Awareness and knowledge regarding risk factors and common symptoms of cervical cancer among female students of Rawalpindi

Objective: To assess the knowledge, attitudes and practice among medical students regarding cervical cancer risk factors, common symptoms and preventive measures

Study Design: Descriptive cross-sectional study

Place and Duration of Study: Foundation Medical University, Rawalpindi from 1st Jul 2016 to 30th Jun 2017

Material and Methods: A total of 173 pre clinical female student of MBBS who give consent were enrolled in the study by non-probability consecutive sampling technique. With informed written consent, data were collected on pretested questionnaire. Data were presented as frequencies and percentages

Results: Total 173 students were enrolled with response rate of 98%. Age ranged from 18-21 years. Fifty three [31%] students had family history of cervical cancer. Majority of the students 101 [59%] had heard about cervical cancer. Knowledge about etiological agent [38, 22%], HPV vaccine available for infection prevention [11, 6%] and its Pap smear screening [61, 36%] was poor. Abnormal vaginal discharge was the most common symptom [98, 57%]. Overall response of symptoms was poor. An attitude towards diagnostic measures for cervical cancer was positive. A total of 127 [74%] students responded that every adult girl should be vaccinated against cervical cancer, 137 [73%] voted for regular cytological examination however 88 [56%] were not in opinion of doing pap testing as OPD procedure

Conclusion: Our study revealed poor knowledge about cervical cancer risk factors and symptoms among female students. Awareness programs are required for early detection and treatment of this fatal cancer

Anxiety among the young cardiac patients - a neglected illness

Objective: To explore the prevalence of anxiety among young cardiac patients visiting tertiary care hospital, Rawalpindi

Study Design: Observational cross-sectional study

Place and Duration of Study: Rawalpindi Institute of Cardiology [RIC], from 27[th] Jun to 30[th] Sep 2016

Material and Methods: After ethical clearance and approval of the supervisor of Rawalpindi Institute of Cardiology, data were collected from the OPD patients of Rawalpindi Institute of Cardiology over a period of one month. Patients were briefed about the nature of study and after informed written consent, information was collected through face to face interviews by trained data collectors using General anxiety Disorder [GAD] scale. SPSS-21 was used for data analysis

Results: A total 237 patients were interviewed and male to female ratio was 1.4:1 [140:97]. Age ranged from 20-40 years with mean of 32 +/- 5.2 years. Overall prevalence of anxiety was 25.5%. There was not statistically significant difference observed in anxiety levels between male [23, 9%] and females [25, 11%], [p-value: 1.000]. The participants were divided into 4 age groups and group 4 [36-40 years] was most affected group. However, none of the group showed statistically association with age groups. A statistically significant relationship is found with unemployment and anxiety [OR: 2.8, p-value: <.005]. However there was no relationship between duration of cardiac illness and anxiety [p-value: .588]

Conclusion: Moderate level of anxiety was most prevalent among the 30-40 years age group

Knowledge and attitude regarding Ebola virus disease among medical students of Rawalpindi: a preventable threat not yet confronted

Objective: To assess the knowledge and attitude regarding Ebola virus disease [EVD] among medical students of Rawalpindi

Methods: A descriptive cross sectional study was carried out in a medical college of Rawalpindi from September 2014-November 2014. About 400 students were inducted with 77% [n=308] response rate

After taking informed verbal consent from students and administration, a pre-designed and pre-tested questionnaire was circulated among students of third, fourth and final year MBBS as well as third and fourth year BDS

The data collected was entered and analyzed using SPSS 20

Results: The response rate was 77% [308/400]. About 244 [79.2%] of students had heard about EVD before

One hundred and sixty four [53.2%] of the students correctly identified that no treatment is available for EVD as yet. Also 163 [52.9%] said that no vaccine was available against the virus either. Washing hands every time after touching a patient in clinics/wards was important for 151 [49.0%] while 223 [72.4%] claimed to use proper techniques to dispose off used injections

Conclusion: Students have basic knowledge regarding EVD. However, there is deficient information regarding the diagnosis and precautionary measures required to control it

Awareness among butchers regarding crimean congo hemorrhagic fever in rawalpindi cantt

Objective: To study the awareness of butchers regarding Crimean-Congo Haemorrhagic fever [CCHF] in relation to their education level

Study Design: Cross sectional survey

Place and Duration of Study: Conducted from January to March 2015 in Qasaiee Chowk and Tench Bhatta markets of ward 5 of Rawalpindi cantt

Material and Methods: Sample size was calculated using G-Power sample size calculator at 95% confidence level with an effect size of 0.38. Ward 5 of Rawalpindi cantt was chosen through lottery method and all available professional butchers in the markets were interviewed with informed consent

A pre-tested 14 items closed ended questionnaire was used and interview was conducted by a well briefed team of medical students. Data was analyzed using SPSS version 20.0

Results: Results showed that only 14 [9.33%] butchers knew the name of CCHF. Out of these 10 [71.4%] had some form of formal education

All 14 of these had heard about CCHF from television proving it to be an important medium of information. However none of the 150 respondents took any preventive measure against CCHF

Conclusion: Our study concluded that the level of awareness regarding CCHF in butchers is very low and no preventive measures are taken by them. Also the level of education has a significant effect on the awareness

prevalence of post traumatic growth among troops in post deployment phase

Objective: To determine the prevalence of post-traumatic growth [PTG] and its association with socio demographic factors among a cohort of troops in post deployment phase

Study Design: Descriptive cross sectional

Place and Duration of Study: A Military battalion in Lahore from Jan-April 2015, one year after deployment in the combat area

Material and Methods: A sample of 296 combat troops was selected using non-probability convenient sampling technique. After taking informed written consent the data was collected using Urdu version of psychometric tool Post Traumatic Growth Inventory [PTGI]. Data was entered and analyzed SPSS version 20

Results: The mean age of the respondents was 29 +/- 6.2 years. Married and unmarried were 214 [72.3%] and 82 [27.7%] respectively. The mean years of service of the troops were 11. In our study the majority of troops 279[94.3%] exhibited greater degree of positive growth [75] ,15 [5.1%] had moderate degree of positive growth [74-51] while only 2[0.7%] had no post traumatic growth[<50]. There was a significant negative correlation of PTG with the age [p < 0.01] and a significant association of Ethnicity with PTG [p=0.03]. However there was no significant association of PTG with marital status [p= 0.06], education [/7=0.52], income [p=0.71], rank [p= 0.96] and years of service [p= 0.49] at 95% confidence level

Conclusion: It was concluded that there was a high prevalence of resilience as PTG in majority of troops one year after deployment in a combat area

Anorexia nervosa among teenage girls:emerging or prevalent?

Objectives: To find out frequency of anorexia nervosa [AN] among teenage girls [TG] and to find out the knowledge and practice regarding anorexia nervosa among teenage girls

Methods: A cross sectional study was conducted at higher secondary public school, Rawalpindi from June 2013 till December 2013. A sample of 100 female students of the age group 13-19 years were inducted by systematic sampling technique. Mixed pretested questionnaire was filled after informed verbal consent. Data was entered and analysed using SPSS version 20

Results: Participants mean age was 15.81 +/- 1.323 years. Mean weight, mean height and mean body mass index were found to be 50.34 +/- 10.445 kg, 160.14 +/- 7.846 cm and 19.675 +/- 4.1477 kg/m2 respectively. Anorexia nervosa was found in 42 [42%] teenage girls while 58 [58%] were not having anorexia nervosa. Sufficient knowledge and positive practice were found to be present in 57 [57%] and 49 [49%] respectively. Statistically no significant association was found between KP and AN [p=0.73]

Conclusion: Anorexia nervosa is an emerging health concern in Pakistan. Anorexia prevalent behaviour was observed in almost half of the teenage girls

Geriatric problems awareness among adults in Rawalpindi

Objective: To assess the knowledge, attitude and practice [KAP] regarding elderly age health problems among adults of Rawalpindi

Study Design: Descriptive cross sectional study

Place and Duration of Study: Airport Housing Society Rawalpindi from July 2011 to Nov 2011

Material and Methods: A total of 200 households of age 50-59 years were included in the study by convenient sampling technique [115 males and 85 females]. Adult population of the age 50-59 years with physical and mental disabilities were excluded from the study. Data collected after taking informed consent was analyzed by SPSS 17

Results: Mean age of respondents was 54.78 +/- 3.41 years. Knowledge regarding age limit of senior citizens was 140 [70%]. A total of 174 [87%] knew about increased incidence of fall with increasing age but only 53 [26.5%] did any practical change. About 152 [76%] considered that prior knowledge about geriatric age problems can help plan for old age; efforts to get information about elderly age problems were reported by 170 [85%]. There was a significant association between level of knowledge and efforts to stay healthy [p<.001]. The difference between level of knowledge of males and females was significant [p=.007]

Conclusion: Prior knowledge among residents of the society was found to be a more preferred option to give people information about optimal aging, but this should be started at a much earlier time by facilitating information, to restore physical health to have a healthy and functional elderly individual in the society

Regular breakfast consumption associated with high intelligence quotient: myth or reality?

To find the frequency of regular breakfast consumption among Pakistani teenagers while the other objective was to find out the association between breakfast consumers [BC] and intelligence quotient [IQ]. This comparative cross sectional study was conducted on 102 students of a Public School Rawalpindi from August 2013 to January 2014. Participants were categorised into two groups i.e. regular breakfast consumers [RBC] and irregular breakfast consumers [IBC] according to their breakfast habits. A standardized questionnaire of Wechsler Intelligence Scale for Childrenwas used for IQ assessment. Data was then entered and analysed in SPSS version 20. Out of the 102 individuals with mean age 17.17 +/- 0.631, 58 [56.9%] were females and 44 [43.1%] were males. There were 63 [61.8%] RBC while 39 [38.2%] were IBC. Among RBC there were 7 [6.9%] in challenged, 5 [4.9%] were below average, 33 [32.4%] in average group, 14 [13.7%] in above average and 4 [3.9%] in gifted group. While among IBC, there was 1 [1%] among the severely challenged, 3 [2.9%] in challenged, 8 [7.8%] in below average, 22 [21.6%] in average group, 4 [3.9%] in above average and 1 [1%] in gifted group. There was no significant association found between breakfast intake and IQ level among students [p=0.98]. More than half of the students were having regular breakfast. There was no significant association found among breakfast consumers and IQ. However the IQ score was more among RBC as compared to IBC

Use of safety belt among army personnel

To assess the knowledge, attitude and practice of safety belt use and the reasons for its non use among army personnel. A cross-sectional descriptive study. The study was carried out at Rawalpindi Cantonment from Jan 2013 to June 2013. The study was carried out among two different categories of Army Personnel i.e. officers and soldiers through a structured questionnaire. Mean age of officers and soldiers was 38 and 29 years respectively. A total of 146 [97.3%] officers and 128 [85.3%] soldiers were in favor of using seat belt while driving whereas 4 [2.7%] officers and 22 [14.7%] soldiers were against it. The study depicted that 147 [98%] officers and 133 [88.7%] soldiers had sufficient knowledge about the significance of safety belt use but the results regarding its use were not encouraging as 56 [37.3%] officers and 40 [26.7%] soldiers did not use safety belt while driving, although 146 [97.3%] officers and 128 [85.3%] soldiers were in favor of using safety belt. Army personnel had sufficient knowledge about the significance of safety belt; similarly attitude towards its use was also satisfactorily positive however, a significant percentage was indeed not putting their knowledge of significance into practice. Inattention and inconvenience along with inadequate law was the main reason for not using safety seat belt

Microbiological contamination in water filtration plants in Islamabad

To determine the frequency of microbiological contamination of water in different water filtration plants in Islamabad. Descriptive cross-sectional study. Water Filtration Plants [WFP] in different sectors of Islamabad, from April to September 2012. Water samples were collected in sterilized bottles according to the standard water sampling protocol fromsite and transported to Pakistan Council for Research in Water Resources [PCRWR] for analysis. Microbiological quality of water was determined in terms of total conforms [< 2.0 MPN/100 ml] and Escherichia coli [< 2.0 MPN/100 ml]. Microbiological contaminated water was defined the sample which had more than 2.0 MPN per 100 ml of either total coliforms or Escherichia [E.] coli. Thirty two WFP were analyzed for microbiological contamination. E. coli was present in 8 [25.0%] water samples, while 24 [75.0%] water samples were free from it. Total coliforms were present in 13 [40.6%] of the samples of WFP, while 19 [59.3%] samples were free from total coliform. Faecal coliforms were present in 8 [25.0%] and absent in 24 [75.0%] samples. Both E. coli and total coliform were present in 8 [25.0%] samples. Nine [59.3] WFP were free from E. coli, total coliform and faecal coliform. Statistically, no significant association was found [p > 0.05] between microbiological contamination and the sectors. Less than half of the water samples of the WFP were contaminated while certain sectors showed more frequent contamination than others

Proportion of exposure of passive smoking in teenage group and symptoms precipitated after exposure to second hand smoke

Exposure of passive smoking and second hand smoke [SHS] exposure in teenage group results in precipitation of several symptoms. Five hundred teenagers between ages of 13 - 19 studying in Army Public School and College Westridge, Rawalpindi, were selected for descriptive cross-sectional study from September 2012 till February 2013. Out of the total 500, 279 [55.8%] were exposed to passive smoking while 221 [44.2%] were not exposed to passive smoking. Out of the exposed 279 [55.8%] students, males were 132 [47.3%] and females were 147 [52.7%] with mean age of 15.06 +/- 1.805 years. After exposure to SHS, multiple responses were observed. Statistical significant association was found between symptoms precipitation and exposure to SHS. Nose irritation was present in 84, while 195 did not complain of it [p = 0.002]. Allergic symptoms were precipitated with SHS in 42, while not in 21 students [p < 0.001]. Asthma attack was precipitated in 38, while 241 did not experience precipitation of asthma attack [p < 0.001]. More cough was present in 168, while not in 111 students [p = 0.037]. Nausea was present in 41, while not in 238 [p < 0.001]. Nose irritation was seen in 84 and not in 195 students [p = 0.002]. More than half of the teenagers had exposure to passive smoking. Statistical significant association was found between passive smoking exposure and precipitation of symptoms

Knowledge, attitude and self-reported hand washing practice among healthcare staff of military hospital, Rawalpindi

Hand washing can be regarded as one of the most effective and important hygiene promotion programmes for community as well as hospital based settings. A cross sectional survey was carried out at Military Hospital, Rawalpindi, over 03 months from September to November 2012. The survey was conducted to assess the knowledge, attitude and self-reported hand washing practice among healthcare staff [nurses] working in family OPD and ward. Data was entered and analyzed in SPSS 16. Descriptive statistics was used in the form of numbers and percentages. It was believed by 95% of staff that handwashing can reduce infection rates in hospitals. Among the respondents, 24.2% expressed strong dissent on washing hands only with water, however, 22.5% considered it enough. Patients never [50%], sometimes [21.7%], seldom [19.2%], often [9.2%] asked health care staff about hand washing. Staff reported their practice of hand washing before touching patients as often [32.5%], sometimes [37.5%], seldom [20.8%] and never [9.2%]

Association of vitamin d deficiency with tuberculosis in adult patients reporting to a tertiary care hospital of Rawalpindi

To compare the mean vitamin D levels in pulmonary tuberculosis patients and healthy controls and to find out the frequency and association of vitamin D deficiency in patients with tuberculosis. Study Design: Case control study. Pulmonology department, Military Hospital Rawalpindi from Jan 2013 to Dec 2013. Patients and Methods: Fifty two incident outdoor pulmonary tuberculosis patients were selected with 52 age and gender matched controls. Tuberculosis was diagnosed by the sputum examination through gene Xpert technique from National Institute of Health [NIH], Islamabad. Serum 25-hydroxvitamin D level <50 nmol/1 [electrochemiluminescene assay] was taken as vitamin D deficiency. Mean vitamin D was much lower [20.688 +/- 14.065 nmol/1] in cases as compared to the controls [57.917 +/- 18.197 nmol/1] which was statistically significant [p<0.001]. Forty nine [94%] cases and 18 [34.6%] controls were found to be vitamin D deficient. [Odd's Ratio = 3.8, 95% CI = 2.423-5.999, p>0.00l]. Sensitive tuberculosis patients had mean vit D levels of 18.55 +/- 9.99 nmol/1 while multi-drug resistant tuberculosis patients had the mean serum vitamin D levels of 22.38 +/- 16.60 nmol/1 but the difference was statistically insignificant [p > 0.05]. Significant vitamin D deficiency was seen in newly diagnosed TB patients. It was found that vitamin D deficiency is associated with tuberculosis, but its causal role has not been established

Type A and Type B personality among undergraduate medical students: need for psychosocial rehabilitation

To find out the frequency of Type A and Type B personality among the students of Undergraduate Medical College. To find association between student year and personality type. A descriptive cross sectional study was conducted at Undergraduate Medical College, Rawalpindi from Sept. 2012 till Feb. 2013. Among 500 sample size, 100 students from each MBBS year were inducted by probability systematic sampling technique. After taking consent from the institute and students, data was collected on BECK anxiety inventory [BAI] questionnaire. According to BAI scale, students were identified as Type A or B personality. Data was analyzed using SPSS version 20. To find association between student year and personality type, Chi-square test of significance with 95% confidence level was used. First, second, third, fourth and final year students had 5 [1%], 6 [1.2%], 11 [2.2%], 13 [2.6%] and 19 [3.8%] type A personality respectively. Among all the study participants [n=500], total number of type A was 54 [10.8%] and type B personality students were 446 [89.2%]. Type A personality was 29 [11.6%] in female students [n=250] and 25 [10%] in male students [n=250]. Association between student year and personality type was significant [p=0.010] at 95% confidence level. Type A personality students existed in every class and there was a gradual increase in the number of type A personality students from 1[st] year to final year in an undergraduate medical college of Rawalpindi. Significant association was observed in student year and type A personality

Gender Wise HIV Disease Awareness among Primary School Teachers in Islamabad

To assess the level of awareness and methods of primary prevention about HIV/AIDS among primary school teachers. A descriptive cross-sectional study of 60 male and female teachers, between 25-40 years of age, teaching for at least three years in public and private schools situated in suburb of Islamabad, was conducted using a structured questionnaire. A stratified random sampling design was used to collect data. Analysis was done on SPSS version 17. The study was conducted at Golra Station suburb in Islamabad from October 2012 to December 2012. 77 percent respondents have heard about the AIDs, 40 percent believe that they should not quit good relations with the AIDs Patient, 88 percent believe it is our moral obligation to help the aids victims, 50 percent believe AIDS is a major issue, and same strength responded that it is not their problem. Most of the respondents believe that AIDS is a preventable disease. Majority of the respondents are of the opinion that Government is not solely responsible to control AIDS, all the stake holders must participate in the control of AIDS. It is inspirational to know that majority has knowledge relating to HIV/AIDS. The study emphasizes the need to educate the teaching community about the prevention methods and to endow them with the crucial information and skills to facilitate them to inculcate knowledge to the younger generation at a younger age group as this can challenge the moral and ethical issue relating with the sexual spread of AIDS. However, taboos of public discussions of sexual illness remain a key limitation towards preventive activities

Preventive medicine department, serves better in hospitals

To measure the current status of preventive activities in civil and military hospitals. To compare the quantum of preventive and curative activities in the hospitals. To make recommendations for promotion of preventive activities to reduce the curative burden from the hospitals. This was a cross-sectional study. Universal sampling. All the major military and public sector hospitals having bed strength more than 400 in Rawalpindi were included in the study. All the preventive and curative work was taken into account. A structured questionnaire was developed and data regarding the quantum of work was collected from all the four major Military and civil hospitals having bed strength more than 400 beds through registers and annual reports of the hospital and was analyzed in the form of frequencies, tabulation, cross tabulation, percentages and was displayed in tables and graphs using SPSS [10.5], Microsoft Excel and calculus. Only seven percent work is preventive and ninety three percent is curative. In the preventive activity MH is marginally higher than the rest of the hospitals. In all the hospitals among the preventive activities 31% are antenatal visits, 20% tetanus toxoid injection, 19% BOG, Growth monitoring 13%, Measles injection 11% and family planning 6% in all the hospitals. Ante natal activities in the army sector hospitals are more prominent 39-44% and also in the public sector 17-26%. Next to the antenatal are tetanus toxoids to pregnant ladies which range from 16-35% in military and 16-20% in the public sector hospitals. Growth monitoring is more efficiently carried out in the Rawalpindi General Hospital i.e. 17% while in others 7-12%. Family Planning services are delivered very poorly only 9% in RGH and 6% in DHQ, zero% in CMH and 5% in MH. Measles vaccination is carried out efficiently in DHQ 27%, 11% in RGH and 8% in MH and again poorly 3% in CMH. BCG is 27% in DHQ, 20% in MH, 17% in RGH and 10% in CMH. The study show that hospitals are showing very poor performance in preventive aspect and this is the reason that countries like Pakistan are facing economic burden on the national exchequer and this burden will keep on increasing if no appropriate action is taken

comparative study on factors causing job dissatisfaction among serving doctors at teaching hospitals of Hyderabad, Pakistan

To determine the main factors of job dissatisfaction among doctors serving in teaching hospitals of Hyderabad, Pakistan. One public sector teaching hospital, i.e., Liaquat University of Medical and Health Sciences Jamshoro and one private teaching hospital, i.e., ISRA University Hospital Hyderabad was selected as study places. Doctors working on contract, part time or having service less than one year were excluded. A pre- tested mailing questionnaire was sent to each one and their response was analyzed on SPSS version 15. Out of 300 questionnaires, 248 were received correctly. Among the respondents, 76.2% doctors were found to be completely dissatisfied with their jobs. Whereas, the mean score for satisfaction characteristics were lowest for working environment [2.12 +/- 0.07], Pay and Perks [2.13+0.08] and work load [2.14 +/- 0.08]. Only the category of Professor showed total satisfaction being 67%, while qualification wise analysis showed none of the degree holders was totally satisfied. On the basis of this study, showing dissatisfaction of hospital doctors towards job conditions, it is suggested to improve job conditions/characteristics with emphasis on the improvements in working environment, pay scale and work load

Frequency of contraceptive practice amongst doctors of Pakistan Armed Forces

This study was undertaken on the exponents of motivation and implementation of family planning measures in Armed Forces i.e., doctors, with emphasis on finding their contraceptive prevalence rate. Cross-sectional prospective study. Armed Forces Postgraduate Institute Rawalpindi from March 2003 to June 2004. A comprehensively structured open and closed ended questionnaire was mailed to selected married medical officers of Pakistan Army, Air Force and Navy. Based on their responses the data was prepared, analysed and interpreted. Seventy seven percent of military doctors were practising some contraceptive method at the time of study. Most of the doctors were using condoms for contraception. Sixteen percentage of all respondents have never used any contraceptive in their life. More than 70% believe that the religion of Islam is not a barrier in family planning. Most of doctors were not satisfied with the performance of family planning centres functioning in the Army. There is a dire need to improve the female literacy, awareness about contraceptive methods and their accessibility among military masses of Pakistan

Large B cell lymphoma-year by year

Non Hodgkin's Lymphoma [NHL] comprises a group of lymphoproliferative disorders the frequency of which continues to rise. Although many classification systems exist for identifying specific histological subtypes, NHL is generally divided into indolent [low-grade] and aggressive [intermediate- and high-grade] forms. Large B Cell Lymphoma [LBCL] is one of the commonest aggressive NHLs. The aim of this review is to provide a general overview of NHL, its clinically practicable cellular classification, epidemiology and in depth overview of the evolution of treatment of LBCL during the past 5 years. Current guidelines from National Cancer Institute [NCI], USA and National Institute on Clinical Excellence [NICE], UK are mentioned and recommendations according to our own set-up are suggested

Present scenario of disease early warning system in district Bagh [Azad Kashmir]

Disease Early Warning System [DEWS] is a programme by which health workers can detect signs of an epidemic at an early stage in order to prevent its occurrence or expansion. It is a cost effective and sustainable programme especially in the developing countries like Pakistan, where infectious diseases cause a significant magnitude of morbidity, and mortality in the country. The objective of this study was to assess the practice of DEWS in district Bagh of Azad Jammu and Kashmir and suggest ways and means to improve its practice in future. It was a cross sectional descriptive study and was conducted in thirteen First Level Care Facilities [FLCFs] of the district where DEWS was in operation. Questionnaires were designed to collect information about present scenario of practice of the system and a checklist was also prepared for physical verification. The study revealed that most of the health personnel dealing with DEWS were not trained properly and many facilities were not having even essential "case definition" documents. Some of the health facilities were deficient in recording and reporting materials. 90% of laboratories of health centres/hospitals/clinics were not having even containers for getting samples and transport media to carry to referral laboratories. Some FLCFs were not having laboratory facility at all. 95% personnel involved in DEWS were not satisfied by the present ways of monitoring by the supervisors. For better functioning of DEWS, following measures are suggested: [a] Proper training of the health personnel about DEWS should be carried out. [b] Provision of DEWS tools to each facility should be ensured. [c] Regular, effective and efficient monitoring of all facilities should be done