Major Functions of Public Health

Public health is the science and art of preventing disease, prolonging life, and promoting physical and mental health through organised community efforts. Its major functions are grouped below.

1. Assessment and Monitoring of Health Status

• Community health assessment: Regular collection, analysis, and interpretation of data on births, deaths, morbidity, and health needs of the population.
• Epidemiological surveillance: Continuous watch over communicable and non-communicable diseases to detect outbreaks and trends early.
• Health situation analysis: Identifying high-risk groups, health inequalities, and determinants of disease (water, sanitation, housing, nutrition, occupation).

2. Policy Development and Planning

• Formulating national health policies, plans, and legislation in line with the country's needs and resources.
• Setting priorities and allocating budgets for preventive, promotive, curative, and rehabilitative services.
• Ensuring equity so that services reach rural, poor, marginalised, and disabled groups.

3. Assurance of Quality Health Services

• Providing and regulating essential public health services such as immunisation, maternal and child health, and safe drinking water.
• Licensing and monitoring health institutions, health personnel, and health-related products (drugs, food, cosmetics).
• Maintaining standards of care and enforcing public health laws.

4. Disease Prevention and Control

• Primary prevention: Immunisation, health education, safe water and sanitation, vector control, and food safety.
• Secondary prevention: Early diagnosis and prompt treatment through screening programmes (e.g., TB, leprosy, cancer of the cervix).
• Tertiary prevention: Rehabilitation and disability limitation for chronic cases.

5. Health Promotion and Health Education

• Educating people about hygiene, nutrition, family planning, and healthy lifestyles.
• Promoting community participation and self-reliance through women's groups, school health programmes, and FCHVs.
• Advocating healthy public policy (tobacco control, road safety, environmental protection).

6. Environmental and Occupational Health Protection

• Ensuring safe water supply, waste disposal, food sanitation, and control of air, water, and noise pollution.
• Protecting workers from occupational hazards and promoting workplace safety.

7. Maternal, Child, and Family Health Services

• Antenatal, delivery, and postnatal care; immunisation; growth monitoring; and nutrition supplementation.
• Family planning and reproductive health services to reduce maternal and infant mortality.

8. Health Surveillance, Research, and Evaluation

• Maintaining vital statistics and disease registers.
• Conducting operational research to improve programme effectiveness.
• Monitoring and evaluating health programmes for accountability and improvement.

9. Disaster Preparedness and Emergency Response

• Planning for epidemics, floods, earthquakes, and other emergencies.
• Coordinating relief, surveillance, and rapid response to protect community health.

10. Intersectoral Coordination and Partnership

• Working with education, agriculture, water supply, local government, NGOs, and international agencies.
• Mobilising community resources and ensuring people's participation in health programmes.

Conclusion: In short, public health performs the core functions of assessment, policy development, and assurance, supported by disease prevention, health promotion, environmental protection, research, and intersectoral coordination, all aimed at improving the health of the whole population rather than the individual alone.

Epidemiology

Definition: Epidemiology is the branch of medical science that studies the distribution (frequency and pattern) and determinants (causes and risk factors) of health-related states or events in specified populations, and the application of this knowledge to the control of health problems. In short, it deals with who gets a disease, when, where, and why, and what can be done about it.

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Case Control Study Method

Definition

A case control study is an analytical, observational, retrospective study in which subjects are selected on the basis of whether they have the disease (cases) or not (controls), and the two groups are then compared retrospectively for the frequency of past exposure to a suspected risk factor.

Basic Design

        Past exposure ──► Present status
                            │
   Exposed ──┐              │
            ├──► CASES (with disease)     ← compare
Unexposed ──┘              │
                           │
   Exposed ──┐             │
            ├──► CONTROLS (without disease)
Unexposed ──┘

The investigator starts from the effect (disease) and looks backward for the cause (exposure) — hence it is also called a retrospective study or "trot-back" study.

Steps in Conducting a Case Control Study

1. Selection of cases — Persons with the disease of interest are identified from hospitals, disease registers, or community surveys. Clear diagnostic criteria are used.
2. Selection of controls — Persons free from the disease are selected from the same population (hospital controls, neighbourhood controls, relatives) so that they are comparable to cases in all respects except the disease.
3. Matching — Cases and controls are matched for confounding variables such as age, sex, and socioeconomic status.
4. Measurement of exposure — Past exposure to the suspected risk factor is ascertained in both groups by interview, records, or laboratory tests, using the same method for both.
5. Analysis — Exposure rates in cases and controls are compared and the odds ratio (OR) is calculated:

$\text{Odds Ratio} = \frac{a \times d}{b \times c}$

where a = exposed cases, b = exposed controls, c = unexposed cases, d = unexposed controls.

6. Interpretation — OR = 1 means no association; OR > 1 means positive association (risk factor); OR < 1 means negative association (protective factor).

Example

To study the association between smoking and lung cancer, 100 lung cancer patients (cases) and 100 persons without lung cancer (controls) are selected. If 90 cases and 40 controls give a history of smoking, then:

$\text{OR} = \frac{90 \times 60}{10 \times 40} = 13.5$

This indicates that smokers have about 13.5 times higher odds of developing lung cancer than non-smokers.

Advantages

• Suitable for rare diseases and diseases with a long latent period.
• Quick, cheap, and easy to conduct; requires fewer subjects.
• Many risk factors can be studied at the same time.
• No risk to subjects; no loss to follow-up.

Limitations

• Cannot measure incidence or absolute risk; only gives odds ratio, not relative risk.
• Recall bias and selection bias are common.
• Temporal relationship between exposure and disease is often difficult to establish.
• Not suitable for rare exposures.
• Cannot prove causation, only association.

Congestive Cardiac Failure

Definition: Congestive cardiac failure (CCF) is a clinical syndrome in which the heart is unable to pump blood at a rate sufficient to meet the metabolic demands of the body tissues, or can do so only at the cost of elevated filling pressures. As a result, blood backs up (congestion) in the pulmonary and/or systemic circulation, producing congestion in the lungs, liver, and peripheral tissues.

Risk Factors

1. Cardiac causes

   • Coronary artery disease and myocardial infarction (most common cause)
   • Hypertension (chronic pressure overload)
   • Valvular heart disease — rheumatic heart disease, aortic stenosis, mitral regurgitation
   • Cardiomyopathies (dilated, hypertrophic, restrictive)
   • Congenital heart disease
   • Arrhythmias, especially atrial fibrillation
   • Myocarditis and rheumatic fever

2. Non-cardiac / precipitating factors

   • Anaemia and thyrotoxicosis (increased demand)
   • Chronic kidney disease and fluid overload
   • Pregnancy
   • Obesity
   • Diabetes mellitus
   • Excessive salt and water intake
   • Non-compliance with medicines
   • Infections, especially respiratory infections
   • Alcohol abuse and smoking

Symptoms

Left-sided failure (pulmonary congestion)

• Exertional dyspnoea, later orthopnoea and paroxysmal nocturnal dyspnoea
• Cough with frothy, blood-tinged sputum
• Fatigue and weakness
• Nocturia

Right-sided failure (systemic congestion)

• Pedal oedema, later generalized (anasarca)
• Distended neck veins (raised JVP)
• Painful hepatomegaly and right upper quadrant discomfort
• Ascites and abdominal distension
• Nausea, anorexia, and weight gain

General

• Palpitations, chest pain, reduced exercise tolerance
• In infants and children: feeding difficulty, failure to thrive, sweating during feeds, and recurrent chest infection

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Malnutrition

Definition: Malnutrition is a condition resulting from an imbalance between the nutrients the body needs and the nutrients it receives — either a deficiency (undernutrition) or an excess (overnutrition) of energy and nutrients — leading to measurable adverse effects on body composition, function, and clinical outcome. In children it commonly presents as underweight, stunting, wasting, and micronutrient deficiencies, and in severe form as kwashiorkor (protein deficiency with oedema) or marasmus (severe energy deficiency).

Measures to Save Children from Malnutrition

1. Promote exclusive breastfeeding for the first 6 months and complementary feeding from 6 months along with continued breastfeeding up to 2 years.
2. Ensure a balanced diet — locally available cereals, pulses, green leafy vegetables, fruits, eggs, milk, and meat in adequate quantity and frequency.
3. Growth monitoring and promotion — regular weighing, plotting on the growth chart, and early detection of growth faltering.
4. Immunization against preventable diseases and deworming every 6 months.
5. Prevent and treat infections — diarrhoea, pneumonia, tuberculosis, and worm infestation, which worsen malnutrition.
6. Micronutrient supplementation — vitamin A, iron–folic acid, zinc, and iodized salt.
7. Management of severe acute malnutrition — therapeutic feeding (RUTF/F-75, F-100), management of hypoglycaemia, hypothermia, dehydration, and infection as per IMCI/CMAM protocol.
8. Health education to mothers and families on hygiene, safe drinking water, sanitation, breastfeeding, and weaning practices.
9. Improve food security through kitchen gardening, poultry, and income-generation programmes.
10. Intersectoral coordination — health, education, agriculture, and social welfare sectors; poverty alleviation and female literacy.
11. Periodic screening in schools and communities with referral of severe cases to nutrition rehabilitation centres.

Quackery is the practice of promoting or selling false or unproven health remedies, treatments, or products — often by people without proper medical qualifications — with the deliberate aim of making money by deceiving people. A quack (or quack doctor) claims to cure diseases or solve health problems using methods that have no scientific basis, such as magic potions, fake miracle drugs, unverified herbal mixtures, or "instant cure" machines. Quackery is different from honest ignorance because the quack usually knows the claim is false but still promotes it for profit.

Effects of quackery among teenagers

1. Harm to health: Teenagers may take fake medicines or harmful substances that cause side effects, poisoning, or worsen an existing disease. Delay in getting proper treatment can turn a simple illness into a serious one.

2. Waste of money: Teenagers and their families spend large amounts on useless products such as fake weight-loss pills, "fairness" creams, or guaranteed height-increasing tonics. This causes financial loss.

3. False hope and disappointment: Quacks promise quick results — clear skin, weight loss, or a cure for a disease. When these fail, teenagers feel cheated, hopeless, and lose confidence.

4. Psychological and emotional harm: Teenagers are very conscious of their body image. Fake products for beauty or bodybuilding can damage self-esteem and lead to anxiety, depression, or eating disorders.

5. Risk of addiction and risky behaviour: Some quack products contain steroids, narcotics, or other harmful substances. Their use can lead to drug habits and other risky behaviour.

6. Spread of misinformation: Through social media, quacks spread false health information among teenagers. This makes young people distrust real doctors and scientific medicine.

7. Delay in correct treatment: Believing in quack remedies, teenagers may avoid hospitals and qualified doctors, allowing diseases to become advanced and difficult to cure.

Conclusion: Quackery is a serious social and health problem. Teenagers, being immature and easily influenced, are its easy victims. Therefore, health education, awareness programmes, and strict legal action against quacks are needed to protect them.

Smoking Cessation Interventions: Strategies and Programs in Nepal

(TU BEd, Second Year — 8 marks)

1. Introduction

Smoking cessation means the process of stopping tobacco smoking. In Nepal, tobacco use is a major public health problem. According to the STEPS Survey, about 27–29% of Nepali adults use tobacco in some form, and smoking causes a large share of deaths from cancer, COPD, heart disease and stroke. Therefore, helping people to quit smoking is an essential component of health promotion and disease prevention.

2. Strategies of Smoking Cessation Intervention

A. Individual-level (behavioural) strategies

1. 5A model (Ask, Advise, Assess, Assist, Arrange) — health workers ask every client about tobacco use, advise quitting, assess willingness, assist with counselling or medicines, and arrange follow-up.
2. 5R model (Relevance, Risks, Rewards, Roadblocks, Repetition) — used for smokers not yet ready to quit, to build motivation.
3. Behavioural counselling — identifying triggers, coping skills, stress management, avoiding smoking environments, and family support.
4. Self-help materials — pamphlets, booklets, and telephone quit-line advice.
5. Pharmacological support — nicotine replacement therapy (gum, patch), bupropion, and varenicline, prescribed under medical supervision.

B. Community and population-level strategies

1. Health education and awareness campaigns through FCHVs, mothers' groups, schools, and mass media.
2. Brief advice at every health contact — integrating tobacco cessation into routine OPD, TB, NCD, and antenatal services.
3. Cessation clinics / quit services in hospitals and health centres.
4. Raising tobacco taxes to reduce affordability and consumption.
5. Enforcement of tobacco control laws — smoke-free public places, ban on advertising, sponsorship and promotion, and pictorial health warnings.
6. School-based programmes to prevent initiation among adolescents.
7. Community mobilization — "tobacco-free ward/village" declarations, peer education, and youth clubs.

3. Smoking Cessation Programs in Nepal

1. Tobacco Product Control Act 2068 (2011) and Rules 2071 — legal basis for smoke-free places, advertising ban, and health warnings; implemented through the National Health Education, Information and Communication Centre (NHEICC).
2. National Tobacco Control Programme under the Ministry of Health and Population, with tobacco control cells in districts and a national focal unit.
3. WHO FCTC implementation — Nepal is a party to the Framework Convention on Tobacco Control and reports on MPOWER measures (Monitor, Protect, Offer help, Warn, Enforce, Raise taxes).
4. Brief tobacco cessation intervention training for doctors, nurses, health assistants, and FCHVs, supported by WHO and NGOs.
5. Tobacco cessation clinics in tertiary hospitals (e.g., Tribhuvan University Teaching Hospital, BP Koirala Memorial Cancer Hospital, Nepal Cancer Hospital) providing counselling and NRT.
6. Quit-line / telephone counselling and mHealth (SMS) support services.
7. NGO and INGO programmes — Nepal Cancer Relief Society, Nepal Heart Foundation, Action on Smoking and Health (ASH) Nepal, and the "Smoke-Free Nepal" campaigns.
8. Integration with NCD and TB programmes — tobacco cessation counselling is part of the Package of Essential Non-communicable Disease (PEN) and TB-DOTS services.
9. School health programmes — awareness in secondary schools, "tobacco-free school" initiatives.
10. Taxation and price policy — annual budget increases in excise duty on tobacco products as a cessation and prevention measure.

4. Conclusion

Smoking cessation in Nepal needs a combined approach — legal enforcement, taxation, health education, counselling, and pharmacological support. Health workers, teachers, FCHVs, and the community must work together so that smokers are motivated and supported to quit, and new generations are prevented from starting. This will reduce the burden of NCDs and improve national health.

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Need and Importance of Maternal and Child Health (MCH) Care

(TU BEd, Second Year — 8 marks)

1. Introduction

Maternal and Child Health (MCH) care refers to the health services provided to women during pregnancy, childbirth and the postnatal period, and to children from birth to five years (and beyond) for their survival, growth and development. In Nepal, MCH is a national priority because mothers and children form a large and vulnerable group.

2. Need of MCH Care

1. High maternal and neonatal risk — pregnancy and childbirth carry risks of haemorrhage, eclampsia, sepsis, obstructed labour, and death.
2. High infant and under-five mortality — due to infections, malnutrition, diarrhoea, pneumonia, and low birth weight.
3. Vulnerable groups — pregnant women, lactating mothers, newborns, and under-five children need special protection.
4. Low awareness and poverty — many families lack knowledge of nutrition, hygiene, immunization, and danger signs.
5. Geographical and social barriers — remote hills and mountains, difficult transport, and limited health facilities.
6. Preventable causes — most maternal and child deaths can be prevented by simple, low-cost interventions.
7. Legal and policy commitment — Nepal's Constitution and health policies guarantee basic health care as a fundamental right.

3. Importance of MCH Care

A. For the mother

1. Reduces maternal mortality and morbidity.
2. Ensures safe motherhood through antenatal, intranatal and postnatal care.
3. Detects and manages high-risk pregnancies early.
4. Improves nutrition (iron, folic acid, calcium) and prevents anaemia.
5. Promotes birth spacing and family planning.

B. For the child

1. Reduces neonatal, infant and under-five mortality.
2. Ensures proper growth and development through breastfeeding, complementary feeding and nutrition.
3. Prevents vaccine-preventable diseases through immunization (BCG, DPT, OPV, measles, etc.).
4. Early detection of congenital problems, malnutrition and disabilities.
5. Promotes physical, mental and social well-being of the child.

C. For the family and community

1. Healthy mothers and children build a healthy family.
2. Reduces health care costs and economic burden.
3. Improves school performance and future productivity.
4. Supports national development through a healthy workforce.

D. For the nation

1. Helps achieve SDG 3 (good health and well-being) and SDG 2 (zero hunger).
2. Reduces IMR, MMR and U5MR — key national health indicators.
3. Strengthens the health system through safe motherhood, FCHV, and immunization programmes.
4. Contributes to human capital formation and economic growth.

4. Major MCH Programs in Nepal (Supporting Evidence)

1. Safe Motherhood Programme — ANC, skilled birth attendance, PNC, and emergency obstetric care.
2. Aama Suraksha Programme — cash incentives for institutional delivery and free delivery care.
3. Expanded Programme on Immunization (EPI) — free vaccines for children and tetanus toxoid for mothers.
4. Nutrition programmes — iron/folate supplementation, deworming, vitamin A, and IYCF (Infant and Young Child Feeding).
5. FCHV programme — community-level maternal and child health services.
6. CB-IMNCI — Community-Based Integrated Management of Newborn and Childhood Illness.
7. Adolescent and reproductive health programmes for school children.

5. Conclusion

Maternal and child health care is not only a health issue but also a social and economic investment. It is needed to save the lives of mothers and children, and it is important for building a healthy, educated and productive society. Therefore, MCH services must be made accessible, affordable and quality-assured for all, especially in rural and remote areas of Nepal.

Health Risk Behaviour of Adolescents

Introduction. Adolescence (10–19 years) is the transitional period between childhood and adulthood. It is a time of rapid physical, emotional and social change. During this stage, adolescents seek independence, are strongly influenced by peers, and often experiment with new behaviours. Many of these behaviours carry health risks and are therefore called health risk behaviours — actions that increase the chance of illness, injury or death, now or later in life. The World Health Organization identifies adolescence as the period when most adult health-risk behaviours begin.

Major health risk behaviours of adolescents:

1. Tobacco use. Peer pressure, curiosity and the desire to look "grown up" lead many adolescents to smoke or chew tobacco. Nicotine is addictive, harms the lungs and heart, and is a major cause of cancer and heart disease in later life. Early initiation makes quitting very difficult.

2. Alcohol and drug abuse. Adolescents often drink or use drugs at parties and gatherings to gain peer acceptance or to escape stress. Alcohol lowers self-control, causes accidents, violence and risky sexual behaviour, and damages the developing brain and liver. Drug use may progress to addiction and criminal activity.

3. Unsafe sexual behaviour. Early sexual activity without condoms or contraceptives leads to teenage pregnancy, unsafe abortion, sexually transmitted infections including HIV/AIDS, and school dropout. Lack of correct information and shyness in seeking advice make the risk greater.

4. Poor dietary habits. Adolescents frequently skip breakfast and eat junk food, chips, cold drinks and fast food. This causes obesity, anaemia (especially in girls), undernutrition, dental caries and later diabetes and hypertension. Dieting to look thin can also lead to eating disorders.

5. Physical inactivity. Long hours of study, television, mobile phones and computer games reduce exercise. Lack of physical activity causes obesity, poor fitness, weak muscles and bones, and increases the risk of lifestyle diseases.

6. Injury and violence. Reckless driving, speeding, not wearing helmets or seat belts, fighting, bullying and use of weapons cause accidents, disability and death. Road accidents are a leading killer of adolescents.

7. Mental health problems. Exam pressure, family expectations, failure in love, and conflict with parents cause stress, anxiety, depression, and in extreme cases self-harm and suicide. Stigma prevents many from seeking help.

8. Screen and internet addiction. Excessive use of mobile phones and social media causes sleep deprivation, eye strain, poor concentration, cyberbullying and exposure to harmful content.

Causes/factors. These behaviours arise from biological changes (hormonal changes, immature decision-making), psychological factors (curiosity, desire for independence, low self-esteem), social factors (peer pressure, family conflict, poor parental supervision), and environmental factors (media influence, easy availability of tobacco, alcohol and drugs, poverty and illiteracy).

Consequences. Health risk behaviours cause immediate problems such as accidents, STIs and teenage pregnancy, and long-term problems such as cancer, heart disease, diabetes, addiction, mental illness, school dropout, unemployment and poverty. They also impose a heavy burden on the family, society and the nation.

Preventive measures. Health education about the harms of tobacco, alcohol and drugs; life-skills education (decision-making, refusal skills, coping with stress); counselling and mental health services; parental love, supervision and open communication; strict laws banning the sale of tobacco and alcohol to minors; promotion of sports, yoga and recreation; and easy access to adolescent-friendly health services.

Conclusion. Adolescence is a golden period of life, but it is also a period of great vulnerability. Health risk behaviours adopted at this age often continue into adulthood and determine the future health of the individual and the nation. Therefore, the family, school, community, media and government must work together to give adolescents correct information, guidance and a supportive environment so that they can pass through this stage safely and become healthy, responsible citizens.

Indicators of Primary Health Care

Primary Health Care (PHC) is evaluated through a set of indicators — measurable variables that show how well PHC is being delivered and whether it is producing the intended health results. These indicators are commonly grouped into the following categories:

1. Health Status Indicators

They measure the health condition of the population:

• Infant Mortality Rate (IMR) and Under-5 Mortality Rate (U5MR)
• Maternal Mortality Ratio (MMR)
• Crude Birth Rate (CBR) and Crude Death Rate (CDR)
• Life expectancy at birth
• Nutritional status — prevalence of underweight, stunting and wasting in children
• Incidence and prevalence of communicable and non-communicable diseases (TB, malaria, diarrhoea, hypertension, diabetes)

2. Health Service Coverage Indicators

They measure how far essential services reach the people:

• Immunization coverage — proportion of children fully immunized (BCG, DPT, OPV, measles, etc.)
• Antenatal care (ANC) coverage — at least four ANC visits
• Delivery by skilled birth attendant and institutional delivery rate
• Contraceptive Prevalence Rate (CPR)
• Availability of essential drugs at health facilities
• Oral Rehydration Solution (ORS) use in diarrhoea and vitamin A distribution

3. Health System / Input Indicators

They measure the resources and capacity of the health system:

• Health facility–population ratio (e.g., one health post per ward, health centre per palika)
• Health worker density — doctors, nurses, ANMs per 10,000 population
• Availability of basic equipment, beds and emergency services
• Budget allocation for health as a share of total government expenditure
• Accessibility — physical distance and travel time to the nearest health facility

4. Socio-economic and Environmental Indicators

They reflect the determinants of health:

• Safe drinking water coverage
• Sanitation coverage — use of improved toilets
• Literacy rate, especially female literacy
• Per capita income and poverty level
• Housing and environmental conditions

5. Quality and Efficiency Indicators

They measure how well services are provided:

• Client satisfaction with health services
• Waiting time and service utilization rate
• Treatment completion rate (e.g., TB cure rate)
• Referral rate and drop-out rate in programmes

6. Community Participation Indicators

They show people's involvement in PHC:

• Functioning of Health Facility Management Committees (HFMCs)
• Female Community Health Volunteer (FCHV) coverage and activity
• Community contribution in kind, cash or labour
• Awareness level about health rights and services

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Conclusion: These indicators together give a complete picture of PHC — whether people are healthy, whether services reach them, whether the system has enough resources, and whether the services are of good quality. In Nepal, indicators such as IMR, MMR, immunization coverage and sanitation coverage are regularly used to monitor PHC and to plan improvements.

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Present Organizational Structure of the Department of Health Services (DoHS)

The Department of Health Services (DoHS) is the central technical body under the Ministry of Health and Population (MoHP) responsible for delivering preventive, promotive, curative and rehabilitative health services throughout Nepal. Its present organizational structure is as follows:

1. Head of the Organization

• The DoHS is headed by the Director General (DG), supported by Deputy Director Generals (DDGs) in charge of different divisions and centres.

2. Divisions

1. Management Division — administration, finance, personnel and procurement support.
2. Family Welfare Division — maternal, newborn and child health, family planning and immunization.
3. Epidemiology and Disease Control Division (EDCD) — surveillance, outbreak response and control of communicable diseases.
4. Curative Service Division — hospital and curative services, standards and quality of care.
5. Logistics Management Division (LMD) — procurement, storage and distribution of drugs and equipment.

3. Centres

1. National Health Training Centre (NHTC) — training of health workers.
2. National Health Education, Information and Communication Centre (NHEICC) — health education and IEC/BCC activities.
3. National Centre for AIDS and STD Control (NCASC) — HIV/AIDS and STI programmes.
4. National Tuberculosis Centre (NTC) — TB control programme.
5. National Public Health Laboratory (NPHL) — laboratory services and quality control.

4. Regional and District Levels

• Health Offices at Province/Regional level coordinate health programmes in their areas.
• District Health Office / District Public Health Office at district level manages and supervises health services.
• Below this, Primary Health Care Centres, Health Posts, Sub-Health Posts and Community Health Units deliver services at the grassroots level.

5. Supporting Bodies

• Nepal Health Sector Support Programme (NHSSP) and other partner organizations work in coordination with DoHS.
• National Health Research Council and related bodies support research and evidence generation.

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Conclusion: The DoHS has a hierarchical structure — from the Director General at the top, through its divisions and centres, down to regional, district and community-level health facilities. This structure ensures that health policies and programmes are planned centrally and implemented effectively at the local level across Nepal.

Vitamin C (Ascorbic Acid)

1. Functions

1. Collagen synthesis — Vitamin C is essential for the hydroxylation of proline and lysine in the formation of collagen. Collagen is the structural protein of skin, bones, teeth, cartilage, tendons, blood vessels and gums. Hence it keeps these tissues strong and healthy.
2. Wound healing and tissue repair — Because of its role in collagen formation, it helps in the healing of wounds, fractures and burns, and in the maintenance of healthy gums and teeth.
3. Antioxidant action — It is a strong water-soluble antioxidant. It neutralises free radicals, protects cell membranes and other tissues from oxidative damage, and helps regenerate vitamin E.
4. Iron absorption — It converts ferric iron (Fe³⁺) to the more absorbable ferrous form (Fe²⁺) and forms a soluble complex with iron in the stomach, thereby increasing the absorption of non-haem (plant) iron. This helps prevent iron-deficiency anaemia.
5. Immune function — It supports the activity of white blood cells (leucocytes) and the production of antibodies, thus increasing resistance to infection.
6. Synthesis of neurotransmitters and hormones — It is needed for the conversion of dopamine to noradrenaline and for the synthesis of carnitine and some steroid hormones.
7. Prevention of scurvy — It prevents scurvy, characterised by bleeding gums, loose teeth, delayed wound healing, swollen and painful joints, and subcutaneous haemorrhages.
8. Absorption of other nutrients — It aids in the absorption and utilisation of calcium and iron and helps in the metabolism of folic acid, tyrosine and phenylalanine.

2. Sources

Rich sources (animal and plant):

Note: Amla and guava are the richest and cheapest sources. Vitamin C is destroyed by prolonged cooking, exposure to air (oxidation), light and alkali; hence vegetables and fruits should be eaten fresh or cooked for a short time in a covered vessel.

3. Daily Requirement

ICMR recommended dietary allowance: 40 mg/day for a normal adult.

Note: The requirement increases during pregnancy, lactation, fever, infection, injury, burns, smoking and in old age. The requirement of vitamin C is the highest among all water-soluble vitamins.

Asthma is a chronic inflammatory disease of the airways (bronchi and bronchioles) in which the air passages become swollen, narrowed and hypersensitive, causing recurrent attacks of wheezing, coughing, chest tightness and difficulty in breathing. The narrowing is partly reversible, either spontaneously or with treatment.

Risk Factors

1. Genetic/Hereditary: Family history of asthma, eczema or allergic rhinitis increases the risk.
2. Allergens: House dust mites, pollen grains, animal dander (fur), cockroach droppings, moulds.
3. Environmental irritants: Tobacco smoke (active and passive), air pollution, vehicle exhaust, strong perfumes, mosquito coils, incense smoke.
4. Infections: Frequent viral respiratory infections (common cold, influenza, pneumonia) in early childhood.
5. Occupational exposure: Dust, chemicals, fumes in industries (flour dust, cotton dust, paint, wood dust).
6. Weather changes: Cold air, sudden change of temperature, fog, rainy and winter season.
7. Physical and emotional factors: Vigorous exercise, stress, anxiety, emotional excitement, laughing or crying loudly.
8. Drugs and foods: Aspirin, certain painkillers, food additives, cold drinks, some sea foods.
9. Other factors: Obesity, gastro-oesophageal reflux, low birth weight, premature birth, not being breastfed.

Symptoms

• Wheezing (whistling sound while breathing out)
• Shortness of breath, difficulty in breathing, especially at night or early morning
• Dry, persistent cough, worse at night
• Tightness or heaviness in the chest
• Rapid and shallow breathing, use of accessory muscles of respiration
• Restlessness, anxiety, sweating, bluish lips and fingertips in severe attack
• Inability to speak full sentences during a severe attack

Controlling Measures

1. Avoid allergens and triggers: Keep the house dust-free, avoid dust, smoke, pollen, animal dander and strong smells; use clean bedding and curtains.
2. Avoid smoking: The patient must not smoke and should stay away from second-hand smoke.
3. Take medicine regularly: Use prescribed bronchodilators (inhalers) and anti-inflammatory drugs; keep a reliever inhaler always at hand.
4. Use inhaler correctly: Learn the proper technique of using an inhaler or spacer, and rinse the mouth after steroid inhalers.
5. Prevent infections: Get influenza and pneumonia vaccination; treat cold and cough promptly.
6. Breathing exercises: Practise deep breathing, pursed-lip breathing and yoga (pranayama) to strengthen the respiratory muscles.
7. Healthy lifestyle: Take a balanced diet, maintain normal body weight, drink plenty of warm water, and avoid cold drinks and refrigerated foods.
8. Exercise with precaution: Do warm-up before exercise and use the inhaler before exercise if advised.
9. Regular follow-up: Visit the doctor regularly, keep a symptom diary, and follow the treatment plan (asthma action plan).
10. Emergency care: During a severe attack, sit the patient upright, give the reliever inhaler, and take him/her to the hospital immediately.
11. Health education: Educate the patient and family about the disease, its triggers and correct use of medicines.
12. Avoid self-medication: Do not stop or change medicines without the doctor's advice.

Different Methods of Anthropometric Measurement of Nutritional Status Among School Children

Introduction

Anthropometry is the measurement of the size, weight and proportions of the human body. In school children, anthropometric measurements are the simplest, cheapest, most non-invasive and most widely used tools for assessing nutritional status. They reflect both past (chronic) and present (acute) nutritional conditions and are recommended by WHO for screening and monitoring.

Methods of Anthropometric Measurement

1. Measurement of Weight

Weight is measured using a calibrated beam balance or digital scale to the nearest 0.1 kg. The child should wear light clothing and no shoes. Weight is used to calculate weight-for-age, weight-for-height and BMI.

2. Measurement of Height (Length)

Height is measured with a stadiometer or an anthropometric rod to the nearest 0.1 cm. The child stands erect, barefoot, heels together, head held in the Frankfurt plane. In children under 2 years, recumbent length is taken. Height is used for height-for-age and weight-for-height.

3. Head Circumference

Measured with a non-stretchable tape around the head at the level of the glabella and occipital protuberance. It is mainly useful in children under 3 years to detect chronic undernutrition and brain growth retardation.

4. Chest Circumference

Measured at the level of the nipple line during mid-expiration. It is compared with head circumference; normally chest circumference exceeds head circumference after 6–12 months. A delayed crossover indicates undernutrition.

5. Mid-Upper Arm Circumference (MUAC)

Measured at the midpoint between the acromion and olecranon process of the left arm using a MUAC tape. It is a simple, quick field indicator of acute malnutrition. In children aged 6–59 months, MUAC below 11.5 cm indicates severe acute malnutrition (SAM) and 11.5–12.5 cm indicates moderate acute malnutrition (MAM); for school children, age- and sex-specific cut-offs are used.

6. Skin-fold Thickness

Measured with a Harpenden or Lange caliper at the triceps, biceps, subscapular and suprailiac sites. It estimates body fat stores and is useful for detecting obesity as well as energy deficiency.

7. Derived Indices (Composite Measures)

• Weight-for-age (WFA): Reflects underweight; low value indicates underweight.
• Height-for-age (HFA): Reflects stunting (chronic malnutrition).
• Weight-for-height (WFH): Reflects wasting (acute malnutrition).
• BMI-for-age: Screens for thinness, overweight and obesity.
• Mid-arm circumference/head circumference ratio: Useful in young children.

8. Body Mass Index (BMI)

BMI = Weight (kg) / Height (m²). Compared with WHO/CDC reference percentiles, it classifies children as thin, normal, overweight or obese.

Interpretation of Measurements

Measurements are compared with WHO Growth Reference Standards (2007) or CDC 2000 charts. Results are expressed as Z-scores or percentiles:

• Stunting: HFA Z-score < –2 SD
• Wasting: WFH Z-score < –2 SD
• Underweight: WFA Z-score < –2 SD
• Overweight: BMI-for-age > +1 SD; Obesity: > +2 SD

Advantages and Limitations

Advantages: Simple, cheap, non-invasive, reproducible, suitable for large school surveys.

Limitations: Requires trained personnel and calibrated instruments; single measurements cannot distinguish acute from chronic causes; reference standards may not fit all ethnic groups; oedema may mask weight loss.

Conclusion

Weight, height, head and chest circumference, MUAC, skin-fold thickness and derived indices such as BMI and Z-scores together provide a reliable picture of the nutritional status of school children. For school health programmes, a combination of weight-for-age, height-for-age and BMI-for-age is most practical for screening undernutrition and obesity.

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Comprehensive Sexuality Education: Meaning, Concept and Aspects

Meaning

Comprehensive Sexuality Education (CSE) is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and adolescents with knowledge, skills, attitudes and values that will empower them to realise their health, well-being and dignity, develop respectful social and sexual relationships, and understand and protect their rights throughout life. It is age-appropriate, culturally relevant, scientifically accurate and based on a human-rights approach.

Concept

CSE is not merely "sex education" limited to reproduction or disease. Its concept rests on the following ideas:

• Sexuality is a natural and positive part of human life, not merely a source of risk.
• Information must be age-appropriate and spiralled, i.e. topics are revisited with increasing depth at each grade.
• It is comprehensive because it covers biological, psychological, social, cultural, ethical, legal and gender dimensions.
• It promotes gender equality, consent, safety and non-discrimination.
• It is grounded in human rights, including the right to health, information and education.
• It involves parents, teachers, health workers and the community as partners.
• It aims at behaviour change, not just knowledge transfer.

Aspects of Comprehensive Sexuality Education

1. Biological and Physical Aspects

Growth and development, puberty, reproductive anatomy and physiology, menstruation, reproduction, contraception, STIs including HIV/AIDS, and prevention of early pregnancy.

2. Psychological and Emotional Aspects

Self-esteem, body image, emotional changes during adolescence, managing feelings, stress, peer pressure, decision-making and assertiveness.

3. Social and Cultural Aspects

Family and social norms, cultural values, marriage, gender roles, media influence, stigma and discrimination, and responsible social behaviour.

4. Gender Aspects

Gender equality, gender-based violence, sexual harassment, harmful practices such as child marriage and dowry, and respect for diversity.

5. Rights and Legal Aspects

Sexual and reproductive rights, right to consent, right to privacy and confidentiality, child rights, laws against abuse, trafficking and child marriage in Nepal.

6. Skills and Behavioural Aspects

Communication, negotiation, refusal skills, seeking help, decision-making, condom use, and safe health-seeking behaviour.

7. Health and Safety Aspects

Personal hygiene, reproductive health services, adolescent-friendly health services, prevention and management of STIs, and mental health.

8. Values and Attitudinal Aspects

Respect, empathy, tolerance, responsibility, equality and non-judgemental attitudes towards others.

Importance for School Children

• Prevents early pregnancy, STIs and HIV.
• Reduces child marriage, sexual abuse and gender-based violence.
• Builds confidence to say "no" and to seek help.
• Promotes healthy attitudes towards body, gender and relationships.
• Supports SDG 3 (health), SDG 4 (education) and SDG 5 (gender equality).

Conclusion

Comprehensive Sexuality Education is a lifelong, age-appropriate, rights-based and holistic approach that goes beyond biology to include emotional, social, cultural, gender, legal and skill dimensions. In the Nepali school context, it should be delivered through the curriculum, teachers, parents and health services in a culturally sensitive and scientifically accurate manner to promote the health and dignity of every child.