBC. Before you go further, first
You should never forget that these services ask yourself the following questions. Why HBC?
compliment the care that is given in your Why can't patients for HBC stay in the health
health facilities. facility and be cared for by trained health care
practitioners? What these questions are really
These components will be revisited in further seeking is the rationale behind HBC.
detail in another section that will focus entirely on
them. Having briefly learnt about the components Rationale for Home-based Care
of HBC, move on to look at a summary which lists
the areas in which HBC services are provided. You are probably well aware of the big problem
presented by HIV/AIDS to the health care services
These areas are: in this country. Demand for health services has
increased due to the growing numbers of
 Nursing care (personal and general individuals who have become ill as a result of HIV
hygiene) infection. This has resulted in an increased
 Nutrition workload and congestion of health facilities.
 Advice and promotion of positive living
habits and behaviour Hospital bed occupancy rates have increased with
 Support through counselling and links over 55% of beds occupied by People Living With
with other services HIV/AIDS (PLWHA). Apart from HIV/AIDS, other
 Treatment of the specific disease-related chronic diseases such as cancer have made
conditions and complications people require long-term care.
 Physical therapy, vocational and
occupational therapy In addition there are other reasons why the home-
based concept has been adopted.
It has been noted that:

 People with AIDS and other debilitating

illnesses are discharged from health
institutions where there are trained
professionals and sent home to be cared
for by untrained relatives with no
professional back-up support. HBC will
train HBC providers to offer continued
quality services and also coordinate
services between the community and
health facility after discharge.
 HBC helps reduce the stigma attached to
some chronic diseases as the providers
are knowledgeable of the diseases, which
assists them to change their attitudes
toward the disease and the patient.
 People with chronic debilitating illnesses,
for example HIV/AIDS, need continuity of
care to prolong their lives and reduce their
suffering.
 Health institutions have many limitations
The concept of HBC, as you may have realised,
such as shortage of health workers, few
does not just address any disease condition but is
hospital beds and a shortage of other
intended for debilitating diseases that make
resources.
patients unable to care for themselves. In
HIV/AIDS for instance, you do not provide HBC to  HBC offers support that will enable the
those who are HIV positive but to those with patient to extend their productive lives for
advanced AIDS illness. HBC concerns those who many years.
are sick but still able to care for themselves as

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This has meant that many patients may have can come with the prolonged care of the
failed to get the care that they deserve. terminally ill.
 Ensuring respect for the basic human
Objectives and Principles of Home- rights.
based Care  Developing the vital role of home-based
The main objectives of the Home-based Care care as the link between prevention
and care.
program are:
 Taking a multi-sector approach to care
and support.
 To facilitate the continuity of the patient's  Addressing the reproductive health needs
care from the health facility to the home of persons living with chronic illnesses.
and community.  Instituting measures to ensure the
 To empower the patients, the family and economic sustainability of home care
the community with the knowledge support.
needed to ensure disease prevention,
 Building and supporting referral
care and support-related to the chronic
networks/linkages and collaboration
illness.
among participating entities.
 To enhance the functioning of critical
 Building capacity at the household,
system and process to enable accessible,
community and institutional levels.
effective and sustainable HBC.
 Addressing the differential gender impact
 To streamline an appropriate structure for
of the HIV/AIDS epidemic and other
the patient referral from the institutions
chronic illnesses and care for the patients.
into the community and from the
community to appropriate health and
social facilities. Advantages and Disadvantages of Home-
 To establish appropriate structures and based Care
systems for management, coordination,
networking and resource mobilisation. Many authors agree that HBC has a positive
 To articulate policy and advocacy impact on the social, economic, psychological and
positions that yield clearly defined roles physical wellbeing of the patient, family,
and responsibilities, build strong community and the general health care system.
leadership support and help reduce
stigma. The Patient
 To establish systems to facilitate provision
of a comprehensive continuum of care
that meets priority needs of infected and The following are the advantages of HBC to the
affected people. patient:

To ensure that the foregoing benefits are realised,  The patient is cared for in a familiar
HBC should be regarded as a holistic system of environment. Such a patient usually
care with provisions for the following principles. suffers less stress and anxiety compared
to the one in hospital, clinic or nursing
home. When people are in a familiar
The principles of home-based care include the environment their illness is more
following: tolerable.
 When the patients are in their homes,
 Ensuring appropriate, cost-effective they continue to participate in family
access to quality health care and support matters. Those who are heads of their
to enable persons living with chronic families continue doing so and can be
illnesses to retain their self-sufficiency consulted on various family issues. It is
and maintain quality of life. quite difficult when one is in hospital or a
 Encouraging the active participation and clinic to make a decision about, for
involvement of the patient and their example, which goat to sell in order to pay
family. for school fees or which part of the farm
 Fostering the active participation and should be tilled.
involvement of those most able to provide  When the patient is at home close to
support to the community at all levels. family members, friends and relatives,
 Targeting social assistance to all affected there is a sense of belonging. This is not
families especially children. the case if one is in a hospital setting
 Caring for caregivers, in order to minimise where the caregivers are strangers who
the physical and spiritual exhaustion that keep changing with every shift.

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  When the patient is in close contact with Disadvantages of HBC
familiar people they are likely to accept
their conditions and illnesses. The  Expensive especially in poor resource
acceptance contributes to quicker countries. It involves training of the care
recovery or, in the case of HIV/AIDS, it providers, availability of equipments and
may assist in better management of the supplies and management of the
syndrome. systems.
 Sustainability may be hard especially
The Family where the community does not see the
importance, where the resources are poor
 Care given in the home can be less or there is no motivation for the providers.
expensive than that in the hospital. You  Requires leadership support and
are aware that patients will pay for bed adequate structures at various levels,
charges, food and other items, which will which limits ability to achieve greater
normally be available and shared at coverage, effectiveness and
home. sustainability.
 Caring for sick people at home prevents  It requires related systems in other areas,
separation and holds family members for example planning and budgeting
together. You will no doubt have heard of processes within MoH, technical support
patients being divorced or separated system, networking to facilitate skills
because of illness. Others get into transfer, psychological and spiritual
adulterous relationships because their support.
spouses are not at home. This can be  Affected by other external factors like
prevented through home-based care. poverty, hunger, stigma, denial and
 When family members are given community expectations.
education and information on diseases, it
helps them to understand these diseases Key Players/Providers of Home-based
better and accept the patients.
Care
The Community
 The patient
 Family members and other caregivers
 Training in home-based care helps
community members to be aware of the  HBC team
various illnesses affecting members of  Health workers
their communities. As always there are  Community and community organisations
myths, misconception and beliefs  Government
especially in relation to chronic illnesses,  NGOs
for example, HIV/AIDS and epilepsy. An
informed community counteracts these All of these providers have a role to play in the
myths and beliefs and is therefore able to delivery of HBC. Some aspects of the roles are
actively participate in prevention efforts. unique to the specific players, but others may
 It's cheap. The cost is shared as overlap to some extent. Every function is
members contribute for upkeep and the important, and none should be thought inferior to
costs of going to visit a person in hospital the others, because they all make vital
are reduced. contributions to the total HBC system.
 Community cohesiveness is maintained.
This ensures that the community is able
to respond to other members' needs.

The Health Care System

 HBC reduces the pressure on hospital

services and hence the health system.
Therefore hospitals have fewer patients to
attend to and thus are able to provide
quality services to those patients who
require short-term care.
 Reduces cost of outreach/mobile clinics.

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Role of the Patient Role of Home Care Team

The patient is one of the main players in home- Home care teams are supervised by a medical or
based care. When the patients are not very sick, social work professional, and may be associated
they may provide their own care. However, in with a local health centre or community
some cases they are too sick and require organisation. They are organised to provide a
somebody else to care for them. Their role in HBC variety of services to patients and their families.
is to: The community health worker is a key member of
this team.
 Identify the primary or alternative
caregiver. The home care teams should be able to:
 Participate in the care process, but not
passively, especially in making decisions  Manage patient's disease-related
on own welfare. conditions.
 If possible, give consent on caregivers  Provide home nursing care.
and where the care will be provided, for  Arrange voluntary counselling and testing
example, home or hospital especially services for HIV.
during the terminal phase of the disease.  Provide supportive counselling.
 Refer the patients for further specialised
Role of Family Members and Caregivers care such as treatment, radiotherapy,
counselling, and emotional/spiritual
The sick person's family members, relatives, support.
friends and other caregivers play an important role  Educate patient/family/community on
in the provision of home-based care. Their role is related diseases.
to:  Arrange spiritual/pastoral care.
 Mobilise resources for support of the
 Learn to accept and adjust to the programme.
situation, including that of the terminally ill  Train the caregiver on all HBC services.
with AIDS.  Provide facilitative supervision to the
 Collaborate with other care providers, for caregiver.
example, religious institutions, support  Train the patients on how to care for
groups, health and social institutions. themselves.
 Be able to volunteer or agree on other
possible caregivers that could be involved Role of Health Workers
in providing the services in the family.
This becomes shared responsibility on The health facility plays a very important role in
issues of referral and networking. the provision of HBC. Having gone through the
 Learn to consult with the patients on last three modules of this course, you are well
matters concerning them. aware of the important contribution made by
 Involve the patient in all care activities health workers in the delivery of health care in
and any other family activities Kenya. These institution-based trained health
without discrimination. workers include nurses, clinical officers,
 Emphasise the need to prepare for death physiotherapists, nutritionists, doctors and many
as inevitable and sensitise the patient others. Their role is to:
about the importance of ensuring the
continuing care of family members who  Initiate, inform and create awareness of
are left behind. the HBC process by recruiting the
 Encourage and help the patient to write a patients to the programme, identifying
will. needs at various levels, and preparing the
 Remember that being present is a major patient for discharge home.
support.  Prepare and educate the family caregiver
for the caring responsibility at home.
As a community health nurse you need to provide  Make initial diagnosis, institute relevant
education on home nursing skills, counselling, as nursing and medical care, help identify
well as information on psychosocial and material psychological and social needs.
support, patient caregiver interaction and  Initiate referral and networking systems,
communication. which may change over time as the
patient's condition and needs change.

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  Care for the terminally ill depending on
their wish.

Role of the Community

 Accept the situation of the patient and

learn to collaborate and work with existing
agencies (such as religious groups,
women's groups, and other social and
health agencies) around to meet the
needs of those infected/affected.
 Prepare a 'memory book' to provide their
children with family history and a tangible The process of linking patients to support services
record of caring. involves:
 Encourage the patient to write a will.
 Identify own spiritual/pastoral needs.
 Assisting patients and their families to
 Be open to the caregiver and share any
identify the support that is needed
worries.
 Identifying groups/agencies/individuals
 Take personal responsibility to prevent
that can provide the support
further transmission of infections like
hepatitis and HIV.  Informing patients about the existence of
the individuals, agencies and the services
 Advocate for behaviour change.
that are offered
 Introducing the identified agencies and
Role of the Government individuals to the patients and
their families
 Create a supportive policy environment  Helping patients to evaluate the
 Develop policies and guidelines individuals and agencies and allowing
 Develop and maintain standards them to work with those who meet their
 Provide/coordinate training needs
 Provide drugs, equipments and supplies  Helping them set up home visits and
 Help in the formation of support groups, transportation if needed
which in turn would lobby and advocate  Following up to ensure that there is
for the rights of the patients coordination of services

The illustration opposite shows the relationship As you will have seen, providing HBC is a
and functioning of the care team and HBC challenging task. One of the biggest challenges is
services. related to the risk of spreading infection to the
patient or acquiring infection from patients. In the
In order to succeed in your role in HBC, you need next section you will look at how you can protect
to cooperate with the other providers of HBC in yourself from infection by adopting effective
your community. You must link the patient to the infection prevention measures.
available support services right from the beginning
when you identify that the patient needs HBC.

Now move on to look at the process of linking

patients to support services.

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SECTION 2: PRINCIPLES OF Overview of Disease Transmission
INFECTION CONTROL AND
PREVENTION As you already know, micro-organisms are found
everywhere in the environment - on
people, animals, plants, soil, air, water and so on.
In this section, you shall revisit the principles and
techniques of infection prevention, which you
Micro-organisms which are associated with
learnt in unit two of module one on general
disease are called pathogens. All micro-
nursing.
organisms can cause infection or disease. They
do this when:
Specifically, you shall apply the knowledge and
skills you learnt in that unit to the provision of
HBC. Before proceeding, move on to look at the  Normal flora is introduced into an area of
the body in which they are not normally
objectives for this section.
found
 Pathogens are introduced into the body
Objectives  Micro-organisms are introduced into the
body of a person who is immuno-
By the end of this section you will be able to: compromised and thus susceptible to
infections
 Describe the disease transmission cycle
 Explain infection transmission in the HBC In the case of HIV/AIDS, cancer and other
setting and its importance terminal illnesses you can see that all the three
 Describe standard precautions for situations are critical during HBC.
minimising risk of infection transmission
The graphic opposite is a presentation of the
As mentioned, you have already covered most of disease transmission cycle.
these objectives in module one, unit two,
however, revise them again in the context of HBC.

Infection Transmission in the Home-based the caregiver has an infection can also transmit an
Care Setting infection to the patient. Finally there can be self-
infection.
Infection transmission in the HBC setting can take
You will now look at how each of these modes of
various forms.
transmission work.
A patient can transmit an infection to a caregiver,
a caregiver can also spread infection from one
patient to another. Caregivers can cross-infect
their family members and the community and, if

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Transmission from Patients to Caregiver Transmission from Caregiver to
Own Families and the Communities
This occurs when the caregiver gets exposed to
the patient's infected body fluids (blood, semen or Caregivers can cross-infect their family and the
saliva) or contaminated air through: community in several ways:

 Not using gloves or other available plastic  When caregivers do not wash their hands
waterproof material while handling soiled after leaving the health facility or patient's
linen, blood and other body fluids. home.
 Attending to a patient while having open  When medical waste such as bandages
uncovered cuts, wounds or abrasions. and drug administration sets, are not well
 Inhaling contaminated air, which may disposed.
cause infections, for example, acquiring  When caregivers wear contaminated
chest infections such as tuberculosis clothes.
while caring for a patient.  When caregivers acquire an infection
 Splashing infected body fluids, for from a patient and spread it to their
example, blood on mucous membranes families who in turn spread it to others in
like on eyes or nose while attending the community.
childbirth by an HIV-positive mother.
Transmission from Caregiver to Patients
HIV/AIDS and hepatitis B are two diseases that
are commonly transmitted by this method. This occurs when the caregiver infects the patient.
In many cases, the patient may have lowered
Transmission from Patient to Sexual immunity as a result of HIV infection or cancer
Partner(s) treatment. If the caregiver is sick with any
infectious disease, it is safer to have another care
Being HIV-positive does not mean the person is provider take care of the patient during the period
no longer capable of having a sexual relationship of the illness.
or in need of sexual satisfaction. In the early
stages of HIV infection, the person has minimal or Common infectious diseases include the
no signs of the disease, so is still capable of following:
passing the infection sexually to any sexual
partner(s). This form of infection can be prevented  Common cold or flu.
by:  Diarrhoeal diseases.
 Skin conditions such as scabies.
 Educating the infected person on the  Typhoid.
infection including mode of spread and all  Chest infections like bronchitis,
known preventive measures. pneumonia and tuberculosis.
 Stressing total abstinence (primary or  Fungal infections, especially those
secondary) as the primary preventive affecting the skin.
measure.
 Urging People Living with Aids (PLWHA) Transmission from Caregiver to Patients
(who are not able to abstain) to have only
one sexual partner, with whom they must
use condoms consistently and correctly to In order to break the cycle of disease
prevent re-infection and spread of the transmission, appropriate infection prevention
disease. practices should be followed in HBC.

Transmission by Caregiver from One Patient Proper use of these practices:

to Another
 Prevents post-procedure infections in
This occurs when the caregiver does not wash patients
their hands before and after caring for different  Provides safe and high quality services
patients. It can also occur through the use of  Prevents infections in service providers
surgical instruments, needles, syringes and other and support staff
equipment that has not been well processed, that  Protects the community from infections
is decontamination, cleaning and/or sterilisation. that originate from health facilities and
other patients

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  Decreases the incidence of drug resistant Scientific evidence shows that hand washing
strains of micro-organisms reduces the risk of micro-organisms and also
 Decreases costs associated with health reduces mortality and morbidity associated with
care these micro-organisms.

Remember: The purpose of infection List six appropriate times for hand washing
prevention is to minimise post-procedure
infection and prevent transmission of  Immediately after arriving at the
infections to patients, health workers, family workstation or home
and community members.  After coming into contact with equipments
used for patient care or contact with the
After completing the next checkpoint patient's body fluids and/or mucous
question, you will then move on to take another membranes
look at the standard precautions that are  Before and after examining a patient
necessary for minimising the risk of transmission  Before and after putting on gloves for
of infections. procedures
 Before and after every procedure
Precautions for Minimising Risk of  Before leaving the home or at the end of
Infection Transmission the work shift

Why do you think these precautions are As you will probably recall there are four different
referred to as 'standard'? types of hand washing. You will have been
practising all these methods in your clinical
They are referred to as standard because they setting.
should be followed routinely all the time. All health
workers are expected to follow a set of clinical List four types of hand washing.
practice recommendations in order to minimise
the risk of exposure to infectious and emerging The four types of hand washing are:
diseases such HIV and hepatitis.
 Routine hand washing using plain soap
What are some of the precautions and running water
 Hand washing with antiseptic and running
 Washing hands. water
 Wearing protective devices like gloves,  Alcohol hand rub
eye shield, boots, face shields and gowns  Surgical hand rub
when appropriate.
 Processing instruments and other items Hand washing techniques and policy statements
used in procedures correctly. were also covered at length in module one, unit
 Preventing injuries with used sharp two. If you have forgotten the details, review that
instruments. topic again.
 Maintaining correct environmental
cleanliness and proper waste In the home care environment hand washing with
disposal practices. plain soap and running water for 10-15 seconds is
 Handling, transporting and processing enough. Antiseptics are not necessary. If there is
used/soiled linen correctly. no tap or running water, the caregiver can use a
'leaky' tin or ask somebody to pour water for them.
Now briefly go through the first three standard
precautions, both to remind yourself as well as to Remember to teach your patients, their families
learn how you can implement them in the HBC and community members proper hand washing
environment. procedures. Also, teach them to use small pieces
of bar soap, how to keep the bar soap dry (not
Hand Washing and Use of Gloves moist) and how to avoid wet hands during
procedures. If water is not available, then alcohol
hand rub can be used. You can prepare the
Having practiced as a nurse, you should know by
now that hand washing is the most important way following hand rub solution at the health facility
of reducing the transmission of micro-organisms. and supply your patients:

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2ml of glycerine or propylene glycol or sorbitol and Antiseptics should only be used for the following
100ml of 60-90% alcohol. purposes:

Remember: Plain water removes 50% of  Surgical scrub.

transient micro-organisms, while soap  Skin, cervical and vaginal preparation
removes 80-90% of micro-organisms. before clinical procedures.
 Hand washing in high-risk situations
Gloves provide a strong barrier against micro- especially before invasive procedures.
organisms. They can also protect us against
hazardous chemicals. In the home care setting, There are two types of disinfectant:
caregivers should always wear gloves to prevent
direct contact with body fluid. If gloves are not
 Low-level disinfectants which kill most
available, they can use plastic bags. bacteria and
some viruses.
They should also protect their feet when cleaning  High-level disinfectants which kill bacteria,
body fluids spilled on the floor. Remember, the viruses, fungi and some but not all
use of two pairs of gloves at the same time bacterial endophores. These can be used
(double gloves) is not recommended because one to process instruments.
may slip off. It is also not cost effective.
Antiseptics and Disinfectants
Antiseptics and Disinfectants
Some common high-level disinfectants are:
In HBC, it is very important to use the correct
procedures for processing instruments and the
other items that are used. Now consider the use  Chlorine
of antiseptics and disinfectants.  Glutaraldehyde (cidex)

Can you remember how antiseptics and Common low-level disinfectants are:
disinfectants are defined?
 Phenols (for example, carbolic acid (lysol)
As a reminder, it was said that antiseptics are  Quarternary ammonium compounds (for
agents used on the skin and mucous membranes example, benzylkonium chloride)
to remove or kill micro-organisms without causing
damage and irritation to the skin or mucous Before you use any of these disinfectants and
membranes. antiseptics always read the label.
You should also assist your patients to choose
Disinfectants are chemical agents used to kill cheap but effective chemicals for use in the home
micro-organisms on inanimate objects, for environment. They should not be contaminated
example, instruments. and they should be well labelled to avoid
accidental poisoning.
Antiseptics commonly used in practice and at
home The advantages and disadvantages of the various
chemicals that have been covered are explained
in detail in module one, unit two. Review them
 Alcohol (60-90% ethyl isopropyl)
again so that you can support other caregivers
 Chlorhexidine (hibitane, hibiclens, effectively.
hibiscrub savlon)
 Hexachlorophene
Ways of preventing injuries from sharp
 Iodine (including tincture of iodine)
 Iodophors (solutions that contain iodine in instruments
a complex form, for example, betadine)
 Para-chloro-meta-xylenol (dettol)  Handle hypodermic needles, syringes and
other sharps minimally after use.
Antiseptics should not be used on inanimate  Do not recap needles.
objects such as instruments and surfaces.  Do not bend, break or cut instruments
before disposing.
 Dispose all sharps in a puncture resistant
container.

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  Always wear utility gloves when disposing decontamination takes place. This kind of
sharps containers. arrangement ensures that only sterile surfaces or
 Try the hands-free technique when articles touch other sterile surfaces or articles in
passing sharp instruments to others. This that home. Remember that whatever is sterile for
is done by placing the sharp in a one patient can only be used for that patient
container, for example a kidney dish, alert alone. Also when handling sterile fluids, they must
your colleague who will then pick it up be poured from a point high enough to prevent
from the kidney dish. The container is accidental touching of the receptacle.
referred to as a 'safe zone'.
 Dispose the puncture resistant container When providing HBC or teaching others to do it,
when ¾ full by incineration or burning you must assess the patient using the nursing
process. This will enable you to know how to
Processing Equipments advise them, and what cost-effective means are
available to institute all the infection prevention
To protect yourself and your patients, it is measures that have been covered. For instance,
important to focus on: some patients may have cupboards and fridges to
keep their food in while others may not. Some
patients may have piped water while others may
 Destroying as many harmful not. A careful assessment enables you to apply all
micro-organisms as possible early in the knowledge you have learnt in general nursing,
the processing. reproductive health and community health to care
 Preventing body fluids from coming into for your patients. This will prevent the
contact with the skin and mucous unnecessary transmission of infection.
membrane.
SECTION 3: PATIENTS FOR HOME-
You will do this through:
BASED CARE SERVICES
 Decontamination, that is, making
instruments and other items safe for Introduction
handling by soaking them in 0.5%
chlorine for 10 minutes. In this section, you will learn how to manage
 Cleaning with a brush, detergent and diseases that may require HBC. You will look at
water. diseases such as HIV/AIDS, cancer, some chronic
 Sterilisation or high-level disinfection. medical and surgical conditions which can be
managed at home.
Processing Equipments
Many conditions require HBC but not all will be
covered in this section. However, the principles of
Review the diagram opposite. It gives you the
management that will be described here apply to
steps to follow in the processing of instruments.
all diseases and conditions.
Although some of the steps may not be
appropriate in HBC, you can still identify the most
appropriate or even better, ask the patients to Do not hesitate to evaluate your patients together
bring their equipment to the health facility for with other members of the health care team in
processing. order to determine who needs HBC.

Finally, before this section is concluded on Before proceeding, move on to look at the
infection prevention, think how you can carry out objectives for this section.
sterile procedures at home with minimum risk of
introducing infection, that is, the aseptic Objectives
technique.
By the end of this section you will be able to:
Aseptic Technique
 Describe basic facts about HIV/AIDS
In the home of the patient, it is important to  Explain the management of AIDS-related
differentiate between places where procedures conditions in HBC
can be done and where they cannot be done.  Describe basic facts about common
Ideally there should be two separate corners: one cancers and HBC management for cancer
for carrying out clean procedures and storing patients
sterile items and the other for dirty items where

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  Describe basic facts about terminal signs or symptoms are present at this stage. It
illnesses, injuries and their management can last from two months to several years. It is
also referred to as the HIV positive phase. It
Home-based Care for HIV/AIDS Patients comprises the seroconversion stage and the
asymptomatic seropositive stage.
HIV is now the fastest growing threat to economic,
social and human development in Africa. Since Phase 3
you had already covered this topic in unit six of
the Reproductive Health module, in this section Phase 3 is the phase when the person shows
you are quickly going to revisit the facts and then signs and symptoms of AIDS and develops full
look at the management of common AIDS-related blown AIDS. It is also called the AIDS phase.
conditions at home.
AIDS, as you know is not transmitted by casual
What is HIV/AIDS? contact, (holding hands, hugging, kissing, sharing
food or drink.) You should therefore show
HIV stands for Human Immunodeficiency Virus, affection to your patients and their families.
while AIDS stands for Acquired Immune
Deficiency Syndrome. The HIV virus causes AIDS You are probably aware that in this country there
by reducing the ability of the body to fight is Voluntary Counselling and Testing centres
infection. (VCTs). You should encourage your patients,
friends and family members to visit the VCT and
How is it transmitted? find out their HIV status.

There are three modes of transmission of the HIV: Counselling and testing has three steps:

 Sexual - unprotected sexual intercourse  The test decision or pre-test counselling

(vaginal, oral and anal) with an infected  The test which is done by a finger prick to
person. This is the most common mode of collect a few drops of blood
transmission in this country.  Post-test or results counselling
 Contact with infected blood or other body
fluids. Transfusion of blood products from Even when caring for people living with HIV/AIDS
an infected person/donor. Use of you should maintain utmost confidentiality of your
contaminated instruments such as patients' conditions unless they desire that others
needles, syringes, knives or blades. know. You should however recommend testing for
These instruments may have been used partners of HBC patients.
for circumcision, skin piercing,
scarification, drug abuse and other
People living with HIV/AIDS need to receive
traditional practices like female genital
education on how to protect themselves, and their
cutting.
partners, through either abstinence or using
 From an infected mother to a child in the condoms consistently and correctly and having
uterus, during labour and delivery or
only one sexual partner.
during breastfeeding.
Now move on to look at the major and minor signs
What are the three phases of HIV/AIDS?
of HIV/AIDS in adults and children.

HIV/AIDS progresses through three main pha Common Signs and Symptoms of HIV/AIDS
Phase 1
The presence of at least two major and two minor
signs is enough to diagnose AIDS in a child, in the
Phase 1 is when HIV is present in the body but absence of other known causes of
laboratory tests can not detect it. This phase lasts immunosuppression. In the adult, the presence of
for up to six months and includes the entry stage at least two major signs and one minor sign are
when the virus enters. enough to diagnose AIDS.

Phase 2

Phase 2 is the detection stage, when laboratory

tests can detect the presence of HIV. However, no

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Major and Minor Signs of AIDS in Adults Medications:

Major: Unexplained 10% weight loss in less than  Aspirin/paracetamol

one month  Anti-malarial tabs
Persistent diarrhoea for over one month  Anti-worm medications, for example,
Fever for over one month albendazole
 Multivitamins
Minor: Cough for over one month  Piriton
General pruritic dermatitis  Iron and folate tabs
Recurrent herpes zoster
Oral thrush: candidiasis Besides these, the caregiver should have a
Generalised enlarged lymph nodes reference book, writing materials, a register/diary
Disseminated progressive herpes simplex and teaching materials

Major and Minor Signs of AIDS in Children The Patient Primary Kit

Major: Weight loss or slow growth The patient also needs to have a primary kit. This
Chronic diarrhoea for over one month kit is restocked by the community based health
Fever for over one month workers when they visit the patient. The primary
kit comprises:
Minor: Recurrent common infections, for
example, tonsillitis, otitis media, laryngitis Medications:
Generalised lymph node enlargement
Generalise dermatitis
Oral thrush  Paracetamol
Cough for over one month  Albendazole
Confirmed maternal HIV infection  ORS (Oral Rehydration Salts)
 Multivitamins
AIDS-Related Conditions and their  Tetracycline skin ointment
Management  Gentamycin eye drops
 Calamine lotion
Home Care Kit  Savlon
 Dettol cream
 Nystatin oral drops
Before you start caring for PLWHAs or teaching
their families and the community how to care for  Antimalaria tabs
them, there are certain materials and supplies that  Iron and folate tablets
they should have. The caregiver should have a  Antihistamine (for example piriton)
community volunteer kit while the patient should
have a patient primary kit. Supplies:

The Caregivers Kit  Gloves

 Soap, toilet paper, vaseline and talcum
A caregiver should have what is called a powder
'community volunteer kit'. It has the following  Bucket with a lid
items:  Basin
 Mosquito net (impregnated with
Supplies: insecticide)
 Nail cutter
 Gloves  Scissors (small)
 Soap  Waste disposal bags
 Toilet paper  Cotton wool
 Scissors (small)  Gauze
 Razor blades  Bandages
 Waste disposal bags  Mackintosh (2m)
 Jik  Jik
 Surgical spirit  Bed sheets
 Plastic apron and plastic sheets  Good comfortable mattress
 Condoms  Condoms

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  Wooden spatula  If it is a child or a mentally confused adult,
put gloves or socks on their hands to
After you have seen the kind of supplies and prevent skin damage due to scratching.
medications that should be available in both the  Washing open sores with clean water and
patients and caregivers kits, move on to look at soap, keeping them dry and applying
the management of specific conditions that affect gentian violet solution.
PLWHAs.  Rubbing pressure areas to improve
circulation.
AIDS-related Conditions  Keeping pressure areas dry.
 Frequent turning of the patient.
Home caregivers need to recognise early and  In the case of patients with incontinence,
manage common illnesses related to HIV/AIDS in cleaning the skin in the area with warm
the home environment. You will now look at some water and dry it to avoid skin irritation.
of the most common illnesses in PLWHAs starting
with skin conditions. Tiredness and Weakness

Skin Problems Tiredness and weakness are common problems

for patients with HIV/AIDS.
About 90% of people with HIV infection will Some of the causes of tiredness and weakness
develop at least one skin problem in the course of include poor nutrition, depression, anaemia,
the disease. These skin problems can be due to: respiratory disease and other AIDS-related
illnesses.
 Fungal infections: ringworm,
cryptococcus. What advice would you give to a patient who
 Bacterial infections: impetigo, folliculitis, is suffering from tiredness and weakness?
abscesses.
 Viral infections: herpes zoster/simplex,  To rest
warts, molluscum contagiosum  To reduce activities that make the patient
 Parasites: scabies, body lice. tired or to make it easier, for example,
 A typical presentation of dermatoses instead of washing while standing, the
including psoriasis, pruritic papular patients could sit
eruptions and seborrheic dermatitis.  To perform simple exercises
 Allergies to drugs, the sun, x-rays and  To take a well-balanced and adequate
eczema. diet
 Tumours such as Kaposi's sarcoma or  Use of support, for example, a cane or
lymphomas. crutches
 Trauma as a result of injury or scratching  Use of energy drinks and food
with dirty nails.
You should teach the family how to help the
In order to minimise skin problems and treat them patient in some of these activities. For example,
properly, you need to teach the caregiver the they can support the patient while they are getting
following simple measures: in and out of bed, while going to the toilet and in
many other activities.
 Keeping skin clean - washing with soap
and water. They can also be taught to give the patient simple
 Keeping nails short to avoid damaging the exercise and massage. They should seek medical
skin during scratching. help when these simple measures do not work.
 Using flat part of hand to rub if itchy, not
the nails. Sore Mouth and Throat
 Cooling the skin with water or fan in cases
of severe itching. Candidiasis is a very common problem among
 Applying lotions for example, calamine PLWHAs. It can lead to patches in the mouth and
lotion to skin rashes, painful and weeping difficulty in swallowing. Other problems which
lesions. interfere with eating and swallowing are: herpes
 Using any local herbal remedies that are simplex in the mouth, malnutrition which causes
effective. cracks and sores in the oral cavity, Kaposi's
 Applying petroleum jelly (for example, sarcoma and dental problems.
vaseline) or glycerine if the skin is dry.

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You should teach the patient, family and caregiver  AIDS-related opportunistic infections such
the following simple measures on how to manage as pneumonia and tuberculosis.
this condition:  Diseases like malaria, measles
and meningitis.
 The patient should rinse the mouth with  Infective diarrhoea.
warm, salty water  The HIV infection itself.
 The patient can suck a lemon and apply
gentian violet in the mouth Fever
 The patient should eat soft foods as
tolerated In the home setting you can manage fever by:
 Use of straws for liquids and soups
 Eating of cold foods, drinks or ice to numb  Checking whether the patient has a fever
the mouth by either using a thermometer if available,
or placing the back of your hand on the
Pain patient's forehead and the back of the
other hand on your own forehead to
Pain can be caused by many factors in a patient compare the two.
with HIV/AIDS. It can present in the form of joint,  Lowering the fever by removing the
chest, muscle and headaches, or just generalised patient's clothing and exposing them to a
pain. It is important to understand the main cause fresh air breeze.
of the pain, whether it is due to an infection or  Cooling the skin by bathing the patient
ectopic pregnancy, and treat it immediately. with lukewarm water or wiping the skin
with wet cloths.
How do we manage pain in PLWHAs?  Give antipyretics, such as aspirin or
paracetamol.
There are a number of things you can do to  Giving plenty of fluids such as water, juice
manage pain in PLWHAs: and soup to replace the fluid that is lost
through sweating, in order to prevent
dehydration.
 The patient can take an analgesics like
aspirin or paracetamol.  If the person is weak they should be
turned, cleaned and observed
 Caregivers can gently massage the area
for dehydration.
while talking to the patient to
distract them.
 They can assist the patient to change Can you remember the signs and symptoms of
position in bed and keep the patient's dehydration? You can refresh your memory by
environment quiet and calm. revising the relevant section in unit three of the
 In the case of chest pain, you can apply a module on General Nursing.
warm compress to the area where the
discomfort seems to be centred. Always advise the caregiver and patient to seek
 If there is pain following a cough, you can treatment for the cause of the fever
hold a pillow or hand tightly over the area
that hurts when coughing. Nausea and Vomiting
 Use distractors like TV, radio, interesting
stories. Nausea and vomiting although frequent can
sometimes be short lived. They are brought about
Fever by HIV infection, drugs, opportunistic infections
and food poisoning. The family and the patient
Fever, as you have learnt from previous units, is a should always watch out for dehydration.
symptom of various illnesses. It makes the patient
very uncomfortable and can be dangerous, Oral Rehydration Salts (ORS) and weak tea can
especially in small children. Fever may cause loss be taken in addition to small frequent meals. If
of body fluids and it may also lead to delirium and certain smells and odours make the patient
convulsions, which can cause brain damage. nauseated, they should be kept away from the
patient.
Fever may be associated with any of the
following conditions:

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Chronic Diarrhoea contagious. Patients should drink lots of fluids
especially if there is fever. They should also sit up
A person has diarrhoea if: in bed if possible and turn frequently. When
coughing, they should cover their mouths with a
piece of paper or cloth which can later be burnt.
 Their stools are frequent (three or more in
a day)
 Change in character, amount and Testing should be done to find out the main cause
consistency of the stool and paracetamol or aspirin taken for fever. When
there is difficulty in breathing, the head of the bed
should be elevated to assist the person to sit up in
Chronic diarrhoea occurs in two forms among
bed. Difficulty in breathing can be very frightening
those with HIV/AIDS. There is the persistent form
and so it is important to talk to the patients and
which lasts for less than two weeks and the acute
soothe them.
form.
Confusion, Fear, Anxiety and Depression
The most common causes of diarrhoea are
infection, side effects of drugs and food poisoning.
HIV infection can cause psychological effects,
especially if the person is not properly counselled
How would you manage diarrhoea in the home
to cope with the situation.
setting? It can also cause mental confusion or dementia
and peripheral nerve damage.
Your answer should include the following simple
management procedures: Mental confusion can be due to the direct effect of
the virus on the brain, head injury, or severe
 Give more fluids than usual, especially depression. Depending on the degree, this can be
those that the person finds favourable: a serious disability. Patients can present with
such as, unsweetened juices, porridge, inability to concentrate, loss of memory, slow
soup, water and ORS. Correct thinking, poor short-term memory and personality
dehydration by giving plenty of fluids after change. In late stages, about half develop motor
every loose motion passed. dysfunctions like weakness of one part of the
 If the patient is a child who is body, tremors, inability to walk and incontinence
breastfeeding, continue to breastfeed the of stool and urine. In anxiety and depression,
child to avoid malnutrition. If the mother is patients have feelings of nervousness, fear,
HIV-infected, adhere to the current sadness and hopelessness.
instructions on how to feed such a child.
 In case of vomiting or loss of appetite, Some of the physical and mental symptoms of
feed the patient frequently with small anxiety are:
amounts of food that form a balanced diet
and that is easily digested.  Lack of appetite.
 After the diarrhoea stops, give an extra  Feeling short of breath.
meal each day for two weeks to help  Shaking, sweating and feeling faint.
regain the lost weight.  Palpitations, tingling sensations.
 Prevent dehydration by early recognition  Insomnia, difficulty to concentrate.
and treatment.  Feeling out of control, worried and
 Care for the perianal area to avoid skin irritable.
break down.
 Maintain infection prevention practices
Signs and symptoms of depression are:
when caring for the patient and also
advise the patient on this practice.
 Feelings of hopelessness and
Remember: The cause of diarrhoea must be helplessness.
 Sleeping too much or too little.
established as you provide these measures.
 Eating too much or loss of appetite.
Coughing and Difficulty in Breathing  Withdrawal from normal activities.
 Comments about wanting to commit
suicide.
These are caused by TB, pneumonia, bronchitis,
heart problems, asthma and common cold among
others. It is important for patients to be The home-care for patients who have fear,
investigated because some of the diseases are anxiety, depression and confusion comprises:

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  Keeping loose and dangerous objects out  Observe the child for infections,
of the reach of the patient. dehydration, pain and other symptoms,
 Helping the person to stand and walk and seek specialised care immediately.
about.  Counsel the mother and other caregivers
 Ensuring the person is always on infant feeding, nutrition, ARV therapy
accompanied. and other care.
 Keeping medicines out of the way.
 Ensuring that the patient rests, eats Promote health by:
properly and is well groomed.
 Spiritual guidance from friends,  Treating infections that may present in a
counsellors and religious persons. timely manner.
 Encouraging peer contact and identifying  Identifying non-specific symptoms that
community persons and groups dealing could be related to HIV infection.
with PLWHAs.  Providing HIV testing.
 Discouraging use of recreational drugs.  Providing multivitamins, in accordance
 Letting the patient know that their feelings with Kenya guidelines.
are normal.  Providing cotrimoxazole preventive
 Communicating unconditional love by the therapy (as per 2004 Kenya National
family and friends. clinical manual for ARV provider for
 Assisting patients to plan their daily, prevention of pneumocystis
weekly and monthly activities. pneumonia and other bacterial infections).
 Assisting patients to relax and teaching  Assessing and support the mother's infant
them that feelings of depression and feeding.
anxiety are normal.  Monitoring growth and assess causes of
growth failure.
Now move on to briefly learn about home-based  Screening for TB and treat if indicated.
care for a child with HIV/AIDS.  Recommending use of insect treated
mosquito bed nets.
Caring For the Child with HIV/AIDS  Treating anaemia as indicated based on
Kenya guidelines.
Children with HIV/AIDS present with the same
problems as those found in the adults. They Patients with HIV/AIDS may require antibiotics,
however may not be in a position to easily anti-retroviral drugs, antipyretics for fever,
communicate how they are feeling. diarrhoea, skin conditions, mouth and genital
problems. They may also require nutritional
Therefore you should teach the family to: supplements at home. You should ensure that the
patients and caregivers are taught how to
prepare, take, and store the medications. Inform
 Maintain good personal and general them about the side effects and adverse reactions
hygiene. of the drugs. The patient should only take the
 Have the child immunised as required. drugs that have been prescribed by a qualified
 Vitamin A supplementation. health worker.
 Love the child and show them that they
are loved. However, treat the child Having covered the HBC management of patients
normally. with HIV/AIDS, now move on to take a look at the
 Promote health. (see below) management of cancer patients.
 Allow other children to play with the sick
child.
Home-based Care for Patients with Cancer
 Teach the older children good personal
hygiene.
When talking about cancer, you should remember
 Hold children who are bed ridden on the
that there are several types of neoplasms (new
lap to prevent pressure sores.
growths). Neoplasms can be either malignant or
 Ensure the child is not wet for long
benign.
periods.
 Avoid wiping their buttocks, instead pat
them dry. The table opposite shows the difference between
 Use simple lotions for skin care. malignant and benign tumours.

The term cancer is commonly used to refer to

malignant neoplasms.

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Cancers affect various organs and tissues in the  Biopsy.
body. There are skin cancers, oral cancer, lung  Imaging.
cancer, colon and rectal cancer, pancreatic  Special tests for enzymes, hormones and
cancer, prostate cancer, bladder cancer, other tumour associated molecules.
leukaemia and lymphomas, ovarian cancer,
breast cancer, uterine cancer, cancer of the Remember that all cancer should be classified in
cervix, the stomach, lungs and prostate among order to determine the extent of illness and assist
many others. in management.

Effects of cancer:
Various classifications are available.
Metastasis. This is when the tumour grows
and spreads beyond its primary site. This has Read and acquaint yourself with at least one
an effect on other organs, which are affected classification system for all cancers.
by the growing tumour.
It alters the function of the organs or the
tumour puts pressure on the Cancer Prevention
surrounding tissues.
Cancer prevention aims at ensuring that there are
Paraneoplastic syndromes: These are fewer cases of cancer.
effects which are systemic and unrelated to Cancer prevention measures are divided into
the location of the tumour. They are caused three: primary, secondary and tertiary.
by substances produced by the tumour, for
example, hormones, cytokins. They include Primary Prevention
anorexia, wasting, fever, hypercalcaemia,
inappropriate secretion of antidiuretic This involves asking people to stop smoking,
hormone and clotting abnormalities, among drinking excessive alcohol, decrease their fat
others. intake, limit exposure to the sun in fair skinned
people, and to limit exposure to carcinogens
Tumour changes, whereby cells change in among people who work with chemicals and in
character and start secreting hormones industries. In addition, it involves protecting
(ectopic hormones). people from:

Pain due to growth of tumour on non-  Exposure to ionising radiation which can
expandable spaces, pressure on nerves lead to cancer of the thyroid.
or tissue.  Developing atrophic gastritis and
pernicious anaemia which can lead to
These effects produce certain signs and cancer of stomach.
symptoms in the patients, i.e.  Early sexual activity and multiple sexual
partners which can cause cancer of
the cervix.
 Anorexia, nausea and vomiting
 Fatigue
 Fever and night sweats Secondary Prevention
 Anaemia
 Difficulty in swallowing Secondary prevention is done by identifying
 Vaginal bleeding individuals with cancer before signs and
 Pain symptoms develop. This takes the form of early
screening for breast cancer, pap smears for
 Wasting
cancer of the cervix, and bimanual/digital
 Enlarged lymph nodes
examination for prostatic cancer. Pelvic exams
 Masses felt at specific organs and endometrial tissue sampling are also
 Nutritional deficiencies important.

The signs and symptoms of each type of cancer

are covered in module one, unit three.

The diagnosis of cancer is done through the

following tests:

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Tertiary Prevention combination with other treatment options.
Radiotherapy may be given over a period of time
Tertiary prevention involves early and quick with varying side effects. These effects can be
treatment before the effects of the cancer become managed while the patient is at home.
widespread and unmanageable.
Patients who are on radiotherapy may have bone
Home-based Care for Cancer Patients marrow depression, frequent infections, skin
changes such as drying, allopecia, nausea and
vomiting, diarrhoea, anaemia and taste
The overall aim of cancer management is to
control the malignancy and extend the life of the alterations, among others.
patient or cure the cancer.
Chemotherapy
Once cancer is diagnosed, several options are
available which include: Various drugs and drug combinations are used in
the treatment of cancers. You will have come
across some of these drugs. They include
 Surgery
vincristine, bleomycin, doxorubicin, cytarabine,
 Radiation therapy methotrexate and mitomycin. These drugs have
 Chemotherapy many side effects. These include: bone marrow
depression, nausea and vomiting, stomatitis,
These options may be used individually or in alopecia and problems affecting fertility, kidneys,
combination. You will probably have nursed lungs and nervous system.
patients undergoing some of these treatment
options. You have also covered the actual The management of these effects require HBC
management of various types of cancers in the services.
previous module.
Home care measures that should be instituted
At this point you must be wondering whether all include:
cancer patients need home-based care. Some
patients may require long term treatment while
others may present too late for a complete cure to  Pain management. This was covered in
occur. It is this latter group that requires HBC. the section on palliative care in module
one unit three. Review it again to better
understand pain management in cancer
Surgery
patients.
 Close monitoring of the patient by
Surgery can be a form of prophylaxis. For relatives, friends and caregivers, in order
example, patients with a history of breast cancer to detect complications of surgery,
may choose to undergo mastectomy instead of radiation and medication.
waiting to suffer the effects of cancer. It may also  A nutritious and appetising diet. Certain
be done for palliation, that is, to control difficult foods may be removed from the diet such
symptoms that could arise later. Patients who as spicy, dry food, alcohol and hot liquids.
have undergone surgery may take time to heal The patient should take small frequent
and instead of staying at the hospital for long meals which are high in calories and
periods, the justification and rationale for HBC to protein.
nurse them at home can be used.  Good personal and general hygiene need
to be practiced in order to reduce the risk
Patients who have undergone surgery may suffer of infection.
from pain at the surgical incision, altered nutrition  Patients with radiation implants should be
and a decrease in self-image due to removal of an cared for in separate rooms to protect
organ or structure from their body such as a other family members from radiation.
breast. Other more acute problems, such as Body secretions should be handled
infections and bleeding, can be managed at the carefully. Precautions should be taken in
health facility in the immediate post-operative patients with isotope administration. The
period. caregivers should observe the following
radiation precautions:
Radiation Therapy (Radiotherapy) - Principle of time, which says that
exposure to radiation is proportional to the
This is the use of high energy ionising radiation to time
kill tumour cells. It can be used singly or in of exposure.

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 - Principle of distance, that is the nearer As you have just seen on the previous page, the
to the emitting source the higher the dose. list is quite long and all the conditions have not
- Principle of shielding, whereby one uses been exhausted. Since you have previously
materials which decrease transmission of looked at these diseases already, you will now
radiation. broadly look at the areas of care that are needed
 Pregnant mothers and children under 18 for these conditions. These are:
years should not visit those with radiation
implants.  Comfort and pain management
 Careful observation, good disposal of  Personal and general hygiene
waste and labelling should be undertaken.  Medications, their administration and
 During and after chemotherapy, minimise safety and management of their side
stimuli from noise, light and odours effects
(especially food).  Activities of daily living for the patient, for
 Teach the patient relaxation techniques. example, elimination, eating, reproduction
 Provide counselling, spiritual care, and others
emotional support and close observation.  Alleviation of fear, anxiety, depression
and general psychological care
Patients with terminal cancer may present with  Nutrition
depression, fear, anxiety, fever, skin problems,  Physiological and spiritual integrity
diarrhoea and vomiting. You should be able to use  Security and safety
the same management protocols that were
mentioned while learning about management of This means that all measures to provide comfort
AIDS-related conditions in the home environment. should be instituted in the home. These include
positioning using assistive devices for example
HBC for Chronic/Terminal and crutches, and walking canes providing rest and
Medical/Surgical Conditions other measures to relieve pain which have already
been covered.
Generally speaking, many patients with medical
and surgical illnesses may require HBC. However, Medical and Surgical Conditions that May
in this sub-section you shall only cover issues Require Home-based Care
related to their management in the home
environment. The patient's hygiene is also very important and
should not be neglected. If the patient requires
Medical and Surgical Conditions that May assistance to feed or bathe, they should be given
Require HBC that assistance. If the patient requires assistance
in elimination, they may require bed pans, urinals
 Spinal injuries and paralysis or catheterisation. Some patients may require to
 End stage chronic obstructive pulmonary be taught how to inject themselves with insulin
disease and other drugs.
 Chronic renal failure
 Liver cirrhosis The patient should not be neglected and if bed
 Patients with ulcerative colitis, Crohn's ridden they should be free from pressure sores.
disease or cancer of the bowel with They should be loved and assisted to maintain
ostomies for faecal diversion physiological integrity through skin care, good
 Chronic hypertension nutrition and close observation. Infections should
 Diabetes be prevented at all costs.
 Age-related body system changes
 Patients with amputations The spiritual and psychological care of the patient
 Patients with mental illnesses is another important area.
 Gout
 Arthritis
 Parkinson's disease
 Epilepsy
 Multiple sclerosis

Medical and Surgical Conditions that May

Require Home-based Care

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SECTION 4: COMPONENTS OF HOME-  General nursing care to meet Activities of
BASED CARE Daily Living (ADL), like toilet needs,
observation of vital signs, care of wounds,
personal hygiene and comfort.
Introduction  Nutritional needs, that is, provision of a
You are now half way through this unit on balanced diet, which is affordable and
home-based care (HBC). As you may have locally available.
realised you are revisiting most of the content you  Physical therapies to include exercise and
covered in earlier modules, and applying what you massage.
learnt earlier in the provision of home-based care.  Information, Education and
Communication (IEC), including up to
You should now be able to identify patients date, accurate information on the illness
for HBC in your health facility and to prepare their and safer sexual behaviour, on writing a
families, relatives, friends, community members will and on preparing for the eventuality of
and caregivers. death.
 IEC on how to take prescribed drugs,
In this section, you will take a detailed look at the prevention and care of the patient‟s
components of HBC which were mentioned in illness.
section one.  Security and safety measures.

Objectives Social Needs

By the end of this section you will be able to: The patient and especially PLWHAs need
company and association without stigma or
 State the various needs of HBC patients discrimination.
and their families Family and community members should facilitate
recreation and exercise at clubs/groups of their
 Describe how the HBC components assist
choice. People living with chronic illnesses need
in meeting patients' needs
to be considered as people of value and having
 Describe medication, follow-up and
rights to be respected. They should not be cut off
counselling for HBC patients
from activities they enjoy, for example, political
rallies, church/mosque/temple and spiritual
Home-based Care Needs gatherings.
HBC needs can be identified as those specific to
the patient, to the family and to the community The social needs of patients living with chronic
within which the patient lives. illnesses include:
These needs may be physical, spiritual/pastoral,
social or psychological and may vary from person
to person, and from one community to another.  Respect and dignity
 Love and acceptance from others
 Company of those around them
These needs should be identified when a patient
 Source of income/income-generating
is being enrolled into a HBC programme, for
activity
example, while still in hospital, so as to ensure
proper planning and integration of activities.  Right to own, inherit and bequeath
property
 Confidentiality regarding their condition by
Early identification also ensures adequate all who know about it
resource mobilisation and the sustainability of
 Help with the activities of daily living
activities initiated.
Spiritual/Pastoral Needs
Needs of the Patients Strengthening existing faith and helping the
patient in spiritual growth boosts the spiritual
Physical Needs aspect of life.
This plays a great part in encouraging the person
 Drugs for treatment. to have a positive view of life and to forgive others
 Clinical care including medication and and themselves for any misconceptions and
regular check ups in case of the onset of liabilities.
new symptoms to ensure immediate
management. The patient will therefore be able to:
 Clothing, housing, food, fuel/energy,
water, education for children and income.
 Accept forgiveness by others

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  Forgive others Psychological Needs
 Have reassurance that God accepts them The families of people who are terminally ill and
 Allow religious groups to offer support especially PLWHA
 Have freedom of worship according to need a lot of support, encouragement and
faith, which should be respected by the acceptance from
health worker and the care providers community members so that they may be
 Call a religious leader of choice for motivated and encouraged
sacraments and fulfilment of other needs to care for the patient without fear of being
isolated.
They should be adequately prepared for:
Psychological Needs
Love, encouragement, warmth, appreciation,
reassurance and help in coping with the disease  The deterioration and eventual death of
are the most important psychological needs. the patient.
 How to give un-smothering love and
Religious groups, volunteer groups and other acceptance.
related support groups can all play a part in  Where and how to meet others who are
meeting these psychological and counselling going through the same experience of
needs. caring for a chronically sick person.
This gives the family members a sense of
hope and a drive to go on.
They can:
 The importance of observing
confidentiality, for example, keeping
 Instil hope so that the patient can matters relating to the patient in
continue with their daily activities confidence.
as long as possible  The very real possibility that they
 Maintain confidentiality and unconditional themselves may need to seek counselling
acceptance and love to help them cope with the situation.
 Provide supportive counselling to live
positively Social and Spiritual/Pastoral Needs
Families don‟t stop being members of the
If you look closely at these needs, you will find community when someone
that they fit into Maslow‟s hierarchy of human gets illnesses like cancer and HIV/AIDS.
needs, which you covered in module two. In
short, HBC must be holistic, encompassing all the More than ever, such families need:
aspects of human living.
 Respect and help with activities of daily
Needs of the Family and Caregivers living when the need arises.
 Acceptance of the patient and
Families and caregivers also have physical, enabling them to socialise
psychological and social/spiritual needs that must and interact in the community.
be met in order to maintain family solidarity and  Solidarity with the patient and the family.
well-being.  Spiritual comfort, including taking the
 Physical Needs initiative to involve the family in spiritual
 Psychological Needs growth through worshipping and praying
together.
 Social and Spiritual/Pastoral Needs

Physical Needs Needs of Orphans

The physical needs of the family are more or less Orphans have a number of needs too.
the same as those of the patient except for
personal needs that are specific to the patient‟s These include:
condition.
 Acceptance by those around them
Family members of PLWHAs will need proper resulting in a sense of belonging
STD/HIV/AIDS education and demonstrations on  Basic needs like food, shelter, clothing,
the care they will be expected to provide. Because education and love
the burden of caring for someone who is very ill or  Legal interventions in cases of property
dying is constant and heavy, the family may also inheritance
need help with household, farm or other chores.  Protection from exploitation

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  Health care  Taking the patient to the hospital or health
facility when the need arises.
Having looked at the needs of various groups  Reassuring the patient at all times.
involved in HBC, you will now proceed to look at
the components of HBC, and how you can meet Since you have learnt and practiced these basic
the needs of the patients starting with nursing skills in your work as a nurse, you need only look
care. at the general guidelines. If you have forgotten
these basic skills, refer to the Nursing Council of
Basic Home Nursing Skills Kenya (NCK) procedure manual and update
yourself. You will now look at some of the basic
When individuals fall sick, both the body and the nursing skills that are needed in the HBC setting.
mind can be affected. This affects their ability to
carry out routine activities. Nursing care in the Bed Bath
Some of the patients for HBC may be too sick to
context of home-based care applies at all levels,
provide their own hygiene. They may therefore
from the health institution down to the family, require to be bathed in bed.
depending on the individual needs of the patient. The caregiver requires equipment and supplies,
Since you qualified as a nurse, you have had a lot such as, gloves, plastic/polythene paper, a large
of time to learn and practice basic nursing skills. basin, a face flannel, warm water, bath towel,
soap, a container for dirty linen, scissors/razor
blade, comb, chair, clean linen and clothes.
How would you define nursing?
Steps you should follow
Nursing is the art of assisting individuals to do
those things that they would do on their own if
they had the strength, knowledge or will. 1. Prepare the resources, patient and
yourself.
2. Assemble your equipment and supplies.
Nursing care can be provided to a sick person in
3. Explain the procedure to the patient.
hospital or at home.
4. Explain the role you want the patient to
Since you have already covered fundamentals in
play.
nursing practice in module one, you need only
review some of the nursing procedures in this 5. Bath the patient as per the recommended
section. procedure for bed bath in the procedure
If you have forgotten the basic nursing skills, refer manual.
to unit two of module one. 6. Clean the materials used.
7. Dispose dirty materials, or wash and hang
The components of nursing care are: to dry.
8. Store away the reusable.
9. Remove the gloves.
 Activities to ensure good personal
hygiene. 10. Wash and dry the hands.
 Care for the patient‟s environment.
 Infection prevention. Although this sounds easy, as it‟s what you have
 Physical therapy. been doing, you will now need to teach this to the
 Pain management. other caregivers who have not received training in
 Administering drugs as per prescription to nursing skills.
ensure compliance.
 Maintaining the nutritional status of the Mouth Care
patient.
 Observing of patients to detect problems Mouth care is intended to promote salivary flow,
like dehydration, dyspnoea, dysphagia, keep one healthy and the mouth clean. It also
oedema or fever. Related conditions that maintains freshness of the mouth.
need attention include:
- Diarrhoea and vomiting, which may For mouth care, the caregiver or patient requires
easily lead to dehydration. gloves, three small cups, toothpaste or salt water
- Pain and discomfort. or baking soda. Glycerine or vaseline, cotton wool
- Chest problems like chronic coughs, balls, a container for used swabs, toothbrush or
colds and infections. stick, plastic paper, a spoon/fork or stick for swab
- Skin conditions, for example, bed sores. and a padded spoon for those who are unable
- Nausea, mouth and throat infections. to keep their mouths open.

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You follow the same steps as those outlined in 4. Clean and disinfect your equipment.
bed bath, that is:
Care of Pressure Areas and Pressure Sores

1. Prepare the items, the patient and Some of the patients who require HBC are
yourself. bedridden and therefore at risk of developing bed
2. Clean the mouth. If the patient is able, sores. The objective here is to prevent the
provide the toothbrush and toothpaste development of pressure sores around the
and a cup with water for rinsing the mouth protruding bony parts of the body in a patient who
and a container to spit into. If the patient is unable to move out of bed, as well as minimise
is unconscious or conscious but weak the risk of infection and promote healing.
then assist as per the recommended
procedure in the procedure manual. List the steps you would take to prevent
3. Clear used items and dispose of those pressure sores in a bedridden patient
that are not reusable
Measures of preventing pressure sores are:
Nail Care

 Getting the patient out of bed as much as

Unclean nails can transmit infection from food to
possible
the mouth or they may scratch and transmit
 Turning the patient every two to four
infection to the skin. The main aim of nail care is
hours
to keep nails short and clean so as to reduce the
collection of micro-organisms and prevent self-  Attending to pressure areas by
injury. The caregiver requires a nail cutter, massaging areas of prominent
scissors or a razor blade, water in a basin, a piece bones with soap and water
of cloth or a towel, nail brush, vaseline or lotion  Using soft bed sheets and changing the
and soap. bedding whenever wet
 Straightening the bedding often
 Putting cushions under the body to keep
You should proceed as follows:
the bony parts from rubbing together
 Holding a bedridden child on someone‟s
1. Prepare the patient by explaining the
lap as often as possible
procedure and obtaining permission to
continue.
2. Wash each hand and finger, scrubbing Care of Pressure Areas and Pressure Sores
the nails with a brush, rinse and dry the
hands. You will also require the following resources for
3. Trim the nails, apply vaseline or lotion and pressure area care:
move to the next hand and to the toes.
4. Upon completion you should clean any  Gloves or plastic/polythene bags to use
equipment used, wash your hands and as gloves if patient is soiled or has
dry them. wounds
 Stool or chair
Hair Care  Container of warm water
 Basin or similar container
Hair care is intended to keep the hair clean and to  Plastic or polythene paper
avoid the scalp itching. You should use the same  Soap
materials and steps as those described earlier  Patient‟s own towel or a clean cloth
when covering Bed Bath. You require a patient‟s  Body powder (if possible)
towel or clean cloth, soap or shampoo, a comb or  Vaseline or lotion
hairbrush, water, a basin and a stool.  Toilet paper and a receiver
 Clean linen
Proceed as follows:  Container for soiled linen
 Material for treatment of sores
1. You should gather your equipment and
supplies and explain to the patient what Once you have assembled all your resources, you
you want to do. should explain the procedure to the patient and
2. Place the patient‟s head near the bed examine the areas to check if pressure sores are
edge and wash it with soap or shampoo. forming.
3. Rinse the hair, dry and comb it.

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Place the plastic paper or towel under the part to also be used).
be treated first. Then with soapy hands you  Clean out and refill the sore at
should gently massage each area in a circular least twice a day. If the honey or
movement and for long enough to stimulate good sugar mixture becomes full of
circulation of blood (count to ten as you massage liquid from the sore, it will feed
each part) then rinse and germs rather than kill them.
pat dry. Apply powder and/or vaseline and ask the
patient how they feel.

Remember to clear the materials used and to

clean the equipment. Also change or straighten General Care of Wounds and Sores
the underlying bed cloth as necessary and
remake the bed so that you leave the patient General wound care is provided to promote
comfortable. Lastly wash and dry your hands. healing.
The requirements and procedures are the same
If the patient has pressure sores, in addition to the as those for pressure sore care. However, the
previous steps, you should dress the pressure caregiver may utilise dressing solutions
sore by: prescribed and obtained from hospitals/health
institutions.
 Dipping a small piece of cloth into the
soapy water and clean the sore. More importantly, you must observe infection
 Wash around the edge of the sore first, prevention procedures by:
then wash from the centre out to the
edges until it looks clean. If possible use  Protecting hands with gloves or plastic
separate pieces of cloth for each wiping. bags
 If the wound has pus or blood in it, cover  Rinsing soiled items in cold water, and
with a clean piece of cloth or a strip of then pouring this water into the
cloth (torn as a bandage) after cleaning; toilet/latrine
leave it loose and change it everyday. If  Soaking soiled items in jik 1:6
the sore is dry, leave it exposed. concentration for ten minutes
 Raise the area with the sore as often as  Putting soiled clothing into a container
possible to relieve it from pressure of the with soap and pounding them vigorously
bedding (this can be done by changing with a stick
the patient‟s position in bed).  Boiling the soaked linen for ten minutes
 Rinse and then dry in the sun
Some home treatments, such as pawpaw, honey
and sugar, are very useful in the treatment of While handling sores, wounds, abscesses and
sores. boils, you should be careful with the handling of
body fluids. The fluids include blood, pus, urine,
Home Treatment for Pressure Sores vomitus, stool, sputum, saliva, vaginal fluid and
This fruit contains chemicals that help semen. These fluids can be found in beddings,
Papaya bandages, clothing, sanitary pads or cotton wool.
make the old flesh in a pressure sore soft
and easy to remove.
 Soak a piece of cloth in the ‘milk’
Other Tasks
that comes from the trunk or green
fruit of a papaya plant.
 Pack this into the sore. Always use gloves and other protective materials.
 Repeat it two or three times as If the items are reusable, make sure you
necessary. decontaminate, clean them and sterilise them.
You should teach all caregivers how to prepare
decontamination solutions such as jik. If the items
This mixture will kill germs, help to are not to be reused they should be burned,
Honey
prevent infection, and speed healing. buried or disposed of in a pit latrine.
and Sugar

 Mix honey and sugar into a thick Other chores which you need to undertake
paste. for HBC patients include:
 Press this deep into the sore and
cover with a clean cloth (molasses  General house cleaning and clearing of
or thin pieces of raw sugar can the compound.

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  Ensuring a constant supply of clean and
safe drinking water as well as water for They include animal products like meat, fish, milk,
other purposes in the home. chicken, eggs and plant proteins like beans, peas,
 Good food storage and food security. groundnuts, green grams, lentils, sim-sim
 Proper waste and garbage disposal and (sesame).
the control of vectors to diseases such as
malaria, typhoid, shigellosis, amoebiasis Energy Giving
and even plague.
These are foods which provide the body
with energy.
One of your biggest roles in the provision of basic
nursing care for HBC patients is training of the
family members, volunteers and community based They include starchy foods like potatoes, yams,
health workers on how to carry out the different cassava, bananas, sugar, wheat, rice, maize
activities. meal, bread, chapati, pasta, as well as fats and
vegetable oils.
Nutrition for Home-based Care Patients
Protective
It is almost impossible to put too much emphasis They provide vitamins and minerals that are key in
on the importance of good nutrition in the strengthening the immune system.
management of HIV/AIDS and other chronic sick
patients at all stages. Good nutrition is essential
They include fruits like oranges, pineapples,
for the wellbeing of the individual. Attention to
nutrition should begin as soon as the person is pawpaw, mangoes and greens/vegetables, like
diagnosed with a disease. carrots, tomatoes, all local green leafy vegetables,
cauliflower, cucumber, eggplant (biringanya)
The patient should be informed very early that and cabbage.
eating well means more than just having a full
stomach; it means eating the right combination of In addition, water and minerals like iron and
foods to provide the nutrients the body needs to calcium are essential to good nutrition. Water is
function properly. Sick people have an even necessary for bodily functions and to prevent
greater need for a well balanced diet than healthy dehydration. Minerals are necessary elements of
persons, but with proper nutrition, they can the blood, bones, teeth, and body processes.
generally stay healthier longer.
Examples of foods that are rich in iron are fish,
Components of a Balanced Diet meat, and dark green leafy vegetables. Calcium is
derived from milk, groundnuts, and eggs. Other
Foods can be divided into three basic categories, important minerals like potassium, selenium, zinc,
with each playing its important role in nutrition. and magnesium are vital for survival.

Body Building A well balanced diet is important for:

These are foods that support the function and
formation of general structures of all tissues,  Repairing worn out body cells
including muscles, bones, teeth, skin and nails.  Providing energy
 Protecting the body against infection
They include animal products like meat, fish, milk,
 Improving the wellbeing of the patient
chicken, eggs and plant proteins like beans, peas,
groundnuts, green grams, lentils, sim-sim  Stimulate appetite
(sesame).
In general the foods should be familiar, that is,
Components of a Balanced Diet what the family uses daily, is available and
accessible. There are a number of factors that
Foods can be divided into three basic categories, may influence the nutrition of HBC patients. It is
with each playing its important role in nutrition. important to be aware of them so that you can
assist the patient accordingly.
Body Building
In most cases, people with some chronic
These are foods that support the function and
illnesses like HIV/AIDS need food
formation of general structures of all tissues,
supplements.
including muscles, bones, teeth, skin and nails.

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Factors that Influence Nutrition  Work with the patient to develop an
individualised nutrition care plan and
People living with HIV/AIDS and chronic diseases implement it.
like cancer and diabetes have many questions  Improve food intake by diagnosing and
about their diet. treating any signs and symptoms that
interfere with food intake.
Loss of appetite or difficulty in eating can be very  Counsel patients about which foods to
distressing for the sick person, making them feel eat.
helpless and ineffective. The loss of weight can  Educate AIDS patients on ART and drug-
cause much fear. food interactions.
 Identify other sources of nutrition supply
All the foods the family is familiar with can be to the patient, for example, if possible
combined to meet the nutritional requirements of income generating activities, support from
the patient and hence allay the fears and answer the community members, link with
their many questions. programmes that provide food to patients
with chronic illnesses.
What factors can influence the nutrition of a
HBC patient? High Risk Signs and Symptoms

Several factors may influence nutrition. These You should train all caregivers to look out for the
include: following high risk signs and symptoms and take
the appropriate action immediately.
 Cultural beliefs, taboos and practices These are:
relating to foods.
 Economic status of the family and
community.  Appetite loss (for a long period of time, for
example, several weeks)
 Natural climatic changes like drought and
floods.  Weight loss of more than 5-10% of the
body weight in less than two weeks
 General conditions of the patient that
(except in diabetes)
decreases the food intake: mouth sores,
lack of appetite, pain when swallowing,  Diarrhoea
nausea, abdominal pain, diarrhoea,  Pain when swallowing (odynophagia)
neurological diseases/anorexia.  Difficulty swallowing (dysphagia)
 Factors that increase the metabolic  Dehydration
demands: fever, acute illness and HIV-  Clinical signs of nutrient deficiency
infection itself.  Loss of muscle mass
 Side effects of drugs used by the patient,
for example, gastrointestinal intolerance, Common Nutrition Problems
nausea, dyspepsia, vomiting and
diarrhoea. Major side effects like The most common problems associated with poor
pancreatitis and hepatitis. nutrition are:
 Dietary restrictions due to the illness or
the drugs the patient is using.  Severe weight loss as a result of poor
appetite leading to failure to meet dietary
What can you do to improve the nutritional requirements. This can be overcome by
status of a HBC patient? encouraging small, frequent feeds.
 Anaemia due to poor dietary intake or
Though it is difficult to overcome some of the lack of iron in the diet. It may be as a
economical and environmental barriers, you can result of infections such as malaria,
take the following actions to improve the hookworm or other parasite infestations
nutritional status of the patients: that destroy red blood cells.
 Skin conditions due to lack of vitamins in
 Assess the nutritional status of all the diet, for example, scurvy and pellagra.
patients.  Failure to thrive or maintain a reasonably
 Identify patients who require more good level of health.
extensive nutrition management.
 Identify „high risk‟ signs and symptoms to
patient‟s nutrition.

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Common Feeding Problems in HBC Patients Fatigue and Lethargy

During certain illnesses, such as HIV/AIDS,  Ask for assistance from a family member,
patients may have extra difficulty eating or may friend or neighbour to assist
need to eat different types of food.  Set time each day for eating
The following advice needs to be given to  Eat slowly
maximise food intake.  Eat fresh fruits that don‟t require
preparation
Diarrhoea (Loose Bowels)
Severe Diarrhoea
 Eat soft mashed foods that are easy to
chew and swallow  Drink liquids frequently, dilute fruit juices
 Eat small meals, five or more times a day
 Drink a lot of fluids to prevent dehydration Nutritional Advice for Diabetic Patients
(water, tea, uji, juice, home made
rehydration solution)
Studies have shown that many complications of
 Eliminate dairy products to see if they are
diabetes can be prevented or delayed through
the cause
effective management. This includes lifestyle
 Decrease high fat foods measures such as a healthy diet, physical activity,
the avoidance of being overweight and obesity
Sore Mouth and Throat and not smoking.

 Eat soft mashed foods Diabetes therapy is not only about lowering blood
 Avoid citrus, tomatoes and spicy foods glucose levels, but also about the overall
 Avoid sugary foods and milk reduction in the risk factors for diabetic
 Eat food at room temperature or cooler complications. This includes the control of blood
pressure and blood lipids. Thus diabetic patients
Fever and Loss of Appetite require lifelong care and management.

 Choose locally available high protein food Diabetes education plays a key role in
and fruit juices empowering people with the knowledge and skills
 Eat small portions of preferred soft foods to manage their own condition effectively.
with a pleasant aroma and texture In order to prevent or delay complications, people
throughout the day with diabetes may have to modify their lifestyle.
 Eat nutritious snacks whenever possible
 Drink liquids often People with type 2 diabetes often require oral
drugs, and sometimes insulin to control their blood
glucose levels. People with type 1 diabetes
Nausea and Vomiting
require insulin to survive. Although insulin has
been designated an essential drug by WHO, it is
 Eat small nutritious snacks during the day not yet universally accessible to all those who
 Eat tosti and other plain dry foods need it in many developing countries. In some of
 Avoid foods that have a strong aroma these countries people with diabetes die because
 Eat simple boiled foods, for example, they cannot get the insulin they need to survive.
porridge
 Drink liquids often Several approaches have been tried to prevent
type 1 diabetes but none of them have been
Fat Malabsorption known to work. The prevention of type 1 diabetes
remains an objective for the future.
 Eliminate oils, butter and margarine and
foods that contain or are prepared with However, simple lifestyle measures have been
them shown to be effective in preventing or delaying the
 Eat only the leanest available meat onset of type 2 diabetes.
 Eat fruits, vegetables and other low fat
foods Increased Physical Activity
It is estimated that currently 60% of the world‟s
population do not do enough physical activity, with
adults in developed countries most likely to be

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inactive. Studies have shown that just 30 minutes The objectives of clinical care are as follows:
of moderate exercise a day, five days a week, is
enough to promote good health and reduce the  Ensuring early detection, treatment of
chances of developing type 2 diabetes. opportunistic infections and other
complications that occur as a result of
A Healthy Diet chronic illnesses.
Eating between three and five servings of fruit and  Reducing the suffering from conditions
associated with the chronic illness like
vegetables a day and eating less sugar and
HIV/AIDS infection, cancer, diabetic,
saturated fats has been shown to be important in hypertension and other
maintaining appropriate weight, and therefore chronic illness.
lowering the risk of type 2 diabetes.  Protecting the patient against further
infections especially during a long hospital
Weight Loss stay.
More than one billion adults worldwide are  Preventing transmission of infections from
overweight, at least 300 million of whom are the patient to the health workers,
considered obese. It is estimated that well over relatives and friends and vise versa.
half of all cases of type 2 diabetes could be  Ensuring that drugs prescribed to the
patient by the clinician are administered at
avoided if excessive weight gain in adults could
home according to the regimen of intake.
be prevented.
The following table is a summary of some
Non-Smoking
symptoms that people living with HIV/AIDS may
People with diabetes are at greater risk of dying present with. Some of these symptoms may also
from coronary heart disease, stroke and be found in patients with other chronic illnesses.
peripheral vascular disease than people without
the condition. Smoking increases the risk even Also included is the care and medicines they may
further. receive. This is adapted from Lamptey, P. et al,
1990, the handbook of AIDS prevention in Africa,
For both types of diabetes, nutritional advice is AIDSCAP/FHI, Virginia. You can look for this book
necessary. and read it further. These symptoms may appear
The main aim is to keep the glucose levels under in other HBC patients as well.
control.
Symptoms, Care and Treatment in PLWHAs
The patient with diabetes needs to be given the Symptoms Care Medicines
same advice mentioned above for preventing type Depend on
2 diabetes. It is important to understand that the
people with diabetes have the same nutritional diagnosis.
needs as anyone else. Physical therapy, Antibiotics
1 Cough/difficulty treatment for TB like
In addition to exercise and medication (insulin and in breathing/ and pulmonary cotrimoxazo
oral diabetes pill), nutrition is important for good chest pain infections. Drink a le
diabetes control. By eating well-balanced meals in lot of fluids, postural adrenaline,
the correct amounts, a person with diabetes can drainage. cough
keep the blood glucose level as close to normal syrup,
(non-diabetes level) as possible. analgesics, a
nti TB
Clinical Care Nutritional support,
treatment for Septrin,
2 Diarrhoea
Clinical care in the context of HBC is the infections, skin care flagyl/ORS
continuation of medical care in the home. around the anus and
buttocks, fluid
The idea is to ensure the continuity of the care replacement
and treatment the patient was receiving from the Nutrition support
health facility. This is referred to as the continuum 3 Weight loss
and care
of care. It is collaborative care provision by the ORS, oral care, fluid Antiemetics,
health care workers, the family members and 4 Vomiting
replacement e.g. stemetil
the community.

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 Dietary changes,  Improving blood circulation and
comfort measures Analgesics, prevention of clot formation
5 Pain  Improving digestion
like distractive antacids
activities, position  Prevention of joint stiffness and muscle
change wasting
Family assistance Crutches, a  Preventing of secondary infections, for
6 Immobility, with daily activities, wheelchair, example, hypostatic pneumonia
weakness skin care, nutritional walking  Relaxing the patient
support skills
Treatment for Several exercises are available for you to choose
infections, comfort from and apply to the patient or teach the
Fever/night caregiver.
7 measures like Antipyretics
sweats
turning the patient
and keeping the
patient clean and Counselling and Psychospiritual Care
dry, increase fluid Counselling helps people to understand and deal
intake with their problems and communicate better with
those around them.

Symptoms, Care and Treatment in PLWHAs You have already learnt about communication and
Symptoms Care Medicines counselling in module one on general nursing.
You should utilise the knowledge, skills and
Cleansing, attitudes you acquired in that unit to care for
Skin ointment,
8 Skin lesions application of
antihistamine, HBC patients.
salt water
analgesics
soaks
Psychospiritual support is also an effective means
Elevate limbs, of helping patients to cope with their feelings.
cool Diuretics and Spiritual concerns about impending death may
9 Oedema
compresses, other give rise to an interest in spiritual matters and a
pain relief, prescriptions search for religious support.
skin care
Urinary infection, Increase fluid Antibiotics, Spiritual care may take various forms. These may
10
dysuria intake analgesics include praying together, reading from the
Provide scriptures of the Koran or bible, etc.
emotional
11 Depression/anxiety support, Prescribed
antidepressants In the context of HBC there are several types
spiritual of counselling:
and anxiolytic
support and
drugs
counselling
 Pre and post-test HIV counselling
(Voluntary Counselling and Testing)
Treat  Behaviour change counselling
infection,  Group counselling
Confusion,
safety Prescribed  Family counselling
12 headache, precautions,
paralysis, loss of drugs  Supportive counselling
pain relief,
vision, personality  Crisis counselling
family
changes
education,  Psychological trauma counselling
emotional  Spiritual/pastoral counselling
support  Death and bereavement counselling
Drug reaction, skin Care as above, Discontinue all
13 The objectives of counselling and psychospiritual
rashes, and review patient drugs, review
diarrhoea patient care in HBC are to:

 Control the spread of HIV/AIDS through

Besides medical treatment, physical exercise is information dissemination, promotion of
important for safer sex, advocacy for behaviour change
home-based patients. It makes muscles well and encouragement of better health
toned. In addition, physical therapy helps in: seeking behaviour.

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  Help the patient to come to terms with While communicating, you should be aware that
the illness and to adopt a positive living this is a two way process.
attitude. It should involve a response from the patient. You
 Help the patient make well informed should be able to persuade, inform and assist the
decisions, for example, about sex patient to take action.
and sexuality.
 Offer psychological and spiritual support Social Support
to patients and their families.
 Help patients to assess and talk about You have already learnt that to be able to take
what their life has meant to them through care of anxiety, anger, guilt or distortion in
their belief systems, whatever they may imagination, the patients need assurance and
be. acceptance by their families and the community.
 Help patients accept the need to talk to
family members about their condition and How can you show your patients that you have
future plans. accepted them?

A good counsellor must have the following tools Patients should be included in day to day
(basic counselling skills) to be effective: activities.
They should eat with the family, eat out in
 Self-awareness restaurants, go to social events, and celebrate
 Communication (verbal and non-verbal) events. Let the patients belong to clubs, groupings
 Active listening and other social structures. Those who are able to
 Attending skills work should be encouraged to do so. Those who
 Paraphrasing want to take over responsibilities should not be
 Reflecting feelings denied the chance.
 Questioning
 Clarifying When patients have a terminal illness they should
 Summarising be assisted to prepare for their deaths with good
psychospiritual care and support. Many patients
can live fulfilling lives and die peacefully. Patients
In counselling, the focus is the person, not the
should be given the opportunity to write their own
disease. You should be able to listen actively and
will.
respond with empathy. Because of the feelings
that your patients may have, you should be able
to influence your patients to be religious. This You may be confused and wondering why all
gives peace to the mind. Forgiveness and these things are done for patients who are already
reconciliation replace anger and guilt. You can out of hospital and dying anyway.
invite spiritual persons to come and talk to the sick You need to remind yourself that when you
person. provide services that meet patients needs, you
help them to:
Many illnesses cause emotional, physical, and
psychosocial pain and stress.  Meet material/physiological needs
You have already covered some of the stages of  Provide a sense of belonging
stress.  Reduce anxiety
These include:  Improve on relationships
 Ensure a high quality of care
 Shock, fear and denial.
 Accepting, withdrawal, depression, This ultimately contributes to a patient‟s quality of
suicide. life.
 Accepting help, making plans about self
and family. You need to refer back to unit three of module
 Becoming ill and weak. one where you can read more about palliative
 Anger, despair and/or sadness. care.
This kind of care can be extended to the home.
Counsel your patients and provide them with the More specifically read about pain
basic physical needs which you have already management.
covered. If possible provide material support or
invite those who are able to provide the support. While providing HBC, ensure that you do not
suffer from burn-out.

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SECTION 5: COMMUNITY  Identify available resource and how the
resources can be used to solve the
MOBILISATION problems.
 Establish relationships within the
Introduction community.
 Ownership and sustainability of the
Providing HBC is a difficult job. If you find programme.
providing care in the health facility draining, just
imagine how it must feel for families who care for HBC has the following advantages:
their loved ones at home.
 It helps to counter the stigma (like for
This is why everybody in the community must be PLWHA and what their families face),
involved and taught how to provide HBC. so that they can live without fear or
discrimination.
Objectives  It involves the patients to fully participate
in their care, thus helping them to „live
By the end of this section you will be able to: positively‟.
 It can increase community awareness and
 Define community mobilisation thus helps prevent the further spread of
 Explain the importance of community infections like HIV.
mobilisation  It facilitates the mobilisation of local
 List factors that can hinder community resources, and it brings the community
mobilisation together in the care of the patients, and
their dependants.
 State key community mobilisers
 It leads to community empowerment,
 Describe the process of community
ownership and sustainability of the
mobilisation
services.
 Describe community mobilisation,
involvement, partnership, ownership and
sensitisation Factors that can hinder community mobilisation
are:
What is Community Mobilisation?
 Lack of involvement in problem
identification
It is the process of getting the community
incorporated to fully participate in the programmes  Lack of appropriate information
for the purpose of ownership and sustainability.  Lack of resources
 Resource mismanagement
 Insecurity
HBC is provided to patients in their communities.
Communities are therefore required to initiate and  Lack of social structure
sustain activities, which support it.  Communication barriers
 Poor health
The community must participate and get involved  Lack of ownership and sustainability
in the decision making process, planning,  Lack of interest
organisation, implementation and monitoring of  Poor infrastructure
activities associated with HBC.  Lack of knowledge of other partners
 Social differences (religious, education,
The importance of community mobilisation is to: cultural, economic, political, tribal)
 Poor leadership
 Man made or natural disasters
 Prepare the community for participatory
 Poor timing
action.
 Create awareness about their health
problems, causes, prevention and care Possible solutions are:
required.
 Identify problems together with the  Training and skills development.
community and seek means of solving  Provision of relevant Information,
them. Education and Communication (IEC)
 Gather information about the community‟s materials.
beliefs‟, feelings, myths and  Involvement of target group to design
misconception of their problems. appropriate information.

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  Encourage Income Generating Activities It is well understood that to be effective at
(IGA) and skills development. mobilising the community, you should start from
 Identification and use of appropriate the top. This gives the leaders their recognition
communication channels/methods. and also allows them to use their influence to get
 Ensuring participation and involvement the people together.
from the beginning.
 Community sensitisation and mobilisation
The Process of Community Mobilisation
in all activities.
 Putting in place mechanisms for disaster
There are four steps involved in community
preparedness.
 Proper planning, monitoring and mobilisation.
evaluation of activities.
These are:
Community Mobilisers
 Step 1: Planning and organising yourself
Community mobilisers are resource persons or for community mobilisation
groups who you can work with in order to promote  Step 2: Entering the community to
home-based care activities. mobilise the people
 Step 3: Conducting community
List three community mobilisers in your mobilisation sessions
catchment area who you can work with.  Step 4: Monitoring the community
response and making reinforcements for
action
 Local administrative officers and leaders
such as chiefs, assistant chiefs,
councillors and area members of
parliament.
 Leaders of various programmes, for
example, district AIDS control committee.
 Religious leaders.
 Organised groups, for example, religious
groups (women‟s guild), youth groups,
women groups (the Maendeleo ya
Wanawake organisation).
 Community based health workers.
 Community Own Resource Persons
(CORP), for example, traditional birth
attendants and traditional healers.
 Other ministries workers like social
workers, school teachers.
 Patients themselves.

Mobilising the community for HBC services can be

done through a variety of ways.
Step 1: Planning and Organising Yourself for
List five methods of mobilising the community Community Mobilisation

Some of the ways of mobilising the community

The first step in community mobilisation is to plan
are:
and organise yourself for the exercise.

 Meeting at specific prefixed times. This you do by:

 Existing committees, such as the village
development committee.
 Knowing about and believing in HBC so
 Home visits to groups and individuals.
that you can explain it well to the people
 Announcements at church, mosque,
in the community.
temple, and school.
 Knowing the community leadership and
 Group community talks.
those who can influence the acceptance
and implementation of HBC services.

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  Preparing yourself psychologically, Step 4: Monitoring the Community Response
emotionally and physically for and Making Reinforcements for Action
involvement/commitment to work with
PLWHA and chronically sick patients. The fourth and final step involves monitoring the
Most of them are people who are coping community response and making arrangements
with a terminal illness. for action.
 Identifying resources and preparing them
for community mobilisation according to This you do by:
the rationale and objectives of HBC
services.
Making arrangements such as the venue  Watching for signs of acceptance of HBC,
(according to the plan or process you for example for PLWHA:
have decided on, which can be home - Community asking for more information
visits, community gatherings, or about HBC.
church/mosque/temple meetings). - Community taking interest in supporting
the activities for PLWHA.
 Sending out information to the relevant
- People volunteering to act or work with
persons involved, for example, to the
the community health workers.
leaders, depending on where you have
- People voluntarily seeking assistance to
decided to begin mobilisation.
take care of PLWHA.
 Confirming appointment date and time,
 Acknowledging the positive responses,
being on time and not keep people
and finding out more about the reasons
waiting.
for negative responses, in order to clarify
issues and further enlighten those
Step 2: Entering the Community to Mobilise concerned.
the People  Finally, giving feedback to the relevant
persons concerned, such as your
As a community health worker, you are already immediate supervisor, the community.
well known.
Community Sensitisation and Motivation
Because you have been working in the
community, this may not be a complicated step. The first and second steps in the process of
Nevertheless HBC is a different activity from your community
normal duties, so take care to plan carefully. mobilisation are to organise yourself to enter the
community and to mobilise people.
Depending on the mode, venue and type of group
or individual you have decided to mobilise, it is You cannot succeed unless you get people to
important to note the following. Remember to understand what HBC is. These are the people
show respect to the community and individuals who will act as advocates of HBC. Community
and be willing to acknowledge and deal with the members must clearly understand both your role
different feelings about HBC services. as well as theirs, otherwise they will view you with
suspicion.
Step 3: Conducting Community Mobilisation
Sessions The members must also know the importance of
their actions.
 Greet people according to their culture. They need to understand what they stand to gain
 Find out what they know about HBC. Do from the process in the short and long term. If
not assume that they do not know people do not understand their role and why they
anything; they could have experiences should participate they may withdraw, causing the
that may be useful for initiative to die out immediately when you leave.
the programme.
 Give correct and complete information Community based health activities, for example,
about HBC services. HBC can die out if there is no motivation.
 Allow the group/individual to express
fears, make contributions and suggest You can work around this by:
approaches. Together with them make
practical agreements on the way forward.
 Identifying traditional beliefs, which are
interfering with HBC

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  Explaining the disadvantages of not If they understand the project and its importance
participating well, they will make it their own. They will know
 Countering negative attitudes by some that HBC is intended to help them and their
people by involving their friends and families.
relatives
 Seminars and workshops for the leaders When this happens the community will feel
 Helping plan for trips for staff from the motivated and willing to invest their energy and
health facility resources, to continue with the project.

Failure of activities can also occur due to SECTION 6: COMMUNITY

problems of:
RESOURCES
 Transport
Introduction
 Punctuality and poor management
 Inaccurate orders for supplies and In this section you will look at how to identify and
inadequate equipment mobilise community resources.
 Long distances between facilities and
communities resulting in less contact and
communication Objectives
 Communication barriers
 Natural and man-made calamities, for By the end of this section you will be able to:
example, bad weather and famine making
some communities shift from one area or  Describe the types of resources available
shift their attention in your community for HBC
 Lack of teamwork  Identify their sources
 Poor referral system  Explain how you would mobilise these
resources for HBC
You can work round these problems by:  Describe the importance of appropriate
technology in HBC
 Planning good orders and requisitions for
supplies for HBC. Resources Needed for Home-based
 Being punctual when required. Care
 Having mobile clinics and using local To effectively provide HBC, there are certain
leaders to pass on instructions and other resources that are needed. These resources can
correspondence. be broadly classified into four categories or the
 Having frequent meetings, discussions 4Ms.
and involvement among health facility
staff, community members and
 Money
other stakeholders.
 Materials
 Establish a well structured referral
 Minutes (Time)
system.
 Manpower
Besides this, when sensitising the community, you
Money
can give out handouts; attend barazas, go to
schools and churches, use film and other media
and make public announcements through radio Money is an important resource in the provision of
programmes about the diseases to ensure HBC.
adequate knowledge and motivation. Diseases like AIDS and cancer are long,
expensive and debilitating illnesses. They
Community Involvement, Participation, eventually render the affected and infected
Ownership and Sustainability incapable of participating in gainful employment.
Yet they need money to pay for services or to buy
goods such as food, clothing, drugs and other
When you start a programme such as HBC in the materials. They may also need to pay for health,
community, you must incorporate the community legal and
right from the start to fully participate in the project other services.
for the purpose of ownership and sustainability.
In the HBC system, money can be provided by the
family, the community, the government or through

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insurance. It is unfortunate that many insurance How do you create time?
organisations discriminate against patients with
terminal illnesses. However you should work hard Make time by planning ahead and organising your
at sensitising the community about the needs of activities to fit into the allocated time schedules,
the patients and how they can be met. being punctual, being specific, restricting activities
to those planned for, involving more people to cut
In Kenya, raising money through Harambee is down on time required for one activity.
common and community members can come
together to raise money to pay a hospital bill, buy Being present is a major source of psychological
a wheelchair or crutches. Whatever the source, and moral support. Friends and relatives should
your role is to sensitise members and patients on understand the importance of sparing time not
the need for the funds, and the likely sources of only to help out as needed, but also just to be with
the funds. the patient and the family members.

Materials Manpower

Many illnesses that require HBC tend to render Manpower is another important resource, which is
the affected persons incapable of meeting even often overlooked. These are the individuals who
the most basic material needs of everyday life. voluntarily spare their time to assist the patients,
For instance a PLWHA may become too weak to their families and children.
fetch water or firewood, or run errands and do
shopping. List four people who can assist the patient
in HBC.
Food production may be affected due to frequent
sickness from opportunistic infections. Thus, the The following people can be counted as
material resources required to assist can be in the
human resources:
form of food, cooking fuel (for example, firewood),
water, or money for drugs and other purposes.
 Health workers at all levels.
 Family members, relatives and friends.
These materials may or may not be readily
available.  Community leaders/organised groups
Within communities, the materials can be bought (e.g. In Kenya, Maendeleo Ya Wanawake
by individuals, communities or families. They can Organisation leaders).
also be donated by organisations. Some non-  Spiritual, political, and administrative
governmental organisations may be willing to leaders/groups.
donate the materials or money to procure them.  Community volunteers including students
from neighbouring institutions.
Some of the materials can also be obtained from
the hospital. These people can provide a variety of services. It
Right now there is a cost sharing policy in Kenya. is important for you to understand what service
You therefore need to explain to your patients each person can provide so that you can refer the
how they can obtain these materials to avoid patient appropriately.
disappointment.
Manpower
Minutes (Time)
In the later stages of a disease such as AIDS
Caring for people who need long term care, can people become too weak to support themselves.
be time consuming and emotionally draining. The This condition calls for continuous assistance from
caregiver may have little time left to attend to relatives and friends.
other important aspects of everyday life, like
working on the shamba (farm), going to work, A volunteer care provider also needs continuous
school, or running errands. support from the community, morally and
The constant demands can be very stressful. materially.

Time is one of the most essential resources Having seen the different types of resources you
known to man. To be able to accomplish tasks, require to support HBC, you will now look at their
time is essential. sources and how to mobilise them.

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Sources of the Required Resources supplies from the hospital pharmacy or from the
local medical stores. You may also have procured
As you can see, resources are required at every vaccines and family planning items. You need to
level of the HBC continuum. The players at each do all you can to mobilise the resources needed at
the local level. If the patient needs mosquito nets,
level are expected to contribute to the fullest
you can link the caregivers with NGOs that give
extent possible. them out. Even some drug manufacturers give out
free drug samples.

 Individual People in the community can also be mobilised to

 Family assist in HBC. These could be trained volunteers,
 Community students or untrained community members who
are willing to be trained. As a community nurse,
From the individual: you must be ready to put in additional effort to
mobilise the resources necessary to provide HBC
 The home environment. for your patients.
 A home care kit (depending on
specific needs). Appropriate Technology
 Time to devote to care and support.
 Sharing of information and experience as Technology is important, low cost technologies
well as advocating for behaviour change. that assist with food presentation, processing and
 Cooperation and openness so as to share storage, water collection, pumping and storage,
responsibility and confidentiality. home improvements and energy conservation.

From the family: Low cost technologies which you have seen in
use in your community
 Basic needs, for example, food, clothing,
shelter and medicine.  Solar food and crop dryer/fixed and
 Time, knowledge and skills of caring. portable
 Social/psychological support.  Fuel fried dryer
 Physical care.  Maize crib for post harvest storage
 Financial support. and drying
 Administration of medicine.  Traditional silo
 Groundnut sheller
From the community:  Hand winnower
 Hand mill
 Social support.  Cement water jar for storage
 Spiritual support. (small and large)
 Material support.  Granary basket water tank
 Financial support.  Flap value water pump
 Time, knowledge and skills of caring.  Rope and washer water pump
 Shallow well pump
 Deep well pump
Resource Mobilisation for Home-based
 Bicycle pump
Care  Kerosene tin oven
The resources that have been mentioned are not  Raised cooking platform
all easily available. As a community nurse, you
 Solar reflector cooker
need to know what is available, where and how to
obtain it.  Charcoal water filter
 Evaporative charcoal cooler
 Raised sink and utensil drying table
Some of the materials can be sourced at your
 Hanging storage shelves
health facility, at the community level,
government, organised groups, at the patient‟s  Hanging pot coconut sheller
home or with an NGO. You also need to  Hanging fly proof food safe
understand the process of procurement. Get to  Homemade improvised bedpans and
know the procurement procedures and the commode
paperwork that needs to be completed. You will
have filled in various forms such as the S11, S12
or S13, which are used for procuring drugs and

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In HBC it is very important to sensitise the  It reduces duplication of work.
caregivers as well as patients on how to improvise  It reduces the isolation of individuals or
and use affordable appropriate technologies that groups working alone and provides a
may be useful. forum for consultation.

SECTION 7: REFERRAL AND In HBC, several networks exist. There are

networks for individuals working with PLWHA,
NETWORKING FOR HOME-BASED cancer patients, and so on. Several networks may
CARE also exist for people infected and affected by, for
example, HIV/AIDS.
Introduction
As a community health nurse, you can facilitate
In this section you will look at referral and networking in the community where you work by
networking for HBC. + doing the following:

 Establishing networking at different levels,

When you work in a community you cannot work for example, district, location and village.
alone. The work is too much and you may not Involving all institutions and groups
have all the resources necessary to accomplish working with the disease, such as
your goals. In order to be effective you must HIV/AIDS.
network and refer your patients. Referral and  Facilitating the exchange of information
networking are essential to ensure continuity of between one group and another. This
quality care for the patient at all times would prevent repetition and duplication
of efforts.
Objectives  Making sure referral channels exist, for
example, from one centre to another.
By the end of this section you will be able to: Letting each organisation or individual be
aware of the existence of the others.
 Ensuring that the basic essentials are
 Describe the community networking for available for the betterment of the patient
HBC who requires HBC.
 Explain the importance of networking for
HBC
You should never forget to establish the correct
 Describe the referral system in HBC
links between one group and another. This is
 Explain an effective referral channel for
where your community mobilisation skills matter.
HBC patients
Also remember to share your experiences and
 State some of the constraints in referral information as often as possible.
and networking

Referral
Networking for Home-based Care
Referral is an effective and efficient two way
What is a network? process of linking a patient from one caring
service to another.
A network is a group of individuals or
organisations that work together, undertake joint As mentioned earlier, you may not be able to do
activities, or exchange information in order to all things by yourself or indeed at the same place.
strengthen and extend their individual capacities. There may be a time when you need to send your
patients or community members to other
Networking has the following advantages: institutions or people for further care.

 It promotes unity, harmony and Before you refer a patient, you should have
understanding among the groups or recognised the signs and symptoms or the need
individuals. for referral.
 It provides a learning experience, people
and groups can learn from each other.
 It can assist individuals and groups to
address complex problems by involving
others.
 It promotes peer support.

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Why are patients referred?  For specialised care in a hospital setting,
especially if the patient is deteriorating.
Patients are referred for the following reasons:  For continuity of care from the health
facility downwards, or from family level
 When services or resources within reach back to the health facility.
are not able to meet the patients‟
immediate needs. Referral to and from the family/community should
 In cases where the acute phase of the be well arranged to avoid unnecessary burdens to
disease has been dealt with, and it is the patient and family.
considered safe to transfer care to other
caring services/organisations within the The patient and the family should be prepared for
community. the discharge and told what equipment and
 When the caregiver experiences burnout supplies they require for HBC.
and has no access to counselling services
for personal growth. The HBC team should also inform the family that
 When the caregiver has limitations in in case of a change of condition of the patient, the
meeting certain needs of the patient, for patient will be referred to a health facility including
example, based on religious beliefs. what the family requires for the referral.
 For better, more competent management
in the next stage of referral.

Resources required for referral  Referral forms that contain information on

patient particulars, disease condition, why
 the referral, who has referred and to
whom, care which has been provided
before the referral and a small note
requesting for feedback. The form should
be easy to understand.
 Information about where you are referring
your patient to.
 A record of all the referrals that have been
undertaken.

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  Competition among various organisations,
so that they do not disclose what they are
doing and which services are offered.
They prefer to work in isolation.
 Lack of evenly distributed community
HBC programmes,
with the result that some areas lack
services and some are overcrowded.
 Lack of resources needed for patients to
travel from one point to another.
 Lack of referral and networking guidelines
as well as standardised referral
procedures.
 Ignorance among family members about
HBC due to lack of awareness and proper
guidance.
 Fear of breach of confidentiality.
 Stigma and discrimination associated with
some chronic illnesses like HIV/AIDS,
which makes PLWHA reluctant to accept
How do you go about referring your patients? referral to certain facilities.
 Poor mobilisation and sensitisation of
partners.
1. Identify those that need referral.
 Lack of confidence in the
2. Decide where to refer them to and make
institution/service where referral is made.
arrangements by calling in advance.
3. Explain to the person being referred about  Lack of updated and proper directory of
the referral and the referral arrangements, referral
for example, what time they will leave and and networking.
how they will travel.  Lack of knowledge by people referring on
how and when to refer or network.
4. Prepare the patient for referral. If the
patient will be admitted they may need to  Cultural, social, religious and economic
take certain items, such as X-ray reports, factors.
lab reports and other things required by  Poor management of referral system.
the institution or the patient themselves.
Make transport arrangements for them. What are the solutions to these constraints?
5. Allow the patient to express themselves
and try to answer their concerns As a health worker, you can address the
genuinely. constraints just mentioned by taking the following
6. Fill in the referral form, obtain an escort steps:
for them and ask them to give you
feedback about any actions taken.  Holding collaborative meetings among
Thank and bid them farewell. various referral and networking partners
7. Follow up on the referral and document  Giving correct/proper information on
what happened to the patient. referral to the relevant organisations and
a proper patient history to the referral
point
 Ensuring confidentiality
Despite the importance of referral and networking  Lobbying and advocating for the rights of
processes, there are many constraints to their the patient
effectiveness. Next you will look at some of their
constraints and how they can be overcome. Appropriate referrals expand capacity and
improve care.
Constraints/Limitations in Referral and
Networking

There exists a number of constraints that can

hinder effective referral and networking.

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