Purpose of family health study in undergraduate M.B; B.S curriculum
-In a real-life situation, the students get an opportunity to see the relationship between environment and health and the health hazards arising out of environmental conditions.
-They get to learn the assessment of housing and environmental conditions at the community level. They also get an opportunity to apply the community health concepts such as safe water, waste management, vector control, and housing standards.
-The second important rationale is to sensitize the student regarding the social practices of the community and prescribe the management which is best suited in that scenario.
Many institutes provide a format (family folder) to the students for recording the data of family allotted to them. One such format has been suggested in the blog and lecture ‘Format for Clinico-social Case Taking’.
‘Format for CSC’ Blog: http://www.ihatepsm.com/blog/format-clinico-social-case-taking-community...
‘Format for CSC’ Lecture: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
‘Format for CSC’ Lecture in HINDI: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
THE TERMS USED IN VARIOUS SECTIONS OF THE FORMAT HAVE BEEN EXPLAINED HERE:
DRAW A MAP
First draw a map of the locality, showing the location of the house. Include the access roads.
Next, draw a map of the house should be drawn. Measure the dimensions and try to draw to scale
The measurements will be useful for the assessment of:
• Overcrowding and
• Ventilation of the household
• Family and the Types of Family:
Family: It is a group of biologically related individuals living together and eating from a common kitchen.
Nuclear (elementary) family: It consists of a married couple and their dependent children. A “new family” is a nuclear family within first 10 years of formation (marriage).
Joint (extended) family: It consists of a number of married couples and their children living in the same household. All the men in the household are related by blood and the women are their wives, unmarried daughters or widows.
Three generation family: It occurs when the married children of a couple continue to stay with their parents and have their own children. Hence, three generations related by direct descent live together.
Household: A “household” is usually a group of persons who normally live together and take their meals from a common kitchen unless the exigencies of work prevent any of them from doing so. Persons in a household may be related or unrelated or a mix of both.
Vital events during last 1 year (Vital events include live birth, fetal death, adoption, marriage, divorce judicial separation, death, etc.)
How to decide who among the family members is the ‘Head’?
Explanation: Criteria for deciding the HOF among the members of the household:
1. The head of the household for census purposes is a person who is reported as the head by the household members. OR
2. She or he is generally the person who bears the chief responsibility for managing the affairs of the household and takes decision on behalf of the household. The head of the household need not necessarily be the oldest male member or an earning member
Sociodemographic Details of the Family
Dependency ratio = (Number of children below 15 years + number of geriatric members >65 years) divided by the number of family members between 15–64 years of age
Further details on ‘Dependency Ratio’: http://www.ihatepsm.com/blog/dependency-ratio
Per capita income per month (of the family/ household):
The income from all the sources should be added up. This is divided by the total number of members of the family, regardless of the age of the individual. For example, even a baby born on the same day is to be counted.
Socioeconomic status (SES) of the family: ____________ class (Kuppuswamy/Pareek's scale and BG Prasad scale)
DETERMINING THE SOCIOECONOMIC STATUS OF THE FAMILY
FOR AN URBAN FAMILY
Modified Kuppuswamy scale is the most commonly used scale for determining the socioeconomic status (SES) of an urban family.
The scale is discussed in detail here: http://www.ihatepsm.com/blog/modified-kuppuswamy-scale
Using Modified Kuppuswamy Scale for determining the SES of the household: http://www.ihatepsm.com/blog/modified-kuppuswamy-scale
DETERMINATION OF SES OF A FAMILY IN A RURAL AREA
“Pareek’s scale” was developed by Pareek for calculating the SES of a family in a rural area. It consists of nine items—caste, occupation of the HOF, education of the HOF, level of social participation of the HOF, landholding, housing, farm power (animals), material possession, and type of family.
Udai Pareek’s Scale: http://www.ihatepsm.com/blog/determination-ses-family-rural-area-uday-pa...
BG Prasad Scale is valid for assessing the socio-economic status of a household in both, urban and rural areas
BG Prasad Scale: http://www.ihatepsm.com/blog/prasad%E2%80%99s-scale
Literate: A “literate” is a person above the age of 7 years who can read and write with understanding in any language.
Poverty line: It is defined as the expenditure required for a daily calorie intake of 2400 per person in rural areas and 2100 in urban areas. The actual cut off in terms of money depends upon the current price index.
Assessing the Presence of Overcrowding
• Three criteria have been used usually of judging the presence of ‘overcrowding’
1. Persons per room criterion
2. Floor space criterion
3. Sex – separation criterion
Presence of any one or more of them leads to a diagnosis of ‘overcrowding’ being present in the household
Reported as: ‘overcrowding is present by the criteria being satisfied (if more than one, mention all those which are satisfied)
Details of the criteria for judging ‘overcrowding’ in the household: http://www.ihatepsm.com/blog/assessment-overcrowding-household
How to judge adequacy of ventilation:
• Every living room should be provided with at least two windows with at least one of these opening directly on to an open space. If this is not the case, advise the family to use an exhaust fan.
• Measure the height and breadth of the windows and the doors.
• Calculate the area of each one by the formula: area = length × breadth.
• Total window area should be 1/5th of the floor area.
• The total area of the doors and the windows taken together should be 2/5th of the floor area.
How to judge adequacy of lighting (natural or artificial)
There are no published guidelines on the adequacy of lighting and how to check for light adequacy without instruments. However, the Illuminating Engineer Society (IES) has recommended that for casual reading an illumination level of 100 lux is sufficient. Also the Government of India recommends up to 100 lux of illumination in living rooms.
Hence, it seems practical that if one is able to read news print in all the corners and the center of the room and also in the darkest portion of the room, the lighting can be considered adequate, provided there is no glare and the light does not directly fall in the eyes.
POTENTIAL Mosquito breeding areas and ACTUAL mosquito breeding areas:
Mosquitoes breed (lay eggs) in accumulated water. Hence we need to look for areas where water accumulates for sufficient time period.
Some common places to check for water accumulation are as follows:
Inside the house
• Desert coolers
• Flower vase
• Potted plants
• Water tanks, cisterns, and other stored water
• Old cans, tires, coconut shells, bottles lying in open, etc.
Around the house
• Puddles and roadside ditches
• Open drains
• Cess pools
• Soakage pits
• Old nonfunctioning fountains, bird baths, ornamental pools, etc.
The water collections should be visually inspected for the presence of mosquito larvae and pupae. These can be seen in the picture below.
Video showing mosquito larvae: https://www.youtube.com/watch?v=jOmA8bbP1RU
If mosquito larvae are spotted in the water, report as ‘mosquito breeding site’. If no larvae are detected yet, report as ‘Potential’ mosquito breeding site.
Fly breeding areas
Some common places to check are as follows:
• Open heaps of garbage
• Decaying fruit and vegetables
• Open cattle dung
• Exposed human excreta
• Accumulated sludge and solid organic waste in open drains
• Other similar sites conducive to fly breeding
Identification of actual breeding of housefly:
• Eggs are laid on organic material such as manure and garbage. Eggs are usually laid in clusters of 120 – 130. These are pearly white in colour. These hatch into larvae.
• The larvae are slender, white, legless maggots that are tapering towards the head end.
• They then form Pupa which looks like a maroon colored capsule. The transformation into adult takes place inside the pupa.
• This usually takes 2–10 days, at the end of which the fly pushes open the top of the case and works its way out and up to the surface.
• Soon after emergence the fly spreads its wings and the body dries and hardens. The adult fly is grey, 6–9mm long and has four dark stripes running lengthwise on the back.
• Housefly Breeding Sites: http://www.ihatepsm.com/blog/checking-fly-breeding-sites-household
Housefly life cycle: http://www.ihatepsm.com/blog/life-cycle-housefly
Types of Piped Water supply
There are two main systems of piped water distribution:
1. Intermittent water supply: Water is supplied only during fixed timings during the day.
2. Continuous water supply: Water is supplied throughout the day.
Most of the cities in India have intermittent supply of water. There are certain disadvantages of the intermittent water supply.
• Water may not be available immediately during an emergency.
• Consumers need to store water. This may lead to contamination of drinking water and potential for mosquito breeding.
• During the time when there is no water supply and the pipes are empty, there may be negative pressure inside the pipes that can lead to suction of filth through leaking joints. This leads to contamination of the water at the time it is supplied through the pipes. This phenomenon has been responsible for a number of waterborne disease outbreaks such as typhoid and Hepatitis A.
• The timing of water supply may not be convenient to some consumers.
Hence the preferred system of water supply is continuous type.
Note: If the household stores water in an overhead and arranges for continuous availability of water in the taps at the household level, this CANNOT be regarded as ‘Continuous water supply’. Water supplied from the local authority has to be considered.
Reference Indian Adult Man and Woman
A reference man: is
• Between 18 and 29 years of age
• Weighs 60 kg with a
• Height of 1.73 m and
• BMI of 20.3 and is
• Free from disease and physically fit for active work.
• On each working day, he is engaged in 8 hours of occupation which usually involves moderate activity.
• While not at work, he spends 8 hours in bed, 4–6 hours in sitting and moving about, 2 hours in walking, and in active recreation or household duties.
A reference woman: is
• Between 18 and 29 years of age
• Not pregnant,
• Not-lactating, and
• Weighs 55 kg with a
• Height of 1.61 m and a
• BMI of 21.2, is
• Free from disease and physically fit for active work.
• On each working day, she is engaged in 8 hours of occupation which usually involves moderate activity.
• While not at work, she spends 8 hours in bed, 4–6 hours in sitting and moving about, 2 hours in walking, and in active recreation or household duties.
Concept of the “Consumption Unit”
When the food intake of a community or a group of people is to be measured, the practical problem that arises is that the group is constituted by individuals of various ages and sex groups. Each group has a different set of such groups.
To resolve this issue, it is usual to assess the needs of women and children in terms of those of the average man by applying appropriate coefficients of calorie consumption suggested for practical nutrition work in India.
The energy consumption of an average male doing sedentary work is taken as one unit. The calorie requirement of women, children and males doing moderate and heavy work is expressed as relative to that of a sedentary man. One unit of coefficient corresponds to energy requirements relative to that of a sedentary man and one unit of coefficient corresponds to an energy requirement of 2400 kcal/day. This unit is the “Consumption Unit” (CU). The concept of Consumption Unit (CU) has been developed by ICMR for assessing the need of energy only. However, National Nutrition Monitoring Bureau (NNMB) has been using the CU for other nutrients and food items intake also (as intake per CU) for nutritional surveys in India.
Table: Coefficient for Computing Calorie Requirement of Different Groups
Calculation of the Total Consumption Units of the Family
Allot the appropriate CU (as per the above table) to each family member. Add up the CUs and the total will be the number of CUs in the family.
An example is given here for the calculation of the number of CUs in the family.
• HOF—Male, 31 years old, clerk (sedentary worker): CU = 1
• Wife of the HOF—28 years old, housewife (moderate worker): CU = 0.9
• Elder child—12 year old, male: CU = 1
• Younger child—8 year old, male: CU = 0.7
Total CUs in the family 1 + 0.9 + 1 + 0.7 = 3.6
Concept of Recommended Dietary Allowance (RDA)
Humans require various nutrients such as carbohydrates, proteins, vitamins, and minerals to keep themselves healthy and active. Continuous research is done to identify these nutrients and to determine the physiological requirement of these in different age and sex group individuals.
Further research is needed to translate this requirement of specific nutrients into the required amounts of food items consumed in the habitual diets of communities. Therefore, each country does its own research to measure the nutrients in the habitual diets of its population and recommends the optimum amounts of each dietary item which can provide the daily requirement of the nutrients.
These recommended amounts are known as the RDAs. RDA is defined as the average daily dietary nutrient intake level sufficient to meet the nutrient requirement of nearly all (97–98%) healthy individuals in a particular life stage and gender group.
RDAs are given for different groups, such as adult male, female, infants, children, pregnant, and lactating women.
In India, this exercise is done by the ICMR which makes the recommendations and releases the RDAs for the Indian population and revises them from time to time.
Methods of Dietary Survey
Dietary survey is done to assess the quantities of food items and nutrients consumed by the family. The nutrition composition is calculated using tables of nutritive value of common foods. These tables are given in the ICMR publication: Nutritive Value of Indian Foods.
There are various methods of dietary survey. Each is suitable for a different set of circumstances.
• Weighment of raw foods: The survey team visits the household and weighs all the food that is going to be cooked and eaten. Also the amount which is left over or discarded is weighed. A surveyor needs to make at least two visits prior to the main meals being cooked
• Weighment of cooked foods: Cooked food is weighed instead of the raw materials. In Indian homes, this is not a very acceptable thing. Hence, this is more appropriate for dietary assessment of institutions, hostels, etc.
• 24-hour recall method (questionnaire method) is explained in detail: http://www.ihatepsm.com/blog/24-hour-recall-questionnaire-method
• Food frequency questionnaire method: This is for assessing how frequently an item is consumed during a fixed time period, e.g., in a week. It is more suitable for studying the diet patterns and dietary habits of a population
• Food balance sheet method: This method is suitable when information regarding the availability and consumption of food is required at a macro level like at the global, national, region, or state levels
• Duplicate sample method
The most popular method utilized in family study is the ’24 Hour Recall Method” and is explained in detail here: http://www.ihatepsm.com/blog/24-hour-recall-questionnaire-method
DEFINITIONS OF TERMS MENTIONED UNDER MATERNAL AND CHILD HEALTH
Puerperium: It is the period of 6 weeks immediately after delivery. In this period, the changes which took place in the organs/systems of the woman during pregnancy, come back to nor-mal. This is also known as the post-partum period.
Recommended time for commencement of breastfeeding:
Early Initiation of Breastfeeding means breastfeeding all normal new-borns (including those born by caesarean section) as early as possible after birth, ideally within first hour. Colostrum, the milk secreted in the first 2-3 days, must not be discarded but should be fed to new-born as it contains high concentration of protective immunoglobulins and cells. No pre-lacteal fluid should be given to the new-born.
Prelacteal feeds: These include any food item given just after delivery, mostly just before commencement of breastfeeding. These usually include honey, ghutti, etc., depending on the local customs. The prelacteal feeds are not recommended at all.
Exclusive breastfeeding means that an infant receives only breast milk from his/her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water. No additional food such as “ghutti” and dal water is to be given. Even water is not to be given even if the weather is extremely hot and dry.
The only exceptions include administration of oral rehydration solution, oral vaccines, vitamins, minerals supplements or medicines. Exclusive breastfeeding is recommended till 6 months of age.
Complementary feeding means complementing solid/semi-solid food with breast milk after child attains age of six months. After the age of 6 months, breast milk is no longer sufficient to meet the nutritional requirements of infants. However infants are vulnerable during the transition, from exclusive breast milk to the introduction of complementary feeding, over and above the breastmilk. For ensuring that thee nutritional needs of a young child are met breastfeeding must continue along with appropriate complementary feeding. The term “complementary feeding” and not “weaning” should be used. The complementary feeding must be:
1. Timely – meaning that they are introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding.
2. Adequate – meaning that they provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs.
3. Safe – meaning that they are hygienically prepared and stored and fed with clean hands using clean utensils and not using bottles or teats.
Weaning is the gradual process through which a baby reduces its reliance on a predominantly liquid milk-based diet and gets used to eating adult foods. It usually involves introduction of semi-solid and then solid foods until the child’s diet consists of, largely the family food. The process varies from culture to culture. Healthy babies of weaning age are growing and developing very fast, so great care has to be taken to see that they get enough and the right kind of food. Weaning does not mean discontinuation of breastfeeding.
“Fully immunized” is defined as a child who has received all the due vaccines up to 1 year of age.
“Completely immunized” is defined as a child who has received all the due vaccines up to 2 years of age.
1. Bhalwar RV. Family health history & individual medico–social history – taking. In: Vaidya R, Tilak R, Gupta R, Kunte R, editors. Text Book of Public Health and Community Medicine, 1st ed. Pune: Dept. Community Medicine, AFMC, in collaboration with WHO, India office, Delhi; 2009.
2. Census of India. Available at: http://censusindia.gov.in/Metadata/Metada.htm#2g. Accessed January 19, 2012.
3. Park K. Demography and family planning. In: Park’s Textbook of Preventive and Social Medicine, 24th ed. Jabalpur, India: M/S Banarasidas Bhanot Publishers; 2017.
4. GOI, Min of Statistics and Programme Implementation. Available at: http://mospi.nic.in/Mospi_New/upload/vital_stat_2010/topic. pdf. Accessed January 19, 2012.
5. ICMR. Nutrient Requirements and Recommended Dietary Allowances for Indians. Hyderabad: National Institute of Nutrition; 2009.
6. ICMR. Nutritive Value of Indian Foods. Hyderabad: National Institute of Nutrition; 1996.
13, Nutrition in India. UN ACC/SCN Country case study supported by UNICEF Annex I: food consumption data: the national nutrition monitoring bureau and national sample survey organization. Available at: http://www.unsystem.org/scn/archives/india/ch13.htm. Accessed January 13, 2012.
7. Gupta RK. Nutritional assessment and surveillance of a community. In: Vaidya R, Tilak R, Gupta R, Kunte R, editors. Text Book of Public Health and Community Medicine, 1st ed. Pune: Dept. Community Medicine, AFMC, in collaboration with WHO, India office, Delhi; 2009.
8. Park K. Nutrition and health. In: Park’s Textbook of Preventive and Social Medicine, 20th ed. Jabalpur, India: M/S Banarasidas Bhanot Publishers; 2009.
9. Sunder L, Adarsh, Pankaj. Applied nutrition. In: Sunder L, Adarsh, Pankaj, editors. Textbook of Community Medicine, 1st ed. New Delhi: CBS Publishers and Distributors; 2007.
10. Toobert DJ, Strycker LA, Hampson SE, et al. Computerized portion-size estimation compared to multiple 24-hour dietary recalls for measurement of fat, fruit, and vegetable intake in overweight adults. J Am Diet Assoc 2011;111(10):1578–83.
11. Sharma M, Rao M, Jacob S, Jacob CK. Validation of 24-hour dietary recall: a study in hemodialysis patients. J Ren Nutr 1998;8(4):199–202.
12. USDA, National Institute of Food and Agriculture. Procedures for collecting 24-hour food recalls. Available at: http:// www.csrees.usda.gov/nea/food/efnep/ers/ documentation/24hour-recall.pdf. Accessed January 12, 2012.
13. Sharma R. Kuppuswamy’s Socioeconomic Status Scale—Revision for 2011 and Formula for RealTime Updating. Ind J Pediatr 2012 Apr 3 (Epub ahead of print).
14. Kuppuswamy's SES Scale for 2018, Online Tool: Available at: http://scaleupdate.weebly.com/real.html ; accessed on 31st January 2018
15. Kuppuswamy B. Manual of Socioeconomic Status (Urban). Delhi: Manasayan Publishers; 1981.
16. Pareek U, Trivedi G. Manual of Socio-Economic Status Scale (rural). New Delhi: Manasayan Publishers; 1995.
17. GOI, 2004. National Guidelines on Infant and Young Child Feeding. New Delhi: Food and Nutrition Board, Dept. of Women and Child Development, Min of Human Res Dev
18. GOI. Reading Material for ASHA, book no. 2. New Delhi: MoHFW; 2006.
19. GOI, 2013. Guidelines for Enhancing Optimal Infant and Young Child Feeding Practices. New Delhi: Food and Nutrition Board, Dept. of Women and Child Development, Min of Human Res Dev
20. WHO, 1998. WEANING from breast milk to family food: A guide for health and community workers. Geneva
21. GOI, 2016. Immunization Handbook for Medical Officers. New Delhi: MoHFW; 2016.
22. Poornima Tiwari, Shashank Tiwari. Chapter 13, In: Mastering Practicals in Community Medicine. 2nd ed. Lippincott Williams & Wilkins, New Delhi
Modified Kuppuswamy Classification of Socio - Economic Class: http://www.ihatepsm.com/blog/modified-kuppuswamy-scale
Prasad's Scale: http://www.ihatepsm.com/blog/prasad%E2%80%99s-scale
Dependency Ratio: http://www.ihatepsm.com/blog/dependency-ratio
Assessment of Overcrowding in a Household: http://www.ihatepsm.com/blog/assessment-overcrowding-household
Checking Adequacy of Lighting in a Room: http://www.ihatepsm.com/blog/checking-adequacy-lighting-room
Assessment of Adequacy of Ventilation: http://www.ihatepsm.com/blog/assessment-adequacy-ventilation
Family and the Types of Family: http://www.ihatepsm.com/blog/family-and-types-family
Checking for Mosquito Breeding Areas in a Household: http://www.ihatepsm.com/blog/checking-mosquito-breeding-areas-household
Life Cycle of Housefly: http://www.ihatepsm.com/blog/life-cycle-housefly
Types of Piped Water supply: http://www.ihatepsm.com/blog/types-piped-water-supply
Reference Indian Adult Man and Woman: http://www.ihatepsm.com/blog/reference-indian-adult-man-and-woman
Concept of the “Consumption Unit”: http://www.ihatepsm.com/blog/concept-%E2%80%9Cconsumption-unit%E2%80%9D
Methods of Dietary Survey: http://www.ihatepsm.com/blog/methods-dietary-survey
24-Hour Recall (Questionnaire) Method: http://www.ihatepsm.com/blog/24-hour-recall-questionnaire-method
Determination of Socio-economic Status of a Family in a Rural Area (the Uday Pareekh Scale): http://www.ihatepsm.com/blog/determination-ses-family-rural-area-uday-pa...
7 Terms used in Maternal and Child Health: Definition and Explanation: http://www.ihatepsm.com/blog/7-terms-used-maternal-and-child-health-defi...
Terms used in Family Health Study: Definitions and Explanations: http://www.ihatepsm.com/blog/terms-used-family-health-study-definitions-...
Lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...
Hindi lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...
Hindi lecture on CSC taking: https://www.youtube.com/watch?v=9gvuXrIJ_gY&t=10s
English lecture on CSC taking: https://www.youtube.com/watch?v=rKxXIyJuBz8&t=24s
Format for CSC taking: http://www.ihatepsm.com/blog/format-clinico-social-case-taking-community...
Geriatric CSC taking: http://www.ihatepsm.com/blog/geriatric-clinico-social-case-community-med...