Non-Communicable

UNIT 2 NON-COMMUNICABLE DISEASES-1 Diseases-1

Structure
2.0 Introduction
2.1 Objectives
2.2 National Response to Non-Communicable Diseases
2.3 National Programme for the Prevention and Control of Cancer, Diabetes,
Cardiovascular Diseases and Stroke (NPCDCS)
2.3.1 Diabetes
2.3.2 Hypertension
2.3.3 Cardiovascular Diseases
2.3.4 Stroke
2.3.5 Obesity
2.4 Blindness
2.4.1 Categories of Visual Impairment
2.4.2 National Programme for Control of Blindness
2.5 National Programme for Prevention and Control of Deafness
2.6 National Tobacco Control Programme
2.7 Thyroid Diseases
2.8 Injuries and Accidents
2.8.1 Operational Guidelines for Trauma Care Facility on National Highways
2.8.2 Risk Factors for Road Traffic Injuries
2.9 National Mental Health Programme
2.10 National Programme for Health Care of the Elderly (NPHCE)
2.11 Let Us Sum Up
2.12 Model Answers
2.13 References

2.0 INTRODUCTION
In the previous unit, you learnt about the epidemiology of non-communicable disease,
which included burden of disease in India, cause and risk factors.
There are National Health Programmes on the non-communicable diseases and key
programme is National Programme on Cancer Diabetes Cardiovascular Diseases and
Stroke (NPCDCS) with objectives of risk reduction for prevention of NCDs and
early diagnosis and appropriate management of these NCDs. The strategies used are
health promotion for the general population and disease prevention for the high risk
groups. The expected outcomes of the programme is to create awareness on healthy
life styles, health promotion at school, community and work places, and management
of Non-Communicable Diseases, particularly Diabetes, Cardiovascular Diseases and
Stroke.
In this unit you will be study objectives and various activities carried out under national
health programme and preventive measures for control of disease.
17
Non-Communicable Diseases
and Management Under 2.1 OBJECTIVES
National Health Programmes
After completing this unit, you should be able to describe:
• national health programmes related to NCDs;
• prevention, screening and management of diabetes, hypertension, cardiovascular
and coronary heart diseases;
• prevention, screening and management of stroke, obesity, blindness and thyroid
diseases;
• prevention, screening and management of injuries and accidents; and
• integrated management for the NCDs.

2.2 NATIONAL RESPONSE TO NON

COMMUNICABLE DISEASES
There are operational guidelines for the prevention, screening and control of common
non-communicable diseases (NCDs) which are a part of comprehensive primary health
care being came into existence in 2016.
The World Health Organization (WHO) has included four major NCDs – Cardiovascular
Diseases (CVD), such as heart attacks, Diabetes, Chronic Respiratory Diseases
(Chronic Obstructive Pulmonary Diseases and Asthma) and Cancer for bigger focus.
Data from community based NCD programmes in India depicts that the NCDs also
account for a significant proportion of illness and deaths.
These NCDs share common risk factors and for which there are a set of similar public
health approaches related to health promotion, prevention and management. Key factors
linked to the onset and course of these four NCDs are :
• Tobacco use and exposure,
• Unhealthy diet,
• Physical inactivity,
• Harmful use of alcohol,
• Indoor and ambient air pollution,
• Stress,
• Poverty (as a cause and consequence),
• Poor health seeking behaviours, and
• Low access to health-care services.
Diabetes and hypertension can cause stroke, heart attack or kidney failure, and all are
amenable to prevention, early detection and treatment.

2.3 NATIONAL PROGRAMME FOR THE

PREVENTION AND CONTROL OF CANCER,
DIABETES, CARDIOVASCULAR DISEASES AND
STROKE (NPCDCS)
Let us now discuss about various guidelines and main focus of the National programme
18
for prevention and control of cancer, diabetes, cardiovascular diseases and stroke as Non-Communicable
Diseases-1
given below:
• The main focus of NPCDCS is to enable opportunistic screening (Opportunistic
screening happens when someone asks their doctor or health professional for a
check or test, or a check or test is offered by a doctor or health professional) at
PHC/CHC and District levels, through the setting up of NCD clinics.
• At the PHC and sub-centre levels, additional funding for glucose testing was
provided for all those over 30 years of age and all pregnant women and
encompassing greater outreach, better follow up through systematic monitoring
and data collection to enable improved surveillance, including the use of IT for
patient records, follow-up and referral Sub-centre level. Community based
assessment checklist for early detection of NCDs is given in Annexure-1.
• These guidelines envisage that the risk assessment, screening, referral, and
follow up for selected NCDs amongst all women and men aged 30 years and
above, would be included in the set of services being offered at the HWC/
SHC.
These operational guidelines are designed to help state and district programme and
facility level managers and service providers to strengthen and expand risk assessment,
screening and management of Hypertension and Diabetes Mellitus.
The main focus of these guidelines is on:
• Screening and diagnosing common NCDs;
• Identifying and addressing modifiable risk factors,
• Treating using standard treatment guidelines,
• Follow up
• Referring patients at appropriate level.
The guidelines are an adjunct to and build on the relevant recommendations of the
NPCDCS guidelines. The roles and responsibilities of the primary health care terms
are given in Annexure 2. The package of services under NPCDCS is shown in Annexure
3 (page no. 9 doc).
In urban areas, states would need to evolve strategies that combine effective outreach
and facility based primary health care services to serve as a platform for the delivery of
this intervention. The range of facilities and outreach mechanisms vary widely between
and within States, and local, context specific mechanisms would need to evolve through
a process of piloting and study before being scaled up. Existing platforms and
partnerships would be strengthened to implement the intervention.
2.3.1 Diabetes
Diabetes is classified into three types namely:
1) Type 1 diabetes (T1DM): Usually occurs in younger people, children and
adolescents. The diagnosis of T1DM can be made throughout childhood but it is
more likely below 15 yrs of age. The onset is usually acute and severe and insulin
is required for survival.
2) Type 2 diabetes (T2DM): It is the commonest type of diabetes. It usually occurs
after the age of forty years but occurs frequently even at lower age among Indians. 19
Non-Communicable Diseases T2DM was previously known as non-insulin dependent diabetes mellitus. The
and Management Under
National Health Programmes
onset is usually insidious and may be mild to severe.
When is a person at high risk for diabetes?
• age of or above 30 years
• overweight (BMI is more than 23 kg/m2).
• physically inactive (exercises less than 3 times a week)
• high blood pressure.
• impaired fasting glucose or impaired glucose tolerance.
• triglyceride and/or cholesterol levels are higher than normal.
• parents/siblings or grandparents have or had diabetes.
• had diabetes or even mild elevation of blood sugars during pregnancy.
When to suspect diabetes?
• Symptoms of uncontrolled hyperglycemia: excess thirst, excess urination, excess
hunger with loss of weight
• Frequent infections
• Non-healing wounds
• Fatigue
• Tuberculosis
The criteria for diagnosis of Type 2 diabetes mellitus is shown in Table 2.1.
Table 2.1: Criteria for diagnosis of T2DM using venous blood samples is by
Fasting Glucose (mg/dl) and 2-hour Post-Glucose Load (mg/dl)

Fasting Glucose 2-hour Post-Glucose

(mg/dl) Load (mg/dl)

Diabetes Mellitus >=126 >=200

Impaired Glucose Tolerance < 110 >140 to <200

Impaired Fasting Glucose >=110 to <126

Source: World Health Organization and International Diabetes Federation. Definition,

diagnosis and classification of diabetes mellitus and its complications. Geneva,
Switzerland: World Health Organization.
Management of Diabetes
Management of T2DM should be initiated as soon as diagnosis is established even if
the patient is asymptomatic. Initial assessment and management of the patients has to
be carried out at Primary Health Centre and Community Health Centre (CHC) level
or at secondary care level.
When to recommend hospitalisation
• Uncontrolled infection,
• Severe cellulitis,
• Unresponsive UTI or other deep seated infections including bad diabetic foot
needing intravenous antibiotics,
• Recurrent UTI not responding to oral antibiotics,
20 • Presence of ketones in urine
Diabetes patient education and diet counselling Non-Communicable
Diseases-1
Patient education on diabetes management and life style modifications is the corner
stone of effective diabetes control and management and prevention of complications.
The visit schedule for counselling of diabetes is shown in Table 2.2.
Table 2.2: Visit schedule for counselling
Initial Visits Follow-up Visits
• What is Diabetes? • Importance of glycaemic control
• Why does it occur? • Prevention of complications
• Lifestyle measures: Diet, Exercise • Foot care
• Detailed lifestyle advice • Pre-conceptional counselling
• Use of Oral Drugs regarding the importance of good
• Advice on identifying signs glucose control prior to pregnancy
and symptoms of hypoglycaemia
and hyperglycaemia and their
management
• Patient should be informed about
the importance of factors other
than glucose control: cholesterol,
blood pressure, stopping smoking,/
tobacco, etc
Complications of Diabetes mellitus
Diabetes complications are classified broadly into two categories:
1) Microvascular complications includes:
• Damage to eyes (retinopathy) leading to blindness,
• Damage to kidneys (nephropathy) leading to renal failure
• Damage to nerves (neuropathy) leading to impotence
• Diabetic foot disorders (which include severe infections leading to amputation)
2) Macrovascular complications includes:
• Cardiovascular diseases such as heart attack and stroke
• Insufficiency in blood flow to legs.

2.3.2 Hypertension
Abnormally elevated blood pressure is a pathological condition which increases the
work load on the heart. This condition is termed as high blood pressure or hypertension.
The criteria for diagnosis of hypertensive is shown in Table 2.3.
Table 2.3: Criteria for diagnosing high blood pressure (mm of Hg)[ JNC-8]

Category Systolic Diastolic

Normal Less than 120 Less than 80
Pre hypertensive 120–139 80–89
Hypertensive
21
Non-Communicable Diseases
and Management Under Category Systolic Diastolic
National Health Programmes
Stage 1 140–159 90–99
Stage 2 160 or higher 100 or higher
Stage 3 180 or higher 110 or higher
Source: Paul A. James et al. 2014 Evidence-Based Guideline for the Management of
High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth
Joint National Committee (JNC 8)

Management of hypertension:
The Risk assessment should cover:
1) Assessment of medical history:
a) Risk factors
• Lack of physical activity (or sedentary lifestyle).
• Obesity or being overweight
• Abdominal obesity (Waist circumference more than 90 cm in male and 80 cm
in females)
• High sodium intake/high salt intake
• Excess alcohol consumption
b) Family history
c) Symptoms of consequences of hypertension
d) Frequent intake of pain relieving drugs (NSAIDS)
e) Steroid intake for asthma
f) Breathing difficulty particularly on exertion
g) Swelling of feet
h) Urinary difficulties, history of passing stones in the past
2) Physical examination:
a) BP measurement
b) Measurement of body weight and height to obtain BMI
c) Measurement of Waist circumference
d) Palpating all peripheral pulses
e) Auscultation for bruit (renal, carotid, abdominal and others)
f) Eye evaluation if ophthalmology facility is available
The management should include the following:
• Life-style management (refer to section on lifestyle modification)
• Drug Therapy
Complications of hypertension
Complications occur as a result of persistent elevation of blood pressure for a longer
duration of period. The impact of raised blood pressure is on various organs of the
body and can lead to organ damage.
22
The following are the organ-wise impact of the hypertension: Non-Communicable
Diseases-1
• Complications affecting the heart: Left ventricular hypertrophy, diastolic
dysfunction, CHF, abnormalities of blood flow and cardiac arrhythmias.
• Complications affecting the brain: Brain infarction and Haemorrhage.
• Complications affecting the eye: Generalised narrowing of the retinal arterioles
and in retina as microaneurysms, haemorrhages, hard exudates, and cotton-wool
spots.
• Complications affecting kidneys: Macroalbuminuria (a random urine albumin/
creatinine ratio > 300 mg/g) or microalbuminuria (a random urine albumin/
creatinine ratio 30–300 mg/g).
2.3.3 Cardiovascular Diseases
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood
vessels. Cardiovascular disease includes coronary artery diseases (CAD) such
as angina and myocardial infarction (commonly known as a heart attack). The
cerebrovascular diseases commonly known as stroke is also common.
Risk factors
Age, gender, tobacco use, physical inactivity, excessive alcohol consumption, unhealthy
diet, obesity, family history of cardiovascular disease, raised blood pressure
(hypertension), raised blood sugar (diabetes mellitus), raised blood cholesterol
(hyperlipidemia), psychosocial factors, poverty and low educational status, and air
pollution.
Coronary Heart Disease
Chest pain (angina) is the commonest symptom.
• Typical angina : Substernal pressure radiating to neck, Jaw, arm with duration<20–
30 minutes which may be associated with dyspnea, palpitations, nausea vomiting
and which increases with exertion, decreases with rest .
• MI : Has increased angina intensity and duration >30 min. Twenty five per cent of
MIs are clinically silent.
Associated symptoms: Weakness, nausea/vomiting, sweating, apprehension, anxiety,
sense of impending doom.
Features not characteristics of myocardial ischemia:
• Sharp pain brought by respiratory movement or cough
• Pain that may be localised by the tip of one finger
• Very brief episode of pain that lasts a few seconds
• Pain reproduced by movement or palpation over the chest
• Constant pain that lasts for many hours without other ischemic symptoms
2.3.4 Stroke
A stroke means that part of the brain is suddenly damaged. If an artery in the brain
becomes blocked by a thrombus, it causes a stroke. If an artery in the brain leaks then
too it damages the brain and causes a stroke.
23
Non-Communicable Diseases Identification of an acute event
and Management Under
National Health Programmes • Sudden onset of weakness of one half of body or one part of body
• Sudden onset of inability or difficulty in speech
• Sudden onset of imbalance
• Sudden onset of blindness
• Sudden onset of dizziness or spinning
• Sudden severe headache
• Sudden loss of consciousness
Management
Patients of stroke presenting within 6 hours of onset of symptoms should be referred
to a secondary care for initial assessment and management. The follow-up of patients
presenting with a completed stroke not requiring acute care (such as respiratory distress)
can be managed at the PHC level.

2.3.5 Obesity
Overweight and obesity are defined as abnormal or excessive fat accumulation that
may impair health.
• Body mass index (BMI) is a simple index of weight-for-height that is commonly
used to classify overweight and obesity in adults. It is defined as a person’s weight
in kilograms divided by the square of his height in meters (kg/m2).
• The criteria based on World Health Organization is given below:

Less than 18.5 kg/m2 (Underweight)

18.5 – 24.9 kg/m2 (Normal)
25.0 – 29.9 kg/m2 (Preobese)
30.0 – 34.9 kg/m2 (Obese Class I)
35.0 – 39.9 kg/m2 (Obese Class II)
>= 40.0 (Obese Class III)

However, the revised criteria for obesity for Asians based on BMI is as follows:

< 18.5 kg/m2 = Under weight

18.5 – 22.9 kg/m2 = Normal or lean
23 – 24.9 kg/m2 = Overweight
>= 25.0 = Obesity

Raised BMI is a major risk factor for noncommunicable diseases such as:
• heart disease
• stroke
• diabetes;
24
• musculoskeletal disorders (especially osteoarthritis – a highly disabling degenerative Non-Communicable
Diseases-1
disease of the joints);
• Some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder,
kidney, and colon).

The risk for these non-communicable diseases increases, with increases in BMI.

Treatment of the overweight and obese patient is a two-step process:

1) Assessment requires determination of the degree of obesity and the absolute risk
status.
2) Management includes the reduction of excess weight by diet control and physical
activity and maintenance of this lower body weight, as well as the institution of
additional measures to control any associated risk factors.
• Waist circumference is the most practical tool a clinician can use to evaluate a
patient’s abdominal fat before and during weight loss treatment.

To measure waist circumference, locate the upper hip bone and the top of the right iliac
crest. Place a measuring tape in a horizontal plane around the abdomen at the level of
the iliac crest. Before reading the tape measure, ensure that the tape is not too tight, not
too loose and does not compress the skin, and is parallel to the floor. The measurement
is made at the end of a normal expiration.

Men who have waist circumferences greater than 90 cm, and women who have waist
circumferences greater than 80 cms, are at higher risk of diabetes, dyslipidemia,
hypertension, and cardiovascular disease because of excess abdominal fat. Individuals
with waist circumferences greater than these values should be considered one risk
category above that defined by their BMI. The relationship between BMI and waist
circumference for defining risk is as defined in the Table 2.4.

Management
A combination of diet modification, increased physical activity, and behaviour therapy
can be effective.

Dietary Therapy: Dietary therapy includes instructions for modifying diets to reduce
weight. The diet should be low in calories, but it should not be too low (less than 800
kcal/day). In general, diets containing 1,000 to 1,200 kcal/day should be selected
for most women; a diet between 1,200 kcal/day and 1,600 kcal/day should be
chosen for men.

Physical Activity: Increased physical activity may help reduce body fat and prevent
the decrease in muscle mass often found during weight loss. All adults should set a
long-term goal to accumulate atleast 30 minutes or more of moderate-intensity physical
activity on 5, and preferably all days of the week.

Behaviour Therapy: Specific behavioural strategies include the following: self-

monitoring, stress management, stimulus control, problem-solving, contingency
management, cognitive restructuring, and social support. Behavioural therapies may
be employed to promote adoption of diet and activity adjustments; these will be useful
for a combined approach to therapy.
25
Non-Communicable Diseases Integrated approach for the NCDs
and Management Under
National Health Programmes
Let us now read about Integrated approach for NCDs. In the context of NCDs, four
of the most prominent chronic diseases – cardiovascular disease, cancer, chronic
obstructive pulmonary disease, and type 2 diabetes – account for 80% of the NCD
mortality and are linked by shared, common, and preventable biological risk factors,
notably high blood pressure, high blood cholesterol, and overweight, as well as by
related major behavioural risk factors: unhealthy diet, physical inactivity, and tobacco
use. So the action to prevent these major chronic diseases should focus on controlling
these risk factors in an integrated manner through motivation with the counselling of the
patients or the high risk people.

Check Your Progress 1

1) Name four major NCDs.

................................................................................................................

................................................................................................................

2) List micro vascular complication of Diabetes Mellitus.

................................................................................................................

................................................................................................................

3) List risk factors for NCD.

................................................................................................................

................................................................................................................

4) Explain the Integrated approach for the NCDs.

................................................................................................................

................................................................................................................

2.4 BLINDNESS
Let us now go through the blindness in detail :
2.4.1 Categories of Visual Impairment
Blindness’ refers to a condition where a person suffers from any of the following
conditions, namely
• Total absence of sight; or persons who does not have light perception or persons
who have light perception but cannot count fingers at a distance of 1 meter even
with spectacles (best possible correction)
• Visual acuity not exceeding 6/60 (Snellen’s Chart) in the better eye with correcting
lenses; or
• Limitation of the field of vision subtending an angle of 20 degree or worse.
26
 Table 2.4 : Categories of visual impairment: Non-Communicable
Diseases-1
Categories Visual Acuity
of Visual Maximum Less than Minimum Equal to or
Impairment Better than
Low vision 1. 6/18 6/60
2. 6/60 3/60
Blindness 3. 3/60 (finger counting at 3 meters) 1/60 (finger counting
4. 1/60(finger counting at 1meter) at 1 meter)
5. No light perception Light perception

Source: WHO. International classification of diseases, vol1, pg.242.

2.4.2 National Programme for Control of Blindness

Main causes of blindness are as follows: Cataract (62.6%), refractive error (19.70%),
corneal blindness (0.90%), glaucoma (5.80%), surgical complication (1.20%), posterior
capsular opacification (0.90%), posterior segment disorder (4.70%), others (4.19%).
Estimated National Prevalence of Childhood Blindness /Low Vision is 0.80 per
thousand.
Objectives
• To reduce the backlog of blindness through identification and treatment of blind at
primary, secondary and tertiary levels based on assessment of the overall burden
of visual impairment in the country.
• Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of
visual impairment; through provision of comprehensive eye care services and quality
service delivery.
• Strengthening and upgradation of Regional Institute of Opthalmology (RIOs) to
become centre of excellence in various sub-specialities of ophthalmology.
• Strengthening the existing and developing additional human resources and
infrastructure facilities for providing high quality comprehensive Eye Care in all
Districts of the country:
• To enhance community awareness on eye care and lay stress on preventive
measures:
• Increase and expand research for prevention of blindness and visual.

2.5 NATIONAL PROGRAMME FOR PREVENTION

AND CONTROL OF DEAFNESS
There is large number of hearing impaired young and old people in India which amounts
to a severe loss of productivity, both physical and economic. In an effort to tackle the
high incidence of deafness in the country, in view of the preventable nature of this
disability.
Objectives
• To prevent the avoidable hearing loss on account of disease or injury.
• Early identification, diagnosis and treatment of ear problems responsible for hearing
loss and deafness. 27
Non-Communicable Diseases • To medically rehabilitate persons of all age groups, suffering with deafness.
and Management Under
National Health Programmes • To strengthen the existing inter-sectoral linkages for continuity of the rehabilitation
Programme, for persons with deafness.
• To develop institutional capacity for ear care services by providing support for
equipment and material and training personnel.

2.6 NATIONAL TOBACCO CONTROL PROGRAMME

Tobacco use is one of the main risk factors for a number of chronic diseases, including
cancer, lung diseases, and cardiovascular diseases.
Objectives
• To bring about greater awareness about the harmful effects of tobacco use and
Tobacco Control Laws.
• To facilitate effective implementation of the Tobacco Control Laws.
• To control tobacco consumption and minimise the deaths caused by it.
The various activities planned to control tobacco use are as follows:
• Training and Capacity Building
• IEC activity
• Monitoring Tobacco Control Laws and Reporting
• Survey and Surveillance

2.7 THYROID DISEASES

The thyroid hormones, triiodothyronine (T3) and its prohormone, thyroxine (T4),
are tyrosine-based hormones produced by the thyroid gland that are primarily
responsible for regulation of metabolism. T3and T4 are partially composed of iodine.
Hyperthyroidism is the condition that occurs due to excessive production of thyroid
hormone by the thyroid gland.
Signs and symptoms
Some of the symptoms of hyperthyroidism include:
• nervousness
• irritability
• increased perspiration
• heart racing
• hand tremors
• anxiety
• difficulty sleeping
• thinning of the skin
• fine brittle hair
• muscular weakness – especially in the upper arms and thighs.
Major clinical signs include
• weight loss (often accompanied by an increased appetite)
• anxiety
28
• intolerance to heat Non-Communicable
Diseases-1
• hair loss (especially of the outer third of the eyebrows)
• muscle aches
• weakness
• fatigue
• hyperactivity
• irritability
• high blood sugar
• excessive urination
• excessive thirst
• delirium, tremor
• pretibial myxedema (in Graves’ disease)
• emotional liability
• sweating
Diagnosis
The diagnosis of hyperthyroidism is confirmed by blood tests that show a decreased
thyroid-stimulating hormone (TSH) level of below 0.05 uIU/ dl and elevated T4 and
T3 levels.
In addition to testing the TSH levels, many doctors test for T3, Free T3, T4, and/or
Free T4 for more detailed results.
Hypothyroidism
Hypothyroidism, also called underactive thyroid or low thyroid, is a common disorder
of the endocrine system in which the thyroid gland does not produce enough thyroid
hormone.
Symptoms
• Fatigue
• Feeling cold
• Poor memory and concentration
• Constipation, dyspepsia
• Weight gain with poor appetite
• Shortness of breath
• Hoarse voice
• In females, heavy menstrual periods (and later light periods)
• Abnormal sensation
• Poor hearing
Signs
• Dry, coarse skin
• Cool extremities
• Myxedema (mucopolysaccharide deposits in the skin)
• Hair loss
• Slow pulse rate
29
Non-Communicable Diseases • Swelling of the limbs
and Management Under
National Health Programmes • Delayed relaxation of tendon reflexes
• Carpal tunnel syndrome
• Pleural effusion, ascites, pericardial effusion
Patients suspected of thyroid disorders should be referred to doctor for further
assessment.

2.8 INJURIES AND ACCIDENTS

Let us now read the various aspects of injuries and accidents.

2.8.1 Operational Guidelines for Trauma Care Facility on

National Highways
Road traffic injuries are important problem in the country. Trauma Care that if basic life
support, first aid and replacement of fluids can be arranged within first hour of the
injury (the golden hour), lives of many of the accident victims can be saved. The critical
factor for this strategy is to provide initial stabilization to the injured within the golden
hour.
Strategic activities to achieve this objective include:
• Initial stabilisation by trained manpower
• Rapid transportation, and
• Developed medical facilities to treat such cases
Road traffic accidents: Urban transport, land use patterns, and recreation areas are
linked to road traffic injuries, as well as to exposure to air pollution and noise.

2.8.2 Risk Factors for Road Traffic Injuries

The important risk factors are mentioned in Box 2.1.
Box 2.1: Risk factors for road traffic injuries

1) Alcohol intake
2) Lack of body protection as helmets and seat belts
3) High speeding
4) Underage driving

There are primary and environmental factor related to road traffic accident as discussed
below:
Primary factors in accidents:
Human factors:
• Age
• Sex
• Education
• Medical conditions– Sudden illness, heart attack, impaired vision
30
• Fatigue Non-Communicable
Diseases-1
• Psychological factors– Lack of experience, risk-taking, impulsiveness, defective
judgement, delay in decision, aggressiveness, poor perception and family
dysfunction
• Lack of body protection– Helmets and safety belts
Environmental factors:
• Relating to road– Defective narrow rods, poor lighting, lack of familiarity
• Relating to vehicle– Excessive speed, overloaded, low driving standards
• Bad weather
• Inadequate enforcement of laws
• Mixed traffic as slow and fast moving, pedestrians and animals
All these above factors increase the vulnerability and risk situation for an accident.
Other precipitating factors are alcohol and drug usage as well as the traffic conditions,
emotion, tensions can lead to injuries and varied accidents.
Referral and Treatment
• Those with a systolic BP of over 140 and a diastolic BP of over 90 mm of Hg, or
random blood sugar of 140 mg/dl and above would be referred to a Medical
officer at the nearest facility, for confirmation, conducting relevant laboratory
investigations, and initiation of treatment.
• You have to follow up with the individual and with the concerned PHC to ensure
confirmation of diagnosis for individuals diagnosed with positive response for the
questions on carcinoma cervix/breast, epilepsy, thyroid disorders or COPD, or
where a suspicious oral lesion, initiation of treatment or referral to the next level.
Subsequent guidelines would deal with details on developing strategies for these
and other NCDs as well.
• Once the diagnosis of HT/Diabetes is established the patient must receive atleast
a month’s supply from the PHC. A three month supply, with the ANM/ASHA
visiting the patient each month for ensuring compliance, checking on diet and life
style modification, and measuring the blood pressure/ blood glucose. Alternatively,
a three-month drug supply could be stocked with the ANM, to be given each
month.
• The patient will need to go the PHC for the first follow up at the end of the first
three months after diagnosis, and sooner if required.
• An annual specialist consultation at the nearest nodal CHC with an NCD clinic, is
also recommended, based on the decision of the MO at the PHC.
• For those individuals who are already on treatment under the care of a private
practitioner, they could be offered the choice of taking drugs from the public health
system but these individuals would be visited regularly by the frontline workers,
monitored for compliance with treatment/lifestyle changes and recorded in the
health card.
• Community follow up of these individuals would be by the ASHA making visits to
enable positive behaviour modifications, treatment compliance, and encouraging
patients to go the sub-centre for regular check-up of BP/blood glucose. 31
Non-Communicable Diseases
and Management Under 2.9 NATIONAL MENTAL HEALTH PROGRAMME
National Health Programmes
Persons with mental illness should be treated like other persons with health problems
and the environment around them should be made conducive to facilitate recovery,
rehabilitation and full participation in society keeping in view the heavy burden of mental
illness in the community.
Objectives:
• To ensure availability and accessibility of minimum mental health care for all in the
foreseeable future, particularly to the most vulnerable and underprivileged sections
of population.
• To encourage application of mental health knowledge in general health care and in
social development.
• To promote community participation in the mental health services development
and to stimulate efforts towards self-help in the community.

2.10 NATIONAL PROGRAMME FOR HEALTH CARE

OF THE ELDERLY (NPHCE)
The programme was initiated to provide promotional, preventive, curative and
rehabilitative services in an integrated manner for the elderly in various Government
health facilities.
This will include health promotion, preventive services, diagnosis and management of
geriatric medical problems (out and in-patient), day care services, rehabilitative services
and home based care as needed.
Objectives : Main objectives of the programme are to:
• provide preventive, curative and rehabilitative services to the elderly persons at
various level of health care delivery system of the country.
• strengthen referral system, to develop specialized man power and to promote
research in the field of diseases related to old age.

Check Your Progress 2

1) What are the signs and symptoms of Hyperthyrodism.
................................................................................................................
................................................................................................................
2) Enlist risk factor for road injuries.
................................................................................................................
................................................................................................................
3) List activities to control tobacco use.
................................................................................................................
................................................................................................................
4) List objectives of National Programme for Health Care of the Elderly.
................................................................................................................
................................................................................................................
32
 Non-Communicable
2.11 LET US SUM UP Diseases-1

The major non-communicable diseases which contributes to the majority of burden of

disease are due to epidemiological transition. For the prevention and control of NCDs
a national programme on cancer, diabetes, cardiovascular diseases and stroke
(NPCDCS) and related programme has been launched and now will cater the whole
of the country. This unit focuses on the description of major NCDs, their prevention
strategies and referral to higher centres.

2.12 MODEL ANSWERS

Check Your Progress 1
1) Four major NCDs are Cardiovascular Diseases (CVD), such as Heart
attacks, Diabetes, Chronic Respiratory Diseases (Chronic Obstructive
Pulmonary Diseases and Asthma) and Cancer.
2) Microvascular complications includes
• Damage to eyes (retinopathy) leading to blindness
• Damage to kidneys (nephropathy) leading to renal failure
• Damage to nerves (neuropathy) leading to impotence
• Diabetic foot disorders (which include severe infections leading to
amputation)
3) Risk factor for NCDs are:
• tobacco use and exposure,
• unhealthy diet,
• physical inactivity,
• harmful use of alcohol,
• indoor and ambient air pollution,
• stress,
• poverty (as a cause and consequence),
• poor health seeking behaviours, and
• low access to health-care services.
4) In the context of NCDs, four of the most prominent chronic diseases–
cardiovascular disease, cancer, chronic obstructive pulmonary disease, and type
2 diabetes – account for 80% of the NCD mortality and are linked by shared,
common, and preventable biological risk factors, notably high blood pressure,
high blood cholesterol, and overweight, as well as by related major behavioural
risk factors: unhealthy diet, physical inactivity, and tobacco use. So the action to
prevent these major chronic diseases should focus on controlling these risk factors
in an integrated manner through motivation with the counselling of the patients or
the high risk people.
Check Your Progress 2
1) Signs and symptoms
Some of the symptoms of hyperthyroidism include
• nervousness 33
Non-Communicable Diseases • irritability
and Management Under
National Health Programmes • increased perspiration
• heart racing
• hand tremors
• anxiety
• difficulty sleeping
• thinning of the skin
• fine brittle hair
• muscular weakness – especially in the upper arms and thighs.
Major clinical signs include
• weight loss (often accompanied by an increased appetite)
• anxiety
• intolerance to heat
• hair loss (especially of the outer third of the eyebrows)
• muscle aches
• weakness
• fatigue
• hyperactivity
• irritability
• high blood sugar
• excessive urination
• excessive thirst
• delirium, tremor
• pretibial myxedema (in Graves’ disease)
• emotional liability
• sweating
2) There are primary and environmental factor related to road traffic accident.
Primary factors in accidents:
• Age
• Sex
• Education
• Medical conditions– Sudden illness, heart attack, impaired vision
• Fatigue
• Psychological factors– Lack of experience, risk-taking, impulsiveness,
defective judgement, delay in decision, aggressiveness, poor perception and
family dysfunction
• Lack of body protection– Helmets and safety belts
Environmental factors:
• Relating to road– Defective narrow rods, poor lighting, lack of familiarity
34
 • Relating to vehicle– Excessive speed, overloaded, low driving standards Non-Communicable
Diseases-1
• Bad weather
• Inadequate enforcement of laws
• Mixed traffic as slow and fast moving, pedestrians and animals
3) Activities to control tobacco use
• Training and Capacity Building
• IEC activity
• Monitoring Tobacco Control Laws and Reporting
• Survey and Surveillance
4) Main objectives of the programme are to:
• provide preventive, curative and rehabilitative services to the elderly
persons at various level of health care delivery system of the country.
• strengthen referral system, to develop specialised man power and to
promote research in the field of diseases related to old age.

2.13 REFERENCES
1) Department of Health and Family Welfare. Government of India.National
Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular
Disease and Stroke (NPCDCS). Operational guidelines 2013-17(pdf)
2) Thakur JS. NCD Surveillance. Public health approaches to non- communicable
diseases. Wolters kluwer, 2015.
3) National Mental Health Programme | National Health Portal of India [Internet].
Nhp.gov.in. 2016 [cited 17 September 2016]. Available from: http://
www.nhp.gov.in/national-mental-health-programme_pg
4) National Programme for Health Care of the Elderly (NPHCE) | National Health
Portal of India [Internet]. Nhp.gov.in. 2016 [cited 17 September 2016].
Available from: http://www.nhp.gov.in/national-program-of-health-care-for-
the-elderly-n_pg
5) Directorate General of Health Services. Ministry of Health and Family
Welfare. Goverenment of India. National Programme for Control of Blindness
2006-07.
6) National Programme for Prevention and Control of Deafness | National Health
Portal of India [Internet]. Nhp.gov.in. 2016 [cited 17 September 2016]. Available
from: http://www.nhp.gov.in/national-programme-for-prevention-and-control-of-
d_pg
7) National Tobacco Control Programme | National Health Portal Of India [Internet].
Nhp.gov.in. 2016 [cited 17 September 2016]. Available from: http://
www.nhp.gov.in/National-Tobacco-Control-Programme1_pg
8) Department of Health and Family Welfare. Government of India. Capacity building
for developing trauma care facilities on national highways. Operational
guidelines.pdf.
<http://dghs.gov.in/WriteReadData/userfiles/file/Operational_Guidelines_Trauma.pdf>
35
Non-Communicable Diseases 9) World Health Organization and International Diabetes Federation. Definition,
and Management Under
National Health Programmes diagnosis and classification of diabetes mellitus and its complications. Geneva,
Switzerland: World Health Organization.
10) Paul A. James et al. 2014 Evidence-Based Guideline for the Management of High
Blood Pressure in Adults Report From the Panel Members Appointed to the
Eighth Joint National Committee (JNC 8).
11) Dalle Grave R, Calugi S, Centis E, El Ghoch M, and Marchesini G. Cognitive-
Behavioral Strategies to Increase the Adherence to Exercise in the Management
of Obesity. Journal of Obesity. 2011;2011:1-11.
12) WHO. International classification of diseases, vol. pg.242.
13) WHO. Diabetes. <http://www.who.int/diabetes/action_online/basics/en/
index3.html>

36