1.

P-value 95 % significant means

2. Major cause of children mortality
3. Single point prevalence
4. TB program indicators
5. Use of surveillance
6. International diseases
7. Vaccination- small pox
8. Pit latrine
9. Anthropometric measurement
10.Incidence & prevalence
11.Survey& surveillance
12.DHS for how many time in Ethiopia
13.Census- conducted in Ethiopia the first time in ______
14.HIV prevalence in Ethiopia decreased due to ______. Urban v rural
15.Hypothesized test HO&HA
16.Variables- age in
17.Health program success in Ethiopia______
18.Sampling—which of the following in non-probability sampling?
19.Ecology v environment
20.Maternal mortality ratio
21.HSDP lll
22.Nutrition intervention in Ethiopia
23.Vit. A strategies
24.Case control v cohort study
25.Sampling biases& other biases
26.RH care v health care
27.Monitoring and evaluation
28.Management function-------------------------------
29.Components of communication v process of communication
30.Behavioral factors
31.HIV type in common in Ethiopia
32.Primary prevention of HIV
33.Type I statical error
34.Which of the following is affected by extreme value? Arithmetic
mean, mode, median, quarnitils
35.Safe motherhood means_________.
Exam new
1. Which of the following is affected by extreme value? Mean, mode,
median
2. P-value of 1% level of significance is ________
3. Which of the following is nominal data?
4. MMR is how much?
5. Most child mortality causing diseases?
6. Considerably eradicated disease________ polio
7. Eradicated from the world _________ small pox
8. 95 %CI means_________________.
9. The primary difference of survey and surveillance is_____________.
10.Life expectancy at birth is_______________.
11.Triangular pyramid shows________________.High birth rate and
high death rate.
12.Which of the following shows social and health conditions?
13.Which of the following is not included in the MDG goals?
14.What is the health financing?
15.Which of the following is not a managerial function?
16.What is the difference between a 6- tier and 4-tier health care system?
17.Which of the following is not a random sampling?
18.Which of the following samples have equal chance of sampling?
19.What is the criteria of priority setting
20.Which of the following is identified during outbreak?
21.HIV prevalence rate in Ethiopia is___________.
22.What motivates you to join MPH program?
MPH MEKELLE DISTANCE
1. Hypothesis to _________ while theory is to_______________.
2. Discrete variable is to __________ while continuous is to
______________.
3. Interventions used to reduce MMR
4. Which of the following is true about the young using family planning
methods?
5. Which of the following is a nominal data?
6. In the experiment performed on the effect of practice over the reaction
time, practice is,
a. Control group
b. Experimental group
c. Independent group
d. Dependant group
7. Which of the following disease is the second to be eradicated?
8. Which one of the following country has a good health indicator?
Cuba, Indonesia, Latvia
9. Tb prevalence increase due to__________
10.Women who live in the place with no TV and radio and reduced
mobility, the contraceptive method used is _____________
11.WHO recommends ANC visits
12.What is health financing
13.Which of the following is not a management function
14.Epidemology triangular shows ---------------
15.EPI coverage
16.Which of the following is not true about family planning
A.MMR 673
B. ANC coverage 70%
C. HIV prevalence is 2.1
17. Which of the following is not true MDG
18.Which of the following is not criteria for priority setting
19.Primary difference between survey and surveillance
20.Which of the following is not included in the case of definition of
outbreak
21.Target population of secondary prevention
Some points on the MPH entrance examination

1. Epidemiology
Epidemiology is the study of the frequency, distribution, and determinants of
health-related states or events in specified populations, and the application of
this study to the control of health problems.

Scope/ coverage/ use of epidemiology.

Its scope in public health ranges from routine surveillance to research strategies for
the testing of hypotheses about causes, measurement of health and disease risks
and evaluations of preventive, diagnostic and therapeutic programmes and
technologies. Epidemiology is also a collection of applied disciplines, i.e., every
disease entity has its own epidemiology (infectious, cardio-vascular,cancer, etc.).
Other studies focus on health risks (occupation, smoking, diet,social conditions,
etc.). Some of the uses of epidemiology in public health practice are mentioned
below:
1. Elucidate (explain) the natural history of disease.
2. Describe the health status of the population.
3. Establish causation of disease.
4. Provide understanding of what causes or sustains disease in populations.
5. Define standards and ranges for normal values of biological and social
measures.
6. Guide health and healthcare policy and planning.
7. Assist in the management and care of health and disease in individuals.
B. Basic Epidemiologic Assumptions!!!!!
In order to fully grasp the notions of epidemiology it is important to understand
the two basic assumptions in epidemiology:
1. Human disease does not occur at random: there are patterns of occurrence in
which some behavioural and environmental factors (exposures) increase the
risk of acquiring/developing a particular disease among group of
individuals.
2. Human disease has causal and preventive factors that can be identified
through systematic investigation of populations or group of individuals
within a population in different places or at different times. Thus, identifying
these factors creates opportunity for prevention and control of diseases in
human population either by eliminating the cause or introducing appropriate
treatment.

Measures of Disease Occurrence.

The number of cases in a given community can give more epidemiologic sense if
they are related to the size of the population. Such tie of the number of cases with
the population size can be determined by calculating ratios, proportions, and
rates. These measures provide useful information about the probability of
occurrence of health events, population at a higher risk of acquiring the disease.
They are also important in designing appropriate public health interventions.
Ratio: the value of x and y may be completely independent, or x may be included
in y.
Example: Male: Female (male to female ratio)
Proportion: is a ratio (expressed as a percent) in which x is included in y.
Example: Male/Both sexes (proportion of male in a community)
Rate: measures the occurrence of an event in a population over time. The time
component is important in the definition. Rates are often proportions. Rates
must: 1) include persons in the denominator who reflect the population from
which the cases in the numerator arose; 2) include counts in the numerator which
are for the same time period as those from the denominator; and, 3) include only
persons in the denominator who are "at risk" for the event.

 Incidence

Incidence: measures the rapidity with which newly diagnosed patients

develop over time.

Most common way of measuring and comparing the frequency of

disease in populations.

the period of time for the rate must be specifies.

Number of new cases during observation period X100

Incidence Rate = Person – time observed

 Prevalence

Prevalence: the amount of disease that is present already in a population.

indicates the number of existing cases in a population.

All new and pre-existing cases during a given time period

X100
Prevalence = population during the same time period

Common Measures of Disease Frequency

The frequency of health related events are measured by risk, prevalence and
incidence rate.
Risk (cumulative incidence):
⎯ Likelihood that an individual will contract a disease.
⎯ The proportion of unaffected individuals who, on average, will contract the
disease of interest over a specified period of time.
Prevalence:
⎯ The amount of disease that is present already in a population. Indicates the
number of existing cases in a population.
Incidence:
⎯ Measures the rapidity with which newly diagnosed patients develop over
time. Most common way of measuring and comparing the frequency of disease
in populations. The period of time for the rate must be specified. New cases
occurring during a given time period
Risk = Population at risk during the same period all new and pre-existing cases
during a given time period. Prevalence = population during the same time
period Incidence Number of new cases during observation period
Rate = Person-time observed

Crude death rate = total death/ total population

Crude rates apply to the total population of a given area. Specific rates apply to
specific subgroups in the population (such as by age, sex, or occupation) or
specific diseases. Adjusted rates and age-specific rates are often used to permit
comparison of mortality rates in populations which differ in age structure.
Mortality rates computed with adjustment techniques are called age-adjusted or
age-standardized mortality rates.

Case fatality rate. Case fatality rate (CFR) is the measure of severity of illness.
* CFR = Number of deaths from a disease
Number of clinical cases of that disease

Variation in Severity of Illness

The infectious process has a wide spectrum of clinical effects which ranges from
in apparent infection to severe clinical illness or death (Figure 2.12). The effect
depends on the nature of the infectious agent and host susceptibility. Case
fatality rate (CFR) is the measure of severity of illness.
* CFR = Number of deaths from a disease
Number of clinical cases of that disease

Recognizing inapparent infections require the use of laboratory tests on

seemingly healthy individuals. Information thus obtained are useful in planning
public health interventions. A good example could be HIV testing to determine
the potentials for the spread of the disease and to plan appropriate control
strategies.
  Level of prevention
Levels of Disease Prevention
Disease prevention means to interrupt or slow the progression of disease.
Therefore, the aim is to push back the level of detection and intervention to the
precursors and risk factors of disease. Fluctuation in patterns of morbidity and
mortality over time in countries and the observation that migrants slowly
develop the patterns of disease of host populations indicate that causes of disease
are preventable.
Hence, epidemiology plays a central role in disease prevention by identifying
those modifiable causes. The levels of prevention in relation to the stage of the
disease process are shown in Table 2.1.
Table 2.1. Levels of prevention in relation to the stage of the disease.
Level of Prevention Stage of disease Target
Primordial
Existence of underlying condition leading to causation
The aim is to avoid the emergence and establishment of the social, economic, and
cultural patterns of living that are known to contribute to an elevated risk of
disease.
Example: smoking, environmental
Pollution of
Total population and selected groups
Primary
Specific causal factors exist, The causative agent exists but the aim is to prevent
the development of disease.
Example: immunization
Measles, polio
Total population, selected groups and health individuals
Secondary
Early stage of disease, the aim is to cure patients and prevent the development of
advanced disease.
Example: Early detection & treatment of cases of tuberculosis & STD Patients
Tertiary
Late stage of disease (treatment & rehabilitation) the aim is to prevent severe
disability and death.
Example: Leprosy Patients

 Screening
Laboratory tests for screening are used in people who are asymptomatic
(apparently healthy individuals) to classify their likelihood of having a particular
disease. A test is anything that produces evidence from a patient at any stage in
the clinical process, based on which a different clinical course will be taken
depending on the different possible test outcomes
(positive or negative, normal or abnormal, present or absent, high or low, ...).

 Sensitivity The concepts of sensitivity (ability to detect true positive)

Sensitivity is defined as the proportion of people with a disease who have a
positive test for the disease (a/a+c).
Specificity is the proportion of people without the disease who have a
negative test (d/b+d).

a b
c d
Validity is the extent to which data collected actually reflect the truth. The
concepts of sensitivity (ability to detect true positive) and specificity (ability to
detect true negatives) can be used to characterize the validity of a measure
("measurement validity"). Study results are also described as "valid" when there
is no systematic misrepresentation of effect or "bias" ("validity in the estimation
of effect"). Validity is often described as internal or external. Internal validity
concerns the validity of inferences that do not\proceed beyond the target
population for the study. Internal
validity is threatened when the investigator does not have sufficient data to
control or rule out competing explanations for the results.
External validity, on the other hand, concerns generalizeability, or inferences to
populations beyond the study's restricted interest. External validity is
threatened, for example, when the investigator attempts to apply the findings of
the study to a population which is not comparable to the population in which the
research was completed. Internal validity should be the primary objective in
study design, however, since efforts to

 Specificity (ability to detect true negatives) can be used to characterize the

validity of a measure ("measurement validity").
 Attack rate

Attack rates- Calculate rates of illness in population at risk by exposure to

specific suspected items and other relevant attributes. The identification of
"relevant" attributes may be a crucial step in the solution of the problem.

Estimation of Confidence Interval

The confidence interval represents the range within which the
true magnitude of effect lies within a certain degree of
Assurance. It is more informative than just P value because it
reflects on both the size of the sample and the magnitude of the

Hypothesis Testing (Test of Statistical Significance)

A statistical hypothesis is an assumption of a statement which may or may not
be true concerning one or more population
Test of statistical significance quantifies the degree to which sampling variability
may account for the observed results. The "P value" is used to indicate the
probability or likelihood of obtaining a result at least as extreme as that observed
in a study by chance alone, assuming that there is truly no association between
exposure and outcome under consideration (i.e., H0 is true). The main hypothesis
which we want to test is called null hypothesis since acceptance of it commonly implies
no effect or no difference For medical research, the P value < 0.05 is set
conventionally to indicate statistical significant.

P value it is the result of observation after the study is completed and is based
on the observed data. it shows the statistical significance of the result. The cut
of point is 0.05 conventionally.

Confidence interval

The Chi-square it is a probability distribution which is useful in making a

statistical inference about the categorical data I which the categories are two and
above

 Measure of association, property and use

 Cohort and case control ( advantage and )
 Study Design
Cohort: is a group of persons with common characteristics, usually an exposure
or involvement in a defined population group, who are followed or traced over a
period of time.. Cohort study (synonyms: concurrent, follow-up, incidence,
longitudinal, prospective study): is the analytical method of epidemiologic study
in which subsets of a defined population can be identified who are, have been, or
in the future may be exposed or not exposed, or exposed in different degrees, to
a factor or factors hypothesized to influence the probability of occurrence of a
given disease or other outcome.

 Collection of specific attack rate

 Variable and significance of association

Variation in disease pattern is the foundation of epidemiology. Anything which

varies and has different values is known as variable. In epidemiology there are
two types of variables: exposure and outcome. The common epidemiological
variables such as age, sex, economic status, social class, occupation, area of
residence, religion and ethnicity are all powerful ways of showing variations in
broad range of diseases and health status. However, most of these variables are
markers for complex, underlying phenomena of interest which cannot be
measured directly and easily. For example, sex may act as a proxy for genetic,
hormonal, psychology or social status in different studies.

Variations in disease occurrence and associations

Changes in disease frequency could be due to two main reasons. The first reason
is that changes are real (natural), and the second reason is that changes are due to
mistakes/errors committed during diagnosing and counting (artefactual). As
demonstration of disease variation is the basis for establishing epidemiological
association it critical to examine whether variations are real or artefact.

Hypothesis Testing (Test of Statistical Significance) P value

Test of statistical significance quantifies the degree to which sampling variability
may account for the observed results. The "P value" is used to indicate the
probability or likelihood of obtaining a result at least as extreme as that observed
in a study by chance alone, assuming that there is truly no association between
exposure and outcome under
consideration(i.e., H0 is true). For medical research, the P value < 0.05 is set
conventionally to indicate statistical significant.
P value is a function of:
• the magnitude of the difference between the groups
• sample size

2.Health Service Management

 Functions of management

7. Management Functions
Function is defined as a broad area of responsibility composed of many
activities aimed at achieving a predetermined objective.

Functions of Management Include

1. Planning Planning (p)
2. Organizing
3. Staffing Implementation (I)
4. Directing
5. Controlling- Evaluation (E)

In addition to these three broad sequential functions Planning, Implementation &

Evaluation
(PIE).
Two continuous functions of management are:-
Communication
Decision- Making
  Tiers of health delivery system (current & past)
four and Six
HPost

Clinic
Health station
Health center
Regional hosptals
Specialized referral hospitals

 Motivation factor
Motivation is an inner impulse that induces a person to act in a certain way. It is
a series of internal drives within a person at different levels.
Level 1. To obtain the necessities of life — food, shelter, clothing, rest and
safety.
Level 2. To satisfy social needs such as those for companionship, love, and a
position of respect.
Level 3. To ensure some degree of personal satisfaction and to pursue ideals.
People need to feel reasonably satisfied with themselves, with what they make of
their lives and with their talents and abilities.

A team leader should understand what encourages people to apply their ability
and energy to work, and what makes people dissatisfied at work. These two
groups of factors may be called motivators and dissatisfies, respectively.

 SWOT analysis
It is a tool to diagnose the organizational system and to define what best
standing merit and opportunities that the organization has to excel and what
are the weaknesses to be improved and what are the threats to be aware of
and are basically challenging from the external or an out side force

SWOT Analysis
SWOT (strengths and weakness, opportunities and threats) is a strategic
planning tool that matches internal organizational strengths and weakness with
external opportunities and threats. By reviewing strengths, weaknesses,
opportunities and threats a useful strategy for achieving objectives will become
evident.

In the health sector, strengths may be considered availability of resources and

trained human power. Weaknesses include lack of managerial talent and
obsolete facilities. Threats include adverse cultural believes towards modern
medical practice and growing cost of essential drugs. Examples of opportunities
are clear and supportive government policies and presence of a functional health
committee in the communities. (Figure 8)

 What is district health office?

District is defined as geographical area that is small enough for health and
related social problems to be properly understood and appropriate action to be
taken and large enough to permit the deployment of essential technical and
managerial skills for planning and management of programme while awarding
over dispersal of skills
It provide a fully comprehensive range of promotive, preventive, curative and
rehabilitative health activities

Essential characteristics of a district health systems based on PHC are:

1. Equity
2. Accessibility
3. Emphasis on Promotion and Prevention
4. Inter-sectorial Action
5. Community Involvement
6. Decentralization and integration of health programmes

 List Components of primary health care (PHC) = 11

PHC IN ETHIOPIA
PHC activities in Ethiopia, which formally began in 1980s, include the following
Education on the prevailing health problems and methods of preventing and
controlling them
1. Locally endemic diseases prevention and control
2. Expanded program on Immunization
3. Maternal and child health including family planning
4. Essential drugs provision
5. Nutrition promotion of food supply
6. Treatment of common diseases and injuries
7. Sanitation and safe water supply
8. Dental health
9. Mental health
HIV/AIDS

Since 1980 PHC has been the main strategy on which the health policy has been
based. The 1985 review of PHC implementation attempts in Ethiopia revealed
the following achievements.
o Expansion of health services to the broad masses especially by
establishing new health station and health posts.
o Expansion of Immunization programmes against six major communicable
disease.
 o Increasing number of medical and paramedical personnel.
o Increased health propaganda attempts to improve health consciousness of
the population.
o Established PHC committees at the lowest local administrative level.

The health policy which was established in 1976 by the ministry of health
includes
o Emphasis on disease prevention
o Priority to rural health service
o Promotion of self reliance and community involvement

The health policy has been further consolidated by the adoption of PHC as a
strategy. Failures to implement these policies can be traced to several factors of
which low government attention and support to the health sector is not the least.
If you were working as health manager
1. what problems do you face and contraceptive utilization rate
2. how did you manage it training HEW net working outreach services
health education

Define
o community diagnosis disease identification with in a given
community ????
o clinical diagnosis institution base clinical investigation laboratory
x-ray …..

what is the contribution of traditional medical belief system to health care

what is the difference between health professional management and health
care workers management skilled manpower on specific program undertaking
The Roles of Health Manager

The managerial roles are categorized into three major areas with further
classification:
Interpersonal role: this role shows the interpersonal contact that a manager does
which is vital in his/her daily activities. The interpersonal roles are designated
by
Figurehead: this role symbolizes the legal authority of the manager such as:
attending ceremonies, signing documents, etc.
Leader: as a leader a manager is accountable, responsible, and motivator of the
staff he is working with.
Liaison: a manager creates links in horizontal as well as vertical chain of
communications that facilitate communication in and out side the organization.
Informational role: this role is related to communication and information
channelling
Monitor: serving as a focal person for all types of communications
Disseminator: communicating selected information to subordinates
Spokesperson: communicating selected information to outsiders
Decision-making role: a manger has a legal authority to decide on matters that
are assigned to him based on his job description.
Entrepreneur: designing and initiating changes within the organization
Disturbance handler: taking corrective action and handling conflicts
Resource allocator: decides on resources and their distribution
Negotiator: negotiating with other parties representing organizational interests

what was the primry health care coverage in 1997 EC in Ethiopia Health
indicator 1998 75%

how would the above coverage change if the privet sector were included?
What are the calculation made in question 1 and 2

Discuss organization and organizational structure

Organization is a process that implies structuring and integrating activities
which has an interdependent nature to execute and fulfill the set objectives.
Organizations are Goal oriented, psychological system(people), Technological
system, and an integration of structured patterned activities and relationships.
Organizing is the function performed after planning. Organizing focuses
attention on the structure and process of allocating jobs so that common
objectives can be achieved.

Formal Organization
A formal organization is often described by means of 'organizational chart'.
Among the advantages of formal organization are those they:
Define broad area of responsibility
Provide a basis for writing job descriptions
Indicate channels of communication
Clarify relationships between people
Avoid complications caused by overlapping of functions

Organization structure has two facets

First:- The form structure
Second:- Function which are to be performed
ORG/Institution, Departments, Divisions, Sections

What is authority, discuss types of authority delegation and leadership

Discuss human resource management
What is the Ethiopian policy look like
What are the priorities of the policy

3.Biostatics

1 Statistics: A field of study concerned with the collection, organization and

summarization of data, and the drawing of inferences about a body of data when
only part of the data are observed.

•Biostatistics: An application of statistical method to

biological phenomena.

Population & Sample

• Target population: A collection of items that have something in common for
which we wish to draw conclusions at a particular time.
• Study Population: The specific population from which data are collected
Sample: A subset of a study population, about which information is
actually obtained.

Characteristics of a good measure of central tendency

•A measure of central tendency is good or satisfactory if it possesses the
following characteristics.
1 1.It should be based on all the observations
2 2.It should not be affected by the extreme values
3 3.It should be as close to the maximum number of values as possible
4 4.It should have a definite value
5 5.It should not be subjected to complicated and tedious calculations
6 6.It should be capable of further algebraic treatment
7 7.It should be stable with regard to sampling

 Measures of central tendency and their computation

The various methods of determining the actual value at which the data tends to
concentrate are called measures of central tendency.
The most important objective of calculating measure of central tendency is to
determine a single figure which may be used to represent a whole series
involving magnitude of the same variable.

- Mean
- Median  affected by extreme value
- Mode

1. Arithmetic mean (x)

The most familiar MCT is the AM. It is also popularly known as average. a)
Ungrouped data If xx ..., x are n observed values, then
Ungrouped data•
1 For given set of data there is one and only one arithmetic mean.
2 •The arithmetic mean is easily understood and easy to compute.
3 •Algebraic sum of the deviations of the given values from their arithmetic
mean is always zero.
4 •The arithmetic mean possesses all the characteristics of a central value,
except No.2,

which is greatly affected by the extreme values.

•In case of grouped data if any class interval is open, arithmetic mean can not be
calculated

The median of a finite set of values is that value which divides the set of values
in to two equal parts such that the number of values greater than the median is
equal to the number of values less than the median.
•If the number of values is odd, the median will be the middle value when all
values have been arranged in order of magnitude.
•When the number of observations is even, there is no single middle
observation but two middle observations.

•In this case the median taken to be the mean of these two middle observations,
when all observations have been arranged in the order their magnitude
Mode (x)

a) Ungrouped data•It is a value which occurs most frequently in a set of

values. •If all the values are different there is no mode, on the other hand, a set
of values may have more than one mode.3.

 Measures of dispersion

1.5. Measures of variability

•The measure of central tendency alone is not enough to have a clear idea about
the distribution of the data.
•Moreover, two or more sets may have the same mean and/or median but they
may be quite different.
•Thus to have a clear picture of data, one needs to have a measure of dispersion
or variability (scatterdness) amongst observations in the set.

- Range affected by extreme value

1 •R = XL-XS, where

XLis the largest value and XSis the smallest value.

Properities
•It is the simplest measure and can be easily understood
•It takes into account only two values which causes it to be a poor
measure of dispersion

- Standardvation  affected by extreme value

- Interquartile range

Interquartilerange (IQR)

•IQR = Q3-Q1, where

Q3is the third quartile and Q1is the first quartile.

•Example: Suppose the first and third quartile for weights of girls 12 months of
age are 8.8 Kg and 10.2 Kg respectively. The interruptible range is therefore,

IQR = 10.2 Kg –8.8 Kg

i.e., 50% of infant girls at 12 months weigh between 8.8 and
10.2 Kg.
 Probability

Mutually exclusive events: Events that cannot occur together

•Independent events: The presence or absence of one does not alter the chance
of the other being present
.•Probability: If an event can occur in N mutually exclusive and equally likely
ways, and if m of these possess a characteristic E, the probability of the
occurrence of E is P(E) = m/N.
An understanding of probability is fundamental for quantifying the uncertainty
that is inherent in the decision-making process• Probability theory also allows us
to draw conclusions about a population of patients based on known information
about a sample of patients drawn from that population.

Standard deviation The deviation from the mean

It is the positive square root of the variance. (σ, S)

1
σ=√σ2 and S=√S2
Standard deviation is considered to be the best measure of
dispersion and is used widely because of the properties of
the theoretical normal curve.
•There is however one difficulty with it. If the units of
measurements of variables of two series is not the same,
then there variability can not be compared by comparing the
values of standard deviation.

Coefficient of variation (CV)

•In situations where either two series have different units of
measurements, or their means differ sufficiently in
size, the coefficient of variation should be used as a
measure of dispersion.
•It is the best measure to compare the variability of two
series of sets of observations.
•A series with less coefficient of variation is considered
more consistent.
•Coefficient of variation of a series of variate values is the
ratio of the standard deviation to the mean multiplied
by 100.

What is probability sampling?

Probability: If an event can occur in N mutually exclusive and equally likely
ways, and if m of these possess a characteristic E, the probability of the
occurrence of E is
P (E) = m/N.
 Probability sampling:

1 •It is a sample obtained in a way that ensures that every member of the
population has a known, none zero probability of being included in the sample.
2 •Probability sampling involves the selection of a sample from a
population, based on chance.
3 •Probability sampling is more complex, more time-consuming and
usually more costly than non-probability sampling.
The following are the most common probability sampling methods:–
o Simple random sampling–
o Systematic random sampling –
o Sampling with probability proportional to size–
o Stratified random sampling –
o Cluster sampling –
o Multi-stage sampling

A health survey (sampling) is a planned study to investigate the health

characteristics of a population

What is P value

Hypothesis Testing (Test of Statistical Significance) P value

Test of statistical significance quantifies the degree to which sampling variability
may account for the observed results. The "P value" is used to indicate the
probability or likelihood of obtaining a result at least as extreme as that observed
in a study by chance alone, assuming that there is truly no association between
exposure and outcome under
consideration (i.e., H0 is true). For medical research, the P value < 0.05 is set
conventionally to indicate statistical significant.
What is power of a test?

What is statistical significance?

What are elements for chi- square test, correlation and regression
Properities of normal distribution, t-distribution and probability calculation
Probability sampling
Two points in determining sample size

4.Nutrition

 Protein energy malnutrition (PEM)

Protein-energy malnutrition (PEM) describes a range of clinical disorders. At one
end marasmus is due to a continued restriction of both dietary energy and
protein, is well as other nutrients. At the other end of kwashiorkor, due to
quantitative and qualitative deficiency of protein, but in which energy intake
may be adequate. These two syndromes are the extremes. Between them are
forms in which the clinical features are due to varying combinations of
deficiency of protein and energy together with deficiencies of minerals and
vitamins and with associated infections. Some children adapt to prolonged
insufficiency of food-energy and protein - by a marked retardation of growth.
Weight and height are both reduced and in the same proportion, so they appear
superficially normal, when weight or height is checked against standards for
normal children it is seen that they resemble children a year or more younger.

 Iron deficiency
Iron deficiency is the world's most common nutritional disorder. It affects
around 2 billion people. Half of that number suffer iron deficiency anemia. In
developing countries, 51% of children under the age of four years, 40% of all
women and 51% of pregnant women are affected.

Iron deficiency anemia reduces the ability of the blood to carry oxygen from the
lungs to the brain muscles and other organs. This phenomenon results in
reduced capacity to work and to learn. Fatigue, shortness of breath even after
slight exertion, dizziness, headache, and loss of appetite are also common with
anemia.

One of the greatest dangers posed by iron deficiency anemia is that it diminishes
the ability to fight infection and thus increases vulnerability to transmissible
diseases. Anemic expectant mothers face the risk of death resulting either from
spontaneous abortion, the stress of labor or other delivery complications
Interventions

There are several concrete and well-defined actions that, if effectively

implemented, can achieve a dramatic level of success in the prevention and
control of iron deficiency with a modest investment. These are;
o food fortification
o supplementation
o dietary improvement
o public health measures
These strategies usually work best in combination with each other.

 Public health importance

Iron deficiency was for long considered to be of little more public health
significance than an important cause of anemia. Now we know that work
capacity may be seriously and in the young mental development and ability to
profit from schooling may be impaired. In the case of iodine the term IDD
(Iodine Deficiency Disorders) has been coined. It is now known that endemic
colloid goiter is not the most significant consequence for public health of iodine
deficiency. Development of the brain in fetal and early postnatal life may be
retarded and relatively minor degrees are much more common that clinical
cretinism.

-Iodine deficiency
Iodine is a mineral essential to human life. Some of the basic functions of the
human body depend on a steady supply of iodine. Iodine is present in its natural
state in the soil and water.
Goiter is the most visible sign of iodine deficiency. It is a swelling in the neck
caused by an enlarged thyroid gland. The thyroid increases in size when there is
not enough iodine available to it. Without enough iodine, a person can become
dull, easily tired and less active.
Iodine deficiency also results in stillbirths and high rates of infant mortality. In
pregnancy, this deficiency leads to mental and physical defects in the baby
ranging from mild mental retardation to cretinism.

Studies from many countries around the world show that children in iodine-
deficient areas suffer from poor hand-eye coordination and have 10 to 15 IQ
points less than children who get enough iodine in the diet. The effects upon a
child born to a severely iodine-deficient mother are rarely reversed. It is,
therefore, best to intervene before or during pregnancy if the child is not to suffer
a lifetime of compromised growth and development and of mental and other
disabilities

-Vitamin A

The term Vitamin A Deficiency (VAD) embraces all forms and degrees of
deficiency, including the most severe, in which the function and structure of the
eye are affected. All stages of the eye changes are covered by the term
Exophthalmia (X). It is only in the past two decades or so that the threat to health
and survival of lesser degrees of VAD has become apparent.

Vitamin A, in all its closely related forms, is only present in nature as a result of
enzymic action on certain precursor compounds within the bodies of most
vertebrate animals. These precursors of vitamin A comprise quite a small
proportion of a large group of compounds known as arytenoids

Vitamin A campaign in Ethiopia

It is streamlined with EPI and polio campaign programs vit A
capsules are provided for under five children during vaccination
 Enhanced outreach service where integrated program implementation
is undertaken
Measles vaccine
Vit A supplementation
De-warming
Nutritional assessment and services and
F/P
Polio eradication strategy
Strengthening routine immunization
Supplemental immunization (national and regional campaign)
Mopping up where the case is observed
Surveillance (continuous search for the disease)it can be passive and
active surveillance

- Growth monitoring and Ethiopian situation

- Institutional base, or clinical base assessment
- Community services IMICI (Integrated management of infant and
childhood illnesses
- Health education and primary health care program

Longitudinal Vs cross sectional

Longitudinal Surveys
Cross-sectional survey techniques may be the most efficient approach to an
initial analysis of health (and nutritional) parameters in a population. However,
longitudinal studies will generally be necessary to defi9ne cause and effect
relationships and demonstrate the effectiveness of specific interventions.

Longitudinal studies have the advantage of demonstrating the incidence of

malnutrition and its determinants. Usually, selected members or families in a
community are kept under continuing, regular, systematic observation for a
relatively prolonged period.

Cut of point for low birth wt, its determinant (cause and effect)
2.5KG

-What are nutritional surveillance and its purpose?

The assessment of nutritional status of a community
Nutritional surveillance may be used to assist the planning, implementation,
management, and evaluation of programs. Questions which must be addressed
include whether the necessary services are provided as planned, particularly to
target groups, as well as whether and why nutritional status is improving or not.
Surveillance may occur before, during, or after program goals and objectives
have been identified; hence its content and scope must be directed to actions
which satisfy these program goals and objectives.
Use in Policy and Planning
Surveillance may also be used for policy and planning processes with regards to
resource allocations for specific programs or projects or other purposes such as
legislation (e.g. food price controls, etc.)
Nutritional surveillance involves watching, on a continuous basis, those factors
responsible for the nutritional status of populations and the early existence of
inadequate nutrition. Surveillance permits timely action to be taken to improve
nutritional status in a given population or to prevent its deterioration. Because of
its broad scope, nutritional surveillance overlaps with health and
epidemiological surveillance and cannot be readily separated from related
disciplines such as economic, social, and agricultural studies.
Surveillance requires regular data collection from populations either specifically
for surveillance or from available sources, or both. Such data must be presented
in an understandable manner for informed decision making.
The cycle of nutritional assessment
Nutritional
-----------------------> Problems --------------------------+
Action Data
Collection
+----------------------- Analysis <-------------------------+
Interpretation

-Who is responsible in doing that in Ethiopia?

Ethiopia established a food and nutrition surveillance system with the Relief and
Rehabilitation Commission in 1975. This early warning system included regular
rainfall, place, and agriculture reporting. Resources permitting information on
the effects of drought can also be sought from satellite photographs.
Cross-sectional Surveys
- The assessment of nutritional status of a community will most often be
evaluated of necessity by short-term cross-sectional studies, plus
information from health services, and perhaps some longitudinal data
of a very limited nature. The degree of complexity of a cross sectional
survey varies greatly; from national country surveys through repeat
cross-sectional studies to rapid surveys of a few weeks duration, in
times emergency as a feasibility of pre-survey before a longitudinal
study is planned and implemented.
- Cross-sectional surveys can be used as a baseline or as a periodic
evaluation of a program. They can be focused on a particular age-
group or geographical urban or rural area where malnutrition is
believed to be common, or they can be more general. They should be
undertaken with as careful sampling procedures as possible, but may
have to compromise with a convenient or supposedly representative
sample.

- Rapid Nutritional Assessment

- The philosophy of the rapid survey is that in needs to be timely, low-
cost, flexible, and have the ability to measure the problem. Ideally, the
findings should be geared to immediate action. The goal is to identify
and sort populations according to need and then intervene as required.
This type of disaster-natural or man-made (refugees, blockades, floods,
droughts, earthquakes, locust plagues, etc).
-
-Relation ship of infant mortality rate and nutrition
-
-
-
-
-
 - List four nutritional problems in Ethiopia?????
The major micronutrient deficiencies of public health importance in Ethiopia are
iodine deficiency disorders (IDD) vitamin A deficiency, and Iron deficiency
anemia. Other deficiencies mainly related to Thiamine, vitamin C and Fluoride
are also observed sporadically in some parts of the country. there is however,
little or no information related to the sporadic deficiency diseases.
Wasting
Stunting
Sever malnutrition
Maternal malnutrition

- List four nutritional interventions that are applicable in Ethiopia

-
- There is also a wide range of measures of primary prevention of
malnutrition which fall under the health sector's responsibility. they
include;
- educational activities for improving dietary practices,
- food fortification,
- supply of safe drinking-water,
- family planning,
- immunization,
- Supplementary feeding programs for vulnerable groups.

- The health sector has an important role within this multisectoral

framework. It provides services for general health care as well as
specific interventions for nutrition promotion. Even in the absence of
specific nutrition intervention, general health measures can have an
appreciable impact on nutritional status.
- Improved sanitation and provision of safe drinking-water can
significantly reduce the incidence of gastrointestinal infections and
parasitic infestations.
- Malaria control is another example of health sector intervention with
considerable impact on nutritional status.
- Immunization programs can control the infectious diseases of
childhood.
- The duration and severity of respiratory and gastrointestinal infections
can be reduced.
- Improved child-spacing can also be encouraged.

5. Environmental health
BASIC CONCEPTS/DEFINITIONS
“Health is a state of complete physical, mental, and social well being and not
merely the absence of disease or infirmity.” (Constitution of WHO).

“Environment is the sum of all external influences and conditions which effect
health, life, and growth. This includes the physical, biological, chemical, and
psycho-social environment”
Ecology is the study of organisms in relation to the surroundings (environment)
in which they live. It is also the study of the interactions between living
organisms and their environment.
Human ecology is the study of the interactions between humans with one
another, with other living things, and with their environment in general.
Public Health is “the science and the art or preventing diseases, prolonging life,
and promoting health through organized efforts of society” (WHO). It is an
organized effort carried out for the benefit of community.
Sanitation is “the establishment of environmental conditions favorable to health.
It is the prevention of diseases by eliminating or controlling the environmental
factors which form links in the chain transmission.” (WHO). This definition can
be equally applied to Environmental sanitation. Sanitation in Latin means sanitas
meaning health. Hygiene and sanitation are often interchangeably used.
Environmental Health is “the control of all those factors in man’s physical
environment which exercises or may exercise a deleterious effect on his physical,
mental, and social well being.” (WHO).
 DDT
 Incinerator
Incineration: burning of contaminated waste like sharps, gauzes, syringes,
pathological wastes, etc.
 Waste management

On-site storage:
 Needles & sharps be kept in a puncture proof container immediately
after use;
 Sorting and segregation of hazardous and non-hazardous and non-
hazardous solid wastes stored in a separate bin of 80-100 litres of
different colour.
 Decontamination of hazardous waste: sharps, cultures, discarded
linens, etc.; use of chemical (chlorine solution, hydrogen peroxide,
Lysol, etc) or thermal disinfectants (boiling, autoclaving, dry heating);
 Hazardous waste in red plastic bag wrapped and stored in red bin
until collection.
 Non-hazardous waste in black bin.
 Aelf care during waste handling: i) Provision of personal protective
devices: head cover, thick rubber gloves, plastic aprons, rubber boots
 covering at least half of the leg; ii) SOP: type of container by waste
type, collection schedule, training for safe handling;
2. Collection:
Collection of the red and black bins is done manually with the use of cart
to the main storage container (transfer station). The two types of wastes
need to be collected separately in every instance.
3. Transport and Disposal:
 Landfill: The domestic or general type of waste can be disposed in
this way.
 Incineration: sharps, gauzes, syringes, pathological wastes, etc.
 A commercial type of incinerator: at 900-1000C0 destructs the waste
with significant volume reduction into ash.
 A domestic type of incinerator: destroys the pathogens with no
significant volume reduction.
 Burial: placenta, blood, excretions, secretions;
 Drainage: only after decontamination.
 Golden rules of food handling

Ten golden rules for safe food preparation and consumption (WHO)
1. Choose food processed for safety
2. Cook food thoroughly
3. Eat cooked food immediately
4. Store cooked food immediately
5. Reheat Cooked foods thoroughly
6. Avoid contact between raw and cooked foods
7. Wash hands repeatedly
8. Keep all kitchen surfaces meticulously clean
9. Protect foods from insects, rodents, and other animals
10. Use pure water.

 Ecology
Ecology is the study of organisms in relation to the surroundings (environment)
in which they live. It is also the study of the interactions between living
organisms and their environment.
Pollution
 Pollution it is contamination with toxic waste. Pollution is the presence of
a substance in a medium with result of change of its “natural” state
potentially to cause an adverse effect to the environment.
 Air pollution: it means the presence in the atmosphere of one or more air
contaminants or combination there of in such quantities and of such
duration that they may be harmful to human, plant, or animal life, or
property, or that may interfere with comfortable enjoyment of life or
property or the conduct of business or other human activities (Purdom
1980).
  Water pollution: is the presence of physical, chemical, and biological
matters in amount that cause adverse effects to man, animals, plants, and
materials
Prevention and Control of Pollution
Recycling and reuse of waste materials;
Waste reduction;
Control the use of chemicals
Proper disposal of wastes;
Treatment of wastes before discharge;
Use of “cleaner” energy sources, such as sun energy, wind, etc.;
Reduce emission of air pollutants using different techniques;
Formulation of rules and regulations
Ozone depletion

1 Identity: found in stratosphere in nature as O 3; its detection in troposphere

(ground level) is an indicator of pollution.
What causes Ozone depletion?
 Human activity: release of halogenated hydrocarbons: CFCs; CCI4;
 Are used as refrigerants, propellants, solvents, foam production,
etc.
 Are stable under normal conditions in the troposphere.

 Describe the relation between population growth and environmental

condition
 The effect of rapid population growth in development and environment

IMPACT OF HUMAN POPULATION GROWTH ON RESOURCES AND

ECOSYSTEM
 There are already 1.9 billion people who are very poor, and who always think
not of the food they are eating but of their next meal.
 Population growth unless matched with corresponding natural resources,
growth of economy and development will create:
a. Unemployment
b. Low literacy rate
c. Shortage of housing
d. Resource depletion
e. Shortage of food
f. Shortage of social services
g. Political and social unrest
h. unstable ecosystem( environmental pollution )

 Types of latrine
 What is the commonest latrine used in Ethiopia? How much percentage?
Discuss its drawbacks
  Environmental health in developing countries are linked to high death of
infant children and adults. Describe how this linkages can be justified
 About 75% registered OPD cases are associated to lack of basic sanitation:
dysentery, diarrhea, skin and eye infections, helminthiasis, protozoal
infections
 proportion of diarrhea among under fives is 45%,
 Two week incidence of diarrhea under fives 16.5% at 3-7 episodes per year
per child.
6. Health education

Define health education process

It is a process that aids people to find out their health needs and activate them for
suitable behavior. The education given for identifying the health need and
matching it with suitable behavior can be termed as health education. In other
words, the entire process of involving people in learning about health and disease
and aiding them to act suitably for overcoming illness and preserving a positive
health is health education.
Essentials of HE

The following essential points are relevant and applicable to HE in all possible
situations.

1. HE may be required for almost every one at some time or other.

2. HE is not a one time affaire. It is a continuing education.
3. HE can be organized as a self-learning process, and also can be a process of
learning from others.
4. HE consists of proper communication of ideas
Since HE aims at change of behavior a health educator has to acquire and develop
skills to educate, to communicate, to motivate and involve the client.
He/she should have working knowledge of social psychology and
principles and theories of community organization.
9. HE is not like teaching of medical and health subjects to undergraduate
medical, nurses and paramedical, etc. People in all walks of life have to be
educated frequently on health practices and health related behavior from
time to time throughout life and as applicable to changing conditions.
10. It must be borne in mind that human behavior is governed by various
influences and therefore, HE must take full cognizance of all the influencing
factors in any given situation. A good health educator has, therefore, to combine
in himself knowledge and skills of behavioral sciences with sufficient rational
understanding of the health problems and their solutions from a scientific and
logical stand point
Write elements of communication process
The process of communication is usually described by models with three distinct
parts and their elements. These are: (1) Sender or communicator; (2) the receiver
of the message or the communicatiee; (3) the message which lies between the
communicator and the communicatee and gets transacted.

Write about predisposition, motivation and reinforcing factor of human behavior

What are components of communication?

What is communication?
To communicate means (dictionary definition) "to impart, pass on or transmit a
message, information, etc.; to exchange ideas or information with, be in touch
with, to have access, to be connected with," and communication means "the act of
communication, the things communicated, the means of communicating."
Essentially communication deals with transmission of information or ideas and
sharing and exchanging of information.

It is needless to emphasize that in learning and education, communication gains

great importance because education implies transfer of knowledge and skill and
communication also means transfer of information and exchange of ideas. In
learning information has to be gathered and acquired; and skills have to be
observed, practiced and developed. Therefore, communication forms an
indivisible component of the process of education and the process of learning.

Health promotion
It is an intervention whose purpose is to minimize or curtail illnesses and
enhance quality of life through change and development of health related
behavior and condition of leaving.
Health Promotion Programs operate either at primary (hygiene and health
enhancement), secondary (early detection) or tertiary (therapeutic) stages of
prevention, it may accurately be seen as an intervention whose purpose is to
short-circuit illness or enhance quality of life through change or development of
health related behavior and conditions of living.
Enhance quality of life through change or development of health related
behavior and conditions of living. The PRECEDE framework (predisposing,
reinforcing and enabling constructs in educational / environmental diagnosis
and evaluation) takes into account the multiple factors that shape health status
and helps the planner arrive at a highly focused subset of those factors as targets
for intervention. PRECEDE also generates specific objectives and criteria for
evaluation. The PROCEED framework (policy, regulatory and organizational
constructs in educational and environmental development) provides additional
steps for developing policy and initiating the implementation and evaluation
process.
PRECEDE-PROCEED works in tandem, providing a continuous series of steps or
phases in the planning, implementation, and evaluation process. The
identification of priorities and the setting of objectives in the PRECEDE phases
provide the objects and criteria for policy, implementation, and evaluation in the
PROCEED phases.

Health promotion programs operate at

1. Primary hygiene and health enhancement
2. Secondary early detection and outcome, early detection of out come
3. therapeutic stage of prevention

Relevance of health education

It helps people to find out their health needs and initiate them selves for suitable
behavior. HE is concerned with change in knowledge feeling and behavior of
people. It provides necessary information and create positive attitude to bring
about sustainable behavior change

What is behavioral health?

Various theories and models have been formulated and tested which are used to
understand and predict health related human behavior. These theories attempt
to analyze why people practice certain health behaviors. In other words, it is
very important to know what kinds of activities encourage learning and behavior
change. A number of theories of health education have been proposed, where
each attempts to identify what skills or knowledge must be learned and how
they are best learned and performed

Is behavioral health an art or a science

Influence of health education

The goal of HE is to possess the abilities necessary for making informed

decisions about the health and acting on these decisions. These go beyond
learning and performing specific health behaviors. It refers to having the
abilities to make ongoing decisions about the health of oneself and others, as well
as being able to organize personal and social resources to act on these decisions.
Decision making abilities include skills that were described as being intellectual,
psychological and social in nature. These include:

1. Seeking and evaluating information

2. Considering one's priorities
3. Comparing the costs and benefits of an action
4. Solving problems
5. feeling confident about one's control
6. Utilizing other's expertise and opinion, and
7. Coordinating the efforts of many people

Mode of communication/ channels of communication?????

Face to face Interpersonal channels - such as face to face communication,
community distribution, home visits, training, group discussions, and counseling-
are generally best for giving credibility to messages, providing information, and
teaching complex skills that need two -communication between the individual and
a credible source of information.
Media Broadcast channels generally provide broad coverage for communication
messages, reaching a large number of the target audience quickly and frequently.
In developing countries, radio has been a powerful channel to reach large numbers
of people with communication messages, and to model target behaviors and their
consequences
Print channels - such as pamphlets, flyers, and posters- are generally considered
best for providing a timely reminder of key communication messages.
Pamphlets and other graphic materials distributed at the individual or
home level can provide complex information in a digestible form, so that
the target audience can use that information when it most needs it Audio-
visual materials - such as videos, slide-tape shows, and flip charts- visually
portray key messages during interpersonal communication sessions.

Telephone
Signs and gestures

Elements of communication
Sender
Receiver
Message
Mode of communication
┌──────┐ ┌────────┐ ┌───────┐ ┌────────┐

│Sender├──>│Encoding├───>│Channel├────>│Decoding├─────>│Recei
ver│
└──────┘ └────────┘ └───────┘ └────────┘
└───┬────┘
^ ┌────────┐ │
└─────────────────────┤Feedback┤<───────────────────
────┘

Parameters of effective communication

 1. -communicator, the sender of the message should be fully aware of the
subject and shuld know the issue very well
Should instigate credibility and show capability of handling the the subject
under discussion
Should have proper communication skill
Should have proper attitude towards the the receiver
2. -Message, the message containt should be very brief and clear
It should be appropriate ,relevant and timely
Should be supported by factual datas
The channel by which the message is sent should be appropriate
3. -Channel, it should be familiar, appropriate for the message and should
be available and accessible
4. receiver, Should have proper attitude and the desire to receive the
communicated message
Should be in good health and have intact sensory functions

Behavioral health research

. A behavior analysis scale is provided to identify what health behaviors should
be changed. Criteria for choosing the target behavior include: high impact on
health, observable consequences of behavior, compatible with existing practices,
behavior not too complex or costly or lengthy. The theory specifies that learning
and behavior change take place as a result of reinforcing feedback from the
behavior. The consequences of an action determine whether it will be performed
or not.

The most highly influential and widely researched theory of why people practice
health behavior is the health belief model. The health belief model of Rosenstock
(1990) and Backer (Janz & Backer, 1984) emphasize the intellectual dimension of
health behavior. Recently it has added the psychological dimension of Social
Learning Theory (Bandura; Rotter), and we might also add the social dimension
from the Theory of Reasoned Action (Ajzen, 1988). The theory identifies the
following knowledge as relevant:

1. Perceived threat is made up of the perception that one is susceptible to the

illness (i.e., personal risk) and the perception that the illness is serious. If
these two perceptions are high, then the perceived threat is high, and one
will be driven to act to avoid the threat. That is cue for action is triggered
by an individual's perception or by reading about health matters. The
perception of personal health threat is influenced by at least three factors:
general health values, which include interest and concern about health;
specific beliefs about vulnerability to a particular disorder; and beliefs
about the consequences of the disorder (i.e., whether or not they are
serious. Thus for example, a person may change his diet to include low-
 cholesterol foods if he values health, feels threatened by the possibility of
heart disease, and perceives that the threat of heart disease is severe.

2. Outcome expectations are made up of the perceived benefits of the

specified action (e.g., effective, inexpensive) minus the perceived barriers to
the action (e.g., costly, time consuming). If the outcome expectations are
high, they will specify exactly what action is taken. Behavior is evaluated
from an estimate of the potential benefits of health seeking action to reduce
susceptibility or severity. The benefits are then weighed against
perceptions of physical, psychological, financial and other costs of barriers
inherent in the health-finding effort. Demographic, social, structural and
personality factors are included in some versions of the model as modifying
factors since in theory they indirectly influence actual behavior. For
example, the man who feels vulnerable to a heart attack and is considering
changing his diet may believe that dietary change alone would not reduce
the risk of a heart attack and that changing his diet would interfere with his
enjoyment of life too much to justify taking action. Thus, although his
belief in his personal vulnerability to heart disease may be great, his faith
that a change of diet would reduce his risk is low and he would probably
not make any changes.

3. Self-Efficacy is confidence that one has the skill and resources to perform
the specified action. This comes from Bandura's social learning theory. If
one has self-efficacy, one can perform the action with confidence and pride,
though not necessarily with skill or expertise. Practice enhances self-
efficacy.

4. Subjective norm refers to one's perception that significant other people

will approve of the action. This comes from Fishbein and Ajzen's (1988)
Theory of Reasoned Action. If you think that most of the important people
you know and live with will approve of the action, you are likely to do it.

2 APPLIED BEHAVIOUR ANALYSIS - HEALTHCOM Group (Graeff, Elder &

Booth, 1993
Antecedents: stimulate action
Behavior: skill and performance
Consequences: strengthen behavior

3 THEORY OF REASONED ACTION - FISCHBEIN & AJZEN (1977 - 1980)

Another cognitive theory that attempts to integrate attitudinal and behavioral
factors is Fishbein and Ajzen’s Theory of Reasoned Action. According to this
theory, a health behavior is a direct result of a behavioral intention - i.e., of
whether or not one intends to perform a health behavior. Behavioral intentions
are made up of two components: attitudes towards the action and subjective
norms about the appropriateness of the action.

4. THEORY OF PLANNED BEHAVIOUR (TPB)

They argue that in addition to knowing a person's attitudes, subjective norms,
and behavioral intentions with respect to a given behavior, one needs to know his
or her perceived behavioral control over that action.
In a test of the revised model, they found that people need not only hold a
behavioral intention toward a particular attitude object but also feel that they are
capable of performing the action contemplated and that the action undertaken will
have the intended effect. Thus, feelings of perceived control and self-efficacy also
appear to be important in demonstrating attitude-behavior consistency; even
when there is a clear behavioral intention to act on the attitude.

Similarities and differences of health education and health promotion

Similarities: They both enhance the knowledge and attitude change and assist
them in finding out the health needs in their community and appropriate action
to be taken
Differences: health education is confined in knowledge and attitude change
through learning and educating mechanisms
Health promotion is an intervention to enhance quality f life by circumventing
the illness and disease causes through promotion planning and implementation
of necessary interventions
Discuss culture, custom, value, knowledge, attitude and their relation with
health education
Health education is a process of interacting with intellectual, psychological and
social conditions
Culture, it is more or less persistent and organized pattern of habits, customs,
attitude and values which transcend generation to generation.
Custom: Agreed upon practice with in a given society. It is a pattern of action
shared by some or all members of the society
Value: the price or weight given for a given condition the worth or preference or
judgment which has an influence on a given action
Knowledge: it is the information or awareness stored in the memories of the
individual to influence his action
Attitude: it is the predisposition to respond to the situation in favor or against or
unfavorable manner towards it
Determinants of health behavior
Predisposing factors include a person's or population's knowledge, attitudes,
beliefs, and perceptions that facilitate or hinder motivation for change. These are
those antecedents to behavior that provide the rationale or motivation for the
behavior.
Enabling factors are those skills, resources or barriers that can help or hinder the
desired behavioral changes as well as environmental changes. They can be
viewed as vehicles or barriers, created mainly by societal forces or systems.
Facilities and health insurance, and laws and statutes may be supportive or
restrictive. The skills required for a desired behavior to occur also qualify as
enabling factors. Enabling factors thus include all the factors that make possible
a desired change in behavior or in the environment. Enabling factors are the
antecedents to behavior that enable a motivation to be realized.
Reinforcing factors, the rewards received, and the feedback the learner receives
from others following adoption of the behavior, may encourage or discourage
continuation of the behavior. Or in other words, reinforcing factors are factors
subsequent to a behavior that provide the continuing reward or incentive for the
behavior and contribute to its persistence or repetition.

Discuss three principles of learning

Prerequisite for good communication

Health education principles and customs

Health education is aimed at insuring the desired health related behaviour
In principle health education should be
a) Need based, it should be felt with both parties
b) It has to get into the culture and custom of the community and introduce new
ideas with care and caution
c) Discuss the health solution advantages and disadvantages in more clarity
d) it has to take the learning and teaching process
e) There should be free flow of communication
f) The health educator has to make him self acceptable and win the confidence of
his clients
e) He should be role model and practice what he teaches
f) The educator has to have reasoning and rationalizing power of the topic he is
discussing
g) Health education has to be well planed to ensure full understanding of the
problem by his audience
h) Use other supportive accessories ( like audio Visual if available)to support and
reinforce the information
i) Health education should be specific relevant to the problem and should
indicate available solution

Discuss stage of communication

Discuss major barriers of communication and their solution

Source or the sender or the communicator

The communicator has to be intelligent and understanding. He should know the
need of the audience. He should have proper judgment.
The communicator should possess the following characteristics:
a. Skill in communicating - verbal, written. including treatment of message,
etc.
b. Knowledge of the channel and audience.
c. Attitude towards the subject (topic), channel and audience.
d. Source credibility
e. Skill in encoding and decoding
f. Skill in utilizing the channel
g. Confidence or attitude towards self.

Message
A message is the information, which a communicator wishes the audience to
receive, understand, accept or act upon. Message will, therefore, consist of
statements made verbally during conversation or transmitted through any media.

Channel
The sender and the receiver of the message have to be connected with each other
through a medium or channel of communication. In face to face communication
there is no particular medium except the atmosphere. When message have to be
transmitted to distant places we resort to various types of media or channels of
communication. The physical bridges between the sender and the receiver of the
message are the channels.

In general, there are three aspects of communication:

a. Encoding and decoding of message
b. Message vehicle - sound waves, electrical wave, etc.
c. Vehicle - air, wire, microphone, radio, etc.

4. Selection of channels
It is very important for the communicator to find the proper channel for his
message. The channel must be easily available and accessible to the receiver and
also the receiver should be acquainted and accustomed to utilize the message
coming through the particular channel. While selecting the channel the
communicator has to make sure that noise is kept to the minimum or eliminated.
Another important precaution is that the medium should not become a barrier.

5. Audience or receiver
In a good communication process the receiver can take the role of source or
communicator for the purpose of giving feedback. Therefore, in teaching/learning
situation the communicatee has to develop skills for proper communication. The
receiver should be able to receive the message physically, mentally and
psychologically. He/she should be confident and eager to receive. He must have
faith in the source and must view the source with due regard and cordially.

The level of intelligence or knowledge is of particular importance to the

communicator. The position or status of both the communicator and
communicatee should also be considered.
Methods and techniques of health education

What are the common teaching aids`

Slides
Transparencies
Picture
Photograph
Poster
Charts & Graphs
Printed materials: books, pamphlets, booklets, brochures
Leaflets, folders, brochure; booklet and pamphlets
Display boards: Flannel Board, Bulletin (notice) Board, and ChalkBoard
AUDIO AIDS
AUDIO-VISUAL AIDS
OTHER AIDS: Folk songs, folk dances, drama, puppet show, puppet stage,
puppet plays

These folk media are used to introduce sociological themes.

How do you conduct IEC in your health facility?

Discuss counseling
Through counseling, an individual is encouraged to think about his problems and
thus comes to a greater understanding of their causes. From this understanding
that person will hopefully omit himself to taking action that will solve the
problems. The kink of action that a person takes, will also be that person's own
decision although guided, if necessary, by the counselor.

Counseling means choice, not force, not advice. A health worker may think that
his advice seems reasonable, but it may not be appropriate to the situation in
which the individual lives. Through counseling, the solutions are more likely to be
appropriate. An appropriate solution will be one that the person can follow with
successful results.

RULES FOR COUNSELLING

Relationships: A counselor shows concern and a caring attitude
Identifying needs: A counselor seeks to understand a problem as the person sees
it himself
Feelings: The counselor develops empathy (understanding and acceptance) for a
person's feelings, not sympathy (sorrow or pity).
Participation; A counselor never tries to persuade a person to accept his advice
Keeping secret: A counselor will hear many personal and possibly embarrassing
problems. This information must be kept secret from all other people, even from
the person's relatives
Information and resources: Although a counselor does not give advice, he should
share information and resource ideas which the person needs to have to make a
resource ideas which the person needs to have to make a sound decision.
All health or community workers can practice a counseling approach in their
work. Parents and friends can be counselors too. The important thing is friends
can be counselors too. The important thing is that the health worker, teacher,
father or friend be willing to listen carefully and encourage the person in need of
advice to take as much responsibility as possible for solving his or her own
problem.

Values, beliefs and customs

In every community there are sets of beliefs about life, which come from
tradition and religion. There are customs that regulate how people behave
towards one another, such as giving respect to elders, demanding obedience
from children.
Customs also determine behavior in marriage and childbirth and at death.
Values shows what people think are most important. Health workers need to
understand very fully the beliefs, customs and values of the people.
7. Reproductive Health

Define RH
Reproductive health has been defined within the framework of the WHO
definition of health as “a state of complete physical, mental and social well-
being, and not merely the absence of disease or infirmity.” Reproductive
health is a state of complete physical, mental, and social well being and not
merely the absence of disease or infirmity, in all matters related to the
reproductive system and to its functions and process.
Reproductive health addresses the human sexuality and reproductive processes,
functions and system at all stages of life and implies that people are able to have
“a responsible, satisfying and safe sex life and that they have the capability to
reproduce and the freedom to decide if, when and how often to do so.”
Components of Reproductive Health
 Quality family planning services
 Promoting safe motherhood: prenatal, safe delivery and post natal care,
including breast feeding;
 Prevention and treatment of infertility
 Prevention and management of complications of unsafe abortion;
 Safe abortion services, where not against the law;
 Treatment of reproductive tract infections including sexually transmitted
infections;
  Information and counseling on human sexuality, responsible parenthood
and sexual and reproductive health;
 Active discouragement of harmful practices, such as female genital
mutilation and violence related to sexuality and reproduction;
 Functional and accessible referral
Describe four important points for eradication of polio

Describe the top 5 diseases in children

Define RH rights
Men and women have the right to be informed and have access to safe, effective,
affordable and acceptable methods of their choice for the regulation of fertility
which are not against the law, and the right of access to appropriate health care
services for safe pregnancy and childbirth and provide couples with the best
chance of having a healthy infant. Reproductive health is life-long, beginning
even before women and men attain sexual maturity and continuing beyond a
woman's child-bearing years.

Indicators show greater disparities among population groups

Indicators in Reproductive Health
Evidence for monitoring: Reproductive health indicators
A health indicator is usually a numerical measure which provides information
about a complex situation or event. When you want to know about a situation or
event and cannot study each of the many factors that contribute to it, you use an
indicator that best summarizes the situation. For example, to understand the
general health status of infants in a country, the key indicators are infant
mortality rates and the proportion of infants of low birth weight.
Which of the following is not used for emergency contraception?

Techniques and services that contribute to the RH wellbeing

 Components of Reproductive Health
 Quality family planning services
 Promoting safe motherhood: prenatal, safe delivery and post natal care,
including breast feeding;
 Prevention and treatment of infertility
Prevention and management of complications of unsafe abortion;
Safe abortion services, where not against the law;
Treatment of reproductive tract infections including sexually transmitted
infections;
Information and counseling on human sexuality, responsible parenthood and
sexual and reproductive health;
Active discouragement of harmful practices, such as female genital mutilation
and violence related to sexuality and reproduction;
Functional and accessible referral
The approach recognizes the central importance of gender equality, men's
participation and responsibility.

Characteristics of gender
Sex is the biological difference between males and females.
Gender refers to the economic, social and cultural attributes and opportunities
associated with being male or female in a particular social setting at a particular
point in time
What are the four strategies for polio eradication
What are the main justification for mother and child health services
Why focus on maternal health?
 In developing countries, pregnancy and child birth are the leading causes
of death, disease and disability among women of reproductive age.
 At least 30 to 40 % of infant deaths are the results of poor care during
pregnancy and delivery.
 Poor Maternal health and nutrition contributes to low birth weight in 20
million babies each year-almost 20 % of all births.
 Motherless children are likely to get less health care and education as
they grow up.
 Maternal health interventions are among the most cost-effective
investments in health.
- US 3$ /person is the approximate cost of ensuring that women in low-
income countries get health care during pregnancy, delivery and after
birth; post partum family planning; and newborn care (WHO).
When a mother dies, the family and community suffer, and surviving children
face higher risk of poverty, neglect or even death.

There is a global effort that aims to reduce deaths and illnesses among women
and infants, especially in developing countries. This effort is called Safe
Motherhood Initiative. The global safe motherhood initiative was launched in
1987 to improve maternal health and reduce the number of maternal deaths by
half in the year 2000. It is led by a unique alliance of co-sponsoring agencies that
work together to raise awareness, set priorities, stimulate research, mobilize
resources, provide technical assistance and share information. When the
initiative was launched, death from the complications of pregnancy and
childbirth was little known. During the initiative’s first decade, these safe
motherhood partners developed model programs, tested new technologies and
conducted research in a wide range of countries and settings. The essential
services that are identified and the most important lessons we have learned
through ten years record
In many developing countries, including Ethiopia, complications of pregnancy
and childbirth are the leading cause of death among women of reproductive age.
More than one-woman dies every minute from such causes. More than 600,000
women die each year worldwide. From this, 99% is accounted by developing
countries. Of these, around 273,000 women die each year in Africa. Particularly
being one of the less developed countries in the world, 46,000 women die each
year in Ethiopia.

Around 50 million pregnant women worldwide had morbid illness each year, of
which 15% of them have disabilities like fistula, infertility, etc. Over 300 million
women in the developing world currently suffer from short term and long term
illness related to pregnancy and childbirth.

Maternal mortality and morbidity can be reduced or avoided by providing and

expanding resources and services that are principally targeted in achieving
maternal health and safe motherhood.
Among the mortality indicators which is known to have the higest difference
b/n the developed and developing countries
Women’s lifetime risk of death is 40 times higher in developing countries as
compared to developed countries. In general women lifetime risk of death in
developing countries is 1 in 48 as opposed to 1:1800 in developed countries.
Mention three points of major reproductive rights

 the right of couples and individuals to decide freely and responsibly the
number and spacing of children and to have the information and means to
do so;
 the right to attain the highest standard of sexual and reproductive health;
and,
 The right to make decisions free of discrimination, coercion or violence.

What are the indicators of quality of care in RH?

A health indicator is usually a numerical measure which provides information
about a complex situation or event. When you want to know about a situation or
event and cannot study each of the many factors that contribute to it, you use an
indicator that best summarizes the situation.

Improving the quality of family planning services

Prevention and control of RTIs/STDs
Maternal mortality ratio (MMR):
Total Fertility rate
Contraceptive prevalence rate
Perinatal mortality rate
Antenatal Coverage
Attended Birth
Postnatal care:
Birth spacing
Women's lifetime risk of death
Infant Mortality Rate
Under five mortality Rate
Neonatal Mortality Rate
Post Neonatal Mortality Rate
8. Why do you want to join MPH programe?

I have been working in the area of FP/RH for over 15 years. I had an opportunity
to work in 3 Government hospitals Health centers in different assignments and
mostly I was assigned in the Gyne and FP units. After I joined Marie stops
International Ethiopia, one of the leading NGOs working in the fields of FP/RH I
got the opportunity and privilege to work in different capacities from a FP/RH
clinical provider to the level of project coordinator and program manager. I now
work as Adolescent Reproductive Sexual Health program manager and FP/RH
technical advisor for Save children USA country office.

Demographic data shows that Ethiopia's population size and growth rate are
among the highest in Africa. The population is estimated at more than 77 million,
making it the second most populous Sub-Saharan African country after Nigeria.
As per the information given by Engender Health, with an annual growth rate
estimated at 2.4%, Ethiopia's population will approach 110 million before 2020.
Nearly 2 million people are added to the country's population each year. Rapid
population growth as a result of continuing high fertility, is a fundamental
constraint to sustainable development in Ethiopia. This unbelievably accelerated
population growth sores the reproductive health problems in general. STI/STD,
HIV/AIDS unwanted pregnancy, abortion and abortion related morbidity and
mortality are some of the endemic reproductive health problems.

The experience I have gained from the different working opportunities and
progressive management positions and the fact that we have at hand makes me
think critically on the problematic issues that we all are facing.
I have been working in the FP clinics and have witnessed the progress of FP
program the intervention and also at the same time and in many instances. I was
confronted with challenges which some times can not get the right answer to
solve the problem. I have been involved with FP/RH service provisions when I
was working as FP/RH nurse and clinic manager. I have tried to address and
voice the problems which the provider and the clients encounter during service
provision and implementation. This work opportunity has also helped me
identify the gaps in quality service provision and the vacuum created in this
regard to forward the FP/RH programs

With regard to the policy issue, we all know that the country is confronted with
great challenge and the policy has to focus and design very practical
reconciliation mechanisms to mach the recourse available with the population
size. The policy decisions made in different policy formulation meetings on
population and FP/RH has to be implemented and the Government and the
policy makers have to take the ownership to spear head these implementations
through net working, partnership and resource mobilization.
The Ethiopian youth comprises 34% of the total population. As the future
country’s developmental force and the future leaders the youth have to be be
given special attention in every direction like health, education, security,
employment. Enhancing ,Strengthening and supporting effective youth
programs on reproductive and sexual health, Family planning and HIV/AIDS,
and other reproductive health problems including streamlining livelihood
programs together with the other undertakings should be the priority for the
country’s policy program. Sharing experience and duplicating best practices in
the area is one and feasible mechanism to start up and create awareness and
trigger self assertive action at the early age.

The social and cultural factors related to gender influence the extent to which
women and men are able to influence decisions affecting their health and the
quality of their lives.
Streamlining HIV/AIDS with other population and RH activities has to be given
a focus to register an impact. I believe we have done a lot in this regard, but the
larger bulk of the work is still dragging behind. There is still a lot to be done to
systematically bridge the observed gaps to address these observed unmet needs
in the area of FP/RH and population issues.

Finally I believe that this post graduate study coupled with my motivation and
dedication to the public health services that I have been with, will be very
instrumental for my carrier and future endeavour.

9. REFERENCES

 LECTURE NOTE ON THE MENTIONED SUBJECTS OF CARTER

CENTER

Summary of Measures of Association

Attributable risk (AR) or Risk difference (RD) indicate how much of the risk is
due to (or attributable to) the exposure. Quantify the excess risk in the exposed
that can be attributable to the exposure by removing the risk of disease that
could have occurred anyway due to other causes.

AR = Risk in exposed – Risk in non-exposed

Relative risk (RR): estimates the magnitude of the association between exposure
and disease and indicates the likelihood of developing the disease in the exposed
group relative to those who are not exposed.
 RR = Risk in exposed
Risk in unexposed

Odds of disease: is a simple ratio, not a proportion. Indicates odds of diseased

relative to the exposure status.

Odds of disease in exposed = a/b or a:b

Odds of disease in unexposed = c/d or c:d

Odds Ratio (OR): is the odds in the exposed over the odds in the unexposed.
Some people call it cross product.

OR = a/b  c/d = ad/bc

Attributable Risk Percent (AR%) among exposed: estimate the proportion of

disease among the exposed that is attributable to the exposure, or the proportion
of the disease that could be prevented by eliminating the exposure.

AR% = Risk in the exposed – Risk in unexposed

Risk in exposed

= OR – 1 X 100
OR

Population Attributable Risk (PAR) is the risk in total population minus risk in
the non-exposed. Estimate the excess rate of disease in the total study population
that is attributabe to the exposure.
l
PAR = Risk in population – Risk in unexposed

Population Attributable risk Percent (PAR%) Estimate the proportion of disease

in the study population that is attributable to the exposure and thus could be
eliminated if the exposure were eliminated.

PAR% = Risk in population – Risk in unexposed

Risk in population