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Efficacy of core stabilization program and conventional exercises in low back pain 核心稳定方案和常规锻炼对腰痛的疗效
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233466
Arvind Kumar, Vivek Gupta, Mansoor A. Khan, Harshika Srivastava
Background: Patients experiencing low back pain (LBP) often benefit from therapeutic exercise. These exercises can retrain trunk muscles and improve spinal stability and sensory integration. Consequently, we aimed to compare the efficacy of a core stabilization program and conventional exercises in low back pain. Methods: This prospective, comparative study comprised 192 subjects aged 20-60 with nonspecific chronic low back pain (NSLBP). Core stabilization or usual physical therapy activities were randomly assigned to groups C or R. Both treatment groups received TENS and ultrasound therapy. Pretreatment, second, fourth, and sixth-week post-treatment outcomes were documented using a visual analogue scale (VAS). Results: Both groups were female-dominated. Height, weight, and BMI were comparable. At baseline, group C had a mean VAS score (5.69±1.80), while group R had (5.52±1.42). P value 0.4684 indicates no significant difference between exercise groups. At the final assessment, group C had a considerably (p<0.0001*) lower mean VAS score (2.96±0.39) than group R (3.89±0.98). Group C had a substantially higher mean VAS score change from baseline to the final evaluation (-2.73±0.51) than group R (-1.18±0.79). Conclusions: Core stabilization exercise is more effective than routine physical therapy exercise in terms of greater reduction in pain in chronic NSLBP.
背景:患有腰痛(LBP)的患者通常受益于治疗性运动。这些运动可以重新训练躯干肌肉,提高脊柱稳定性和感觉统合。因此,我们的目的是比较核心稳定方案和常规锻炼对腰痛的疗效。方法:这项前瞻性比较研究纳入192名年龄在20-60岁的非特异性慢性腰痛(NSLBP)患者。将核心稳定或常规物理治疗活动随机分为C组和r组。两组均采用TENS和超声治疗。使用视觉模拟量表(VAS)记录治疗前、治疗后第二、第四和第六周的结果。结果:两组均以女性为主。身高、体重和BMI具有可比性。基线时,C组VAS平均评分为(5.69±1.80)分,R组平均评分为(5.52±1.42)分。P值0.4684表示运动组间差异无统计学意义。最终评估时,C组VAS平均评分(2.96±0.39)明显低于R组(3.89±0.98)(p<0.0001*)。C组从基线到最终评估的平均VAS评分变化(-2.73±0.51)明显高于R组(-1.18±0.79)。结论:在减轻慢性非slbp疼痛方面,核心稳定运动比常规物理治疗运动更有效。
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引用次数: 0
Uptake of indoor residual spray as a malaria vector control strategy among the residents in Migori County, Kenya 肯尼亚米戈里县居民采用室内滞留喷雾作为疟疾病媒控制策略
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233430
John Odira, Mary W. Gitahi, Alloys S. S. Orago
Background: Globally unexpected 219 million malaria cases occurred in 2021, with 90% of these cases happening in the WHO Africa region and unexpected 435,000 malaria transmissions worldwide, with children less than five years being the most-at-risk (61%) of malaria infections (World Malaria Report, 2021). In 2019, IRS coverage was 94.6%. This was reason enough to assess contributing factors leading to not reaching targeted 100% of the households mapped despite massive resources. Methods: The study adopted analytical cross-sectional design. The study area was Migori County (Awendo, Uriri, Rongo, Suna East, Suna West and Nyatike sub counties) where IRS had been implemented in four sessions. The study period November 2021 to April 2022. The respondents sample size was determined using Cochran (1963) for a single population of 1,000 households. The respondents were randomly selected villages from purposively selected Migori County. Kenyatta University Ethics Review Committee and NACOSTI provided ethical clearance. Quantitative data analyzed using SPSS version 2.6 and thematically for qualitative data. A Chi-squared test used to compute statistically significant differences between independent variables at p value <0.05. Results: Some 249 (90%) of the respondents confirmed their houses were IRS- covered while 32 (10%) of the houses were not sprayed because they were not informed in advance (p value <0.000). Conclusions: Using the Chi-squared test of significance the spray operators` arrival time for IRS activities affected the respondents daily calendar of events significantly (p=0.013, <0.05) resulting into respondents’ non-participation and unmet targets.
背景:2021年全球意外发生2.19亿例疟疾病例,其中90%发生在世卫组织非洲区域,全球意外发生43.5万例疟疾传播,5岁以下儿童是疟疾感染的高危人群(61%)(《2021年世界疟疾报告》)。2019年,美国国税局的覆盖率为94.6%。这是充分的理由来评估导致没有达到目标的100%的家庭,尽管有大量的资源。方法:采用分析截面设计。研究地区是米古里县(Awendo、Uriri、Rongo、苏纳东部、苏纳西部和尼亚蒂克分县),在那里已经实施了四届室内室内污染评估。研究期间为2021年11月至2022年4月。受访者的样本量是使用Cochran(1963)对1000户家庭的单一人口确定的。调查对象是从有意选择的米哥里县随机选择的村庄。肯雅塔大学伦理审查委员会和NACOSTI提供了伦理许可。定量数据分析使用SPSS 2.6版和主题定性数据。卡方检验用于计算自变量之间p值为<0.05的统计学显著差异。结果:约有249(90%)的受访者确认他们的房屋被IRS覆盖,而32(10%)的房屋因为事先没有被告知而没有喷洒(p值<0.000)。结论:通过卡方显著性检验,喷雾器操作人员到达IRS活动的时间显著影响被调查者的日常活动日程(p=0.013, <0.05),导致被调查者不参与和未达到目标。
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引用次数: 0
A retrospective study of attempted self-harm in a secondary care setting in rural India 印度农村二级医疗机构中自残未遂的回顾性研究
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233451
Seetharam Mysore, Vidyashree M., Shruti Sajjalguddam, Deepak Murthy, Nagarathna N., Maria Martinez Rangel
Background: Suicides and non-suicidal self-injuries (NSSI) pose a serious public health problem, affecting communities all over the world. Adolescents and young adults are particularly vulnerable to commit self-harm (SH). SH causes serious emotional, physical, and economic repercussions, and leads to long-term health impacts. Methods: A retrospective study was conducted in a rural secondary care hospital from Feb 2020 to March 2022. Data regarding demographics, cause and type of SH, and treatment provided to 190 patients were analysed. Results: Majority of patients were in the 16-35 years age group. Poison consumption was the commonest method used. Pesticides and pills were the commonly-used agents. Agricultural activities and pre-existing illness in families facilitated access to these agents, as did the unregulated availability and unsafe storage. 31 patients disclosed the reason for SH, with the commonest reason being strained relationships. Emotional states described by the patients which pushed them to SH included dejection, hopelessness, anger, recklessness, altered mood, lack of purpose in life, cynicism and a sense of lack of support. 16% were discharged against medical advice. Conclusions: The study identified the need for methodical documentation, referral and follow-up of patients, with adequate psychiatric and counselling support. Access to care for SH patients is lacking especially in rural areas, and is at best available only for management of the SH event. SH should be considered not as a disease by itself, but as an outcome of stress due to socio-economic and other factors. Multi-stakeholder convergent approaches are needed to tackle this challenge in a holistic manner.
背景:自杀和非自杀性自伤是一个严重的公共卫生问题,影响着世界各地的社区。青少年和年轻人特别容易自残。性刺激素会引起严重的情绪、身体和经济影响,并导致长期的健康影响。方法:于2020年2月至2022年3月在某农村二级医院进行回顾性研究。分析了190例患者的人口统计学、原因和类型以及治疗方面的数据。结果:患者以16 ~ 35岁年龄组居多。服毒是最常用的方法。杀虫剂和药片是常用的药剂。农业活动和家庭中已有的疾病,以及不受管制的供应和不安全的储存,都有助于获得这些药物。31例患者透露了发生性高潮的原因,最常见的原因是关系紧张。患者描述的促使他们进入SH的情绪状态包括沮丧、绝望、愤怒、鲁莽、情绪改变、生活缺乏目标、玩世不恭和缺乏支持感。16%的人不遵医嘱出院。结论:该研究确定了有必要对患者进行系统的记录、转诊和随访,并提供足够的精神病学和咨询支持。特别是在农村地区,性传播疾病患者缺乏获得护理的机会,而且最多只能用于性传播疾病的管理。性冲动不应被视为一种疾病,而应被视为社会经济和其他因素造成的压力的结果。需要多方利益攸关方采取协调一致的办法,以整体方式应对这一挑战。
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引用次数: 0
How is COVID nursing different? A phenomenological analysis of the nurses’ experience from a tertiary care COVID units COVID护理有何不同?对三级护理COVID单位护士经验的现象学分析
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233485
Jasleen Kaur, Manju Dhandapani, Sukhpal Kaur, None Venkadalakshmi, Sivashanmugam Dhandapani, Karobi Das
Healthcare workers face specific challenges during infectious disease outbreak. Along with fear of getting infection, performing new, unfamiliar tasks in unfamiliar setting with new outfit (PPE) complicates their working. We explore perceptions and lived experiences of front-line nurses who cared for COVI9-19 confirmed patients in a tertiary hospital of North India eighteen in-depth, telephonic, semi structured interviews were conducted. Interviews were transcribed and analysed using Colaizzi’s phenomenological method. Nurses were challenged by risk of infection or fear of transmission, working in a new setting, unfamiliar clinical roles, heavy workloads, ineffective communication and discomforts of protective gear. Despite facing various challenges, nurses showed great strength and resilience. Good administrative support, PPE surveillance, developing nurses’ task force with distinct responsibilities, orientation, training and empowerment are suggested strategies to overcome the challenges and enhance the resilience. Nurses lived experiences will be helpful to healthcare organizations preparing for or responding to outbreaks or disaster.
在传染病暴发期间,卫生保健工作者面临着特殊的挑战。除了担心感染外,在不熟悉的环境中穿着新装备(个人防护装备)执行不熟悉的新任务使他们的工作变得复杂。我们对北印度一家三级医院护理covid -19确诊患者的一线护士进行了18次深度、电话、半结构化访谈,探讨了这些护士的看法和生活经历。访谈记录和分析采用Colaizzi的现象学方法。护士面临的挑战包括感染风险或对传播的恐惧,在新环境中工作,不熟悉的临床角色,繁重的工作量,无效的沟通和不舒服的防护装备。尽管面临各种挑战,护士们表现出了巨大的力量和韧性。良好的行政支持、个人防护装备监测、建立职责明确的护士工作队、指导、培训和赋权是克服挑战和增强复原力的建议策略。护士的生活经验将有助于医疗机构准备或应对疫情或灾难。
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引用次数: 0
Rating scales in psychiatric disorders - why? 精神疾病的评定量表——为什么?
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233502
Bhuvaneswari Rajachandrasekar, Sakthivel Vaiyapuri
Clinical and research instruments are available for assessing patients with psychiatric illness along specific dimensions of symptoms, comorbidities, and other health outcomes. Rating scales in clinical practice and research standardize diagnosis and assessment. Here, we focus on rating scales for common psychiatric disorders like schizophrenia, obsessive-compulsive disorder, depression, anxiety disorder, and stress-related disorders. Structured observation is most commonly used with this tool. Here are a few tools with basic characteristics, such as clarity, relevance, variety, objectives, and uniqueness. Rating scales will be discussed in clinical and research settings and future directions in their use. People using scales for commercial purposes should check for access and availability since some scales are copyrighted. The more standardization can be achieved, the easier it will be to compare individuals or groups of individuals. We will be able to assess care quality and outcomes across settings.
临床和研究仪器可用于评估精神疾病患者的具体症状、合并症和其他健康结果。临床实践和研究中的评定量表规范了诊断和评估。在这里,我们关注的是常见精神疾病的评定量表,如精神分裂症、强迫症、抑郁症、焦虑症和压力相关疾病。结构化观察最常用于此工具。以下是一些具有基本特征的工具,如清晰度、相关性、多样性、目标和独特性。评定量表将在临床和研究环境中进行讨论,并讨论其使用的未来方向。出于商业目的使用秤的人应该检查其访问权限和可用性,因为有些秤是受版权保护的。标准化程度越高,就越容易对个人或个人群体进行比较。我们将能够评估不同环境下的护理质量和结果。
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引用次数: 0
Awareness and practices regarding climate change and its effects on health, in an urban community: a cross sectional study 城市社区关于气候变化及其对健康影响的认识和做法:一项横断面研究
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233462
Ishwar Gopinath, P. Arulmozhi, S. Arun Murugan
Background: Aim was to assess the level of awareness and practices related to climate change and its effects on health among urban population in metropolitan city. To recommend awareness programs regarding climate change and its health hazards for urban population based on results. Methods: Community based cross sectional study was conducted among 180 adults from January 2022 to March 2022. The data was entered in MS Excel and was analyzed by using SPSS-16 software. Results: The awareness about climate change was 63%. 76% of the respondents did not agree that climate change is related to extreme weather phenomenon. All the participants believed that climate change affects health, but none of them were aware that it is causing increased incidence of cancer. 73% of the participants always adopted climate friendly alternatives to using own motor vehicles. None of the participants practiced garbage segregation. Only 19% always used climate friendly alternatives to plastic bags. 74% respondents were unable to give concrete solutions to control climate change. 14% participants suggested planting more trees, 10% called for control of industrialization and population explosion. 66% obtained their information from newspapers. None of them viewed scientific journals. There was no significant association between educational status and awareness of climate change. Conclusions: The population is moderately aware of climate change. They are not well aware of its long-term impacts on health. There is an urgent need for them to be well informed with verified sources of information. Appropriate campaigns must be initiated.
背景:目的是评估大都市城市人口对气候变化及其对健康影响的认识和做法水平。根据结果,推荐有关气候变化及其对城市人口健康危害的认识方案。方法:于2022年1月至2022年3月对180名成人进行基于社区的横断面研究。数据在MS Excel中录入,采用SPSS-16软件进行分析。结果:气候变化的知晓率为63%。76%的受访者不同意气候变化与极端天气现象有关。所有的参与者都认为气候变化影响健康,但没有人意识到它正在导致癌症发病率的增加。73%的参与者总是采用气候友好型替代方式来使用自己的机动车辆。没有一个参与者实行垃圾隔离。只有19%的人总是使用环保的塑料袋替代品。74%的受访者无法给出控制气候变化的具体解决方案。14%的人建议种植更多的树木,10%的人呼吁控制工业化和人口爆炸。66%的人从报纸上获取信息。他们都不看科学期刊。受教育程度与气候变化意识之间无显著关联。结论:人口对气候变化的意识处于中等水平。他们并不十分清楚烟草对健康的长期影响。迫切需要让它们充分了解经核实的信息来源。必须发起适当的运动。
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引用次数: 0
Burn injury as a public health problem in Odisha: clinico-epidemiological study of patients admitted in a tertiary care hospital and prospects for control 烧伤作为奥里萨邦的一个公共卫生问题:三级保健医院住院患者的临床流行病学研究和控制前景
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233452
Ranjit Kumar Sahu, Debarati Chakraborty, Soumen Jana
Background: Burn injuries continue to pose a significant and preventable global health challenge, with developing countries like India experiencing a troubling rise in cases. This study aimed to investigate the socio-demographic characteristics and patterns of burn injuries among patients admitted to a tertiary care hospital's. Methods: Over a six-month period, a hospital-based cross-sectional study was conducted using semi-structured questionnaires, with prior consent from patients or their caregivers. Clinical assessments were also conducted to determine the percentage of total body surface area (TBSA) affected and the most severely affected body part. Results: 145 patients included in the study, the females were (56.55%), primarily aged between 21 and 40 years. Hindus (58.62%), lived in rural areas (63.45%), and were married (66.90%). Accidental burns accounted for 81.38% of cases, mainly occurring at home (84.83%). Flame burns were more common among females, while electric burns were more prevalent among males. The majority of burn injuries covered up to 30% of TBSA (44.83%), with the upper limbs being the most severely affected (42.76%). Alarmingly, only 36.55% of patients were admitted on the same day as the injury. Infection (55.86%) and amputation (8.97%) were the most common complications observed, and 14 deaths (9.66%) occurred during the study period. Conclusions: This study highlights the vulnerability of females to flame burns, often stemming from unsafe cooking practices. Delayed hospital admissions were associated with a higher mortality rate. Efforts to promote safety and awareness, particularly in rural areas, are crucial to reducing the burden of burn injuries in India.
背景:烧伤继续构成重大和可预防的全球健康挑战,印度等发展中国家的病例正在令人不安地上升。本研究旨在调查社会人口学特征和模式的烧伤患者入院的三级护理医院。方法:在六个月的时间里,在患者或其护理人员事先同意的情况下,采用半结构化问卷进行了一项基于医院的横断面研究。还进行了临床评估,以确定受影响的总体表面积(TBSA)和受影响最严重的身体部位的百分比。结果:145例患者纳入研究,女性占56.55%,主要年龄在21 ~ 40岁之间。印度教徒占58.62%,居住在农村(63.45%),已婚(66.90%)。意外烧伤占81.38%,主要发生在家中(84.83%)。火焰烧伤在女性中更为常见,而电烧伤在男性中更为普遍。烧伤占TBSA的30%(44.83%),其中上肢损伤最为严重(42.76%)。令人震惊的是,只有36.55%的患者在受伤当天入院。感染(55.86%)和截肢(8.97%)是最常见的并发症,研究期间发生14例死亡(9.66%)。结论:这项研究强调了女性对火焰烧伤的脆弱性,通常源于不安全的烹饪方法。延迟住院与较高的死亡率相关。努力促进安全和意识,特别是在农村地区,对于减轻印度烧伤的负担至关重要。
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引用次数: 0
Breast cancer screening a literature review 乳腺癌筛查的文献综述
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233497
Mai Alsammak, Marwa Khattabi
This article is looking at literature on breast cancer screening. Being the most common cancer worldwide and a leading cause of death, screening asymptotic women leads to early detection hence early treatment and with advances in treatments, breast cancer has better survival outcomes.
这篇文章是关于乳腺癌筛查的文献。作为世界上最常见的癌症和死亡的主要原因,对无症状妇女进行筛查可以早期发现,从而早期治疗,随着治疗方法的进步,乳腺癌的生存结果更好。
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引用次数: 0
Modified Kuppuswamy socioeconomic scale 2023: stratification and updates 修正Kuppuswamy社会经济量表2023:分层与更新
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233487
Manukrishnan Radhakrishnan, Sharath Burugina Nagaraja
Socioeconomic status (SES) is evaluated by considering a family's income, level of education, and occupation of head of household. SES serves as significant indicator of the family's overall health and their access to resources. Modified Kuppuswamy scale is among the most used tools to assess SES of urban residents, but it necessitates regular updates due to consistent inflation. In this study, present updated version of modified Kuppuswamy socioeconomic scale for the year 2023 in India. Additionally, we have further refined the income points for the scales that were previously underutilized. This refinement aims to ensure more accurate categorization of families based on their societal position.
社会经济地位(SES)是通过考虑家庭收入、教育水平和户主的职业来评估的。社会经济状况是家庭整体健康状况及其获得资源情况的重要指标。修正库普斯瓦米量表是评估城市居民社会经济状况最常用的工具之一,但由于持续的通货膨胀,需要定期更新。在本研究中,提出了2023年印度修正库普斯瓦米社会经济规模的更新版本。此外,我们进一步完善了以前未充分利用的比额表的收入点。这种改进的目的是确保根据家庭的社会地位更准确地对其进行分类。
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引用次数: 0
A study to assess the prevalence of substance abuse and its impact among medical students in a medical college 某医学院医学生药物滥用情况及其影响的研究
Pub Date : 2023-10-31 DOI: 10.18203/2394-6040.ijcmph20233482
Aishwarya Sharma, Manali Shashidhar, Varshini Lakshmi Tripura Maddali, Srinivas Rajiv, Mahima Shivanna, Harshith Ramesh
Background: Psychoactive drug is an emerging global problem. This is a disturbing matter, especially in the case of medical students, affecting their health and academic performance, which in turn affects the health outcomes of patients. The objectives of our study were to assess the prevalence and impact of substance abuse among medical students. Methods: This was cross-sectional study conducted in tertiary care center. A pretested semi structured questionnaire was used to collect the data. Medical students who were available during the study period and who were willing to participate were included in the study. A total of 301 students were interviewed. Data was entered and analysed in SPPSS version 22.0. Descriptive statistics and inferential statistics were used for the statistical analysis. Results: We had a total of 301 responders. Among them, only 70(23.3%) have been a subject to substance abuse. Alcohol was the most abused substance (19.3%). The most common reason for starting these substances was out of curiosity (15.6%). 24.6% of the students have either thought of or tried stopping, however majority of them have not. Out of these students, 10 (3.3%) have experienced withdrawal symptoms. Conclusions: The substance abuse among youngsters in medical colleges is a highly alarming situation. Proper counselling with planned policies should be implemented to root out this evil among the future doctors which will help in providing better health care services to the people.
背景:精神药物是一个新兴的全球性问题。这是一个令人不安的问题,特别是对医学生而言,影响到他们的健康和学习成绩,进而影响到患者的健康结果。本研究的目的是评估医学生药物滥用的发生率及其影响。方法:采用横断面研究方法在三级保健中心进行。采用预测半结构化问卷收集数据。在研究期间有时间且愿意参与研究的医学生被纳入研究。共采访了301名学生。数据在SPPSS 22.0版本中输入和分析。采用描述性统计和推理统计进行统计分析。结果:共有301名应答者。其中,仅有70人(23.3%)曾滥用药物。酒精是滥用最多的物质(19.3%)。使用这些药物最常见的原因是出于好奇(15.6%)。24.6%的学生想过或尝试过戒烟,但大多数人没有。在这些学生中,10人(3.3%)经历过戒断症状。结论:医学院校青少年药物滥用状况令人高度警惕。应该实施适当的咨询和有计划的政策,以根除未来医生中的这种邪恶,这将有助于向人民提供更好的医疗保健服务。
{"title":"A study to assess the prevalence of substance abuse and its impact among medical students in a medical college","authors":"Aishwarya Sharma, Manali Shashidhar, Varshini Lakshmi Tripura Maddali, Srinivas Rajiv, Mahima Shivanna, Harshith Ramesh","doi":"10.18203/2394-6040.ijcmph20233482","DOIUrl":"https://doi.org/10.18203/2394-6040.ijcmph20233482","url":null,"abstract":"Background: Psychoactive drug is an emerging global problem. This is a disturbing matter, especially in the case of medical students, affecting their health and academic performance, which in turn affects the health outcomes of patients. The objectives of our study were to assess the prevalence and impact of substance abuse among medical students. Methods: This was cross-sectional study conducted in tertiary care center. A pretested semi structured questionnaire was used to collect the data. Medical students who were available during the study period and who were willing to participate were included in the study. A total of 301 students were interviewed. Data was entered and analysed in SPPSS version 22.0. Descriptive statistics and inferential statistics were used for the statistical analysis. Results: We had a total of 301 responders. Among them, only 70(23.3%) have been a subject to substance abuse. Alcohol was the most abused substance (19.3%). The most common reason for starting these substances was out of curiosity (15.6%). 24.6% of the students have either thought of or tried stopping, however majority of them have not. Out of these students, 10 (3.3%) have experienced withdrawal symptoms. Conclusions: The substance abuse among youngsters in medical colleges is a highly alarming situation. Proper counselling with planned policies should be implemented to root out this evil among the future doctors which will help in providing better health care services to the people.","PeriodicalId":73438,"journal":{"name":"International journal of community medicine and public health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135869957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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International journal of community medicine and public health
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