Family Health

Family Health
Subject code: BPH 206
FM: 100
PM: 50
nd
BPH 2 year
UNIT-1: CONCEPT OF FAMILY HEALTH 18hrs

Community and Society:
"Community" has been defined as a group of interacting people living in a common location and
organizing around common values and Social cohesion.
Human society is the condition in which the members of a community live together for their mutual
benefit by functional interdependence, possibly include characteristics such as national or cultural
identity, social solidarity, language or hierarchical organization.
Social structure
Social Organization
Individual
Family
Kinship
Lineage
Relatives
Caste
Verna
Territorial
Individual
Family
Village
Inter-village organization
Religion
Nation
Process of socialization
By: Keshab Shrestha (1st Batch)
(L.B.College of Health Science)
Family:
Family is a group of two or more persons joined by ties of marriage blood or adoption who
constitute a single household, who interact with one another in their respective roles and
who create and maintain a common culture
- Dr. Levine
Type/classification of family
Based on nature of residence
Patriarchal
Matriarchal
According to marriage
Monogamy
Polygamy
Polyandry
Depending on size: interrelationship, interdependence
Nuclear
Extended
Joint
Family Health:
Meaning:
Experiencing the optimum health by each and every members of the family resulting from
positive dynamic interaction between them.
Why family health:
Assisting family to cope effectively with health problem by increasing its capacity to perform
the health related tasks.
Family Health (Vision)
Integrated approach to health of families (preventive, Curative and Promotive)

Aim to promote health of families
Participation of family members on all activities
Equitable distribution of resources
Social unit of health care
Mutual responsibility and understanding other rights and interest
Concept of family physician, clinic within family environment
Sound family environment
Positive factors that influence health of family
Family Environment
Social
Cultural
Economical
Political
Family support:
Personal growth: self-confident, self-sufficient and make their own decisions

Expressiveness: encouragement to express their feelings
Cohesion: degree of commitment and support family members provide for one another
System management
Scope of Family Health / Family health need

Scope of family health:
Maternal health
Child health
Adolescent health
Adult health
Elderly health
Family health need:
Freedom from serious illness/disability (physical / mental); attention for slight or mild illness
with important consequences for general growth and household economics
Housing and general environment favorable to health
Information on the health and other community services available and use of them effectively and
efficiently as per need.
Access to food in sufficient quantity and quality to ensure adequate growth and development and
maintenance of good nutrition.
Availability of medical care esp. for pregnancy or lactating mother, infants, and young children
Fertility regulation services, sex education, and counseling
Social system for assistance with the effect of physical and mental illness on the family as a
whole.
Identification of need as per areas:

Physical need: diseases, disability, environment, good housing, food supply, water
supply, availability of health services etc
Social need: love, respect, prestige, relationship etc
Psychological/Mental need: Positive thinking, good wishing, good and helpful
behaviors, cooperation etc.
Economical need: income compatible to needs, economy etc
Health need: Health services available, achievable, affordable, accessible,
appropriate, comprehensive, preventive, promotive, curative etc.
Educational need: Environmental education, nutritional education, sex education
etc.
Principle, components and Health statues:

Principle of Family Health:
Accessible to family
Family centered
Respectful
Integrated (agencies + programs)
Effective outcome
Within normal environment
Community based decision making
Holistic model of family health:

Family health is a state of positive dynamic interaction between family members which
enables each and every members of the family to experience optimal physical, mental,
social and spiritual well being whether diseases or infirmity is present or not.
Family health is concern with the total health care of individual and family. It integrates
biological, clinical and behavioral sciences and not limited by age, sex, and organ system
or disease entity. Therefore, it is holistic model.
Prerequisites for health and family wellbeing:
Love and acceptance

Security
Honesty between members
Equitable right and responsibility in decision making process
Participation
Healthful housing environment
Education and understanding of each other
Employment
Sharing feelings
Assess to HE and other social services
Recreation and respecting the hobbies of each other
Health as a responsibility of all
Family provides environment/ support:
Food, shelter, security and identity

Transmission of genetic and contagious diseases
Standard of living and quality of care
Belief system and health care utilization
Learning of health behavior
Food habits,
personal hygiene,
marital fidelity
Breast feeding and child care pattern
Child spacing and family planning
Child discipline and social responsibility
Place where children pick up
Parental role modeling
Attitudes and values
Addictive behaviors
Interpersonal skills and family interaction
Belief system
Health care utilization and health seeking behavior
Sense of right and responsibility
Function of family in maintaining health:

Bring a function / socialization
Decision making concerning all aspects of health care / family size
Special care / attention for special group member / individual
Participatory action and responsibility of each family member

Proper use of traditional medicine and available resources
Seek information of new technology and modern medical care
Other non-health sectors
Components of family health
Neonatal health
Child health
Adolescent health
Adult health
Elderly health
Health of disabled and handicap
Vulnerable group within the family
Infants / children
Adolescents
Pregnant / lactating women
Orphan
Aged (elderly people)
Member with special need
Handicapped
Alcoholic, drug abuse etc.
Health Status:
Degree to which a person is able to function physically, emotionally and socially with or
without aid from the health care system.
Indicators need to assess family health status:

Mortality Indicators
CDR
MMR
NMR
PNR
Still Birth Rate
IMR
<5 MR
Morbidity Indicator
Incidence Rate
Prevalence Rate
Disability indicators
Bed Disability Days
Blind Rate
Deaf Rate
Health Care Delivery Indicator
Dr. Population Ratio
Pop. Bed Ratio
Pop. Per HP/SHP
Nutritional Status Indicators

Shunted Rate
LBW
Iodine Deficiency Rate
Vit. A Def. Rate
Anaemia Prevalence Rate
Per Capita Food Intake
Utilization Indicator
CPR
Immunization Coverage
Percentage of Delivery by Trained HW
PNC Coverage / ANC Coverage
Hosp. Delivery Rate
Bed Occupancy Rate
Environmental Indicators
Coverage of Toilets
Coverage of Safe Drinking Water
Household with Improve Chulo
Person Per Room
Social Indicators
Population Growth Rate
Per capita Income
Dependency Ratio
Literacy Rate
Family Size
Other health related Indicators
Life Expectancy at Birth
Proportion of children receiving exclusive breast feeding
Primary school enrolment
Total Fertility Rate
Non-therapeutic Abortion Rate
Birth Rate for girls <15 &>35 years
Birth Interval
Average wt. gain in Pregnancy
Proportion of Married Women
Median age at marriage
% of women who smoke and drink
Median age of first birth etc.
The Sick Role:

The Sick Role (Talcott Parson 1951):
The prominent functionalist thinker Talcott Parson describes the view of sickness role in
order to describe the patterns of behavior which the sick person adopts to minimize the
disruptive impact of illness. Pattern of behavior is appropriate for people who are ill.
There is distinction between the biological basis of illness and its social basis. What constitutes
illness in any given culture is related to the norms and values that prevail.
According to Parsons, people learn the sick role through socialization and perform it,
with the cooperation of others when they fall ill.
There are 3 pillars of sick role:
1. The sick person is not personally responsible for being sick. Illness is seen as the result of
physical causes beyond the individual control
2. The sick person is entitled to certain right and privileges, including a withdrawal from
normal responsibilities
3. The person must work to regain health by consulting a medical expert and agreeing to
become a patient.
Sick role:
Sick: Being ill and perceive generally by other
Sick person should play the role to minimize the tense of family members.
The important sickness roles are:
Should not hide the problem. Share in detail with family members
Give and take suggestions and take action with support of family members for check up
Should not oppose to take medicines and advices as prescribed. (Rest / Exercise)
Do not take prohibited food.
Try to make happy self / other by positive thinking and will etc.
Role of Father in Family Health

Father stands as a Administrator/owner
Responsible to arrange food, cloth, shelter, security to wife and children
Modeling role: teach child about bad practices/habit and their impact on health . Cultivate
good habits
Teach family about the utility of food, personal hygiene
Encourage wife for exclusive breast feeding and weaning
Collect information and practical use of them / disseminate
Love to all family members and encourage to participate in healthy and supportive
behaviors.
Ensure no gender discrimination in family
Especial care for vulnerable group
Provide nutritious food, care and support to wife while pregnant / lactation
Timely antenatal check up, natal care, post natal care
Provision of education etc.
Counseling:
Came from middle English Counsel old French Counsel Latin Consilium
Counseling is an interpersonal helping relationship which begins with the client exploring the
way of thinking, how they feel and what they do, for the purpose of enhancing their life.
Counseling:
Counseling is a process of encouraging and helping an individual in identifying his/her
health problem, the cause of the problem, and the ways of its solution and also encourages taking
necessary actions to solve it.
Counseling is one of the effective means for developing human potential.
In the process of counseling the client's problems are discussed and relevant information
is provided in-between.
In the end of the counseling process, the client himself/herself have a insight to the
problem and he/she become empowered to take own decision.
Counseling is a helping process where one person explicitly and purposefully fives his/her
time, attention, and skill to assist a client to explore situation, identity, and act upon
solution within the limitation of their given environment
- WHO
The client determines and declares to the counselor what the issues or behavior to be overcome
and then makes decisions about which one (s) will be worked on. The counselor helps the client
to set the goal that pave the way of positive change to occur.
Effective counselor:
Have a good will ( are optimistic and hopeful)

Fully present for other
Equalize the counseling relationship
Have a sense of openness
Have self respect
Willing for appropriate thought, feeling and behaviors
Turn mistakes into learning experience
Have a sense of humor
Sympathetic and kind
Demonstrate patience (tolerance)
Active listener
Care about client well-being
Principle of counseling:
Treat each client well

Interest
Tailor information to the client (correct and accurate information)
Avoid too much information
Provide the method that the client wants
Help the client understand and remember
Thumb rule of counseling:
Do not make decision for the clients

Listening is helpful
Avoid thinking me/ them terms
Support them and hold them accountable for their action
Response normally to trouble
Avoid asking why question
Maintain privacy
Assure that you only want to know what he/she wants to tell you
Help to preserve hope
Be open to the broad variety of effective human coping style
Use open-ended question
Effective counseling skill:
Active listening
Reflection of feeling
Questioning
Paraphrasing
Interpretating
Repeating
Summarizing
Prioritizing or structuring
Empowerment:
Empowerment:
Empowerment as the process by which the powerless gain greater control over the
circumstances of their lives. It includes both control over resources (physical, human,
intellectual, financial) and over ideology (beliefs, values, and attitudes). It means not only greater
extrinsic control, but also growing intrinsic capability greater self confidence and an inner
transformation of ones consciousness that enables one to overcome external barriers to
accessing resources or changing traditional ideology
- Baltiwala (1994)
It is shared power and responsibility between women and men
At home
At work
And in the world
Consequences of women powerlessness:
1. Limited exposure to information and new ideas related to:
Ignorance of good health practice
Lack of knowledge of where to find health services
Ignorance of their legal right
2. Womens lack of control over their lives, reflected in
Limited decision making authority
Limited physical mobility

Limited access to economic resources
3. Disrespected by the service providers lead to:
Womens negative experiences and perception concerning quality of case
Unwillingness to use the available services
Empowerment is critical to womens health because it enables women to:
Articulate health needs and concerns
Access services with confidence and without delay
Seek accountability among service provider and program manager
More reduce gender bias in the family
Community and markets provide greater opportunities to practices in social and
economical development.
Strategies for empowerment of women:

Long term:
Expanding educational opportunity for women
Expanding labour market and economic opportunities for women
Making and enforcing women centered legislation
Short term:
Promoting womens understanding of their needs and assertion (Claim) of their
right.
Developing life skills for adolescent
Community education about pregnancy/ child birth (health seeking behaviors)
Make health service more responsible to women need
Skill development and make environment to participate in economical sectors.
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By: Keshab Shrestha (1st
Batch)
Measuring the status of women:

The five indicators:
1. Life expectancy
2. Contraceptive use
3. Literacy
4. Secondary school enrolment
5. Labor force participation
Above indicator is useful for cross national comparisons but not for comparison wit
mens status
UNIT-2: MATERNAL HEALTH 18hrs

Reproductive Health:
Reproductive Heath is a state of complete physical, mental and social wellbeing and not
merely the absence of disease or infirmity in all matters relating to the reproductive
system and its function and process.
Reproductive health therefore implies that people are able to have a satisfying and safe
sex life and that they have the capability to reproduce and the freedom to decide if, when
and how often to do so. Implicit in this last condition are the
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right of men and women to be informed of and to have access to safe, effective,
affordable and acceptable methods of their choice for regulation of fertility which are not
against the law, and
the right of access to appropriate health care services that will enable women to go safely
through pregnancy and childbirth and provide couples with the best chance of having a
healthy infant.
- UN 1995
A condition in which reproduction is accomplished in a state of complete physical, mental and
social wellbeing and not merely the absence of diseases of the reproductive processes
- WHO
The constellation of method, techniques and services that contribute to reproductive health and
wellbeing through preventing and solving reproductive health problem
- ICPD
Objective of Reproductive Health:
Safe pregnancy and delivery
Fertility regulation and treatment of abortion
Avoiding unwanted pregnancies
Reduce morbidity and mortality
Control STD, HIV/AIDS
Healthy reproductive behavior
Stages of Reproductive life cycle:
Before sexual maturation
Sex matured but unmarried
Sex matured and married
After fertile period
Reproductive life cycle:
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Components of Reproductive Health:

Family Planning
Safe motherhood
Safe abortion facilities (Prevention and management of complication of abortion)
RTI / STDs and HIV/AIDS
Newborn care (infant and child care)
Prevention and management of infertility
Adolescent reproductive health
Reproductive health problem of elderly women
Male participation and responsible behaviors
Cancers of reproductive tract
Reproductive health needs of disables
Reproductive right includes:
Reproductive and sexual health as a component of life long health
Reproductive decision making
Marriage
Family formulation
Information on services to exercise these rights
Free from gender discrimination
Sexual and reproductive security
Free from violence
Free from coercion
Right to privacy
Effect of denying reproductive right:
Maternal death
Unavailability of Family Planning methods
Unsafe abortion
Morbidity / mortality due to RTI including STDs
Sex-selection during pregnancy
Rape
Trafficking of girls and women
High illiteracy among girls, semi-education
Sexual abuse of adolescent and children
Domestic violence
Empowerment and Reproductive Health:
Empowerment in RH means enabling women and men to make fully informed choices,
particularly in the areas affecting the most intimate aspect of their lives, namely their
reproductive health.
Scope of Reproductive health:
It has broadened since ICPD held in Cairo, Egypt in 1994. Now RH includes FP, SM,
womens health care, prevention and treatment of infertility and prevention of unsafe sex and
abortion and management of its consequences. However it is important to prioritize issues to
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address RH according to the specific situation of each country and area due to limited resources
and capability. Making pregnancy safer and FP are the priority issues that need to be address.
Areas of RH services include:
There are five areas:
1. Improving antenatal, perinatal, postpartum and newborn care
2. Providing high quality services for FP including infertility
3. Eliminate unsafe abortion
4. Combating STI including HIV, RTI, Cervical cancer and other gynecological morbidity
5. Promoting sexual health
Women Health:
Womens health refers to a state of complete physical, spiritual and social well-being
for all female infants, girls, and women regardless of age, socio-economic class, race, ethnicity,
and geographic location.
Womens health can be spoken of in terms of the search for solution for high MMR, IMR, Malnutrition, anaemia and other micronutrient deficiencies, early and unwanted pregnancies,
illiteracy, FGM, high fertility, unsafe abortion, RTI, STI, HIV/AIDS, work-related health risk,
cancers, substance abuse, sexual harassment, domestic abuse and VAW, depression and other
problem related to aging, gender inequities, the unfair low social status accorded to women, the
hindrances to their empowerment and the obstruction of their basic human right.
RH Target group:
Women at different stages
Men at different stages
Adolescents
Infant and children
Infertile couples
RH in the world: bare facts:
On any given day, sexual intercourse takes place 120 million times on earth. Thus, with
240 million people having sex daily and a world population of just under 6.1 billion (as of 2000),
about 4% of the world's population (1 out of every 25 people) is having or had sex today.
-Penguin Atlas of Human Sexual Behavior
These sexual act results in more than 91000 conception (2006)

3, 56,000 sexual transmitted bacterial and viral infection. (2006)
About 50% of conceptions are unplanned and about 25% are unwanted
Of the estimated 211 million pregnancies that occur each year, about 46 million end in
induced abortion; 32 million miscarries and still birth.
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1/3rd of induced abortion are performed under unsafe condition and in an adverse social
and legal climate, resulting 500 deaths every day.
-Alan Guttmacher Institute, 1999, New York / WHO
Every minute, more than 30 women are seriously injured or disabled during labor, thus
rendering vast numbers of women in the developing world physically and socially
disabled. For every woman who dies from complications of pregnancy, between 30 and
100 more live with painful and debilitating consequences. However, those 15 50
million women generally go unnoticed.
-The world Bank Groups mission
One in 12 infants born this year will not see his/her 1st birth day and one in eight will not
see the 5th birth day.
Estimated that in 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm.
Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia,
- WHO
Every year nearly 80 million unintended pregnancies occur worldwide, and more than
half of these pregnancies end in abortion. An estimated 150 million women in developing
countries say they would prefer to plan their families but are not using contraception, and another
350 million women lack access to effective family planning methods.
- Population action International
Female sterilization is the most common contraceptive method, with 19 percent of
couples of reproductive age using it. The next most used methods are the intrauterine device
(IUD), used by 13 percent of couples, the contraceptive pill (8 percent), and traditional methods
(8 percent). Vasectomy and condoms are the only modern male methods currently available and
are the least used, at just 4 percent each worldwidereflecting a massive disparity between
female and male use of contraception. In developing countries, only 2 percent of couples use
condom
- Population action International
Surveys from around the world show that between 10 and 50 percent of women are
victims of physical abuse by their intimate partners sometime during their lifetimes. In the
United States alone, an estimated 1.5 million women are battered by their partners each year.
-Population action International
Number of abortions per year: Approximately 46 Million
Number of abortions per day: Approximately 126,000
Where abortions occur:
78% of all abortions are obtained in developing countries and 22% occur in developed
countries.
Legality of abortion:
About 26 million women obtain legal abortions each year, while an additional 20 million
abortions are obtained in countries where it is restricted or prohibited by law.
Abortion averages:
Worldwide, the lifetime average is about 1 abortion per woman.
- Amozon.com (Abortion statistics)
RH Care need for children:
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HE to mothers on child bearing

Nutrition and breast feeding
Maintain immunization schedule
Distribution of ORS and Vitamin. A capsules
Treatment of illness
RH Care need for Adolescent:
Proper nutrition and hygiene practices

Information about healthy sexual behavior
Informs parents about their health and physiological needs and proper treatment
Treatment of common ailments and menstrual problems
RH Care need for women:
Routine identification & Treatment of RH problems

Reduce side effects of contraceptives
Adequate screening for any illness and treat them
Adequate stock maintained for services
RH Care need for men:
Special attention and counseling for contraception

Need treatment for severe symptoms
Screening and treatment for STD, HIV/AIDS
Counseling for their special need etc.
Holistic Approach to RH Care:

Access to a range of safe and affordable modern contraceptive methods and counseling;
Maternal and neonatal health care;
Prevention and management of HIV and AIDS among high risk groups, including other
sexually transmitted infections;
Support to strengthen national response to AIDS;
Adolescents sexual and reproductive health care and awareness;
Advocacy for promoting reproductive health, gender equality and women's
empowerment;
Medical and psychological assistance for gender based violence survivors;
Care for complications of abortion;
Specific measures to address in systematic way uterine prolapse prevention and
treatment;
Prevention and care for reproductive health of elderly;
Reproductive health commodity security and quality;
Improvement in capacity of local communities especially among excluded groups, to
participate in local-level planning, monitoring and evaluation of quality reproductive
health services.
Recommendations to help improve reproductive health (WB March 2009):

Single window for complete package of essential reproductive health services: Poor
women often do not have the time, money, or the power to approach providers for health
care, family planning, and childbirth. They, therefore, need to be provided a continuum of
care through a single window.
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Antenatal care and skilled birth attendance need to be stepped up: Institutional delivery
or the presence of a skilled birth attendant can make a critical difference to the survival of
mothers and their babies. In Nepal it is only 21 percent births take place in institutions;.
Decentralized and action oriented planning is needed: The focus should be on action
planning which involves poor women themselves, their institutions, local governments
and health staff. This will increase relevance and accountability.
Disseminating know-how: Good practices that have worked within the developed
world and in the region need to be shared and is an important central function that must
be stepped up.
Efficient financing: The report calls for innovative financing to the reproductive health
sub-sector to ensure the inputs for additional and better services. Increasing allocations
to in-patient maternal and child health services over current low levels in most areas
could substantially increase the use of needed health care by the poor.
Innovative financing: Vouchers, reimbursement, insurance and social marketing are
some feasible approaches that will reduce heavy out-of-pocket expenditures by the poor
on reproductive health care.
Safe motherhood & neonatal care

Safe motherhood:
Womans ability to have SAFE and healthy pregnancy and childbirth.
Safe motherhood means: creating the circumstances with in which:
A woman is enable to choose whether she will become pregnant
Ensuring the services care for prevention and treatment of pregnancy complication
Has access to emergency obstetric care (EOC) if she needs it and care after birth
- So that she can avoid death or disability from complication of pregnancy and childbirth.
Maternal morbidity prevention and control:
There are 3 essential interventions
1. Reducing the number of high risk and unwanted pregnancies.
2. Reducing the number of obstetric complication
3. Reducing deaths among women who develop complication
Prime message for safe motherhood:

There are 6 messages:
1. The risk of childbirth can be drastically reduced by going to the nearest health institutions
for regular check-ups during pregnancy
2. A trained person should assist at every birth
3. To reduce the danger of pregnancy and childbirth, all families should know the warning
signs
4. All women need more food during pregnancy. All pregnant need more rest.
5. Spacing pregnancies at least 2 years apart and avoiding pregnancies below the age of 18
and above the age of 35 years drastically reduce the danger of child bearing
6. Girls who are healthy and wealthy during their own childhood and teenage years have
fewer problems in pregnancy and childbirth.
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Ten action messages in SM:

1. Safe motherhood through right
2. Empowerment of women to ensure choices
3. Vital social and economic investment
4. Delayed marriage and childbirth
5. Skilled attendance at birth
6. Access to quality MCH services
7. Prevent unwanted pregnancy and unsafe abortion
8. Measure progress
9. Shared (integrated) efforts
10. Limit number of pregnancy
Maternal Health status:

Women continue to die of pregnancy-related causes at a rate of about one a minute. In
2005, 536,000 women died of maternal causes, compared to 576,000 in 1990.
Ninety-nine per cent of maternal deaths occur in developing countries, primarily in
Africa and South Asia.
Lifetime risk of maternal death is 1 in 92.
-October 2007 UNFPA, WHO, UNICEF and The World Bank
In Nepal, approximately 80-90% of births take place at home, often conducted by
family members, sometimes assisted by a traditional birth attendant (TBA), but many
without any attendant at all.
Estimated 211 million pregnancies that occur each year
About 182 m. pregnancies in developing countries
In Nepal maternal mortality ratio is 281 per 100,000 live births
Maternal Death:
The death of a woman while pregnant or within 42 days of the termination of pregnancy,
irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated
by the pregnancy or its management, but not from accidental or incidental causes
-Sullivan & King 2006
"A maternal death is defined as the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management but not from accidental or
incidental causes."
-WHO
Direct deaths result from obstetric complications of the pregnant state (pregnancy, labour and
puerperium), from interventions, omissions, incorrect treatment, or from a chain of events
resulting from any of the above. They are complications of the pregnancy itself, for example,
eclampsia, amniotic fluid embolism, rupture of the uterus, postpartum haemorrhage.
Indirect deaths result from pre-existing disease or disease that developed during pregnancy and
was not due to direct obstetric causes, but which may have been aggravated by the physiological
effects of pregnancy (for example, heart disease, diabetes, renal disease).
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Global Scenario of Maternal Death:
Region
Africa
Asia
Latin America/Caribbean
Oceania
Developed regions
World Total
Number of Death
2,51,000 per year
2,53,000 per year
22,000 per year
530 per year
2,500 per year
5,29,000 per year
(Source: MM in 2000; WHO/UNICEF/UNFPA Geneva 2004.)
Note: 99% MM in developing countries and 1% in developed countries.
Importance of Maternal health:
They are adult member of the society in productive age group

More vulnerable and less empowered
More neglected and uncared
Bear the burden of pregnancy
Care taker of the family
Safe Motherhood Program goal:

The goal of the National Safe Motherhood Program is to reduce maternal and neonatal
mortalities by addressing factors related to various morbidities, death and disability
caused by complications of pregnancy and childbirth.
STRATEGIES:
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Safe Motherhood goals and objectives are to be achieved through:

Promoting inter-sectoral collaboration by ensuring advocacy for and commitments to
reproductive health, including safe motherhood, at the central, regional, district and
community levels focusing poor and excluded groups
Strengthening and expanding delivery by skilled birth attendant, basic and
comprehensive obstetric care services (including family planning) at all levels
Supporting activities that raise the status of women in society
Promoting research on safe motherhood to contribute to improved planning, higher
quality services, and more cost-effective interventions.
Critical importance to the outcomes of an OE:
Three key delays:
Delay in seeking care,
Delay in reaching care and
Delay in receiving care.
Three major strategies:

Promoting birth preparedness and complication readiness including awareness raising
and improving the availability of funds, transport and blood supplies.
Promoting the use of skilled birth attendants at every birth, either at home or in a health
facility
Provision of 24-hour emergency obstetric care services (basic and comprehensive) at
selected public health facilities in every district
Global initiatives for MCH services:
1788: ANC began as a social service (UK & Sweden)
1873: Birth and death registration acts promulgated (England)
1902: First ANC bed was endowed in Edinburgh
1912: Maternal and child welfare law established in England
1931: maternal child welfare bureau was established under Indian Red crescent society
1946: concept of MCH undertaken in subcontinent in India as per Bhore committee
recommendation
1952-53: MCH program in Pakistan Govt. established
1961-71: Discovered the tragedy of Thalidamide in deformed babies
1987 First Int. safe motherhood conference held in Nairobi
1990:The world children initiative
1994: International conference on population development (ICPD)
1995: Beijing conference: 4th world conference on women
1997: International technical consultation meeting held in Colombo
2000: Declaration of MDG
Maternal Morbidity and Mortality:

Key Factors Affecting Maternal Mortality:
Antenatal Care
Place of Delivery
Assistance during Childbirth
Post Natal Care
Birth Preparedness
Family Planning
Comprehensive Abortion Care (CAC)
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Blood Transfusion
Health Service Delivery System
Other factors:
Socio-economic Factors:
Residence,
Educational status
Family status
Occupation / Employment
Income / Economic status
Migration
Socio cultural factors:
Types of Family
Belief,
Tradition,
Health seeking behavior,
Access to resources,
Personal habits
Religion
Caste
Gender
Decision making
Age at marriage etc
Gravidae / Parity
Utilization of health care
Availability, Affordability, Accessibility and Acceptability of health care services
Efficiency and accountability of health care provider:
Physical distance
Availability of infrastructures and supplies
Political factor:
Government policy
Expenditure on health care
Service coverage
Commitment of different stakeholders
Role of Public and private sectors
Community participation
Risk factors contributors:

1)
2)
3)
4)
5)
6)
Socio-economic and cultural factors

Women reproductive status / other demographic factors
Health status of women
Access to health services
Health care behaviors / Use of health services
Unknown / unpredicted factors
1) Socio-economic and cultural factors:
21
Batch)
Discrimination in feeding and extra demands for energy result in mal-nutrition and poor
health for women
Girls are considered as economic liability
Female feticide and selective abortion
2) Women reproductive status:
Old age / young age

Gravidity
Birth spacing
3) Health status of Women:
Following leading condition that are exacerbated by pregnancy and delivery:

Malaria
Hepatitis
Account for 25% of maternal death
Anemia
Mal-nutrition
4) Access to health services:
Though the medical technology to prevent mortality been available access to those services in
limited in developing countries.
Physical distance
Financial access
Shortage of trained personnel
Poor performance on part of trained personel

Maternal morbidity:
Refers to any complication related to pregnancy or its management any time during
ante-partum, intra-partum and post-partum period up to 42 days of after confinement.
Scenario of morbidity and mortality:
211 m women get pregnancy every year in the world.
182 m pregnancy in developing countries
80-120m. Pregnancies are unwanted
Half of nearly 120m. Women who give birth each year experience complications during
pregnancy
15-20 m. develop disabilities
- (Ankita Handoo 2006)
>5,29 m. women die every year from pregnancy related causes
>99% of these death take place in the developing countries
80% of maternal death are due to direct obstetric complication
20% maternal death are indirect causes
- (WHO 2005, Pop. Action International 2005)
123 m. women in developing countries, not using contraceptives in spite of an express
desire
50% of all pregnancies are unplanned and 35% are definitely unintended
Around 6 out of 10 such unplanned pregnancy result in an induced abortion
95% of illegal abortion takes place in developing countries, which lead to death of more
than 200 women daily. (Body politics, Dr. Aruna Upreti 1998)
Worldwide maternal death due to unsafe abortion is 13%
Nepal Situation:
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Batch)
281 per 100,000 live births (Annual report 2063/64)

4500 women die every year from pregnancy related complication
67% maternal death occurs at home
11% on the way to health facilities
11% in health facility (90% of which occur in rural setting)
-Kathmandu University medical journal 2006
4000 women die each year from illegal abortion
-Kathmandu University medical journal 2006
Most of the deliveries occur at home and only 9% occurs at health facilities
48% of pregnant women received any antenatal care and only 14.3% of them had four or
more antenatal check-ups.
- Demographic health survey 2001
Supporting factors for maternal mortality / morbidity in women in Nepal:
Custom and culture
Illegal abortion
Poor physical access to health facilities
Limited health infrastructure
Discriminate women from childhood
Less medical care, education & opportunity
Women low status in society
Poor communication / information system
Poorly equipped health care facilities
Early marriage
Domestic violence and harassment
Political instability
Cost for essential services and supply
Lack of resources
Shortage of trained health professionals etc
Maternal mortality indicators:

Maternal Mortality Rate: Number of maternal death per 100000 women aged 15-49
years per year
This measure reflects:
Both the risk of death among pregnant and recently pregnant women and
the proportion of all women who become pregnant in a given year.
Maternal Mortality Ratio: Number of maternal death per 1,00,000 live birth per year
This measure indicates the risk of maternal death among pregnant and recently
pregnant women
It reflects a womans basic health status, her access to health care and the quality
of service that the receives.
Lifetime risk of maternal death: It is the risk of an individual woman dying from
pregnancy or child birth during her life time. A lifetime risk of 1 in 3000 represents a low
risk of dying from pregnancy and childbirth, while 1 in 100 is high risk.
This measure reflects the probability of death faced by an average women over
her entire reproductive lifespan
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Batch)
It reflects both womans risk of dying from maternal death as well as her risk of
becoming pregnant
Proportionate maternal mortality: Ratio of number of maternal death to all death
among women of reproductive age.
This figure represents how important maternal mortality is as a cause of death
among mother
Lifetime risk of maternal death 2000 (AD):

Region
North Africa
Sub Saharan Africa
Latin America
Eastern Asia
South Central Asia
Western Asia
Oceania
LR of M death, 1 in
210
16
160
840
46
120
83
(Source: WHO/UNICEF/UNFPA)
Country (South East Asia Region):

Region
Bangladesh
Bhutan
DPR Korea
India
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Thailand
LR of M death, 1 in
59
37
590
48
150
140
190
24
430
900
(Source: WHO/UNICEF/UNFPA)
Maternal Mortality Ratio in SAARC:

Country
Sri Lanka
MMR/1000 live birth

0.92
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Batch)
Maldives
Bangladesh
Bhutan
Pakistan
India
Nepal
1.1
3.2
4.2
5.0
5.4
7.4
(Source: WHO/UNICEF/UNFPA 2003)
Safe motherhood indicator:

Indicators collected from the health facilities
CBR
NMR
Still Birth Rate
Coverage of ANC
Coverage of trained delivery services
Coverage of STI screening (e.g. Syphilis)
Coverage of post partum care
Incidence of obstetric complecation
Disability experience by women:
Women who experience complications and develop disabilities when give birth could be:
Acute : affecting a woman during or immediately after child birth
Chronic : lasting for months, years or a lifetime
Long term complications
Uterine prolapse,
Fistulae **
Incontinence
Infertility
Pain during intercourse
Nerve damage
PID
Fistulae: 2 million women are currently living with obstetric fistulae and 50,000 to
1,00,000 new cases occur each year (UN 2000)
Reducing maternal morbidity:
Three pronged strategy
1. All women have access to contraception to avoid unintended pregnancies
2. All pregnant women have access to skilled care at the time of birth
3. All those with complication have timely access to quality emergencies obstetric
care
Prevention of Maternal morbidity and mortality
1. Essential care for all : ANC, delivery, post natal
2. Early detection of complication
3. Emergency care
Millennium Development Goal:
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Batch)
GOAL 1: ERADICATE EXTREME POVERTY & HUNGER:

Target 1:
Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a
day
Target 2:
Achieve full and productive employment and decent work for all, including women and
young people
Target 3:
Halve, between 1990 and 2015, the proportion of people who suffer from hunger
GOAL 2: ACHIEVE UNIVERSAL PRIMARY ED nUCATION
Target 1:
Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete
a full course of primary schooling
GOAL 3: PROMOTE GENDER EQUALITY AND EMPOWER WOMEN
Target 1:
Eliminate gender disparity in primary and secondary education, preferably by 2005, and
in all levels of education no later than 2015
GOAL 4: REDUCE CHILD MORTALITY
Target 1:
Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
GOAL 5: IMPROVE MATERNAL HEALTH
Target 1:
Reduce by three quarters the maternal mortality ratio
Target 2:
Achieve universal access to reproductive health
GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
Target 1:
Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Target 2:
Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
Target 3:
Have halted by 2015 and begun to reverse the incidence of malaria and other major
diseases
GOAL 7: ENSURE ENVIRONMENTAL SUSTAINABILITY
Target 1:
Integrate the principles of sustainable development into country policies and programmes
and reverse the loss of environmental resources
Target 2:
Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
Target 3:
Halve, by 2015, the proportion of the population without sustainable access to safe
drinking water and basic sanitation
Target 4:
By 2020, to have achieved a significant improvement in the lives of at least 100 million
slum dwellers
GOAL 8: DEVELOP A GLOBAL PARTNERSHIP FOR DEVELOPMENT
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Batch)
Target 1:
Address the special needs of least developed countries, landlocked countries and small
island developing states
Target 2:
Develop further an open, rule-based, predictable, non-discriminatory trading and
financial system
Target 3:
Deal comprehensively with developing countries debt
Target 4:
In cooperation with pharmaceutical companies, provide access to affordable essential
drugs in developing countries
Target 5:
In cooperation with the private sector, make available benefits of new technologies,
especially information and communications.
Fertility:
Fertility is the natural capability of giving life.
Human fertility depends upon factors viz.
Nutrition
Sexual behaviors
Culture
Instinct (natural pattern of behaviors)
Endocrinology
Timing
Economics
Way of life
Emotions etc.
Both women and men have hormonal cycles which determine both when a woman can
achieve pregnancy and when a man is most virile (sexually potent).
The female cycle is approximately 28 days long, but the male cycle is variable. Man can
ejaculate and produce sperm at any time of the month
The ovule is usually fertilizable for up to 48 hours after it is released from the ovary.
However, sperm can survive inside the uterus between 48 to 72 hours on average, with
the maximum being 120 hours (5 days)
Female fertility:
Women fertility peaks around the age of 19-24, and often declines after 30. With a rise in
women postponing pregnancy; this can create an infertility problem.
A) Possibility of Pregnancy:
At the age of 30, 75% will get pregnancy within one year and 91% within 4 years.
At the age of 35, 66% will get pregnancy within one year and 84% within 4 years
At the age of 40, 44% will get pregnancy within one year and 64% within 4 years
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Batch)
B) Possibilities of miscarriage
At the age of 20-24, about 9% recognized pregnancy ended in miscarriage
At the age of 35-39, about 20% recognized pregnancy ended in miscarriage
At the age of >42, about 50% recognized pregnancy ended in miscarriage
C) Possibilities of birth defect
At the age of 25, about 1 in 1250 chance of having baby with down syndrome
Erectile dysfunction increases with the age but fertility does not decline in men sharply as
it does in women. However, increased male age is associated with a decline in semen
volume, sperm motility and sperm morphology
Sperm count decline with the age with men aged 50-80 years producing sperm at an
average rate of 75% compared with men aged 20-50 years. However, an even larger
difference is seen in how many of the seminiferous tubules in the testes contain mature
sperms
In male:
20-39 years, 90% of seminiferous tubules contain mature sperms
40-69 years 50% of seminiferous tubules contain mature sperms
80 years and older 10% of seminiferous tubules contain mature sperms
Natural fertility: It is a concept developed by French demographer Louis Henry to refer to the
level of fertility that would prevail in a population that makes no conscious effort to limit,
regulate or control fertility, so that fertility depends only on physiological factors affecting
fecundity.
Here people follow the traditional means of contraception or pregnancy prevention e.g.
coitus interruptus or from social norms or practice regarding celibacy, the age at marriage and
the timing and frequency of sexual intercourse, including periods of prescribed sexual
abstinence.
Fecundity: It is an ability to reproduce.
Human sexuality: How people experiences and express themselves as sexual being.
Biologically, sexuality can encompass sexual intercourse and sexual contact in all its form, as
well as medical concerns about the physiological and psychological aspect of sexual behavior.
Sociologically, it can cover the cultural, political and legal aspects and philosophically, it can
span the normal, ethical, theological, spiritual or religious aspects.
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Batch)
Cancer
Cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and
which can then invade adjoining parts of the body and spread to other organs. This process is
referred to as metastasis. Metastases are the major cause of death from cancer.
Key Facts
Cancer is a leading cause of death worldwide: it accounted for 7.4 million deaths (around
13% of all deaths) in 2004.
Lung, stomach, liver, colon and breast cancer cause the most cancer deaths each year.
The most frequent types of cancer differ between men and women.
More than 30% of cancer deaths can be prevented.
Tobacco use is the single most important risk factor for cancer.
Cancer arises from a change in one single cell. The change may be started by external
agents and inherited genetic factors.
Deaths from cancer worldwide are projected to continue rising, with an estimated 12
million deaths in 2030.
B - Feb. 2009 WHO
Global burden of cancer:

Cancer is a leading cause of death worldwide. The disease accounted for 7.4 million
deaths (or around 13% of all deaths worldwide) in 2004. The main types of cancer
leading to overall cancer mortality each year are:
lung (1.3 million deaths/year)
stomach (803 000 deaths)
colorectal (639 000 deaths)
liver (610 000 deaths)
breast (519 000 deaths).
More than 70% of all cancer deaths occurred in low- and middle-income countries.
Deaths from cancer worldwide are projected to continue rising, with an estimated 12
million deaths in 2030.
The most frequent types of cancer worldwide (in order of the number of global deaths)
are:
Among men - lung, stomach, liver, colorectal, oesophagus and prostate
Among women - breast, lung, stomach, colorectal and cervical.
Cancer facts:
KEY FACTS
Cancer is a leading cause of death worldwide: it accounted for 7.9 million deaths (around
13% of all deaths) in 2007.
Lung, stomach, liver, colon and breast cancer cause the most cancer deaths each year.
The most frequent types of cancer differ between men and women.
About 30% of cancer deaths can be prevented.
-WHO Sep. 2009
Tobacco use is the single most important risk factor for cancer.
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Batch)
Cancer arises from a change in one single cell. The change may be started by external
agents and inherited genetic factors.
About 72% of all cancer deaths in 2007 occurred in low- and middle-income countries.
Deaths from cancer worldwide are projected to continue rising, with an estimated 12 million
deaths in 2030.
Most cancers can be treated and some cured, depending on the specific type, location,
and stage. Once diagnosed, cancer is usually treated with a combination of surgery,
chemotherapy and radiotherapy
The prognosis of cancer patients is most influenced by the type of cancer, as well as the
stage, or extent of the disease.
Cancers that occur mainly in women:

Breast: Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk
to the nipple) and lobules (glands that make milk). It occurs in both men and women,
although male breast cancer is rare
Cervical: Cancer that forms in tissues of the cervix (the organ connecting the uterus and
vagina). It is usually a slow-growing cancer that may not have symptoms but can be
found with regular Pap tests (a procedure in which cells are scraped from the cervix and
looked at under a microscope). Cervical cancer is almost always caused by human
papillomavirus (HPV) infection.
Endometrial: Cancer that forms in the tissue lining the uterus (the small, hollow, pearshaped organ in a woman's pelvis in which a fetus develops). Most endometrial cancers
are adenocarcinomas (cancers that begin in cells that make and release mucus and other
fluids).
Gestational Trophoblastic Tumor: Any of a group of tumors that develops from
trophoblastic cells (cells that help an embryo attach to the uterus and help form the
placenta) after fertilization of an egg by a sperm. The two main types of gestational
trophoblastic tumors are hydatidiform mole and choriocarcinoma. Also called gestational
trophoblastic disease.
Ovarian: Cancer that forms in tissues of the ovary (one of a pair of female reproductive
glands in which the ova, or eggs, are formed). Most ovarian cancers are either ovarian
epithelial carcinomas (cancer that begins in the cells on the surface of the ovary) or
malignant germ cell tumors (cancer that begins in egg cells).
Uterine Sarcoma: A rare type of uterine cancer that forms in muscle or other tissues of
the uterus (the small, hollow, pear-shaped organ in a woman's pelvis in which a fetus
develops). It usually occurs after menopause. The two main types are leiomyosarcoma
(cancer that begins in smooth muscle cells) and endometrial stromal sarcoma (cancer that
begins in connective tissue cells).
Vaginal: Cancer that forms in the tissues of the vagina (birth canal). The vagina leads
from the cervix (the opening of the uterus) to the outside of the body. The most common
type of vaginal cancer is squamous cell carcinoma, which starts in the thin, flat cells
lining the vagina. Another type of vaginal cancer is adenocarcinoma, cancer that begins
in glandular cells in the lining of the vagina.
Vulvar: Cancer of the vulva (the external female genital organs, including the clitoris,
vaginal lips, and the opening to the vagina).
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Batch)
Prevention:
Greater than 30% of cancer is preventable via avoiding/controlling risk factors including:
tobacco, overweight or obesity, low fruit and vegetable intake, physical inactivity,
alcohol, sexually transmitted infection, air pollution, occupational hazards, exposure of
sunlight etc.
Screening (early detection)
medical intervention (chemoprevention, treatment of pre-malignant lesions)
Prophylactic vaccines have been developed to prevent infection by oncogenic infectious
agents such as viruses, and therapeutic vaccines are in development to stimulate an
immune response against cancer-specific epitopes
human papillomavirus vaccine
hepatitis B vaccine
Components of Maternal Health care
Harmonious gender relationships

Empowerment and self help women
Families and Communities;
Prevention of teenage marriage
Pregnancy and safe motherhood
A quality family planning program
Women education in health and hygiene.
Accessible basic maternity care/ Essential M Care (ANC, INC,PNC)
Early detection of complication
Available and accessible essential obstetric Emergency care.
Maternity waiting home
Safe birthing practice
Enumeration and referral system;
Neonatal Care
Role and training to the HW who deals with mothers in community
Five basic principles:

Cross-sectoral and multi-disciplinary approach; Integration
Male participation and responsibility;
Continuous monitoring system;
Effective coordination by local and regional government and line agencies
Planning, organizing, managing and evaluating the health services
Antenatal Care (ANC):

Care during pregnancy:
Objective/Purpose:
Screen sign of illness or complication
Treat mother to make her healthy and healthy delivery by her
Service provided in ANC
General examination
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Batch)
BP Checkup
Weight taking
Other essential investigation i.e. Hb%, grouping, VDRL urine exam etc.
Importance of weight checkup:

Average weight: about 11 Kg increase during pregnancy: 1 Kg in 1 st trimester, 5 Kg in
2nd trimester and 5 Kg in 3rd trimester
Stationary and falling weight could be:
Intrauterine growth retardation (IUGR)
Intrauterine death (IUD)
Getting more weight : >1 lb/week or >5 lb/week (2 Kg) a month later months of
pregnancy is the sign of Toximia of pregnancy
Intra Natal Care (INC):

Care during labour or delivery:
Objective/ Purpose:
Prevention of infection
Delivery by skilled health professional
Delivery with minimum injury to mother and infant
Ready to deal with complication
Post Natal Care (PNC):

Care of mother and newborn after delivery
Objective/ Purpose:
Prevention and early detection of complication
Restoration of mother health through rest and improve nutrition
Counseling on family spacing, breast feeding
Immunization
Aim of these care:
To achieve a healthy mother and healthy child at the end of pregnancy
To reduce the maternal and infant mortality and morbidity
Early detection of complication:
Warning signs before pregnancy
Was pregnancy less than 2 years
Is less than 18 yrs or more than 35 yrs
Has four or more previous children
Previous baby weight less than 2.5 Kg at birth
Previous premature birth
Previous miscarriage abortion or still birth
Weight less than 38 Kg before pregnancy
Measure less than 145 cm. in height
Has chronic disease
Warning signs developing during pregnancy
Failing to gain weight
Paleness of inside eyelids (Anaemia)
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Batch)
Unusual swelling of legs, arm and face

Passing fluid that is not urine
Warning signs after delivery
Excessive bleeding
Convulsion
Fever, chill and discharge (bad smell discharge : sepsis or piamia)
Six danger warning signs:

Should get help immediately if :
Bleeding from the vagina during pregnancy
Severe headache (Sign of high BP)
Severe vomiting
High fever
Convulsion (Fits)
Woman has been in labour for more than 24 hours
Importance of knowing warning signs:
To reduce the danger of pregnancy and child birth : indicate the extra care and regular
visit to the health professional are needed
All family members should know the warning signs

Emergency Obstetric Care (EmOC).
Introduction:
One way of reducing maternal mortality is by improving the availability, accessibility,
quality and use of services for the treatment of complications that arise during pregnancy and
childbirth. These services are collectively known as Emergency Obstetric Care (EmOC).
Why Emergency Obstetric Care:
Emergency Obstetric Care (EmOC) to ensure timely access to care for women
experiencing complications
Maternal mortality claims 514,000 womens lives each year. Nearly all these lives could
be saved if affordable, good-quality obstetric care were available 24 hours a day, 7 days a
week.
Most of the deaths are caused by haemorrhage, obstructed labour, infection (sepsis),
unsafe abortion and eclampsia (pregnancy induced hypertension). Indirect causes
likemalaria, HIV and anaemia also contribute to maternal deaths.
For every woman who dies, an estimated 15 to 30 women suffer from chronic illnesses or
injuries as a result of their pregnancies. Obstetric fistula is a serious and isolating injury
that would be significantly prevented through EmOC.
About fifteen per cent of all pregnancies will result in complications. Most complications
occur randomly across all pregnancies, both high- and low-risk. They cannot be
accurately predicted and most often cannot be prevented, but they can be treated.
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Batch)
Obstetric Emergencies:
Ante-partum / Post partum haemorrhage
Post partum sepsis
Abortion complication
Retained placenta
Pre-eclampsia / eclampsia
Premature labour / prolonged obstructive labour
Premature rupture of membrane
Abnormal position of foetus
Cord, hand and foot proplapse
Emergency obstetric function:
1) Obstetric first-aid
2) Basic emergency obstetric care
3) Comprehensive emergency obstetric care
Standards for first-aid, basic and comprehensive EmOC:
1. Obstetric first-aid
IV/IM antibiotics
IV/IM oxytoxics
IV/IM anticonvulsants
2. Basic EmOC Functions Performed in a health centre without the need for an operating theatre
Obstetric first-aid
Manual removal of placenta
Assisted vaginal delivery
Removal of retained products
3. Comprehensive EmOC Functions Requires an operating theatre and is usually performed in
district hospitals
All six Basic EmOC functions plus
Caesarean section
Blood transfusion
Interventions to reduce maternal mortality:
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Batch)
Three Delays Model:

Phase 1 delay. Delay in decision to seek care
Failure to recognize complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care: women's mobility, ability to command resources,
decision-making abilities, beliefs and practices surrounding childbirth and delivery,
nutrition and education
Phase 2 delay. Delay in reaching care
Poor roads, mountains, islands, rivers - poor organization
Phase 3 delay. Delay in receiving care
Inadequate facilities, supplies, personnel
Poor training and demotivation of personnel
Lack of finances
MHNC- Human Sexuality, Body politics:

Human Sexuality:
The term can also cover cultural, political, legal and philosophical aspects. It may also
refer to issues of morality, ethics, theology, spirituality or religion and how they relate to
all things sexual. Recent studies on human sexuality have highlighted that sexual aspects
are of major importance in building up personal identity and in the social evolution of
individuals
Human sexuality is not simply imposed by instinct or conservative, as it happens in
animals, but it is influenced both by superior mental activity and by social, cultural,
educational, and normative characteristics of those places where the subjects grow up and
their personality develops. Consequently, the analysis of sexual sphere must be based on
the meeting of several lines of development such as affectivity, emotions, and relations.
Body Politics:
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Batch)
The Politics of Reproductive Health, Gender, Social Policy etc.

Womens reproductive health and sexuality is a gender issue that is impacted by factors
of ethnicity, socioeconomic status, and culture. Each of these factors represents social
negotiations of power that determine a womans freedom of choice and movement in
regards to her health and well-being these comes under the body politics.
Human reproductive events (conception, contraception, abortion, childbirth, infertility
treatment, infant feeding, etc.) are not given by our biological nature, but are informed by
cultural beliefs and shaped by social, medical and political institutions
The term body politics refers to the practices and policies through which powers of
society regulate the human body, as well as the struggle over the degree of individual and
social control of the body.
Body politics was first used in this sense in the 1970s, during the second wave of the
feminist movement in the United States. It arose out of feminist politics and the abortion
debates. Body politics originally involved the fight against objectification of the female
body, and violence against women and girls, and the campaign for reproductive rights for
women.
Second-wave feminist body politics promoted breaking the silence about rape, sexual
abuse, and violence against women and girls, which many interpreted as extreme
examples of socially sanctioned male power
Womens bodies were the political battleground of the abortion debates.
The attribution of ethical, moral, temperamental, and social characteristics to individuals
or populations based on skin color, facial features, body types, and sexual anatomy figure
prominently in racial body politics
36
Batch)
37
Batch)
UNIT-3: CHILD HEALTH - 18hrs

Introduction:
Biologically, a child is anyone in the developmental stage of childhood, between infancy
and adulthood
The United Nations Convention on the Rights of the Child defines a child as "a human
being below the age of 18 years unless under the law applicable to the child, majority is
attained earlier. It means A child means every human being below the age of 18 years,
unless National laws fix an earlier age maturity.
Characteristic of the children:
Innocent, vulnerable and dependent
Curious, active and full of hope
Time of joy, peace of playing, learning and growing
Lives should mature as the broaden their perspectives and gain new experiences
Their future should shape in harmony and co-operation
Importance of childhood period:
Transmission of attitude, customs and behaviors
Children represent the future, and ensuring their healthy growth and development ought
to be a prime concern of all societies. Newborns are particularly vulnerable and children
are vulnerable to malnutrition and infectious diseases, many of which can be effectively
prevented or treated.
Vulnerable to disease, death and disability due to their:
Age
Sex
Place of living
Socio-economic class
Child Health Priorities:
Acute respiratory infections
Diarrhoea
Malnutrition
Other newborn issues
Child Health Needs:
ANC, NC, PNC
Breast feeding
Immunization
Weaning
Rearing / nurturing
Nutrition supplementation
Love
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Batch)
Major causes of Morbidity and Mortality <5 yrs age in Nepal:

ARI
Early neonatal and perinatal causes
Obstetric complication and birth injuries
Asphyxia
Congenital abnormalities
Infection
Tetanus
Death of mother
Low birth weight
Diarrhoea
Mal-nutrition
Accident / Injury
Measles
ARI with Diarrhoea
Undefined
At risk child:
Children with a recent history of infection
Children who are recently weaned
Children with no weight gain for 3 months at any time during the first 3 yrs or weight
loss
Children with unfavorable condition at home
Absent parents
Large family / twins
> 3 siblings have died
Contact with person having open TB
Children from very poor family and uneducated or sick person
Children with acute diseases, including severe anemia and oedema or when
immediate treatment is required
Child health:
Major causes of death in Neonates and children <5 in the world:
Major causes of death in Neonates
Congenital anomalies 7%
Neonatal tetanus 3%
Diarrhoeal diseases 3%
Neonatal Infection 25%
Birth asphyxia and trauma 23%
Premature and LBW 31%
Other 9%
Major causes of death in <5 years
ARI (post neonatal) 17%
Diarrhoeal diseases 16%
Malaria 7%
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Batch)
Measles 4%
HIV/AIDS 2%
Non communicable diseases 4%
Injuries 4%
Other infection and parasitic diseases 9%
Neonatal causes 37%
35% of <5 death are associated with under nutrition
- WHO updated 2008; published 2009
Child Mortality:
Globally, child mortality has declined by about 2% per year for the past 25 years
Between 1960 and 1990, the global child mortality rate was reduced by half from 191 to
95
The 1990 the world submit for children set a goal of reducing child mortality by another
one-third by year 2000. That goal was not achieved. By 2000, the global death rate fallen
to 84/1000 about 10% drop from 1990
-Global Health council 2005
In 2000, the MDG for child survival pledged countries to reduce their 1990 CMR by 2/3rd
by 2015. But some are on-track and other having little and no success and some are
losing ground.
Although CMR has been decreasing over the past 40 years, the global child mortality rate
is still 12 times higher than the rate of industrialized countries (72/1000 live birth Vs
6/1000 live birth respectively). In many developing countries it is 25 to 30 times more.
- Global Health council 2005
Nearly 98% of neonatal deaths each year occur in developing countries and more than
half of neonatal deaths occur in large countries: India, China, Pakistan, and Nigeria.
Highest number of deaths occur on the first day of life
A quarter of 3.3 million babies who are stillborn each year die during the birthing
process
Majority of births in Sub-Saharan Africa (59%) and Asia (62%) take place
without skill attendant present, increases death and disability for both mothers and
children.
Incomplete record of vital statistics an under reporting
About half of <5 years deaths in 6 countries: India, Nigeria, Congo, Ethiopia, Pakistan
and China.
- Global Health Council 2005
Highest number of child death 10 countries: India, Nigeria, Congo, Ethiopia, Pakistan,
China, Afghanistan, Bangladesh, Uganda, Angola,
- WHO 2005
Nearly 10 million children under the age of five die each year more than 1000 every
hour but most could survive threats and thrive with access to simple, affordable
interventions.
The risk of death is highest in the first month of life. Preterm birth, birth asphyxia and
infections cause most newborn deaths. Health risks to newborns are minimized by:
quality care during pregnancy;
safe delivery by a skilled birth attendant; and
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strong neonatal care: immediate attention to breathing and warmth, hygienic cord
and skin care, and early initiation of exclusive breastfeeding.
-WHO July 2008
From one month to five years of age, the main causes of death are pneumonia, diarrhoea,
malaria, measles and HIV. Malnutrition is estimated to contribute to more than one third of all
child deaths.
Pneumonia is the prime cause of death in children under five years of age. Nearly threequarters of all cases occur in just 15 countries. Addressing the major risk factors
including malnutrition and indoor air pollution is essential to preventing pneumonia, as
are vaccination and breastfeeding. Antibiotics and oxygen are vital tools for effectively
managing the illness.
Malaria: One African child dies every 30 seconds from malaria. Insecticide-treated nets
prevent transmission and increase child survival.
HIV: Over 90% of children with HIV are infected through mother-to-child transmission,
which can be prevented with antiretrovirals, as well as safer delivery and feeding
practices.
Malnutrition: About 20 million children under five worldwide are severely
malnourished, which leaves them more vulnerable to illness and early death.
Diarrhoeal diseases are a leading cause of sickness and death among children in
developing countries. Breastfeeding helps prevent diarrhoea among young children.
Treatment for sick children with Oral Rehydration Salts (ORS) combined with zinc
supplements is safe, cost-effective, and saves lives.
About two-thirds of child deaths are preventable through practical, low-cost interventions. WHO
is improving child health by helping countries to deliver integrated, effective care in a continuum
- starting with a healthy pregnancy for the mother, through birth and care up to five years of age.
Investing in strong health systems is key to prevention and delivery of quality care.
- WHO July, 2008
Trend of <5 mortality in SAARC Countries (World Bank, 8 May 2010):
Country/Year
Afghanistan
Pakistan
Bhutan
India
Bangladesh
Nepal
Maldives
Sri Lanka
1990
260
130
148
116
149
142
111
29
1995
257
121
125
104
122
117
83
25
2000
257
108
106
94
91
85
55
21
2005
257
96
90
77
66
62
36
17
2008
257
89
81
69
54
51
28
15
Mortality:
Infant mortality is defined as the number of infant deaths (the probability of dying before
the first birthday) per 1000 live births
Perinatal mortality only includes deaths between the foetal viability (22 weeks gestation)
and the end of the 7th day after delivery
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Neonatal mortality only includes deaths in the first 28 days of life (the probability of dying
within the first month of life).
Postneonatal mortality only includes deaths after 28 days of life but before one year. The
difference between infant and neonatal mortality
Child mortality includes deaths within the first five years (between 1st and 5th birthday.
Top Five Causes of newborn Mortality per 1000 live birth:
Congenital malformations, deformations, and chromosomal abnormalities 137.6
Disorders related to short gestation and low birth weight 109.5
Sudden infant death syndrome 55.5
Newborn affected by maternal complications of pregnancy 37.3
Respiratory distress of newborn 25.3
Source: Centers for Disease Control and Prevention
Major causes of Infant and child mortality
Dehydration from diarrhea.
Pneumonia.
Malnutrition,
Malaria,
Congenital malformation,
Infection and SIDS.
Infanticide, child abuse, child abandonment, and neglect may also contribute to infant
mortality.
Infant Mortality Rates:
World historical and predicted infant mortality rates per 1,000 births (19502050)
Years
19501955
19551960
19601965
19651970
19701975
19751980
19801985
19851990
19901995
19952000
Rate
152
136
116
100
91
83
74
65
61
57
Years
20002005
20052010
20102015
20152020
20202025
20252030
20302035
20352040
20402045
20452050
Rate
52
47
43
40
37
34
31
28
25
23
- UN; World Population Prospects: The 2008 Revision,
Child Rearing:
"Children are a bit like chickens they need to be kept safe, guided, fed and loved,
Child rearing practices are those practices, which are done to rear a child. it includes
total care of a child, from basic needs to protect rights of children.
Parenting is the process of promoting and supporting the physical, emotional, social, and
intellectual development of a child from infancy to adulthood. Parenting refers to the
activity of raising a child rather than the biological relationship.
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Child-rearing practices in every society occur in accordance with the cultural norms of
the society. In most societies, however, child-rearing practices share a common value: the
preservation of life and maintenance of the health and well-being of a new-born infant.
Cultural beliefs and practices and social issues regarding infant care and child-rearing and
infant feeding practices as well as early motherhood in different societies differ.
Traditional practices surrounding infant care and child-rearing continue to live despite the
fact that many societies have been modernized.
Socio-economic, an educational and cultural factor affects the child rearing practices and
child health care activities.
Child rearing practices are those practices, which are done to rear a child. it includes total
care of a child, from basic needs to protect rights of children.
Child rearing practices differ from one parent to another. Different child rearing practices
lead to different child upbringing
Mother's parenting practices, Culture Income, Religion, Tradition etc affect the rearing
practices
Many child-rearing practices, both positive and negative,
Components of child health care:

UNICEF's GOBI strategy of 1982 emerged after intervention of selective PHC Strategies
that are being adopted to improve maternal and child health as part of primary care. Respectively
they include,
G - Growth monitoring
O - Oral rehydration therapy
B - Breast-feeding
I - Immunization
F - Family Spacing (planning)
F - Female Education
F - Food Supplementation
Long-term health plan:
The second long-term health plan (1997-2017) aims at improving health status of the
people, particularly those whose health needs are often not met; the most vulnerable
groups, women and children, the rural population, the poor, the under-privileged and the
marginalized. It emphasizes on assuring equitable access by extending quality essential
health care services with full community participation and gender sensitivity by
technically competent and socially responsible health personnel throughout the country.
In addition to essential health care, specialist services are also to be extended gradually
on a cost-effective basis.
Targets to be achieved by the SLTHP by the end of the plan period of 1997-2017:
IMR will be reduced to 34.4 per thousand live births from its present level ;
Under- five mortality rate to be reduced to 62.5 per thousand live births from the its
present level;
TFR to be reduced to 3.05 from its present level;
Increase life expectancy to 68.7 from its present level;
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To reduce CBR to 26.6 per thousand population from the its present level;
To reduce CDR to 6 per thousand population from its present level;
To reduce maternal mortality ratio to 250 per 100,000 births from the its present level;
To increase CPR to 58.2 percent of its present level;
To reduce percentage of new born < 2,500 gm to 12, and
To provide essential health care services at district level to 90 percent of the population
living within 30 minutes of travel time
Baby friendly hospital:

The Baby Friendly Hospital Initiative (BFHI) is a worldwide programme of the World
Health Organization and UNICEF, launched in 1991.
It is a effort for improving the role of maternity services to enable mothers to breastfeed
babies for the best start in life.
It aims at improving the care of pregnant women, mothers and newborns at health
facilities that provide maternity services for protecting, promoting and supporting
breastfeeding, in agreement with the International Code of Marketing of Breast-milk
Substitutes.
Criteria for a Baby Friendly Hospital's:
The official approval includes:
1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one half-hour of birth.
5. Show mothers how to breastfeed and maintain lactation, even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than breastmilk, not even sips of water,
unless medically indicated.
7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic
Baby Friendly Hospital:
The program also restricts use by the hospital of free formula or other infant care aids
provided by formula companies.
Between 1991 and 2005, approximately 15,000 facilities worldwide have been inspected
and accredited as "Baby-Friendly.
The concept of rooming-in is rapidly being converted to the concept of bedding-in, where
the neonate is transferred to the mother within 30 minute after a normal vaginal delivery
and maximum of 4 hours following a caesarean section.
Breast-feeding:
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Breast-feeding is the feeding of an infant or young child with breast milk directly from
female human breasts rather than from a baby bottle or other container. Babies have a
sucking reflex that enables them to suck and swallow milk. Most mothers can breastfeed
for six months or more, without the addition of infant formula or solid food.
Breast-feeding promotes health, helps to prevent disease, and reduces health care and
feeding costs. Artificial feeding is associated with more deaths from diarrohea in infants
in both developing and developed countries.
Human breast milk is the healthiest form of milk for human babies
World Health Organization (WHO) and the American Academy of Pediatrics (AAP) both
recommend exclusive breastfeeding for the first six months of life and then supplemented
breastfeeding for at least one year and up to two years or more
Breastfeeding is the normal way of providing young infants with the nutrients they need
for healthy growth and development.
Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is
recommended by WHO as the perfect food for the newborn, and feeding should be
initiated within the first hour after birth.
Exclusive breastfeeding is recommended up to 6 months of age, with continued
breastfeeding along with appropriate complementary foods up to two years of age or
beyond.
Breastfeeding is one of the most effective ways to ensure child health and survival. A
lack of exclusive breastfeeding during the first six months of life contributes to over a
million avoidable child deaths each year.
Normal Breastfeeding management:

1. Preparation of BF: Physically and mentally
2. The baby at birth: Immediate contact between mother and baby
3. Feeding schedule: Should not be stricked on schedule. A reasonable self-demand
schedule is the common-sense schedules. All babies are different. Some becoming sooner
than others. Baby can demand more frequent feeds until he has caught up to the average
weight. It does allow the mother to satisfy his basic need, which includes particularly
food, love and comfort.
Sometime difficulty to identify demand e.g.
Cry for reason : other than hunger
The baby who is drowsy, premature, ill, mentally sub-normal etc
Between 5th and 9th day demand usually increases (up to 12 in 24 hours)
Insufficient stimulus is given to the breast and lactation fails
Mother may find it difficult to feed a baby at regular period
4. Fluid intake by mother: it is unnecessary and undesirable to try to cause the lactating
mother to drink large quantity of fluid. The best regulator to the mothers fluids needs is
thrust
5. Duration of the feed: most babies obtain nearly all the milk in the first 5 minute. If s/he
is given too long, s/he swallows air, may make the nipple sore. Baby should be fed on the
breast until s/he suddenly shows down in sucking, and fed on the second breast until s/he
goes to sleep or stop sucking
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6. Emptying the breast: the amount of milk produced depends in large part on the
emptying of the breast. Manual expression of milk may needed. Expressed milk is given
to the baby by sterile spoon
Breast is best:
For baby:
Fresh, safe and free from infection
Designed by nature
Easy to digest
Available in right temperature
Contains some antibodies
Help baby receive love from mother
For mother:
Cost nothing
Always ready and saves time
Suckling helps the uterus to retract
Helps mother to express love for her baby
Failure of Breast-feeding:
1. Caused by the baby
Pre-maturity
Birth injury cerebral depression
Infection Pneumonia, Meningitis
Congenital abnormalities cleft palate, lip
2. Causes by mother
Engorgement of the breast
Cracked nipples
Mastitis / abscess
Inverted or flat nipple
Worry or lack of confidence
Wrong belief about bottle feeding
Death of mother
Feeding schedule:
Age
0-4months
From 4 months
B. Milk
BM only
BM
From 6 months
From 9 months
From 12
months
From 18-24
months
BM
BM
BM
BM
Additional food
Fruit juice (usually after 4 months)
Increasing amount of liquid or mashed carbohydrate food
e.g. Fruit & porridge with protein and vegetable added
2/3 larger meals as above, with increasing amount of protein
3 meal of food. The child has teeth so encourage to chew
3/4 meals of the same food the family is eating, but with
enough protein
Normal food as family is eating with ensured 16 gm. of
protein is getting every day (monitor the normal growth)
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Complementary feeding:
Complementary feeding is defined as the process starting when breast milk alone is no
longer sufficient to meet the nutritional requirements of infants, and therefore other foods
and liquids are needed, along with breast milk. The target age range for complementary
feeding is generally taken to be 6 to 24 months of age, even though breastfeeding may
continue beyond two years.
When breast milk is no longer enough to meet the nutritional needs of the infant,
complementary foods should be added to the diet of the child. The transition from
exclusive breastfeeding to family foods, referred to as complementary feeding, typically
covers the period from 6 to 18-24 months of age, and is a very vulnerable period. It is the
time when malnutrition starts in many infants, contributing significantly to the high
prevalence of malnutrition in children under five years of age world-wide. WHO
estimates that 2 out of 5 children are stunted in low-income countries.
Complementary feeding should be timely, meaning that all infants should start receiving
foods in addition to breast milk from 6 months onwards.
It should be adequate, meaning that the nutritional value of complementary foods should
parallel at least that of breast milk.
Foods should be prepared and given in a safe manner, meaning that measures are taken to
minimize the risk of contamination with pathogens. And
They should be given in a way that is appropriate, meaning that foods are of appropriate
texture and given in sufficient quantity.
The adequacy of complementary feeding (adequacy in short for timely, adequate, safe
and appropriate) not only depends on the availability of a variety of foods in the
household, but also on the feeding practices of caregivers. Feeding young infants requires
active care and stimulation, where the caregiver is responsive to the child clues for
hunger and also encourages the child to eat. This is also referred to as active or
responsive feeding.
WHO recommends that infants start receiving complementary foods at 6 months of age
in addition to breast milk, initially 2-3 times a day between 6-8 months, increasing to 3-4
times daily between 9-11 months and 12-24 months with additional nutritious snacks
offered 1-2 times per day, as desired.
Screening and child health surveillance:
Screening:
Screening, in medicine is a strategy used in a population to detect a disease in idividual
without sign or symptom of that disease. The intention of screening is to identify disease
in a community early thus enabling earlier intervention and management in the hope to
reduce mortality and morbidity from a disease.
PPD test (Mountoux) Tuberculosis
Beck depression inventory depression
POP smear Cervical cancer
Mammography Breast Cancer
Bitewing radiograph dental caries
Advantages and disadvantages of screening:
Advantages
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Screening can detect medical conditions at an early stage before symptoms

present
Treatment is more effective than for later detection.
Disadvantages
Screening involves cost and use of medical resources on a majority of people who
do not need treatment
Adverse effects of screening procedure (e.g. stress and anxiety, discomfort,
radiation exposure, chemical exposure).
Stress and anxiety caused by a false positive screening result.
Unnecessary investigation and treatment of false positive results.
Stress and anxiety caused by prolonging knowledge of an illness without any
improvement in outcome.
A false sense of security caused by false negatives, which may delay final
diagnosis
Principle of screening (WHO 1968):

1. The condition should be an important health problem
2. There should be a treatment for the condition
3. Facilities for diagnosis and treatment should be available
4. There should be a latent stage of the disease
5. There should be a test or examination for the condition
6. The test should be acceptable to the population
7. The natural history of the disease should be adequately understood
8. There should be an agreed policy on what to treat
9. The total cost of funding a case should be economically balanced in relation to medical
expenditure as a whole
10. Case finding should be a continuous process, not just a once and for all project.
Surveillance:
Surveillance is the continuous scrutiny of the factors that determine the occurrence and
distribution of disease and other condition of ill-health
Surveillance is the monitoring of the behaviour, activities, or other changing
information, among people and often in a secret manner
Disease surveillance is an epidemiological practice by which the spread of disease is
monitored in order to establish patterns of progression. The main role of disease
surveillance is to predict, observe, and minimize the harm caused by epidemic, and
pandemic situations, as well as increase our knowledge as to what factors might
contribute to such circumstances
Health Surveillance : Health surveillance is about systematically watching out for early
signs of work-related ill health in employees exposed to certain health risks
Health Surveillance means watching out for early signs of work-related ill health in
employees exposed to certain health risks.
Public Health Surveillance:
Public Health Surveillance has been defined as the ongoing, systematic collection,
analysis, and interpretation of data (e.g., regarding agent/hazard, risk factor, exposure,
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health event) essential to the planning, implementation, and evaluation of public health
practice, closely integrated with the timely dissemination of these data to those
responsible for prevention and control
Objective of the surveillance:
To provide information about new and changing trends in the health status of a
population. e.g. morbidity, mortality, nutritional status or other indicators and
environmental hazards, health practice and other factors that may affect health
To provide feedback which may be expected to modify the policy and the system itself
and lead to redefinition of objectives
Provide timely warning of public health disasters so that intervention can be mobilized.
Child health surveillance:

Health throughout life is influenced by the experiences in early years of childhood.
Child health surveillance is a programme of care initiated and provided by professionals
with the aim of preventing illness and promoting good health and development of the
children.
This will help to ensure the needs and rights of the children are respected
This gives comprehensive advice on health and social care throughout a child's life
Greater focus on antenatal care.
A major emphasis on support for both parents.
Early identification of at-risk families.
New vaccination programs.
New focus on changed public health priorities.
Diarrhoea:
Diarrhoea is a loose, watery stool occurring more than a three times a day. It is a common
problem that usually lasts a day or two and goes away in its own without any special
treatment. However, prolonged diarrhoea can be a sign of other problem
Causes of diarrhea:
Bacterial infection : E. Coli
Viral infection : Rotavirus
Food intolerance : e.g. lactose, sugar found in milk etc
Parasites : Giardia lambia, E. Hystolytica
Reaction to medicines e.g. antibiotics, BP medication, antacids etc
Intestinal diseases: coeliac diseases
Functional bowel disorder : irritable bowel syndrome e.g. stomach surgery
Other : fear, tense, unknown
Complication
Dehydration
Types of diarrhea:
Acute and persistent diarrhoea are not two separate diseases but form a continuum.
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Most episodes of diarrhoea last less than one week, but a small proportion of episodes
last for two or more weeks.
The definition of persistent diarrhoea has varied, but it is helpful to have a standard one
so that different studies can be compared, and recommendations made for treatment.
In 1987, a meeting sponsored by WHO defined persistent diarrhoea as an episode which
starts acutely but which lasts at least 14 days. This definition has been adopted by most
investigators and programmes.
Persistent diarrhoea may account for a large proportion of all deaths due to diarrhoea.
WHO and UNICEF estimated that in 1991 persistent diarrhoea accounted for only 10 per
cent of diarrhoeal episodes, but as many as 35 per cent of diarrhoeal deaths in children
under 5 years of age. Evidence from studies in Bangladesh, India, Peru and Brazil
indicated that approximately 45 per cent (range 23 per cent to 62 per cent) of diarrhoea
associated deaths were due to persistent diarrhoea.
Although findings from some studies indicate that persistent diarrhoea most often
occurs in children below 2 years of age, most persistent diarrhoeal deaths occur in
children aged 1 to 4 years old when malnutrition is most common, because deaths from
persistent diarrhoea are frequently associated with malnutrition.
Increasing the risk of persistent diarrhea:
Previous diarrhoea infection
A relatively small proportion of children have many episodes of diarrhoea, and it is
predominantly these children who develop persistent diarrhoea
High-risk children are in an environment where there is greater transmission of
pathogens, or if they have greater susceptibility to illness. Frequency of diarrhoea
infections affects the child's immune status and ability to resist the following infection.
Nutritional status
malnutrition is strongly associated with persistent diarrhoea. Researchers have found a
small increased risk of diarrhoea incidence in malnourished children, but a large
increased risk of prolongation of the episode. malnutrition significantly increases the risk
of dying in children suffering from persistent diarrhoea
Feeding practice
Breastfed babies are less likely to have persistent diarrhoea. Breastfeeding shortens the
duration of diarrhoeal episodes, and that lack of breastfeeding is associated with persistent
diarrhoea.
Other factors
For example :deficiency of vitamin A, zinc, iron and other micronutrients; behaviours
related to water source and use, food preparation and consumption and hygiene; presence
of other diseases such as measles; suppression of immunity; and the interaction of these
factors.
Prevention and Treatment:
Awareness regarding home management of diarrhoea and symptoms
Healthy food habit: Ensure that the child receives enough nutritious food. Dietary
management should be based on foods that are inexpensive, readily available, culturally
acceptable, and easy to prepare in the home. Avoid milk products and foods that are
greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhea.
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Breast feeding
Vitamin A
Personal hygiene and sanitation
Rehydration: ORS. It is estimated that more than three quarters of all diarrhoea deaths
could be prevented with full coverage and utilization of zinc and ORS
Safe drinking water
Treat causative agents / take help of health workers
Zinc tablets
Vaccination
Role of Mothers and other caregivers:

Prevent dehydration through the early administration of increased amounts of appropriate
fluids available in the home, and ORS solution, if on hand
Continue feeding (or increase breastfeeding) during, and increase all feeding after the
episode
Recognize the signs of dehydration and take the child to a health-care provider for ORS
or intravenous electrolyte solution, as well as
familiarize themselves with other symptoms requiring medical treatment (e.g., bloody
diarrhoea)
Provide children with 20 mg per day of zinc supplementation for 1014 days (10 mg per
day for infants under six months old).
Role of Health care workers:
Counsel mothers to begin administering suitable available home fluids immediately upon
onset of diarrhoea in a child
Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases
of severe dehydration)
Emphasize continued feeding or increased breastfeeding during, and increased feeding
after the diarrhoeal episode
Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or
shigellosis, and abstain from administering anti-diarrhoeal drugs
Provide children with 20 mg per day of zinc supplementation for 1014 days (10 mg per
day for infants under six months old)
Advise mothers of the need to increase fluids and continue feeding during future
episodes.
Health-care workers treating children for diarrhoea are encouraged to provide caretakers
with packets of the new ORS, and enough zinc supplements to continue home treatment for 10
14 days along with the heath information.
Dehydration:
General signs of dehydration include:
Thirst
Less frequent urination
Dry skin
Fatigue
Light-headedness
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Dark colored urine

Signs of dehydration in children include:
Dry mouth and tongue
No tears when crying
No wet diapers for 3 hours or more
Sunken abdomen, eyes, or cheeks
High fever
Listlessness or irritability
Skin that does not flatten when pinched and released
When Should a Doctor Be Consulted:
Diarrhea for more than 3 days.
Severe pain in the abdomen or rectum.
Fever of 102 degrees Fahrenheit or higher.
Blood in your stool or have black, tarry stools.
Signs of dehydration
Points to remember:
Diarrhoea is common problems, usually resolves on its own
Dangerous if dehydrated
Causes include viral, intestinal diseases and functional tolerance, drug side effects,
intestinal diseases and functional bowel disorder
Treatment involves replacing lost fluids and electrolytes
Common Disorders in children:

Mental, Emotional and behavioral disorder:
Disorders are the sources of stress for children: mainly come from his or her environment
e.g. exposure to violence, extreme stress or loss of an important person and some disorders in
children are due to biological factors e.g. genetics, chemical imbalance in body and damage of
CNS.
Anxiety disorder:
Phobia: unrealistic fear of objects or situation
Panic disorder: rapid heart beat, dizziness
Obsessive compulsive disorder repeated thought and behaviors such as counting,
hand washing etc
Post-traumatic stress disorder Flash backs and other symptoms who experience
distressing events such as abuse, violence, disasters etc.
Depression:
Emotion: Often feel sad, cry, or feel valueless
Motivation: lose interest in play activities
Physical wellbeing : Changes in appetite or sleeping
Thought: believe that they are ugly, unable to do anything right, hopeless risk for
suicide
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Bipolar disorder:
Exaggerated mood swing ( extreme high to low )
Extreme high : e.g. nonstop talking, very little sleep, poor judgment
Extreme low: e.g. severe depression.
Attention deficit / hyperactivity disorder:
Unable to focus attention and often easily distracts e.g. remaining still, taking turn and
keeping quite
Learning disorder:
Harder to receive or express information. Problem with spoken and written language,
coordination attention or self control
Conduct disorder:
Act out feelings or impulses in destructive ways. e.g. lying, theft, aggression, setting of
fire, non-attendance, damage/destruction
Eating disorder:
Afraid of gaining weight and do not believe that they are under weight
Eat huge amount of food in one sitting
Autism:
Problem in interacting and communicating with others and bang their heads, objects etc.
Schizophrenia:
Hallucination
Withdrawal from others
Loss of contact with reality
Disorder thought, false belief
Inability to experience pleasure
Important message about Children and Adolescent mental health:
Every childs / Adolescents mental health is important
Many children have mental health problem
Problems are real, painful and can be severe
Mental health problem can be recognized and treated
Caring families and community working together can help.
Addictive diseases (Addiction):
Recurring compulsion by an individual to engage in some specific activity, despite
harmful consequences to the individuals health, mental state or social life.
It is often reserve for drug addition but sometime applied to other compulsion, such as
problem of gambling, compulsive overeating etc.
Addiction is a disease, a state of physiological or psychological dependence or
attachment to something obvious as a condition in which medically significant symptoms
liable to have damaging effect are present
Physiological:
When receive induced pleasure
Eating disorder?
Psychological:
Craving, irritability, insomnia, depression, anorexia, etc.
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Other activities and behavioral pattern: gambling, internet addiction, computer

addiction, sexual addiction, pornography addiction, reading, eating, self-harm,
work addiction etc.
Treatment, management and support Services:
Most of the symptoms and distress associated with childhood and adolescent mental,
emotional, and behavioral disorders can be alleviated with timely and appropriate
treatment and supports.
Political commitment
Social support
Family support
School health program
Counseling to parents
Behavior modification or management plan
Healthy Lifestyle
Improving and Maintaining the Quality of Life :empower self and play an active role in
the way to live day-to-day with illness
Reduce Stress: identify and deal with stressors and ways to minimize your overall day-today stress level
Communication: set aside time to talk to one another about stressful issues and offer
support and guidance.
Relaxation
Walking
Listening to music
Light exercise such as dancing or bicycling
Breathing, muscle tension or visualization exercises. These involve taking deep
breaths and concentrating on your breathing; or tensing, then relaxing muscle
groups one by one, from toes to head; or visualizing a calm, safe, stress-free
place. Ask a therapist for suggestions or instructions.
Meditation or yoga
Music
Art
Physical Well-Being
Sleep
Eating Right
Exercise
Relationships: maintain friendships, family relationships and intimate partnerships
Acquaintances
Be interested in others
Ask them about themselves and listen to what they have to say etc
Acute respiratory infections (ARI):

Acute respiratory infections (ARIs) continue to be the leading cause of acute illnesses
worldwide and remain the most important cause of infant and young children mortality,
accounting for about two million deaths each year
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The populations most at risk for developing a fatal respiratory disease are the very young,
the elderly, and the immunocompromised.
Pneumonia, with a global burden of 5 000 childhood deaths every day, is a tangible
threat. Pneumonia is responsible for about 21% of all deaths in children aged less than 5
years (due to acute lower respiratory infection), leading to estimate that of every 1000
children born alive, 12-20 die from pneumonia before their fifth birthday
The main etiological agents responsible for ARIs in children include Streptococcus
pneumoniae, Haemophilus influenzae type b (Hib), Staphylococcus aureus and other
bacterial species, respiratory syncytial virus (RSV), measles virus, human parainfluenza
viruses type 1, 2, and 3 (PIV-1, PIV-2 and PIV-3), influenza virus and varicella virus.
-WHO updated 2009
Low Birth weight, malnourished and non-breastfed children and those living in
overcrowded condition are at higher risk of getting pneumonia. These children are also at
a higher risk of death from pneumonia
Acute infection of the respiratory tract nose, throat, Larynx, trachea, bronchi, and
alveoli are a common cause of morbidity in children
Though details due to acute respiratory infections have become rare due to availability of
powerful antimicrobials and good supportive care many children do suffer from severe
diseases requiring hospitalization
Infection of airways results in swelling of the wall of the airways. As the airways are
narrow in children even slight swelling can cause significant narrowing of airways and
difficulty in breathing
Classification:
URTI (Upper respiratory tract infection): They are more common but less serious and
include infections of nose, throat and ear. The usual manifestation are cough and cold and
fever
LRTI (Lower respiratory tract infection): involve epiglottis, trachea bronchi, bronchioles
and alveoli. They are more dangerous and even life threatening. Viral infections are more
common than bacterial.
Management:
Children with pneumonia usually need hospitalization and intravenous administration of
antibiotics. They may also require oxygen, IV fluids if they are not able to take orally and
drugs to liquefy the thick secretion inside the lungs so that it can be cough up easily.
Medicines to suppress cough should not be given to children with pneumonia as the
infected secretion stays in the lungs instead of getting eliminated and can even cause an
abscess (collection of pus).
Prevention of ARI through improved nutrition and breastfeeding, immunizations, and
reduced indoor air pollution
Early recognition of ARI and improved home management by caregivers
Appropriate illness management by health workers in the community and at primary
health facilities
Balance diet and plenty of fluid
Rapid referral of the most serious ARI cases
A sick child and the people in the household should wash their hands frequently.
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In general, the more intimate physical contact (such as hugging, snuggling, or bed
sharing) that takes place with an ill child, the greater the risk of spreading the infection to
other family members
Rest
Case management of ARI in children 2 months to 5 years:
Assessment, classification and treatment of ARI are summarized as pre the standard
chart. All children presenting with cough or difficult breathing should be assessed
according to these charts
All children should also be assessed for signs of severe malnutrition
Children with danger signs should be referred to a hospital
Supportive measures include increased oral fluids to prevent dehydration, continued
feeding include frequent breastfeeding and keeping the young infant warm to avoid
malnutrition and anti-pyretic to reduce high fever.
Indication for immediate consultation:
High fever of 39 degree centigrade or more
Rapid breathing and difficulty in feeding
Chest retraction
Frequent vomiting and dehydration
Mal-nutrition:
Malnutrition is the insufficient, excessive or imbalanced consumption of nutrients. A
number of different nutrition disorders may arise, depending on which nutrients are under
or overabundant in the diet
The cellular imbalance supply of nutrients and energy and the bodys demand for them
to ensure growth, maintenance and specific function.
-WHO
In the world, approximately 62 million people, all causes of death combined, die each
year. One in twelve people worldwide is malnourished.
In 2006, more than 36 millions died of hunger or diseases due to deficiencies in
micronutrients
- United Nations Special Rapporteur on the Right to Food
According to the World Health Organization, malnutrition is by far the biggest
contributor to child mortality, present in half of all cases. Underweight births and interuterine growth restrictions cause 2.2 million child deaths a year. Poor or non-existent
breastfeeding causes another 1.4 million. Other deficiencies, such as lack of vitamin A or
zinc, for example, account for 1 million.
There were 923 million malnourished people in the world in 2007, an increase of 80
million since 1990, despite the fact that the world already produces enough food to feed
everyone - 6 billion people - and could feed the double - 12 billion people (FAO/UN
2008)
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Batch)
On the average, a person dies every second as a direct or indirect result of malnutrition 4000 every hour - 100 000 each day - 36 million each year - 58 % of all deaths (20012004 estimates). (FAO/UN 2008)
On the average, a child dies every 5 seconds as a direct or indirect result of malnutrition 700 every hour - 16 000 each day - 6 million each year - 60% of all child deaths (20022008 estimates).
- FAO/UN 2008
Consequences of malnutrition:
Mortality and morbidity mostly infants, young children and mothers
Major damage in the womb and first 2 years of life: Irreversible damage
Lower intelligence and reduced physical capacity
Public health problem
Malnutrition passes from generation to generation
30%-50% of children below 2.5 kg birth weight
Under weight and wasting are more common in terrain
IUGR
In labour and delivery-related complication such as
Premature rupture of membrane
Placental abruption
Preterm labour
Inefficient uterine contraction
Protein energy malnutrition: It is identified as a major health and nutrition problem in
Nepal. The PEM is primarily due to:
an inadequate intake of food (food gap)
Infections, notably diarrhoea, respiratory infection, measles and intestinal worms
with increase requirement for calories, proteins and other nutrients, while
decreasing their absorption and utilization. It is a vicious cycle infection
contributing to malnutrition contributing to infection, both acting synergistically.
Malnutrition and consequences:
Nutrients
Deficiency
Food energy
Starvation, Marasmus
Simple carbohydrates
None
Complex carbohydrates
None
Saturated fat
low sex hormone levels
Trans fat
None
Unsaturated fat
None
Fat
Malabsorption of Fat-soluble
vitamins
Omega 3 Fats
Cardiovascular Disease
Bleeding
Omega 6 Fats
None
Cholesterol
None
Vitamin E
nervous disorders
Protein
Kwashiorkor
57
Excess
Obesity, diabetes , CVD
diabetes, Obesity
Obesity
CVD
CVD
Obesity
CVD
Hemorrhages
CVD, Cancer
Cardiovascular disease
Hypervitaminosis E
(anticoagulant: excessive
bleeding)
Rabbit starvation
Batch)
Sodium
Iron
Iodine
Hyponatremia
Anemia
Goiter, hypothyroidism
Vitamin -A
Vitamin B1
Vitamin B2
Vitamin B3 (Niacin)
Xerophthalmia and Night

Blindness, low testosterone
levels
Beri-Beri
Cracking of skin
Pellagra dyspepsia
Vitamin B12
Vitamin C
Vitamin D
Pernicious anemia
Scurvy
Rickets
Vitamin K
Calcium
Hemorrhage
Osteoporosis, tetany,
carpopedal spasm,
laryngospasm, cardiac
arrhythmias
Hypertension
Magnesium
Potassium
Hypokalemia, cardiac
arrhythmias
Hypernatremia, hypertension
Cirrhosis, heart disease
Iodine Toxicity (goiter,
hypothyroidism)
Hypervitaminosis A (cirrhosis,
hair loss)
Corneal Ulceration
cardiac arrhythmias, birth
defects
diarrhea causing dehydration
Hypervitaminosis D
(dehydration, vomiting,
constipation)
Fatigue, depression, confusion
anorexia, nausea, vomiting
constipation, pancreatitis,
increased urination
Weakness, nausea, vomiting,
impaired breathing, and
hypotension
Hyperkalemia, palpitations
Prevention of Malnutrition:
Breast-feeding a baby for at least six months is considered the best way to prevent earlychildhood malnutrition. Programs that distribute infant formula and discourage
breastfeeding should be discontinued, except in areas where many mothers are infected
with HIV.
Food security
Oral health
De-worming
Agricultural development,
public health programs (especially programs that monitor growth and development, as
well as programs that provide nutritional information and supplements),
Improved food distribution systems.
Early diagnosis and treatment of malnutrition consequences
Preventive interventions can include:
Improve access to high-quality foods and to health care;
Improve nutrition and health knowledge and practices;
Effectively promote exclusive breastfeeding for the first six months of a childs life
where appropriate;
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Promote improved complementary feeding practices for all children aged 624 months
with a focus on ensuring access to age-appropriate complementary foods (where
possible using locally available foods);
Improve water and sanitation systems and hygiene practices to protect children against
communicable diseases.
Causes of malnutrition in context of Nepal:
Poverty:
No purchasing power for different food items
Insufficient food intake in each meal
Depends upon only one or two types of food
No meal everyday
Hunger
Illiteracy:
In some area availability of food is not problem, but due to illiteracy people do
not eat food in a balancing way
Unemployment
No purchasing power
No sufficient food intake
Muscle power left the area to search the job and left women, children and old
people: fall in starvation
Tradition and culture
In some district, during pregnancy and after delivery women are not allowed to
eat many kinds of food stuffs
Daughter-in-law is the least important certainly receives least food
Discrimination between male and female from the childhood (young girls are
usually last in line for food; they receive less food, of lower nutritional value, than
their brother
Unavailability of foodstuffs in some hilly areas
Due to no fertile land and no good climate for agriculture in some area, food are
not available in sufficient quantity
High cost to carry the food to deficit area
Political conflicts
Transportation of feed depends upon political power
Food Hijack
Unrest political movement deficit food stuff increased hunger
Commission and bribery
No attention of the government and political leaders
Supporting factors of malnutrition in context of Nepal:
Family size and income
Household headship
More children
Illiteracy
Socio-cultural factors
No good planning and policy for the nutrition program
No special activities
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No advocacy
Behavioural change communication:
Government should coordinate and bring the related I/NGOs and other agencies and
through them run the several activities for women empowerment
Multi-sector and Intra-sector coordination by the government
Organize different activities as kitchen gardening, women empowerment, hygiene
and sanitation, right to health, nutrition program, health education etc
Different medias should be used to access the community people on nutrition education
Literacy program focusing to women and policy to enroll more girls in all level of
education to be adopted
Community based school health program should be run in each school
Male participation in women empowerment activities
Adequate and judicious use of inexpensive, locally available, cereals, pulse and vegetable
based diet
Conclusions:
Government intervention in nutrition
Improve well-being of the peoples health and productivity
Yield significant benefits for families, communities and the national economy
Government should develop
Long term and short term plan of action to address malnutrition
Policies and set plan of action to eliminate gender biases in access to food, heath,
equality and equity
Child Abuse:
Child abuse is harm to, or neglect of, a child by another person, whether adult or child.
Child abuse happens in all cultural, ethnic, and income groups. Child abuse can be
physical, emotional - verbal, sexual or through neglect. Abuse may cause serious injury
to the child and may even result in death.
Abuse:
Physical
Emotional
Sexual
Physical Abuse:
Unexplained or repeated injuries such as wound, bruises, or burns.
Injuries that are in the shape of an object (belt buckle, electric cord, etc.)
Injuries not likely to happen given the age or ability of the child. For example, broken
bones in a child too young to walk or climb.
Disagreement between the child's and the parent's explanation of the injury.
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Unreasonable explanation of the injury.

Obvious neglect of the child (dirty, undernourished, inappropriate clothes for the weather,
lack of medical or dental care).
Fearful behavior.
Emotional - Verbal Abuse:
Aggressive or withdrawn behavior.
Shying away from physical contact with parents or adults.
Afraid to go home.
.
Sexual Abuse:
Child tells you he/she was sexually mistreated.
Child has physical signs such as:
Difficulty in walking or sitting.
Stained or bloody underwear.
Genital or rectal pain, itching, swelling, redness, or discharge
Bruises or other injuries in the genital or rectal area.
Child has behavioral and emotional signs such as:
Difficulty eating or sleeping.
Soiling or wetting pants.
Acting like a much younger child.
Excessive crying or sadness.
Withdrawing from activities and others.
Talking about or acting out sexual acts beyond normal sex play for age
Risk family for Child Abuse:
Abuse can happen in any family, regardless of any special characteristics. However, in
dealing with parents, be aware of characteristics of families in which abuse may be more likely:
Families who are isolated and have no friends, relatives, any social attachment or other
support systems.
Parents who tell, they were abused as children.
Families who are often in crisis (have money problems, move often).
Parents who abuse drugs or alcohol.
Parents who are very critical of their child.
Parents who are very rigid in disciplining their child.
Parents who show too much or too little concern for their child.
Parents who feel they have a difficult child.
Parents who are under a lot of stress.
Effects of Child Abuse:
Long-term physical problems, including physical disabilities
Behavioral problems
Psychological problems
Difficulties in school and social relationships
Criminal behavior and a high risk of being arrested for a violent crime as a juvenile or
adult
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Signs of Child Abuse:

Sudden changes in a child's behavior
A child with unexplained bruises or burns, etc.
The child's medical problems are not being cared for properly, for example, he may have
regular asthma attacks or a lingering cough and hasn't been to the doctor
A child being left without adult supervision
A parent who doesn't seem to have appropriate concern for her children
Families who seem to have entirely negative relationships
A child who isn't dressed appropriately in cold weather, is dirty, or frequently misses
school
A child who talks about age-inappropriate sexual behaviors
Why many Child Abuse cases not come front?
Not wanting to get involved
Not being sure if it really is child abuse
They aren't sure how to make a report of child abuse
Thinking that someone else will do it
Not being aware of child abuse laws in their states, which could make reporting
mandatory for certain people
Being afraid of getting in trouble for filing a report if the child isn't really being abused,
which doesn't happen as long as you are making the report in good faith
Types of child abuse:
Emotional child abuse:
Emotional abuse can severely damage a childs mental health or social development,
leaving lifelong psychological scars. Examples of emotional child abuse include:
Constant criticism, shaming, and humiliating a child
Calling names and making negative comparisons to others
Telling a child he or she is no good," "worthless," "bad," or "a mistake."
Frequent yelling, threatening, or harassment.
Ignoring or rejecting a child as punishment, giving him or her the silent treatment.
Limited physical contact with the childno hugs, kisses, or other signs of
affection.
Exposing the child to violence or the abuse of others, whether it be the abuse of a
parent, a sibling, or even a pet.
Child neglect:
Child neglecta very common type of child abuseis a pattern of failing to provide for
a child's basic needs, whether it be adequate food, clothing, hygiene, or supervision.
Child neglect is not always easy to spot. Sometimes, a parent might become physically or
mentally unable to care for a child, such as with a serious injury, untreated depression, or
anxiety. Other times, alcohol or drug abuse may seriously impair judgment and the ability
to keep a child safe.
Older children might not show outward signs of neglect, becoming used to presenting a
competent face to the outside world, and even taking on the role of the parent. But at the
end of the day, neglected children are not getting their physical and emotional needs met.
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Physical child abuse:

Physical abuse involves physical harm or injury to the child. It may be the result of a
deliberate attempt to hurt the child, but not always. It can also result from severe
discipline, such as using a belt on a child, or physical punishment that is inappropriate to
the childs age or physical condition.
Many physically abusive parents and caregivers insist that their actions are simply forms
of disciplineways to make children learn to behave. But there is a big difference
between using physical punishment to discipline and physical abuse. The point of
disciplining children is to teach them right from wrong, not to make them live in fear
Warning signs of child abuse and neglect:

Warning signs of emotional abuse in children:
Excessively withdrawn, fearful, or anxious about doing something wrong.
Shows extremes in behavior (extremely obedient or extremely demanding;
extremely passive or extremely aggressive).
Doesnt seem to be attached to the parent or caregiver.
Acts either inappropriately adult (taking care of other children) or inappropriately
infantile (rocking, thumb-sucking, tantruming (outbrust with bad temper).
Warning signs of physical abuse in children:
Frequent injuries or unexplained bruises, welts, or cuts.
Is always watchful and on alert, as if waiting for something bad to happen.
Injuries appear to have a pattern such as marks from a hand or belt. Shies away
from touch, jump back at sudden movements, or seems afraid to go home.
Wears inappropriate clothing to cover up injuries, such as long-sleeved shirts on
hot days
Warning signs of neglect children:
Clothes are ill-fitting, filthy, or inappropriate for the weather.
Hygiene is consistently bad (unbathed, matted and unwashed hair, noticeable
body odor).
Untreated illnesses and physical injuries.
Is frequently unsupervised or left alone or allowed to play in unsafe situations and
environments.
Is frequently late or missing from school.
Warning signs of sexual abuse in children
Trouble walking or sitting.
Displays knowledge or interest in sexual acts inappropriate to his or her age, or
even attractive behavior.
Makes strong efforts to avoid a specific person, without an obvious reason.
Doesnt want to change clothes in front of others or participate in physical
activities.
An STD or pregnancy, especially under the age of 14.
Runs away from home.
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Risk factors for child abuse and neglect:

While child abuse and neglect occurs in all types of familieseven in those that look
happy from the outsidechildren are at a much greater risk in certain situations
Domestic violence. Witnessing domestic violence is terrifying to children and
emotionally abusive. Even if the mother does her best to protect her children and keeps
them from being physically abused, the situation is still extremely damaging. If you or a
loved one is in an abusive relationships, getting out is the best thing for protecting the
children.
Alcohol and drug abuse. Living with an alcoholic or addict is very difficult for children
and can easily lead to abuse and neglect. Parents who are drunk or high are unable to care
for their children, make good parenting decisions, and control often-dangerous impulses.
Substance abuse also commonly leads to physical abuse.
Untreated mental illness. Parents who suffering from depression, an anxiety disorder,
bipolar disorder, or another mental illness have trouble taking care of themselves, much
less their children. A mentally ill or traumatized parent may be distant and withdrawn
from his or her children, or quick to anger without understanding why. Treatment for the
caregiver means better care for the children.
Lack of parenting skills. Some caregivers never learned the skills necessary for good
parenting. Teen parents, for example, might have unrealistic expectations about how
much care babies and small children need. Or parents who where themselves victims of
child abuse may only know how to raise their children the way they were raised. In such
cases, parenting classes, therapy, and caregiver support groups are great resources for
learning better parenting skills.
Stress and lack of support. Parenting can be a very time-intensive, difficult job,
especially if youre raising children without support from family, friends, or the
community or youre dealing with relationship problems or financial difficulties. Caring
for a child with a disability, special needs, or difficult behaviors is also a challenge. Its
important to get the support you need, so you are emotionally and physically able to
support your child.
Managing suspected child abuse of any kind by:
Take the child to a quiet, private area.
Gently encourage the child to give you enough information to evaluate whether abuse
may have occurred.
Remain calm so as not to upset the child.
If the child discloses the abuse, reassure him/her that you believe him/her, that he/she is
right to tell you, and that he/she is not bad.
Tell the child you are going to talk to persons who can help him/her.
Return the child to the group (if appropriate).
Record all information.
Immediately report the suspected abuse to the proper local authorities. In most states,
reporting suspected abuse is required by law.
Child Abuse Prevention:
Supporting program for:
Substance abuse
Domestic violence
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Poverty
Lack of parenting skills
A small social support network
In addition to supporting programs target to those high risk groups to prevent child abuse,
such as education programs, parent support groups, and mentoring (trusted advising), some other
good child abuse prevention strategies include learning the signs of child abuse and reporting the
suspected child abuse are also important.
Breaking the cycle of child abuse:

Learn what age appropriate is and what is not.
Having realistic expectations of what children can handle at certain ages will help
to avoid frustration and anger at normal child behavior. For example, newborns are not
going to sleep through the night without a peep, and toddlers are not going to be able to
sit quietly for extended periods of time.
Develop new parenting skills.
While learning to control the emotions is critical, it needs a game plan of what is
going to do instead. Start by learning appropriate discipline techniques and how to set
clear boundaries for the children. Parenting classes, books, and seminars are a way to get
this information. Better to turn to other parents for tips and advice.
Take care of self.
If you are not getting enough rest and support or youre feeling overwhelmed, you
are much more likely to succumb to anger. Lack of Sleep, common in parents of young
children, adds to moodiness and irritabilityexactly what you are trying to avoid.
Get professional help.
Breaking the cycle of abuse can be very difficult if the patterns are strongly deeprooted. If you cant seem to stop yourself no matter how hard you try, its time to get
help, be it therapy, parenting classes, or other interventions. Your children will thank you
for it.
Learn how you can get your emotions under control.
The first step to getting your emotions under control is realize the situation. If you
were abused as a child, you may have an especially difficult time getting in touch with
your range of emotions. You may have had to deny or repress them as a child, and now
they spill out without your control. For a step by step process on how you can develop
your emotional intelligence, take suggestion from the concern trusty professionals.
Prostitution:
The practice of engaging in relatively indiscriminate sexual activity, in general with
individuals other than a spouse or friend, in exchange for immediate payment in money
or OTHER valuables
The commercial sex business consists of these types of selling
Street prostitution, massage brothels, guide services, outcall services, strip clubs,
lap dancing, phone sex, adult and child pornography, child prostitution, video and
internet pornography, trafficking, and prostitution tourism.
Prostitution in figure:
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According to UNICEF, more than one million children in Asia including Thailand,
Philippines, and India, have been sold to brothels or street pimps for sexual exploitation.
In the meantime, ECPAT (Ending Child Prostitution, Pornography and Trafficking), a
nongovernmental organization estimates indicate that 20% of 20 million of children in
India alone are part of the commercial sexual exploitation network.
Children are mostly trafficked for sexual exploitation
According to ECPAT, about 100 thousand children are forced into child prostitution in
Taiwan. Child prostitutes are in demand in other counties too. Venezuela has around 40
thousand underage prostitutes; there are approximately 25 thousands prostitutes aged 12
to 17 in the Dominican Republic; Peru has about 500 thousand child prostitutes, another
500 thousand child prostitutes are in Brazil; Canada has 200 thousand child prostitutes.
From 300 thousand to 600 thousand of 2 million prostitutes in the USA are children and
teenagers under 18. Most of them are under the category of street prostitutes.
(Data : 11/10/2006)
The above statistics clearly indicate that child prostitution has become a global problem.
40,000 Nepalese girls under 16 in Indian brothels are forced into prostitution. (Penelope
Saunders, "Sexual Trafficking and Forced Prostitution of Children", 29 October
1998)
More than 9,000 girls are trafficked each year from Nepal and Bangladesh into bondage
in India and Pakistan, often with the agreement or cooperation of state officials. (CATW
Fact Book, citing Amnesty International press release, 22 April 1998)
Available data suggests that approximately 7,000 girls between 10 -18 are drawn in or
abducted into prostitution each year. In many cases, parents or relatives sell young girls
into sexual slavery. (EI, EI Barometer on Human and Trade Union Rights in the
Education Sector, 1998)
It is estimated that 5000-7000 Nepalese girls are annually trafficked out of Nepal to
India, and increasingly, to the Gulf States for prostitution purposes. (ECPAT, CSEC
Database,http://www.ecpat.net/eng/ecpat_inter/projects/monitoring/online_database/in
dex.asp)
As an illustration, it is believed that 200,000 of the prostitutes in India are Nepalese. 20%
are thought to be under 16.
(ECPAT, CSEC Database,
http://www.ecpat.net/eng/ecpat_inter/projects/monitoring/online_database/index.asp)
Every year around 10,000 Nepalese girls, most between the age of nine and 16, are sold
to brothels in India. (Tim McGirk, "Nepal's Lost Daughters, India's soiled goods,"
Nepal/India:News, 27 January 1997)
Nepalese women who are trafficked and prostituted in debt bondage in India's sex
industry are forced to work longer hours and have more clients than local women.
(CATW - Asia Pacific, Trafficking in Women and Prostitution in the Asia Pacific)
Hong Kong is the second biggest market for trafficked Nepalese women. (CATW - Asia
Pacific, Trafficking in Women and Prostitution in the Asia Pacific)
In Nepal, India, Bangladesh and Sri Lanka child marriage is accepted, and considered the
best method to obtain girls for prostitution
Parents sell their daughters and husbands get rid of their young unwanted wives.
Organizers in rural areas, brokers and even family members sell girls. Husbands
sometimes sell their wives to brothels
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In Nepal, there is a system, called "deukis," where by rich childless families buy girls
from poor rural families and offer them to the temples as though they were their own.
These girls are forced into prostitution. In 1992, 17,000 girls were given as deukis.
(Radhika Coomaraswamy, UN Special Report on Violence Against Women, Gustavo
Capdevila, IPS, 2 April 1997)
Every year between 5,000 and 7,000 Nepalese girls are trafficked into the red light
districts in Indian cities. Many of the girls are barely 9 or 10 years old.
200,000 to over 250,000 Nepalese women and girls are already in Indian brothels. The
girls are sold by poor parents, tricked into fraudulent marriages, or promised employment
in towns only to find themselves in Hindustan's brothels. They're locked up for days,
starved, beaten, and burned with cigarettes until they learn how to service up to 25 clients
a day.
Some girls go through 'training' before being initiated into prostitution, which can include
constant exposure to pornographic films, tutorials in how to 'please' customers, repeated
rapes.
- Soma Wadhwa, "For sale childhood," Outlook, 1998
Trafficking in Nepalese women and girls is less risky than smuggling narcotics and
electronic equipment into India. Traffickers ferry large groups of girls at a time without
the bother of paperwork or threats of police checks. The procurer-pimp-police network
makes the process even smoother. Bought for as little as Rs (Nepalese) 1,000, girls have
been known to fetch up to Rs 30,000 in later transactions. Police are paid by brothel
owners to ignore the situation. Girls may not leave the brothels until they have repaid
their debt, at which time they are sick, with HIV and/or tuberculosis, and often have
children of their own.
-Soma Wadhwa, "For sale childhood," Outlook, 1998
The areas used by traffickers to procure women and girls are the isolated districts of
Sindhupalchowk, Makwanpur, Dhading and Khavre, Nepal where the population is
largely illiterate.
-Soma Wadhwa, "For sale childhood," Outlook, 1998
Health and Well-Being:
Of the 218 Nepalese girls rescued in February 1996 from a Bombay police raid, 60-70%
of them were HIV positive.
(Tim McGirk "Nepal's Lost Daughters, 'India's soiled goods,"Nepal/India News, 27
January 1997)
The government has reported a range of estimates for the number of child trafficking
victims. Some 5,000 to 12,000 girls may be trafficked for commercial sexual
exploitation annually, and as many as 200,000 trafficked Nepalese girls are estimated to
reside in Indian brothels.. Girls as young as 9 years old have been trafficked.
In 2001, a local NGO recorded 265 cases of girl trafficking victims, of which 34 percent
were below 16 years of age.
Street children are the most vulnerable lot. Sexual abuse is hidden but a widely prevalent
suffering among them. No child is safe and away from this cauldron of suffering.
Approximately 99 per cent of them are physically and psychologically abused.
Prostitution in figure in Nepal:
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In Nepal, there are both female and male sex workers, however, number of female sex
workers (FSWs) are much higher than their male counterparts. All groups cater for the
needs of male clients. There are both street-based as well as established based sex
workers.
According to the governments data, there are around 60,000 commercial sex workers in
the country and studies estimated up to 25,000 sex workers in the capital - Kathmandu
Valley only.
In addition, in mid and far western Nepal, there exist a community called badi community
who has been practicing prostitution from many generations.
Further, prostitution of Nepalese women is not restricted within the borders of Nepal.
Many Nepalese women are trafficked into the brothels of India, specifically Mumbai and
Kolkata.
According to the Study conducted by ILO around 12,000 Nepalese women are trafficked
out of Nepal every year. Out of these 5,000 to 7,000 of them being trafficked to India
annually. Number of Nepalese girls and women working in Indian brothels are at about
200,000.
Thus, Nepalese women are practicing prostitution within and outside Nepal, and after the
spread of HIV epidemic many HIV-positive prostitutes are sent back to Nepal by Indian
brothels.
Causes of prostitution in Nepal:
Women possess secondary status in every sphere of their lives. The low status of women
and girls in Nepal coupled with the lack of education and employment opportunities have
led to a large number of young women from rural areas of Nepal being sold into
prostitution by their relatives, friends or contacts, or being trafficked to other countries
for prostitution.
Due to a constant lack of female empowerment and an acute absence of overall
awareness on the matter, many children and women fall into the sex market
Trafficking:
Trafficking in persons means the recruitment, transportation, purchase, sale, transfer,
harboring or receipt of persons: (i) by threat or use of violence, abduction, force, fraud,
deception (dishonesty) or coercion (force including abuse of authority), or debt bondage,
for the purposes of; (ii) placing or holding such person, whether for pay or not, in forced
labour or slavery-like practices, in a community other than the one in which such person
lived at the time of the original act described in (i).
- (UN report, 2000 p. 4)
Causes:
The root causes of Trafficking Human Beings are in patriarchal structures that worldwide
keep so many women in a condition of subordination to men, lack of recognition of their
human rights, lack of equal opportunities, unemployment and poverty.
Combat the curse of girl trafficking:
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Amongst measures which could be adopted by the Nepalese government to combat the
curse of girl trafficking, the following, paraphrased from the HRW report, appear to be fairly
comprehensive and reasonable:
1) To break up the nexus between criminals (in this case, the actual girl traffickers), corrupt
police and government officials by the proper investigation of complaints and the timely
prosecution (hearing) of the guilty.
2) To improve the human rights training of the police forces and prosecute those found
guilty of indulging in corruption.
3) In accordance with Article 20 of the Convention of the Suppression of Traffic in Persons,
the government needs to monitor and break up the recruitment networks seen to function
in places notorious for trafficking. These include Nuwakot, Sindhupalchowk, and the
carpet factories in Kathmandu and border towns.
4) Maintain and update a registry of missing persons and be more conscientious (careful)
about following up investigations into the incidence especially of women and girls who
have mysteriously disappeared.
5) Facilitate better cooperation with India regarding their shared border with Nepal to enable
the monitoring and prosecution of traffickers (comp.ibid, 85-86).
Child protection:
Protecting children from violence, exploitation and abuse is an integral component of
protecting their rights to survival, growth and development
UNICEF uses the term child protection to refer to preventing and responding to
violence, exploitation and abuse against children including commercial sexual
exploitation, trafficking, child labour and harmful traditional practices, such as female
genital mutilation/cutting and child marriage.
Ensure Child Right:
The Convention on the Rights of the Child (1989) outlines the fundamental rights of
children, including the right to be protected from economic exploitation and harmful work, from
all forms of sexual exploitation and abuse, and from physical or mental violence, as well as
ensuring that children will not be separated from their family against their will.
These rights are further refined by two Optional Protocols,
One on the sale of children, child prostitution and child pornography,
Other on the involvement of children in armed conflict.
Child Labour:
Facts and figures:
Globally, 218 million children are child labourers. Approximately 126 million children
aged 517 are believed to be engaged in hazardous work excluding child domestic
labour. 73 million working children are less than 10 years old
Every year, 22,000 children die in work-related accidents
The largest number of working children-122 million-are in the Asia-Pacific region. The
highest proportion of working children is in sub-Saharan Africa, where nearly one third
of the children aged 14 and under (48 million children) are in the labour force
More than 1 million children worldwide are in custody by law enforcement officials.
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8.4 million children are trapped in slavery, trafficking, debt bondage, prostitution,
pornography and other illicit activities
Child labour is still common in some parts of the world, it can be factory work, mining,
prostitution, quarrying, agriculture, helping in the parents' business, having one's own
small business (for example selling food), or doing odd jobs. Some children work as
guides for tourists, sometimes combined with bringing in business for shops and
restaurants (where they may also work as waiters). Other children are forced to do
tedious and repetitive jobs such as: assembling boxes, polishing shoes, stocking a store's
products, or cleaning.
Child labour includes:
Work performed by children under the age of 15
Long hours of work on a regular or full-time basis
Abusive treatment by the employer
No access, or poor access, to education
Abusive treatment by the employer
Three types of bonded labour exist in practice around the world.
The first is when a child inherits a debt carried by his or her parents.
Another form of bonded labour occurs when a child is used as collateral for a loan. For
example, a parent facing an unusually large or urgent expense would use this method to
obtain necessary money.
Finally, a child worker can enter into bondage to their employer by requesting an advance
on future wages they expect to earn.
The non-discrimination approach should encompass the prevention of all forms of
marginalization social stigmatization against trafficked persons, as illegal migrants and/or
prostitutes.
Prevention:
Information campaigns among targeted groups, especially children, with particular
attention to girls.
Discouraging and reducing the demand of sexual services should be taken first in the
field of education. Equality in the relationships between women and men is essential to
enhance an approach to sexual life based on respect of dignity and freedom of the partner.
Public awareness campaigns should specifically address clients, to make it clear that
behind prostitution on the streets or in brothels, lies the possibility of slavery-like
conditions and forced prostitution. Solidarity towards kidnapped, raped or abused women
should be encouraged.
Child Labour in Nepal:
Exploitive child labor is a serious problem in Nepal. Reports have shown that 2.6 million
(2,596,000) children between the ages of 5 and 14 are working in Nepal. Of this, nearly
5% (127,000 children) are involved in what the International Labor Organization defines
as the Worst Forms of Child Labor
-CWIN 2003
Child Labour worksites:
Fifteen areas where children work are identified.
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1. Factory/Industry: Working in extremely poor conditions, children (usually migrants)

work 15 hours/day often injuring themselves in the filthy, hazardous factories. Other
factories/industries include: carpet factories (India), garments/textiles, handicrafts,
printing press, welding, confectionery, bread making, making matches, pottery and brick
kilns
2. Mines and Quarry: In addition to mining magnetite, children also labor in coal mines
and quarries.
3. Plantation: A large portion of the population is involved in agriculture. Children assist in
planting substances such as sugar cane, tea, tobacco, millet, maize and rice.
4. Domestic Service: Possibly one of the more dangerous forms of works because domestic
servants are more prone to abuse, children often conduct household activities such as
fetching water, cooking, cleaning, and caring for others.
5. Shop Keeper/Service: Children may work in small shops selling sweets, tea, liquor, and
other goods.
6. Transportation: Children work in public transportation as conductors, ticket collectors,
and rickshaw drivers.
7. Porters: According to IPEC, (The International Program on the Elimination of Child
Labor,) there are two types of porters long distance porters, and short distance porters.
Long distance porters carry goods in rural areas, whereas short-distance porters generally
work in urban settings. There are street porters, tourist/trekking porters, and domestic
porters.
8. Construction Work: Children work in the hazardous areas of building roads, houses,
bridges, and sewage systems.
9. Street Work: More likely to contract HIV/AIDS and partake in criminal acts, working as
newspaper vendors, rag pickers, beggars, street singers, and shoe shiners/makers.
10. Commercial Sexual Exploitation: With the high chance of getting STDs, children
involved in CSE act as prostitutes, pimps, work in massage parlors, and dance bars. In
this sector we see a high volume of children being trafficked to India to work in the sex
industry.
11. Bonded Labor: Constrained by the chains of their own or their familys debts, bonded
child laborers tend to work in carpet factories, as domestic servants, in restaurants, etc.
Although the Kamaiya system (the bonded labor system) was abolished in July 2000, the
problem and its aftermath still continue.
12. Migrant Child Labor: Those children who migrate from rural to urban settings in hopes
to find employment.
13. Refugee Children: Many Tibetan and Bhutanese refugee children work in the factory
setting.
14. Circuses/Music Industry: A growing trend, children often work in circuses both in
Nepal and other South Asian countries, particularly India. In addition, they work in magic
shows and music programs.
15. Publicity and Advertising: Children work in TV advertisements, radio programs,
newspapers, and magazines
Causes:
Monetary hardships
Rigid social structure : Inequalities between groups in society
Discrimination against minority group
Land ownership and rural migration
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Refugee children
Corruption of power. Businessmen, workers, police officers, and other high-ranking
governmental officials are often inclined to accept or pay a bribe in order to have things
Elimination of Child Labor:
Nepalese children need international legal protection and other protective measures to
ensure their safety
Decrease the number of children trafficked out of the country
There should also be a minimum age law restricting the travel of minors without parent
approval
Needs to be a intensive global effort to eliminate the worst forms of child labor
Education: education of a child should not be hindered by a familys income
School health education / peer education
Income generation activities
Parents must also be aware of the dangers of child labor, the devastating effects working
may have on their child and on the larger society, and most importantly, their feasible
options (i.e., education, government programs, etc.).
Human right:
Human rights are those basic standards without which people cannot live in dignity
Rights ensure that everybody is treated equally and fairly. Sadly not everyone around the
world has their human rights respected
Rights are the foundation of democratic society.
Since its adoption in 1989 after more than 60 years of advocacy, the Convention on the
Rights of the Child (CRC) has been confirmed more quickly and by more governments
(all except Somalia and the US) than any other human rights instrument. Its basic
principle is that children are born with fundamental freedoms and the natural rights of all
human beings.
On the 20th November 1989, the United Nations (UN) approved the Convention on the
Rights of the Child. It is called the 'United Nations Convention on the Rights of the
Child'.
The UN Convention on the Rights of the Child has 54 articles. Each article outlines a
different right. They cover four different groupings of rights;
survival,
protection,
development and
participation.
Convention on the Rights of the Child (CRC) Articles:
In article 1, the CRC defines children as "all human beings below the age of 18".
As stated in article 3, CRC is geared towards ensuring that the "best interest of the
child" is protected.
Under article 4, States are obliged (grateful) to do all it can to ensure the rights set out in
the CRC.
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Children's rights:
Children's rights are the perceived human rights of children with particular attention to
the rights of special protection and care afforded to the young, including their right to
association with both biological parents, human identity as well as the basic needs for
food, universal state-paid education, health care and criminal laws appropriate for the age
and development of the child
Children's rights are about treating children with the equality, respect and dignity to
which they are entitled, not because they are the adults of tomorrow, but because they
are human beings today.
Interpretations of children's rights range from allowing children the capacity for
autonomous action to the enforcement of children being physically, mentally and
emotionally free from abuse, rights to care and nurturing
Children are to be regarded as a minority group towards whom society needs to think
again the way it behaves
Children face particular exclusions and discrimination against which they have a right to
full protection
Truth of children:
The fact that children are not adults, and the low social status afforded to them in most
societies, means they may receive unfair treatment, or be left out of decision-making. For
example, in almost every country children under 18 are denied political power because
they cannot vote, and most countries allow parents to hit their children.
Children's status in society, among other factors, also means they are more vulnerable to
sexual abuse and other forms of violence and exploitation.
Types of rights:
Children's rights are defined in numerous ways, including a wide spectrum of civil,
cultural, economic, social and political rights
These have been labeled as the
right of empowerment and
right to protection
Children's rights are divided into three categories by a Canadian organization:
Provision: Children have the right to an adequate standard of living, health care,
education and services, and to play. These include a balanced diet, a warm bed to sleep
in, and access to schooling.
Protection: Children have the right to protection from abuse, neglect, exploitation and
discrimination. This includes the right to safe places for children to play; constructive
child rearing behavior, and acknowledgment of the developing capacities of children.
Participation: Children have the right to participate in communities and have programs
and services for themselves. This includes children's involvement in libraries and
community programs, youth voice activities, and involving children as decision-makers
Child Rights Information Network (CRIN) categorizes rights into two groups:
Economic, social and cultural rights, related to the conditions necessary to meet basic
human needs such as food, shelter, education, health care, and gainful employment.
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Included are rights to education, adequate housing, food, water, the highest attainable
standard of health, the right to work and rights at work, as well as the cultural rights of
minorities and indigenous peoples.
Environmental, cultural and developmental rights, which are sometimes called "third
generation rights," and including the right to live in safe and healthy environments and
that groups of people have the right to cultural, political, and economic development.
The following rights "allow children to grow up healthy and free
Freedom of speech
Freedom of thought
Freedom from fear
Freedom of choice and the right to make decisions
Ownership over one's body
Convention on the Rights of the Child:
The United Nations' 1989 Convention on the Rights of the Child, or CRC, is the first
legally binding international instrument to incorporate the full range of human rights civil, cultural, economic, political and social rights.
The CRC is based on four core principles, namely
The principle of non discrimination,
The best interests of the child,
The right to life, survival and development, and
Considering the views of the child in decisions which affect them (according to
their age and maturity).
Situation of childrens rights in Nepal:
In a country like Nepal, it is obvious that protecting and promoting childrens rights is
exceptionally challenging.
Traditional beliefs and lack of awareness of the value of education often result in children
being deprived of their basic rights including the right to life, to protection, to education
and self-development.
Children do not get opportunities to practice their rights
Children who understand their rights are more able to protect themselves from abuse, but
in a country where half a million children do not attend school, lack of knowledge is one
of the key challenges
Some of the challenges for children in Nepal are trafficking of children, forced child
labour and discrimination. Protecting childrens rights is the responsibility of our
government as well as the welfare agencies in Nepal.
Child Laws:
This study attempts to assess the Nepalese laws related to the rights of the child,
particularly the Children's Act of 1992 in respect to international laws particularly
focused on the UN Convention on the rights of the Child of 1989.
After close exploration of the CRC, the Children's Act of 1992, the Constitution of the
Kingdom of Nepal of 1992 and the reality we do have, it is revealed that the legal
framework is a necessary but not the sufficient condition for the children and their
concerns.
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To support the legal framework, the second condition of a socio-economic framework

must be aligned which is not done in parallel in the Nepalese context therefore the
implementation is a fatal problem.
Children are the majority in statistics but a minority with respect to social status in the
real world. Nepal has ratified most of the human right conventions and optional protocols
but domestic initiation enforcement in that respect is poor.
The role of society and non-government organizations is essential for effective
implementation of the rights of children and their concern.
Achievement in child right issue in Nepal:
Nepal ratified the Convention on the Rights of the Child on September 14, 1990.
According to Article 126 of the Constitution of the Kingdom of Nepal (promulgated in
1990), international agreements that are duly approved are binding on the government.
In 1992 the Nepalese Parliament passed The Children's Act codifying some sections of
the Convention. The Constitution of Nepal and the 1992 Children's Act were the first
time in the history of Nepal that the country has shown a deep interest in protecting the
rights of the child.
The political unrest in Nepal has prevented the country from making further efforts to
implement the Convention since the reforms in the early nineties.
Child neglect is not a crime in Nepal but it is recognized in the Children's Act which
defines an abandoned child as one who has been neglected by his father, mother or any
other member of his family even though they exist.
The role of the State:
The best interest of the child shall be a primary consideration (art.3)
The State shall assure that the childs point of view is heard (art.12)
The child shall have the right to freedom of expression (art.13), of thought, conscience
and religion (art.14), of association (art.15)
The enjoyment of the highest attainable standard of health (art.24) of social security
(art.26), and education (art.28)
A guarantee of protection against all forms of exploitation (art.32, 33, 34, 35, 36, 37, 38)
The establishment of authorities and institutions specifically applicable to children
(art.40).
Abandoned children:
Child abandonment is the practice of relinquishing (handover) interests and claims over
one's offspring with the intent of never again restarting it. Causes include many social
and cultural factors as well as mental illness. An abandoned child is called a foundling
(as opposed to a runaway or an orphan).
Abandoned children in figure:
In 2004 there were over 143 million orphaned and abandoned children, in 93 developing
countries, worldwide. This is 8.4 % off all children in the world. (UNICEF)
In 2003 alone, more then 16 million children were orphaned. (UNICEF)
Numbers of orphans will increase dramatically by 2010/2015, at an estimated growth of
15 to 20 million per year. (International Advocates for Children)
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By 2015, children and youth will account for 45% of the population in developing
countries. (World Bank)
In Africa, there are 60 million orphaned and vulnerable children (HIV/Aids, conflict,
disability, street children). (World Bank)
India estimated 35 million orphans in 2003 (UNICEF)
In 2003 over 800,000 children became newly orphaned in Nigeria alone (UNICEF)
In 2003 an estimated 12.3 % of all children in sub-Saharan Africa were orphans
(UNICEF)
For every 3 months in an orphanage a child loses one months of grow (Dr.Charles
Nelson)
Girls in orphanages reach their puberty 2 years later then girls in families (Dr.Charles
Nelson)
In Tanzania school attendance for orphans is only 52 %. (UNICEF)
An estimated 1.2 million children, mostly orphans, are trafficked every year.
(International Advocates for Children)
Some 300,000 children are currently involved in diverse fighting forces. (World Bank)
At the end of 2004, roughly 48 % of all refugees worldwide were children. (UNICEF)
Over 246 million children are engaged in child labour (SOS Kinderdorf)
Institutional care in Africa is 6 to 14 times more expensive than foster care (UNAIDS)
Some 50 million births go unregistered every year, about 40% of all estimated births
worldwide. (UNICEF)
Causes:
Political conditions
Poverty
Trouble with the law, financial insecurity, the child's mental or physical challenges, and
sometimes population control policies. Involuntary loss of a parent, such as through
divorce or death, can also create abandonment issues.
Abandoned child syndrome:
Abandoned child syndrome is a behavioral or psychological condition that results from
the loss of one or both parents. Abandonment may be physical (the parent is not present
in the child's life) or emotional (the parent withholds affection, nurturing, or stimulation
Parents who leave their children, whether with or without good reason, can cause
psychological damage to the child. Abandoned children may also often suffer physical
damage from neglect, malnutrition, starvation, and abuse
Symptoms:
Symptoms may be physical and/or mental, and may extend into adulthood and perhaps
throughout a person's life
Isolation from the environment - withdrawal from social activities, resistance
towards others
Guilt - the child believes that he/she did something wrong that caused the
abandonment (often associated with depression
Fear and uncertainty - clinginess, insecurities
Sleep and eating disorders - malnutrition, starvation, disturbed sleep, nightmares
(frightening dreams)
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Physical ailments (illness) - fatigue, depression, lack of energy and creativity,

anger, grief (sorrow)
Responsibility of society:
Society has an obligation to support abandoned children and offer them a positive home
environment also when budget resources are limited
Street children:
Street children are a term used to refer to children who live on the streets of a city. They
are basically deprived of family care and protection. Most children on the streets are
between the ages of about 5 and 17 years old, and their population between different
cities is varied.
UNICEF has defined three types of street children: Street-Living, StreetWorking, and Street-Family.
Street Living Children: children who ran away from their families and live alone on the
streets.
Street Working Children: children who spend most of their time on the streets, fending
for themselves, but returning home on a regular basis.
Children from Street Families: children who live on the streets with their families.
A widely accepted set of definitions, commonly attributed to UNICEF, divides street children
into two main categories:
Children on the street are those engaged in some kind of economic activity ranging from
begging to vending. Most go home at the end of the day and contribute their earnings to
their family. They may be attending school and retain a sense of belonging to a family.
Because of the economic weakness of the family, these children may eventually choose
for a permanent life on the streets.
Children of the street actually live on the street (or outside of a normal family
environment). Family ties may exist but are tenuous (Weak) and are maintained only
casually or occasionally.
Street children exist in many major cities, especially in developing countries, and may
be subject to abuse, neglect, exploitation, or even, in extreme cases, murder by "cleanup
squads" hired by local businesses or police.
Causes:
No choice they are abandoned, orphaned, or disowned (reject) by their parents.
Secondly, they may choose to live in the streets because of mistreatment or neglect or
because their homes do not or cannot provide them with basic necessities.
Many children also work in the streets because their earnings are needed by their
families. But homes and families are part of the larger society and the underlying reasons
for the poverty or breakdown of homes and families may be social, economic, political or
environmental or any combination of these.
Causes for Abandoned children:
In a 1993 report, WHO offered the following list of causes for the phenomenon:
Family breakdown
Armed conflict
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Poverty
Natural and man-made disasters
Famine (shortage of food etc)
Physical and sexual abuse
Exploitation by adults
Dislocation through migration
Urbanization and overcrowding
Acculturation
Disinheritance or being disowned or rejected
The orphaning of children as a result of HIV/AIDS is another cause that might be
added to this list
Responses by Governments:
Little attention
Governments are often found difficult to deal with the problem of street children and may
blame parents or neighboring countries
Non-Governmental Organizations (NGOs) may also be blamed for encouraging children
to live in the streets by making street life more bearable or attractive through the services
they provide
Governments implement programs to deal with street children these generally involve
placing the children in orphanages, juvenile homes or correctional institutes. However,
some children are in the streets because they have fled from such institutions
Governments sometimes remove all the children from city streets and deposit
them elsewhere or imprison them
In the most extreme cases, governments may participate in social cleansing
operations that murder street children.
NGO responses:
Advocacy
Preventive :prevent children from taking to the streets
Institutional
residential rehabilitation programs
full-care residential homes
Street-based programs
feeding program
medical services
legal assistance
street education
financial services (banking and entrepreneur programs)
drop-in centers / night shelters
outreach programs designed to bring the children into closer contact with
the agency
Change street children's attitudes to their circumstances - view themselves as an
oppressed minority and become leading role rather than passive recipients of aid
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The constitution:
The Constitution is the fundamental law of Nepal
The Right against Exploitation (article 20) specifically prohibits any trafficking in
persons: "Traffic in human beings, slavery, serfdom or forced labor in any form is
prohibited. Any contravention of this provision shall be punishable by law.
(Serfdom-Bandhuwa)
Obligation (Task) imposed by law:
Judiciary:
The judiciary in Nepal is based upon the Mulaki Ain code, which is a combination of
Hindu traditions and English common law.
Domestic laws:
There are three domestic laws in place that address girl trafficking and forced child labor.
These include the Labor Act of 1992, the Human Trafficking Control Act of Nepal
(1986), and the National Human Rights Commission Act (1996).
The 1992 Labor Act prohibits the employment of minors, who are considered to
be less than 14 years old.
The Human Trafficking Control Act of Nepal was passed in 1986, which prohibits the
trafficking of girls and women. Trafficking is defined as "an act of threat, incitement, and
sale of women for the purpose of prostitution. Those found guilty of trafficking face 520 years imprisonment
In 1996, the Parliament created the National Human Rights Commission Act. This
commission was established to investigate human rights violations within Nepal. So far,
the Commission has not come together to address girl trafficking
Major problem with Nepals domestic laws:
A major problem with Nepals domestic laws is lack of enforcement.
Corruption in the legal system is prevalent.
Despite the formal recognition of girl trafficking as a major problem, the existence of
laws to reduce it, trafficking continues
Effect of conflicting situation, urbanization, refugee situation of children:

Effect of conflict on children:
Parental conflict is the biggest predictor of poor outcome for children. The most powerful
determinants are the level of the conflict between parents. Parental conflict is toxic for
kids.
Summary of the Research on the Effects of Conflict
Some children respond to parental conflict by acting out. They may demonstrate
behavior problems, increased anger and inability to manage anger, violent behavior,
delinquency (criminal behaviour), and gang involvement.
Some children respond to parental conflict by turning inward. They are likely to
demonstrate depression (many times anti-depressants are prescribed). Mostly they show
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the behavior as isolation from friends and activities, physical symptoms like headaches,
stomach aches, ulcers etc., and substance abuse.
Children who are exposed to parental conflict do not interact well with others. These
kids often have very poor social skills, low self esteem and poor relationships when they
become adults.
Some children exposed to high conflict have trouble thinking. Advances in
neuropsychology have shown that when exposed to conflict our brains release stress
hormones that over time can actually change brain functioning. Frightening! The effects
of being exposed to conflict show up as problems in school, truancy (Avoid to go to
school), impaired thinking (things like problem-solving, memory are affected) and
symptoms that Attention Deficit Disorder.
Conflict puts society's most vulnerable children at terrible risk. Conflict can displace
children, destroy schools and break down education systems
Exposure to repeated conflict in multiple unions may have a compounding negative effect
on childrens development
Physical injury, gender-based violence, psychosocial distress, are offend to every wish
The disruption of food supplies, the destruction of crops and agricultural infrastructures,
the disintegration of families and communities, the displacement of populations and the
destruction of educational and health services and of water and sanitation systems, all
take a heavy toll (charge) on children
Armed conflict is a major public health hazard that cannot be ignored. Any disease that
caused as much large-scale damage to children would long ago have attracted the urgent
attention of public health specialists. When armed conflict kills and maims (injures) more
children than soldiers, the health sector has a special obligation to speak out.
Thousands of children are killed every year as a direct result of fighting - from knife
wounds, bullets, bombs and landmines, but many more die from malnutrition and disease
caused or increased by armed conflicts.
During conflicts, mothers may experience hunger, exhaustion and distress that can make
them less able to care for their children. Breastfeeding may be endangered by the
mother's loss of confidence in her ability to produce milk.
The fragmenting of family and community, rapid social change, the breakdown of
support systems, increased sexual exploitation and rape, malnutrition, and inadequate
health services, including poor ante-natal care
Many families are forced to flee their homes, and end up living in temporary
accommodation where there is no access to schools and other facility needed for the
growth and development of the children.
Children, particularly girls, face increased threats from trafficking, exploitation and
gender-based violence. These can result in serious health problems, including the spread
of HIV/AIDS
Effect of urbanization on children:

Urbanization placed stress on the available resources and led to overcrowding, which in
turn has led to several problems. These include shortages of houses and the development
of slums, crime and violence, unemployment and underemployment and the incidence of
street people which directly affect the children
The link between urbanization and the incidence of street children live or work on the
streets as a regular daily activity
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Street children as any child for whom the street has become his or her habitual abode
(domicile) and /or source of livelihood, and who is inadequately protected, supervised, or
directed by adults.
Reduce opportunity to learn and to practice responsible and helpful behavior. Increase
selfish behavior and greediness.
Develops three categories of street children:
Children on the streets those who still have links with families and attend
school, but work on the streets outside of school hours. Occasionally disappear
from the house and spend night on road.
Children of the streets those whose links with the family are remote and who
consider the street to be their home.
Abandoned children - those who are completely on their own and have no links
with their families.
Effect of Refugee situation on children:
Poor parents forced to work as low payee labour and children live with neglect. They
forced to send their children out on the streets, forces them to look after themselves hence
causing child labour.
Physical, sexual or emotional abuse, caused by parents or guardians usually leads to the
child running away from home and thereby being forced into child labour
Peer pressure The feeling of inadequacy at school discourages them from wanting to
learn, especially if they are being teased and ridiculed (laughter) and hence they are push
into child labour.
Severe poverty The children are forced unto the streets to supplement the inadequate
income of the household,
Those who enter into child labour primarily of their own choice, in order to help out their
parents or to become more independent themselves; and
Those entering as a direct result of family crisis like the illness or death of the primary
caregiver.
They are overcrowded and epidemics
Unavoidable exposure to a sub-nutritional diet Epidemics of nutrition-related diseases are
common in camps. These include night blindness, beri-beri, pellagra, and scurvy.
Domestic violence always increases in refugee situations and family breakdown is
common
Substance abuse
anxiety and depression
children in camps are growing up in conditions which do not permit their socialization
according to the values of their own culture
Inadequate for general cleaning and personal hygiene requirements
Education never constitutes a priority and also even if some get opportunity school
absenteeism is higher
Miss their parents and can feel in the wrong and disloyal about leaving them
Domestic Violence even show symptoms similar to Post Traumatic Stress Disorder
(PTSD) and Sexual violence
The ways children respond to violence are varied. Some can become withdrawn and find
it difficult to communicate; others express their feelings through behaviour problems,
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some bed wet or experience difficulties at school. All children living with abuse are
under stress
Effect of Refugee situation on children:

That stress may lead to any of the following:
Withdrawal.
Aggression or harassment.
Bad temper.
Vandalism (destruction).
Problems in school, absence, speech problems, difficulties with learning.
Attention seeking.
Nightmares or insomnia.
Anxiety, depression, fears of abandonment.
Feelings of inferiority.
Drug or alcohol abuse.
Eating disorders.
Constant colds, headaches, mouth ulcers, asthma, eczema.
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Translation:
International Agreements:
Convention on the Rights of the Child, ratified September 14, 1990
Article 12:
1) States Parties shall assure to the child who is capable of forming his or her own views the
right to express those views freely in all matters affecting the child, the views of the child
being given due weight in accordance with the age and maturity of the child.
2) For this purpose, the child shall in particular be provided the opportunity to be heard in
any judicial and administrative proceedings affecting the child, either directly, or through
a representative or an appropriate body, in a manner consistent with the procedural rules
of national law.
Convention on the Rights of the Child, ratified September 14, 1990:
Statutes
Children's Act 2048 (1992)
Chapter I, Article 2
(5)(b):"Abandoned Child" means a Child- Who has been neglected by his father, mother
or any other member of his family even though they exist.
Chapter II, Article 7
No Child shall be subjected to torture or cruel treatment. Provided that, the act of
scolding and minor beating to the Child by his father, mother, member of the family,
Guardian or teacher for the interests of the Child himself shall not be deemed to violate
the provisions of this Section.
Chapter II, Article 20
(1)For the enforcement of the rights set out in this Chapter, every person shall have the
right to file a petition on behalf of the Child to a District Court of the district where the
Child is residing.
Chapter IV, Article 35
(1) The Children Welfare Officer and the police personnel shall handover the Abandoned
Child, they have found or handed over to them by any person, to the nearest Children's
Welfare Home
(5)The Children Welfare officer, Police Officer or Chief of the concerned Children's
Welfare Home may, in order to find out father, mother, relatives or Guardian of the
Abandoned Child cause to publish a notice including the description and photograph of
such Child in any or cause to communicate through any other medium of communication
(3) If the father, mother or the Guardian of the Abandoned Child desires to take the Child
with them, the Chief of the Children's Welfare Home shall allow taking the Child at any
time and preparing a document for such take over of the Child.
Chapter VI, Article 49
(1) The legal practitioner or the father, mother, relatives Guardian of the Child and if the
officer hearing the case deems it appropriate and permits any person or the representative
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of the social organization involved in safeguarding the rights and interests of the Child
may attend in the proceedings of any case related with the Child initiated under this Act
or existing laws.
(3) In case any person commits any offence in contravention to Section 7 [cruel treatment
of a child] or 15, he shall be punished with a fine up to five thousand rupees or with
imprisonment for a term which may extend to one year or with both. In case of torture
and cruel treatment he shall be made liable to pay a reasonable amount of compensation
to the Child.
The case under this Act in which a Child is a plaintiff or defendant shall have to be given
priority for hearing and deciding
Child Health Services:

Ensuring children's health is critical not only for reducing child morbidity and mortality,
but also for increasing the likelihood of a healthier adult life.
The primary goal of Child Health Services is that all children served will be functioning
to their full-capacity physically and psychologically; and that their families will be able
to find and use support services effectively.
The goal of child health services, however, is to prevent the major causes of death,
difficulties, and disease during childhood: accidental injuries, infections, education
problems, and behavioral problems.
Child health services address environmental risks, problems related to low family
income, socio-psychological stress, and traditional medical services.
Immunization:
"Immunization is the right of child". Immunization saves millions of lives each year.
Immunization can protect the unprotected.
The immunization of mothers and children is the most important factors of the maternal
and child health care services.
Government of Nepal (GON) has been frequently emphasizing to reduce infant and child
mortality by improving health condition of Nepalese citizens
GON is providing immunization services through National Immunization Program for
control, elimination and eradication the diseases
Immunization is considered as one of the most cost-effective health interventions
National Immunization Program is priority program of Government of Nepal.
Nepal started the Expanded Program on Immunization (EPI) in 1979, initially in three
districts with two antigens, which was rapidly extended to cover all 75 districts with all
six recommended antigens by 1988.
In Nepal, six traditional antigens were in use till 2002, and HepatitisB (Hep B) came in
existence in 2003 with the support of GAVI (Global Alliance for Vaccines and
Immunization ).
NIP targets all children under one year to complete all 7 antigens in their first year of life.
NIP also targets to all pregnant women to immunize with 5 dose of TT vaccine in their
reproductive life.
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National immunization programme is guided by its Multi Year Plan of Action (MYPA
2007-2011). The programme covers all the districts and Village Development
Committees (VDCs) of the country.
NIP under Child Health Division has a lead role in all immunization related activities at
the national level. It includes coordinated actions with other Divisions of the DoHS and
all other partners of the programme.
The Regional Health Directorate (RHD) acts as a facilitator between the Central and the
District levels. It is the responsibility of the D(P)HO to ensure that a successful
immunization programme is implemented at the district level and below.
Immunization service is provided through the fixed (Health facility) as well as out reach
session. All health facilities be it a Primary Health Care Center (PHC), Health Post (HP),
Sub-health Post (SHP) and Hospitals provides immunization through an established clinic
where all children of their respective Village Development Committees (VDCs) ensure to
access with immunization
Regular monitoring of the National Immunization Programme is continuing with the use
of data collected through the Health Management Information System (HMIS). Data
generated at the service level are reported to the district, region and the central level on
monthly basis. On the basis of HMIS data, NIP monitors the coverage, drop out, vaccine
wastage and the number of unvaccinated children against DPT3 and measles in every
district and village Development Committee and sends its feedback to the area of
concern.
In addition to HMIS, vaccine preventable diseases are reported through integrated Acute
Flaccid Paralysis (AFP) surveillance system supported by WHO and immunization
preventable diseases (IPD). In AFP surveillance, data related to Vaccine preventable
diseases (VPD) are collected through the sentinel sites. Similarly any outbreak of vaccine
preventable diseases is reported through both the HMIS and integrated AFP network.
To ensure equity and high vaccine coverage, NIP is focusing in municipalities to
strengthen immunization network
NIP has initiated coordination with D (P) HO and municipalities of the respective district,
and micro-planning workshop is jointly conducted with municipalities, district health
office and all local NGOs and I/NGOs including private sectors to ensure adequate
service outlets.
Goal and objectives of the National Immunization Program:
GOAL:
The overall goal of the EPI is to reduce child morbidity, mortality and disability
associated with vaccine-preventable diseases.
OBJECTIVES:
The objectives of the National Immunization Programme are as follows.

Achieve and sustain 90% coverage: DPT3 by 2008, and of all antigens by 2010.
Maintain Polio free status.
Sustain MNT (Maternal and Neonatal Tetanus) elimination status.
Initiate Measles elimination.
Expand Vaccine Preventable Diseases (VPDs) surveillance.
Accelerate control of other vaccine preventable diseases through introduction of new
vaccines.
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Improve and sustain immunization quality.

Expand immunization services beyond infancy
Target population for EPI:

All infants (under one year/under 12 months) for BCG, DPT-HepB, OPV, and Measles
vaccines
All pregnant women for TT vaccine
All 1, 2 and 3 grade students for School Immunization Programme
Immunization Schedule of National Immunization Programme:

Type of Vaccine
BCG
OPV
DPT Hepatitis-B
Measles
TT
TT
Number of Doses
1
3
3
1
2
3
Recommended Age
At birth or on first contact
6, 10, &14 weeks of age
6, 10, & 14 weeks of age
9 months of age
Pregnant women
Grade 1,2, 3 students
NATIONAL IMMUNIZATION SCHEDULE UNDER EPI:

In Nepal, immunization program is launched for under one year children in EPI program but the booster
doses and other preventable vaccine can be given within 1 year and after that time. The immunization
under National EPI program area as follows which is given on National EPI schedule:
1) BCG
2) DPT 3) Tetanus 4) Polio 5) Measles
6) Hepatitis B
Immunization schedule for under one year children according to WHO

SN
Name of Time for Dose of Interval

vaccines
vaccination vaccine
& no. of
vaccines
BCG
Soon after 0.05ml
Single
(Bacillus
birth upto
dose
Calmette
1 year
Guerin)
DPT
6
weeks 0.5ml
One
(Toxoid
after birth
month,3
Diphtheria, to 1 year
dose
Pertusis
bacilli,
tetanus
bacilli)
Polio
6
weeks 2-3 drops One
(Live
after birth
month, 3
vaccine
to 1 year
dose
oral drops)
Hepatitis
6
weeks 0.5ml
One
B
after birth
month, 3
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Prevent
from
Route
of Site
of
administration Injection
Tuberculosis
Intra-dermal
Right
upper arm
Diphtheria,
Pertusis,
Tetanus
Intramuscular
Left
lateral
mid thigh
Poliomyelitis
Oral
Oral
Hepatitis B
Intramuscular
Right
lateral
Batch)
Measles
(attenuated
live
vaccine)
to 1 year
9 months
to 1 year
dose
Single
dose
0.5ml
Measeles
Subcutaneous
mid thigh
Right
lateral
mid thigh
(EPI=Expanded Program on Immunization)
Strategies National Immunization Program:

1) Delivery of services: National Immunization Programme delivers the Immunization
services through Routine and Supplemental Immunization Programme
Routine Immunization:
Fixed facilities: Immunization services are provided at hospitals, primary
healthcare centers, health posts and sub health posts
Outreach services: Immunization services are provided through out reach
session or clinic
Mobile teams: Geographical conditions such as lack of roads and bridges
hamper immunization in remote areas
Private and NGOs INGO clinic: clinics of hospitals, nursing homes and
through NGOs
2) Strengthen municipality immunization network
3) Conduct supplemental immunization activities to support:
Polio eradication initiative
Measles and Japanese Encephalitis control
4) Expansion of School Immunization Programme to sustain Maternal and Neonatal Tetanus
elimination.
5) Strengthen monitoring system
6) Strengthen and expand integrated surveillance of VPDs built on AFP Surveillance (AFP,
Measles, Neonatal Tetanus and Japanese encephalitis) and initiation of study of disease
burden of other vaccine preventable diseases like Hib and Rubella.
7) Control outbreak of VPDs through appropriate interventions
8) Increase and promote public awareness and demand through social mobilization for
immunization services and IEC/BCC interventions.
9) Strengthening of cold chain capacity in all 75 districts and ensure their functioning
10) Training to Health Workers (Mid Level Manager, Vaccine management and Cold Chain)
11) Strengthening and expansion of AEFI surveillance
12) Strengthen supportive supervision
13) Adaptation of multi dose vial policy to minimize missed opportunity and waste rate
14) Adaptation of safe injection practice to improve quality of immunization services
15) In country observation tour of 20 cold chain assistant to share and learn from better
performing districts.
Control of Diarrhoeal Diseases (CDD):
Diarrhoeal diseases is one of the major public health problems among children under five
in Nepal
National Control of Diarrhoeal Diseases Programme (NCDDP) has been given priority
status by HMG and shall remain an integral part of Primary Health Care.
Objectives of CDDP:
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The objective of the Control of Diarrhoeal Diseases (CDD) Programme is to reduce

mortality due to diarrhoea and dehydration (from the estimated 30,000 deaths per year) to
a minimum, and to reduce morbidity from 3.3 episodes per child per year to a minimum.
Strategies:
General Strategies:
1. Establish functioning ORT Corners and replenish (restock) ORT Corner sets in each
health facility in order to educate mothers/caretakers, to demonstrate proper ORS
preparation, and to treat children suffering from diarrhoea;
2. Increase access to JJ packets through FCHVs, PHCCs, HPs, SHPs, hospitals and
commercial outlets;
3. Increase access to Zinc Tablets through FCHVs, SHPs, HPs, PHCCs, hospitals and
commercial outlets
4. Raise public awareness;
5. Promote specific preventive measures through communication and information activities;
6. Involve Community Health Workers (FCHVs and MCHWs), District Development
Committee (DDC) and VDC members, local NGOs and local decision-makers;
7. Create a combined child health package, combining the CDD, EPI, Nutrition, and Acute
Respiratory Infection (ARI) programmes;
8. Emphasize programme management.
Strategies of Tenth Five Year Plan
1. Train all levels of health workers including VHWs/MCHWs/ FCHVs/ community
leaders;
2. Orient community opinion leaders, VDC members, faith healers;
3. Supply Oral Rehydration Solution to all health institutions;
4. Supply Oral Rehydration Solution to all FCHVs;
5. Supply Zinc Tablets to all health institutions and FCHVs of Zinc Program implemented
districts;
6. Develop health education materials (including development and printing of IEC
materials) to be used by mothers, FCHVs, and through channels of radio and TV
communication;
7. Promote supervision and monitoring at all levels;
8. Promote "Knowledge, Attitude and Practice" (KAP) on Diarrhoeal Diseases (DD) among
health workers, mothers and FCHVs
Acute Respiratory Infection:

Basic facts
About 20% of all deaths in children under 5 years are due to Acute Lower Respiratory
Infections (ALRIs - pneumonia, bronchiolitis and bronchitis); 90% of these deaths are
due to pneumonia. Early recognition and prompt treatment of pneumonia is life saving.
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Causative organisms may be bacterial (most commonly Streptococcus pneumoniae and

Haemophilus influenzae) or viral. However, it is not possible to differentiate between
bacterial and viral ARIs based on clinical signs or radiology.
Low birth weight, malnourished and non-breastfed children and those living in
overcrowded conditions are at higher risk of getting pneumonia. These children are also
at a higher risk of death from pneumonia.
-WHO
Acute Respiratory Infection (ARI) is one of the major public health problems in Nepal
among children under 5 years of age
National Control of ARI Programme is an integral part of primary health care and has
been accorded high priority by the MoH
The programme focuses on children under five years because the majority of deaths in
this age group are ARI-related.
WHO guidelines for the classification;
1. Severe pneumonia;
2. Pneumonia; or
3. No pneumonia.
Objectives
The main objective of the ARI Programme is to reduce under-five ARI-related morbidity
and mortality and to improve the situation of child health in Nepal.
Target
To reduce the mortality from pneumonia in under-five children through proper diagnosis
and management of cases;
To reduce morbidity from ARI in under-five children.
ARI strategies:
General Strategies
Educate mothers and child caretakers in supportive care strategies and in recognizing the
signs and symptoms of ARI and pneumonia.
Develop a health education programme aimed at raising awareness of ARI as a public
health problem for the community in general and for families in particular, and encourage
active community participation in coping with the problem.
Train health workers and CHWs according to WHO guidelines on standard ARI case
management.
Support related activities to encourage breastfeeding, provide nutrition education,
increase EPI coverage, promote maternal and child health care, and utilize family
planning services.
Avoid use of cough suppressants, remedies and antibiotics in the management of coughs
and colds
Deliver the programme through a primary health care approach.
Utilize operational studies to define local ARI problems and to measure the effect of
introducing new ARI approaches.
Continue monitoring of the ARI Control Programme.
Strengthen the ability of the District Health Offices (DHOs) to supervise the ARI
Programme according to WHO guidelines.
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Specific Strategies for the Tenth Five Year Plan:

Train all levels of health workers in IMCI
Orient drug sellers
Expand community-based IMCI training in more districts
Orient community leaders, including DDC and VDC members, faith healers, and
mothers.
Supply Cotrimoxazole Paediatric tablets to all health institutions
Supply Cotrimoxazole Paediatric tablets to all FCHVs
Supply of sound timers to all FCHVs in 39 districts
Develop IEC materials as and when necessary
Assist NHEICC in the revision of ARI messages
Manage ARI cases, applying standard ARI case management protocol
Supervise/monitor at all levels and provide feedback accordingly.
Malnutrition:
Malnutrition remains a serious obstacle to child survival, growth and development in
Nepal. The most common forms are protein-energy malnutrition (PEM) i.e., Moderate
Acute Malnutrition (MAM) and at some extent Severe Acute Malnutrition (SAM) and
micronutrient deficiency states i. e. Vitamin A deficiency (VAD), Iodine Deficiency
Disorders (IDD), and Iron deficiency Anaemia (IDA).
Government of Nepal has taken a multi-sectoral approach to address the issue of
malnutrition, involving the Ministry of Agriculture, the Ministry of Health, and the
Ministry of Education.
Nutrition program of MoH:
The present Nutrition Programme in the Ministry of Health aims to ensure improvement
in the overall nutritional status of vulnerable groups. Major components of the
programme include:
Promotion of breastfeeding,
Growth monitoring of children under three years,
Prevention of iodine deficiency and vitamin A deficiency disorders,
Control of anaemia, and
Nutrition education for mothers to help them meet the daily nutritional
requirements of their children through locally-available resources.
Goal of Nutrition program:
OVERALL GOAL
Achieving nutritional well being of all people in Nepal so that they can maintain a
healthy life and contribute to the socio-economic development of the country, through
improved nutrition programme implementation in collaboration with relevant sectors to
achieve the following national goals
IMR to reduce 45/1000 and <5 mortality rate to 72/1000 by the end of 2007;
IMR 34 / 1000, <5 mortality rate 54/1000 and Maternal Mortality Ratio (MMR)
213 or 134/100,000 live births by 2015 (MDGs)
Nutritional Specific MDGS Goal:
The following are Nutrition Specific Goals to be achieved by the end of 2015 (MDGs)
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1.
2.
3.
4.
5.
Reduce sub-clinical VAD to 7%

Reduce anemia in pregnant women to 43%
Reduce anemia in all age women to 42%
Reduce anemia in children to 43%
Increase consumption of adequately iodized salt (more or equal to 15 PPM) at HHs level
to 88%
6. Reduce prevalence of night blindness in pregnant women to 1%
7. Reduce prevalence of underweight in <5 years children to 27%
8. Reduce prevalence of stunting in <5 years children to 28%
9. Reduce prevalence of wasting in <5 years children to 5%
10. Increase exclusive breast-feeding in <6 months children to 88%
11. Reduce prevalence of thinness (BMI 18.5 below 25) in women to 15%
12. Reduce worm infestation rate in children (Pre-school) to 16%
Adolescent and youth health:

Global Data:
1.2 Billion adolescent
1.75 billion young people
85% living in developing countries
Girls have fewer opportunity for schooling: 13% girls vs 22% boys in 2 ndary education
Girls morbidity : RT and pregnancy related causes
Boys morbidity : violence, accident and suicide
1/3rd of 333 million new STDs cases occur in young people below 25 years of age
of 7000 new HIV cases belong to 10-24 years of age.
Adolescence has been defined by the World Health Organization as the period of life
spanning the ages between 10-19 years, and youth as between 15-24 years. Young people
are those between10-24 years of age (WHO, 1997).
Adolescence is the period of physical, psychological and social maturing from childhood
to adulthood.
Main health problems among adolescent and youth:
Reproductive health problem
Early marriage
Teenage pregnancy
Abortion
STDs / HIV and AIDS
Substance abuse and use
Intentional and non-intentional injuries
Mental health illness
Violence and sexual abuse
Underlying factors contributing to adolescentt health issues and concerns:
Lack of information
About physical and psychological change
Potential risk to health and development of risky behaviors
Right to health, education
Availability of services
Lack of life skill
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Necessary skills such as communication, decision making, negotiation, critical

thinking skill to make responsible decision.
Underlying factors contributing to adolescent health issues and concerns:
Lack of access to health services
Need services that are adolescent friendly with emphasis on confidentially, nonjudgmental attitude of service providers
Lack of safe and supportive environment
Hindering factors to access and utilization of health services:
Most dont realize illness and not aware of serious consequences of illness
Dont know they can get help to prevent or treat illness
Lack of skills of service providers to deal with adolescent concerns
Three-fold objective for adolescent and youth:

Promote their fullest health, wellbeing and potential
Meet their social, economical, political, educational, health and other special concerns
Encourage them, particularly young women to continue their education, avoid early
marriages and high risk pregnancies, thereby reducing associated risk of mortality and
morbidity
Teenagers guide for a healthy lifestyle:
Think well, look good and feel better
Discuss about your body and its function
Let talk about sex and sexual responsibility
Stay away from harmful substances
Dont worry be happy
Well informed, empowered, responsible, healthy adolescent and youth.
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Special need for growth and development of spiritual, physical, emotional and social life
Child:
Newborn (ages 01 month);
Infant (ages 1 month 1 year);
Toddler (ages 13 years);
Preschooler - (ages 46years);
School-aged child - (ages 613 years);
Adolescent - (ages 1320 some time it says 10 -19 years).
Adolescents are children who are 10 to 20 years of age
Adolescence, of course, is that period of life between childhood and adulthood. But when
does childhood end and when does adulthood begin? There is no definite margin.
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Adolescence is time of great change and transition for teens and parents alike; it is the
period when an individual first begins to let go of childish ways in an effort to hold adult
behavior. It can be a period of great stress and anxiety, as teenagers face many questions
about their own identity.
Adolescent developmental problems, such as behavior disturbances, developmental
disabilities, and the dangers of teen alcohol, tobacco, and drug use.
This time period is divided into three stages, including early (10 to 13 years of age),
middle (14 to 17 years of age), and late (18 to 20 years of age). During this time, child
goes through many changes in his physical, psychological (mental and emotional), and
social growth.
Spiritual development:
Spiritual development: many religious aspects of adolescence, such as their behavior,
attitudes, influences, and understandings of religion.
Spirituality emphasizes fear, wonder, and other experiences that are beyond ordinary,
everyday life, and that connect the individual to something transcendent (inspiring)
and/or of key importance
Spiritual development involves confessing (acknowledge) and turning from sin,
experiencing difficult times when God seems remote. Spiritual formation activities can
assist this process, including prayer, retreats, meditation, fasting, and the like.
Physical growth:
Child's body changes quickly during puberty. Puberty is a period in adolescence where
the body develops and matures sexually. This period usually starts at 7 to 13 years of age
in girls, and 9 to 14 years of age in boys. Hormones, family history, and nutrition all add
to childs growth.
Body make-up
Sexual growth
Height and weight
Mental changes occur during adolescence:
Change in self-image : defines his own ideals, values, and principles. By late
adolescence, s/he is happier with who he is, and his/her place in society.
Intellectual development and skills: Adolescents learn to think in new ways to
understand complex ideas. They learn through selective and divided attention, and better
memory. Problem solving skills also improve. They are able to think in a logical way, use
sound judgment, and develop abstract thinking
Setting goals and ambitions: As an adolescent learns who he is, s/he begins to plan for
the future. Based on his beliefs and values, he decides who s/he wants to be and what s/he
wants to do in life. By late adolescence, s/he begins to work hard to reach his goals.
Social changes occur during adolescence:
Family: An adolescent may begin to spend less time with parents and more with friends.
He often longs for freedom and starts to detach himself from his family. He begins to
depend on himself more and learn responsibility.
Friends: During early adolescence, having close relationships and being accepted into a
peer group is very important. A child's actions can be greatly changed by peers or peer
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pressure. More time spent with friends gives a child more chances to try new things. S/he
tries smoking, drinking alcohol, or sexual activity. By middle adolescence, boys and girls
start to become friends.
Community: As a child grows older, his relationships with others also grow. By late
adolescence, s/he learns to think about the needs of others instead of thinking only of
himself.
What problems may occur during adolescence:
Early or delayed puberty: The age a child enters puberty depends on many things.
Some children develop sexually sooner or later than others. Early or delayed puberty may
be caused by certain medical conditions.
Low self-esteem: Child may not feel good about him/herself, especially during early
adolescence. Most children focus on their bodies as changes occur, and this may cause
poor body image.
Mood problems or depression: Mood problems such as depression or anxiety may
affect adolescents. These often occur because of changes during puberty. Deep
depression is serious and may lead to thoughts or attempts of suicide
Need for independence: Adolescents seek freedom. They tend to move away from their
parents emotionally, and feel comfortable with their peers. This may lead to conflict and
problems between parents and their child. S/he may begin to reject parents rules and
values, and struggles to learn who he is.
Poor nutrition or low physical activity: Unhealthy eating habits and lack of physical
activity can lead to children being underweight, overweight, or at risk of growing
overweight. These conditions may lead to medical problems, such as diabetes (high blood
sugar), hypertension (high blood pressure), and hyperlipidemia (high blood cholesterol).
Risky behaviors: As the child starts making his/her own choices, peer pressure may
cause poor judgment. S/he may choose to take unsafe risks. Risky behaviors include
trying drugs, alcohol, cigars or tobacco. They also include getting into physical fights or
having risky sex. They may decide not to wear seatbelts or helmets, drive while drunk, or
carry a weapon. A child is more likely to do these things if he has problems with selfcontrol, family, or the community. Younger adolescents that cannot control their temper
often act without thinking about the results of their actions
Special need to keep adolescent safe:
Caregivers: Children who are sexually active, smoke tobacco, use street drugs, or overdo
drink may benefit from talk therapy, or counseling.
Know child: Get involved in childs activities. Spend time with him, and be there when
he needs you. Stay in contact with child's teachers to find and deal with problems early.
Get to know his/her friends
Promote good nutrition and physical activity: Make sure child eats a balanced diet and
limits the amount of foods high in fat and sugar
Set clear rules that do not change: Be a good role model for the child. Limit television
and movies. Even if your child is older, limit the amount of violence, sex, and drugs and
alcohol use that s/he sees. Talk about the dangers of sex, alcohol, and drug use.
Talk to your child: Talk to your adolescent about the risks of being sexually active.
Teach him about birth control and protection against sexually transmitted diseases.
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Teach road safety: Explain to your child why he must wear helmets or seat belts. Help
him/her understand the risk of riding with a driver who has used drugs or drunken
alcohol.
Understand your child's actions and signs: Learn the signs of drug use, early sexual
activity, depression, and eating problems, such as anorexia nervosa (starving to stay thin).
Knowing the early signs of problems can give you a chance to get your child help before
problems get more serious.
Adolescent problems in Nepal, including teenage pregnancy, STDs,

HIV/AIDS, drug abuse, alcoholism, smoking, accidents, violence,
crime, etc. will emphasis on prevention and rehabilitation:
Issues and Challenges:
AHD program still on Adhoc basis
Government experience in Adolescent Health programming is limited
Capacity building of program managers required
A major challenge is mobilizing adequate resources to implement adolescent health
programs
Adolescent health challenges and opportunity:
There is growing recognition that because of a combination of biological, psychological
and social factors adolescents faces many different health risks and problems such as
sexually transmitted infections including HIV/AIDS, early and frequent pregnancy,
substance abuse, accidents and violence.
On the other hand adolescents are usually very energetic and receptive to information that
pertains to them and are anxious to become more autonomous in their decision-making.
Such curiosity and interest in learning offers great opportunities for improving adolescent
health and development.
Adolescent and influencing factors:
Healthy development of adolescents is dependent upon several complex factors:
Socio-economic circumstances,
Environment in which they live and grow,
Quality of family, community and peer relationships,
Available opportunities for education and employment, and
Access to health information and services.
National Adolescent Health and Development:
Goal and Objective:
GOAL:
The goal of the National Adolescent Health and Development Strategy is to improve the
health and socio-economic status of adolescents.
MAIN OBJECTIVES:
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To increase the availability and access to information about adolescent health and
development, and provide opportunities to build skills of adolescents, service providers
and educators.
To increase accessibility and utilization of adolescents health and counseling services for
adolescents, and
To create safe and supportive environments for adolescents in order to improve their
legal, social and economic status.
Interventions
To achieve the above mentioned objectives, appropriate interventions will be identified
and implemented through inter and intra-sectoral coordination and collaboration in the
following areas to achieve the objective;
Information and skills,
Health services and counseling, and
Safe and supportive environment
Adolescents need to be empowered with correct, age appropriate and current information and
skills to develop and practice responsible behaviors to protect themselves from risks as well as to
help them seek appropriate services. Information for parents, teachers and social workers is
equally important as they play key roles in adolescent health and development.
Adolescent figure in Nepal:
In Nepal, adolescents comprise more than one fifth (22%) of the total population. As a
result of population momentum the adolescent population will continue to grow for at
least twenty years. Existing studies show that nearly half (50%) of 15-19 year old
adolescent girls and a fifth (20.6%) of the adolescent boys aged 15-19 years are married
(1991 census)
According to Nepal Family Health Survey (NFHS), one fourth (24%) of adolescents are
already pregnant or mothers with their first child (NFHS, 1996). The contraceptive
prevalence rate (CPR) is reportedly only 6.5% among adolescents. The 1996 NFHS also
revealed that 50% of adolescent mothers do not receive antenatal care and the majorities
(90%) of adolescent mothers deliver their babies at home-a trained health worker assists
only 14% of these deliveries.
The Maternal Mortality and Morbidity Study (DoHS, 1998) reports that a significant
proportion of maternal deaths (18.9%) occur in the adolescent age group
According to a study on the nutritional status of adolescent girls conducted in three
districts of Nepal, 40% had iodine deficiency and 47.4% had nutritional anemia (New
Era, 1994).
A majority of adolescents (64%) had their first sexual intercourse when they were
between 15-17 years of age. The mean age of first sexual intercourse among males was
16.4 years while among female was 16 years (VaRG, 1999).
Of all HIV cases, 13% were found in the 14-19 year age group and 70% of them were
female (NCASC 2000). Young people aged 16-19 constituted 22.5% in the total drugs
abusers (New Era 1996).
Within Nepal, the number of female commercial sex workers is estimated to be 25,000;
of them 20% are estimated to be under the age of 16.
Twenty three percent of, children between the ages of 10 and 14 years and 62.8 % of the
5-19 age groups are reported to work in the labour force. (NLSS 1996).
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Adolescents in Nepal often encounter problem, which include lack of awareness and
knowledge about sexual and' reproductive health, early marriage, early and frequent child
bearing, unsafe abortion, STD/HIV AIDS, and substance abuse. These problems are often
exacerbated by social problems such as poverty, illiteracy, dropping out of school, child
labour, gender discrimination, violence and abuses including girl trafficking and
prostitution
Adolescent problems:
The problems of adolescence are classified as
morphological / developmental
psychological
social
educational
Some problems are absolutely unimportant and trivial. They could be easily ignored. But
even such problems cause great concern to adolescent people.
Morphological / Developmental Problems:
over growth of hair or undergrowth of hair
over weight and underweight
skin colour problems
Facial deformities, pimples, etc.
Limb deformities
Abnormal growth of genitals and breasts.
Psychological Problems:
Ignorance about many basic facts leads to psychological problems like
Misconceptions about sexual feelings, sex related issues.
Misconceptions about child birth, reproduction.
Misconceptions about coitus, menstrual cycles.
Fear about sex and sexual issues.
Guilt feeling about sex related issues.
Inferiority / Superiority complex about skin colour, beauty, mental ability and IQ
(Intelligence Quotients)
Curious perceptions about dress and fashion codes.
Wrong and unrealistic ideologies about friendship and courtship.
Perceptional or communicational or preconceived complications about their teachers and
parents.
Attraction towards opposite sex.
Unrealistic and irrational curiosity about sex and sex related issues.
Exceptional vulnerability to suicide psychology.
Social:
Anticipated unemployment and insecurity due to unemployment.
Unwarranted and mysterious extreme dislike towards brother / sisters, friends.
Strong closeness with brothers / sisters, friends.
Unstable relationships with friends.
Unrealistic social perceptions about violence, love, sex as influenced by media.
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Unusually vulnerable and unstable relations with relatives.

Fear / imagination about married life, life partners
Educational:
Tensions of attending the classes, examinations and tests.
Low IQ feeling.
Fear about failure in examination.
Fear about low score.
Fear and concern about a future career.
Misconceptions about teachers
Others:
Teenage pregnancy: which is harmful to the health of mother and child, is a common public
health problem worldwide
Social factors and prevalent norms in the community determine the proportion of teenage
pregnancy in the community. In the light of high risk associated with teenage pregnancy,
the socio-cultural determinants, which influence the conception among teenagers in
Nepal
Adolescent pregnancy continues to be a complex and challenging issue for families,
health workers, educators, societies and governments, and adolescents themselves
One of the important factors for the rapid population growth in the world is adolescent
childbearing
Adolescent childbearing is heavily concentrated among poor and low-income teenagers,
Teenage mothers seem to be at higher maternal and perinatal risks.
Adolescents comprise of 23% of 23 millions of Nepalese population. (CBS, UNFPA
2002) The median age at first marriage for ever married women in Nepal (age 15-49) is
16.6 years, which indicates that majority of newly married couples are adolescents.
(FHD, New ERA 2002)
Causes and risk factors of teenage pregnancy:
Poverty
Early marriage
Culture
Low value and self-esteem of girls,
Low level of education
Unemployment
Low level of contraceptive use,
Sexual abuse and assault.
Early dating and risky sexual behaviors
Early use of alcohol and/or other substance use
Lack of a supportive environment; lack of involvement in school, family, or community
activities and /or poor quality family relationships
Perceiving little or no opportunities for success and/ or negative outlook on the future;
living in a community where early childbearing is common and viewed as the norm
rather than as a cause for concern;
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Consequences of Teenage Pregnancy:

Higher rates of morbidity and mortality for both the mother and infant
Greater risk of socioeconomic disadvantage throughout their lives
Terminates a girl's educational career, threatening her future economic prospects,
More prone not only to pregnancy and child bearing but also to diseases and conditions
specially STI, substance abuse and accidents
Pregnancy complications like obstructed labor, retardation of fetal growth, premature,
birth etc
Unsafe abortion,
Babies are usually associated with birth injuries, serious childhood illness and mental and
physical disabilities.
The incidence of low birth weight (<2500 g) is more than double the rate for adult
pregnancies, and the neonatal death rate is almost three times higher
Low birth weight and prematurity raise the probability of a number of adverse conditions,
including infant death, blindness, deafness, mental retardation and cerebral palsy
Incidence of nutritional anemia in pregnancy
Prevention of Adolescent Pregnancy:
Delaying the initiation of sexual activities and early marriages
Directed at preventing pregnancy for sexually active adolescents by the use of effective
contraception
Ensuring the well-being of adolescent parents, including the avoidance of further
pregnancies.
Create awareness through abstinence education program, clinic-focused program to bring
about behavioral changes in the teens
Prevention of marriage at teenage
Adolescent sex education to prevent teenage pregnancy
Family planning services, offered at no cost, teen friendly environments, provision of
adolescent clinics
Teen Awareness Programs by media on sexual abstinence and delaying sexual activity
Enactment and enforcement of laws that specify a minimum age for marriage, as well as
Actions to mobilize families and communities to give their daughters the additional time
they need to grow and develop from girlhood into womanhood before becoming wives
and mothers.
Alongside this, health services should be ready to provide adolescents who are pregnant
with the antenatal care they need,
Obtain a safe abortion where this is permitted by law.
Some problem of adolescent:

Mental health:
Many mental health problems emerge in late childhood and early adolescence. Enhancing
social skills, problem-solving skills and self confidence can help prevent mental health problems
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such as conduct disorders, anxiety, depression and eating disorders as well as other risk
behaviours including those that relate to sexual behaviour, substance use, and violent behaviour.
Health workers need to have the competencies to relate to young people, to detect mental
health problems early, and to provide treatments which include counselling, cognitivebehavioural therapy and, where appropriate, psychotropic medication.
Substance use
In addition to laws that limit the availability of illicit substances, tobacco and alcohol,
interventions to reduce demand for these substances improve the conditions for healthy
development.
Increasing their awareness of the dangers of substance use, building their competence to
resist peer pressure and to manage stress in a healthy manner is effective in reducing
adolescents' motivation for substance use.
Unintentional injuries
Approaches for reducing road traffic crashes, and the occurrence of serious injuries if and
when crashes occur, are important for safeguarding adolescent health. These include:
Enforcing speed limits;
Combining education with laws to promote seat belt (and helmet) use and to
prevent driving under the influence of alcohol or other psychoactive substances;
Providing alternatives to driving by increasing the availability of safe and
inexpensive public transport.
Actions to make the environment safer and to educate children and adolescents on how to
avoid drowning, burns and falls can help reduce the likelihood of their occurrence. When
someone is injured, prompt access to effective trauma care can be life saving.
Nutrition:
Chronic malnutrition in earlier years is responsible for widespread stunting and to
adverse health and social consequences throughout the life span. This is best prevented in
childhood but actions to improve access to food could benefit adolescents as well.
Anaemia is one of the key nutritional problems in adolescent girls. Preventing too-early
pregnancy and improving the nutritional status of girls before they enter pregnancy could
reduce maternal and infant mortality, and contribute to breaking the cycle of
intergenerational malnutrition.
Improving access to nutritious food, to micronutrient supplementation and in many places
to preventing infections as well. Adolescence is a timely period to shape healthy eating
and exercise habits which can contribute to physical and psychological benefits during
the adolescent period and to reducing the likelihood of nutrition-related chronic diseases
in adulthood. Promoting healthy lifestyles is also crucial
Sexual and reproductive health:

Programs that aim to educate adolescents about sexual and reproductive health need to be
combined with programs aimed at motivating them to apply what they have learnt in their
lives
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HIV/STD:
Young peoples risk of HIV/STD infection is closely correlated with age of sexual
entrance. Abstinence from sexual intercourse and delayed initiation of sexual behaviour are
among the central aims of HIV/STD prevention efforts for young people.
Decreasing the number of sexual partners and increasing access to, and utilization of
comprehensive prevention services, including prevention education and provision of
condoms, are essential for young people who are sexually active
Programs should also focus on prevention and early intervention in other health risk
behaviors, such as substance use. Young people need HIV testing services that are
accessible and appropriate. Young people living with HIV need treatment, care, support
and positive prevention services. All HIV services for young people should involve
young people living with HIV in their planning and provision.
Substance abuse
Substance abuse is a major public health problem that puts millions of adolescents at
increased risk for alcohol-related and drug-related traffic accidents, risky sexual
practices, poor academic performance, juvenile delinquency, and developmental
problems
Smoking:
Many youth in Nepal are spoilt in smoking as they want to explore things that they see or
are told about by their friends. Many of the youth smoke to be "smart" -- believing what
they are shown in the movies and advertisements. Another reason from which the youth
are spoilt in cigarette is that they have lack of proper guidance and an unhealthy circle of
friends. The parents who are very busy give their children unnecessarily money as they
think that money can occupy the space for love, giving them time, understanding their
feelings, etc. As these youth are tortured mentally, they go for smoking as they want
relaxation and experiment with smoking as nobody says anything about smoking
Cigarette smoking is a social custom and tradition
Cigarette companies also sponsor concerts, sport events, sport figures, and even dance
parties where the youth are present. At these events caps, t-shirts, and other items with
brand logos and colors are displayed and given away, and are very popular.
As 3 million people die of cigarette smoking each year, 70% of which are from
developing countries, it is really necessary to minimize cigarette smoking. Studies
indicate that 80% of the lung cancer is caused by cigarette smoking and as cigarette
smoking is often the precursor to drugs. (Panorama Aug 25, 2002)
Crime:
Violence, destruction, shoplifting (Theft), burglary (robbery), bloodshed, etc
Causes:
Individual characteristics (social bonds and morality and self-control) and
Lifestyles (as defined by antisocial peers, substance use and exposure to risky behaviour
settings) and
Their joint influence on adolescent involvement in crime, against the setting of the
juveniles' social context - taking into account family, school and neighbourhood
influences.
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Consequences of Adolescent Substance Abuse:

Adolescents are at serious risk for a number of direct and indirect consequences,
including the following:
Traffic AccidentsNearly half (45 percent) of all deaths from traffic accidents are
related to the consumption of alcohol, and an estimated 18 percent of drivers age 16 to 20
(or 2.5 million adolescents) drive under the influence of alcohol.
School-Related ProblemsAdolescent substance abuse is associated with declining
grades, absenteeism from school, and dropping out of school. Cognitive and behavioral
problems experienced by teens abusing substances may interfere with their academic
performance.
Risky Sexual PracticesAdolescents who use drugs and alcohol are more likely than
nonusing teens to have sex, initiate sex at a younger age, and have multiple sex partners,
placing them at greater risk for unplanned pregnancies and HIV/ AIDS, hepatitis C, and
other sexually transmitted diseases.
Delinquent BehaviorAdolescents who use marijuana weekly are six times more likely
than nonusers to report they run away from home, five times more likely to say they steal
from places other than home, and four times more likely to report they physically attack
people.
Juvenile CrimeAdolescents age 12 to 16 who have ever used marijuana are more
likely at some point to have sold marijuana (24 percent vs. less than 1 percent), carried a
handgun (21 percent vs. 7 percent), or been in a gang (14 percent vs. 2 percent) than
youth who have never used marijuana.
Developmental ProblemsSubstance abuse can compromise an adolescents
psychological and social development in areas such as the formation of a strong selfidentity, emotional and intellectual growth, establishment of a career, and the
development of rewarding personal relationships.
Physical and Mental ConsequencesSmoking marijuana can have negative effects on
the users mind and body. It can impair short-term memory and comprehension, alter
ones sense of time, and reduce the ability to perform tasks that require concentration and
coordination, such as driving a car. Evidence also suggests that the long-term effects of
using marijuana may include increased risk of lung cancer and other chronic lung
disorders, head and neck cancer, sterility in men, and infertility in women.
Future Use DisordersThe earlier the age at which a person first drinks alcohol, the
more likely that person is to develop an alcohol use disorder. A person who starts
drinking alcohol at age 13 is four times more likely to develop alcohol dependence at
some time in his or her life than someone who starts drinking at age 20.
Main causes of use of substances:
Individual
Value attached to image of happiness and socialization
Use within family
Peer pressure
Psychological factors
Socio-cultural environment
Availability
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Lack of effective law and its implementation

Lack of monitoring and supervision
Advertisement / Promotion
Use by role model
Support Adolescents in Treatment, Recovery, Rehabilitation:

Support they can get from their families and communities.
Encourage schools to offer student assistance programs, counseling on substance abuse,
and confidential referral to treatment and recovery resources in the community
Encourage treatment centers, schools, and community-based youth organizations to
conduct support groups for children of parents who are addicted to alcohol and drugs.
Encourage adolescents who have recovered successfully from addictive disorders to
participate in community events that target their peers.
Because alcohol and drug use among youth often occurs in groups, be aware that
encouraging one young person to seek help may lead others in his or her social group to
seek treatment.
Encourage environmental changes in community that promote recovery such as reducing
the number of billboards advertising alcoholic beverages and holding alcohol-free
recreational events. Encourage the participation of family members in all aspects of the
treatment and recovery process for adolescents, and foster the availability of familycentered support groups and other services that address the needs of the entire family.
Be a positive role model for young people in treatment and recovery by not engaging in
any illegal or unhealthy substance use.
Get involved in organizations that advocate public policies and funding to support
substance abuse treatment and recovery programs for adolescents.
Stay informed about available local resources for treatment and recovery and uses this
knowledge to help others.
Training to youth and concerned health worker
Community awareness activities
Peer education
School health program
Campaign and celebration
IEC activities
Advocacy and effective rule and regulation
Implementation of rule and regulation
Involvement of adolescents in positive social activities
Proper information, Opportunities for the adolescents
Recreation, sports and other facilities
Early diagnosis, counseling, treatment and other rehabilitation activities
Care of Handicapped and disabled and those weight chronic conditions:
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Disabilities:
Disabilities have been defined in many ways. Disability is a broad term that compares
actual ability to normal functioning. In general, disabilities are characteristics of the
body, mind, or senses that, to a greater or lesser extent, affect a persons ability to engage
independently in some or all aspects of day-to-day life.
In general, disabilities are characteristics of the body, mind, or senses that, to a greater or
lesser extent, affect a persons ability to engage independently in some or all aspects of
day-to-day life.
"Disabilities is an umbrella term, covering impairments, activity limitations, and participation
restrictions. An impairment is a problem in body function or structure; an activity limitation is
a difficulty encountered by an individual in executing a task or action; while a participation
restriction is a problem experienced by an individual in involvement in life situations. Thus
disability is a complex phenomenon, reflecting an interaction between features of a persons
body and features of the society in which he or she lives
-WHO
Different kinds of disabilities affect people in different ways. The same kind of disability
can affect each person differently
Disability can become a fact of life for anyone at any time.
Some people are born with a disability; some people get sick or have an accident that
results in a disability; and some people develop a disability as they age.
Disability is neither inability nor sickness
Most persons with disabilities are just as healthy as people who dont have disabilities;
however, for a variety of reasons, persons with disabilities can be at greater risk for
illness.
Most people with disabilities can, and do, work, play, learn, and enjoy full healthy lives
in their communities.
Truth on disability:
Injuries / accidents cause disability. But more disability is due to:
Illnesses like cancer, heart attack or diabetes cause the majority of long-term
disabilities. Back pain, injuries, and arthritis are also significant causes.
Most disabilities are not work-related.
Lifestyle choices and personal behavior that lead to obesity are becoming major
contributing factors
Persons with disabilities may face challenges because of their physical or mental
limitations. But the attitudes of other people may also create barriers. Understanding this social
aspect of disability is essential.
Impairment/Disabilities:
Impairments may be acquired at birth or through accident or disease.
Many impairments which result in disabilities are also associated with aging. This is
especially significant, as the population as a whole is growing older. Although there is a
great variety of specific causes, as well as combinations and severity of disabilities.
Disability can relate with the basic impact at four major categories of impairment. The
four categories are:
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Visual Impairments
Hearing Impairments
Physical Impairments
Cognitive/Language Impairments
Visual Impairment
Low vision / functional limitation
Blind
Hearing impairment
hard of hearing / deafness
Sensorineural hearing loss
Conductive hearing loss
Physical Impairments
poor muscle control, weakness and fatigue, difficulty walking, talking, seeing,
speaking, sensing or grasping (due to pain or weakness), difficulty reaching
things, and difficulty doing complex or compound manipulations (push and turn).
Individuals with spinal cord injuries may be unable to use their limbs. Twisting
motions may be difficult or impossible for people with many types of physical
disabilities (including cerebral palsy, spinal cord injury, arthritis, multiple
sclerosis, muscular dystrophy, etc.).
Physical Impairments:
Nature and Causes of Physical Impairments
Neuromuscular impairments include
paralysis
weakness (lack of muscle strength, nerve enervation, or pain), and
Interference with control, via spasticity (where muscles are tense and
contracted), ataxia (problems in accuracy of motor programming and
coordination), and athetosis (extra, involuntary, uncontrolled and
purposeless motion).
Skeletal impairments include joint movement limitations (either mechanical or
due to pain), small limbs, missing limbs, or abnormal trunk size.
Cognitive/Language Impairments
Cognitive impairments are varied, but may be categorized as memory, perception,
problem-solving, and conceptualizing disabilities
Language impairments can cause difficulty in comprehension and/or expression
of written and/or spoken language.
Causes of Disabilities:
Prenatal
Chromosomal
Genetic
Rhfactor
Maternal stress
Environmental causes:
External agents
Drugs
Alcohol
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Maternal Nutrition
Some infections
Maternal diseases
Mothers age
Chromosomal
Genetic
Perinatal
Drugs during labor & delivery
Premature infants
Oxygen deprivation
Infections
Childhood
Injuries
Childhood disease
Rhfactor
Environmental causes
Obesity and disability:
Obesity is being defined as a pandemic in itself, however, obesity diseases are
also rising in alarming incidence, which is not only costing the person ill health,
but putting greater demand on other people to base their medical costs
Obesity related diseases include diabetes, heart disease, stroke, arthritis, asthma
and cancer, which in turn have their own complications and leads to disability.
Obesity is the most curable and preventable condition with determination, support
from employers, a healthy attitude to eating small, regular meals, and exercise.
There are many causes of disability, both biomedical and socio-environmental.
Causal factors may operate independently, or combine to produce a disability. It is
important to know the causes of a disability in order to prevent further
occurrences. However, despite all that is known about the causes of various
disabilities, there are many conditions for which no cause has been identified.
There are many causes of disability, both biomedical and socio-environmental. Causal
factors may operate independently, or combine to produce a disability. It is important to
know the causes of a disability in order to prevent further occurrences. However, despite
all that is known about the causes of various disabilities, there are many conditions for
which no cause has been identified.
Prevention of disability:
Enabling timely medical intervention
Efforts required in order to reduce the expression and severity of disability
Continuous health care system, home help and other supportive services,
The management of childhood disabilities requires considerable medical, educational,
social and rehabilitative care
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Stages of prevention:
1) Primary prevention:
Prevention desirable for everyone
Prevention recommended for high-risk groups
Prevention in individuals with an identified risk
Primary prevention efforts include:
Genetic counseling
Pre-pregnancy planning
Improved prenatal, perinatal and postnatal care
Immunization programs
Primary prevention in the environment: injuries associated with our daily
activities, life-style and behavior patterns
2) Secondary prevention: aim at reducing the duration or severity of disability. These
activities provide early identification of the disabling condition followed by prompt
treatment and intervention to minimize the development of disability which mainly
develops either at the prenatal or neonatal period.
Early intervention methods vary widely depending on the nature of the disability and its
etiology but include the following:
Genetic counseling to prevent further cases
Specific treatment of underlying conditions, as in congenital hypothyroidism
Treatment of specific contributory disabilities, e.g., hearing, vision
Optimizing the functioning of the disabled individual and his or her family by:
Identifying and addressing the childs strengths and weaknesses, which will allow
achievement of his or her full potential during the most crucial early years.
Preventing a single handicap from leading to secondary defects on other areas of
development.
Preventing deterioration in development due to inappropriate physical and emotional
handling by parents, peers, and society.
Improving interaction with siblings, between child and parents, and between parents, by
lessening parental emotional reactions and promoting greater understanding the childs
needs. This supportive relationship contributes to more successful developmental patterns
later.
Helping families focus on the broad needs of the child.
Improving interaction and coordination among health and developmental providers.
Teaching parents how to utilize community resources more effectively and efficiently.
Providing direct supportive service to families in lower socioeconomic levels whose
children are at increased risk for continuing developmental problems.
3) Tertiary prevention:
Aims at limiting or reducing the effects of a disorder or disability that is already present.
It involves long-term care and management of a chronic condition, e.g. rehabilitation or
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correction of the disability by surgical measures or by adopting strategies by which the

disabled person can lead a normal or near normal life.
Main aims of rehabilitation of the disabled are:

To increase awareness of disabilities and the needs of disabled
people;
To encourage their full integration in society; and
To improve prevention and stimulate a more sensitive and understanding attitude.
Conclusion:
Some disabilities can be prevented, others cannot. By the application of known
techniques, a large number of disabilities can be prevented, or their severity reduced.
Primary prevention is extremely effective because it targets the whole population, and, if
it is successful, the disability addressed never occurs. Secondary and tertiary prevention
efforts are also extremely valuable as they focus on specific groups with definite needs,
and deal with their immediate situations. Some methods of disability prevention are
controversial, but others involve the development of good health habits, good parenting
skills, and adequate social supports.
Injuries:
Injuries account to 8% deaths in Nepal. Road traffic accidents are the major cause of
injuries followed by occupational injuries, burns, violence and suicide related, poisoning,
falls and drowning respectively.
(WHO 2002)
Age group of people from 15 to 40 years is most vulnerable in road accident.
Occupational injuries occur when a person is injured in the course of their employment.
They may occur on the employer's premises.
Burn injuries can be accidental, suicidal and homicidal. Depending on the extent and
severity of burns, and the availability and accessibility to health care, the impact varies
Major causes of accident and handicapped condition in Nepal:
Injuries are a major public health problem in Nepal and disabilities due to violence and
injuries are increasing.
Underlying causes of injury and disability include
Traffic accidents,
Domestic accidents and violence,
Rapid urbanization
Lifestyle changes.
lack of safety systems
Diseases
Problem in developing strategies to prevent disability:
Lack of reliable and good quality national or regional data on injury and disability and
causes
Scientific estimates of injury deaths in Nepal are not available from any single source
No National Crime Records Bureau as such in Nepal that should be responsible for the
collection, compilation, analysis and dissemination of injury-related information.
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Very few studies have been done on injuries in Nepal and data collected from those
studies are even not reliable
No official data on the number of injuries in Nepal except for the road traffic accidents
Initiation on disability prevention:

Ministry of Health and Population and World Health Organization collaborative program
on injury and disability prevention has recently conducted various training programs for
the doctors, health workers and community volunteers on prevention and control of
injury, violence and disabilities in Nepal.
Recording and reporting forms on injuries, violence and disabilities have been developed
and used in the different level of health services in Lalitpur district and gradually
expanding to other districts for data collection on injury, violence and disabilities
Steps to be taken to prevent injuries and disability in Nepal:
A specified annual budget for injury prevention program
Conduction of injury surveillance to track the growing epidemic
Conduction of an in depth situation analysis of injuries, violence and disability in the
country
Making of a National guidelines/protocols/policy on injury prevention and control
Establishment of a nodal agency within ministry to coordinate the range of activities
Enunciating a definitive policy on curriculum on accident prevention and control for
undergraduate, postgraduate medical education and allied medical subjects
Formulating a prioritized plan for human resource development and capacity-building
programmes
Having a mechanism for co-coordinated activities (as several agencies are involved in
prevention and control of injuries)
Specifying a prioritized, targeted, time-bound activity schedule for injury prevention and
control
Need to work out preventive measures as soon as possible as numbers of road traffic
accidents and occupational injuries are alarmingly high
(Kathmandu University Medical Journal (2007), Vol. 5, No. 1, Issue 17, 2-3)
Impairment / disability/ Handicap:

Impairment refers to failure at the level of organs or systems of the body. This means
loss or abnormality of psychological, physiological or anatomical structure or function.
Disability refers to the resulting reduction or loss of ability to perform an activity in the
manner considered normal for a human being e.g. climbing stairs or manipulating a
keyboard.
Handicap is a social disadvantage resulting from an impairment or disability which
limits or prevents the fulfillment of a normal role.
The World Health Organization (WHO), in the context of its health experience, makes the
following distinction between impairment, disability and handicap which was included in the
World Program of Action:
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Impairment: Any loss or abnormality of psychological, physiological, or anatomical

structure or function.
Disability: Any restriction or lack (resulting from an impairment) of ability to perform an
activity in the manner or within the range considered normal for a human being.
Handicap: A disadvantage for a given individual, resulting from an impairment or
disability, that limits or prevents the fulfillment of a role that is normal, depending on
age, sex, social and cultural factors, for that individual.
Rehabilitation:
Rehabilitation includes all measures aimed at reducing the impact of disability for an
individual, enabling him or her to achieve independence, social integration, a better
quality of life and self actualization. Rehabilitation can no longer be seen as a product
to be dispensed; rather rehabilitation should be offered as a process in which all
participants are actively and closely involved.
Basically rehabilitation has two model
Institutional (Medical)
Community Based
Institutional (Medical) Rehabilitation:
Institutional rehabilitation provides excellent services to address the problems of
individual disabled person and is often available only for a small number at a very high
cost. It is often in context to the felt needs of the disabled person, and thus falls short of
their expectations. In an institutional rehabilitation program, the community is not linked
with the process. Hence, when the disabled person returns home, it may become difficult
for them to integrate into their community.
IR is an approach that only focuses on the physical or medical needs of a person or
delivering care to disabled people as passive recipients. It is outreach from a centre. It is
determined by the needs of an institution or groups of professionals, it is segregated and
separate from services for other people.
Institutionalization means work planning, assigning certain professional actions to
relevant professionals, division of functions among people remaining in formalized
relations, introducing the timetable of clients sessions, formalizing diagnostic
procedures, procedures of assistance and reporting to particular professionals and
reporting on actions realized in a given institution. Institution is thus, on the one hand, a
structured organization having relevant material equipment, and on the other hand, it may
appear as a dynamic changeable form whose basic system are indicated by mutual
interactions between clients and personnel
The World Health Organization (WHO) estimates that less than 5% of the world's 480
million people living with a disability have access to medical and rehabilitation services
(WHO, 2005b)
Medical model (Institutional)
Followed by Institutes i.e. Institutional Based Rehabilitation (IBR)
Usually from Centre/ Outreach/ Mobile/Camp
Service providers only concentrate on medical problems -look at the eyes, hands
or legs
Prescribe, occasionally intervenes and consider medical rehabilitation is the only
answer-RELATIONSHIP OFTEN GIVER & TAKER
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Community Based Rehabilitation:

It is a strategy within general community development for the rehabilitation, equalization
of opportunities and social inclusion of all people with disabilities. The primary objective
of CBR is the improvement of the quality of life of people with disability / marginalized
persons. Key principles relating to CBR are equality, social justice, solidarity, integration
and dignity
CBR involves partnerships with disabled people, both, adults and children, their families
and careers. It involves capacity building of disabled people and their families, in the
context of their community and culture. It is an holistic approach encompassing physical,
social, employment, educational, economic and other needs. It promotes the social
inclusion of disabled people in existing mainstream services. It is a system based in the
community, using district and national level services.
Disability often requires life-long management, therefore, activities aimed at enabling
people with disability should be community based as much as possible.
1.
2.
3.
4.
5.
6.
7.
CBR has seven different components

Creation of a positive attitude towards people with disabilities
Provision of rehabilitation services
Provision of education and training opportunities
Creation of micro and macro income generation opportunities
Provision of long term care facilities
Prevention of causes of disabilities
Monitoring & Evaluation.
The core values of individual dignity, autonomy or self-determination, equality and

the ethic of solidarity are fundamentals of human rights law that concern disability. To
achieve this there is an increased focus on the participation and involvement of disabled
people and their representatives
Community based rehabilitation is fully agreement with the concept of Primary
Health Care. This approach promotes awareness, self reliance and responsibility for
rehabilitation within the community. It builds on manpower resources in the community,
including the disabled themselves, their families and other community members. CBR
encourages the use of simple methods and techniques that are acceptable, affordable,
effective and appropriate to the local setting.
There are three main meanings attached to the notion (view) of CBR
People Taking Care of Themselves'
Programs, Projects, Organizations' :CBR programme tries to promote and
facilitate CBR by
By visiting disabled and their families in their home, providing
information, training, therapy, promoting their rights
Approaches to Rehabilitation
Medical + Social Model
Medical + Social model
Community and persons with disabilities (PWD) are major resource
More democratic- PWD are principal decision makers
Reflects rights perspective rather than typical charity
Rehabilitation takes place at the doorstep of PWD
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Social inclusion more important than medical rehabilitation

Early Intervention+ Regular Follow Up+ Total Rehabilitation
Components of CBR program:
Prevention of cause of disability
Provision of care facilities.
Creating a positive attitude towards people with disabilities.
Provision of functional rehabilitation services.
Empowerment, provision of education and training opportunities.
Creation of micro & macro income generation opportunities.
Management / monitoring and evaluation of CBR projects
The essence of empowerment is that people with disabilities and their families take responsibility
for their development within the context of general community development.
For empowerment to happen five approaches can be used:
1. Social mobilization.
2. Political participation.
3. Language & communication.
4. Self Help Groups (SHGs).
5. Disabled Peoples Organizations. (DPOs)
Advantage of CBR Programs:
Home based
Less expensive
Existing community responses and resources
Focus on quality rather than quantity
Multiple approaches based on community needs
Limitations of CBR Programs:
Different priorities in poor: Survival needs have more priorities than solving problems
of disabled. CBR program should therefore be focusing on essential needs.
Complex Organization Low field activity: Educated workers rarely go to field and also find hard to
communicate with low educated disabled people.
Low Social status to CBR worker: Frontline CBR is low profile job so less educated
workers may influence quality of services provided
Lack of community ownership: Breakdown of traditional social structure that
contribute to several problems
Expensive approach: as focus on quality (few hardcore patients)
Good CBR Program builds on:
1. Widespread and existing resources of community
2. Ideas and skills which are existing in minds of family members, community and disabled
3. Has inbuilt community level programmes
4. Part of national agenda in dealing with disability
5. Training to general MPW in rehabilitation
6. Coordination between various H&FW programmes
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7. Hospital to add CBR component to their outreach services

8. Professional and political commitment
Therefore in summary, for a good CBR PROGRAMME, SMALL existing community
input (knowledge and skills) should lead to LARGE output (application and energy)
(An Introduction to Community Based Rehabilitation Continuing Medical Education.
The Internet Journal of Health. 2007 Volume 6 Number 2)
Activities on disability in Nepal:

The Government at both central and local levels, NGOs working on disability, and
INGOs/UN Agencies has been involved in disability sector mainly in following areas.
Conducting Community Based Rehabilitation (CBR) programmes.
Raising awareness and advocacy activities to protect and promote the rights and
opportunities of people with disabilities.
Providing preventive and corrective measures of disability in health sector.
Providing scholarship and conducting special education through integrated
approach.
Providing vocational training and other income generating opportunities to
support and promote livelihood.
Introducing policies and laws for protecting rights and opportunities of people
with disabilities.
Legal issue of disabled:
The disabled is the most marginalized group of societies universally. The status of the
disabled in the developing and the least developed countries is more vulnerable than in
the developed countries. Being a least developed country, in Nepal, the disabled are
deprived of their basic human rights
Discrimination on businesses, jobs and housing accessible to persons with disabilities
Legal rights of the disabled of Nepal and activities:

Legal Provisions pertaining the rights of the disabled
1. The Constitution of Nepal 1990:
Right to equality is enshrined (Protected) in the article 11 of the Constitution. The Article
stipulate (Specify) that everybody is deemed equal before the law. No one shall be
discriminated on the ground of religion, sex, cast or personal belief. However, based on
the concept of equity, the article allows formulating special provisions for the protection
and promotion of the right of the marginalized groups, women and disabled people.
Chapter 4 of the Constitution concerns with the directive principle suggested to the state
by the constitution. Such principles are not mandatory and cannot be enforced by any
court. However, these principles are deemed to be direction for the government and it is
expected that the government will gradually implement such principles making essential
laws.
Under the Chapter 4, Article 26 proposes special provisions with regard to health,
education, and social security for the protection and development of disable people.
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2. Child Act 1991

Section 36 of the Act concerns with the right of disabled children, who do not have
parents, to be placed in the child welfare home until they are transferred to the special
welfare home.
3. The Disabled- Protection and Welfare Act 1982
As mentioned in the preamble (introduction), the act was promulgated for the following
reasons: Protection and promotion of the interest of the disabled. Elimination of the
circumstances that trigger people to be disabled. Formulating welfare provisions for the
disabled with regard to education, employment and so on that enable them to be active
and productive citizens.
The Act defines the term disable as powerlessness to perform the day-to-day business due
to physical and mental weakness. Section 5 guarantees the right to equality to the
disabled and further stipulates: the disabled shall not be discriminated with regard to
providing education, training. In addition, the disabled shall not be excluded from to be
involved in associations, organizations and programs on the ground of their physical or
mental inability.
The same section further pronounces that the disabled shall be provided with the political
right, economic and social security, dignity, right to employment and any profession they
choose.
4. The Disabled Protection and Welfare Regulation 1994:
Rule 4 guides Village Development Committees and Municipalities to keep data of the
disabled residing therein. Rule 8 directs the government to set up welfare homes for the
disabled. Rule 15 directs the government to cooperate the NGOs that provide the
disabled with education and trainings.
5. Local Self Government Act 1999:
The Act mandates the local Development Committees to keep and update the data of the
disabled residing their respective territory
Implementation of the international and national laws that deal with the rights of the
Disabled:
In Nepal, the implementation of the rights of the disabled guaranteed by the national and
international laws is not satisfactory. The disabled are not able to utilize their
fundamental rights enshrined (preserved) in the constitution. An example of such
situations is that the disabled do not have the equal access to public services. Right to
equal access to public service is guaranteed by the Universal Declaration of Human
Rights and the constitution as well. However, due to the disabled unfriendly
infrastructure of the public buildings and buses, the disabled do not have easy access to
such facilities.
Necessity of an international convention on Disability:
We all are aware of the fact that the disabled are the mostly marginalized people in
societies universally. There are a number of international conventions to deal with the
different issues. For example, there are conventions to deal the right of women, children,
and refugees. However, there is no single convention to advocate the rights of the
disabled. Therefore, in order to advocate the rights of the disabled, an international
convention is indispensable.
Conclusion:
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In Nepal, there are limited numbers of laws that endeavor to protect and promote the
rights of the disabled. However, due to lack of effective implementation of the laws, the
disabled of Nepal are deprived of their basic human rights.
There is not any international convention to deal with the rights of the disabled.
Therefore, it is indispensable to have a convention. It is expected that the proposed
convention would bring positive change in the status of the disabled universally.
Legality:
Do disabled persons enjoy the same rights as others?
Do they have specific rights? If they do have such rights, where are those rights
established? Are they to be found mostly in declaratory provisions, which afford no legal
protection?
Are they recognized as being entitled to exercise them on an equal basis with other
persons?
the right to a standard of living adequate for the health and well-being of himself
and of his family
the right to security in the event of unemployment, sickness, disability,
widowhood, old age or other lack of livelihood in circumstances beyond his
control
Article 5
Disabled persons are entitled to the measures designed to enable them to become as selfreliant as possible.
Article 6
Disabled persons have the right to medical, psychological and functional treatment,
including prosthetic and orthotic appliances, to medical and social rehabilitation,
education, vocational training and rehabilitation, aid, counseling, placement services and
other services which will enable them to develop their capabilities and skills to the
maximum and will hasten the process of their social integration or reintegration.
Article 7
Disabled persons have the right to economic and social security and to a decent level of
living. They have the right, according to their capabilities, to secure and retain
employment or to engage in a useful, productive and remunerative occupation and to join
trade unions.
Article 8
Disabled persons are entitled to have their special needs taken into consideration at all
stages of economic and social planning.
Article 9
Disabled persons have the right to live with their families or with foster parents and to
participate in all social, creative or recreational activities. No disabled person shall be
subjected, as far as his or her residence is concerned, to differential treatment other than
that required by his or her condition or by the improvement, which he or she may derive
there from. If the stay of a disabled person in a specialized establishment is indispensable,
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the environment and living conditions therein shall be as close as possible to those of the
normal life of a person of his or her age
Article 10
Disabled persons shall be protected against all exploitation, all regulations and all
treatment of a discriminatory, abusive or degrading nature.
Article 11
Disabled persons shall be able to avail themselves of qualified legal aid when such aid
proves indispensable for the protection of their persons and property. If judicial
proceedings are instituted against them, the legal procedure applied shall take their
physical and mental condition fully into account.
Five vision statements on disability:

1) Promote people with disabilities to be equal and participatory members of a
nondiscriminatory society.
2) Remove/minimize social barriers for differently-able persons so that they will be able to
contribute to a socially and economically productive and quality life.
3) Remove all barriers to ensure that disabled people are absorbed into society.
4) Ensure equal rights and opportunities for disabled people.
5) Persons with disabilities are here to stay; therefore, do not treat them differently;
minimize their disabilities through services.
Integrated Management of Childhood Illness (IMCI):

Background of development:
Everyday million of parents seek health care for their sick children
Sick children are not properly assessed and treated
Radiology and lab support are minimal in low-income countries
Limited supply and equipment and limited doctors
Often rely on history and sign an symptoms to determine a course of management
Most of children present with signs and symptoms related to more than one condition
Quality care to sick children is a serious challenges
Due to above situation and to provide quality care to sick children WHO and UNICEF
developed a strategy known as IMCI.
IMCI is better than single condition approach because:
Children in developing world are often suffering from more than one condition,
making a single diagnosis impossible
IMCI is an integrated strategy, which takes into account the variety of factors that,
put children at serious risk
It ensures the combined treatment of the major childhood illness, emphasizing
prevention of diseases through immunization and improved nutrition
History of IMCI in Nepal:
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The Community-Based Integrated Management of Childhood Illnesses (CB-IMCI)

program in Nepal evolved from earlier programs including the Control of Diarrheal
Disease (CDD) Program, initiated in 1982 and the Acute Respiratory Infection (ARI)
program, in 1987. Emphasis on community-level involvement in Nepal started with the
ARI Strengthening Program in 1995, followed by CDD in 1996. These approaches were
combined into the CBAC (community-based ARI/ CDD) Program.
The WHO/UNICEF IMCI program, with its emphasis on detecting and managing major
illnesses in children, was first implemented in a few health facilities (HFs) in 1997.
Combined with a community-level component, based on CBAC, it is now known as the
CB-IMCI program. JSI took this approach, combining CBAC with IMCI to three districts
in 1999 and as of April 2007, the CB-IMCI program has been gradually but steadily
expanded to 41 districts.
The CB-IMCI initiative in Nepal is gaining international recognition because of its very
strong community case-management component, in which peripheral health workers,
especially Female Community Health Volunteers (FCHVs), are trained to recognize and
treat pneumonia and diarrhea in children under five years of age. This strategy in IMCI is
unique to Nepal.
Objectives of IMCI:
To reduce deaths and the frequency and severity of illness and disability and to contribute
to improved growth and development
Strategy includes 3 main components:
Improvements in the case-management skills of health staff through the provision
of locally adopted guidelines on IMCI and through activities to promote their use
Improvements in the health system required for effective management of
childhood illness
Improvements in family and community practices.
The core of the IMCI strategy is integrated case management of the most common
childhood problems, with a focus on the most important causes of death i.e. diarrhea,
ARI, malaria, measles, and malnutrition
For effective IMCI program:
Family need knowledge, skill motivation and support
Family need to know what to do in specific circumstances and during the period of child
growing
They need skill to provide appropriate care and to solve the problem
They need to motivate to try and to sustain new practices
They need social and material support from the community.
Key family practices to be improved to reduce MM <5 along with IMCI:
Exclusively breast feeding for six months
Energy and nutrient rich complementary food from six month of age and breast feeding
up to two years or longer
Ensure that children receive adequate amount of micro-nutrients (vitamin A, iron etc)
either in their diet or through supplementation
Dispose of feaces and personal cleanliness and food hygiene
Full course of immunization before the first birth day
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Protect the child in malaria epidemic area
Morbidity
Acute respiratory infections
Diarrhea
Fever
Ear infections
Malnutrition
Local skin infections
Oral thrush
Mortality
Pneumonia
Severe dehydration
Meningitis/encephalitis
Cerebral malaria
Kwashiorkor/marasmus
Sepsis
Hypothermia
Hypoglycemia
Promote mental and social development by responding to a childs need for care and
through talking, playing and providing a stimulating environment
Continue feed and offer more fluid, including breast feeding to children when get sick
Give sick children appropriate home treatment when get sick
Recognize when sick children need treatment outside home and care from appropriate
provider
Follow the health workers advice about treatment, follow-up and referral
Ensure that every pregnant woman has adequate antenatal care.
Common causes of morbidity and mortality:
Needed to reduce morbidity and mortality:

National goal for reducing the morbidity and mortality.
Holistic approach.
Improving family practices.
Equipping the health facility.
Upgrading the health workers skills.
Emphasis on counseling
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How IMCI helps in reducing M/M:

Identifies a child who needs urgent referral.
Gives evidenced based clinical signs for the diagnosis of common problems.
Provides guidelines for the appropriate treatment.
Educates the parent.
Upgrades the health care facility.
Follow-ups the child.
CB-IMCI:
Integrated Management of Childhood Illness (IMCI) is a strategy formulated by the
World Health Organization (WHO) and the United Nations Children's Fund (UNICEF),
presented in 1996 as the principal strategy to improve child health.
It focuses on the care of children under five, not only in terms of their overall health
status but also on the diseases that may occasionally affect them.
IMCI incorporates a strong component of prevention and health promotion as an integral
part of care. IMCI implementation involves the participation of the community, the
health-service sector and the family.
Impact of IMCI:
IMCI improves health worker performance and their quality of care;
IMCI can reduce under-five mortality and improve nutritional status, if implemented
well;
IMCI is worth the investment, as it costs up to six times less per child correctly managed
than current care;
Major Program Components:
Assessing and managing pneumonia and diarrhea by FCHVs and HF-based health
workers. This has increased coverage of these services mostly due to their provision by
CHWs, especially the FCHVs, who manage over half the cases. Monitoring data has
consistently documented that FCHVs can correctly assess, classify and manage sick
children at the community level.
Checking the childs vaccination status and advising the caretaker to return to the clinic
on an immunization day, if the child has not completed his/her immunization schedule.
Checking if the child was given Vitamin A and de-worming tablets during the last
nationwide bi-annual campaign and providing them if necessary.
FCHVs refer serious cases to health facilities.
Orienting traditional healers, village development community (e.g., political leaders) and
health facility operations and management committee (HFOMC) members to encourage
them to play a supporting role to FCHVs.
Organizing Mothers Group orientations about when and where to seek care for sick
children.
CONSTRAINTS AND CHALLENGES:
Maintaining a regular supply of commodities such as Cotrim-P, ORS and timers is
essential though it can be difficult to ensure 100% availability in all locations.
Providing an adequate supply of all CB-IMCI training and program-related materials to
ever increasing numbers of CB-IMCI districts is difficult and expensive.
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Maintaining the quality of the program as CB-IMCI rapidly expands throughout the
country is difficult.
Having a consistent and adequate supply of first and second line CB-IMCI drugs
to meet the growing demands has been challenging.
Maintaining knowledge and skills of health workers and volunteers is difficult for
two reasons. First, frequent monitoring and supervision of volunteers is essential,
but it is also extremely costly and time consuming to conduct review monitoring
meetings. Second, the GON transfers trained workers every two years to nonprogram districts, creating a void in trained workers in the program districts.
CB-IMCI program sustainability can only be achieved if the GON is able to take more
responsibility for the program in each district.
UNIT-4: FAMILY PLANNING 18hrs

Family Planning:
A way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitude
and responsible decision by individuals and couple in order to promote the health and welfare of
family group and thus contribute effectively to the social development of a country
WHO 1971
Family planning not only means the cutting number of children; FP means quality and
preventive health care for women and their families
Objective of Family Planning:
Family planning refers to practices that help individuals or couple to attain certain objectives:
To avoid unwanted pregnancies
To bring about wanted pregnancies
To regulate the interval between pregnancies
To control the time at which birth occur in relation to the age of the parents
To determine the number of children in the family.
Scope of Family Planning (Modern concept):
It varies from country to country as per national policy and objective.
Proper spacing and limitation of birth
Advice on sterility
Education for parenthood
Sex education
Screening for pathological condition related to the reproductive system
Genetic counseling
Premarital consultation and examination
Carrying out pregnancy test
Marriage counseling
Preparation of couple for the arrival of their first child
Providing services for unmarried mother
Teaching home economics and nutrition
Providing adoption services
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Family Planning (focal group):

Focal group: Most of the consequences related to RH is Female concerned thus FP also
has more focus in female.
Save mothers life, protect health and reproductive right by:
Reducing high risk pregnancies
Allowing sufficient time between pregnancies
Provide information on FP methods
Counsel to fight against HIV/AIDS and STDs
Prevent unwanted pregnancies
Help adolescents make responsible choices
Allow men to share responsibility for RH and child rearing
Benefits couple, family and community
SUPPORT TO BE FREE FROM DESCRIMINATION, COERCION AND
VIOLENCE
Role of Family Planning in health:
Decrease population growth and increase quality of life which is measured by human
suffering index:
Income
Employment opportunity
Urban population pressure
IMR
MMR
Nutrition
Safe Water
Energy use
Literacy
Personal freedom etc.
Benefits of Family Planning:
Benefits to child:
Prevent young mother to be pregnant who cannot provide optimal child care
Decrease risk of still birth, IMR, Birth defect, abortion by preventing being
pregnancy in older age
Decreasing birth of higher order that affects in nutritional status of child
Benefits to mother:
Between 40% - 60% of death among women aged 15 35 are related to
pregnancy related causes (WHO-2005)
Prevents from continuous cumulative nutritional deficiency in pregnant and
lactating period in some cultural practices in-turn less able to combat infection
associated with pregnancy, childbirth, abortion etc.
Some contraceptives provides non-contraceptive benefits as condom prevents
STD, PDI etc Oral pill: Ovarian and endometrial cancer, breast masses etc.
Benefit to couple:
Provide more sexual relation
Proper timing of pregnancies (Availability of time for socio-economic
development for both couple and child.
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Prevent STD spread

Benefit to family
Decrease IMR, MMR that increase emotional and physical health
Decrease morbidity that save resources of the family
Increase socio-economic status
Benefits to the economical system and society ( decrease population growth and its
consequences
FP services in Nepal:
Family planning services are designed to provide a constellation of contraceptive
methods/ services that reduce fertility, enhance maternal and neonatal health, child survival, and
contribute to bringing about a balance in population growth and socio-economic development,
resulting in an environment that will help the Nepalese people improve their quality of life.
Objectives:
Within the context of reproductive health, the main objectives of the Family Planning
Program are to
Assist individuals and couples to:
Space and/or limit their children;
Prevent unwanted pregnancies;
Improve their overall reproductive health
Target:
Total Fertility Rate (TFR): To reduce TFR from 4.1 children per women in 2001 to 3.5
by the end of the 10th Five Year Plan and further to 3.05 by 2017.
Contraceptive Prevalence Rate (CPR): To increase the Contraceptive Prevalence Rate
(CPR) from 39 percent in 2001 to 47 percent by the end of 10th Five Year Plan period,
50 percent by the end of Nepal Health Sector Strategy Program - Implementation Plan
(NHSP-IP) (2005-2009) and to 67 percent by 2015 (MDG).
Family Planning Continuing Users: In order to achieve the CPR and the TFR targets
mentioned above, approximately 2,293,000 couples must be using modern contraception
by the end of the 10th Five Year Plan period
Indicators use in FP in Nepal:
Total Fertility Rate (TFR): Expresses the average number of children a woman will
bear by the end of her reproductive life under prevailing fertility conditions. While data
on TFR are not available from HMIS, Nepal undertakes Fertility or Demographic and
Health Surveys every five years, which provide an updated estimate of TFR.
Contraceptive Prevalence Rate (CPR): Expresses the percentage of MWRA using any
modern contraceptive device at a point of time. CPR is calculated as follows:
Number of current users of Modern FP Method X 100
Married Women of Reproductive Age (MWRA)
Couple Years of Protection (CYP): Expresses the number of years for which a couple
would be protected from being pregnant by modern contraceptive methods provided
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during the year (VSC=13 CYPs, Norplant=5 CYPs, IUCD=8 CYPs, 13 pill cycles=1
CYP, 4 doses Depo=1 CYP, 150 Condoms=1 CYP)
Method-specific new acceptors as a percent of MWRA :Expresses the percentage of
MWRA using specific FP methods for the first time in specific period, which is
calculated as follows: Expresses the percentage of MWRA using specific FP methods for
the first time in specific period, which is calculated as follows:
Number of method specific New Acceptors X100
Married Women of Reproductive Age (MWRA)
Policy related to national health program:
Expand and sustain adequate quality of FP services to the community level through all
health facilities
Mobile voluntary surgical contraception camps
Encourage NGO and social marketing organization, private practitioners to complement
and supplement government effort
Mobilization of FCHV to promote condom distribution and pills re-supply
Awareness through various IEC/BCC intervention
Active involvement of FCHVs and Mothers Groups
FP Activities in Nepal:
Voluntary Surgical Contraception (VSC): vasectomy, minilap, and laparoscopic
sterilization
Spacing Methods: Depo Provera (injectables), Oral Pills and Condoms (available up to
the community level), and Norplant and IUCDs (available at selected HPs, PHCCs and
Hospitals). Spacing methods were also made available through private practitioners,
Contraceptive Retail Sales (CRS) outlets, pharmacies, and other NGOs and INGOs.
FP Counseling: Counseling services are provided to potential clients by FP providers.
Training: Comprehensive Family Planning (CoFP) and counseling training for various
categories of FP service providers
Referral: In the community level, condoms and pills are re-supplied, through a network
of FCHVs, while requests for other family planning services are referred to the PHC
Outreach clinics, SHPs or to mobile VSC camps. In turn, the SHPs refer Norplant, IUCD,
and VSC clients to the HPs, PHC centers or hospitals as appropriate.
Problem / challenges facing for the successful FP program in Nepal:
Under utilization of FP health services
Lack of resources and shortage of trained health professional
Womens position in the society and womens vulnerability
Lack of information
Tradition and culture
Affordability / accessibility
Communication and transformation
Population problems:
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Inadequate fresh water for drinking water use as well as sewage treatment and effluent
discharge. Water shortage in some hilly areas
Depletion of natural resources,
Increased levels of pollutions: air pollution, water pollution, soil contamination and
noise pollution.
Deforestation and loss of ecosystems
Changes in atmospheric composition and consequent global warming
Irreversible loss of arable land and increases in desertification
Mass species extinctions from reduced habitat in tropical forests due to slash-and-burn
techniques that sometimes are practiced by shifting cultivators, in the process of
urbanization etc
High infant and child mortality High rates of infant mortality are caused by poverty.
Intensive factory farming: It results in human threats including the evolution and
spread of antibiotic resistant bacteria diseases, excessive air and water pollution, and new
virus that infect humans.
Increased chance of the emergence of new epidemics due to many environmental and
social reasons, including overcrowded living conditions,
Malnutrition and inadequate, inaccessible, or non-existent health care, the poor are
more likely to be exposed to infectious diseases
Poverty coupled with inflation
Unhygienic living conditions for many based upon water resource depletion, discharge
of solid waste disposal.
Elevates crime rate
Conflict over scarce resources and crowding, leading to increased levels of warfare
Less Personal Freedom / More Restrictive Laws
Low life expectancy in countries with fastest growing populations
Population policy of Nepal:

A population policy is a formalized set of procedure to guide behavior of the population.
Its purpose is to maintain the behavior of the people in order to achieve a specified goal. The
population policy represents a strategy for achieving a particular pattern of population change. It
consists of specific goal, objective and strategies that contribute ultimately the development of
the nation. It covers the area viz. migration, mortality and fertility. It also addresses the areas for
widening educational opportunities, human welfare, child survival, improving the status of the
women and empowerment, antipoverty program and socio-economic development etc.
The population policy includes: deliberate effort by a national government to:
Retard growth
Promote growth
Maintain growth
Nepal has high growth rate 2.25 / annum: if continue as same would be double in 30 years,
thus the control of population growth became an urgent attention.
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Goal:
Main Goal: Substantial, positive and sustainable change in living standard of Nepalese
people
Goal: Substantial and sustained reduction of poverty incidence of Nepalese people
(Gender perspective)
Objective: Poverty dwindling
Overall strategy:
1. Good Governance:
Participatory economic development
Strengthening monitoring and evaluation system
Decision making and public expenditure are made accountable and transparent
Administration system active and disciplined
Effective resource mobilization
Decentralization process
2. Economic Growth:
Economic reform process to promote open and liberal economic policies
Government role for the development of disadvantages group from backward and
remote area and draw attention and interest of private sectors
Support local bodies and private sector to come (push) forward
Creating employment and income generating activities by developing agriculture,
forestry, industries and water resources
Develop tourism, communication, IT, finance etc.
3. Social sector and infrastructure development
Enhancing the standard of living of the Nepalese people
Agency for rapid development of infrastructure
4. Targeted program:
Poverty alleviation : increasing income resource
Targeted and employment program for weak, helpless, disabled, disadvantages,
older citizen and other oppressed group
National Demographic Goal:
Family Size: 4
TFR: reduce TFR from 4.1 children per women in 2001 to 3.5 by the end of the 10th
Five Year Plan and further to 3.05 by 2017.
CBR: reduce the crude birth rate to 26.6 per thousand population
CDR: reduce the crude death rate to 6 per thousand population
NMR: A reduction in the neonatal mortality ratio from the current 33 per 1,0002 to 15
per 1,000 by 2017.
IMR: reduce the infant mortality rate to 34.4 per thousand live births by 2017
CPR: increase the Contraceptive Prevalence Rate (CPR) from 39 percent in 2001 to 47
percent by the end of 10th Five Year Plan period, 50 percent by the end of NHSP-IP
(2005-2009) and to 67 percent by 2015
Some highlighted areas in new policy:
Age at marriage: Publicity and appropriate adjustment in the law
Two child family norm
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Female literacy
Demand for contraception (increase CPR)
Promotion of spacing method
Enhancing child survival through immunization and promotion of ORT
Developing infrastructure and improving program management in all level
Linkage with antipoverty schemes
Securing maximum involvement of I/NGOs
History of contraception:
Existed since ancient time i.e. withdrawal and abstinence

Pessaries and primitive barrier thousand of years
Modern barrier method 1800s
IUD, Hormonal contraception 20th century
Biblical reference to coitus interrupts in book of Genesis (38:9)
Kahun Papyrus ( writing materials made in ancient Egypt from pithy stem) dating
back to 1850 BC (oldest written document) describe :
Pessary of crocodile dung and formented dough
Vaginal plug of honey, gum and acacia (tree bark)
nd
2 century: Soranus practiced in Rome, provided instructions for mixing fruits
and nuts into highly acidic spermicidal concoctions (up to 40 different
combinations are described). Soft wool was soaked in these mixtures and placed
at the cervical os.
3rd / 4th century BC: First oral contraception (liquid) made from plant and bark
(oldest known plant Silphium)
Hippocrates described: wild carrot as an oral contraception and abortifacient
6th century : women were advice to wear tubes containing liver or testicles of ct to
prevent pregnancy. Ear wax of mule was believed to hold contraceptive
properties.
Middle age: women often died of lead, arsenic, mercury after drinking for their
supposed contraceptives or abortifacient effect.
During 1800s Canada women were taking beaver testicle in alcohol to create
contraceptive potion.
Evolution of condom:
Gabriello Fallopius (Egypt) in 1564 described the linen condom to protect against
disease. Fallopius advocated covering the glans penis with a linen sheath as prophylaxis
against infection
Dr. Condom is believed to have served the promiscuous King Charles II; by a cloth
sheath for Charles following the kings complaints at the member of his illegimate
children. This may be the first known use of condom for contraception.
Late 1700s to 1800s: cloth, linen and animal membrane were used
1844 : Vulcanization of rubber (treat with sulphur) used
1850 : a good rubber condom developed
Condom use increase during 1980s and 1990s (due to AIDS). In 1990 6 billion condoms
were distributed throughout the world. In 2000 20 billion condoms were manufactured.
18 century: Female barrier methods
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Lemon halves over the cervix

Contraceptive sponges
Intra-vaginal plugs made of wood and other materials
Variety of passaries (including one containing quinine used in England in 1940)
19 century: Syringes used to inject alum or zinc sulphate solution into vagina
immediately after ejaculation
Around 1860 Gynecologist EB Foote (New York) developed cervical cap
1880s : A German Gynecologist, C. Haase developed Diaphragm. Design changed by
many perosns. Diaphragm widely use in US in 1 st 20 Century
From 1960, popularity of Diaphragm gradually decreased after introduction of oral
contraceptives and IUD
20th century: development and use of spermicidal products. By 1950, more than 90
spermicidal products were commercially available. Today only about 1% of married
couple currently use spermicidal agent alone, which include Nonoxynol-9, Otoxynol-9
and Menfegel
In 20th century varieties of IUD developed. Today progesterone containing and copper
containing IUDs are widely used. Hormonal capsules (Norplant) for Subcutaneous
implantation has developed and widely used
Contraceptive methods:
Contraceptive methods are preventive methods to help women avoid unwanted pregnancy.
The success of any contraception method depends not only on its effectiveness in
preventing pregnancy but on the rate of continuation of its proper use.
Classification of Contraceptive methods:

A) Spacing method (Temporary):
1) Barrier method
a) Physical method : Condom, Diaphragm, Vaginal sponge
b) Chemical method : spermicides
Foams: foam tablet, foam aerosol
Cream, jellies and pastes
Suppositories
Soluble films
2) Combined method
3) Intra-uterine device (IUD)
4) Hormonal method (Oral, injectable, subdermal implant)
5) Post contraception methods
6) Miscellaneous
B) Terminal method (Permanent):
Male sterilization
Female sterilization
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1) Barrier method:
a) Physical Method of FP (Condom):
Male condom:
Condom is an effective, simple spacing method of contraception without side-effect.
The condom is fitted on the erect penis before intercourse. The air must be expelled from
the teat end to make room for the ejaculate. The condom must be held carefully when
withdrawing it from the vagina to avoid spilling seminal fluid into the vagina after the
intercourse. A new one should be used for each sexual act.
The effectiveness may be increased by using it in conjunction with a spermicidal jelly
inserted into the vagina before the intercourse. Failure rate is 2-3 per 100 women mainly
due to incorrect use.
Advantages:
Easily available, safe and inexpensive
Easy to use and not required medical supervision
No side effect
Light compact and disposable
Provide protection not only against pregnancy but from STIs too
Disadvantages:
May slip off or tear during coitus due to incorrect use
Interfere with sex sensation locally about which some complain while others get used to
it.
Limitation: many men do not use them regularly or carefully, even when the risk of unwanted
pregnancy or sexually transmitted diseases is high.
Female condom:
The female condom is a pouch made of polyurethane, which lines the vagina. An internal
ring in the close end of pouch covers the cervix and an external ring remains outsides the vagina.
It is pre-lubricated with silicon, and a spermicidal need not be used.
Advantage:
Effective against pregnancy and STIs
Disadvantage:
High cost and low acceptability rate
Diaphragm (Dutch Cap):

It is made up of synthetic rubber of plastic material. It ranges in diameter from 5-10 cm.
It has a flexible rim made of spring or metal. It is important that a woman be fitted with a
diaphragm of the proper size.
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It is held in position partly by the spring tension and partly by the vaginal muscle tone.
This means vaginal muscle tone must be reasonable for successful use.
The diaphragm is inserted before sexual intercourse and must remain in place for not less
than 6 hours after sexual intercourse. A spermicidal jelly is always used along with the
diaphragm.
The side effect is practically nil. Failure rate vary from 6-12 per 100 women- years.
Advantages:
Absence of risk of getting pregnancy and medical contraindication
Disadvantages:
Initially a technical or trained person is needed to demonstrate the technique of inserting
it into the vagina and to ensure a proper fit.
After delivery, it can be used only after involution of the uterus is completed.
Practice at insertion, privacy for is needed
Washing and storing needed.
Vaginal sponge:
Small polyurethane foam sponge (called today):
Measuring 5 cm X 2.5 cm, saturated with the spermicide, nonoxynol 9. The
sponge is less effective than the diaphragm. The failure rate is between 20 to 30
per 100 women years
b) Chemical methods:
Spermicidal:
Foams: foam tablet, foam aerosol
Cream, jellies and pastes : squeezed from a tube
Suppositories inserted manually
Soluble films C film inserted manually
The spermicidal contain a base and commonly used modern spermicidal are surface acting
agent which attach themselves to spermatozoa and inhibit oxygen uptake and kill sperms
Advantages:
They are only good enough when used in conjunction with other barrier method
Disadvantages:
High failure rate
Must be used almost immediately before intercourse and must be repeated before each
sex
Must be placed into the vagina where sperms are likely to be deposited
May cause mild burning or irritation
2) Combined method:
Combined of physical and chemical methods increases the effectiveness of the contraceptives
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3) Intra-uterine device (IUD):

IUD causes a foreign body reaction in the uterus causing cellular and biochemical
changes in the endometrium and uterine fluids, and it impair the viability of the gamete and thus
reduce its chances of fertilization, rather than its implantation.
Basically two types:

1. Non-medicated
2. Medicated
Both types are made of polyethelene or other polymeres; in addition, the medicated medicated or
bioactive IUDs release either metal ions (cupper) or hormones (Progesteron)
Types in use:
Lippes loop, TCu-200B, Tcu-380A, Tcu-220C, Nova T, Cupper 7, Multiload 375,
progestasert, Levonorgestrel IUD etc.
1. Non-medicated: the first generation:
They appeared different shape and size loops, spirals, coils, rings, and bows. Among
them commonly used device is loop (Lippers loop) which is available in different sizes
Advantages:
Non-toxic, non tissue reactive, and extremely durable
Contains barium sulphate to allow X-ray observation
The tail of loop (nylon thread) project into vagina which can easily felt and is reassurance
to the user that the loop is in its place and it also helps to remove easily.
Disadvantages:
Side effect could be pain and bleeding if larger size inserted
Some time expel out
2. Medicated:
Cupper IUD: second generation: Including the effect as non-medicated copper seems
to enhance the cellular response in the endometrium. It also affects the enzymes in the
uterus. By altering the bio-chemical composition of cervical mucous, copper ion may
affect sperm motility, capacitating and survival. Thus it is found a strong anti-fertility
effect
Earlier devices:
Copper 7; copper T-200
Newer devices:
T devices: T Cu 220C; T Cu -380A or Ag
Nova T
Multiload devices : ML Cu 250; ML Cu 375
Advantages:
Low expulsion rate
Lower incidence of side effect : pain and bleeding
Easier to fit
Increase contraceptive effectiveness
Effective as post-coital contraceptive, if inserted within 3-5 days of unprotected
intercourse.
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Hormone releasing IUD: third generation: The widely used IUD releases the hormone
progesterone which releases slowly in the uterus and has a direct local effect on the
uterine lining, on the cervical mucous and possibly on the sperms. The devices increase
the viscosity of the cervical mucous and thereby prevent sperm from entering the cervix.
They also maintain high level of progesterone in the endometrium and thus, relatively
low level of oestrogen makes the endometrium unfavorable to implantation.
Another hormonal device LNG-20 releases levonorgestrel which has a low pregnancy
rate 0.2 per 100 women and less number of ectopic pregnancies. It has 10 years life.
Effectiveness:
It is most effective reversible contraceptive methods. Effectiveness is less than that of
oral and injectable hormone.
Insert IUDs such as Lippers loop may be left in place as long as required, if there is no
side effect. Copper devices cannot be used indefinitely because copper corrodes and
mineral deposits build up on the copper affecting the release of copper ions. They have
to be replaced periodically. Same applies to the hormone releasing devices.
Timing of insertion:
Any time during a womans reproductive age (except during pregnancy), the most
propitious time for loop insertion is during menstruation or within 10 days of the
beginning of a menstrual period. It also be taken up during the first week after delivery,
but with caution due to the risk of perforation of the uterus and also there is high
expulsion rate.
Advantages:
Simple to insertion, takes few minutes, no hospitalization is required
Once inserted IUD stays in place as long as required
Inexpensive
Contraceptive effect is reversible by removal of IUD
Effective as post-coital contraceptive, if inserted within 3-5 days of unprotected
intercourse.
Practically free of systemic metabolic side-effects associated with hormonal pills
No need for the continual motivation required
Disadvantages:
Can produce side effects such as heavy menstruation and / or pain
Pelvic infection
Uterine perforatin
Ectopic pregnancy
Can spill-out (Expulsion)
Follow up is needed
4) Hormonal contraceptives:
It consist gonadal steroids i.e. oestrogens and progestogens.
Classification: Currently in use are:
A. Oral pills:
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Combined pill
Progestogen only pill (POP)
Post-coital pill
Once-a-month (long acting pill)
Male pill
B. Depot (slow release) formulation:
Injectable
Subcutaneous implants
Vaginal rings
A) Oral pills:
1) Combined pill: 30 35 mcg of synthetic oestrogen and 0.5 to 1 mcg of a progestogen.
It is given orally for 21 consecutive days beginning on the 5 th day of the menstrual cycle
followed by a break of 7 days during which period menstruation occurs called withdrawal
bleeding rather than menstruation. The loss of blood which occurs is about half that
occurring in a woman having ovulatory cycle. If bleeding does not occur, the woman is
instructed to start the second cycle one week after the preceding one. Mostly the women
menstruate after the second course of pill intake.
The pill should be taken everyday at a fixed time, preferably before going to the bed at
night. During course if the user forgets to take a pill, she should take it as soon as she
remembers, and that she should take the next days pill at the usual time.
2) Progestogen only pill (POP or Mini pill or micro pill): it is given in small doses
throughout the cycle.
It has poor cycle control and an increased pregnancy rate therefore usually
prescribed for older women for whom the combined pill is contraindicated and to young
women with risk factor for neoplasm
3) Post-coital contraception: It is recommended within 72 hours of an unprotected
intercourse. The two methods are:
1. IUD : mostly copper device
2. Hormonal: double dose of the standard combined pill, i.e. 50 g oestrogen, the
recommended regimen was 2 pills immediately followed by another 2 pills 12
hours later. Today pills containing 30-35 g oestrogen are available and for
emergency contraception 4 pills rather than 2 pills in each dose.
4) Once a month pill: under study
5) Male pill: (made of gossypol a derivative of cotton seed oil: four main line of approach (in
search) :
Preventing spermatogenesis
Interfering with sperm storage and maturation
Preventing sperm transport in the vas
Affecting constituents of the seminal fluid
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Effectiveness: Oral contraceptives of the combined type are almost 100 percent effective in
preventing pregnancy if taken as prescribed.
Combined pills:
Adverse effect:
Cardiovascular effect
Carcinogenesis - ? Possible association between the use of hormonal
contraceptives and neoplasma
Metabolic effect :
Elevation of BP, decreasing high density of lipoprotein, blood clotting, elevation
of blood glucose and plasma insulin. Myocardial infraction and stroke
Other adverse effects:
Liver disorder
Premature cessation of lactation
Subsequent fertility : delay in conception
? Birth defect
Common unwanted effects:
Breast tenderness
Weight gain
Headache and migraine
Bleeding disturbances
Advantages:
The single most benefit of the pill is almost 100 percent effectiveness in preventing
pregnancy
Protection against at least 6 diseases: i.e. benign breast disorder including fibrocystic
diseases and fibroadenoma, ovarian cyst, iron deficiency anaemia, pelvic inflammatory
diseases, ectopic pregnancy and ovarian cancer. (Prospective study by Royal college of
General Practitioner and the Oxford Family Planning Association)
Contraindication:
Cancer, thromboembolism, cardiac abnormalities, congenital hyperlipidaemia,
undiagnosed uterine bleeding
Age over 40 yrs.
Smoking and age over 35 years
Mild hypertension
Chronic renal diseases
Epilepsy
Migraine headache
Nursing mother in the first 6 months
Diabetes mellitus
Gall bladder disease
History of frequent bleeding, amenorrhea etc.
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B) Depot (slow release) formulation:

1) Injectable:
Progesterone only injectable :
DMPA (Depot-medroxyprogesterone acetate): 150mg in every 3 months
intramuscularly.
Advantages:
99 percent protection
3 monthly use
Safe effective and acceptable
Minimum motivation or non at all
Does not affect lactation
Good for multiparae of age over 35 years
No cardiovascular risk and excess risk of breast cancer
Side effects:
Increase in weight
Irregular menstrual bleeding
Prolong infertility after the use
2) Subdermal implants (Norplant):
Consist 6 silastic capsules containing 35 mcg (each) of levonorgestrel. The capsules are
implanted beneath the skin of the forearm.
Advantages:
Effective for 5 years
Can remove
Disadvantages:
Irregular menstrual bleeding
Surgical procedure is needed to insert and removal
3) Vaginal rings:
Contain levonorgestrel, absorb slowly through the vaginal mucosa. The ring is worn in
the vagina for 3 weeks of the cycle and removed for the fourth.
Factors affecting the Use and non-use of Contraception methods:
Income
Education : Basic and Health
Status of women in society
Preference of male child
Desire of children
Infertility as social stigma
Lack of inter-spouse communication
Fatalism
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Lack of convenient and effective method

Lack of follow-up, case-services by field worker
Availability and accessibility
Acceptance and continue use of FP methods:

Recommended strategies:
(FP program depends upon social, cultural, economical, political situation and stage of
development of the country)
Improvement of FP services:
Variety of alternative methods and services, readily available, acceptable
to all members who have need.
Counseling / Training
Development of new contraceptive technique with reduced incidence and
side effects especially to those who have low health, nutritional and socioeconomic status.
Communication program:
Counteract to unfavorable rumors through different medias
Reinforcement for continuation or alternative method
Advocacy
Involvement of influential person to counter the rumors or promote the
methods
Communication strategies:
Small family norms
Communication through local language
Communication to target group
Incentives:
Cash, Kind, award
Political support
Integrated approach
Population education : Formal education
Improvement of status of women
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Newborn care
(Not in syllabus but its important for Exam :)
The Two-Thirds Rule:
Almost 2/3rd of Infant deaths occur in the first month of life
Among those, more than two-thirds die in their first week
Among those, two-thirds die in their first 24 hours;
Source: J. Lawn et al., The Healthy Newborn: A Reference Manual for Program
Managers (2001).
Causes of neonatal death in developing countries:
Causes of death:
Birth Asphyxia
Birth Injury
Neonatal Tetanus
Sepsis / Meningitis
Pneumonia
Diarrhoea
Prematurity
Congenital anomalies
Others
Essential newborn care intervention:
Cleanliness: clean delivery and clean cord care for the prevention of newborn infection
(tetanus and sepsis)
Thermal protection: Prevention and /or management of neonatal hypothermia and
hyperthermia
Early and exclusive breast feeding
Initiation of breathing, resuscitation
Eye care: prevention and management of opthalmia neonatorum
Immunization
Management of newborn illness
Care of the preterm and /or LBW newborn
1) Cleanliness: clean delivery and clean cord care for the prevention of newborn infection
(tetanus and sepsis). Principle of cleanliness at birth are:
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Clean hands
Clean perineum
Nothing unclean to be introduced into the vagina
Clean delivery surface
Cleanliness in cutting the umbilical cord
Cleanliness for cord care of the newborn baby
2) Thermal protection: Prevention and /or management of neonatal hypothermia and

hyperthermia
Normal body temperature of infant: 36.5 37.50C
Hypothermia occurs when the body temp drops below 36.5 0C
Most sensitive during stabilization period in the first 6 12 hours after birth (It
may occur at any time if the environmental temp is low and thermal protection is
inadequate
Bathing practice of newborn within 24 hour can cause hypothermia
Hypothermia causes:
Less active, lethargic, hypotonic, sucks poorly and the cry becomes weaker
Respiration becomes shallow and slow and the heart-beat decreases.
Sclerema-hardening of skin with redness-develops mainly on the back and the
limbs
Face becomes bright red.
As the condition progresses it causes profound changes in body metabolism
resulting in impaired cardiac function, haemorrhage (especially pulmonary),
Jaundice and death.
The principle for prevention of preventing hyperthermia in newborn requires:
Delivery of the baby in a warm room
Drying thoroughly after birth
Take hold of baby by mother with Kangaroo method (early skin to skin contact
for the first few hours after birth is more than just a measure for preventing
hypothermia)
Wrapping in a dry warn cloth while keeping out of draughts (sharp current air) on
a warn surface and giving to mother as earliest possible
Vermix is lubricating and anti-infection properties and does not need to remove.
Swaddling is not a good way to keep babies warm.
Use clothes or wrap the baby in loose layers of light but warm materials. Body temp
should check regularly.
Hyperthermia: body temp goes above 37.50C Newborn develop hyperthermia if exposed
to an environment that is too warm (sun, near to heater etc)
The baby initially irritated, breathes fast, with increased heart rate, hot and dry
skin and the face appears flushed.
Gradually becomes apathetic, lethargic and pale.
When temp goes up to 410C, stupor, coma and convulsion develop.
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The infant should be moved from heat, undressed and the body should be cooled.
Dehydration is a serious complication of hyperthermia and usually needs
hospitalization
3) Early and exclusive breast feeding:

Provides optimal nutrition and promotes the childs growth and development
Provides colostrums.
It is the beginning of the immunization process, protects infections
Helps for uterine contraction FP method
Establishing and maintaining breast-feeding after birth are:
Giving the first feed within one hour of birth
Correct position
Frequent feeds
No prelactal feed or other supplements
Psychosocial support for breast-feeding mothers
Rooming in
4) Initiation of breathing, resuscitation:
It may be due to :
Prolonged labour, prematurity, infection and many other unknown causes
Emergency or active resuscitation needed
5) Eye care: prevention and management of ophthalmia neonatorum (conjunctivitis with
discharge occurring during the first two weeks of life. It is typically appears 2-5 days
after birth (range 1 13 days).
Eyelids become swollen and red with purulent discharge.
Corneal damage with ulceration, perforation, syneachiae and pan-ophthalmitis
develop.
6) Immunization:
BCG, OPV, Hepatitis B Vaccine
7) Management of newborn illness:
Early recognize S/S and manage the newborn effectively
8) Care of preterm and LBW:
Emergency services if needed after recognition of the conditions
Referral in time in appropriate place.
Essential newborn care:
Improving newborn health is part of any poverty reduction strategy, given the wide gap
between rich and poor in neonatal outcomes. Health experts agree that the Millennium
Development Goal to reduce child mortality by two-thirds between 1990 and 2015 cannot be met
unless neonatal mortality is halved.
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Preventing newborn death:

Preventing newborn deaths begins with the health of the mother. Cost-effective prenatal
and delivery interventions that improve maternal health and nutrition and save mothers
lives can save most newborns too
First, essential care needs to be provided during pregnancy. Tetanus toxoid
immunization, proper nutrition including iron/folate supplements, and treatment
of maternal infections, such as malaria and sexually transmitted infections, have a
strong influence on newborns health and survival.
Second, two priority interventions during labor and delivery are critical, in
addition to managing obstetric complications: reducing the risk of infection to
mothers and newborns by keeping the birth attendants hands and all contact with
the umbilical cord clean and resuscitating newborns who are not breathing
normally.
Third, certain actions can make the postnatal period safer for newborns.
Immediate and exclusive breastfeeding and keeping the baby warm and the
umbilical cord clean contribute to the health and survival of newborns. Since most
newborn deaths occur during the first hours or days after birth, contact with an
appropriately trained health provider is key to newborn health and survival. In
addition to counseling on newborn care practices, particularly careful
management of low birth weight babies, and timely recognition and antibiotic
treatment of infections such as pneumonia, sepsis, and meningitis are key.
Essential Newborn Care (ENC) Interventions:

Normal Care:
Antenatal Care
Tetanus toxoid immunization
Adequate diet
Iron, folate & iodine
Syphilis detection & treatment
Malaria prophylaxis
Breastfeeding counseling
Birth preparedness
Labor & Delivery Care
Clean delivery
Prevention of hypothermia
Immediate breastfeeding
Prophylactic eye care
Postnatal Care
Exclusive breastfeeding**
Warmth
Hygiene, cord care
Immunization
Maternal nutrition
Birth spacing counseling
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Children's Issues
Children in Nepal: Issues and Challenges:
Introduction:
Child labor is one of the major issues in many parts of the world including Nepal. An estimate in
1996 showed that about 250 million children of ages between 5 to 14 years were working fulltime of part-time. Most of these working children were in developing countries, over 50% of
them in South Asia.
Nepal is one of the countries with very high proportion of child labor Force Survey in
1998/99 showed that about 2 million(14%) children out of the total population of 4.9 million of
ages between 5 to 14 years were involved in work.
The Gravity of the Child Labor Problem:
The Gravity of The Child Labor Problem Awareness towards the gravity of child labor problem
is a relatively new development in Nepal as in many other parts of the world. Though children's
health and education has remained a priority of His Majesty's Government of Nepal for decades,
it was only during the 1990s that the magnitude of the problem of child labor was realized. Since
the early 1990s the issue of child rights and child labor has received greater attention which is
being reflected in national policies and programs. Because of the social and economic
circumstances of the country, child labor issue in Nepal is rather difficult and complex. Nepal is
one of the least developed countries. About 90% of the population in Nepal lives in rural areas.
About 81% of the total population depends of agriculture, mostly subsistence farming. About
42% Nepalese live under the absolute poverty, with income less than one dollar per day. Because
most of the adults are illiterate (adult illiteracy rate about 50%), the capacity of most families to
undertake alternatives to develop social and economic organize themselves to develop social and
economic safety measures ate seriously constrained. Accordingly, HMG/N has adopted poverty
reduction Strategy Paper and the Tenth Plan has emphasized poverty reduction as their
overarching goal. (HMG/N) considers educational development as one of the crucial strategy to
remove the problem of poverty and child labor. Provision of basic and primary educational is
essential for breaking the problem of poverty as well as eliminating child labor. Accordingly,
HMG/N has committed itself to the provision of universal quality basic and primary education
for all. It has also been engaged in the global campaign of Education for All. Since early 1990,
HMG/N is implementing Basic and Primary Education Program which is currently at its second
phase to universalize access and it improve the quality and relevance of basic and primary
education in Nepal. Many INGOs and NGOs are also working towards solving the problems of
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poverty and child labor in Nepal. The issues of child labor in Nepal, however, remain ever big
and challenging as the number and sectors of employment of children keep growing.
Social Dimension of Child Labor:
Unlike in the case of developing countries like Nepal, Child labor is a thing of history in most of
the industrialized and developed countries. The success relates it realization of the need it stop
child labor and m=nurture childhood in a protective joyful and educational environment. Today,
mostly of the developed countries have compulsory school education up to 16 to 18 years(grade
10 to 12), whereby the government guarantees free education up to that level and the parents are
required by the law to send their children to school. However, in many underdeveloped countries
this realization has yet to come not only among the poor rural families whose children are
vulnerable to child labor but also among many privileged communities and families who employ
children as laborers. It is often taken for granted that children of poor need to work. 'The riches
of poor are their children" goes a Nepali proverb. On the one hand, the proverb reflects the future
prospects with able people in the family; on the other hand it indicates that children need to bear
with the parents in toiling work fro subsistence. For marginally poor families in Nepal there is
simply no alternative, no hope, except to accepting the fate. The social perspective that child
labor is compulsive reality is rather of higher concern because it eludes social responsibly.
Employment of children as household servants is a normal phenomenon, even a show of
affluence by the employer because of such perceptions. The employers of children as laborer
even argue that they are providing protection and helping poor children, and therefore, they feel
good about it. They fail to realize that such immediate 'favor' results in destruction of childhood.
In the absence of a feeling of social responsibility the task of protecting child laborers, proving
them with educational environment and enabling them to live like children and grow with
positive aspirations becomes all the challenging.
Nepalese society needs to look at the issue from humanitarian stance as well as from the
perspectives of positive social transformation towards greater creativity and prosperity.
HIV/AIDS and Working Children:
HIV/AIDS is gradually on the increase in the country affection the children associated with sex
workers as well as people who visit them. Studies indicate that many low income workers such
as those involved in transportation, those who are away from family seeking labor in the urban
areas are more likely to visit sex workers. The children of these groups are more vulnerable to
worst forms of child labor. The other causes of HIV/AIDS are drug abuse and abnormal sexual
behavior which is also on the increase especially among the children and teenagers. Street
children and working children away from their families are more vulnerable to such situation.
Obviously, working children are more venerable to HIV/AIDS because of their exposure to the
situational circumstances as well as because of the lack of awareness, care and support. There is
still a need for detailed and critical studies in this area to generate analytical information and
deeper understanding about the problems, issues and the overall actions needed. However, there
is also a need for immediate measures to prevent proliferation of the problems as well as to
address the needs of those already affected.
Street Children:
With increasing urbanization and urban-focused opportunities and facilities, the problem of street
children is growing year by year. Children from rural villages and districts end up on city streets
as a result of poverty, broken families. Physical and mental abuse in the family, abandonment,
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helplessness, and desire to live in the city. Street children face hunger, lack of health and
education facilities, lack of opportunity for skills development, physical and sexual exploitation
by elder and former street children, drug abuse, etc. It is also reported that as they grew up they
face difficulties in making a livelihood and, consequently, became involved in immoral and
illegal activities, contributing to social disorder.
Some NGOs address the issues of street children with transit homes, skills training, socialization
centers, counseling, provision of food and education, family reunion, etc.
However, it is recognized that there needs to be preventive and controlling measures at the
origins and destinations of these children with issuance of identity cards for rehabilitative
services for those who have already arrived in urban centers.
Disabled Children:
HMGN initiated special education with a program for blind children in Kathmandu. Now,
special education programs for children with many types of disabilities are being launched.
However, most children with disabilities are out of reach of such facilities, as these facilities are
mainly urban based. HMGN has ratified most declarations related to children with disabilities
and promotion of their rights and development. Since the early 1980s government agencies and
various associations' federations and NGOs have been working for children with disabilities
mainly in education, skills training, community-based rehabilitation and against social stigma,
discrimination and exclusion. Such NGOs are spread throughout the country raising a voice for
the rights and development of children with disabilities.
A government survey on the 'Situation of Disability in Nepal" reports that about two
percent of children have disabilities; however other studies place the figure at between one
percent and 15 percent. Only about 10 percent of children with disabilities have access to formal
and non-formal education.
Children in Armed Conflict
Under the Royal Army Recruitment Rules (1962), no one aged less than 18 years is eligible
to join the Army; however at present children as young as 15 years are able to enlist for
military training. The Maoist insurgency that started in 1996 has to date claimed several
thousand lives including 300 children and injured many others. It is reported that the
Maoists recruit children and youths into their movement. Detailed information on the
number of children involved and their situation is however not available. Although the
insurgency originated in Nepal's western and mid-western regions and increasing number of
districts ate affected by disruptions and insecurity. Development activities have been
adversely affected and the situation for children is deterioration.
Sexual abuse, exploitation and trafficking:
Sexual abuse exploitation and trafficking are major issues of concern for child rights in Nepal.
These practices continue unabated despite efforts by HMGN and civil society organizations.
Studies show that sexual abuse and exploitation is found everywhere including at home in
schools, communities and workplaces and even in public. Moreover, it is reported that children
ate trafficked for sexual and labor exploitation. HMGN is trying to control sexual abuse;
exploitation and trafficking in the commercial sector but is yet to address the non-commercial
sector. District-level committees have been formed to address the issue of trafficking. NGOs are
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working on the protection, prevention and rescue of exploited and abused children (inside and
outside the country) and their rehabilitation. Some activities to prevent trafficking of girls
include community mobilization and peer counseling through child clubs and women's groups.
Child Labor:
The constitution of the Kingdom of Nepal (1991) forbids the employment of minors in a factory,
mine or dangerous workplace. The Children's Act prohibits the employment of children aged
below 14 years in factories/industries. It also provides for protective and safety measures for
children aged 14 and above. The act also requires employers to send photographs and details of
all child laborers to the local DCWB.
The Nepal Labor Force Survey of 1998/99 found that over 40 percent of all children aged
5-14 years or 1.987 million children were economically active. More girls than boys work and
the proportion of working children in rural areas is greater than in urban areas. Child labor
exploitation has been a major problem in the promotion of the rights of children as a result of
weak implementation of laws poverty, landlessness, lack of a monitoring mechanism and lack of
a social security scheme. There is also a lack of administrative and legislative mechanisms to
address the issues of child labor in the informal sector. It is necessary to classify child laborers
based on vulnerability and exploitation and prioritize program interventions to protect the rights
of working children. Maoist activities against child; labor are to be targeted at the rural setting
addressing the causes and consequences.
Legal Provisions:
There ate a number of international and national legal instruments in place. However, in Nepal
their implementation remains a difficult challenge in the face of limited institutional and human
resources.
In the first place, the system that is responsible for the implementation has to be made
rational committed and adequately sensitive to the issues. Second the society needs to be
prepared for the transition to new social responsibility and for co-operation in the law
enforcement. There must be a comprehensive approach to eliminate prejudices to enable all
concerned to use legal provision and feel self-responsibility. A clear vision is necessary to
prepare and mobilized all concerned in a collaborated and coordinated way for an effective
enforcement of law.
Lack of social Contexts and Effective Alternative:
The bottom line for effective elimination of the issue of child labor is the provision of at
pragmatic and effective alternative to children and parents. Schools should be the place for all
school age children. For this schools need to be accessible, affordable, directly benefits are
relative to the current situation of the children and the parents and it goes beyond the physical
entities and professional articulations.
For a marginally poor and disadvantaged family a school at its doorstep could still be
socially inaccessible. Similar situation applies in the case of affordability and perception of
benefit. For many parents, it is even difficult to meet the minimum requirements for daily
subsistence. It is difficult to expect from such families to afford any cost, time or money for the
schooling needs of their children. Further it is difficult to expect from such children to be
effective and regular students. The future benefit for them from traditional education would be
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beyond their anticipation and grasp. A report of basic and primary education indicates that 30%
of the total primary school age children are still outside the formal school system. Similarly the
report of country assessment of EFA, 2000 show that the total enrolment at grade 1, about 40%
repeats the class and about 23 % drop out. Although the repetition and drop out at higher grades
are not as big as at grade one, the effectiveness and efficiency of school education remains very
poor. Those who complete the primary education cycle ate about 50% only. The problem of nonenrolment and dropouts are acute among the poor and disadvantaged communities particularly
girls and children with special needs.
Studies show that the current provisions of schooling do not address the educational needs of the
disadvantaged parents and children vulnerable to child labor. Similarly, according to annual
school based data of MOES (2000), of the total primer school age children 19.6% are never
enrolled in school, 45.4% of the children enrolled in priory schools drip out without completing
grade five. Dropout occurs mostly at grade one which stand at 14%.The magnitude of the
problems of illiteracy non-enrolment and school drop-out varies by region be gender and by
difference in social groups. Most disadvantaged family's need it engages in physical work for
long hours in the field or in the factories or as porters just to earn day-to-day living. Education
for intellectual tact, skill and health are crucial for any improvement of the disadvantaged
groups. However achieving educational provisions that address the needs and prepare a base for
effective and sustainable economic development still remains a challenge.
Challenges of Child Labor: Complex Web of Causes:
There are several reasons for children joining the workforce: social reasons, economic reasons,
psychological reasons, inadequate policy and regulatory system, lack of comprehensive social
and developmental infrastructure etc. Complex relationship exists among the various causes as
many of these reasons ate interwoven to one another. Often one cause is an effect of another.
A generic causal-relations model is proposed here to understand the relationship of
different causes. Mainly, sixteen generic causes are identified in this model.These are: geophysical and political constraints 'corrupted' parents, discriminating behaviors to girls, bad family
behavior and break0ups, work opportunities in urban areas, community apathetic attitude,
inadequate commitments, instruments and supports, special physical characteristics needed to
specific activities cost advantages to employers, non-pecuniary advantage to employers,' help to
community' rather than 'trading-a-child' attitude of the society, majority agrarian an small scale
handicraft economy lack of quality and employment opportunities, high fertility rates and large
family sizes and unavailability of schooling.
The consequences and social costs of child labor on the affected children are very high. It
impairs their physical, mental and moral health at a very crucial and critical stage of life that
leaves permanent consequences. Even more destructive to quality of life in long-term is
permanent damage caused to the social development of the child.
Refugee Children:
There are more than 100,000 Bhutanese refugees of ethnic Nepali origin who have been living in
UNHCR-administered camps in east Nepal for the past 10 years. While repatriation talks
continue refugees are provided with food, education, health and other services by HMG, UN
bodies and a number of NGOs and INGOs (including SC UK, World Lutheran service and
OXfam)
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Conflict and Child Labor:

The conflict situation in Nepal is increasingly affecting the economic and social arenas. The
situation is causing adverse conditions in the affected areas. Schools are highly affected by this
condition; Schools in rural areas are not being run effectively. Because of the conflict situation
many parents are not sending their children to school and many school teachers in rural areas
have moved out. Similarly the local bodies including the VDCs, health posts and local
development offices are displaced without any economic support and they are displaced without
any economic support and they including the children are forced to seek economic engagement
for survival.
Secondly dysfunctional schooling means more children without having to engage in
recognized future oriented or hope generating activity in school. So children are amore
vulnerable to falling on the worst forms of child labor. And thirdly sometimes children are
reported to be drawn into the conflict through forced recruitment in the rural areas. This is
contributing to worsening of the situation regarding child labor particularly the worst forms of
child labor.
The last situation, involvement of children in conflict situation is new development in the
country and is of big concern. There is definitely a need for building consensus and commitment
to prevent children falling into the conflict situation in general and direct involvement in the
conflict in particular. A stronger campaign by all stakeholders, particularly by the civil society is
called for to make schools zone of peace. It also necessitates a more comprehensive and
integrated intervention package for the children and families affected or displaced by conflict.
Economic Dimension of Child Labor: The Demand Side of the Issue:
The child labor issue has always been studied only from the supply side. The studies often point
out poverty, high population expansion, illiteracy, biased social values, repressive culture and so
on as the main causes behind the child labor issue. All these supply side factors indicate the need
for improvement in socioeconomic conditions and support for the poor and disadvantaged
through a more inclusive policy and institutional framework.
There are a number of factors in the demand side as well bearing on child labor. There
are monetary as well as non-monetary incentives for the demand of child labor. Children are
easier to manage as they are submissive, innocent, less demanding. Trustworthy, less inclined to
absenteeism and less aware of their rights. Child labor is therefore cheap and easy to manage.
The tradition of transferring workmanship to new generation is another non-pecuniary
factor from the demand side that cannot be neglected. Parents feel that their children will be
benefited if the children follow their traditional family occupation. Some jobs demand children
due to their childlike physical, behavioral and psychological characteristics-non-threatening,
charming, amicable and submissive. Children are preferred as domestic workers, sex workers,
drug peddlers etc.
Accordingly demand side appears equally responsible, if not more for the current
problems of child labor in Nepal. There is a need for combining awareness creation with
sensitization and punitive action in a well-concerted way to cope with the demand situation.
(National Plan of Action for Children)
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Batch)

Family Health

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Family Health

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Family Health

Subject code: BPH 206

UNIT-1: CONCEPT OF FAMILY HEALTH 18hrs

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Integrated approach to health of families (preventive, Curative and Promotive)

Personal growth: self-confident, self-sufficient and make their own decisions

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Scope of Family Health / Family health need

Identification of need as per areas:

Principle, components and Health statues:

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Holistic model of family health:

Prerequisites for health and family wellbeing:

Love and acceptance

Family provides environment/ support:

Food, shelter, security and identity

Function of family in maintaining health:

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Participatory action and responsibility of each family member

Components of family health

Vulnerable group within the family

Indicators need to assess family health status:

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Nutritional Status Indicators

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

The Sick Role:

Role of Father in Family Health

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Have a good will ( are optimistic and hopeful)

Treat each client well

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Thumb rule of counseling:

Do not make decision for the clients

Effective counseling skill:

By: Keshab Shrestha (1st Batch)

(L.B.College of Health Science)

Limited physical mobility

Strategies for empowerment of women:

By: Keshab Shrestha (1st

(L.B.College of Health Science)

Measuring the status of women:

UNIT-2: MATERNAL HEALTH 18hrs

By: Keshab Shrestha (1st

(L.B.College of Health Science)

By: Keshab Shrestha (1st

(L.B.College of Health Science)

Components of Reproductive Health:

By: Keshab Shrestha (1st

(L.B.College of Health Science)

These sexual act results in more than 91000 conception (2006)

By: Keshab Shrestha (1st

(L.B.College of Health Science)

RH Care need for children:

By: Keshab Shrestha (1st

(L.B.College of Health Science)