Department of Community Medicine

Bankura Sammilani Medical College, Bankura

1
Family HealthCare Project

Name of the student: Ms./Mr.-------------------------------------------------------------

Session: ----------------------------

University roll number: -----------------------

Remarks: Complete/ Incomplete

Signature of guide Signature of HOD,

Community Medicine,
BSMC, Bankura

2
Foreword

I am very glad to know that the faculty members of department of Community Medicine,
Bankura Sammilani Medical College have composed a practical guide book of ‘Family Health
care’ for the students.

It is now considered that the modern medicine treats the disease in man, not the man in the midst
of diseases as the socio-cultural factors which are at the root of the most of the health and
nutritional problems are not properly considered. Modern medicine is nothing but recurrent
expenditure compared to ‘Family Medicine’ which is regarded as permanent investment as it
tries to eliminate the diseases by exterminating their roots.

Family medicine is emerging fast and more and more specialists in Family medicine are
necessary for the society. The medical student has to learn ‘Family Health care’ as a part of
Family medicine in the form of a project work in the tenure of 6 th semester. This book has been
compiled with a view to help the learners to acquire the art and science of Family medicine. It
provides the opportunity to have a ‘hands on training’ in Family medicine through the principles
of “what we see, we remember and what we do, we learn”.

I thank the contributors who have made it successful with their great endeavour.

I wish the success of our students in their learning to acquire adequate knowledge and skill in
‘Family Health care’.

Prof. Parthapratim Pradhan

Principal, Bankura Sammilani Medical College
Lokepur, Bankura-722102.
Date:

3
Contributors

1. Dr. Indrajit Saha, Prof. & Head, Department of Community Medicine, BSMC
2. Dr. Gautam Narayan Sarkar, Superintendent, BSMC
3. Dr. Banamali Sinha Mahapatra, Ex Professor, Department of community Medicine,
BSMC
4. Dr. Asit Baran Saren, Ex Assoc. Prof., Department of Community Medicine, BSMC
5. Dr. Aditya Prasad Sarkar, Prof., Department of Community Medicine, BSMC
6. Dr. Dibakar Haldar, Prof., Department of Community Medicine, BSMC
7. Dr. Subhra Samujjwal Basu, Ex Assistant Professor, Department of community Medicine,
BSMC
8. Dr. Sanjay Saha, Ex Assistant Professor, Department of community Medicine, BSMC
9. Dr. Debobrata Mallik, Ex Asst. Prof., Department of community Medicine, BSMC
10. Dr. Rajib Saha, Asst. Prof., Department of Community Medicine, BSMC
11. Dr. Surajit Lahiri, Asst. Prof., Department of Community Medicine, BSMC
12. Dr. Manisha Sarkar, Asst. Prof., Department of Community Medicine, BSMC
13. Dr. Atanu Biswas, Asst. Prof., Department of Community Medicine, BSMC
14. Dr. Tanjib Hassan Mullick, Asst. Prof, Department of Community Medicine, BSMC
15. Dr Sumanta Chakraborty, Demonstrator, Department of Community Medicine, BSMC
16. Dr. Tridibesh Bhattacharya, Demonstrator, Department of Community Medicine, BSMC
17. Dr. Gautam Kumar Mondal, Demonstrator, Department of Community Medicine, BSMC
18. Dr. Bishanka Biswas, Ex Demonstrator, Department of community Medicine, BSMC
19. Dr Sohanjan Chakraborty, Senior Resident, Department of community Medicine, BSMC

4
Contents

Section Topic Page

1 Introduction, why and how the family health care project is to be carried 0-4
2.a out? Identification of family 5-7
2.b Environmental survey 8-10
2.c Questionnaire Assessment of awareness & practice about diseases and 10-13
for data RMNCH+A
2.d Assessment of nutritional status 13-16
collection
2.e Health check up 17-40
2.f. Summary, MSD, action taken, recommendation 41-44
3. a A List of acronyms used 45-47
3. b Guide to collect information about identification of 48-53
P family; family’s type, size, composition, socio-
economic status, possessions, problems etc.
3. c P Guide to conduct environmental survey 54-62
3. d Outline of the steps for performing diet survey and salt 63-65
E
testing
3. e N Guide to perform health check up of individual family 66-69
members
3. f D Tips for making medico-social diagnosis, Hints for 70
taking actions by the team
3. g I Guide for making recommendations 71
3. h Images/Figures 72-77
C
4 References 78
E

5
 Introduction
Family:
“A family is a place where minds come in contact with one another.” » Buddha

“To put the world right in order, we must first put the nation in order; to put the nation in order,
we must first put the family in order; to put the family in order, we must first cultivate our
personal life; we must first set our hearts right.” » Confucius

“The secret of national health lies in the homes of people” » Florence Nightingale

“What can you do to promote world peace? Go home and love your family.” » Mother Theresa.

Family is the basic unit of any society and the most powerful example of social cohesion.

Operational definition: Family can be defined as ‘a group of individuals related biologically

(blood relation) or by marriage or adoption living together and sharing a common kitchen.

Family can be divided into –

1) Family of origin or family into which one is born, &
2) Family of procreation or the family which an individual sets up after marriage.
Functions of family:
 It provides shelter to its members
 Now-a-days the concept of ‘communal family’ is emerging where all members play part
in its management (contrasting to the primitive/old family where there was a well defined
division of labour)
 It gives scope of reproduction and rearing up children
 It secures socialization of the young members
 It ensures economic support to the dependent ones
 Social recognition-family gives its members a status in the society, protects them from
defamation, regulates marital activities of members, controls behaviour of members in
relation to religious & political affairs/sex relation etc.

6
 Section-1: Why Family health care project?

Introduction

After keeping foot in the earth man learnt to live in groups for the sake of his safety and survival.
Gradually he developed society what is ‘a group of individuals drawn together by a common
bond of nearness and who act together in general for the achievement of certain common goals’.
So, man is a socialized animal. He forms various groups for fulfillment of his different purposes.
These groups comprise social organization e.g. family, caste, religion, village, town/city, state
and functional groups like club, Panchayat, various associations etc.

Family is the basic social organization where an individual is born and grown up.

Characteristics of family:

o Biologically family shares a common pool of genes

o Society creates rules & norms to regulate the activities of its members for the safety,
progress and welfare of the human being. These rules & regulation are transmitted from
one generation to other and are called culture i.e. learned behavior which help an
individual to grow as a responsible member of the society. Being the basic unit family
reflects the culture of the society in which it is situated.
o Socially: Family shares a common physical and social environment.
Health status of an individual depends on multiple factors like socio-demographic characteristics
e.g. age, gender; religion, caste, residence, education, occupation, income, marital status,
addiction; size and composition of the family, social status, dietary habits; environmental factors
such as housing, sanitation, water supply, social norms; perception and practice about health viz-
care seeking behavior, life style, standard of living, sex behavior, etc. Because an individual is
reared up in a family, his/her every activity, including health behaviour is guided by the cultural
norms prevailing in the family.

Therefore, family plays an important role in health and diseases, in the prevention and treatment
of individual illness, in providing care in dire situation(s) like pregnancy/ childhood/old
age/illness, proper upbringing/development of children and stabilizing the personality of family
members, emotional support and rehabilitation of members during loss/bereavement/broken

7
relation etc. Moreover, family is the most important social unit in the community around which
various medical and social services evolve and revolve and it is also considered as an
epidemiological unit to study the determinants of diseases. So, no practice towards a person is
complete without studying his/her family where s/he has been brought up, spends his/her day to
day life, initiates every steps guiding by the values/norms prevailing in the family.

Despite its spectacular success modern medicine, as practiced today, has begun to be questioned
and criticized because:

o With increased medical costs hasn’t come increased benefits in terms of health
o Despite tremendous advances in medicine, the threat posed by certain major diseases
such as malaria, schistosomiasis, leprosy, filariasis, trypanosomiasis and leishmaniasis
etc. either hasn’t lessened or has actually increased
o The expectation of life has remained low and infant and child mortality rates are high in
many developing countries, despite advances in medicine
o Historical epidemiological studies showed that significant improvements in longevity had
been achieved through improved food supplies and sanitation long before the advent of
modern drugs and high technology
o There is no equity in the distribution of health services, resulting in limited access to
health care for large segments of the world’s population, and
o Modern medicine is also attacked for its elitist orientation even in health systems adapted
to overcome social disparities.
It has given rise to the notion that limits had been reached on the health impact of medical care
and research. This is labeled as a “failure of success”. One of the causes of this failure is the fact
that modern medicine rarely considers socio-cultural factors (social pathology) behind health and
disease.

In short, approach to an individual as is done in the traditional practice of medicine must be

supplemented by the approach of social medicine with individual as beneficiary, family as bed
and community as ward. It is the domain of ‘family medicine’ which is emerging.

Family medicine: It can be defined as “a field of specialization in medicine which is neither

disease nor organ oriented. It is rather family oriented medicine or health care centered on the

8
family as the unit from the first contact to the ongoing care of chronic problems (from prevention
to the rehabilitation)”.

When family medicine is applied to the care of patients and their families, it becomes the ‘family
practice’, a horizontal specialty which, like pediatrics and internal medicine, shares large areas of
content with other clinical disciplines. The specialty of family practice is specially designed to
deliver ‘primary care’ i.e. provision of an integrated preventive, promotive, curative service/care
considering human, social and cultural aspects of health and disease prevailing at family
level. As apprenticeship it is the opportunity of medical students to learn how to provide family
health care in the perspective of our country.

Objectives of family health care project:

o To describe the composition, socioeconomic condition of the family

o To assess the housing condition, water supply and sanitation measures (environmental
condition) of the family
o To ascertain the awareness & practice related to common diseases and maternal & child
health
o To find out the nutritional status of individual members and dietary practices of the
family
o To determine the morbidity profile of the family
o To recommend remedial measures for the betterment of any unfavorable issue.

Methods and Materials:

o Study design: Descriptive cross-sectional survey

o Place of study:

o Study duration: 01 month

o Study population: all the members of the allotted family

o Study variables: composition, size & type of family; education/occupation/ addiction of

members; SES/social problems/amenities of the family; type of housing, water supply,

9
 sanitation; awareness & practice regarding RMNCH+A; dietary habits, care seeking;
individual health profile etc.
o Study tools: Predesigned questionnaire, equipments for clinical examination including
anthropometry; observation checklist for environmental survey; spot iodine testing kit;
few medicines for managing acute illness (e.g. ORS, Paracetamol etc.);
o Techniques of data collection: Interview, clinical examination including anthropometry,
observation, environmental survey, reviewing of records, demonstration
o Study procedure: After the briefing about the importance of family care project,
questionnaire for data collection, and various methods/procedures to be followed etc. a
family is allotted to a team of students for collecting information to fulfill the above
objectives. During the first visit accompanied by teacher (guide), the team introduces
politely with the HOF and explains the purpose of visit. After developing a rapport with
HOF data collection is started obtaining prior verbal consent from him/her. The team
members always behave politely with the family members and collect data in a
systematic way using the questionnaire. The interviewer waits patiently if the
HOF/interviewee wants to perform minor household work(s) during interview. The
interview is done in local vernacular with explaining question(s) if the interviewee
doesn’t understand. The respondent is given time for answering questions. Neither a
hurry nor a prolong interview is allowable. Any sort of rudeness and coercion isn’t
permitted. More than one visit is usually required to collect all necessary information.
Sensitive issues are asked at last and in one to one situation if required. Neither any
gift/promise nor any bribe is allowed for the purpose of data collection apart from toffee
for the children. The family or its individual member is helped to acquire something
(health talk, prescribing or giving some medicines, helping to be checked in OPD etc.)
out of these visit(s). At last the family members’ cooperation is appreciated for helping
fulfilling the purpose family visits.
o Compilation and analysis of data

o Action taken by the team

o Recommendations made for different levels

o Submission of report

10
 Section-2: Questionnaire for data collection
1. Identification of the family

o Name of head of the family (HOF):………………………………………………………

o Address & contact number.……………………………………………………………….

Ward no…………..(if Municipality area)

o Duration of stay in present address:

o State of origin, if applicable:

o Mother tongue:

o Type of family: Nuclear/Joint

o Religion: Hindu/Muslim/Other (specify…………………………)

o Caste: General/OBC/SC/ST

o Name and Contacts of Some important persons of the community:

a) Councilor:
b) Community Health Worker :
Table-1: Composition of family (Particulars of family members)
S/N Name Relation A S Education Occupation Marital Physical Physiological CU Remarks
with g e status activity status
HOF e x

CU=Consumption unit, Write age in month for <5 [week & day for late & early neonates]

11
Fig 1: Family tree pedigree chart

12
Fig. 2.1: Road map to approach the allotted family (schematic diagram)

Fig. 2.2: Layout of the house of the allotted family (schematic diagram)

13
2. Socio-economic condition:

o Total monthly income of the family from all sources: INR………………

 Per capita monthly income: INR..…………………………………..

 Socioeconomic status score of family(as per updated & modified Kuppuswamy’s scale)

Criteria Score

1. Education of HOF:

2. Occupation of HOF:

3. Total monthly income of the family:

Total score:

 Socio-economic status of the family:

o Possession of modern amenities and recreational facilities:

i) Possession of: Bicycle/Motorcycle/ Electric rickshaw(toto)/Electricity/Fan/Radio/Television/

power banks/Telephone/Cell phone/ Almirah/ Others specify.................................................)

ii) How does the family get information/news: Newspaper/Radio/Television/Personal contact/ Group

meeting/ Others (specify………………………………………………………………)

iii) How do they pass their leisure time:

o Any Social Security measure availed:

o Social Problem(s) existing in the family

 Addiction [state type, frequency, duration for each addicted members]

Box-1: Addiction prevailing in the family
Name of the family member Type of addiction Frequency Duration

 Any unemployed adult member in the family:

 Dependency ratio: 1) Age wise: 2) Income wise:

14
 Any lady/mother who is unmarried, divorced or abandoned by husband’s family and considered

as a burden to the family by other members:

 Any handicapped or chronically ill/mentally ill family member [seems to be a burden to the

family]:

 Any child >6 years age is not going to school for 3 months or more: Present/Absent.

o If yes, mention the reason:

 Whether any mother is working outside? Yes/No

o If yes, who looks after the children in her absence:

 Is there any child below 15 years of age forced to work for earning money? Yes/No

 If there is other problem like marital disharmony/gambling/juvenile delinquency/ debt?

 Is it a problem/broken family? Yes/No

 Have any infertility issue within the family? Yes/ No

 Have any history of Domestic violence? Yes/ No; If Yes: Physical/ Verbal/ Sexual [Respondent:

Reproductive age grouped marital women]

 Enquire about other family problem(s) which has socio-cultural and health impacts:

o Monthly expenditure of the family in INR:

 Food..……………………………………
 Fuel (types of fuel used &cost).……………………………………
 Clothing.…………………………………
 Education……………………………….
 Electricity………………………………
 Housing (rent/maintenance/taxes) ……
 Social functions (marriages, festivals etc.)……..
 Health& illness………………………………….
 Travel/transport…………………………………
 Recreation (cinema, games etc.)…………………
 Other (specify) 1) Mobile bill………………
2) Cable bill……………….
3) Addiction………………………

Total expenditure: INR.……………………………

15
 Fig.3: Pie chart showing monthly expenditure of the family

 Balance: + ve/-ve:

 Savings (mention mode & type): INR…………………………………………………..

 Debt (mention the type & amount): INR……………………………………………….

16
 3. Environment
o Housing
 Mode of possession: Own/rented/other

 Type of house: Kuccha/Pucca/Mixed (Wall……………, Floor…………….., Roof…………)

 Site and approach road:

 Setback:…………..sq ft.; ……..of total area; Adequate/ Inadequate

 No. of living rooms with floor space:

 Verandah: Present/Absent

 Box-2: Room wise overcrowding assessment in the family

Criteria Observed Remarks
No. of person per room 1) 1)
2) 2)
3) 3)
Per capita floor space [calculate 1) 1)
separately for each room] 2) 2)
3) 3)
Sex separation 1) 1)
2) 2)
3) 3)

 Ventilation [assess separately for each room]

Box-3: Ventilation of living room(s)
Criteria (% of floor space) Height of the Cross- Set Back area
Door Window (DS+WS) windows from ventilation along the door &
Room space space X 100/ the floor (Present/ window(Sufficient Adequate/Inadequate
Floor Absent) / Insufficient)
space
1
2
3
4
 Natural lighting: Adequate/Inadequate;
 Status of lighting and status of noise level:
Rooms In Natural With Artificial Sufficient/ Noise level (dBA) Accepted/
light (Lux) Light (Lux) Insufficient [measured by sound unaccepted level
[measured by lux meter meter app]
app]
Bed rooms
Kitchen
Other…….

17
 Dampness: Present/Absent/Can’t be determined

 Cooking place: Separate kitchen present/Inside the living room/Verandah

 Platform: present/absent

 Platform used for coking y/n

 Washing area for utensils:

 Type of fuel used:

 Biomass fuel: Wood/Cow dung cake/Dry leaves/…………………..

 Fossil fuel: Coal/Kerosene/LPG

 Others: Electricity [heater/induction heater]/ other…………….

 Smoke outlet/ exhaust fan: Present/ Absent

 Smoke nuisance in bed room: Present/Absent

 Indoor air pollution (IAP): Present/Absent

 Storage of raw food: Proper/Improper (Specify…………………………………………….)

 Storage of cooked food: Proper/Improper (Specify…………………………………………….)

 Storage of cooking salt: Proper/Improper (Specify…………………………………………….)

 Cooking practice [observe else ask the homemaker]: Good/Unsatisfactory (Specify……………)

 Cleanliness in and around the house including kitchen: Good/Satisfactory/Poor

(Specify………………………………………………………………………………………….)

 Drainage system:

Site covered Frequency of Condition of drain

/uncovered cleaning of the drain

Drainage system of
the house

Drainage system of
the toilet/ Bathroom

Drainage system of
the kitchen

18
o Waste disposal

 Solid waste-

 Liquid waste-

 Presence of housefly/mosquito: Detected/Not detected

 Other medically important pests/insects/small animal e.g. rodent: Present/Absent (Specify…….)

 Breeding places / Potential breeding places of mosquitoes/Fly: Present/Absent; if present mention

the sites…………………………………………………………………………………………..

 Kitchen garden: Present/Absent

o Water supply

 Source of drinking water:

 Mode of supply: Continuous/intermittent (mention timing………………………………..)

 Adequacy of supply: Adequate/Inadequate [as stated by respondent & judged by interviewer]

 Distance of water source from the house hold (in meter):

 No. of families/persons using the water source:

 Comment on the water source: [Platform is concrete in case of tube well/ deep and protected in case

of well/distance from the source of pollutants etc.]

 How does the family fetch water from the source(s):

 Is drinking water given any special treatment at house hold? Yes/No, If yes , specify:

 How water is stored at household?

 How water is drawn from the stored vessels for use?

 Water source (s) for other domestic uses :

19
o Excreta disposal

 Where do the family members along with the children go for defecation:

 If use latrine:

 Type of latrine: Sanitary/insanitary

 Possession: Own/common

 In case of common, no. of people using it:

 How it is maintained: good/poor

o Pet animal/bird: Present/Absent; If present:

 Type & number of animals:

 Animal shed: Present/absent [if absent then where the animal is kept………………]

 Distance of the animal shed/bird cage from the dwelling house:…………meters

 Where & how the animal’s excreta disposed…………………….

20
3. Health awareness and practice of the family

3. A. Care seeking behaviour

 System of Medicine preferred: Allopath/Homeopath/other (specify………………….)

 Usual source of care seeking: Government/Private/Other (specify……………...........)

2. B. Awareness and Practice of the family towards:

Table-2: Awareness & practice about locally prevalent communicable diseases; Respondent: ………
Disease or Knowledge Practice

syndrome Causation & Main symptoms Care seeking Prevention Prevention Care seeking

transmission

Malaria

Dengue

Japanese

Encephalitis

TB

ARI/

Pneumonia

Diarrhea

HIV/AIDS

Rabies

Leprosy

Other………

if needed

21
Table-3: Awareness & practice about common non-communicable diseases; Respondent:………………
Knowledge Practice
Disease Causation Main symptoms Care seeking Prevention Prevention Care seeking
DM

HTN

Cancer

CHD

Mental
disease
Other……
…if needed

Table-4: Awareness & practice about personal hygiene, Respondent: …………………………..

Knowledge
Hygiene Practice
How to maintain What happens if not maintained
Oral

Hair

Nail

Skin

Hand washing

Menstrual
Hygiene
Other……if
needed

 Views of HOF regarding women empowerment (Employment and education):

22
3. C. Awareness in the family about RMNCH+A ; Respondent: …………………………..

 Legal age of marriage (yr.): Male- Female-

 Desirable age (yr.) of child birth:
 No. of children (with gender) a couple should have: B……. G……/Any……

 Minimum gap between two children (birth interval in yr.):

 Is there awareness in the family about

ANC 1) Number of Visits required

2) TT injection

3) IFA Supplementation

4) Diet & Bed rest

5) Danger Signs of pregnancy

INC 1) Place of delivery should be

PNC 1) Danger signs of post partum mother and

child
2) Breast feeding positioning and attachment

 Awareness about infant feeding

Knowledge Remark
(Good/Satisfactory/Poor)
Initiation of breast feeding
Colostrum feeding
Prelacteal feeding
Exclusive breast feeding
Complementary feeding
Feeding during illness
Frequency of feeding

 Immunization of the child:

o Name of Vaccine Preventable Diseases (VPDs):
o Importance of vaccination:
o Age of different vaccinations:

23
  Family planning services

o Awareness about small family:

o Name of some FP methods known:

o Place of availability:

o Family planning method adopted: Yes/ No; If Yes (Specify)…………………………………

 Awareness regarding the availability and importance of ICDS/MDM: Aware/ Not aware
 Awareness regarding WIFS & Biannual deworming of adolescents: Aware/ Not aware
 Awareness on Vitamin A & IFA prophylaxis for <5 children: Aware/ Not aware

3. D. Reproductive health practices

Table-5: Practice about reproductive health in the family

Issues Name of married woman

Age (husband) at marriage

Age (wife) at marriage
Age at first child birth
Total no. of live birth
Mode of delivery
Place of delivery
No. of abortion/still births
Any complication during AN/ IN/ PN period
No. of living children[B/G]
Birth interval (yrs) if applicable
SN from AWC during pregnancy/lactation

24
 4. Nutritional status of the family members:
Clinical examination- Box-4: Nutritional deficiency signs among the family members
Findings of clinical examination Individuals examined
1 2 3 4 5 6 7 8 9
General appearance [normal/thin/sick]
Hair [depigmented/flag sign]
Face [moon shaped/nasolabial dyssebacea]
Lips [angular stomatitis/cheilosis]
Tongue[pale/raw/magenta color/fissured/ smooth]

Teeth [mottling/cavities/attrition]
Gums [swollen/bleed on touch]
Eyes [nyctalopia/xerosis/Bitot’s spot/pallor]
Thyroid gland[enlargement with grade]
Skin [dry/follicular hyperkeratosis/

phrynoderma/pellagra dermatitis]

Nails [koilonychia]
Edema in dependent part
Hepatomegaly
Calf tenderness
Ankle & knee jerks [delayed/lost]
Rachitic change[bow legs/knock knees/ ricketic

rossary]

Mental state (of the child)

Anthropometry: Table-6:
[apathy/irritable/anorexia] Anthropometric measurement of family members
Variable/characteristic Measurement values for individuals
1 2 3 4 5 6 7 8 9

Length (cm) [child <2 yrs]/Height (cm) [2yrs]

Weight (kg)

BMI (kg/m2) [2 yrs]

Head circumference (cm) [for <5 yrs]
Chest circumference (cm) [for <5 yrs]
Mid-upper-arm circumference (cm) [1-4yrs]
Waist circumference (cm)[for adult]
Hip circumference (cm) [for adult]
Waist Hip Ratio(WHR)[for adult]

25
  Diet survey
 Method used: 24 hours recall based on oral questionnaire for ……….day(s)
 Respondent: House-wife and or cook of the family
 Selection of day:[In case of single day diet survey: day shouldn’t be preceded or followed by
festival/ occasion and on which there is no invitation or religious food restriction.
In case of three days diet survey: select two week days and Sunday
Preferably average consumption of 1 week (one dietary cycle) is considered]
 Dietary habit: Vegetarian/Non-vegetarian
 Views of HOF: Have any food taboo within the family?:
Table-7: Foods consumed by the family in last 24 hours/average daily consumption
Food groups Food items with quantity (gm/ml) Total consumption Total requirement (ICMR) Remark

1. Rice ……………………..
2. Wheat…………………...
Cereals
3. Puffed rice……………...
4. Flattened rice……………
1. Lentil……………………
Pulses 2. Green gram……………..
3. Bengal gram……………
1……………………………
Roots & tubers 2……………………………
3…………………………...
1…………………………...
Other vegetables 2…………………………..
3……………………………...
1…………………………….
Green leafy veg.
2…………………………….

Milk & milk 1…………………………….

product 2…………………………….

1…………………………….
Fruits
2…………………………….

1……………………………
Egg/ Flesh food
2……………………………

1…………………………….

Fats & oils 2…………………………….

1…………………………….
Sugar & Jaggery
2…………………………….

26
 Food groups Food items with quantity (gm/ml) Total consumption Total requirement (ICMR) Remark

1…………………………….
Nuts & oil seeds
2…………………………….

Spices & 1. Chilies……………………

condiments 2…………………………….

Salt (gm)

Salt test by spot iodine testing kit Remark:

Table-8: Nutrients Intake: as calculated based on the book-‘Nutritive values of Indian foods, ICMR’.

Foodstuff Quantity Energy Fat Protein Iron Vit- Thiamin Riboflavi Vit-C Folic acid
(gm/ml) (kcal) (gm) (gm) (mg) A(μg) (mg) n (mg) (mg) (mg)

Total

27
 Table-9: Daily nutritional requirement versus consumption
Family member Calories Protein Fat Iron Vit- Thiamin Riboflavin Vit-C Folic acid
(Kcal) (gm) (gm) (mg) A(μg) (mg) (mg) (mg) (mg)
Adult
Sedentary
Moderate
Male worker
Heavy worker
worker
NPNL Sedentary
Moderate
female worker
Heavy worker
worker
Pregnant woman
Lactating women (mention the
Adolescents
phase)
10-12 yrs. B.
13-15 yrs. B.
G.
16-18/19 yrs. B.
G.
G. Infants, toddlers and young children
<1 yr. 0-6 months
6-12 months
1-3 yrs.
4-6 yrs
Total requirement/day
7-9 yrs.
Total consumption/day
Balance[surplus/deficit]

Fig.4: Bar diagram showing nutrient and energy balance of the family.

28
5. Health check up
A.1. Under five children:

*Age (months/weeks): *Place & mode of delivery: *Birth wt (kg):

*Initiation of breast feeding [for infant]: *Prelacteal feeding given [for infant]: Y/N

*Exclusive breast feeding given: Y/N for…………months/NA

*Current feeding practice:

 ≤6 mo. of age on EBF: Demand feeding/schedule feeding/mixed for ……times in 24 hrs

 ≤6 mo. of age not on EBF: Predominant/partial/token breast feeding/top feeding for ...times in 24 hrs

 Complementary feeding (CF) [for >6 months of age] started at:……..months.

 >6 mo. of age and or on CF: Frequency of feeding: ……………………….

Breakfast Supple- Meal Snacks Tiffin Meal

mentary (Lunch) (Dinner)
nutrition
Type of food

Texture (Mashed/fine
chopped/ chopped/
family diet)
Amount of food (ml)

 Feeding during illness: altered/reduced/usual

Developmental milestone [Box-5.1]

Age Motor development Achievement Language development Achievement
3 months Head holding ---------------------
4-5 months ----------------------- Listening
6-8 months Sits without support Experimenting with noises
9-10months Crawling Increasing range of sounds
10-11months Stands with support First words
12-14months Walks wide base -----------------
24 months Runs Short sentences

29
  Chief complaints:

 H/o present illness:

 H/o past illness:

 Family history:

 Treatment history:

 Clinical examination:

o General survey:

o Systemic Examination:

Table-10.1: Immunization status of <5 child

Vaccine Source Recommended Date Delay, if Cause of Remark

age(days/weeks/months) [Age(days/weeks/ any delay/non- [Fully/partially/non-
months) at receiving immunized/Up to
vaccination] date]
BCG

DPT-1/Pentavalent-1

DPT-2/Pentavalent-2

DPT-3/Pentavalent-3

DPT-B(1st )

DPT-B (2nd)

OPV-0

OPV-1

OPV-2

30
OPV-3

OPV-B

fIPV1

fIPV2

Rotavirus 1

Rotavirus 2

Rotavirus 3

HepB-birth dose

HepB-1/Pentavalent-1

HepB-2/Pentavalent-2

HepB-3/Pentavalent-3

Measles-I

Measles-2

JE-1

JE-2

Any other

*Vitamin A prophylaxis of the baby [for >9 months of age]:

*IFA prophylaxis of the baby [for >6 months of age]:

*Whether the baby received IPPI doses:

*Does the baby attend to AWC [for >6 months of age]: Yes/No

*If not what is the reason?

*Growth monitoring- done by: AWW/Pvt. Clinic/Other (specify………………………………)

*Nutritional status of the child (anthropometry):

 MUAC(cm)=

 Weight for age [Growth chart, vide Fig.3,4]:

 Length/ height for age[Growth chart, vide Fig.5-6]:

 Weight for length/height [Growth chart, vide Fig.7-8]:

 Crossing over of CC over HC: Achieved/ Not achieved/Not applicable

31
 Fig.5: Growth chart (weight for age-boys)
Remark:

32
 Fig.6: Growth chart (weight for age-girls)
Remark:

33
 Fig.7. Growth chart (Length/height for age-boys)
Remark:

34
 Fig.8: Growth chart (Length/height for age-girls)
Remark:

35
Fig.9: Growth chart (Length/height for weight-boys)
Remark:

36
 Fig.10: Growth chart (weight for height-girls)

Remark:

37
 Box-6.1: Waterlow’s classification of malnutrition
Ht for age  - 2Z < - 2Z
Wt for length/ht
 - 2Z Normal Stunted (chronic)

< - 2Z Wasted (acute) Wasted & Stunted (acute on chronic)

 Provisional diagnosis:

 Management suggested:

38
A.2. Under five children:

*Age (months/weeks): *Place & mode of delivery: *Birth wt (kg):

*Initiation of breast feeding [for infant]: *Prelacteal feeding given [for infant]: Y/N

*Exclusive breast feeding given: Y/N for…………months/NA

*Current feeding practice:

 ≤6 mo. of age on EBF: Demand feeding/schedule feeding/mixed for ……times in 24 hrs

 ≤6 mo. of age not on EBF: Predominant/partial/token breast feeding/top feeding for ...times in 24 hrs

 Complementary feeding (CF) [for >6 months of age] started at:……..months.

 >6 mo. of age and or on CF: Frequency of feeding: ……………………….

Breakfast Supple- Meal Snacks Tiffin Meal

mentary (Lunch) (Dinner)
nutrition
Type of food

Texture (Mashed/fine
chopped/ chopped/
family diet)
Amount of food (ml)

 Feeding during illness: altered/reduced/usual

Developmental milestone [Box-5.1]

Age Motor development Achievement Language development Achievement
3 months Head holding ---------------------
4-5 months ----------------------- Listening
6-8 months Sits without support Experimenting with noises
9-10months Crawling Increasing range of sounds
10-11months Stands with support First words
12-14months Walks wide base -----------------
24 months Runs Short sentences
 Chief complaints:

39
  H/o present illness:

 H/o past illness:

 Family history:

 Treatment history:

 Clinical examination:

o General survey:

o Systemic Examination:

Table-10.1: Immunization status of <5 child

Vaccine Source Recommended Date Delay, if Cause of Remark

age(days/weeks/months) [Age(days/weeks/ any delay/non- [Fully/partially/non-
months) at receiving immunized/Up to
vaccination] date]
BCG

DPT-1/Pentavalent-1

DPT-2/Pentavalent-2

DPT-3/Pentavalent-3

DPT-B(1st )

DPT-B (2nd)

OPV-0

OPV-1

OPV-2

OPV-3

40
OPV-B

fIPV1

fIPV2

Rotavirus 1

Rotavirus 2

Rotavirus 3

HepB-birth dose

HepB-1/Pentavalent-1

HepB-2/Pentavalent-2

HepB-3/Pentavalent-3

Measles-I

Measles-2

JE-1

JE-2

Any other

*Vitamin A prophylaxis of the baby [for >9 months of age]:

*IFA prophylaxis of the baby [for >6 months of age]:

*Whether the baby received IPPI doses:

*Does the baby attend to AWC [for >6 months of age]: Yes/No

*If not what is the reason?

*Growth monitoring- done by: AWW/Pvt. Clinic/Other (specify………………………………)

*Nutritional status of the child (anthropometry):

 MUAC(cm)=

 Weight for age [Growth chart, vide Fig.3,4]:

 Length/ height for age[Growth chart, vide Fig.5-6]:

 Weight for length/height [Growth chart, vide Fig.7-8]:

 Crossing over of CC over HC: Achieved/ Not achieved/Not applicable

41
 Fig.11: Growth chart (weight for age-boys)
Remark:

42
 Fig.12: Growth chart (weight for age-girls)
Remark:

43
 Fig.13. Growth chart (Length/height for age-boys)
Remark:

44
 Fig.14: Growth chart (Length/height for age-girls)
Remark:

45
Fig.15: Growth chart (Length/height for weight-boys)
Remark:

46
 Fig.16: Growth chart (weight for height-girls)

Remark:

47
 Box-6.1: Waterlow’s classification of malnutrition
Ht for age  - 2Z < - 2Z
Wt for length/ht
 - 2Z Normal Stunted (chronic)

< - 2Z Wasted (acute) Wasted & Stunted (acute on chronic)

 Provisional diagnosis:

 Management suggested:

48
B.1. For pregnant woman.

*Name: *Age

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

Obstetric history: : *LMP: *EDD: *Gravida:

*Parity: *Duration of pregnancy: *Date of registration:

 Is the pregnancy planned? Yes/No (unwanted/mistimed)

Table-11.1: MCH care availed: From- Government facility/Pvt. facility/ Others (specify….........)
Services Response/recorded in MCPC Current findings / Practice
No. of antenatal visit availed

Anthropometry

Measuring BP &fundal height;

Antenatal checking lie, fetal heart sound,
pedal edema, pallor
care Immunization against Tetanus

(ANC) FA/IFA [no. of tablet supplied/

no. of tablet consumed]
Hb estimation, Blood grouping/
typing, VDRL, HbsAg/HIV,
urine for alb, USG
Treatment/Referral for any
complication

49
 Dietary advices

Advices about rest, life style,

breast feeding, work, drugs etc.
Told about danger signs

Told about birth preparedness 1) Identified skilled birth

attendant for delivery: Y/N
and complication readiness 2) Identified health facility
for emergency: Y/N
3) Arranged transport: Y/N
4) Saved money: Y/N
Supplementary nutrition from AWC

 Treatment history, if any:

 Clinical examination:

o General survey:

o Systemic examination:

o Obstetric examination

 Provisional diagnosis:

 Management suggested:

50
B.2. Pregnant women:

*Name: *Age: *LMP: *EDD:

*Gravida: *Parity: *Duration of pregnancy: *Date of registration:

*Is the pregnancy planned? Yes/No (Unwanted/Mistimed)

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

 Obstetric history:

Table-11.2: MCH care availed: From- Government facility/Pvt. facility/ Others (specify……)
Services Response/recorded in MCPC Current findings/ Practice
No. of antenatal visit availed

Anthropometry

Antenatal Measuring BP &fundal height;

checking lie, fetal heart sound,
care pedal edema, pallor
Immunization against Tetanus
(ANC)
FA/IFA [no. of tablet supplied/
no. of tablet consumed]
Hb estimation, Blood grouping/
typing, VDRL, HbsAg/HIV,
urine for alb, USG

51
 Treatment/Referral for any

complication

Dietary advices

Advices about rest, life style,

breast feeding, work, drugs etc.
Told about danger signs

Told about birth preparedness 1) Identified skilled birth

and complication readiness attendant for delivery: Y/N
2) Identified health facility for
emergency: Y/N
3) Arranged transport: Y/N
4) Saved money: Y/N
Supplementary nutrition from AWC

 Treatment history, if any:

 Clinical examination:

o General survey:

o Systemic examination:

o Obstetric examination

 Provisional diagnosis:

 Management suggested:

52
C.1. Lactating (delivered within last 1 year) women:

*Name: *Age: *Parity: *Date of delivery:

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

 Menstrual history:

 Contraceptive history:
Table-12.1: MCH care availed: From- Government facility/Pvt. facility/ Others (specify………)
Services Response/recorded in MCPC Practice

No. of antenatal visit availed

Anthropometry

Measuring BP & fundal height; checking

lie, fetal heart sound, pedal edema, pallor
Immunization against Tetanus

FA/IFA [no. of tablet supplied/ no. of

tablet consumed]
Antenatal
Hb estimation, Blood grouping/ typing,
care
VDRL, HbsAg/HIV, urine for alb, USG
(ANC)
Treatment/Referral for any complication

Dietary advices

Advices about rest & others (life style,

breast feeding, work, drugs etc.)
Told about danger signs

Told about birth preparedness &

complication readiness
Intra- Place of delivery

natal care Mode of delivery

(INC) Delivery conducted by

Complications during delivy

53
 Services Response/recorded in MCPC Practice

Essential newborn care

No. of PN visit [mention days of visit]

received
Postnatal Measurement of birth wt within 24 hrs
care
IFA supplementation [if given note down
the no. of tab, supplied & consumed]
(PNC)
Advices regarding feeding, care of cord,
prevention of hypothermia, FP,
immunization, diet, physical activity
Assessment of sick child

Supplementary nutrition from AWC

 Treatment history, if any:

 Clinical examination:

o General survey:

o Breast Examination:

o Positioning and attachments during breastfeeding

Mother’s Mother relaxes and gets comfortable

Position
Mother’s back, neck, arms and feet are well supported

Baby’s The baby is positioned in close alignment to his mother, and baby’s hips
Position and feet are supported
Mother holds her baby close, supported and facing the breast

She supports the baby’s neck, back and shoulder which will allow the
baby to be free to tilt his head back easily
Attachment Baby has a big wide mouthful of breast in his mouth, with his chin
touching the breast leaving his nose free to breathe
to breast Lower lip turned out, upper lip should encompass nearly all of the areola
and more areola visible above rather than below the baby’s mouth
His cheeks are full and rounded, the cheeks should not dimple when baby
is feeding
The baby starts to feed with short quick sucks, then changes to long deep
sucks with pauses to breathe

54
 o Systemic examination:

 Provisional diagnosis:

 Management suggested:

55
C.2. Lactating (delivered within last 1 year) women:

*Name: *Age: *Parity: *Date of delivery:

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

 Menstrual history:

 Contraceptive history:
Table-12.1: MCH care availed: From- Government facility/Pvt. facility/ Others (specify………)
Services Response/recorded in MCPC Practice

No. of antenatal visit availed

Anthropometry

Measuring BP & fundal height; checking

lie, fetal heart sound, pedal edema, pallor
Immunization against Tetanus

FA/IFA [no. of tablet supplied/ no. of

tablet consumed]
Antenatal
Hb estimation, Blood grouping/ typing,
care
VDRL, HbsAg/HIV, urine for alb, USG
(ANC)
Treatment/Referral for any complication

Dietary advices

Advices about rest & others (life style,

breast feeding, work, drugs etc.)
Told about danger signs

Told about birth preparedness &

complication readiness
Intra- Place of delivery

natal care Mode of delivery

(INC) Delivery conducted by

Complications during delivery

56
 Services Response/recorded in MCPC Practice

Essential newborn care

No. of PN visit [mention days of visit]

received
Postnatal Measurement of birth wt within 24 hrs
care
IFA supplementation [if given note down
the no. of tab, supplied & consumed]
(PNC)
Advices regarding feeding, care of cord,
prevention of hypothermia, FP,
immunization, diet, physical activity
Assessment of sick child

Supplementary nutrition from AWC

 Treatment history, if any:

 Clinical examination:

o General survey:

o Breast Examination:

o Positioning and attachments during breastfeeding

Mother’s Mother relaxes and gets comfortable

Position Mother’s back, neck, arms and feet are well supported
Baby’s The baby is positioned in close alignment to his mother, and baby’s
Position hips and feet are supported
Mother holds her baby close, supported and facing the breast
She supports the baby’s neck, back and shoulder which will allow
the baby to be free to tilt his head back easily
Attachment Baby has a big wide mouthful of breast in his mouth, with his chin
to breast touching the breast leaving his nose free to breathe
Lower lip turned out, upper lip should encompass nearly all of the
areola and more areola visible above rather than below the baby’s
mouth
His cheeks are full and rounded, the cheeks should not dimple when
baby is feeding
The baby starts to feed with short quick sucks, then changes to long
deep sucks with pauses to breathe

57
 o Systemic examination:

 Provisional diagnosis:

 Management suggested:

58
D.1 Adolescent (Boy) Health Check Up
*Name: *Age:

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

 Pubertal development:
Delayed puberty (If the above changes are not achieved by age of 15 years): yes/ no

 Home and personal life: 1) relationship with parents…………………………………

2) Household chores: active (efficient/ inefficient) / dependent
3) relationship with friends……………….
4) difficulties in communication with peer of opposite gender: yes/ no, if yes……(specify)
 Education: 1) Class:……………
2) Academic performance& Achievements …………………..
3) Extra-curricular interest/ activity & Achievements …………………..
4)Aim & Goal in life………………………..
 Addiction: Smoking/ Chewing tobacco/ Alcohol/ Drug………./ Other………..
 Dietary habit: 1) Binge eating (Y/N) 2) Chronically skipping meal (Y/N) 3) Consumption
of junk food daily (Y/N)
 H/O Abuse: 1) Physical abuse: Yes/ No; if yes (by Whom, How, When)……………..
2) Verbal abuse: Yes/ No; if yes (by Whom, How, When)……………..
3) Sexual abuse: Yes/ No; if yes (by Whom, How, When)……………..
 H/O Psychological wellbeing: Have you any feelings of low/ depression and self harm?
Yes/ No; if Yes Why?......................................................................................................................
 Knowledge about STD and Contraceptive methods:
 Do you attend AFHC (Adolescent Friendly Health Clinic):

59
 Clinical examination:

o General survey:

o Anthropometric measurements:

o Systemic examinations:

 Provisional diagnosis:

 Management suggested:

60
Fig.17: Growth chart according to BMI
Remark:

61
D.2 Adolescent (Girl) Health Check Up
*Name: *Age:

 Chief complaints:

 H/o present illness:

 H/o relevant past illness:

 Relevant family history:

 Personal history:

 Pubertal development:
Delayed puberty (If the above changes are not achieved by age of 14 years): yes/ no
 Menstrual History (if started):
 Menstrual Hygiene practice (if started):

 Home and personal life: 1) relationship with parents…………………………………

2) Household chores: active (efficient/ inefficient) / dependent
3) relationship with friends……………….
4) difficulties in communication with peer of opposite gender: yes/ no, if yes……(specify)
 Education: 1) Class:……………
2) Academic performance& Achievements …………………..
3) Extra-curricular interest/ activity & Achievements …………………..
4)Aim & Goal in life………………………..
 Addiction: Smoking/ Chewing tobacco/ Alcohol/ Drug………./ Other………..
 Dietary habit: 1) Binge eating (Y/N) 2) Chronically skipping meal (Y/N) 3) Consumption
of junk food daily (Y/N)
 H/O Abuse: 1) Physical abuse: Yes/ No; if yes (by Whom, How, When)……………..
4) Verbal abuse: Yes/ No; if yes (by Whom, How, When)……………..
5) Sexual abuse: Yes/ No; if yes (by Whom, How, When)……………..
 H/O Psychological wellbeing: Have you any feelings of low/ depression and self harm?
Yes/ No; if Yes Why?......................................................................................................................
 Knowledge about STD and Contraceptive methods:

 Do you attend AFHC (Adolescent Friendly Health Clinic):

62
 Clinical examination:

o General survey:

o Anthropometric measurements:

o Systemic examinations:

 Provisional diagnosis:

 Management suggested:

63
Fig.18: Growth chart according to BMI
Remark:

64
 E. Individual health status:
Table-13: Health check up for other members
Individuals
Components 1.Name: 2.Name: 3.Name: 4.Name:

Chief Complaints

H/o present illness

H/o past illness

Family history

Personal history

Menstrual history

in case of female

Contraceptive

practice

General

Clinical survey

findings Systemic

Exam.

Provisional

diagnosis

Management

suggested

65
6. Summary:

o Identification of family:

o Socioeconomic status:

o Environment:

o Health awareness and practice:

o Nutritional profile:

o Health status of family members:

66
7. Medico-social diagnosis:

67
8. Action Taken by the team: [That is done by the team for individual member/ whole family]

68
9. Recommendation(s):

 Individual level:

 Family level:

 Community level:

 Authority level:

69
 Section-3: Appendices

3.1. Acronyms used in this booklet

ACU: Adult consumption unit

AWC: Anganwadi center

AWW: Anganwadi worker

BCG: Bacille-Calmette-Guerin

CC: Chest circumference

CHD=Coronary Heart Disease

COPD=Chronic obstructive pulmonary disease

CU: Consumption unit (same as ACU)

DM=Diabetes mellitus

DPT: Diphtheria Pertussis-Tetanus

EDD: Expected date of delivery

FP=Family planning

GIT=Gastro-intestinal tract

GOI= Government of India

HC: Head circumference

HIV/AIDS: Human immunodeficiency virus /Acquired immunodeficiency syndrome

HOF: Head of the family

HTN=Hypertension

70
ICDS: Integrated child development services

ICMR=Indian Council of Medical Research

IDD= Iodine deficiency disorders

IFA: Iron and Folic Acid

INR=Indian National Rupee

IPPI: Intensified Pulse Polio Immunization

IYCF= Infant and young child feeding

JE: Japanese encephalitis (B)

KMC: Kangaroo mother care

LBW=Low birth weight

LMP: Last menstrual period

LPCD=Liter per capita day

LPG=Liquid petroleum gas

MCPC=Mother and child protection card

MDM=Mid-Day-Meal

NPNL= Nonpregnant-nonlactating

MSD=Medico-social diagnosis

MUAC: Mid-upper arm circumference

OPD: Out-patient-department

OPV: Oral polio vaccine

ORS: Oral rehydration solution

71
PCMI: Per capita monthly income

PN=post-natal

ppm= parts per million

RDA: Recommended daily allowance

RMNCH+A: Reproductive-maternal -neonatal-child health plus adolescent

SES: Socioeconomic status

STD=Sexually transmitted disease

SN=Supplementary nutrition

TB=Tuberculosis

TT: Tetanus toxoid

WC: Waist circumference

WFA=Weight for age

WHO: World Health Organization

WHR: Waist-Hip ratio

WIFS: Weekly Iron & Folic Acid Supplementation

72
 3.2. Guide for collecting information for identification of family with its SES

Respondent(s): HOF [Try to schedule/ re-schedule your visit(s) to hold the interview with HOF
because s/he can divulge all the required information to the best possible extent]. If it isn’t
possible i.e. in his/her absence try hold the interview with any responsible adult member who can
furnish all your required information

Technique: Interview, observation, environmental survey, record review etc.

Tools: Schedule/questionnaire, measuring tape, torch etc.

Definition

HOF: A person in the family who is the decision maker in all matters. S/he may (in most cases)
or mayn’t be also the highest/principal earner of the family. For example, husband in a nuclear
family (in our perspective).

Type of family.

o Nuclear family: Family consisting of husband and wife (or any spouse) with or without
unmarried children sharing single kitchen is called nuclear family.
o Joint family: Family comprising of more than one couples or spouses sharing a common
kitchen is called joint family
o Three generations family/extended nuclear family: for the sake of simplicity in the field
level exercise family other than nuclear family will be considered by default joint family.
House-hold: Family differs from another group which is called ‘house-hold’ and can be defined
as ‘group of individual living together and sharing a common kitchen without biological relation’
e.g. your hostel/mess, a family with servant(s) etc.

Age determination: Try to note down age in complete year for the adults and children other than
under five in whom age is to be determined in complete month. However, for the neonates age
can be ascertained in week(s) and even in days in case of early neonates.

For the purpose of age determination use birth certificate issued by appropriate authority or
discharge certificate in case of a newborn where the birth certificate is yet to be obtained.

73
In certain cases definite document related to birth may be unavailable (though the possibility is
very remote in present days) and you have to adopt ‘local event calendar’ for the purpose of
determining the age of the individual e.g. the person was born during the year of Aila storm /
during last Assembly or Parliament election/ during last Durga Puja or Eid or Kalipuja etc.

Gender: Record as M=male, F=female, O=other (transgender/third gender)

Marital status: M=Married, UM=unmarried, W=widow/widower, S=separated, D=divorcee

Education: As per the guideline used in Indian Census Act, 1948 “any person aged 7 years and
above who can read and write in any language with comprehension is called literate”. So, any
other person i.e. person under the age of 7 years who can read and write in any language with
understanding or persons above 7 years of age who can’t are by default illiterate. However, we
can follow this legal framework for persons aged 7 years and above but in case <7 years aged
individual his/her year(s) of schooling /grade e.g. KG1/2 or Nursery/ Preparatory can be
mentioned.

For the purpose of documentation note down last school/Board/University examination s/he
passed e.g. BA 1st year should be noted as higher secondary (H S) passed, reading in class IX is
to be noted as class-VIII passed etc.

Occupation: Consider only the predominant source of earning as occupation if you find that the
person(s) is/are engaged in more than one occupation. However, if other minor occupation(s) the
person engaged with is a health hazard that must be mentioned e.g. driving, bidi making etc.

o Professional: For example, doctor/lawyer/architect/mechanic etc. who earn through the

expertise of their professional degree.
o Semi-professional: Some occupations like college/school teacher may be considered
under this section.
o Service: Specify the category of post the person occupies as the social status of
individual depends on the post held by him/her or nature of occupation to which s/he is
engaged e.g. professions like Medical/Engineering/Legal hold the highest social status
whereas college teachers/administrative personnel/bankers hold next level of status in our
society. The high or primary school teachers/clerks come next. The persons engaged as

74
 support staff in any office or organization e.g. group IV staffs are usually not considered
to have high social status. Again service may be categorized as government or private. It
also carries some bearing on the health of the person concerned as the workers of private
sectors are frequently found not to enjoy job satisfaction. For the sake of simplicity, the
retired persons, specially the pension holders are to be considered as ‘service holder’
during determining their occupation.
o Business:
o Large scale business: Big shop owner/Show room of TV/Refrigerator/two
wheeler etc.
o Small scale business: petty shop/hawker/vegetable vendor etc.
o Skilled worker: Occupation which requires certain amount of formal/informal
training is called skilled job/work e.g. motor mechanic/tailor/ blacksmith/
goldsmith/ carpenter/barber/potter/bidi maker/artisan etc. Usually many of these
occupations run in the family and the concerned person can develop the skill from
his/her family.
o Unskilled worker: Persons engaged in any casual jobs other than the types of
activities mentioned above and get wages on daily basis to maintain their
livelihood are called unskilled workers. Agricultural workers; people engaged in
house-hold activities, cooking, loading/unloading; coolie, rickshaw puller etc. are
the example of unskilled workers.
o At home: Persons who aren’t engaged in any type of activity e.g. a 67 years old
lady/gentleman.
o Home maker: Women who perform house hold activities of the family. They
shouldn’t be called unemployed in true sense.
o Not applicable: Children under the age of 15 years aren’t expected to earn for the
family or shouldn’t be engaged in any activity with an intention to avoid/escape
expenditure e.g. collecting wood/making cow dung cake for fuel/taking care of
cattle etc. Document the occupation of this group of individuals as ‘not
applicable’ if the child doesn’t do any of the above mentioned activities.

75
Physical activity: Energy expenditure depends on age, gender, physical activities (like
occupation, playing/exercise), health status as well as physiological status. The following are the
classification of physical activity depending upon the occupation of an individual:

o Sedentary worker: Students/doctors/lawyers/teachers/home-makers/executives/ clerks/

managers/ shopkeepers/tailors/barbers/ nurses/landlords/priests/ shoemakers/ postmen
etc.
o Moderate worker: Housemaids/coolies/drivers/weavers/potters/basket makers/ masons/
bidi makers/agriculture laborers/rickshaw pullers/ electricians/ welders/ fitters/ industrial
workers/ carpenters/goldsmiths.
o Heavy worker: Miners/Gang men/woodcutters/stone crushers/ blacksmiths/ laborers
engaged in loading-unloading etc.
Physiological status: Certain physiological conditions, specially in relation to the women are
related to altered metabolism, requiring extra energy and excess vulnerability to health hazards.

o Pregnancy- mention it as ‘P’

o Lactation- mention as ‘L’. Don’t forget to mention the phase of lactation as the 1 st
phase (1st 6 months) which is more important in regard to the growth of the newborn
and thereby requires much more attention as well as more extra energy provision to
the mother
o Document as NPNL for non-pregnant – non-lactating women.
Adult consumption unit or consumption unit: Energy requirement of an adult sedentary male is
considered as one consumption unit (CU) or adult consumption unit (ACU) and the coefficients
for energy requirement of other age/sex group is determined by using CU as base as follows
[Box-7]:
Group Consumption unit(CU)
Adult male sedentary worker 1.0
Adult male moderate worker 1.2
Adult male heavy worker 1.6
Adult female sedentary worker 0.8
Adult female moderate worker 0.9
Adult female heavy worker 1.2
Pregnant women* 0.97,1.1,1.38
Lactating women(1st half)* 1.08,1.22,1.49
Lactating women (2nd half)* 1.04,1.19,1.45

76
 Group Consumption unit(CU)
Adolescent 12-21 years of age 1.0
Children 9-12 years of age 0.8
Children 7-9 years of age 0.7
Children 5-7 years of age 0.6
Children 3-5 years of age 0.5
Children 1-3 years of age 0.4
*In respect of different physical activity (sedentary, moderate & heavy)

However, now-a-days the use of CU is replaced by direct energy calculation of different age/sex/
physiological status as per RDA determined by ICMR.

Social problem: In our society there may be both individual problem(s) and social problem(s).
An individual’s problems become social problem when they affect a larger section of the society
amounting to a threat to their welfare and or safety. So, all individual problems aren’t social
problems. Poverty, crime etc. are social problems. Many public health problems are also social
problems and vice versa. Alcoholism, STDs etc. are such type. Specifically, enquire about the
following problems in the family:

o School dropout: If any child within the age group 6 -14 year remains absent from school
for consecutive three months except vacation and certified illness then it is called school
dropout.
o Child labor: The Child Labour (Prohibition and Regulation) Act, 1986 defines a child as
a person who has not completed fourteen years of age. So, if a child below 14 years of
age is engaged in any work in/outside the family with an intention of earning or
avoiding/escaping expenditure of money is called child labour.
o Alcoholism
o Chronically ill patients
o Handicapped children
Economic status: It is very sensitive area. Handle with care. Poor people usually suppress their
income with a hope that the team may recommend some government financial assistance for the
family. On the other hand rich people also want to hide their income because of security/tax
issue etc. So, proceed to explore information pertaining to this section only after developing a
good rapport with HOF/other responsible adult member in the family. One trick may be adopted
that ask the expenditure first along with saving(s), if any. Then, ask for the total monthly income.
Remember per capita monthly income (calculated dividing the total monthly income of the
family by total family member including the infant, if any) is a better measure than the total
income. However, at present total monthly income of the family from all sources is considered
77
for determining the SES of the family by using Modified updated Kuppuswamy’s scale.
Modified updated B G Prasad’s scale can also be used which consider only one criteria i.e. per
capita monthly income of the family. However, former is better than the later as it includes other
two variables (apart from total monthly income of family) i.e. education & occupation of the
HOF which themselves are indicators of social status of a person/family.

Box - 8: Modified BG Prasad social classification (2019)

Box -9: Table 1: Modified Kuppuswamy scale (update for February 2019)

78
 Box - 10: Udai Pareek’s socio-economic class for rural areas.

Ref: Pareek U, Trivedi G. Manual of socio-economic status scale (rural). New Delhi: Manasayan Publishers; 1995

79
 Section 3.3: Guidelines for environmental survey

All of you know the role of environment in health and disease by studying the communicable
disease model i.e. epidemiological triad of Agent-Host-Environment and non-communicable
disease model i.e. epidemiological triangle. We are always to interact with our environment i.e.
whatever are there around us. Most of the diseases are caused by the imbalance between the
environment and the host. The third component of the triad i.e. the agent is dependent on
environment. That is to say that environment either external or internal, macro or micro helps the
interaction between host and agent either by increasing the growth of the organism in
reservoir/vector or by enhancing the transmission of agents by increasing vector population or by
enhancing the interaction between the host and agent or by disturbing the host’s resistance. So,
environment is the prime determinant of physical, mental and social wellbeing. Much of the
health problems of India are due to poor sanitation, unsafe drinking water supply, polluted
soil/air, substandard housing, indiscriminate solid-waste disposal, increase insects & rodents.
Improvement in environment is therefore a priority for improving health and wellbeing of the
people by decreasing morbidity and mortality. Environmental sanitation can be defined as ‘the
control of all those factors in man’s physical environment which exercise or may exercise
deleterious effects on his physical development, health and survival.’ [WHO] So, assessment of
environment in which the family is residing is very crucial for the purpose of provision of family
health care. After detecting the unfavorable factors/ aspects present in the environment the
health team can suggest remedial measure(s) to the family to make favorable change(s).

Environment has major three components as follows:

o Physical- Air, water, soil, house, waste (both solid & liquid), human excreta etc.
o Biological-microbial agents like bacteria/virus/protozoa; medically important insects
o Psychosocial- relation between men via different social & political organizations,
culture, customs, habits, belief, attitudes, religion, castes, education, and health
services etc.
Collection of information:
o Respondent: HOF or any responsible adult member in his/ her absence
o Tool: Questionnaire/checklist, measuring tape, torch, magnifying glass etc.
o Technique: Interview, environmental survey etc,
80
Analyze the data to make inference about the status of environment in which the family is living.

Actions taken or recommendations are made for betterment, if required.

Health hazards of environmental pollutions:

 Soil borne infection: hook worm, tetanus, fungal infections,

 Waterborne diseases:
 Bacterial-typhoid/cholera/dysentery/cholera/paratyphoid
 Viral-Poliomyelitis, viral hepatitis A & E, rotavirus diarrhea in infant
 Protozoa: amoebiasis, giardiasis
 Helminthes: round worm, thread worm, hydatid disease
 Others: Schistomiasis, guineaworm, fish tape worm, fluorosis /Arsenicosis etc.
 Fly borne diseases:
 Bacterial: typhoid/paratyphoid, dysentery, cholera, anthrax,Yaws etc.
 Viral: Poliomyelitis, viral diarrhea etc.
 Protozoa: Amoebiasis, giardiasis,
 Chlamydia: Trachoma
 Helminthes: round worm
 Diseases spread by cockroach: Typhoid/paratyphoid, viral hepatitis A & E, cholera,
dysentery,
 Diseases spread by rodent: Plague/Leptospirosis
 Impacts of air pollution:
 Health: Chronic bronchitis, asthma, emphysema, lung cancer, respiratory allergy
 Economic: Loss of fertility of soil and damage to the plants due to acid rain
 Social: Damage to the architects (e.g. Taj Mahal) caused by acid rain.
 Health hazards of sound pollution: Noise induced hearing loss (NIHL), insomnia/loss
of concentration/giddiness etc.

81
Definition:

House: ‘Housing’, in the modern concept includes not only the ‘physical structure’ providing
shelter but also the immediate surroundings and the related community services and facilities.

Pucca house- walls and floor as well as roof are concrete or Walls and floor are concrete with
tinned/asbestos roof

Kuccha house: Walls and floor are made up of mud and the roof is thatched/tiles

Mixed house: Any other combination apart from the above two e.g. walls & floor concrete but
the roof is thatched or tiles

Living room: the room(s) used for resting & sleeping purpose

Per capita floor space: determined by measuring the floor space and dividing it by the total
number of persons use this space for resting & sleeping purpose. The child 1-9 years of age is
considered half unit and infant isn’t considered for this purpose. [See the box given below]

Moral overcrowding: When two individuals above the age of 9 years and not related as husband
& wife are forced to sleep within one room is called moral overcrowding.

Box-11: Criteria and standard of overcrowding

Criteria Standard
1 room 2 persons
No. of person per room 2 rooms 3 persons
3 rooms 5 persons
4 rooms 7 persons
5 rooms 10 person [add 2 for each further room]
Per capita floor space [calculate separately for each room] Minimum 50 ft2/capita

Sex separation 2 persons >9 years age of opposite sex not

husband & wife obliged to sleep in 1 room

Effects of overcrowding:

 Physical health problems: increased incidence of respiratory tract infection like TB,
Mumps, Measles, Diphtheria, Pertussis, Pneumonia etc. via droplet infection & droplet

82
 nuclei. Person to person transmission of GIT diseases like Cholera, viral hepatitis A &,
typhoid/paratyphoid, worm infestations; skin diseases like pediculosis, scabies, ring
worm, leprosy etc. is enhanced. Chance of domestic accident is increased.
 Psychological problems: People living in overcrowded house usually suffer from
insomnia, low self-esteem, depression etc.
 Loss of productivity: Overcrowding hinders productivity due lack of space or silence
(e.g. in case of reading).
Lighting: Open the doors and windows of the room, put off all the natural lights and proceed to
the center of the room. Try to read the normal text (not the headings) from a usual distance i.e.
30-35 cm from the eye. If it is possible then the natural lighting is considered adequate.

Effects of inadequate lighting:

o Physical health problems-

 Antimicrobial activity of infrared or ultraviolet rays of Sunlight is absent so the
inhabitants are exposed to extra risk of infectious disease
 Dim lighted/dark rooms may be the habitat/resting place of mosquito/
cockroach/rodent/vermin/snake etc. which carry many health hazards including
vector borne infectious diseases
 Works like reading requires optimum light otherwise the persons may suffer from
headache, fatigue etc.
 Domestic accidents is high in dark places
o Loss of productivity: Due to inadequate light production rate in some works may be less
like reading etc.

Assessment of ventilation:

o Adequacy: Every individual requires optimum 500 ft 3 of air space for his/her physical
comfort as well as safety in relation to the chemical component of air. But air
entry/ventilation must be ensured to supply 02 to the occupants continuously. For
adequate ventilation provision of windows and doors must be there and minimum 20% of
the floor space of the room is to be constituted by windows and doors each i.e. gap

83
 amounting to minimum 40% of the floor space will be there in the walls of the room to
secure optimum air entry. Take measurement of doors and windows separately and check
whether they fulfill the criteria.
Box-12: Criteria and standard for ventilation in living room
Criteria Standard (% of floor area)
Door space 20
Window area 20
Total space 40
o Cross-ventilation: However, good ventilation can’t be ensured merely by providing
minimum 50 ft2 per capita floor space and 40% gap (for air entry & exit) in the walls of
the rooms. Adequate ventilation mayn’t be possible if the air change in the room is
inadequate. Air change is more important than cubic space. It is recommended that in the
living rooms there should be 2 or 3 air change per hour compared to 4 to 6 in work place/
assemblies. Air change becomes evident when the doors and windows of the rooms are
face each other and they are kept opened up with windows opened up in open space.
o Set-back of the house: In spite of above criteria the natural ventilation of a house may be
hampered if the air entry and exit of the house get any obstruction. Setback i.e. free space
around the house and its adjacent houses is a provision to make the flow of air/light free.
Health hazards of inadequate ventilation:

 Health hazard arising out of respiratory tract diseases is increased due to enhanced
transmission of these diseases via direct (droplet infection) and indirect (droplet nuclei)
mode of transmission.
Separate kitchen: Provision for a separate kitchen is a must for healthful housing. It is an
integral part of the housing. It reduces the risk of accidents, chance of IAP with its health
hazards, ensures safe storage of raw as well as cooked food/fuel/water etc. If biomass fuel is used
there must be arrangement of smokeless chulah to avoid hazards of excess smoke exposure.

Types of fuel: Biomass fuel, though cheap but produces more smoke and definitely is a health
hazards to those who are exposed to it. Moreover, its efficiency is less. So, time and amount of
fuel required is more. On the other hand the fossil fuels like kerosene, LPG etc. are more
efficient, produce less smoke and thereby less harmful. But the cost is prohibitive to the poorer
section. Use of electric heater/induction heater is more complex and costly and beyond the

84
capacity of people belongs to low SES. Obviously, it apparently seems to be less air pollutant as
it doesn’t make smoke but its use produces much more air pollution for it is produced from
combustion of coal.

Indoor air pollution (IAP): When the air inside the room is vitiated by various major and minor
air pollutants like smoke from cooking oven, act of smoking, burning of mosquito coils/incense
sticks, mosquito/insect vaporizers/aerosols etc. the condition is called IAP. It increases the
vulnerability to ARI in extreme of age (infant/elderly people) and LBW among the pregnant
women. The most common source is smoking inside the living room but the heaviest form of
IAP is smoke from cooking oven, specially where biomass fuel is used and the kitchen is either
absent or improperly constructed adjacent to living room and without any smoke outlet.

Smokeless Chulah: To avoid the health hazards arising out of IAP caused by cooking oven
smoke, GOI launched the National Programme on Improved Chulha (NPIC) in 1984-5. To start
with, the main objective of the programme was to reduce the demand for fuel-wood. This was
expected to ease the pressure on the forests and check deforestation, on the one hand, and
translate into economic benefits for the fuel-wood user (in terms of saving of time and money),
on the other hand.

 Benefits of smokeless chulah (vide Fig.9):

o Health benefits: No IAP and less ARI to children and women; less smoke causes
less incidence of COPD/lung cancer among the individuals engaged in cooking
o Other benefits: less time spent for cooking, less requirement of fuel wood, less
expenditure on health caused by exposure to cooking smoke, healthier women &
children, less emission of co 2 and thereby less environment pollution.
Intermittent water supply:

 Advantage: Water wastage doesn’t occur

 Disadvantage: Water may be unavailable at the time of its need and users may use
contaminated water, during empty stage microbial pollutants may be sucked in due to
negative pressure inside the pipe

85
Continuous water supply:

 Advantage: Water is available round the clock, due to constant positive pressure inside
the pipe there is no chance of entry of any microbial agent to contaminate the water
column within the pipe
 Disadvantage: wastage of water is a problem as well as water lodging and mosquito
breeding in the collection of waste water.
Inadequate water supply: From a water stand post 40 LPCD is the norm, whereas in a house-
hold connection in towns without sewerage system it is 70 LPCD and in towns with sewerage
system it is 135 LCPD. In metropolitan and megacity like Kolkata the norm is 150 LPCD.
Inadequate supply may force the users to consume/use unsafe water making them vulnerable to
water borne diseases.

Distance of water source: It should be as close as possible to the habitat but shouldn’t be in any
means more than 100 meters away from habitat in plains or 100 meters elevation in hills.

Number of user per water source: A hand pump or water stand post caters 250 people maximum.

Sanitary latrine: Human excreta (also called night soil in many parts of the world) contain lots
of infective agents and are a threat to human by causing:

 Soil pollution
 Water pollution
 Contamination of food
 Increasing fly population

The causative organism of diseases like typhoid, cholera, dysentery, hookworm, ascariasis,
poliomyelitis, hepatitis A & E etc. contained in faeces are transmitted to susceptible human host
via soil and 5 F’s like (Fig.10):

 Finger
 Flies
 Fluid (water, milk etc.)
 Food
 Fomite (small article like spoon)
86
Every society should be responsible to dispose the excreta of its members safely so that it can’t
endanger the safety of its members. Proper disposal of human excreta is an elementary
environmental health service without which the community health can’t be improved.

Prevention of disease by stopping its transmission breaking the vulnerable points of disease cycle
is the aim of Community Medicine. Excreta caused disease cycle can be broken at various points
like:

 Protection of water supplies

 Protection of foods
 Improving personal hygiene
 Controlling flies
 Segregating the faeces

Of these the last one has been established to be the most cost-effective method i.e. safe and
scientific disposal of human excreta by preventing its contact with flies, food, water and others
articles as well as man. This segregation is done by placing a barrier between the faeces and
other components including man. This barrier is called ‘sanitation barrier’ which can be imposed
by installing a ‘sanitary latrine’, specially in areas where sewerage system and sewage
treatment plan is absent.

Latrine: A toilet is a sanitation fixture used for the storing or disposal of human urine and feces.
The word latrine can refer to a toilet or a simpler facility which is used as a toilet within
a sanitation system.

Sanitary latrine: A latrine is called ‘sanitary latrine’ when it fulfills the following criteria:

 Night soil isn’t accessible to flies, rodents, other animals like dogs, goats, cows, pigs etc.
or any other vehicles of transmission
 Excreta shouldn’t create any nuisance due to its odd appearance or bad odour
 Excreta shouldn’t contaminate the ground or surface water
 Excreta doesn’t pollute the soil

87
Open field defecation: It is a health hazards because indiscriminate defecation produces soil
pollution/water pollution/air pollution/propagation of flies and transmission of fly borne diseases
etc.

Community Latrine: Community toilet and public toilet aren’t the same. Poor people can’t
afford for installation of sanitary latrine. Government and various nongovernmental agencies
help this section of people by installing one latrine for a group of people. As per the Guidelines
for Community Toilets, 1995; Ministry of Urban Affairs & Employment, GOI, latrine is
constructed @ one per 50 users i.e. approximately 10 families. This type of latrine i.e. one for
many users is called community latrine or common latrine popularly known as ‘Sulabh
Souchalaya’ when it is constructed and maintained by ‘Sulabh International’, an NGO (Founded
by Dr. Bindheswari Pathak, Sociologist, social activist, and Founder of Sulabh Sanitation and
Social Reform Movement) working in this filed. Its disadvantage is that sometimes it isn’t
maintained and at times when there is long queue people may be compelled to do open field
defecation in urgency. So, a good joint community action is needed to maintain the common
latrine.

Box-13: Norms for community and public toilet

88
 3.4. Tips for diet survey

Health and nutrition are twin brothers. Assessment of one remains incomplete without the
assessment of other. It is like laboratory investigation done in clinical medicine to corroborate
the clinical features and helps in establishing the diagnosis. For example, dietary assessment
reaffirms the clinical signs arising out of deficiency of various nutrients e.g. angular stomatitis
due to deficiency of Riboflavin.

Assessment of dietary intake can be done in various ways like-

o Inventory method -
o Weighment of raw foods-
o Weighment of cooked food-
o Oral questionnaire method-
The last one is simple and can easily be carried out for a large number of people within a short
period of time. Duration of survey may vary from 1 to 21 day(s). It is done based on 24 or 48
hours recall of the persons involved in cooking and distributing foods. If it is taken carefully
based on 24 hours recall it is reliable. But taking one days’ consumption may be erroneous as our
food habit is guided by food taboos arising out of cultural belief that consumption of different
foods is prohibitive on various days in relation to lunar month. This is why the dietary
consumption throughout 21 days, or 14 days or at least for one week (i.e. one ‘dietary cycle’) is
recommended. But due to time constraint you can consider the average consumption of three
days (2 week days & Sunday). Dietary analysis based on one day’s consumption mayn’t be
reliable or even may be misleading. However, for learning purpose as well as constraint of time
one day’s consumption is considered in the present field exercise.

Choose a day when there won’t be festive or starvation of one or more member (s) or a day for
consumption of vegetarian diet for a non-vegetarian family for ritual or there won’t be any
invitation. Ensure that outside food intake is avoided.

Respondent: House-wife or individual who is engaged in cooking and distribution of food

Tool: Questionnaire, spot I2 testing kit (vide Fig.11)

89
Technique: Interview, physical verification (for back calculation), salt testing for I 2 level.

Analyze of data & draw inference.

Salt testing: Common salt in India is fortified with I 2 to prevent IDDs. I2 concentration of 30
ppm and 15 ppm at production and consumer levels, respectively, has been recommended for the
purpose. It is the duty of public health worker to monitor the I 2 consumption by the people. It can
be done easily at field level by estimating the I 2 concentration in salt using spot iodine testing kit
which contains check/test solution (starch solution), recheck solution(dilute acid)and colour
scale.

 Steps to be followed: Take one teaspoonful common salt in a piece of plain white paper.
Make the upper part of the heap of the salt evenly spread using your finger(s). Then, add
one drop of test solution to the salt and match the colour developing as a result of
reaction between starch and I2. If colour doesn’t develop within 30 seconds then add one
drop of recheck solution to the salt and wait for another 30 seconds. If colour still doesn’t
develop add one drop of test solution once more. Wait for 30 seconds. Match the
developed colour with the colour scale. If colour doesn’t still develop then the salt
doesn’t really contain I2.
 Explanation: Sometimes the I2 in the salt forms complexes with the impurities present in
the salt and isn’t available for reacting with starch. Adding of weak acid makes the I 2
released and available for making complex with starch.

90
Table-14a: Recommended dietary allowance (RDA values for Indian

91
Table-14b: Recommended food values for balanced diets

92
 Table-14c: Nutritive value of common foods per 100 gms (Source: Nutritive value of Indian Foods, ICMR)

Food staff Energy Protein Fat Iron Carotene Vitamin Thiamin Riboflavin Folic Acid
(Kcal) (g) (g) (mg) (μg) C (mg) (mg) (mg) (μg)
Cereals
1. Parboiled milled 346 6.4 0.4 1.0 ------ 0 0.21 0.05 11.0
rice 341 12.1 1.7 4.0 29 0 0.49 0.17 35.8
2.Wheat floor (whole) 325 7.5 0.1 6.6 0 0 0.21 .01 -
3. Puffed rice
Pulses
1.Green gram 348 24.5 1.2 3.90 49 0 0.47 0.21 0
2.Lentil 343 25.1 0.6 7.60 270 0 0.45 0.20 36
3. Soyabean 432 43.2 19.5 10.4 426 0 0.73 0.39 100.0
Green leafy
vegetables 26 2.0 0.7 1.14 5580 28 0.03 0.26 123.0
1. Spinach 45 4.0 0.5 3.49 5520 99 0.03 0.30 149.0
2.Amarant 27 1.8 0.1 0.80 120 124 0.06 0.09 0
3.Cabbage
Non-leafy vegetables
1.Bottle gourd 12 0.2 0.1 0.46 0 0 0.03 0.01 0
2.Brinjal 24 1.4 0.3 0.38 74 12 0.04 0.11 34.0
3.Cauliflower 30 2.6 0.4 1.23 30 56 0.04 0.01 0
4.Ladies finger 35 1.9 0.2 0.35 52 13 0.07 0.10 105.1
5.Green pappya 27 0.7 0.2 0.90 0 12 0.01 0.01 0
6.Parwar 20 2.0 0.3 1.70 153 29 0.05 0.06 0
7.Pumpkin 25 1.4 0.1 0.44 50 02 0.06 0.04 13.0
8.Plantain,green 64 1.4 0.2 6.27 30 24 0.05 0.02 16.4
Roots & Tubers
1. Potato 97 1.6 0.1 0.48 24 17 0.10 0.01 17.0
2.Onoin 50 1.2 0.1 0.60 0 11 0.08 0.01 6.0
3.Carrot 48 0.9 0.2 1.03 1890 03 0.04 0.02 15
4. Radis, pink 32 0.6 0.3 0.37 03 17 0.06 0.02 0
Fruits
1. Amla 58 0.5 0.1 1.2 9 600 0.03 0.01 0
2.Apple 59 0.2 0.66 1.00 0 1 0 0 0
3.Ripe Banana 116 1.2 0.36 0.9 78 7 0.05 0.08 0
4.Grape 71 0.5 0.3 0.5 0 1 0 0 0
5.Lemon 57 1.0 0.9 0.26 0 39 0.02 0.01 0
6.Guava 51 0.9 0.3 0.27 0 212 0.03 0.03 0
7.Ripe mango 74 0.6 0.4 1.3 2743 16 0.08 0.09 0
8.Orange 48 0.7 0.2 0.32 1104 30 0 0 0
9.Ripe papaya 32 0.6 0.1 0.5 666 57 0.04 0.25 0
10. Ripe tomato 20 0.9 0.2 0.64 351 27 0.12 0.06 30
Animal foods
1.Egg, hen 173 13.3 13.3 2.10 420* 0 0.1 0.4 0
2.Rohu fish 92 16.6 1.4 1.0 0 22 0.05 0.07 0
3. Chicken 109 25.9 0.6 - - - - 0.14 4.5
4.Mutton/Flesh 194 18.5 13.3 2.5 9 - 0.18 0.14 0
Milk & milk product
1. Milk, cow 67 3.2 4.1 0.2 53* 2 0.05 0.19 8.5
2. Curd 60 3.1 4.0 0.2 31 1 0.05 0.16 -
Nuts & Oilseeds
1.Groundnut 567 25.3 40.1 2.50 37 0 0.9 0.13 20
Others
1.Cooking oil 900 0 100 0 0 0 0 0 0
2.Sugar 398 0.1 0 0.16 0 0 0 0 0
3.Jaggery 383 0.4 0.1 2.64 - - - - -
4.Chillies, green 29 2.9 0.6 4.4 175 111 0.19 0.39 29
5.Ginger 67 2.3 0.9 3.5 40 6 0.06 0.03 -

93
 3.5. Guidelines for individual health check up

Respondent(s): The concerned person in case of adult and elder children but for infant &
younger children/differently able children the mother or care giver is considered as the
respondent.

Tool: Questionnaire, equipments for clinical examination and anthropometry, WHO growth
charts for <5.

Technique(s): Interview, clinical examination including anthropometry, record (e.g. medical

record, MCPC) review etc.

Anthropometry:

o Measuring length- Specification is centimeter (cm). Measure length (cm) for child up to 2
years of age as they can’t stand and cooperate so as to allow perfect measurement of
height. Use infantometer for measuring length. Two persons are required for this purpose.
First, unfold the infantometer and remove the shoes and cap of the baby. Then, after
laying the baby on the infantometer in supine position (so that the baby looks towards the
roof) one person will fix the head of the baby to the head piece of infantometer. The 2 nd
person holds the legs of the baby straight by one hand. Using the second hand s/he moves
the foot-piece of the infantometer accordingly to make it fixed on the dorsiflexed feet and
note the reading (vide Fig.12).
o For measuring height of an individual more than two years of age the stadiometer is used.
The person is asked to stand on the foot plate of stadiometer after making his/her shoes
off with the legs in close apposition. S/he has to stand erect so as to touch his/her heels,
buttocks, shoulder and occiput on the vertical stand of the stadiometer (vide Fig.13). The
person is now helped to look forward in such a way that his/her lower border of the orbit
and the upper border of the external auditory meatus will be in one horizontal plane i.e.
Frankfurt (Frankfort) plane (vide Fig.14). Now, the head piece of the stadiometer is
moved downwards to fix it on the scalp of the person snugly. It’s the time now to take the
reading (cm).
o Where the stadiometer isn’t available the height of the adult and elderly children can be
measured by making an innovative scale on the plain wall of a room using nonstretchable
94
 measuring tape and markings made by H B pencil on the wall. A card board may be used
as head piece.
o Measuring weight (kg): Specification is nearest to 100 gm. For adult and elder children
aged 5 years or more the Bathroom scale/weighing machine (digital one is better than that
with indicator) can be used. For <5 children Salter weighing scale or baby weighing pan
can be used.
o Procedure: Make the weighing machine (Fig.15) adjusted to Zero. Asked the person to be
with minimum clothing and put off his/her shoes. Now, ask him/her to stand on the
middle portion of the weighing machine putting legs in designated place. Let the
indicator to be steady (or take the reading directly if it is a digital weighing machine).
Then, take the reading standing in such position to keep your eyes perpendicular to the
indicator of the weighing machine in any of its position e.g. at 12’o clock,10’o clock, 6’o
clock, 3’o clock, 9’o clock etc.. Note down the reading. Allow the person to get down
from the weighing machine. Then, look at the indicator once again. If it is in zero
position (zero reading in case of digital machine) then the weight can be considered
reliable and if it isn’t so discard it and the machine isn’t usable. Arrange for another
weighing machine.
For <5 children the Salter weighing scale is used. Bar Scale may be used in absence of Salter’s
scale.

The following few pictures/diagrams are copied from the ‘Growth monitoring module’ prepared
by ‘National Institute of Public Cooperation and Child Development’, New Delhi. (Fig.16-20).
Use the same growth chart (e.g. WFA chart) for more than one child of same gender, if any.
Mark the plot for each child e.g. child 1, child 2 etc.

Spring balance can also be used for the purpose of growth monitoring of <5 children (Fig.21).

In case of unavailability of any weighing scales for infant, you have to use the adult weighing
scale where you measure the weight of the mother with her baby in her lap in 1 st attempt and 2nd
time without her baby. Now, you get the baby’s weight by subtracting the 2 nd value from the 1st
one.

95
Body Mass Index (BMI) for Adults:

Body circumference of <5 children:

o MUAC: It is measured by using nonstrechable malleable tape, specially for children 1-4
years of age. Nondominant hand is to be chosen for this purpose. The measurement is to
be taken in the mid point of the line joining the tip of the acromian process of the scapula
and tip of the olecranon process of the ulna bone in relaxed arm hanging by the side of
the body. The measurement shouldn’t be taken over the shirt/ clothes.
Box-13: Cut-off values of MUAC for determining nutritional status
Value of MUAC(cm) Nutritional status
>13.5 Normal
12.5 to 13.5 Mild-moderate malnutrition
<12.5 Severe malnutrition
For this purpose, Shakir’s tricolored (red, yellow & green) tape can be used (Fig.22). If
the measurement falls in the red colored area of the tape it indicates severe malnutrition;
if it is in yellow or green zone it reflects mild-moderate malnutrition or normal nutritional
status, respectively.

o Head circumference (HC): An accurate HC measure is obtained with a flexible non-

stretchable measuring tape. A plastic tape such that one end inserts into the other is
recommended. HC is generally measured on infants and children until the age of 03
years. HC or occipital frontal circumference [OFC] is measured over the most prominent

96
 part on the back of the head (occiput) and just above the eyebrows (supra-orbital
ridges=glabellas). (Fig.23) This can be translated to mean the largest circumference of the
head. The measurement is read to the nearest 0.2 cm or 1/4 inch and recorded on the
chart.
o Chest circumference (CC): CC in centimeter (cm) is measured by placing the flexible
measuring tape (stretch‐resistant) around the chest just above the nipples midway
between natural inspiration and expiration. Place the measuring tape under the child and
bring it around the baby’s back to the chest to meet the zero mark (Fig.24). The mother is
to be asked to make the baby quiet and your fellow-mates help you to take the
appropriate measurement.

Body circumferences in adult:

o Waist circumference (WC): WC is a better indicator of body fat deposition. It is

especially helpful to measure body fat deposition in Asian Indians who are more prone to
central/truncal/abdominal obesity. The participant is asked to stand with his/her feet
together and body weight evenly distributed across both feet with both arms hanging
relaxed by the sides of the body. Measurement is to be taken without or with minimum
clothing. The WC is measured midway between natural inspiration and expiration, at a
level parallel to the floor, midpoint between the top of the iliac crest and the lower
margin of the last palpable rib in the mid-maxillary line.
o Hip circumference (HC): Measure the HC at a level parallel to the floor, at the largest
circumference of the buttocks i.e. at the level of greater trochanters of femur.
Measurement is taken over thin inner wear only. The participant is asked to stand with
his/her feet together and body weight evenly distributed across both feet and both arms
hanging relaxed by the sides of the body.
o Take the ratio of the above two i.e. waist to hip ratio (WHR) which is considered another
good indicator of extra body fat deposition.
Make both measurements with a stretch‐resistant tape that is wrapped snugly around the subject
but not to the point that the tape is constricting. Keep the tape level and parallel to the floor at the
point of measurement. Specification is up to 0.1cm. Each measurement can be repeated twice

97
and the average may be considered to avoid intraobserver/intra-instrumental error, if any.
Privacy and presence of an attendant is to be ensured, specially during measurement on female
subject.

Pubertal development for boys:

Changes Expected Achieved/

age Unachieved
 The testicles and skin around the testicles (scrotum) begin to 11 years
get bigger.
 Also, early stages of pubic hair forms on the base of
the penis.
 Penis gets longer as testicles continue to grow bigger. 13 years
 Breast nodule
 Voice change starts
 Wet dreams (Ejaculation at night)
 Armpit hair 14 years
 Deeper voice permanent
 Penis, testicles, and scrotum will have reached adult size. 15 years
 Pubic hair has filled in and spread to the inner thighs.
 Facial hair will start coming in and some boys will need

to begin shaving.
Pubertal changes for girls:

Changes Expected Achieved/

age Unachieved
 Breast budding 9 to 11
 The darker area around the nipple (areola) will also expand.
 small amounts of pubic hair start growing on the lips of years
the vagina.
 Breast “buds” continue to grow and expand. 12 years
 Pubic hair gets thicker and curlier.
 Hair starts forming under the armpits.
 The highest growth rate for height begins
 Hips and thighs start to build up fat.
 Breasts take on a fuller shape, passing the bud stage. 13 years
 Many girls get their first period [typically between ages of 12
and 14, but it can happen earlier]

98
For Psychological assessment

Depressed Anxiety
Insomnia, hypersomnia Hypervigilance, Increased Startle,Avoidance
Diminished Interest, Worthlessness/Guilt Negative Cognitions, Excessive Worry,
Loss of energy, Diminished concentration Panic Attacks, Obsessions, Compulsions
Significant weight loss, Reduced appetite
Irritability

3.6. Medico-social diagnosis

Make a precise, comprehensive family diagnosis what is more popularly called “Medico-
social diagnosis” (MSD) incorporating the following points chronologically in a meaningful
way:

 Precise identification of the family like type of family, composition, mother tongue,
caste, religion, address etc.
 Salient social problem (s) the family has like poverty, illiteracy, poor housing, less
awareness regarding health & diseases, addiction, child labour, school dropout,
dietary deficieny etc.
 Mention the medical problem (s) existing in the family at the time of your visit.

3.7. Action taken

Help the individual(s) or the family to make necessary change or adopt favorable
measures/behavior conducive to the health and hygiene of the member(s) or the family itself. It
entails the action taken mainly by the team. Advice regarding those aspects which seem feasible
and help to practice or adopt them e.g. if the child doesn’t attend to the ICDS already-accompany
the mother & <5 child to the AWC & introduce with the AWW, prescribing medicines for
current acute illness by the help of your guide teacher with supply of emergency medicine,
accompanying the addicted or ill person to the psychiatry department or other related
OPDs/departments for his/her treatment/follow up/investigation, Health talks related to issues

99
like dietary modification/personal hygiene/food/environmental/genital hygiene; demonstration
related to infant feeding/KMC, ORS preparation, hand washing, hand dipping during drawing
water from bucket etc.

3.7. Recommendations

Mind it that the ‘action taken’ and ‘recommendation’ are very overlapping areas. Someone may
face difficulty to decide about which one is ‘action taken’& which one is ‘recommendation’. But
the idea is to help the individual(s) or the family to adopt favorable measures/behavior/life style
congenial to the health of the member(s) or the family as a whole. It may be certain action not
taken by the team directly but has advised, motivated and pursued the member/family to adopt it.
So, restrict your advice to those aspects only which seem to be feasible and help to practice or
adopt it. For example, recommendation for sleeping of mother & younger child inside the living
room and father with his elder child in the verandah to avoid overcrowding, making a new
window in the living room, using long handle mug to draw water from bucket, use a temporary
bin within the house to collect solid waste to be disposed finally in the municipal dustbin or
prepare and use a manure pit for this purpose rather than to throw indiscriminately.

100
 Section-4: Images/Figures

Fig.19: Model of smokeless chulah

Fig.20. Sanitation barrier

Fig.21: Spot salt iodine testing kit

101
 Fig.22: Measuring length in Infantometer

Fig.23. Measuring height of elder children in stadiometer.

Fig.24. Frankfurt/Frankfort horizontal plane Fig.25: Adult weighing machine

102
Fig.26. Salter’s weighing scale with different components

103
Fig.27: Salter’s weighing scale with different parts after hanging

Fig.28: Salter’s weighing scale is being adjusted

104
 Fig.29. Baby is being place inside the sling

Fig.30. Reading is taken from Salter’s scale with the help of mother/care giver

105
Fig.31. Images of spring balance Fig.32. MUAC measurement using Shakir’s tape

Fig.33.Measuring HC Fig.34. Measuring C C

Fig.35: Bitot’s spot

106
Fig 36: Steps of Hand washing

107
References:

1. K Park. Textbook of preventive and social Medicine. 23 rd Edn., Banarshidas Bhanot,

Jabalpur, 2015.
2. Taneja D K. Health Policies and programmes in India, 12th Edn., Doctors Publication,
Delhi,2014.
3. Biswas AB, Mitra J. Family Health Care: A Practical Guide Book.4 th Edn, Kolkata, 2007.
4. Gopalan C et.al. Nutritive value of Indian Foods. National Institute of Nutrition,
Hyderabad, 1989.
5. The Guidelines for Community Toilets, 1995; Ministry of Urban Affairs & Employment,
Government of India
6. Hanbar RD, Karve P. National Programme on Improved Chulha (NPIC) of the
Government of India: an overview. Energy for Sustainable Development 2002; 6(2):49-
55.
7. Internet references.

108